Prophylactic antibiotics in children at risk for urinary tract infection.

The outcome of using prophylactic antibiotics in children considered at risk for a urinary tract infection (UTI) was documented in 66 children during the period of suppressive antibiotics and for a follow-up period of 3.7+/-2.2 years (range 0.92-9.83 years). A breakthrough UTI occurred in 13 girls but none of the boys during the initial course of prophylactic antibiotics. During the follow-up period, 33 girls and 5 boys had no recurrence of infection, while 25 girls and 3 boys had UTIs. Statistical analysis of the data using chi-square and risk estimate relating factors for infection to the occurrence of a UTI showed that during the period of initial prophylactic antibiotic there was significant risk of infection among children with voiding dysfunction and abnormal kidneys and during the follow-up there was increased risk of infection among those with voiding dysfunction and vesicoureteric reflux (VUR) of grade 3 or greater severity. Lesser grades of VUR and constipation did not significantly increase the risk of UTI. These observations should be useful in developing a study to define the risks and benefits of prophylactic antibiotic in "at-risk" children

Comparison of treatment of mastitis by oxytocin or antibiotics following detection according to changes in milk electrical conductivity prior to visible signs.

Mastitis was induced in dairy cows by infusion of 500 cfu of Streptococcus uberis into the mammary gland. Most infections developed to clinical disease, and the majority were predicted by changes in the electrical conductivity of the foremilk. The benefits of clinical prognosis and bacteriological cure were determined for cases that were treated when predicted to develop into clinical mastitis and compared with cases that were allowed to develop until milk clotted or until pyrexia before intramammary antibiotic treatment was used. Treatment prior to clinical mastitis included use of intramammary antibiotic or intramuscular oxytocin to allow stripping of residual milk to remove bacteria. All infections in which treatment was delayed resulted in clinical mastitis that was cured clinically and bacteriologically by sustained treatment using a broad-spectrum intramammary antibiotic preparation once daily but requiring a mean treatment time of 10 d. It was possible to prevent clinical mastitis from developing and to eliminate all infections in cows that were treated early when the developing disease was predicted by changes in the electrical conductivity of quarter foremilk and was treated aggressively by administering an intramammary antibiotic at each milking for 3 d. Treatment of 20 IU of oxytocin at six successive milkings of cows that were predicted to develop disease eliminated 25% of the infections, but 75% of the cows developed clinical mastitis. Those cases were resolved by sustained daily treatment using the same intramammary antibiotic. Elimination (100% clinical and bacteriological cure) of all infections caused by Strep. uberis was possible with early and aggressive or sustained use of the intramammary antibiotic. The early intervention using an intramammary antibiotic, when infection was first indicated by changes in the electrical conductivity of milk, was the most efficient method to achieve cure and led to quicker recovery of milk quality to a saleable standard

Development of surgical antibioprophylaxis kits: evaluation of the impact on prescribing habits

