var title_f0_30_480="Traumatic cataract";

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" Traumatic cataract",
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" </div>",
" <div class=\"lgnd\">",
" A photograph of a patient following blunt trauma showing traumatic cataract.
Retroillumation of the lens demonstrates posterior-subcapsular opacification of the
lens.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Photo courtesy of Kathryn A. Colby, MD, PhD, Massachusetts Eye and Ear
Infirmary, Boston.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
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" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
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" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 470px\">",
" <div class=\"ttl\">",
" Lymphocytic interstitial pneumonia",
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" </div>",
" <div class=\"lgnd\">",
" Prone&nbsp;high resolution computed tomography (HRCT) scan&nbsp;shows diffuse
ground glass attenuation with multiple lung cysts.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
" </div>",
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var title_f0_30_482="Patient information: Serotonin syndrome (The Basics)";
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" The Basics",
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" <dd>",
" <a href=\"UTD.htm?11/57/12179\">",
" Patient information: Depression (The Basics)",
" </a>",
" </dd>",
" <dd>",
" <a href=\"UTD.htm?24/6/24675\">",
" Patient information: Medicines for depression (The Basics)",
" </a>",
" </dd>",
" <dt class=\"beyondthebasics\">",
" Beyond the Basics",
" </dt>",
" <dd>",
" <a href=\"UTD.htm?19/41/20116\">",
" Patient information: Depression in adults (Beyond the Basics)",
" </a>",
" </dd>",
" <dd>",
" <a href=\"UTD.htm?21/24/21894\">",
" Patient information: Depression treatment options for adults (Beyond the
Basics)",
" </a>",
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" Patient information: Serotonin syndrome (The Basics)",
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editors/patient-information\">",
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" <div id=\"topicText\">",
" <p class=\"headingAnchor\" id=\"H630547279\">",
" <span class=\"h1\">",
" What is serotonin syndrome?",
" </span>",
" &nbsp;&mdash;&nbsp;Serotonin syndrome is a serious problem that can cause a
number of symptoms, including:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Anxiety, restlessness, or confusion",
" </li>",
" <li>",
" Sweating",
" </li>",
" <li>",
" Muscle spasms and muscle rigidity",
" </li>",
" <li>",
" Rapid back and forth eye movements",
" </li>",
" <li>",
" Shaking or trembling",
" </li>",
" <li>",
" Fever",
" </li>",
" <li>",
" Rapid heart rate",
" </li>",
" <li>",
" Vomiting",
" </li>",
" <li>",
" Diarrhea",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H630547294\">",
" <span class=\"h1\">",
" What causes serotonin syndrome?",
" </span>",
" &nbsp;&mdash;&nbsp;Serotonin syndrome happens to people after they take
certain medicines or combinations of medicines. It can also happen with certain
herbal products and street drugs. There are many medicines and drugs that can lead
to serotonin syndrome. In general, they all affect a chemical in the brain and body
called &ldquo;serotonin.&rdquo;",
" </p>",
" <p>",
" Examples of the medicines and drugs that can cause serotonin syndrome
include:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Antidepressants",
" </li>",
" <li>",
" Some pain relievers, such as",
" <a class=\"drug drug_patient\" href=\"UTD.htm?23/46/24293?
source=see_link\">",
" meperidine",
" </a>",
" (brand name: Demerol),",
" <a class=\"drug drug_patient\" href=\"UTD.htm?30/5/30805?
source=see_link\">",
" tramadol",
" </a>",
" (brand name: Ultram), and",
" <a class=\"drug drug_patient\" href=\"UTD.htm?32/23/33140?
