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Alan Cheng, MD

Kinetic models of antibody tional travelers antibiotic resistance and livestock order 100mg zithromax amex, household or sexual contacts antibiotic kills good bacteria buy generic zithromax line, nonhousehold decline indicate that protective levels of antibody persist for contacts antibiotic resistance medical journals purchase generic zithromax canada. A combined hepatitis A and hepatitis B vaccine has been developed and licensed for use as a 3-dose series in adults aged Diagnosis 18 years (Table 3) antibiotics side effects buy discount zithromax online. Patients with acute hepatitis A usually require only supportPrevaccination Serologic Testing for Susceptibility ive care antibiotic resistance essay zithromax 100 mg low cost, with no restrictions in diet or activity antibiotic resistant virus in hospitals buy discount zithromax 250 mg. Hospitalization might be necessary for patients who become dehydrated Approximately one third of the U. The potential cost-savings of testing should Hepatitis B be weighed against the cost and the likelihood that testing will Hepatitis B is caused by infection with the hepatitis B virus interfere with initiating vaccination. The incubation period from the time of exposure to who is already immune is not harmful. This vaccine is recommended for persons aged 18 years who are at increased risk for both hepatitis B and hepatitis A virus infections. Periodic testing to determine antibody health-care provider should consider the need to achieve levels after routine vaccination in immunocompetent persons completion of the vaccine series. Approved adolescent and is not necessary, and booster doses of vaccine are not currently adult schedules for both monovalent hepatitis B vaccine. Pain at the injection site and low-grade fever are A 4-dose schedule of Engerix-B at 0, 1, 2, and 12 months is reported by a minority of recipients. When scheduled to receive the second dose, adovaccine administered, approximately one vaccinee will experilescents aged >15 years should be switched to a 3-dose series, ence this type of reaction. No deaths have been reported in with doses two and three consisting of the pediatric formulathese patients (3,4,447). If the vaccine series is interrupted after the adults, acknowledgement of a specifc risk factor is not a frst or second dose of vaccine, the missed dose should be requirement for vaccination. The series does not need to Hepatitis B vaccine should be routinely ofered to all unvacbe restarted after a missed dose. Exposed persons who are known to have recommended for persons whose subsequent clinical manageresponded to vaccination are considered protected; therefore, ment depends on knowledge of their immune status. Persons who have health-care workers or public safety workers at high risk for written documentation of a complete hepatitis B vaccine series continued percutaneous or mucosal exposure to blood or body who did not receive postvaccination testing should receive a fuids). Studies are limited on the maximum interval after exposure during which postexposure prophylaxis is efective, but the interval is unlikely to exceed 7 days for percutaneous exposures and 14 days for sexual exposures. The following counseling messages should be partner as their only risk for infection (437). They should discuss the low but present risk identifying them and then providing medical management for transmission with their partner and discuss the need for and antiviral therapy, if appropriate. Evaluation should involve testing condom use might not be necessary in such circumstances. Sexually transmitted gastrointestinal syndromes include Prompt identifcation of acute infection is important, because proctitis, proctocolitis, and enteritis. Evaluation for these synoutcomes are improved when treatment is initiated earlier in dromes should include appropriate diagnostic procedures. Proctitis occurs predominantly among persons who participate Patients should be advised that approximately six of every 100 in receptive anal intercourse. Reinfection might be difcult to intestinal illness can be caused by other infections that usually distinguish from treatment failure. Multiple Management of Sex Partners stool examinations might be necessary to detect Giardia, and Partners of persons with sexually transmitted enteric infecspecial stool preparations are required to diagnose cryptospotions should be evaluated for any diseases diagnosed in the ridiosis and microsporidiosis. When laboratory diagnostic capabilities are available, treatment decisions should be based on the specifc diagnosis. Ectoparasitic Infections Diagnostic and treatment recommendations for all enteric Pediculosis Pubis infections are beyond the scope of these guidelines. Pediculosis pubis Acute proctitis of recent onset among persons who have is usually transmitted by sexual contact. Malathion can be used when treatshould be managed in the same manner as those with genital ment failure is believed to have resulted from drug resistance. If painful perianal ulcers The odor and long duration of application for malathion make are present or mucosal ulcers are detected on anoscopy, preit a less attractive alternative than the recommended pediculsumptive therapy should include a regimen for genital herpes cides. Bedding and clothing should be decontamiIvermectin 200ug/kg orally, repeated in 2 weeks nated. It should only be used as an alternative if eggs are observed at the hair-skin junction. Patients who do the patient cannot tolerate other therapies or if other therapies not respond to one of the recommended regimens should be have failed. Lindane should not be used immediately after a bath Management of Sex Partners or shower, and it should not be used by persons who have Sex partners that have had sexual contact with the patient extensive dermatitis, women who are pregnant or lactating, or within the previous month should be treated. Lindane resistance has been reported in abstain from sexual contact with their sex partner(s) until some areas of the world, including parts of the United States patients and partners have been treated and reevaluated to rule (474). Special Considerations Permethrin is efective and safe and less expensive than Pregnancy ivermectin (471, 474). One study demonstrated increased mortality among elderly, debilitated persons who received Pregnant and lactating women should be treated with ivermectin, but this observation has not been confrmed in either permethrin or pyrethrins with piperonyl butoxide; subsequent studies (475). However, pruritus might transplant recipients, mentally retarded or physically incaoccur within 24 hours after a subsequent reinfestation. Substantial risk for treatment failure might exist with especially if treatment with topical scabicides fails. Ivermectin should be Infants, Young Children, and Pregnant or combined with the application of either 5% topical benzyl Lactating Women