Journal of Antimicrobial Chemotherapy (1978) 4 (Suppl. B), 223-225
Cefoxitin sodium treatment of anaerobic and polymicrobial aerobic infections R. V. McCloskey
Among 23 patients with anaerobic infections, 9 1 % were cured or improved by treatment with cefoxitin sodium, as were 88% of 41 patients with polymicrobial aerobic infections. Treatment was either by intermittent i.v. infusion over 30 min, 2 g every 6 or 8 h, or by i.m. injection, 1 g every 6 h. Clinical improvement occurred in some patients despite persistence of pathogenic organisms.
Introduction
This study evaluated the efficacy of cefoxitin sodium, a new cephamycin ^-lactamaseresistant antibiotic, in a group of patients with anaerobic or polymicrobial aerobic infections co-existent with severe non-infectious or surgical disease. The 64 patients in this study were part of a total population of 214 patients treated with cefoxitin i.v. and 90 patients treated with cefoxitin i.m. Materials and methods
Cultures of blood, sputum, urine, body fluids, and purulent exudates were obtained from each patient before, during, and after treatment with cefoxitin. All aetiologic agents of infection were identified as to genus and species. The minimal inhibitory concentration (MFC) of cefoxitin for each organism was determined, in the case of aerobes, by use of the SteeTS replicator technique (Steers, Foltz, Graves & Rider, 1959). For anaerobic organisms, the method used to determine MIC was that of Sutter (Sutter & Finegold, 1975). Tn a group of 23 patients (Table I), infections were caused by one or more anaerobic species. The organisms most commonly isolated were Bacteroides spp., together with streptococci and clostridia. The average number of organisms isolated per patient was 1 -5. Surgical drainage was employed when warranted by the location of the infection; when the co-existing disease required them, supportive measures were employed. Tn 15 of the 23 patients, cefoxitin (2 g in 250 ml of physiologic saline solution) was given by intermittent i.v. infusion OVCT 30 min, 2 g every 6 or 8 h, as determined by clinical presentation. The mean i.v. dose of cefoxitin was 10-5 g/day. In 8 patients less seriously ill, cefoxitin, 1 g in 2 ml of 0-5 % xylocaine, was injected i.m. alternately into left and right buttocks every 6 h. 223
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Department of Medicine, Section of Infectious Diseases, Albert Einstein Medical Center, Daroff Division, Philadelphia, Pennsylvania, U.S.A.
R. V. McCloskey
224
In 41 other patients, polymicrobial aerobic infections co-existed with serious noninfectious medical problems (Table I). Most frequently, the non-infectious conditions weTe diabetic ketoacidosis, congestive heart failure, malnutrition, cancer, anaemia, and chronic alcoholism. Infection was most commonly caused by some combination of Escherichia coli, Proteus spp., staphylococci, and streptococci. The average number of organisms isolated per patient was 2-8. Cefoxitin i.v. therapy was employed in 33 of these 41 patients and i.m. therapy was employed in 8 others. Table I. Results of cefoxitin therapy in anaerobic infections Route of administration
Number of patients 15 8 23
Intravenous* Intramuscularf Total
33 8 41
Pathogens persistent
Cured
Improved
Improved
Failed
10 3 13 (57%)
Anaerobic 4 3 7 (30%)
0 1 1 (4%)
1 1 2 (9%)
Polymicrobial aerobic 14 9 3 2 3 0 16 12 3 (39%) (29%) (7%)
5 3 8 (19%)
2 0 2 (5%)
*2 g every 6 or 8 h (2 g in 250 ml of physiologic saline solution infused intermittently over 30 min). •fl g in 2 ml of 0-5 % xylocaine injected alternately into left and right buttocks every 6 h.
Before, during, and after treatment with cefoxitin, the following laboratory determinations were made for each patient: complete haemogram, prothrombin time, quantitative platelet concentration, direct Coombs test, alkaline phosphatase, bilinibin, SGOT, SGPT, LDH, semm concentrations of sodium, potassium, chloride, CO 2 , and creatinine, blood urea nitrogen (BUN), blood glucose concentration, and urinalysis. Results Among patients with purely anaerobic infections, clinical cure and eradication of infecting organisms was achieved in 13 of the 23 patients (57%), and an additional 7 patients (30 %) showed clinical improvement. Of 3 patients in whom the infecting organisms persisted, 1 showed clinical improvement. Among patients with polymicrobial aerobic infections, clinical cure was achieved in 16 of 41 patients (39 %), and 20 others (49 %) showed clinical improvement. Five patients (12%) failed to improve. The infecting pathogens were eradicated in 31 of 41 patients (76%). In some instances, the clinical response was one of improvement, even though not all of the original infecting pathogens had been eradicated. Discussion Under actual clinical conditions, the treatment of seriously ill patients whose infection is likely to have been caused by mixed anaerobic or polymicrobial aerobic bacteria cannot
Downloaded from http://jac.oxfordjournals.org/ at University of Michigan on July 14, 2015
Intravenous* Intramuscular! Total
Pathogens eradicated
Anaerobic and polymicroblal aerobic infections
225
References Fass, R. J., Ruiz, D. F., Gardner, W. G. & Rotilie, C. A. Clindamycin and gentamicin for aerobic and anaerobic sepsis. Archives of Internal Medicine 83: 375-89 (1977). Kosmidis, J., Hamilton-Miller, J. M. T., Gilchrist, J. N. G., Kerry, D. W. & Brumfitt, W. Cefoxitin, a new semi-synthetic cephamycin: an in vitro and in vivo comparison with cephalothin. British MedicalJournal iv: 653-5 (1973). McCIoskey, R. V. Results of a clinical trial of cefoxitin, a new cephamycin antibiotic. Antimicrobial Agents and Chemotherapy (in press). Steers, E. E., Foltz, E. L., Graves, B. S. & Rider, J. An inocular replicating apparatus for routine testing of bacterial susceptibility to antibiotics. Antibiotics and Chemotherapy 9: 308-11 (1959). Sutter, V. L. & Finegold, S. M. Susceptibility of anaerobic bacteria to carbenicillin, cefoxitin, and related drugs. Journal of Infectious Diseases 131: 417-22 (1975).
