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By: Joseph St. Geme, MD

  • Chair, Department of Pediatrics, Professor of Pediatrics and Microbiology, Perelman School of Medicine at the University of Pennsylvania
  • Physician-in-Chief, Leonard and Madlyn Abramson Endowed Chair in Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania

https://www.chop.edu/doctors/st-geme-joseph-w

Rubeola must be distinguished from cutaneous drug reactions as well as other viral exanthems medications diabetic neuropathy purchase septra master card. Complications may arise from viral dissemination medications qd order septra visa, secondary bacterial infection cold medications order septra on line, or hypersensitivity phenomena medicine 95a pill buy septra with paypal. Viral myocarditis and thrombocytopenic purpura (owing to immune-mediated platelet destruction) may occur. Alternative drugs for acute herpes zoster are famciclovir, 500 mg three time daily for 7 days, and valacyclovir, 1 g three times daily for 7 days. Cool compresses and antihistamines may help to remove crusts and alleviate pruritus. Disease occurs most often in children under age 15, with the attack rate highest in infants 6­12 months of age. Asymptomatic colonization of the nasopharynx is common and provides a source of person-to-person transmission through infected droplets. People with deficiencies of the terminal components of the complement cascade (C5­9) are particularly susceptible to invasive and recurrent meningococcal disease. The cutaneous lesions are a consequence of damage to small dermal blood vessels both by direct bacterial involvement of skin vessels and by lipopolysaccharide endotoxins. Laboratory Findings-Serologic studies of paired specimens are the most practical method of confirming the diagnosis. Measles virus may be isolated from the blood, urine, nasopharyngeal washings, and throat or from conjunctival secretions. Aerosolized ribavirin may be beneficial for the treatment of measles pneumonitis, but its effectiveness has not yet been proved. Intravenous immunoglobulin and interferon are other treatment options for measles pneumonitis and encephalitis. Symptoms and Signs-Invasive meningococcal disease usually results in meningitis or meningococcemia. The onset may be insidious, following a flulike illness, or abrupt, with fever, chills, malaise, signs of meningeal irritation, prostration, and shock. A rash that is characteristically petechial or, less commonly, urticarial or morbilliform is often among the earliest signs of generalized infection. The petechiae typically appear on the trunk and lower extremities but also can be found on the palms, soles, and mucous membranes. Extensive hemorrhagic bullae and areas of necrosis develop in patients with meningococcemia whose disease is complicated by purpura fulminans. Obtundation, hypotension, and death may ensue within hours despite appropriate antimicrobial therapy. Absence of meningeal signs is a feature of this acute fulminant form of meningococcal disease. Children under age 2 have the highest mortality rate, perhaps as a consequence of immaturity of the protein C system. Other complications of invasive meningococcal disease are arthritis, myocarditis, pericarditis, cervicitis, and Waterhouse-Friderichsen syndrome. More rare meningococcal diseases include occult bacteremia and chronic meningococcemia. Laboratory Findings-Confirmation of the diagnosis depends on demonstration of the organism. Blood and cerebrospinal fluid cultures are indicated in all patients suspected of having invasive disease. Counterimmunoelectrophoresis or latex agglutination with group-specific antisera of cerebrospinal fluid, urine, or tears can facilitate rapid diagnosis. If complicated by purpura fulminans, extensive hemorrhagic bullae and areas of necrosis. Other features of meningococcal meningitis or disseminated meningococcemia, including meningeal signs, arthritis, myocarditis, pericarditis, and acute adrenal infarction; hypotension and shock are often present. Confirmation of Neisseria meningitidis by culture, Gram stain, or immunologic tests. Depending on the clinical presentation, other infections, such as gram-negative septicemia, Rocky Mountain spotted fever, echovirus and coxsackievirus infections, and atypical