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Cialis Super Active

By H. Corwyn. Dixie State College.

To delay emergence of resistance cialis super active 20mg mastercard erectile dysfunction and premature ejaculation, these drugs should be reserved for patients who cannot be treated with a more narrow- spectrum agent order genuine cialis super active on line erectile dysfunction washington dc. Imipenem Imipenem [Primaxin] buy cialis super active in united states online erectile dysfunction and diabetes ppt, a beta-lactam antibiotic 20 mg cialis super active amex impotence and depression, has an extremely broad antimicrobial spectrum—broader, in fact, than nearly all other antimicrobial drugs. As a result, imipenem may be of special use for treating mixed infections in which anaerobes, S. Imipenem is supplied in fixed-dose combinations with cilastatin, a compound that inhibits destruction of imipenem by renal enzymes. Antimicrobial Spectrum Imipenem is active against most bacterial pathogens, including organisms resistant to other antibiotics. The drug is highly active against gram-positive cocci and most gram-negative cocci and bacilli. In addition, imipenem is the most effective beta-lactam antibiotic for use against anaerobic bacteria. When employed alone, imipenem is inactivated by dipeptidase, an enzyme present in the kidneys. To increase urinary concentrations, imipenem is administered in combination with cilastatin, a dipeptidase inhibitor. When the combination is used, about 70% of imipenem is excreted unchanged in the urine. Hypersensitivity reactions (rashes, pruritus, drug fever) have occurred, and patients allergic to other beta-lactam antibiotics may be cross-allergic with imipenem. Fortunately, the incidence of cross sensitivity with penicillins is low —only about 1%. Interaction With Valproate Imipenem can reduce blood levels of valproate, a drug used to control seizures (see Chapter 19). If no other antibiotic will suffice, supplemental antiseizure therapy should be considered. Therapeutic Use Because of its broad spectrum and low toxicity, imipenem is used widely. The drug is effective for serious infections caused by gram-positive cocci, gram- negative cocci, gram-negative bacilli, and anaerobic bacteria. This broad antimicrobial spectrum gives imipenem special utility for antimicrobial therapy of mixed infections (e. Consequently, imipenem should be combined with another antipseudomonal drug when used against this microbe. Children/adolescents Cephalosporins are commonly used to treat bacterial infections in children, including otitis media and gonococcal and pneumococcal infections. Pregnant women Administration of telavancin during pregnancy should be avoided because of risk for adverse developmental outcomes. Breastfeeding Cephalosporins are generally not expected to cause adverse effects in breastfed infants. Other Carbapenems Meropenem Actions and Uses Meropenem [Merrem] is a beta-lactam antibiotic similar in structure and actions to imipenem. Meropenem is active against most clinically important gram- positive and gram-negative aerobes and anaerobes. Approved indications are (1) bacterial meningitis in children age 3 months or older, (2) intraabdominal infections in children and adults, and (3) complicated skin and skin structure infections in children and adults. Meropenem may prove especially useful for health care− or community-associated infections caused by organisms resistant to other antibiotics. The drug has a plasma half-life of 1 hour and is eliminated primarily unchanged in the urine. In contrast to imipenem, meropenem is not degraded by renal dipeptidases and hence is not combined with cilastatin. Adverse Effect and Interactions Like other beta-lactam antibiotics, meropenem is generally well tolerated. Like imipenem, meropenem can reduce levels of valproate and may permit breakthrough seizures in patients taking the drug. Ertapenem Actions and Uses Like other carbapenems, ertapenem [Invanz] weakens the bacterial cell wall and thereby causes cell lysis and death. Also like other carbapenems, ertapenem is highly resistant to beta-lactamases and thus has a very broad antimicrobial spectrum—but less broad than that of imipenem or meropenem. However, in contrast to imipenem and meropenem, the drug has little or no activity against P. In addition, ertapenem has minimal activity against pneumococci that are highly resistant to penicillin and has no activity against methicillin-resistant staphylococci, Enterococcus