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The increased prevalence of drug- 53 purchase 130 mg viagra extra dosage visa,067 cases per 100 buy cheap viagra extra dosage 120mg on-line,000 adult women discount viagra extra dosage 120 mg on-line, based on the resistant bacteria has made susceptibility testing National Health and Nutrition Examination Survey particularly important generic viagra extra dosage 130mg on-line. Self-reported incidence of physician-diagnosed urinary tract infection during the previous 12 months by age and history of urinary tract infection among 2000 United States women participating in a random digit dialing survey. The average standard error for the total incidences in each of the age groups is 2. Urinary tract infections may be associated with The need for urine culture is also an area of debate. It is as frst-line therapy for patients without an allergy generally believed that asymptomatic bacteriuria in to this compound (5). Specifc fuoroquinolones were elderly patients does not need to be treated, although recommended as second-line agents. Prescribing trends from 1989 through 1998a Adjusted Odds Ratio (95% Confdence Interval) for Predictor, Antibiotic Prescribed 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 Year (per decade)b Trimethoprim-sulfamethoxazole 48 35 30 45 24 0. All trends adjusted for age younger than 45 years and history of urinary tract infection. These using more-expensive antimicrobials such as medications cost less than newer antimicrobials fuoroquinolones as initial therapy. In addition, reserving be due in part to increased rates of outpatient care fuoroquinolones and broad-spectrum antimicrobials and increased availability and marketing of these for complicated infections or cases with documented products. However, it has the potential to increase resistance to frst-line therapy may help reduce the both overall costs and antimicrobial resistance. Expenditures for female urinary tract infection (in millions of $) and share of costs, by site of service 1994 1996 1998 2000 Totala 1,885. Trends in visits by females with urinary tract infection listed as primary diagnosis, by site of service and year. While the overall indicates that there was a gradual decline in the rate of inpatient stays for women 84 years of age rate of admissions between 1994 and 2000 (Table and younger has remained relatively constant, there 10). This trend is refected across essentially all age was even higher for women over 95, increasing from strata analyzed. It likely refects increased use of oral 1,706 per 100,000 in 1992 to 2,088 in 1998. Urinary antimicrobials and home-based intravenous therapy tract infections may be more severe in frail elderly in the treatment of women with pyelonephritis. The women due to additional comorbidity, and this may decline in age-unadjusted rates of hospitalization for necessitate more aggressive treatment with inpatient women with pyelonephritis was most noticeable in hospitalization and intravenous antimicrobial African American and Caucasian women. African American women had higher rates relatively stable in Hispanic and Asian women. Rates of inpatient treatment than did other ethnic groups of hospitalization declined in all geographic areas, (1. This trend age) and has been relatively stable overall for those was seen across all age groups, although elderly aged 55 to 74 (Table 9). The most striking fnding in the data is that women 85 and older had inpatient Outpatient Care hospitalization rates 2. Nosocomial infections may also infuence The overall rate of hospital outpatient visits for the rates of hospitalization in this patient group. The most 162 163 Urologic Diseases in America Urinary Tract Infection in Women 162 163 Urologic Diseases in America Urinary Tract Infection in Women 164 165 Urologic Diseases in America Urinary Tract Infection in Women striking increases were observed in young women Table 11. Trends in mean inpatient length of stay (days) for adult females hospitalized with urinary tract infection 18 to 34 years of age. Overall rates of hospital listed as primary diagnosis outpatient visits by young women for any reason Length of Stay were 1. These increases in physician outpatient services occurred in the 35 to 64 and 65 year old age groups, but not in 18- to 34- year-old groups. National trends in visits by females for urinary tract infection by patient age and site of service. When physician outpatient services are stratifed a general increase in utilization between 1992 and by provider specialty, some interesting trends 1995, which remained relatively stable in 1998 (Table emerge. The most striking observation in this analysis consistently