measles, must be excluded. Clinical Features the incubation period is usually about 1 week, ranging from 1­14 days. Symptoms and Signs-Sudden onset of fever, headache, myalgia, and nausea or vomiting are initial features. On the second to fourth days of illness, a blanchable pinkish red macular rash appears over the ankles, wrists, and forearms, spreading to involve the soles, palms, extremities, trunk, and face within hours. Over the next 1­2 days, the eruption becomes papular and nonblanchable (purpuric) and may evolve into gangrene of the digits, nose, earlobes, scrotum, or vulva. Laboratory Findings-The diagnosis of Rocky Mountain spotted fever can be established retrospectively by one of many serologic techniques, including complement fixation, latex agglutination, or microagglutination tests. However, these tests are not reliably positive before the second week of the illness. A Giemsastained smear of tissue sections occasionally may demonstrate the organism. Immunofluorescent microscopic examination of skin biopsy specimens may confirm the diagnosis as early as the fourth day of illness. Hemodynamic and other supportive measures must be provided as necessary to maintain organ system function. Close contacts of patients with meningococcal disease should be given rifampin prophylaxis and monitored closely. After incubation period of 1­14 days, sudden onset of fever, headache, myalgia, and nausea or vomiting. Appearance on days 2­4 of blanchable pinkish red macular rash over ankles, wrists, and forearms, spreading to involve the soles, palms, extremities, trunk, and face within hours; bilaterally symmetric petechiae of the palms and soles are a major finding. Diagnosis can be confirmed by serologic tests, but these are not reliable before the second week of illness. Differential Diagnosis Rocky Mountain spotted fever must be differentiated from other serious febrile illnesses such as viral and bacterial meningitis, meningococcemia, measles, vasculitis, and thrombotic thrombocytopenic purpura. The disease is transmitted to humans by the bite of a tick infected with the causative organism Rickettsia rickettsii. Transmission reflects the tick season in a particular geographic area, with highest incidence in spring and summer. The major indication for operative treatment is fasciitis spreading despite empirical antibiotics in an acutely ill patient. Erythema, edema, and pain develop 1­2 days following surgery or trauma with central areas of dusky gray-blue discoloration, occasionally in association with serosanguineous blisters. Involved areas become gangrenous within a few days; culture frequently grows multiple aerobic and anaerobic bacteria. General Considerations Necrotizing fasciitis is a rare, life-threatening soft tissue infection characterized by acute and widespread fascial necrosis. The pathogenesis involves the introduction of organisms into the subcutis with subsequent spread through fascial planes. Many different virulent bacteria have been isolated in association with necrotizing fasciitis, including -hemolytic streptococci, staphylococci, coliforms, enterococci, Pseudomonas, and Bacteroides. Rapid onset of fever, vomiting, watery diarrhea, sore throat, and profound myalgias, with hypotension. Diffuse, blanching erythema appears early, predominantly truncal, with accentuation in the axillary and inguinal folds and spreading to the extremities; desquamation of the involved skin and of the palms and soles seen during the second or third week. Symptoms and Signs-Erythema, edema, and pain develop 1­2 days following introduction of the organism into the subcutis. Clinically, there are central areas of dusky gray-blue discoloration, occasionally in association with serosanguineous blisters. Within a few days, these areas become gangrenous; liberation of toxins and organisms into the bloodstream leads to severe systemic toxicity. The extremities are the most commonly affected site, but the trunk, perineum, and abdomen also may be affected. Necrotizing fasciitis may be confused with cellulitis, angioedema, eosinophilic fasciitis, and clostridial myonecrosis. Laboratory Findings-Incisional biopsy of both the advancing edge and the involved tissue should be performed early, looking for necrotic fascia and the causative organism.