faecium, Enterococcus fecalis, or atypical respiratory tract pathogens, including Chlamydia species, Legionella species, and Mycoplasma pneumoniae. Ertapenem is indicated for parenteral therapy of acute pelvic infections, community-acquired pneumonia, prophylaxis after elective colorectal surgery, and complicated infections of the urinary tract, abdomen, skin, and skin structures. The drug undergoes some hydrolysis of the beta-lactam ring before excretion in the urine and feces. Its half-life is approximately 4 hours (compared with only 1 hour for imipenem or meropenem). Adverse Effects and Interactions Like other carbapenems, ertapenem is generally well tolerated. In clinical trials, the most common adverse effects were diarrhea, nausea, infused-vein complications, headache, vomiting, and edema. Like imipenem and meropenem, ertapenem can cause seizures, but the incidence is relatively low (0. Like other carbapenems, ertapenem can reduce levels of valproate and may thereby cause loss of seizure control. Doripenem Actions and Uses Doripenem [Doribax] is active against a broad spectrum of gram-positive, gram- negative, and anaerobic bacteria. Doripenem has two approved indications: complicated intraabdominal infections and complicated urinary tract infections. To delay emergence of resistance, the drug should be reserved for seriously ill patients with mixed infections or infection with multidrug-resistant, gram-negative bacteria or Pseudomonas species. In patients with renal impairment, the half-life is longer, and hence these people require a reduced dosage to prevent doripenem from accumulating to dangerous levels. Adverse Effects and Interactions Like other carbapenems, doripenem is generally well tolerated. The most common side effects are headache, nausea, diarrhea, rash, and injection-site phlebitis. However, like other carbapenems, doripenem can reduce levels of valproic acid and may cause loss of seizure control. Other Inhibitors of Cell Wall Synthesis Vancomycin Vancomycin [Vancocin] is the most widely used antibiotic in U. Unlike most other drugs discussed here, vancomycin does not contain a beta-lactam ring. Mechanism of Action Like the beta-lactam antibiotics, vancomycin inhibits cell wall synthesis and thereby promotes bacterial lysis and death. Instead, it disrupts the cell wall by binding to molecules that serve as precursors for cell wall biosynthesis. Other susceptible organisms include streptococci, penicillin-resistant pneumococci, and C. The drug is also employed as an alternative to penicillins and cephalosporins to treat severe infections (e. Risk is dose related and increased by concurrent use of other nephrotoxic drugs (e. To minimize risk, trough serum levels of vancomycin should be no greater than needed (see later). If significant kidney damage develops, as indicated by a 50% increase in serum creatinine level, vancomycin dosage should be reduced. Risk is increased by prolonged treatment, renal impairment, and concurrent use of other ototoxic drugs (e. Rapid infusion of vancomycin can cause a constellation of disturbing effects —flushing, rash, pruritus, urticaria, tachycardia, and hypotension—known collectively as red man syndrome. These effects, which may result from release of histamine, can usually be avoided by infusing vancomycin slowly (over 60 minutes or more). The reaction can be minimized by administering vancomycin in dilute solution and by changing the infusion site frequently. Rarely, vancomycin causes immune-mediated thrombocytopenia, a condition in which platelets are lost and spontaneous bleeding results. The underlying mechanism is development of unusual antibodies that bind to platelets—but only if the platelets first bind with vancomycin (forming a vancomycin-platelet complex). The resulting antibody-vancomycin-platelet complexes are then removed from the circulation by macrophages. Accordingly, vancomycin is an alternative to penicillins in patients with penicillin allergy. Preparations, Dosage, and Administration Intravenous Dosing For systemic infection, vancomycin is administered by intermittent infusion over 60 minutes or longer. One recommended regimen consists of giving 500 mg in 100 mL of normal saline every 6 hours, using a retention enema. Symptoms range from mild (abdominal discomfort, nausea, fever, diarrhea) to very severe (toxic megacolon, pseudomembranous colitis, colon perforation, sepsis, death). Any object that feces contact—including toilets, bathtubs, and rectal thermometers—can be a source of infection.

