Corticosteroids and peritonsillar abscess formation in infectious mononucleosis

Peritonsillar abscess formation is an uncommon complication of infectious mononucleosis (IM). Early case reports implicated corticosteroids in the development of such abscesses, however, subsequent studies suggested that these drugs do not promote the formation of abscesses at several sites outside the central nervous system. It has recently been demonstrated that zwitterionic polysaccharides, in bacterial capsules, form complexes with CD4+ T lymphocytes leading to abscess formation. A patient is presented who developed peritonsillar abscess a few days after initiation of corticosteroid therapy for IM; the medical literature was reviewed in respect of this subject. It appears that the occurrence of these abscesses in IM is not strongly linked to corticosteroid treatment. The authors, therefore, recommend that steroids should not be withheld from patients with severe IM on the basis that they may precipitate the development of peritonsillar abscess.

[Antibiotic prophylaxis in abdominal surgery]

The results of prospective randomized research of the comparison of different modes antibiotic prophylaxis by the patients with abdominal pathology are presented. In group of patients which for preventive maintenance of a surgical infection before the operation introducted intravenous 1.5 g Zinacef (cefuroxime), frequency of complications was the least. The results allow to approved, that before operation short antibiotic prophylaxis by the Zinacef--the modern standard of preventive maintenance of postoperative complications in abdominal surgery.

Intragastric floating drug delivery system of cefuroxime axetil: in vitro evaluation

This investigation describes the development of an intragastric drug-delivery system for cefuroxime axetil. The 3(2) full factorial design was employed to evaluate contribution of hydroxypropyl methyl cellulose (HPMC) K4M/HPMC K100 LV ratio (polymer blend) and sodium lauryl sulfate (SLS) on drug release from HPMC matrices. Tablets were prepared using direct compression technique. Formulations were evaluated for in vitro buoyancy and drug release study using United States Pharmacopeia (USP) 24 paddle-type dissolution apparatus using 0.1N HCl as a dissolution medium. Multiple regression analysis was performed for factorial design batches to evaluate the response. All formulations had floating lag times below 2 minutes and constantly floated on dissolution medium for more than 8 hours. It was found that polymer blend and SLS significantly affect the time required for 50% of drug release, percentage drug release at 12 hours, release rate constant, and diffusion exponent (P < .05). Also linear relationships were obtained between the amount of HPMC K100 LV and diffusion exponent as well as release rate constant. Kinetic treatment to dissolution profiles revealed drug release ranges from anomalous transport to case 1 transport, which was mainly dependent on both the independent variables.

Sigmoid sinus thrombosis secondary to Lemierre's syndrome

Lemierre's syndrome, a rare and almost forgotten cause of internal jugular vein thrombosis, is usually caused by an anaerobic head and neck infection. Left untreated, it can result in the release of septic emboli. We describe the case of a 42-year-old man who presented with fever and a tender, swollen neck mass. Computed tomography revealed an edematous parapharyngeal area and a compressed internal jugular vein. Despite antibiotic treatment, the patient's condition worsened, and a parapharyngeal fluid collection was drained 4 days later. Six weeks later, the patient returned to the outpatient department complaining of headaches, and he was found to have a tender, firm neck. He was readmitted, and magnetic resonance venography revealed a right internal jugular vein thrombosis that extended intracranially to the sigmoid sinus. He was anticoagulated for 6 months, and he remained well during outpatient follow-up. We examine the controversial roles that anticoagulation and thrombolysis play in Lemierre's syndrome and sigmoid sinus thrombosis, and we review the diagnostic options.

Biomechanical properties of bone cement with addition of cefuroxime antibiotic

Antibiotic-loaded bone cement has been used as prophylaxis against infection in total joint replacement surgery. Its effect on the mechanical strength of cement is a major concern as high dose of antibiotic was associated with a significant reduction in mechanical strength of bone cement. However, the cut-off antibiotic that weakens the mechanical strength of cement remains to be determined. This study was undertaken to observe the changes in the mechanical properties of bone cement with gradual increments of Cefuroxime antibiotic. Cefuroxime at different doses: 0, 1.5, 3.0 and 4.5gm were added to a packet of 40gm bone cement (Simplex P) and study samples were prepared by using third generation cementing technique. Mechanical impact, flexural and tensile strength were tested on each sample. Significant impact and tensile strength reduction were observed after addition of 4.5 gm of Cefuroxime. However, flexural strength was significantly reduced at a lower dose of 3.0 gm. The maximum dose of Cefuroxime to be safely added to 40mg Surgical Simplex P is 1.5gm when third generation cementing technique is used. Further study is needed to determine whether it is an effective dose as regards to microbiological parameters.