benzoate or 5% topical permethrin (full body application to Infants, young children, and pregnant or lactating women be repeated daily for 7 days then 2 times weekly until release should not be treated with lindane; however, they can be treated from care or cure). Ivermectin is not recommended for pregnant risks for neurotoxicity associated with both heavy applications or lactating patients, and the safety of ivermectin in children and denuded skin. Fingernails should be closely trimmed to who weigh <15 kg has not been determined. Even when treatment is successful and reinfection is avoided, symptoms can persist or worsen as a Adults and Adolescents result of allergic dermatitis. Treatment with an alternative regimen is recomspecimens for forensic purposes, and management of potential mended for persons who do not respond to the recommended pregnancy or physical and psychological trauma are beyond treatment. Management of Sex Partners and Examinations of survivors of sexual assault should be Household Contacts conducted by an experienced clinician in a way that minimizes further trauma to the survivor. Evidentiary privilege an epidemic can only be achieved by treatment of the entire against revealing any aspect of the examination or treatment population at risk. If treatment was provided, testing should prophylactic antimicrobial treatment, compliance with follow be conducted only if the survivor reports having symptoms. As a result, routine preventive women are of particular concern because of the possibility of therapy after a sexual assault should be encouraged. Reproductive-aged female survivors should be evaluated for this vaccine should be administered to sexual assault pregnancy, if appropriate. Decisions to perform these twice a day for 7 days tests should be made on an individual basis. Follow-Up Examinations For those requiring alternative treatments, refer to the specifc sections in this report relevant to the specifc agent. After the initial postassault examination, follow-up examiThe efcacy of these regimens in preventing infections after nations provide an opportunity to 1) detect new infections sexual assault has not been evaluated. Clinical manthe sexual abuse of children is frequently associated with mulagement of the survivor should be implemented according to tiple episodes of assault and might result in mucosal trauma the following guidelines (78). The investigation of sexual Reporting abuse among children who have an infection that could have All U. Although the exact requirements with recommendations by clinicians who have experience and difer by state, if a health-care provider has reasonable cause training in all elements of the evaluation of child abuse, neglect, to suspect child abuse, a report must be made. The social signifcance of an infection that might providers should contact their state or local child-protection have been acquired sexually and the recommended action service agency regarding child-abuse reporting requirements regarding reporting of suspected child sexual abuse varies by in their states. Collection of vaginal specimens in preThe general rule that sexually transmissible infections pubertal children can be very uncomfortable and should be beyond the neonatal period are evidence of sexual abuse has performed by an experienced clinician to avoid psychological exceptions. Because of the legal and psychosocial consequences substitute for an intraurethral swab specimen. Because of a false-positive diagnosis, only tests with high specifcities of the legal implications of a diagnosis of N. The potential beneft to the child of a reliable infection in a child, if culture for the isolation of N. Gram stains are inadequate to ers with experience in the evaluation of sexually abused and evaluate prepubertal children for gonorrhea and should assaulted children. Specimens The scheduling of an examination should depend on the from the vagina, urethra, pharynx, or rectum should be history of assault or abuse. If the initial exposure was recent, streaked onto selective media for isolation of N. Isolates should be preserved to a repeat physical examination and collection of additional enable additional or repeated testing. The exact timing and nature of either sex because the yield is low, perinatally acquired follow-up examinations should be determined on an individual infection might persist beyond infancy, and culture sysbasis and should be performed to minimize the possibility tems in some laboratories do not distinguish between for psychological trauma and social stigma. Only standard culture follow-up appointments might be improved when law enforcesystems for the isolation of C. Such concerns might be an appropriate sexually abused child should be weighed against the risk for indication for presumptive treatment in some settings and adverse reactions. Efcacy of risk-reduction counseling to prevent human of human papillomavirus: a randomized clinical trial. Workshop summary: scientifc evidence on condom efectiveness transmitted disease clinics. Non-latex versus Recommendations for incorporating human immunodefciency virus latex male condoms for contraception. Using patient risk indicators versus male condom in preventing sexually transmitted disease in women. Quadrivalent human papillomavirus vaccine: recommendations of and future research directions. Efect of expevention in young men in Kisumu, Kenya: a randomised controlled trial. Patient-delivered men: results of a randomized controlled trial conducted in Orange Farm, partner treatment for male urethritis: a randomized, controlled trial. A randomized controlled trial of partner sion and Neisseria gonorrhoeae, Chlamydia trachomatis and Trichomonas notifcation methods for prevention of trichomoniasis in women. Screening for chlamydial infection: facilities, 2005: implications for screening policy. Natural history of cervical and educable moments: sexually transmitted disease risk assessment intraepithelial neoplasia during pregnancy. Prevalence of rectal, urethral, and in pregnancy to prevent preterm delivery: recommendation statement. Sexual risk factors among selftransmitted infections among female adolescents aged 14 to 19 in the identifed lesbians, bisexual women, and heterosexual women accessing United States. Trends in herpes simplex the management of persons infected with human immunodefciency virus type 1 and type 2 seroprevalence in the United States. Use of a glycoprotein and valacyclovir for suppression of recurrent genital herpes and viral G-based type-specifc assay to detect antibodies to herpes simplex virus shedding. The psychosocial impact the acceptance of herpes simplex virus type 2 antibody testing among of serological diagnosis of asymptomatic herpes simplex virus type 2 adolescents and young adults. The psychosocial impact of testing antibodies in subjects with culture-documented genital herpes simplex individuals with no history of genital herpes for herpes simplex virus virus-1 or 2 infection.

