Patients preferred to have family members present during their resuscitation. However, most of the positive responders wanted only certain members present, and approximately one in five patients, who tended to be older and white, did not want any family present. This study does not support an open policy of allowing family members into a resuscitation without prior knowledge of the patient's preferences.

SUMMARYThe relation between the timing of prophylactic antibiotic administration and the occurrence of bacteraemia during transurethral operations was studied in 112 patients whose urine was infected before operation. Blood cultures taken during operation were positive in 15 (60%) of 25 patients who did not receive appropriate antibiotics, in 13 (21 %) of 63 patients who were given appropriate antibiotics less than 24 h before operation, and in none of 24 patients in whom antibiotic "cover" was started more than 24 h before operation. In all cases the bacteraemia was transient. No patient developed septicaemia.The implications of these findings for the optimum timing of antibiotic administration to patients with preoperative bacteriuria are discussed.Bacteraemia has been shown during more than half of prostatectomy and other operations on the lower urinary tract in men with infected urine.' This perioperative bacteraemia is usually transient and symptomless. In a few cases, however, it progresses to postoperative septicaemia, defined as protracted bacteraemia with fever, chills, rigor, and shock.' Postoperative septicaemia is the most dangerous infective complication of urological operations, and in our experience perhaps the commonest cause of postoperative death.2 Of 31 cases that we studied previously, four were fatal, eight patients had profound shock, and one developed osteomyelitis. ensure that the urine is sterile before operation, will prevent septicaemia. But since patients are often admitted only a day or two before operation and many are then found to have infected urine (over 30% of those admitted to this department5), such a policy would prolong the stay of some patients in hospital, upset operating lists, and be difficult to enforce unless the advantages of delaying operation were evident. In a previous study5 we showed that postoperative septicaemia could be prevented, without delaying operation, by administering an appropriate antibiotic perioperatively, starting only a few hours before operation, often at the time of premedication. An appropriate antibiotic was defined as one shown to be active against the organisms in urine that had been cultured, with a direct antibiotic sensitivity test, one to two days before operation. The antibiotic was administered parenterally at a dosage that would give an antibacterial concentration in the blood during and after operation.5 The agents most often used were ampicillin, cephradine, aminoglycosides, and co-trimoxazole.Two drugs were sometimes given to patients with mixed infections, a common occurrence in patients treated with indwelling catheters before operation. Perioperative antibiotics cannot be expected to sterilise the urine before operation nor, presumably, to prevent bacteraemia during operation. By ensur-673 on 9 May 2018 by guest. Protected by copyright.

Cyst infection in patients with autosomal-dominant polycystic kidney disease (ADPKD) is often refractory to therapy, in part because of the limited entry of commonly used antibiotics into cyst fluid. To study the efficacy of trimethoprim-sulfamethoxazole in cyst infection, cyst fluid was obtained by percutaneous aspiration or at surgery from eight patients with ADPKD receiving trimethoprim-sulfamethoxazole. Cysts were categorized as nongradient or gradient by cyst-fluid sodium concentration. Trimethoprim-sulfamethoxazole concentrations within cysts were determined and cyst fluid inhibitory and bactericidal titers were assessed in vitro against Escherichia coli, Proteus mirabilis and Streptococcus fecalis. The mean cyst fluid trimethoprim and sulfamethoxazole concentrations were 15.2 micrograms/ml and 42.5 micrograms/ml, respectively. Preferential accumulation of trimethoprim was observed in gradient cysts, exceeding serum levels more than eightfold. Sulfamethoxazole penetrated cysts to a lesser extent, with concentrations ranging from 10 to 70 percent of the serum level. Cyst fluid sampled prior to trimethoprim-sulfamethoxazole administration (control) demonstrated no antibacterial activity, while cyst fluid inhibitory and bactericidal titers following antibiotic administration were 1:32 or greater in most instances. These studies indicate that trimethoprim-sulfamethoxazole is likely to be efficacious in the treatment of cyst infection in polycystic kidneys.

Renal cyst infection in patients with polycystic kidney disease (PKD) is often unresponsive to standard antimicrobial therapy, in part because of the failure of most antibiotics to adequately penetrate cyst fluid. Ciprofloxacin, a new quinolone antibiotic, possesses in vitro activity against most pathogens likely to be encountered in renal cyst infection. To study the potential usefulness of ciprofloxacin for the treatment of cyst infection, fluid from 70 cysts was obtained from seven patients with polycystic kidney disease who were receiving the drug. Cysts were categorized as nongradient or gradient by the sodium concentration in the fluid. The ciprofloxacin concentration within cysts was measured, and the cyst fluid bactericidal activity against likely cyst fluid pathogens was determined. The mean (+/- standard error) ciprofloxacin concentration was 12.7 +/- 2.9 micrograms/ml. Preferential accumulation of ciprofloxacin occurred in gradient cysts; these levels exceeded levels in serum by more than fourfold. Cyst fluid bactericidal activity titers were uniformly high against Escherichia coli and Proteus mirabilis, while less activity was observed against Streptococcus faecalis, Pseudomonas aeruginosa, Staphylococcus aureus, and Staphylococcus epidermidis.

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