In our hospital, surgical antibioprophylaxis (ATBP) was too often administered too late, thus raising the infectious risk. Antibiotic stocks of the anaesthesia department were also systematically used, instead of nominal prescriptions of these drugs. The pharmacy could neither charge antibiotics to each surgical department nor quantify and differentiate ATBP from curative antibiotic therapy. The pharmacy and anaesthesia departments therefore set out to standardize surgical ATBP, in order to adapt this treatment to each surgical indication, and particularly in the case of allergy to beta-lactamase antibiotics (second line treatment kits). Consequently, prescription forms were developed and supplied to each surgery department, as well as ATBP kits. The kits were prepared and distributed by the pharmacy, and comprised boxes containing antibiotics in sufficient quantities to respect the protocols approved by the French Society of Anaesthesia and Resuscitation (SFAR). A protocol describing prescriptions, dispensation and administration has been presented to physicians and nurses. Fifteen surgical departments were included in our study and 30 different kits were prepared. From 1998 to 2001, 5586 surgical operations required administration of a kit (second line treatment kits in 5% of cases): 1848 (33%) in visceral surgery; 764 (13.8%) in urology; 802 (14%) in orthopaedics; 13 (0.2%) in vascular and thoracic surgery; 1236 (22%) in ear-nose-throat (ENT), periodontics and ophtalmology, and 923 (17%) in gynaecology and obstetrics. 93% of filled prescriptions forms were spontaneously returned to the pharmacy, the others were obtained during the renewal of kit stocks. The cost (over 4 years) of ATBP was quantified: 157,871 F for the 15 departments included, 26,123 F in visceral surgery, 13,520 F in urology, 73,741 F in orthopaedics, 569 F in vascular surgery, 39,720 F in ENT/ophthalmology/periodontics and 4,198 F in gynaecology and obstetrics. According to the Altemeier classification, 2226 class I, 3151 class II, and 209 class III surgical operations were performed. Since the kits have been brought into use, the committee for the protection against nosocomial infections (CLIN) has observed a reduction in the incidence of post-operative infections, according to the Altemeier classification: from 1.6% to 0.5% in class I, from 6.5% to 4.3% in class II, and from 11% to 8.5% in class III. The difference was statistically significant only for classes I (p < 0.01) and II (p < 0.001), and unchanged for class III (p = 0.3). No analysis was carried out for class IV (curative treatments). Both nurses and physicians have greatly appreciated the implementation of this organization. The advantage in terms of post-operative infections, administration exhaustiveness and stock management is obvious. The prescribed kits were systematically appropriate for the surgical interventions. In orthopaedics, cefamandole was used over 24 h (188 kits) in ligament plasty and osteotomy, or for 48 h (499 kits) in prosthetic surgery; 24 amoxicillin/clavulanic acid (first line) and 9 clindamycin/gentamicin (second line) single dose kits have been prescribed in traumatic indications. In ophthalmology, kits were only prescribed in endophtalmitis (24 ofloxacin/fosfomycin single amount kits), implant replacement or cornea graft (1076 ofloxacin 24 h kits) and cataract surgery in diabetic patients (12 ofloxacin single amount kits). In ENT and periodontics, 124 surgical operations required cefazolin single dose kits. In vascular surgery, 5 pefloxacin/gentamicin 48 h kits and 1 amoxicillin/clavulanic acid 48 h kit were used in contaminated limb amputation, 1 cefamandole 48 h kit in class I surgery and 1 vancomycin 24 h kit (betalactamase antibiotic allergy); in thoracic surgery, 1 cefamandole 24 h kit was used for a thoracic wound. In visceral surgery, 9 different kits have been used, depending on the opening (class II) or not (class I) of the digestive tract. 797 cefazolin (first line) and 68 clindamycin/gentamicin (second line) single dose kits were used in class I surgery, and 689 amoxicillin/clavulanic acid single dose (SD) kits in class II surgery. Specific protocols consisted of 18 ceftriaxone/metronidazole and 48 metronidazole/gentamicin SD kits in oesophagus surgery, 11 ceftriaxone and 17 gentamicin SD kits in biliary endoscopy, 137 metronidazole SD kits in proctology and 34 amoxicillin/gentamicin 6 h kits for prevention of endocarditis. In urology, 133 cefotaxime and 20 pefloxacin/gentamicin SD kits were precribed in renal lithiasis, 102 amoxicillin/clavulanic acid SD kits in cystectomy, 27 amoxicillin/gentamicin 6 h kits in endocarditis prevention and 58 cefamandole SD kits in all other indications. In gynaecology and obstetrics, 534 cefazoline and 19 clindamycin/gentamicin (second line) SD kits were used, and 370 doxycyclin SD kits were prescribed in pregnancy termination. Some departments (orthopaedics and visceral surgery) adapted the protocols to their needs, specifically with regard to treatment duration. However, these situations were quickly corrected. A constant follow-up and update of this system, associated with routine audits, should allow the maintenance and possibly the improvement of these results, hence shortening treatment duration

Antibiotic prescribing by general dental practitioners in the Greater Glasgow Health Board, Scotland.

OBJECTIVE: To investigate antibiotic prescribing patterns by general dental practitioners (GDPs) in the Greater Glasgow Health Board Area, Scotland. STUDY DESIGN: A 10% sample of prescriptions were selected at random from 35,545 prescriptions written by GDPs over a 6-month period. MAIN OUTCOME MEASURES: Absolute and relative frequencies were used to describe the different classes of antibiotics used and the variations in prescribing practice. RESULTS: GDPs prescribed a wide range of antibiotics. Seventeen different antibiotics were prescribed with amoxycillin, metronidazole and penicillin V accounting for almost 90% of the prescriptions. In general the antibiotics were prescribed at the British National Formulary (BNF) recommended doses. There were, however, wide variations in the frequencies and durations of the prescriptions for all antibiotics. CONCLUSIONS: The present study provides evidence of sub-optimal prescribing of antibiotics by dentists in Scotland, with considerable variation from the recommended frequencies and doses

The effect of sampling method on the elution of tobramycin from calcium sulfate.

