Albert H. Park, M.D.

• Department of Otolaryngology
• University of Utah health Sciences Center
• Salt Lake City, Utah

Concomitant cellulitis or myositis may also be present in the setting of bone and joint infection and can make it difficult to determine whether there is an underlying osteomyelitis or septic arthritis based on clinical examination findings medications 6 rights purchase generic antabuse online. Vertebral osteomyelitis presents in a nonspecific manner symptoms 6dpo order antabuse with a mastercard, which often leads to a delay in diagnosis medications zoloft buy antabuse 250 mg without prescription. Infants may present with sepsis treatment lymphoma order genuine antabuse line, while older children generally have concerns of abdominal treatment qt prolongation buy cheap antabuse 500mg line, leg medications quizzes for nurses buy 500mg antabuse with amex, chest, or back pain. Point tenderness should be present over the infected area, and surrounding soft-tissue swelling may be seen. Neurologic deficits related to spinal cord compression may be present at diagnosis and occur in up to 20% of cases. Pelvic osteomyelitis accounts for 6% to 9% of bone infections and is similar to vertebral infection in that it often presents with symptoms that are nonlocalizing, which may lead to delayed diagnosis. The ilium and ischium are the 2 most common bones involved, and pain in the hip, leg, and buttock are often seen. Septic hip is oftentimes considered in this setting; however, in converse to septic arthritis, movement of the hip joint is less restricted, pain is elicited with pelvic girdle rocking, and point tenderness over the affected bone is commonly seen in pelvic osteomyelitis. Evaluation Bacteremia is present in approximately 50% of cases of osteomyelitis and slightly less prominent in septic arthritis (40%). Bacteria may also be identified from bone aspirate, or synovial fluid, in 60% of infections. K kingae is a fastidious organism whose growth is enhanced by inoculation of aspiration specimens into a blood culture bottle. Polymerase chain reaction testing is also available for K kingae, with a high degree of sensitivity. Cell counts within the joint fluid should be analyzed in addition to obtaining specimens for culture. Inflammatory markers, such as C-reactive protein level and erythrocyte sedimentation rate, are elevated in greater than 90% of infections. C-reactive protein level should peak on the second day and typically normalizes after 1 week of appropriate therapy. Marrow changes related to infection appear low in signal intensity on T1 images and high on T2. Gadolinium enhancement helps delineate abscesses and soft-tissue involvement, which is especially useful in certain clinical situations when it is difficult to distinguish between type of infection on physical examination, or the presence of more than one type is suspected. Bone scan has the ability to show abnormalities in both the affected bone and joint prior to appearance on plain radiograph. Increased uptake in the metaphysis is indicative of osteomyelitis, while increased uptake on both sides of a joint indicates articular infection. The sensitivity is between 80% and 100% and most useful in the setting of suspected multifocal infection. Plain radiograph may show abnormalities such as periosteal elevation, a lytic lesion, and new bone formation in as few as 10 days into the course of infection. In the setting of articular infection, plain radiograph may reveal a widening of the joint space and displacement of fat planes surrounding the joint. Sclerosis of the bone may be seen when infection has been present for longer than 1 month. In patients who have undergone multiple previous radiographies or other radiation exposures, reducing further exposure should also be a consideration. Surgical debridement is imperative in the setting of septic hip, but arthrocentesis may be sufficient for infection in other joints. Surgical management not only aids in delineating an organism and thus optimal antimicrobial therapy but also allows for improved antimicrobial penetration into the bone or joint, and serves to hasten clinical recovery. Antimicrobial therapy should be empirically initiated to provide coverage for the typical pathogens according to age and mechanism of infection. In addition, local susceptibility patterns should be taken into consideration when choosing therapy. In the hospitalized patient, parenteral therapy is typically initiated, including anti-staphylococcal penicillins (eg, oxacillin), firstgeneration cephalosporins (eg, cefazolin), or clindamycin. All of these agents possess good bone penetration and provide good S aureus coverage. Further, in some communities the resistance rate to clindamycin is rising for both methicillin-susceptible S aureus Table 5-2. Fluoroquinolones are not recommended routinely for children with bone and joint infections but are sometimes necessary in the setting of infection related to soil-contaminated wound or sacral decubitus ulcer. Gentamicin or a thirdgeneration cephalosporin (eg, cefotaxime) should be a part