[Neurologic side effects of fluoroquinolones. Apropos of 9 cases concerning pefloxacin]. / Effets indésirables neurologiques des fluoroquinolones. A propos de 9 observations concernant la péfloxacine.

Neurological side-effects were a limiting factor with older quinolones. Although they appear to be less frequent with the newer fluoroquinolones, we observed nine such cases at Amiens University Hospital over a four-year period. The patients were six women and three men, with a mean age of 61 years. They received a mean dose of 800 mg/day of pefloxacin. Four had septic shock, one left ventricular failure, and seven had signs of cholestasis (signs of liver failure were absent). Neurological manifestations occurred between 24 hours and seven days after starting treatment and disappeared within 24 to 48 hours of stopping the drug or reducing the dosage. They included myoclonia (3 cases), convulsions (2 cases, one with concomitant theophylline), delirium and agitation (2 cases, one in a patient on steroids) and confusion (3 cases). Plasma drug levels were determined in six patients and were above normal peak levels (10 micrograms/ml) in five. Pefloxacin was measured in the cerebrospinal fluid in two cases (8.7 and 15.0 micrograms/ml). Neurological manifestations during pefloxacin treatment are probably related to overdose (plasma levels were above normal in 5/6 cases), possibly being favoured by cholestasis (7/9 cases) and/or hemodynamic factors (5/9). Symptoms can resolve when the pefloxacin dosage is reduced.

The clinical significance of antibiotic-associated pseudomembranous colitis in the 1990s.

Antibiotic-associated pseudomembranous colitis is an uncommon but potentially serious adverse reaction, resulting in acute diarrhoea and characterised by colonic pseudomembranes. A direct relationship between the disease, recent antibiotic therapy and proliferation of Clostridium difficile in the colonic lumen was established in the late 1970s. It is thought that antibiotic therapy may alter the enteric flora, enabling C. difficile to proliferate and produce toxins with cytopathic (toxin B or cytotoxin) and hypersecretory (toxin A or enterotoxin) effects on the mucosa. Apart from clindamycin, the first antibiotic recognised to be clearly associated with pseudomembranous colitis, the antimicrobial agents most commonly responsible are cephalosporins and ampicillin (or amoxicillin). However, virtually all antibiotics except parenterally administered aminoglycosides can cause the disease. Vancomycin and metronidazole, 2 drugs used to treat antibiotic-associated pseudomembranous colitis, have also been reported to be responsible for the complication when used parenterally. Pseudomembranous colitis may develop after perioperative prophylactic antibiotic therapy with cephalosporins. Antibiotic-associated pseudomembranous colitis is most frequent in elderly and debilitated patients and in intensive care units. Nosocomial acquisition of C. difficile has been documented. Therefore it has been recommended that enteric isolation precautions should be taken with patients with this disease. The clinical symptoms include watery diarrhoea, abdominal cramping, and frequently fever, leucocytosis and hypoalbuminaemia. Toxic megacolon and acute peritonitis secondary to perforation of the colon are the most serious complications. The pseudomembranes are usually seen during endoscopic procedures, sigmoidoscopy or, if possible, colonoscopy; the most useful microbiological tests for confirmation of the diagnosis include cycloserine cefoxitin fructose agar (CCFA) stool cultures and stool toxin assays on tissues or by immunological techniques. However, cultures and toxin tests may be positive in patients without pseudomembranous colitis or C. difficile-associated diarrhoea. Mild cases may respond to discontinuation of the drug responsible, but therapy with an anticlostridial antibiotic is often necessary: a 10-day course of oral vancomycin, metronidazole or bacitracin should be given. Relapses are seen in 5 to 50% of patients treated. Antibiotic treatment should avoid sporulation leading to other relapses. 'Biotherapy' (lactobacilli, Saccharomyces) has also been proposed.

[Clinical and pharmacokinetic study of pefloxacin in spontaneous ascitic fluid infections]. / Etude clinique et pharmacocinétique de la péfloxacine dans les infections spontanées du liquide d'ascite.

Ten patients with spontaneous ascitic fluid infections received intravenously 400 mg of pefloxacin for pharmacokinetic evaluation of the drug and its diffusion into peritoneal space. The patients were then treated with oral pefloxacin (400 mg every 36 h except for icteric patients: 48 h) during 21 days. Total body clearance was decreased (0.66 +/- 0.16 ml/min/kg) and elimination half life was increased as compared to that observed in normal subject (28.2 +/- 7.6 h), the longest half-lives being observed in the cases with the most severe alteration of hepatic function. Peritoneal concentrations were higher than 1 microgram/ml (i.e. exceeding the minimal inhibitory concentrations for most of the bacterial species involved in ascitic fluid infections) from the first half-hour after infusion to at least 36 hours. 9 of the 10 cases were cured. Pefloxacin provided a well spaced rythm of administration is a suitable antibacterial drug for ascitic fluid infections in cirrhotic patients with two advantages: its effectiveness against Enterobacteriaceae and an oral administration.

[Treatment of aspiration pneumonia with piperacillin]. / Traitement des pneumopathies d'inhalation par la pipéracilline.

