Concentrations of doxycycline and penicillin G in sera and cerebrospinal fluid of patients treated for neuroborreliosis

Concentrations of doxycycline and penicillin G in serum and cerebrospinal fluid (CSF) were analyzed in 46 patients during treatment for neuroborreliosis. Twenty patients were treated intravenously with penicillin G at 3 g every 6 h (q6h), and 26 patients were treated orally with doxycycline at 200 mg q24h. All samples were collected on day 13 of treatment. The median concentrations of penicillin G in serum were 0.5, 37, and 5.6 micrograms/ml before and 1 and 3 h after drug administration, and that in CSF was 0.5 (range, 0.3 to 1.6) microgram/ml after 2 to 3 h. The median concentrations of doxycycline in serum were 2.1, 6.1, and 4.7 micrograms/ml before and 2 and 6 h after drug administration, and that in CSF was 0.6 (range, 0.4 to 2.5) microgram/ml after 4 h. All patients had concentrations of penicillin G or doxycycline in CSF above the lowest reported MICs of penicillin G (0.003 microgram/ml) and doxycycline (0.12 microgram/ml) for Borrelia burgdorferi. However, no patients had a drug concentration in CSF above the highest reported MIC of penicillin G (8 micrograms/ml), and only one had a drug concentration in CSF above the highest reported MIC of doxycycline (2 micrograms/ml), despite good clinical response to treatment. No treatment failure or relapse was observed during a 1-year follow-up, although one patient treated with penicillin G and one treated with doxycycline were retreated because of residual pain. The chosen dosages of penicillin G and doxycycline seem to give sufficient concentrations in serum and CSF for the treatment of neuroborreliosis.

Successful treatment of ozena with ciprofloxacin

Rhinitis chronica foetida, or ozena, is a rare chronic inflammatory disease. The aetiology and pathogenesis are still not satisfactory explained. For many years various medical and surgical methods for the treatment of this slowly progressive and disabling disease have been tried without permanent success so far. The new fluoroquinolones with excellent effect on gram-negative bacteria and high suitability for oral use offer a potentially attractive treatment for ozena. We review our experience in the treatment of 10 patients with ciprofloxacin in a daily dose of 500-750 mg b.i.d. for 1-3 months. The patients have been followed regularly for up to 26-74 months after treatment and in all of them we registered permanent disappearance of odour, crusting, and growth of Klebsiella ozenae. We conclude that ciprofloxacin provides a step towards better conservative therapy for patients with ozena.

Meropenem versus imipenem/cilastatin in the treatment of intra-abdominal infections

In order to compare the clinical and microbiological efficacy and safety of meropenem with imipenem/cilastatin, 249 patients with intra-abdominal infections participated in an open randomised comparative multicentre trial. Seventy-five men and 57 women (mean age 51 years) were enrolled in the meropenem group and 67 men and 50 women (mean age 52 years) in the imipenem/cilastatin group. The patients received either meropenem, 500 mg q 8 h, or imipenem/cilastatin, 500 mg/500 mg q 8 h by intravenous infusion for up to 17 days (mean 5 days). Ninety-seven of 99 patients (98%) receiving meropenem were clinically cured while 86 of 90 patients (96%) in the imipenem/cilastatin group were clinically cured. The microbiological response was satisfactory in 89 of 94 evaluable patients (95%) receiving meropenem and in 78 of 81 evaluable patients (96%) receiving imipenem/cilastatin. There was no significant difference in clinical and microbiological efficacy between the two treatment groups. Adverse reactions were noted in 26 patients receiving meropenem and in 36 patients receiving imipenem/cilastatin. The present study shows that meropenem is effective and well tolerated in the treatment of intra-abdominal infections.

Bacterial colonisation with Xanthomonas maltophilia--a retrospective study in a cystic fibrosis patient population

Xanthomonas maltophilia was isolated from 25 of 150 patients with cystic fibrosis during a period of 10 years (1983-1992). Twelve patients harboured X. maltophilia chronically, i.e. repeatedly for more than 6 months. No predisposing factors for the colonisation could be identified by studying the clinical and laboratory data of the patients, including preceding and concurrent bacterial colonisation with other bacteria, antibacterial treatments, pulmonary function and biochemical markers. Up to 2 years after the chronic colonisation was established no clinical deterioration could be verified, but the patients with X. maltophilia generally had a worse lung function at the latest follow-up (2-7 years after colonisation) than controls colonised with Pseudomonas aeruginosa (p < 0.05). Our data imply that X. maltophilia is a pathogen and the colonisation appears to follow the same pattern as the colonisation by P. aeruginosa. The development of resistance to different antibiotics, as revealed by analysis of the inhibition zones, was related to antibacterial treatment courses. X. maltophilia showed reduced sensitivity to the most commonly used antibiotics, ceftazidime and tobramycin.