of the empiric therapy regimen in neonates. Additionally, a third-generation cephalosporin should be used in the setting of N meningitidis or N gonorrhoeae articular infection. Disease caused by M tuberculosis is treated with surgical debridement when an abscess is present or stabilization surgery in the setting of spinal instability. Therapy length is not often determined at diagnosis but is determined over time involving multiple factors, including response to therapy, surgical intervention, extent of disease, specific pathogen, and chronicity of infection. The guideline further recommends 4 to 6 weeks of therapy for osteomyelitis and 3 to 4 weeks for septic arthritis in children, which may be longer if contiguous osteomyelitis is present (occurs in 75% of neonates and 30% in older children). However, 10% to 25% of children with articular infection will develop long-term sequelae, including decreased joint mobility, chronic dislocation, and avascular necrosis of the femoral head. Risk factors for development of sequelae because of septic arthritis are listed in Box 5-1. Laboratory monitoring may provide early clues of a developing adverse effect and is important for defining the duration of therapy (see Table 5-2). A subset of patients with S aureus disease from a Panton-Valentine leukocidin-producing strain are more likely to develop more severe disease and phlebothrombosis as a complication. Involvement of a hematologist is important in this setting to initiate and manage anticoagulation therapy and provide guidance regarding testing for an underlying hypercoagulable state. In addition, Panton-Valentine leukocidin-producing strains may increase the risk of developing chronic infection. Acute osteomyelitis develops into chronic infection in less than 5% of cases, and this is more often associated with non-hematogenous osteomyelitis (eg, hardware-associated infection). The patient may have a prolonged asymptomatic period followed by recrudescence of pain, edema, and sinus tract formation that does not improve, or only partially improves with prolonged antimicrobial therapy. Polymicrobial infection is often present in such cases, making surgical debridement for culture and to remove necrotic bone and tissue the key to management. Skin grafts and muscle flaps are used to enhance blood flow in some traumatic wounds and in wounds with impaired sensation (eg, decubitus ulcers). Antibiotic-impregnated beads or cement material is sometimes placed at the time of debridement to enhance antibiotic delivery to the area and promote stability of the bone. Additionally, intraarticular antibiotics have been used in the setting of infected joint prosthesis. Retrospective review of osteoarticular infections in a pediatric sickle cell age group. Specific real-time polymerase chain reaction places Kingella kingae as the most common cause of osteoarticular infections in young children. Current understanding of the pathogenesis and management of chronic recurrent multifocal osteomyelitis. Clinical practice guidelines for the Infectious Diseases Society of America for the treatment of methicillin-resistant Staphylococcus aureus infections in adults and children. A chest radiograph should be reserved for younger infants, those with respiratory distress or recurrent pneumonia, or those with failed outpatient amoxicillin therapy. If chest radiograph shows lobar infiltrate or moderate-large pleural effusion, this favors the diagnosis of bacterial pneumonia. For clinically stable, hospitalized children with pneumonia, ampicillin or a third-generation cephalosporin should be used for empiric coverage, with the addition of vancomycin in those with suspected staphylococcal pneumonia or who are seriously ill. Antiviral therapy should be used for hospitalized children with suspected influenza. Pneumonia with empyema (loculated pleural effusion) should be managed with antibiotics and pleural drainage with fibrinolysis or video-assisted thoracoscopic surgery. Overview Pneumonia is a clinical condition that results from inflammation of the lower respiratory tract and alveoli caused most commonly by respiratory viruses or bacteria. Communityacquired pneumonia may be classified on the basis of the microbiologic pathogen detected or radiographic appearance on chest radiograph. Neonates (3 Weeks) Pneumonia in neonates and young infants may be early-onset (within 7 days of life) or late-onset (after 7 days of life). Young infants with pneumonia can present with early-onset pneumonia alone or as part of the spectrum of early-onset sepsis, most commonly with group B Streptococcus, Listeria monocytogenes, and Escherichia coli following aspiration of infected amniotic fluid or genital secretions during birth. Chlamydia trachomatis, Bordetella pertussis, Mycoplasma hominis, and Ureaplasma urealyticum, as well as the bacteria causing early-onset pneumonia, should be considered in all young infants presenting after 7 days of life. Congenitally and perinatally acquired infection with herpes simplex virus, cytomegalovirus, and Treponema pallidum can cause pneumonia in young