Downloaded from http://jac.oxfordjournals.org/ at University of Michigan on July 14, 2015
await the identification of organisms and a determination of their sensitivity to antibiotics. The use of a combination of an aminoglycoside antibiotic with clindamycin, penicillin, or a cephalosporin is often recommended (Fass, Ruiz, Gardner & Rotilie, 1977). The frequency of occurrence of mixed anaerobic or polymicrobial aerobic infections prompted us to test cefoxitin as a single antibiotic in the treatment of such infections. Most of the patients in this series were seriously ill, as well as having one or more coexisting major medical or surgical complications (McCIoskey, in press). Nevertheless, 91 % of those patients with anaerobic infections were cured or improved, as were 88 % of the patients with polymicrobial aerobic infections. Too few patients were treated with cefoxitin i.m. to permit an analysis of differences between the results of i.v. and i.m. therapy, but there was only 1 failure among 16 patients treated i.m. Since cefoxitin is not reliably effective against enterococci or Pseudomonas spp. (Kosmidis, Hamilton-Miller, Gilchrist, Kerry & Brumfitt, 1973), it would be inappropriate to use it as the sole treatment for infections likely to have been caused by these bacteria. The combination of cefoxitin sodium with an aminoglycoside antibiotic may offer advantages over the antibiotic combinations mentioned earlier for the treatment of infections caused by mixtures of anaerobic bacteria, Gram-negative aerobic bacteria (including Pseudomonas spp.) and enterococci.
Cefoxitin sodium treatment of anaerobic and polymicrobial aerobic infections R. V. McCloskey
Among 23 patients with anaerobic infections, 9 1 % were cured or improved by treatment with cefoxitin sodium, as were 88% of 41 patients with polymicrobial aerobic infections. Treatment was either by intermittent i.v. infusion over 30 min, 2 g every 6 or 8 h, or by i.m. injection, 1 g every 6 h. Clinical improvement occurred in some patients despite persistence of pathogenic organisms.
Introduction
This study evaluated the efficacy of cefoxitin sodium, a new cephamycin ^-lactamaseresistant antibiotic, in a group of patients with anaerobic or polymicrobial aerobic infections co-existent with severe non-infectious or surgical disease. The 64 patients in this study were part of a total population of 214 patients treated with cefoxitin i.v. and 90 patients treated with cefoxitin i.m. Materials and methods
Cultures of blood, sputum, urine, body fluids, and purulent exudates were obtained from each patient before, during, and after treatment with cefoxitin. All aetiologic agents of infection were identified as to genus and species. The minimal inhibitory concentration (MFC) of cefoxitin for each organism was determined, in the case of aerobes, by use of the SteeTS replicator technique (Steers, Foltz, Graves & Rider, 1959). For anaerobic organisms, the method used to determine MIC was that of Sutter (Sutter & Finegold, 1975). Tn a group of 23 patients (Table I), infections were caused by one or more anaerobic species. The organisms most commonly isolated were Bacteroides spp., together with streptococci and clostridia. The average number of organisms isolated per patient was 1 -5. Surgical drainage was employed when warranted by the location of the infection; when the co-existing disease required them, supportive measures were employed. Tn 15 of the 23 patients, cefoxitin (2 g in 250 ml of physiologic saline solution) was given by intermittent i.v. infusion OVCT 30 min, 2 g every 6 or 8 h, as determined by clinical presentation. The mean i.v. dose of cefoxitin was 10-5 g/day. In 8 patients less seriously ill, cefoxitin, 1 g in 2 ml of 0-5 % xylocaine, was injected i.m. alternately into left and right buttocks every 6 h. 223
Downloaded from http://jac.oxfordjournals.org/ at University of Michigan on July 14, 2015
Department of Medicine, Section of Infectious Diseases, Albert Einstein Medical Center, Daroff Division, Philadelphia, Pennsylvania, U.S.A.
