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Marenco Swisshelicopter, which announced its helicopter project last year at Heli-Expo, has unveiled the "high-visibility cockpit" of the SKYe SH09 light single, which features a wide windshield, thin uprights, large windows (including chin windows) and even a transparent floor between the front seats. Marenco is emphasizing the expected benefits in surveillance, sightseeing and passenger flights, as well as in carrying external loads. "The high-visibility cockpit will open the sky to your eyes and make the mission more efficient, pleasant and improve safety drastically," the company said. The aircraft is equipped with 10-inch Sagem primary and multifunction displays, which free up space in front of the crew. Its air-conditioning system has also been adapted to the large transparent surfaces. The first prototype is currently being assembled near Zurich, Switzerland, and the company aims to fly it by year-end. Certification is slated for 2014. Belonging to the 5,500-pound class, the $3 million SH09 will seat five to eight passengers. Deliveries are slated to start in 2015.
New Swiss Helo To Feature 'High Visibility' Cockpit
- January 31, 2012, 6:16 PM


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ROCEPHIN - ceftriaxone sodium injection, powder, for solution
----------Ceftriaxone for Injection USP 1 g
Rx Only
To reduce the development of drug-resistant bacteria and maintain the effectiveness of ceftriaxone sodium and other antibacterial drugs, ceftriaxone for injection should be used only to treat or prevent infections that are proven or strongly suspected to be caused by bacteria.
Ceftriaxone for injection is a sterile, semisynthetic, broad-spectrum cephalosporin antibiotic for intravenous or intramuscular administration. Ceftriaxone sodium is (6R,7R)-7-[2-(2-Amino-4-thiazolyl)glyoxylamido]-8-oxo-3-[[(1,2,5,6-tetrahydro-2-methyl-5,6-dioxo-as-triazin-3-yl)thio]methyl]-5-thia-l-azabicyclo [4.2.0]oct-2-ene-2-carboxylic acid, 72-(Z)-(O-methyloxime), disodium salt, sesquaterhydrate.
The molecular formula of ceftriaxone sodium is C18H16N8Na2O7S3 . 3.5 H2O. It has a calculated molecular weight of 661.60 and the following structural formula:
Ceftriaxone for injection is a white to yellowish-orange crystalline powder which is readily soluble in water, sparingly soluble in methanol and very slightly soluble in ethanol. The pH of a 1% aqueous solution is approximately 6.7. The color of ceftriaxone for injection solutions ranges from light yellow to amber, depending on the length of storage, concentration and diluent used.
Ceftriaxone for injection contains approximately 83 mg (3.6 mEq) of sodium per gram of ceftriaxone activity.
Average plasma concentrations of ceftriaxone following a single 30-minute intravenous (IV) infusion of a 0.5, 1 or 2 g dose and intramuscular (IM) administration of a single 0.5 (250 mg/mL or 350 mg/mL concentrations) or 1 g dose in healthy subjects are presented in Table 1.
|Dose/ Route
|Average Plasma Concentrations (mcg/mL)
|0.5 hr
|1 hr
|2 hr
|4 hr
|6 hr
|8 hr
|12 hr
|16 hr
|24 hr
|0.5 g IV*
0.5 g IM250 mg/ mL
0.5 g IM350 mg/mL
|1 g IV*
|1 g IM
|2 g IV*
|*IV doses were infused at a constant rate over 30 minutes.
|ND = Not determined.
Ceftriaxone was completely absorbed following IM administration with mean maximum plasma concentrations occurring between 2 and 3 hours postdosing. Multiple IV or IM doses ranging from 0.5 to 2 g at 12- to 24-hour intervals resulted in 15% to 36% accumulation of ceftriaxone above single dose values.
Ceftriaxone concentrations in urine are high, as shown in Table 2.
|Dose/ Route
|Average Urinary Concentrations (mcg/mL)
|0-2 hr
|2-4 hr
|4-8 hr
|8-12 hr
|12-24 hr
|24-48 hr
|0.5 g IV
|0.5 g IM
|1 g IV
|1 g IM
|2 g IV
|ND = Not determined.
Thirty-three percent to 67% of a ceftriaxone dose was excreted in the urine as unchanged drug and the remainder was secreted in the bile and ultimately found in the feces as microbiologically inactive compounds. After a 1 g IV dose, average concentrations of ceftriaxone, determined from 1 to 3 hours after dosing, were 581 mcg/mL in the gallbladder bile, 788 mcg/mL in the common duct bile, 898 mcg/mL in the cystic duct bile, 78.2 mcg/g in the gallbladder wall and 62.1 mcg/mL in the concurrent plasma.
Over a 0.15 to 3 g dose range in healthy adult subjects, the values of elimination half-life ranged from 5.8 to 8.7 hours; apparent volume of distribution from 5.78 to 13.5 L; plasma clearance from 0.58 to 1.45 L/hour; and renal clearance from 0.32 to 0.73 L/hour. Ceftriaxone is reversibly bound to human plasma proteins, and the binding decreased from a value of 95% bound at plasma concentrations of <25 mcg/mL to a value of 85% bound at 300 mcg/mL. Ceftriaxone crosses the blood placenta barrier.
The average values of maximum plasma concentration, elimination half-life, plasma clearance and volume of distribution after a 50 mg/kg IV dose and after a 75 mg/kg IV dose in pediatric patients suffering from bacterial meningitis are shown in Table 3. Ceftriaxone penetrated the inflamed meninges of infants and pediatric patients; CSF concentrations after a 50 mg/kg IV dose and after a 75 mg/kg IV dose are also shown in Table 3.
|50 mg/kg IV
|75 mg/kg IV
|Maximum Plasma Concentrations (mcg/mL)
|Elimination Half-life (hr)
|Plasma Clearance (mL/hr/kg)
|Volume of Distribution (mL/kg)
|CSF Concentration – inflamed meninges (mcg/mL)
|Range (mcg/mL)
|1.3 – 18.5
|1.3 – 44
|Time after dose (hr)
|3.7 (± 1.6)
|3.3 (± 1.4)
Compared to that in healthy adult subjects, the pharmacokinetics of ceftriaxone were only minimally altered in elderly subjects and in patients with renal impairment or hepatic dysfunction (Table 4); therefore, dosage adjustments are not necessary for these patients with ceftriaxone dosages up to 2 g per day. Ceftriaxone was not removed to any significant extent from the plasma by hemodialysis. In 6 of 26 dialysis patients, the elimination rate of ceftriaxone was markedly reduced, suggesting that plasma concentrations of ceftriaxone should be monitored in these patients to determine if dosage adjustments are necessary.
|Subject Group
|Elimination Half-life (hr)
PlasmaClearance (L/hr)
|Volume of Distribution (L)
|Healthy Subjects
|5.8 – 8.7
|0.58 – 1.45
|5.8 – 13.5
|Elderly Subjects (mean age, 70.5 yr)
|Patients with renal impairment
|Hemodialysis patients (0-5 mL/ min)*
|Severe (5-15 mL/ min)
|Moderate (16-30 mL/min)
|Mild (31 – 60 mL/ min)
|Patients with liver disease
In one study, total ceftriaxone concentrations (bound and unbound) were measured in middle ear fluid obtained during the insertion of tympanostomy tubes in 42 pediatric patients with otitis media. Sampling times were from 1 to 50 hours after a single intramuscular injection of 50 mg/kg of ceftriaxone. Mean (± SD) ceftriaxone levels in the middle ear reached a peak of 35 (± 12) mcg/mL at 24 hours, and remained at 19 (± 7) mcg/mL at 48 hours. Based on middle ear fluid ceftriaxone concentrations in the 23 to 25 hour and the 46 to 50 hour sampling time intervals, a half-life of 25 hours was calculated. Ceftriaxone is highly bound to plasma proteins. The extent of binding to proteins in the middle ear fluid is unknown.
The bactericidal activity of ceftriaxone results from inhibition of cell wall synthesis. Ceftriaxone has a high degree of stability in the presence of beta-lactamases, both penicillinases and cephalosporinases, of gram-negative and gram-positive bacteria.
Ceftriaxone has been shown to be active against most strains of the following microorganisms, both in vitro and in clinical infections described in the INDICATIONS AND USAGE section.
Aerobic gram-negative microorganisms:
Acinetobacter calcoaceticus
Enterobacter aerogenes
Enterobacter cloacae
Escherichia coli
Haemophilus influenzae (including ampicillin-resistant and beta-lactamase producing strains)
Haemophilus parainfluenzae
Klebsiella oxytoca
Klebsiella pneumoniae
Moraxella catarrhalis (including beta-lactamase producing strains)
Morganella morganii
Neisseria gonorrhoeae (including penicillinase- and nonpenicillinase-producing strains)
Neisseria meningitidis
Proteus mirabilis
Proteus vulgaris
Serratia marcescens
Ceftriaxone is also active against many strains of Pseudomonas aeruginosa.
NOTE: Many strains of the above organisms that are multiply resistant to other antibiotics, e.g., penicillins, cephalosporins, and aminoglycosides, are susceptible to ceftriaxone.
Aerobic gram-positive microorganisms:
Staphylococcus aureus (including penicillinase-producing strain)
Staphylococcus epidermidis
Streptococcus pneumoniae
Streptococcus pyogenes
Viridans group streptococci
NOTE: Methicillin-resistant staphylococci are resistant to cephalosporins, including ceftriaxone. Most strains of Group D streptococci and enterococci, e.g., Enterococcus (Streptococcus) faecalis, are resistant.
Anaerobic microorganisms:
Bacteroides fragilis
Clostridium species
Peptostreptococcus species
NOTE: Most strains of Clostridium difficile are resistant.
The following in vitro data are available, but their clinical significance is unknown. Ceftriaxone exhibits in vitro minimal inhibitory concentrations (MICs) of < 8 mcg/mL or less against most strains of the following microorganisms, however, the safety and effectiveness of ceftriaxone in treating clinical infections due to these microorganisms have not been established in adequate and well-controlled clinical trials.
Aerobic gram-negative microorganisms:
Citrobacter diversus
Citrobacter freundii
Providencia species (including Providencia rettgeri)
Salmonella species (including Salmonella typhi)
Shigella species
Aerobic gram-positive microorganisms:
Streptococcus agalactiae
Anaerobic microorganisms:
Prevotella (Bacteroides) bivius
Porphyromonas (Bacteroides) melaninogenicus
Quantitative methods are used to determine antimicrobial minimal inhibitory concentrations (MICs). These MICs provide estimates of the susceptibility of bacteria to antimicrobial compounds. The MICs should be determined using a standardized procedure1. Standardized procedures are based on a dilution method (broth or agar) or equivalent with standardized inoculum concentrations and standardized concentrations of ceftriaxone powder. The MIC values should be interpreted according to the following criteria² for aerobic organisms other than Haemophilus spp, Neisseria gonorrhoeae, and Streptococcus spp, including Streptococcus pneumoniae:
|MIC (mcg/mL)
|< 8
|(S) Susceptible
|16 – 32
|(I) Intermediate
|> 64
|(R) Resistant
The following interpretive criteria2 should be used when testing Haemophilus species using Haemophilus Test Media (HTM).
|MIC (mcg/mL
|< 2
|(S) Susceptible
The absence of resistant strains precludes defining any categories other than "Susceptible". Strains yielding results suggestive of a "Nonsusceptible" category should be submitted to a reference laboratory for further testing.
