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By: Michael B. Kays, PharmD, FCCP

  • Associate Professor, Department of Pharmacy Practice, Purdue University College of Pharmacy, West Lafayette and Indianapolis
  • Adjunct Associate Professor, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana


Debris in the airspaces and increased surface tension from low surfactant production and function exacerbate alveolar collapse arthritis valgus knee purchase cheap pentoxifylline on-line. This leads to arthritis in back and exercise discount 400 mg pentoxifylline visa hypoxia in areas that are perfused but not ventilated arthritis joint replacement purchase genuine pentoxifylline online, also known as V/Q mismatch viral arthritis in back pentoxifylline 400 mg free shipping, or shunt. In addition, fluid in the interstitium leads to decreased lung compliance and low tidal volumes. Repetitive and forceful opening and closing of lung units to maintain tidal volume can exacerbate the inflammatory cascade, leading to the secretion of proinflammatory cytokines, continuing the cycle of increased capillary permeability. For the girl in the vignette, the history does not support a diagnosis of aspiration pneumonia. Postobstructive pulmonary edema can occur after an airway obstruction is relieved, but this child did not have airway obstruction. There is no fever, infection, or end-organ perfusion compromise to suggest septic shock. During a recent camping trip in Arkansas, one of his bunkmates was bitten by a tick and developed fever and a rash 1 week later. Your patient’s mother is now very concerned about tick-borne infections and inquires as to the best means of protecting her children in the future. Long sleeved shirts and long pants limit the vectors’ access to the host and limit the ability to transmit infection. Prevention of tick-borne infections involves personal protection, environmental measures, and reducing the time a tick is attached to a human. It is recommended that light-colored clothing be used in order to more easily identify an attached tick. The longer a tick is attached, the more likely it is to transmit an infectious illness. Similarly, prevention of mosquito-borne infections involves both personal protection and environmental measures to discourage mosquito habitats, including removal of standing water and cleaning of pools. Personal protection includes use of nets, covering exposed skin, and use of repellents. In general, longer protection is provided by repellents with higher concentrations of their active ingredients. The use of permethrin-embedded bed nets when sleeping would protect a child from mosquito-borne infections but not tick-borne infections. His vital signs show a temperature of 39°C, heart rate of 130 beats/min, respiratory rate of 28 breaths/min, blood pressure of 90/62 mm Hg, and oxygen saturation of 97% by pulse oximetry on room air. A physical examination shows mild dehydration and a prominent suprapubic area that is dull on percussion. The laboratory and ultrasonography results show: Complete blood cell count: 9 o White blood cell count, 20,000/µL (20. Some of these patients may present in the neonatal period with respiratory distress. This would lead to pulmonary hypoplasia because normal amniotic fluid levels are required for normal lung development. Voiding cystourethrogram demonstrates the characteristic findings of a dilated and elongated posterior urethra during the voiding phase (after catheter removal). The membranous urethra is the shortest, least dilatable, and the narrowest part of the urethral canal (except the external urethral orifice). Therefore, such patients are regularly followed to monitor their renal function, blood pressure, and growth. It extends from the apex of the prostate to the urethral bulb and perforates the urogenital diaphragm behind the pubic symphysis. Unilateral hydronephrosis is more common in children with congenital or acquired uretropelvic or uretrovesical obstruction. Hydronephrosis without ureteral dilatation is seen in uretropelvic junction obstruction. Hydronephrosis with dilation of the distal ureter without bladder distension indicates obstruction at the ureteral orifice (uretrovesical). Ureteropelvic and ureterovesical obstructions are not associated with the thickened bladder wall or dilated posterior