source=see_link\">",
" cyclobenzaprine",
" </a>",
" (brand name: Flexeril)",
" </li>",
" <li>",
" Saint John&rsquo;s wort (an herbal medicine used to treat depression)",
" </li>",
" <li>",
" Medicines used to treat migraine headaches, called
&ldquo;triptans&rdquo;",
" </li>",
" <li>",
" Street drugs, such as ecstasy, cocaine, and amphetamines",
" </li>",
" </ul>",
" </p>",
" <p>",
" Doctors do not know why some people get serotonin syndrome and others do
not. But they do know that people usually develop it within hours of taking a new
medicine or drug, a new dose, or a new combination of medicines or drugs.",
" </p>",
" <p class=\"headingAnchor\" id=\"H630547309\">",
" <span class=\"h1\">",
" Should I see a doctor or nurse?",
" </span>",
" &nbsp;&mdash;&nbsp;If you have symptoms of serotonin syndrome, and you
recently took a new drug or medicine or a new dose, call your doctor right away. If
your symptoms are severe go to the emergency room or call 9-1-1 for an ambulance.",
" </p>",
" <p class=\"headingAnchor\" id=\"H630547324\">",
" <span class=\"h1\">",
" Will I need tests?",
" </span>",
" &nbsp;&mdash;&nbsp;Maybe. There is no single test that can show whether or
not you have serotonin syndrome. Still, some of the things the doctor will do
during the exam can help him or her figure out if you have it. For instance, the
doctor might test your leg muscles to see if they spasm. The doctor will also ask a
lot of questions about any medicines, herbal products, or street drugs you might
have taken.",
" </p>",
" <p>",
" If you have serotonin syndrome, it&rsquo;s very important that you be honest
with your doctor about what you took, how much, and when.",
" </p>",
" <p class=\"headingAnchor\" id=\"H630547339\">",
" <span class=\"h1\">",
" How is serotonin syndrome treated?",
" </span>",
" &nbsp;&mdash;&nbsp;As part of treatment, the doctor will stop the medicines
or drugs that caused the serotonin syndrome in the first place. He or she will also
monitor your breathing, heart rate, blood pressure, and body temperature, and try
to keep these as close to normal as possible.",
" </p>",
" <p>",
" Depending on what you need, he or she might also:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Give you medicines to calm you",
" </li>",
" <li>",
" Give you medicines to block the effects of serotonin",
" </li>",
" <li>",
" Work with you to decide whether you should keep taking the medicines that
caused your serotonin syndrome",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H630547354\">",
" <span class=\"h1\">",
" Can serotonin syndrome be prevented?",
" </span>",
" &nbsp;&mdash;&nbsp;No, but there are things you can do to protect
yourself.",
" </p>",
" <p>",
" Doctors have no way to predict who will get serotonin syndrome, so
it&rsquo;s not possible to prevent cases caused by properly prescribed medicines.
Even so, there are things you can do to protect yourself from dangerous reactions
to medicines:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Always tell any doctor who prescribes medicines for you about ALL the
medicines, herbal products, and street drugs you take. That way, the doctor can be
careful not to give you medicines that could cause problems when combined.",
" </li>",
" <li>",
" When starting a new medicine, have the pharmacist check for drug
interactions and double-check that you are taking the right amount.",
" </li>",
" <li>",
" If you are already on medicine, do not take a new herbal or over-the-
counter medicine without first checking with your doctor, nurse, or pharmacist.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H630547369\">",
" <span class=\"h1\">",
" More on this topic",
" </span>",
" </p>",
" <p>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?24/6/24675?
source=see_link\">",
" Patient information: Medicines for depression (The Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?11/57/12179?
source=see_link\">",
" Patient information: Depression (The Basics)",
" </a>",
" </p>",
" <p>",
" <a class=\"medical medical_patient\" href=\"UTD.htm?19/41/20116?
source=see_link\">",
" Patient information: Depression in adults (Beyond the Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_patient\" href=\"UTD.htm?21/24/21894?
source=see_link\">",
" Patient information: Depression treatment options for adults (Beyond the
Basics)",
" </a>",
" </p>",
" </div>",
" <div id=\"reviewProcess\">",
" <span>",
" All topics are updated as new evidence becomes available and our",
" <a class=\"policy policy_editorialpolicy\" href=\"/home/editorial-
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" </h1>",
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" <ul>",
" <li class=\"plainItem\">",
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" What is serotonin syndrome?",
" </a>",
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" <a class=\"outlineLink\" href=\"#H630547294\">",
" What causes serotonin syndrome?",
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" </a>",
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" How is serotonin syndrome treated?",
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" <a class=\"outlineLink\" href=\"#H630547354\">",
" Can serotonin syndrome be prevented?",
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" Patient information: Depression (The Basics)",
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source=related_link\">",
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source=related_link\">",
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Basics)",
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source=related_link\">",
" Patient information: Medicines for depression (The Basics)",