Pharmacokinetic evaluation of imipenem combined with cilastatin in cystic fibrosis

The pharmacokinetics of imipenem (MK-787) and cilastatin (MK-791) were studied in 30 patients with cystic fibrosis (CF) receiving the drug for therapeutic purposes at doses of 11 mg/kg given as a 30-min infusion. The serum concentrations and urine elimination were studied after the first dose and during steady state. The concentrations were assayed by high-pressure liquid chromatography. The total areas under the imipenem serum concentration curves (AUCs) to infinity were 30.4 +/- 6.8 mg.h/l after the first dose compared with 29.1 +/- 7.1 mg.h/l during steady state (NS). The cilastatin AUCs on the 2 days were 40.3 +/- 9.3 and 38.3 +/- 0.4 mg.h/l (NS), respectively. The urinary recovery of imipenem was 47.8 +/- 17.8% after the first dose and 57.8 +/- 24.2% during steady state (NS). The amounts of cilastatin eliminated in the urine during 6 h were 6/7.3 +/- 22.9% after the first dose and 60.5 +/- 17.0% of the dose during steady state (NS). The mean half-life of imipenem in these CF patients was 1.2 +/- 0.4 h on the first day of the examination and within the same range during steady state. The distribution volume (Vd beta) was in the range of 28 liters, the total body clearance was 16.3 liters/h (285 ml/min) on the first day. The t1/2 of cilastatin was 0.59 +/- 0.14 h after the first dose and 0.61 +/- 0.14 h during steady state. Thus patients with CF eliminated cilastatin more quickly than imipenem.

Infections in human liver recipients: different patterns early and late after transplantation

The first 49 consecutive patients who underwent orthotopic liver transplantation between 1984 and 1989 in our department were studied with regard to symptomatic and asymptomatic post-transplantation infections. The major infections carrying a risk of fatal outcome are presented. During the first 4 weeks, fungal and bacterial infections predominated, the percentages of patients affected being 27% and 35%, respectively. Eight patients (17%) suffered from bacterial septicemia, which in six cases was due to gram-negative micro-organisms. The bacterial septicemia was often associated with severe ischemic damage to the graft, rejection, or cholangitis. In addition, a concomitant invasive fungal infection supervened in seven out of eight septic patients, further aggravating the patients' condition. Seventeen of the 49 patients (35%) died after transplantation within 3.3 years. Infection was the cause of death in nine patients (18%), with bacterial septicemia and/or fungemia in eight of these. Cytomegalovirus (CMV) disease was the dominant cause of illness after the 1st month. While only 5 of the 49 patients developed CMV disease during the 1st month (10%), as many as 16 of the 40 recipients who survived beyond that time suffered from symptomatic CMV viremia (40%). CMV mismatching, i.e., the donation of a CMV-positive organ to a CMV-seronegative recipient, entailed the highest risk for CMV disease. Pneumocystis carinii pneumonia occurred within 4 months in 10% of the patients. The four liver recipients affected were among the 20 patients not receiving trimethoprim-sulfamethoxazole prophylaxis. None of the 28 patients who received this prophylaxis over a 12-month period developed this complication (P < 0.005).(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro activity of sparfloxacin compared with ciprofloxacin and ofloxacin against respiratory tract pathogens

The in vitro activity of sparfloxacin, a new fluoroquinolone, was compared with ciprofloxacin and ofloxacin against 166 consecutive isolates from the upper respiratory tract of outpatients. The strains were fully susceptible to three quinolones. The antibacterial activity of sparfloxacin was comparable or better than that of ofloxacin and ciprofloxacin against all strains. Sparfloxacin was fourfold more active against Staphylococcus aureus and Streptococcus pneumoniae. The favourable MIC values and a prolonged half-life makes sparfloxacin interesting for treating respiratory tract infections in out-patient care.

Piperacillin-tazobactam versus imipenem-cilastatin for treatment of intra-abdominal infections

In order to compare the clinical and microbiological efficacies and safety of piperacillin plus tazobactam with those of imipenem plus cilastatin, 134 patients with intra-abdominal infections (73 patients with appendicitis) participated in an open randomized comparative multicenter trial. A total of 40 men and 29 women (mean age, 53 years; age range, 18 to 92 years) were enrolled in the piperacillin-tazobactam group and 40 men and 25 women (mean age, 54 years; age range, 16 to 91 years) were enrolled in the imipenem-cilastatin group. The patients received either piperacillin (4 g) and tazobactam (500 mg) every 8 h or imipenem and cilastatin (500 mg each) every 8 h. Both regimens were given by intravenous infusion. A total of 113 patients were clinically evaluable. Of 55 patients who received piperacillin-tazobactam, 50 were clinically cured, while 40 of 58 patients in the imipenem-cilastatin group were clinically cured. The differences were significant (Wilcoxon test; P = 0.005). There were 4 failures or relapses in the piperacillin-tazobactam group and 18 failures or relapses in the imipenem-cilastatin group. The microorganisms isolated were eradicated in similar proportions in the two patient groups. Adverse reactions, mainly gastrointestinal disturbances and nausea, were noted in 13 patients who received piperacillin-tazobactam and in 14 patients who received imipenem-cilastatin. Results of the present study show that piperacillin-tazobactam is effective and safe for the treatment of intra-abdominal infections.

