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Single-dose tetracycline therapy for shigellosis in adults
Single-dose tetracycline therapy for shigellosis in adults. Pickering LK, DuPont HL, Olarte J, JAMA 239:853-854,
quired dopamine infusion to m a i n t a i n a n adequate blood pressure. Because of seizure activity, these p a t i e n t s were started on phenytoin sodium intravenously, with a loading dose of 11 mg/kg and a rate of 25 mg/minute. This has not been noted to cause appreciable h y p o t e n s i o n in previous studies. In each case, cardiac arrest or hypotension occurred either during infusion or shortly afterwards. The hypothesis t h a t a dopamine-phenytoin interaction led to cardiac arrest or hypotension was tested in dogs subjected to hemorrhage and r e q u i r i n g dopamine for m a i n t a i n i n g blood pressure. T h e s e animals became hypotensive within m i n u t e s of infusion of phenytoin. Controls did not become hypotensive. The m e c h a n i s m of this interaction is unknown. (Editor's note: While this drug interaction is rarely encountered in emergency medicine, it should remind us of possible drug effects that we neither desire nor anticipate.) Howard Lee, MD
(Feb) 1978. A clinic for the study of d i a r r h e a was set up at Universidad de las Americas in the summer of 1975. Students were enrolled in the study and stools were collected before any illness developed. Twenty-six students with diarrhea and 16 a s y m p t o m a t i c s t u d e n t s grew s h i g e l l a from t h e i r stools. Twenty-four strains of shigella were resistant to tetracycline: 52% of S flexneri and 80% S sonnei. Students with shigella isolated from stools were given 2.5 g tetracycline in a single dose. All patients with tetracycline-sensitive shigella and 16 of 18 patients with tetracycline-resistant shigella (89%) h a d clinical improvement~ and bacterial eradication of shigella ~ o m the stool within 48 hours of the single dose. The stools remained free of shigella for the duration of the study (14 to 19 days). The a u t h o r s feel t h a t single dose t r e a t m e n t of shigella with 2.5 g tetracycline is effective regardless of symptoms or in vitro sensitivity. This is especially applicable to emergency medicine since the dose can be given without waiting for susceptibility testing where such testing is not a v a i l a b l e , a n d w h e r e follow-up p o s s i b i l i t i e s a r e poor. (Editor's note: While there is evidence that the course of disease is shortened, for the emergency department probably the most important therapy is volume replacement. Antibiotics are not necessary and unless the patient is on a drip, we usually will not give constipating agents. I f cramps are severe and do not respond to volume and electrolyte replacement, we will use a single dose of atropine.) Harvey B. Price, MD
dopamine-phenytoin interaction Vaginitis emphysematosa. Laing FC, Shanser JD, Salmen BJ, Arch Surg 113:156-158, (Feb) 1978. In the course of a year, five patients were seen with vaginitis e m p h y s e m a t o s a , a b e n i g n self-limited c o n d i t i o n characterized by a myriad of gas-filled spaces in the subepithelial lining of vaginal wall. Four of the five patients were diagnosed by the characteristic x-ray films. One patient underwent intravenous pyelogram for recurrent u r i n a r y tract infections. Multiple air bubbles were noted in the p e n i s on x-ray. Because she was a diabetic and on h i g h dose steroids for central nervous system sarcoidosis, it was presumed t h a t she h a d uterine necrosis: Though she had no pelvic tenderness or masses, she u n d e r w e n t emergency hysterectomy. Pathologic diagnosis was vaginitis emphysematosa. Patients may be asymptomatic or have a vaginal discharge or bleeding. Associations include pregnancy, trichomonal vaginitis, cor pulmonale, and congestive h e a r t failure. Vaginitis emphysematosa has been confused with many serious diseases and, if misdiagnosed, may lead to unnecessary t r e a t m e n t including surgery. (Editor's note: Another zebra to be aware of. The safest approach will be to exclude the more serious possibilities.) Howard Lee, MD
