Jacquelyn Gayle Bolwell, MD

• Medical Instructor in the Department of Medicine

https://medicine.duke.edu/faculty/jacquelyn-gayle-bolwell-md

Valaciclovir versus aciclovir in patient initiated treatment of recurrent genital herpes: a randomised acne free generic 20 mg accutane amex, double blind clinical trial acne blemishes generic 5 mg accutane amex. Oral famciclovir for the suppression of recurrent genital herpes: a randomized controlled trial acne 5 pocket jeans purchase accutane 20 mg on-line. Oral famciclovir for suppression of recurrent genital herpes simplex virus infection in women: a multicenter tretinoin 05 acne cheap accutane 20mg amex, double-blind acne zoomed in generic 5 mg accutane, placebo-controlled trial skin care quiz order 20mg accutane. Long-term suppression of recurrent genital herpes with acyclovir: a 5-year benchmark. Recurrence and resistance patterns of herpes simplex virus following cessation of 6 years of chronic suppression with acyclovir. Herpes simplex virus type 2 serological testing and psychosocial harm: a systematic review. Reactivation of herpes simplex virus type 2 after initiation of antiretroviral therapy. Acyclovir-resistant genital herpes among persons attending sexually transmitted disease and human immunodeficiency virus clinics. A controlled trial comparing foscarnet with vidarabine for acyclovir-resistant mucocutaneous herpes simplex in the acquired immunodeficiency syndrome. Neonatal herpes disease following maternal antenatal antiviral suppressive therapy: a multicenter case series. Lymphogranuloma venereum proctocolitis: a silent endemic disease in men who have sex with men in industrialised countries. Clinical predictors of rectal lymphogranuloma venereum infection: results from a multicentre case-control study in the U. Recommendations for the laboratory-based detection of Chlamydia trachomatis and Neisseria gonorrhoeae-2014. Syphilis testing algorithms using treponemal tests for initial screening-four laboratories, New York City, 2005-2006. Screening for syphilis with the treponemal immunoassay: analysis of discordant serology results and implications for clinical management. Cerebrospinal fluid abnormalities in patients with syphilis: association with clinical and laboratory features. Single-dose azithromycin versus penicillin G benzathine for the treatment of early syphilis. A randomized, comparative pilot study of azithromycin versus benzathine penicillin G for treatment of early syphilis. Lack of allergic cross-reactivity to cephalosporins among patients allergic to penicillins. Response of latent syphilis or neurosyphilis to ceftriaxone therapy in persons infected with human immunodeficiency virus. Effectiveness of interventions to improve screening for syphilis in pregnancy: a systematic review and meta-analysis. Congenital syphilis: still a serious, underdiagnosed threat for children in resource-poor countries. Prevalence and characteristics of reported penicillin allergy in an urban outpatient adult population. The incidence of antimicrobial allergies in hospitalized patients: implications regarding prescribing patterns and emerging bacterial resistance. Results of the National Institute of Allergy and Infectious Diseases Collaborative Clinical Trial to test the predictive value of skin testing with major and minor penicillin derivatives in hospitalized adults. Safely diagnosing clinically significant penicillin allergy using only penicilloyl-poly-lysine, penicillin, and oral amoxicillin. The use of penicillin skin testing to assess the prevalence of penicillin allergy in an emergency department setting. IgE-mediated hypersensitivity to cephalosporins: cross-reactivity and tolerability of penicillins, monobactams, and carbapenems. Anaphylaxis to amoxycillin but good tolerance for benzyl penicillin: in vivo and in vitro studies of specific IgE antibodies. Etiologies of nongonococcal urethritis: bacteria, viruses, and the association with orogenital exposure. Chlamydial and gonococcal infection in men without polymorphonuclear leukocytes on gram stain: implications for diagnostic approach and management. Repeat infection with chlamydia and gonorrhea among females: a systematic review of the literature. Chlamydial and gonococcal reinfection among men: a systematic review of data to evaluate the need for retesting. Mycoplasma genitalium in cervicitis and pelvic inflammatory disease among women at a gynecologic outpatient service. Vaginal leucocyte counts in women with bacterial vaginosis: relation to vaginal and cervical infections. Combination of bacterial vaginosis and leukorrhea as a predictor of cervical chlamydial or gonococcal infection. Prevention of pelvic inflammatory disease by screening for cervical chlamydial infection. Decreasing incidences of gonorrhea- and chlamydia-associated acute pelvic inflammatory disease: a 25-year study from an urban area of central Sweden. The cost-effectiveness of screening men for Chlamydia trachomatis: a review of the literature. Asymptomatic gonorrhea and chlamydial infections detected by nucleic acid amplification tests among Boston area men who have sex with men. Nucleic acid amplification tests for diagnosis of Neisseria gonorrhoeae oropharyngeal infections. How reliable is self-testing for gonorrhea and chlamydia among men who have sex with men? High performance and acceptability of self-collected rectal swabs for diagnosis of Chlamydia trachomatis and Neisseria gonorrhoeae in men who have sex with men and women. Rectal self-sampling in nonclinical venues for detection of sexually transmissible infections among behaviourally bisexual men. Chlamydia trachomatis and Neisseria gonorrhoeae transmission from the female oropharynx to the male urethra. A randomized controlled trial comparing amoxicillin and azithromycin for the treatment of Chlamydia trachomatis in pregnancy. Repeat screening for sexually transmitted infection in adolescent obstetric patients. Evaluation of four commercial transport media for the survival of Neisseria gonorrhoeae. Outbreak of cefozopran (penicillin, oral cephems, and aztreonam)-resistant Neisseria gonorrhoeae in Japan. Treatment of uncomplicated gonococcal urethritis by double-dosing of 200 mg cefixime at a 6-h interval. First Neisseria gonorrhoeae strain with resistance to cefixime causing gonorrhoea treatment failure in Austria, 2011. Neisseria gonorrhoeae treatment failure and susceptibility to cefixime in Toronto, Canada. The efficacy and safety of gentamicin plus azithromycin and gemifloxacin plus azithromycin as treatment of uncomplicated gonorrhea. Emergence of highlevel azithromycin resistance in Neisseria gonorrhoeae in England and Wales. Intersecting epidemics and educable moments-Sexually transmitted disease risk assessment and screening in men who have sex with men. Early repeat Chlamydia trachomatis and Neisseria gonorrhoeae infections among heterosexual men. Surveillance of gonococcal antimicrobial susceptibility resulting in early detection of emerging resistance. Periocular ulcerative dermatitis associated with gentamicin ointment prophylaxis in newborns. Severe ocular reactions after neonatal ocular prophylaxis with gentamicin ophthalmic ointment. Association of bacterial vaginosis with adverse fetomaternal outcome in women with spontaneous preterm labor: a prospective cohort study. Effectiveness of two tinidazole regimens in treatment of bacterial vaginosis: a randomized controlled trial. Association of Atopobium vaginae, a recently described metronidazole resistant anaerobe, with bacterial vaginosis. The association of Atopobium vaginae and Gardnerella vaginalis with bacterial vaginosis and recurrence after oral metronidazole therapy. The effects of intravaginal clindamycin and metronidazole therapy on vaginal mobiluncus morphotypes in patients with bacterial vaginosis. The efficacy of retreatment with the same medication for early treatment failure of bacterial vaginosis. Boric acid addition to suppressive antimicrobial therapy for recurrent bacterial vaginosis. Reduced incidence of preterm delivery with metronidazole and erythromycin in women with bacterial vaginosis. Treatment of abnormal vaginal flora in early pregnancy with clindamycin for the prevention of spontaneous preterm birth: a systematic review and metaanalysis. