Robert P. Lewis

Bone infections involving anaerobic bacteria.

Over 700 cases of anaerobic osteomyelitis have been reported in the literature. Nonetheless, most reviews of osteomyelitis have paid little attention to the potential role of anaerobes in bone infections. There have, as yet, been no prospective studies of osteomyelitis utlizing optimal anaerobic transport and culture techniques. In a retrospective study of osteomyelitis at Wadsworth VA Hospital from 1973--1975, 39 percent of 58 patients with osteomyelitis had an infection involving anaerobes. Anaerobes were isolated from 81 percent of 27 patients whose specimens were cultured anaerobically. Anaerobes were isolated from nine of ten samples of bone. Anaerobic bacteria were part of a mixed flora involving facultative bacteria in all but two cases. All of the patients with anaerobic infection had non-hematogenous osteomyelitis. Non-hematogenous disease comprises 80--90 percent of the osteomyelitis seen in adults. Our experience at Wadsworth VA Hospital and a review of the literature lead us to believe that anaerobes play a much larger role in osteomyelitis than has been appreciated previously. Infections of the calvarium, mastoid, mandible, maxilla and the extremities are most likely to involve anaerobes. Predisposing conditions include paranasal sinusitis, otitis media, periodontal disease, trauma, peripheral vascular disease, peripheral neuropathy and/or chronic osteomyelitis. The presence of a foul odor is a valuable clinical clue to the presence of anaerobes. Bacteroides, fusobacteria and anaerobic cocci have been reported with almost equal frequency from anaerobic bone infections. While Bacteroides fragilis is the most common anaerobe isolated in infections of other organ systems, it does not appear to be a common pathogen in anaerobic bone infections. The role of anaerobes in osteomyelitis is not yet resolved. They have been isolated in pure culture from infected bone, and under those circumstances are clearly pathogenic. Anaerobes are found more frequently as part of a mixed flora with facultative streptococci, gram-negative bacilli, and less often with S. aureus. In this setting it is unclear which organism or organisms are the primary invaders, or whether there is a synergistic mechanism of infection. The reliability of sinus drainage cultures also remains to be determined. Our retrospective study suggests that certain anaerobes isolated from sinus drainage are not present in infected bone. Cultures of bone or an abscess adjacent to bone would be expected to give more reliable data. The majority of anaerobes other than B. fragilis are susceptible to levels of penicillin achievable with parenteral administration of the antibiotic. Anaerobic pathogens should be sought in the situations noted above. We feel that parenteral penicillin should be part of the initial antibiotic regimen in patients with suspected or documented anaerobic bone infection...

Antibacterial Activity of Selected Beta-Lactam and Aminoglycoside Antibiotics Against Cephalothin-Resistant Enterobacteriaceae

The in vitro antibacterial activity of four β-lactam antibiotics (cefatrizine [BL-S640], cefamandole, cefoxitin, and carbenicillin) and three aminoglycosides (amikacin, gentamicin, and tobramycin) was determined against 197 strains of cephalothin-resistant Enterobacteriaceae. Eighty strains were found to be gentamicin-sensitive, and 117 were found to be gentamicin-resistant. Carbenicillin was the most active β-lactam antibiotic against gentamicin-sensitive Serratia marcescens and Enterobacter spp. Cefoxitin was the most active β-lactam antibiotic against the remaining gentamicin-sensitive and -resistant Enterobacteriaceae, including Providencia stuartii and indole-positive Proteus spp. Cefatrizine exhibited little activity against the organisms studied. Cefamandole was less active than cefoxitin and carbenicillin. Amikacin was the most effective agent in vitro. With the exception of S. marcescens, cefoxitin appeared to be the next most promising agent in vitro against gentamicin- and cephalothin-resistant Enterobacteriaceae.

Amikacin Therapy for Gram-Negative Septicemia

Amikacin was administered to 18 patients with gram-negative septicemia. Ten of the patients had blood culture isolates highly resistant to gentamicin; six of these patients had persistent bacteremia while receiving gentamicin alone or in combination with other agents. Fourteen of the 18 patients were cured with amikacin therapy and adjunctive measures. Nine of the 10 patients with gentamicin-resistant pathogens were cured. The occurrence of nephrotoxicity in four patients with elevated amikacin serum levels and serious underlying disease indicates the desirability of monitoring serum amikacin levels. Minor ototoxicity occurred in two patients and was associated with prolonged therapy and high serum amikacin levels. Amikacin is a highly effective agent for treating patients with gram-negative bacteremia; it is the agent of choice in the therapy of patients with suspected or documented gram-negative bacteremia caused by pathogens resistant to gentamicin and susceptible to amikacin.

Effect of carbon dioxide on in vitro susceptibility of anaerobic bacteria to erythromycin.

The activity of erythromycin against 317 strains of anaerobic bacteria, including 133 strains of the Bacteroides fragilis group, was tested by the agar dilution method in an anaerobic atmosphere with two different concentrations of carbon dioxide and without CO2. The effect of the atmosphere of incubation on the agar surface pH was also determined. All strains grew well in the GasPak (GP) environment. However, 3.5 and 30.3% of strains failed to grow in the 2 and 0% CO2 environments, respectively. The quality of growth was best in the GP environment and poorest in the 0% CO2 environment. Minimal inhibitory concentrations in the GP and 2% CO2 environments were frequently the same or one dilution lower in the 0% than in the GP environment. In the 0% CO2 atmosphere, minimal inhibitory concentrations were usually two to three dilutions lower than in the GP environment. Consequently, only 24% of B. fragilis strains were susceptible to erythromycin in the GP environment, whereas 77% were susceptible in the 0% CO2 environment. For Fusobacterium species, 12% were susceptible to erythromycin in the GP environment, and 73% were susceptible in the 0% CO2 environment. There was a comparable decrease in pH in all three atmospheres tested. In vitro susceptibility testing of erythromycin against anaerobic bacteria should be performed in an atmosphere containing carbon dioxide.

Amikacin therapy of serious gram-negative bacillary infections in chronic hemodialysis patients.

Amikacin was used to treat 7 serious gram-negative bacillary infections in patients undergoing chronic hemodialysis. 4 were caused by pathogens resistant to gentamicin. 5 infections were cured; 1 was improved and another failed to respond. Mean 1-hour peak serum levels of amikacin ranged from 25.8 to 44.3 microgram/ml. Mean serum levels of amikacin after 6 h of hemodialysis were 61.5% of predialysis levels. Amikacin is highly effective but doses must be reduced in patients requiring hemodialysis and serum levels monitored to avoid ototoxicity.