L. Barth Reller

DOUBLE-BLIND PLACEBO CONTROLLED TRIAL OF ERYTHROMYCIN FOR TREATMENT OF CAMPYLOBACTER ENTERITIS

Although most strains of Campylobacter jejuni are susceptible in vitro to erythromycin and the drug has been recommended for treatment of campylobacter enteritis, prospective controlled trials have not been done. Erythromycin (250 mg 6-hourly for adults and 40 mg/kg daily for children) has been compared with placebo in a double-blind trial of 5-day therapy for acute campylobacter enteritis. The mean number of days of illness at onset of therapy was 5.6 for the treatment group (n = 15) and 6.5 for the placebo group (n = 14). There were no differences in temperature, symptoms, and stool characteristics between the two groups. The mean duration of unformed stools after treatment was 4.1 days in the erythromycin group and 3.5 days in the placebo group. Fever, when present, abated within 48 h in all but two patients in each group. Follow-up faecal cultures 2 days after completion of therapy, however, were negative in all 15 of the erythromycin-treated patients compared with 6 out of 14 controls. Thus erythromycin promptly eradicates C. jejuni from the faeces but does not alter the natural course of uncomplicated campylobacter enteritis when therapy begins 4 or more days after the onset of symptoms.

Multicenter Collaborative Evaluation of a Standardized Serum Bactericidal Test as a Predictor of Therapeutic Efficacy in Acute and Chronic Osteomyelitis

Forty-eight episodes of osteomyelitis, 30 acute and 18 chronic, were evaluated in a prospective multicenter collaborative study to determine whether a standardized serum bactericidal test could predict outcome of infection. All centers used a microdilution test method that defined the recognized important test variables, including inoculum size, culture medium, dilution technique, incubation time, method of subculture, and bactericidal endpoint. In patients with acute osteomyelitis, peak serum bactericidal titers had no predictive value; however, trough titers of 1:2 or greater accurately predicted cure, whereas trough titers of less than 1:2 predicted therapeutic failure. In patients with chronic osteomyelitis, peak serum bactericidal titers of 1:16 or greater and trough titers of 1:4 or greater accurately predicted cure, whereas peak titers of less than 1:16 and trough titers of less than 1:2 accurately predicted failure. It is concluded that this standardized serum bactericidal test provides good prognostic information in patients with osteomyelitis, and it is recommended that patients with acute osteomyelitis have serum bactericidal titers of 1:2 or greater at all times and that patients with chronic osteomyelitis have serum bactericidal titers of 1:4 or greater at all times.

Rifampin-resistant meningococcal disease in a contact patient given prophylactic rifampin

In 1943, sulfonamide chemoprophylaxis was shown to be effective in l imiting the spread of epidemic meningococcal disease2 Sulfonamides remained the preferred chemoprophylactic agents until the widespread emergence of sulfonamide-res is tant meningococcal s trains in the 1960s. 2 Studies in mil i tary and civilian populations subsequent ly demons t ra ted tha t both minocycline and r i fampin were 60% to 90% effective in eradicat ing nasal carr iage of Neisseria meningitidi s. Although nei ther agent has been proven effective by controlled clinical trials in prevent ing secondary cases, they are considered effective agents for meningoc0ccal chemoprophylaxis. 2 Because of f requent vest ibular toxici ty associated with prophylact ic minocYcline use, r i fampin is the ,preferred chemoprophylac t ic agent. However, r i fampin prophylaxis has been associated with up to a i2% subsequent frequency of res is tant meningococcal isolates in the nasopharynx? -6 W e now report meningococcal disease caused by a r i fampinresistant organism in a person who had received r i fampin chemoprophylaxis .

Susceptibility of Clostridium perfringens Isolated from Human Infections to Twenty Antibiotics

The proper choice of antibiotic for Clostridium perfringens infections in patients allergic to penicillin is not clear; the usual recommendations and recent in vitro studies disagree. We tested the susceptibility of 57 strains of C. perfringens to eight penicillins, seven cephalosporins, two tetracyclines, clindamycin, chloramphenicol, and rifampin by the agar dilution method. All strains were inhibited by (per milliliter) 4 μg or less of any of the penicillins, chloramphenicol, or clindamycin and 8 μg or less of any of the cephalosporins tested. Penicillin G and amoxicillin inhibited all strains at 0.12 μg or less per ml. Only 54% of the strains were inhibited by 1 μg of tetracycline per ml. Penicillin G remains the drug of first choice for infections with C. perfringens; it need not be added to a regimen containing a penicillinase-resistant penicillin given parenterally in high doses. The cephalosporins should be considered as alternative drugs for penicillin-allergic patients. Clindamycin and chloramphenicol are also effective. Tetracyclines cannot be depended upon in clostridial infections without in vitro testing, which is impracticable for initial empirical therapy.

Biliary flora and antimicrobial concentrations after Kasai's operation***

In 1976, a prospective study of children following hepatic portoenterostomy was initiated to determine (1) the efficacy of hepatic antimicrobial excretion, (2) the relationship of antimicrobial levels in bile to bilirubin clearance, and (3) the effect of antimicrobials in bile on the growth of bacteria within the bilioenteric conduit. Fifty simultaneous blood-bile peak-trough antimicrobial levels were assayed in 10 patients. Cephalosporin, aminoglycoside, and trimethoprim-sulfamethoxazole levels were determined 20, 19, and 4 times, respectively. Simultaneous quantitative bile cultures and bilirubin clearance measurements also were obtained. Adequate mean antimicrobial concentrations in serum were achieved. Detectable antimicrobial concentrations in bile were found in 100% of the patients receiving trimethoprim-sulfamethoxazole, 65% of those receiving cephalosporins, and 10% receiving aminoglycosides. Mean bile levels for each antimicrobial were always less than simultaneous serum levels. The mean bile to serum ratios of trimethoprim-sulfamethoxazole, cephalosporins, and aminoglycosides were 0.90, 0.32, and 0.01, respectively. There was no correlation between bilirubin clearance and antimicrobial levels in bile. The presence of antimicrobials in bile did not alter the frequency, type, or concentration of bacterial growth within the bilioenteric conduit. Antimicrobial activity in bile after hepatic portoenterostomy is characterized by: (1) moderate concentrations of trimethoprim-sulfamethoxazole and cephalosporins and low levels of aminoglycosides, (2) the independence of bilirubin clearance and antimicrobial bile concentrations, and (3) the inability to eliminate bacterial growth within the bilioenteric conduit with the achieved biliary antimicrobial levels.

Current status of the serum bactericidal test as a monitor of therapeutic efficacy in serious infections

In this issue, authors Weinstein, Stratton, and Relier review the clinical and methodological history of the serumcidal endpoint assay and cite their recent experience that documents the tests effectiveness. The Schlichter or serum bactericidal test closely mirrors the vicissitudes in the struggle between host and parasite. The assay represents one of the few in vitro tests performed in the laboratory that monitor the net interaction between bug, drug, and host. The test procedure encompasses offending microorganism and patients serum, which represents CURRENT STATUS OF THE SERUM BACTERICIDAL TEST AS A MONITOR OF THERAPEUTIC EFFICACY IN SERIOUS INFECTIONS

Valve Resection for Endocarditis

Excerpt To the editor: The report by Chandraratna and colleagues (1) states that surgical resection of a vegetation, without valve replacement, has not been previously reported. As a medical inte...