Pharmacokinetics of ticarcillin-clavulanate in premature infants.

Ticarcillin-clavulanate covers a broad spectrum of pathogens that are common in premature infants. In infants <30 weeks gestational age, pharmacokinetic data to guide ticarcillin-clavulanate dosing are lacking. We enrolled 15 premature infants <30 weeks gestational age, determined pharmacokinetic parameters, and performed dosing simulations to determine optimal dosing for ticarcillin-clavulanate. The infants had a median (range) postnatal age (PNA) of 18 days (6-44 days) and gestational age of 25 weeks (23-28 weeks). Clearance was lower in infants with a PNA <14 days (0.050 L/kg/h [range 0.043-0.075]) compared with a PNA ≥14-45 days (0.078 L/kg/h [0.047-0.100]), consistent with maturation of renal function. Dosing simulations determined that ticarcillin 75 mg/kg q12h (PNA <14 days) or q8h (PNA ≥ 14-45 days) achieved the target exposure for organisms with a minimum inhibitory concentration ≤16 µ/mL in >90% of simulated infants. For highly resistant organisms (minimum inhibitory concentration 32 µg/mL), increased dosing frequency or extended infusion are necessary.

Oral Ambulatory Treatment of Acute Osteomyelitis in Children: A Case-Control Study.

The treatment of acute hematogenous osteomyelitis has evolved in recent years to a shorter parenteral treatment with an early switch to the oral route. Current publications recommend a 2- to 4-day parenteral treatment before the oral switch. We retrospectively analyzed a series of 45 children aged 1 to 11 years and treated in our department for acute osteomyelitis without severity criterion. Nineteen of 45 patients were treated by an exclusive ambulatory oral treatment by amoxicillin and clavulanic acid. Twenty six of 45 patients had a 2- to 4-day parenteral treatment before the oral switch. The minimum follow-up was 6 months. The primary endpoint was a clinical, radiographic, and biologic healing, 6 months after the beginning of the treatment. The secondary endpoints evaluated were the length of hospitalization, the total duration of treatment, and the type of antibiotic used. On the primary endpoint, we did not find any significant difference between the 2 treatments (P = 0.38). On the duration of treatment, we found a significant difference (P = 0.049) in favor of oral treatment. The ambulatory oral treatment by amoxicillin and clavulanic acid seems to be a valid alternative to the classical parenteral then oral sequence in the treatment of acute hematogenous osteomyelitis in children without severity criterion.

Stenotrophomonas maltophilia infection among young children in a cardiac intensive care unit: a single institution experience.

Stenotrophomonas maltophilia can present as bacteremia, respiratory tract infection, urinary tract infection, soft tissue and wound infections, bone and joint infections, meningitis, and endocarditis especially in immunosuppressed patients and those with underlying medical conditions. The incidence and impact of S. maltophilia in young children with heart disease are poorly defined. A single center retrospective observational study was conducted in infants <180 days of age with positive S. maltophilia cultures over a period of 5 years. The overall incidence for S. maltophilia infection was 0.8 % (n = 32/3656). Among 32 identified infants, there were 47 episodes of S. maltophilia infection 66 % of infants had prior exposure to broad spectrum antibiotics. 97 % of positive isolates were susceptible to trimethoprim/sulfamethoxazole and 91 % to levofloxacin as well as ticarcillin/clavulanate. Ventilator-free days and absolute lymphocyte count prior to acquiring infection were significantly lower in non-survivors than in survivors. 100 % of survivors had clearance of positive cultures compared to 50 % in non-survivors (p < 0.05). The crude all-cause mortality rate was 37.5 %. All non-survivors had increased length of ICU stay and duration of mechanical ventilation and had delayed clearance of infection and required longer duration of treatment.

Accumulation of amikacin in synovial fluid after regional limb perfusion of amikacin sulfate alone and in combination with ticarcillin/clavulanate in horses.

