The distribution of aminoglycosides in the cerebrospinal fluid (CSF) space was examined after intralumbar, intraventricular, and systemic administration during seven episodes of gram-negative bacillary meningitis. Six episodes were associated with culture proved ventriculitis. Parenteral therapy with gentamicin or tobramycin produced low concentrations of aminoglycoside (less than 1.0 mug/ml) in the lumbar, ventricular, and cisternal CSF. Administration of 5 to 10 mg of aminoglycoside into the lumbar intrathecal space resulted in 27-81 mug/ml in the lumbar CSF, but 0-2.1 mug/ml in the ventricular CSF. In contrast, aminoglycoside administered into the cerebral ventricles produced concentrations in the lumbar CSF of 11.5-27.5 mug/ml and ventricular CSF of 12.8-40 mug/ml. All six episodes treated via the ventricular route resulted in a bacteriologic cure. Intraventricular administration of aminoglycosides offers a reliable means of achieving high aminoglycoside concentrations throughout the subarachnoid space.

These results provide no evidence of a reduction in NICU-related stress for parents who receive an intervention to increase their understanding and involvement in infant pain management. However, parents in the intervention group were better prepared to take an active role in infant pain care and had more positive views about their role attainment in the postdischarge period.

Peer management reduced provider variability by addressing the imperfect ability of clinicians to rescind testing in a timely manner. Hospitals with growing health care costs can improve their resource utilization through peer management of testing behaviors by using CPOE systems.

Traditionally, women receiving azathioprine have been discouraged from breastfeeding because of theoretical potential risks of neonatal bone marrow suppression, susceptibility to infection, and pancreatitis. The aims of this study were to measure the concentration of 6-mercaptopurine (6-MP) in breast milk of mothers receiving azathioprine and in the blood of their babies and to investigate any immunosuppressive effects on the babies. Women receiving azathioprine, who after appropriate counselling wished to breastfeed their babies, were approached for inclusion in the study. Breast milk samples were obtained from recruited women, and 6-MP levels were measured in each breast milk sample. Haemoglobin level, white cell and platelet counts, and 6-MP and 6-thioguanine nucleotides (6-TGN) levels were measured in the respective neonatal blood samples. Clinical signs of immunosuppression in the neonates were noted. Thirty-one breast milk samples were collected from ten women. Low concentrations of 6-MP (1.2 and 7.6 nanograms/ml, compared with therapeutic immunosuppressant level of 50 nanograms/ml in serum) were detected in two breast milk samples obtained from one woman. 6-MP was not detected in any of the other 29 samples. 6-MP and 6-TGN were undetectable in the neonatal blood. There were no clinical or haematological signs of immunosuppression in any of the ten neonates. We conclude that breastfeeding should not be withheld in infants of mothers receiving azathioprine.

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Preoperative and intraoperative antibiotic prophylaxis of infection in peripheral vascular surgery has been widely used although controlled studies have been lacking. A randomized, a prospective, double-blind study of cefazolin versus placebo during 565 arterial reconstructive operations was performed at this hospital from February 1976 through August 1977. Among the 462 patients undergoing surgery of the abdominal aorta and lower extremity vasculature, there was a highly significant difference in the infection rates: 6.8% for placebo recipients versus 0.9% for cefazolin recipients (p less than .001). Of the 18 infections, four involved vascular grafts and all four graft infections occurred in the placebo group. Over 8% of abdominal wounds of patients receiving placebo became infected versus 1.2% of cefazolin patients (p less than .05). Groin wounds were infected infrequently, 1.1% for placebo patients versus none for cefazolin patients. No infections occurred among 103 brachiocephalic procedures. Skin antisepsis was analyzed retrospectively. Infection rates were significantly higher (p less than .01) following hexachlorophene-ethanol versus a povidone-iodine skin preparation. Adverse effects of cefazolin were carefully monitored: no rash, phlebitis, or emergence of resistant strains was observed. A breif perioperative course of cefazolin and povidone-iodine skin antisepsis are recommended in vascular reconstructive surgery of the abdominal aorta and lower extremity vasculature.

Perioperative parenteral cefoxitin was compared with oral erythromycin, neomycin and parenteral cefazolin in a prospective, double-blind, randomized evaluation of 119 patients undergoing colorectal operations. Patients receiving cefoxitin had a higher wound infection rate than patients receiving erythromycin-neomycin-cefazolin (12.5% v 3.2%, respectively, p = .06). A direct correlation existed between the duration of the operation and the infection rate. Cefoxitin prophylaxis was as effective as erythromycin-neomycin-cefazolin in patients undergoing surgical procedures of 4 hours or less (infection rates of 4.8% and 4.0%, respectively). However, for surgical procedures lasting more than 4 hours, 5 of 14 patients (37.5%) receiving cefoxitin developed a wound infection v 0 of 13 patients receiving erythromycin-neomycin-cefazolin (p less than .05). It is speculative as to whether frequent two-gram doses of cefoxitin given during the operation would provide prophylaxis equivalent to erythromycin-neomycin-cefazolin.