urethra. He has not had any new food exposures in the week prior to developing the symptoms. On admission to the hospital, his vital 0 signs are a temperature of 38 C, heart rate of 140 beats/min, and respiratory rate of 30 breaths/min. It affects most children before 5 years of age, although vaccination, initiated in 2006 in the United States, is changing the epidemiology. Prior to the availability of vaccination, rotavirus was the most common cause of diarrhea in the United States, especially in childcare centers. Since the introduction of the vaccine, rotavirus gastroenteritis cases have been reduced by more than 80%. The primary mechanism of transmission of rotavirus is believed to be fecal-oral, although fomites and respiratory spread have been reported. The virus is present in highest titers several days before and after onset of clinical symptoms. Rotavirus infection begins with acute onset of vomiting and fever, followed 1 to 2 days later with watery diarrhea. Severe cases can develop significant dehydration, acidosis, and electrolyte abnormalities. A small number of children experience neurologic issues including seizures and less commonly, encephalitis, encephalopathy, and cerebellitis. Polymerase chain reaction techniques have been shown to be more sensitive in detection of the virus at all stages of infection and are the primary tool used in research. Viral cultures are time consuming and are not generally used to diagnose the cause of the acute vomiting and diarrhea seen in the patient described in the vignette. The mother reports that her child has attention problems, depression, impulsiveness, and occasional delusional thinking. She states that her daughter is paranoid that "people are always talking about her. She had significant hypocalcemia and low parathyroid hormone with seizures in infancy. Physical examination is remarkable for a thin teenager with slender, hyperextensible hands and fingers. She has a long narrow face with a narrow nose with a squared nasal root, short upward-slanting palpebral fissures, a bifid uvula, and a high arch palate. She has a short, thick webbed neck with reduced range of motion and mild scoliosis. Major findings with this disorder include congenital heart disease, palatal abnormalities, characteristic facial dysmorphology (including facial asymmetry), learning difficulties, hypocalcemia, and immune deficiency. An example of a patient with these findings is shown in Item the heart disease often manifests as conotruncal defects including tetralogy of Fallot, perimembranous ventricular septal defect, truncus arteriosus, or interrupted aortic arch. The palatal deformities can range from velopharyngeal incompetence to cleft palate. Additional clinical findings can include feeding and swallowing problems, gastrointestinal and laryngotracheoesophageal anomalies, hearing loss, growth hormone deficiency, seizures, central nervous system anomalies, skeletal abnormalities (club feet, scoliosis, vertebral anomalies), renal abnormalities, ophthalmologic problems, thyroid problems, psychiatric disorders, autism, and enamel hypoplasia. A contiguous gene deletion syndrome is caused by a microdeletion that encompasses 2 or more genes in tandem position along a chromosome. By virtue of the fact that several genes are involved, contiguous gene syndromes often impact multiple systems of the body. Thus, one must assess the function of the specific genes involved within the deletion and thoroughly examine the patient for involvement for those specified regions (heart, kidney, brain, etc). Other common contiguous gene deletions include Williams syndrome, Ip36 deletion, Smith-Magenis syndrome, and Cri-du chat syndrome. Growth hormone may be required if poor growth in association with growth hormone deficiency is present. Sixty percent of adults have a psychiatric disorder (schizophrenia, anxiety, and depression) that will require a psychiatrist. Oculo-auriculo-vertebral syndrome, otherwise known as Goldenhar syndrome or craniofacial microsomia, presents with facial asymmetry caused by maxillary or mandibular hypoplasia, ear anomalies (preauricular facial tags or pits), hearing loss, and vertebral defects. Bronchiolitis, the clinical syndrome of inflammation of the bronchioles, is usually caused by an acute viral infection in children younger than 2 years.

