Antibiotic dry buffalo therapy: effect of intramammary administration of benzathine cloxacillin against Staphylococcus aureus mastitis in dairy water buffalo.

BACKGROUND: Mastitis is one of the most costly diseases in Mediterranean buffalo (MB). At present, just a few specific antibiotics registered for this dairy specie have been synthetized. Efficacy of an antibiotic dry buffalo therapy (aDBT) against Staphylococcus aureus (S. aureus) mastitis, based on intra-quarter administration of 600 mg of benzathine cloxacillin, have been evaluated for the first time. Eighty MB's quarters received a drying-off therapy (aDBT-group) and 80 were left untreated (no-aDBT-group). They were sampled at drying-off (pre-treatment) and at the resumption of milking [< 10 days in milk (DIM)]. Fresh calver mastitis rate, dry period new mastitis rate, dry period cure rate, and persistent mastitis rate were calculated for clinical monitoring. Overall proportion of positive quarters/animals, quarters affected by mastitis or intramammary infections (IMI), effects on somatic cell count (SCC) and milk yield were also assessed. RESULTS: An inter-group difference (aDBT vs. no-aDBT) was recorded for all the indexes considered. An intra-group (drying-off vs. < 10 DIM) difference was detected in aDBT-group regarding the proportion of positive-cultured quarters and animals. Concerning the latter, an inter-groups difference was also recorded at second sampling. No clinical mastitis due to the S. aureus was observed. Regarding the subclinical ones, a higher intra-group difference was observed in aDBT than no-aDBT group, while an inter-group difference was recorded at second sampling. No protective effect was observed against IMI. SCC showed an inter-group difference at second sampling, while none difference was instead detected for milk yield. CONCLUSIONS: The effects against S. aureus mastitis of benzathine cloxacillin administration at drying-off were assessed for the first time in MB. Its use shows encouraging results in reducing the proportion of mastitis and positive animals at the resumption of the lactation.

Cloxacillin benzathine-loaded polymeric nanocapsules: Physicochemical characterization, cell uptake, and intramammary antimicrobial effect.

The present work shows the development and evaluation of the veterinary antibiotic cloxacillin benzathine (CLOXB) loaded into poly-ε-caprolactone (PCL) nanocapsules (NC), as a potential new treatment strategy to manage bovine intramammary infections, such as mastitis. Staphylococcus aureus-induced mastitis is often a recurrent disease due to the persistence of bacteria within infected cells. CLOXB-PCL NC were prepared by interfacial deposition of preformed biodegradable polymer followed by solvent displacement method. The mean diameter of NC varied from 241 to 428 nm and from 326 to 375 nm, when determined by dynamic light scattering and by atomic force microscopy, respectively. The zeta potential of NC was negative and varied from -28 to -51 mV. In vitro release studies from the NC were performed in two media under sink conditions: PBS with 1% polyethylene glycol or milk. A reversed-phase HPLC method was developed to determine the NC entrapment efficiency and kinetics of CLOXB release from the NC. Free CLOXB dissolution occurred very fast in both media, while drug release from the NC was slower and incomplete (below 50%) after 9 h. CLOXB release kinetics from polymeric NC was fitted with the Korsmeyer-Peppas model indicating that CLOXB release is governed by diffusion following Fick's law. The fluorescence confocal microscopy images of macrophage-like J774A.1 cells reveal NC uptake and internalization in vitro. In addition, antimicrobial effect of the intramammary administration of CLOXB-PCL NC in cows with mastitis resulted in no clinical signs of toxicity and allowed complete pathogen elimination after treatment. The in vivo results obtained in this work suggest that CLOXB-PCL NC could be a promising formulation for the treatment of intramammary infections in cattle, considering their physicochemical properties, release profiles and effects on bovine mastitis control.

Randomized noninferiority study evaluating the efficacy of 2 commercial dry cow mastitis formulations.

