O. Jaroll. University of Houston, Clear Lake.

A historical approach to understanding antibiotic-associated resistance from a clinical standpoint indicates that some antibiotics are more likely to cause resistance than others generic vardenafil 10 mg on-line erectile dysfunction medication for sale. These antibiotics may be termed “high-resistance potential” antibiotics indicating the resistance potential is not necessarily high in terms of percentage but relatively higher than those with a “low-resistance potential vardenafil 20 mg cheap std that causes erectile dysfunction. While antibiotics should not be used thoughtlessly, all other things being equal, it is always preferable to use an antibiotic with a low resistance potential, in preference to one with a high resistance potential. There is no good explanation for why within each antibiotic class there are one or more antibiotics that have high resistance potential while the others in the group with a similar structure and pattern/volume of use have not been associated with significant resistance problems. Low-resistance potential antibiotics have been used for decades without causing widespread resistance, i. Antibiotic-induced resistance, therefore, is not related to antibiotic class, volume, or duration of antibiotic use, but rather is an attribute of one or more antibiotics in each antibiotic class that may be considered as high-resistance potential antibiotics whereas the other antibiotics in the class may be termed low-resistance potential antibiotics. However, it should be remembered that if an institution has a resistance problem with a particular organism, i. All antibiotics with anti-pseudomonal activity in the institution must also be changed substituting anti-pseudomonal, low-resistance potential antibiotics for those on formulary that have a high antibiotic resistance potential. Therefore, in this case, not only should amikacin be substituted for gentamicin but meropenem must be substituted for imipenem, cefepime should be substituted ceftazidime, and levofloxacin substituted for ciprofloxacin. If multiple formulary substitutions are not implemented, the antibiogram of the institution will show increasing resistance among the low-resistance potential anti-pseudomonal antibiotics that have not replaced their high-resistance potential counterparts. In this setting, if amikacin is substituted for gentamicin but imipenem, ciprofloxacin, and ceftazidime usage continues, resistance problems will be manifested by the worsening susceptibility patterns of meropenem, levofloxacin, and cefepime. Intrinsic resistance refers to the lack of activity of an antibiotic against an isolate, e. In contrast, acquired antibiotic resistance refers to isolates that were once formally sensitive to an antibiotic that have subsequently become resistant and the resistance is related to antibiotic use not mutation, i. Acquired antibiotic resistance may be further subdivided into relative resistance and absolute or high-level resistance. Although reported as “resistant,” such an isolate may in fact be susceptible in body sites that concentrate the antibiotic to greater than serum levels, i. Pseudomonas is not an infrequent colonizer of the urine in patients with indwelling urinary catheters, i. These strains should be identified as such and their spread limited by effective infection-control containment measures. The reason for this is that colonizing strains exist in sites where the concentration of antibiotics may be subtherapeutic. All other things being equal, subtherapeutic concentrations of antibiotics are more likely to predispose to resistance than our supra therapeutic concentrations. It is important to differentiate colonization from infection to avoid needless antibiotic use (3–6). The incorrect clinical assumption is that the isolate in the respiratory secretions is reflective of the pathological process in the parenchyma of the lung. Respiratory secretions and parenchyma of the lung are rarely related and nearly always represent colonization rather than infection. In ventilated patients with fever and leukocytosis with a shift to the left and pulmonary infiltrates, it is well known that the cause of such patients’ pulmonary infiltrates is more commonly noninfectious than infectious. The necrotic/invasive nature of this fulminating/necrotic pneumonia is manifested by demonstrating elastin fibers using an elastin stain in respiratory secretions. Aminoglycosides concentrate the high concentration in the urine and are ideal agents to use in P. There are relatively few anti-pseudomonal antibiotics that are effective and reach therapeutic concentrations in the lung. Aminoglyco- sides have modest anti-Klebsiella activity but cephalosporins are highly active against K.