If ulcers develop order cialis super active american express erectile dysfunction pump how do they work, glucocorticoids should be slowly withdrawn—unless their continued use is considered essential for life—and antiulcer therapy should be instituted purchase cialis super active 20 mg with visa erectile dysfunction doctor malaysia. Systemic glucocorticoids can cause psychological disturbances buy cheap cialis super active 20mg line erectile dysfunction qof, both mild (insomnia cheap cialis super active generic erectile dysfunction treatment gurgaon, anxiety, agitation, irritability) and severe (delirium, hallucinations, depression, euphoria, mania). Depression is more likely with low-dose, long- term therapy, whereas psychoses (mania, delirium) are more likely with high- dose, short-term therapy. Psychological disturbances are reversible and usually resolve within days to weeks after drug withdrawal. Use in Pregnancy and Lactation Glucocorticoids can induce adrenal hypoplasia in the developing fetus. When large doses have been employed, the newborn should be assessed for adrenal insufficiency and given replacement therapy if indicated. During high-dose therapy, the glucocorticoid content of breast milk may become high enough to affect the nursing infant. Other Adverse Effects Myopathy and Cushing syndrome can be minimized by implementing the general measures noted at the beginning of this section. Glucocorticoid-induced potassium loss can be augmented by potassium- depleting diuretics (thiazides, loop diuretics) and can increase the risk for toxicity from digoxin. If digoxin and glucocorticoids are used concurrently, potassium levels should be monitored. Diabetic patients may need to increase their dosage of insulin or other hypoglycemic drugs. Glucocorticoids can decrease antibody responses to vaccines and can increase the risk for infection from live virus vaccines. P a t i e n t E d u c a t i o n Glucocorticoids Instruct patients to take their medicine in the morning to mimic natural physiologic timing of hormone release. Warn the patient against abrupt discontinuation of treatment when therapy is with high or prolonged dosing. Trauma and other emergencies will require higher doses of glucocorticoids to mimic the normal stress response. To decrease the risk of cataracts and glaucoma, reinforce the need for eye examinations during therapy. It is important to avoid over-the-counter drugs without first checking with the provider. Inform patients about possible psychological reactions, and instruct them to report disturbing symptoms. Explain that dosage adjustments or other medications may be needed to manage these symptoms. Each year, the disease results in more than 9 million physician visits and more than 250,000 hospitalizations. However, among patients older than 60 years, the incidence in men and women is equal. Rheumatoid arthritis follows a progressive course and can eventually cause joint deformities and functional limitations. As inflammation intensifies, the synovial membrane thickens and begins to envelop the articular cartilage. Damage to the cartilage is caused by enzymes released from the pannus and by chemicals and enzymes produced by the inflammatory process raging within the synovial space. Ultimately, the articular cartilage undergoes total destruction, resulting in direct contact between bones of the joint, followed by eventual bone fusion. E, Complete destruction of joint cavity together with fusion of articulating bones. Joint destruction is caused by an autoimmune process in which the immune system mounts an attack against synovial tissue. During the attack, mast cells, macrophages, and T lymphocytes produce cytokines and cytotoxins— compounds that promote inflammation and joint destruction. Overview of Therapy Treatment is directed at (1) relieving symptoms (pain, inflammation, and stiffness), (2) maintaining joint function and range of motion, (3) minimizing systemic involvement, and (4) delaying disease progression. To achieve these goals, a combination of pharmacologic and nonpharmacologic measures is used. Physical therapy may consist of massage, warm baths, and applying heat to the affected regions. A balanced program of rest and exercise can decrease joint stiffness and improve function. However, excessive rest and excessive exercise should be avoided: too much rest will foster stiffness, and too much activity can intensify inflammation. For patients with severe disease of the hip