The study objective was to compare the efficacy of 2 commercial dry cow mastitis formulations containing cloxacillin benzathine or ceftiofur hydrochloride. Quarter-level outcomes included prevalence of intramammary infection (IMI) postcalving, risk for cure of preexisting infections, risk for acquiring a new IMI during the dry period, and risk for clinical mastitis between dry off and 100 d in milk (DIM). Cow-level outcomes included the risk for clinical mastitis and the risk for removal from the herd between dry off and 100 DIM, as well as Dairy Herd Improvement Association (DHIA) test-day milk component and production measures between calving and 100 DIM. A total of 799 cows from 4 Wisconsin dairy herds were enrolled at dry off and randomized to 1 of the 2 commercial dry cow therapy (DCT) treatments: cloxacillin benzathine (DC; n=401) or ceftiofur hydrochloride (SM; n=398). Aseptic quarter milk samples were collected for routine bacteriological culture before DCT at dry off and again at 0 to 10 DIM. Data describing clinical mastitis cases and DHIA test-day results were retrieved from on-farm electronic records. The overall crude quarter-level prevalence of IMI at dry off was 34.7% and was not different between treatment groups. Ninety-six percent of infections at dry off were of gram-positive organisms, with coagulase-negative Staphylococcus and Aerococcus spp. isolated most frequently. Mixed logistic regression analysis showed no difference between treatments as to the risk for presence of IMI at 0 to 10 DIM (DC=22.4%, SM=19.9%) or on the risk for acquiring a new IMI between dry off and 0 to 10 DIM (DC=16.6%, SM=14.1%). Noninferiority analysis and mixed logistic regression analysis both showed no treatment difference in risk for a cure between dry off and 0 to 10 DIM (DC=84.8%, SM=85.7%). Cox proportional hazards regression showed no difference between treatments in quarter-level risk for clinical mastitis (DC=1.99%, SM=2.96%), cow-level risk for clinical mastitis (DC=17.0%, SM=15.3%), or on risk for removal from the herd (DC=10.7%, SM=10.3%) between dry off and 100 DIM. Finally, multivariable linear regression with repeated measures showed no overall no difference between treatments in DHIA test-day somatic cell count linear score (DC=2.19, SM=2.22), butterfat test (DC=3.84%, SM=3.86%), protein test (DC=3.02%, SM=3.02%), or 305-d mature-equivalent milk production (DC=11,817 kg, SM=11,932 kg) between calving and 100 DIM. In conclusion, DC was noninferior to SM in effecting a cure, and there was no difference in efficacy between these 2 DCT formulations as related to all other udder health or cow performance measures evaluated between dry off and 100 DIM.

Tissue distribution of cloxacillin after intramammary administration in the isolated perfused bovine udder.

BACKGROUND: Various intramammary suspensions containing cloxacillin benzathine are registered for use in cattle as antibiotics for intramammary use at drying off. To ensure antibacterial efficacy, the glandular tissue concentration of an antimicrobial agent must be sufficient. Since the possibilities to measure concentrations in the different areas of the glandular tissue in vivo are very limited, it was the aim of the present study to examine the distribution of cloxacillin in vitro using the isolated perfused bovine udder. METHODS: Mammary glands taken at slaughter from healthy lactating cows were perfused in vitro with warmed and gassed Tyrode solution. 600 mg cloxacillin benzathine were administered as Orbenin Extra Dry Cow by the intramammary route to six front and rear quarters each. Samples of glandular tissue--at different distances from and vertical to the teat right up to the udder base--were gathered from the treated quarters after 6 h. Perfusate was also sampled before and hourly after treatment for 6 h. The cloxacillin content of the tissue samples and perfusate samples was analysed by high performance liquid chromatography. RESULTS: The concentration of cloxacillin in the glandular tissue of front quarters measured 6 h after administration tended to decrease with increasing vertical distance from the teat. The decrease pattern of the concentration was not quite clear in rear quarters. A considerable variation in the tissue concentrations of cloxacillin was obvious, which reflects in vivo conditions. The concentrations measured in the perfusate samples were below the limit of quantification at all time points, indicating limited absorption of the antibiotic from the glandular tissue. CONCLUSION: After intramammary administration of the dry off product containing cloxacillin benzathine concentrations of more than 0.5 µg/g (MIC) were reached in all regions of the front and rear quarters.

Influence of the genotype of Staphylococcus aureus, determined by pulsed-field gel electrophoresis, on dry-period elimination of subclinical mastitis in Canadian dairy herds.