Several cases have been reported order 10mg vardenafil with visa impotence sexual dysfunction, but only from bird to human transmission (not human to human) vardenafil 10mg with amex impotence blood pressure. Guided Discussion with Writing Activity (20 minutes) Instructor will draw the fre house they work at in the center of the board. Around it, instructor will draw a fre fghter, a family, a fre department and a town. A5- Unit 5 Appendices August 2007 Infectious Diseases International Association Unit 5 – Avian & Pandemic Infuenza of Fire Fighters Module 1: In My Fire House continued… Start with the fre house. Suggested responses: • More calls because so many people are sick • One third of workforce would be out sick is predicted by experts • Continuous restocking of equipment or limited supplies • Death of coworker • Quarantine or isolation Next, ask them to step into the shoes of the fre chief. Suggested responses: • Staffng issues, such as mandatory staffng, overtime Is the department ready? Suggested responses: • Family sick • Shift changes • Child care unavailable • Deaths of elderly or young members of family • Quarantine or isolation What might happen in the community? Suggested responses: • Schools close • Grocery or other stores understaffed, limited supplies available • Banks close • Transportation system running slow • Lack of available medical care • Quarantine or isolation Can you name other areas that might be affected across the nation? It is important that frst responders have a plan for their families so that, with the peace of mind that their own families are prepared, they can do their job in the event of pandemic fu or any major emergency that may occur. Summary This lesson is focused on creating a family plan in case of a major emergency. Learning objectives • Decide what work/family issues need to be addressed in an emergency. Materials needed for each student • Pen or pencil • Handout “Emergency Plan for First Responder Families” worksheet Facilitator Instructions 1. Scenario (20 minutes) Read the scenario below aloud (or have a student read) about a family under a major emergency. Ask students: What are some factors that the family must consider in this emergency? They just moved to Kansas two weeks ago, leaving behind relatives in another state. The mother has been called to work at the hospital and the father is being required to stay on shift. A5- Unit 5 Appendices August 2007 Infectious Diseases International Association Unit 5 – Avian & Pandemic Infuenza of Fire Fighters Module 2: Making a Plan continued… Lead a discussion with the following questions: • What are some of the challenges this family needs to take care of? Ask other discussion questions: • What will they do if their cell phones don’t work? Group Activity (25 minutes) Have students develop a plan for their families based on predicted factors. Hand out worksheet “Emergency Plan for First Responder Families” for participants to fll out during the activity. Ask students to develop a backup plan based on childcare, transportation, communication and health and welfare. Groups should discuss the issues they might face with their own families and assist others with solutions to challenges they might face. They should help each other complete the worksheet, which includes coming up with alternative plans. Write the bulleted list below on an easel pad or chalkboard to remind students of the factors behind an emergency family plan: • Child care • Transportation • Communication • Health and welfare Encourage students to fll out the form to the best of their ability and acknowledge they will have to consult their spouse to get more information, and fnish it later if time is limited. After students have completed the form, ask the following evaluation questions: • What are some of the challenges they encountered while making their plans? A5-50 Unit 5 Appendices August 2007 Infectious Diseases International Association Unit 5 – Avian & Pandemic Infuenza of Fire Fighters Module 3: Protecting Myself continued… Scenario Your unit has been dispatched to an unknown sickness at a local bus stop.

Biopsy reveals that there is subepidermal fluid cheap vardenafil 10mg on-line erectile dysfunction treatments that work, with polymorphs and eosinophils in the infiltrate subepidermally (Fig vardenafil 20 mg fast delivery erectile dysfunction treatment pdf. Patients with widespread blistering may need to be nursed in hospital and treated as though they had severe burns. High doses of corticosteroids (60 mg per day of prednisone, or even more) are needed to control the disease. Immunosuppressive treatment with azathioprine or methotrexate is usually started simultaneously. A biopsy from the skin around the site of blistering was frozen and the cryostat section treated with fluorescein-tagged anti-immunoglobulin antibodies. Variants of bullous pemphigoid There are other rare blistering diseases in which the blister forms subepidermally. These include: ● benign mucous membrane pemphigoid, in which lesions occur chronically in the mouth and in the conjunctivae as well as on the skin ● ‘bullous disease of childhood’, in which bullous lesions occur in infancy, par- ticularly in the buttock and perigenital area. In the latter disorder, and in some blistering conditions in adults, IgA is depo- sited instead of IgG. Dermatitis herpetiformis Intensely itchy vesicles, papulovesicles and urticarial papules appear in crops over the knees, elbows, scalp, buttocks and around the axillae (Fig. Minor abnormalities of small-bowel absorptive function are dermatitis herpetiformis. There are collections of polymorphs in the tips of the dermal papillae where the subepidermal blistering begins. Biopsy of new lesions demonstrates that the vesicle forms subepi- dermally and develops from collections of inflammatory cells in the papillary tips (the papillary tip abscess: Fig. Direct immunofluorescent examination reveals the presence of IgA in the papillary tips in the skin around the lesions in all patients. Unfortunately, however, dapsone has many toxic side effects, including haemolysis, methaemoglobinaemia, sulphaemoglobinaemia and rashes such as fixed drug eruption. A gluten-free diet will improve the gastrointestinal lesion and improves the skin disorder in many patients after some months. Epidermolysis bullosa This is not a single disorder, but a group of similar, inherited blistering diseases. The blisters may just be confined to the 90 Pemphigus soles of the feet and not prove troublesome until adolescence. There is no effective treat- ment other than to avoid trauma and to keep the blistered areas clean and dry. Blistering and scarring cause marked tissue loss over the hands and feet, with even- tual webbing of the fingers and toes and possibly loss of these structures. There is also marked scarring of the mucosae, which affects the pharynx and oesophagus too, so that severe dysphagia is a problem. Squamous cell carcinoma develops on the most severely affected sites in some patients. This is a terrifyingly destructive and disabling group of disorders for which there is at present no adequate treatment. Pemphigus Pemphigus causes blistering because of a loosening of desmosomal links between epidermal cells caused by immunological attack. The lesions are thin-walled, delicate blisters that usually rapidly rupture and erode (Fig. They occur any- where on the skin surface and very frequently occur within the mouth and throat, where they cause much discomfort and disability. The presence of the antibody and its titre are determined by indirect immunofluorescence methods.