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" Patient information: Drug allergy (The Basics)",
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" Patient information: Medicine brand and generic names (The Basics)",
" </a>",
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" Patient information: Reducing the costs of medicines (The Basics)",
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" Patient information: Stevens-Johnson syndrome (The Basics)",
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" Patient information: Taking medicines when you're older (The Basics)",
" </a>",
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" <dt class=\"beyondthebasics\">",
" Beyond the Basics",
" </dt>",
" <dd>",
" <a href=\"UTD.htm?31/61/32726\">",
" Patient information: Reducing the costs of medicines (Beyond the
Basics)",
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" Patient information: Dealing with side effects from medicines (The Basics)",
" </div>",
" <span class=\"view\">",
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" <a class=\"contributor contributor_credentials\" href=\"./authors-and-
editors/patient-information\">",
" Written by the doctors and editors at UpToDate",
" </a>",
" <div id=\"topicText\">",
" <p class=\"headingAnchor\" id=\"H8525907\">",
" <span class=\"h1\">",
" What are side effects?",
" </span>",
" &nbsp;&mdash;&nbsp;Side effects are unintended or unwanted effects that
medicines can cause. Not everyone gets side effects, but many people do. Sometimes
side effects can be a problem because they keep people from taking medicines they
need. If side effects are a problem for you, you should know there are often ways
to avoid, reduce, or manage side effects. &nbsp;",
" </p>",
" <p>",
" Some of the more common side effects of medicines include:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Nausea or vomiting",
" </li>",
" <li>",
" Dizziness",
" </li>",
" <li>",
" Headache",
" </li>",
" <li>",
" Upset stomach, diarrhea, or constipation",
" </li>",
" <li>",
" Increased or decreased appetite",
" </li>",
" <li>",
" Trouble sleeping",
" </li>",
" <li>",
" Dry mouth",
" </li>",
" <li>",
" Dry cough that doesn&rsquo;t go away",
" </li>",
" <li>",
" Skin rashes",
" </li>",
" <li>",
" Feeling tired or sleepy, or getting tired easily",
" </li>",
" <li>",
" Feeling sad, depressed, anxious or jittery",
" </li>",
" <li>",
" Sex problems",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H8525922\">",
" <span class=\"h1\">",
" What should I do if my medicines cause side effects?",
" </span>",
" &nbsp;&mdash;&nbsp;That depends on how serious the side effects are. Most
side effects are annoying but not really dangerous. On the other hand, some side
effects can be very dangerous or even life threatening. For example, people can
have severe allergic reactions to medicines, which can kill them.",
" </p>",
" <p>",
" <strong>",
" Call 9-1-1",
" </strong>",
" for an ambulance if you start a new medicine and develop any of the symptoms
listed below:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Wheezing or trouble breathing",
" </li>",
" <li>",
" Chest tightness or pain",
" </li>",
" <li>",
" Passing out or feeling as if you will pass out",
" </li>",
" <li>",
" Swelling of your face, lips, tongue, or throat",
" </li>",
" <li>",
" Seizures",
" </li>",
" </ul>",
" </p>",
" <p>",
" Call your doctor if you start a new medicine and develop any of the symptoms
listed below:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Hives (raised red welts on the skin that are usually very itchy)",
" </li>",
" <li>",
" Feeling like you want to hurt or kill yourself",
" </li>",
" <li>",
" Severe stomach ache or vomiting",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H8525945\">",
" <span class=\"h1\">",
" What if I have side effects that annoy me but aren&rsquo;t dangerous?",
" </span>",
" &nbsp;&mdash;&nbsp;If you have annoying side effects, talk to your doctor,
nurse, or pharmacist. Do not simply stop taking the medicine that you think is
causing the problem. The medicine might be very important for your health and well-
being. Plus, stopping the medicine might cause other problems. Your doctor or nurse
can work with you to reduce or manage your side effects. &nbsp;",
" </p>",
" <p>",
" Your doctor or nurse can help you figure out if the symptoms you are having
are really side effects of your medicines, or whether they are caused by something
else. If it turns out your symptoms are actually side effects, your doctor or nurse
might be able to lower your dose or switch you to a different medicine that doesn't
cause the same problems.",
" </p>",
" <p>",
" Even if the side effects you have can't be avoided, it's still important to
talk to your doctor or nurse. He or she might be able to help you understand why
the medicine you are taking is worth it even if it causes side effects. Besides,
there might be other ways to fix your problem.",
" </p>",
" <p>",
" Here are some things you should know about dealing with your side effects:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" <strong>",
" Some side effects go away over time",
" </strong>",
" , as your body gets used to the medicine. For example, medicines to treat
depression can bother your stomach for a while but that side effect goes away after
1 or 2 weeks.",
" </li>",
" <li>",
" <strong>",
" People often learn to manage side effects",
" </strong>",
" , or find ways to take their medicines so they cause fewer problems. For
example, some medicines can make you feel sleepy, but if you take them just before
bed, the side effect is less of a problem. Sometimes side effects depend on whether
