Nephrotoxicity in combined cephalothin and gentamicin therapy

Thirty-two series of treatment with cephalothin and gentamicin for 5-10 days have been administered to 26 patients. An increase in serum creatinine occurred in 6 series. Important factors for the renal damage were elevated pretreatment serum creatinine, elevated serum gentamicin and probably a high serum cephalothin. In 2 patients the nephrotoxicity was fully reversible; the others died before a dicisive improvement in renal function could be expected. In 11 out of 28 treatment series there was a transient drop in serum potassium. Since the combination of cephalothin and gentamicin as the primary treatment of life-threatening infection has often proved effective, and since short-lasting treatment seems to entail only a minute risk of nephrotoxicity in patients with normal pretreatment serum creatinine, we still prefer this treatment in such cases.

Acute interstitial nephritis during treatment with penicillin and cephalothin

A case of non-oliguric acute interstitial nephritis during treatment with ampicillin, benzylpenicillin and cephalothin is reported. There were symptoms of drug hypersensitivity, including fever, exanthema, eosinophilia and elevated serum IgE. Renal biopsy showed marked interstitial edema and infiltration with numerous eosinophils, some mononuclear cells and giant cells, and scattered tubular damage, but normal glomeruli and vessels. There was no pathological deposition of immunoglobulins or complement in the renal tissue. Renal function recovered after withdrawal of antibiotics and treatment with steroids. The findings suggest a drug-induced, hypersensitivity-mediated pathogenesis of the renal lesions, with participation of both humoral and cell-mediated immunological reactions.

Flare up to betalactams

BACKGROUND

The flare up phenomenon has most frequently been described with nickel. Not many cases of flare up to drugs have reported in the literature, however we have reported it with different medications.

METHODS AND RESULTS

A 31-year-old woman developed an adverse reaction with an antibiotic during her childhood. Prick test with penicillin (100,000 IU/ml), penicilloyl polylysine (PPL), minor determinant mixture (MDM), amoxicillin (200 mg/ml), ampicillin (200 mg/ml) and cephalotin (200 mg/ml), and intradermal test to the same substances diluted in saline were all negative immediately. We performed an oral challenge test with 500 mg of amoxicillin. Twelve hours later, the intradermal test to PPL and MDM became positive (PPL 10 x 10 mm, MDM 8 x 7 mm). All patch tests were positive after 72 hours with erythema, vesicles and infiltration and the patient also had exanthema with pruritus on her entire body.

CONCLUSIONS

We present one patient with delayed allergic reaction caused by amoxicillin and penicillin, that we all know as Flare up. We suggest that this phenomenon of Flare up occurs by a Type IV mechanism mediated by T-cells without participation of IgE antibodies. The betalactam hypersensitivity mechanism which has usually been described is an IgE mediated reaction, but there are other not very well known mechanisms that are responsible for the delayed reactions.

Cefoxitin and cephalothin: antimicrobial activity, human pharmacokinetics, and toxicology

Cefoxitin, a semisynthetic cephamycin, has been compared with the widely used parenteral cephalosporin, cephalothin, in terms of antibacterial activity, human pharmacokinetics, and toxicity. For both compounds, minimal inhibitory concentrations were within the therapeutic range against the 156 gram-positive cocci tested (except group D streptococci), but cephalothin was 8 to 20 times more active. Regarding the 313 gram-negative organisms tested, both antibiotics were of approximately equal activity against cephalothin-susceptible strains, but cefoxitin was outstandingly superior against Providencia spp. and indole-producing Proteus spp., and markedly better against Serratia marcescens and Bacteroides fragilis. Against these organisms, cefoxitin but not cephalothin would be expected to be therapeutically valuable. Antibiotic activity levels in the serum and urine of 18 human volunteers after parenteral administration were higher and more prolonged in the case of cefoxitin, which had an average terminal serum half-life of about 45 min and a urinary recovery of about 90%. Cefoxitin was entirely nontoxic and, given intramuscularly, slightly less painful then cephalothin. These preliminary results suggest that cephamycins may prove to be a significant chemotherapeutic advance.

Removal of an infected silicone rod frontalis sling without recurrence of ptosis

We examined a child with congenital ptosis. She underwent a bilateral silicone rod frontalis sling operation. One of the slings became infected and necessitated removal. We noticed no recurrence of her ptosis after sling removal. Removal of a frontalis sling does not invariably lead to recurrence of ptosis. We hypothesize that a scar tract formed in the plane of tissue from which the sling was removed. This band of scar tissue can act as a frontalis sling to elevate the eyelid.