Increased oral bioavailability of ciprofloxacin in cystic fibrosis patients

The altered pharmacokinetic properties of, e.g., aminoglycosides in cystic fibrosis patients have to be considered when pulmonary exacerbations are treated. Since reported data on ciprofloxacin, a fluorinated quinolone, are conflicting, we compared intravenous and oral administration in cystic fibrosis patients when treating them for mild symptoms of pulmonary infection. All of the patients were colonized with Pseudomonas species. Ciprofloxacin was administered orally (15 mg/kg of body weight) or intravenously (6 mg/kg) twice a day for at least 10 days during separate treatment periods. Five healthy volunteers received single intravenous and oral doses. Pharmacokinetic evaluations were performed at first dose and at steady state. The results showed that cystic fibrosis patients have increased oral bioavailability of ciprofloxacin (80% in cystic fibrosis patients versus 57% in volunteers) and increased total clearance (688 ml/min in CF patients versus 528 ml/min in volunteers). Our data indicate that the pharmacokinetic properties of ciprofloxacin are altered in cystic fibrosis patients with mild symptoms of pulmonary exacerbations and that the changes most probably are due to cystic fibrosis per se or to the impact of chronic infection.

Calcium supplementation and thyroid hormone protect against gentamicin-induced inhibition of proximal tubular Na+,K(+)-ATPase activity and other renal functional changes

Gentamicin can cause proximal tubule necrosis. We have shown that inhibition of PT Na+,K(+)-ATPase activity is rapidly induced by gentamicin. We have now investigated whether manipulations known to attenuate the negative effects of gentamicin on renal excretory capacity, i.e. high calcium intake and L-thyroxine treatment, will also attenuate gentamicin-induced inhibition of Na+,K(+)-ATPase activity and ameliorated signs of proximal tubule damage. Rats were gentamicin- or vehicle-treated for 7 days. Sub-groups were given 4% calcium (Ca) supplements or L-thyroxine 20 micrograms 100 g-1 body weight daily. Gentamicin significantly reduced the glomerular filtration rate and increased the urinary excretion of the proximal tubule lysosomal enzyme, N-acetyl-beta-D-glucosaminidase. Gentamicin significantly reduced proximal tubule Na+,K(+)-ATPase activity, measured in single permeabilized proximal tubule segments. Sodium excretion was inversely correlated to proximal tubule Na+,K(+)-ATPase activity. Both calcium and L-thyroxine alleviated all gentamicin-induced side-effects on renal function as well as on proximal tubule Na+,K(+)-ATPase activity. Calcium and L-thyroxine had no significant effect on renal function. L-thyroxine, but not calcium, increased proximal tubule Na+,K(+)-ATPase activity in control rats. Renal cortical tissue gentamicin concentration was not influenced by calcium but was significantly lowered by L-thyroxine. Two procedures which, via different mechanisms, afford protection from gentamicin-induced changes in renal function also give protection from gentamicin-induced inhibition of Na+,K(+)-ATPase activity. This suggests that loss of integrity of the Na+,K(+)-ATPase enzyme contributes to gentamicin-induced nephrotoxicity.

Home intravenous antibiotic treatment of patients with cystic fibrosis

We report one-year's experience of home iv antibiotic treatment in 31 patients with cystic fibrosis chronically colonized with Pseudomonas aeruginosa. The patients were aged 4-67 years and had a mild to severe disease as indicated by a Shwachman score of 46-95 (mean 77). Ninety-two courses of iv antibiotic therapy were given (mean 3.0 per patient). The mean duration of the courses was 15.4 days. The entire antibiotic course, except for the first dose, was administered at home in 70% of the courses. Most patients (94%) were given a combined treatment of a beta-lactam and an aminoglycoside, administered by the patients themselves or their parents. One inserted venous cannula could be used for the whole treatment period in 30% of the courses. There were no complications. The clinical and bacteriological outcome was good to excellent in 89% of the courses, with temporary eradication or semi-quantitative decrease of Pseudomonas growth in sputum. Lung function (forced expiratory volume at 1 s) and blood gases improved significantly (p less than 0.001) and p less than 0.01, respectively). Most patients were able to attend work or school as usual, and 96% of the patients preferred this type of treatment to hospitalization. Apart from the psychosocial advantages, the economical savings were substantial. In comparison to traditional treatments in hospital (21 patients, 41 courses) home iv antibiotic treatment was safe and effective.