Clinical efficacy and safety of piperacillin were evaluated in 30 patients with a severe aspiration pneumonia admitted in our intensive care unit from july 1987 to december 1988. 20 women and 10 men (with a mean SAPS: 14) had a right pneumonia in 17 cases, left in 6, bilateral in 7 cases. A pathogen was isolated in 18 patients by protected distal catheterism, in 3 patients by blood cultures. 25 patients cured. However with a high isolation of Staphylococci it appears reasonable to associate piperacillin with an aminoglycoside before the obtention of bacteriological results.

[Prospective, randomized, controlled study of imipenem-cilastatin versus cefotaxime-amikacin in the treatment of lower respiratory tract infection and septicemia at intensive care units]. / Etude prospective randomisée contrôlée imipénème-cilastatine versus céfotaxime-amikacine dans le traitement des infections respiratoires inférieures et des septicémies de réanimation.

In a multicentre, prospective, controlled trial 211 patients with suspected septicaemia or pneumonia were allocated at random to either imipenem-cilastatin 500 mg 8-hourly or cefotaxime 1 g 6-hourly combined with amikacin 5 mg/kg 8-hourly. The treatments were administered for at least 5 days. Seventy patients on imipenem and 70 patients on cefotaxime-amikacin were assessable for comparison. There were no statistically significant differences between the two groups in underlying pathology and in the clinical results obtained: septicaemia 20/26 patients of the imipenem group and 20/25 patients of the cefotaxime-amikacin group were cured; pneumonia 38/44 patients of the imipenem group and 34/45 patients of the cefotaxime-amikacin group were cured. There were also no differences in the initial organisms and in the bacteriological cure rate, except for Pseudomonas aeruginosa. At the moment, imipenem administered alone is as effective as the cefotaxime-amikacin combination in the treatment of septicaemia or pneumonia in intensive care patients, with the exception of P. aeruginosa pneumonia in patients under assisted ventilation.

[10 fatal endocarditis: autopsy observations, causes of death]. / Dix endocardites mortelles: constatations autopsiques, causes du décès.

Among 841 autopsies realized between january 1982 and september 1988, by the Pathological the department of Amiens University Hospital the ten patients dead of infectious endocarditis have been autopsied. Macroscopic and microscopic observations have two cases of acute endocarditis and eight of subacute endocarditis. For the two patients dead of acute endocarditis, autopsy affirms the cardiovascular etiology of death. For the eight cases of subacute endocarditis, necropsic findings differs from the germs. In the three cases where the germ is a Staphylococcus aureus, the diagnosis of endocarditis was made before death and the cardiovascular etiology of death was affirmed by autopsy. For the other germs (3 Streptococcus sp, 1 Salmonella typhimurium, and 1 germ unknown), the diagnosis of endocarditis was made by autopsy, but necropsy disclosed the cause of death in only two cases.

[Choice of an anesthetic technic for venous surgery of the lower limbs]. / Choix d'une technique d'anesthésie pour la chirurgie veineuse des membres inférieurs.

The introduction of new anesthetic drugs and the option of administering anesthesia to outpatients for venous surgery of the lower limbs have modified the anesthesiologist's strategy. In addition, the final decision depends on the number of attending physicians (family doctor, phlebologist, surgeon, anesthesiologist, and of course, on the patient). The essential elements which determine the choice are: the methods preferred by the anesthesiologist, the patient's wishes, the duration, type and painful nature of the procedure. All types of anesthetic protocols may be employed. General anesthesia is often preferable because of its flexible administration and local anesthesia because it is simple to administer. Loco-regional anesthetics can be substituted for local types of anesthesia in bilateral surgical procedures but these are difficult to administer on an outpatient basis. Development of new drugs such as propofol is tending to give general anesthesia in outpatients an important role once again.

[The role of infection in the precipitation of periarteritis nodosa]. / Rôle de l'infection dans le déclenchement des angéites nécrosantes.

Circulating immune complexes are thought to play an essential part in the pathogenesis of necrosing angiitis. This theory also allows a role to be attributed to certain infectious agents (viral, bacterial, parasitic) in the development of periarteritis nodosa (PAN). An infectious syndrome was found in all our 9 patients, aged 26 to 69 years, with histologically confirmed PAN: previous infection (over 15 days before hospital admission): otitis, hepatitis B, tonsillitis, ascaris (Case n.7), pulmonary tuberculosis, brucellosis, seropositivity for Chlamydia trachomatis (Case n.9), paratyphoid (Case n.5), seropositivity for Yersiniosis pseudo-tuberculosis (Case n.2), seropositivity for Chlamydia trachomatis (Cases 3 and 4), seropositivity for toxoplasmosis (Cases 4 and 6), seropositivity for rubella (Case n.8). Recent infection (less than 15 days before hospital admission): staphylococcus aureus septicaemia (Case n.1); Group A betahemolytic streptococcal urinary infection (Case n.2); Group A betahemolytic streptococcal otitis media; pseudomonas aeruginosa and Klebsiella septicaemia; enterococcal cystitis (Case n.4); progressive pulmonary tuberculosis (Case n.6), acinetobacter pneumonia (Case n.9). The HBs antigen was only found in one patient (Case n.6), who had an active hepatitis.