Nosocomial and Device-Related Infections The fact that 25–50% or more of nosocomial infections are due to the combined effect of the patient's own flora and invasive devices highlights the importance of improvements in the use and design of such devices. Intensive education and "bundling" of evidence-based interventions (Table 125-2) can reduce infection rates through improved asepsis in handling and earlier removal of invasive devices, but the maintenance of such gains requires ongoing efforts.
Patients in whom diphtheria is suspected should be hospitalized in respiratory isolation rooms, with close monitoring of cardiac and respiratory function. A cardiac workup is recommended to assess the possibility of myocarditis. In patients with extensive pseudomembranes, consultation with an anesthesiologist or an ear, nose, and throat specialist is recommended because of the possibility that tracheostomy or intubation will be required. In some settings, pseudomembranes can be removed surgically.
Adjunctive treatments may reduce morbidity and mortality and include dexamethasone for bacterial meningitis; intravenous immunoglobulin (IVIg) for TSS and necrotizing fasciitis caused by group A Streptococcus; low-dose hydrocortisone and fludrocortisone for septic shock; and drotrecogin alfa (activated), also known as recombinant human activated protein C, for meningococcemia and severe sepsis.
This syndrome (formerly termed nonspecific vaginitis, Haemophilus vaginitis, anaerobic vaginitis, or Gardnerella-associated vaginal discharge) is characterized by symptoms of vaginal malodor and a slightly to moderately increased white discharge, which appears homogeneous, is low in viscosity, and evenly coats the vaginal mucosa. An interesting observation is that new genital HPV infection in young women is associated with increased subsequent risk of developing bacterial vaginosis.
Vaccination (See also Chap. 116) The development of conjugate vaccines that prevent invasive infections with Hib in infants and children has been a dramatic success. Three such vaccines are licensed in the United States. In addition to eliciting protective antibody, these vaccines prevent disease by reducing rates of pharyngeal colonization with Hib.
The widespread use of conjugate vaccines has dramatically reduced the incidence of Hib disease in developed countries. Even though the manufacture of Hib vaccines is costly, vaccination is cost-effective.
Adverse drug reactions are frequently classified by mechanism as either dose-related ("toxic") or unpredictable. Unpredictable reactions are either idiosyncratic or allergic. Dose-related reactions include aminoglycoside-induced nephrotoxicity, linezolid-induced thrombocytopenia, penicillin-induced seizures, and vancomycin-induced anaphylactoid reactions. Many of these reactions can be avoided by reducing dosage in patients with impaired renal function, limiting the duration of therapy, or reducing the rate of administration.
Antimicrobial Therapy for Selected Settings
For uncomplicated skin and soft tissue infections, the use of oral antistaphylococcal agents is usually successful. For other infections, parenteral therapy is indicated.
S. aureus endocarditis is usually an acute, life-threatening infection. Thus prompt collection of blood for cultures must be followed immediately by empirical antimicrobial therapy. For S. aureus native-valve endocarditis, a combination of antimicrobial agents is often used.
Pharyngitis: Treatment Antibiotic treatment of pharyngitis due to S. pyogenes confers numerous benefits, including a decrease in the risk of rheumatic fever. The magnitude of this benefit is fairly small, however, since rheumatic fever is now a rare disease, even among untreated patients. When therapy is started within 48 h of illness onset, however, symptom duration is also decreased. An additional benefit of therapy is the potential to reduce the spread of streptococcal pharyngitis, particularly in areas of overcrowding or close contact.
Herpes Simplex Virus Within the first 2 weeks after transplantation, most patients who are seropositive for HSV-1 excrete the virus from the oropharynx. The ability to isolate HSV declines with time. Administration of prophylactic acyclovir (or valacyclovir) to seropositive HSCT recipients has been shown to reduce mucositis and prevent HSV pneumonia (a rare condition reported almost exclusively in allogeneic HSCT recipients). Both esophagitis (usually due to HSV-1) and anogenital disease (commonly induced by HSV-2) may be prevented with acyclovir prophylaxis.