you take the medicine with food, what time you take it, or whether you combine it
with alcohol or other medicines. If this is true for the side effects you have,
your doctor or pharmacist can give you advice on what to do to manage them.",
" </li>",
" <li>",
" <strong>",
" Sometimes you can change your diet or take another medicine to deal with
a side effect",
" </strong>",
" . For example, if a pain medicine makes you constipated, you can eat more
fiber, drink more water, and use a stool softener. Or if a blood pressure medicine
or antidepressant causes sexual problems, you might be able to take another
medicine to improve sex.",
" </li>",
" <li>",
" <strong>",
" Side effects can sometimes be important clues about what your medicines
are doing to your body.",
" </strong>",
" Having certain side effects can mean that a medicine is harming your body,
for example by stressing your liver. This is another reason it is so important to
tell your doctor or nurse about any side effects you have.",
" </li>",
" <li>",
" <strong>",
" Not taking your medicines correctly can cause side effects.",
" </strong>",
" People sometimes bring on side effects by missing doses, taking medicines
at the wrong times, or taking too much medicine. People can also bring on side
effects if they don&rsquo;t follow the instructions on how to take medicines. Take
your medicines exactly as prescribed.",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H8525962\">",
" <span class=\"h1\">",
" How can I find out the known side effects of my medicines?",
" </span>",
" &nbsp;&mdash;&nbsp;There are a few different ways you can find this out:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Ask your doctor or nurse what side effects to expect when he or she
prescribes the medicines. Ask also what you should do if you have any side
effects.",
" </li>",
" <li>",
" Ask your pharmacist about the side effects when you get your prescriptions
filled. Ask also what you should do if you have any side effects.",
" </li>",
" <li>",
" Read the printed materials that come with the medicine (",
" <a class=\"graphic graphic_figure graphicRef73468 \" href=\"UTD.htm?
18/39/19066\">",
" figure 1",
" </a>",
" ).",
" </li>",
" <li>",
" Check online at FDA.gov for information about the medicine.",
" </li>",
" </ul>",
" </p>",
" <p>",
" For more detailed information about your medicines, ask your doctor or nurse
for information from Lexicomp available through UpToDate. The Lexicomp hand-outs
explain how to use and store your medicines. They also list possible side effects
and warn you if your medicines should not be taken with certain other medicines or
foods.",
" </p>",
" <p class=\"headingAnchor\" id=\"H8525977\">",
" <span class=\"h1\">",
" More on this topic",
" </span>",
" </p>",
" <p>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?31/34/32290?
source=see_link\">",
" Patient information: Taking medicines when you're older (The Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?6/21/6483?
source=see_link\">",
" Patient information: Reducing the costs of medicines (The Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?36/43/37554?
source=see_link\">",
" Patient information: Medicine brand and generic names (The Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?33/16/34050?
source=see_link\">",
" Patient information: Going home from the hospital (The Basics)",
" </a>",
" <br/>",
" <a class=\"medical medical_basics\" href=\"UTD.htm?12/38/12898?
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var title_f0_30_484="Ofloxacin (otic): Drug information";
var content_f0_30_484=[" <noscript>",
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" <div id=\"drugTitle\">",
" Ofloxacin (otic): Drug information",
" </div>",
" <div id=\"lexiTitleImg\">",
" <img height=\"17\" src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\"
width=\"71\"/>",
" </div>",
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" </div>",
" <div id=\"drugCopy\">",
" Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
" </div>",
" <div id=\"topicText\">",
" (For additional information",
" <a class=\"drug drug_patient\" href=\"UTD.htm?16/6/16484?source=see_link\">",
" see \"Ofloxacin (otic): Patient drug information\"",
" </a>",
" and",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?19/42/20131?
source=see_link\">",
" see \"Ofloxacin (otic): Pediatric drug information\"",
" </a>",
" )",
" <br/>",
" For abbreviations and symbols that may be used in Lexicomp (",
" <a class=\"graphic graphic_table\" href=\"UTD.htm?23/39/24183\">",
" show table",
" </a>",
" )",
" <div class=\"ex_sect_xr thclist drugH1Div drugBrandNames\" id=\"F9498000\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pharmacologic Category",
" </span>",
" <ul>",
" <li>",
" Antibacterial, Otic;",
" </li>",
" <li>",
" Antibiotic, Quinolone",
" </li>",
" </ul>",
" </div>",
" <div class=\"block doa drugH1Div\" id=\"F9497841\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Adult",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" <b>",
" Otitis media, chronic suppurative with perforated tympanic membranes:",
" </b>",
" Otic: Instill 10 drops (or the contents of 2 single-dose containers) into
affected ear twice daily for 14 days",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" <b>",
" Otitis externa:",
" </b>",
" Otic: Instill 10 drops (or the contents of 2 single-dose containers) into
affected ear(s) once daily for 7 days",
" </p>",
" </div>",
" <div class=\"block dop drugH1Div\" id=\"F9497840\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Pediatric",
" </span>",
" <p>",
" (For additional information",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?19/42/20131?