infants. Presentation is biphasic, with typical influenza-like illness that begins to resolve over several days followed by acute deterioration with the development of chest pain and new infiltrates, and bacteriologic evidence of infection. Focal outbreaks caused by M pneumoniae occur, and community-wide outbreaks have been reported to occur every 2 to 4 years. Chlamydia trachomatis, M hominis, and U urealyticum also cause pneumonia in newborns and young infants. Rare Microorganisms Causing Pediatric Community-Acquired Pneumonia or Occurring in Specialized Populations Microorganism Viruses Varicella-zoster virus Potential complication after primary chickenpox infection. Exposure to wild and domesticated herbivores or unpasteurized dairy (eg, cattle, sheep, goats). Exposure to wild and domesticated animals or unpasteurized dairy (eg, cattle, sheep, pigs, goats, deer, dogs). Leptospira interrogans Mycobacterium tuberculosis Brucella abortus Burkholderia pseudomallei 82 Succinct Pediatrics Table 6-2 (cont) Microorganism Fungi Histoplasma capsulatum Histoplasmosis. Culture of respiratory tract secretions; urinary antigen test; serum immunodiffusion antibody test; serum Histoplasma complement fixation antibody test Culture of respiratory tract secretions; serum immunodiffusion antibody test Culture of respiratory tract secretions; cryptococcal capsular antigen in serum, urinary, or bronchoalveolar lavage specimens Comment Diagnostic Methods Blastomyces dermatitidis Blastomycosis. Cryptococcus neoformans Coccidioides immitis Culture of respiratory tract Primary coccidioidomycosis (also called valley fever). Environmental secretions; serum immunoexposure to fungal spores (dry, dusty diffusion antibody test environments). Other common clinical symptoms include hypoxia, chest and abdominal pain, physical signs of tachypnea, and retraction, with auscultation findings of rales and decreased breath sounds (Table 6-3). Gradual onset, preceding nasal congestion, cough, and bilateral wheezing, is suggestive of viral pneumonia and more commonly associated with atypical bacteria than traditional bacterial infections. High temperature, rigors, and chest and abdominal pain, along with rales and bronchial breath sounds, are significantly more common on presentation in patients with bacterial or mixed infection. However, significant overlap limits the utility of these clinical signs and symptoms. A staccato-like cough in an infant older than 3 weeks is suggestive of infection with C trachomatis; conjunctivitis may be present. These complications are associated with significant morbidity (eg, prolonged hospital stay, intensive care unit admission) but infrequent mortality. Effusions and empyema are associated with significant morbidity and some mortality. This progression results in empyema, defined as the presence of grossly purulent fluid in the pleural cavity or positive bacterial culture of pleural fluid. Incidence of parapneumonic effusion and empyema increased in the United States coincident with the widespread use of pneumococcal 7-valent conjugate vaccine, but has decreased since the transition to the pneumococcal 13-valent conjugate vaccine. Because of prior antibiotic therapy before pleural fluid drainage, a pathogen is detected by blood or pleural fluid culture in less than 30% of cases. Overall, S pneumoniae remains the most common cause of empyema and accounts for much of the increase in the burden of empyema. Fluid in the pleural cavity can be identified by a chest radiograph (blunting of the costophrenic angle), ultrasound, or computer tomography, as described next. Reasons for this difficulty include scarcity of samples obtained from the lower respiratory tract, antibiotic therapy before presentation, and lack of sensitive diagnostic methods that distinguish between colonizing respiratory viruses and bacteria and those responsible for the illness. Respiratory Viral Pathogens Antigen detection testing of respiratory specimens is quick and useful in some clinical settings. Sputa with 10 or fewer epithelial cells and 25 or more polymorphonuclear leukocytes under low power are considered to be appropriate for culture. Measurements of serologic responses to M pneumoniae and C pneumoniae are available. Polymerase chain reaction testing for M pneumoniae and C pneumoniae in respiratory specimens is more sensitive. Antigen testing of urine for pneumococcal antigen has been useful in detecting pneumococcal pneumonia in adults. Pleural Fluid Evaluation Pleural fluid, when present, should be submitted for Gram stain and bacterial culture to identify likely bacteria commonly responsible for parapneumonic effusion and empyema. Anemia or thrombocytopenia may raise suspicions for hemolytic uremic syndrome, which may occur with pneumococcal pneumonia. Although procalcitonin concentration is consistently higher in children with bacterial pneumonia, moderate elevations do not distinguish nonserious bacterial from viral pneumonia in children. A supine anteroposterior chest view (young children) or upright posteroanterior chest view (>4 years) is recommended.