Skin concentrations of phenoxymethylpenicillin in patients with erysipelas

In 45 patients hospitalized with febrile erysipelas that had been treated with oral penicillin, punch biopsies of infected skin were performed and analysed for phenoxymethylpenicillin (pcV) concentrations. The curves for the concurrent serum and tissue levels followed the same course, indicating a rapid diffusion of pcV from serum into tissue. Penicillin concentrations in infected skin exceeded the minimal inhibitory concentrations (MIC) of the streptococci isolated for the first 4 h after tablet ingestion. Venous insufficiency was highly prevalent and pcV concentrations in affected patients were slightly but not significantly higher. A theoretical basis for the successful treatment of erysipelas with oral penicillin is therefore at hand.

Gentamicin inhibition of Na+,K(+)-ATPase in rat kidney cells

Na,K(+)-ATPase activity is decreased in homogenized renal tissue from GM-treated rats. This study examines whether the site of the active effect of GM on Na,K(+)-ATPase activity in the kidney can be localized to the proximal convoluted tubules (PCT) where the drug is taken up and where it will produce necrosis. In rats treated with gentamicin (50 micrograms.kg-1.day-1 i.m.) for 7 days, PCT Na,K(+)-ATPase activity was reduced as compared to vehicle-treated rats but returned to control levels 7 days after treatment withdrawal. In another nephron segment, the medullary thick ascending limb of Henle (mTAL), where GM induced lesions are uncommon, Na,K(+)-ATPase activity was the same in GM- and vehicle-treated rats treatment. To study the in vitro effect of GM, dissected PCT and mTAL segments from untreated rats were preincubated for 30 min with GM 10(-3) M, a dose similar to the tissue concentration in chronically treated rats. In tubule segments that were permeabilized to allow the drug to enter the cells, GM 10(-3) M significantly inhibited Na,K(+)-ATPase activity both in PCT and mTAL. In non-permeabilized mTAL segments GM did not inhibit Na,K(+)-ATPase activity. GM inhibition of Na,K(+)-ATPase activity in permeabilized PCT segments persisted after the tubules were rinsed in GM free medium. GM does not inhibit Na,K(+)-ATPase partly purified from the renal cortex. Conclusion. Gentamicin inhibits Na,K(+)-ATPase activity in renal tubule cells when it has access to the cytoplasm. Treatment with GM will therefore cause a selective inhibition of Na,K(+)-ATPase in the proximal tubule cells.

Renal function in rats with essential fatty acid deficiency

1. Renal function was studied in 50-, 70-, 90- and 200-day-old rats with essential fatty acid deficiency. The pharmacokinetics of tobramycin was investigated in 90-day-old essential fatty acid-deficient rats. 2. A higher glomerular filtration rate and a higher serum concentration of urea were seen in 50-day-old essential fatty acid-deficient rats compared with age-matched controls. Later, the glomerular filtration rate progressively deteriorated in parallel with a decline in effective renal plasma flow and with a concomittant rise in serum levels of urea and creatinine. The serum concentration of protein was lower in the rats with essential fatty acid deficiency and that of sodium was higher than in the control rats. The non-renal clearance of tobramycin was increased in the rats with essential fatty acid deficiency. 3. The early hyperfiltration in essential fatty acid-deficient rats with the subsequent fall in glomerular filtration rate, which was paralleled by a rise in serum levels of urea and creatinine, as well as the increased non-renal clearance of tobramycin, are in accordance with the clinical manifestations of cystic fibrosis. Rats with essential fatty acid deficiency might be a useful model with which to study the pathophysiological renal changes in cystic fibrosis related to the progressive essential fatty acid deficiency in this disease.

Hospital and catchment area antibiotic utilization and bacterial sensitivity in primary infections following gastric surgery in Huddinge, Sweden

The relationship between hospital and catchment area utilization of antimicrobial agents and the antibiotic sensitivity of bacteria isolated from primary infections has been studied after 750 gastric operations performed between 1972 and 1986 at the Huddinge University Hospital. Over 80% of the antibiotics were used in the catchment area. Penicillins (G and V) overall were the most commonly used drugs and comprised 37% of the total antibiotic consumption in 1977-1986. Narrow-spectrum antibiotics dominated throughout the period under investigation. No change in the bacterial resistance to antimicrobial agents was found over time. Many strains of Klebsiella/Enterobacter and E. coli resistant to ampicillin and tetracyclines were recovered throughout the period under investigation. No aerobic Gram-negative bacteria were resistant to gentamicin. All Bacteroides strains except two were sensitive to cefoxitin. Tetracyclines and ampicillin/amoxycillin were mainly used in the catchment area, and cefoxitin and aminoglycosides were almost exclusively used in the hospital. Antimicrobial agents primarily used for out-patients in the catchment area seemed to have more influence on the susceptibility of microorganisms isolated from post-operative infections than agents primarily used in the hospital.

