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The biliary excretion and pharmacokinetics of mezlocillin have been studied in jaundiced patients with total external bile drainage through a percutaneous transhepatic catheter. In 10 of 11 studies, 2 g mezlocillin intravenously resulted in biliary concentrations sufficient to exceed the minimum inhibitory concentrations of most common biliary pathogenic organisms. In 6 h, 0.2-6.2% of the dose given was recovered in bile. The biliary clearance was 0.21-7.82 ml/min and increased with the duration of biliary decompression. The serum half-life of mezlocillin was prolonged (1.81 +/- 0.23 h, mean +/- SD), and was due to reduced biliary and renal clearance.

We review the discovery and development of the cephalosporins and subsequently cefaclor. Cefaclor is active against a wide range of commonly encountered bacterial pathogens, acting by inhibiting cell wall synthesis. Its in vitro activity compares favourably with other beta-lactam antibiotics. Its pharmacokinetic properties indicate that an 8-hourly dosing schedule is appropriate. In addition a delayed release formulation allowing twice daily dosage has been developed. The efficacy of both formulations of cefaclor has been verified by many clinical trials. Cefaclor has been widely used in infections of the respiratory tract (including otitis media), urinary tract and soft tissues. The results of therapy are summarized. The low incidence of adverse events is highlighted and the beneficial influence of this on compliance is described. Finally, the pharmaco-economics of cefaclor are considered.

Twenty-four general practitioners completed a questionnaire on behalf of their partners in the practices before attending the symposium. The main points that emerged were that trimethoprim was the most popular antibiotic for treatment of acute urinary infection and that the most common duration of treatment was 5 to 7 days. A panel discussion, with audience participation, covered duration of treatment, antibiotic resistance, specimen collection, management of different patient groups and availability of information concerning resistance patterns. Nineteen of the original 24 general practitioners returned the post-meeting questionnaire, and stated that, as a result of what they had heard at the symposium, they were contemplating changing the way in which they managed urinary infections. Information concerning bacteriuria in pregnancy and changing patterns of bacterial resistance to antibiotics were of particular interest.

All episodes of recurrent infection in a CAPD unit over a 26-month period have been analysed to discover whether relapse and reinfection have different prognostic importance. Relapse and reinfection were distinguished by detailed microbiological investigation. Prognosis was expressed in terms of outcome of treatment and the fate of the Tenckhoff catheter. Twenty-nine patients suffered recurrent infections (i.e. more than one infection during a 12-month period). Nine (6 male, 3 female, age range 42-73 years) had relapses, and 20 (16 male, 4 female, age range 42-74 years) reinfections. The characteristics of the two groups of patients were indistinguishable. Relapse was of graver prognostic consequence: patients who relapsed were significantly less likely to respond to antibiotic treatment (78% versus 20%) and have to have their catheters removed (78% versus 10%) than those with reinfections. Thus it is important to differentiate relapse from reinfection in CAPD peritonitis. In addition to being helpful for the management of individual patients, this is essential if results of therapeutic trials are to be interpreted correctly.

Growing points and problem areas in the field of urinary tract infections are critically surveyed. It is concluded that there is a particular need for advances in rapid tests for bacteriuria (to distinguish between symptomatic patients who are infected and those who are not) and for the determination of antibiotic sensitivity of infecting organisms. The aetiology of the "urethral syndrome" (dysuria and/or frequency without a significant bacteriuria) is still obscure although it is becoming clear what suggested possible causes are not responsible for it. Another unresolved problem is whether or not to treat asymptomatic bacteriuria in all groups of patients especially the elderly, and in the absence of pyuria. Similarly it is still not decided what are the optimal lengths of time and dosages of antibiotics to treat various types of urinary infections. Finally, difficulties involved in preventing infections of in-dwelling catheters, and the possibility of obtaining a protective vaccine are discussed.