Mike brings pill bottles for furosemide symptoms definition purchase antabuse toronto, which Jeff has prescribed himself medicine 7253 buy antabuse in united states online, even though he has no medical conditions that would require this therapy 7r medications purchase antabuse 250mg free shipping. A 24-year-old female graduate student is brought to you by her parents for evaluation treatment 7 february purchase antabuse toronto. They are concerned that she has "anorexia symptoms ruptured ovarian cyst cheap antabuse 500 mg on line," and they request your opinion on further management symptoms your having a girl cheap 250mg antabuse amex. After obtaining a history with the parents present, you ask them to leave the room to obtain a history from the patient herself. In discussing her eating habits, she typically eats 1600 kcal/day; however, during periods of the spring and summer, she will limit herself to 1000 kcal/day for a few months. Since she enrolled in college at age 18, she would go to a different fast food chain and eat over 2500 kcal at a time at least twice a week. After doing so, she feels ashamed and employs an over-the-counter laxative to help prevent weight gain. You ask what she thinks of her weight, and she confesses she feels "chubby" and far too overweight for her personal goals. A 52-year-old man presents 3 years after Roux-en-Y gastric bypass surgery to your office for a continuity visit. His body mass index has gone from 41 kg/m2 to 28 kg/ m2, and he reports feeling quite well. He incidentally jokes that "this whole surgery has aged me," noting a rapid progression of graying hair on his scalp and mild memory problems as well as "losing half a step on the tennis court. A 32-year-old woman with a body mass index of 40 kg/ m2 and no other past medical or surgical history comes to you for advice about whether to pursue gastric bypass for weight loss. In discussing the risks and benefits, you attempt to counsel the patient on how much weight loss to expect. Which of the follow most accurately reflects how much weight the patient could be expected to lose A 29-year-old man presents to the emergency department 3 weeks after Roux-en-Y bypass surgery with hematemesis. In addition to executing an endoscopic intervention to stop the bleeding, what discharge medications would be best to recommend for treatment of his ulcer She has had intermittent, epigastric abdominal pain that has gradually become more frequent and more intense over the past few months. You decide to perform an esophagogastroduodenoscopy, and during your exam you find a surgical suture with a small (5 mm), white-based ulcer approximating it. Jeff, a 32-year-old male cardiologist, is brought to you by Mike, his brother, for evaluation. Jeff was a male model in his late teens and early 20s, and Mike describes Jeff as "always in shape, almost obsessive about how he looks and how much he weighs. A Dobhoff tube was placed, and the patient has been receiving enteral feeding at a rate of 2200 kcal/day. Which of the following lab values would have been most important to closely monitor for prevention of this condition A 45-year-old woman with a body mass index of 32 kg/ m2 comes to your office for evaluation of obesity. She is very distressed about her weight, and she wants to discuss options for bariatric surgery. Upon taking a careful history, you note that she has tried caloric restriction diets numerous times over the past 10 years, but they have all been unsuccessful. When tracking food diaries over the past few months, you note meticulous counts of caloric intake revealing multiple days during the week in which she has ingested well over 2500 kcal/day. The next day she would "punish" herself at the gym by working out for twice as long, even doing so if injured. She drinks caffeinated beverages to manage her appetite, and for a time, even tried smoking cigarettes. A 19-year-old male student is referred to your clinic from his university health center for multiple episodes of pruritus, mild swelling of the lips, and sensation of throat swelling after eating certain fruits. You take a detailed history and realize that in each of the episodes, his symptoms started within 2 minutes of ingesting fruits (in particular watermelon, honeydew, or cantaloupe) and then completely resolved within 30 minutes. He may also become symptomatic after eating certain cooked fruits or vegetables C. A 6-week-old infant is being evaluated for presence of small amount of blood in his stool noted in the last 2 weeks. An 11-month-old infant has been evaluated by pediatric gastroenterology service for vomiting, failure to thrive, and generalized edema. Upper endoscopy with biopsy was performed, which showed prominent eosinophilic infiltration in the stomach and small bowel. Which of the following statements is correct regarding the underlying disorder in this infant It has a particular value in the assessment and management of nutritional status in patients with cirrhosis or severe alcoholic hepatitis. Fist-grip dynamometry uses maximal handgrip strength as a surrogate of total body protein. It has shown considerable promise for rapid and convenient assessment of protein-calorie status in both inpatients and outpatients, but its use is limited in patients with altered mental status or encephalopathy. Although it is an excellent tool for assessment of total skeletal muscle mass, glucocorticoid administration can alter this index independently of muscle mass. The serum levels of prealbumin, transferrin, or retinol-binding protein are used as indicators of nutritional status; however, all these proteins act as negative acute-phase reactants, and their synthesis by the liver drops in the acutely ill patient with severe alcoholic hepatitis. C (S&F ch5) Chronic proton pump inhibitors use can potentially impair B12 absorption by causing small intestinal bacterial overgrowth or decreased gastric acid/pepsin