The following interpretive criteria² should be used when testing Neisseria gonorrhoeae when using GC agar base and 1% defined growth supplement.
|MIC (mcg/mL)
|< 0.25
|(S) Susceptible
The absence of resistant strains precludes defining any categories other than "Susceptible". Strains yielding results suggestive of a "Nonsusceptible" category should be submitted to a reference laboratory for further testing.
The following interpretive criteria² should be used when testing Streptococcus spp including Streptococcus pneumoniae using cation-adjusted Mueller-Hinton broth with 2 to 5% lysed horse blood.
|MIC (mcg/mL)
|< 0.5
|(S) Susceptible
|(I) Intermediate
|> 2
|(R) Resistant
A report of "Susceptible" indicates that the pathogen is likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable. A report of "Intermediate" indicates that the results should be considered equivocal, and if the microorganism is not fully susceptible to alternative, clinically feasible drugs, the test should be repeated. This category implies possible clinical applicability in body sites where the drug is physiologically concentrated or in situations where high dosage of the drug can be used. This category also provides a buffer zone which prevents small uncontrolled technical factors from causing major discrepancies in interpretation. A report of "Resistant" indicates that the pathogen is not likely to be inhibited if the antimicrobial compound in the blood reaches the concentrations usually achievable; other therapy should be selected.
Standardized susceptibility test procedures require the use of laboratory control microorganisms to control the technical aspects of the laboratory procedures. Standardized ceftriaxone powder should provide the following MIC values:²
MIC (mcg/mL)
|Escherichia coli
|0.03 - 0.12
|Staphylococcus aureus
|1 – 8*
|Pseudomonas aeruginosa
|8 - 32
|Haemophilus influenzae
|0.06 - 0.25
|Neisseria gonorrhoeae
0.004 - 0.015
|Streptococcus pneumoniae
|0.03 - 0.12
Quantitative methods that require measurement of zone diameters also provide reproducible estimates of the susceptibility of bacteria to antimicrobial compounds. One such standardized procedure³ requires the use of standardized inoculum concentrations. This procedure uses paper discs impregnated with 30 mcg of ceftriaxone to test the susceptibility of microorganisms to ceftriaxone.
Reports from the laboratory providing results of the standard single—disc susceptibility test with a 30 mcg ceftriaxone disc should be interpreted according to the following criteria for aerobic organisms other than Haemophilus spp, Neisseria gonorrhoeae, and Streptococcus spp:
|Zone diameter (mm)
|> 21
|(S) Susceptible
|(I) Intermediate
|< 13
(R) Resistant
The following interpretive criteria3 should be used when testing Haemophilus species when using Haemophilus Test Media (HTM).
|Zone diameter (mm)
|> 26
|(S) Susceptible
The absence of resistant strains precludes defining any categories other than "Susceptible". Strains yielding results suggestive of a "Non-susceptible" category should be submitted to a reference laboratory for further testing.
The following interpretive criteria3 should be used when testing Neisseria gonorrhoeae when using GC agar base and 1% defined growth supplement.
|Zone diameter (mm)
|> 35
|(S) Susceptible
The absence of resistant strains precludes defining any categories other than "Susceptible". Strains yielding results suggestive of a "Non-susceptible" category should be submitted to a reference laboratory for further testing.
The following interpretive criteria³ should be used when testing Streptococcus spp other than Streptococcus pneumoniae when using Mueller Hinton agar supplemented with 5% sheep blood incubated in 5% CO2.
|Zone diameter (mm)
|> 27
|(S) Susceptible
|(I) Intermediate
|< 24
(R) Resistant
Interpretation should be as stated above for results using dilution techniques.
Interpretation involves correlation of the diameter obtained in the disc test with the MIC for ceftriaxone.
Disc diffusion interpretive criteria for ceftriaxone discs against Streptococcus pneumoniae are not available, however, isolates of pneumococci with oxacillin zone diameters of >20 mm are susceptible (MIC ≤ 0.06 mcg/mL) to penicillin and can be considered susceptible to ceftriaxone. Streptococcus pneumoniae isolates should not be reported as penicillin (ceftriaxone) resistant or intermediate based solely on an oxacillin zone diameter of ≤19 mm. The ceftriaxone MIC should be determined for those isolates with oxacillin zone diameters < 19 mm.
As with standardized dilution techniques, diffusion methods require the use of laboratory control microorganisms that are used to control the technical aspects of the laboratory procedures. For the diffusion technique, the 30 mcg ceftriaxone disc should provide the following zone diameters in these laboratory test quality control strains:3
|Zone Diameter Ranges (mm)
|Escherichia coli
|29 - 35
|Staphylococcus aureus
|22 - 28
|Pseudomonas aeruginosa
|17 - 23
|Haemophilus influenzae
|31 - 39
|Neisseria gonorrhoeae
|39 - 51
|Streptococcus pneumoniae
|30 - 35
Anaerobic Techniques: For anaerobic bacteria, the susceptibility to ceftriaxone as MICs can be determined by standardized test methods.4 The MIC values obtained should be interpreted according to the following criteria:
|MIC (mcg/mL)
|< 16
|(S) Susceptible
|(I) Intermediate
|> 64
(R) Resistant
As with other susceptibility techniques, the use of laboratory control microorganisms is required to control the technical aspects of the laboratory standardized procedures. Standardized ceftriaxone powder should provide the following MIC values for the indicated standardized anaerobic dilution4 testing method:
MIC (mcg/mL)
|Bacteroides fragilis
|Bacteroides thetaiotaomicron
|Bacteroides thetaiotaomicron
ATCC® is a registered trademark of the American Type Culture Collection.
Before instituting treatment with ceftriaxone for injection, appropriate specimens should be obtained for isolation of the causative organism and for determination of its susceptibility to the drug. Therapy may be instituted prior to obtaining results of susceptibility testing.
To reduce the development of drug-resistant bacteria and maintain the effectiveness of ceftriaxone for injection and other antibacterial drugs, ceftriaxone for injection should be used only to treat or prevent infections that are proven or strongly suspected to be caused by susceptible bacteria. When culture and susceptibility information are available, they should be considered in selecting or modifying antibacterial therapy. In the absence of such data, local epidemiology and susceptibility patterns may contribute to the empiric selection of therapy.
Ceftriaxone for injection is indicated for the treatment of the following infections when caused by susceptible organisms:
LOWER RESPIRATORY TRACT INFECTIONS caused by Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, Haemophilus parainfluenzae, Klebsiella pneumoniae, Escherichia coli, Enterobacter aerogenes, Proteus mirabilis or Serratia marcescens.
ACUTE BACTERIAL OTITIS MEDIA caused by Streptococcus pneumoniae, Haemophilus influenzae (including beta-lactamase producing strains) or Moraxella catarrhalis (including beta-lactamase producing strains).
NOTE: In one study lower clinical cure rates were observed with a single dose of ceftriaxone for injection compared to 10 days of oral therapy. In a second study comparable cure rates were observed between single dose ceftriaxone for injection and the comparator. The potentially lower clinical cure rate of ceftriaxone for injection should be balanced against the potential advantages of parenteral therapy (see CLINICAL STUDIES).
SKIN AND SKIN STRUCTURE INFECTIONS caused by Staphylococcus aureus, Staphylococcus epidermidis, Streptococcus pyogenes, Viridans group streptococci, Escherichia coli, Enterobacter cloacae, Klebsiella oxytoca, Klebsiella pneumoniae, Proteus mirabilis, Morganella morganii*, *Pseudomonas aeruginosa, Serratia marcescens, Acinetobacter calcoaceticus, Bacteroides fragilis* or Peptostreptococcus species.
URINARY TRACT INFECTIONS (complicated and uncomplicated) caused by Escherichia coli, Proteus mirabilis, Proteus vulgaris, Morganella morganii or Klebsiella pneumoniae.
UNCOMPLICATED GONORRHEA (cervical/urethral and rectal) caused by Neisseria gonorrhoeae, including both penicillinase- and nonpenicillinase-producing strains, and pharyngeal gonorrhea caused by nonpenicillinase-producing strains of Neisseria gonorrhoeae.
PELVIC INFLAMMATORY DISEASE caused by Neisseria gonorrhoeae. Ceftriaxone for injection, like other cephalosporins, has no activity against Chlamydia trachomatis. Therefore, when cephalosporins are used in the treatment of patients with pelvic inflammatory disease and Chlamydia trachomatis is one of the suspected pathogens, appropriate antichlamydial coverage should be added.
BACTERIAL SEPTICEMIA caused by Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Haemophilus influenzae or Klebsiella pneumoniae.
BONE AND JOINT INFECTIONS caused by Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, Proteus mirabilis, Klebsiella pneumoniae or Enterobacter species.
INTRA-ABDOMINAL INFECTIONS caused by Escherichia coli, Klebsiella pneumoniae, Bacteroides fragilis, Clostridium species (Note: most strains of Clostridium difficile are resistant) or Peptostreptococcus species.
MENINGITIS caused by Haemophilus influenzae, Neisseria meningitidis or Streptococcus pneumoniae. Ceftriaxone for injection has also been used successfully in a limited number of cases of meningitis and shunt infection caused by Staphylococcus epidermidis* and Escherichia coli.*
*Efficacy for this organism in this organ system was studied in fewer than ten infections.
SURGICAL PROPHYLAXIS: The preoperative administration of a single 1 g dose of ceftriaxone for injection may reduce the incidence of postoperative infections in patients undergoing surgical procedures classified as contaminated or potentially contaminated (e.g., vaginal or abdominal hysterectomy or cholecystectomy for chronic calculous cholecystitis in high-risk patients, such as those over 70 years of age, with acute cholecystitis not requiring therapeutic antimicrobials, obstructive jaundice or common duct bile stones) and in surgical patients for whom infection at the operative site would present serious risk (e.g., during coronary artery bypass surgery). Although ceftriaxone for injection has been shown to have been as effective as cefazolin in the prevention of infection following coronary artery bypass surgery, no placebo-controlled trials have been conducted to evaluate any cephalosporin antibiotic in the prevention of infection following coronary artery bypass surgery.
When administered prior to surgical procedures for which it is indicated, a single 1 g dose of ceftriaxone for injection provides protection from most infections due to susceptible organisms throughout the course of the procedure.
