Objectives-To remind clinicians of the dangers of delayed diagnosis and the importance of early treatment of spinal epidural abscess. Methods-A review of the literature on spinal epidural abscess and a comparison of the published literature with local experience. Results-Imaging with MRI or CT enables early diagnosis of spinal epidural abcess and optimal therapy is surgical evacuation combined with 6-12 weeks (median 8 weeks) of antimicrobial chemotherapy. Clinical features are fever, pain, and focal neurological signs and may be associated with preceding and pre-existing bone or joint disease. The commonest aetiological organism is S aureus. Conclusion-Early diagnosis and appropriate early antimicrobial chemotherapy with surgery is associated with an excellent prognosis. (J Neurol Neurosurg Psychiatry 1998;65:209-212)

Introduction: Human Immunodeficiency Virus (HIV) has an estimated prevalence of 0.9% in India (5.2 million). Anti-retroviral drugs (ARV) are the treatments of choice and non-adherence is an important factor in treatment failure and development of resistance, as well as being a powerful predictor of survival. This study assesses adherence to ARV in HIV positive patients in Bangalore, India, a country where only 10% of those who need therapy are receiving it.

Injecting drug use, mainly of heroin, currently represents a major public health issue in the North East of Scotland. The recent tendency of the committed injecting drug user to inject into the groin has created novel problems for the Infection Unit.Data are presented on 20 consecutive patients admitted between 1994 and 1999 with iliofemoral venous thromboses, often complicated by severe soft tissue infections and bacteraemia as a result of heroin injection into the femoral vein. Nine had coexistent groin abscesses, four had severe streptococcal soft tissue infection of the right thigh, groin and lower abdomen, and two had coincidental soft tissue infections of the upper limb. Nine were bacteraemic on admission. All of the patients were chronic injecting drug users with a median injection duration of 6.5 years. The 18 patients tested for hepatitis C virus were all seropositive. None of the 14 patients tested was positive for HIV.Seventeen patients were treated with subcutaneous low molecular weight heparin (tinzaparin), three having received intravenous unfractionated heparin initially. The tinzaparin was self administered and given for a median duration of seven weeks. One patient declined to have any treatment. Three months after presentation eight patients were asymptomatic, seven had a persistently swollen leg, and five were lost to follow up. None developed clinically apparent pulmonary embolism after institution of anticoagulant therapy.The management of iliofemoral venous thrombosis in injection drug users is problematic because of poor venous access, non-compliance with prescribed treatment, ongoing injecting behaviour, and coexistent sepsis. It is unlikely that a randomised trial of standard treatment with heparin and warfarin versus low molecular weight heparin alone would be practical in this patient group. These retrospective data indicate that the use of tinzaparin in injecting drug users is feasible and appears to result in satisfactory clinical responses.The possibility of concomitant infection in injecting drug users with venous thrombosis should always be addressed, as it appears to be a common phenomenon. Early drainage of abscesses and antimicrobial chemotherapy, often administered intramuscularly or orally because of lack of peripheral venous access, is central to the appropriate care of these patients.

The effect of an intravenous (i.v.)-to-oral switch policy on antibiotic prescribing in general medical wards was examined. Three audits, each of 2 months' duration, were carried out to examine the duration of i.v. therapy and length of patient stay. The first audit (S1) was performed before the introduction of switch guidelines, the second (S2) after guidelines had been placed in patient case-notes and the third (S3) after the guidelines had been introduced into the drug charts. The duration of i.v. therapy was significantly shorter in the S3 group (mean = 3.7 days) than in the S2 or S1 groups (mean 4.4 and 4.35 days, respectively) (P < 0.05). There was no significant difference in the length of patient stay between the three audit periods but the stay was significantly shorter in 81 switched patients (mean duration = 8.9 days) than in matched controls (mean duration = 12.6 days) (P = 0.01). Fewer patients with respiratory infection were treated for > 24 h with i.v. antimicrobials in the S3 audit period (75/549) than in the S2 (85/372) and S1 audits (83/326) (P < 0.01). The introduction of switch guidelines to drug charts reduces the length of i.v. therapy. Switched patients spend less time in hospital than their matched controls.