Survey of Surgical Antimicrobial Prophylaxis in Czech Republic

OBJECTIVE

To characterize the pattern of surgical antimicrobial prophylaxis in the Czech Republic.

METHOD

Cross sectional survey with a self-administered postal questionnaire. Data collected included use of antimicrobial prophylaxis, surgical site infection rate, pathogens causing surgical site infection and demographics of the institution. Descriptive and multivariate analyses were performed.

SETTING

Hospital, surgical departments in the Czech Republic.

MAIN OUTCOME MEASURE

Prevalence of surgical antimicrobial use, factors associated with use, the profile of antimicrobial use, timing, route, dosage regimen and duration of initiated prophylaxis.

RESULT

The response rate was 55.5%. Surgical antimicrobial prophylaxis was used in 97.5% of departments, and 85% departments justified prophylaxis based on guideline. The timing of the first dosage was within 2 h of operation in 95.0% of departments and 36.7% of all departments administered more than 2 doses of SAP in operations that lasted less than 4 h of all respondents. The three most common prophylactic antimicrobial agent used were cefazolin, co-amoxiclav and cefuroxime amongst the 26 single antimicrobial agents and 16 antimicrobial combinations. Penicillins and enzyme inhibitor was the most frequent class used. Surgical antimicrobial prophylaxis was administered intravenously in 82.5% of all cases. The regimen used varied markedly in dose and duration prescribed. The surgical site infection rate occurred. 1-5% in 71.7% of departments. Most departments identified the causative pathogen at all times. Staphylococcus aureus was the most frequent pathogen of surgical site infection and was detected in 90.8% of all departments. There was significant association between Pseudomonas aeruginosa with cefuroxime use and Bacteriodes fragilis with co amoxiclav use.

CONCLUSION

This survey has identified several areas for improvement in surgical antimicrobial prophylaxis in the Czech Republic. Particular areas of concern include route of administration, duration and timing of first dosage of SAP, and the inappropriate use of broad-spectrum antimicrobials.

Risk factors for endophthalmitis following cataract surgery: a retrospective case–control study

To gain further knowledge of possible risk factors for the development of postoperative endophthalmitis (POE) following cataract surgery, a single-centre retrospective case-control study was conducted for 1994-2000. In total, 46292 cataract procedures were performed during the study period. Sixty cases of POE were noted and 240 control cases were selected at random. Parameters pertaining to patient history and to peri-operative technique and complications were analysed. The relative risk of POE was calculated using univariate analyses and multi-variate forward stepwise logistic regression. In the logistic regression analyses, three statistically significant parameters were found. The use of intracameral prophylaxis with cefuroxime as opposed to topical treatment alone, and performing phaco-emulsification instead of extra- or intracapsular cataract extraction appeared to be protective against POE. Silicone intra-ocular lenses carried a higher risk than heparin surface modified poly (methyl methacrylate) implants. In summary, the important finding of this study was the protective effect against POE of intracameral prophylaxis with cefuroxime compared with topical anti-infectives alone.

Optimum duration of prophylactic antibiotics in acute non-perforated appendicitis

BACKGROUND

The effect of extended prophylactic antibiotic therapy on postoperative infective complications such as wound infection and intra-abdominal abscess for non-perforated appendicitis is poorly defined.

METHODS

In a randomized controlled trial of 269 patients aged 15-70 years with non-perforated appendicitis undergoing open appendicectomy; 92 received single dose preoperative (group A), 94 received three-dose (group B) and 83 received 5-day perioperative (group C) regimens of cefuroxime and metronidazole. Postoperative infective complication was the primary endpoint. Secondary outcomes included length of hospital stay and complications related to antibiotic therapy.