OBJECTIVES: To determine the effect of regional limb perfusion (RLP) with amikacin sulfate alone and in combination with ticarcillin/clavulanate on synovial fluid concentration and antimicrobial activity of amikacin. SAMPLE POPULATION: Experimental study. METHODS: RLP with amikacin alone (A; 2.5 g) or amikacin and ticarcillin/clavulanate (AT; 2.5 g amikacin, 7 g ticarcillin/clavulanate) was performed with a tourniquet placed at mid-antebrachium in standing, sedated horses. Perfusate blood was collected immediately after injection and again before tourniquet release. Blood from the jugular vein was collected before tourniquet release. Synovial fluid from the middle carpal joint was collected 0, 30, and 60 minutes after tourniquet release. Amikacin concentration and antimicrobial activity of synovial fluid against Escherichia coli, Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa were determined. RESULTS: There was significantly lower amikacin concentration in the middle carpal joint synovial fluid of group AT compared with group A at 30 minutes (AT = median 4.4 µg/mL, IQR 3.0-11.2 µg/mL; A = 17.5 µg/mL, 6.6-80.1 µg/mL) and 60 minutes (AT = median 4.6 µg/mL, IQR 3.1-8.1 µg/mL; A = 15.0 µg/mL, 6.7-61.7 µg/mL) after tourniquet release. Zones of inhibition for ticarcillin-resistant Klebsiella pneumoniae from group AT were significantly smaller than group A from synovial fluid at 30 and 60 minutes after tourniquet release and in the perfusate serum before tourniquet release. CONCLUSIONS: The combination of amikacin with ticarcillin/clavulanate during RLP resulted in significantly lower amikacin synovial concentration and antimicrobial activity on amikacin susceptible and ticarcillin resistant cultures compared with amikacin alone.

Biological efficacy and stability of diluted ticarcillin-clavulanic acid in the topical treatment of Pseudomonas aeruginosa infections.

Topical compounded Timentin(®) diluted with an inactive vehicle has been reported to be effective in the treatment of otitis externa caused by Pseudomonas aeruginosa. The aims of this study were to determine the biological efficacy of Timentin(®) (ticarcillin and clavulanic acid) when diluted in the carrier vehicle Methopt(®) against P. aeruginosa and to determine the efficacy and stability of Timentin(®) aqueous stock concentrate solution. Timentin(®) stock concentrate was tested against four P. aeruginosa isolates on days 0, 7, 14, 21 and 28; then after 2, 3, 4, 5, 6, 9 and 12 months of storage at 4 or -20°C. The diluted Timentin(®)-Methopt(®) solutions were tested against all isolates after 0, 2, 4, 6, 8, 10, 12, 14, 17, 21, 24 and 28 days of storage at 24 or 4°C. Minimal inhibitory concentration (MIC) levels for all strains were determined using the broth microdilution method. The MIC of the stock solution remained relatively constant and acceptable throughout the study when stored at -20°C and was also acceptable for shorter time periods (6-9 months) when stored at 4°C. The MIC for the diluted Timentin(®)-Methopt(®) solution remained relatively constant and acceptable throughout the study for all four bacterial strains, with no difference between the solutions stored at 4 or 24°C. The results of this study indicate that storage of the Timentin(®) stock solution at -20°C does not compromise efficacy for at least 12 months and that Timentin(®) diluted in Methopt(®) was stable for 28 days when stored at either 4 or 24°C.

In vitro synergy of ticarcillin/clavulanate in combination with aztreonam and ceftolozane/tazobactam against SPM-1-producing Pseudomonas aeruginosa strains.

Minimal inhibitory concentrations (MICs) of ticarcillin/clavulanic acid (TLc), ceftolozane/tazobactam (C/T), and aztreonam (AT) were determined for 6 SPM-1-producing Pseudomonas aeruginosa (PSA) using Etest® strips and the synergistic effect of such antimicrobials against was evaluated by gradient diffusion strip crossing (GDSC) test. The fraction inhibitory concentration indexes (FICI) were calculated and showed a synergistic (n = 3) and additive (n = 2) effects of TLc + AT against SPM-1 producers, while TLc + C/T combination caused no effect. Average MIC reduction of TLc and AT by GDSC was 3-fold and 2-fold dilutions, respectively. Thus, TLc + AT might be a candidate as a combination therapy to treat SPM-1-producing PSA infections.

Second order Horner's syndrome in a cat.

This case report describes the clinical and magnetic resonance imaging (MRI) findings of a 3.5-year-old, male neutered, domestic shorthair cat with second order Horner's syndrome as the only clinical abnormality. The neuroanatomical pathway of the sympathetic innervation to the eye, differential diagnoses for Horner's syndrome in cats, and the interpretation of pharmacological testing are reviewed. The unusual MRI findings and the value of fat-suppressed MRI sequences are discussed.