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Intravaginal clindamycin to reduce preterm birth in women with abnormal genital tract flora. The prevalence of Trichomonas vaginalis infection among reproductive-age women in the United States, 2001-2004. Prevalence and predictors of sexually transmitted infection among newly incarcerated females. Screening for sexually transmitted diseases and hepatitis in 18-29-year-old men recently released from prison: feasibility and acceptability. Prevalence of urethral Trichomonas vaginalis in black and white men who have sex with men. Use of nucleic acid amplification testing for diagnosis of anorectal sexually transmitted infections. Concentrations of metronidazole and tinidazole in female reproductive organs after a single intravenous infusion and after repeated oral administration. The minimum single oral metronidazole dose for treating trichomoniasis: a randomized, blinded study. Tinidazole in the treatment of trichomoniasis, giardiasis and amoebiasis: report of a multicentre study. Prevalence, incidence, natural history, and response to treatment of Trichomonas vaginalis infection among adolescent women. Does patient-delivered partner treatment improve disclosure for treatable sexually transmitted diseases? Recalcitrant Trichomonas vaginalis infections successfully treated with vaginal acidification. Persistent and recurrent Trichomonas vaginalis infections: epidemiology, treatment and management considerations. Management of Trichomonas vaginalis in women with suspected metronidazole hypersensitivity. Treatment of trichomoniasis in pregnancy in sub-Saharan Africa does not appear to be associated with low birth weight or preterm birth. Clinical relevance of the pharmacokinetic interactions of azole antifungal drugs with other coadministered agents. Evolution of antifungal susceptibility among Candida species isolates recovered from human immunodeficiency virus-infected women receiving fluconazole prophylaxis. A serological study of the role of Mycoplasma genitalium in pelvic inflammatory disease and ectopic pregnancy. Endometritis does not predict reproductive morbidity after pelvic inflammatory disease. Effects of human immunodeficiency virus 1 infection on microbial origins of pelvic inflammatory disease and on efficacy of ambulatory oral therapy. Estimates of the annual direct medical costs of the prevention and treatment of disease associated with human papillomavirus in the United States. Sinecatechins, a defined green tea extract, in the treatment of external anogenital warts: a randomized controlled trial. Topical Polyphenon E in the treatment of external genital and perianal warts: a randomized controlled trial. Condyloma in pregnancy is strongly predictive of juvenile-onset recurrent respiratory papillomatosis. Frequency of occult high-grade squamous intraepithelial neoplasia and invasive cancer within anal condylomata in men who have sex with men. Genital warts and vulvar intraepithelial neoplasia: natural history and effects of treatment and human immunodeficiency virus infection. Self-reported Papanicolaou smears and hysterectomies among women in the United States. Interventions that increase use of Pap tests among ethnic minority women: a meta-analysis. Providing high quality information about human papillomavirus for women after treatment for high-grade cervical dysplasia. Psychosocial outcomes of three triage methods for the management of borderline abnormal cervical smears: an open randomised trial. The effectiveness and safety of two cervical cytologic techniques during pregnancy.

Reported complications include major bleeding or hematoma at the administration site skin care with retinol discount 10 mg accutane mastercard, compartment syndrome acne 5 days after ovulation purchase accutane 10 mg line, intracranial hemorrhage acne 4 weeks pregnant accutane 5 mg without a prescription, and gastrointestinal hemorrhage acne neutrogena purchase accutane 20 mg fast delivery. Black Box Warning Epidural or spinal hematomas skin care 08 generic accutane 20mg otc, which may result in long-term or permanent paralysis acne- buy accutane 20mg without prescription, may occur in patients who are anticoagulated with low molecular weight heparins or heparinoids and are receiving neuraxial anesthesia or undergoing spinal puncture. Pharmacology Enoxaparin is a low-molecular weight heparin that has considerably less activity against thrombin than does standard heparin. Monitoring Measure anti-factor Xa concentrations 4 to 6 hours after a dose (therapeutic range, 0. Obtain anti-factor Xa levels initially, weekly during hospitalization, and then every 3 to 4 weeks in stable patients. Dix D, Andrew M, Marzinotto V, et al: the use of low molecular weight heparin in pediatric patients: a prospective cohort study. Klinger G, Hellmann J, Daneman A: Severe aortic thrombosis in the neonate successful treatment with low-molecular-weight heparin: Two case reports and review of the literature. Monagle P, Chalmers E, Chan A, et al: Antithrombotic therapy in neonates and children: Antithrombotic and thrombolytic therapy, 8th Ed. Ignjatovic V, Najid S, Newall F et al: Dosing and monitoring of enoxaparin (Low molecular weight heparin) therapy in children. Summerhayes R, Chan M, Ignjatovic V et al: Stability and sterility of diluted enoxaparin under three different storage conditions. Adequate iron and protein intake is necessary for epoetin to be effective (additional Vitamin E intake may be necessary as well). Adverse Effects the only adverse effect in premature neonates is neutropenia, which occurs rarely and resolves with discontinuation of the drug. Ohls R: Human recombinant erythropoietin in the prevention and treatment of anemia of prematurity. Do not use single-dose vials admixed with bacteriostatic saline containing benzyl alcohol in neonates and infants. Uses To stimulate erythropoiesis and decrease the need for erythrocyte transfusions in highrisk preterm infants. It is recommended that for (adult) patients with renal failure, the lowest dose should be used that will maintain hemoglobin levels sufficient to reduce the need for red blood cell transfusions. Donato H, Vain N, Rendo P, et al: Effect of early versus late administration of human recombinant human erythropoietin on transfusion requirements in premature infants: Results of a randomized, placebo-controlled, multicenter trial. It is a motilin receptor agonist and induces stomach and small intestine motor activity. Adverse Effects the risk of hypertrophic pyloric stenosis is increased 10-fold in neonates under 2 weeks of age who receive oral erythromycin for pertussis prophylaxis (1 additional case per every 42 infants treated). No studies of premature infants with feeding intolerance have been large enough to assess safety. Bilateral sensorineural hearing loss has been reported rarely in adults, usually associated with intravenous administration and renal or hepatic dysfunction. Tobramycin ophthalmic ointment may be used if azithromycin solution is not available. Acyclovir, aminophylline, amiodarone, cimetidine, enalaprilat, esmolol, famotidine, heparin, hydrocortisone succinate, lidocaine, lorazepam, magnesium sulfate, midazolam, morphine, nicardipine, penicillin G, pentobarbital, potassium chloride, ranitidine, sodium bicarbonate, and zidovudine. Product Information: Eryped oral suspension, erythromycin ethylsuccinate oral suspension. Title Erythromycin Dose Oral Treatment of pneumonitis and conjunctivitis due to Chlamydia trachomatis: 12. Pharmacology Erythromycin may be bacteriostatic or bactericidal depending on the tissue concentration of drug and the microorganism involved. Digoxin, midazolam, theophylline and carbamazepine serum concentrations may be significantly increased because of prolongation of their half-life. Adverse Effects the risk of hypertrophic pyloric stenosis is increased 10-fold in neonates under 2 weeks of age who receive oral erythromycin for pertussis prophylaxis (1 additional case per 317 Micormedex NeoFax Essentials 2014 every 42 infants treated). The hearing loss occurred after the first few doses and was reversible after discontinuing the drug. Reconstituted solution stable for 24 hours at room temperature or 2 weeks in refrigerator. Acyclovir, aminophylline, amiodarone, cimetidine, enalaprilat, esmolol, famotidine, heparin, hydrocortisone succinate, lidocaine, 318 Micormedex NeoFax Essentials 2014 lorazepam, magnesium sulfate, midazolam, morphine, nicardipine, penicillin G, pentobarbital, potassium chloride, ranitidine, sodium bicarbonate, and zidovudine. Terminal Injection Site Incompatibility Ampicillin, cefepime, cefotaxime, ceftazidime, chloramphenicol, fluconazole, furosemide, linezolid, and metoclopramide. Nuntnarumit P, Kiatchoosakun P, Tantiprapa W, Boonkasidecha S: Efficacy of oral erythromycin for treatment of feeding intolerance