ITEMS IN AFP WITH MESH TERM:
ABSTRACT: Community-acquired pneumonia is diagnosed by clinical features (e.g., cough, fever, pleuritic chest pain) and by lung imaging, usually an infiltrate seen on chest radiography. Initial evaluation should determine the need for hospitalization versus outpatient management using validated mortality or severity prediction scores. Selected diagnostic laboratory testing, such as sputum and blood cultures, is indicated for inpatients with severe illness but is rarely useful for outpatients. Initial outpatient therapy should include a macrolide or doxycycline. For outpatients with comorbidities or who have used antibiotics within the previous three months, a respiratory fluoroquinolone (levofloxacin, gemifloxacin, or moxifloxacin), or an oral beta-lactam antibiotic plus a macrolide should be used. Inpatients not admitted to an intensive care unit should receive a respiratory fluoroquinolone, or a beta-lactam antibiotic plus a macrolide. Patients with severe community-acquired pneumonia or who are admitted to the intensive care unit should be treated with a beta-lactam antibiotic, plus azithromycin or a respiratory fluoroquinolone. Those with risk factors for Pseudomonas should be treated with a beta-lactam antibiotic (piperacillin/tazobactam, imipenem/cilastatin, meropenem, doripenem, or cefepime), plus an aminoglycoside and azithromycin or an antipseudomonal fluoroquinolone (levofloxacin or ciprofloxacin). Those with risk factors for methicillin-resistant Staphylococcus aureus should be given vancomycin or linezolid. Hospitalized patients may be switched from intravenous to oral antibiotics after they have clinical improvement and are able to tolerate oral medications, typically in the first three days. Adherence to the Infectious Diseases Society of America/American Thoracic Society guidelines for the management of community-acquired pneumonia has been shown to improve patient outcomes. Physicians should promote pneumococcal and influenza vaccination as a means to prevent community-acquired pneumonia and pneumococcal bacteremia.
Short Course of Antibiotics for Acute Otitis Media Treatment - Cochrane for Clinicians
ABSTRACT: Acute pyelonephritis is a common bacterial infection of the renal pelvis and kidney most often seen in young adult women. History and physical examination are the most useful tools for diagnosis. Most patients have fever, although it may be absent early in the illness. Flank pain is nearly universal, and its absence should raise suspicion of an alternative diagnosis. A positive urinalysis confirms the diagnosis in patients with a compatible history and physical examination. Urine culture should be obtained in all patients to guide antibiotic therapy if the patient does not respond to initial empiric antibiotic regimens. Escherichia coli is the most common pathogen in acute pyelonephritis, and in the past decade, there has been an increasing rate of E. coli resistance to extended-spectrum beta-lactam antibiotics. Imaging, usually with contrast-enhanced computed tomography, is not necessary unless there is no improvement in the patient’s symptoms or if there is symptom recurrence after initial improvement. Outpatient treatment is appropriate for most patients. Inpatient therapy is recommended for patients who have severe illness or in whom a complication is suspected. Practice guidelines recommend oral fluoroquinolones as initial outpatient therapy if the rate of fluoroquinolone resistance in the community is 10 percent or less. If the resistance rate exceeds 10 percent, an initial intravenous dose of ceftriaxone or gentami- cin should be given, followed by an oral fluoroquinolone regimen. Oral beta-lactam antibiotics and trimethoprim/sulfamethoxazole are generally inappropriate for outpatient therapy because of high resistance rates. Several antibiotic regimens can be used for inpatient treatment, including fluoroquinolones, aminoglycosides, and cephalosporins.
ABSTRACT: Urinary tract infections are the most common bacterial infections in women. Most urinary tract infections are acute uncomplicated cystitis. Identifiers of acute uncomplicated cystitis are frequency and dysuria in an immunocompetent woman of childbearing age who has no comorbidities or urologic abnormalities. Physical examination is typically normal or positive for suprapubic tenderness. A urinalysis, but not urine culture, is recommended in making the diagnosis. Guidelines recommend three options for first-line treatment of acute uncomplicated cystitis: fosfomycin, nitrofurantoin, and trimethoprim/sulfamethoxazole (in regions where the prevalence of Escherichia coli resistance does not exceed 20 percent). Beta-lactam antibiotics, amoxicillin/clavulanate, cefaclor, cefdinir, and cefpodoxime are not recommended for initial treatment because of concerns about resistance. Urine cultures are recommended in women with suspected pyelonephritis, women with symptoms that do not resolve or that recur within two to four weeks after completing treatment, and women who present with atypical symptoms.
