Treatment of recurrent acute tonsillitis
Tonsillitis is an infection of the tonsils, which consist of pairs of lymph tissue in the nasal and oropharyngeal passages. Bacterial or viral pharyngitis usually precedes infection of the tonsils. Inflammation and edema of the tonsillar tissue creates difficulty swallowing and talking, and forces the child to breathe through the mouth. Advanced infection can lead to cellulitis in adjacent tissue or formation of an abscess which may require drainage. The tonsils removed during a tonsillectomy are the palatine tonsils located in the oropharynx. The adenoids are tonsils located in the nasopharynx and also sometimes removed by adenoidectomy.
This condition is characterized by sore throat, dysphagia, and pyrexia. The appearance of the tonsils varies. An obviously purulent exudate covering the tonsils is common, and is either diffuse or punctate (Fig. 4.52a, b). An apparently less severely infected throat with hyperemia of the tonsils only may, however, be associated with severe symptoms. The tonsillar lymph nodes near the angle of the mandible are large and tender. With acute tonsillitis, the exudate and hyperemia are centered on the tonsils. In an acute pharyngitis, as may be associated with a head cold, the mucous membrane of the entire oropharynx is hyperemic. The gonococcus may cause acute pharyngitis, and a throat swab must be placed in Stewart's medium for laboratory examination if this infection is suspected. The throat swab in acute tonsillitis commonly grows the hemolytic streptococcus, and a course of oral penicillin (often supplemented with an intramuscular injection) is invariably curative. An analgesic may...
Mean LOS 1.5 days Description SURGICAL Tonsillectomy and or Adenoidectomy Only Age 0-17 Tonsils are defined as the masses of lymphatic tissue that are located in the depressions of the mucous membranes of the fauces (constricted opening, leading from the mouth to the oral pharynx) and pharynx. The tonsils act as a filter to protect the body from bacterial invasion via the oral cavity and also to produce white blood cells. Tonsillitis is generally referred to as an inflammation of a tonsil, particularly a faucial tonsil. Acute tonsillitis is considered acute pharyngitis. When tonsillar involvement is severe, the term tonsillopharyngitis or tonsillitis is used when the involvement is minor, the term nasopharyngitis is used. Nearly all children have at least one episode of tonsillitis during their childhood.
Tonsillectomy is one of the most frequently performed operations in the world. Stricter indications for operating, however, are reducing the number of tonsillectomies. Recurrent episodes of acute tonsillitis, interfering with school or work, are the main indications. A quinsy or chronic tonsillitis are other indications, along with marked enlargement interfering with the airway. Fig. 4.62 The tonsillar fossae following tonsillectomy. These are covered with a white yellow membrane for about 10 days until the fossae are epithelialized. Fig. 4.63 Tonsils after removal to demonstrate the lingual pole (arrow). The pole must be included at tonsillectomy. A tonsil remnant may be left inadvertently at this site, giving rise to further infection, but tonsils do not regrow. Adenoid tissue is, however, not possible to enucleate and remove in toto it may recur, particularly when removed before age 4. Fig. 4.62 The tonsillar fossae following tonsillectomy. These are covered with a white yellow...
Postoperatively, relieve pain with analgesics and ice packs as needed. Monitor the patient for fever or chills, sore throat, or red or draining wounds, and administer prophylactic antibiotics as prescribed. Treat the patient's reactions to postoperative chemotherapy or radiation therapy as prescribed, by administering antiemetics to control nausea and vomiting.
Patients may describe symptoms of botulism within 12 hours of exposure. Initially, patients may describe nausea and vomiting, although often they remain alert and oriented without sensory or neurological deficits. Some patients report diarrhea or constipation, whereas others describe a very dry, sore throat and difficulty swallowing some may experience GI symptoms prior to neurological symptoms, or the symptoms may occur simultaneously. Patients also describe neuromuscular abnormalities. Symptoms usually occur in a descending order from the head to the toes. Ask the patient if he or she has experienced blurred vision, double vision, difficulty swallowing, difficulty speaking, or weakness of the arms and legs.
Report any ampicillin rashes a dull, red, itchy, flat or raised rash occurs more often with this drug than with other penicillins and is usually benign. If a late skin rash develops with symptoms of fever, fatigue, sore throat, generalized lymphade-nopathy, and enlarged spleen, a heterophil antibody test may be considered to rule out mononucleosis.