A prospective, randomized trial of two antibiotic regimens in the treatment of peritonitis in CAPD patients: teicoplanin plus tobramycin versus cephalothin plus tobramycin

A multicentre, comparative, randomized study was performed to compare the efficacy and tolerability of two antibiotic regimens in the treatment of peritonitis in continuous ambulatory peritoneal dialysis (CAPD) patients: teicoplanin plus tobramycin versus cephalothin plus tobramycin. After informed consent had been obtained, 68 patients were randomized prospectively to receive either teicoplanin plus tobramycin or cephalothin plus tobramycin. Patients were followed throughout the study and for up to 4 weeks after the end of treatment, when clinical and microbiological parameters were assessed again. The incidence of clinical failure was 4.6 times higher in the cephalothin plus tobramycin group than in the teicoplanin plus tobramycin group (7/28 versus 2/37; P < 0.05). There was no significant difference in bacterial eradication between the two groups. Local and systemic tolerability were good for both regimens. The study shows that teicoplanin plus tobramycin is more effective than cephalothin plus tobramycin and might become a 'first-line' treatment for peritonitis in CAPD patients.

[Protein binding of various cephems in healthy subjects and patients with chronic renal failure]

This study was employed to investigate whether the serum protein binding of various cephems [cefpiramide (CPM), cefalotin (CET), latamoxef (LMOX)] differ among healthy subjects and patients with chronic renal failure (CRF) by means of in vitro equilibrium dialysis. The protein binding capacities of cephems in patients with CRF (hemodialysis, continuous ambulatory peritoneal dialysis, non-dialysis) decreased significantly compared to those in healthy subjects. The binding capacities correlated directly with total protein, albumin concentration and correlated inversely with blood urea nitrogen and serum creatinine concentration. In the study of protein binding during and after hemodialysis, the binding capacities of CPM and LMOX decreased immediately after dialysis and then increased with the time. However, the binding capacities of CET increased immediately after dialysis and then decreased. The binding capacities of CPM and LMOX correlated inversely with non-esterified fatty acids (NEFA) and those of CET correlated directly with NEFA. In the study of protein binding in pooled sera from healthy subjects with or without palmitic acid (PA), the binding capacities of CPM and LMOX decreased by increasing the concentration of PA, while those of CET increased by increasing PA up to 3 mM. The changes in binding capacity of cephems during and after hemodialysis have been possibly caused by increase of NEFA due to activation of lipase in use of heparin as an anticoagulant. In conclusion, changes in protein binding capacity of cephems in sera from CRF, which should be taken into consideration to avoid possible side effects.

[Intraoperative anaphylactic shock--report of two cases]

Allergic reactions are often unpredictable, sudden in onset and may be potentially lethal. Clinical manifestations are confined to skin (rash, urticaria, angioedema), respiratory tract (laryngeal edema, bronchospasm) and cardiovascular system (hypotension, bradycardia, dysrhythymia). Because cardiovascular collapse is the most common life-threatening clinical feature, immediate and proper treatment is necessary. We have experienced two cases of intraoperative anaphylatic shock between September 1988 and April 1989. The precipitating factors were of nonanesthetic origin (case 1 was probably due to cephalothin and case 2 was due to dextran 40). Both cases manifestated with hypotension, bradycardia, cutaneous rash and urticaria. Recovery was smooth and without sequela after volume expansion and sympathomimetic drug. We discuss these two cases with a brief review.

Survival after a second episode of toxic epidermal necrolysis

Toxic epidermal necrolysis resulting from severe hypersensitivity to medication has a reported mortality of up to 66%. A patient surviving two episodes with more than a 50% skin loss is unprecedented in the medical literature. Mortality has been associated with many factors, including delayed reepithelialization, persistent skin slough, coagulopathy, severe hypoproteinemia, and sepsis. It may be possible to decrease morbidity and mortality by preventing the shearing of epidermis, thereby limiting the denuded areas. This case report describes the successful management of our patient's second episode of toxic epidermal necrolysis. The treatment of this patient in our specialized burn center consisted of careful fluid and electrolyte management, nutritional support, standard topical antimicrobials, and new modalities of local wound management.