RESULTS

The rate of postoperative infective complication was not significantly different among the groups (6.5% group A, 6.4% group B, 3.6% group C). The duration of antibiotic therapy had no significant effect on the length of hospital stay. Complications related to antibiotic treatment were significantly more common for 5-day perioperative antibiotic group (C) compared with single dose preoperative antibiotic group (A) (P = 0.048).

CONCLUSION

Single dose of preoperative antibiotics is adequate for prevention of postoperative infective complications in patients with non-perforated appendicitis undergoing open appendicectomy. Prolonging the use of antibiotics can lead to unnecessary antibiotic related complications.

[Preseptal and orbital cellulitis in childhood: response to intravenous antibiotics]

PURPOSE

To evaluate retrospectively the response of preseptal and orbital cellulitis in children to empiric antibiotic treatment.

METHOD

We included nine patients (five male and four female) admitted to our hospital between October 2002 and October 2003 because of preseptal or orbital cellulitis.

RESULTS

Four patients (44.4%) responded to empiric antibiotic treatment (R); five (55.5%) did not respond (NR) and required a second antibiotic to resolve the infection. The presence of an upper respiratory infection was the most common associated disease in both groups, R and NR. However we also found two cases of acute dacryocystitis in the NR. Four patients (44.4%) were treated with cefotaxime intravenously with the infection resolving in three of these. Five patients (55.6%) were treated with cefuroxime intravenously as first empiric option, however only one patient responded.

CONCLUSIONS

We found a high prevalence of acute dacryocystitis as a potential cause of the cellulitis. Children with preseptal and orbital cellulitis responded better to cefotaxime than to cefuroxime. The presence of acute dacryocystitis was associated with a lack of response to cefuroxime.

[Chronic sinusitis therapy with antibiotics (axetyl cefuroxym, clarithromycin) and steroid (prednisone)]

We started therapy sinusitis of our patients with antibiotics cefuroxime axetil (Zinnat, GSK), clarithromycin (Klacid Uno, Abbott) and orally given steroid-prednisone in one group (A+S) 56 patients. Second group of 60 patients were cured only with antibiotics (A). We compare effects of this therapy. There were 50% totally cured patients in the first group (A+S) and 46.6% cured in the second group. Percentage totally cured patients with (A+S) is 3.4% better that cured only with antibiotics in the same time. It is statistically important. We present benefits for patients who were operated in the next step. Post therapy with the use of antibiotics and steroids there were less bleeding from the mucosal membrane, and there was no edema. It is a good method of therapy if patients have no contraindications.

Bacteriological efficacy of 5-day therapy with telithromycin in acute maxillary sinusitis

Increasing resistance among the key pathogens responsible for community-acquired respiratory tract infections, namely Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis, has the potential to limit the effectiveness of the antibacterial agents available to treat these infections. Moreover, there are regional differences in the susceptibility patterns observed and, as treatment is usually empirical, choosing an effective treatment can be challenging. Telithromycin, the first ketolide to be approved for clinical use, offers an activity profile that covers the key respiratory pathogens including penicillin- and macrolide-resistant S. pneumoniae as well as beta-lactamase-producing H. influenzae and M. catarrhalis. In a pooled analysis of three large controlled clinical trials involving patients with acute maxillary sinusitis, the bacteriological efficacy of 5- or 10-day treatment with telithromycin and 10-day treatment with comparators was evaluated. Telithromycin administered as a once-daily 800 mg dose for 5 days achieved eradication rates of 91.8, 87.5 and 92.9% for S. pneumoniae, H. influenzae and M. catarrhalis, respectively. Bacteriological eradication of 8/10 and 12/14 isolates of S. pneumoniae resistant to penicillin and erythromycin, respectively, was also reported following 5-day treatment with telithromycin. The clinical efficacy of this regimen was equivalent to that of a 10-day regimen of telithromycin or standard 10-day courses of amoxicillin-clavulanic acid or cefuroxime axetil. Telithromycin 800mg given for 5 days was well tolerated, with the majority of adverse events being of mild or moderate intensity. These data suggest that telithromycin provides effective first-line therapy for use in patients with acute maxillary sinusitis in a short and convenient once-daily dosage regimen.