Provide information about the surgery as needed. Teach parents that an important risk after a tonsillectomy is excessive bleeding from the operative site. Teach to observe for excessive swallowing and to encourage the child to avoid putting anything in the mouth, and to avoid excess coughing and clearing the throat.
Five of these six had fever plus a prolonged maculopapular rash. Sore throat not associated with painful oral ulcers or reactive cervical lymphadeopathy was also noted. Reactivated HHV-8 infection may also present with symptoms, as evidenced by the case of an immunosuppressed, HHV-8-seropositive adult who developed fever, hepatitis, a maculopapular rash, and pancytopenia secondary to marrow failure in association with detectable HHV-8 DNA in the plasma (62).
Uses Otitis media due to Streptococcus pneumoniae, Hemophilus influenzae, Streptococcus pyogenes, and staphylococci. Upper respiratory tract infections (including pharyngitis and tonsillitis) caused by S. pyo-genes. Lower respiratory tract infections (including pneumonia) due to S. pneumoniae, H. influenzae, and S. pyogenes. Skin and skin structure infections due to Staphylococcus aure-us and S. pyogenes. UTIs (including pyelonephritis and cystitis) caused by Escherichia coli, Proteus mirabilis, Klebsiella, and coagulase-negative staphylococci. Extended-release tablets Acute bacterial exacerbations of chronic bronchitis due to non- -lac-tamase-producing strains of H. in-fluenzae, Moraxella catarrhalis (including -lactamase-producing strains), or S. pneumoniae. Secondary bacterial infections of acute bronchitis due to H. influenzae (non- -lactamase-producing strains only), M. catarrhalis (including -lactamase-producing strains), or S. pneumoniae. Pharyngitis or tonsillitis due to S....
Uses Acute bacterial exacerbations of chronic bronchitis due to Haemophilus influenzae (including beta-lacta-mase-producing strains), Moraxella eatarrhalis (including beta-lacta-mase-producing strains), and penicillin-susceptible strains of Strepto-eoeeus pneumoniae. Acute bacterial otitis media due to H. influenzae, M. eatarrhalis, and Staphylococcuspyo-genes. Pharyngitis and tonsillitis due to S. pyogenes. Contraindications Hypersensitiv-ity to cephalosporins. Special Concerns Although cefti-buten has been approved for pharyngitis or tonsillitis, only penicillin has been shown to be effective in preventing rheumatic fever. Not approved to treat urinary infections. Hypersen-sitivity to penicillins. Use with caution in patients with renal impairement, infants 6 months, and in patients with pseudomembraneous colitis. Oral suspension contains 1 g sucrose per 5 mL. Children pharyngitis, tonsillitis, acute bacterial otitis media. 9 mg kg, up to a maximum of 400 mg daily, for a total of 10...
Defining Characteristics (Specify, e.g., child states it hurts to drink, decreased intake specify amount post-tonsillectomy risk for hemorrhage.) Goal Child will not experience deficient fluid volume by (date time to evaluate). Outcome Criteria Observe post-tonsillectomy client for signs of bleeding assess operative site using a flashlight (specify frequency), monitor child for excessive swallowing, even during sleep.
Inform patients and families about the disease process, prognosis, and treatment plan. Discuss with them the possibility that abnormal urinary findings may persist for years after AGN has been diagnosed. Demonstrate all home care techniques, such as medication administration. Discuss the dosage, action, route, and side effects of all medications. If the patient is placed on antibiotics, encourage her or him to complete the entire prescription. Teach the patient and family to seek professional assistance for all infectious processes (particularly respiratory infections with sore throat and fever) monitor body weight and blood pressure at home or through a clinic avoid contact with individuals with infectious processes. Discuss the need for ongoing laboratory monitoring of electrolytes and renal function tests during the months of convalescence, as recommended by the physician. Explain that after acute poststreptococcal glomerulonephritis, any gross hematuria that occurs when the...
Typhoidal 5-day prodrome, fever, chills, sore throat, joint pain, rose spots (30 ) cramps, hepatosplenomegaly (H S) (50 ), neuropsychi-atric symptoms, lymphadenopathy, constipation, no diarrhea, bradycardia, CFR 30 . Complications Bowel perforations from perforated Peyer's patch, osteomyelitis. Warning Infants and elderly in homes with pet amphibians and reptiles turtles lizards (iguanas) snakes.