lower than those for visits to family is the peak in utilization among women between 75 practitioners and general practitioners. The signifcance of this is dwelling 75- to 84-year-old population who are treated unclear, but the trend may refect increased access to as outpatients. Although this trend has been observed in some of the other analyses, Emergency Room Care it is most pronounced in this comparison. Utilization ambulatory surgery centers (Table 18) revealed that rates for young women ranged from 2. When patients are stratifed or current diagnosis among female nursing home by age, little variation in utilization rates is seen over residents declined from 9,252 per 100,000 in 1995 this time period. Rate of emergency room visits by females with urinary tract infection listed as primary diagnosis, by patient race and year. Inpatient services accounted for the majority of incontinence than did women in the general nursing treatment costs, although the fraction of expenditures home population (Tables 22 and 23). The overall $100 million in 1998 among Medicare enrollees under rate of indwelling catheter use in nursing homes 65, primarily the disabled. A substantial number of inpatient costs in the South were the highest in the United hospitalizations, outpatient hospital and clinic visits, States. The associated direct and An analysis of prescribing costs refects a indirect costs are also large and include substantial propensity to prescribe expensive medications such out-of-pocket expenses for the patients. Expenditures for female Medicare benefciaries for treatment of urinary tract infection (in millions of $), by may occur incident to the use of fuoroquinolones. Productivity Management survey suggest that 24% of women with a medical claim for pyelonephritis missed some work time related to treatment of the increases in health care costs driven by prescription condition, the average being 7. These data do not refect the suggest that diabetes may be a risk factor for the success of treatment or whether prescriptions were development of infection (Table 30). Average annual spending and use of outpatient that lead to an increase in urinary retention, which prescription drugs for treatment of urinary tract infection in turn provides a nidus for infection. Drug Name Rx Claims Price ($) Expenditures ($) Assuming a prevalence of diabetes in the 40- to 70- Cipro 774,067 60. Including expenditures on these excluded medications would increase total outpatient drug spending for urinary tract infec- There appears to have been some decrease in the use tions by approximately 52%, to $146 million. There has been an overall trend Cost toward increased use of outpatient care in a variety ($ millions) of settings for acute pyelonephritis and selected cases Direct costs of complicated infections. Analysis of prescribing Medical expenses patterns reveals great reliance on fuoroquinolones Clinic charges 385 over more traditional frst-line antimicrobials. Prescriptions 89 This could have a variety of signifcant impacts in Nonmedical expenses terms of both cost and biology. Efforts to slow the Travel and childcare for visits 77 development of drug-resistant pathogens will depend Output lost due to time spent for visits 108 heavily on future prescribing patterns. Additional studies will be needed to identify the clinical effcacy and cost-utility of this approach. Guidelines for antimicrobial treatment of uncomplicated acute bacterial cystitis and acute pyelonephritis in women. National patterns in the treatment of urinary tract infections in women by ambulatory care physicians. Prevalence of diabetes, impaired fasting glucose, and impaired glucose tolerance in U. Fluoroquinolones are both men and women, clinical studies suggest that particularly effective for this condition. Bacterial prostatitis, which may be acute or Basic concepts related to the defnition and diagnosis chronic, is an uncommon clinical problem. Even though a causal relationship has are the most common organisms in cases of chronic been diffcult to prove, chronic prostatic obstruction bacterial prostatitis. Patients may also complain or catheterization, both of which are common in the of obstructive and irritative urinary symptoms, sexual evaluation of men with obstructive voiding symptoms. The most common associated organisms 187 Urologic Diseases in America Urinary Tract Infection in Men The pathogenesis of prostatitis may be Cultures typically yield mixed fora with both aerobic multifactorial. The risk of mortality with prostatic ducts in the posterior urethra occurs in some Fournier s gangrene is high because the infection can patients, while ascending urethral infection plays a spread quickly along the layers of the abdominal wall role in others. Urethral instrumentation As described above, male anatomic structures that and chronic indwelling catheters may also increase may be involved with infectious processes include the risk. Today, however, most cases are associated with coliform organisms, Pseudomonas spp.