A diagnosis of asthma in young children is therefore based largely on recurrent symptom patterns combined with a careful clinical assessment of family history and physical findings with careful consideration of the differential diagnostic possibilities antibiotics for pustular acne generic 100 mg zithromax free shipping. A positive family history of allergic disorders antibiotics for uti metronidazole 100 mg zithromax otc, or the presence of atopy or allergic sensitization provide additional predictive support antibiotics for acute sinus infection buy zithromax 500mg online, as early allergic sensitization increases the likelihood that a wheezing child will develop persistent asthma virus 5 days of fever purchase genuine zithromax line. Features suggesting a diagnosis of asthma in children 5 years and younger Feature Characteristics suggesting asthma Cough Recurrent or persistent non-productive cough that may be worse at night or accompanied by wheezing and breathing difficulties Cough occurring with exercise antibiotic jock itch cheap zithromax 100mg visa, laughing antibiotics kidney stones buy zithromax without a prescription, crying or exposure to tobacco smoke, particularly in the absence of an apparent respiratory infection Wheezing Recurrent wheezing, including during sleep or with triggers such as activity, laughing, crying or exposure to tobacco smoke or air pollution Difficult or heavy breathing or Occurring with exercise, laughing, or crying shortness of breath Reduced activity Not running, playing or laughing at the same intensity as other children; tires earlier during walks (wants to be carried) Past or family history Other allergic disease (atopic dermatitis or allergic rhinitis, food allergy). Use of a video questionnaire,649 or asking a parent to record an episode on a smartphone if available can help to confirm the presence of wheeze and differentiate from upper airway abnormalities. Diagnosis and management of asthma in children 5 years and younger Wheeze Wheeze is the most common and specific symptom associated with asthma in children 5 years and younger. Wheezing occurs in several different patterns, but a wheeze that occurs recurrently, during sleep, or with triggers such as activity, laughing, or crying, is consistent with a diagnosis of asthma. Clinician confirmation is important, as parents may describe 650 any noisy breathing as wheezing. Cough Cough due to asthma is generally non-productive, recurrent and/or persistent, and is usually accompanied by wheezing episodes and breathing difficulties. A nocturnal cough (when the child is asleep) or a cough that occurs with exercise, laughing or crying, in the absence of an apparent respiratory infection, supports a diagnosis of asthma. The common cold and other respiratory illnesses are also associated with coughing. Prolonged cough in infancy, and cough without cold symptoms, are associated with later parent-reported physician-diagnosed asthma, independent of infant wheeze. Characteristics of cough in infancy may be early markers of asthma susceptibility, particularly among children with maternal asthma. Breathlessness that occurs during exercise and is recurrent increases the likelihood of the diagnosis of asthma. In infants and toddlers, crying and laughing are equivalent to exercise in older children. Activity and social behavior Physical activity is an important trigger of asthma symptoms in young children. Young children with poorly controlled asthma often abstain from strenuous play or exercise to avoid symptoms, but many parents are unaware of such changes in their childrens lifestyle. Engaging in play is important for a childs normal social and physical development. For this reason, careful review of the childs daily activities, including their willingness to walk and play, is important when assessing a potential asthma diagnosis in a young child. Parents may report irritability, tiredness and mood changes in their child as the main problems when asthma is not well controlled. Response should be evaluated by symptom control (daytime and night-time), and the frequency of wheezing episodes and exacerbations. Marked clinical improvement during treatment, and deterioration when treatment is stopped, support a diagnosis of asthma. Due to the variable nature of asthma in young children, a therapeutic trial may need to be repeated in order to be certain of the diagnosis. Diagnosis and Management of asthma in children 5 years and younger 143 Tests for allergic sensitization Sensitization to allergens can be assessed using either skin prick testing or allergen-specific immunoglobulin E. Allergic sensitization is present in the majority of children with asthma once they are over 3 years of age; however, absence of sensitization to common aeroallergens does not rule out a diagnosis of asthma. Allergic sensitization is the best predictor for development of persistent asthma. Other imaging investigations may be appropriate, depending on the condition being considered. Lung function testing Due to the inability of most children 5 years and younger to perform reproducible expiratory maneuvers, lung function testing, bronchial provocation testing, and other physiological tests do not have a major role in the diagnosis of asthma at this age. However, by 5 years of age, many children are capable of performing reproducible spirometry if coached by an experienced technician and with visual incentives. It is particularly important in this age group to consider and exclude alternative causes that can lead to symptoms of wheeze, cough, and breathlessness before confirming an asthma diagnosis (Box 6-3). Common differential diagnoses of asthma in children 5 years and younger Condition Typical features Recurrent viral respiratory Mainly cough, runny congested nose for <10 days; no symptoms between infections tract infections Gastroesophageal reflux Cough when feeding; recurrent chest infections; vomits easily especially after large feeds; poor response to asthma medications Foreign body aspiration Episode of abrupt, severe cough and/or stridor during eating or play; recurrent chest infections and cough; focal lung signs Persistent bacterial Persistent wet cough; poor response to asthma medications bronchitis Tracheomalacia Noisy breathing when crying or eating, or during upper airway infections (noisy inspiration if extrathoracic or expiration if intrathoracic); harsh cough; inspiratory or expiratory retraction; symptoms often present since birth; poor response to asthma medications Tuberculosis Persistent noisy respirations and cough; fever unresponsive to normal antibiotics; enlarged lymph nodes; poor response to bronchodilators or inhaled corticosteroids; contact with someone who has tuberculosis Congenital heart disease Cardiac murmur; cyanosis when eating; failure to thrive; tachycardia; tachypnea or hepatomegaly; poor response to asthma medications Cystic fibrosis Cough starting shortly after birth; recurrent chest infections; failure to thrive (malabsorption); loose greasy bulky stools Primary ciliary dyskinesia Cough and recurrent chest infections; neonatal respiratory distress, chronic ear infections and persistent nasal discharge from birth; poor response to asthma medications; situs inversus occurs in about 50% of children with this condition Vascular ring Persistently noisy breathing; poor response to asthma medications Bronchopulmonary Infant born prematurely; very low birth weight; needed prolonged mechanical ventilation dysplasia or supplemental oxygen; difficulty with breathing present from birth Immune deficiency Recurrent fever and infections (including non-respiratory); failure to thrive 6. Children should be switched from a face mask to mouthpiece as soon as they are able to demonstrate good technique. Maintaining normal activity levels is particularly important in young children because engaging in play is important for their normal social and physical development. It is important to also elicit the goals of the parent/carer, as these may differ from conventional medical goals. In young children, as in older patients, both symptom control and future risk should be monitored (Evidence D). Diagnosis and management of asthma in children 5 years and younger Assessing asthma symptom control Defining satisfactory symptom control in children 5 years