source=see_link\">",
" see \"Ofloxacin (otic): Pediatric drug information\"",
" </a>",
" )",
" </p>",
" <p style=\"text-indent:0em;display:inline\">",
" Not for systemic use.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Acute otitis media with tympanotomy tubes:",
" </b>",
" Otic: Children 1-12 years: Instill 5 drops (or the contents of 1 single-dose
container) into affected ear twice daily for 10 days.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Otitis externa:",
" </b>",
" Otic:",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Children 6 months to 13 years: Instill 5 drops (or the contents of 1 single-
dose container) into affected ear(s) once daily for 7 days",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Children &ge;13 years: Refer to adult dosing.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Otitis media, chronic suppurative with perforated tympanic membranes:",
" </b>",
" Otic: Children &gt;12 years: Refer to adult dosing.",
" </p>",
" </div>",
" <div class=\"block foc drugH1Div\" id=\"F9497976\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosage Forms: U.S.",
" </span>",
" <p style=\"text-indent:0em;text-align:justify;display:inline\">",
" Excipient information presented when available (limited, particularly for
generics); consult specific product labeling.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Solution, otic [drops]: 0.3% (5 mL, 10 mL)",
" </p>",
" </div>",
" <div class=\"block geq drugH1Div\" id=\"F9496349\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Generic Equivalent Available: U.S.",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Yes",
" </p>",
" </div>",
" <div class=\"block adm drugH1Div\" id=\"F9497905\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Administration",
" </span>",
" <p style=\"text-indent:0em;margin-left:0em;text-
align:justify;display:inline\">",
" Prior to use, warm solution by holding container in hands for 1-2 minutes.
Patient should lie down with affected ear upward and medication instilled. Pump
tragus 4 times to ensure penetration of medication. Patient should remain in this
position for 5 minutes.",
" </p>",
" </div>",
" <div class=\"block use drugH1Div\" id=\"F9496350\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Use",
" </span>",
" <p style=\"text-indent:0em;margin-left:0em;text-
align:justify;display:inline\">",
" Otitis externa, chronic suppurative otitis media, acute otitis media",
" </p>",
" </div>",
" <div class=\"block mst drugH1Div\" id=\"F9496297\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Medication Safety Issues",
" </span>",
" <div class=\"collapsible\">",
" <span class=\"collapsible-title\">",
" Sound-alike/look-alike issues:",
" </span>",
" <div class=\"collapsible-wrap\">",
" <p style=\"text-indent:-2em;margin-left:4em;\">",
" Floxin may be confused with Flexeril&reg;",
" </p>",
" </div>",
" </div>",
" <div class=\"collapsible\">",
" <span class=\"collapsible-title\">",
" International issues:",
" </span>",
" <div class=\"collapsible-wrap\">",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Floxin: Brand name for ofloxacin [U.S., Canada], but also the brand name
for flunarizine [Thailand], norfloxacin [South Africa], and perfloxacin
[Philippines]",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Floxin [U.S., Canada] may be confused with Flexin brand name for diclofenac
[Argentina], cyclobenzaprine [Chile], and orphenadrine [Israel]; Flogen brand name
for naproxen [Mexico]",
" </p>",
" </div>",
" </div>",
" </div>",
" <div class=\"block ars drugH1Div\" id=\"F9497565\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Adverse Reactions Significant",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" &gt;10%: Local: Application site reaction (&lt;1% to 17%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" 1% to 10%:",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Central nervous system: Dizziness (&le;1%), vertigo (&le;1%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Dermatologic: Pruritus (1% to 4%), rash (1%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Gastrointestinal: Taste perversion (7%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Neuromuscular &amp; skeletal: Paresthesia (1%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" &lt;1% (Limited to important or life-threatening): Diarrhea, fever, headache,
hearing loss (transient), hypertension, nausea, otorrhagia, tinnitus, transient
neuropsychiatric disturbances, tremor, vomiting, xerostomia",
" </p>",
" </div>",
" <div class=\"block coi drugH1Div\" id=\"F9497552\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Contraindications",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Hypersensitivity to ofloxacin or other members of the quinolone group, such
as oxolinic acid, cinoxacin, norfloxacin, and ciprofloxacin; hypersensitivity to
any component of the formulation",
" </p>",
" </div>",
" <div class=\"block war drugH1Div\" id=\"F9497553\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Warnings/Precautions",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Concerns related to adverse effects:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Hypersensitivity reactions: Severe hypersensitivity reactions,
including anaphylaxis, have occurred with quinolone therapy (primarily with
systemic use). The spectrum of these reactions can vary widely; reactions may
present as typical allergic symptoms (eg, itching, urticaria, rash, edema) after a
single dose or may manifest as severe idiosyncratic dermatologic (eg, Stevens-
Johnson, toxic epidermal necrolysis), vascular (eg, vasculitis), pulmonary (eg,
pneumonitis), renal (eg, nephritis), hepatic (eg, hepatic failure or necrosis),
and/or hematologic (eg, anemia, cytopenias) events, usually after multiple doses.