Screening for occult heart disease in patients being considered for use of stimu- lant medication or as part of pre sports participation evaluation requires careful and directed history and physical examination discount 200 mg viagra extra dosage, but does not include screening echocar- diography purchase viagra extra dosage without a prescription. If further concerns arise buy viagra extra dosage 150 mg low price, the patient should then be referred to a cardiologist for further evaluation purchase viagra extra dosage 120 mg amex. What to Expect from an Echocardiogram Echocardiography is the imaging modality of choice for defining intracardiac anatomy of congenital heart defects. The connections of major systemic veins and pulmonary veins can be defined, as well as the pulmonary arteries and the aortic arch with its major branches. In most cases, coronaries arteries, at least proximally, can also be imaged and their origins clearly defined. Doppler technology allows the detection of blood flow velocity and direction, and provides an ability to estimate pressures and pressure gradients. Color Doppler enables detection of shunting, even in cases where defects are too small to detect by imaging. In addition, global systolic and diastolic function as well as regional wall mechanics can now be investigated in detail. Stress echocardiogra- phy can assess changes in hemodynamics and function with exertion. Limitations of Echocardiography Echocardiography is highly dependent on the skill, expertise, and experience of the sonographer and the interpreting physician. Important congenital defects can be missed due to incomplete or inadequate imaging or to incorrect interpretation of the images. Ultrasonography requires adequate tissue windows, without interference from air or other structures that reflect sound. Hijazi Key Facts Diagnostic cardiac catheterization is performed with much less frequency than the past due to advancement of other, less invasive, imaging modali- ties. Diagnostic cardiac catheterization may be required if other imaging modalities are not informative, hemodynamic evaluation to assess extent of shunts, cardiac output and pressure measurements are needed. Common interven- tional procedures include balloon dilation of stenotic valves, cardiac biopsy, closure of septal defects, and occlusion of abnormal communica- tions and unwanted vessels. Introduction Cardiac catheterization uses intravascular catheters to access cardiac chambers and vascular structures to obtain hemodynamic information such as pressure and oxygen saturation as well as enable injection of contrast material while recording radiographic movie clips (angiogram), thus providing details of cardiac anatomy and pathology. Pressure measurements obtained through catheters and wires during catheteriza- tion allow accurate pressure measurements of various chambers and vessels and the detection of any pressure gradients across stenotic valves or vessels. Hijazi (*) Department of Pediatrics and Internal Medicine, Rush University Medical Center, 1653 W. The combination of pressure and cardiac output measurements allow for the determination of vascular resistances (systemic and pulmonary) which are essential to determine therapeutic options in children with heart diseases. Angiograms obtained through opacifying cardiac chambers and vascular structures through contrast injection continue to be an essential tool in diagnosis of heart diseases in children. Images obtained from angiography provide great details of specific regions of the cardiovascular system not easily accessible to echocardiography. Indications Cardiac catheterization is a valuable tool in diagnosis and management of heart diseases in children. It is more common nowadays to perform cardiac catheterization for therapeutic (interventional) purposes rather than for diagnosis. This is secondary to the increasing tools available for interventional pediatric cardiologists in manag- ing heart defects in the cardiac catheterization laboratory, thus providing more indications for interventional catheterization procedures. Indications for cardiac catheterization include: Limited echocardiographic window. This may be due to structures not accessible by echocardiography such as peripheral pulmonary vasculature or pulmonary pathology rendering echocardiographic window small such as with