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Also rheumatoid arthritis diagnosis code discount 400mg pentoxifylline amex, you are not to treating elbow arthritis in dogs buy generic pentoxifylline 400 mg line clean the incision line with anything; there is a possibility of dissolving the glue arthritis in back joints discount pentoxifylline online amex. If you have sutures arthritis relief cats purchase pentoxifylline 400mg without a prescription, they will either be taken out in the clinic or by a home health nurse. Showering requires physician approval in the immediate post–operative period, and he or she will advise you whether you can or cannot shower immediately post-op. If you can’t see your incision, look in a mir ror or have someone else look at it. Fever When your incision has no open areas or scabs, you can massage with a water-based lotion (approximately 4 weeks after surgery). There are sev eral things you can do to decrease the chances of blood clots forming. When you are lying in bed after surgery and not moving around like you normally would, it is very important that you begin leg exercises (see examples in booklet). These are done by pressing the backs of both knees into the bed, tightening your calf and thigh muscles and moving your ankles up and down. It is important that you get up into the chair and start walking as soon as possible with assistance. You will wear special elastic stockings that help to circulate the blood in your legs. They will be placed on your legs right after surgery in the recovery room and you will need to wear them the entire time that you are in the hospital. We will remove them to wash your legs every day and check to make sure your skin is alright. Wear them after you go home until there is no tendency for your legs to swell, usually around 10 days. You will be wearing another special type of machine called a sequential compression device that helps circulate the blood in your legs. The pump hooks onto the end of your bed and the hoses are attached to the sleeves. Your doctor may order one of these medications for you, especially if you have had blood clots in the past. If you are taking Coumadin, it is important that your blood is checked everyday (while in the hospital) until the desired blood lab value is obtained. If your doctor has you continue to take Coumadin after you go home, you will need to have your blood values checked once or twice a week. In addition, you will receive dietary instructions from the dietician because some foods may afect your Coumadin level. Aspirin, heparin, Lovenox (enoxaparin) are other drugs that help prevent blood clots. If your doctor orders one of these drugs, we will give you information at that time. It is important that you stick to your prescribed medication in order to decrease your chances of blood clots. Although blood clots are rare, it is important to know the signs and symptoms to look for. Pain in your lower legs or swelling not relieved by lying down and putting your legs up. Heat and redness in the calf muscle area You should notify your doctor immediately if you have any of these symptoms! If you are diabetic, you will be put on a diabetic diet to keep your blood sugar under control. If you have allergies to food or are a strict vegetarian, please let the doctor know at pre-op. Depending on your dietary restrictions, your family may bring food into the hospital for you to eat. The doctors put you on stool softeners and laxatives after surgery but you still may have difculty. Passing gas is normal and lets us know that your bowel function is starting to come back; don’t be embarrassed by this. If you haven’t had a bowel movement (pooped) by the second day post-op, please ask your nurse to give you a laxative. If you normally have problems with constipation, let the doctors know what works at home to resolve the issue and hopefully we can do the same for you here in the hospital. Your nurses will ask you take long, deep breaths several times each hour and to cough up any mucous. You will be taught to use a device called an incentive spirometer that will help you with your deep breathing exercises. Also, getting up in a chair as soon as possible with assistance helps prevent lung problems. If you smoke, quitting before surgery will help your recovery and decrease your chances of getting pneumonia. Antibiotics will be needed before you have dental work, surgery or other procedures such as colonoscopy. It is important that you tell your dentist and other health care providers that you have a knee prosthesis. Our health care team is dedicated to helping you recover and maximize your new joint! Your patient experience with us important, so please let us help you make your stay a satisfying one. You will be up and moving right after surgery, perhaps the same day of surgery, so be ready! You will be using an assistive device, such as a walker or crutches initially, so expect that when you are getting up. You need to increase your activity, exercise bouts, and be out of bed more than in it while staying with us. Getting dressed is allowed, so feel free to bring loose ftting clothes that can easily be donned over a bulky knee dressing or immobilizer. You will have continued therapy outside of the hospital if your insurance ofers this beneft. You will need to continue your exercises at home, walking frequently, and staying active. When your surgery was scheduled, you received a packet that included this booklet, and a general information sheet about surgery at Shands. You will also be asked to get a clearance letter from your “family doctor or internist”. It is up to you to make sure this is done and that we get the clearance before your pre-op day at the clinic. If you have a cardiac condition, you must have your cardiac doctor clear you for surgery. If you don’t bring them, make sure you have a list of all medications that you take both over-the-counter (such as aspirin, Motrin, vitamins, and herbal remedies) and prescribed medications with dosages and how often you take them. The correct medication and dosages are important so we can maintain your health throughout your hospital experience. You will be talking to a nurse case manager either pre-op or post-op who will assist you in obtaining any equipment or services needed after discharge from the hospital. Please be aware that not all insurance pays for inpatient rehab, outpatient rehab, homecare rehab, etc. If you have questions or concerns about where you will be discharged to after leaving the hos pital, call the clinic and ask to speak to the case manager for your doctor. If you get the case man ager’s voice mail, please leave your name, your doctor’s name, your phone number and what type of surgery you will be having and when. Prior to your surgery date, you will be scheduled to come to the orthopaedic clinic and the pre operative anesthesia clinic. At this time, a complete history and physical will be done to be sure you are in the best condition for surgery. The surgeon and anesthesiologist will explain the surgery and the anesthesia plan to you and your family, answer any questions, and have you sign the operative and anesthesia permits. List of questions: Bring this sheet with your questions to pre-op so you can remember to ask the doctor, nurse, anesthesiologist what you want to know and address any concerns you may have. Please leave your valuables at home; the hospital cannot be responsible for your items. You are scheduled to have an elective knee replacement in the near future, and the Rehabilitation Department wanted to give you some information on what to expect day by day in regards to your post-operative care.

