Breaking Antimicrobial Resistance: High-Dose Amoxicillin with Clavulanic Acid for Urinary Tract Infections Due to Extended-Spectrum Beta-Lactamase (ESBL)-Producing Klebsiella pneumoniae.

BACKGROUND Carbapenems are the primary treatment for urinary tract infections (UTIs) caused by extended-spectrum beta-lactamase (ESBL)-producing Klebsiella pneumoniae. However, the recurrence rate is high, and patients often require rehospitalization. We present the results of an observational study on patients with recurrent UTIs who were treated in an outpatient setting with maximal therapeutic oral doses of amoxicillin with clavulanic acid. MATERIAL AND METHODS All patients had pyuria and ESBL-producing K. pneumoniae in urine culture. The starting dosage was 2875 g of amoxicillin twice daily and 125 mg of clavulanic acid twice daily. We down-titrated the doses every 7-14 days and continued prophylactic therapy with amoxicillin/clavulanic acid at 250/125 mg for up to 3 months. We defined therapeutic failure as ESBL-positive K. pneumoniae in urine culture during therapy and recurrence as positive urine culture with the same strain within 1 month after the end of treatment. RESULTS We included 9 patients: 7 kidney graft recipients, 1 liver graft recipient, and 1 patient with chronic kidney disease. We observed no therapeutic failures and no recurrences in the study group during the study period. In 1 case, the patient experienced a subsequent UTI caused by ESBL-producing K. pneumoniae 4 months after completing the therapy. CONCLUSIONS In conclusion, it is possible to break the resistance of ESBL-producing K. pneumoniae strains with high doses of oral amoxicillin with clavulanic acid. Such treatment could be an alternative to carbapenems in select cases.

Evaluation Of Anti-Inflammatory Efficacy Of Ascorbic Acid After Third Molar Surgery.

BACKGROUND: Abstraction of wisdom teeth or impacted third molar under local anaesthesia is one of the most frequent interventions by an oral and maxillofacial surgeon. The abstraction of the third molar is usually followed by the release of liberation and consequent trismus, pain, and swelling due to the area of the third molar being highly vascularized and rich in loose connective tissue. Objective of the study was to evaluate the anti-inflammatory effect of ascorbic acid following surgical extraction of the third molar. METHODS: The current study was carried out Armed Forces Institute of Dentistry, Rawalpindi, from October to December 2022. This was a cross-sectional observational study. Fifty participants who required surgical extraction of the impacted third molar were included in the study via non-probability purposive sampling and were segregated equally into two groups, i.e., Group A and Group B, comprising twenty-five participants in each group. Group A received amoxicillin with clavulanic acid (625 mg) thrice a day and metronidazole (400 mg) twice daily. In comparison, Group B received amoxicillin with clavulanic acid (625 mg) thrice daily, ascorbic acid (500 mg) twice daily, and metronidazole (400 mg) twice daily. Both groups received naproxen sodium as per requirement (550 mg). Pain, facial swelling, and C reactive protein concentration were evaluated until the 7th postoperative day. RESULTS: There was a reduction in pain and facial swelling in both groups, but in the ascorbic acid group, there was more reduction in pain and facial swelling compared to the control group. However, the difference between the two groups in reducing pain and facial swelling was statistically significant (p<0.01). There was a reduction in CRP in both groups, but in the ascorbic acid group, there was more reduction in CRP 2.35 (1.60-5.30) compared to the control group 2.6 (0.86-5.03). However, the difference between the two groups in reducing C reactive protein concentration was statistically insignificant (p>0.05). CONCLUSIONS: Our study concluded that ascorbic acid significantly reduced inflammation and C reactive protein, so ascorbic acid should be used as an adjuvant supplement with other conventional drugs.

Antibiotic therapy does not alter mitochondrial bioenergetics in lymphocytes of patients with septic shock - A prospective cohort study.