Breastfeeding education in term of knowledge and attitude through mother support group symptoms sleep apnea cheap 480 mg septra mastercard. Knowledge medicine ball slams order online septra, Attitude symptoms sleep apnea order 480mg septra with amex, and Practices of Breastfeeding and Weaning Among Mothers of Children up to medications 377 generic 480mg septra overnight delivery 2 Years Old in a Rural Area in El-MiniaGovernorate, Egypt. Attitudes towards infant feeding among adults in a low socioeconomic community: what social support is there for breastfeeding? Knowledge, attitudes, and breast feeding practices of postnatal mothers:A cross sectional survey. Knowledge, attitude and practice regarding exclusive breastfeeding among mothers attending primary health care centers in Abha city. Factors associated with knowledge about breastfeeding among female garment workers in Dhaka city. Factors associated with low incidence of exclusive breastfeeding for the first 6 months. Bureau of health promotion, Department of health,Ministry of Public Health Thailand. An exploration of the knowledge and attitudes towards breastfeeding among a sample of Chinese mothers inIreland. Early Exclusive Breastfeeding and Maternal AttitudesTowards Infant Feeding in a Population of New Mothers in San Francisco, California. Maternalbreastfeeding attitudes: association with breastfeeding intent andsocio-demographicsamongurbanprimiparas. Afterthatexpertconducteddiscussionwhichaimedtorefineandsharpen the question model which had been developed from the informants. This policy direction was elaborated into a strategy involving activeroleofmulti-stakeholdercollaboration(3). There were several main Indian Journal of Public Health Research & Development, January 2019, Vol. For this reason, it is necessary to develop indicators for crosssector collaboration to measure collaboration and obtain the expected collaboration model with changes in the structure of cross-sector coordination. After the indicator was formed, the expert discussion wasconductedtorefineandsharpentheindicatorsthat have been developed from the informants. Collaborative dimensions are the dimensions of Governance, Administration, Autonomy (Institutional Independence), Mutuality, and Norms (Trust). Dimensions of Governance: DimensionofGovernance describes the involvement of various institutions in managingtheprogram. Basedontheresultsofinterviews with informants, there were several indicators formed from this dimension. Inthisstage,the search for indicators and how to measure the dimensions of the collaboration process were carried out according to stakeholders who have direct involvement and impact. Research conducted by Bryson, Barbara & Stone, 2006producedthreedimension;membership,structural configuration, and institutional structure. Thomson and Perry, 2006 stated that governance is a jointly decision making in arranging the rules that can affect the behavior and relationships among institutions. From several indicators proposed by several collaboration experts,thereareseveralsimilaritieswiththeindicators developed in this study, including related rules and membership. Program Sustainability Administration Dimension: the administrative dimension describes the means used in supporting the implementation of the institutional process in collaborating. Some important points that must be considered in the administrative dimension based on the statements of the informants above are communication usedincoordination,clarityofrolesandresponsibilities, conflictresolution,andinstitutionalinformationsystems. Toachievethisgoal,administrative structures must exist that can move governance into action. The administrative structure focuses on implementation and management to do what needs to be done to achieve goals(7-10). Referring to the collaborative theory of Barbara Gray,Thomson & Perry andAnsell & Gash, there are several indicators that describe this dimension as; Clarity of roles and responsibilities, communication channels to improve coordination, mechanisms to monitor each activity in relation to roles and responsibilities(4,6,10). Institutional Independence Dimension: the third dimension of the collaboration process reflects the independence of the institution which means how each institutionhasastronglegallawintheformofpolicy, in collaboration(5). Based on the results of interviews withtheinformants,thereareseveralindicatorsformed from this dimension. Therefore, it can concluded from the interview is that the independence is associated with policies where support comes from regional leaders, budgeting from the regional government and donors. They maintain their own organizational identity and authority which is separated from the collaborative identity and authority of the collaboration itself. Based on the results of interviews with the informants, there are several indicators formed from this dimension. The excerpts from interviews with informants are outlined asfollows: "Communication is important. Communication should not be too formal so that each member is free to express opinions". Collaborating organizations must feel interdependent one another and mutually beneficial even though they havedifferentinterests(9,10). In his study at the National Sevice,Thomson(1999)foundthatcommitmenttothe same target population proved to be one of the most important factors in collaborating(13). Dimension of Norms: the fifth dimension of the collaboration process reflects the trust built by collaborating institutions. The excerpts from interviews aredescribedasfollows: 570 Indian Journal of Public Health Research & Development, January 2019, Vol. From the aboveinterviews,severalindicatorswereformedonthe dimensionsofnormssuchastrustinotherinstitutions, believing that collaboration can solve problems and trust in the leaders of institutions that act as coordinators. Then the researcher asked for input from the experts related to