A five day course of clavulanate-potentiated amoxicillin (Augmentin) has been compared with a single oral dose of fosfomycin trometamol in the treatment of patients complaining of symptoms suggesting urinary tract infection. The study took place in a single urban general practice of 15,000 patients in Cheshire. The microbiology was performed at a London Teaching Hospital. 141 patients entered the trial. 65 had a significant bacteriuria, 62 of which were assessable for the ability of the trial drugs to eradicate bacteriuria: 29 patients received clavulanate-potentiated amoxicillin and 33 fosfomycin trometamol. The cure rates, assessed at five to ten days and at four to six weeks post treatment, were 72% and 65%, respectively for clavulanate-potentiated amoxicillin and 85% and 81%, respectively for fosfomycin trometamol. Side effects, assessed in all 141 patients, occurred in 11.6% receiving clavulanate-potentiated amoxicillin and in 8.3% receiving fosfomycin. Statistically there is no difference between any of these findings and the effect of sample size is discussed. 69 patients were symptomatic but did not have a significant bacteriuria ("urethral syndrome"). These patients were assessed for the effect of treatment in relieving symptoms: 33 received fosfomycin trometamol and 36 clavulanate-potentiated amoxicillin. The success and speed of relieving the symptoms were very similar in the two groups. The finding that both groups responded equally well appears to refute an aetiological role for lactobacilli and diphtheroids in the "urethral syndrome", since these organisms are resistant to fosfomycin but sensitive to clavulanate-potentiated amoxicillin.

Summary The pH of urine samples from patients suffering symptoms suggesting urinary infection (e.g. dysuria, frequency, urgency) was measured while the patients were symptomatic and again when they had become asymptomatic. There was no correlation between the urine pH and the incidence or number of symptoms. No differences were observed between either the distribution or means of urine pH values in symptomatic and asymptomatic patients. There were also no significant differences in either symptomatology or urine pH between patients with significant bacteriuria and those without significant bacteriuria. These results cast doubt upon the traditional (but unproved) belief that alkalinizing the urine helps to reduce symptoms of dysuria and/or frequency, whether or not associated with urinary infection.

A prospective, randomised study of 56 patients comparing teicoplanin with vancomycin for suspected or proven severe Grampositive infection was conducted. The majority of infections were soft tissue infections (8 teicoplanin; 16 vancomycin) and by chance a significantly higher number of Hickman catheter-related infections occurred in the vancomycin arm (4 vs. 14, P < 0.01). Teicoplanin was administered as a single daily dose of 400 mg iv or im; 5 patients received 200 mg following the initial dose of 400 mg. Vancomycin was given 1 g every 12 h. Fifty-four patients were evaluable for efficacy (26 teicoplanin, 28 vancomycin). Of these, 18 episodes in 17 patients (teicoplanin) and 19 episodes in 18 patients (vancomycin) gave an evaluable clinical response, the success rates being similar (76% teicoplanin; 68% vancomycin). Staphylococcus aureus was the most common pathogen isolated; all pathogens were susceptible to both glycopeptides with MICs < 4 mg/l. Bacteriological elimination rates were similar in both groups (71% teicoplanin; 78% vancomycin). Significantly more patients given vancomycin experienced adverse events (7 teicoplanin; 16 vancomycin; P = 0.03). This caused treatment to be discontinued in 4 cases, compared with only one receiving teicoplanin. The most common vancomycin-related events were histamine-associated reactions (15 patients), including 2 cases of Red Man Syndrome, and nephrotoxicity (5 patients). There were no histamine-mediated events and only one case of nephrotoxicity with teicoplanin. Teicoplanin and vancomycin show similar clinical and bacteriological efficacy and teicoplanin is significantly less toxic and easier to use in patients with severe infection.

Co-trimoxazole is still widely used for indications where trimethoprim alone is equally effective. Microbiological and pharmacokinetic considerations reveal that trimethoprim alone provides adequate anti-microbial activity for treatment of conditions for which co-trimoxazole is often given. Synergy may be shown in vitro, but in clinical practice is an unusual occurrence. There is no evidence from clinical studies that the sulphonamide moiety fo co-trimoxazole prevents the development of resistance to trimethoprim. The adverse event profile of co-trimoxazole is a summation of that of sulphonamide and of trimethoprim. Thus, using trimethoprim alone should reduce both the incidence and potential severity of adverse events seen when co-trimoxazole is used. Clinical trials have shown trimethoprim to be as effective as co-trimoxazole in many of the common bacterial infections of the urinary and respiratory tracts. However, there are a few specific varieties of infection for which co-trimoxazole can be shown to be superior to trimethoprim: these include toxoplasmosis, brucellosis, nocardiosis, chancroid and pneumonia caused by Pneumocystis carinii. For many common infections, scientific, rational, economic and clinical reasons dictate that trimethoprim is preferable to co-trimoxazole.