Latex immunoagglutination assay was first described in 1956 by Singer and Plotz 1 and applied to rheumatoid factor. One can realize the importance of this kind of assays when perusing the specialized literature. In the last decade alone more than 400 publications in medicine and veterinary journals reported the use of latex immunoagglutination assays as analysis or research tools. The popularity of this diagnostic technology is illustrated by the fact that in 1992 there were over 200 commercial reagents available employing this approach to detect infectious diseases from strep throat to AIDS 2 . These include bacterial, fungal, parasitic, rickettsial, and viral diseases. The tests are also useful for cancer detection and for identification of many other substances (hormones, drugs, serum proteins, etc). The most familiar application of latex immunoas-says is the pregnancy determination. In this procedure, a suspension of latex particles covered by human chorionic gonadotropin (HCG) is...
There are several controversial issues regarding both the assessment and the treatment of patients with cervical metastases from an unknown primary site. In the realm of assessment, controversy arises over which of the diagnostic studies should be routinely done in order to find the primary site. Imaging studies such as computed tomography (CT), magnetic resonance imaging (MRI), positron emission tomography (PET), and 2- fluorine-18 -2-deoxy-D-glucose single photon emission computed tomography (FDG-SPECT) for surveillance of potential primary sites are central to any assessment controversy.3 In addition, the role of serologic Epstein-Barr viral (EBV) tests or EBV genomic DNA assays in patients with cervical lymph node metastases from an occult primary is also uncertain.4 Furthermore, the routine use of random aerodigestive tract biopsies and routine ipsilateral tonsillectomy in the diagnostic workup has been recommended by some and rejected by others.3,5
CLINICAL PRESENTATION Erythema multiforme minor is characterized by round erythematous rapidly progressive mucocutaneous macules or papules. The borders are bright red with central petichiae, vesicles, or purpura. Conjunctivitis with blisters and ulcerations can be seen, and secondary infection is common. Lesions may coalesce and become generalized. Burning may be significant, but pruritis is generally absent. These lesions usually resolve over one to several weeks, but postinflammatory hyper- or hypopigmentation may occur. In EM major (Stevens-Johnson syndrome) prodromal symptoms occur in 50 of cases and include fever, malaise, sore throat, arthral-gia, vomiting, and diarrhea. Mucocutaneous involvement shows bullous lesions which become hemorrhagic and necrotic, leading to extensive denuded areas of skin and mucous membrane including the mouth and conjunctiva. Scarring results in lagophthalmos, trichiasis, symblepharon,
Most side effects of antithyroid drugs develop within eight weeks of starting therapy. However, adverse effects may develop later. Parents should be instructed to contact their physician promptly if fever, sore throat, oral ulceration, rash, joint pain, nausea, abdominal pain, or any other unusual symptoms develop, and stop medical therapy.
Uses Infections of the respiratory tract (including lobar pneumonia, tonsillitis, pharyngitis), urinary tract (including prostatitis and enterococcal infections), skin, skin structures, and bone. Otitis media, septicemia, prophylaxis in surgery, following cesar-ean section to prevent infection. In severe infections, therapy is usually initiated parenterally. Contraindications Hypersensitiv-ity to cephalosporins. Special Concerns Safe use during pregnancy, of the parenteral form in infants under 1 month of age, and of the PO form in children less than 9 months of age have not been established. Hypersensitivity to penicillins. Use in renal impairment. Side Effects See also Cephalosporins. Drug Interactions See also Cepha-losporins.
Action Kinetics Sixty percent is recovered in the urine unchanged. Uses Pharyngitis and tonsillitis due to Streptococcus pyogenes. Acute bacterial sinusitis due to Streptococcus pneumoniae, Staphylococcus aure-us, Haemophilus influenzae, and Moraxella catarrhalis. Otitis media
Pharyngitis look for sore throat with fever, tonsillar exudate, enlarged tender cervical nodes, and leukocytosis. Streptococcal throat culture confirms the diagnosis. Elevated an tistreptolysin O (ASO) and anti-DNase titers also are used retrospectively when needed (rheumatic fever, post-streptococcal glomerulonephritis).Treat with penicillin to avoid rheumatic fever and scarlet fever.
