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Isolate Surveillance Project GISP ; Regional Laboratory, Denver Health, Colorado. KK Holmes, MD, J Hale, MS, W Whittington, PhD, K Winterscheid, MS, Seattle GISP Regional Laboratory, Univ of Washington, Seattle. JS Knapp, PhD, DL Trees, PhD, Div of AIDS, STD, and TB Laboratory Research, National Center for Infectious Diseases; AB Harvey, SM Conner, MPH, Div of STD Prevention, National Center for HIV, STD, and TB Prevention, CDC. REFERENCES 1. Fleming DT, Wasserheit JN. From epidemiological synergy to public health policy and practice: the contribution of other sexually transmitted diseases to sexual transmission of HIV infection. Sex Transm Infect 1999; 75: 3-17. CDC. Sexually transmitted disease surveillance 2001. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, 2002. 3. CDC. Sexually transmitted disease surveillance 2001 supplement: Gonococcal Isolate Surveillance Project GISP ; Annual Report--2001. Atlanta, Georgia: U.S. Department of Health and Human Services, 2002. 4. Iverson CJ, Wang S, Ohye R, et al. Emergence of a possible endemic focus of ciprofloxacin-resistant Neisseria gonorrhoeae in Hawaii [Abstract]. In: Program and abstracts of the International Conference on Emerging Infectious Diseases. Atlanta, Georgia: U.S. Department of Health and Human Services, CDC, July 16-19, 2000. 5. WHO Western Pacific Gonococcal Antimicrobial Surveillance Programme. Surveillance of antibiotic resistance in Neisseria gonorrhoeae in the WHO Western Pacific Region, 2000. Commun Dis Intell 2001; 25: 274-7. CDC. Sexually transmitted diseases treatment guidelines 2002. MMWR 2002; 51 No. RR-6 ; . 7. CDC. Discontinuation of cefixime tablets-- United States. MMWR 2002; 51: 1052 CDC. Fluoroquinolone-resistance in Neisseria gonorrhoeae in Hawaii, 1999, and decreased susceptibility to azithromycin in N. gonorrhoeae, Missouri, 1999. MMWR 2000; 49: 833-6. CDC. Antibiotic-resistant strains of Neisseria gonorrhoeae: policy guidelines for detection, management, and control. MMWR 1987; 36 No. S-5 ; . 10. Roy K, Wang S, Meltzer M. Identifying the optimal diagnostic and treatment strategy for gonorrhea in a time of increasing ciprofloxacin-resistance [Abstract]. In: Program and abstracts of the 2002 Conference on Antimicrobial Resistance. Bethesda, Maryland: National Foundation for Infectious Diseases, June 27-29, 2002. * Defined as N. gonorrhoeae resistant to ciprofloxacin minimal inhibitory concentration [MIC] 1.0 g mL by agar dilution or disk diffusion zone size 27 mm ; or ofloxacin MIC 2.0 g mL or disk diffusion zone size 24 mm ; by the National Committee on Clinical Laboratory Standards.
If you have observed comparable cases or any other serious events, please report them to the adverse drug reaction reporting unit, continuing assessment division, bureau of drug surveillance, al 4103b1, ottawa on k1a 1b9, fax 613 957-0335; or to a participating regional centre.
WHO has identified the following RH medicines and medical devices for inclusion in national essential medicines lists. * azithromycin; * cefixime; * clotrimazole; * condoms; * ethinylestradiol + levonorgestrel; ethinylestradiol + norethisterone; * copper-bearing intrauterine contraceptive devices IUD * levonorgestrel for oral hormonal contraception; * levonorgestrel for emergency contraception; * magnesium sulfate; * medroxyprogesterone acetate DMPA ; depot injection: methyldopa; misoprostol; mifeprpistone with misoprostol; nifedipine; * oxytocin * Already in the WHO prequalification process in 2006 * Considered by WHO to be priorities for inclusion in the prequalification project beginning in 2007.