SUMMARY Eighty-eight women with a history of recurrent urinary tract infection (at least four attacks in the preceding 12 months) were randomized to take either norfloxacin 200 mg at night (45 patients) or macrocrystalline nitrofurantoin 100 mg at night (43 patients) for 12 months. A decrease in the number of symptomatic attacks while taking this prophylaxis was observed in 94 per cent of the patients and this improvement was maintained during the 6 months following the end of prophylaxis in 69 per cent. The mean interval between symptomatic episodes while taking prophylaxis was 7.2-fold and 6.9-fold greater, respectively, than in the 12 months before starting prophylaxis. There were only nine breakthrough infections during 74 patient-years of prophylaxis, four in patients taking norfloxacin (two enterococci, one Staphylococcus epidermidis , one Escherichia coli ), and five in those taking macrocrystalline nitrofurantoin (four E. coli , one Klebsiella pneumoniae ). Adverse events caused four patients taking norfloxacin (8 per cent) and seven taking macrocrystalline nitrofurantoin (14 per cent) to stop prophylaxis. Norfloxacin had a marked suppressive effect on the coliform part of the faecal flora, with no emergence of resistance. Thus, norfloxacin appears to be an excellent alternative agent to macrocrystalline nitrofurantoin for the prevention of recurrent urinary infections.

Effective drugs are available for the short-term treatment and long-term prophylaxis of UTI in the elderly population in the absence of obstructive uropathy, just as in younger patient groups. The frequency of treatment failures and adverse reactions varies with the type and dosage of the drug in use as well as the subpopulation of elderly patients being treated.

The evolution of the fluoroquinolones is described, and structure-activity relationships outlined. The in-vitro antimicrobial activities of ciprofloxacin, enoxacin, norfloxacin, ofloxacin and pefloxacin against a wide range of organisms are critically reviewed. In-vitro factors influencing fluoroquinolone activity are discussed. Reports of the acquisition of resistance to the fluoroquinolones are evaluated. Finally, possible future directions for this group of antibiotics are discussed.

Eighty-eight female patients with a history of recurrent urinary tract infections were treated according to a randomization scheme with either 1 g of cephradine every 12 h (47 patients) or 375 mg of amoxicillin-clavulanate every 8 h (41 patients) for 7 days. The treatments were equally effective (cure rates of 89% for cephradine and 88% for amoxicillin-clavulanate) and showed similar relapse rates (cephradine, 14%; amoxicillin-clavulanate, 11%). Adverse effects were similar in both groups (cephradine, 23%; amoxicillin-clavulanate, 22%).

We report five cases of continuous ambulatory peritoneal dialysis in which the mechanisms and sources of infection were established. We show how diligent enquiry and environmental investigation can explain the pathogenesis of infection and help in prevention by motivation of the patient.

A clinical trial comparing 5 days' treatment with amoxycillin/clavulanate (group A) and a single dose of fosfomycin trometamol (group B) is presented. The study was done in symptomatic patients presenting to their family practitioner, with the microbiological testing being carried out in a university hospital laboratory. Of 62 patients with significant bacteriuria, 29 were given amoxycillin/clavulanate and 33 fosfomycin trometamol, in a randomized fashion. Cure rates 1 week and 5 weeks after the end of treatment were 72 and 65% in group A and 85 and 81% in group B. Adverse events assessed in 141 patients were unusual (10.1% in group A and 8.3% in group B) and were mild in nature. The results of this study suggest that single-dose treatment with fosfomycin trometamol is effective and acceptable as a conventional course of amoxycillin clavulanate for the treatment of simple acute dysuria and/or frequency with infection.

In patients with a history of recurrent infections, treatment with enoxacin (200 mg/12 h for 3 days) relieved symptoms of acute urinary infection significantly more rapidly than treatment with cefuroxime axetil (125 mg/12 h for 7 days). Other parameters, including clinical and bacteriological cure rates and patients' overall opinion of their treatment, did not differ significantly between the treatments.