R. V. McCloskey
224
In 41 other patients, polymicrobial aerobic infections co-existed with serious noninfectious medical problems (Table I). Most frequently, the non-infectious conditions weTe diabetic ketoacidosis, congestive heart failure, malnutrition, cancer, anaemia, and chronic alcoholism. Infection was most commonly caused by some combination of Escherichia coli, Proteus spp., staphylococci, and streptococci. The average number of organisms isolated per patient was 2-8. Cefoxitin i.v. therapy was employed in 33 of these 41 patients and i.m. therapy was employed in 8 others. Table I. Results of cefoxitin therapy in anaerobic infections Route of administration
Number of patients 15 8 23
Intravenous* Intramuscularf Total
33 8 41
Pathogens persistent
Cured
Improved
Improved
Failed
10 3 13 (57%)
Anaerobic 4 3 7 (30%)
0 1 1 (4%)
1 1 2 (9%)
Polymicrobial aerobic 14 9 3 2 3 0 16 12 3 (39%) (29%) (7%)
5 3 8 (19%)
2 0 2 (5%)
*2 g every 6 or 8 h (2 g in 250 ml of physiologic saline solution infused intermittently over 30 min). •fl g in 2 ml of 0-5 % xylocaine injected alternately into left and right buttocks every 6 h.
Before, during, and after treatment with cefoxitin, the following laboratory determinations were made for each patient: complete haemogram, prothrombin time, quantitative platelet concentration, direct Coombs test, alkaline phosphatase, bilinibin, SGOT, SGPT, LDH, semm concentrations of sodium, potassium, chloride, CO 2 , and creatinine, blood urea nitrogen (BUN), blood glucose concentration, and urinalysis. Results Among patients with purely anaerobic infections, clinical cure and eradication of infecting organisms was achieved in 13 of the 23 patients (57%), and an additional 7 patients (30 %) showed clinical improvement. Of 3 patients in whom the infecting organisms persisted, 1 showed clinical improvement. Among patients with polymicrobial aerobic infections, clinical cure was achieved in 16 of 41 patients (39 %), and 20 others (49 %) showed clinical improvement. Five patients (12%) failed to improve. The infecting pathogens were eradicated in 31 of 41 patients (76%). In some instances, the clinical response was one of improvement, even though not all of the original infecting pathogens had been eradicated. Discussion Under actual clinical conditions, the treatment of seriously ill patients whose infection is likely to have been caused by mixed anaerobic or polymicrobial aerobic bacteria cannot
Downloaded from http://jac.oxfordjournals.org/ at University of Michigan on July 14, 2015
Intravenous* Intramuscular! Total
Pathogens eradicated
Anaerobic and polymicroblal aerobic infections
225
References Fass, R. J., Ruiz, D. F., Gardner, W. G. & Rotilie, C. A. Clindamycin and gentamicin for aerobic and anaerobic sepsis. Archives of Internal Medicine 83: 375-89 (1977). Kosmidis, J., Hamilton-Miller, J. M. T., Gilchrist, J. N. G., Kerry, D. W. & Brumfitt, W. Cefoxitin, a new semi-synthetic cephamycin: an in vitro and in vivo comparison with cephalothin. British MedicalJournal iv: 653-5 (1973). McCIoskey, R. V. Results of a clinical trial of cefoxitin, a new cephamycin antibiotic. Antimicrobial Agents and Chemotherapy (in press). Steers, E. E., Foltz, E. L., Graves, B. S. & Rider, J. An inocular replicating apparatus for routine testing of bacterial susceptibility to antibiotics. Antibiotics and Chemotherapy 9: 308-11 (1959). Sutter, V. L. & Finegold, S. M. Susceptibility of anaerobic bacteria to carbenicillin, cefoxitin, and related drugs. Journal of Infectious Diseases 131: 417-22 (1975).
Downloaded from http://jac.oxfordjournals.org/ at University of Michigan on July 14, 2015
await the identification of organisms and a determination of their sensitivity to antibiotics. The use of a combination of an aminoglycoside antibiotic with clindamycin, penicillin, or a cephalosporin is often recommended (Fass, Ruiz, Gardner & Rotilie, 1977). The frequency of occurrence of mixed anaerobic or polymicrobial aerobic infections prompted us to test cefoxitin as a single antibiotic in the treatment of such infections. Most of the patients in this series were seriously ill, as well as having one or more coexisting major medical or surgical complications (McCIoskey, in press). Nevertheless, 91 % of those patients with anaerobic infections were cured or improved, as were 88 % of the patients with polymicrobial aerobic infections. Too few patients were treated with cefoxitin i.m. to permit an analysis of differences between the results of i.v. and i.m. therapy, but there was only 1 failure among 16 patients treated i.m. Since cefoxitin is not reliably effective against enterococci or Pseudomonas spp. (Kosmidis, Hamilton-Miller, Gilchrist, Kerry & Brumfitt, 1973), it would be inappropriate to use it as the sole treatment for infections likely to have been caused by these bacteria. The combination of cefoxitin sodium with an aminoglycoside antibiotic may offer advantages over the antibiotic combinations mentioned earlier for the treatment of infections caused by mixtures of anaerobic bacteria, Gram-negative aerobic bacteria (including Pseudomonas spp.) and enterococci.