Release rate is a critical property of all drug delivery vehicles, including antibiotic-laden bioerodibles. In vitro elution studies, used to evaluate release rates, use different sampling methods, including changing the entire amount of buffer and partial exchanges each day. Two groups of 10% calcium sulfate-tobramycin pellets were eluted in 20 mL of buffer for 30 days. Group I had 5 mL of buffer withdrawn and replaced daily whereas Group II had the entire 20 mL of buffer changed daily. The results show that the complete exchange method caused a significantly faster release of antibiotic than the partial exchange method. In the complete exchange group, greater than 50% of the tobramycin was released by 24 hours, whereas in the partial exchange group, 50% of the antibiotic was not released until Day 6. The two methods of sampling used to evaluate this bioerodible material provide data that allow the user to anticipate how the material will function in relatively inert and volatile environments. The method used to sample the elution of antibiotics from bioerodible materials affects the amount of antibiotic eluted. It therefore is important to know the method of sampling when making a decision to use a bioerodible material to deliver antibiotics locally

Natural antibiotic susceptibility of Escherichia coli, Shigella, E. vulneris, and E. hermannii strains.

The natural antibiotic susceptibility of 139 Escherichia coli strains (including 18 enterohemorrhagic E. coli), 73 Shigella strains (S. sonnei (n = 37), S. flexneri (n = 29), S. boydii (n = 6), S. dysenteriae (n = 1)), 23 E. vulneris, and 20 E. hermannii strains toward 71 antibiotics was examined. MICs were determined using a microdilution procedure. All examined taxa were naturally sensitive/intermediate toward tetracyclines, aminoglycosides, some penicillins (amoxycillin/clavulanate, ampicillin/sulbactam, piperacillin [with and without tazobactam], mezlocillin, azlocillin), cephalosporins, carbapenems, monobactams, quinolones, trimethoprim, cotrimoxazole, and chloramphenicol and were naturally resistant/intermediate toward benzylpenicillin, oxacillin, macrolides, lincosamides, glycopeptides, rifampicin, and fusidic acid. No differences in natural antibiotic susceptibility were seen between enterohemorrhagic and other E. coli strains. Likewise, with one exception, no significant differences in natural antibiotic susceptibility were seen either among the Shigella subgroups or between Shigella and E. coli. The natural population of S. flexneri was slightly more susceptible to chloramphenicol than the natural populations of other taxa within the Shigella-E. coli complex. E. vulneris and E. hermannii showed susceptibility patterns to many antibiotics similar to Shigella and E. coli, but there were other antibiotics toward which there were significant differences in natural susceptibility. E. vulneris and E. hermannii were less susceptible to nitrofurantoin and slightly more susceptible to several aminoglycosides than E. coli and Shigella. E. hermannii was the only species that was naturally resistant/intermediate to ticarcillin and amoxycillin (DIN standard). The addition of clavulanic acid to the latter resulted in a decrease of seven twofold dilution steps (E. vulneris: four twofold dilution steps, E. coli/Shigella: two twofold dilution steps) of the MICs of the natural population. With the exception of cefoperazone and cefepime, E. hermannii was more susceptible to cephalosporins than strains of the other species. E. vulneris was the species most susceptible to ticarcillin and the only species that was highly resistant to fosfomycin (MIC > 256 micrograms/mL). The antibiotic susceptibility to fosfomycin was also unique for E. hermannii (MIC 32-128 micrograms/mL), whereas the natural populations of E. coli and Shigella showed lower MIC values. The data of this study represent an assessment of the natural susceptibility of strains of Escherichia spp. and Shigella subgroups to a wide range of antibiotics. These databases can be used for the validation of antibiotic susceptibility test results of Escherichia spp. and shigellae. The conformity of the natural antibiotic susceptibility test results not only among the Shigella subgroups but also between Shigella and E. coli support the status of Shigella as a subgroup of the species E. coli

Understanding variation in quality improvement: the treatment of sore throats in primary care.