and younger depends on information derived from family members and carers, who may be unaware either of how often the child has experienced asthma symptoms, or that their respiratory symptoms represent uncontrolled asthma. Few objective measures to assess symptom control have been validated for children <4 years. It incorporates assessment of symptoms; the childs level of activity and their need for reliever/rescue treatment; and assessment of risk factors for adverse outcomes (Evidence D). Symptom control Level of asthma symptom control Well Partly In the past 4 weeks, has the child had: Uncontrolled controlled controlled Daytime asthma symptoms for more than a few minutes, YesNomore than once a week Diagnosis and management of asthma in children 5 years and younger 147 Assessing future risk of adverse outcomes the relationship between symptom control and future risk of adverse outcomes, such as exacerbations (Box 6-4, p. Although exacerbations may occur in children after months of apparently good symptom control, the risk is greater if current symptom control is poor. This can be minimized by ensuring that the prescribed treatment is appropriate and reduced to the lowest dose that maintains satisfactory symptom control and minimizes exacerbations. If decreased growth velocity is seen, other factors should be considered, including poorly controlled asthma, frequent use of oral corticosteroids, and poor nutrition, and referral should be considered. As with older children and adults, medications comprise only one component of asthma management in young children; other key components include education, skills training for inhaler devices and adherence, non-pharmacological strategies including environmental control where appropriate, regular monitoring, and clinical review (see later sections in this chapter). When recommending treatment for a young child, both general and individual questions apply (Box 3-3, p. These decisions are based on data for efficacy, effectiveness and safety from clinical trials, and on observational data. The following treatment recommendations for children of 5 years of age or younger are based on the available evidence and on expert opinion. Although the evidence is expanding it is still rather limited as most clinical trials in this age group have not characterized participants with respect to their symptom pattern, and different studies have used different outcomes and different definitions of exacerbations. Generally, treatment includes the daily, long-term use of controller medications to keep asthma well-controlled, and reliever medications for as-needed symptom relief. Diagnosis and management of asthma in children 5 years and younger Which children should be prescribed regular controller treatment Intermittent or episodic wheezing of any severity may represent an isolated viral-induced wheezing episode, an episode of seasonal or allergen-induced asthma, or unrecognized uncontrolled asthma. Further treatment of the acute wheezing episodes themselves is described below (see Acute asthma exacerbations in children 5 years and younger, p. However, uncertainty surrounds the addition of other drugs in these children, especially when the nature of the episode is unclear. Regular controller treatment may also be indicated in a child with less frequent, but more severe episodes of viralinduced wheeze (Evidence D). It is important to discuss the decision to prescribe controller treatment and the choice of treatment with the childs parents or carers. They should be aware of both the relative benefits and risks of the treatments, and the importance of maintaining normal activity levels for their childs normal physical and social development. Treatment steps to control asthma symptoms and minimize future risk for children 5 years and younger Asthma treatment in young children follows a stepwise approach (Box 6-5), with medication adjusted up or down to achieve good symptom control and minimize future risk of exacerbations and medication side-effects. Before considering a step-up of controller treatment If symptom control is poor and/or exacerbations persist despite 3 months of adequate controller therapy, check the following before any step up in treatment is considered. If good asthma control is not achieved with a given therapy, trials of the alternative Step 2 therapies are recommended prior to moving to Step 3. The child should be referred for expert assessment if symptom control remains poor and/or flare-ups persist, or if sideeffects of treatment are observed or suspected. The relative cost of different treatment options in some countries may be relevant to controller choices for children. In addition, reassess and address control of environmental factors where relevant, and reconsider the asthma diagnosis. Benefits, and risks of side effects, should be considered, as described previously. The need for additional controller treatment should be re-evaluated at each visit and maintained for as short a period as possible, taking into account potential risks and benefits. Treatment goals and their feasibility should be re-considered and discussed with the childs family/carer. The doses listed here are the lowest approved doses for which safety and effectiveness have been adequately studied in this age group. Higher doses are associated with an increased risk of local and systemic side-effects, which must be balanced against potential benefits. Asthma-like symptoms remit in a substantial proportion of children of 5 years or younger,675-677 so the need for continued controller treatment should be regularly assessed. Marked seasonal variations may be seen in symptoms and exacerbations in this age-group. For children with seasonal symptoms whose daily long-term controller treatment is to be discontinued. The dose delivered may vary considerably between spacers, so consider this if changing from one spacer to another. The optimal number of breaths required to empty the spacer depends on the childs tidal volume, and the dead space and volume of the spacer. Young children can use spacers of all sizes, but theoretically a lower volume spacer (<350 mL) is advantageous in very young children. Multiple actuations into the spacer before inhalation may markedly reduce the amount of drug inhaled. This varies between spacers, but to maximize drug delivery, inhalation should start as soon as possible after actuation. This charge can be reduced by washing the spacer with detergent (without rinsing) and allowing it to air dry, but it may re-accumulate over time. If a patient or health care provider carries a new plastic spacer for emergency use, it should be regularly washed with detergent. Crucial to a successful asthma education program are a partnership between patient/carer and health care providers, with a high level of agreement regarding the goals of treatment for the child, and intensive follow-up (Evidence D). Action plans, developed through collaboration between an asthma educator, the health care provider and the family, have been shown to be of value in older children,679 although they have not been extensively studied in children of 5 years and younger. Details of treatments that can be initiated at home are provided in the following section, Part C: Management of worsening asthma and exacerbations in children 5 years and younger, p. If there is failure of resolution, or relapse of symptoms with dexamethasone, consideration should be given to switching to prednisolone. Arrange follow up within 1 week of an exacerbation to plan ongoing asthma management. This combination predicted around 70% of exacerbations, with a low false positive rate of 14%. In contrast, no individual symptom was predictive of an imminent asthma exacerbation. In a randomized controlled trial of acetaminophen versus ibuprofen, given for pain or fever in children with mild persistent asthma, there was no evidence of a difference in the subsequent risk of flare-ups or poor symptom control. The action plan should include specific information about medications and dosages and when and how to access medical care. The child should be observed by the family/carer and, if improving, maintained in a restful and reassuring atmosphere for an hour or more. Primary care management of acute asthma or wheezing in children 5 years and younger 6.