lung disease. In addition, it is important to review previous studies such as electrocardiography and echocardiography, chronic illnesses, recent lab studies like blood count and renal function tests. Patient should not be given solid food or milk 6 h and clear fluids 2 h prior to the procedure. Vascular Access Access to vascular structures is done through a needle to puncture the vessel percutaneously, followed by a wire introduced through the needle to secure vascular access. Vascular sheaths are hollow structures with a built in diaphragm to prevent bleeding. Access to the Cardiovascular System Femoral arterial and venous access (Seldinger technique) is the method of choice in the pediatric age group. This port of access provides advantage of being away from the thoracic region for ease of catheter manipulation away from the radiographic cameras surrounding the child s thorax. Umbilical arterial and venous access is used in newborn babies up to 7 days of age. Internal jugular, subclavian, axillary, and transhepatic venous access is occa- sionally required due to lack of femoral vascular access or need to position the catheter at a particular trajectory not provided through femoral venous access. In transhepatic venous access a needle punctures the liver transcutaneously to enter hepatic vein, then a wire is introduced to reach the right atrium though the hepatic venous system. Catheters Large selection of catheters and wires are available for the pediatric age group. Catheters are of two categories: End-hole catheters used mainly for measurement of pressures, obtaining blood samples, reaching different locations, and exchanging over wires. Wires are also diverse including stiff and soft wires and used mainly to guide and stiffen catheters to reach different 70 A. A particular type of wire (Radi wire) has a pressure transducer at its tip to allow for pressure measurements in areas where catheters are difficult to introduce. Hemodynamic Measurements Cardiac catheterization is the only source of reliable hemodynamic data. Hemodynamic data obtained through catheterization include pressures and flow volumes. Pressure measurement of a vascular chamber may suggest stenosis, which can then be confirmed by pull back pressure measurement which would uncover an area of obstruction to blood flow. Measurement of oxygen saturation in different chambers and vessels can be used in formulas to calculate cardiac output (from the right or left heart chambers, referred to as Qp and Qs respectively). In the presence of a shunt, measurement of oxygen saturations from the high superior vena cava represents the mixed venous oxygen saturation, while oxygen saturation of the pulmonary artery and aorta represent the oxygen saturation of the pulmonary and systemic circulations respectively. The pulmonary vein saturations are assumed to be similar to the aortic saturations unless there exists a right to left shunt or there are concerns about pulmonary vein pathology in which case they are measured directly. By knowing the oxygen saturation and hemoglobin concentration of blood going out of the heart to the pulmonary or systemic circulation, the oxygen content of that blood can be determined. Similarly, by measuring the oxygen content of the blood returning back to the heart from the systemic or pulmonary circulations, the volume of blood flow return- ing to each circulation can be determined (please see cardiac output formulas below). Cardiac output measurement reflects capability of the heart to generate blood flow to the body. Low cardiac output may reflect myocardial disease such as with myocarditis or dilated cardiomyopathy. On the other hand the cardiac output from the left ventricle may be different from that of the right ventricle due to intracardiac shunts, which again can be determined by comparing both cardiac outputs. A patient with an atrial septal defect with left to right shunting will have more pulmonary cardiac output than systemic. A small atrial septal defect may cause the pulmonary output to be mildly elevated (e. On the other hand, a large atrial septal defect with excessive pul- monary blood flow will cause an increase of Qp:Qs to 3:1 or more. Therefore mea- surement of Qp and Qs provide valuable information regarding extent of shunts. This is possible through measuring oxygen consumption prior to cardiac catheterization 5 Cardiac Catheterization in Children: Diagnosis and Therapy 71 (this may be assumed using tables providing oxygen consumption values for different age groups). The difference in oxygen content of blood going out to a circulation (systemic or pulmonary) and that of blood returning from that circulation can be used to determine how much blood carried that oxygen, thus providing a cardiac output. Measurements of Pulmonary and Systemic Vascular Resistance The vascular resistance of the pulmonary or arterial circulation is the result of resis- tance offered by the arterioles at the distal end of the circulation. Elevation in vas- cular resistance reflects damage to that circulation such as noted in pulmonary vascular obstructive disease due to long standing excessive pulmonary blood flow leading to pulmonary hypertension. Measurement of vascular resistance is important in determining the health of the vascular resistance and whether the blood pressure would return to normal if shunt is eliminated.