Prompt discontinuation of drug should occur if skin rash or other symptoms arise.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Superinfection: Prolonged use may result in fungal or bacterial
superinfection. If superinfection is suspected, institute appropriate alternative
therapy.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Tendon inflammation/rupture: There have been reports of tendon
inflammation and/or rupture with systemic quinolone antibiotics. Exposure following
otic administration is substantially lower than with systemic therapy. Discontinue
at first sign of tendon inflammation or pain.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Dosage form specific issues:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Otic use: Not for injection or for ophthalmic use.",
" </p>",
" </div>",
" <div class=\"block cyt drugH1Div\" id=\"F9497665\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Metabolism/Transport Effects",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" None known.",
" </p>",
" </div>",
" <div class=\"block dri drugH1Div\" id=\"F9497666\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Drug Interactions",
" </span>",
" <br/>",
" <br/>",
" <div class=\"lexi\" id=\"lexiInteractAddInfo\">",
" (For additional information:",
" <a class=\"dip\" href=\"./drug-interaction\" target=\"_blank\">",
" Launch Lexi-Interact&trade; Drug Interactions Program",
" </a>",
" )",
" </div>",
" <div class=\"lexi\" id=\"lexiInteractImgB\">",
" <img border=\"0\" height=\"17\"
src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\" width=\"71\"/>",
" </div>",
" <div class=\"clear\">",
" </div>",
" <p style=\"text-indent:0em;display:inline\">",
" There are no known significant interactions.",
" </p>",
" </div>",
" <div class=\"block prf drugH1Div\" id=\"F9496359\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pregnancy Risk Factor",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" C (",
" <a class=\"graphic graphic_table\" href=\"UTD.htm?16/42/17068\">",
" show table",
" </a>",
" )",
" </p>",
" </div>",
" <div class=\"block pri drugH1Div\" id=\"F9775942\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pregnancy Implications",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Adverse events have been observed in some animal studies; therefore, the
manufacturer classifies ofloxacin otic as pregnancy category C. When administered
orally, ofloxacin crosses the placenta. Refer to the Ofloxacin (Systemic) monograph
for details. The amount of ofloxacin available systemically following topical
application of the otic drops is significantly less in comparison to oral doses.",
" </p>",
" </div>",
" <div class=\"block lac drugH1Div\" id=\"F9497527\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Lactation",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Enters breast milk/not recommended (AAP rates \"compatible\"; AAP 2001 update
pending)",
" </p>",
" </div>",
" <div class=\"block brc drugH1Div\" id=\"F9497551\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Breast-Feeding Considerations",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" When administered orally, ofloxacin enters breast milk. Refer to the
Ofloxacin (Systemic) monograph for details. The amount of ofloxacin available
systemically following topical application of the otic drops is significantly less
in comparison to oral doses; however, due to the potential for adverse events in a
nursing infant, breast-feeding is not recommended by the manufacturer.",
" </p>",
" </div>",
" <div class=\"block fee drugH1Div\" id=\"F9497978\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pricing: U.S. (Medi-Span&reg;)",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" Solution",
" </b>",
" (Ofloxacin Otic)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" 0.3% (5 mL): $74.00",
" </p>",
" </div>",
" <div class=\"list fbnlist drugH1Div drugBrandNames\" id=\"F14721645\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" International Brand Names",
" </span>",
" <ul>",
" <li>",
" Anli (CL);",
" </li>",
" <li>",
" Dizoflox (PH);",
" </li>",
" <li>",
" Earflo Otic (TW);",
" </li>",
" <li>",
" Inoflox (PH);",
" </li>",
" <li>",
" Oflaxsyn (CO);",
" </li>",
" <li>",
" Ofven (IN);",
" </li>",
" <li>",
" Otoflox (AR, DO, EC);",
" </li>",
" <li>",
" Otonil (PY);",
" </li>",
" <li>",
" Tarivid (CL, HK, ID, KP, MY, SG, TW);",
" </li>",
" <li>",
" Tructum (PE)",
" </li>",
" </ul>",
" </div>",
" <div class=\"block pha drugH1Div\" id=\"F9497805\"
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" Ofloxacin is a DNA gyrase inhibitor. DNA gyrase is an essential bacterial
enzyme that maintains the superhelical structure of DNA. DNA gyrase is required for
DNA replication and transcription, DNA repair, recombination, and transposition;
bactericidal",
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" Absorption: Only small amounts are absorbed systemically after otic
instillation.",
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" <div id=\"topicAgreement\">",
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" <div class=\"headingAnchor\" id=\"references\">",
" <h1>",
" REFERENCES",
" </h1>",
" <ol id=\"reference\">",
" <li>",
" <div class=\"reference\">",
" American Academy of Pediatrics Committee on Drugs, \"Transfer of Drugs and
Other Chemicals Into Human Milk,\"",
" <i>",
" Pediatrics",
" </i>",
" , 2001, 108(3):776-89.",
" <span class=\"pubmed-id\">",
" [PubMed",
" <a href=\"UTD.htm?0/30/484/abstract-text/11533352 /pubmed\"
id=\"11533352 \" target=\"_blank\">",
" 11533352",
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" ]",
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" <a class=\"outlineLink\" href=\"#F9497527\">",
" Lactation",
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" Breast-Feeding Considerations",
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" <h1>",
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" <a class=\"drug drug_general\" href=\"UTD.htm?31/2/31780?