Case records from 219 female patients between 1975 and 1992 who were given long-term prophylaxis (1 year) with nitrofurantoin for the prevention of recurrent urinary infections have been reviewed. Patients' age ranged from 9 to 89 years (median 31-35 years, mode 26-30 years); most (61%) were40 years old. The median number of symptomatic episodes in the 12 months immediately before prophylaxis was six (mode 4, mean 6.9). 14.4% of the patients were allergic to an antibiotic, and 23.6% had an imaging abnormality. Three regimens were used: group A (43 patients), 50 mg microcrystalline nitrofurantoin, bd; group B (110 patients), 100 mg macrocrystalline nitrofurantoin (Macrodantin), od; group C (66 patients), 50 mg Macrodantin, od. There were no obvious differences in efficacy between the patient groups (173 assessable patients). The mean incidence of symptomatic episodes decreased 5.4-fold during prophylaxis. Four-fifths of the 43 breakthrough infections (mostly due to Escherichia coli), were caused by nitrofurantoin-sensitive strains. An important finding was that patients with an imaging abnormality responded as well as those with no such abnormalities. In 16% of patients, prophylaxis was not helpful, objectively or subjectively, for no obvious reasons. In most patients where prophylaxis was successful, clinical improvement was maintained for at least 6 months after the end of prophylaxis. Nausea was more common in group A (P0.001), as were 'all adverse events'. Of those in group A 25.6% stopped prematurely as a result of an adverse event of any type, compared with 13% of those taking Macrodantin (P0.01). Older patients (65 years) did not report more adverse events than younger patients. No adverse event was life-threatening. Faecal flora analysis showed neither overgrowth by nitrofurantoin-resistant bacteria nor elimination of sensitive coliforms. Thus, macrocrystalline nitrofurantoin 50 mg at bedtime is appropriate for use in the long-term (12 months) prophylaxis of recurrent urinary infections, in view of its efficacy and favourable safety and tolerability profile. Patients can be managed by their family doctor.

Sir: We have noted with some concern that Schinella and colleagues (1) find that teicoplanin is ineffective in an intermittent intraperitoneal schedule for the treatment of CAPD peritonitis. This is at variance with our experience of more than 2 years' use in such patients. During that time we have reported our pharmacokinetic data (2) in detail, as well as results of a pilot therapeutic study in 12 patients (3) and an interim report of a randomized trial of teicoplanin compared with vancomycin (4). A total of 86 infections have now been treated in the latter trial: bacteriologi cal cure rates were 75% with teicoplanin and 86% with vancomycin (not significantly different). The treatment schedule with teicoplanin was as follows: patients received 400 mg i.v. on entry, and for 1 week 40 mg teicoplanin was added to each 2 L bag ( 4 bags are used every 24 h). Thereafter, the dosage was tapered: during the second week, 40 mg teicoplanin was added to alternate bags, and in the third week 40 mg teicoplanin was added to the overnight dwell bag only. Our success rate using this regime has been very similar to that observed with vancomycin. The majority of the small numbers of therapeutic failures have been due to Staphylacaccus aureu8, where tissue involvement (tunnel infections) has been a clinical feature. We are now exploring the possibility of reducing the total dosage of teicoplanin. Obvious means of doing this are to dispense with the initial i. v. dose, and to shorten the overall treatment period from 21 to 14 days. The consequence of therapeutic failure in this type of patient are potentially serious, as they involve the possible necessity of replacing the peritoneal catheter and the risk of losing the dialysing capacity of the peritoneal membrane. Therefore, we feel it is important to err on the side of overdosing rather than underdosing. In this context we would recommend that teicoplanin be added to every bag during the first week of treatment, rather than to alternate bags as suggested by Schinella et at. (1).

Twelve male subjects, aged 19 to 40 years, shown to be healthy by examination and laboratory tests, took 500 mg of ciprofloxacin every 12 h for 7 days. After the first and the last dose, blood and urine samples were taken and drug concentrations were determined by bioassay. There was a significant buildup in mean concentrations in serum from day 1 to day 7; mean peak levels (attained after 1 to 2 h) were 1.9 and 2.8 micrograms/ml, respectively. The terminal half-life was 3.5 to 4 h. About 40% of the drug was excreted into the urine during the 12-h period after dosing; minimum mean concentrations in urine were 105 micrograms/ml on day 1 and 174 micrograms/ml on day 7. Considerable amounts of ciprofloxacin were found in the feces on day 7 (185 to 2,220 micrograms/g). Marked changes in the aerobic part of the fecal flora were observed as a result of taking ciprofloxacin: coliforms were absent on day 7, and concentrations of streptococci and staphylococci were significantly reduced. There was no overgrowth by yeasts. One week later the fecal flora had returned to a state similar to that found before treatment. Anaerobes were little affected quantitatively but acquired resistance to ciprofloxacin. Side effects were mild and transient.

