ITEMS IN AFP WITH MESH TERM:
Hope for Patients with Asplenia or Hyposplenism - Editorials
ABSTRACT: Rhinosinusitis can be divided among four subtypes: acute, recurrent acute, subacute and chronic, based on patient history and a limited physical examination. In most instances, therapy is initiated based on this classification. Antibiotic therapy, supplemented by hydration and decongestants, is indicated for seven to 14 days in patients with acute, recurrent acute or subacute bacterial rhinosinusitis. For patients with chronic disease, the same treatment regimen is indicated for an additional four weeks or more, and a nasal steroid may also be prescribed if inhalant allergies are known or suspected. Nasal endoscopy and computed tomography of the sinuses are reserved for circumstances that include a failure to respond to therapy as expected, spread of infection outside the sinuses, a question of diagnosis and when surgery is being considered. Laboratory tests are infrequently necessary and are reserved for patients with suspected allergies, cystic fibrosis, immune deficiencies, mucociliary disorders and similar disease states. Findings on endoscopically guided microswab culture obtained from the middle meatus correlate 80 to 85 percent of the time with results from the more painful antral puncture technique and is performed in patients who fail to respond to the initial antibiotic selection. Surgery is indicated for extranasal spread of infection, evidence of mucocele or pyocele, fungal sinusitis or obstructive nasal polyposis, and is often performed in patients with recurrent or persistent infection not resolved by drug therapy.
ABSTRACT: Fulminant, potentially life-threatening infection is a major long-term risk after splenectomy or in persons who are functionally hyposplenic as a result of various systemic conditions. Most of these infections are caused by encapsulated organisms such as pneumococci, Haemophilus influenzae and meningococci. A splenectomized patient is also more susceptible to infections with intraerythrocytic organisms such as Babesia microti and those that seldom affect healthy people, such as Capnocytophaga canimorsus. Most patients who have lost their spleens because of trauma are aware of their asplenic condition, but some older patients do not know that they are asplenic. Other patients may have functional hyposplenism secondary to a variety of systemic diseases ranging from celiac disease to hemoglobinopathies. The identification of Howell-Jolly bodies on peripheral blood film is an important clue to the diagnosis of asplenia or hyposplenia. Management of patients with these conditions includes a combination of immunization, antibiotic prophylaxis and patient education. With the increasing prevalence of antibiotic-resistant pneumococci, appropriate use of the pneumococcal vaccine has become especially important.
ABSTRACT: Since the introduction of antimicrobial agents, there has been an association between antibiotic use and the development of antimicrobial resistance. Antibiotic therapy eradicates not only pathogenic organisms but also the protective normal flora. This so-called "selective pressure" results in colonization with bacteria that are resistant to the original therapy. The result has been an increase over the past two decades in antibiotic resistance among common bacterial causes of outpatient infections. Several studies have demonstrated that a substantial portion of the antibiotics prescribed in the outpatient setting are given for viral illnesses or bacterial diseases where the benefit of antibacterial therapy is marginal. The reasons for prescribing antibiotics in these situations are related to medical and social factors. Physicians should be familiar with the clinical situations in which they should provide antibiotics and those in which they may safely be withheld. Physicians should understand the motivations of patients who are seeking antibiotics and provide education, empathy and alternative treatments.
ABSTRACT: A practice guideline for the management of febrile infants and children younger than three years of age sparked controversy when it was published in 1993. Surveys indicate that many office-based physicians do not agree with recommendations for venipuncture and bladder catheterization in nontoxic febrile children, and that many employ watchful waiting rather than empiric antibiotic therapy. Surveys of parents note a preference for less testing and treatment. More aggressive management may be appropriate in febrile infants younger than three months old; however, criteria have been proposed to identify infants older than one month who are at low risk for serious bacterial infection. Because of widespread vaccination against Haemophilus influenzae infection, Streptococcus pneumoniae has become the cause of most cases of bacteremia. The risk of serious bacterial infection is greater in younger children and in those with higher temperatures and white blood cell counts. Controversy persists regarding the age, temperature and white blood cell count values that serve as indications for further evaluation or empiric antibiotic therapy.