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After 2 years there was a progressive reduction (about 40%) in the incidence of fibrocystic disease of the breast arthritis in back care purchase 400 mg pentoxifylline amex. Women who used oral contraception were one-fourth as likely to pills for arthritis in dogs effective pentoxifylline 400 mg develop benign breast disease as nonusers arthritis medication for cats over the counter discount pentoxifylline online american express, but this protection was limited to how to detect arthritis in fingers pentoxifylline 400mg free shipping current and recent users. It is still uncertain whether this same protection is provided by the lower dose products. A French case-control study indicated a reduction of nonproliferative benign breast disease associated with low-dose oral 174 contraceptives used before a first full-term pregnancy, but no effect on proliferative disease or with use after a pregnancy. However, patients were enrolled in these studies at a time when oral contraception was used primarily by married couples spacing out their children. Beginning in the 1980s, oral contraception was primarily being used by women early in life, for longer durations, and to delay an initial pregnancy (remember, a full-term pregnancy early in life protects against breast cancer). Over the last decade, case-control studies have focused on the use of oral contraception early in life, for long duration, and to delay a first, full-term pregnancy. Because the cohort of women who have used oral contraception in this fashion is just now beginning to reach the ages of postmenopausal breast cancer, the studies have had to focus on the risk of breast cancer diagnosed before age 45 (only 13% of all breast cancer). Some 180, 181, 182, 183, 184, 185, 186 and 187 studies have indicated an overall increased relative risk of early, premenopausal breast cancer, while others indicated no increase in 188, 189 and 190 191, 192, 193, 194, 195 and196 197, 198, 199, 200 and 201 overall risk. The most impressive finding indicates a link in most studies, but not all, of early breast cancer before age 40 with women who used oral contraception for long durations of time. A collaborative group composed of an enormous number of epidemiologists and cancer investigators from around the world re-analyzed data from 54 studies in 26 countries, a total of 53,297 women with breast cancer and 100,239 without breast cancer, in order to assess the relationship between the risk of breast cancer and the 202 use of oral contraceptives. Oral contraceptives were grouped into 3 categories: low, medium, and high dose (which correlated with <50µg, 50 µg, and >50 µg of estrogen). At the time of diagnosis, 9% of the women with breast cancer were under age 35, 25% were 35–44, 33% were 45–54, and 33% were age 55 and older. A similar percentage of women with breast cancer (41%) and women without breast cancer (40%) had used combined oral contraceptives at some time in their lives. The relative risk analyzed by duration of use was barely elevated and not statistically significant (even when long-term use, virtually continuous, was analyzed). Women who had begun use as teenagers had about a 20% statistically significant increased relative risk. In other words, recent users who began use before age 20 had a higher relative risk compared with recent users who began at later ages. The evidence was strong for a relationship with time since last use, an elevated risk being significant for current users and in women who had stopped use 1–4 years before (recent use). No influence on this risk was observed with the following: a family history of breast cancer, age of menarche, country of origin, ethnic groups, body weight, alcohol use, years of education, and the design of the study. There was no variation according to specific type of estrogen or progestin in the various products. Importantly, there was no statistically significant effect of low, medium, or high dose preparations. Ten or more years after stopping use, there was no increased risk of breast cancer. Indeed, the risk of metastatic disease compared with localized tumors was reduced: Relative Risk = 0. The re-analysis indicated that the results were similar to those with combined oral contraceptives, but a close look at the numbers reveals that not one relative risk reached statistical significance. Even though the data indicated that young women who begin use before age 20 have higher relative risks of breast cancer during current use and in the 5 years after stopping, this is a time period when breast cancer is very rare; and, thus, there would be little impact on the actual number of breast cancers. The difference between localized disease and metastatic disease was statistically greater and should be observable. Thus many years after stopping oral contraceptive use, the main effect may be protection against metastatic disease. Breast cancer is more common in older years, and 10 or more years after stopping, the risk was not increased. What other explanation could account for an increased risk associated only with current or recent use, no increase with duration of