Antibiotics may trigger alterations in mitochondrial function, which has been explored in cells culture, and in animal model of sepsis. This study sought to evaluate whether antibiotic therapy affects mitochondrial bioenergetics in a 68-patients clinical study. We studied mitochondrial respiratory rates at two time points: the first day of antibiotic administration and three days after. The Δbasal, ΔCI, ΔCII respiration, and ΔBCE respiratory rates were not different between patients administered with polymyxin, vancomycin, amoxicillin-clavulanate, and azithromycin compared to those who were not administered. Specific beta-lactams are associated with specific modifications in mitochondrial respiratory endpoints - patients who used meropenem had higher delta C2 values compared to those who did not (p = 0.03). Patients who used piperacillin-tazobactam had lower delta C1 (p = 0.03) values than those who did not, but higher delta C2 values (p = 0.02). These mitochondrial metabolic signatures in isolated lymphocytes challenges the proposed effects of antibiotics in mitochondrial bioenergetics of cell cultures, but at current status have an uncertain clinical significance.

Evaluation of Drug Susceptibility of Microorganisms in Odontogenic Inflammations and Dental Surgery Procedures Performed on an Outpatient Basis.

Bacterial infections are the most common cause of purulent soft tissue inflammations in the head and neck area. These bacteria are also responsible for the majority of inflammatory complications after third molar removal. The key to success of antibacterial treatment in both cases is the use of an appropriate antibacterial agent. The aim of the study was to evaluate the susceptibility profile of bacteria isolated from material collected from patients with intraoral odontogenic abscesses. The test material consisted of swabs taken from the odontogenic abscesses, after their incision and drainage. Another swab was collected from the lesion area, 10 days after the initial visit. Results were compared with an identical study conducted on a control group of healthy patients, who had undergone third molar removal. Bacteria identified in this study consisted of aerobic and anaerobic strains, both Gram-positive and Gram-negative. According to the EUCAST guidelines, none of the tested antibiotics was recommended for all identified bacteria. The percentage of bacterial strains sensitive to amoxicillin and clavulanic acid was 78.13% and 81.48% in the study and control groups, respectively, whereas, the percentage of those sensitive to clindamycin was 96.43% and 80.00%, respectively. For Gram-negative aerobic bacteria, gentamicin and ciprofloxacin were among medications affecting all cultured species. 100.00% of strains were found to be susceptible to these antibiotics. Statistically significant relationship between the presence of Gram-negative aerobic strains and the occurrence of complications was found. In the case of the most frequently occurring bacteria in the study, amoxicillin with clavulanic acid and clindamycin were shown to be very effective. In cases of severe purulent odontogenic inflammations, it is recommended to use a combination of antibiotics. Amoxicillin with ciprofloxacin and clindamycin with cefuroxime seem to be the proper choices based on the results of this study.

Aztreonam plus Clavulanate, Tazobactam, or Avibactam for Treatment of Infections Caused by Metallo-ß-Lactamase-Producing Gram-Negative Bacteria.

Metallo-ß-lactamase (MBL)-producing Gram-negative bacteria are often extremely resistant, leading to a real therapeutic dead end. Here, we evaluated the in vitro and in vivo efficacy of aztreonam in combination with ceftazidime-avibactam, ceftolozane-tazobactam, or amoxicillin-clavulanate for the treatment of infections caused by MBL-producing Enterobacteriaceae, MBL-producing Pseudomonas aeruginosa, and extremely drug-resistant Stenotrophomonas maltophilia First, we report two clinical cases, namely, a urinary tract infection caused by an NDM-5-producing Escherichia coli isolate and a pulmonary infection caused by a S. maltophilia isolate efficiently treated with the association of aztreonam-ceftazidime-avibactam and aztreonam-amoxicillin-clavulanate, respectively. Then, a total of 50 MBL-producing Enterobacteriaceae isolates, 3 MBL-producing P. aeruginosa isolates, and 5 extremely drug-resistant S. maltophilia isolates were used to test aztreonam susceptibility in combination with ceftolozane-tazobactam, ceftazidime-avibactam, or amoxicillin-clavulanate. The Etest strip superposition method was used to determine the MICs of the aztreonam/inhibitor combinations. According to CLSI breakpoints, aztreonam susceptibility was fully restored for 86%, 20%, and 50% of the MBL-producing Enterobacteriaceae isolates when combined with ceftazidime-avibactam, ceftolozane-tazobactam, and amoxicillin-clavulanate, respectively. In P. aeruginosa, the aztreonam-ceftazidime-avibactam combination was the most potent, even though the reduction in MICs was at most 2-fold. With the 5 S. maltophilia isolates, aztreonam-ceftazidime-avibactam and aztreonam-amoxicillin-clavulanate were found to be equal (100% susceptibility). Overall, aztreonam-ceftazidime-avibactam was the most potent combination to treat infections caused by MBL producers compared with aztreonam-amoxicillin-clavulanate and aztreonam-ceftolozane-tazobactam. However, in many cases aztreonam-amoxicillin-clavulanate was found to be as efficient as aztreonam-ceftazidime-avibactam, offering the main advantage to be markedly cheaper. We also confirmed the validity of Etest superpositions as a very simple method to determine MICs of aztreonam combinations.