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" Ofloxacin (ophthalmic): Drug information",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"drug drug_patient\" href=\"UTD.htm?29/20/30020?
source=related_link\">",
" Ofloxacin (ophthalmic): Patient drug information",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?20/55/21363?
source=related_link\">",
" Ofloxacin (ophthalmic): Pediatric drug information",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"drug drug_patient\" href=\"UTD.htm?16/6/16484?
source=related_link\">",
" Ofloxacin (otic): Patient drug information",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?19/42/20131?
source=related_link\">",
" Ofloxacin (otic): Pediatric drug information",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"drug drug_general\" href=\"UTD.htm?1/41/1688?
source=related_link\">",
" Ofloxacin (systemic): Drug information",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"drug drug_patient\" href=\"UTD.htm?29/29/30165?
source=related_link\">",
" Ofloxacin (systemic): Patient drug information",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"drug drug_pediatric\" href=\"UTD.htm?33/28/34246?
source=related_link\">",
" Ofloxacin (systemic): Pediatric drug information",
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var title_f0_30_485="Exemestane: Patient drug information";
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" <div id=\"disclaimer\">",
" The content on the UpToDate website is not intended nor recommended as a
substitute",
"for medical advice, diagnosis, or treatment. Always seek the advice of your own
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" &copy;2013 UpToDate, Inc.",
" </div>",
" <div id=\"drugTitle\">",
" Exemestane: Patient drug information",
" </div>",
" <div id=\"lexiTitleImg\">",
" <img height=\"17\" src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\"
width=\"71\"/>",
" </div>",
" <div class=\"clear\">",
" </div>",
" <div id=\"drugCopy\">",
" Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
" </div>",
" <div id=\"topicText\">",
" <p>",
" (For additional information",
" <a class=\"drug drug_general\" href=\"UTD.htm?7/4/7238?source=see_link\">",
" see \"Exemestane: Drug information\"",
" </a>",
" )",
" </p>",
" <div class=\"list ubnlist drugH1Div drugBrandNames\" id=\"F169505\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Brand Names: U.S.",
" </span>",
" <ul>",
" <li>",
" Aromasin&reg;",
" </li>",
" </ul>",
" </div>",
" <div class=\"list cbnlist drugH1Div drugBrandNames\" id=\"F169506\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Brand Names: Canada",
" </span>",
" <ul>",
" <li>",
" Aromasin&reg;;",
" </li>",
" <li>",
" CO Exemestane",
" </li>",
" </ul>",
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" <div class=\"ord-stmt yya-os drugH1Div\" id=\"F10016428\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" What is this drug used for?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2691764",
" </span>",
" </span>",
" <span class=\"content\">",
" It is used to treat breast cancer in women after change of life.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s3558634",
" </span>",
" </span>",
" <span class=\"content\">",
" It is used to stop breast cancer.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s3558635",
" </span>",
" </span>",
" <span class=\"content\">",
" It is used to treat some uterine cancers.",
" </span>",
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" </ul>",
" </div>",
" <div class=\"ord-stmt coi-os drugH1Div\" id=\"F10016427\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" What do I need to tell my doctor before I take this drug?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
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" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2702094",
" </span>",
" </span>",
" <span class=\"content\">",
" If you have an allergy to exemestane or any other part of this drug.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
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" &bull;",
" </span>",
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" urn:lims:b498:s2705171",
" </span>",
" </span>",
" <span class=\"content\">",
" If you are allergic to any drugs, foods, or other substances. Tell your
doctor about the allergy and what signs you had, like rash; hives; itching;
shortness of breath; wheezing; cough; swelling of face, lips, tongue, or throat; or
any other signs.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2701080",
" </span>",
" </span>",
" <span class=\"content\">",
" If you are pregnant or may be pregnant.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2701047",
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" </span>",
" <span class=\"content\">",
" If you are breast-feeding.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2703796",
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" If you have not stopped your period.",
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" &bull;",
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" <li class=\"statement\">",
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" &bull;",
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" urn:lims:b498:s2698407",
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" Have a bone density test. Talk with your doctor.",
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" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
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" <span class=\"content\">",
" Check all drugs you are taking with your doctor. This drug may not mix well
with some other drugs.",
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" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
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" urn:lims:b498:s2699677",
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OTC) with you. Give this list to your doctor.",
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" <li class=\"statement\">",