secretion. Cholestyramine can adsorb folate and vitamin D in the small bowel and decrease their absorption. Less commonly reported abnormalities include elevated plasma free fatty acid concentrations, neuropathy, or encephalopathy. Copper, selenium, or molybdenum deficiency can also occur in patients on long-term total parenteral nutrition lacking these trace minerals. Clinical features of copper deficiency include dermatologic abnormalities (skin or hair depigmentation), hematologic disorders (leukopenia or microcytic anemia), neurologic disturbances, and skeletal abnormalities. The anemia is secondary to impaired uptake of iron and therefore iron deficiency anemia. Molybdenum deficiency may result in hyperoxypurinemia, hypouricemia, and central nervous system disturbances. On the other hand, there are reports of manganese toxicity from total parenteral nutrition causing deposition of the mineral in the basal ganglia that resulted in extrapyramidal symptoms or seizures. A (S&F ch5) Chronic vitamin A toxicity may manifest as alopecia, bone and muscle pain, dermatitis, cheilitis, conjunctivitis, pseudotumor cerebri (headache and nausea), ataxia, transaminitis, hyperlipidemia, and hyperostosis. However, habitual daily intake of large dose of vitamin B6 may cause photosensitivity or peripheral neuropathy. Moreover, in theory, acidification of urine with high doses of vitamin C may increase the risk of oxalate nephrolithiasis. Toxicity with vitamin D can give rise to very high serum concentrations of calcium and phosphate with metastatic calcifications, kidney injury, and altered mental status. D (S&F, ch6) Enteric nutrition is generally preferred over parenteral nutrition in critically ill patients; however, in this particular case with high demand of vasopressor agents and hemodynamic instability from septic shock and peritonitis, small bowel feeding is not feasible. On the other hand, in previously healthy individuals without evidence of malnutrition, parenteral nutrition should be started after 7 days of hospitalization. Moreover, in all critically ill individuals who are on total parenteral nutrition, permissive underfeeding with provision of 80% of caloric requirement (25 kcal/kg actual body weight) at the beginning is recommended to reduce the incidence of hyperglycemia and infection and also shorten the length of mechanical ventilation or hospital stay. C (S&F ch6) Enteric nutrition has been proved to be an important part of inflammatory bowel disease therapy. B (S&F ch5) Zinc depletion is a particularly important issue to remember in patients with chronic diarrhea or fistula in inflammatory bowel disease. Dysgeusia (impaired taste), alopecia, glossitis, dermatitis on the extremities, and loss of dark adaptation are commonly seen in marked zinc deficiency. Plasma or other body fluid zinc levels are not accurate indicators of zinc status because it can shift from serum into the liver in acute illness. For this reason, it is usually recommended to proceed with zinc supplementation in patients with high risk of zinc deficiency based on the clinical scenario. Copper or niacin deficiency is not completely consistent with the clinical scenario mentioned in the question. Although copper deficiency can be seen in individuals on longterm total parenteral nutrition without copper, it usually manifests with skin or hair depigmentation, leukopenia, microcytic anemia, and neurologic abnormalities. Niacin deficiency (pellagra) is often seen in carcinoid syndrome or individuals in which corn is the major source of nutrition. Measurement of urinary excretion of the niacin metabolites is the most reliable tests of assessment. A (S&F ch5) Based on the history of heavy alcohol use, steatorrhea, and hyperglycemia, the patient has developed chronic pancreatitis with possible malabsorption of fat-soluble vitamins (A, D, E, and K vitamins). This patient shows manifestations of vitamin E deficiency, including hemolytic anemia and neurologic abnormalities from posterior column spinal disease or peripheral neuropathy. Serum levels of -tocopherol (the most biologically active form of vitamin E) is used to measure vitamin E status. Although it is water soluble, vitamin B12 deficiency is also seen in pancreatic insufficiency (secondary to lack of pancreatic proteases to free cobalamin from R protein in the proximal small bowel). It takes several years to deplete the entire B12 storage in the liver, and this patient has shown clinical signs of pancreatic insufficiency only in the past year. On the other hand, anemia from B12 deficiency is characteristically megaloblastic with macrocytosis and hypersegmented neutrophils (not hemolytic anemia). Neurologic diseases like posterior column spinal disease is also seen in B12 deficiency. Clinical features of vitamin A deficiency include follicular hyperkeratosis and night blindness in the early stages. Conjunctival xerosis (dryness), degeneration of the cornea (keratomalacia), and blindness are seen in late stage of severe deficiency. Riboflavin (vitamin B2) and pyridoxine (vitamin B6) are water-soluble vitamins and are not part of the pancreatic insufficiency syndrome. Deficiency of riboflavin may result in angular stomatitis, glossitis, cheilosis, seborrheic dermatitis, and normocytic anemia. Vitamin B6 deficiency may produce angular cheilosis, stomatitis, glossitis, depression, irritability, and confusion in moderate depletion and normochromic, normocytic anemia in severe cases. After 3 weeks and after 1 year of treatment, 60% to 71% and 42% to 56%, respectively, of patients will be in remission and will remain in remission with either therapy. Jejunal feeding tubes should never be checked for residual content as it has poor correlation with actual residual content in the small bowel. More importantly, these are small-bore tubes and aspirating the residuals through them increases the chance of clogging. Nasoenteric tubes should