Michael R. Alexander

Bronchial Secretion Levels of Amikacin

Amikacin was given to 14 noninfected men as three consecutive intramuscular injections (7.5 mg/kg) at 12-h intervals. Serum and bronchial secretion specimens were obtained at various times during flexible fiberoptic bronchoscopy after the final dose. Serum and bronchial secretion concentrations obtained between 1.5 and 2.0 h after the final dose ranged from 17 to 40 μg/ml and 2.3 to 8.4 μg/ml with a mean of 23.7 ± 2.9 and 5.23 ± 1.5 μg/ml, ±1 standard error of the mean, respectively. The highest bronchial secretion concentration in each subject correlated with the highest serum concentration (r = 0.83, P < 0.001), and all concurrent serum and bronchial secretion concentrations demonstrated a significant correlation (r = 0.82, P < 0.001). Clearance occurred at the same rate (half-life serum = 2.84 h; half-life of bronchial secretion = 2.60 h, P > 0.5). The mean bronchial secretion concentration of the 15 specimens obtained more than 7 h after the final dose was less than 1.0 μg/ml, with a range from 0.3 to 1.6 μg/ml. It is concluded that amikacin may achieve minimal inhibitory concentrations for many gram-negative bacteria in the bronchial secretions of noninfected patients 1 to 2 h after the final dose. However, levels fall below the reported minimal inhibitory concentrations against negative bacteria 6 to 7 h after the final dose. Furthermore, bronchial secretion levels may never reach the minimal inhibitory concentration against Pseudomonas aeruginosa.

IV Infusion Devices: Are they Always Justified?

Electronic infusion device (EID) use is increasing and contributes substantially to hospital costs, approximately

Selection of an Erythromycin for the Treatment of Pertussis

1 000 000 per year at the University of Michigan Hospitals. Only two studies have been conducted with the purpose of determining potential advantages of EID over less-expensive roller clamps. Neither clearly demonstrated that controllers are more beneficial than roller clamps. Pumps have not received this type of study. EID use should, therefore, be limited only to those situations in which they are decidedly advantageous.

Therapy of Chronic Obstructive Airways Disease

Pertussis is one of the most communicable diseases of the respiratory tract and the incidence of this disease has increased substantially in recent years. Bordetella pertussis is the major pathogen implicated and erythromycin is considered the drug of choice. Because more studies have reported bacteriological and clinical relapses with ethylsuccinate and stearate formulations than with the estolate preparation, erythromycin estolate 50 mg/kg/d in divided doses over a 14-day period is recommended for the treatment of pertussis. None of the studies, however, have directly compared various forms of erythromycin in these patients to establish superiority of one form over the others. Treatment should be initiated as soon as possible and patients should be followed closely to achieve maximal efficacy and minimize the spread of the disease.

Multi-Drug-Resistant Pulmonary Tuberculosis A Continuing Problem

The most frequently employed measure in attempts to alleviate symptoms and improve the quality of life of patients with chronic obstructive airways disease (COAD) is to prescribe medications. However, COAD is largely an irreversible condition and no therapeutic intervention has been shown to be universally useful. Theophylline or corticosteroid are occasionally helpful but most patients will not benefit. Of the remaining options, only oxygen has been shown to be effective in selected patients and should be administered on a continuous basis. It is becoming increasingly evident that clinicians should be more discriminating when making therapeutic decisions for persons with COAD. Maintenance therapy with pharmacological agents should be entertained only after individually conducted therapeutic trials. Moreover, enormous costs can result from treating even a small fraction of the population estimated to have COAD.

Treatment of Chronic Obstructive Pulmonary Disease With Orally Administered Theophylline: A Double-Blind, Controlled Study

A case of multiple-drug-resistant pulmonary tuberculosis (TB) is presented. The patients refusal to complete a course of drug therapy culminated in numerous relapses, treatment failures, and finally, death. Noncompliant drug behavior is probably the major cause of treatment failure. Supervised intermittent and short-course regimens can be utilized when patients demonstrate poor cooperation in self-medication programs. Resistance to first-line agents complicates retreatment of TB. Drug selection in these cases should be based on the results of sensitivity studies, and effective regimens frequently require the use of more toxic secondary agents. Although published guidelines for appropriate treatment of TB are available, inappropriate therapy continues to occur. Resistant organisms can be transmissible and virulent, and patients infected with them may serve as infector pools that produce new cases of primary resistance. The control of resistant TB depends on our ability to identify these individuals and to insure that they comply with effective drug regimens.