[Renal dipeptidylpeptidase IV excretion in drug-induced kidney changes]

The course of the excretion of dipeptidyl-peptidase IV (DP IV)-alanine aminopeptidase, beta-glucuronidase and total protein with the urine was investigated during the treatment of 11 patients with pyelonephritis with gentamicin, after application of a renal radiographic contrast medium in 7 patients with arterial hypertension and after regional perfusion of an extremity in 10 patients with malignant melanoma. In the reference group in male test persons with 147.0 nmol/s X l a higher DP IV activity in the urine was recognized than in the female test persons (100.0 nmol/s X l). After application of the drugs a rhythmically intermitting increased excretion of all enzymes mentioned develops. The study confirms the usuability of the DP IV-activity for enzymological investigations of the urine.

Effect of high-dose ampicillin and cloxacillin on bleeding time and bleeding in open-heart surgery

To determine if platelet dysfunction caused by high doses of penicillin compounds is of practical importance in patients with additional haemostatic defects perioperatively, a study was made of patients undergoing open-heart surgery. They were randomly assigned to prophylactic treatment with ampicillin 8 g plus cloxacillin 4 g daily for three days, or with cephalothin 8 g daily for three days. Fifty patients in each group were evaluated. The median bleeding time preoperatively and on days 1 and 4 postoperatively did not differ between the groups. The bleeding time was prolonged beyond the normal range in eight patients of the ampicillin/cloxacillin group and in three of the cephalothin group (p less than 0.05). Prolonged bleeding time was not associated with lower platelet count or greater blood loss. The total blood loss and the amounts of transfused blood, platelets and cryoprecipitate were all greater in the ampicillin/cloxacillin group, but the difference was not statistically significant. Combined use of ampicillin and cloxacillin in open-heart surgery is associated with increased bleeding, but the increase is without practical importance.

[Urinary enzyme excretion in cephalothin therapy in adults and children]

A damage of the kidney, particularly of proximal tubular cells, can be indicated by an increased concentration of definite enzymes in urine. After gynecological operation the repeated application of 8 g cephalothin daily provokes an higher increase of enzyme concentrations in urine than the application of ampicillin under the same conditions. These results show that cephalothin produces a slight alteration of tubular cells, probably without practical importance. In contrast to this, in children a total dose of 1.5 up to 6 g cephalothin, administered after an operative correction of vesikoureterale reflux, provokes no marked changes in urinary enzyme excretion. Probably, in these children the determination of urinary enzyme excretion is not a suitable parameter to demonstrate a slight tubulotoxic damage.

Comparative efficacy of cefotiam versus cephalothin in the therapy of skin and soft tissue infections

Cefotiam was evaluated by a comparative open-label randomized trial with cephalothin in the therapy of skin and soft tissue infections in 39 patients. The most common organism isolated was Staphylococcus aureus (78%). We established evidence of primary infection with gram-negative bacilli in four patients, three of whom were diabetic. Eight patients had mixed infections or superinfections. No patient was evaluated as a treatment failure; for 10 of 39 patients we were unable to recover an etiological agent but demonstrated a clinical cure. Cefotiam was found to be as effective as cephalothin in the therapy of skin and soft tissue infections.

[Comparison of side effects of intravenous cephapirin and cephalothin with special reference to the incidence of phlebitis]

The frequency and severity of side effects, above all, phlebitis, associated with an intravenous use of cephapirin (CEPR) or cephalothin (CET) was compared in 69 patients with infections. Two grams of each drug were administered intravenously twice a day with a 21-G vein needle in one of the two arms of the patients. CEPR was administered to 32 patients, and CET to 37 patients respectively. After treatment, the status of the veins was checked, and laboratory findings and other side effects were evaluated daily. Each drug appeared to be equally efficacious in the treatment of infections. The administration of CEPR was associated with a slightly lower rate of phlebitis and other side effects, but the difference between the 2 drugs was not significant (0.05 less than P less than 0.10). Phlebitis was observed in 1 patient (3.1%) of CEPR group and in 3 patients (8.1%) of CET group. Side effects, including phlebitis, were observed in 4 patients (12.5%) of CEPR group and in 12 patients (32.4%) of CET group. In CET group, drug exanthema (3 cases), drug fever (3 cases), and abnormalities in liver function (4 cases) were observed. These findings, together with the results of other reports, suggest that CEPR is a safe and useful drug in the treatment of infection as compared with CET.