in preterm infants. Oei J, Lui K: A placebo-controlled trial of low-dose erythromycin to promote feed tolerance in preterm infants. Patole S, Rao S, Doherty D: Erythromycin as a prokinetic agent in preterm neonates: a systematic review. Pharmacology Esmolol is a potent cardio-selective beta-blocking agent with a uniquely short half-life (2. There appears to be no correlation between age and pharmacodynamic response or pharmacokinetic profile. Continuous infusion of the daily dose in adults provides better gastric acid suppression than intermittent dosing. No short term adverse effects have been reported in infants and children, although data are limited to a few small studies. Constitute by slowly adding 46 mL Purified Water and shaking vigorously for 5-10 seconds. Elimination halflife is dependent on renal function, and decreases with age from 11 hours (range 5 to 22) in neonates to 8 hours (range 4 to 12) by 3 months of age. The minimum dose should be used in infants with severe hyperbilirubinemia, sepsis, or severe pulmonary dysfunction. There are no specific data regarding the compatibility of dobutamine or dopamine and fat emulsions. Terminal Injection Site Incompatibility Acyclovir, amikacin, amphotericin B, ganciclovir, lorazepam, magnesium chloride, midazolam, octreotide acetate, pentobarbital, phenobarbital, and phenytoin. Strict adherence to the recommended total daily dose and hourly infusion rates is recommended. Clearance is via endogenous lipoprotein lipase activity, which is limited in very premature (less than 28 weeks gestation) and infected infants. Twenty percent emulsions are preferred due to lower total phospholipid and liposome content per gram of triglyceride. Ten percent emulsions have been associated with hypercholesterolemia and hyperphospholipidemia. Pharmacology Synthetic opioid narcotic analgesic that is 50 to 100 times more potent than morphine on a weight basis. Significant withdrawal symptoms have been reported in patients treated with continuous infusion for 5 days or longer. Terminal Injection Site Incompatibility Azithromycin, pentobarbital and phenytoin. Fahnenstich H, Steffan J, Kau N, Bartmann P: Fentanyl-induced chest wall rigidity and laryngospasm in preterm and term infants. Muller P and Vogtmann C: Three cases with different presentation of fentanyl-induced muscle rigidity-A rare problem in intensive care of neonates. Transient rebound in fentanyl serum concentration may reflect sequestration and subsequent release of fentanyl from body fat. Monitoring 334 Micormedex NeoFax Essentials 2014 Monitor respiratory and cardiovascular status closely. Alprostadil, amiodarone, atropine, caffeine citrate, cimetidine, dexamethasone, dobutamine, dopamine, enalaprilat, epinephrine, esmolol, furosemide, heparin, hydrocortisone succinate, lidocaine, linezolid, lorazepam, metoclopramide, midazolam, milrinone, morphine, nafcillin, nicardipine, pancuronium bromide, potassium chloride, propofol, ranitidine, remifentanil, and vecuronium. Nausea, constipation, black stools, lethargy, hypotension, and erosion of gastric mucosa. Optimal effect may take 2 to 3 days of therapy to achieve, and steady-state plasma levels may not be reached until 3 to 5 days at a given dosage in patients with normal renal and hepatic function. Therefore, do not increase dosage more frequently than approximately once every 4 days. Follow trough serum concentrations closely at initiation, 3 to 5 days after any dose change, and with any significant change in clinical status or diet. Uses Treatment of supraventricular arrhythmias not responsive to conventional therapies. Flecainide is not recommended for use in patients with chronic atrial fibrillation. Elimination half-life in newborns after maternal administration is as long as 29 hours. Product Information: flecainide acetate oral tablets, flecainide acetate oral tablets. A retrospective study using historical controls reports direct hyperbilirubinemia in the absence of elevated transaminases in some infants treated prophylactically for 6 weeks. May also interfere with metabolism of aminophylline, caffeine, theophylline, and midazolam. Huttova M, Hartmanova I, Kralinsky K, et al: Candida fungemia in neonates treated with fluconazole: report of forty cases, including eight with meningitis. Extended dosing intervals should be considered for neonates with renal insufficiency (serum creatinine greater than 1. Note: the higher doses are based on recent pharmacokinetic data but have not been prospectively tested for efficacy or safety. Uses Treatment of systemic infections, meningitis, and severe superficial mycoses caused by Candida species. Resistance has been reported with C glabrata and C krusei and in patients receiving long-term suppressive therapy. Well absorbed after oral administration, with peak serum concentrations reached within 1 to 2 hours. Monitoring 346 Micormedex NeoFax Essentials 2014 Serum fluconazole concentrations are not routinely followed. Prepare both concentrations by adding 24 mL distilled water to bottle of powder and shaking vigorously. Manzoni P, Stolfi I, Pugni L, et al: A multicenter, randomized trial of prophylactic fluconazole in preterm neonates. Fluconazole prophylaxis in extremely low birth weight infants: association with cholestasis. Saxen H, Hoppu K, Pohjavuori M: Pharmacokinetics of fluconazole in very low birth weight infants during the first two weeks of life. Uses Antifungal agent used in combination with amphotericin B or fluconazole for treatment of infections caused by Candida, Cryptococcus, and other sensitive fungi. Close monitoring of hematologic, renal, and hepatic status of all patients is essential. Suspension is stable for at least 90 days when stored at room temperature or under refrigeration. References Marr B, Gross S, Cunningham C, et al: Candidal sepsis and meningitis in a very-lowbirth-weight infant successfully treated with fluconazole and flucytosine. Uses 349 Micormedex NeoFax Essentials 2014 Antifungal agent used in combination with amphotericin B or fluconazole for treatment of infections caused by Candida, Cryptococcus, and other sensitive fungi. Serum half-life in adults is 3 to 5 hours if renal function is normal, but 30 to 250 hours if renal impairment is present. Fatal bone marrow depression (related to fluorouracil production), hepatitis, severe diarrhea, rash. Uses Reversal of sedative effect from benzodiazepines, in cases of suspected benzodiazepines overdose, and in neonatal apnea secondary to prenatal benzodiazepine exposure. Monitoring 351 Micormedex NeoFax Essentials 2014 Monitor for the return of sedation and respiratory depression. Terminal Injection Site Compatibility Aminophylline, cimetidine, dobutamine, dopamine, famotidine, heparin, lidocaine, procainamide, and ranitidine. Carbajal R, Simon N, Blanc P, et al: Rectal flumazenil to reverse midazolam sedation in children. Administer intravenously through a freely running large vein to minimize pain upon injection. Uses 352 Micormedex NeoFax Essentials 2014 Reversal of sedative effect from benzodiazepines, in cases of suspected benzodiazepines overdose, and in neonatal apnea secondary to prenatal benzodiazepine exposure. Seizures are most frequent in patients who have been on benzodiazepines for long-term sedation. A review of its benzodiazepine antagonist properties, intrinsic activity and therapeutic use. Although the risk of cardiovascular toxicity increases with infusion rates above the recommended infusion rate, these 354 Micormedex NeoFax Essentials 2014 events have also been reported at or below the recommended infusion rate. Pharmacology Fosphenytoin is a water-soluble prodrug of phenytoin rapidly converted by phosphatases in blood and tissue. Because fosphenytoin is a prodrug and is converted to phenytoin after administration, any concern regarding this association is also applicable to fosphenytoin. Product Information: Dilantin(R) intravenous injection solution, phenytoin sodium intravenous injection solution. Careful cardiac monitoring is needed during and after administering intravenous fosphenytoin. Although the risk of cardiovascular 357 Micormedex NeoFax Essentials 2014 toxicity increases with infusion rates above the recommended infusion rate, these events have also been reported at or below the recommended infusion rate. Nonlinear (zero order) kinetics (as dose increases, saturation of elimination mechanisms occur leading to progressive accumulation of phenytoin). Conversion half-life of fosphenytoin administered intravenously to infants and children is approximately 8 minutes.