the instrument especially the content of the instrument being developed. Ingeneral,expertsassessedwhatwascontainedinthe instrument in terms of content and operational concepts related to institutional cross-sectoral coordination. Conflict of Interest:Thereisnoconflictofinterestin this research Source of Funding: this study support by Ministry of Research, Technology and Higher Education (Kemenristekdikti) Ethical Clearance: this research was approved by ethicscommitteeofPublicHealthFaculty,Universitas Indonesia. Linking Collaboration Processes and Outcomes Foundations for Advancing Empirical Theoryle. Treating networks seriously: Practical and research-based agendas in public administration. Getting agencies to work together: the practice and theory of managerial craftsmanship. Thisresearchwasobservational,crosssectional study 10 workers as the total population. Oneoftheinformal sectors that use chemicals was home industry such as shoes or sandals industry that uses glue materials in their productionprocess. Ingeneral,glueoradhesivecontains Corresponding Author: Abdul Rohim Tualeka DepartmentofOccupationalHealthandSafety, PublicHealthFaculty,AirlanggaUniversity,KampusC, JalanMulyorejo,Surabaya,60115,Indonesia Tel:+6281335519732 E-mail:inzut. Benzeneiswellknownasagood organic solvent for various industrial processes such as rubber industry, shoes, paint solvents, components in motor fuel, component in detergents, pesticides and pharmaceutical manufacturing. The impacts that can arise from acute exposure to benzene Indian Journal of Public Health Research & Development, January 2019, Vol. There is a process of gluing shoes with the use of glue materials in which there was benzene chemical content. The independent variable in this study was the ventilation on the nominal measurement scale. For nonair conditioned working, rooms should have a ventilationholeatleast15%ofthefloorareaby applying a cross ventilation system. Fuel pump operators have a risk carcinogenic effect of each individual can be concluded that at 3 years exposure there is 1 employee who is at risk of cancer effect, and at lifetime exposure all employees are at risk of cancer. All of the population but the administrative staffwasatriskofacarcinogeniceffectonallthe duration of exposure. The results of this study showed that the ventilation system controls the exposure of benzene in the shoe industry Romokalisari Surabaya, because the ventilation system works to draw more air into the work room by using fan to encourage air to rise and can be dilutied by mixing with fresh air enteringventilation,andequippedwithexhauster tosuckaircontaminantsouttheroom. Inaddition, workers are encouraged to use personal protective equipment, especially masks, placing some plants that work to accelerate the decomposition of benzene vapor, and always maintain good hygiene,andpromotehealthylifestyle. The most of worker in the shoe home industryofRomokalisari,SurabayahadExcessCancer Risk (80. Ethical Clearance: the study was approved by the institutional Ethical Board of the Public Health, AirlanggaUniversity. Effect of food containing high Fe (iron) intake to urinary trans, trans-muconic acid (Tt-ma) levels on workers exposedtobenzene. Sri Maywati, Siti Novianti, Hubungan Faktor Pemajanan (Masa Kerja Dan Ventilasi) Dengan Kadar Fenol Urin Pekerja Bagian Pengeleman Pada Industri Sandal Kota Tasikmalaya, 2011 (jurnal).

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Topical carbonic anhydrase inhibitors medications or drugs quality septra 480 mg, such as dorzolamide and brinzolamide medications made easy order generic septra line, have the advantage of not causing any systemic effects medicine 0031 cheap 480mg septra with mastercard. Mountain sickness: Less commonly treatment yeast order 480 mg septra with amex, acetazolamide can be used in the prophylaxis of acute mountain sickness among healthy, physically active individuals who rapidly ascend above 10,000 feet. Acetazolamide given nightly for 5 days before the ascent prevents the weakness, breathlessness, dizziness, nausea, and cerebral as well as pulmonary edema characteristic of the syndrome. Adverse effects: Metabolic acidosis (mild), potassium depletion, renal stone formation, drowsiness, and paresthesia may occur. If the substance that is filtered subsequently undergoes little or no reabsorption, then the filtered substance will cause an increase in urinary output. Because osmotic diuretics are used to effect increased water excretion rather than Na+ excretion, they are not useful for treating conditions in which Na+ retention occurs. They are used to maintain urine flow following acute toxic ingestion of substances capable of producing acute renal failure. Osmotic diuretics are a mainstay of treatment for patients with increased intracranial pressure or acute renal failure due to shock, drug toxicities, and trauma. Maintaining urine flow preserves long-term kidney function and may save the patient from dialysis. The expansion of extracellular water results because the presence of mannitol in the extracellular fluid extracts water from the cells and causes hyponatremia until diuresis occurs. Which of the following drugs would be appropriate for them to take to prevent mountain sickness? Overview the neuroendocrine system, which is controlled by the pituitary and hypothalamus, coordinates body functions by transmitting messages between individual cells and tissues. This contrasts with the nervous system which communicates locally by electrical impulses and neurotransmitters directed through neurons to other neurons or to specific target organs, such as muscle or glands. The endocrine system releases hormones into the bloodstream, which carries these chemical messengers to target cells throughout the body. Hormones have a much broader range of response time than do nerve impulses, requiring from seconds to days, or longer, to cause a response that may