Triple oral beta-lactam containing therapy for Buruli ulcer treatment shortening.

The potential use of clinically approved beta-lactams for Buruli ulcer (BU) treatment was investigated with representative classes analyzed in vitro for activity against Mycobacterium ulcerans. Beta-lactams tested were effective alone and displayed a strong synergistic profile in combination with antibiotics currently used to treat BU, i.e. rifampicin and clarithromycin; this activity was further potentiated in the presence of the beta-lactamase inhibitor clavulanate. In addition, quadruple combinations of rifampicin, clarithromycin, clavulanate and beta-lactams resulted in multiplicative reductions in their minimal inhibitory concentration (MIC) values. The MIC of amoxicillin against a panel of clinical isolates decreased more than 200-fold within this quadruple combination. Amoxicillin/clavulanate formulations are readily available with clinical pedigree, low toxicity, and orally and pediatric available; thus, supporting its potential inclusion as a new anti-BU drug in current combination therapies.

Imported malaria caused by Plasmodium falciparum ­ case report

INTRODUCTION: Malaria is caused by the Plasmodium spp. which are spread through Anopheles mosquitoes. Disease is not endemic in Poland currently but can be brought from other countries, mostly from Africa and Asia. The main sign of the disease is fever with shivers repeated periodically. There is highly effective chemoprophylaxis available and treatment, which should be given quickly CASE REPORT: A 35-year-old man have worked monthly in Nigeria since two years. He was using Malarone chemoprophylaxis, but contrary to recommendations. Patient presented to a hospital after four days of having fever in a medium-serious state. He reported three similar incidents in the past. Physical examination revealed hepatomegaly, depressive state, oliguria and diarrhoea. Lab tests showed DIC with thrombocytopenia, renal injury, liver injury, hypoalbuminemia. ECG indicated myocardial ischemia. Malaria Rapid Test and blood smear confirmed Plasmodium falciparum infection with 9,9% parasitemia. When antimalarial treatment was given, patient condition improved, but after three days in hospital he got pneumonia as a complication of malaria ­ antibiotic admission was committed. Moreover, quinine caused temporary deafness and serological tests revealed chronic HBV infection. After 23-days of hospitalisation the patient was discharged in a good condition. A month later patient went to follow-up and only mild anaemia was shown. CONCLUSIONS: This case shown that even such severe disease like malaria can be cured well without serious complications if patient will be diagnosed quickly. Moreover patient's experience and respecting symptoms improve prognosis. There also should be stronger emphasis on the role of chemoprophylaxis ­ patient did not use it properly, so it did not have to prevent development of malaria.

Prophylactic antibiotic therapy for chronic obstructive pulmonary disease (COPD).