Ciprofloxacin concentrations and impact of the colon microflora in patients undergoing colorectal surgery

Ciprofloxacin was given perorally in two doses of 750 mg each with a 12-h interval starting 24 h prior to surgery, 400 mg of ciprofloxacin was given intravenously at the induction of anesthesia, and 400 mg of ciprofloxacin was given 12 h later to 21 patients undergoing elective colorectal surgery. The maximum concentrations in serum (mean value +/- standard deviation, 11.1 +/- 7.8 mg/liter) during surgery were reached 30 min after ciprofloxacin was administered. The ciprofloxacin concentrations in the intestinal mucosa samples were 2.7 to 37.8 mg/kg of tissue weight, and the concentrations in the fecal samples were less than 0.1 to 858 mg/kg. The aerobic and anaerobic bacteria in the fecal flora were suppressed markedly during the prophylaxis period. No postoperative infections occurred.

Penetration of pefloxacin into human allograft pancreatic juice

The penetration of pefloxacin (400 mg) into pancreatic juice, following a single oral dose, was investigated in five patients subjected to pancreatic transplantation as treatment for insulin-dependent diabetes mellitus. The pancreatic juice was temporarily diverted to the exterior by means of a pancreatic duct catheter. Studies on pure human pancreatic juice were thus made possible. Simultaneous blood and pure pancreatic juice samples were collected at regular intervals for up to 24 h after drug intake. The antibiotic concentrations were determined by bioassay. The average concentration of pefloxacin in pancreatic juice was 100% of that in serum. The mean peak concentration in pancreatic juice was 4.6 +/- 0.9 mg/l (+/- S.E.) and occurred at 2.5 h after drug intake. The decrease in concentration with time was parallel to the serum concentration curve. The concentrations of pefloxacin in pancreatic juice exceeded the MICs of many bacteria associated with pancreatic infections for several hours after administration of a single oral dose.

Comparison of Oxoid Signal and biphasic blood culture systems in clinical practice

The 1-bottle Oxoid Signal blood culture system was compared with a biphasic 2-bottle system in a clinical trial. A total of 851 routine blood samples were processed in the study which was run as a multicenter study at 4 university hospitals. Microorganisms were isolated from 104 (12.2%) blood cultures by one or both methods. 75 (72%) were clinically significant isolates, 61 of them were recovered in both systems, 9 in Oxoid Signal only and 5 in the biphasic system only. 29 isolates (28%) were judged as contaminants, 6 of them were found in both systems, 18 in Oxoid Signal only and 5 in the biphasic system only. The Oxoid Signal System had many advantages although it sometimes gave false positive signals in the device. The growth of pathogens was equally good, 93% versus 88% positive cultures.

Serum and sputum concentrations of netilmicin in combination with acylureidopenicillin and cephalosporins in clinical treatment of pulmonary exacerbations in cystic fibrosis

The pharmacokinetics of netilmicin was studied in 14 patients with cystic fibrosis, aged 4-21 years (mean 16 years) during treatment of pulmonary exacerbations of pseudomonas infection. The patients received 24 courses of netilmicin (10 mg/kg/day) in combination with azlocillin (600 mg/kg/day), cefsulodin (200 mg/kg/day) or ceftazidime (150 mg/kg/day) for 9-14 days. Seven patients received two or three courses of different combinations. Serum and sputum concentrations of netilmicin were determined on day 2 and 6. Mean (+/- S.E.M.) trough serum values were 1.4 +/- 0.2 mg/l (same on day 2 and 6), peak values at 10 min 13.6 +/- 1.0 and 13.7 +/- 0.9 mg/l, and serum concentration at 1 h 7.5 +/- 0.6 and 7.5 +/- 0.5 mg/l, on days 2 and 6 respectively. The half-life was about 1 h. The pharmacokinetics did not differ on day 2 and 6. Sputum concentrations increased up to 2-3 h after administration, mean (+/- S.E.M.) peak values being 2.6 +/- 0.6 and 1.5 +/- 0.4 mg/l at day 2 and 6, respectively. The study shows that the pharmacokinetics of netilmicin was not influenced by different combinations with beta-lactams. All patients improved clinically, but pseudomonas growth was only reduced in nine courses. In one case transient resistance to netilmicin developed during the treatment. The clinical efficacy and tolerance were good and similar to those seen with combinations with other aminoglycosides.

Septic complications in relation to factors influencing the gastric microflora in patients undergoing gastric surgery

Postoperative septic complications and micro-organisms found in primary infections were studied in 750 gastric operations performed between 1972 and 1986. The overall rate of primary infections was 23%. The infection rates were related to the diagnosis and to factors that could influence the colonization of the stomach. No significant differences in the rates of postoperative infections were found between patients who had received preoperative antibiotic prophylaxis and those who had not. In all groups of patients, aerobic and anaerobic gram-positive and gram-negative bacteria and yeasts were isolated in primary infections. Enterobacteriaceae, enterococci and Bacteroides fragiis were more frequent in patients with gastric bleeding or carcinoma.