Ceftriaxone for injection is contraindicated in patients with known allergy to the cephalosporin class of antibiotics.
Hyperbilirubinemic neonates, especially prematures, should not be treated with ceftriaxone for injection. In vitro studies have shown that ceftriaxone can displace bilirubin from its binding to serum albumin and bilirubin encephalopathy can possibly develop in these patients.
Ceftriaxone for injection should not be co-administered with calcium-containing IV solutions, including continuous calcium-containing infusions such as parentral nutrition, in neonates because of the risk of precipitation of ceftriaxone-calcium salt. Cases of fatal reactions with ceftriaxone-calcium precipitates in lung and kidneys in neonates have been described. In some cases the infusion lines and the times of administration of ceftriaxone and calcium-cotaining solutions differed.
For information regarding all other patients, (see WARNINGS).
There are no reports to date of intravascular or pulmonary precipitations in patients, other than neonates, treated with ceftriaxone and calcium-containing IV solutions. However, the theoretical possibility exists for an interaction between ceftriaxone and IV calcium-containing solutions in patients other than neonates. Therefore, ceftriaxone for injection and calcium-containing solutions, including continuous calcium-containing infusions such as parenteral nutrition, should not be mixed or co-administered to any patient irrespective of age, even via different infusion lines at different sites. As a further theoretical consideration and based on 5 half-lives of ceftriaxone, ceftriaxone for injection and IV calcium-containing solutions should not be administered within 48 hours of each other in any patient (see CONTRAINDICATIONS and DOSAGE AND ADMINISTRATION).
No data are available on potential interaction between ceftriaxone and oral calcium-containing products or interaction between intramuscular ceftriaxone and calcium-containing products (IV or oral).
Clostridium difficile associated diarrhea (CDAD) has been reported with use of nearly all antibacterial agents, including ceftriaxone, and may range in severity from mild diarrhea to fatal colitis. Treatment with antibacterial agents alters the normal flora of the colon leading to overgrowth of C. difficile.
C. difficile produces toxins A and B which contribute to the development of CDAD. Hypertoxin producing strains of C. difficile cause increased morbidity and mortality, as these infections can be refractory to antimicrobial therapy and may require colectomy. CDAD must be considered in all patients who present with diarrhea following antibiotic use. Careful medical history is necessary since CDAD has been reported to occur over two months after the administration of antibacterial agents.
If CDAD is suspected or confirmed, ongoing antibiotic use not directed against C. difficile may need to be discontinued. Appropriate fluid and electrolyte management, protein supplementation, antibiotic treatment of C. difficile, and surgical evaluation should be instituted as clinically indicated.
Prescribing ceftriaxone for injection in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria.
Although transient elevations of BUN and serum creatinine have been observed, at the recommended dosages, the nephrotoxic potential of ceftriaxone for injection is similar to that of other cephalosporins.
Ceftriaxone is excreted via both biliary and renal excretion (see CLINICAL PHARMACOLOGY). Therefore, patients with renal failure normally require no adjustment in dosage when usual doses of ceftriaxone for injection are administered, but concentrations of drug in the serum should be monitored periodically. If evidence of accumulation exists, dosage should be decreased accordingly.
Dosage adjustments should not be necessary in patients with hepatic dysfunction; however, in patients with both hepatic dysfunction and significant renal disease, ceftriaxone for injection dosage should not exceed 2 g daily without close monitoring of serum concentrations.
Alterations in prothrombin times have occurred rarely in patients treated with ceftriaxone for injection. Patients with impaired vitamin K synthesis or low vitamin K stores (e.g., chronic hepatic disease and malnutrition) may require monitoring of prothrombin time during ceftriaxone for injection treatment. Vitamin K administration (10 mg weekly) may be necessary if the prothrombin time is prolonged before or during therapy.
Prolonged use of ceftriaxone for injection may result in overgrowth of nonsusceptible organisms. Careful observation of the patient is essential. If superinfection occurs during therapy, appropriate measures should be taken.
Ceftriaxone should be prescribed with caution in individuals with a history of gastrointestinal disease, especially colitis.
There have been reports of sonographic abnormalities in the gallbladder of patients treated with ceftriaxone for injection; some of these patients also had symptoms of gallbladder disease. These abnormalities appear on sonography as an echo without acoustical shadowing suggesting sludge or as an echo with acoustical shadowing which may be misinterpreted as gallstones. The chemical nature of the sonographically detected material has been determined to be predominantly a ceftriaxone-calcium salt. The condition appears to be transient and reversible upon discontinuation of ceftriaxone for injection and institution of conservative management. Therefore, ceftriaxone for injection should be discontinued in patients who develop signs and symptoms suggestive of gallbladder disease and/or the sonographic findings described above.
Patients should be counseled that antibacterial drugs including ceftriaxone for injection should only be used to treat bacterial infections. They do not treat viral infections (e.g., common cold). When ceftriaxone for injection is prescribed to treat a bacterial infection, patients should be told that although it is common to feel better early in the course of therapy, the medication should be taken exactly as directed. Skipping doses or not completing the full course of therapy may (1) decrease the effectiveness of the immediate treatment and (2) increase the likelihood that bacteria will develop resistance and will not be treatable by ceftriaxone for injection or other antibacterial drugs in the future.
Diarrhea is a common problem caused by antibiotics which usually ends when the antibiotic is discontinued. Sometimes after starting treatment with antibiotics, patients can develop watery and bloody stools (with or without stomach cramps and fever) even as late as two or more months after having taken the last dose of the antibiotic. If this occurs, patients should contact their physician as soon as possible.
Carcinogenesis: Considering the maximum duration of treatment and the class of the compound, carcinogenicity studies with ceftriaxone in animals have not been performed. The maximum duration of animal toxicity studies was 6 months.
Mutagenesis: Genetic toxicology tests included the Ames test, a micronucleus test and a test for chromosomal aberrations in human lymphocytes cultured in vitro with ceftriaxone. Ceftriaxone showed no potential for mutagenic activity in these studies.
Impairment of Fertility: Ceftriaxone produced no impairment of fertility when given intravenously to rats at daily doses up to 586 mg/kg/day, approximately 20 times the recommended clinical dose of 2 g/day.
Reproductive studies have been performed in mice and rats at doses up to 20 times the usual human dose and have no evidence of embryotoxicity, fetotoxicity or teratogenicity. In primates, no embryotoxicity or teratogenicity was demonstrated at a dose approximately 3 times the human dose.
There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproductive studies are not always predictive of human response, this drug should be used during pregnancy only if clearly needed.
In rats, in the Segment I (fertility and general reproduction) and Segment III (perinatal and postnatal) studies with intravenously administered ceftriaxone, no adverse effects were noted on various reproductive parameters during gestation and lactation, including postnatal growth, functional behavior and reproductive ability of the offspring, at doses of 586 mg/kg/day or less.
Low concentrations of ceftriaxone are excreted in human milk. Caution should be exercised when ceftriaxone for injection is administered to a nursing woman.
Safety and effectiveness of ceftriaxone for injection in neonates, infants and pediatric patients have been established for the dosages described in the DOSAGE AND ADMINISTRATION section. In vitro studies have shown that ceftriaxone, like some other cephalosporins, can displace bilirubin from serum albumin. Ceftriaxone for injection should not be administered to hyperbilirubinemic neonates, especially prematures (see CONTRAINDICATIONS).
Ceftriaxone for injection is generally well tolerated. In clinical trials, the following adverse reactions, which were considered to be related to ceftriaxone for injection therapy or of uncertain etiology, were observed:
LOCAL REACTIONS - pain, induration and tenderness was 1% overall. Phlebitis was reported in <1% after IV administration. The incidence of warmth, tightness or induration was 17% (3/17) after IM administration of 350 mg/mL and 5% (1/20) after IM administration of 250 mg/mL.
HYPERSENSITIVITY - rash (1.7%). Less frequently reported (<1%) were pruritus, fever or chills.
HEMATOLOGIC – eosinophilia (6%), thrombocytosis (5.1%) and leukopenia (2.1%). Less frequently reported (<1%) were anemia, hemolytic anemia, neutropenia, lymphopenia, thrombocytopenia and prolongation of the prothrombin time.
GASTROINTESTINAL - diarrhea (2.7%). Less frequently reported (<1%) were nausea or vomiting, and dysgeusia. The onset of pseudomembranous colitis symptoms may occur during or after antibacterial treatment (see WARNINGS).
HEPATIC - elevations of SGOT (3.1%) or SGPT (3.3%). Less frequently reported (<1%) were elevations of alkaline phosphatase and bilirubin.
RENAL - elevations of the BUN (1.2%). Less frequently reported (<1%) were elevations of creatinine and the presence of casts in the urine.
CENTRAL NERVOUS SYSTEM - headache or dizziness were reported occasionally (<1%).
GENITOURINARY - moniliasis or vaginitis were reported occasionally (<1%).
MISCELLANEOUS - diaphoresis and flushing were reported occasionally (<1%).
Other rarely observed adverse reactions (<0.1%) include abdominal pain, agranulocytosis, allergic pneumonitis, anaphylaxis, basophilia, biliary lithiasis, bronchospasm, colitis, dyspepsia, epistaxis, flatulence, gallbladder sludge, glycosuria, hematuria, jaundice, leukocytosis, lymphocytosis, monocytosis, nephrolithiasis, palpitations, a decrease in the prothrombin time, a decrease in the prothrombin time, renal precipitations, seizures, and serum sickness.
Cases of fatal reactions with calcium-ceftriaxone precipitates in lung and kidneys in neonates have been described. In some cases the infusion lines and times of administration of ceftriaxone and calcium-containing solutions differed (see CONTRAINDICATIONS).
In the case of overdosage, drug concentration would not be reduced by hemodialysis or peritoneal dialysis. There is no specific antidote. Treatment of overdosage should be symptomatic.
Ceftriaxone for injection may be administered intravenously or intramuscularly.
Do not use diluents containing calcium, such as Ringer's solution or Hartmann's solution, to reconstitute ceftriaxone for injection. Particulate formation can result. ceftriaxone for injection and calcium-containing solutions, including continuous calcium-containing infusions such as parenteral nutrition, should not be mixed or co-administered to any patient irrespective of age, even via different infusion lines at different sites (see CONTRAINDICATIONS AND WARNINGS).
Hyperbilirubinemic neonates, especially prematures, should not be treated with ceftriaxone for injection (see CONTRAINDICATIONS).
For the treatment of skin and skin structure infections, the recommended total daily dose is 50 to 75 mg/kg given once a day (or in equally divided doses twice a day). The total daily dose should not exceed 2 grams.
For the treatment of acute bacterial otitis media, a single intramuscular dose of 50 mg/kg (not to exceed 1 gram) is recommended (see INDICATIONS AND USAGE).
