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Mortality of sepsis is still high. Crucial for therapeutic response are the early start of treatment as well as the choice of antibiotics or antibiotic combinations. β-lactam antibiotics with bactericidal mode of action are often recommended in guidelines. But this antibiotic class can trigger the immune system to a maximum by releasing cell wall components or exotoxins. This may lead to a worsening of the patient's clinical situation. In contrast, antibiotics with bacteriostatic action often inhibit bacterial protein synthesis with decrease of production of virulence factors and minimize release of cell wall components. The purpose of this review is to summarise the significance of some bacteriostatic antibiotics and to discuss whether a combination of bactericidal and bacteriostatic agents may improve the course of the illness.

History and Clinical Findings: A previously healthy 32-year-old woman was admitted with shock symptoms 5 days after an uneventful home delivery. She developed a fever up to 39.5 degrees C during the days after delivery with sore throat, diarrhoea and muscle aches in all limbs. On physical examination there were swellings of the arms and lower legs as well as macular and vesicular erythrodermia, especially of the trunk., Investigations: Abnormal laboratory findings were thrombocytopenia (20,000/microliters), increased serum concentrations of fibrin breakdown products (102 mg/dl) and of C-reactive protein (> 200 mg/dl), increased creatine kinase (5700 U/l), transaminases (GOT 220 U/l, GPT 52 U/l), creatinine (2.0 mg/dl) and urea (114 mg/dl). Streptococcus pyogenes was grown on blood culture and from vaginal smear. Sonography, echocardiography and radiological examinations failed to demonstrate a septic focus., Treatment and Course: Mechanical ventilation was required for 7 days because of respiratory failure and shock symptoms (toxic shock-like syndrome, TSLS). Penicillin G and tobramycin were given after the bacteriological diagnosis. Severe consumption coagulopathy was successfully treated with antithrombin III and platelet concentrates. After extubation she was found to have a flaccid tetraparesis, especially of the right and of the legs, due to soft-tissue necrosis and damage to peripheral nerves. An embolic occlusion of the right brachial artery 4 weeks after onset of the disease required upper-arm amputation., Conclusion: One of the decisive factors for the prognosis of TSLS is early antibiotic treatment. The prodromal symptoms in this case underline the necessity of early recognition and treatment to prevent a full-blown picture of the syndrome.

History and Clinical Findings: Two hard, pressure-sensitive nodules developed in the lower jaw of a 22-year-old woman. After a dental cause had been excluded, she was treated for suspected tonsillitis with Ceftibuten. Erythrocyte sedimentation rate was increased to 18 mm in the first hour. There were no other significant biochemical findings and fine-needle biopsy of one of the nodules showed nonspecific inflammatory reaction., Investigations: Sonography revealed two lymph nodes, 7 and 22 mm in diameter. Suspected cat scratch disease was confirmed by immunofluorescence with Bartonella (Rochalimaea) henselae and quintana antigens., Treatment and Course: After a course of Clarithromycin (250 mg twice daily) for 6 weeks the lymph nodes had shrunk and the overlying skin was thin and discoloured brown. One node was incised and drained and the material examined. Microbiology was negative, but DNA sequencing confirmed Bartonella henselae. As a consequence, Rifampicin was given for 2 months (600 mg daily). Wound healing was very slow and the scar had regressed little after 9 months.

After returning from a holiday in the USA a 24-year-old man fell ill with diarrhoea, high fever and marked rash including the palms of the hands and soles of the feet. When a history of a tick bite in the USA was elicited, a rickettsial infection was suspected. Treatment with doxycycline, 100 mg twice daily, was instituted finally and the fever slowly resolved. The patient became completely well again within four weeks. Serological tests confirmed the diagnosis of Rocky Mountain spotted fever.