or knee, total joint replacement can be performed. When joints of the hands or wrists have been damaged severely, function can be improved through removal of the diseased synovium and repair of ruptured tendons. If loss of mobility limits function at home, on the job, or in school, consultation with a social worker, occupational therapist, or specialist in vocational rehabilitation may be appropriate. Drug Therapy Antiarthritic drugs can produce symptomatic relief, and some drugs, if started very early in the disease process, can induce protracted remission. However, remission is rarely complete, and the disease typically advances steadily. As a result, drug therapy is chronic and hence success requires patient motivation and cooperation. Unfortunately, although glucocorticoids are effective, with long-term use they can cause serious toxicity. Both leflunomide and methotrexate can cause fetal death and congenital abnormalities. Hydroxychloroquine may cause fetal ocular toxicity; however, in some conditions such as maternal lupus or malaria, the drug decreases fetal risk associated with the conditions it treats. The document, 2015 American College of Rheumatology Guideline for the Treatment of Rheumatoid Arthritis, is available at http://www. Accordingly, it may be necessary to try more than one agent to achieve an optimal response. Dosage Dosages employed for antiinflammatory effects are considerably higher than those required for analgesia or fever reduction. However, if only one or two joints are affected, intraarticular injections may be employed. Most often, glucocorticoids are used for temporary relief until drugs with more slowly developing effects (e. They may also be employed for flares, which are disease exacerbations that occur in patients whose condition was previously controlled. Long-term therapy should be limited to patients who have failed to respond adequately to all other options. Benefits are the result of immunosuppression secondary to reducing the activity of B and T lymphocytes. Periodic tests of liver and kidney function are mandatory, as are complete blood cell and platelet counts. Methotrexate can cause fetal death and congenital abnormalities and therefore is contraindicated during pregnancy. B l a c k B o x Wa r n i n g : M e t h o t re x a t e [ R h e u m a t re x, Tre x a l l ] Methotrexate can cause numerous and potentially fatal toxicities of the bone marrow, liver, lungs, and kidneys. Other fatalities have occurred associated with skin reactions and due to hemorrhagic enteritis and gastrointestinal perforation. Gastrointestinal reactions (nausea, vomiting, diarrhea, anorexia, abdominal pain) are the most common reasons for stopping treatment. These reactions can be minimized by using an enteric-coated formulation and by dividing the daily dosage. Fortunately, serious adverse effects—hepatitis and bone marrow suppression—are rare. To ensure early detection, periodic monitoring for hepatitis and bone marrow function (complete blood counts, platelet counts) should be performed. Because of its structure, sulfasalazine should not be prescribed for patients with sulfa allergy. In clinical trials, the drug decreased signs and symptoms and slowed disease progression. Compared with methotrexate, leflunomide is about equally effective but is potentially more hazardous and more expensive. Leflunomide is a prodrug that undergoes conversion to its active form— metabolite 1 (M1)—in the body. M1 inhibits dihydroorotate dehydrogenase, a mitochondrial enzyme needed for de novo synthesis of pyrimidines, which in turn are needed for T-cell proliferation and antibody production. Pharmacokinetics After oral dosing, leflunomide is converted to M1 by enzymes in the intestine and liver. The active form undergoes further metabolism followed by excretion in the urine and bile. Adverse Effects The most common adverse effects occur in at least 10% of patients: diarrhea, respiratory infection, reversible alopecia, and rash. The drug has also been associated with much more serious reactions: pancytopenia, Stevens-Johnson syndrome, and severe hypertension. In postmarketing reports, the drug has been associated with more than 130 cases of severe liver injury, including 14 that were fatal. Liver function should be assessed at baseline, every month for the first 6 months of treatment, and every 6 to 8 weeks thereafter. Leflunomide should be avoided in patients with liver impairment, hepatitis B, or hepatitis C.