For the treatment of serious miscellaneous infections other than meningitis, the recommended total daily dose is 50 to 75 mg/kg, given in divided doses every 12 hours. The total daily dose should not exceed 2 grams.
In the treatment of meningitis, it is recommended that the initial therapeutic dose be 100 mg/kg (not to exceed 4 grams). Thereafter, a total daily dose of 100 mg/kg/day (not to exceed 4 grams daily) is recommended. The daily dose may be administered once a day (or in equally divided doses every 12 hours). The usual duration of therapy is 7 to 14 days.
The usual adult daily dose is 1 to 2 grams given once a day (or in equally divided doses twice a day) depending on the type and severity of infection. The total daily dose should not exceed 4 grams.
If Chlamydia trachomatis is a suspected pathogen, appropriate antichlamydial coverage should be added, because ceftriaxone sodium has no activity against this organism.
For the treatment of uncomplicated gonococcal infections, a single intramuscular dose of 250 mg is recommended.
For preoperative use (surgical prophylaxis), a single dose of 1 gram administered intravenously 1/2 to 2 hours before surgery is recommended.
Generally, ceftriaxone for injection therapy should be continued for at least 2 days after the signs and symptoms of infection have disappeared. The usual duration of therapy is 4 to 14 days; in complicated infections, longer therapy may be required.
When treating infections caused by Streptococcus pyogenes, therapy should be continued for at least 10 days.
No dosage adjustment is necessary for patients with impairment of renal or hepatic function; however, blood levels should be monitored in patients with severe renal impairment (e.g., dialysis patients) and in patients with both renal and hepatic dysfunctions.
Intramuscular Administration: Reconstitute ceftriaxone for injection powder with the appropriate diluent (see COMPATIBILITY AND STABILITY ).
Inject diluent into vial, shake vial thoroughly to form solution. Withdraw entire contents of vial into syringe to equal total labeled dose.
After reconstitution, each 1 mL of solution contains approximately 250 mg or 350 mg equivalent of ceftriaxone according to the amount of diluent indicated below. If required, more dilute solutions could be utilized. A 350 mg/mL concentration is not recommended for the 250 mg vial since it may not be possible to withdraw the entire contents.
As with all intramuscular preparations, ceftriaxone for injection should be injected well within the body of a relatively large muscle; aspiration helps to avoid unintentional injection into a blood vessel.
|Vial Dosage Size
|Amount of Diluent to be Added
|250 mg/mL
350 mg/mL
|250 mg
|0.9 mL
|500 mg
|1.8 mL
1.0 mL
|1 g
|3.6 mL
|2.1 mL
|2 g
|7.2 mL
|4.2 mL
Ceftriaxone for injection should be administered intravenously by infusion over a period of 30 minutes. Concentrations between 10 mg/mL and 40 mg/mL are recommended; however, lower concentrations may be used if desired. Reconstitute vials with an appropriate IV diluent (see COMPATIBILITY AND STABILITY ).
|Vial Dosage Size
|Amount of Diluent to be Added
|250 mg
|2.4 mL
|500 mg
|4.8 mL
|1 g
|9.6 mL
|2 g
|19.2 mL
After reconstitution, each 1 mL of solution contains approximately 100 mg equivalent of ceftriaxone. Withdraw entire contents and dilute to the desired concentration with the appropriate IV diluent.
Ceftriaxone has been shown to be compatible with Flagyl®*IV (metronidazole hydrochloride). The concentration should not exceed 5 to 7.5 mg/mL metronidazole hydrochloride with ceftriaxone 10 mg/mL as an admixture. The admixture is stable for 24 hours at room temperature only in 0.9% sodium chloride injection or 5% dextrose in water (D5W). No compatibility studies have been conducted with the Flagyl®*IV RTU® or using other diluents. Metronidazole at concentrations greater than 8 mg/mL will precipitate. Do not refrigerate the admixture as precipitation will occur.
Vancomycin and fluconazole are physically incompatible with ceftriaxone in admixtures. When either of these drugs is to be administered concomitantly with ceftriaxone by intermittent intravenous infusion, it is recommended that they be given sequentially, with thorough flushing of the intravenous lines (with one of the compatible fluids) between the administrations.
Do not use diluents containing calcium, such as Ringer's solution or Hartmann's solution, to reconstitute ceftriaxone for injection. Particulate formation can result.
Ceftriaxone solutions should not be physically mixed with or piggybacked into solutions containing other antimicrobial drugs or into diluent solutions other than those listed above, due to possible incompatibility (see WARNINGS).
Ceftriaxone for injection sterile powder should be stored at 20° to 25°C (68° to 77°F) [See USP Controlled Room Temperature] and protected from light. After reconstitution, protection from normal light is not necessary. The color of solutions ranges from light yellow to amber, depending on the length of storage, concentration and diluent used.
Ceftriaxone for injection intramuscular solutions remain stable (loss of potency less than 10%) for the following time periods:
Room Temp.(25°C)
Sterile Water for Injection
100250, 350
2 days24 hours
10 days3 days
0.9% Sodium ChlorideSolution
100250, 350
2 days24 hours
10 days3 days
5% Dextrose Solution
100250, 350
2 days24 hours
10 days3 days
Bacteriostatic Water+ 0.9% Benzyl Alcohol
100250, 350
24 hours24 hours
10 days3 days
1% Lidocaine Solution(without epinephrine)
100250, 350
24 hours24 hours
10 days3 days
Ceftriaxone for injection intravenous solutions, at concentrations of 10, 20 and 40 mg/mL, remain stable (loss of potency less than 10%) for the following time periods stored in glass or PVC containers:
|Room Temp. (25°C)
|Refrigerated (4°C)
|Sterile Water
|2 days
|10 days
|0.9% Sodium Chloride Solution
|2 days
|10 days
|5% Dextrose Solution
|2 days
|10 days
|10% Dextrose Solution
|2 days
|10 days
|5% Dextrose + 0.9% Sodium Chloride Solution*
|2 days
|5% Dextrose + 0.45% Sodium Chloride Solution
|2 days
The following intravenous ceftriaxone for injection solutions are stable at room temperature (25°C) for 24 hours, at concentrations between 10 mg/mL and 40 mg/mL: Sodium Lactate (PVC container), 10% Invert Sugar (glass container), 5% Sodium Bicarbonate (glass container), Freamine III (glass container), Normosol-M in 5% Dextrose (glass and PVC containers), Ionosol-B in 5% Dextrose (glass container), 5% Mannitol (glass container), 10% Mannitol (glass container).
After the indicated stability time periods, unused portions of solutions should be discarded.
Note: Parenteral drug products should be inspected visually for particulate matter before administration.
Ceftriaxone for injection reconstituted with 5% Dextrose or 0.9% Sodium Chloride solution at concentrations between 10 mg/mL and 40 mg/mL, and then stored in frozen state (-20°C) in PVC or polyolefin containers, remains stable for 26 weeks.
Frozen solutions should be thawed at room temperature before use. After thawing, unused portions should be discarded. DO NOT REFREEZE.
Concretions consisting of the precipitated calcium salt of ceftriaxone have been found in the gallbladder bile of dogs and baboons treated with ceftriaxone.
These appeared as a gritty sediment in dogs that received 100 mg/kg/day for 4 weeks. A similar phenomenon has been observed in baboons but only after a protracted dosing period (6 months) at higher dose levels (335 mg/kg/day or more). The likelihood of this occurrence in humans is considered to be low, since ceftriaxone has a greater plasma half-life in humans, the calcium salt of ceftriaxone is more soluble in human gallbladder bile and the calcium content of human gallbladder bile is relatively low.
Ceftriaxone for injection is supplied as a sterile crystalline powder in glass vials. The following packages are available:
Vials containing 1 g equivalent of ceftriaxone. Box of 10 (NDC 10019-098-01).
In two adequate and well controlled U.S. clinical trials a single IM dose of ceftriaxone was compared with a 10 day course of oral antibiotic in pediatric patients between the ages of 3 months and 6 years. The clinical cure rates and statistical outcome appear in the table below:
|Clinical Efficacy in Evaluable Population
|Study Day
|Ceftriaxone Single Dose
|Comparator – 10 days of Oral Therapy
|95% Confidence Interval
|Statistical Outcome
Study 1 – U.S.
58% (167/ 288)
amoxicillin/ clavulanate
Ceftriaxone is lower than control at study day 14 and 28
Study 2 – U.S.5 1428
35% (73/ 206)
60% (124/ 206)45% (93/ 205)
Ceftriaxone is equivalent to control at study day 14 and 28.
An open-label bacteriologic study of ceftriaxone without a comparator enrolled 108 pediatric patients, 79 of whom had positive baseline cultures for one or more of the common pathogens. The results of this study are tabulated as follows:
Week 2 and 4 Bacteriologic Eradication Rates in the Per Protocol Analysis in the Roche Bacteriologic Study by pathogen:
|Study Day 13-15
|Study Day 30+2
|No. Analyzed
|No. Erad. (%)
|No. Analyzed
|No. Erad. (%)
|Streptococcus pneumoniae
|32 (84)
|25 (71)
|Haemophilus influenzae
|28 (85)
|22 (71)
|Moraxella catarrhalis
|12 (80)
|9 (60)
*Flagyl and IV RTU are Registered trademarks of G.D.Searle & Co.
Manufactured for: Amerinet Choice
St. Louis, MO 63146
By Lupin Limited
Mumbai 400 098 INDIA
For Product Inquiry 1 800 ANA Drug (1-800-262-3784)
Revised: December, 2007 ID#: 212326 460-594-01
Ceftriaxone for Injection USP Vial Label
for Injection USP
1 g
For I.M. or I.V. Use
Rx only Single Use Vial
Each vial contains sterile
ceftriaxone sodium USP
equivalent to ceftriaxone 1 g
Mfd. for Amerinet Choice
by Lupin Limited
Mumbai 400 098 INDIA
For I.M. Administration: Reconstitute with 2.1 mL
1% Lidocaine Hydrochloride Injection (USP) or Sterile
Water for Injection (USP). Each 1 mL of solution contains
approximately 350 mg equivalent of ceftriaxone.
For I.V. Administration: See package insert.
USUAL DOSAGE: See package insert.
Storage Prior to Reconstitution:
Store powder at 20°-25°C (68°-77°F)
[See USP Controlled Room Temperature].
Storage After Reconstitution: See package insert.
Code No. MP/DRUGS/28/18/88
Lot No:
Ceftrixone for Injection USP Shelf-Pack Label
Ceftriaxone for Injection USP
1 g
For Intramuscular or Intravenous Use
Rx only
Each vial contains sterile ceftriaxone sodium USP
equivalent to ceftriaxone 1 g
10 Vials Single Use Vials
Amerinet Choice
Manufactured for Amerinet Choice
St. Louis, MO 63146
by Lupin Limited
Mumbai 400 098 INDIA
Directions for Use:
For I.M. Administration: Reconstitute with 2.1 mL 1 %
Lidocaine Hydrochloride Injection (USP) or Sterile Water
for Injection (USP). Each 1 mL of solution contains
approximately 350 mg equivalent of ceftriaxone.