BACKGROUND: There has been renewal of interest in the use of prophylactic antibiotics to reduce the frequency of exacerbations and improve quality of life in chronic obstructive pulmonary disease (COPD). OBJECTIVES: To determine whether or not regular (continuous, intermittent or pulsed) treatment of COPD patients with prophylactic antibiotics reduces exacerbations or affects quality of life. SEARCH METHODS: We searched the Cochrane Airways Group Trials Register and bibliographies of relevant studies. The latest literature search was performed on 27 July 2018. SELECTION CRITERIA: Randomised controlled trials (RCTs) that compared prophylactic antibiotics with placebo in patients with COPD. DATA COLLECTION AND ANALYSIS: We used the standard Cochrane methods. Two independent review authors selected studies for inclusion, extracted data, and assessed risk of bias. We resolved discrepancies by involving a third review author. MAIN RESULTS: We included 14 studies involving 3932 participants in this review. We identified two further studies meeting inclusion criteria but both were terminated early without providing results. All studies were published between 2001 and 2015. Nine studies were of continuous macrolide antibiotics, two studies were of intermittent antibiotic prophylaxis (three times per week) and two were of pulsed antibiotic regimens (e.g. five days every eight weeks). The final study included one continuous, one intermittent and one pulsed arm. The antibiotics investigated were azithromycin, erythromycin, clarithromycin, doxycyline, roxithromycin and moxifloxacin. The study duration varied from three months to 36 months and all used intention-to-treat analysis. Most of the pooled results were of moderate quality. The risk of bias of the included studies was generally low.The studies recruited participants with a mean age between 65 and 72 years and mostly at least moderate-severity COPD. Five studies only included participants with frequent exacerbations and two studies recruited participants requiring systemic steroids or antibiotics or both, or who were at the end stage of their disease and required oxygen. One study recruited participants with pulmonary hypertension secondary to COPD and a further study was specifically designed to asses whether eradication of Chlamydia pneumoniae reduced exacerbation rates.The co-primary outcomes for this review were the number of exacerbations and quality of life.With use of prophylactic antibiotics, the number of participants experiencing one or more exacerbations was reduced (odds ratio (OR) 0.57, 95% CI 0.42 to 0.78; participants = 2716; studies = 8; moderate-quality evidence). This represented a reduction from 61% of participants in the control group compared to 47% in the treatment group (95% CI 39% to 55%). The number needed to treat for an additional beneficial outcome with prophylactic antibiotics given for three to 12 months to prevent one person from experiencing an exacerbation (NNTB) was 8 (95% CI 5 to 17). The test for subgroup difference suggested that continuous and intermittent antibiotics may be more effective than pulsed antibiotics (P = 0.02, I² = 73.3%).The frequency of exacerbations per patient per year was also reduced with prophylactic antibiotic treatment (rate ratio 0.67; 95% CI 0.54 to 0.83; participants = 1384; studies = 5; moderate-quality evidence). Although we were unable to pool the result, six of the seven studies reporting time to first exacerbation identified an increase (i.e. benefit) with antibiotics, which was reported as statistically significant in four studies.There was a statistically significant improvement in quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) with prophylactic antibiotic treatment, but this was smaller than the four unit improvement that is regarded as being clinically significant (mean difference (MD) -1.94, 95% CI -3.13 to -0.75; participants = 2237; studies = 7, high-quality evidence).Prophylactic antibiotics showed no significant effect on the secondary outcomes of frequency of hospital admissions, change in forced expiratory volume in one second (FEV1), serious adverse events or all-cause mortality (moderate-quality evidence). There was some evidence of benefit in exercise tolerance, but this was driven by a single study of lower methodological quality.The adverse events that were recorded varied among the studies depending on the antibiotics used. Azithromycin was associated with significant hearing loss in the treatment group, which was in many cases reversible or partially reversible. The moxifloxacin pulsed study reported a significantly higher number of adverse events in the treatment arm due to the marked increase in gastrointestinal adverse events (P < 0.001). Some adverse events that led to drug discontinuation, such as development of long QTc or tinnitus, were not significantly more frequent in the treatment group than the placebo group but pose important considerations in clinical practice.The development of antibiotic resistance in the community is of major concern. Six studies reported on this, but we were unable to combine results. One study found newly colonised participants to have higher rates of antibiotic resistance. Participants colonised with moxifloxacin-sensitive pseudomonas at initiation of therapy rapidly became resistant with the quinolone treatment. A further study with three active treatment arms found an increase in the degree of antibiotic resistance of isolates in all three arms after 13 weeks treatment. AUTHORS' CONCLUSIONS: Use of continuous and intermittent prophylactic antibiotics results in a clinically significant benefit in reducing exacerbations in COPD patients. All studies of continuous and intermittent antibiotics used macrolides, hence the noted benefit applies only to the use of macrolide antibiotics prescribed at least three times per week. The impact of pulsed antibiotics remains uncertain and requires further research.The studies in this review included mostly participants who were frequent exacerbators with at least moderate-severity COPD. There were also older individuals with a mean age over 65 years. The results of these studies apply only to the group of participants who were studied in these studies and may not be generalisable to other groups.Because of concerns about antibiotic resistance and specific adverse effects, consideration of prophylactic antibiotic use should be mindful of the balance between benefits to individual patients and the potential harms to society created by antibiotic overuse. Monitoring of significant side effects including hearing loss, tinnitus, and long QTc in the community in this elderly patient group may require extra health resources.