By combining information from 2 databases, we investigated the possibility of an association between the genotype of Staphylococcus aureus causing bovine intramammary infection and dry-period cure of subclinical infection. The 1st database contained bacteriologic and cow data from a field study evaluating the efficacy in such infections of a new intramammary dry-cow therapy (DCT) containing tilmicosin phosphate, in comparison with a commercially available DCT containing benzathine cloxacillin. Isolates of S. aureus from that study were frozen and later independently analyzed by pulsed-field gel electrophoresis (PFGE) and macrorestriction DNA fingerprinting. The molecular information, summarized and published elsewhere, constituted the 2nd database. Data from 121 subclinically infected quarters of 92 cows from 40 herds were studied by univariate and multivariable regression analysis. Infection by an isolate of PFGE lineage group D was more likely than infection by an isolate of group A or F to be cured (P < 0.05). Cows infected by lineage group D had a higher linear somatic cell count score (LS) from the last Dairy Herd Improvement test before the dry period than did cows infected by the other lineage groups (P = 0.04). Although the probability of cure was significantly lower for cows with an LS at or above the mean of 5.7 for the study population (P = 0.05), when such a cow was infected with lineage group D, cure was significantly more likely (P < 0.001) than when it was infected by another lineage group. Significantly more (P = 0.02) of the infections treated with tilmicosin (74%) than of those treated with benzathine cloxacillin (53%) were cured, and significantly more (P = 0.05) of the infections by group D (81%) than of those by group A (57%) or group F (54%) were cured. However, there was no difference in cure rate for any PFGE genotype when tilmicosin phosphate was administered; when benzathine cloxacillin was administered, 87% of lineage group D isolates were eliminated, as compared with 46% of group A and 33% of group F isolates (P < 0.05). This research demonstrates that certain genotypes of S. aureus may naturally elicit a greater inflammatory response, yet be more susceptible to elimination by antibiotics in the dry period, than other genotypes.

Efficacy of intramammary tilmicosin and risk factors for cure of Staphylococcus aureus infection in the dry period.

The objective ofthis study was to evaluate the efficacy of intramammary tilmicosin, administered at drying-off, for eliminating Staphylococcus aureus infection, and to identify risk factors for S. aureus cure during the dry period. A total of 219 naturally infected cows, representing 308 quarters, were randomized to receive either one of two treatments at drying-off. Cows received either an intramammary infusion of 500 mg of benzathine cloxacillin, or a sterile solution containing 1,500 mg of tilmicosin. All cows had quarter milk samples taken aseptically three times before dry-off, and at wk 1, 2, and 4 of the subsequent lactation. Overall, 62% of cows and 67.5% of quarters infected with S. aureus cured during the dry period. The cure following administraton of tilmicosin was 67.3 and 72.5% for cows and quarters, respectively. By comparison, the cure achieved with cloxacillin was 56.9 and 62.9% of cows and quarters. Cows receiving tilmicosin were 2.1 times more likely to cure. The cure rate for cows decreased as the linear score on the last DHI test increased, and as the amount of S. aureus being shed increased. Quarters that cultured positive multiple times before drying-off were less likely to cure. Staphylococcus aureus infections located in front quarters of the udder were 2 times more likely to cure than those in hind quarters. Results of this study demonstrate that intramammary tilmicosin at drying-off is efficacious in curing existing S. aureus during the dry period. Risk factors associated with the cure of S. aureus were identified.

The synthesis and evaluation of 6-alkylidene-2'beta-substituted penam sulfones as beta-lactamase inhibitors.

Penicillin sulfones, which structurally incorporate both a 6-position alkylidene substituent and a 2'beta substituent, have been synthesized and evaluated as inhibitors of class C and class A serine beta-lactamases. Incorporation of the 2'beta-substituent generally improves inhibitory activity. Substituents that improve transport across the bacterial cell membrane have also been incorporated.

Strategies for mastitis control: dry cow therapy and culling.