Imipenem concentrations in colorectal surgery and impact on the colonic microflora

Twenty patients undergoing colorectal surgery were given, as prophylaxis, imipenem-cilastatin intravenously. Ten of them received a dose of 0.5/0.5 g of imipenem-cilastatin at induction of anesthesia, followed by subsequent doses of 0.5/0.5 g every 6 h for 48 h. The other 10 patients were given 1.0/1.0 g imipenem-cilastatin in the same way for 48 h. Samples from serum, intestinal mucosa, and feces were taken for analysis of imipenem concentrations during the day of surgery. The mean concentrations in serum at 1 h after the first imipenem dose were 15.9 +/- 1.7 micrograms/ml for the 0.5-g dose and 68.2 +/- 8.2 micrograms/ml for the 1.0-g dose. The mean half-lives were 1.5 and 1.4 h, respectively, and the mean areas under the serum concentration-time curve were 41.2 +/- 6.0 and 128.3 +/- 13.5 mg.h/liter, respectively. The imipenem concentrations in the intestinal mucosa varied between less than 0.1 and 3.6 mg/kg for the 0.5-g dose and 3.2 and 13.4 mg/kg for the 1.0-g dose. The concentrations in the fecal samples varied between less than 0.1 and 5.0 mg/kg for the 0.5-g dose and 0.7 and 11.3 mg/kg for the 1.0-g dose. Fecal samples were also collected during the investigation period for cultivation of aerobic and anaerobic bacteria. The aerobic bacteria--staphylococci, streptococci, enterococci, and enteroaerobic enterococci, and enterobacteria--were and anaerobic bacteria. The aerobic bacteria--staphylococci, streptococci, enterococci, and enterobacteria--were suppressed significantly during the imipenem prophylaxis period. Among the anaerobic bacteria, cocci, bifidobacteria, eubacteria, lactobacilli, clostridia, fusobacteria, and bacteroides decreased markedly during the same period. The microfloras were normalized after 2 weeks. There were no differences between the patients receiving 0.5-g doses of imipenem and those receiving 1.0-g of imipenem. No postoperative infections occurred.

Penetration of imipenem into human pancreatic juice following single intravenous dose administration

The penetration of imipenem into the human pancreatic juice following a single intravenous dose of 500 mg was investigated in five patients who had undergone pancreatic transplantation. With a special technique for segmental pancreatic transplantation it was possible to collect pure pancreatic juice at regular intervals. Simultaneous blood and pancreatic juice samples were collected immediately before drug administration and then at 0.5, 1, 1.5, 2.5, 3.5 and 5.5 h thereafter. The antibiotic concentrations were determined by the agar diffusion method. The mean peak level in serum was 24.6 +/- (SE) 2.6 mg/l and occurred 0.5 h after administration. The mean peak concentration in pancreatic juice was not reached until 1.5 h after administration, and the level was then 1.7 +/- (SE) 0.3 mg/l. Thereafter the levels in serum and pancreatic juice declined in parallel, and the concentration in pancreatic juice was then about 13% of that in serum. Although imipenem penetrates into the pancreatic juice at a very low degree, the concentrations exceeded the MIC values for many bacteria associated with pancreatic infections. Imipenem could therefore be an alternative as monotherapy in the treatment of pancreatic infections.

Penetration of ciprofloxacin and ofloxacin into human allograft pancreatic juice

The penetration of ciprofloxacin (500 mg) and ofloxacin (400 mg) into pancreatic juice following a single oral dose, was investigated in seven patients who had undergone pancreatic transplantation. With a special technique for segmental pancreatic transplantation it was possible to collect pure pancreatic juice at regular intervals for up to 24 h after drug intake. The antibiotic concentrations were determined by the agar-well diffusion method. The concentration of ciprofloxacin in pancreatic juice was 36% of that in serum. The same figure for ofloxacin was 92%. The mean peak level in pancreatic juice was 0.5 +/- 0.0 mg/l (+/- S.E.) for ciprofloxacin and occurred at 4 h after drug intake. The same figure for ofloxacin was 2.7 +/- 0.7 mg/l (+/- S.E.) occurring at 3.6 h. The decrease in concentrations with time was parallel to the serum concentration curves for both antibiotics. The concentrations of ofloxacin in pancreatic juice exceeded the MIC values for most of the organisms causing infections in the pancreas for several hours after an oral dose. The concentrations of ciprofloxacin only briefly exceeded the MIC for the same organisms.