Continuous infusion of ticarcillin-clavulanate for home treatment of serious infections: clinical efficacy, safety, pharmacokinetics and pharmacodynamics.

Continuous infusion (CI) ticarcillin-clavulanate is a potential therapeutic improvement over conventional intermittent dosing because the major pharmacodynamic (PD) predictor of efficacy of beta-lactams is the time that free drug levels exceed the MIC. This study incorporated a 6-year retrospective arm evaluating efficacy and safety of CI ticarcillin-clavulanate in the home treatment of serious infections and a prospective arm additionally evaluating pharmacokinetics (PK) and PD. In the prospective arm, steady-state serum ticarcillin and clavulanate levels and MIC testing of significant pathogens were performed. One hundred and twelve patients (median age, 56 years) were treated with a CI dose of 9.3-12.4g/day and mean CI duration of 18.0 days. Infections treated included osteomyelitis (50 patients), septic arthritis (6), cellulitis (17), pulmonary infections (12), febrile neutropenia (7), vascular infections (7), intra-abdominal infections (2), and Gram-negative endocarditis (2); 91/112 (81%) of patients were cured, 14 (13%) had partial response and 7 (6%) failed therapy. Nine patients had PICC line complications and five patients had drug adverse events. Eighteen patients had prospective PK/PD assessment although only four patients had sufficient data for a full PK/PD evaluation (both serum steady-state drug levels and ticarcillin and clavulanate MICs from a bacteriological isolate), as this was difficult to obtain in home-based patients, particularly as serum clavulanate levels were found to deteriorate rapidly on storage. Three of four patients with matched PK/PD assessment had free drug levels exceeding the MIC of the pathogen. Home CI of ticarcillin-clavulanate is a safe, effective, convenient and practical therapy and is a therapeutic advance over traditional intermittent dosing when used in the home setting.

Tunable release of clavam from clavam stabilized gold nanoparticles--design, characterization and antimicrobial study.

A facile one-step approach is developed to synthesize highly stable (up to 6months) gold nanoparticles (GNPs) using Clavam, pharmaceutical form of amoxicillin which contains a mixture of amoxicillin and potassium salt of clavulanic acid, at room temperature (25-30°C). The clavam stabilized GNPs are characterized using various techniques including UV-Visible, FT-IR spectrophotometry and transmission electron microscopy (TEM). Tunable release of clavam from clavam stabilized GNPs is demonstrated using intracellular concentrations of glutathione (GSH). The process is monitored using an UV-Vis spectroscopy and the amount of clavam released in terms of amoxicillin concentration is quantitatively estimated using reverse phase high performance liquid chromatographic (RP-HPLC) technique. In vitro study reveals that the clavam released from GNPs' surface was found to show a significant enhancement in antibacterial activity against Escherichia coli and the cause of enhancement is addressed.

Once-daily, high-dose levofloxacin versus ticarcillin-clavulanate alone or followed by amoxicillin-clavulanate for complicated skin and skin-structure infections: a randomized, open-label trial.

This study tested whether levofloxacin, at a new high dose of 750 mg, was effective for the treatment of complicated skin and skin-structure infections (SSSIs). Patients with complicated SSSIs (n=399) were randomly assigned in a ratio of 1:1 to 2 treatment arms: levofloxacin (750 mg given once per day intravenously [iv], orally, or iv/orally) or ticarcillin-clavulanate (TC; 3.1 g given iv every 4-6 hours) followed, at the investigator's discretion, by amoxicillin-clavulanate (AC; 875 mg given orally every 12 hours). In the clinically evaluable population, therapeutic equivalence was demonstrated between the levofloxacin and TC/AC regimens (success rates of 84.1% and 80.3%, respectively). In the microbiologically evaluable population, the overall rate of eradication was 83.7% in the levofloxacin treatment group and 71.4% in the TC/AC treatment group (95% confidence interval, -24.3 to -0.2). Both levofloxacin and TC/AC were well tolerated. These data demonstrate that levofloxacin (750 mg once per day) is safe and at least as effective as TC/AC for complicated SSSIs.

Clinical pharmacology of timentin (ticarcillin and clavulanic acid).