Inhibition of Protein Synthesis
Most of the antibacterial agents that inhibit protein synthesis interact with the bacterial ribosome. The difference between the composition of bacterial and mammalian ribosomes gives these compounds their selectivity.
Aminoglycosides Aminoglycosides (gentamicin, kanamycin, tobramycin, streptomycin, neomycin, and amikacin) are a group of structurally related compounds containing three linked hexose sugars. They exert a bactericidal effect by binding irreversibly to the 30S subunit of the bacterial ribosome and blocking initiation of protein synthesis.
Harrison's Internal Medicine Chapter 128. Pneumococcal Infections
Pneumococcal Infections: Introduction
Streptococcus pneumoniae (the pneumococcus) was recognized as a major cause of pneumonia in the 1880s. Although the name Diplococcus pneumoniae was originally assigned to the pneumococcus, the organism was renamed Streptococcus pneumoniae because, like other streptococci, it grows in chains in liquid medium.
(Table 128-4) Current treatment recommendations for otitis media are based on the following points: (1) Acute otitis media is the most common diagnosis leading to an antibiotic prescription in the United States. (2) The diagnosis is often based on inadequate evidence for true middle-ear infection. (3) In proven cases, S. pneumoniae and H. influenzae are the most likely causes.
Table 129-3 Antimicrobial Therapy for Serious Staphylococcal Infectionsa
Sensitivity/Resis tance of Isolate
Drug of Choice s)
n G (4 mU q4h) g q4h) or oxacillin 5% of isolates are (2 g q4h), cefazolin sensitive (2 g q8h), penicillin.
Emergencies in medicine are difficult on two fronts: they may challenge both the
health of the patient and the skills of the doctor in charge. If the latter, the former
may deteriorate rapidly. Thus, the definition of an emergency indeed depends on
who is facing it. As we mature along our clinical pathways of education, training, and
experience, the risk of going through a personal professional emergency is continuously
reduced. Nevertheless, throughout our medical career, accurate self-assessment
and subsequent control of our actions remain our most important qualities.
Nutrient requirements for optimum health and function of aging physiological systems often are
quite distinct from those required for young ones. Recognition and understanding of the special
nutrition problems of the aged are being intensively researched and tested, especially due to the
increases in the elderly in the general population. In developed countries, economic restrictions and
physical inactivity during aging can significantly reduce food intakes, contributing to nutritional
stresses and needs. Many disease entities and cancers are found with higher frequency in the aged.
It has been recognized for many years that states of nutrient deficiency are associated
with an impaired immune response and with increased susceptibility to infectious
disease. In turn, infection can affect the status of several nutrients, thus setting
up a vicious circle of under nutrition, compromised immune function and infection.
Bivalve culture such as clam production is a promising activity as it is more profitable despite a low production rate. However, clam culture has the disadvantage of mainly relying on capture of seed source from the wild. At the same time, due to disease outbreak in the prawn farming sector as a consequence of water deterioration, there has been an overall reduction in aquaculture production. Clam is recognized as a water cleaning machine(filter feeder), thus water quality will be improved if clam can be incorporated into the shrimp farming system.
EU enlargement, the CAP reform, changing consumer demands and globalization have also
impacted negatively on the agricultural sector (Rudmann, 2008), with the scale of support
provided to farmers drastically reduced (Alsos, Carter, Ljunggren & Welter, 2011). A
gradual decline in income from traditional farming activities has forced many farming
businesses to diversify in order to remain viable. Diversification requires farmers to combine
other, typically non-agricultural activities with their core farm business.
All subjects interviewed received the first draft of the Apheis 2 report, which included a compilation of
findings section and a sample city report. Subjects were then asked to rate the documents on scientific
soundness, trustworthiness, relevance of content to their needs, and organization and presentation of
All subjects interviewed in Spain rated the Apheis documents favorably to very favorably overall, and
rated them slightly better than did the subjects interviewed in London.
The evidence base for the insulin secretagogues was more extensive than ascertained for the
parent guideline. However, in many of the papers in which they are compared to other drugs
they were being used as the comparator therapy rather than the investigated therapy. New
evidence did not lead to new conclusions about the role of these drugs in clinical management,
either from the point of view of efficacy or safety.