Patients should store the pens cold—2° to 8°C (36°−46°F)—but not frozen discount cialis super active line erectile dysfunction related to prostate, and should take them out of the cold only to make an injection cialis super active 20 mg line fast facts erectile dysfunction. The cost for each syringe (a 28- day supply) in the United States is more than $2400 buy discount cialis super active line impotence may be caused from quizlet, so treatment costs can be very expensive purchase cialis super active 20 mg without a prescription erectile dysfunction shake. Dosage is much higher in patients with bone metastases than in patients with osteoporosis, and hence side effects are more severe in patients with bone metastases. Prolia is used for men and women with a high risk for fractures or who have bone loss due to anticancer therapy. Clinical Trials Osteoporosis in Postmenopausal Women Denosumab was tested in a 3-year study that enrolled 7868 postmenopausal women with osteoporosis. Half the women received denosumab (60 mg injected subQ every 6 months), and the other half received placebo injections. Compared with the women who got placebo injections, those who got denosumab had 68% fewer vertebral fractures, 40% fewer hip fractures, and 20% fewer fractures at other sites (wrist, leg, or shoulder). Taken together, these data suggest that denosumab is equal to bisphosphonates for treating postmenopausal osteoporosis. Adverse Effects In postmenopausal women with osteoporosis, the most common adverse effects are back pain, pain in the extremities, musculoskeletal pain, hypercholesterolemia, and urinary bladder infection. In cancer patients with bone metastases, the most common adverse effects are fatigue, hypophosphatemia, and nausea. Hypocalcemia Denosumab can exacerbate preexisting hypocalcemia, presumably by reducing osteoclast activity. The risk for hypocalcemia is elevated in patients with impaired renal function (including those on dialysis) and patients with other risk factors (e. The manufacturer recommends monitoring levels of calcium, magnesium, and phosphorus in this at-risk group. Serious Infections Denosumab increases the risk for serious infections, although the absolute risk is low. In clinical trials, some patients developed endocarditis, serious skin infections, and infections of the abdomen, urinary tract, and ear. Patients who develop signs of severe infection should seek immediate medical attention. Dermatologic Reactions Denosumab increases the risk for dermatitis, eczema, rashes, and other skin reactions. Prolia: Dosage and Administration Prolia is indicated for osteoporosis in postmenopausal women and in men at risk for fractures. The drug is supplied in (1) single-use vials containing 1 mL of a 60-mg/mL solution and (2) single-use, prefilled syringes containing 1 mL of a 60-mg/mL solution. The recommended dosage is 60 mg every 6 months, by subQ injection into the upper arm, upper thigh, or abdomen. The recommended dosage is 120 mg every 4 weeks by subQ injection into the upper arm, upper thigh, or abdomen. As with Prolia, patients should take calcium and vitamin D to prevent hypocalcemia. Prolia and Xgeva: Storage, Warming, and Inspection Solutions should be stored under refrigeration and then warmed before use (by standing at room temperature for 15–30 minutes). Cinacalcet increases the sensitivity of the calcium-sensing receptors to activation by extracellular calcium. Cinacalcet undergoes extensive hepatic metabolism, followed by excretion in the urine (80%) and feces (15%). Adverse Effects The most common adverse effects are nausea, vomiting, and diarrhea. Accordingly, calcium levels should be monitored, and patients should be informed about possible manifestations of hypocalcemia (e. Drug Interactions Cinacalcet is metabolized in part by cytochrome P450 isoenzyme 3A4, so inhibitors of this enzyme (e. If cinacalcet is used with one of these drugs, cinacalcet dosage may need an adjustment. Monitoring In patients with parathyroid carcinoma, measure serum calcium within 1 week of the first dose and each dosage change. After a maintenance dosage has been established, measure serum calcium every 2 months. Preparations, Dosage, and Administration Cinacalcet [Sensipar] is available in tablets (30, 60, and 90 mg) for oral use. Then, every 2 to 4 weeks, dosage is increased as follows—60 mg twice daily, 90 mg twice daily, 90 mg 3 times/day, up to a maximum of 90 mg 4 times a day —until the dosing goal (normalization of serum calcium) is achieved. In patients with secondary hyperparathyroidism, the initial dosage is 30 mg once daily. Drugs for Hypercalcemia Furosemide Furosemide, a loop diuretic, promotes renal excretion of calcium. The dosage of furosemide for adults is 80 to 100 mg every 1 to 2 hours as needed, infused no faster than 4 mg/min. To