use, and a return to normal 10 years after exposure? The slightly increased risk could be influenced by detection/surveillance bias (more interaction with the health care system by oral contraceptive users). And some have found that a 204, 205 concurrent or recent pregnancy adversely affects survival. It is argued that breast cells that have already begun malignant transformation are adversely affected by the hormones of pregnancy, while normal stem cells become more resistant because of a pregnancy. It is possible that early and recent use of oral contraceptives also accelerates the growth of a pre-existing malignancy, explaining the limitation of the finding to current and recent use and the increase in localized disease. In a case-control study of women in Toronto, Canada, age 40–69 years, those women who had used oral contraceptives for 5 or more years, 15 or more years previously, had a 50% reduced 206 risk of breast cancer. Conclusion Adding up the benefits of oral contraception, the possible slight increase in risk of breast cancer is far outweighed by positive effects on our public health. But the impact on public health is of little concern during the private clinician—patient interchange in the office. Here personal risk receives highest priority; fear of cancer is a motivating force, and compliance with effective contraception requires accurate information. For these reasons, we provide the following summary of our assessment of the impact of oral contraceptives on the risk of breast cancer. This finding may be due to detection/surveillance bias and accelerated growth of already present malignancies, a situation similar to the effects of pregnancy and postmenopausal hormone therapy on the risk of breast cancer (as reviewed in Chapter 18). Further comfort can be derived from the fact that the increase in breast cancer in American women was greater in older women from 1973 to 1994, those who did 207 not have the opportunity to use oral contraception. In women under 50 years of age, there was only a slight increase during this same time period. Previous oral contraceptive use may be associated with a reduced risk of metastatic breast cancer later in life, and possibly with a reduced risk of postmenopausal breast cancer. Oral contraceptive use does not further increase the risk of breast cancer in women with positive family histories of breast cancer or in women with proven benign breast disease. The clinician should not fail to take every opportunity to direct attention to all factors that affect breast cancer. Breastfeeding and control of alcohol intake are good examples, and are also components of preventive health care. The protective effect of breastfeeding is exerted (although it is probably a small one; see Chapter 16) on premenopausal breast cancer, the cancer of concern to younger women using oral contraception. Other Cancers the Walnut Creek study suggested that melanoma was linked to oral contraception; however, the major risk factor for melanoma is exposure to sunlight. More recent and accurate evaluation utilizing both the Royal College General Practitioners and Oxford Family Planning Association prospective cohorts and accounting for 208, 209 exposure to sunlight did not indicate a significant difference in the risk of melanoma comparing users to nonusers. There is no evidence linking oral 210 contraceptive use to kidney cancer, gallbladder cancer, or pituitary tumors. Long-term oral contraceptive use may slightly increase the risk of molar pregnancy, but 211 there is no convincing evidence of a cause-and-effect association. It had been thought that the increase in plasma cortisol while on oral contraception was due to increased binding by this globulin and not an increase in free active cortisol. Estrogen decreases the ability of the liver to metabolize cortisol, and in addition, progesterone and related compounds can displace cortisol from transcortin, and thus contribute to the elevation of unbound cortisol. The effects of these elevated levels over prolonged periods of time are unknown, but no obvious impact has become apparent. To put this into perspective, the increase is not as great as that which occurs in pregnancy, and, in fact, it is within the normal range for nonpregnant women. Initial studies indicated that the response to metyrapone (an 11b-hydroxylase blocker) was abnormal, suggesting that the pituitary was suppressed. However, estrogen accelerates the conjugation of metyrapone by the liver; and, therefore, the drug has less effect, thus explaining the subnormal responses initially reported. The pituitary-adrenal reaction to stress is normal in women on oral contraceptive pills. Thyroid Estrogen increases the synthesis and circulating levels of thyroxine-binding globulin, Prior to the introduction of new methods for measuring free thyroxine levels, evaluation of thyroid function was a problem. Oral contraception affects the total thyroxine level in the blood as well as the amount of binding globulin, but the free thyroxine level is unchanged. Oral Contraception and Reproduction the impact of oral contraceptives on the reproductive system is less than initially thought.