last for weeks or months. For example, in several instances, the release of hormones is stimulated or inhibited by the nervous system, and some hormones can stimulate or inhibit nerve impulses. Chapters 24 to 26 focus on drugs that affect the synthesis and/or secretion of specific hormones and their actions. In this chapter, the central role of the hypothalamic and pituitary hormones in regulating body functions is briefly presented (Figure 23. In addition, drugs affecting thyroid hormone synthesis and/or secretion are discussed. Hypothalamic and Anterior Pituitary Hormones the hormones secreted by the hypothalamus and the pituitary are all peptides or low-molecular-weight proteins that act by binding to specific receptor sites on their target tissues. The hormones of the anterior pituitary are regulated by neuropeptides that are called either вoereleasingв or вoeinhibitingв factors or hormones. These are produced in cell bodies in the hypothalamus, and they reach the cells of the pituitary by the hypophysial portal system (Figure 23. The interaction of the releasing hormones with their receptors results in the activation of genes that promote the synthesis of protein precursors. These are then processed posttranslationally to the hormones and are released into the circulation. The hypothalamic-releasing hormones are primarily used for diagnostic purposes (that is, to determine pituitary insufficiency). Stress stimulates its secretion, whereas cortisol acting via negative feedback suppresses its release. This pathway ends with the synthesis and release of the adrenocorticosteroids and the adrenal androgens (see Figure 23. Somatotropin influences a wide variety of biochemical processes; for example, through stimulation of protein synthetic processes, cell proliferation and bone growth are promoted. Somatotropin and somatrem should not be used in individuals with closed epiphyses or an enlarging intracranial mass. Originally isolated from the hypothalamus, somatostatin is a small polypeptide that is also found in neurons throughout the body as well as in the intestine and pancreas. Its half-life is longer than that of the natural compound, and a depot form is also available. Gallbladder emptying is delayed, and asymptomatic cholesterol gallstones can occur with long-term treatment. These are effective in suppressing production of the gonadal hormones and, thus, are effective in the treatment of prostatic cancer, P. Adverse effects of gonadorelin include hypersensitivity, dermatitis, and headache. In women, the analogs may cause hot flushes and sweating as well as diminished libido, depression, and ovarian cysts. In men, they initially cause a rise in testosterone that can result in bone pain; hot flushes, edema, gynecomastia, and diminished libido also occur. Gonadotropins: Human menopausal gonadotropin, follicle-stimulating hormone, and human chorionic gonadotropin the gonadotropins are glycoproteins that are produced in the anterior pituitary. The hormone enters a cell, where it activates a tyrosine kinase to promote tyrosine phosphorylation and gene activation. On the other hand, hyperprolactinemia, which is associated with galactorrhea and hypogonadism, is usually treated with D2-receptor agonists, such as bromocriptine and cabergoline. Both of these agents also find use in the treatment of microadenomas and macroprolactinomas. They not only act at the D2 receptor to inhibit prolactin secretion but also cause increased hypothalamic dopamine by decreasing its turnover. Among their adverse effects are nausea, headache, and sometimes, psychiatric problems. Hormones of the Posterior Pituitary In contrast to the hormones of the anterior lobe of the pituitary, those of the posterior lobe, vasopressin and oxytocin, are not regulated by releasing hormones. Instead, they are synthesized in the hypothalamus, transported to the posterior pituitary, and released in response to specific physiologic signals, such as high plasma osmolarity or parturition. Its only use is in obstetrics, where it is employed to stimulate uterine contraction to induce or reinforce labor or to promote ejection of breast milk. Oxytocin causes milk ejection by contracting the myoepithelial cells around the mammary alveoli. Although toxicities are uncommon when the drug is used properly, hypertensive crises, uterine rupture, water retention, and fetal death have been reported. Its antidiuretic and pressor activities are very much lower than those of vasopressin. The chemically synthesized nonapeptide has replaced that extracted from animal posterior pituitaries. In the kidney, it binds to the V 2 receptor to increase water permeability and resorption in the collecting tubules. It also finds use in controlling bleeding due to esophageal varices or colonic diverticula. Other effects of vasopressin are mediated by the V1 receptor, which is found in liver, vascular smooth muscle (where it causes constriction), and other tissues. As might be expected, the major toxicities are water intoxication and hyponatremia. Caution must be used when treating patients with coronary artery disease, epilepsy, and asthma. This analog is now preferred for diabetes insipidus and nocturnal enuresis and is longer-acting than vasopressin. Thyroid Hormones the thyroid gland facilitates normal growth and maturation by maintaining a level of metabolism in the tissues that is optimal for their normal function. The two major thyroid hormones are triiodothyronine (T3; the most active form) and thyroxine (T4). Although the thyroid gland is not essential for life, inadequate secretion of thyroid hormone (hypothyroidism) results in bradycardia, poor resistance to cold, and mental and physical slowing (in children, this can cause mental retardation and dwarfism). If, however, an excess of thyroid hormones is secreted (hyperthyroidism), then tachycardia and cardiac arrhythmias, body wasting, nervousness, tremor, and excess P.

