Acute Otitis Media
John C Watkinson, Raymond W Clarke, Christopher P Aldren, Doris-Eva Bamiou, Raymond W Clarke, Richard M Irving, Haytham Kubba, Shakeel R Saeed in Paediatrics, The Ear, Skull Base, 2018
Although simple mastoidectomy represents the most reliable and effective surgical method to treat acute mastoiditis, a more conservative approach consisting of adequate parenteral antibiotic coverage with or without myringotomy is being increasingly adopted for children suffering from uncomplicated acute mastoiditis. The antibiotic of choice is generally a third-generation cephalosporin, or an aminopenicillin combined with a ²-lactamase inhibitor. If Pseudomonas aeruginosa is suspected, treatment should include ciprofloxacin, piperacillin or fosfomycin.45 Cases where there is a suspicion of intracranial complication and those not responding to conservative treatment should undergo cortical mastoidectomy. This may be combined with myringotomy with or without ventilation tube placement, and culture of the aspirate. This can be challenging surgery for the less experienced as the mastoid is often full of granulations and the facial nerve superficial in the young child. There is no uniformity in the literature as to the appropriate duration of observation prior to proceeding with surgery, with authors recommending periods in the wide range of 24–72 hours. The presence of a subperiosteal abscess, an unwell child, or a deteriorating clinical picture should prompt more rapid intervention. If in doubt, it is our recommendation to intervene to prevent complication, and sooner rather than later.
Enterococcus
Dongyou Liu in Laboratory Models for Foodborne Infections, 2017
For susceptible Enterococcus isolates, β-lactam agents (ampicillin and penicillin/aminopenicillin) are the drugs of choice for treating monomicrobial enterococcal infections (e.g., UTIs and nonendocarditis bacteremia). Treatment of polymicrobial infections (e.g., skin and subcutaneous infections and intraabdominal or pelvic infections) relies on a combination of ampicillin and other broad-spectrum antibiotics or a β-lactamase inhibitor (e.g., ampicillin-clavulanic acid or piperacillin-tazobactam). A glycopeptide (vancomycin or teicoplanin) may be employed as a single agent to treat simple enterococcal infections in patients with a serious allergy to penicillins. A combination of a glycopeptide and an aminoglycoside (gentamicin or streptomycin) may be considered for patients with serious allergies. Additionally, nitrofurantoin may be used to treat lower-tract urinary infections [3].
Drug Allergy
Pudupakkam K Vedanthan, Harold S Nelson, Shripad N Agashe, PA Mahesh, Rohit Katial in Textbook of Allergy for the Clinician, 2021
A 55-year-old woman with multiple myeloma reports that 10 years ago she received oral amoxicillin for pneumonia and developed immediate hives and throat swelling after the first dose. She was treated with diphenhydramine and steroids and switched to levofloxacin. In the years prior to this she had been treated with penicillin on at least two occasions without adverse events. She has avoided penicillin since that event. Five years ago she was treated with oral cephalexin for cellulitis and after the first dose developed immediate hives and wheezing. She has since been labeled with a penicillin and cephalosporin allergy and has avoided all beta-lactam antibiotics. She will likely need antibiotics during her upcoming therapy and is referred for evaluation and planning for desensitization. Given this history, skin testing is performed with penicillin, penicilloyl-polylysine, amoxicillin and ceftazadime. The only positive reaction is to amoxicillin. It is determined she is allergic to the shared side chain that is in both amoxicillin and cephalexin and not to the core beta-lactam ring of either penicillin or cephalosporin. Her allergies are specific to the aminopenicillin and a small subset of cephalosporin that share this common side chain. She tolerates all other beta-lactam antibiotics without issue.