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| Table 3. Results of Cox Regression Model for Drug Discontinuation, Controlling for Demographics, Year of Initial Prescription 2001 as Referent ; , and Concomitant Treatment Regimens and cefpodoxime.
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| Eligible for participation if they reported or were advised by health department officials of sexual activity with men who received a diagnosis of gonococcal or chlamydial urethritis or nongonococcal urethritis. Females were eligible regardless of the duration of time that had passed since the sexual encounter with the infected male partner. We excluded from analysis those females for whom test results for bacterial vaginosis, gonorrhea, or chlamydial infection were unavailable. Additional exclusion criteria included pregnancy, receipt of antibiotic treatment within the preceding 14 days, gynecologic surgery within the past 6 weeks, and previous hysterectomy. After informed consent was obtained, a standardized interview was completed, which elicited medical, sexual, social, and demographic information. All participants then underwent a comprehensive gynecologic examination. Samples of vaginal fluid from the lateral vaginal walls were obtained for pH measurement, Whiff amine testing, and microscopy. An additional vaginal swab was streaked on a glass slide and air dried for Gram stain interpretation. A polyester fibertipped swab was used to obtain a sample from the posterior vaginal fornix for culture for T. vaginalis growth. Endocervical samples were obtained to test for the presence of N. gonorrhoeae and C. trachomatis. All patients were uniformly treated with single doses of azithromycin 1 g ; , cefixime 400 mg ; , and metronidazole 2 g ; , in accordance with standard STD treatment guidelines [6]. Microbiologic analysis. Air-dried slides of vaginal fluid were stained with Gram stain and interpreted for the presence of bacterial vaginosis, in accordance with standardized scoring criteria [7]. Bacterial vaginosis was diagnosed if the score was 710; a score of 46 indicated intermediate vaginal flora; and a score of 03 indicated normal vaginal flora. Swabs of vaginal fluid were transported to the laboratory in Amies transport medium MML Diagnostics Packaging ; . Swabs were plated for growth of lactobacilli, and the organism's H2O2 production was tested by means of a qualitative assay on tetramethylbenzidine agar plates, as described elsewhere [8]. For T. vaginalis culture, vaginal swabs were placed in modified Diamond's media, incubated at 37 C, and examined every second day, for a maximum of 1 week, for the presence of motile trichomonads. Endocervical samples were streaked on modified Thayer-Martin medium and chocolate medium to test for N. gonorrhoeae growth; identification of N. gonorrhoeae was confirmed by means of Gram stain examination, oxidase testing, and Gonochek-II analysis EY Laboratories ; . C. trachomatis was identified by PCR amplification of endocervical samples, performed in accordance with the manufacturers' recommendations Roche Diagnostics ; . Statistics. The characteristics used for comparison of subjects with and without N. gonorrhoeae and C. trachomatis infection were chosen because they have been associated with STDs by other investigators or because of their biological po664 CID 2003: 36 1 March ; HIV AIDS.
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Reported "severe" pain at the injection site. Three of these clients received their injections from the same CRHW and all four were interviewed by the same interviewer, so researchers had difficulty determining whether one provider had poor technique or whether one interviewer might have exaggerated problems. For the sake of safety, the provider who gave those injections was asked to cease giving Depo shots until he could receive a training update. Table 4 shows the types of problems reported, by provider. CRHW clients reported a slightly higher percentage of problems, but the difference was never greater than 1%. Table 4: Reported Problems at Injection Site CRHW Clients n 435 ; 1.6% 7 ; 1.6% 7 ; 0.6% 3 ; 0.6% 3 ; 0.9% 4 ; % Clinic Clients n 313 ; 0.9% 3 ; 0.6% 2 ; 0.6% 2 ; 0.3% 1 ; 0.0% 0 and cetirizine.
