ITEMS IN AFP WITH MESH TERM:
Screening for Asymptomatic Bacteriuria in Adults: Reaffirmation Recommendation Statement - U.S. Preventive Services Task Force
Management of COPD Exacerbations - Article
ABSTRACT: Exacerbations of chronic obstructive pulmonary disease contribute to the high mortality rate associated with the disease. Randomized controlled trials have demonstrated the effectiveness of multiple interventions. The first step in outpatient management should be to increase the dosage of inhaled short-acting bronchodilators. Combining ipratropium and albuterol is beneficial in relieving dyspnea. Oral corticosteroids are likely beneficial, especially for patients with purulent sputum. The use of antibiotics reduces the risk of treatment failure and mortality in moderately or severely ill patients. Physicians should consider antibiotics for patients with purulent sputum and for patients who have inadequate symptom relief with bronchodilators and corticosteroids. The choice of antibiotic should be guided by local resistance patterns and the patient's recent history of antibiotic use. Hospitalized patients with exacerbations should receive regular doses of short-acting bronchodilators, continuous supplemental oxygen, antibiotics, and systemic corticosteroids. Noninvasive positive pressure ventilation or invasive mechanical ventilation is indicated in patients with worsening acidosis or hypoxemia.
ABSTRACT: The increasing incidence of skin and soft tissue infections requires family physicians to be familiar with the management of these conditions. Evidence of systemic infection, such as fever, tachycardia, and hypotension, is an indication for inpatient management. Urgent surgical referral is imperative for those with life-threatening or rapidly advancing infections. In patients with uncomplicated abscesses measuring less than 5 cm in diameter, surgical drainage alone is the primary therapeutic intervention. Wound irrigation using tap water has similar outcomes as irrigation using sterile water. When antimicrobials are indicated, choice of agents depends on local resistance and susceptibility patterns. In settings where suspicion of methicillin-resistant Staphylococcus aureus (MRSA) is low, beta-lactam antibiotics are the first-line treatments for uncomplicated skin and soft tissue infections without focal coalescence or trauma. When empiric coverage for MRSA is indicated and the infection is uncomplicated, oral agents, such as tetracyclines, trimethoprim/sulfamethoxazole, and clindamycin, are preferred. Vancomycin is the first-line agent for MRSA in hospitalized patients, and newer agents, such as linezolid, daptomycin, and tigecycline, should be reserved for patients who do not respond to or cannot tolerate vancomycin therapy. There are insufficient data to support eradicating the carrier state in patients with MRSA or their contacts with nasal mupirocin or antibacterial body washes. Standard infection-control precautions, including proper and frequent handwashing, are a mainstay of MRSA prevention.
Prostatitis: Diagnosis and Treatment - Article
ABSTRACT: Prostatitis ranges from a straightforward clinical entity in its acute form to a complex, debilitating condition when chronic. It is often a source of frustration for the treating physician and patient. There are four classifications of prostatitis: acute bacterial, chronic bacterial, chronic prostatitis/chronic pelvic pain syndrome, and asymptomatic. Diagnosis of acute and chronic bacterial prostatitis is primarily based on history, physical examination, urine culture, and urine specimen testing pre- and post-prostatic massage. The differential diagnosis of prostatitis includes acute cystitis, benign prostatic hyperplasia, urinary tract stones, bladder cancer, prostatic abscess, enterovesical fistula, and foreign body within the urinary tract. The mainstay of therapy is an antimicrobial regimen. Chronic pelvic pain syndrome is a more challenging entity, in part because its pathology is poorly understood. Diagnosis is often based on exclusion of other urologic conditions (e.g., voiding dysfunction, bladder cancer) in association with its presentation. Commonly used medications include antimicrobials, alpha blockers, and anti-inflammatory agents, but the effectiveness of these agents has not been supported in clinical trials. Small studies provide limited support for the use of nonpharmacologic modalities. Asymptomatic prostatitis is an incidental finding in a patient being evaluated for other urologic problems.
ABSTRACT: Recurrent urinary tract infections, presenting as dysuria or irritative voiding symptoms, are most commonly caused by reinfection with the original bacterial isolate in young, otherwise healthy women with no anatomic or functional abnormalities of the urinary tract. Frequency of sexual intercourse is the strongest predictor of recurrent urinary tract infections in patients presenting with recurrent dysuria. In those who have comorbid conditions or other predisposing factors, recurrent complicated urinary tract infections represent a risk for ascending infection or urosepsis. Escherichia coli is the most common organism in all patient groups, but Klebsiella, Pseudomonas, Proteus, and other organisms are more common in patients with certain risk factors for complicated urinary tract infections. A positive urine culture with greater than 102 colony-forming units per mL is the standard for diagnosing urinary tract infections in symptomatic patients, although culture is often unnecessary for diagnosing typical symptomatic infection. Women with recurrent symptomatic urinary tract infections can be treated with continuous or postcoital prophylactic antibiotics; other treatment options include self-started antibiotics, cranberry products, and behavioral modification. Patients at risk of complicated urinary tract infections are best managed with broad-spectrum antibiotics initially, urine culture to guide subsequent therapy, and renal imaging studies if structural abnormalities are suspected.