Impact of Antimicrobial Treatment for Acute Otitis Media on Carriage Dynamics of Penicillin-Susceptible and Penicillin-Nonsusceptible Streptococcus pneumoniae.

Background: Despite concerns that antimicrobial treatment of prevalent infections may select for drug-resistant bacteria, the effects of antimicrobial treatment on colonization dynamics have not been well quantified. Methods: We measured impacts of antimicrobial treatment on nasopharyngeal carriage of penicillin-susceptible Streptococcus pneumoniae (PSSP) and penicillin-nonsusceptible (PNSP) lineages at the end of treatment and 15, 30, and 60 days after treatment in a previously conducted randomized, double-blinded, placebo-controlled trial of amoxicillin-clavulanate for stringently defined acute otitis media. Results: In intention-to-treat analyses, immediate treatment with amoxicillin-clavulanate reduced PSSP carriage prevalence by 88% (95% confidence interval [CI], 76%-96%) at the end of treatment and by 27% (-3%-49%) after 60 days but did not alter PNSP carriage prevalence. By the end of treatment, 7% of children who carried PSSP at enrollment remained colonized in the amoxicillin-clavulanate arm, compared with 61% of PSSP carriers who received placebo; impacts of amoxicillin-clavulanate persisted at least 60 days after treatment among children who carried PSSP at enrollment. Amoxicillin-clavulanate therapy reduced PSSP acquisition by >80% over 15 days. Among children who carried PNSP at enrollment, no impacts on carriage prevalence of S. pneumoniae, PSSP, or PNSP were evident at follow-up visits. Conclusions: Although the absolute risk of carrying PNSP was unaffected by treatment, antimicrobial therapy conferred a selective impact on colonizing pneumococci by accelerating clearance and delaying acquisition of PSSP.

Is There an Association Between Use of Amoxicillin-Clavulanate and Resistance to Third-Generation Cephalosporins in Klebsiella pneumoniae and Escherichia coli at the Hospital Level?

AIMS: Amoxicillin-clavulanate is extensively used in European hospitals. Whether the hospital use of amoxicillin-clavulanate is associated with nonsusceptibility to third-generation cephalosporins (3GC) in Klebsiella pneumoniae is unknown. Our aim was to assess the relationship between the hospital use of amoxicillin-clavulanate and 3GC nonsusceptibility in K. pneumoniae and Escherichia coli. METHODS: Yearly data of antibiotic use and 3GC nonsusceptibility in K. pneumoniae and E. coli were obtained from 33 French hospitals between 2011 and 2016. Decreased susceptibility to 3GC and Extended-Spectrum Beta-Lactamase (ESBL) production were modelled from antibiotic use with linear mixed models on years 2011 to 2015, and validated on year 2016. RESULTS: Nonsusceptibility to 3GC increased in K. pneumoniae and E. coli. In a multivariable model that included year and use of 3GC and fluoroquinolones as explanatory variables, amoxicillin-clavulanate use was protective against 3GC nonsusceptibility in K. pneumoniae (incidence rate ratio [IRR], 0.992 [0.988-0.997]), and with ESBL production in K. pneumoniae (IRR, 0.989 [0.985-0.992]). The correlation coefficient between observed and predicted numbers of 3GC-nonsusceptible K. pneumoniae in 2016 was 0.95 (95% confidence interval, 0.89-0.98). There was no significant association between amoxicillin-clavulanate use and 3GC nonsusceptibility in E. coli. CONCLUSION: Amoxicillin-clavulanate hospital use was protective against nonsusceptibility to 3GC in K. pneumoniae. Conversely, it was not associated with susceptibility to 3GC in E. coli. To decrease the hospital use of 3GC and fluoroquinolones, and 3GC nonsusceptibility in K. pneumoniae, it may be acceptable to increase the hospital use of amoxicillin-clavulanate. Interventional studies are necessary to confirm this hypothesis.