avoid fluid and electrolyte imbalance, urinary losses must be measured and replaced. Glucocorticoids Glucocorticoids reduce intestinal absorption of calcium and can thereby reduce hypercalcemia. Because glucocorticoids can produce serious adverse effects when taken chronically, the risks for long-term treatment must be carefully weighed against the benefits. Inorganic Phosphates Phosphates reduce plasma levels of calcium and thus can be used to treat hypercalcemia. Suggested mechanisms for reducing plasma calcium include (1) decreased bone resorption, (2) increased bone formation, and (3) decreased intestinal absorption of calcium (secondary to decreased renal activation of vitamin D). Intravenous use of phosphates is hazardous and limited to patients with life-threatening hypercalcemia. These agents should not be given to patients with renal impairment or elevated serum phosphate. Oral phosphates should not be combined with antacids that contain aluminum, magnesium, or calcium—agents that bind phosphate and thereby prevent its absorption. Osteoporosis General Considerations Osteoporosis is a serious medical problem characterized by low bone mass, altered bone architecture, and increased bone fragility. Because of bone fragility, patients are susceptible to fractures from minor traumatic events, such as coughing, rolling over in bed, or falling from a standing position. More than 10 million Americans have osteoporosis—80% of them older women—and another 34 million have reduced bone mass, a risk factor for osteoporosis. The most common fracture sites are the vertebrae (spine), distal forearm (wrist), and femoral neck (hip). Vertebral fractures can result in loss of height, spinal deformity, chronic back pain, and impaired breathing. Complications from hip fractures are a significant cause of mortality: of the 300,000 Americans who get hip fractures each year, about 50,000 die of complications. Each year in the United States, osteoporosis-related fractures lead to more than 432,000 hospital admissions, nearly 2. Bone mass peaks in the third decade, remains stable to age 50 years, and then slowly declines—at a rate that is usually less than 1% a year. In addition to this slow, aging-related decline, women go through a phase of accelerated bone loss (2%–3% a year) that begins after menopause and continues for several years. In both the slow and accelerated phases of decline, bone is lost because resorption of old bone outpaces deposition of new bone. In this instance it is advised only for “skeletally mature” adolescents adolescents who are 13–17 years old. The remaining drugs are classified in Pregnancy Risk Category C; however, there is a theoretical concern that bisphosphonates could cause harm that has not yet been verified owing to inadequate long-term studies. Nasal spray formulations of calcitonin-salmon are not recommended during pregnancy. Although vitamin D2 and calcium formulations receiving an assigned Pregnancy Risk Category were given a C classification, this is generally considered to be a concern only if the intake exceeds recommendations. For the remaining drugs, with the exception of calcium and vitamin D, breastfeeding is not recommended because of inadequate studies. Older adults Estrogen meets Beers Criteria (strength of recommendation: strong) for potentially inappropriate use in older patients. Because frail older adults commonly have difficulty swallowing, those who take bisphosphonates may be at an increased risk for esophagitis. Owing to occurrences of low-impact atypical femur fractures in older women who have had long-term bisphosphonate therapy, some orthopedists recommend against continuing bisphosphonate therapy beyond 5 years. Primary Prevention: Calcium, Vitamin D, and Lifestyle The risk for osteoporosis can be reduced by lifelong implementation of measures that can help maximize bone strength. Specifically, we need to ensure sufficient intake of calcium and vitamin D, and we need to adopt a lifestyle that promotes bone health. Calcium is needed to maximize bone growth early in life and to maintain bone integrity later in life. Note that calcium requirements are greatest for adolescents and teens (1300 mg/day), then drop for younger adults (1000 mg/day), and then rise for older adults (1200 mg/day). Other important predictors include a family history of hip fractures, a personal history of fractures, low body mass index, and use of oral glucocorticoids. Individual risk is calculated after entering the following data: • Age • Gender • Weight • Height • Previous fracture • Hip fracture in a parent • Secondary osteoporosis (i. In 2016, The American Association of Clinical Endocrinologists and the American College of Endocrinology released joint clinical practice guidelines for diagnosis and treatment of postmenopausal osteoporosis.