Pleural infection: a closer look at the etiopathogenesis, microbiology and role of antibiotics
Published in Expert Review of Respiratory Medicine, 2019
Eihab O. Bedawi, Maged Hassan, David McCracken, Najib M. Rahman
Whilst certainly dated, lacking in humans, and based on ancient regimes, the literature seems to suggest that most antibiotics show good pleural fluid penetration, with the antibiotic exceeding the minimum inhibitory concentration (MIC) for the bacteria for which it would be normally used [73]. As mentioned earlier, the notable exception is gentamicin and current guidelines, therefore, recommend against the use of aminoglycosides in pleural infection [40,74]. The initial selection of agent should always depend on whether the patient is likely to have a community or hospital-acquired infection, given our greater understanding in the last decade, of the variation in microbiology as described above. This should then be correlated with local hospital policies and antibiotic resistance patterns. In community-acquired infection, treatment with an aminopenicillin will cover the common causative organisms, but a beta-lactamase inhibitor such as co-amoxiclav or metronidazole should also be given due to the frequent co-existence of penicillin-resistant aerobes (including staph aureus) and anaerobic bacteria. Clindamycin, alone, or in combination with ciprofloxacin or a cephalosporin are likely to provide good alternatives for patients with penicillin allergy [40]. In the setting of hospital-acquired or post-surgical infection, vancomycin and piperacillin/tazobactam will cover the added risk of MRSA and Pseudomonas. Vancomycin and meropenem may be indicated if there is a history or suspicion of extended-spectrum beta-lactamase producing organisms [40,80].
Listeria monocytogenes sepsis in the nursing home community: a case report and short review of the literature
Published in Acta Clinica Belgica, 2018
Griet Buyck, Veronique Devriendt, Anne-Marie Van den Abeele, Christian Bachmann
Listeria is susceptible to most antibiotics but establishes intrinsic resistance to cephalosporins. In case of gastroenteritis in immunocompetent patients, the illness has usually resolved by the time Listeria is identified and antibiotic treatment is not necessary. Aminopenicillin or benzylpenicillin is considered the gold standard in antibiotic treatment of serious Listeria infections, in high dosage for adults (2 g intravenous every four hours and 4 million units every four hours, respectively). In case of central nervous system (CNS) infections, endocarditis, infections in neonates and immunocompromised patients, combination therapy with an aminoglycoside is being added. The alternative for penicillin-allergic patients is trimethoprim-sulfamethoxazole. Patients at risk of Listeria monocytogenes are often immunocompromised and vulnerable, and guidelines for empiric antibiotic treatment may therefore recommend broad-spectrum antibiotics like piperacillin/tazobactam or carbapenems. However, no randomized trials exploring optimal antimicrobial treatment or duration of therapy for invasive Listeria monocytogenes infections have been conducted [1]. Two weeks of antibiotic treatment is sufficient for bacteremia in immunocompetent patients, and two to four weeks for CNS infections. In immunocompromised patients, relapses can occur after two weeks of treatment so three to six weeks is advisable in case of bacteremia and four to eight weeks in case of CNS infections [11].
Combatting resistant enterococcal infections: a pharmacotherapy review
Published in Expert Opinion on Pharmacotherapy, 2018
Nicholas J Mercuro, Susan L Davis, Marcus J Zervos, Erica S Herc
Clinical and in vitro data support aminopenicillin combinations for E. faecalis endocarditis [90]. A multicenter observational cohort described similar mortality in patients receiving ceftriaxone and ampicillin compared to patients who received ampicillin and gentamicin, despite patients in the ampicillin/ceftriaxone group having more comorbidities. Interruption in antibiotic treatment due to adverse effects was more common in the aminoglycoside group, mostly from renal failure [41]. These regimens may be applicable to other severe, complicated infections on a case-by-case basis [91]. An assessment of harm and benefit should be performed when selecting an adjuvant aminoglycoside vs. cephalosporin, in the absence of HLAR. While cephalosporins increase the risk of C. difficile, many patients will not tolerate aminoglycoside toxicities. To improve safety in high-risk populations, reducing aminoglycoside duration of therapy to two weeks and reducing frequency to once-daily dosing may attenuate nephrotoxicity [92]. If penicillin allergic, we strongly suggest obtaining an accurate allergy history and undergoing desensitization if necessary. If desensitization is not feasible, daptomycin in combination with a cephalosporin, aminoglycoside, or intravenous fosfomycin (when available) can be considered for complicated bloodstream infections (Figure 3). While guidelines recommend vancomycin with an aminoglycoside in these cases, patients are unlikely to tolerate the regimen for a long duration due to nephrotoxicity.
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