Table 6: Acceptable zone diameter mm ; ranges for control strains on Iso-Sensitest agar supplemented with 5% defibrinated horse blood with or without the addition of NAD, plates incubated at 35-370C in 4-6% CO2 for 18-20 h. Antimicrobial agent Disc content g unless stated ; Pasteurella multocida NCTC 8489 Azithromycin Cefixime Cefotaxime Ceftriaxone Cefuroxime Ciprofloxacin Erythromycin Nalidixic acid Penicillin Rifampicin Spectinomycin Tetracycline 15 5 unit 2 25 10 Neisseria gonorrhoeae with NAD ; NCTC 12700 30-40 33-44 Staphylococcus aureus Haemophilus influenzae with NAD ; Streptococcus pneumoniae.
Right 4 1 ; Mrs B had the right to medical services provided with reasonable care and skill. In my opinion Dr C provided medical care of an appropriate standard and did not breach Right 4 1 ; of the Code. Cardiac investigation Dr C was Mrs B's general practitioner for many years. He fully understood that she was at considerable risk of developing coronary artery disease as she had diabetes, hypertension, high cholesterol and she was overweight. Dr C referred her to the Diabetic Clinic regularly and followed up on its recommendations. The Diabetic Clinic did not recommend that Mrs B undergo cardiac investigation. The diabetologist at the Diabetic Clinic, Dr G, advised me that Mrs B was at significant risk of coronary artery disease. He would not routinely subject diabetes patients to regular cardiac screening because non-invasive investigations, such as ECG, do not have `sufficient sensitivity' to be useful, and invasive investigations, such as angiography, are too risky for patients who do not have symptoms of coronary disease. My independent general practitioner confirmed Dr G's advice. She indicated that programmes aimed at detecting and screening for cardiac disease in cases such as Mrs B are difficult for the reasons outlined by Dr G. Even if it is known that a patient has coronary artery disease, there is no evidence to support surgical intervention. Medical treatment would be more effective at specifically targeting the symptoms. My independent general practitioner said that exercise ECG may have been useful but would be recommended only for patients with specific cardiac symptoms. Mrs B's family believed that she had suffered cardiac symptoms for some time before her death and consulted Dr C regularly with these symptoms. My advisor noted that, in reading Mrs B's medical records, she could find no symptoms indicating cardiac disease and cinnarizine.
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Jones RN, Edson DC, The Microbiology Resource Committee of the College of American Pathologists 1988. The identification and antimicrobial susceptibility testing of Neisseria gonorrhoeae 1980-1987. Arch Pathol Lab Med 112: 485-488. Jones RN, Fuchs PC, Washington II JA, Gavan TL, Murray PR, Gerlach EH, Thornsberry C 1990a. Interpretive criteria, quality control guidelines and drug stability studies for susceptibility testing of cefotaxime, cefoxitin, ceftacidime, and cefuroxime against Neisseria gonorrhoeae. Diagn Microbiol Infect Dis 13: 499-507. Jones RN, Gavan TL, Thornsberry C, Fuchs PC, Gerlach EH, Knapp JS, Murray P, Washington JA 1989. Standardization of disk diffusion and agar dilution susceptibility test for Neisseria gonorrhoeae: interpretive criteria and quality control guidelines for ceftriaxone, penicillin, spectinomycin, and tetracycline. J Clin Microbiol 27: 2758-2766. Jones RN, Gerlach EH, Koontz FP, Murray PR, Pfaller MA, Washington JA, Erwin ME, Knapp CC 1990b. Development of Neisseria gonorrhoeae in vitro susceptibility test methods for cefixime including quality control guidelines. Diagn Microbiol Infect Dis 14: 383-388. Knapp JS, Zenilman JM, Biddle JW, Perkins GH, Dewitt WE, Thomas ML 1987. Frequency and distribution in the United States of strains of Neisseria gonorrhoeae with plasmid-mediated, high-level resistance to tetracycline. J Infect Dis 155: 819-822. Lorian V 1986. Antibiotics in Laboratory Medicine, Williams and Wilkins, Baltimore, p. 281-286. Maier TW, Beilstein HR, Zubrzycki L 1974. Antibiotic disk susceptibility test with Neisseria gonorrhoeae. Antimicrob Agents Chemother 4 Suppl. 