AMERICAN
JOURNAL
OF EMERGENCY
MEDICINE
n Volume 6. Number 2 n March 1988
gram-negative rod that is part of the normal oral flora. This bacterium has been implicated as a pathogen in 20 to 30% of hand infections due to human bites.5,6 E. corrodens is sensitive to penicillin and cefoxitin, variably resistant to other cephalosporins, and resistant to penicillinaseresistant penicillins, clindamycin. and aminoglycosides.3*4 In one study on the microbiology of human and animal bites, beta-lactamase activity was present in 18 of 59 bacterial isolates.4 These data support the use of a penicillinaseresistant penicillin in an attempt to prevent infection in these wounds by such organisms. Prophylactic antibiotic coverage must include antibiotics that are active against the potential pathogens for that wound. Therefore, in mammalian bites, if prophylactic coverage is chosen, penicillin and a penicillinase-resistant penicillin should be used in combination therapy. An alternative is amoxicillin-clavulanate, which has been shown to be as effective as the previously mentioned combination.’ Oral cephalosporins can replace penicillinase-resistant penicillins. Tetracycline is an alternative for both P. multocidu and E. corrodens coverage, and erythromycin is another alternative for E. corrodens prophylaxis.8 fastidious
The opinions or assertions expressed herein are those of the author and do not necessarily reflect the views of the United States Army or the Department of Defense. ANDREW T. GUERTLER,MD Madigan Army Medical Center Tacoma, Washington
References 1. Altman RS, Harris GD, Kruth CJ: Initial management of hand injuries in the emergency patient. Am J Emerg Med 1987;5:400-404 2. Kaplan K: Animal bites and infection. Infect Dis Pratt 1978;9:1-8 3. Goldstein EJC: Clenched-fist 1986;Jul:384-390
injury
infection.
4. Brook I: Microbiology of human and animal children. Pediatr Infect Dis J 1987;6:2932 5. Welch CE: Human bite infections 1936;215:901-908
Infect
Surg
bite wounds
Oral P-adrenergic sympathomimetic agents are frequently prescribed for children who have chronic asthma not adequately controlled by theophylline alone or who have side effects of theophylline such as gastric intolerance or hyperactivity. Aerosol bronchodilators are also effective in treating bronchospasm.‘4 These agents include the &-sympathomimetics (terbutaline, albuterol, metaproterenol). They have the advantages of being minimally absorbed and having little systemic effect. They are usually free of side effects and can be administered to children younger than 7 years of age. Although not all bronchodilators are approved for use in children less than 12 years of age, the advantage of their use in the management of acute exacerbation of asthma has been described.5 The disadvantage of using the aerosolized bronchodilators has been the lack of physical application with the metered dose inhalers in children unable to use them correctly. Lee has described a technique of delivery of bronchodilators in young asthmatic children. He used a freezer bag (Ziploc) with the corner snipped off, with a small caliber cylinder piece inserted and secured with rubber bands. The nebulizer is then placed inside and the freezer bag relocked. The bag is then half-inflated by blowing air into the bag through the mouthpiece. The mouthpiece is left between the child’s lips while the operator then activates the canister from outside the bag. The child is instructed to breathe in and out of the bag five or more times. With proper instructions children between 3 and 6 years of age have demonstrated their ability to use this system effectively.’ This method is easier for small children to use than the direct use of the metered dose inhalant used in older children and adult patients. The technique should only be used under the direct supervision of a responsible adult. Parents should be warned against altering the design system. such as substituting a more pliable plastic bag for the freezer bag and thus increasing the risk of aspiration. This technique is inexpensive, portable, easy to use, and an effective method that may find application in the emergency department as well as home.
in
MAJDAVID A. BERMAN, DO CAPT ROBERTNORRIS, MD Department of Emergency Medicine Brooke Army Medical Center Fort Sam Houston, Texas
of the hand. N Engl J Med
6. Goldstein EJC, Citron DM, Wield B, et al: Bacteriology of human and animal bite wounds. J Clin Microbial 1978;8:667-672 7. Goldstein EJC, Reinhardt JR, Murray PM, et al: Animal and human bite wounds: a comparative study, Augmentin vs penicillin +Idicloxacillin. Postgrad Med Custom Commun 1984;(Sep-Oct):105-110 8. Sanford JP: Guide to Antimicrobial Therapy. West Bethesda, MD, Antimicrobial Therapy Inc, 1987, pp 35-36
INHALED BRONCHODILATORS IN YOUNG PEDIATRIC ASTHMATIC: A METHOD OF DELIVERY To the Editor:-The goal of long-term pharmacologic management of chronic asthma is the prevention of acute exacerbations. Theophylline is the most effective noncorticosteroid maintenance drug for the suppression of symptoms in children with chronic asthma.’ 206
References 1. American Academy of Pediatrics, Section of Allergy and Immunology: Management of asthma. Pediatrics 1981;68: 874-880 2. Lee H: Proper aerosol inhalation technique for delivery of asthma medications. Clin Pediatr 1983;22:440-443 3. Lee H, Evans H: Aerosol bag for administration of bronchodilators to young asthmatic children. Pediatrics 1984;73: 230-232 4. Lee J, Evans H: Evaluation of inhalation aids of metered dose inhalers in asthmatic children. Chest 1987;91:35$ 361 5. Stempel D, Mellon M: Management of acute severe asthma. Pediatr Clin North Am 1984;31:879-890