For I.V. Administration: Reconstitute with 9.6 mL of
an I.V. diluent specified in the accompanying package
insert. Each 1 mL of solution contains approximately
100 mg equivalent of ceftriaxone. Withdraw entire
contents and dilute to the desired concentration with
the appropriate I.V. diluent.
For dosage recommendations and other important
prescribing information, read accompanying insert.
Storage Prior to Reconstitution:
Store powder at 20°-25°C (68°-77°F) [See USP
Controlled Room Temperature].
Storage After Reconstitution: See package insert.
ceftriaxone sodium injection, powder, for solution
|Marketing Information
|Marketing Category
|Application Number or Monograph Citation
|Marketing Start Date
|Marketing End Date
|Labeler - BAXTER HEALTHCARE CORPORATION (005083209)
|Registrant - BAXTER HEALTHCARE CORPORATION (005083209)

subset: commoncrawl


text:
Today's Devotional
Actions SpeakWhat do your actions reveal about your character?
Top Music Videos
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I am a fully devoted follower of christ, well thats what i would like to be able to say. The fact is fully devoted describes only a very small percentage of christians, I believe striving follower would be the better term at least for myself. I feel that God is calling me into ministry, I am just uncertain of what kind of ministry that would be. I am a pastor's kid, and I love music. I play many different instruments. If you wanna know more about me, just talk to me. Below is my church's website.


text:
It will be 'Broadway, She Wrote' for Murder, She Wrote star Angela Lansbury when the actress makes her return to the Broadway stage in May.
The legendary star, whose last Broadway performance was in 1984's "Mame" revival, will lend her talents to "Deuce," a new play conceived by Terrence McNally. She will appear alongside Marian Seldes in the play, which begins May 6 at the Music Box Theater.
In preparation for her stint on stage, four-time Tony winner Lansbury will also appear in the Nov. 5 benefit performance being staged at the Schoenfeld Theater and benefiting the York Company. The evening will showcase "This Is on Me: An Evening of Dorothy Parker," a staged reading Parker's works, adapted by Tom Fontana.
Lansbury continues to chair the Actors Advisory Board of the Acting Company.


text:
County closes out block grant
Business Directory
By Roxanne McKnight
Staff Writer
Limestone County commissioners court closed out an old community development block grant, completing the requirements needed to finish the paperwork for it. The commissioners also approved the sale of 14 Groesbeck lots that had been struck off the tax rolls.
The court approved three administrative actions required for the county to have on file to close out the last Community Development Block Grant, which was administered by County Engineer Ted Kantor.
"It's the one we got through the state to help fix some bridges from some flooding several years ago," Burkeen said later.
To read more, pick up a copy of Saturday's Mexia News, or subscribe to our e-edition.


text:
Posted Thu Sep 10th by Monty
Got a link worth sharing? Email us at broncotalk AT gmail (dot) com.
- Kyle Orton is embracing Colorado. Seriously. He went camping and stuff. [Denver Post]
- A fan-focused McDebate. [DPO]
- Chad Ochocinco says he has a surprise for the NFL this Sunday. [NFL.com]
- Pat Bowlen: The Real Man in Charge. [DPO]
- Knowshon Moreno is poised for the 2009 Rookie of the Year honor. [Skinny Post]
- Carson Palmer expects to be "rust proof." [Cincinnati Enquirer]
- Marshall stil a Bronco, Ochocinco still a Bengal. [DPO]
- Tony Scheffler had a lousy 2007 preseason, then had his best regular season numbers as a pro. Current Broncos will be testing that theory. [Colorado Springs Gazette]
- Klis steps out on a lone limb, saying a Marshall deal is not imminent. [DPO]
- Hey, whaddya know, Woody Paige made me laugh. [DPO]
Previously on BT
Sometimes during the regular season, we get busy. It's possible, although foolish on your part, that you might have missed something. Here are some recent headlines:
- Orton can't make any promises, but hopes to play Sunday.
- Moreno and Marshall also look good to go.
- Exploring the provenance of one Josh McDaniels.
- Marshall and the Broncos talking contract extension.
- Could the Broncos' season opener be blacked out in Cincinnati?
- Wednesday: Quotes, Injury Report
- Wesley Woodyard among seven team captains named. Kudos the second-year player.
- Mario Haggan is too, and got a shiny new contract to boot. How 'bout them underdogs?
- The Merriman/Tequila thing gets downright silly. [National Football Post]
- Matt Cassel will be listed as questionable for the Chiefs opener. [Kansas City Star]
- It's a problem when a team's "Fresh Face to Watch" (Richard Seymour) hasn't even reported yet. [Contra Costa Times]
- Word is Brady Quinn got the gig in Cleveland. The Broncos play the Browns next week. [NFL.com]
- Another crazy win for the Rockies last night. Leading early, losing late, two-run walk off single in the ninth. Can they finish the sweep of the Reds tonight and give Denver some Cincinnati good luck? [Purple Row]


text:
The MPFPD serves Menlo Park, Atherton, East Palo Alto and portions of unincorporated San Mateo County.
Deputy Chief Belville previously served as chief in San Mateo and Foster City; his 36-year career also included a stint in San Carlos.
He is the second temporary appointment made by the district in recent months. Interim Fire Chief Douglas Sporleder stepped in after Chief Harold Schapelhouman fell from a ladder at his San Jose home in mid-May. The chief is undergoing intensive therapy to recover from back injuries and the fire district does not know when he will return to duty.
The fire district also saw the departure of long-time marshal and division chief Geoff Aus at the end of May.


text:
Yesterday I had my second hair removal treatment on my lower legs and now they are covered with small red spots (around follicles) - it's has been more than 24 hours after treatment - no improvement.. First treatment did not have any reaction at all.. I had no sun exposure, etc. What should I do and when it will disappear? Naturally I have very white skin and had a dark hair. Thank you!!!
Bright Red Spots After Hair Removal Treatment? (photo)
Doctor Answers 1
Bright red spots after hair removal.
{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
{{ voteCount >= 0 ? '+' + (voteCount + 1) : (voteCount + 1) }}
You have a condition caused folliculitis - inflammation around the hair follicle.
It will resolve spontaneously.
Keep the skin well moisturized and use sunscreen daily, regardless of the weather.
If the condition is still present in a few weeks, see your doctor. Treatment with .5% cortisone cream could be considered.
Good Luck
David Evdokimow M.D.
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.


text:
Garowe (Somali: Garoowe, Arabic: غاروي) is the administrative capital of the autonomous Puntland region in northeastern Somalia.
The area was ruled in the 19th century by the Majeerteen Sultanate. It would later be incorporated into Italian Somaliland. Garowe is located in the Nugal province, and is the seat of the regional parliament, the presidential palace and government ministries. A fast-growing city, it has also evolved into a local media and cultural hub.
Get in[edit]
Garowe is situated in northeastern Somalia, in the heart of the Puntland region. Nearby settlements include to the east Gillab (4.8 nm), to the northeast Qalqalooc (15.3 nm), to the north Libaax Seexay (2.5 nm), to the northwest Geida Debabo (12.2), to the west Bixin (5.9 nm), to the southwest Lugo (6.0 nm), to the south Salaxley (5.3 nm), and to the southeast War Weytan (9.7 nm). The largest cities close to Garoowe are Qardho (205 km), Galkacyo (216 km) and Erigavo (275 km). Shimbiris, the highest peak in Somalia, is located some 293 km to the northwest in the Cal Madow mountain range.
Get around[edit]
You can visit historical places and enjoy the city
Garowe is traversed by a 750 km north–south highway. It connects major cities in the northern part of the country, such as Bosaso and Galkayo, with towns in the south.[21] In 2012, the Puntland Highway Authority completed rehabilitation work on the central artery linking Garowe with Galkayo.[22] The transportation body also began an upgrade and repair project in June 2012 on the large thoroughfare between the city and Bosaso. Additionally, plans are in the works to construct new roads connecting littoral towns in the region to the main highway.[23] Local air transport needs are served by Garowe International Airport, a major new airport situated about 12 km from the city center. It was officially opened in 2010 under the aegis of the Ministry for Civil Aviation and Airports. The first phase of the airport's construction was completed through a public-private partnership over a period of seven years, with the Garowe-based Mubarak construction company having assisted significantly in completing the project. The airport also attempts to adhere to the air transport standards established by the International Civil Aviation Organization (ICAO).[24]
Being the retail and fashion hub of Somalia it is no surprise that shopping is one of Garowe's greatest pleasures. From the local suuqa injida (injimarket) and olympic shapping mall, to top end shopping malls and everything in between, you will be sure to find something to suit you budget and style.
Somali Shaah "Tea"
Garowe has more than 30 hotels which 10 of them are 3-stars and some are 4-star hotels like New Rays, RugsanMeka Hote, Rayan Park and Towfiq Hotel. Additionally, Garowe has various places of accommodation. Among these guest houses situated downtown.
- Rayaan Park Hotel, isbartiibada Road (bus). Check-in: 2:00 pm, check-out: 2:00 pm. $15.


text:
cording to well-founded reports in New York, the real purpose of his visit was to engage here in an extensive anti-Semitic Nazi campaign.
"It is not so," Weidemann declared. "My only aim in this country is to represent the German Government at the Chicago World Fair to which we have been officially invited."
"Are you going to meet members of the German Nazi party in this country and are you going to deliver lectures at meetings while here?" the Hitler envoy was asked.
"I am not going to deliver any political speeches while here, and as far as meeting Nazi members in this country is concerned, no appointment has been arranged so far, and I do not know as yet, whether I shall see them," replied Mr. Weidemann. He repeated that his was a purely technical mission.
"But why should the Hitler Government send on this 'technical mission' an official of the Propaganda Ministry and not of the trade ministry?" he was asked.
"Well, Germany is represented in Chicago by an art department and art is a part of the activities of the ministry of Propaganda and Enlightenment," he replied.
He denied the report that his chief, Dr. Goebbels, was supposed to come to this country and that he had changed his mind, after protests by Chicago Jews to the management of the Fair.
"What is your attitude towards the anti-Jewish measures taken by the Hitler Government? Do you concur with the expulsion of Jewish professors from German universities, of Jewish physicians from the hospitals and Jewish judges from the courts?" a reporter asked Weidemann.
"I am a member of the Hitler Government. I am a National Socialist and I naturally, fully agree with all the steps taken by our government against the Jews. This is obvious, otherwise I would not be a member of this government and I would not be here now as a representative of the Nazi government," Weidemann stoutly replied.
