Practice Guidelines
IDSA Releases Guidelines on Travel Medicine
Guideline source: Infectious Diseases Society of America
Literature search described? No
Evidence rating system used? Yes
Published source: Clinical Infectious Diseases, December 15, 2006
Available at: http://www.journals.uchicago.edu/IDSA/guidelines/
Travel medicine is a multidisciplinary field focusing on prevention of infectious diseases and patient safety during international travel. Family physicians may advise travelers who are in good health and who are visiting low-risk destinations; however, physicians trained in travel medicine should advise high-risk travelers.
Although further research is needed, travel medicine standards are increasingly based on evidence and do not rely solely on expert opinion. The Infectious Diseases Society of America (IDSA) has released recommendations based on this evidence, expert opinion, and clinical experience.
Pretravel Care
The key element of the pretravel physician's visit is a health risk assessment. After completion of a risk assessment, patients should receive travel education and advice. To ensure consistent care, it is helpful to meet with family members at the same time and to give a group presentation to travel organizations (e.g., missionary, corporate, student, and tour groups); individual appointments should follow.
risk assessment
The pretravel risk assessment should include a determination of the traveler's current health status and health risks based on the specific travel itinerary (e.g., destination, mode of travel, planned activities). Information on destination-specific health risks is available at http://www.cdc.gov/travel/.
Standardized medical records, including patient demographics, travel details, clinical and immunization histories, medications prescribed before travel, and advice given, should be maintained for travelers. It is also important to document when patients decline prophylactic treatment. These records can be used in the pre- and posttravel evaluations.
pretravel education
All travelers should receive education about risk avoidance; topics include vaccine-preventable illnesses, avoidance of insects, malaria chemoprophylaxis, prevention and self-treatment of traveler's diarrhea, personal safety, travel and evacuation insurance, and access to medical care during travel. Further education should be tailored to the traveler and itinerary.
Written materials are important to reinforce and give further details about verbal advice. Physicians should also provide Web-based resources (e.g., http://www.cdc.gov/travel, http://www.who.int/ith/en/). Some practices maintain a database of country-specific health information from which they can print information for patients.
Immunization
Travelers should be educated about updating routine vaccinations such as tetanus, pertussis, diphtheria, Haemophilus influenzae type b, measles, mumps, rubella, varicella, and Streptococcus pneumoniae. Vaccinations such as hepatitis A and B, poliomyelitis, and Neisseria meningitidis also may be recommended to patients. Travelers are not at risk of many diseases if their vaccinations are up to date. If a vaccination history cannot be obtained, these patients should be considered susceptible, and appropriate vaccinations should be initiated.
Other vaccinations (e.g., yellow fever, Japanese B encephalitis, rabies, tick-borne encephalitis, typhoid fever, meningococcal disease) should be recommended based on travel destination and patient risk. Accepted vaccine standards and schedules should be used. Special consideration should be given to young children, pregnant women, and persons with special health needs (e.g., diabetes; chronic renal, cardiac, or pulmonary disease; immunodeficiency). Table 1 presents an overview of travel vaccinations.