ABSTRACT: Recent events have demonstrated that bioterrorists have the ability to disseminate biologic agents in the United States and cause widespread social panic. Family physicians would play a key role in the initial recognition of a potential bioterrorism attack. Familiarity with the infectious agents of highest priority can expedite diagnosis and initial management, and lead to a successful public health response to such an attack. High-priority infectious agents include anthrax, smallpox, plague, tularemia, botulism, and viral hemorrhagic fever. Anthrax and smallpox must be distinguished from such common infections as influenza and varicella. Anthrax treatment is stratified into postexposure prophylaxis and treatment of confirmed cutaneous, intestinal, or inhalation anthrax. Disease prevention by vaccination and isolation of affected persons is key in preventing widespread smallpox infection. Many resources are available to physicians when a bioterrorism attack is suspected, including local public health agencies and the Centers for Disease Control and Prevention.
ABSTRACT: Acute rhinosinusitis is one of the most common conditions that physicians treat in ambulatory practice. Although often caused by viruses, it sometimes is caused by bacteria, a condition that is called acute bacterial rhinosinusitis. The signs and symptoms of acute bacterial rhinosinusitis and prolonged viral upper respiratory infection are similar, which makes accurate clinical diagnosis difficult. Because two thirds of patients with acute bacterial rhinosinusitis improve without antibiotic treatment and most patients with viral upper respiratory infection improve within seven d antibiotic therapy should be reserved for use in patients who have had symptoms for more than seven days and meet clinical criteria. Four signs and symptoms are the most helpful in predicting acute bacterial rhinosinusitis: purulent nasal discharge, maxillary tooth or facial pain (especially unilateral), unilateral maxillary sinus tenderness, and worsening symptoms after initial improvement. Sinus radiography and ultrasonography are not recommended in the diagnosis of uncomplicated acute bacterial rhinosinusitis, although computed tomography has a role in the care of patients with recurrent or chronic symptoms.
ABSTRACT: To help physicians with the appropriate use of antibiotics in children and adults with upper respiratory tract infection, a multidisciplinary team evaluated existing guidelines and summarized key practice points. Acute otitis media in children should be diagnosed only if there is abrupt onset, signs of middle ear effusion, and symptoms of inflammation. A period of observation without immediate use of antibiotics is an option for certain children. In patients with sinus infection, acute bacterial rhinosinusitis should be diagnosed and treated with antibiotics only if symptoms have not improved after 10 days or have worsened after five to seven days. In patients with sore throat, a diagnosis of group A beta-hemolytic streptococcus pharyngitis generally requires confirmation with rapid antigen testing, although other guidelines allow for empiric therapy if a validated clinical rule suggests a high likelihood of infection. Acute bronchitis in otherwise healthy adults should not be treated with antibiotics; delayed prescriptions may help ease patient fears and simultaneously reduce inappropriate use of antibiotics.
ABSTRACT: Most children will have been evaluated for a febrile illness by 36 months of age. Although the majority will have a self-limited viral illness, studies done before the use of Haemophilus influenzae type b and Streptococcus pneumoniae vaccines showed that approximately 10 percent of children younger than 36 months without evident sources of fever had occult bacteremia and serious bacterial infection. More recent studies have found lower rates of bacterial infection (1.6 to 1.8 percent). Any infant younger than 29 days and any child that appears toxic should undergo a complete sepsis work-up. However, nontoxic-appearing children one to 36 months of age, who have a fever with no apparent source and who have received the appropriate vaccinations, could undergo screening laboratory analysis and be sent home with close follow-up. Empiric intramuscular antibiotics are suggested for some children; however, cerebrospinal fluid studies should be obtained first. Because immunizations have recently decreased infection rates for S. pneumoniae and H. influenzae type b, the recommendations for evaluation and treatment of febrile children are evolving and could involve fewer tests and less-presumptive treatment in the future. A cautious approach should still be taken based on the potential for adverse consequences of unrecognized and untreated serious bacterial infection.