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Outside antibiotic resistance uptodate order zithromax with mastercard, they do not build webs but instead construct a flat tubular sac opened at both ends inside rolled leaves or crevices bacteria 3d cheap 100 mg zithromax amex, or under loose bark or stones virus 8 catamaran purchase zithromax 500 mg otc. However bacterial throat infection discount zithromax 100mg otc, misapplied chemical treatments may cause more harm then real or perceived threat from spiders bacteria used for bioremediation purchase 100 mg zithromax otc. They are important predators and scavengers antibiotics for acne that are safe during pregnancy discount zithromax online american express, helping to manage pests and recycle organic materials, but they can also sting humans and their pets. Although often grouped together with bees, yellowjackets pose a more serious threat to people. Multiple stings from yellowjackets are common, because they aggressively defend their nest when it is disturbed. Identification and Biology Yellowjacket and hornet are the common names given to wasps in the genera Dolichovespula, Vespula, and Vespa; but for the sake of simplicity, the term yellowjacket will be used. Note that these common names are not reliable indicators of whether or not they are pests. Yellowjackets are relatively short and stout, and hold their legs closer to their bodies than other wasps do. Their nests are always enclosed with a paper envelope and can be found in the ground, hanging from eaves or tree branches, and occasionally in wall voids. Once the larvae develop into adult workers, they expand the nest into tiers, built one on top of the other. After mating, the queens seek a sheltered place to spend the winter and all the workers die. Early in the warm season, colonies are small and yellowjackets are usually not a problem. Later in the season, when colonies are at their peak, these insects become pestiferous. In their search for protein and carbohydrate sources, they are attracted to garbage cans, dumpsters, lunch counters, and playgrounds, where they scavenge for food. Stings Insect stings are the leading cause of fatalities from venomous animals in the United States. The people who die from yellowjacket or bee stings are people who experience large numbers of stings at once or who suffer severe allergic reactions to the inflammatory substances in the insect venom. These allergic reactions include soreness and swelling, not only at the site of the sting, but also on other parts of the body that may be distant from the site. Other symptoms include fever, chills, hives, joint and muscle pain, and swelling of the lymph glands and small air passageways. In severe cases, the individual may suffer a sudden drop in blood pressure and lose consciousness. While many individuals who experience allergic reactions have become sensitized over time by previous stings, half of all fatalities occur in individuals stung for the first time. Ordinary reactions to stings include localized pain, itching, redness, and swelling that may last for hours and up to a day or two after the event. All wasps defend their colonies, but some yellowjackets are more sensitive to nest disturbance and more aggressive in their defense. This can occur when someone accidentally steps on an underground nest opening or disturbs a nest in a shrub or building. Sometimes merely coming near a nest, especially if it has been disturbed previously, can provoke an attack. Thus, mowing lawns or athletic fields can be hazardous, and operators may need to wear protective clothing when mowing during the late summer season when colonies are large. If there are only one or two wasps, back slowly away from them until they stop attacking you. Otherwise, it is best to run away from a colony rapidly, protecting your face and eyes as much as possible. It is important to educate children about the beneficial role of these wasps (they feed on pest insects, particularly caterpillars) and to remind them repeatedly of ways to avoid stings. Since problems with yellowjackets are most common in late summer and fall, teachers can be provided with this information at the beginning of the fall term. Detection and Monitoring If there is a chronic problem with yellowjackets around outdoor lunch areas or school athletic fields, inspect the area methodically to locate the nests. Ground nests are frequently, but not always, located under such things as shrubs, logs, piles of rocks, and other protected sites. Nest openings in the ground or in buildings can be recognized by observing the wasps entering and leaving. Management Options the objective of a yellowjacket management program should be to reduce human encounters with the wasps, but not to eliminate them from the entire area since they are beneficial predators of insects. The two most productive and least environmentally destructive ways to do this are to modify the habitat to reduce yellowjackets access to food in the vicinity of human activities, and to use physical controls such as trapping and nest removal. Areawide poison baiting should be used only as a last resort when other methods have failed and stings are frequent. Physical Controls Habitat Modification Garbage containers on school grounds should have tight-fitting lids. The cans should be emptied frequently enough to prevent the contents from impeding the closure of the lid. When these practices are not followed, school garbage (and the flies around 73 it) becomes a food source for yellowjackets in the area. If a large number of wasps are around garbage containers, students may be afraid to get close enough to place garbage all the way inside, and spilled food will attract more wasps. Dumpsters should be cleaned frequently by washing them with a strong stream of water. If the dumpster service company has a cleaning clause in their contract, make sure it is enforced. To limit yellowjacket infestations inside the school buildings, repair windows and screens and caulk holes in siding. Building inspections for yellowjackets can be done at the same time as inspections for other pests, such as rats, mice, and termites. Inspections should be conducted monthly to ensure that developing nests are found before they get large enough to be problematic. Trapping Trapping with a sturdy trap and an attractive bait can significantly reduce yellowjacket numbers if a sufficient number of traps are used. In general, cone-type traps are more useful for long-term trapping that will last many weeks. In some schools, unbaited yellow sticky traps (like those used to catch whiteflies) affixed to fences near underground nests have provided sufficient management to protect children from stings. A homemade, cone-type flytrap can be used to catch yellowjackets simply by using the captured flies inside the trap as bait. If you use baits such as dog food, ham, fish, or other meat scraps, or fermenting fruit and jelly, make sure the traps are placed in areas inaccessible to students, because large numbers of yellowjackets may be attracted to the baits. However, the traps should be placed near the nest if it can be found, or near the area where the yellowjackets are troublesome. Teachers can be instructed to make a short presentation on the purpose of the traps to satisfy the curiosity that students will undoubtedly have. Show students the traps, explain how they work, and try to impress upon them the importance of the traps in maintaining the safety of the playground. When traps are full they can either be placed in a freezer for a day to kill the wasps, or enclosed in a heavy-duty plastic garbage bag and placed in the direct sun for several hours. A third way of killing the wasps is to submerge the traps in a bucket of soapy water until the wasps drown the traps should be out only during the period that yellowjackets are