hero
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in hyperparathyroidism When do we answer "surgical exploration"? Does it mean "exploration AND removal" or can be only exploration?
Had q in kap qbook - case of lobar pneumona, with gr+diplococci in sputum, without comorbidities pt - treatment - ? - correct option given penicillin, is it correct for today? Isn't it outpatient tx for CAP macrolide or doxy?
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Hi Hero, Well this is what I think.Surginal exploration is no longer done.The candidates for surgery undergo Sestamibi scan with USG for identifying hyperfunctioning glands which are then surgically removed.
The following patients are candidates for surgery:
- Patients with overt clinical manifestations of disease
- Age younger than 50 years
- Serum calcium concentration more than 1 mg/dL above upper limit of reference range
- Urinary calcium excretion greater than 400 mg/d
- Low or declining bone mineral density
- Uncertain prospect for successful medical monitoring
- Patient requests surgery
- Poor or uncertain follow-up
- Coexistent disease that may confound or contribute to disease progression
- Reduction in creatinine clearance of 30% or more
- Reduction of bone mineral density greater than 2.5 standard deviations below the reference range for bone density in terms of age, gender, and race (T score <2.5)
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99/99/cs passed/2007 grad/need visa/no USCE/no USLOR/no research
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| hero
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thank you, dear, great review!
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About pneumococci I too feel that penicillin does not work most often....macrolide or newer fluoroquinolone is better.
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99/99/cs passed/2007 grad/need visa/no USCE/no USLOR/no research
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| hero
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i checked pneumonia - guidelines give macrolide as a 1st choice
http://www.emedicine.com/med/fulltopic/topic1852....
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| hero
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actually, doubt again. There is empiric Tx for CAP and there is a definitely pneumococcal pneumonia, based on gram-stain
"Penicillin (penicillin G/amoxicillin) remains the drug of choice for strains that are fully sensitive or have a moderately decreased susceptibility to penicillin, whereas cefotaxime and ceftriaxone are the first-line alternatives in cases with higher levels of resistance."
But
Empiric therapy for community-acquired bacterial pneumonia - Based on recommendations by the American Thoracic Society (1993) and consensus guidelines by the Canadian Infectious Disease Society/Canadian Thoracic Society (2000)
Table 1. Outpatient Pneumonia Without Comorbidity in Patients Aged 60 Years or Younger*
Organisms †
S pneumoniae
M pneumoniae
C pneumoniae
H influenzae
Miscellaneous
Legionella species, S aureus,
aerobic gram-negative bacilli
Therapy
1st choice - Macrolide ‡
2nd choice - Doxycycline
So, we know for sure (=it is not empirical) that it is pneumococcus - what should we give? Penicillin?
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| hero
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again, how do we know that it is "fully sensitive or have a moderately decreased susceptibility to penicillin" ???
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| Eagle_303
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Treatment of Outpatients
Empiric antibiotic options for patients with community-acquired pneumonia who do not require hospitalization include the following: (1) Macrolides (clarithromycin, 500 mg orally twice a day, or azithromycin, 500 mg orally as a first dose and then 250 mg once a day for 4 days, or 500 mg daily for 3 days). (2) Doxycycline (100 mg orally twice a day). (3) Fluoroquinolones (with enhanced activity against S pneumoniae, such as levofloxacin 500 mg orally once a day, or moxifloxacin 400 mg orally once a day). Some experts prefer doxycycline or macrolides for patients under 50 years of age without comorbidities and a fluoroquinolone for patients with comorbidities or who are older than 50 years of age. Alternatives include erythromycin (250–500 mg orally four times daily), amoxicillin-potassium clavulanate—especially for suspected aspiration pneumonia—500 mg orally three times a day or 875 mg orally twice a day, and some second- and third-generation cephalosporins such as cefuroxime axetil (250–500 mg orally twice a day), cefpodoxime proxetil (100–200 mg orally twice a day), or cefprozil (250–500 mg orally twice a day).
There are limited data to guide recommendations for duration of treatment. The decision is influenced by the severity of illness, the etiologic agent, response to therapy, other medical problems, and complications. Therapy until the patient is afebrile for at least 72 hours is usually sufficient for pneumonia due to S pneumoniae. A minimum of 2 weeks of therapy is appropriate for pneumonia due to S aureus, P aeruginosa, Klebsiella, anaerobes, M pneumoniae, C pneumoniae, or Legionella species.
Treatment of Hospitalized Patients
Empiric antibiotic options for patients with community-acquired pneumonia who require hospitalization can be divided into those for patients who can be cared for on a general medical ward and those for patients who require care in an ICU. Patients who only require general medical ward care usually respond to an extended-spectrum -lactam (such as ceftriaxone or cefotaxime) with a macrolide (clarithromycin or azithromycin is preferred if H influenzae infection is suspected) or a fluoroquinolone (with enhanced activity against S pneumoniae) such as gatifloxacin, levofloxacin, or moxifloxacin. Alternatives include a -lactam/-lactamase inhibitor (ampicillin-sulbactam or piperacillin-tazobactam) with a macrolide.
Patients requiring admission to the ICU require a macrolide or a fluoroquinolone (with enhanced activity against S pneumoniae) plus an extended-spectrum cephalosporin (ceftriaxone, cefotaxime) or a -lactam/-lactamase inhibitor (ampicillin-sulbactam or piperacillin-tazobactam). Patients with penicillin allergies can be treated with a fluoroquinolone (with enhanced activity against S pneumoniae) with or without clindamycin. Patients with suspected aspiration pneumonia should receive a fluoroquinolone (with enhanced activity against S pneumoniae) with or without clindamycin, metronidazole, or a -lactam/-lactamase inhibitor. Patients with structural lung diseases such as bronchiectasis or cystic fibrosis benefit from empiric therapy with an antipseudomonal penicillin, carbapenem, or cefepime plus a fluoroquinolone (including high-dose ciprofloxacin) until sputum culture and sensitivity results are available. For expanded discussions of specific antibiotics, see Infectious Diseases: Common Problems & Antimicrobial Therapy.
Almost all patients who are admitted to a hospital for therapy of community-acquired pneumonia receive intravenous antibiotics. Despite this preference, no studies demonstrate superior outcomes when hospitalized patients are treated intravenously instead of orally if patients can tolerate oral therapy and the drug is well absorbed. Duration of antibiotic treatment is the same as for outpatients with community-acquired pneumonia.
Ref: CMDT 2008
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| hero
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so, it's never penicillin?
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| Eagle_303
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hero wrote:
so, it's never penicillin?
Nowadays there seems to be resistance to Pencillin for Strep Pneumo
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