be flushed after every use, including feeding or medication instillation. To minimize the risk of tube clogging, only liquid or completely dissolved medications should be placed in the tube. Due to potential longterm complications of nasoenteric tubes, including nasal mucosal ulcerations, pharyngitis, sinusitis, tube migration, or obstruction, they are indicated to be used for less than 1 month and more permanent access like jejunostomy or gastrojejunostomy may need to be considered in this patient with gastroparesis if he tolerates post-pyloric feeding. B (S&F ch6) this patient has been experiencing the symptoms of early dumping syndrome in the last 2 weeks. The likely cause of developing dumping syndrome is migration of the feeding tube into the duodenum and bolus delivery of the moderately hyperosmolar tube feed in the small bowel. The picture shows migrated gastrostomy tube with only short segment of the tube visible and external bumper against the abdominal wall. Migration of the gastrostomy tube can also cause gastric outlet obstruction; however, the symptoms that this patient has been experiencing are not consistent with obstruction. Buried bumper syndrome is a consequence of excessive pressure between internal and external bumpers of the tube and occurs when the internal bumper slowly erodes into the gastric mucosa. Its manifestations include peristomal inflammation, inability to rotate or mobilize the tube, leakage, or pain with enteral feeding. Colocutaneous fistula usually manifests after the original tube is removed and a replacement gastrostomy tube is passed through the tract into a part of colon that has been interpositioned between the stomach and the wall of the abdomen. These cases present with diarrhea and malnutrition secondary to delivery of the tube feeds straight into the colon. E (S&F ch6) Measures to reduce the risk of aspiration include converting bolus feedings to continuous infusion, keeping the head of the bed elevated 30 to 45 degrees, administering prokinetics (metoclopramide or erythromycin) or narcotic antagonists (naloxone or alvimopan), and changing to post-pyloric feeding. Unless there are obvious signs of intolerance, tube feeding should not be withheld for gastric residual volumes less than 500 mL. Based on available data, tube feeding via gastrostomy tube can be initiated within 2 hours of placement in adults. E (S&F ch6) Vitamin A deficiency can be seen in cirrhosis and has been shown to be a risk factor for hepatocellular carcinoma. It has been found that diet with a normal protein intake does not worsen hepatic encephalopathy and limiting protein intake can lead to protein-calorie malnutrition in this group of individuals with increased protein needs. Branched-chain amino acids (leucine, isoleucine, and valine) are not metabolized in the liver and could be used in patients with "liver failure. However, due to their high cost and poor tastiness, they are not routinely recommended. Hypomagnesemia (not hypermagnesemia) could be seen in this cirrhotic patient on diuretics and potentially could be associated with dysgeusia (alteration in the sense of taste). A (S&F ch6) In patients with short bowel syndrome who only have a limited length of ileum remaining and an intact colon, bile-binding resins like cholestyramine, can cause relative bile salt deficiency and fat malabsorption, which will lead to worsening of the diarrhea. Fat restriction in the oral diet may be useful in these patients for reducing the diarrhea.

Guidelines for treatment of infective endocarditis do not address treatment of disease caused by C diphtheriae medications reactions order cheapest antabuse. Experts generally recommend 4 to 6 weeks of therapy with a -lactam antibiotic medicine 773 order discount antabuse, such as penicillin or ceftriaxone medications causing hyponatremia 500mg antabuse with amex. Close contacts of those with suspected diphtheria symptoms 11 dpo order 250mg antabuse overnight delivery, especially household members and those who have been exposed to oral secretions treatment bursitis generic 500mg antabuse overnight delivery, should be screened for nasal and pharyngeal carriage and treated prophylactically with either a 10-day course of oral erythromycin or a single intramuscular dose of benzathine G penicillin (600 7 medications that can cause incontinence antabuse 250 mg lowest price,000 U for children <30. Intramuscular penicillin is preferred when surveillance of close contacts cannot be performed. Those proven to be carriers should undergo follow-up testing to document eradication of the organism. Persistent recovery of C diphtheriae mandates an additional 10-day course of erythromycin and repeat cultures. Five doses of diphtheria and tetanus toxoids and acellular pertussis vaccine are recommended for children 2 months to 6 years of age. As long as the fourth dose is administered before the fourth birthday, a fifth dose is recommended at 4 to 6 years. More than 95% of infants develop protective antibody against diphtheria after 4 doses of vaccine, and clinical efficacy is estimated at 97%. A single dose of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis is recommended at age 11 to 12 years, with booster doses of tetanus and diphtheria toxoids given every 10 years thereafter. All suspected and proven cases of respiratory diphtheria should be promptly reported to public health authorities. Cutaneous diphtheria associated with non-toxigenic strains of C diphtheriae is no longer a reportable disease in the United States. Hospitalized patients with diphtheria should be treated with standard and droplet precautions until 2 cultures collected from the nose and throat 24 hours after completion of antimicrobial therapy are negative for C diphtheriae. Contact precautions are recommended for patients with cutaneous diphtheria until 2 cultures obtained from the skin lesion are negative. Cultures should be obtained 24 