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Therefore medicine 5113 v order 480mg septra visa, appropriate isolation precautions are essential when caring for these patients treatment episode data set order 480mg septra. Note that conventional handwashing is necessary for hospital personnel because alcoholbased hand cleansers do not kill C medicine interactions cheap septra 480 mg visa. However oxygenating treatment buy septra online pills, these strategies have not been adequately studied to support formal recommendations. Diarrhea may develop after a single dose of an antibiotic or may be delayed as long as 6 weeks following the last dose of the antimicrobial agent. If the patient develops pseudomembranous colitis, sigmoidoscopy may reveal characteristic white or yellow plaques or pseudomembranes. Patients may become seriously ill, with fluid and electrolyte imbalance, toxic megacolon, and colonic perforation. Laboratory Findings-It is recommended that diarrheal stools of patients who have been hospitalized for more than 72 hours with a history of prior antibiotic use be evaluated for C. The most sensitive and specific test for this disorder is a tissue culture assay for toxin B cytotoxicity, with a sensitivity of 94­100% and a specificity of 99%. Enzyme-linked immunoassays for identification of toxins A and B have a sensitivity of 63­99% and a specificity of 75­100%. In 20% of patients, toxin assays on multiple stool samples may be required to demonstrate the presence of the toxin. Antimicrobial administration can cause diarrhea by altering normal bowel flora (eg, ceftriaxone, tetracycline, and amoxicillin-clavulanic acid) or by bowel irritation (eg, erythromycin). A comparison of vancomycin and metronidazole for the treatment of Clostridium difficile-associated diarrhea, stratified by disease severity. Symptoms and Signs-Most patients with hematogenously disseminated candidiasis have no systemic symptoms or signs of infection other than persistent fever in the setting of broad-spectrum antibiotics. Careful physical examination should be performed to assess the presence of skin lesions characteristic of candidemia. Three types of lesions have been described with hematogenously disseminated candidiasis: the classic lesion is macronodular, erythematous, and 0. Lesions resembling ecthyma gangrenosum and purpura fulminans also have been described. In all three types of lesions, the organisms are seen readily on histopathologic examination of punch biopsy specimens. Patients should undergo daily physical examination looking for new cardiac murmurs, bone or joint findings, and hepatosplenomegaly. Endocarditis, osteomyelitis, arthritis, and hepatosplenic candidiasis are all documented complications of candidemia. All patients should have a thorough ophthalmoscopic examination to rule out candidal endophthalmitis, typically appearing as white "cotton ball" lesions that may extend into the vitreous. Laboratory Findings-Laboratory findings in hematogenously disseminated candidiasis are nonspecific. Appropriate imaging studies should be obtained when there is suspicion of end-organ dissemination; biopsy of suspicious lesions should be pursued to look for histopathologic evidence of invasive candidal infection. General Considerations Candida species are an increasing cause of nosocomial bloodstream infections and are associated with high rates of mortality and morbidity. However, the widespread use of empirical fluconazole may exert selective pressure leading to the emergence of Candida species that are less sensitive to the triazoles. Empirical Antifungal Therapy-The diagnosis of hematogenously disseminated candidemia typically is made on clinical grounds, and patients are often treated empirically based on the presence of multiple risk factors or evidence for mucosal colonization with Candida species. A critical intervention in the treatment of candidemia is the removal of all potentially infected venous catheters, especially in neutropenic patients. In the pretriazole era, amphotericin B was used exclusively in all patients with suspected or documented fungal infection. However, data now suggest that in a nonneutropenic patient who is hemodynamically stable, fluconazole will provide response rates of 60­100%. Factors that may prompt the physician to use amphotericin B as empirical therapy include hemodynamic instability or known colonization of the patient with non-albicans species, such as C. There is general agreement that a neutropenic patient with suspected invasive fungal infection