2 ; : 42-43. Mc Cormack WM 1982. Penicillinase-producing Neisseria gonorrhoeae. A retrospective. N Engl J Med 307: 438-439. NCCLS-National Committee for Clinical Laboratory Standards 1990a. Approved standard M2-A4. Performance standards for antimicrobic disk susceptibility tests, Villanova, Pa. NCCLS-National Committee for Clinical Laboratory Standards 1990b. Approved standard M7-A2. Standard methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically, Villanova, Pa. Perine PL, Schalla W, Siegel MS 1977. Evidence for two distinct types of penicillinase-producing Neisseria gonorrhoeae. The Lancet ii: 993-995. Phillips I 1976. Beta-lactamase-producing, penicillinresistant gonococcus. The Lancet ii: 656-657. Putnam SD, Lavin BS, Stone JR, Oldfield EC, Hooper DG 1992. Evaluation of the standardized disk diffusion and agar dilution antibiotic susceptibility test methods by using strains of Neisseria gonorrhoeae from the United States and Southeast Asia. J Clin Microbiol 30: 974-980. Siegel MS, Thornsberry C, Biddle JW, O'Mara PR, Perine PL, Weisner PJ 1978. Penicillinase-producing Neisseria gonorrhoeae: results of surveillance.
24Staff fail to follow basic universal precautions which have led to dangerous health hazards for youth in the facilities. A nurse at Oakley was observed by our expert giving one resident a pre-filled syringe of the hepatitis B immunization. She accidentally inserted the same needle into the arm of the next resident before realizing her mistake. Moreover, a scalpel blade is repeatedly used by Columbia's facility physician to shave warts, permitting the transmission of blood-borne pathogens from patient to patient. In violation of standard medical practice and at the risk of contamination, Oakley staff store food in the same refrigerator as pharmaceuticals such as immunizations and control solutions to analyze blood. Our expert noted that the Oakley physician conducted nine examinations in one day and never changed the roll of paper that lined the surface of the examination table. 2. Health Assessments and propulsid and cefixime.
Body system 0.2% and 0.2% ; . In the ESPRIT study, the following non-bleeding adverse events leading to discontinuation occurred in the eptifibatide and placebo groups with an incidence of 0.1%: "other" 1.2% and 1.1% ; . In the IMPACT II study, non-bleeding adverse events leading to discontinuation occurred in the 135 0.5 eptifibatide and placebo groups in the following body systems with an incidence of 0.1%: whole body 0.3% and 0.1% ; , cardiovascular system 1.4% and 1.4% ; , digestive system 0.2% and 0% ; , hemic lymphatic system 0.2% and 0% ; , nervous system 0.3% and 0.2% ; , and respiratory system 0.1% and 0.1% ; . Post-Marketing Experience. The following adverse events have been reported in postmarketing experience, primarily with eptifibatide in combination with heparin and aspirin: cerebral, GI and pulmonary hemorrhage. Fatal bleeding events have been reported. OVERDOSAGE There has been only limited experience with overdosage of eptifibatide. There were 8 patients in the IMPACT II study, 9 patients in the PURSUIT study and no patient in the ESPRIT study who received bolus doses and or infusion doses more than double those called for in the protocols. None of these patients experienced an intracranial bleed or other major bleeding. Eptifibatide was not lethal to rats, rabbits, or monkeys when administered by continuous intravenous infusion for 90 minutes at a total dose of 45 mg kg about 2 to 5 times the recommended maximum daily human dose on a body surface area basis ; . Symptoms of acute toxicity were loss of righting reflex, dyspnea, ptosis, and decreased muscle tone in rabbits and petechial hemorrhages in the femoral and abdominal areas of monkeys. From in vitro studies, eptifibatide is not extensively bound to plasma proteins and thus may be cleared from plasma by dialysis. DOSAGE AND ADMINISTRATION The safety and efficacy of eptifibatide has been established in clinical studies that employed concomitant use of heparin and aspirin. Different dose regimens of eptifibatide were used in the major clinical studies. See CLINICAL STUDIES. ; Acute Coronary Syndrome The recommended adult dosage of eptifibatide in patients with acute coronary syndrome and normal renal function is an intravenous bolus of 180 g kg as soon as possible following diagnosis, followed by a continuous infusion of 2.0 g kg min until hospital discharge or initiation of CABG surgery, up to 72 hours. If a patient is to undergo a percutaneous coronary intervention PCI ; while receiving eptifibatide, the infusion should be continued up to hospital discharge, or for up to 1824 hours after.