hours apart beginning 24 hours after completion of antimicrobial therapy. Human clinical isolates of Corynebacterium diphtheriae and Corynebacterium ulcerans collected in Canada from 1999 to 2003 but not fitting reporting criteria for cases of diphtheria. Laboratory guidelines for the diagnosis of infections caused by Corynebacterium diphtheriae and C ulcerans. Corynebacterium diphtheriae endocarditis: a case series and review of the treatment approach. Risk factors for diphtheria: a prospective casecontrol study in the Republic of Georgia, 1995-1996. Screening for Corynebacterium diphtheriae and Corynebacterium ulcerans in patients with upper respiratory tract infections, 20072008: a multicentre European study. Suppurative complications, including peritonsillar or retropharyngeal abscess, otitis media, mastoiditis, sinusitis, and suppurative adenitis, may complicate upper respiratory tract infection. Antibiotic therapy not only treats focal sites of infection but also is effective to prevent acute rheumatic fever and may be beneficial in preventing secondary spread of nephritogenic strains causing acute glomerulonephritis. Pharyngitis is the most common manifestation of streptococcal infection in the school-aged child, and is the only commonly occurring cause of bacterial pharyngitis for which therapy is indicated. In the young child (ie, <3 years), streptococcal pharyngitis is rare (Evidence Level I). However, streptococcosis, a respiratory tract infection characterized by serous rhinitis, fever, anorexia, and irritability, may occur in this age group. Although pharyngitis is the most common presentation of streptococcal infection, much overlap exists between streptococcal pharyngitis and pharyngitis from alternate etiologies, including other bacterial and viral agents (Table 13-1). Group C Streptococcus is an endemic bacterium and thought to be a frequent cause of pharyngitis in college-aged individuals and adults. Fusobacterium necrophorum is a well-described but uncommon cause of bacterial pharyngeal infection, usually in adolescents, and may be complicated by metastatic foci resulting from associated suppurative jugular vein thrombophlebitis (so-called Lemierre syndrome). Group A Streptococcus may also cause invasive infection, including bacteremia, pneumonia, skin and soft-tissue infection, and bone and joint infection (Box 13-1). Similarly, necrotizing fasciitis may be caused by Clostridium species, mixed enteric gram-negative and anaerobic organisms, S aureus, and other Streptococcus species. In patients with pre-existing renal disease, a greater than twofold elevation over the baseline level. In patients with pre-existing liver disease, a greater than twofold increase over the baseline level. The specification of the 48 hour time constraint was for purposes of assessing whether the case was considered nosocomial, not whether it was a case or not. Presence of viral signs or symptoms effectively rules out streptococcal pharyngitis, obviating the need for testing. Peritonsillar abscess (ie, quinsy) and retropharyngeal abscess are suppurative sequelae of streptococcal pharyngitis that typically occur in the older child and adolescent. Peritonsillar abscess is characterized by fever, severe sore throat and odynophagia with peritonsillar swelling, uvular deviation to the contralateral side, muffled voice, trismus, drooling, and cervical lymphadenopathy. Acute otitis media and mastoiditis are typically seen in children younger than 5 years, and are similar in appearance to these infections caused by other organisms with fever, otalgia, abnormal findings on otoscopy, and posterior auricular swelling along with erythema and pain in the setting of mastoiditis. Streptococcosis is also seen in the toddler age group and manifests as serous rhinorrhea with nasal excoriations followed by fever, malaise, and anorexia. Skin and soft-tissue infections, including pyoderma, cellulitis, wound infections, and myositis, are similar in appearance to infections caused by S aureus and may occur at any age from birth (eg, omphalitis) through adulthood. Clinical signs and symptoms include erythema, warmth and tenderness of the site, and possible fluctuance in the setting of abscess formation. Erysipelas has a distinct appearance, however, with an edematous plaque and slightly raised, well-demarcated borders because of lymphatic involvement compared with cellulitis caused by S aureus. Streptococcal perianal cellulitis 148 Succinct Pediatrics peaks at 3 to 5 years of age and is characterized by superficial, well-demarcated erythema around the anus and surrounding skin. Vulvar, vaginal, and penile involvement with erythema and discharge may occur in prepubertal girls and boys, respectively. Bone and joint infections are similar in presentation to infections caused by other organisms and include erythema, edema, warmth, pain, and refusal to use the affected limb. Fasciitis is a clinical emergency but oftentimes difficult to recognize early in the course because patients may appear relatively well at presentation. The hallmark of this infection is patient-reported pain that is out of proportion to findings on examination. Edema and induration of the affected area may be seen in the first 24 hours followed by rapid blistering and bleb formation with subsequent tissue necrosis. Most notable are viral pathogens such as adenovirus, Epstein-Barr virus, and influenza. Several clinical scoring systems have been developed to predict the likelihood of streptococcal pharyngitis in children and adults with sore throat. They are based on clinical findings including fever, tonsillar swelling or exudate, enlarged and tender cervical lymphadenopathy, and absence of cough and other viral symptoms. In addition, age is included in some systems, providing 1 point to those between 3 and 15 years of age. Clinical signs and symptoms alone are inadequate in determining infection, and a scoring