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Table 1. Vaccination Indications for Travelers |
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Vaccine |
Indication* |
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DTaP (Tripedia) |
Children seven years and younger |
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Haemophilus influenzae type b (Acthib) |
Children five years and younger |
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Hepatitis A (Havrix) |
Travelers to developing countries; children 12 months and older; persons with clotting disorders or chronic liver disease; men who have sex with men; some persons may benefit from prevaccine hepatitis A antibody testing |
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Hepatitis B (Recombivax HB) |
Health care workers who come in contact with blood; persons at risk of coming in contact with blood, body fluids, or blood-contaminated medical or dental instruments; persons residing in areas of intermediate to high endemicity for hepatitis B |
|
Hepatitis A and B antigens, |
Travelers 18 years and older who are at risk of hepatitis A and B; at least two doses of vaccine should be given before departure to protect against hepatitis A |
|
Immunoglobulin |
For prevention of hepatitis A; some travelers may benefit from pretravel hepatitis A antibody testing |
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Influenza (Fluarix) |
High-risk persons six months and older; persons with chronic diseases; healthy adults 50 years and older; healthy children six to 23 months of age; health care workers; at-risk travelers; pregnant women in the second or third trimester during influenza season; others who want vaccination |
|
Influenza (Flumist) |
Alternative to inactivated vaccine; for patients five to 49 years of age; international travelers |
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Japanese B encephalitis (Je-Vax) |
Travelers to area of risk with rural exposure or prolonged residence |
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Measles (Attenuvax) |
Persons born after 1956 who have not had documented measles or two doses of live vaccine |
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Meningococcal conjugate |
As with meningococcal polysaccharide; children 11 or 12 years of age; 15-year-olds not previously vaccinated |
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Meningococcal polysaccharide (Menomune) |
Travelers to areas with epidemic meningococcal disease; religious pilgrims to Saudi Arabia; college freshmen; microbiologists exposed to Neisseria meningitidis; patients with asplenia or certain complement-deficiency conditions |
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Mumps (Mumpsvax) |
Persons born after 1956 who have not had documented mumps or mumps vaccine |
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Pneumococcal conjugate (Prevnar) |
Children two to 23 months of age; at-risk children 24 to 59 months of age |
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Pneumococcal polysaccharide (Pneumovax) |
Persons five years and older who are at increased risk of pneumococcal disease and its complications; healthy adults 65 years and older |
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Poliomyelitis (Ipol) |
Only formulation of polio vaccine used in United States; for travelers to countries where polio is endemic |
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Rabies (Rabavert) |
Itineraries and activities that place the traveler at risk of rabies; dogs are the primary threat in developing regions; for health care workers in areas where rabies is endemic |
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Rotavirus (Rota Teq) |
Infants |
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Rubella (Meruvax II) |
Persons, particularly women of childbearing age, who have not had documented illness or live vaccine on or after their first birthday |
|
Tdap (Boostrix for patients 10 to |
Persons 11 to 64 years of age who need boosting for any of the three antigens |
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Tetanus-diphtheria (Deca Vac) |
Persons seven years and older |
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Typhoid (Typhim) |
Persons at risk of exposure to typhoid fever |
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Typhoid (Vivotif Berna) |
Children six years and older at risk of exposure to typhoid fever |
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Varicella (Varivax) |
Patients 12 months and older who have not had varicella |
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Yellow fever (YF-Vax) |
As required by individual countries; for travelers to regions where yellow fever is endemic |
| Tdap = tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis; DTaP = diphtheria and tetanus toxoids and acellular pertussis. *- Accepted vaccine standards and schedules should be used. Vaccine manufacturer's full prescribing information, precautions, and contraindications should be considered. Information from Hill DR, Ericsson CD, Pearson RD, Keystone JS, Freedman DO, Kozarsky PE, et al. The practice of travel medicine: guidelines by the Infectious Diseases Society of America. Clin Infect Dis 1006;43:11-3 and http://www.clinicalpharmacology.com. |
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Traveler's Diarrhea
Traveler's diarrhea, caused by bacterial enteropathogens, viruses, or parasites, is the most common illness among persons traveling from developed to underdeveloped countries. The illness is characterized by three or more loose stools during a 24-hour period that are accompanied by an enteric symptom (e.g., fever, nausea, vomiting, abdominal cramps); tenesmus and bloody stools are uncommon. Management should include education about prevention (e.g., proper food precautions, hygiene) and self-treatment strategies.
prevention
Travelers should try to eat at restaurants that have a reputation for food safety. Fruits and vegetables peeled by the traveler, dry foods, and foods that are piping hot and thoroughly cooked are generally safe for travelers. The following should be avoided: tap water, ice cubes, fruit juice, fresh salads, unpasteurized dairy products, cold sauces and toppings, open buffets, and undercooked or reheated foods.
There is no vaccine for general traveler's diarrhea. Routine chemoprophylaxis for traveler's diarrhea is not recommended; however, it may be considered in healthy travelers for whom wellness is critical (e.g., some athletes) and in travelers at increased risk of severe illness or complications. When chemoprophylaxis is initiated, fluoroquinolone antibiotics are considered first-line agents, and the regimen should be limited to two to three weeks.
treatment
Self-treatment is the recommended management strategy for traveler's diarrhea. This includes hydration, symptom management, and short-course antibiotic therapy.