Antibiotic Treatment of Hospitalized Patients with Pneumonia Complicated by Clostridium Difficile Infection.

Clostridium difficile infection (CDI) is one of the most common gastrointestinal complication after antimicrobial treatment. It is estimated that CDI after pneumonia treatment is connected with a higher mortality than other causes of hospitalization. The aim of the study was to assess the relationship between the kind of antibiotic used for pneumonia treatment and mortality from post-pneumonia CDI. We addressed the issue by examining retrospectively the records of 217 patients who met the diagnostic criteria of CDI. Ninety four of those patients (43.3 %) came down with CDI infection after pneumonia treatment. Fifty of the 94 patients went through severe or severe and complicated CDI. The distribution of antecedent antibiotic treatment of pneumonia in these 50 patients was as follows: ceftriaxone in 14 (28 %) cases, amoxicillin with clavulanate in 9 (18 %), ciprofloxacin in 8 (16.0 %), clarithromycin in 7 (14 %), and cefuroxime and imipenem in 6 (12 %) each. The findings revealed a borderline enhancement in the proportion of deaths due to CDI in the ceftriaxone group compared with the ciprofloxacin, cefuroxime, and imipenem groups. The corollary is that ceftriaxone should be shunned in pneumonia treatment. The study demonstrates an association between the use of a specific antibiotic for pneumonia treatment and post-pneumonia mortality in patients who developed CDI.

Occult Klebsiella pneumoniae bacteremia at emergency department: A single center experience.

BACKGROUND/PURPOSE: Patients with undetected bacteremia when discharged from a hospital are considered to have occult bacteremia. Klebsiella pneumoniae bacteremia (KPB) is endemic to Taiwan. Our purpose was to study the impact of occult KPB. METHODS: We retrospectively reviewed the records of patients who were discharged from our emergency department (ED) and subsequently diagnosed with KPB (occult bacteremia), from January 2008 to March 2014. All patients are followed for at least 3 months after the index ED visit. The study group was compared to KPB patients who were directly hospitalized (DH) from ED in 2008. Thirty-day mortality was the primary endpoint. RESULTS: A total of 913 patients were admitted to our ED with KPB, and 88 of these patients (9.6%) had occult KPB. Among them, 43 had second ED visit and 41 were admitted. The overall 30-day mortality was 2.3%. Relative to patients with occult KPB, DH patients had more respiratory tract infections (p < 0.001) but fewer other intra-abdominal infections (p = 0.015). Liver abscess was the major diagnosis for the second ED visit (37.2%). DH patients had significantly greater 30-day mortality than that of overall patients with KPB (19.2% vs.2.3%, p < 0.001). CONCLUSION: Most patients with occult KPB had favorable outcomes, but about half of them required a second ED visit. Clinicians should aggressively follow patients with occult KPB and should seek to identify the focus of infection in this endemic area.

First series of patients with XDR and pre-XDR TB treated with regimens that included meropenen-clavulanate in Argentina.

XDR (extensively drug-resistant) and pre-XDR tuberculosis (TB) seriously compromise prognosis and treatment possibilities, and inevitably require the use of group V drugs (World Health Organization). The progress of all patients with XDR and pre-XDR TB seen in a specialized unit during 2012 and 2013 and treated with regimens that included at least 6 months of meropenem-clavulanate (MPC), capreomycin, moxifloxacin, linezolid, clofazimine, high-dose isoniazid, PAS, and bedaquiline in 1 case, were retrospectively analysed. Ten patients were treated, 9 with an extensive pattern of resistance to at least 6 drugs, and 1 because of adverse reactions and drug interactions leading to a similar situation. Eight of the 10 patients treated achieved bacteriological sputum conversion (2 consecutive negative monthly cultures) over a period of 2-7 months, while 2 died. No adverse reactions attributable to prolonged administration of MPC were observed.

