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Appendix A: The Clinical Use of Antimicrobials and the Development of Resistance
Pages 65-78

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From page 65...
... A transcription of the public meeting held August 23, 1979 also formed part of the working papers used by the committee. These records may be obtained on loan from Dr.
From page 67...
... Between 1960 and 1976 there were 131 published studies of the prophylactic use of antimicrobials to reduce the possibility of infection after surgical procedures. Although only 24 of these studies describe controlled, prospective, double-blind studies, they report striking statistically significant reductions in various types of wound infections when antimicrobials were administered in conjunction with repair after hip fracture, hip prosthesis, vaginal hysterectomy, and colon, biliary, and gastrointestinal surgery (Chodak and Plaut, 1977~.
From page 68...
... Antimicrobials administered prophylactically to immunodeficient patients lacking the benefit of a protected environment have produced variable results. Immunodeficiency may result from a disease state or from the use of drugs.
From page 69...
... Controlled trials indicate that either a tetracycline or ampicillin is effective in preventing febrile disease and loss of time from work for patients with chronic obstructive pulmonary disease (Batten, 1976~. However, the magnitude of that population and the cost-benefit ratio are so great that this method of preventing recurrent infection has not been widespread.
From page 70...
... Indeed, were this not usually the case, antimicrobial therapy could rarely, if ever, be justified. Streptomycin, first used in 1945, remains as a single drug treatment for one infection by Francisella tularensis (tularemia)
From page 71...
... For the anaerobic infections, which commonly cause intracerebral, pulmonary, peritoneal, or pelvic infections (usually with abscesses) , one has a choice of four drugs: chloramphenicol, clindamycin, metronidazole, or cefoxitin, depending upon which sideeffect is less disturbing to the physician, e.g., enterocolitis from clindamycin or the idiosyncratic pancytopenic reactions from chloramphenicol.
From page 72...
... Other useful agents include vancomycin, which is enjoying a resurgence of interest because it is so helpful in patients on dialysis, with Clostridium difficile in necrotizing, pseudomembranous enterocolitis and in Gram-positive coccal infections that are resistant to penicillin. A special mention must be made of the cephalosporins because there are so many of them, because they are remarkably active against many Gram-negative and Gram-positive bacteria, and because minute chemical changes have resulted in such great activity against previously unsusceptible organisms, e.g., Enterococcus and Pseudomonas aeruginosa.
From page 73...
... An examination of alternative drugs to combat penicillin- and tetracycline-resistant pneumococci reveals problems in therapy caused by antibiotic resistance quite well. In order of decreasing desirability, alternatives include the cephalosporins, which can be administered orally or parenterally, but are less active; chloramphenicol, which has the danger of fatal aplastic anemia in approximately 1 in 30,000 individuals; vanc~mycin, which is the most active but can only be administered intravenously and is ototoxic; and erythromycin, which, while being the least toxic, is also the least active.
From page 74...
... aeruginosa, especially the highly mucous variant, is an acknowledged problem, but it is difficult to attribute this directly to chemotherapy (Mearns _ al., 1972~. The second group is composed of patients taking tetracycline for either acne vulgaris (adolescents)
From page 75...
... It is well known that a patient entering a hospital with a urinary tract infection usually has sensitive E colt, whereas the patient hospitalized for only 3 or 4 days who develops such an infection has a much more resistant isolate, presumably acquired from the hospital flora which has been subjected to selection pressure by the use of antimicrobials.
From page 76...
... There is no reason to anticipate a radical departure from the past in the development of emergent and primary resistant organisms, of new and challenging diseases, of better and better drugs, and of ebbs and flows in drug selection and usage. Thus, we can expect a continuing production of newer vaccines, most imminently for hepatitis B antigen.
From page 77...
... van Zermarel; S Acres; State epidemiologists from Iowa, Missouri, Pennsylvania, and Wisconsin; and the Center for Disease Control.
From page 78...
... 1973. Bacteriological examination of rectal specimens during long-term oxytetracycline treatment for acne vulgaris.


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