Efficacy of low-dose heparin in prevention of extensive deep-vein thrombosis in patients undergoing total-hip replacement acne leather jacket buy accutane 30 mg online. Incidence of venous thromboembolism following major abdominal surgery: a multi-center acne 9 year old daughter generic accutane 10 mg otc, prospective epidemiological study in Japan acne epiduo accutane 5 mg on line. Direct thrombin inhibitors versus vitamin K antagonists or low molecular weight heparins for prevention of venous thromboembolism following total hip or knee replacement skin care 3m proven accutane 40 mg. Predictors of wound infection in hip and knee joint replacement: results from a 20 year surveillance program acne under the skin discount accutane 10mg with mastercard. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors acne rash buy cheap accutane 20mg. The John Charnley Award: heritable thrombophilia and development of thromboembolic disease after total hip arthroplasty. Extended venous thromboembolism prophylaxis after total hip replacement: a comparison of low-molecular-weight heparin with oral anticoagulant. Venous thromboembolism prevention in surgery and obstetrics: clinical practice guidelines. Quantification of risk factors for venous thromboembolism: a preliminary study for the development of a risk assessment tool. An electronic tool for venous thromboembolism prevention in medical and surgical patients. Fatal pulmonary embolism after bariatric operations for morbid obesity: a 24-year retrospective analysis. A costeffectiveness analysis comparing prolonged oral anticoagulants with screening for deep vein thrombosis. Thromboembolic prophylaxis with use of aspirin, exercise, and graded elastic stockings or intermittent compression devices in patients managed with total hip arthroplasty. Aspirin-sulfinpyrazone in prophylaxis of deep venous thrombosis in total hip replacement. Identifying orthopedic patients at high risk for venous thromboembolism despite thromboprophylaxis. Post-thrombotic syndrome after total hip or knee arthroplasty: incidence in patients with asymptomatic deep venous thrombosis. Long-term follow-up of percutaneous vena cava filters: a prospective study in 100 consecutive patients. Prevention of deep vein thrombosis in orthopedic surgery with the combination of low dose heparin plus either dihydroergotamine or dextran. Retrievable inferior vena cava filters may be safely applied in gastric bypass surgery. Surveillance venous duplex is not clinically useful after total joint arthroplasty when effective deep venous thrombosis prophylaxis is used. Randomized controlled trial, comparative to evaluate the efficacy and security of enoxaparin comparated by heparin in prophylaxis of thromboembolism in patients with arthroplasty replacement hip. Prophylaxis against venous thromboembolic disease in patients having a total hip or knee arthroplasty. Elective total hip replacement: incidence, emergency readmission rate, and postoperative mortality. Venous thromboembolism in patients undergoing surgery: low rates of prophylaxis and high rates of filter insertion. Paucity of studies to support that abnormal coagulation test results predict bleeding in the setting of invasive procedures: An evidence-based review. Efficacy and safety of venous thromboembolism prophylaxis in highest risk plastic surgery patients. Ins and outs of inferior vena cava filters in patients with venous thromboembolism: the experience at Monash Medical Centre and review of the published reports. Lack of complications in minor skin lesion excisions in patients taking aspirin or warfarin products. Effects of epidural anesthesia on the incidence of deep-vein thrombosis after total knee arthroplasty. Factors affecting deep vein thrombosis rate following total knee arthroplasty under epidural anesthesia. Factors influencing deep vein thrombosis following total hip arthroplasty under epidural anesthesia. Changes in mortality after total hip and knee arthroplasty over a ten- year period. Dose response of intravenous heparin on markers of thrombosis during primary total hip replacement. Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. A study of 2153 cases using routine mechanical prophylaxis and selective chemoprophylaxis. A clinico-pathological study of fatal pulmonary embolism in a specialist orthopaedic hospital. Multiple antithrombotic agents increase the risk of postoperative hemorrhage in dermatologic surgery. Venous thromboembolism after orthopedic surgery: implications of the choice for prophylaxis. Continuous lumbar plexus block provides improved analgesia with fewer side effects compared with systemic opioids after hip arthroplasty: a randomized controlled trial. The natural history and aetiology of deep vein thrombosis after total hip replacement. Low-molecular-weight heparin in combination with intermittent pneumatic compression. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty. Effects of intravenous patient-controlled analgesia with morphine, continuous epidural analgesia, and continuous femoral nerve sheath block on rehabilitation after unilateral total-hip arthroplasty. Risk factors associated with major intraoperative blood loss in hepatic resection for hepatobiliary tumor. The costeffectiveness of extended-duration antithrombotic prophylaxis after total hip arthroplasty. Staggered bilateral total knee arthroplasty performed four to seven days apart during a single hospitalization. Predicting bleeding in common ear, nose, and throat procedures: a prospective study. Prophylaxis for deep venous thrombosis in neurosurgical oncology: review of 2779 admissions over a 9-year period. Inferior vena cava filters in trauma patients: Efficacy, morbidity, and retrievability. Factors influencing the long-term outcome of primary total knee replacement in haemophiliacs: a review of 116 procedures at a single institution. Development of a preliminary index that predicts adverse events after total knee replacement. Primary total knee arthroplasty in California 1991 to 2001: does hospital volume affect outcomes? Acetylsalicylic acid in a trial to diminish thromboembolic complications after elective hip surgery. Association between plasma levels of tissue plasminogen activator and postoperative deep vein thrombosis-influence of prophylaxis with a low molecular weight heparin. Bedside placement of removable vena cava filters guided by intravascular ultrasound in the critically injured. Does comorbidity account for the excess mortality in patients with major bleeding in acute myocardial infarction? Failure of aspirin to prevent postoperative deep vein thrombosis in patients undergoing total hip replacement. Prophylaxis of deep venous thrombosis after total hip arthroplasty by using intermittent compression of the plantar venous plexus. Extended interval for retrieval of vena cava filters is safe and may maximize protection against pulmonary embolism. Intraoperative blood losses and transfusion requirements during adult liver transplantation remain difficult to predict. Evaluation of the safety and efficacy of enoxaparin and warfarin for prevention of deep vein thrombosis after total knee arthroplasty. A modified fascia iliaca compartment block has significant morphine-sparing effect after total hip arthroplasty. The impact of bleeding times on major complication rates after percutaneous real-time ultrasoundguided renal biopsies. Preoperative or postoperative start of prophylaxis for venous thromboembolism with low-molecular-weight heparin in elective hip surgery? How well does the activated partial thromboplastin time predict postoperative hemorrhage? Clinical efficacy of mechanical thromboprophylaxis without anticoagulant drugs for elective hip surgery in an Asian population. The effect of pre-operative aspirin on bleeding, transfusion, myocardial infarction, and mortality in coronary artery bypass surgery: A systematic review of randomized and observational studies. Duration and magnitude of the postoperative risk of venous thromboembolism in middle aged women: prospective cohort study. Lower-limb deep-vein thrombosis in a general hospital: risk factors, outcomes and the contribution of intravenous drug use. Assessment of thrombotic risk factors predisposing to thromboembolic complications in prosthetic orthopedic surgery. Randomized study of adjusted versus fixed low dose heparin prophylaxis of deep vein thrombosis in hip surgery. Sequential foot compression reduces lower limb swelling and pain