should receive amphotericin B, micafungin or caspofungin. Flucytosine may be used in combination with either amphotericin B, micafungin or fluconazole in severe infections. Itraconazole is available in an intravenous formulation, but formal studies to support recommendations for its use have not been completed. Betts R et al: Efficacy of caspofungin against invasive Candida or invasive Aspergillus infections in neutropenic patients. National nosocomial surveys have demonstrated an increase in the prevalence of vancomycin-resistant enterococci among enterococcal isolates to levels of 25% or greater. Case-control studies have identified several risk factors for acquisition of vancomycin-resistant enterococci. Host factors include advanced age, severity of underlying disease, hematologic malignancy, neutropenia, cirrhosis, hemodialysis, recent intraabdominal surgery, prior nosocomial infection, the presence of pressure sores, prolonged hospitalization, invasive procedures, contact with another person colonized or infected with vancomycin-resistant enterococci, and previous antimicrobial therapy (especially with a third-generation cephalosporin and vancomycin). Mechanism of Resistance-Enterococci develop resistance to vancomycin through acquisition of genes conferring resistance; these genes are specified as vanA or vanB. The most common phenotype, vanA, is transmitted by a transposon and confers high-level resistance to vancomycin and teicoplanin. The vanB phenotype is chromosomally based and confers variable resistance to vancomycin while maintaining susceptibility to teicoplanin. Both phenotypes are easily transferable among different enterococci via conjugation. The mechanism of resistance involves a change in the cell wall building block, D-alanine-D-alanine, the target site for vancomycin, to D-alanine-D-lactate. Therapy-Treatment of serious vancomycin-resistant enterococcal infections is difficult. Many strains are resistant to ampicillin and aminoglycosides, so the remaining options are few in number, and antienterococcal activity is limited. Carbapenems, fluoroquinolones, tetracyclines, chloramphenicol, rifampin, novobiocin, and nitrofurantoin all have been used in various combinations in an attempt to treat infection with vancomycin-resistant enterococci. Quinupristindalfopristin, linezolid, and daptomycin are drugs recently licensed in the United States that include vancomycinresistant enterococci in their spectrum of activity. Urinary tract infections may be treated successfully with nitrofurantoin and removal of the urinary catheter. Mixed infections, such as intraabdominal abscesses or skin and soft tissue infections, should undergo aggressive debridement. Indwelling venous catheters and prosthetic devices should be removed whenever possible. Treatment of serious vancomycinresistant enterococcal infection should include at least two antimicrobial agents to which the organism is susceptible, and one of these should be an aminoglycoside unless the class is contraindicated or resistance is present. Patients with serious nosocomial infections caused by enterococci have high morbidity and mortality rates owing to their underlying disease. The most common site of origin of enterococcal infection is the urinary tract, followed by intraabdominal or pelvic infection as part of a polymicrobial process. Scanning and transmission electron microscopy of the insensitive organisms show a thickened bacterial cell wall. It is hypothesized that decreased vancomycin access to the target sites may occur as a result of sequestration of the drug in the cell wall. Full vancomycin resistance is mediated via the vanA gene, which confers vancomycin resistance to enterococci. Preliminary in vitro data suggest that as the bacteria become more resistant to vancomycin, they become more susceptible to oxacillin. A role for quinupristin-dalfopristin, linezolid, and daptomycin in the treatment of these infections is a possibility as well. Thus strict infection control measures are necessary to prevent spread and persistence of the organisms. Strict contact isolation should be observed for any patient infected or colonized with the organism. In addition, the use of empirical vancomycin for the treatment of hospitalized patients should be limited to those with clear indications. Presence of the mecA gene is also associated with resistance to other antibiotics, including all -lactams, aminoglycosides, macrolides, tetracycline, rifampin, and fluoroquinolones.

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