Epiglottitis is the acute inflammation of the epiglottis and surrounding laryngeal area with the associated edema that constitutes an emergency situation as the supraglottic area becomes obstructed. The child characteristically appears very ill with a fever, severe sore throat, muffled voice, and insists on sitting upright with the chin extended and mouth open. Drooling is common because of inability to swallow, and respiratory distress is progressive as the obstruction advances. No examination of the oropharynx is performed until emergency equipment and personnel are readily available. Respiratory distress must be relieved by endotracheal intubation or tracheostomy in severe cases. Onset is rapid (over 4-12 hours) and breathing pattern usually re-established within 72 hours following intubation and antimicrobial therapy. Children most commonly affected are between 2 and 7 years of age.
In this condition there is a generalized hyperemia of the pharyngeal mucous membrane, with hyperemic masses of lymphoid tissue on the posterior wall of the oropharynx. A persistent, slightly sore throat is the main symptom. The cause is usually irritative rather than due to chronic infection. Environment, occupation, diet, and tobacco are the common factors.
Spread by nasal droplet infection incubation period of 14-19 days, with onset of rash usually on the 15th day disease contagious from a few days before to 5-7 days after the appearance of the exanthem most contagious when rash is erupting may have no prodrome in children, with rash being first manifestation in adults, fever, sore throat, and rhinitis may occur discrete macules on the face that spread to the neck, trunk, and extremities, with coalescence into plaques exanthem lasts 1-3 days, first leaving the face nonspecific enanthem (Forscheimer's spots) of pinpoint red macules and petechiae visible over the soft palate and uvula just before or with the exanthem
Hematologic Agranulocytosis, thrombocytopenia. Allergic Fever, sore throat, respiratory distress, rash, pharyngitis, laryngospasm, anaphylaxis. Skin Fever, pruritus, rash. Ophthalmic Dry eyes. GU Decreased libido, impotence, urinary tract infection. Other Hypoglycemia. Respiratory Bron-chospasm, dyspnea, wheezing. Additional Side Effects Psoriasislike eruptions, skin necrosis, SLE (rare).
Begins with the penetration of the infecting organism, the spirochete Treponema pallidum, into the skin or mucosa of the body. Within 10 to 90 days after the initial infection, the primary stage begins with the appearance of a firm, painless lesion called a chancre at the site of entry. In women, the chancre often forms in the vagina or on the cervix and therefore goes unnoticed. If it is left untreated, the chancre heals spontaneously in 1 to 5 weeks. As this primary stage resolves, systemic symptoms appear, thus signaling the start of the secondary stage. Secondary stage symptoms include malaise, headache, nausea, fever, loss of appetite, sore throat, stomatitis, alopecia, condylomata lata (reddish-brown lesions that ulcerate and have a foul discharge), local or generalized rash, and silver-gray eroded patches on the mucous membranes. These symptoms subside in 1 week to 6 months, and the infected person enters a latent stage, which may last from 1 to 40 years. During latency,...
Tonsillar hypertrophy is a positive factor in determining surgical outcome. If a patient has large obstructive tonsils, this alone or in conjunction with UPPP often creates a surgical cure. I consider significant tonsillar hypertrophy a contraindication for CPAP, because surgical intervention can create a cure and will not require patient compliance for the use of CPAP in the future. Conversely, in a patient with a long palate or a large uvula with normal tonsils (not beyond the anterior pillar), or both, I do not recommend tonsillectomy. Postoperative constriction of the tonsillar fossa with loss of lateral dimension often replaces a lost volume of tonsillar tissue. In addition, the superior-to-inferior contraction of the fossa with the loss of a tonsillar lingual sulcus pulls the tongue base superiorly, limiting the oropharyngeal opening somewhat as well. The risk of postoperative hemorrhage and airway swelling is not justified unless the tonsils are enlarged and the overall net...
Special Concerns Use with caution in infants up to 1 month of age, in clients with GI disease, liver or renal disease, or a history of allergy or asthma. Safety and efficacy of topical products have not been established in children less than 12 years of age. Side Effects Oral Candidiasis. GI N&V, diarrhea, bloody diarrhea, abdominal pain, GI disturbances, te-nesmus, flatulence, bloating, anorexia, weight loss, esophagitis. Nonspecific colitis, pseudomembranous colitis (may be severe). Allergic Morbilliform rash (most common). Also, maculopapular rash, urticaria, pruritus, fever, hypotension. Rarely, polyarteritis, anaphylaxis, erythema multiforme. Hematologic Leukope-nia, neutropenia, eosinophilia, thrombocytopenia, agranulocytosis. Miscellaneous Superinfection. Also sore throat, fatigue, urinary frequency, headache.