[Drug induced nephropathy and enzymes of renal origin in the urine]

A report is given on the excretion of the renal enzymes alaninaminopeptidasis (AAP), N-acetyl-beta-D-glucosaminidasis (NAG), beta-glucoronidasis (GBC) and alpha-galactosidasis (GAC) in urine after administration of Gentamycin, Cephalotin, Dextran, Carbencillin or combinations of these medicaments. Moreover the effective level of Gentamycin in the urine was measured after isolated administration of Gentamycin. A rhythmic excretion of ciliated-border and lysomal enzymes was observed. Gentamycin was also rhythmically excreted with the urine. It is assumed that this reflects cyclic changes in the cells of the renal tubule. Under long-term administration of Gentamycin or Dextran the excretion of enzymes already reduced during therapy. This was interpreted as an adaptation of the kidney to the medicament. On the other hand there are combinations of medicaments whose effect on the epithelium of the renal tubule is potentiated.

Severe nephrotoxicity: a probable complication of cis-dichlorodiammineplatinum (II) and cephalothin-gentamicin therapy

A 53-year-old patient with metastatic testicular choriocarcinoma died of renal failure after treatment with cis-platinum and antibiotics. Serum creatinine was first noted to be elevated on day 8 of cis-dichlorodiammineplatinum (DDP) therapy. However, a sharp rise in its level occurred soon after the start of antibiotic therapy with cephalothin, gentamicin and carbenicillin. Renal failure was progressive in nature and persisted until death occurred on day 24 of therapy and after 8 days of antibiotic treatment. The most likely explanation for the progressive worsening of renal function in this patient was renal injury incurred by DDP and antibiotics. The combination of cephalothin-gentamicin should be discouraged in the treatment of patients receiving platinum.

Antibiotic combination-associated nephrotoxicity in granulocytopenic patients with cancer

Antibiotic combination-associated nephrotoxicity was reviewed in 491 granulocytopenic patients with cancer and fever. Nephrotoxicity was defined as a rise in the serum creatinine level of more than 0.4 mg/dL. The different aminoglycosides, when combined with ticarcillin disodium, were found to have an equivalent nephrotoxic potential and, for the purpose of analysis, were combined and termed "aminoglycoside plus ticarcillin" (Ags + ticarcillin). Groups treated with gentamicin or amikacin plus cephalothin sodium were combined and termed "aminoglycoside plus cephalothin" (Ags + cephalothin). The rate of nephrotoxicity was statistically less for the Ags + ticarcillin group, eight (3.1%) of 262 patients, than for the Ags + cephalothin group, 23 (18.3%) of 126 patients. Age greater than 50 years was a potentiating factor for the occurrence of nephrotoxicity in the Ags + cephalothin group. We have concluded that for granulocytopenic patients with cancer and fever, the antibiotic combination of the Ags + cephalothin should not be used as empiric antibiotic therapy.

Skin testing to detect penicillin allergy

Skin testing for penicillin allergy with penicillin G (Pen G), penicilloic acid (PA), and penicilloyl poly-L-lysine (PPL) was performed on 740 subjects, and the results were assessed from epidemiologic and immunologic perspectives. Approximately 95% of these patients had histories of apparent allergic reactions to beta-lactam antibiotics, and 63% were skin-test positive. The prevalence of positive skin tests was related to the time that had elapsed between clinical reactions and skin testing. Ninety-three percent were skin-test positive 7 to 12 mo after reactions, and 22% were positive 10 yr or more after reactions. Patients under 30 yr of age had a prevalence of positive skin tests 1.7-fold higher than older patients. Testing with PPL, PA, and Pen G detected 76.3%, 55.3%, and 57.1% of the positive patients, respectively. Omission of PPL, PA, or Pen G would have led to a failure to detect 25.6%, 7.2%, and 6.2% of the positive patients, respectively. Subjects with skin tests positive to penicillin often reacted to skin tests with other beta-lactam antibiotics; 73% (41 of 56) reacted to ampicillin and 51% (38 of 74) reacted to cephalothin. No serious allergic reactions were provoked by testing. None of the 83 skin test--negative patients treated with beta-lactam antibiotics immediately after testing experienced acute allergic reactions. Two patients developed mild urticaria beginning 3 and 5 days into therapy. One skin test--negative patient experienced urticaria 3 hr after receiving oral penicillin 6 mo after skin testing. This patient's skin-test status immediately before therapy was unknown. These results support the position that testing with PPL, PA, and Pen G is a rapid, safe, and effective method for identifying patients at risk, or not at risk, for allergic reactions to penicillin.