The effects of three selection strategies for dry cow therapy on prevention of new infections and rate of antibiotic usage were compared. Quarter infection status of 1044 cows in 12 herds was determined by bacteriological methods at drying off, calving and three to five months into the following lactation. Cows that were uninfected at drying off were randomly allocated to treatment (whole udder, dry cow therapy) and non-treatment groups. Infected cows were randomly allocated to whole udder or infected quarter only treatments. The strategies compared were blanket treatment (treat all quarters of all cows), selective cow treatment (treat all quarters of any cow infected in one or more quarters) and selective quarter treatment (treat infected quarters only). Selective cow treatment was identified as the preferred strategy. Blanket treatment resulted in increased antibiotic usage (15.5 vs 6.4 tubes per infection eliminated) with no additional benefit, and selective quarter treatment resulted in a higher new infection rate (6.4% vs 3.9% quarters) in the dry period. The prevalence of infection within a herd at drying off had no influence on new infection rates in the dry period or early lactation. The cure rate after dry cow treatment (mean of 66%) decreased significantly with increasing age (P < 0.001). Cows infected in the previous lactation contributed over 76% of infections at calving and nearly 70% at mid-lactation. To lower the incidence of mastitis in a herd, a greater emphasis on culling of older infected cows and prevention of new infections during lactation is needed.

Effects of antibiotic therapy at drying off on mastitis in the dry period and early lactation.

Four strategies for selecting cows for intramammary therapy with benzathine cloxacillin at drying off were compared in 12 Victorian dairy herds. The bacteriological status of all quarters of all (1044) cows was determined just before drying off, within 2 d of calving, and again 3 to 5 months after calving. All cases of clinical mastitis (from calving to mid-lactation) were recorded. Cows not infected at drying off were allocated randomly to 2 subgroups of approximately 350 cows each: not infected, not treated (NI-NT), or not infected, all quarters treated (NI-AT). New infection rates in the dry period (3.8% for NI-NT vs 2.1% for NI-AT) and in early lactation (4.1% for NI-NT vs 3.9% for NI-AT) were low and these differences were not significant. Incidence of clinical mastitis in early lactation was almost 50% higher for the treated group of uninfected cows compared with the untreated group (0.05 less than p less than 0.1). Cows infected in one or more quarters at drying off were split randomly into 2 subgroups of approximately 170 cows each: infected, all quarters treated (I-AT), or infected quarters treated only (I-QT). The new infection rate during the dry period was nearly 4 times higher for I-QT (15.3%) due to significantly more new infections by Staphylococcus aureus and Streptococcus uberis.(ABSTRACT TRUNCATED AT 250 WORDS)

Flucloxacillin induced delayed cholestatic hepatitis.

We report four cases of severe delayed cholestatic hepatitis induced by flucloxacillin. All patients presented with deep jaundice and pruritus which developed soon after ceasing flucloxacillin. Liver function tests were abnormal in all patients with markedly elevated serum bilirubin concentration, alkaline phosphatase and aspartate transaminase levels. Extrahepatic biliary obstruction and infective hepatitis were excluded in all cases. Liver biopsies showed centrilobular cholestasis with portal and lobular inflammation and eosinophil infiltration. Although symptoms resolved within six weeks in all patients, cholestatic liver function tests have persisted in two patients for more than six months. With the increasing usage of this drug and the delayed presentation of cholestasis, flucloxacillin needs to be considered in the differential diagnosis of all patients presenting with cholestatic jaundice.

[Therapy of bacterial pharyngo-tonsillitis in children with piperacillin-flucloxacillin combination]. / Terapia delle faringotonsilliti batteriche nei bambini con l'associazione piperacillina-flucloxacillina.

The authors evaluated the activity and safety of piperacillin/flucloxacillin in 40 children suffering from bacterial pharyngo-tonsillitis. The combination proved to be effective with regard to this pathology and no toxic or allergic side-effects were reported. This confirms the wide spectrum of the antibiotic.

Effects of bovine mammary secretion during the early nonlactating period and antibiotics on polymorphonuclear neutrophil function and morphology.

The effect of bovine mammary secretion during the early nonlactating period and of antibiotic preparations on bovine polymorphonuclear neutrophil (PMN) phagocytic function and morphology were evaluated in a series of in vitro multifactorial experiments. Benzathine cloxacillin (CL), benzathine cephapirin (CE), sodium novobiocin (NO), and a combination of dihydrostreptomycin with procaine penicillin G (DP) were prepared in the presence and absence of a peanut oil aluminum monostearate vehicle. The PMN were isolated from bovine blood, and the effect of each antibiotic preparation on PMN function and morphology was evaluated in a buffer, fat, skin, and a combination of fat with skim from bovine mammary secretion during the nonlactating period. The fat and skim were diluted with buffer to approximate their concentration in mammary secretion. Phagocytic functions of PMN were monitored by fluorescent microscopy, which made it possible to estimate both ingestion and intracellular killing of bacteria by PMN. Changes in PMN morphology were monitored by transmission electron microscopy. The ability of PMN to ingest and kill Staphylococcus aureus ATCC 25923 was significantly decreased by fat, skim, CL, CE, NO, and DP. Effects of some antibiotics on ingestion and killing of bacteria by PMN were influenced by the addition of vehicle and by interactions with mammary secretion. Neutrophil morphology was altered by fat, skim, CL, CE, NO, and DP. The detrimental effects of CL, CE, NO, and DP on PMN morphology were influenced (some significantly) by the presence of vehicle and interactions with mammary secretion. There were significant correlations among secretion- and antibiotic-induced changes in PMN ingestion of bacteria, PMN killing of bacteria, and PMN morphology.