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Remarkable delayed symptoms were observed beginning with the first day of exposures and continued through the next day Fig. 3 ; . No marked differences were apparent in the nasal and ocular symptom scores between the placebo and BB536 groups. There was no difference in the scores for each of the nasal or ocular symptoms between groups data not shown ; . Throat symptom scores tended to be lower on the day after the exposures, and scores for disruption of normal activities tended to be lower on the two days following exposure in the BB536 group compared with the placebo. AUC analysis indicated a significant difference p 0.011 ; for the scores of disruption of normal activities between the two groups, but there was no difference for the other symptoms Table 2 ; . Medication use for relieving symptoms was observed in some subjects, particularly on both the first.
Meglumine diatristudy did not show leakage of contrast medium from duodenum. Note oxidized cellulose swab Surgicel [Johnson and Johnson Medical, Arlington, 1'X] ; arrows.
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Single-Agent Rituximab as First-line Therapy In a study conducted by Dr. Hainsworth and colleagues, 60 patients with previously untreated NHL received rituximab 375 mg m2 week I.V. for 4 weeks followed by maintenance therapy with 4 consecutive weekly infusions at 6-month intervals for a maximum of 4 courses or until disease progression.2 The overall response rate ORR ; after induction therapy was 47%, with 7% of the patients achieving a CR. Sixteen of the 27 patients with stable disease SD ; after induction therapy achieved an additional Table 1 Rituximab in Patients With Non-Hodgkin Lymphoma clinical response with maintenance rituximab. The ORR and CR rate Study Disease Type Study Design improved to 73% and 37%, respecRituximab followed by tively, after maintenance therapy. Untreated Hainsworth2 maintenance rituximab Median progression-free survival Rituximab followed by PFS ; was 34 months. This regimen maintenance rituximab Relapsed Ghielmini3 was tolerable, with only 2 patients or observation experiencing grade 3 4 adverse Rituximab followed by events; 1 patient was removed from maintenance rituximab Relapsed Hainsworth4 therapy after experiencing flushing, or rituximab retreatment at disease progression dyspnea, and ischemic chest pain. All other toxicities were grade 1 2 Chemotherapy followed Relapsed and were related mainly to the first by maintenance rituximab Hochster5, 6 refractory or observation rituximab infusion. Single-Agent Rituximab in Relapsed Disease Dr. Ghielmini and colleagues conducted the Swiss Group for Clinical Cancer Research SAKK ; 35 98 study of extended rituximab dosZinzani7 Untreated Chemotherapy followed by rituximab for persistent disease Chemotherapy with or without rituximab followed by maintenance rituximab or observation.