a problem, usually late summer and early fall. When the traps are taken down for the year, they should be cleaned with soap and water and stored. Tips on Trapping Yellowjackets in a Homemade Cone-Type Fly Trap Yellowjackets can be caught in a cone-type fly trap using only the trapped flies as bait. The following tips will help improve yellowjacket trapping: Use this trapping method where students cannot gain access to the traps or at a time when students are not in school. Set up the fly trap with the fly bait in the area where the yellowjackets are a nuisance. If your trap stops catching yellowjackets at some point, but is still catching flies, try switching to a sweet bait such as fruit punch or jam. Note: To avoid being stung, you should replenish the fly bait or move the trap in the cool parts of the day, early morning or late evening. To kill everything in the trap before emptying, put the trap into a large plastic garbage bag and seal the bag. Nest Removal A nest can be destroyed through physical removal (vacuuming) or by using a pesticide (see Chemical Controls). Either way, great care must be exercised, because any disturbance around a nest can cause multiple stings. It is best to have a pest management professional or other experienced person remove the nest. Nest removal should take place at night, when the children are out of school and the yellowjackets are in the nest. When illumination is needed, use a flashlight covered with red acetate film so it will not disturb the wasps. Adequate protective clothing and proper procedures can minimize problems and stings. Complete body coverage is essential, because yellowjackets and other wasps can find even the smallest exposed area. This includes: A bee veil or hood that either contains its own hat or can be fitted over a light-weight pith helmet or other brimmed hat that holds the veil away from the head. This is worn over regular pants and a long-sleeved shirt to provide extra protection from stings. Secure pant legs over the boots with duct tape to prevent wasps from getting into trousers. Gloves with extra-long arm coverings so sleeves can be taped over them to protect the wrists. Vacuuming Vacuuming out entire nests is not recommended unless it is done by a pest management professional, experienced in handling stinging insects. Vacuuming is particularly effective when nests occur in wall voids, in emergencies where nests have already been disturbed, and in environmentally sensitive areas where nests should not be treated with insecticides. Some pest management professionals in some cities will perform this service for free so they can collect the wasps to sell to pharmaceutical companies for their venom. If the school is interested in this option, take time to find a company that will perform this service for you. When an insecticide is considered necessary for the management of yellowjackets, the best approach is to confine it to the nest itself. Anyone applying insecticides should use special clothing that protects against the chemical as well as against wasp stings. Insecticides should be applied in the evening or very early morning when children are absent, the wasps are inside the nest, and cooler temperatures reduce insect activity. The following are most appropriate for use in schools: Silica Aerogel and Pyrethrins Silica aerogel combined with pyrethrins is an effective insecticidal dust that can be used to destroy an underground nest or a nest in a wall void. Silica aerogel is made from sand and works by abrading the outer waxy coating on insect bodies. Once this coating is damaged, the insects cannot retain water and die of dehydration. Products with Components That Freeze Wasps Pyrethrins can be used to quickly knock down guard wasps at the nest entrance and to kill yellowjackets in an aerial nest when they must be destroyed in the daytime. These aerosol products are designed to project a stream of spray 10 to 20 feet and contain highly evaporative substances that freeze or stun the yellowjackets. Also, any synthetic pyrethroid is considered to be a non-low impact pesticide and will trigger the notification process in New Jersey Schools. This dangerous practice creates a fire hazard, contaminates the soil, and prevents the growth of vegetation for some time. A ground application of gasoline poses greater harm to children and the environment than a yellowjacket nest. Avoid Area-Wide Control Measures Mass control measures are seldom, if ever, necessary, and they are expensive due to the labor involved in the frequent mixing and replacement of bait. The effectiveness of bait mixtures is also questionable, since the baits face considerable competition from other food sources that are more attractive to scavenging yellowjackets. Rats and mice consume or contaminate large quantities of food and damage structures, stored clothing, and documents. They also serve as reservoirs or vectors of numerous diseases, such as rat bite fever, leptospirosis (Weils disease), murine typhus, rickettsial pox, plague, trichinosis, typhoid, dysentery, salmonellosis, hymenolepis, tapeworms, and lymphocytic choriomeningitis (Mallis 1997). In most cases of rodent infestation, the pest animals can be managed without having to resort to the use of poisons. If rodents do find their way indoors, small populations can be easily eliminated with various nontoxic methods. Rodenticides (rodent baits) need only be used in cases of large or inaccessible infestations. Traps prevent rodents from dying in inaccessible places and causing odor problems. Rodent Ecology the house mouse is the most common commensal rodent invading schools. The presence of mice is usually indicated by sightings, damage caused by gnawing into food containers, or the presence of droppings. However, they have a small home range and usually stay within 10 to 30 feet of their nest. Nests usually are built in structural voids, undisturbed stored products or debris, or in outdoor burrows.

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Retrospecdrug allergic reactions virus 98 discount zithromax online amex, including IgE-mediated systemic retive studies of hospitalized patients with a history of penicilactions antibiotic resistance neisseria gonorrhoeae buy zithromax 100 mg. Nonirritating Concentrations of 15 Antibiotics428 ries antimicrobial lighting cheap zithromax 500mg mastercard, a graded challenge procedure may be considered antibiotics while breastfeeding buy zithromax american express. Ceftazidime 100 mg/mL 10 1 10 mg/mL Up to 4% of patients treated with sulfonamide antibiotics 1 experience allergic reactions oral antibiotics for acne vulgaris cheap zithromax 500mg overnight delivery. There are Nafcillin 250 mg/mL 10 25 g/mL 1 data suggesting that patients with a history of allergy to Ticarcillin 200 mg/mL 10 20 mg/mL 1 sulfonamide antibiotics are at slightly increased risk of reactTobramycin 80 mg/2 mL 10 4 mg/mL Vancomycin 50 mg/mL 10 4 5 g/mL ing to nonantibiotic sulfonamides antimicrobial metals purchase zithromax 500mg, although this does not appear to be due to immunologic cross-reactivity but rather a nonspecific predisposition to react to drugs. More than 50% of treated patients experience antibiotics, evaluation of a possible allergy should not be some of these manifestations, although most of them are performed electively but rather be limited to situations when mild. Premedication with an histamine1 receptor antilarge-scale validation of such skin testing has not been achistamine also helps to alleviate symptoms. It is well recognized that most antibiotics have anaphylaxis to vancomycin has also been observed and may multiple end products, and therefore it is possible that the be identified by skin tests, but skin tests at concentrations of relevant allergens may be metabolites and not the parent 100 g or greater may elicit false-positive