A combination of nitrofurantoin (100 mg) and sulphadiazine (300 mg) given 12-hourly for 7 days was used to treat 51 patients with recurrent urinary infections who were attending an out-patient clinic. Either nitrofurantoin or sulphadiazine was active in vitro against all the organisms isolated. The cure rate 1 week after the end of treatment was 82%; 10 patients relapsed during the following month, giving a cure rate 5 weeks after the end of treatment of 57%. Side effects, although relatively common (37%), were mild. The outcome of treatment with these two long-established drugs is thus as good as that obtained with some newer and more expensive preparations.

24 patients, admitted to hospital with lower respiratory tract infection, were treated with either co-trimoxazole (800 mg sulphamethoxazole + 160 mg trimethoprim) or trimethoprim (200 mg) orally twice daily. All showed a clinical improvement and with one exception respiratory pathogens were eliminated. Pharmacokinetics in blood, sputum and saliva were studied in 11 patients taking trimethoprim and 9 taking co-trimoxazole. No sulphamethoxazole was detected in either the sputum or saliva. Trimethoprim was found in higher concentrations in the sputum than in the blood, although there were wide and significant variations in individual patient's sputum pharmacokinetic profiles. Trimethoprim penetrates into the sputum at therapeutic concentrations in patients with chronic respiratory infections.

The properties of trimethoprim (TM), reviewed here, show it to be an excellent antimicrobial agent in its own right. However, with very few exceptions, TM has been made available clinically only in combination with a sulphonamide, usually sulphamethoxazole (SMX). We present evidence to suggest that the decision so to restrict the availability of TM was mistaken. Synergy between TM and SMX can be shown clearly in vitro, but there is no evidence from clinical trials that it plays a significant therapeutic role in urinary infections. Also, there is no evidence that combining the two antibiotics suppresses the emergence of resistance. Recently, sulphonamides other than SMX have been proposed as partners for TM, mainly on pharmacokinetic grounds. Compounds other than sulphonamides may also be logical partners for TM: we have made extensive studies on TM + rifampicin, for instance, and have obtained excellent results in certain clearly-defined patient groups. Only clinical trials of these new combinations will reveal whether they are superior to TM/SMX. There is already sufficient evidence to suggest that TM alone will be as effective as, and more acceptable than, TM/SMX. We propose that further large-scale clinical trials with TM alone be carried out, both to treat acute urinary infections and in prophylaxis.

The incidence of primary resistance to rifampicin in Mycobacterium tuberculosis has been analysed in countries where rifampicin is restricted to use for treating tuberculosis and in countries where its use is not restricted. There is no evidence that rifampicin-resistant M tuberculosis strains are more common where the use of the drug is unrestricted. Resistance to rifampicin is less common than is resistance to streptomycin or to isoniazid. We can thus see no danger of producing resistant strains of M tuberculosis if rifampicin therapy is used for short periods for non-tuberculosis infections. The problem of resistance mutants arising in the non-tuberculous species being treated is overcome by combining rifampicin with trimethoprim.

Experimental data, pharmacokinetic results, and clinical trials suggest that trimethoprim (TMP) is effective when used alone and is not associated with the toxicity and adverse effects caused by sulfonamides. Because an analysis of in vitro, pharmacokinetic, and clinical data suggested that the combination of rifampicin and TMP (Rifaprim) would be safe and highly active, an eight-year study of this combination for the treatment of urinary tract infection was done. The results were encouraging. Furthermore, a large multicenter trial of Rifaprim in 800 patients showed Rifaprim to be superior to trimethoprim-sulfamethoxazole for the treatment of chronic infections of the upper urinary tract. In another controlled trial, Rifaprim proved valuable for the treatment of urinary tract infections that resisted eradication and recurred frequently. Evidence suggests that Rifaprim may be useful in the treatment of other disease, such as staphylococcal osteitis (especially that caused by highly resistant organisms). Unlike antibiotics such as gentamicin, the use of which requires hospitalization of the patient and careful monitoring of levels in blood, Rifaprim can be used at home. Thus the danger of nosocomial infection is avoided.

366 specimens of serum from children and adults without liver disease were screened for antibody to hepatitis A virus (anti-HAV) by means of radioimmunoassay. 56% were born in London, 26% came to London from various parts of the United Kingdom and the remainder (18%) from various parts of the world. The prevalence of antibody was related to increasing age, ranging from 7% in children under ten years of age to 77% in adults aged 50 years or more. The prevalence of anti-HAV was significantly higher in females, in the lower socio-economic class and in those not indigenous to London. In comparison to other urban populations such as those of the United States and Western Europe, the prevalence of anti-HAV was similar in terms of the overall prevalence and age distribution. By contrast, these findings were entirely different from the countries of Eastern Europe and the Middle East where the overall prevalence was higher but the anti-HAV was equal in all ages. Thus, the findings presented indicate that hepatitis A virus infection is common in London and also shows a clear relationship to advancing age, lower socioeconomic class and the country of origin.