after total knee arthroplasty. Meta-analysis of low molecular weight heparin versus placebo in patients undergoing total hip replacement and post-operative morbidity and mortality since their introduction. Dipyridamole preserved platelets and reduced blood loss after cardiopulmonary bypass. Immediate weight bearing after uncemented total hip arthroplasty with an anteverted stem: A prospective randomized comparison using radiostereometry. A retrospective analysis of inferior vena caval filtration for prevention of pulmonary embolization. Spinal and general anaesthesia in total hip replacement: frequency of deep vein thrombosis. Prediction of excessive bleeding after coronary artery bypass graft surgery: the influence of timing and heparinase on thromboelastography. Dual antiplatelet therapy and heparin "bridging" significantly increase the risk of bleeding complications after pacemaker or implantable cardioverter-defibrillator device implantation. Fondaparinux for prevention of venous thromboembolism in major orthopedic surgery. The effect of intravenous fixed-dose heparin during total hip arthroplasty on the incidence of deep-vein thrombosis. A randomized, double-blind trial in patients operated on with epidural anesthesia and controlled hypotension. Duplex ultrasound evaluation for acute deep venous thrombosis in 962 total joint arthroplasty patients. Inferior vena cava filter placement for pulmonary embolism risk reduction in super morbidly obese undergoing bariatric surgery. Rivaroxaban vs dabigatran for thromboprophylaxis after jointreplacement surgery: exploratory indirect comparison based on meta-analysis of pivotal clinical trials. The safety and efficacy of bilateral simultaneous total hip replacement: an analysis of 2063 cases. Risk factors for bleeding after endoscopic submucosal dissection for gastric lesions. Overview of current trends and the future of thromboprophylaxis in orthopaedic surgery. Efficacy of a postoperative regimen of enoxaparin in deep vein thrombosis prophylaxis. A meta-analysis of fondaparinux versus enoxaparin in the prevention of venous thromboembolism after major orthopaedic surgery. Rivaroxaban for the prevention of venous thromboembolism after hip or knee arthroplasty. Risk factors for hospitalizations resulting from pulmonary embolism after renal transplantation in the United States. Comparison of three techniques for evaluation of de novo asymptomatic pulmonary arterial thrombosis following deep vein thrombosis in total knee arthroplasty. Resternotomy for bleeding after cardiac operation: a marker for increased morbidity and mortality. Is perioperative point-of-care prothrombin time testing accurate compared to the standard laboratory test? Impact of preoperative clopidogrel in off pump coronary artery bypass surgery: a propensity score analysis. Low bleeding risk from cardiac catheterization in patients with advanced liver disease. Modified Child-Pugh score as a marker for postoperative bleeding from invasive dental procedures. Prevention of symptomatic thrombosis with short term (low molecular weight) heparin in patients with rheumatoid arthritis after hip or knee replacement. Comparison of postoperative coumarin, dextran 40 and subcutaneous heparin in the prevention of postoperative deep vein thrombosis. Key interventions and outcomes in joint arthroplasty clinical pathways: a systematic review. Meta-analysis of effectiveness of intermittent pneumatic compression devices with a comparison of thigh-high to knee-high sleeves.

Reducing or eliminating foods containing these products may be considered as part of an elimination diet acne studios order accutane 10 mg otc. This means eliminating all products that might contain wheat and wheat flour acne-fw13c discount accutane 10 mg fast delivery, as well as other offending grains such as rye skin care addiction 20mg accutane sale, oats and barley acne 5 months postpartum discount 5 mg accutane amex. Elimination of these products need not be lifelong acne 3 days 40mg accutane sale, but adjusted according to symptom occurrence skin care quotes sayings quality accutane 20 mg. Researchers suggest that lactobacillus supplement works by preventing diseasecausing bacteria from attaching to the bowel wall. In general, patients should be encouraged to adhere to a healthy, well-balanced diet avoiding foods that aggravate symptoms. Patients should be referred to a dietitian for additional assistance in menu planning if necessary. As a result, patients can learn how to find healthier ways of responding to those situations, thereby reducing stress. Breathing techniques and physical activity have proven useful in alleviating or helping patients deal with stress in their lives. Biofeedback and relaxation techniques, such as imagery or self-hypnosis, encourage control of physical and emotional responses-especially when coping with stress. The diary should include the date and time, the symptom experienced and its severity (for example, pain or diarrhea on a scale of 1-10), associated factors (such as diet, activity or stress), emotional response (angry, sad, anxious), and thoughts associated with the incident (out of control, hopeless). A written record of stressors and associated responses may help patients more easily identify triggers and more rapidly implement appropriate stress management techniques. However, it should be noted that these trials have been criticized for methodological failings, and the efficacy of anticholinergics and antispasmodics has not yet been proven definitively. As a result, these drugs are only recommended on an "as needed" basis, with dosing up to twice a day for bloating, distention and acute attacks of pain. Currently available antispasmodics are separated into the general therapeutic classifications of anticholinergics, calcium-channel blockers, and opiod receptor modulators. Opiates such as trimebutine have often been used not only as antidiarrheals but also as antispasmodics. Antidiarrheal agents Antidiarrheal agents are used to treat diarrhea adjunctly with rehydration therapy to correct fluid and electrolyte depletion. In patients with diarrhea as the predominant symptom, small bowel and proximal colonic transit times are accelerated. This synthetic opioid is also effective in reducing postprandial urgency and improving control at times of anticipated stress. Cholestyramine may also be useful as a second or third line treatment for bile acid malabsorption. This therapy is typically recommended in patients with severe symptoms, or symptoms resistant to first-line approaches, due to side effects. Lower dosages are used compared with dosages used for the treatment of depression Tricyclic agents function as analgesics by modulating pain via their anticholinergic properties. It is hypothesized that tricyclic antidepressants directly influence brain-gut axis abnormalities inherent to the function process. Initially, a low dose is administered, and subsequently the dose is titrated to control pain. In addition, low doses have been found to slow orocecal transit, potentially replacing antidiarrheals in diarrhea-predominant patients. Because of the delayed onset of action, 3 to 4 weeks of therapy should be attempted before considering a dose insufficient. Amitriptyline, at a starting dose of 10 to 25 mg daily, or imipramine, at 25 to 50 mg daily, is useful for this purpose. Certain tricyclic agents, such as amitriptyline, may be particularly helpful for patients who complain of insomnia or who have well-defined depression or panic attacks. As in the case of any drug therapy, patients should be warned about anticholinergic side effects (see chart below). The results of this study demonstrated that the drug induced a small degree of colonic relaxation, increased colonic tone and reduced the degree of discomfort associated with colonic distention. In this study, in contrast to research using low-dose tricyclic antidepressants, a correlation was found between paroxetine use and reduction of psychological ratings. Drugs used for the treatment of Irritable Bowel Syndrome Alternative Therapy Alternative therapies have been found to be useful for some patients. Herbs, including chamomile, ginger and mint have been found to be helpful in alleviating gastrointestinal pain in a subgroup of patients. One particular Chinese herb, which is made up of 20 herbs, has demonstrated efficacy in a formal clinical trial. Patients should understand that some herbs can interact negatively with