[Neonatale mastitis in a 4-week-old infant]

This is a case report of a four week old newborn, presenting with a red and swollen right breast gland. Clinical examination and ultrasound confirmed the diagnosis of a suppurative mastitis. The abcess was incised and drained and systemic antibiotic therapy started. Staphylococcus aureus was isolated from the culture. The important aspects of aetiology, pathogenesis, diagnosis and therapy of suppurative mastitis in the newborn are discussed in a short literature review.

Effect of the Freezing Conditions and Microwave Thawing Power on the Stability of Cefuroxime in Dextrose 5% Infusion Polyolefin Bags at 4 °C

BACKGROUND

Intravenous cefuroxime sodium solution could be prepared in advance by a centralized hospital pharmacy service to improve safety and time management.

OBJECTIVE

To investigate the effect of freezing and microwave thawing on the solution stability of cefuroxime.

METHODS

Cefuroxime 1.5 g in 100 mL of dextrose 5% in polyolefin bags was frozen individually (group A) or in one package (group B) for 98 days at −20 °C. The solutions were then thawed using microwaves at 270 (light cycle) or 800 watts (hard cycle) and stored at 4 °C. The cefuroxime concentration was measured by HPLC. Visual inspection was performed and pH was measured at that time. Stability of the solution was defined as a concentration remaining superior to 90% of the initial concentration by regression analysis.

RESULTS

No color change or precipitation in the solutions was observed. In group A, stability was at least 23 and 21 days after light and hard cycle thawing, respectively. In group B, stability was at least 21 and 18 days, respectively, with the pH increasing without affecting chromatographic parameters.

CONCLUSIONS

The optimal conditions for advance preparation of a solution containing cefuroxime 1.5% in dextrose 5% may be freezing of individual containers followed by a light cycle of microwave thawing.

[Efficacy of antibiotic prophylaxis using zinacef in postoperative period]

The results of intravenous injection of Zinacef for purulent--septic complications in patients with various acute surgical diseases of the abdominal cavity organs were presented. Main principles and rules of antibioticoprophylaxis and antibioticotherapy conduction in surgery were substantiated.

Cefuroxime-induced coronary artery spasm manifesting as Kounis syndrome

Allergic angina and allergic myocardial infarction (Kounis syndrome) occurring during the course of a drug-induced allergic reaction in the absence of angiographically stenosed coronary arteries, is rare in clinical practice. This paper reports the case of a 70-year-old woman with no significant risk factors for coronary artery disease who developed coronary artery spasm after intravenous injection of cefuroxime. A subsequent coronary angiogram revealed normal coronary arteries (type I variant of the syndrome). The allergic reaction following cefuroxime administration seems to have triggered the development of coronary artery spasm. Susceptible individuals expressing an amplified mast cell degranulation effect may be more vulnerable to coronary artery spasm. The clinical implications of this syndrome are also discussed.

Macular thickness after cataract surgery with intracameral cefuroxime

PURPOSE

To determine whether the use of prophylactic intracameral cefuroxime during phacoemulsification cataract surgery is associated with increased macular thickening in the postoperative period.

SETTING

Hull and East Yorkshire Eye Hospital, Hull, United Kingdom.

METHODS

In this prospective randomized double-masked clinical study, the study group received 1 mg of intracameral cefuroxime and the control group received intracameral balanced salt solution only. Ocular coherence tomography was performed 5 (+/-1) weeks after surgery.

RESULTS

Intracameral cefuroxime did not have a statistically significant effect on postoperative macular thickness compared with nonadministration of intracameral antibacterials. All patients in both groups achieved a postoperative best corrected visual acuity of 6/9 or better.

CONCLUSION

Use of 1 mg of intracameral cefuroxime was not associated with increased macular thickness 4 weeks to 6 weeks postoperatively.