Summary A total of 120 patients, including 53 pregnant women with significant bacteriuria, received 163 7-day courses of oral antimicrobial agents allocated in a randomised manner. The cure rates after 6 weeks' follow-up ranged from 73% to 86%, and there was no statistical difference between preparations of ampicillin, carbenicillin indanyl ester, and 2 different formulations of nifuratel. Side-effects occurred in 30% to 40% of the courses of penicillin drugs, but in under 15% of the course of nifuratel. It is concluded that the new oral preparation of carbenicillin is a useful addition to the list of antimicrobial agents which are effective in the treatment of urinary infections in domiciliary patients. Furthermore, nifuratel has been confirmed as a highly active non-toxic drug which is valuable in the treatment of urinary infections.

STAPHYLOCOCCUS AUREUS is one of the most versatile human pathogens. In the late 1930s, sulfonamides offered the first challenge to S. aureus, but they failed because of their poor clinical performa...

The cephamycins are a group with great potential. The first member of the group intended for therapeutic use offers the following advantages over existing cephalosporins: 1. Stability to various beta-lactamases; in an environment increasingly threatened by R-factors, this property may be of increasing value as time passes. 2. Possible lack of cross-allergenicity with other beta-lactam antibiotics. 3. Activity against anaerobic strains. Cefoxitin is only the first semi-synthetic derivative; presumably there are other compounds awaiting assessment which have even more favourable properties.

48 non-pregnant domiciliary patients referred by general practitioners and 50 pregnant women were treated for bacteriuria with either 500 mg cephradine or 400 mg pivmecillinam every 6 h for 7 days. In the pregnant women, cure rates were over 90% after 2 weeks for both compounds, and after 6 weeks were 86% for cephradine and 78% for pivmecillinam. Cure rates in the non-pregnant were 83% for cephradine and 95% for pivmecillinam at 6 weeks. Seven patients (3 given cephradine, 4 given pivmecillinam) stopped treatment due to side-effects. Overall, side-effects (many of which were trivial) were more common in patients treated with cephradine (51%) than in those receiving pivmecillinam (33%). It is concluded that both drugs are highly effective in these two common types of urinary infection.

Twelve cases of peritonitis caused by Gram-positive bacteria in 11 dialysis patients were treated with teicoplanin. Treatment, which was continued for three weeks, consisted of the addition of teicoplanin to the dialysis fluid. Six patients who were febrile on admission were also given a single intravenous dose of 400 mg teicoplanin. For patients on continuous ambulatory peritoneal dialysis 20 mg teicoplanin per litre was added to each dialysis bag during the first week of treatment, to alternate bags during the second week, and only to the overnight dwell bag in the third week. For patients on intermittent peritoneal dialysis, 20 mg/l teicoplanin was added at each dialysis session. Resolution of peritonitis occurred in all patients within one to five days (mean 2.2); nine were discharged within this period and the patients continued to treat themselves at home. The other two patients were kept in hospital for reasons unconnected with the peritonitis. Nine patients have remained well at follow-up 2-13 months (mean 6.3) later. Two patients, both of whom had Staphylococcus aureus peritonitis, relapsed three months after the end of treatment. Mean serum teicoplanin concentrations were less than 10 mg/l, except in one patient who was re-treated when he relapsed. No adverse effects were recorded; one patient who developed a conductive hearing loss was found to have otitis media and obstruction due to wax. We conclude that teicoplanin is safe and effective in treating peritonitis in patients on peritoneal dialysis.

Thirteen patients with a mean age of 67 years admitted to hospital with signs and symptoms of lower respiratory infections were treated with ‘Augmentin’ (500 mg amoxycillin + 250 mg clavulanic acid) given orally every 8 hours, for 7 days. The clinical response was ‘good’ in ten cases and one ‘failed’. Two patients could not be assessed. Side-effects were not serious: only one patient had to stop treatment (due to diarrhoea). The pharmacokinetic results show that peak levels of amoxycillin and of clavulanic acid in the blood and in sputum are achieved at a later time in the patients studied than occurs in healthy volunteers.