The white-tailed deer (Odocoileus virginianus) is an important host for blood meals for the tick but is not a reservoir host of B microti syphilitic arthritis definition buy genuine pentoxifylline on line. An increase in the deer population in some geographic areas arthritis fingers jiu jitsu purchase 400mg pentoxifylline amex, including some subur ban areas arthritis pain groin buy 400mg pentoxifylline free shipping, during the past few decades is thought to arthritis diet restrictions cheap 400mg pentoxifylline with amex be a major factor in the spread of I scapularis and the increase in numbers of reported cases of babesiosis. The reported vectorborne cases of B microti infection have been acquired in the Northeast (particularly, but not exclusively, in Connecticut, Massachusetts, New Jersey, New York, and Rhode Island) and in the upper Midwest (Wisconsin and Minnesota). Occasional human cases of babesiosis caused by other species have been described in various regions of the United States; tick vectors and reservoir hosts for these agents typically have not yet been identifed. B microti and other Babesia species can be diffcult to distinguish from Plasmodium falciparum; examination of blood smears by a reference laboratory should be considered for confrmation of the diagnosis. Serologic and mole cular testing are performed at the Centers for Disease Control and Prevention and at some other reference laboratories and are important adjunctive tests. If indicated, the possibility of concurrent B burgdorferi or Anaplasma infection should be considered. Therapy with atovaquone plus azithromycin is associated with fewer adverse effects. However, the combination of clindamycin and quinine remains the stan dard of care for severely ill patients. In addition, exchange blood transfusions should be considered for patients who are critically ill (eg, hemodynamically unstable), especially but not exclusively for patients with parasitemia concentrations 10% or greater. The frst is the emetic syndrome, which, like staphylococcal foodborne illness, develops after a short incubation period and is characterized by nausea, vomiting, abdominal cramps, and in approximately 30% of patients, diarrhea. The second is the diarrhea syndrome, which, like Clostridium perfringens foodborne illness, has a slightly longer incubation period and is characterized predominantly by moderate to severe abdomi nal cramps and watery diarrhea, with vomiting in approximately 25% of patients. Both syndromes are mild, usually are not associated with fever, and abate within 24 hours. The emetic toxin is cytotoxic, can cause rhabdomyolysis, and has been associated with fulmi nant liver failure. The diarrhea syndrome is caused by in vivo production of 1 or 2 heat labile enterotoxins. The organism is thought to be a fairly common cause of foodborne illness in the United States but rarely is diagnosed, because clinical laboratories do not test for it. Spores of B cereus are heat resistant and can sur vive pasteurization, brief cooking, or boiling. Vegetative forms can grow and produce enterotoxins over a wide range of temperatures, from 25°C to 42°C (77°F–108°F). The emetic syndrome occurs after eating food containing preformed toxin, most commonly fried rice. Disease can result from eating food contaminated with B cereus spores, which produce enterotoxin in the gastrointestinal tract. Spore-associated disease most commonly is caused by contaminated meat or vegetables and manifests as the diarrhea syndrome. Risk factors for invasive disease attributable to B cereus include history of injection drug use, presence of indwelling intravascular catheters or implanted devices, neutro penia or immunosuppression, and preterm birth. B cereus endophthalmitis has occurred after penetrating ocular trauma and injection drug use. Bacillus-contaminated 70% alco hol pads not labeled as sterile can lead to outbreaks. Because the organism can be recovered from stool specimens from some well people, the presence of B cereus in feces or vomitus of ill people is not defnitive evidence of infection. Food can be tested for the diarrhea syndrome toxins using com mercially available tests. In patients with risk factors for invasive disease, isolation of B cereus from wounds, blood, or other usually sterile body fuids is signifcant. Oral rehydration or, occasionally, intravenous fuid and electrolyte replacement for patients with severe dehydration is indicated. Prompt removal of any potentially infected foreign bodies, such as central lines or implants, is essential. B cereus usually is susceptible to vancomycin, which is the drug of choice, and also to alternative drugs, including clindamycin, meropenem, imipenem, and ciprofoxacin. Food should be kept at