prescribed or over-the counter medications and information about the use of any complimentary medicine should be shared with the responsible physician. Some patients report symptom improvement from meditation and biofeedback therapies. Still others have achieved a degree of success and relief from symptoms with relaxation therapy. Several small studies suggest acupuncture provides significant relief from chronic pain. By focusing the patient on the physiology of the gut through visualization techniques, colonic motility and visceral sensitivity may be modified. Several randomized controlled trials have demonstrated improvement in bowel function, pain, abdominal distention and global well-being associated with hypnosis. While this type of therapy is more expensive than traditional medications, symptom cessation may be longer-lasting than with other agents. Regular exercise, such as walking, can reduce stress and encourage bowel movements. It is hypothesized that in these cases, spinal manipulation may have a balancing effect on the nerves that supply impulses to the intestinal tract. These strategies should be offered to patients with disabling symptoms, associated psychiatric disorders, and abuse history, although patients with less severe symptoms may also benefit. The biopsychosocial model offers a framework that helps both the physician and the patient understand the interaction of physical and psychosocial factors and their contribution to illness. Newer Therapy Options Overview Several novel treatment approaches are currently being studied. These agents seem to reduce gut sensation in addition to altering motility (Figure 15). Specific locations in the enteric nervous system of the colon wall targeted by newer therapies. These events include ischemia, colitis, and serious complications of constipation, which may lead to hospitalization. Otolaryngology: Throat and tonsil discomfort and pain, allergic rhinitis, bacterial ear, nose, and throat infections. These events include: Blood and Lymphatic: Rare: Quantitative red cell or hemoglobin defects, hemorrhage, and lymphatic signs and symptoms. Gastrointestinal: Infrequent: Hyposalivation, dyspeptic symptoms, gastrointestinal spasms, ischemic colitis and gastrointestinal lesions. Rare: Abnormal tenderness, colitis, gastrointestinal signs and symptoms, proctitis, diverticulitis, positive fecal occult blood, hyperacidity, decreased gastrointestinal motility and ileus, gastrointestinal obstructions, oral symptoms, gastrointestinal intussusception, gastritis, gastroduodenitis, gastroenteritis, and ulcerative colitis. Hepatobiliary Tract and Pancreas: Rare: Abnormal bilirubin levels and cholecystitis. Rare: Memory effects, tremors, dreams, cognitive function disorders, disturbances of sense of taste, disorders of equilibrium, confusion, sedation, and hypoesthesia. Non-site Specific: Infrequent: Malaise and fatigue, cramps, pain, temperature regulation disturbances. Rare: General signs and symptoms, non-specific conditions, burning sensations, hot and cold sensations, cold sensations, and fungal infections. Reproduction: Rare: Sexual function disorders, female reproductive tract bleeding and hemorrhage, reproductive infections, and fungal reproductive infections. Because they were reported voluntarily from a population of unknown size, estimates of frequency cannot be made. Gastrointestinal: Constipation, ileus, impaction, obstruction, perforation, ulceration, ischemic colitis, small bowel mesenteric ischemia Neurological: Headache. Geriatric Use: Elderly patients may be at greater risk for complications of constipation. However, individual oral doses of 16 mg have been administered in clinical studies without significant adverse events (usual dose is 2mg). These changes are reflective of the serious gastrointestinal adverse events, some fatal, that have been reported with its use. Once a physician is enrolled in the Prescribing Program by confirming qualifications, acknowledging described responsibilities, and submitting the Physician Attestation Form, they will receive a prescribing kit from GlaxoSmithKline. At this point, both the physician and patient sign the Agreement Form and provide the patient with a copy of the form. In order for the patient to fill the prescription and any refills, the Prescribing Program Sticker must be on the prescription. Once the prescription is filled, the patient will be given a Retail Pack containing the Medication guide, Package Insert, Medicine, and the Follow-up Survey. At this time, the pharmacist will once again encourage the patient to enroll in the follow-up survey. Tegaserod-treated patients reported greater relief from symptoms and a greater increase in number of stools than placebo-treated patients, with the largest difference during the first four weeks. Monitoring: Relief of constipation should be demonstrated, with diarrhea the most common side effect. Contraindications: Tegaserod is contraindicated in patients hypersensitive to the drug and in those with a history of bowel obstruction, gallbladder disease, and severe renal impairment, moderate to severe hepatic impairment, abdominal adhesion, and suspected sphincter of Oddi dysfunction. Caution should be exercised in patients with diarrhea and in pregnant and breast-feeding patients. Prednisone Oral Solution contains alcohol, citric acid, disodium edetate, fructose, hydrochloric acid, maltol, peppermint oil, polysorbate 80, propylene glycol, saccharin sodium, sodium benzoate, vanilla flavor and water. Prednisone Intensol contains alcohol, citric acid, poloxamer 188, propylene glycol and water. Glucocorticoids are adrenocortical steroids, both naturally occurring and synthetic, which are readily absorbed from the gastrointestinal tract. The chemical name for prednisone is pregna-1,4-diene-3,11,20-trione monohydrate,17,21-dihydroxy-. Their synthetic analogs are primarily used for their potent anti-inflammatory effects in disorders of many organ systems. Rheumatic Disorders As adjunctive therapy for short-term administration (to tide the patient over an acute episode or exacerbation) in: psoriatic arthritis, rheumatoid arthritis, including juvenile rheumatoid arthritis (selected cases may require low-dose maintenance therapy), ankylosing spondylitis, acute and subacute bursitis, acute nonspecific tenosynovitis, acute gouty arthritis, post-traumatic osteoarthritis, synovitis of osteoarthritis, epicondylitis. Collagen Diseases During an exacerbation or as maintenance therapy in selected cases of: systemic lupus erythematosus, systemic dermatomyositis (polymyositis), acute rheumatic carditis. Ophthalmic Diseases Severe acute and chronic allergic and inflammatory processes involving the eye and its adnexa such as: allergic corneal marginal ulcers, herpes zoster ophthalmicus, anterior segment inflammation, diffuse posterior uveitis and choroiditis, sympathetic ophthalmia, allergic conjunctivitis, keratitis, chorioretinitis, optic neuritis, iritis and iridocyclitis. Neoplastic Diseases For palliative management of: leukemias and lymphomas in adults, acute leukemia of childhood. Edematous States To induce a diuresis or remission of proteinuria in the nephrotic syndrome, without uremia, of the idiopathic type or that due to lupus erythematosus. Gastrointestinal Diseases To tide the patient over a critical period of the disease in: ulcerative colitis, regional enteritis. Increased dosage of rapidly acting corticosteroids is indicated in patients on corticosteroid therapy subjected to any unusual stress before, during and after the stressful situation. Cardio-Renal Average and large doses of hydrocortisone or cortisone can cause elevation of blood pressure, salt and water retention, and increased excretion of potassium. These effects are less likely to occur with the synthetic derivatives except when used in large doses. Adrenocortical insufficiency may result from too rapid withdrawal of corticosteroids and may be minimized by gradual reduction of dosage. Metabolic clearance of corticosteroids is decreased in hypothyroid patients and increased in hyperthyroid patients. Infection General Patients who are on corticosteroids are more susceptible to infections than are healthy individuals. There may be decreased resistance and inability to localize infection when corticosteroids are used. Infection with any pathogen (viral, bacterial, fungal, protozoan or helminthic) in any location of the body may be associated with the use of corticosteroids