Raltegravir can cause potentially fatal hypersensitivity reactions discount cialis super active 20 mg without a prescription impotence quotes the sun also rises, including Stevens-Johnson syndrome and toxic epidermal necrolysis order cialis super active 20 mg otc erectile dysfunction drugs in kenya. The treatment recommendations presented in this chapter reflect those guidelines discount cialis super active 20mg with visa erectile dysfunction 17, which are available at http://www discount cialis super active 20 mg mastercard erectile dysfunction massage techniques. Infection is frequently asymptomatic in women and may also be asymptomatic in men. Treatment Adults and Adolescents For uncomplicated urethral, cervical, or rectal infections in adults or adolescents, treatment with either azithromycin [Zithromax] or doxycycline [Vibramycin, others] is recommended. Patients who are unable to take these medications may take erythromycin, levofloxacin [Levaquin], or ofloxacin [generic]. If the patient cannot take azithromycin, the approved alternatives are amoxicillin, erythromycin base, or erythromycin ethylsuccinate. Conjunctivitis does not result in blindness and spontaneously resolves in 6 months. The preferred treatment for both infections is oral erythromycin base or erythromycin ethylsuccinate. Although topical erythromycin, tetracycline, or silver nitrate may be given to prevent conjunctivitis, these drugs are not completely effective—and they have no effect on pneumonia. Preadolescent Children Although infection in preadolescent children can result from perinatal transmission, sexual abuse is the more likely cause, especially in children older than 2 years. For children who weigh less than 45 kg, the preferred treatment is oral erythromycin base or erythromycin ethylsuccinate. For children who weigh 45 kg or more, but are younger than 8 years, the preferred treatment is azithromycin. For children at least 8 years old, the preferred treatments are azithromycin or doxycycline. From this site, the organism migrates to regional lymph nodes, causing swelling, tenderness, and blockage of lymphatic flow. Erythromycin base serves as an alternative for those who cannot take tetracycline antibiotics. Gonococcal Infections Characteristics Gonorrhea is caused by Neisseria gonorrhoeae, a gram-negative diplococcus, often referred to as the gonococcus. In men, the main symptoms are a burning sensation during urination and a pus-like discharge from the penis. In contrast, gonorrhea in women is often asymptomatic or may present as mild cervicitis. However, serious infection of female reproductive structures (vagina, urethra, cervix, ovaries, fallopian tubes) can occur, ultimately resulting in sterility. Among people who engage in oral sex, the mouth and throat can become infected, causing sore throat and tonsillitis. Among people who engage in receptive anal sex, the rectum can become infected, causing a purulent discharge and constant urge to move the bowels (tenesmus). Bacteremia can develop in males and females, causing cutaneous lesions, arthritis, and, rarely, meningitis and endocarditis. Treatment Owing to antibiotic resistance, treatment of gonorrhea has changed over the years—and undoubtedly will continue to evolve. In the 1930s, virtually all strains of the gonococcus were sensitive to sulfonamides. Fortunately, by that time penicillin had become available, and the drug was active against all gonococcal strains. This recommendation was changed yet again in 2012, also triggered by antimicrobial resistance—this time to oral cephalosporins. If a patient is allergic to azithromycin, a 7-day course of doxycycline may be substituted. Spectinomycin, an aminoglycoside, has also been suggested; however, it is not currently available in the United States. Pharyngeal Infection Gonococcal infection of the pharynx is more difficult to treat than infection of the urethra, cervix, or rectum; therefore, parenteral therapy is recommended for all patients. Azithromycin is preferred over doxycycline because patients are more likely to adhere to a single-dose regimen of azithromycin than the full-week regimen of doxycycline taken twice a day. Conjunctivitis Gonococcal conjunctivitis can be reliably eradicated with ceftriaxone plus azithromycin. Symptoms include petechial or pustular skin lesions, arthritis, arthralgia, and