Although traveler's diarrhea does not usually cause dehydration in adults, patients should increase their fluid intake as needed. Young children with dehydration should drink fluids prepared with oral rehydration salts, which can be obtained over the counter throughout the world.
Loperamide (Imodium) is the first-line antimotile agent. Although bismuth subsalicylate (Pepto-Bismol) reduces loose stool episodes by about one half, loperamide has been shown to be more effective with a shorter onset of action. Loperamide is not recommended in patients with gross blood in the stool or a temperature more than 101.3ºF (38.5ºC) or in young children. Kaolin pectin absorbents and probiotics (e.g., Lactobacillus species) provide little or no relief.
Diarrhea may improve rapidly with a combination of loperamide and antibiotic therapy. Antibiotics can reduce the illness duration by one to several days, although some antibiotics are no longer recommended because of increased resistance. Fluoroquinolones are first-line agents for the treatment of traveler's diarrhea. Azithromycin (Zithromax) is an alternative to fluoroquinolones, especially in areas of fluoroquinolone resistance. Rifaximin (Xifaxan) is an option for patients with afebrile, nondysenteric diarrhea. Patients should seek medical attention if symptoms do not improve after 48 hours despite combination therapy.
Malaria
The best prevention and treatment methods for malaria, one of the most severe infectious diseases among travelers, include risk awareness, avoidance of mosquito bites, chemoprophylaxis, and prompt diagnosis in the event of febrile illness during or after travel. A careful risk assessment should be made based on itinerary, species of malaria present at the travel destination, season, duration of travel, and access to medical care.
Travelers to areas in which malaria is endemic should be advised on how to avoid mosquito bites. Precautions include sleeping under netting that is treated with insecticide, staying in screened or well air-conditioned rooms, wearing clothing that reduces the amount of exposed skin, and using insect repellant that contains N,N-diethyl-m-toluamide. Mosquito coils and vaporizing mats may also be helpful in enclosed areas.
Chemoprophylaxis decisions should be made after balancing the possible adverse effects of the treatment with the patient's risk of acquiring malaria and whether the patient will have access to reliable medical care while traveling. Although chloroquine (Aralen) is effective for the prevention of malaria in travelers to Central America, the Dominican Republic, and much of the Middle East, alternative medications should be used in travelers to areas where resistant Plasmodium strains are common.
Patient Personal Safety
All travelers should be aware of personal safety during travel (e.g., road and pedestrian safety; avoidance of animal bites; understanding of the effects of climate and altitude; awareness of risks such as assault, infections, and excessive alcohol use). The risk of motion sickness, jet lag, and deep venous thrombosis from long flights also should be discussed.
Posttravel Care
Patients should be educated about symptoms of major travel diseases and should receive medical care or referral after travel, if needed. Physicians who are not trained to recognize key travel-related illnesses should have preestablished subspecialists for referral.
The most common conditions seen in returning travelers are diarrhea, respiratory tract illness, skin conditions, and fever. Although many bacterial and viral infections will present while the traveler is abroad or soon after his or her return, diseases with longer incubation periods (e.g., giardiasis, amebiases, viral hepatitis, malaria, tuberculoses) may present weeks or months after the traveler returns. General and disease-specific testing is usually needed to diagnose illness after travel. Patients with fever need immediate medical attention because of the risk of malaria or other serious illness.
Practice Guideline Briefs
CDC Changes Treatment Guidelines for Gonorrhea
Guideline source: Centers for Disease Control and Prevention
Literature search described? No
Evidence rating system used? No
Published source: Morbidity and Mortality Weekly Report, April 13, 2007
Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5614a3.htm
Fluoroquinolone antibiotics are no longer recommended for treatment of gonococcal infections and associated conditions such as pelvic inflammatory disease, according to revised guidelines from the Centers for Disease Control and Prevention (CDC). Consequently, cephalosporins are the only class of drugs that is still recommended and available for the treatment of gonorrhea.