wheal-and-flare drug. For patients for whom an alternate antibiotic cannot skin test reactivity in a panel of normal, nonexposed volunbe used, successful rapid induction of drug tolerance for teers) may provide useful information. Table 18 lists nonirIgE-mediated hypersensitivity to vancomycin has been ritating concentrations for intradermal skin testing for 15 described. If the skin test result is positive Although aminoglycosides rarely cause hypersensitivity under these circumstances, it is likely that drug specific IgE reactions, there are individual case reports of IgE-mediated antibodies are present. On the other hand, a negative antibodies and no alternative antibiotic is available. The degree of allergic cross-reactivity among aminothe amount of drug injected intracutaneously can be used as glycosides is unknown but is assumed to be high. Antimycobacterial Drugs Leukocytoclastic vasculitis, generalized arteritis, granuloSummary Statement 120: Allergic drug reactions to antimatous hepatitis, and autoimmune pemphigus vulgaris are mycobacterial drugs present significant problems in the imrare immune-mediated reactions that have been described to plementation of long-term treatment regimens and preventing occur during treatment with metformin and/or sulfonylurea drug resistance to Mycobacterium tuberculosis. Cancer Chemotherapeutic Agents for tuberculosis, it became apparent that these drugs can Summary Statement 123: Cancer chemotherapeutic agents, induce both minor and life-threatening allergic reactions. Reactions range leprosy and neutrophilic dermatoses, may rarely induce from mild cutaneous eruptions to fatal anaphylaxis. In addition to life-threatening reactions, cancer chemother(C) apeutic agents (eg, cyclophosphamide, methotrexate) may Since the introduction of purified human recombinant ininduce a variety of cutaneous IgE and non-IgE allergic mansulin, allergy to insulin is rare and is now encountered in less ifestations. Pretreatment with corticosteroids and such as Stevens-Johnson syndrome or toxic epidermal antihistamines does not prevent these reactions. Methotrexate is a cause of noncytotoxic pulmonary reacmonly referred to as being allergic, it is likely that both tions. There are within the first year of treatment, and the reported incidence data to support several risk factors for the development of of this reaction varies from 0. These infever, cough, and dyspnea may occur anywhere from several clude coexistent cytomegalovirus or Epstein-Barr virus infecdays to several months after initiation of therapy. The chest tions, altered drug metabolism, slow acetylator phenotype, radiograph is characterized by a diffuse, fine interstitial inrelative deficiency of glutathione or other scavengers, infiltrate. When use of the drug is discontinued, symptoms and creased expression of major histocompatibility complex class pulmonary infiltrates typically clear within a few days. However, unlike reactions to reported to cause reactions similar to those ascribed to metho505 506 66,240 amoxicillin and antimycobacterial agents, adverse reactrexate. The degree of clinical cross-sensitivity allergic reactions and syndromes to a number of other agents, between trimethoprim-sulfamethoxazole and dapsone is including antituberculous agents, pentamidine, amoxicillinthought to be low, and it appears that most patients who react clavulanic acid, clindamycin, carbamazepine, phenytoin, thato trimethoprim-sulfamethoxazole tolerate dapsone. The fact sone, however, probably should not be used in those patients that these reactions are clinically diverse suggests that they in whom trimethoprim-sulfamethoxazole caused severe reacare likely produced by a variety of mechanisms. The oside analogue reverse transcriptase inhibitor, causes severe spectrum of clinical manifestations of sulfonamide reactions hypersensitivity in 4% to 5% of patients. This combination is induction of drug tolerance protocols have been developed associated with 3 major complications: (1) induction of cyand used successfully. Modifying Drugs for Dermatologic Diseases is rarely associated with phototoxic and photoallergic dermaSummary Statement 135: Allergic reactions to immunosuptitis. The macrolide immunosuppressants, which are extensively used to prevent transplantation rejecH. In general, tions to several unique therapeutic agents for autoimmune immune-mediated reactions to these agents are rare. Hypersensitivity reactions in the form of 535,536 associated with elevated total IgE levels. Apart from its toxic effects of methemoAlthough the efficacy results were promising, anaphylactic globulinemia, hemolytic anemia, and previously discussed reactions to the self-peptide were encountered. Skin reactions 540 hypersensitivity effects, dapsone may induce a potentially are common after the use of interferon beta-1b. Urticaria and a severe papulosquathematosus provides multiple therapeutic targets and cormous skin eruption have been reported after use of CellCept responding therapies: B cells (rituximab), Tand B-cell (mycophenolate mofetil). Anaphylactic or anaphylactoid reactions are not infrequent Immunomodulation strategies are being actively pursued 565 during general anesthesia. The incidence of these reactions for prevention or attenuation of type 1 diabetes. The higher incidence (1 Among the most promising of these immunotolerance interper 2,100 operations) was reported in a 12-year French peventions are (1) chain of insulin in incomplete Freund diatric survey. As previously discussed, human monoclonal antibodies threatening reactions to muscle relaxants has been estimated differ with respect to allergic effects, so it is not yet known at 1 in 4,500 anesthesia events. Drug specific IgE antibodies opiates are difficult to interpret because these agents cause have been demonstrated to some of these agents so that it is release of histamine from skin mast cells in all patients. Narcotic-induced pseudoallerdiagnosis and management of reactions occurring during gic reactions are rarely life-threatening. If there is a history of and after surgery are discussed in more detail in the Anaphysuch a reaction to an opiate and analgesia is required, a laxis Practice Parameter326 and Diagnostic Testing Practice nonnarcotic alternative pain medication should be selected. Blood and Blood Products Summary Statement 137: Reactions due to blood and blood M. Evaluation should tigranulocytic) into patients whose leukocytes express the include skin testing with the corticosteroid in question, alcognate antigen and/or (2) pulmonary endothelial activation though its predictive value is uncertain. Skin testing with the leading to endothelial damage and capillary leak syndrome diluent itself may also be helpful. If a patient with suspected allergy to a corticosteSummary Statement 138: Opiates and their analogs are a roid requires treatment with it, rapid induction of drug tolercommon cause of pseudoallergic reactions that are generally ance should be performed. Immediate generalized reactions to protamine, includsomewhat analogous to C1 inhibitor deficiency in which ing hypotension, shock, and death, have been reported. Local Anesthetics intravenous administration may be a manifestation of non582 Summary Statement 144: Most adverse reactions to local specific histamine release. However, the fact that diabetic anesthetics are not due to IgE-mediated mechanisms but are patients receiving protamine-containing insulins appear to be due to nonallergic factors that include vasovagal responses, at 40 to 50 times greater risk for developing anaphylaxis and anxiety, toxic reactions including dysrhythmias, and toxic or other adverse reactions to intravenous protamine suggests 102,103 idiosyncratic reactions due to inadvertent intravenous epithat immune mechanisms are also involved. There are no widely available alternate with a reaction