Ticarcillin (4 gm) and clavulanic acid (0.1 gm) were simultaneously administered as timentin to patients with cancer as therapy for infections. The pharmacokinetics of both ticarcillin and clavulanic acid were studied in 15 patients after 30-minute and 2-hour intravenous infusions. The mean (+/- SD) ticarcillin plasma peak concentrations after the two infusions were 341 +/- 76 and 210 +/- 60 micrograms/ml. The plasma terminal t1/2 values of ticarcillin were 80 +/- 32 and 56 +/- 12 minutes. The AUCs were 631 +/- 189 and 601 +/- 230 mg/L X hr. The volumes of distribution of the area were 15 +/- 5 and 21 +/- 7 L and total clearances were 115 +/- 36 and 127 +/- 54 ml/min. The corresponding values for clavulanic acid after the infusions are as follows: mean peak concentrations, 5 +/- 1 and 4 +/- 1 micrograms/ml; plasma terminal t1/2 values, 84 +/- 24 and 74 +/- 36 minutes; AUCs, 11 +/- 3 and 11 +/- 6 mg/L X hr; volumes of distribution of the area, 22 +/- 3 and 32 +/- 6 L; and total clearances, 170 +/- 58 and 175 +/- 68 ml/min.

Use of ticarcillin disodium plus clavulanate potassium in the management of acute bacterial infections in children.

Ticarcillin disodium plus clavulanate potassium (in a ratio of 30:1) was used to treat 30 children (mean age equal to 4.9 years) with acute infections of the urinary tract, skeletal system, respiratory tract, gastrointestinal tract, skin and subcutaneous tissue, and blood. The drug was administered by the intravenous or intramuscular route in a dose of 310 mg/kg per day in six divided doses (26 patients) or 207 mg/kg per day in four divided doses (four patients). Duration of therapy ranged from two to 14 days (mean equal to 5.4 days), and resolution of infection was quite satisfactory in all cases, including those involving beta-lactamase-producing bacteria, although reinfection occurred five days after successful therapy of a urinary tract infection due to Escherichia coli. No adverse clinical or biochemical changes attributable to administration of ticarcillin disodium plus clavulanate potassium were observed. Ticarcillin disodium plus clavulanate potassium appears to be safe and effective therapy for a wide range of acute infections in children, including those caused by at least some pathogens that produce beta-lactamase.

A controlled study of ticarcillin plus clavulanic acid versus piperacillin as empiric therapy for fever in the immunocompromised host.

Clavulanic acid, a potent beta-lactamase inhibitor, was studied in fixed combination with ticarcillin and used with tobramycin as empiric therapy for fever in the immunocompromised host. Fifty febrile episodes were evaluated in patients with hematologic malignancy and/or neutropenia. Eighty-one percent of evaluable infections treated with the study regimen of ticarcillin, clavulanic acid, and tobramycin responded. Seventy-four percent of evaluable infections treated with the control regimen of piperacillin, tobramycin, and vancomycin responded (p = 0.4). Resistance to piperacillin and ticarcillin were noted in 23.8 percent of 21 isolated organisms. Resistance to ticarcillin and clavulanic acid was noted in only one (4.7 percent) of the isolated organisms (p = 0.092). Untoward reactions, including rash, nephrotoxicity, and superinfection, were unusual and occurred with equal frequency in the study and control groups. Clavulanic acid in combination with ticarcillin was effective and safe in treating fever in the immunocompromised host.

Pharmacology of ticarcillin combined with clavulanic acid in humans.

Serum and urine levels of ticarcillin and clavulanic acid after administration of doses of 50 mg/kg and 1.7 mg/kg or 50 mg/kg and 3 g/0.1 g, respectively, are potentially toxic to susceptible bacteria. Both compounds are widely distributed in body tissues and fluids, with concentrations exceeding the minimal inhibitory concentrations of most pathogens. Excretion is primarily renal, although there is some metabolism of clavulanate in the body. Due to accumulation, dosage adjustment is required for patients with renal insufficiency. Both ticarcillin and clavulanic acid are cleared by hemodialysis.

Ticarcillin plus clavulanic acid in the treatment of patients with cancer.