alone or in combination with other immunosuppressive agents that affect cellular immunity, humoral immunity, or neutrophil function. With increasing doses of corticosteroids, the rate of occurrence of infectious complications increases. Fungal Infections Corticosteroids may exacerbate systemic fungal infections and therefore should not be used in the presence of such infections unless they are needed to control life-threatening drug reactions. Special Pathogens Latent disease may be activated or there may be an exacerbation of intercurrent infections due to pathogens, including those caused by Amoeba, Candida, Cryptococcus, Mycobacterium, Nocardia, Pneumocystis, Toxoplasma. It is recommended that latent amebiasis or active amebiasis be ruled out before initiating corticosteroid therapy in any patient who has spent time in the tropics or any patient with unexplained diarrhea. Similarly, corticosteroids should be used with great care in patients with known or suspected Strongyloides (threadworm) infestation. In such patients, corticosteroid-induced immunosuppression may lead to Strongyloides hyperinfection and dissemination with widespread larval migration, often accompanied by severe enterocolitis and potentially fatal gram-negative septicemia. Tuberculosis the use of prednisone in active tuberculosis should be restricted to those cases of fulminating or disseminated tuberculosis in which the corticosteroid is used for management of the disease in conjunction with an appropriate antituberculous regimen. If corticosteroids are indicated in patients with latent tuberculosis or tuberculin reactivity, close observation is necessary as reactivation of the disease may occur.

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Persons who receive a diagnosis of latent syphilis and have neurologic signs and symptoms acne in pregnancy buy cheap accutane 30 mg on line. If a person misses a dose of penicillin in a course of weekly therapy for latent syphilis za skincare discount 10mg accutane, the appropriate course of action is unclear skin care and pregnancy cheap 40mg accutane overnight delivery. For more information acne 40s accutane 30 mg free shipping, see Management of Persons Who Have a History of Penicillin Allergy and Syphilis during Pregnancy acne redness order 5mg accutane fast delivery. Special Considerations Penicillin Allergy Providers should ask patients about known allergies to penicillin acne zip back jeans discount 20mg accutane fast delivery. If concern exists regarding the safety of ceftriaxone for a patient with neurosyphilis, skin testing should be performed (if available) to confirm penicillin allergy and, if necessary, penicillin desensitization in consultation with a specialist is recommended. Alternative therapies should be used only in conjunction with close serologic and clinical follow-up. Pregnant women with reactive treponemal screening tests should have additional quantitative nontreponemal testing, because titers are essential for monitoring treatment response. No mother or neonate should leave the hospital without maternal serologic status having been documented at least once during pregnancy, and if the mother is considered high risk, documented at delivery. For women with a history of adequately treated syphilis who do not have ongoing risk, no further treatment is necessary. Women without a history of treatment should be staged and treated accordingly with a recommended penicillin regimen. Evidence is insufficient to determine optimal, recommended penicillin regimens (444). Recommended Regimen Pregnant women should be treated with the penicillin regimen appropriate for their stage of infection. Stillbirth is a rare complication of treatment, but concern for this complication should not delay necessary treatment. Inadequate maternal treatment is likely if delivery occurs within 30 days of therapy, clinical signs of infection are present at delivery, or the maternal antibody titer at delivery is fourfold higher than the pretreatment titer. Pregnant women who have a history of penicillin allergy should be desensitized and treated with penicillin. Tetracycline and doxycycline are contraindicated in the second and third trimester of pregnancy (317). Moreover, as part of the management of pregnant women who have syphilis, information concerning ongoing risk behaviors and treatment of sex partners should be obtained to assess the risk for reinfection. All neonates born to women who have reactive serologic tests for syphilis should be examined thoroughly for evidence of congenital syphilis. In addition to these tests, for stillborn infants, skeletal survey demonstrating typical osseous lesions might aid in the diagnosis of congenital syphilis. The absence of a fourfold or greater titer for a neonate does not exclude congenital syphilis. Other causes of elevated values should be considered when an infant is being evaluated for congenital syphilis. When possible, a full 10-day course of penicillin is preferred, even if ampicillin was initially provided for possible sepsis. Scenario 2: Possible Congenital Syphilis Any neonate who has a normal physical examination and a serum quantitative nontreponemal serologic titer equal to or less than fourfold the maternal titer and one of the following: 1. Before using the single-dose benzathine penicillin G regimen, the complete evaluation. Special Considerations Penicillin Allergy Infants and children who require treatment for congenital syphilis but who have a history of penicillin allergy or develop an allergic reaction presumed secondary to penicillin should be desensitized and then treated with penicillin (see Management of Persons with a History of Penicillin Allergy). If aqueous or procaine penicillin G is not available, ceftriaxone (in doses appropriate for birthweight) can be considered with careful clinical and serologic follow-up and in consultation with an expert, as evidence is insufficient to support the use of ceftriaxone for the treatment of congenital syphilis. For neonates without any clinical evidence of congenital syphilis (Scenario 2 and Scenario 3), use a. Follow-Up All neonates with reactive nontreponemal tests should receive careful follow-up examinations and serologic testing. Treponemal tests should not be used to evaluate treatment response because the results are qualitative and passive transfer of maternal IgG treponemal antibody might persist for at least 15 months. Evaluation and Treatment of Infants and Children with Congenital Syphilis Infants and children aged 1 month who are identified as having reactive serologic tests for syphilis should be examined thoroughly and have maternal serology and records reviewed to assess whether they have congenital or acquired syphilis (see Primary and Secondary Syphilis and Latent Syphilis, Sexual Assault or Abuse of Children). The serologic response after therapy might be slower for infants and children than neonates. Re-administration of penicillin to patients with a history of IgE-mediated hypersensitivity reactions can cause severe, immediate reactions. Because anaphylactic reactions to penicillin can be fatal, every effort should be made to avoid administering penicillin to penicillin-allergic persons, unless they undergo induction of drug tolerance (also referred to as "desensitization") to temporarily eliminate IgE-mediated hypersensitivity. However, many persons with a reported history of penicillin allergy likely have had other types of adverse drug reactions or have lost their sensitivity to penicillin over time and can safely be treated with penicillin. Risk is highest with first-generation cephalosporins and cephalosporins that have similar R-group side chains to specific penicillins (465,466). In these situations, testing should be performed in a monitored setting in which treatment for an anaphylactic reaction is available. Epicutaneous (Prick) Tests Duplicate drops of skin-test reagent are placed on the volar surface of the forearm. The histamine controls should be positive to ensure that results are not falsely negative because of the effect of antihistaminic drugs. Penicillin G should either be freshly prepared or come from a fresh-frozen source. If the full battery of skin-test reagents is available, including both major and minor determinants (see Penicillin Allergy Skin Testing), persons who report a history of penicillin reaction and who are skin-test negative can receive conventional penicillin therapy. If the full battery