Early, acute phase in an immunocompetent person to an HIV infection. Widespread level of viral production occurs with widespread seeding of lymph tissues. Symptoms are generally nonspecific, such as sore throat, myalgia, fever, weight loss, and fatigue. Symptoms occur 3-6 weeks after infection and resolve 2-4 weeks later
Pityriasis rosea (PR) is a common dermatitis that acts like a viral exanthem. Peak incidence is during the second and third decades, although it can occur at any age. Onset is acute and usually consists of the sudden appearance of a single skin lesion, referred to as the herald plaque or patch. About 5 of cases have a prodrome with mild constitutional symptoms, sore throat, GI complaints, and or cervical adenopathy. In a significant number of patients, the initial lesions are overlooked or occur in hidden locations therefore, it presents as an acute generalized eruption. Outbreaks often cluster in an epidemic fashion during the spring and fall. This supports speculation of a viral etiology. Cause, however, remains unproven and concurrent cases within family units are rare.
While conditions like luetic or diphtheric laryngitis are no longer seen, occasional cases of acute epiglottitis will be seen in the medical examiner's office. Most people think of this as a disease of young children. Increasingly, however, it has become a disease of adults.61,62 With acute epiglottitis, there is always the potential for sudden fatal airway obstruction, which can occur extremely rapidly. The individual may have very minor symptoms such as a sore throat, difficulty swallowing, and hoarse speech. From there, the patient can rapidly develop airway obstruction, even while talking to a physician. Acute epiglottitis is often a medical emergency, requiring immediate tracheostomy or insertion of an endotracheal tube if the individual begins to develop acute airway obstruction.
Influenza, commonly called the flu, is an infection caused by a virus that affects the respiratory system. Symptoms include fever, chills, headache, muscle aches, and a sore throat. Influenza is spread from person to person through direct contact, such as shaking hands, or by inhaling droplets containing the virus in the air after an infected person coughs or sneezes. New strains of influenza virus appear every year, so you must get a shot of the influenza vaccine yearly, in the fall, just before the flu season starts. Doctors recommend the influenza vaccine for all men over age 65 and for younger men who have medical problems such as heart disease, lung disease, or diabetes or who have close contact with high-risk people.
Ness, drowsiness, fatigue, hallucinations, insomnia, lethargy, mental changes, memory loss, strange dreams. GI Diarrhea, ischemic colitis, nausea, mesenteric arterial thrombosis, vomiting. Hematologic Agranulocytosis, thrombocytopenia. Allergic Fever, sore throat, respiratory distress, rash, pharyngitis, laryngos-pasm, anaphylaxis. Skin Pruritus, rash, increased skin pigmentation, sweating, dry skin, alopecia, skin irritation, psoriasis. Ophthalmic Dry, burning eyes. GU Dysuria, impotence, nocturia. Other Hypoglycemia or hyperglycemia. Respiratory Bronchospasm, dyspnea, wheezing. Drug Interactions See also Drug Interactions for Beta-Adrenergic Blocking Agents and Antihypertensive Agents.
The issue of performing an ipsilateral tonsillectomy during this evaluation has been controversial.20 However, there is growing evidence that such a procedure should be done, as a tumor located in the depths of the tonsil may be missed on a simple biopsy. In a report by Righi and Sofferman29 6 of 19 patients had occult carcinoma in an ipsilateral tonsil which was diagnosed only by examination of the whole tonsil. Microscopy demonstrated that all six tonsils had extensive areas of normal squamous epithelium overlying the malignancies suggesting that simple random biopsies might well have missed the lesion. CT scanning, inspection, and palpation showed no evidence of disease in all of these six patients. There are other reports in the literature supporting such a recommendation.22,30
The value of routine ipsilateral tonsillectomy to identify the source of a metastatic squamous cell carcinoma has been debated.3,9 One small retrospective review concluded that ipsi-lateral tonsillectomy was the only reliable screening technique to rule out an occult tonsil carcinoma.17 This conclusion was made on the basis of a case series no comparison was made to other methods of detection, such as palpation under anesthesia or tonsil biopsy. By contrast, a larger review by Mendenhall et al.3 concluded that the diagnostic value of routine ipsilateral tonsillectomy was uncertain.