Fluoroquinolones (i.e., ciprofloxacin [Cipro], ofloxacin [Floxin], and levofloxacin [Levaquin]) have been used since 1993 for the treatment of gonorrhea because of their effectiveness, availability, and convenience as a single-dose oral therapy. However, the prevalence of fluoroquinolone resistance in Neisseria gonorrhoeae has been increasing in the United States, necessitating changes in treatment regimens. Since 1999, increasing resistance of N. gonorrhoeae to fluoroquinolones has been reported, first in Hawaii, then in California and other Western states, then among men who have sex with men, and now in other populations and regions. Data from 2005 and 2006 show that the prevalence of fluoroquinolone-resistant N. gonorrhoeae has continued to increase among heterosexual men and is present in all regions of the United States.
Because fluoroquinolones are no longer recommended for the treatment of gonorrhea, treatment options are limited. For the treatment of uncomplicated urogenital and anorectal gonorrhea, the CDC now recommends a single 125-mg intramuscular dose of ceftriaxone (Rocephin) or a single 400-mg oral dose of cefixime (Suprax). Alternative regimens include a single 400-mg oral dose of cefpodoxime (Vantin) or a 1-g dose of cefuroxime (Ceftin).
For pharyngeal gonorrhea, the CDC now recommends a single 125-mg intramuscular dose of ceftriaxone.
ACS Recommendations on MRI and Mammography for Breast Cancer Screening
Guideline source: American Cancer Society
Literature search described? Yes
Evidence rating system used? No
Published source: CA: A Cancer Journal for Clinicians, March/April 2007
Available at: http://caonline.amcancersoc.org/cgi/content/full/57/2/75
See related article on page 1660 and related editorial on page 1623.
Women at high risk of developing breast cancer should receive annual magnetic resonance imaging (MRI) as an adjunct to mammography, according to new guidelines from the American Cancer Society (ACS).
Groups for whom MRI screening is recommended include the following:
• Women with a BRCA mutation
• Women with a first-degree relative who has a BRCA mutation
• Women with a 20 to 25 percent or greater lifetime risk for breast cancer, based on BRCAPRO or other risk models that depend largely on family history
• Women exposed to chest radiation between the ages of 10 and 30 years
• Women with Li-Fraumeni syndrome, and first-degree relatives of women with this syndrome
• Women with Cowden and Bannayan-Riley-Ruvalcaba syndromes, and first-degree relatives of women with these syndromes
MRI screening has been proven to detect cancer with early-stage tumors, which are associated with better outcomes. Studies have found high sensitivity for MRI, ranging from 71 to 100 percent versus 16 to 40 percent for mammography alone in high-risk populations. MRI also finds smaller tumors compared with mammography, and the types of cancers found with MRI contribute to reduced mortality rates.
Three approaches are available for identifying women with a high risk for breast cancer: family history, genetic testing, and clinical history. Although many women have at least one relative with breast cancer, most of these women are not at increased risk. Only 1 to 2 percent of women have a family history suggestive of the inheritance of an autosomal-dominant, high-penetrance gene that confers up to an 80 percent lifetime risk of breast cancer. In some families, there is also a high risk of ovarian cancer. Family history findings that suggest the presence of such a high-penetrance gene include two or more close relatives (i.e., first- or second-degree) with breast or ovarian cancer; breast cancer occurring before 50 years of age in a close relative; a family history of breast and ovarian cancers; one or more relatives with two cancers (breast and ovarian cancers or two independent breast cancers); and male relatives with breast cancer.
Inherited mutations in the two breast and ovarian cancer susceptibility genes, BRCA1 and BRCA2, are present in approximately one half of families in which an inherited risk is strongly suspected. Several models can help physicians determine risk estimates: the Gail, Claus, and Tyrer-Cuzick models are based on family history, and BRCAPRO and the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA) estimate the likelihood of BRCA mutations.
Genetic testing for BRCA mutations usually is offered to adult members of families with a known mutation and to women with a 10 percent or greater likelihood of carrying such a mutation. If a woman from a family in which a BRCA mutation has been identified does not have that mutation, her breast cancer risk is no higher than it would have been if she did not have a family history of breast cancer. However, in women from high-risk families without a known mutation, failure to find a mutation does not reduce risk.
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| Copyright © 2007 by the American
Academy of Family Physicians. |