In this regard purchase viagra extra dosage 130 mg visa, our laboratory is conducting a more rigorous characteri zation of secondary metabolites found in these plants by using spectroscopic techniques (e buy viagra extra dosage with american express. From this concentration the experiment was performed with a duplicated calibration curve at different concentrations cheap viagra extra dosage amex, which was read at 517nm order 200mg viagra extra dosage mastercard. An average concentration of 72 Oxidative Stress and Chronic Degenerative Diseases - A Role for Antioxidants those used for standard curve analysis was chosen for the initial concentration of the metha nol extract from leaves of Morinda citrifolia. Through a mathematical analysis of linear regression curve was obtained concentration vs. Oleifera leaves was carried out in methyl alcohol for the phytochemical sieve, the results are shown in the following table (Table 2), and qualitative tests that were performed for each secondary metabolite are named in the same table. Reagent Test Dragendorf ++ Mayer + Alkaloids Wagner + Sonneshain + Silicotungstine + Tanines ferric chloride - phenols Potassium ferricianide + Fehling - reducing sugars Benedic - ammonium hydroxide - Coumarins Erlich + Flavonoids Sodium Hydroxide + Sesquiterpenlactones hidroxylamine chlorehydrate - Saponines Libermann Bouchard + cardiotonic Glycosides Kedde, Baljet, legal - cyanogenic Glycosides Guignar - Table 2. The results of this phytochemical analysis presented in Table 2, shows qualitatively the sec ondary metabolites found in the methanol extract of leaves of M. The more abun dant compounds in the leaves of this tree and also the must reported in several articles are: i. Flavonoids 74 Oxidative Stress and Chronic Degenerative Diseases - A Role for Antioxidants v. Saponins In the case of metabolites such as tannins, cardiac glycosides, cyanogenic glycosides, the tests results were negative for the methanol extract of leaves of M. Phytochemical results for the extracts obtained from leaves of Guarumbo (Cecropia obtusi folia Bertolt), Musaro (Lophocereus sp. Description of those plants collected in Mxico and presenting high content of antioxidant compounds 6. Azadirachta indica Active compounds of Neem have been identified while others have not, and analyzed the most common are: nimbin; nimbidin; ninbidol; gedunin; sodium nimbinate; queceretin; sal annin and azadirachtin. Fruits from Neem Tree The flowers are astringent and expectorant and also Seed oil is extracted. Flowers from Neem Tree Neem kills some infectious organisms, contributes to the immune response at various levels, this increases the possibility that the body fight bacterial infections alone, viral and fungal. Neem increases the production of antibodies, improves the response of immune cells that release mediators white blood cells. For Diabetes: Neem extract orally reduces insulin re quirements by between 30% and 50% to people who are insulin dependent. With Cancer: polysaccharides and limonoids found in the bark, leaves and Neem oil reduces tumors and cancer [39]. Passiflora edulis Sims Another plant which has been described with therapeutic applications is the genus Passi flora, whics comprises about 500 species and is the largest in the family Passifloraceae. Passi flora edulis Sims is native from the Brazilian Amazon, known by the common name for passion fruit [40, 41]. The word passion comes from the Portuguese- Brazilian passion fruit, which means food prepared in Totuma [41, 42]. Leaves and flower of passion fruit The ethnopharmacological information reveals that Passiflora edulis Sims has been used in traditional medicine around the world. In India, the fresh leaves of this plant are boiled in small amount of water and the extract is drunk to treat dysentery and hypertension, and the fruits are eaten to relieve constipation. The flowers are nocturnal, appear only on copies of more than two meters high and are colored green, but in the four seasons can take a pink