system should be used only to determine whether testing is indicated or not (Evidence Level I). Testing for streptococcal pharyngitis is not routinely indicated in children younger than 3 years because of the rarity of acute rheumatic fever in this age group, absence of classic symptomatology, and low incidence of streptococcal pharyngitis overall (Evidence Level I). Selective testing of those in whom clinical and epidemiologic features are consistent with infection is thus important in making the correct diagnosis. Testing patients with clear viral symptoms or lack of features consistent with streptococcal pharyngitis results in unnecessary antibiotic use, contributing to adverse drug events and rising resistance rates in some antimicrobials (Evidence Level I). Culture results of focal sites of infection such as pleural fluid or wound are often positive as well and remain positive for several days after effective therapy has been initiated. Diagnostic studies are generally not indicated in the presence of high clinical suspicion of necrotizing fasciitis. This disease process is a surgical emergency, and irrigation and debridement should not be delayed to obtain radiologic imaging (Evidence Level I). In this setting, tissue should be sent for culture and pathologist review, which is key to defining the etiologic agent and demonstrating the extent of disease. A rise in antibody titers to streptolysin O, deoxyribonuclease B, and other streptococcal enzymes may be seen 3 to 6 weeks after acute infection. While these serve as useful aids in the diagnosis of nonsuppurative sequelae such as rheumatic fever and glomerulonephritis, they are not of diagnostic benefit during acute infection (Evidence Level I). Duration of treatment depends on the clinical syndrome with 10 days being the typical course for bacterial eradication. Prompt treatment is important for decreasing disease transmission and individual morbidity and preventing suppurative and nonsuppurative sequelae. Patients with penicillin allergy without a history of anaphylaxis may receive a narrow spectrum (first-generation) cephalosporin for 10 days (Evidence Level I). Intramuscular penicillin may be used for the child in whom adherence to therapy is of concern. Long-acting penicillin G benzathine is effective but 150 Succinct Pediatrics Table 13-3. Clindamycin is a reasonable alternative in patients with immediate or type I hypersensitivity to penicillin (Evidence Level I). Macrolides such as azithromycin for 5 days or clarithromycin for a 10-day course are also alternatives (Evidence Level I). Hemodynamic monitoring and fluid resuscitation along with surgical intervention should not be delayed for radiologic testing. Nonsuppurative sequelae primarily include acute rheumatic fever and glomerulonephritis. Acute rheumatic fever is rare (<3: 100,000 population) and follows untreated pharyngeal infection. The true incidence of glomerulonephritis is unknown, but it is the most common cause of nephritis and acute renal insufficiency in preschool- and school-aged children that may follow either pharyngeal or skin infection. Poststreptococcal arthritis was originally described in patients with arthritis following streptococcal pharyngeal infection without concomitant carditis. It occurs in a bimodal age distribution and is thought to be increasing in prevalence, while acute rheumatic fever has decreased in developed countries. The prognosis for acute glomerulonephritis is quite good, with greater than 95% recovering fully without sequelae. Less than 5% may continue to have abnormalities on urinalysis for up to 15 years after the acute period. Antibiotic therapy may eliminate the nephrogenic strain, but does not alter the clinical course of disease in acute glomerulonephritis. Treatment largely consists of supportive measures because anti-inflammatory medications have not been shown to hasten recovery. Poststreptococcal reactive arthritis manifests as a nonmigratory polyarthritis that is not improved by use of nonsteroidal medications. The arthritis can occur in any joint, persist for several months, and be recurrent. Some experts advocate penicillin prophylaxis for 3 to 12 months in the setting of poststreptococcal arthritis with monitoring for development of valvular heart disease for several months. If carditis develops, a diagnosis of acute rheumatic fever should be made and prophylaxis should be continued. Prevention of rheumatic fever and diagnosis and treatment of acute streptococcal pharyngitis. Empirical validation of guidelines for the management of pharyngitis in children and adults. Accuracy and precision of the signs and symptoms of streptococcal pharyngitis in children: a systematic review. Clinical practice guidelines for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. The use of intrapartum antibiotic prophylaxis has resulted in an 80% reduction in early-onset infection but has not appreciably changed the incidence of late-onset infection. Cultures of blood, cerebrospinal fluid, and any other focal site of infection are recommended to establish the diagnosis. Ampicillin plus gentamicin remains the combination of choice for empiric treatment of presumptive invasive group B streptococcal infection. The combination of ampicillin and cefotaxime should be considered in empiric treatment of life-threatening early-onset infection (to cover potential of ampicillin-resistant gram-negative agents) or if meningitis is suggested by cerebrospinal fluid evaluation. Severe neurologic sequelae are reported in approximately 20% with meningitis; only 51% demonstrate normal age-appropriate development. Vertical transmission occurs by ascending route following rupture of membranes or contact with the organism in the birth canal during childbirth. After delivery, person-to-person transmission can occur in the nursery or from colonized family members.

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