diarrhea, tetracycline Effect of ampicillin and chloramphenicol against haemophilus influenzae. Feldman WE, Pediatrics 61:406-409, (Mar) 1978. Because of the r e c e n t e m e r g e n c e of a m p i c i l l i n - r e s i s t a n t Haemophilus influenzae type b, the combination of chloramphenicol and ampicillin has been recommended for the initial t r e a t m e n t of suspected bacterial meningitis. The results of clinical studies to determine the efficacy of this combination in contrast to ampicillin alone are conflicting. Some suggest a synergistic effect, while others indicate t h a t the two agents a r e mutually antagonistic. In the present case, synergistic or additive effects-of ampiciUin and chloramphenicol were noted against ampicillin-resistant H. influenzae type b in vitro. No antagonism was observed. Chloramphenicol is considered to be a bacteriostatic agent. The combination of a bacteriostatic antibiotic with a bacteriocidal one, such as ampicillin, is usually regarded as inadvisable, because, in theory, the two agents would be expected to antagonize each other. However, recent evidence suggests t h a t chloramphenicol is bacteriocidal against H. influenzae type b. This, with the results of the current study, supports t h e recommendation t h a t chloramphenicol and ampicillin be used concurrently in cases of suspected Haemophilus meningitis. The clinical effect of this combination on meningitis due to Streptococcus pneumoniae or Neisseria m e n i n g i t i d i s is still not clearly determined. (Editor's note: Many infectious disease specialists are enthusiastic about chloramphenicol. Its drawbacks must be respected, however, and it should be used only with a clear indication or high suspicion.) Jeffrey Menkes, MD
vaginitis, pyelography Intermittent hydronephrosis. Dunn DH, Williams RD, Gonzalez R, Arch Surg 113:329-330 (Mar) 1978. A 29-year-old woman presented t h r e e times w i t h episodes of acute, colicky left-upper-quadrant and left flank pain. Results of urinalysis and i n t r a v e n o u s pyelogram (IVP) were n o r m a l . On h e r f o u r t h visit d u r i n g an episode of pain, m a r k e d pyelocaliectiasis and delayed emptying of the left kidney were noted on IVP. The diagnosis was i n t e r m i t t e n t hydronephrosis. Pyeloplasty was performed a n d t h e patient has remained asymptomatic. Almost all cases of i n t e r m i t t e n t hydronephrosis are in those kidneys with acute angles of the ureteropelvic junction. Urine flow rate is limited by the relatively nondistensible ureteropelvic junction. Hence, when there is high urine flow, renal-pelvic distension occurs, leading to pain. The preferred method of diagnosis is by IVP when a n episode of pain occurs. Pyeloplasty is the indicated t r e a t m e n t and is usually curative. (Editor's note: Another argument in favor of the emergency IVP. It is unlikely that this condition will go undiagnosed when the I V P is done in followup.) Howard Lee, MD
Haemophilus influenzae; antibiotics Dopamine-phenytoin interaction. Bivins BA, Rapp RP, Griffen WO, et al, Arch Surg 113:245-249, (Mar) 1978. Five critically ill patients with multisystem organ failure
68/460
hydronephrosis; kidney diseases, pye/op/asty
re-
JACEP
7:12 (Decem ber) 1978
quired dopamine infusion to m a i n t a i n a n adequate blood pressure. Because of seizure activity, these p a t i e n t s were started on phenytoin sodium intravenously, with a loading dose of 11 mg/kg and a rate of 25 mg/minute. This has not been noted to cause appreciable h y p o t e n s i o n in previous studies. In each case, cardiac arrest or hypotension occurred either during infusion or shortly afterwards. The hypothesis t h a t a dopamine-phenytoin interaction led to cardiac arrest or hypotension was tested in dogs subjected to hemorrhage and r e q u i r i n g dopamine for m a i n t a i n i n g blood pressure. T h e s e animals became hypotensive within m i n u t e s of infusion of phenytoin. Controls did not become hypotensive. The m e c h a n i s m of this interaction is unknown. (Editor's note: While this drug interaction is rarely encountered in emergency medicine, it should remind us of possible drug effects that we neither desire nor anticipate.) Howard Lee, MD
(Feb) 1978. A clinic for the study of d i a r r h e a was set up at Universidad de las Americas in the summer of 1975. Students were enrolled in the study and stools were collected before any illness developed. Twenty-six students with diarrhea and 16 a s y m p t o m a t i c s t u d e n t s grew s h i g e l l a from t h e i r stools. Twenty-four strains of shigella were resistant to tetracycline: 52% of S flexneri and 80% S sonnei. Students with shigella isolated from stools were given 2.5 g tetracycline in a single dose. All patients with tetracycline-sensitive shigella and 16 of 18 patients with tetracycline-resistant shigella (89%) h a d clinical improvement~ and bacterial eradication of shigella ~ o m the stool within 48 hours of the single dose. The stools remained free of shigella for the duration of the study (14 to 19 days). The a u t h o r s feel t h a t single dose t r e a t m e n t of shigella with 2.5 g tetracycline is effective regardless of symptoms or in vitro sensitivity. This is especially applicable to emergency medicine since the dose can be given without waiting for susceptibility testing where such testing is not a v a i l a b l e , a n d w h e r e follow-up p o s s i b i l i t i e s a r e poor. (Editor's note: While there is evidence that the course of disease is shortened, for the emergency department probably the most important therapy is volume replacement. Antibiotics are not necessary and unless the patient is on a drip, we usually will not give constipating agents. I f cramps are severe and do not respond to volume and electrolyte replacement, we will use a single dose of atropine.) Harvey B. Price, MD