EDS in Sask non-formulary in Sask prior approval for NIHB coverage covered by NIHB not NIHB Cost approximate $ drug cost per 10 days unless noted otherwise noted dose for renal dysfunction Amox clav amoxicillin + clavulanate CLAVULIN AMG aminoglycoside tobramycin gentamicin against Pseudomonas ; lactam lactam Inh inhibitor ; Amox clavulanate oral ; , piperacillin tazobactam TAZOCIN 2ndG Ceph cephalosporin ; cefuroxime CEFTIN, cefprozil CEFZIL; 3rdG Ceph cefotaxime CLAFORAN, ceftriaxone ROCEPHIN, cefixime SUPRAX oral 4thG Ceph cefepime MAXIPIME B&D'06 Bugs & Drugs 2006 Macrolide erythromycin, clarithromycin BIAXIN, azithromycin ZITHROMAX New macrolide clarithromycin, azithromycin Ketolide Telithromycin KETEK PRSP penicillin resistant S. pneumoniae ie MIC 4mg L ; . DRSP drug resistant Respiratory fluoroquinolones FQ Resp. ; gatifloxacin TEQUIN D C by Co, levofloxacin LEVAQUIN, moxifloxacin AVELOX NOT ciprofloxacin unless pseudomonas suspected TCN tetracycline S. pneumoniae Antipseudomonal: antiP lactam imipenem PRIMAXIN, meropenem MERREM, ceftazidime FORTAZ, cefepime MAXIPIME, piperacillin tazobactam TAZOCIN; antiP FQ ciprofloxacin CIPRO Dose may need adjustment for severity of illness, renal function, etc. Treatment duration variable typically 7-14day or 4-5day post-improvement; longer if complicated; 2-3 weeks suggested for Legionella, S. aureus, Gram -, also for C. pneumoniae & M. pneumoniae due to risk of relapse ; . Pregnancy: `B' no evidence of risk in animal studies or uncontrolled human studies ; cephalosporins, penicillins, erythromycin , azithromycin, clindamycin & metronidazole. Pathogens for select conditions: Airway obstruction & poor dental hygiene anaerobes; Bats bird droppings Histoplasma capsulatum; Birds Chlamydia psittaci; Farm animals cats Coxiella burnetti; IV drug use S. aureus, anaerobes, M. tuberculosis & Rabbits Francisella tularensis.
Cause of pelvic inflammatory disease, ectopic pregnancy, and infertility, and it can facilitate human immunodeficiency virus HIV ; transmission.1 Gonorrhea is the second most frequently reported communicable disease in the United States, with 361, 705 reported cases in 2001.2 During the 1980s, gonococcal resistance to penicillin and tetracycline became widespread; as a result, CDC recommended using cephalosporins as first-line treatment for gonorrhea. Since 1993, CDC also has recommended using fluoroquinolones i.e., ciprofloxacin, ofloxacin, or levofloxacin ; for gonorrhea treatment. Fluoroquinolone therapy is used widely because it is a relatively inexpensive, oral, and singledose therapy. However, fluoroquinolone-resistant N. gonorrhoeae QRNG ; is being identified more frequently.3 This report summarizes investigations of increases in QRNG in Hawaii and California in 2001 and provides data to support the recommendation that cephalosporins i.e., ceftriaxone or cefixime ; be used instead of fluoroquinolones as firstline treatment for gonorrhea acquired in these two states. The increases in QRNG highlight the importance of monitoring gonococcal resistance throughout the United States to guide local treatment decisions. Hawaii In 2001, the Hawaii State Laboratory performed gonorrhea culture and antimicrobial susceptibility tests on specimens from 265 44% ; of 605 reported gonorrhea cases. Patients seeking care at the public sexually transmitted disease STD ; clinic ac and suprax.
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Alternatives Listed In Spec: ODS Use: ODS CHEM 1: PRIMARY REFS: Standard Propellent Gases in Lecture Bottles from Matheson Gas Produts or another supplier ; : Vinyl Chloride, Fluorocarbons No. 11, 12, 114, see Interim Amendment #1 4.4.2.4.1 page 1 ; . CFC 11 CFC-11 CFC-12 1ST LEVEL REFS: General Comments: 40 CFR Part 82 subpart C makes it illegal for manufacturers to produce aerosol propellants that contain class I or class II ODSs, except for certain medical devices, mold release agents, document preservation sprays and other specialty uses. Recommend deleting requirement to use or test for CFC propellants from this specification. ODS CHEM 2: Comments: CFC 12.
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