tenosynovitis. Neonatal Infection Neonatal gonococcal infection is acquired through contact with infected cervical exudates during delivery. To protect against neonatal ophthalmia, a topical antibiotic should be instilled into both eyes immediately postpartum—as required by law in most states. If this antimicrobial is not available, parenteral therapy with ceftriaxone is to be used. Possible manifestations include sepsis, arthritis, meningitis, and scalp abscesses. Preadolescent Children Among preadolescent children, the most common cause of gonococcal infection is sexual abuse. For children with localized infection who weigh more than 45 kg, treatment is the same as for adults. Other likely agents are Ureaplasma urealyticum, Trichomonas vaginalis, and Mycoplasma genitalium. The recommended treatment is either azithromycin [Zithromax] or doxycycline [Vibramycin]. Alternative regimens are erythromycin base, erythromycin ethylsuccinate, levofloxacin, or ofloxacin. Azithromycin should be added to the regimen if it had not been used during initial therapy. Unfortunately, we have no easy tests for this bacterium, and hence definitive diagnosis may not be possible. However, Mycoplasma hominis, as well as assorted anaerobic and facultative bacteria, may also be present. This may be attributable to intensified patient education efforts, increased and improved screening practices, or improved adherence to single- dose treatment. Because multiple organisms are likely to be involved, drug therapy must provide broad coverage. For the hospitalized patient, treatment can be initiated with either cefoxitin or cefotetan, combined with doxycycline. The syndrome occurs primarily in young adults (under 35 years old) and may be associated with urethritis. Primary symptoms are fever accompanied by pain in the back of the testicles that develops over the course of several hours. For patients with gonococcal or chlamydial infection, the recommended treatment is ceftriaxone [Rocephin] plus doxycycline [Vibramycin, others]. For patients who engage in insertive anal sex, the addition of levofloxacin or ofloxacin is recommended to target enteric bacteria. Non–sexually transmitted epididymitis generally occurs in older men and in men who have had urinary tract instrumentation. Characteristics Syphilis develops in three stages, termed primary, secondary, and tertiary. After an incubation period of 1 to 4 weeks, a primary lesion, called a chancre, develops at the site of entry. Skin lesions and flu-like symptoms (fever, headache, reduced appetite, general malaise) are typical. The symptoms of secondary syphilis resolve in 4 to 8 weeks—but may recur episodically over the next 3 to 4 years. Infection of the brain—neurosyphilis—is common and can cause senility, paralysis, and severe psychiatric symptoms. Early signs of congenital syphilis include sores, rhinitis, and severe tenderness over bones. However, instead of receiving a single dose, adults and children receive three doses 1 week apart. Syphilis in pregnancy should be treated with penicillin G, using a dosage appropriate to the stage of the disease. For nonpregnant patients with early or late syphilis, either doxycycline or tetracycline may be used. For patients with neurosyphilis, ceftriaxone can be effective, but possible cross-reactivity with penicillin is a concern. Bacterial Vaginosis Bacterial vaginosis is a common vaginal infection in women of childbearing age. Organisms responsible for the syndrome include Gardnerella vaginalis (also known as Haemophilus vaginalis), Mycoplasma hominis, and various anaerobes. The syndrome occurs most commonly in sexually active women, although it may be transmitted in other ways. Bacterial vaginosis is characterized by a malodorous vaginal discharge, elevation of vaginal pH (above 4. Clue cells (epithelial cells whose borders are obscured by bacteria) are typically found on microscopic examination of vaginal secretions. The recommended therapy for bacterial vaginosis is either oral or vaginal metronidazole [Flagyl] or vaginal clindamycin cream. Clindamycin cream is available as a short-acting 2% clindamycin cream [Cleocin] and a long-acting 2% clindamycin cream [Clindesse]. Clindesse cream is formulated to adhere to the vaginal mucosa for several days and hence can clear bacterial vaginosis with just one application.