High-dose amoxicillin with clavulanate for the treatment of acute otitis media in children.

OBJECTIVE: This study uses the acute otitis media clinical practice guideline proposed in 2004 as a reference to evaluate whether antibiotics doses that are in line with the recommendations lead to better prognosis. The study also attempts to clarify possible factors that influence the outcome. STUDY DESIGN: Retrospective cohort study. SUBJECTS AND METHODS: A total of 400 children with acute otitis media were enrolled. The dosage of amoxicillin was considered to be appropriate when in accord with clinical practice guidelines, that is, 80-90 mg/kg/day. The outcome was defined according to the description of tympanic membrane on medical records. Multivariate logistic regression was used to analyze the relationship between antibiotic dosage and prognosis after adjusting for baseline factors. RESULTS: The majority of prescriptions were under dosage (89.1%) but it was not noticeably associated with outcome (P = 0.41). The correlation between under dosage and poor prognosis was significant in children below 20 kg with bilateral acute otitis media (odds ratio 1.63; 95% CI 1.02-2.59, P = 0.04). CONCLUSION: Treating acute otitis media in children, high-dose amoxicillin with clavulanate as recommended in the clinical practice guideline was superior to conventional doses only in children under 20 kg with bilateral diseases.

Diagnosis and treatment of Fusobacterium nucleatum discitis and vertebral osteomyelitis: case report and review of the literature.

STUDY DESIGN: Case report. OBJECTIVE: We present a case of vertebral osteomyelitis and discitis caused by Fusobacterium nucleatum in a 42-year-old female. SUMMARY OF BACKGROUND DATA: Infection of the vertebral bodies or disc space with this organism is rare. A review of the English literature disclosed 13 cases of vertebral osteomyelitis caused by Fusobacterium spp. Because of the negative impact of this condition on the affected patients' activities of daily living, it is important to understand the clinical character and effective management of the disease to improve quality of life. Fusobacterium is an anaerobic and gram-negative microbe that is part of the normal flora of the mouth, gastrointestinal tract, and female genital tract. It is the main cause of Lemierre syndrome and has also been seen in septicemia. METHODS: The patient presented to our institution with a 3-month history of severe lower back pain. Her back pain was diagnosed as vertebral osteomyelitis. Magnetic resonance images of the lumbar spine revealed decreased T2 signal in the L3 and L4 vertebral bodies. Computed tomographic scan demonstrated asymmetrical disc height loss between vertebral bodies L3 and L4 and associated periosteal reaction. RESULTS: Computed tomography-guided biopsy of vertebral bodies L3 and L4 revealed microorganism Fusobacterium nucleatum with the following in vitro susceptibilities: clindamycin ≤0.5 S, metronidazole ≤0.5 S, penicillin ≤0.5 S, ertapenem ≤4 S. Parenteral ertapenem, at a dose of 1 g every 24 hours for 8 weeks in combination with oral amoxicillin and clavulanate as oral suppression was used as medical management. At 1-month follow-up after medical treatment, the patient's inflammatory markers returned to normal values, and the infection resolved with L3-L4 autofusion. CONCLUSION: We report a rare case of Fusobacterium vertebral osteomyelitis. This condition is associated with several comorbid and concomitant conditions including gastrointestinal complications. Effective treatment includes thoracolumbar orthosis bracing and intravenous antibiotic therapy.

Gemcitabine-induced radiation recall phenomenon in a post-operative and post-radiotherapy case of peri-ampullary carcinoma during adjuvant chemotherapy.

