Burns. Infection may be reduced by application of silver sulphadiazine cream. Substantial absorption can occur from any raw surface and use of aminoglycoside, e.g. neomycin, preparations can cause ototoxicity.
Gas gangrene. The skin between the waist and the knees is normally contaminated with anaerobic faecal organisms. However assiduous the skin preparation for orthopaedic operations or thigh amputations, this will not kill or remove all the spores. Surgery done for vascular insufficiency where tissue oxygenation may be poor is likely to be followed by infection. Gas gangrene (Clostridium perfringens) may occur; it may be prevented by benzylpenicillin or metronidazole prophylaxis.
Wounds. Systemic chemoprophylaxis is necessary for several days at least in dirty wounds where sutures have to be left below the skin, and in penetrating wounds of body cavities. Flucloxacillin is probably best, but in the case of penetrating abdominal wounds, metronidazole should be added, and consideration given to adding an agent active against aerobic Gram-negative bacteria, e.g. gentamicin (see also Tetanus).
Abscesses and infections in bone and serous cavities are treated according to the antimicrobial sensitivity of the organism concerned but require high doses because of poor penetration. Local instillation of the drug may be needed.
Actinomycosis. The anaerobe Actinomyces israelii is sensitive to several drugs, but not metronidazole, and access is poor because of granulomatous fibrosis. High doses of benzylpenicillin or amoxicillin are given for several weeks; the infections are often mixed with other anaerobic bacteria so metronidazole is often given in addition to ensure activity against all components of the mixture. Co-amoxiclav may be a convenient alternative. Surgery is likely to be needed.
Leptospirosis. To be maximally effective, chemotherapy should be started within 4 days of the onset of symptoms. Benzylpenicillin is recommended; a Herxheimer reaction may be induced (see Syphilis). General supportive management is important, including attention to fluid balance and observation for signs of hepatic, renal or cardiac failure.
Lyme disease. Keeping the skin covered and use of insect repellants are effective to prevent tick bites and tick removal shortly after attachment (within 24 h) will prevent infection. In most manifestations of the disease, Borrelia burgdorferi responds to amoxicillin or doxycycline orally for up to 21 days but when the central nervous system is invaded large doses of cefotaxime should be given i.v. for 14 days.
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