Ocular and serum disposition kinetics of cloxacillin after topical administration of benzathine cloxacillin and intravenous administration of sodium cloxacillin to calves.

Disposition kinetics of cloxacillin were examined in calves after topical administration of benzathine cloxacillin and single IV administration of sodium cloxacillin, and the susceptibility of 17 field isolates of Moraxella bovis was measured. For the IV pharmacokinetic phase, sodium cloxacillin was administered at dosage of 10 mg/kg of body weight to male Holstein calves (n = 6, weighing 146 to 170 kg), and serum concentration of cloxacillin was measured thereafter for 10 hours. For the ocular pharmacokinetic phase, 6 calves were given either of 4 benzathine cloxacillin topical formulations consisting of 50-, 125-, 250-, or 375-mg doses. Treatment was repeated every 10 days until all 4 benzathine cloxacillin dosages were tested in the same 6 calves. Blood and tears were collected for 72 hours after each benzathine cloxacillin formulation was administered, and the concentration of cloxacillin in each specimen was measured, using a bioassay. The minimal inhibitory concentration of cloxacillin for 17 field isolates of M bovis was determined by use of an agar pour-plate dilution assay. After single IV administration of sodium cloxacillin, its half-life, body clearance, and volume of distribution were 19.5 +/- 12.8 minutes, 18.3 +/- 2.2 ml/min.kg, and 496 +/- 290 ml/kg, respectively. After topical administration of benzathine cloxacillin, cloxacillin concentration in lacrimal fluid peaked between 30 and 45 minutes and ranged between 963 micrograms/ml and 3,256 micrograms/ml for the 125- and 375-mg doses, respectively. There was no detectable cloxacillin activity in the lacrimal fluid of any calf by 36 hours after topical administration of benzathine cloxacillin, and cloxacillin was not detected in the serum at any time.(ABSTRACT TRUNCATED AT 250 WORDS)

Topically applied benzathine cloxacillin for treatment of experimentally induced infectious bovine keratoconjunctivitis.

The efficacy of an ophthalmic ointment containing benzathine cloxacillin for treatment of infectious bovine keratoconjunctivitis was determined in 2 experiments. In the first experiment, Holstein calves (n = 6/group) were inoculated with Moraxella bovis and treated on postinoculation days 3 and 6 with either topically applied benzathine cloxacillin (250 mg/eye) or long-acting oxytetracycline formulation (20 mg/kg of body weight, IM). A third group of inoculated calves remained untreated as controls. For the second experiment, 4 groups of calves (n = 6/group) were inoculated and treated on postinoculation days 3 and 6 with 50, 125, 250, or 375 mg of benzathine cloxacillin; a fifth untreated group served as controls. Ocular specimens were obtained for microbiologic culture, and eyes were observed and assigned a clinical score daily. Eyes were photographed on alternate days. Ulcer surface area was measured, using a planimeter. In experiment 1, the week-2 ulcer surface area measurements for both groups of treated calves were smaller than those for controls. There was a greater frequency of M bovis isolation from the ocular secretions of controls than from those of benzathine cloxacillin-treated calves during postinoculation weeks 2 and 3. The number of M bovis isolations from the benzathine cloxacillin- and oxytetracycline-treated calves was not significantly different at any sample collection interval. On week 3, the scores of the benzathine cloxacillin-treated calves were smaller than those of controls. In experiment 2, calves of the 250- and 375-mg groups had smaller ulcer surface area measurements than did controls on week 2. By week 3, calves of the 375-mg group had smaller scores than did controls.(ABSTRACT TRUNCATED AT 250 WORDS)

A randomised comparison of ceftazidime and piperacillin, both in combination with flucloxacillin for treatment of febrile episodes in neutropenic children. Finnish Three-Centre Study.