ABSTRACT: The incidence of chronic osteomyelitis is increasing because of the prevalence of predisposing conditions such as diabetes mellitus and peripheral vascular disease. The increased availability of sensitive imaging tests, such as magnetic resonance imaging and bone scintigraphy, has improved diagnostic accuracy and the ability to characterize the infection. Plain radiography is a useful initial investigation to identify alternative diagnoses and potential complications. Direct sampling of the wound for culture and antimicrobial sensitivity is essential to target treatment. The increased incidence of methicillin-resistant Staphylococcus aureus osteomyelitis complicates antibiotic selection. Surgical debridement is usually necessary in chronic cases. The recurrence rate remains high despite surgical intervention and long-term antibiotic therapy. Acute hematogenous osteomyelitis in children typically can be treated with a four-week course of antibiotics. In adults, the duration of antibiotic treatment for chronic osteomyelitis is typically several weeks longer. In both situations, however, empiric antibiotic coverage for S. aureus is indicated.
Outpatient Burns: Prevention and Care - Article
ABSTRACT: Most burn injuries can be managed on an outpatient basis by primary care physicians. Prevention efforts can significantly lower the incidence of burns, especially in children. Burns should be managed in the same manner as any other trauma, including a primary and secondary survey. Superficial burns can be treated with topical application of lotions, honey, aloe vera, or antibiotic ointment. Partial-thickness burns should be treated with a topical antimicrobial agent or an absorptive occlusive dressing to help reduce pain, promote healing, and prevent wound desiccation. Topical silver sulfadiazine is the standard treatment; however, newer occlusive dressings can provide faster healing and are often more cost-effective. Physicians must reevaluate patients frequently after a burn injury and be aware of the indications for referral to a burn specialist.
Approach to Septic Arthritis - Article
ABSTRACT: Prompt diagnosis and treatment of infectious arthritis can help prevent significant morbidity and mortality. The acute onset of monoarticular joint pain, erythema, heat, and immobility should raise suspicion of sepsis. Constitutional symptoms such as fever, chills, and rigors are poorly sensitive for septic arthritis. In the absence of peripheral leukopenia or prosthetic joint replacement, synovial fluid white blood cell count in patients with septic arthritis is usually greater than 50,000 per mm3. Isolation of the causative agent through synovial fluid culture is not only definitive but also essential before selecting antibiotic therapy. Synovial fluid analysis is also useful to help distinguish crystal arthropathy from infectious arthritis, although the two occasionally coexist. Almost any microorganism can be pathogenic in septic arthritis; however, septic arthritis is caused by nongonococcal pathogens (most commonly Staphylococcus species) in more than 80 percent of patients. Gram stain results should guide initial antibiotic choice. Vancomycin can be used for gram-positive cocci, ceftriaxone for gram-negative cocci, and ceftazidime for gram-negative rods. If the Gram stain is negative, but there is strong clinical suspicion for bacterial arthritis, treatment with vancomycin plus ceftazidime or an aminoglycoside is appropriate. Evacuation of purulent material with arthrocentesis or surgical methods is necessary. Special consideration should be given to patients with prosthetic joint infection. In this population, the intraarticular cutoff values for infection may be as low as 1,100 white blood cells per mm3 with a neutrophil differential of greater than 64 percent.
Ocular Prophylaxis for Gonococcal Ophthalmia Neonatorum: Reaffirmation Recommendation Statement - U.S. Preventive Services Task Force
ABSTRACT: Infectious endocarditis results from bacterial or fungal infection of the endocardial surface of the heart and is associated with significant morbidity and mortality. Risk factors include the presence of a prosthetic heart valve, structural or congenital heart disease, intravenous drug use, and a recent history of invasive procedures. Endocarditis should be suspected in patients with unexplained fevers, night sweats, or signs of systemic illness. Diagnosis is made using the Duke criteria, which include clinical, laboratory, and echocardiographic findings. Antibiotic treatment of infectious endocarditis depends on whether the involved valve is native or prosthetic, as well as the causative microorganism and its antibiotic susceptibilities. Common blood culture isolates include Staphylococcus aureus, viridans Streptococcus, enterococci, and coagulase-negative staphylococci. Valvular structural and functional integrity may be adversely affected in infectious endocarditis, and surgical consultation is warranted in patients with aggressive or persistent infections, emboli, and valvular compromise or rupture. After completion of antibiotic therapy, patients should be educated about the importance of daily dental hygiene, regular visits to the dentist, and the need for antibiotic prophylaxis before certain procedures.