BACKGROUND: In 1988, two practices attempted to improve the prescribing of antibiotics for sore throat. The initiative produced only modest improvements in prescribing practice, a finding the authors found difficult to explain. This paper reanalyses the data from an audit of antibiotic prescribing for sore throat in general practice. OBJECTIVE: Our aim was to demonstrate the use of Shewhart control charts and to obtain fresh insight into the variations in clinical practice revealed in clinical audit data. METHODS: We use Shewhart control charts to explore variation in antibiotic prescribing between GPs and to suggest the action most likely to result in improvement. RESULTS: Using control charts, it is possible to distinguish two categories of GPs: low prescribers of antibiotics and high prescribers of antibiotics. Low prescribers of antibiotics show common cause variation, indicating that their prescribing is a stable process. Among low prescribers, improvement can best be achieved by changing the common underlying process. One high prescriber of antibiotics is affected by special cause variation. Among high prescribers, improvement can best be achieved by investigating the special causes affecting this GP and learning lessons from the findings. CONCLUSION: The original improvement effort took the same action on all GPs in both practices. Our analysis suggests that such an approach was unlikely to be successful and that different actions were needed for high and low prescribers. The control charts provide fresh insights on the original data and guide improvement efforts

Sequential intravenous/oral antibiotic vs. continuous intravenous antibiotic in the treatment of pyogenic liver abscess.

AIM: Pyogenic liver abscesses result in substantial morbidity and mortality. Antimicrobial regimens using sequential intravenous/oral therapy may reduce the length of hospital stay. In this retrospective analysis, the efficacy of continuous intravenous antibiotic therapy (group I) vs. sequential intravenous/oral antibiotic therapy (group II) was studied in patients with pyogenic liver abscess. METHODS: One hundred and twelve consecutive patients (55 in group I and 57 in group II) with pyogenic liver abscess were analysed. Clinical response, length of hospital stay and relapse rates were examined. RESULTS: Group II had a significantly shorter duration of intravenous antibiotic treatment (3.2 weeks vs. 5.9 weeks, P < 0.01) and a shorter length of hospital stay (28 days vs. 42 days, P < 0.01) when compared to group I. Oral antibiotics were prescribed for a median duration of 2.9 weeks in group II after discharge. No relapse occurred within 6 weeks after the completion of treatment in both groups. The cost of therapy was significantly lower in group II than in group I by 33%. CONCLUSIONS: A sequential intravenous/oral antibiotic regime is a safe and effective treatment for pyogenic liver abscess. This reduces the cost of therapy and the length of hospital stay

Antibiotic resistance analysis of fecal coliforms to determine fecal pollution sources in a mixed-use watershed.

Antibiotic resistance analysis was performed on fecal coliform (FC) bacteria from a mixed-use watershed to determine the source, human or nonhuman, of fecal coliform contamination. The study consisted of discriminant analysis of antibiotic resistance patterns generated by exposure to four concentrations of six antibiotics (ampicillin, gentamicin sulfate, kanamycin, spectinomycin dihydrochloride, streptomycin sulfate, and tetracycline hydrochloride). A reference database was constructed from 1125 fecal coliform isolates from the following sources: humans, domestic animals (cats and dogs), agricultural animals (chickens, cattle, and horses), and wild animals. Based on similar antibiotic resistance patterns, cat and dog isolates were grouped as domestic animals and horse and cattle isolates were grouped as livestock. The resulting average rate of correct classification (ARCC) for human and nonhuman isolates was 94%. A total of 800 FC isolates taken from the watershed during either a dry event or a wet event were classified according to source. Human sources contribute a majority (> 50%) of the baseflow FC isolates found in the watershed in urbanized areas. Chicken and livestock sources are responsible for the majority of the baseflow FC isolates found in the rural reaches of the watershed. Stormwater introduces FC isolates from domestic (approximately 16%) and wild (approximately 21%) sources throughout the watershed and varying amounts (up to 60%) from chicken and livestock sources. These results suggest that antibiotic resistance patterns of FC may be used to determine sources of fecal contamination and aid in the direction of water quality improvement

Antibiotic resistance pattern of foodborne Salmonella isolates in Addis Ababa (Ethiopia).

A total of 39 Salmonella cultures isolated from raw minced beef and chicken (gizzard, liver, and heart) samples in Addis Ababa were examined for susceptibility to a group of 10 selected antimicrobials. 34 isolates (87.2%) were resistant to one or more antibiotics. The antibiotics to which isolated Salmonella strains were most often fully resistant included nitrofurantoin (48.7%), furazolidone (48.7%) and streptomycin (46.2%). Only 4 antimicrobials (gentamycin, kanamycin, rifampicin and sulphamethoxazole-trimethoprim) were effective against all Salmonella isolates with the exception of 2 which were intermediate in resistance to kanamycin (1) and sulphamethoxazole-trimethoprim (1). 77.8% of the S. Enteritidis strains showed multiple resistance to up to four antibiotics followed by S. Typhimurium (60.0%) and S. Dublin (33.3%). The high level of antibiotic resistance of foodborne Salmonella isolates in the study area is an indication of indiscriminate and continuous use of subtherapeutic doses of antibiotics in animals