Following a report of increased hair growth on the scalp of a balding man taking minoxidil tablets (47) buy generic vardenafil 10 mg online erectile dysfunction labs, extem- poraneous formulations of minoxidil solution were developed for topical application in the treat- ment of hair loss (initial reports concentrated mainly on alopecia areata) purchase vardenafil 20 mg with mastercard impotence and depression. Food and Drug Administration for the treatment of male balding and marketed by the Upjohn Company in 1986. The rapid response of hair growth to minoxidil suggests that the drug acts mainly to promote entry into anagen of fol- licles in a latent stage of the hair cycle. There is no convincing evidence that minoxidil reverses follicular miniaturization although it may prevent or delay it. Clinical trials using various endpoints including hair counts, hair weight, and global pho- tography have confirmed improvement in male balding with the use of minoxidil solution (49,50). The mean increase in target area hair counts is about 8% with 2% minoxidil solution and 10–12% with the 5% formulation. When assessed by global photography, nearly 60% of men show improvement with 5% minoxidil solution and 40% with 2%, compared to 23% with placebo. The response to minoxidil in terms of increased hair counts and hair weight is rapid and peaks by 16 weeks although the cosmetic response may take longer to become apparent. Clinical experience suggests the former regimen is equally effective but is unlicensed and unsupported by clinical trial data Treatment options for men Mild/moderate vertex balding 2–5% minoxidil solution Finasteride 1 mg daily Mild/moderate frontal balding Finasteride 1 mg daily Advanced frontal and/or vertex balding Surgery Prosthesis Treatment options for women Mild/moderate hair loss 2% minoxidil solution (5% more effective but unlicensed) If clinical or biochemical signs of androgen excess consider: Oral anti-androgen, e. Concomitant contraceptive measures needed in fertile women Severe hair loss Medical treatment as above may help to prevent progression Surgery Prosthesis Trials continued for up to 2 years suggest the improvement is sustained providing treatment is maintained. Any positive effect on hair growth is lost within 4–6 months of stopping treatment (49,51). Constituents of the vehicle occasionally cause scalp irritation, more commonly with the 5% formulation. Allergic reac- tions to minoxidil or propylene glycol (a component of the vehicle) are rare but necessitate stopping treatment. Some patients notice an increase in hair shedding 2–8 weeks after start- ing treatment. This is self-limiting and patients should be forewarned not to stop treatment if this happens. Large, long-term placebo-controlled studies using hair count and global photographic technology show that finasteride 1mg daily prevents or slows the progression of male balding in most men and about two-thirds experience some improvement (17). The improvement peaks at around 12 months and, on average, there is some decline after two years. However, after five years those on placebo continued to lose hair more rapidly than those on finasteride (53). Similar results were obtained in a trial where the treatment response was assessed using hair weight as the primary endpoint. The level of finasteride in semen is very low and poses no risk to a male fetus in a pregnant sexual partner. Data from a long-term trial in 18,882 men aged over 54 taking 5mg finasteride daily or Androgenetic Alopecia 113 placebo showed a 25% overall reduction in the incidence of prostatic cancer in those taking fin- asteride but a small increase in the frequency of high-grade prostatic cancer (54). The relevance of this finding to men taking 1 mg daily for male balding is unknown but it is advisable to warn patients of this uncertainty. Minoxidil versus Finasteride There are no blinded controlled trials comparing the response of male balding to minoxidil solution and oral finasteride, although one open study reported a greater degree of improve- ment in men taking finasteride compared to those using 5% minoxidil solution (55). Minoxidil is a little cheaper and it has been in use for longer so more is known about long-term safety. On the other hand, it is more conve- nient to take a single tablet of finasteride daily than apply a solution twice daily to the scalp.