111 febrile episodes in 98 neutropenic children were randomly treated with either ceftazidime (CAZ) 150 mg/kg/day or with piperacillin (PIP) 200 mg/kg/day, both combined with flucloxacillin (FLUC) 50 mg/kg/day. A total of 37/47 (79%) eligible episodes in the CAZ group and 41/53 (77%) in the PIP group were cured without needing to stop the initial therapy. The success without modification of the treatment in the verified septicaemias in the CAZ group was 8/18 (44%) and in the PIP group 5/18 (28%). Of the bacteriologically documented infections, 13/24 (54%) in the CAZ group and 11/24 (46%) in the PIP group were cured without modification of the therapy. Similarly, 17/31 (55%) of all the isolated bacteria in the CAZ group and 14/33 (42%) in the PIP group were eradicated with the initial therapy. Overall there were 13 deaths of which 4 in the CAZ group and 5 in the PIP group occurred during the infection. An increasing granulocyte count exceeding 0.25 x 10(9)/l at the end of the therapy was a good prognostic sign for the outcome of the infection. This study indicates that CAZ is as effective as PIP in the treatment of infections in neutropenic children.

Prolonged hepatic cholestasis after flucloxacillin therapy.

A severe prolonged illness that was characterized by deep jaundice and debilitating pruritus occurred in five patients after the use of flucloxacillin. The symptoms and signs of liver disease took at least two months to resolve; after four- to nine-months' follow-up, liver enzyme activities have remained abnormal in all patients. Examination of liver biopsy specimens showed severe cholestasis in all cases, with evidence of significant bile-duct injury in three cases. In one patient, in whom symptoms have persisted for nine months, examination of a liver biopsy specimen showed marked bile-duct depletion. All patients were seen during a four-month period and it is felt that flucloxacillin-induced liver disease probably has been under-diagnosed and underreported. The use of flucloxacillin has been increasing rapidly and it is anticipated that more cases of flucloxacillin hepatotoxicity will occur in the future.

Effectiveness of two benzathine cloxacillin formulations for treatment of naturally occurring infectious bovine keratoconjunctivitis.

A field study was performed to determine the effectiveness of benzathine cloxacillin for the treatment of infectious bovine keratoconjunctivitis in cattle from 2 farms located in northern California. The study was performed between June and September of 1987. Affected calves ranging from 2 to 9 months of age were selected from the main herd when signs of corneal ulceration were observed. The study was conducted in 2 phases. For phase I, the affected calves of herd 1 (n = 21; Holsteins) and herd 2 (n = 43 Angus crossbred), were randomly assigned to 1 of 3 groups, and were either treated with 250 (n = 23) or 375 mg (n = 21) of benzathine cloxacillin, or mineral oil (n = 20) on days 1 and 4. For phase II, affected calves (n = 16; Angus crossbred, 3 to 9 months of age) from herd 2 were treated with benzathine cloxacillin (250 mg). Eight of these calves were retreated on day 4. After treatment, all calves were examined every 72 hours for 16 days. For examinations, a clinical score was assigned to each eye, and the surface areas of photographed corneal ulcers were measured. The ocular secretions were collected and examined culturally for Moraxella bovis. On days 7, 10, and 13, the calves treated with benzathine cloxacillin had significantly (P less than 0.05) lower lesion scores, compared with the controls.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy of the combination of teicoplanin or flucloxacillin with netilmicin in the treatment of Staphylococcus aureus bacteraemia.

Twenty one patients with serious Staphylococcus aureus infection and bacteraemia were randomized prospectively to receive either teicoplanin and netilmicin or flucloxacillin and netilmicin. After at least 48 h of treatment serum samples were collected for the determination of trough and peak antibiotic concentrations, the serum killing level and the serum bactericidal rate. With the help of a severity-of-disease scoring system (APACHE II) the clinical efficacy of antimicrobial therapy was assessed. Eighteen patients were evaluable. The clinical results and the results of the serum assays suggest that treatment with teicoplanin or flucloxacillin, combined with netilmicin, is a safe approach in patients with bacteraemia caused by S. aureus.