Mr. Schneider, his assistant, obviously a more experienced politician than Herr Weidemann, often interposed and tried to rescue his chief from embarrassing questions.
Efforts by the Jewish Telegraphic Agency to establish the whereabouts of the Nazi envoy after he disappeared on the tug, were fruitless. Neither the German Consulate, nor officials of the North German Lloyd would disclose the hotel or residence of Mr. Weidemann while in this city. Although at the pier it was said that he is to leave for Chicago immediately, Mr. Schlitter, the vice-consul, declared later that the Nazi envoy was to stay in New York over night and proceed to Chicago today.
Three policemen and several communists were injured and fifteen men were arrested as a result of the clash between police and communists taking part in the demonstration at the pier.


text:
TEL AVIV (Jan. 5)
Labor Minister Joseph Almogi reported today that 18,000 Arabs from the occupied territories are currently working in Israel. He said 13,000 came from the Samaria and Judaea regions (West Bank) and the rest were from the Gaza Strip. All were employed through local labor exchanges set up in the occupied territories.
The Arab work force in Israel rose by 3,000 recently. They are employed mainly in harvesting and port work and in citrus packing houses. More hands will be needed shortly as the citrus picking and export season reaches its peak.


text:
Sending astronauts to asteroids
In a speech outlining his plans for the U.S. space program, President Barack Obama said, "We'll start by sending astronauts to an asteroid for the first time in history. Four months after that statement, the details are still sketchy, as Congress continues to debate the financing and overall direction of U.S. space policy. But experts say a human mission to an asteroid could become NASA's next great challenge – a deep space journey that compares to the moon missions of the 1960s and 1970s, It could even be seen as a steppingstone to Mars.
NASA and contractor Lockheed Martin have begun to design and build a prototype of Orion, a capsule that could be used to send astronauts into deep space. A propulsion module and possibly extra crew space could be added, said Thomas Jones, a former shuttle astronaut and space consultant.
Tens of thousands of asteroids orbit the sun in an "asteroid belt" beyond Mars. But a human mission to an asteroid would focus on one that comes closer to Earth.
Why go to an asteroid?
Big asteroids have hit Earth before — this may be what caused dinosaurs to become extinct. Another big one could wipe out human civilization. This mission would give NASA better information on how to save Earth from the impact of another big one (kind of like Armegeddon, the fun but scientifically inaccurate film with an asteroid plot).
The six-month mission could be a good dress rehearsal for a mission to Mars. It's challenging, but not as far and not as complicated because of the asteroid's limited gravity.
Asteroids hold keys to understanding the origins of the solar system. Astronauts could collect many samples and return them to Earth.
The challenges:
The journey could take six months, said former astronaut Jones. That's a long time to be in the cosmic radiation of space. And the journey home could take weeks, even if there's an emergency. The new spacecraft and a new rocket must be developed with continued funding over several congressional terms and more than one presidential administration.
Sources: NASA, White House, space consultant Thomas Jones.


text:
Severus Snape stood against the wall of the Great Hall, leering at every dunderhead that decided to walk past him giggling like children. Well, he supposed they were children, but still. Are they capable of maturing at all? His dark eyes lifted to the immaculate Halloween decorations that were surrounding him. He still didn't understand the reasoning behind why Dumbledore had decided to plan this event. Yes, the wizarding world was crazy at the moment and incredibly dark. But did that really signify a reason to have a ball? Sure it made the students happy and perhaps forget for a night that their lives and their families' lives were in grave danger. But it sure didn't stop the fact that Severus desperately didn't want to chaperone this thing. It had been horrifying enough during the Yule Ball a couple years ago. And back then, he had sworn off these sorts of things.
Yet there he was. With no ulterior choice but to stay and watch over these idiots.
While most of the teachers were dressed for the occasion, either in costume – like Minerva had seemed to want to do, donning appropriate cat ears – or in formal attire, Severus had not changed his appearance at all. He wasn't going to be looking ridiculous at any point in his adult life, figuring he'd had enough of that cruelty in his childhood. His figure was draped in his usual black cloak as his arms were crossed over his chest. His hair hung in his face, hiding his true expression of loathing everything at that point. His black eyes stared ahead at the dance floor, wishing they'd all pass out already. Didn't they get exhausted at all during the weeks of his vigorous defense classes and his essays of unnecessary lengths?
That and the blasted music that seemed to get louder each time a new song came on. Gods, it was all so moronic. He would definitely need a drink soon. A strong one.
And with that thought, did it carry over to the doors were a certain girl entered. Just as she had during the Yule Ball, she seemed to attract every set of eyes in the room. Including his, shamefully enough.
Granger, as he preferred to refer to her in his mind and aloud, looked completely opposite of what she looked like the day before in his class. The day before, she had worn her hair up in a high bun, books stacked high in her arms, and her Gryffindor robes hanging neatly on her body. Not that he'd noticed...
And even that morning at breakfast, had she looked quite the same in her muggle clothing that fit her quite graciously rather than the school robes...again, not like he noticed.
However, that night, she was a completely different creature and hardly looked her age. As it had happened back in her 4th year, when she had begun to form into the woman she was destined to be, this night, she was forming even more so. In fact, she looked to be almost full grown. The dress hung to her form quite delectably and when she moved it created little sparkles as if she was made of magic herself. It didn't take a genius to know she had performed the "lumamorta" spell to achieve her dress, but he could honestly think to himself, that she looked absolutely stunning.
Clearing his suddenly dry throat, he tried to look away from her, especially when she made her way over to Potter and his date. He failed. He kept his eyes on her the whole time, noticing how she barely noticed that there were several pairs of eyes following her every move. She had to be aware of it though. The tiny smile on her face told him so. Had she been expecting this reaction?
And then she looked in his direction, making his eyes dart away from her immediately as to not get caught. She too looked away though, he noticed when their eyes had briefly met. Of course she wouldn't acknowledge him. He was just a shadow in the dark corner.
Not that he wanted her to notice him!
This past year had changed his outlook on Miss Granger and he wasn't sure why. He automatically told himself he wasn't getting enough sleep, even Dumbledore reminded him of that. But he wasn't sure if it was completely just lack of sleep that was making him notice a teenaged girl that he undoubtedly hated for her annoying knack of having to be an insufferable know it all. Which he'd call her out on almost every day. She could be quite infuriating when she wanted to be.
Maybe Lucius had been right at the Malfoy's Manor Halloween party that he had been forced to attend. Maybe he had been away from a female's company for far too long.
But whatever it was, it was starting to itch at his skin as if it was a disease.
He needed to go and insult them quickly to change his thought process. Straightening himself up, he walked over to the snack table and poured himself another glass of wine, wishing it was firewhiskey so he could get more of a buzz. He downed it and then poured himself another one. He'd need it if he was going to have to put up with how Granger looked that night.
Severus took a step backwards and casted his gaze around the room, holding the glass of wine in one hand, pretending to be paying attention to the students. When in all honesty, he was only paying attention to one of them and her group of friends. None of them had noticed him yet, which was what he sought after, but either way he could make out their conversation. Apparently Granger's dress had attracted Potter's eyes as well. His black eyes narrowed.
As he was still only listening, it wasn't until a presence in front of him caught his attention. About to bark at them for respecting personal space -meaning 5 feet from one another- he looked down into honey colored eyes and had to stop himself from gasping aloud. Just the girl he'd been pretending to not pay attention to was standing in front of him at the snack table, staring up into his eyes. His heart sped up rather quickly.
"Hi professor," She said with a nod. "Enjoying the party?"
Everything in Severus froze up when she spoke to him, making his tongue swell up inside of his mouth. Which was a pretty good thing in this situation, since he wasn't sure by this point what would come out of it – the truth or a snarky remark. His face remained expressionless as he stared down at her, not even his lips pursing into a sneer like it should have. However, nothing was noticed because he suddenly saw nerves spark in Granger's eyes and she swiftly moved aside to give him some room.
Which he was thankful for. She had been rather close to him the whole time and he could smell her floral perfume. And it was effecting him in an inappropriate way.
His eyes remained on her face as she looked away from him and looked around for her friends. He too gave a glance in their direction, but they seemed to have disappeared. They both looked back at each other at the same time and she gave him a tiny smile before sipping her glass of punch. He watched her ruby lips around the glass for a second, before tearing his gaze away after realizing he'd been staring way too hard. He needed to get a grip on himself. But it was becoming difficult when she wasn't acting like that insufferable know-it-all he knew her to be. What was wrong with her? Why wasn't she annoying him?
A waltz began playing, taking over the loud screaming music, and the students grabbed their dates to prepare to dance. He bit the inside of his cheek, finding it all to be rather nauseating. He'd much rather look at... Granger was looking around too, possibly finding her own date. Did she have one? He hadn't seen him if she did. Forcing down the quick unnecessary jealousy that bubbled up inside of him at the thought of some immature bloke trying to feel this girl up, Severus caught her gaze – breaking his angry thoughts and making his mind go blank.
She smiled again, that cute awkward smile that she seemed to have around him that night. And then she looked down.
Was she...? He'd seen that reaction before. Lily had done it to him once when they'd had to suffer a Christmas dance and he hadn't caught on at first. She then had to explain to him that when a girl does that, they are shyly asking you to ask them to dance. His heart fluttered and he tried to reason with himself. There was no way that he could dance with a student. Especially Granger. It was impossible! Inappropriate! No, he couldn't!
But he wanted to.
Glancing around for Dumbledore, as his conflicted mind continued to argue with itself, he found the old wizard dancing with Eloise Midgen as Minerva danced with Terry Boot. Okay, so maybe it wouldn't be as inappropriate as it seemed. But he was Severus Snape! He didn't do that sort of thing. He stood in a corner to brood and get intoxicated to relieve the splitting headache that formed.
All right, that's it. He needed to walk away. Leave Severus, he scolded. He turned on his heel like he had wanted to, but he found himself pausing in mid-step as he walked away from Granger. Instincts and wants were overwhelming him and the wine that he had just downed minutes prior was clouding his judgment. Maybe just one dance...no one could blame him for one.
Severus then turned back around and walked back over to her, standing directly in front of her with a determined look. Then words failed him, his mouth opening to speak but nothing came out. Making a fist around the wine glass he was still holding, he winced at what he was about to do before doing it.
Slowly, he sat the glass aside and then stuck his hand out in front of Granger silently. An impatient, expectant look came over his face, hoping she'd catch on and spare him the embarrassment of having to explain himself. This wasn't going to end well, he knew it. And he just hoped that Dumbledore wouldn't mock him for it later.
Severus was beginning to feel embarrassed as she was taken off guard by his hand outstretched towards her. Granger looked like a deer in headlights and the way her eyes were wondering around the room as if she was trying to find an exit didn't help him feel any more secure about his rash decision to ask her to dance with him. Growing impatient with her, his hand twitched to retreat but then her eyes found his and all was lost.