temperatures higher than 60°C (140°F) or rapidly cooled to less than 10°C (50°F) after cooking. Hand hygiene and strict aseptic technique in caring for immunocompromised patients or patients with indwelling intravascular catheters are important to minimize the risk of invasive disease. Classic signs, when present, include a thin white or grey, homogenous, adherent vaginal discharge with a fshy odor often noted to increase after intercourse. Causes of vaginitis in prepubertal girls frequently are nonspecifc but include foreign bodies or infections attributable to group A streptococci, Escherichia coli, herpes simplex virus, Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, or enteric bacteria, including Shigella species. Typical micro biologic fndings of vaginal specimens show an increase in concentrations of Gardnerella vaginalis, genital mycoplasmas, anaerobic bacteria (eg, Prevotella species and Mobiluncus species), Ureaplasma species, Mycoplasma species, and a marked decrease in concentration of hydrogen peroxide-producing Lactobacillus species. A Gram stain of vaginal secretions is an alternative means of establishing a diagnosis and is considered by some experts the gold standard for making the diagnosis. A paucity of large gram-positive bacilli consistent with decreased lactobacilli and a predominance of gram-negative and gram-variable rods and cocci (eg, G vaginalis, Prevotella species, Porphyromonas species, and Peptostreptococcus species) with or without the presence of curved gram-negative rods (Mobiluncus species) are characteristic. Douching, recent intercourse, menstruation, and coexisting infection can alter fndings on Gram stain. All nonpregnant patients who are symptomatic should be treated after discussion of patient preference for oral versus intravaginal treatment, possi ble adverse effects, and need to evaluate for other coinfections. Nonpregnant patients with symptoms should be treated with metronidazole for 7 days, tinidazole for 2 days, metro nidazole gel intravaginally for 5 days, or clindamycin cream intravaginally, at bedtime, for 7 days (see Table 4. Use of these agents for young children generally has not been evaluated; doses should be based on age of the child. Clindamycin cream can weaken latex condoms and diaphragms for up to 5 days after completion of therapy. Approximately 30% of appropriately treated females have a recurrence within 3 months. For patients with multiple recurrences, metronidazole gel, twice weekly for 4 to 6 months, may be considered. Asymptomatic preg nant women with a history of adverse pregnancy outcomes (eg, previous preterm birth, premature rupture of membranes, chorioamnionitis) may be considered for treatment. Metronidazole (500 mg, twice daily for 7 days; or 250 mg, orally, 3 times a day for 7 days) is the preferred treatment during pregnancy. Current data suggest that oral treatment regimens are preferred, although intravaginal clindamycin may be an option but only during the frst half of pregnancy. Recurrences are common and can be treated with the same regimen that was given initially. Species from the gastrointestinal tract are recovered in patients with peritonitis, intra-abdominal abscess, pelvic infammatory dis ease, postoperative wound infection, or vulvovaginal and perianal infections. Soft tissue infections include synergistic bacterial gangrene and necrotizing fasciitis. Invasion of the bloodstream from the oral cavity or intestinal tract can lead to brain abscess, meningitis, endocarditis, arthritis, or osteomyelitis. Skin involvement includes omphalitis in newborn infants; cellulitis at the site of fetal monitors, human bite wounds, or burns; infections adjacent to the mouth or rectum; and decubitus ulcers. Neonatal infections, including conjunctivitis, pneumonia, bacteremia, or meningitis, rarely occur. Members of the Bacteroides fragilis group predominate in the gastrointestinal tract fora; members of the Prevotella melaninogenica (formerly Bacteroides melaninogenicus) and Prevotella oralis (formerly Bacteroides oralis) groups are more common in the oral cavity. These species cause infection as opportunists, usually after an alteration of the body’s physical barrier and in conjunction with other endogenous species. Endogenous infection results from aspiration, spillage from the bowel, or damage to mucosal surfaces from trauma, surgery, or chemotherapy. Except in infections result ing from human bites, no evidence of person-to-person transmission exists. The incubation period is variable and depends on the inoculum and the site of involvement but usually is 1 to 5 days. Because infections usually are polymicrobial, aerobic cultures also should be obtained.

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