Becoming violaceous and forming concentric target lesion lesions appear predominantly on the extensor surfaces of acral extremities and spread centripetally mild erosions of one mucosal surface palms, neck, and face frequently involved Erythema multiforme major variant prodrome of moderate fever, general discomfort, cough, sore throat, vomiting, chest pain, and diarrhea, usually for 1-14 days preceding the eruption skin lesions same as with erythema multiforme minor severe erosions of at least 2 mucosal surfaces generalized lymphadenopathy
Spores from a biological weapons facility in Sverdlovsk in 1979, in which 66 deaths occurred. The incubation time ranged from 2 to 43 days, with an average of about 10 days. The mortality rate was approximately 80 (9). Despite its rarity, inhalational anthrax was the mode of infection in 50 of the anthrax cases in the 2001 attacks, and would be expected to be the prevalent form of the disease in a biological weapons attack (10). In the setting of an anthrax outbreak, clinical features favoring inhalational anthrax over an influenza-like illness include presence of dyspnea, hypoxemia, chest pain, lack of sore throat or rhinorrhea, and presence of mediastinal widening, pulmonary infiltrate, or pleural effusion on chest radiography. Laboratory evaluation may reveal neutrophilia with bandemia and elevated liver enzyme tests (11).
In choking, asphyxia is caused by obstruction within the air passages. The manner of death can be natural, homicide, or accident. Natural deaths are seen in individuals with acute fulminating epiglottitis, where there is obstruction of the airway by the inflamed epiglottis and adjacent soft tissue. Such individuals represent medical emergencies and can die literally in front of a physician. The individual develops a sore throat, hoarseness, respiratory difficulty, inability to speak and then suddenly collapses as the airway is completely obstructed. Inhalation of steam can cause a similar picture, with a markedly edematous, beefy-red mucosa in the larynx with obstruction (Figure 8.6).
This is a complication of acute tonsillitis in which a peritonsillar abscess forms. The symptoms may be extremely severe, with absolute dysphagia and pain referred to the ear and trismus, as well as malaise, fever, and marked swelling of the tonsillar lymph node. Examination shows the signs of acute tonsillitis with medial displacement of the tonsils to the mid-line. Quinsies not infrequently occur in those who have suffered previous episodes of tonsillitis. Tonsillectomy, which is often indicated after a quinsy, is delayed by four to six weeks until the acute phase has passed. Vascular fibrous tissue found lateral to the tonsil after a quinsy make tonsillectomy technically difficult, and some advocate tonsillectomy at the time of the acute quinsy (quinsy tonsillectomy).
Action Kinetics Cefuroxime axetil is used PO, whereas cefuroxime sodium is used either IM or IV. Uses PO (axetil). Pharyngitis, tonsillitis, otitis media, sinusitis, acute bacterial exacerbations of chronic bronchitis and secondary bacterial infections of acute bronchitis, uncomplicated UTIs, uncomplicated skin and skin structure infections, uncomplicated gonorrhea (urethral and endocervical) caused by non-penicillinase-producing strains of Neisseria gonorrhoeae. Early Lyme disease due to Borrelia burgdorferi. The suspension is indicated for children from 3 months to 12 years to treat pharyngitis, tonsillitis, acute bacterial otitis media, and impetigo. Contraindications Hypersensitivity to cephalosporins. Use in infants 1 month. Pharyngitis, tonsillitis. Children, 3 months to 12 years 20 mg kg day in 2 divided doses, not to exceed 500 mg total dose day, for 10 days.
Uses Uncomplicated UTIs caused by E. coli and P. mirabilis. Otitis media due to H. influenzae (beta-lacta-mase positive and negative strains), Moraxella catarrhalis, and S. pyogenes. Pharyngitis and tonsillitis caused by S. pyogenes. Acute bronchitis and acute exacerbations of chronic bronchitis caused by S. pneumoniae and H. influenzae (beta-lactamase positive and negative strains). Uncomplicated cervical or urethral gonorrhea due to N. gonorrhoeae (both penicillinase- and non-penicillinase-producing strains). Contraindications See also Ce-phalosporins.