color, the stem prolifera tion and leads to masses of slender spines long they can get to cover it completely. These plants are drought resistant so as to avoid daily water ing and exposure to damp, besides being very sensitive to frost. It is endemic to Baja California Sur, Baja California and Sonora in Mexico and Arizona in the United States It is a common species that has spread efficiently over the worldwide. The fruits are edible, but are hard to come by competition with birds and in sects. Southeastern Mexican indians prepare a tea from the pulp and skin of the cactus to relieve arthritis. Some members of this ethnic group say the plants with five ribs are very good for treating cancer. For diabetes: using the Musaro with a seven-pointed cladode, boiled in 1 liter of water, strain and drink three glasses of cooking, one before each meal. Musaro or gooseberry is the tea made by slicing sections fifteen or twenty two inches long from the stems of cactus. These cuts are then placed in a container large enough to contain five gallons of water and boiled for eight to ten hours until the liquid is reduced to approximately one gallon. People take this treatment for serious stomach diseases but they should drink tea in large amount. From extracts of Lophocereus sp two compounds have been isolated: pylocereine and lophocine a dimeric alkaloid with cytotoxic activity [46, 47]. Cecropia obtusifolia Bertolt Family: Cecropiaceae Common name: The names that are known are "guarumbo", "chancarro", "hormiguillo", "chifln" and "koochlle" among others. Its trunk is straight and presents a cavity where you can find some ants inside it, with branches that grow along this horizontally. Distribution in Mexico: located along the coasts of Tamaulipas and San Luis Potosi to Ta basco on the side of the Gulf of Mexico and Sinaloa to Chiapas Pacific side. Traditionally the dried leaves (15 g) are heated in water (500 mL) and the result is an infusion which is then filtered and taken as "daily water", cold infusion is often consumed in hot weather. It is reported that this plant contains -sitosterol, stigmasterol, 4-ethyl-5-(n-3 valeroil)-6-hexahydrocoumar ins. Conclusion The plant kingdom has been the best source of remedies for curing a variety of disease and pain. This is why medicinal plants have played a key role in the worldwide maintenance of health. Traditional herbal medicine is intimately related to the Mexican popular culture; its use has origins based on ancestral knowledge. Natural products of higher plants are an im portant source of therapeutic agents; therefore, many research groups are currently screen ing the different biological activities of plants. Mexico has an extensive variety of plants; it is the fourth richest country worldwide in this aspect. Some 25 000 species are registered, and it is thought that there are almost 30 000 not yet described. Natural antioxidants that are present in herbs and spices are responsible for inhibiting or preventing the deleterious con sequences of oxidative stress. Spices and herbs contain free radical scavengers like polyphe nols, flavonoids and phenolic compounds, having antioxidant activities, Indeed all these plant studied have several biological effects and they could also be used as a source of natu ral antioxidants. Further pharmacological studies are underway to identify the active con stituents of the plant extracts responsible for the showed activities. As a final comment, compounds in plants are of great importance for the treatment of several chronic and degen erative diseases like diabetes and cancer, among others. Author details Jorge Alberto Mendoza Prez and Toms Alejandro Fregoso Aguilar1 2* 1 Department of Environmental Systems Engineering at National School of Biological Scien ces-National Polytechnic Institute. Free Radicals and Antioxidants in Human Health: Currens Status and Future Prospects. Comparison of the Total Antioxidant Content of 30 Widely Used Medicinal Plants of New Mexico. Free Radicals and Grape Seed Proanthocyanidin Extract: Importance in Human Health and Disease Prevention. Deter mination of the Phenolic Composition of Sherry and Table White Wines by Liquid Chromatography and their Relation with Antioxidant Activity. Correlation of Pigment and Flavanol Content with Antioxidant Properties in Selected Aged Regional Wines from Greece. Phytochemical and Biological Studies of Leaf Extract and Fruit of Morinda citrifolia (Noni) in a Mouse Model of Diabetes. Antioxidant Activity and Total Phenolic Content of Moringa Oleifera Leaves in Two Stages of Maturity. Antiinflamato ry and Antioxidant Activity of Plants Used in Traditional Medicine in Ecuador. Differential Antioxi dant Properties of Red Wine in Water Soluble and Lipid Soluble Peroxyl Radical Generating Systems.