She was just as nervous as he, which was relieving. At least he wasn't the only one feeling uncomfortable by this. However, there was something deep within him that was reassured that she was even considering him. Nonetheless he didn't want to pay attention to that part of him. If he did, he knew he'd be in more trouble than he was already with just wanting to dance with her.
Finally, as if 10 years had passed, Granger gave him a small smile and a nod showing her approval to his silent question. Breathing hard through his nose, he gently took her hand and pulled it along with him before leading her to the dance floor. He purposefully avoided eye contact with any other person in the room in fear of what they were judging him for, but he felt the odd tingles of a blue eyed stare on his back. Leave me alone, old man, he thought resentfully.
Steering himself back to the situation at hand and the girl in his own, Severus slid his hand upon her waist while keeping enough distance between the two to make sure it looked appropriate and then made sure to keep her hand in his to place them in position to dance. He waited for her to place her hand on his shoulder before beginning to step.
Although never dancing in public, Severus had learned how to dance quite a while back. Actually with Lily. It had been the most embarrassing and wonderful torture he'd ever encountered with her, and he of course had to dance to keep face at the Malfoy's get-togethers every year. Now, for the first time in quite some time, Severus could put the hidden talent to good use.
Keeping an impassive appearance, he tore his gaze from her eyes to stare at their hands while he led them, as a gentleman should, around the room – careful to not look anywhere around them. He was planning to stay silent the whole time, not caring for conversation that had to make him explain himself in asking her to dance, but he found himself wanting to create small talk. For some weird, strange, incoherent reason.
"I'm surprised you aren't waltzing around with that redheaded oaf you usually tail behind," he mentioned to her in a quiet but loud enough derisive tone. Perhaps it wasn't the best way to begin a conversation, but he was mildly curious as to why she wasn't with Weasley. Hadn't they had something going on or whatever? Not that he'd noticed.
When she didn't say anything at first, he chanced a glance in her direction. She was frowning and a small light blush had dusted her cheeks, contrasting with her brown honey colored eyes. Finally, she replied with a: "He and I have our differences as of late."
With only that as a response, Severus found himself wanting to know what those differences were. His eyes wondered the room in search for the red haired boy but could not find him. Normally he was quite easy to spot, as he had red hair and he was usually glued to the hip of one Harry Potter. Curious, but not feeling it necessary to question her about it he fell into another silence.
After a few moments time, it was Granger who broke the moment of peace. "Thank you for dancing with me…" Her voice was small and unsure. The appreciation was shocking and his black eyes darted to her face, that was turned away from him slightly – as if not wanting to show off her embarrassment for having said what she had said.
Severus wasn't sure if he should oblige and tell her that she was welcome. For one, he was rarely polite. For two, this was Granger and he was in quite a big deal of denial when it came to how he saw her. However, the warmth of her body radiating towards his and the fact that they were holding hands was causing some sort of reaction that he was desperately trying to ignore.
So, at last, Severus gave a sharp nod when she glanced up at him. They then became silent once more, the awkward tension of the situation becoming a bit more comfortable for them as they turned around the room. It wasn't until the song promptly ended that Severus even realized that many eyes had been following them. His insides froze with the realization and he took a step back from her as if being shocked. She gave him a quizzical expression but seemed to understand. As he began to panic, Granger bowed slightly and then turned on her heel to return to her friends.
Severus, still rooted to the spot, felt a certain pair of eyes on him and he scowled at the old man. He needed to leave. Forgetting the fact that he was supposed to be chaperoning the ball, Severus exited the Great Hall without a look back. He locked himself in his classroom, breaking into the spare bottle of firewhiskey he kept in his desk drawer and took a large swig.
He'd danced with Granger. Shuddering at the thought he stared up at the ceiling with a look of contempt. There was something wrong with him. He'd been effected by her alluring dress and the way she smelled. He sat up straighter at the thought. Had she been wearing an intoxication perfume that effected male's attention? She'd never been a female that many males had sought after, unless it was Weasley… that he knew, of course. So it would be practical for her to take advantage of the fact that the ball could be considered a romantic evening. And if what she had said about Weasley had been true, then it would make sense for her to attempt to attract males with a potion.
That had to be it, he confirmed. With another gulp from the bottle in his hand, he nodded to himself. Had to be.
A slam of the classroom door across the hallway from him jolted him from his thoughts and he stood in alert. Mindlessly forgetting that he had the bottle in his hand, he swept out of his classroom and into the corridor. Wondering if it was students fooling around in an abandon classroom or simply a ghost, Severus made it his mission to find out. It could possibly make his night better if he could announce detention or take away a good portion of a house's points.
Using his wand, he opened the door in front of him quickly – taking whoever was in there by surprise as he saw their shadow in the dark room flit across the floor. "You… are not supposed to be in here," he sneered dangerously, before lighting the torches of the room.
The sight before him stilled his movements and silenced his mouth. Granger was standing against the far wall with her magically woven dress hanging off her shoulder, while her once immaculate hair do was messily falling down her shoulders, and her make up was beginning to run down her cheeks. He really wished he could have told her to leave for Gryffindor tower and assign her a detention, but the fact that she was so obviously crying had the words dying on his lips. If they even reached his lips at all.
"What's… going on here?"
Granger tried to shift her dress strap back to her shoulder, but it seemed to have been stretched somehow and so she was failing at fixing it. Severus cursed himself for bluntly staring at the creamy expanse of skin that was exposed from the disjointed strap.
"I-I – I'm sorry sir. I just-t – didn't want to go return to my common room yet and – sorry, sir," she said with a few sobs thrown in between as if she was trying to cover it up but failing, as was her continuance to keep the strap upon her shoulder.
"And why… couldn't you return to your common room?" he asked her, justly curious and not afraid to ask her this time, while attempting to keep his teacher persona in check and his eyes kept falling to the top of her right breast that was teasing his vision from the fallen strap.
"I – well, Ron was there and I couldn't face him sir," she said honestly as she finally gave up on fixing the stubborn strap.
The mention of Weasley had him suspicious. The fact that he hadn't seen him the whole night and the fact that Granger had told him personally that they were having problems didn't give Weasley a great start. His black eyes narrowed at the name, not liking where this was heading. He had never particularly had a tolerance for Weasley as he hated him just about as much as he did Potter. He was bluntly stupid, terrible with magic, and didn't seem to care for proper instructions. Those were three things that Severus couldn't live with.
Despite his distaste for the Weasley boy, Severus knew he had to continue to behave. "Well you were not allowed to stay here for the night Miss Granger, so I'd suggest you get over yourself and either return to the ball or leave for Gryffindor Tower at once."
That seemed to sober Granger up and she gave him a bleak nod, while wiping at her eyes religiously as she began to walk forward. "Sorry sir," she mumbled pitifully and Severus took a step sideways to let her pass. As she reached him, her perfume invaded his nostrils for a second time that night and he concentrated on it for a moment. Was it a potion to attract males? No… it was… vanilla? He stubbornly still believed that she had done something on purpose in order to gain his attention.
On her way out, Granger paused and then turned slightly to look up at him. Severus quirked an eyebrow with inquiry and watched as her eyes dropped down to his hands. He followed her gaze and he realized that he still had the firewhiskey bottle in hand.
"Sir why—"
Her question abruptly ended as he magically made the bottle disappear back into his desk drawer of his classroom. He tried to keep a stoic nature about him, to not let the fact that a student had found out about his drinking. His eyes stared back into her brown ones and began to feel paranoid. It was as if she was trying to figure him out and he really didn't like that feeling.
"Miss Granger… you—" his words broke off as she shifted on her feet, her perfume intoxicating him all over again. "—were going to bed?" he finished with a low voice. His eyes involuntarily lowered back down to her lost strap that was hanging to her elbow, leaving a grand view of her cleavage. He swallowed hard. He needed to control himself.
"Y—yes sir," Granger answered a little over a whisper, sending tingles from his stomach down to his groin. She needed to leave. Now.
Granger turned away from him once again and he held back a breath of relief at her finally leaving him. He raised his wand to turn out the fires of the torches as a hand touched his arm gently. He pulled back swiftly, sending his wand to the face of Hermione Granger. Her eyes were wide but she held herself together, despite her appearance as he stared at her in disbelief. No student had ever laid a hand on him. Let alone Granger.
His wand slowly lowered and he about told her to get off of him, but once again the words died on his lips as she spoke instead.
"Thank you Professor… for dancing with me. It meant a lot to me," she said softly, her hand running down his arm to give his hand a small squeeze before she finally let go to leave. Her words stunned him and he had done it before he registered it. Before her fingers could even leave the contact of his skin, he had grabbed her wrist in a firm hold – keeping her still. She once again turned her head in his direction, her eyes even wider with surprise as she looked up at him.
Severus didn't know what he was doing. In all his life, he'd never felt that way before. He'd been in control over himself fully always. Until now. Something… either it was her perfume, her dress, or just her… he wasn't sure. But he knew that he needed to do something about it.
Slowly, as if time was inching by, Severus took the necessary step towards her. With them standing closer now then when they had been dancing, Granger had to crane her neck to look at his face fully and it was then that he realized how short she was compared to himself. He'd always liked females on the shorter side. His eyes held hers with captivity and her mouth fell open. He heard her breathing as well as feel it against his neck. Did she have any idea what she was doing to him? Just by breathing in his direction?
"Prof—" Her whispered word was cut off as he couldn't take it any longer and he leaned down to capture her lips with his.
From the start, the sensation he'd felt around her that night intensified with the kiss. His lips pressed against hers and he could feel the shock gasp that she inhaled when he did so. Mind reeling at what he was doing, he moved his lips upwards over her top lip in order to deepen the kiss quickly. Apparently having gotten over the shock of it, Granger finally responded to his movements. Her lips surrounded his bottom lip and pulled it gently into her mouth as her hand captured his free arm to steady herself. He too had to take hold of her as he continued to take what he wanted.
She gently pulled away too soon, and Severus' hands rose to her waist, pulling her into his body in order to keep her close. He didn't want to face what he was doing just yet. The fact that he was kissing a student wasn't even registering on his mind level. He knew that if he stopped to think that he'd most likely throw himself off the Astronomy tower which was thankfully not very far from where they were standing.
In response to him pulling her against him, her hands slid up his chest as her mouth slowly opened to grant him permission to invade it. Which he happily did. With her vanilla scent wafting through his nostrils as he breathed hard onto her face, his tongue swept into her warm cavern and slid its way across hers. The first taste of her saliva and the punch from the ball wasn't enough and he quickly invaded more of her mouth in order to get his fill.