Dermatologic Emergencies - Article
ABSTRACT: Life-threatening dermatologic conditions include Rocky Mountain spotted fever; necrotizing fasciitis; toxic epidermal necrolysis; and Stevens-Johnson syndrome. Rocky Mountain spotted fever is the most common rickettsial disease in the United States, with an overall mortality rate of 5 to 10 percent. Classic symptoms include fever, headache, and rash in a patient with a history of tick bite or exposure. Doxycycline is the first-line treatment. Necrotizing fasciitis is a rapidly progressive infection of the deep fascia, with necrosis of the subcutaneous tissues. It usually occurs after surgery or trauma. Patients have erythema and pain out of proportion to the physical findings. Immediate surgical debridement and antibiotic therapy should be initiated. Stevens-Johnson syndrome and toxic epidermal necrolysis are acute hypersensitivity cutaneous reactions. Stevens-Johnson syndrome is characterized by target lesions with central dusky purpura or a central bulla. Toxic epidermal necrolysis is a more severe reaction with full-thickness epidermal necrosis and exfoliation. Most cases of Stevens-Johnson syndrome and toxic epidermal necrolysis are drug induced. The causative drug should be discontinued immediately, and the patient should be hospitalized for supportive care.
Urinary Tract Infection in Children - Clinical Evidence Handbook
ABSTRACT: Cough is the most common symptom bringing patients to the primary care physician’s office, and acute bronchitis is usually the diagnosis in these patients. Acute bronchitis should be differentiated from other common diagnoses, such as pneumonia and asthma, because these conditions may need specific therapies not indicated for bronchitis. Symptoms of bronchitis typically last about three weeks. The presence or absence of colored (e.g., green) sputum does not reliably differentiate between bacterial and viral lower respiratory tract infections. Viruses are responsible for more than 90 percent of acute bronchitis infections. Antibiotics are generally not indicated for bronchitis, and should be used only if pertussis is suspected to reduce transmission or if the patient is at increased risk of developing pneumonia (e.g., patients 65 years or older). The typical therapies for managing acute bronchitis symptoms have been shown to be ineffective, and the U.S. Food and Drug Administration recommends against using cough and cold preparations in children younger than six years. The supplement pelargonium may help reduce symptom severity in adults. As patient expectations for antibiotics and therapies for symptom management differ from evidence-based recommendations, effective communication strategies are necessary to provide the safest therapies available while maintaining patient satisfaction.
ABSTRACT: Although the annual incidence of bacterial meningitis in the United States is declining, it remains a medical emer- gency with a potential for high morbidity and mortality. Clinical signs and symptoms are unreliable in distinguishing bacterial meningitis from the more common forms of aseptic meningitis; therefore, a lumbar puncture with cerebro- spinal fluid analysis is recommended. Empiric antimicrobial therapy based on age and risk factors must be started promptly in patients with bacterial meningitis. Empiric therapy should not be delayed, even if a lumbar puncture cannot be performed because results of a computed tomography scan are pending or because the patient is awaiting transfer. Concomitant therapy with dexamethasone initiated before or at the time of antimicrobial therapy has been demonstrated to improve morbidity and mortality in adults with Streptococcus pneumoniae infection. Within the United States, almost 30 percent of strains of pneumococci, the most common etiologic agent of bacterial meningitis, are not susceptible to penicillin. Among adults in developed countries, the mortality rate from bacterial meningitis is 21 percent. However, the use of conjugate vaccines has reduced the incidence of bacterial meningitis in children and adults.
Management of Inflammatory Bowel Disease - Article
ABSTRACT: Patients with an inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, have recurrent symptoms with considerable morbidity. Patient involvement and education are necessary components of effective management. Mild disease requires only symptomatic relief and dietary manipulation. Mild to moderate disease can be managed with 5-aminosalicylic acid compounds, including olsalazine and mesalamine. Mesalamine enemas and suppositories are useful in treating proctosigmoiditis. Antibiotics such as metronidazole may be required in patients with Crohn's disease. Corticosteroids are beneficial in patients with more severe symptoms, but side effects limit their use, particularly for chronic therapy. Immunosuppressant therapy may be considered in patients with refractory disease that is not amenable to surgery. Inflammatory bowel disease in pregnant women can be managed with 5-aminosalicylic acid compounds and corticosteroids. Since longstanding inflammatory bowel disease (especially ulcerative colitis) is associated with an increased risk of colon cancer, periodic colonoscopy is warranted.