A preferred over vancomycin because vancomycin is less 2-week course of ceftriaxone and gentamicin achieves rapidly cidal viagra extra dosage 200mg free shipping, and failure rates of up to 40% have been comparable results buy 130 mg viagra extra dosage free shipping. In the penicillin-allergic patient with antibiotic therapy should be initiated immediately after methicillin- sensitive S proven 120mg viagra extra dosage. In combination of vancomycin discount 200 mg viagra extra dosage with amex, ampicillin, and gentam- patients with enterococcal endocarditis, cephalo- icin is recommended to cover the most likely pathogens sporins are ineffective and should not be used. Empiric therapy for bined with gentamicin are preferred, and this culture-negative subacute bacterial endocarditis should combination is recommended for the full course of include ampicillin and gentamicin to cover for entero- therapy. With the exception of uncomplicated synergistic regimen consisting of a -lactam antibiotic infection with S. Combination therapy with naf- Antibiotic therapy for prosthetic valve endocarditis cillin or oxacillin and gentamicin may shorten the presents a particularly difcult challenge. The deposi- duration of positive blood cultures, but has not been tion of biolm on the prosthetic material makes cure shown to improve mortality or overall cure rates, and with antibiotics alone difcult, and the valve often has therefore dual antibiotic therapy is not recommended. The decision to operate is About Antibiotic Therapy often complex, and appropriate timing of surgery must balance the risk of progressive complications with the of Infective Endocarditis risk of intraoperative and postoperative morbidity and mortality. A delay a) Therapy for 4 to 6 weeks (except for uncom- in surgery often results in a fatal outcome because of plicated Streptococcus viridans infection, in irreversible left ventricular dysfunction. The ability to b) Therapy must be guided by minimum inhibitory concentration and synergy testing. In some studies, large c) Synergistic therapy not shown to be of ben- vegetations (exceeding 10 mm in diameter) and vege- et in Staphylococcus aureus infection. Whenever possible, -lactam antibiotics are found to have a higher probability of embolizing. For methicillin-sensitive strains, nafcillin or oxacillin (2 g every four hours) should be substituted for 1. Indications for surgery include hours) combined with tobramycin (1 mg/kg three times a) moderate-to-severe congestive heart failure. Neither positive blood cultures at the time of debridement of vegetations greatly increases the likeli- surgery nor positive valve cultures have been hood of survival. About Prophylaxis in Infective Endocarditis As discussed earlier in Neurologic complications, a focal neurologic decit is not an absolute contraindica- 1. Whenever possible, surgery should be however,it is considered the standard of care. Give to high risk (prosthetic valve, previous risk of septic intraoperative complications. Give in time to achieve peak antibiotic levels at the time of surgery or to positive valve cultures. Prognosis Invasive procedures that warrant prophylaxis include these: Cure rates depend on the organism involved and the valve infected. Patients Tonsillectomy and adenoidectomy with an infected aortic valve accompanied by regurgita- Surgical procedures that involve intestinal or respiratory tion also have a 50% mortality. Fungal infections and mucosa infections with gram-negative aerobic bacilli are associ- The timing of antibiotic prophylaxis is important. Often prolong hospital Prevention stay, and can be complicated by metastatic lesions and bacterial endocarditis. High-risk patients are dened as patients with A 53 year-old white woman was admitted to the prosthetic valves (including bioprosthetic and homograft hospital with complaints of severe shaking during infu- valves), a past history of endocarditis, complex cyanotic sion of her hyperalimentation solution. She had had multiple complications from her and lumen of the catheter from the skin of a caregiver or intravenous lines,including venous occlusions and line- as a consequence of a contaminated infusate. At that the catheter, they generate a biolm that protects them time,a tunneled catheter had been placed in her left sub- from attack by neutrophils. This condition makes steril- clavian vein, and she had been doing well until the ization by antibiotics alone difcult. The risk of infection is greater for some devices than others: evening before admission. As she was infusing her solu- tion, she developed rigors, and her