Since the combination of ticarcillin with clavulanic acid is active against many otherwise resistant organisms that commonly affect patients with cancer, a therapeutic trial with ticarcillin disodium plus clavulanate potassium for treating infections in cancer patients was conducted. A total of 127 evaluable patients were treated with this antibiotic. Of these, 63 percent were women with breast carcinoma, 28 percent were patients with leukemia, and the remainder were patients with sarcomas and lung cancer. The median duration of therapy was 7.7 days. There were 63 documented infections, with bacteriologic documentation in 39 episodes. Because of the high incidence of gram-positive infections and after the failure of ticarcillin plus clavulanate potassium in two of these episodes, vancomycin was added to the regimen. The overall response rate was 75 percent. In microbiologically proved infections, the response rate was 79 percent. Thirteen of 17 gram-negative infections responded (76 percent), including four of four episodes caused by Pseudomonas aeruginosa. The only failures in this group were two episodes with Klebsiella species, one episode with Escherichia coli, and one episode with Enterobacter species. Of the gram-positive infections treated without vancomycin, five of eight (63 percent) responded and only two episodes due to Staphylococcus aureus and one due to JK diphtheroid bacteria failed. All episodes treated with the combination of ticarcillin plus clavulanate potassium and vancomycin responded. Seven of eight (88 percent) polymicrobial infections and 73 percent of those infections without identified organisms responded as well. The overall response rates for septicemia, pneumonia, soft tissue infections, and urinary tract infections were 71, 50, 71, and 83 percent, respectively. Of five microbiologically proved superinfections, three were fungal, and one each was due to Klebsiella species and S. aureus. No toxicity was observed. For 12 organisms, the minimal inhibitory concentration was lower for ticarcillin plus clavulanate potassium than for ticarcillin alone; in six it was identical. Five organisms were resistant to both, and three that were resistant to ticarcillin were sensitive to ticarcillin plus clavulanate potassium. Ticarcillin plus clavulanate potassium is a safe drug with an expanded spectrum of activity. More therapeutic trials need to be conducted to better define its role in the therapy of serious infections in cancer patients.

Lower respiratory tract infection.

The most important lower respiratory infection is pneumonia, the fourth leading cause of death. Most cases of bronchitis are of viral etiology and are not major problems. Empyema can present an important problem in management. Although the diagnosis of pneumonia is usually relatively straightforward, the specific etiologic diagnosis remains a major problem. Availability of empyema fluid or a positive blood culture result can be helpful in making the etiologic diagnosis, but these are unavailable in most patients. Screening of sputum Gram stains under 100 X magnification is very important; there should be fewer than 10 squamous epithelial cells, more than 25 polymorphonuclear leukocytes, or both per field of this size. The major causes of pneumonia are Streptococcus pneumoniae, Mycoplasma pneumoniae, anaerobic bacteria, Staphylococcus aureus, various gram-negative aerobic or facultative bacilli and Legionella. However, many other organisms are capable of causing pneumonia, even in the immunocompetent host. Further adding to the problem is the fact that a number of different organisms are manifesting increasing resistance to antimicrobial agents. Our study with ticarcillin plus clavulanic acid included seven patients with pneumonia, one with empyema, and one with purulent tracheobronchitis. Organisms recovered from pleural fluid, transtracheal aspiration and sputum or tracheostomy aspirate included multiple anaerobes, pneumococci, S. aureus, Hemophilus influenzae, Klebsiella pneumoniae, K. ozaenae, Pseudomonas aeruginosa, Acinetobacter, Enterobacter cloacae, Proteus mirabilis, beta-hemolytic streptococci, Neisseria meningitidis and Branhamella catarrhalis. Several of the organisms were ticarcillin resistant. Eight of the patients had cures and the other patient showed improvement. Only minor side-effects were encountered--Coombs' positivity (without hemolysis), eosinophilia, drug fever and one case of questionable neutropenia.

Ticarcillin plus clavulanic acid in the treatment of pneumonia and other serious infections.

Clavulanic acid is a potent inhibitor of bacterial beta-lactamases, and ticarcillin is a potent antipseudomonal penicillin. The combination of ticarcillin disodium and clavulanate potassium provides an excellent spectrum of activity against the majority of bacterial pathogens responsible for serious infections in both normal and abnormal hosts. Eighteen courses of therapy were administered to 16 patients; 35 percent of the patients were in poor or critical condition, and all but one had severe underlying disease. Thirteen separate episodes of pneumonia were treated, of which nine were in patients with cystic fibrosis, and 11 involved Pseudomonas aeruginosa. Of the 13 cases of pneumonia, 11 showed clinical cure or improvement, whereas only three showed bacteriologic cure. Of the four nonpulmonary cases, three showed clinical improvement or cure, and one showed a bacteriologic cure. In two patients, phlebitis developed at the site of intravenous infusion. The combination of ticarcillin and clavulanic acid is safe and effective therapy for pneumonia in anatomically compromised hosts.