dopamine-phenytoin interaction Vaginitis emphysematosa. Laing FC, Shanser JD, Salmen BJ, Arch Surg 113:156-158, (Feb) 1978. In the course of a year, five patients were seen with vaginitis e m p h y s e m a t o s a , a b e n i g n self-limited c o n d i t i o n characterized by a myriad of gas-filled spaces in the subepithelial lining of vaginal wall. Four of the five patients were diagnosed by the characteristic x-ray films. One patient underwent intravenous pyelogram for recurrent u r i n a r y tract infections. Multiple air bubbles were noted in the p e n i s on x-ray. Because she was a diabetic and on h i g h dose steroids for central nervous system sarcoidosis, it was presumed t h a t she h a d uterine necrosis: Though she had no pelvic tenderness or masses, she u n d e r w e n t emergency hysterectomy. Pathologic diagnosis was vaginitis emphysematosa. Patients may be asymptomatic or have a vaginal discharge or bleeding. Associations include pregnancy, trichomonal vaginitis, cor pulmonale, and congestive h e a r t failure. Vaginitis emphysematosa has been confused with many serious diseases and, if misdiagnosed, may lead to unnecessary t r e a t m e n t including surgery. (Editor's note: Another zebra to be aware of. The safest approach will be to exclude the more serious possibilities.) Howard Lee, MD
diarrhea, tetracycline Effect of ampicillin and chloramphenicol against haemophilus influenzae. Feldman WE, Pediatrics 61:406-409, (Mar) 1978. Because of the r e c e n t e m e r g e n c e of a m p i c i l l i n - r e s i s t a n t Haemophilus influenzae type b, the combination of chloramphenicol and ampicillin has been recommended for the initial t r e a t m e n t of suspected bacterial meningitis. The results of clinical studies to determine the efficacy of this combination in contrast to ampicillin alone are conflicting. Some suggest a synergistic effect, while others indicate t h a t the two agents a r e mutually antagonistic. In the present case, synergistic or additive effects-of ampiciUin and chloramphenicol were noted against ampicillin-resistant H. influenzae type b in vitro. No antagonism was observed. Chloramphenicol is considered to be a bacteriostatic agent. The combination of a bacteriostatic antibiotic with a bacteriocidal one, such as ampicillin, is usually regarded as inadvisable, because, in theory, the two agents would be expected to antagonize each other. However, recent evidence suggests t h a t chloramphenicol is bacteriocidal against H. influenzae type b. This, with the results of the current study, supports t h e recommendation t h a t chloramphenicol and ampicillin be used concurrently in cases of suspected Haemophilus meningitis. The clinical effect of this combination on meningitis due to Streptococcus pneumoniae or Neisseria m e n i n g i t i d i s is still not clearly determined. (Editor's note: Many infectious disease specialists are enthusiastic about chloramphenicol. Its drawbacks must be respected, however, and it should be used only with a clear indication or high suspicion.) Jeffrey Menkes, MD
vaginitis, pyelography Intermittent hydronephrosis. Dunn DH, Williams RD, Gonzalez R, Arch Surg 113:329-330 (Mar) 1978. A 29-year-old woman presented t h r e e times w i t h episodes of acute, colicky left-upper-quadrant and left flank pain. Results of urinalysis and i n t r a v e n o u s pyelogram (IVP) were n o r m a l . On h e r f o u r t h visit d u r i n g an episode of pain, m a r k e d pyelocaliectiasis and delayed emptying of the left kidney were noted on IVP. The diagnosis was i n t e r m i t t e n t hydronephrosis. Pyeloplasty was performed a n d t h e patient has remained asymptomatic. Almost all cases of i n t e r m i t t e n t hydronephrosis are in those kidneys with acute angles of the ureteropelvic junction. Urine flow rate is limited by the relatively nondistensible ureteropelvic junction. Hence, when there is high urine flow, renal-pelvic distension occurs, leading to pain. The preferred method of diagnosis is by IVP when a n episode of pain occurs. Pyeloplasty is the indicated t r e a t m e n t and is usually curative. (Editor's note: Another argument in favor of the emergency IVP. It is unlikely that this condition will go undiagnosed when the I V P is done in followup.) Howard Lee, MD
Haemophilus influenzae; antibiotics Dopamine-phenytoin interaction. Bivins BA, Rapp RP, Griffen WO, et al, Arch Surg 113:245-249, (Mar) 1978. Five critically ill patients with multisystem organ failure
68/460
hydronephrosis; kidney diseases, pye/op/asty
re-
JACEP
7:12 (Decem ber) 1978