temperature rose to 1. She continued to experience chills and developed a) Internal jugular vein femoral vein subclavian a headache. On physical examination, her temperature was b) Non-tunneled tunneled found to be 38 C and her blood pressure,136/50 mm Hg. Ports and other devices culture-positive 6 hours after being drawn,and a simul- a) Tunneled totally implanted taneous peripheral blood sample became culture-posi- b) Hyperalimentation standard infusion tive 5 hours after that (11 hours after being drawn). Regular exchange of central venous catheters over guidewires does not reduce the incidence of infection. In fact, reinsertion of a catheter through an infected soft-tissue site can precipitate bacteremia. Epidemiology and Pathogenesis The organisms most commonly associated with More than 200,000 nosocomial bloodstream infections intravascular device infection are skin flora. A large proportion of positive cocci predominate, with coagulase-negative these infections are related to intravascular devices. The nding of purulence around the of Intravascular Catheter-Related Infections intravascular device is helpful, but this sign is not always present. Bacteria infect catheters in three ways: teremia should always raise the possibility of intravascular device infection. Catheter location and type affect the risk of olution of symptoms following removal of the device, plus infection. Regular exchange of central venous catheters cocci, corynebacteria, or a fungus are other ndings that over guidewires does not reduce the inci- suggest an infected intravascular device. However, the dence of infection; the technique is not absence of these ndings does not exclude the diagnosis. Gram-positive cocci predominate: sample to cytospin, and performing Gram and acridine a) Coagulase-negative staphylococci are the most common, adhere to catheters using a glycocalyx b) S. Candida albicans also forms an adherent glyco- c) Blood cultures positive for Staphylococcus epi- calyx; associated with high glucose solutions. Purulence around the catheter site provides strong evidence, but this sign is absent in many cases. Cytospin Gram or acridine orange staining of corynebacteria are other common gram-positive catheter sample provides rapid diagnosis. Roll and sonication methods can be used for one third of infections, with Klebsiella pneumoniae, quantitating bacteria on the catheter tip. Positive blood cultures for Klebsiella, Cit- simultaneously from the catheter and the robacter, and non-aeruginosa strains of Pseudomonas peripheral veins. Patients than 2 hours earlier than positive growth in a receiving high glucose solutions for hyperalimentation are peripheral sample indicates catheter infection. However, this method is less sensitive than 48 hours, and if the patient is infected with virulent, dif- culture of the removed catheter tip. Polymi- (catheter is rolled across the culture plate) is semiquantita- crobial bacteremia suggests heavy contamination of the tive (positive with 15 cfu or more); the vortex or sonication line and usually warrants catheter removal. Other indica- method (releases bacteria into liquid media) is quantitative tions for removal include neutropenia, tunnel or pocket (positive with 100 cfu or more). The roll method detects infection, valvular heart disease or endocarditis, septic bacteria on the outer surface of the catheter; the vortex or thrombophlebitis, or the presence of metastatic abscesses. The duration of therapy has not been examined in The sonication method is more sensitive, but more difcult carefully controlled trials. For patients and silver-impregnated catheters may lead to false negative with coagulase-negative staphylococci, treatment for results with these methods. Cultures of removed catheter 5 to 7 days is sufcient if the catheter is removed, but tips should be performed only when a catheter-related treatment should be continued for a minimum of bloodstream infection is suspected. On average, most catheter-associated should be drawn: one set from the intravenous catheter infections are treated for 3 weeks. A negative incidence of relapse, follow-up blood cultures are blood culture from a sample drawn from the intravenous important if the line was kept in place. A positive culture requires by lling the catheter lumen with pharmacologic concen- clinical interpretation. A nding of colony counts from the 5 mL of solution) is usually recommended, and for gram- catheter sample that are 5 to 10 times those found from negative bacilli, gentamicin (5 mg in 5 mL) is the agent the peripheral samples suggests catheter-related infection. This treatment exposes the bacteria to very high A more practical approach (used in case 7.