Safety and effectiveness of ticarcillin plus clavulanic acid in the treatment of community-acquired acute pyelonephritis in adult women.

An open study was conducted to evaluate the safety and effectiveness of ticarcillin plus clavulanic acid in the treatment of 18 adult women with community-acquired Escherichia coli acute pyelonephritis. Eleven of the 18 patients had a history of urinary tract infections, primarily acute pyelonephritis. Six patients had blood culture results positive for E. coli in addition to positive urine culture results. Ticarcillin plus clavulanic acid was administered as the 3.2 g formulation to 11 patients and as the 3.1 g formulation to the other seven. The mean duration of treatment was 9.2 days. Five of the 18 (28 percent) patients had clinical and bacteriologic cures; there were 11 (69 percent) relapses or reinfections and two (11 percent) clinical failures. Adverse reactions (all reversible) were reported in 11 (61 percent) patients, the most frequent of which was phlebitis. These results should prompt further investigation into the treatment of acute pyelonephritis with ticarcillin plus clavulanic acid versus other antibiotics.

Overview of bacterial infections of the skin and soft tissue and clinical experience with ticarcillin plus clavulanate potassium in their treatment.

The etiology, diagnosis, and treatment of skin and soft tissue infections are discussed, and the results of clinical experience with ticarcillin plus clavulanate potassium in these diseases at one clinic are reported. In a randomized and controlled clinical trial, the safety and effectiveness of ticarcillin plus clavulanate potassium and cefazolin were compared in the treatment of soft tissue infections in 20 patients. The 12 patients in the group treated with ticarcillin plus clavulanate potassium included 10 men and two women, with a mean age of 61 years; the eight patients in the group treated with cefazolin were five men and three women, with a mean age of 63.8 years. Ticarcillin plus clavulanate potassium was administered for four to 26 days (mean 12.5 days), and cefazolin for four to 20 days (mean 12 days). There were 29 evaluable pathogens in the group receiving ticarcillin plus clavulanate potassium and 22 in the group receiving cefazolin. Of the 29 pathogens in the former group, 22 were eradicated; three reinfections or superinfections occurred but were ultimately eradicated, and four pathogens persisted. Eighteen of the 22 pathogens in the cefazolin-treated group were eliminated and the other four persisted. Clinically, six of the 12 patients in the ticarcillin plus clavulanate potassium-treated group had cures, four showed improvement, and two failed to show a response. In the cefazolin-treated group, five of the eight patients had cures, one showed improvement, and two failed to show a response.

Ticarcillin plus clavulanic acid versus moxalactam in the treatment of skin and soft tissue infections.

A formulation of 3.0 g of ticarcillin and 0.1 g of clavulanic acid was evaluated in the treatment of skin and soft tissue infections, and its efficacy was compared with that of moxalactam in a randomized open study. Thirty-three patients received 3.1 g of ticarcillin plus clavulanic acid every six hours via intravenous infusion, and 36 patients received 2.0 g of moxalactam every eight hours via intravenous infusion. Diagnostic categories included intramuscular abscesses, cellulitis, skin ulcers, gangrene, and perirectal abscesses. The average age of the patients and the duration of therapy were similar in both groups. Overall, 45 aerobic and 25 anaerobic bacteria were isolated from the ticarcillin plus clavulanic acid-treated patients; 58 aerobic and 24 anaerobic bacteria were isolated from the moxalactam-treated patients. Thirty of 33 patients in the ticarcillin plus clavulanic acid-treated group had a satisfactory response; a skin rash developed in one patient; therapy failed in one patient with Staphylococcus aureus infection; and one patient died as a result of a bleeding peptic ulcer. In the moxalactam-treated group, 32 of 36 patients had a satisfactory response; a skin rash developed in one patient; therapy failed in a patient with Pseudomonas aeruginosa infection; and two patients were unevaluable. Ticarcillin plus clavulanic acid as a single agent was found to be as effective as moxalactam in the treatment of skin and soft tissue infections.