Radiation recall phenomenon is an inflammatory process occurring at sites of previous radiation subsequent to administration of pharmacologic agents. The most common chemotherapeutic agents implicated with radiation recall phenomenon are anthracyclines and taxanes. Skin is the most common site for radiation recall. About 63% of the radiation recall events are reported to manifest as dermatitis. This finding differs from radiation recall due to Gemcitabine, in which approximately 70% cases manifested as inflammation of internal organs or tissues and 30% manifested as dermatitis. Here, we report a case of post-operative peri-ampullary carcinoma who developed radiation recall dermatitis during adjuvant chemotherapy with inj. Gemcitabine and inj. Carboplatin after concurrent chemoradiation with capecitabine.

Randomized controlled trial of antibiotic prophylaxis regimens for transrectal ultrasound-guided prostate biopsy.

BACKGROUND: A prior study showed significant antibiotic resistance to quinolone in our population. In this study we aimed to evaluate and compare the efficacy of a single versus a combined prophylactic antibiotic regimen before transrectal ultrasound-guided prostate biopsy (TRUGPB). METHODS: A prospective randomized study was conducted at a university hospital. Patients undergoing TRUGPB were randomized into an amoxicillin-clavulanate alone (1 mg; one dose before and two doses after biopsy) or an amoxicillin-clavulanate + ciprofloxacin group (250 mg; one dose before and two doses after biopsy). Patients were surveyed for infection symptoms by phone on days 3 and 30 after TRUGPB. We defined an infective complication as the occurrence of symptoms including fever, chills or rigor within 30 days after prostate biopsy, requiring medical treatment or hospitalization, aided by a territory-wide electronic medical record system. RESULTS: Between November 2007 and July 2009, 367 patients were randomized to either amoxicillin-clavulanate alone or amoxicillin-clavulanate + ciprofloxacin group. The infection rates after TRUGPB were 3.91% in the former group (7 out of 179 patients) versus 0.53% (1 out of 188 patients) in the latter. Sixty-three percent (5/8) of patients with infective complications needed hospitalization. There was no intensive care unit admission or mortality during the study period. CONCLUSIONS: Combining prophylactic antibiotics with amoxicillin-clavulanate + ciprofloxacin significantly reduced the incidence of infective complications after TRUGPB. We recommended a combination regimen, especially in centre with high incidence of post-TRUGPB infection.

Mecillinam/clavulanate combination: a possible option for the treatment of community-acquired uncomplicated urinary tract infections caused by extended-spectrum ß-lactamase-producing Escherichia coli.

BACKGROUND: Extended-spectrum ß-lactamases (ESBLs) have emerged as an important mechanism of ß-lactam resistance among community uropathogens. We characterized the ESBLs of a collection of Escherichia coli isolates recovered from outpatients with urinary tract infection during nationwide surveillance conducted from 2005 to 2006 in Greece, and evaluated the in vitro activity of mecillinam and mecillinam/clavulanate against them. MATERIALS AND METHODS: ESBLs were characterized with PCR and sequencing. In vitro interactions were evaluated with agar dilution with and without clavulanate (4 mg/L) using an inoculum of 10(4) or 10(6) cfu/spot as well as with time-kill methodology. RESULTS: Among 48 ESBL producers, 47 (97.9%) were susceptible to mecillinam. CTX-M-type enzymes were produced by 87.2%, with CTX-M-3 being the most prevalent. SHV enzymes were found in 10.6%, VEB enzymes in 2.1%, TEM enzymes in 19.2% and OXA-type enzymes in 12.8%. Synergy with clavulanate was detected in 60.4% using the agar dilution method and in 43.8% using the time-kill methodology. An inoculum effect was detected in 64.6% of isolates, but this phenomenon was inverted and synergy was evidenced for 85.4% with clavulanate. When a high inoculum was used, 60.4% (29/48) were resistant to mecillinam, but 97.9% (47/48) were susceptible in the presence of clavulanate. CONCLUSIONS: CTX-M-type enzymes were the most prevalent among ESBL-producing E. coli uropathogens in Greece. Mecillinam may be useful in uncomplicated cystitis caused by ESBL producers with low MICs. The addition of the inhibitor could improve and extend the activity of mecillinam, even in the setting of infection with a high bacterial inoculum, and merits clinical evaluation.