Systemic availability of prophylactic cefuroxime in patients submitted to coronary artery bypass grafting with cardiopulmonary bypass

Cardiopulmonary bypass and hypothermia (HCPB) is a procedure commonly used during heart surgery, representing a risk factor for the patient by promoting extensive haemodilution and profound physiological changes. Cefuroxime is used for the prevention of infection following heart surgery, and several dose schemes have been suggested for prophylaxis with cefuroxime. The objective of the present study was to assess, in a comparative manner, the systemic availability of cefuroxime administered intravascularly as a bolus dose of 1.5 g to 17 patients having heart surgery with or without HCPB. Plasma cefuroxime concentrations were determined by high-pressure liquid chromatography-UV, and the following values, expressed as medians, were obtained for the study group compared with controls: 69.1 vs. 62.7 mg/L (1st h), 35.8 vs. 26.0mg/L (3rd h), 14.6 vs. 8.7 mg/L (6th h, P<0.05), 6.1 vs. 3.0mg/L (9th h, P<0.05) and 2.6 vs. 1.0mg/L (12th h, P<0.05). Despite the differences recorded during the study period as a consequence of HCPB, low antibiotic concentrations were found as early as 6h post dose for both groups investigated. Thus, the low systemic availability of cefuroxime after the administration of a 1.5-g dose may not protect against postoperative infections. The data obtained permit us to recommend a change in the dose scheme in order to maintain adequate plasma levels of cefuroxime.

[Neonatal suppurative parotitis]

This report describes the case of a 10 days old newborn of a diabetic mother with gestosis, who developed erythema and swelling of the right cheek. A diagnosis of acute suppurative parotitis due to S. aureus was made. Following this case report the most important facts of epidemiology, pathogenesis, clinical manifestation, diagnostics, and therapy of suppurative parotitis are discussed.

[Etiology and therapy of the internal jugular vein thrombosis]

BACKGROUND

Thromboses of the upper limp and neck are rare in comparison with those of the lower extremities. Internal jugular vein thrombosis (IJVT) is a serious event with a potentially fatal outcome. Complications include pulmonary embolism, sepsis with septic emboli to different organs and tissues as well as intracranial propagation of the thrombus with cerebral edema. As any thrombosis, IJVT is precipitated by Virchow's triad: endothelial damage, alteration of blood flow and hypercoagulability. The history and examination in patients with an IJVT may be vague and misleading. Patients may present with a painful swelling of the neck but they may also be absolutely asymptomatic. Imaging procedures frequently used to diagnose an IJVT include sonography with color-coded duplex sonography, computed tomography, magnetic resonance imaging as well as magnetic resonance venography. Up to date, there is no standardized treatment regimen for patients with an IJVT.

PATIENTS AND METHODS

This retrospective study includes all ten patients with an IJVT who were seen at our department between January 2000 and January 2004. There were six female and four male patients. The average age was 49.7 years, ranging from 28 to 79 years.

RESULTS

In five cases, the thrombosis was associated with a malignant tumor. In four patients, it was caused by a deep neck space infection and in one case the IJVT was due to cervical, intravenous drug abuse. Two patients were found to be pregnant (one tumor patient and one patient with a deep neck space infection). In all cases, a ten day treatment regimen with intravenous antibiotics and anticoagulant therapy was initiated. Oral or subcutaneous anticoagulation was continued for six weeks to six months. No complications were seen in any patient. In three patients a revascularization of the affected vessel could be demonstrated with color-coded duplex sonography six months after the initial presentation.

CONCLUSIONS

Thrombosis of the IJV is probably underdiagnosed. Since the clinical presentation may be vague or misleading, a high degree of suspicion is required to make the diagnosis. The potential complications such as pulmonary embolism or intracranial propagation of the thrombus may be fatal. Whenever the thrombosis is not caused by an inflammatory process, a malignant tumor should be excluded. We recommend a therapy with intravenous antibiotics as well as a systemic anticoagulation. Ligation or resection of the internal jugular vein is reserved for patients who develop complications despite adequate medical therapy.

Postcoital allergic reaction in a woman

Postcoital allergic reaction to drugs is a rare condition that has not been previously described in the Emergency Medicine literature. We report a case of postcoital allergic reaction in a woman who had a history of allergy to cephalosporins, which were used by her sexual partner.

[Pharmacoeconomic analysis of patients with acute exacerbation of chronic bronchitis treated with telithromycin or cefuroxime-axetil]

INTRODUCTION

A pharmacoeconomic analysis was done to compare the efficiency of two treatments in the acute exacerbation of chronic bronchitis: telithromycin and cefuroxime-axetil.