Cutaneous necrosis associated with intravenous nafcillin therapy

Four children had cutaneous necrosis associated with the administration of intravenous (IV) nafcillin sodium therapy. One patient required skin grafting. Hospitalization was prolonged with this patient and with one other in an effort to ensure healing. Adult rats, inoculated subcutaneously with nafcillin that was appropriately diluted according to manufacturer's recommendations, exhibited similar lesions. Oxacillin sodium, methicillin sodium, and cephalothin sodium, similarly diluted, did not necrose skin. Nafcillin should be added to the list of agents that produce similar toxic conditions. Frequent observation of the IV infusion site to detect extravasation may obviate this hazard.

Prophylactic antibiotics in hip fractures. A double-blind, prospective study

Three hundred and seven patients, each of whom had a fracture of the proximal part of the femur, were studied in a randomized, double-blind fashion to determine whether perioperative administration of cephalothin would prevent postoperative infection. Major postoperative wound infections were significantly reduced in the cephalothin-treated group (4.7 per cent versus 0.7 per cent; p less than 0.05). There also was a reduction in the incidence of postoperative urinary-tract infections and a reduction in mean peak body temperatures. The duration of hospitalization was not affected and no hospital stay was prolonged by complications of antibiotic administration. However, in the cephalothin-treated group, a strong trend toward colonization by cephalothin-resistant organisms was noted.

Prospective comparative evaluation of gentamicin or gentamicin plus cephalothin in the production of nephrotoxicity in man

Recent studies in animal models have demonstrated that in contrast with humans, cephalothin (CTIN) does not increase gentamicin (GENT) nephrotoxicity, but rather protects against it, particularly when CTIN is given simultaneously with GENT. To investigate this phenomenon in humans a study was designed in which 67 patients suffering from mild infections were investigated. Thirty-three of them served as the control group receiving GENT alone at a dose of 1.5 mg/kg/8 hourly, while the remaining 34 received CTIN at a dose of 2 g or 3 g 8 hourly by i.v. bolus, either simultaneously with GENT or separated by a 4-h interval. Findings showed that: (a) cylindruria developed in 66.6% and 82.3% and 82.3% in the GENT and GENT + CTIN groups respectively, (b) urinary beta-glycuronidase activity increased in 57.5% and 75% (c) serum creatinine exceeded by 0.3 mg the initial values in 21.2% and 27.6% and (d) the blood urea was above 50 mg% in 18.1% and 17.6% of the patients. These results indicate that: (a) regardless of the route and order of administration simultaneous treatment did not protect against nephrotoxicity in humans; (b) the combination of GENTA plus CTIN has no synergistic effect on the production of elevated serum creatinine and rising blood urea; (c) urinary beta-glycuronidase is not a significant predictor of eventual nephrotoxicity; (d) the following risk factors influenced the appearance of nephrotoxicity in both groups: (1) elevated GENT trough levels greater than or equal to 2 mg/l; (2) a course of treatment longer than 10 days.

Relationship between aminoglycoside-induced nephrotoxicity and auditory toxicity

We have reviewed our data from 391 patients entered into three prospective, double-blind studies of aminoglycosides and evaluated 127 cases to determine whether aminoglycoside-induced auditory toxicity and nephrotoxicity are independent events. The cases selected for evaluation included all patients treated for greater than 3 days (mean, 7.7 days) who had serial creatinine determinations and were able to cooperate with serial bedside audiograms (250 to 8,000 Hz). Patients received either gentamicin, tobramycin, or amikacin. Drug dosage was altered to keep serum levels 1 h after administration between 5 and 10 mug/ml (gentamicin or tobramycin) or 20 and 40 mug/ml (amikacin). The investigators evaluating auditory toxicity and nephrotoxicity were blind to the aminoglycoside being administered. The incidence of auditory toxicity in the nephrotoxic group (18.2%) was not significantly different from that in the nonnephrotoxic group (15.2%) (P = 0.75; Fisher exact test). There was no statistical difference between the nephrotoxic and auditory toxic groups in patient age, total dose of aminoglycoside, initial creatinine level, duration of therapy, or concurrent use of furosemide or cephalothin. We conclude that aminoglycoside-induced auditory toxicity and nephrotoxicity are independent events when the drug is administered for approximately 7 days and when aminoglycoside levels are maintained within a predefined range.