Penetration of clindamycin, cefoxitin, and piperacillin into pancreatic juice in man

In our segmental pancreatic transplantation technique the pancreatic juice is temporarily diverted to the exterior via a pancreatic duct catheter. This permits studies on pure pancreatic juice to be carried out. In 11 such patients we studied the penetration of clindamycin, cefoxitin, and piperacillin into pancreatic juice. These three antibiotics all have good effect against the bacteria commonly isolated during pancreatic infections. Simultaneous blood and pancreatic juice samples were collected immediately before drug administration and at 30, 60, 90, and 120 minutes and 3, 4, 5, 6, and 8 hours after administration. The concentration of clindamycin in pancreatic juice was 34% of that in serum and exceeded the minimum inhibitory concentration for most bacteria associated with pancreatic infections. In spite of adequate serum concentrations of cefoxitin and piperacillin, the concentrations in pancreatic juice were only 8% and 5%, respectively, and did not exceed the minimum inhibitory concentration for the relevant bacteria. In view of these findings, clindamycin seems to be preferable in the treatment of pancreatic infections.

Effect of ofloxacin on oral and gastrointestinal microflora in patients undergoing gastric surgery

The effect of ofloxacin on the microflora in saliva, gastric juice, and feces was evaluated in 24 patients undergoing gastric surgery. A single peroral dose of 400 mg ofloxacin was given to each patient 2-4 h before surgery. The concentrations of ofloxacin in serum, saliva, gastric juice, and gastric mucosa tissue were assayed. Only Branhamella cocci were affected in the saliva. In the gastric juice, both the aerobic and anaerobic flora were suppressed on the day of surgery, but increased in number afterwards. There was a significant correlation between gastric pH and the number of microorganisms isolated in the gastric juice on day 0. In faeces, the aerobic and part of the anaerobic flora were suppressed by the administration of ofloxacin. Ofloxacin was well tolerated by the patients. Four of 24 patients developed postoperative complications. Microorganisms isolated from wound sepsis and intraabdominal sepsis (three patients) were Staphylococcus epidermidis, Staphylococcus aureus, hemolytic streptococci group A, Streptococcus sp. and Escherichia coli. All related infections occurred in patients with very low ofloxacin serum concentrations, probably due to impaired absorption. Oral antibiotic prophylaxis is not recommended in patients in whom impaired gastric emptying can be expected.

Imipenem/cilastatin, an alternative treatment of pseudomonas infection in cystic fibrosis

Imipenem, a new N-formimidoyl thienamycin was given together with cilastatin to 20 patients with cystic fibrosis and pulmonary infection due to Pseudomonas aeruginosa. The antibiotic was given in short-term infusions for 9-14 days (mean 11.5) in a dose of 45-60 mg/kg body weight/day. Good clinical results were obtained in all patients with significant improvement of clinical score, pulse rate, vital capacity and FEV1.0 (P less than 0.001). Blood PO2 increased and WBC decreased significantly. A slight increase in the minimum inhibitory concentration was noted during treatment but all strains examined were fully susceptible at follow-up one month later. The peak serum concentration was significantly increased in patients receiving the high dose of imipenem, but the sputum concentration was low in all patients and there was no difference in clinical or bacteriological outcome. The plasma and urinary clearance increased with body weight and was inversely correlated to clinical score. Imipenem/cilastatin appears a good alternative for the treatment of pulmonary infections caused by P. aeruginosa in cystic fibrosis.

Enoxacin distribution in human tissues after multiple oral administration

Enoxacin was administered to six patients undergoing nephrectomy; 200 mg was given orally twice a day for three days preoperatively. The last dose was given on the morning of the day of operation. Samples of blood, skin, subcutaneous fat, muscle, rib bone, and renal cortex and medulla were taken during the procedure. Urine was collected 24 h preoperatively. The concentrations of enoxacin in the different tissues were measured by an agar-well diffusion method. The mean (24 h) urinary excretion of enoxacin was 62.7% of the daily dose. The concentrations in renal cortex and medulla and muscles exceeded those in serum; the mean tissue/serum concentration ratios were 3.8, 3.2 and 1.4, respectively. The ratios for skin and fat were 0.8 and 0.2, respectively. Only four bone samples were obtained and two of them had no detectable levels. The results indicate that enoxacin may be effective for treatment of skin and soft tissue infections and infections in the upper and lower urinary tract.

Effects of antimicrobial prophylaxis on colonization resistance

The effect of antimicrobial agents on the intestinal microflora of patients undergoing colorectal surgery was examined. Two narrow spectrum agents, clindamycin and aztreonam, disturbed colonization resistance. This was preserved with the broad spectrum compound, imipenem. Ecological effects are difficult to predict and clinical studies of new antibiotics should include investigations of their impact on the normal human intestinal flora.