METHODS

Restrospective analysis, modeled through a decision tree. The effectiveness of the treatments was estimated through a randomized and double-blind clinical trial in which 800 mg/day (5 days) of telithromycin were compared with 1,000 mg/day (10 days) of cefuroxime-axetil in patients with acute exacerbation of chronic bronchitis (140 and 142 patients, respectively). Resources use was estimated from clinical trial and from Spanish data, and the unit costs through a health costs dabatase. The model was validated by a panel of Spanish clinical experts.

RESULTS

Since the clinical trial was designed to demonstrate equivalence, there were no significant differences of effectiveness among both treatments (with a rate of clinical cure of 86.4% and 83.1%, respectively) which means that an analysis of costs minimization was done. In the average case, the average cost of the disease by patient was 174.83 Euros with telithromycin and 194.68 Euros with cefuroxime-axetil (a difference of 19.85 Euros). The results were maintained in the analysis of sensitivity, with favorable differences for telithromycin that ranged between 18.04 Euros and 22.25 Euros.

CONCLUSIONS

With telithromycin up to 22 Euros by patient with acute exacerbation of chronic bronchitis could be saved, in comparison with cefuroxime-axetil.

Medical management of parapneumonic pleural disease

Considerable heterogeneity exists in the management of parapneumonic pleural disease. A randomized controlled trial (RCT) demonstrated the effectiveness of small-catheter drainage with fibrinolysis, but surgical devotees suggest this may only be applicable to "early" cases. We examined evidence-based medical management in "all-comers." We performed a retrospective database analysis of the management of all children with complex pleural effusion admitted to the John Radcliffe Hospital over the 7-year period 1996-2003. One hundred and ten children were admitted. Ten were excluded as they were part of a multicenter RCT and had received intrapleural saline instead of urokinase. Of the remaining 100, 51 were female and 49 male. Median age on admission was 5.8 years (range, 0.3-16.5). Symptoms preadmission averaged 11 days, with December the most common month for presentation. Ninety-six underwent chest ultrasound, confirming an effusion in all, described as loculated/septated (68) or echogenic (11). In 17 cases, no specific comment was made regarding the nature of the fluid seen on ultrasound. Ninety-five had subsequent chest tube drainage and then received intrapleural fibrinolysis with urokinase. An etiological organism was identified in 21 cases (21%) (Streptococcus pneumoniae in 10, group A Streptococcus in 5, Staphylococcus aureus in 4, Haemophilus influenzae in 1, and coliform in 1). In a further 9 cases (9%), Gram-positive organisms were seen on pleural fluid microscopy, but did not grow on culture. Two (2%) required surgery due to the persistence of symptoms and an inadequate response to medical management. Median duration of admission was 7 days (range, 2-21 days); median duration of stay from intervention was 5 days (range, 2-19 days). At median follow-up of 8 weeks (range, 3-20 weeks), all children were symptom-free, with minimal pleural thickening on chest X-ray. In conclusion, antibiotic therapy with chest drain insertion and intrapleural urokinase is effective in treating complex parapneumonic effusion and is associated with a good long-term outcome.

[Levofloxacin (oftaquix) a fluoroquinolone of a new generation in prevention of the postoperative endophthalmitis following uncomplicated cataract surgery--the study of the European Society of Cataract and Refractive Surgeons (ESCRS)]

Randomised multi-centre european clinical trial of antibiotic prophylaxis for endophthalmitis following cataract surgery - study has just begun in Poland. Poland is joining one of the largest prospective european clinical study of antibiotic prophylaxis and the largest in ophthalmology - the ESCRS endophthalmitis prophylaxis clinical trial. Up to 35 000 cataract patients are going to be recruited for this randomized, controlled, multi-centre study in 16 centres from 10 european countries. The goal is to reduce the incidence of endophthalmitis after cataract phacoemusification in Europe to less than 0.05% (less than 1 per 2 000 surgeries). The patients will be divided into four groups; different regimes of two antibiotics: cefuroxime injected intra-camerally and levofloxacine eye drops topically will be compared.