of skin-test reagents, including the minor determinants, is not available, skin testing should be conducted using the major determinant (Pre-Pen) and penicillin G. If the major determinant is not available for skin testing, all persons with a history suggesting IgE-mediated reactions to penicillin. In persons with reactions not likely to be IgE-mediated, outpatientmonitored graded challenges can be considered. Although the two approaches have not been compared, oral desensitization is regarded as safer and easier to perform. After desensitization, penicillin should be maintained continuously for the duration of the course of therapy. Signs of urethral discharge on examination can also be present in persons without symptoms. Further testing to determine the specific etiology is recommended to prevent complications, re-infection, and transmission because a specific diagnosis might improve treatment compliance, delivery of risk reduction interventions, and partner notification. Diagnostic Considerations Clinicians should attempt to obtain objective evidence of urethral inflammation. Such men should be treated with drug regimens effective against gonorrhea and chlamydia. If symptoms persist or recur after completion of therapy, men should be instructed to return for re-evaluation. Symptoms alone, without documentation of signs or laboratory evidence of urethral inflammation, are not a sufficient basis for retreatment. Azithromycin 1 g orally in a single dose should be administered to men initially treated with doxycycline. Certain observational studies have shown that moxifloxacin 400 mg orally once daily for 7 days is highly effective against M. Cervicitis frequently is asymptomatic, but some women complain of an abnormal vaginal discharge and intermenstrual vaginal bleeding. For reasons that are unclear, cervicitis can persist despite repeated courses of antimicrobial therapy. Because most persistent cases of cervicitis are not caused by recurrent or reinfection with C. Other Considerations To minimize transmission and reinfection, women treated for cervicitis should be instructed to abstain from sexual intercourse until they and their partner(s) have been adequately treated. For women who are not treated, a follow-up visit gives providers an opportunity to communicate results of tests obtained as part of the cervicitis evaluation. Pregnancy Diagnosis and treatment of cervicitis in pregnant women does not differ from that in women that are not pregnant. For more information, see Cervicitis, sections on Diagnostic Considerations and Treatment. Chlamydial Infections Chlamydial Infections in Adolescents and Adults Chlamydial infection is the most frequently reported infectious disease in the United States, and prevalence is highest in persons aged 24 years (118). To detect chlamydial infections, health-care providers frequently rely on screening tests. The efficacy of alternative antimicrobial regimens in resolving oropharyngeal chlamydia remains unknown. However, this regimen is more costly than those that involve multiple daily doses (518). Delayed-release doxycycline (Doryx) 200 mg daily for 7 days might be an alternative regimen to the doxycycline 100 mg twice daily for 7 days for treatment of urogenital C. Erythromycin might be less efficacious than either azithromycin or doxycycline, mainly because of the frequent occurrence of gastrointestinal side effects that can lead to nonadherence with treatment. If retesting at 3 months is not possible, clinicians should retest whenever persons next present for medical care in the 12-month period following initial treatment. Among heterosexual patients, if health department partner management strategies. Providers should also provide patients with written educational materials to give to their partner(s) about chlamydia in general, to include notification that partner(s) have been exposed and information about the importance of treatment. To avoid reinfection, sex partners should be instructed to abstain from sexual intercourse until they and their sex partners have been adequately treated. Other Management Considerations To maximize adherence with recommended therapies, onsite, directly observed single-dose therapy with azithromycin should always be available for persons for whom adherence with multiday dosing is a concern. In addition, for multidose regimens, the first dose should be dispensed on site and directly observed. To minimize risk for reinfection, patients also should be instructed to abstain from sexual intercourse until all of their sex partners are treated. Recommended Regimens Azithromycin 1 g orally in a single dose tolerance is a concern. Chlamydial Infections Among Neonates Prenatal screening and treatment of pregnant women is the best method for preventing chlamydial infection among neonates. Although the efficacy of neonatal ocular prophylaxis with erythromycin ophthalmic ointments to prevent chlamydia ophthalmia is not clear, ocular prophylaxis with these agents prevents gonococcal ophthalmia and therefore should be administered (see Ophthalmia Neonatorum Caused by N. Diagnostic Considerations Sensitive and specific methods used to diagnose chlamydial ophthalmia in the neonate include both tissue culture and nonculture tests. Specimens for culture isolation and nonculture tests should be obtained from the everted eyelid using a dacron-tipped swab or the swab Because of concerns about chlamydia persistence following exposure to penicillin-class antibiotics that has been demonstrated in animal and in vitro studies, amoxicillin is now considered an alternative therapy for C. Ocular specimens from neonates being evaluated for chlamydial conjunctivitis also should be tested for N. Tracheal aspirates and lung biopsy specimens, if collected, should be tested for C. Treatment Because test results for chlamydia often are not available at the time that initial treatment decisions must be made, treatment for C. Although data on the use of azithromycin for the treatment of neonatal chlamydia infection are limited, available data suggest a short course of therapy might be effective (530). Topical antibiotic therapy alone is inadequate for treatment for ophthalmia neonatorum caused by chlamydia and is unnecessary when systemic treatment is administered. The possibility of concomitant chlamydial pneumonia should be considered (see Infant Pneumonia Caused by C. Data on the effectiveness of azithromycin in treating chlamydial pneumonia are limited. Management of Mothers and Their Sex Partners Mothers of infants who have chlamydia pneumonia and the sex partners of these women should be evaluated, tested, and Infant Pneumonia Caused by C. Therefore, a culture should be obtained at a follow-up visit approximately 2 weeks after treatment is completed. Additional risk factors for gonorrhea include inconsistent condom use among persons who are not in mutually monogamous relationships, previous or coexisting sexually transmitted infections, and exchanging sex for money or drugs. Screening for gonorrhea in men and older women who are at low risk for infection is not recommended (108). A recent travel history with sexual contacts outside of the United States should be part of any gonorrhea evaluation. However, because of lower sensitivity, a negative Gram stain should not be considered sufficient for ruling out infection in asymptomatic men. Detection of infection using Gram stain of endocervical, pharyngeal, and rectal specimens also is insufficient and is not recommended. To minimize disease transmission, persons treated for gonorrhea should be instructed to abstain from sexual activity for 7 days after treatment and until all sex partners are adequately treated (7 days after receiving treatment and resolution of symptoms, if present). Men or women who have been treated for gonorrhea should be retested 3 months after treatment regardless of whether they believe their sex partners were treated. If retesting at 3 months is not possible, clinicians should retest whenever persons next present for medical care within 12 months following initial treatment. Use of ceftriaxone or cefixime is contraindicated in persons with a history of an IgE-mediated penicillin allergy. Data are limited regarding alternative regimens for treating gonorrhea among persons who have either a cephalosporin or IgE-mediated penicillin allergy. A potential therapeutic option is dual treatment with intramuscular gentamicin 240 mg plus oral azithromycin 2 g (569).