A small noise came from her and it sent little jolts down his body to pleasure himself. Throwing caution to the wind, he pulled her with him back into the abandoned classroom and pinned her up against the stone wall. They finally broke their kiss in order to take a deep breath. His eyes popped open to see hers still closed, as her mouth hung open with her lips swollen from the kiss. She too was panting with a strawberry blush across her cheeks. Arousal bending his usual control, Severus grabbed her hips to steady her against the wall. And just as she opened her eyes, he took her mouth once more. Her hands clutched his shoulders as she was held a little too high for her height against the wall so he could access her better, which he didn't mind. They seemed to respond to each immediately both of their mouths opened simultaneously. This time, it was her tongue that invaded his mouth curiously and one of his hands slammed hard against the wall behind her.
Tongues swirling against one another, one of her own hands slid from his shoulder to his chest and he half feared that she'd push him away but she didn't. Whatever the reason for her to continue on with this, he appreciated it at that time and momentarily filled all the passion that was feeling towards this woman – yes, woman – into the kiss that they were sharing. He felt as if he was being forceful, demanding and he dominated her mouth as much as he could while taking her slender neck into his hand to hold her firmly up to him.
A moan escaped her and it jacked his heart rate up dramatically as he pressed his body into hers in response, feeling her warmth against his own. Her legs opened on their own to hold him to her, which was in his favor as his reaction to what they were doing was now firmly in between her legs. There was no hiding it at this point. His hands slid down over the curve of her waist to latch onto her leg, his fingers skimming the bare skin of underneath her knee as the dress she was wearing slid upwards to her waist to reveal a smooth creamy thigh. The high heel on her foot dropped to the floor with a thud but it went unnoticed. The new position while they were kissing was creating an exited exhilaration between them that Severus could feel all too well.
In the depths of his mind, he wondered if she was enjoying this as much as he was but at the moment – because she wasn't pushing him away or rejecting him thus far – he stopped himself from thinking about it any further.
However, with that thought still in his mind, he felt panic stricken his heart as Granger broke away from this kiss to take a deep needed breath. His eyes opened immediately to catch her reaction and she stared with heavily lidded brown eyes for a moment. They continued to stare, trying to figure out what they were doing and who they were doing it with. The only sound was their breathing throughout the room and Severus was beginning to think rationally again. That is… until a strangle shine overtook her eyes and she leaned forward to press a warm kiss to his jaw. The small gesture had him breaking all over again and his eyes slid closed as her lips trailed down to his neck.
He leaned his forehead against her shoulder, letting her have free range to kiss him if she wanted. Her soft lips were still slightly wet from their heavy kissing before and he could feel her hot breath against his skin as she moved her mouth against him. Breathing hard through his nose, he let it out to fan across her bare shoulder, his hand on her knee sliding upwards across her thigh. Her breathing hitched against him and he relented in the fact that he could effect her so with just his touch. Her mouth hesitantly opened on his skin suddenly and his skin was lightly sucked into her inviting cavern. The sensitive tingles spread over his neck and down his arms, which in turn hardened his erection that he mindlessly grinded into her. Granger moaned against his skin while she continued to kiss him from his reaction and he smirked, pressing into her again just to see if he could get another sound to emerge from her. It worked.
The hand on her smooth thigh moved upwards even farther, under the dress's skirt to reach her hip. Her knickers were in reach now and his fingers lightly brushed the outside of her. Her sharp intake of breath left him to take advantage of it and he lifted his head to break her apart from his neck in order to press another heated kiss. Distracting her was easy and he slid his fingers over her, feeling her breath deeply against him in anticipation.
Pulling away to hover over her lips, his eyes slightly opened with a smirk. "I'm going to touch you." It wasn't a question, but it could have been if she had wanted it to. He didn't want to think about what her answer would have been if she had decided to call it all to a stop. He'd already broken so many school rules already.
All that came forth from her was another moan and gasp as his fingers slid the satiny fabric away to touch her warmth. She was wet and that was an incredibly good sign as the insecure part of him was still fighting with his passionate part. At his touch she gasped again, and he kissed down her own throat, leaving a wet trail as he did so against her soft skin. The vanilla scent was all too much for him and he inhaled to savor it as his let a finger move down the bundle of nerves – making her legs twitch – and to where he slid his finger in.
Oh she was tight.
A small growl like sound came from his own body but he didn't recognize it. Granger slid her hands up to his shoulders once more, as her head fell backwards against the wall, her eyes closing with a look of pure satisfaction. His finger probed her entrance, before slinking all the way in. She cried out then, sending goose bumps to appear under all of his black clothing.
"Prof-fessor-r…" she moaned out and he pumped his finger into her deeper, urged on by her speech. "Mmm."
Severus pulled from her neck after leaving a rather red looking mark against her pale skin as his finger stretched her and penetrated her, just like he wanted to do to her with his own body and not by hand. She was writhing against him as he did this, making the most beautiful sounds to his ears that he could fathom. She was suddenly clenching around him time and time again, her moans getting faster as he realized he was bringing her to the edge. It was at this point that he knew what he had to do.
Giving her a rather passionate but chaste kiss, Severus pulled her knickers off of her to hang off one foot, before unbuttoning his pants. Granger's gaze slid down his form heatedly and he almost blushed by her expression of him but he was thankful he didn't. As he went to pull his hard on out from his clothing, a small hand shot out to touch him, spreading a new kind of fire within him. Oh gods, Granger was touching him…
A small panted breath left him uncontrollably and she slid her fingers around him and gently pulled. His hips moved with her guide, pulling him back closer to her as she lightly moved her hand over him. His breath was catching and he couldn't think properly anymore, if he was even doing that to begin with. He wasn't sure. A finger slid over the head of him, wiping away the small amount of moisture collecting there and he practically broke apart.
Grabbing her hand and shoving it away, Severus took a hold of her hips and lifted her up. Her legs wound around his hips while her hands grabbed his shoulders again. This was it. Catching her eyes, he slid her slowly onto his erection, watching her lips fall open and her eyes slide closed as he filled her. It was amazing to see a woman react so intensely from him as that had never happened to him before.
"Professor…" she sighed and he gritted his teeth harshly, not wanting to cause her pain but also wanting to drive himself deeply within her as hard and fast as he could.
"Does it…" he trailed off to lick his dry lips. "Does it hurt?" he whispered to her, watching her carefully for any sign of a cringe.
Granger opened her eyes and caught his worried gaze before shaking her head a little. For some reason her answer didn't satisfy him. He might not have had too many experiences with virgins, but he knew that if a woman didn't have sex then it did feel uncomfortable to them at first. So… that poised a question. Was she a virgin?
Not wanting to ponder that too long, with the situation at hand, Severus tilted his hips and slid himself completely inside of her. The small cry from her was all he needed to know that this was going to be even more exciting than just kissing her. It didn't take long for him to find himself comfortable with a rhythm that matched hers and he took her lips once more to have another taste that he couldn't get enough of.
Her hips began to move against his own, urging him on as he pounded into her more harshly than necessary. He couldn't help it, her muscles were clenching around him tightly as he slid in her each time. One of his hands slid up her side, taking a hold of the glittery strap that had given her so much trouble and tugged it farther down, exposing a breast to him. Still thrusting into her as well as he could, he leaned his head down to capture the hardened nipple into his inviting mouth. Granger moaned loudly at that and he felt her tightened around him even more, almost making it impossible for him to move in and out of her at a regular pace.
It was not too long from then, when he was biting and nipping at her nipple and the area around it that he felt her climax around him suddenly and he knew he'd lose it completely. Grabbing her hips, he straightened up and pounded into her as fast as he could, loving the feeling of her around him along with the slickness that had come from her orgasm. The wet sound of their actions sounded through the room, her pants coming out in short breaths between them, and just the general heat radiating from each body had him releasing into her with a throaty groan. His head fell to the crease between her neck and shoulder and her hands slid up his back as he emptied himself within her.
All too soon, the wild moment of need and lust was beginning to wane and Severus fought to let it end just yet. But he knew that they couldn't stay this way forever. Slowly, to not cause her any discomfort, he lifted her off of himself and let her find her footing. She wobbled slightly, and his hands shot out to steady her, expecting the worse that she would fall – while his pride floated high above them. And then crashed as he slowly began to rationalize what he'd just done with a student.
Quickly zipping himself back up, he stepped slightly away from her as she was still pressed against the wall for support. Her eyes found his and he held his breath. Was she going to run away screaming now? Would this be the last night that he'd ever spend in the castle? Dread and fear spread throughout him, moreso than when he was face to face with the Dark Lord. His fate at the school and his position in the Death Eaters was held in the hand of Hermione Granger.
But what he found within her eyes was nothing for him to worry over. She seemed almost… content. Happy. Elated. Blissful. And he was even more taken aback by the small smile that spread over her face.
"I… I'm sure you're worried if I'll say anything…"
Severus's hands clenched tightly into fists, not wanting to hear it aloud just yet. But it didn't seem to phase her.
"Professor…" her voice trailed off as she looked down at the ground as if debating with herself. He was quickly growing impatient. "I… I have a confession to make. I, well, I've grown up a lot this year and I've started to accept the fact that I don't fit in with the other students my age. It's just…" Her brown eyes slipped upwards to meet his confused ones and she took a deep breath before finishing. "I've realized that over the past couple years, my fascination with you has become more than just a teacher inspiration. I've found myself daydreaming about you when I shouldn't be. And I…" her cheeks were burnt red by this point and Severus was frozen from shock at her words. "Well, I don't regret doing this and I'd never tell a soul. I swear on Harry Potter's life…"
Severus stared at her, stunned. He had not been expecting that in a million years. And how in the hell was he supposed to respond to something like that? It wasn't like Granger and he were on the best of terms, teacher and student wise. How had this even come about? Swallowing down his confusion, Severus crossed his arms to hide his vulnerability. Would he be able to live on with this? That Granger now had a secret about him that she could spill to anyone at any moment. Including Potter? But she had sworn on his life… and he was willing to believe it, despite the fact that Potter could be killed at any moment. Severus had a little bit more faith in Potter and his friends than he'd like to admit.
Still…. It had felt great to let loose some pent up tension that he'd had coursing through him for quite some time.
Making his final thought, Severus knew what he must do. The fact that he'd been in denial over the fact that he too had been fascinated by her in the past wasn't going unnoticed now.
"I expect you to be in my office tomorrow night at six. No later. And… wear black," he said in his velvety baritone voice, watching as her eyes widened largely and her mouth go slack from shock. He smirked as he took a step towards her, pressing himself against her once more. Yes, he could do this more often. "I'm trusting you Granger, don't screw this up."
Her eyes narrowed from their wide disposition at the threat, but she nodded her head. "I wouldn't dream of it," she murmured.
Severus stared hard into her eyes to make sure he was reading honesty before kissing her quickly on the mouth and then promptly leaving her in the room to clean herself up.
Beat that Weasley.