history suggestive of possible IgE-mediated agents for heparin reversal. Therefore, the history of a previous low-molecular-weight heparin are uncommon and include reaction must be carefully evaluated. It is necessary to deterthrombocytopenia, various cutaneous eruptions, hypereosinomine the type of local anesthetics to be used. Mild thrombocytopenia is due to ics are either group 1 benzoic acid esters (eg, procaine, platelet aggregation and occurs in 1% to 3% of patients benzocaine) or group 2 amides (eg, lidocaine, mepivacaine). Severe thrombocytopeOn the basis of patch testing, the benzoic acid esters crossnia is caused by immune complexes, a component of which is react with each other, but they do not cross-react with the heparin-dependent IgG specific for platelet factor 4. It is not known what, if any, relevance reaction usually occurs after approximately 5 days of treatthis has on immediate-type reactions to local anesthetics. This test reagent should not contain epinephreactions, but it may cause thrombocytopenia. When mediate hypersensitivity reactions to unfractionated heparin there is concern about a previously reported reaction, skin and low-molecular-weight heparin are rare, anaphylactic and testing and incremental challenge with a local anesthetic is a anaphylactoid reactions have been documented. Skin prick patients with allergic reactions to heparin may require switchtests are first performed with the undiluted anesthetic. If the ing to a direct thrombin inhibitor such as a hepanoid (danapresult is negative, successive injections (subcutaneous or inaroid) or a hirudin (lepirudin or argatroban). A placebo step may be added after United States and Germany was attributed to a contaminant in the skin prick test and before challenging with the local heparin lots, an oversulfated form of chondroitin sulfate. With this protocol, there have been no serious oversulfated chondroitin sulfate contaminant has been shown allergic reactions reported after administration of local anesin vitro and in vivo to cause activation of the kinin-kallikrein thetics if the skin test results and test dosing are negative. Chemotoxic reactions (cardiotoxicity, neurothat contain either preservatives and/or epinephrine. Chemotoxic reactions tend to occur in occurs, patch testing should be performed to determine the medically unstable patients who are debilitated. Anaphylacdegree of sensitization to the suspected local anesthetic and toid reactions occur in approximately 1% to 3% of patients identify the agent(s) that is least likely to produce a reaction. There is no graded incremental approach after skin tests have been reconvincing evidence in the medical literature that individuals ported to be a safe method in a study of 236 patients with with seafood allergy are at elevated risk for anaphylactoid histories of adverse reactions to local anesthetics. The tively, a more rapid subcutaneous challenge approach using pathogenesis of anaphylactoid reactions is also unrelated to 1. Rates of anaphylactoid reactions to low-osmolar conof undiluted local anesthetic was a safe and effective method trast agents are significantly lower than rates observed with in a study of 252 patients. Complement actiSummary Statement 147: Risk factors for anaphylactoid vation may account for some reactions. However, the ceptor antihistamines; this will significantly reduce, but not latter agents may not be favorable from a risk-benefit standeliminate, risk for anaphylactoid reaction with reexposure to point in patients with cardiovascular disease. The during which the drug is tolerated suggests an IgE-mediated diagnosis is usually established by history, but if the history mechanism, but attempts to detect drug specific IgE have is unclear or when definite diagnosis is required, a controlled been unsuccessful in most cases. However, a recent investioral provocation challenge with aspirin may be performed. These proximately 85% will have a respiratory reaction confirming 140 specific IgE tests were specific in that other pyrazolone the diagnosis. A recent study showed that 100% of patients derivatives (antipyrine, aminophenazone, or metamizol) were with a history of aspirin causing a severe reaction (poor unable to inhibit IgE binding in the in vitro system. The response to albuterol with need for medical intervention) had 141 reaction is not due to arachidonic acid dysfunction, and any positive oral aspirin challenges. A 619 pharmacologic induction of drug tolerance procedure (also of chronic urticaria. This type throughout several days, until a dosage of 650 mg (2 tablets) of reactions also occurs in individuals without a prior history of chronic urticaria. Aspirin desensitization treatment imare also at increased risk for the development of chronic proves clinical outcomes for both upper and lower respiratory urticaria. The cough resolves with disconunpredictable and differs from the temporal pattern of other tinuation of the drug therapy in days to weeks. Because there is no diagnostic test to prove sporadically despite persistent treatment. Cough occurs in up to 20% of patients, is typically dry and nonproductive, and occurs more commonly reactions are related to high cytokine levels administered in women, blacks, and Asians. Cross-reactive reactions may occur when accumulation of bradykinin, which may cause stimulation of the biologic agent is intended for a pathologic cell type but vagal afferent nerve fibers to produce cough. Finally, biologics may also also been shown to induce the production of arachidonic acid result in nonimmunologic adverse effects. Cytokines ute to cough production through proinflammatory mecha149 Summary Statement 171: Allergic drug reactions ranging nisms. Such reactions should be clearly disA variety of immune-mediated reactions have occurred tinguished from cytokine release or acute respiratory distress during infliximab (Remicade) treatment for adult and juvenile syndromes caused by other monoclonal antibodies (eg, rituxrheumatoid arthritis, Crohns disease, and psoriasis. A recent retrospective treatment, slowing infusion rates, or induction of drug tolerevaluation of safety with this agent revealed that immediate 184 ance. In patients with immediate-type reactions, successful hypersensitivity reactions (9/84 or 11%) were a major reason 645 induction of tolerance to rituximab, infliximab, and trastufor discontinuation of the drug therapy. A subset of patients zumab has been reported using a 6-hour protocol in combiexperienced allergic reactions as a result of antibodies to 175 nation with corticosteroid and antihistamine premedication. Other possible immunologically related reactions include the Guillain-Barre syndrome, peripheral neu4. A contemporaneous review of omalizumab (Xolair; Genentech) clinical trials and postmarketing 3. The Omalizumab Joint A patient who had experienced anaphylaxis to basiliximab subTask Force report recommended that patients receiving omasequently tolerated a humanized version (daclizumab) with im649 lizumab should be directly observed, in a physicians office, punity. Anticancer Monoclonal Antibodies nal antibody against the epidermal growth factor receptor), inSummary Statement 175: the cytokine release syndrome cluding IgE-mediated anaphylaxis, has been reported to occur at must be distinguished between anaphylactoid and anaphylaca national rate of 3% or less but much higher (22%) in the Mid tic reactions due to anticancer monoclonal antibodies. Anaphylactoid reactions and istration of the first dose of the drug due to a cytokine release deaths have been associated with intravenous iron prepara185,186 tions. Life-threatening reactions to the osmotic diadulterated with synthetic medications. There are also anecdotal reports of reactions to about the use of herbs and health supplements.

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