Susceptibility to beta-lactam antibiotics and gentamicin of gram-negative bacilli isolated from hospitalized patients: a Swedish multicenter study

A total of 952 blood and 1543 urine isolates of gram-negative bacilli from hospitalized patients in 1986-1987 were consecutively collected by 10 Swedish laboratories and tested for susceptibility to 8 beta-lactam antibiotics and to gentamicin. The isolates were mostly Escherichia coli (58% and 44%, respectively) and Klebsiella sp. (17% and 18%). Resistance to ampicillin in blood and urine isolates was found in 35% and 45%, respectively, to piperacillin in 5% and 6%, to cephalothin in 26% and 34%, to cefuroxime in 12% and 22%, to cefotaxime in 3% and 5%, to ceftazidime in 1% and 1%, to imipenem in 0.5% and 0.1%, to aztreonam in 3% and 2%, and to gentamicin in 0.8% and 0%. Resistance of clinically important gram-negative bacilli to new beta-lactam antibiotics and to gentamicin is infrequent in Sweden.

Urinary tract infection caused by Haemophilus influenzae. A case report

In a patient with frequent symptoms of urinary tract infection during the past 5 years and steadily deteriorating renal function, standard urine cultures were mostly negative. Following microscopy of freshly voided, gram-stained urine, culture on haematin agar plates incubated in 10% CO2 resulted in isolation of Haemophilus influenzae. Augmented culture procedures may identify the cause of symptoms in similar cases.

Granulocyte elastase-alpha 1-antiproteinase complex in cystic fibrosis: sensitive plasma assay for monitoring pulmonary infections

Elastase in plasma was determined as a complex of granulocyte elastase and alpha 1-antiproteinase (GEC) by an enzyme-linked immunosorbent assay in 67 patients with cystic fibrosis. The patients were observed for 1 years, when clinically infected and noninfected. Although noninfected patients had GEC levels within the normal range, the mean value was significantly higher than the mean values in patients in an optimal noninfectious state (P less than 0.01) and in healthy controls (P less than 0.001). Clinical signs of (in most cases) low-grade infection were paralleled by significant increases in GEC levels (P less than 0.001). There was no correlation with different types of bacteria or age of patients. No cross reaction to Pseudomonas elastase could be found in vitro or in vivo. Significant decreases of GEC values were seen after intravenously administered antimicrobial therapy (P less than 0.001), and although the white blood cell count and erythrocyte sedimentation rate were rarely increased above the normal range, they decreased congruently (P less than 0.001), and lung function improved (P less than 0.001). The sensitivity of GEC was significantly higher than that for erythrocyte sedimentation rate (P less than 0.01) and white blood cell count (P less than 0.05). Determination of GEC values seems to be a simple and sensitive measurement for monitoring treatment in cystic fibrosis, especially of low-grade infections in patients with normal standard blood tests.

N-acetylcysteine and 2-mercaptoethane sulphonate inhibit anti-pseudomonas activity of antibiotics in vitro

The in vitro activity against Pseudomonas aeruginosa was investigated for serial dilutions of eight anti-Pseudomonas antibiotics in combination with serial dilutions of N-acetylcysteine (NAC) and 2-mercaptoethane sulphonate (MES). The results indicated that addition of NAC and MES to the antibiotics increased the MIC values for tobramycin, netilmicin, piperacillin, azlocillin, cefsulodin, ceftazidime and imipenem but not for colistin. The decrease of MIC found in high concentrations of NAC and MES was probably due to the bacteriostatic effect of the drugs per se and not to synergism with the antibiotics.

Conformity of bacterial growth in sputum and contamination free endobronchial samples in patients with cystic fibrosis

The use of sputum cultures to guide the antimicrobial treatment of patients with cystic fibrosis has been questioned. Bacterial growth and antibiotic susceptibility patterns of 33 culture pairs from sputum and contamination free endobronchial swabs from 14 patients with cystic fibrosis were compared. As expected, Pseudomonas aeruginosa of the mucoid and non-mucoid type, Staphylococcus aureus, and Haemophilus influenzae were the organisms most frequently found. Absolute or good agreement was found in 73% of the culture pairs. The accuracy of the sputum cultures improved with the duration of antimicrobial treatment. The extra information gained from the endobronchial culture did not change the antimicrobial strategy from that based on the sputum culture alone. It is concluded that sputum cultures provide accurate information about the bacterial colonisation of the lower respiratory tract in patients with cystic fibrosis and therefore can be trusted both at onset of treatment and during the entire treatment period.

In vitro aminoglycoside resistance of gram-negative bacilli and staphylococci isolated from blood in Sweden 1980-1984

The in vitro susceptibility to gentamicin, tobramycin, amikacin and netilmicin in septicaemia isolates was followed during 1980-1984 in 6-8 Swedish laboratories. The bacterial distribution was similar over the years and was dominated by Escherichia coli and staphylococci. Resistance to gentamicin was found in 2.3-3.6%, to tobramycin in 1.4-3.4%, to amikacin and netilmicin in 0.5-0.9%. Production of aminoglycoside modifying enzymes was observed among resistant strains.