Comparative study of prophylactic antibiotics in cardiac surgery. Clindamycin versus cephalothin

A randomized, prospective study of the relative effectiveness of clindamycin versus cephalothin was performed in 263 adult patients having cardiac surgery from September, 1977, to August, 1978. There were no statistically significant differences in frequency of postoperative infections in these two antibiotic groups. Wound infection developed in 6.5 percent of the cephalothin group and 3.2 percent of the clindamycin group. Urinary tract infection developed in 5.6 percent of the clindamycin group and 2.1 percent of the cephalothin group. Four bacteremic episodes occurred in the clindamycin-treated patients, and one episode of bacteremia occurred in a cephalothin-treated patient. No cases of endocarditis occurred during the study. Clindamycin deserved consideration as an alternative prophylactic agent to cephalothin for cardiac surgery.

Eosinophilic occlusive pulmonic panarteritis associated with long-term antibiotic therapy

The administration of antibiotics through central catheters for short periods of time frequently is encountered clinically. This report is an in vivo experimental study of long-term bolus administration of antibiotics through a central catheter inserted in the external jugular vein. Approximately 30 calves, which weighed between 180 and 225 kg, had silicone-rubber catheters inserted for protracted periods of time. Various concentrations of either penicillin, cephalothin, or streptomycin were given intravenously in bolus doses. Minimal doses given for long periods of time or large doses given over short periods of time did not produce any pulmonary vascular lesions. Large doses of antibiotics administered for long experimental periods routinely produced a pulmonary vascular lesion in the medium-size and small-size pulmonary arterioles. The vasculitis consists of a diffuse eosinophilic infiltrate located perivascularly and throughout the intima and media. Associated with the vasculitis was a diffuse hyperplasia of the intima and media which frequently stenosed the vascular lumen. These studies suggest an association between large bolus dosages of antibiotics given over a prlonged period via a central catheter and a constrictive pulmonary arteriolar eosinophilic panvasculitis.

Peripheral nerve injection injury: an experimental study

In an attempt to answer questions regarding nerve injection injuries, we injected 11 agents in current use and commonly administered by intramuscular injection into the sciatic nerves of adult Wistar rats. Equal volumes of normal saline were used as control. We harvested the sciatic nerves at various times after injection and examined them by both light and electron microscopy. We performed myelinated nerve fiber counts and constructed histograms. Any impairment of motor function was also noted. We gave injections to 79 animals a total of 158 times; 116 injections were directly into the nerve fascicle (intrafascicular) and 42 were into the epineural tissue (extrafascicular). The results revealed considerable variation in the degree of nerve fiber injury according to the agent injected. Minimal damage resulted from the injection of iron-dextran, meperidine, and cephalothin, and maximal nerve injury followed the injection of penicillin, diazepam, and chlorpromazine. The site of injection was crucial. Intrafascicular injection was invariably associated with severe nerve injury, but, with few exceptions, extrafascicular injection resulted in minimal damage. The quantity of drug injected was also important in determining the degree of injury. Large, heavily myelinated fibers were more susceptible to injection injury than smaller, thinly myelinated nerve fibers. The effect of the injected drug seemed to be related to injury of the nerve fiber unit--both the axon and the Schwann cell with its myelin sheath. Regeneration in damaged nerves was a constant finding; even the most severely injured nerves, with total axonal degeneration, underwent subsequent regeneration.

Tetracycline-induced aplastic anemia

A 54-year-old man developed mild renal insufficiency after treatment with gentamicin and cephalothin. He then received tetracycline for eight days, 500 mg orally four times daily, for a total dose of 15 gm. Twelve days after discontinuation of the drug, a severe but reversible aplastic anemia developed. We propose that bone-marrow-toxic concentrations of tetracycline resulted from the preexisting renal insufficiency. Because of the temporal relationship between tetracycline administration and aplastic anemia, and the lack of any other explanation, we conclude that this case illustrates a rare but potentially fatal complication of this drug.

Safety of cefoxitin: an approach to the analysis of laboratory data

The safety of cefoxitin, in terms of values obtained in laboratory tests during and after therapy, was estimated by three methods for analysis of data derived from controlled clinical comparisons of cephalothin and cefoxitin. Both antibiotics were found to be safe with respect to hematologic, renal, and hepatic function and did not differ significantly from each other. Laboratory data confirmed by tests performed serially and by paired related tests were analyzed by a novel method of comparison.

Renal tubular necrosis following cephalothin

Renal tubular necrosis was observed following intramuscular injections of cephalothin into rats. Lesions were consistently produced with 5.0g/kg and were maximal in severity at the 2nd and 3rd days following injection. Renal tubular necrosis following cephalothin was similar in morphology to that produced by nephrotoxic doses (2.0 g/kg) of cephaloridine. The nephrotoxic potential of cephalothin has been demonstrated in the rat model and caution is urged in using large doses of cephalothin.