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" &bull;",
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" <span class=\"link\">",
" urn:lims:b498:s2698416",
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" Have your blood pressure and heart rate checked often. Talk with your
doctor.",
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" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
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" urn:lims:b498:s2697111",
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doctor before using OTC products that may raise blood pressure. These include cough
or cold drugs, diet pills, stimulants, ibuprofen or like products, and some natural
products or aids.",
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" <span class=\"entity\">",
" &bull;",
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" urn:lims:b498:s2697997",
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" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698119",
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" </span>",
" <span class=\"content\">",
" Headache.",
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" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698279",
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" </span>",
" <span class=\"content\">",
" Nervous and excitable.",
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" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698094",
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" </span>",
" <span class=\"content\">",
" Flushing. Wearing layers of clothes or summer clothes and staying in cool
places may help.",
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" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
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hard, sugar-free candy, or chewing sugar-free gum may help.",
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" &bull;",
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" urn:lims:b498:s2698114",
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" <span class=\"content\">",
" Hair loss. Hair most often grows back when this drug is stopped.",
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" <li class=\"statement\">",
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" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698162",
" </span>",
" </span>",
" <span class=\"content\">",
" Not able to sleep.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698390",
" </span>",
" </span>",
" <span class=\"content\">",
" Weak bones with long-term use.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyh-os drugH1Div\" id=\"F10016435\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" What are some side effects that I need to call my doctor about right away?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698721",
" </span>",
" </span>",
" <span class=\"content\">",
" If you think there has been an overdose, call 1-800-222-1222 (the American
Association of Poison Control Centers), your local poison control center
(file://www.aapcc.org), or emergency room (ER) right away.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699066",
" </span>",
" </span>",
" <span class=\"content\">",
" Signs of an allergic reaction, like rash; hives; itching; red, swollen,
blistered, or peeling skin with or without fever; wheezing; tightness in the chest
or throat; trouble breathing or talking; unusual hoarseness; or swelling of the
mouth, face, lips, tongue, or throat.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698626",
" </span>",
" </span>",
" <span class=\"content\">",
" Chest pain or pressure.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698619",
" </span>",
" </span>",
" <span class=\"content\">",
" Change in strength on 1 side is greater than the other, trouble speaking or
thinking, change in balance, or blurred eyesight.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699031",
" </span>",
" </span>",
" <span class=\"content\">",
" Very bad headache.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698988",
" </span>",
" </span>",
" <span class=\"content\">",
" Numbness or tingling in your hands or feet.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699042",
" </span>",
" </span>",
" <span class=\"content\">",
" Very upset stomach or throwing up.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698603",
" </span>",
" </span>",
" <span class=\"content\">",
" Any rash.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2698977",
" </span>",
" </span>",
" <span class=\"content\">",
" Side effect or health problem is not better or you are feeling worse.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyc-os drugH1Div\" id=\"F10016430\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" How is this drug best taken?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2695852",
" </span>",
" </span>",
" <span class=\"content\">",
" Take this drug at the same time of day.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2695844",
" </span>",
" </span>",
" <span class=\"content\">",
" Take after a meal.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2696101",
" </span>",
" </span>",
" <span class=\"content\">",
" This drug works best when used with calcium/vitamin D and weight-bearing
workouts like walking or PT (physical therapy).",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyd-os drugH1Div\" id=\"F10016431\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" What do I do if I miss a dose?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2696563",
" </span>",
" </span>",
" <span class=\"content\">",
" Take a missed dose as soon as you think about it.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2696496",
" </span>",
" </span>",
" <span class=\"content\">",
" If it is close to the time for your next dose, skip the missed dose and go
back to your normal time.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2696475",
" </span>",
" </span>",
" <span class=\"content\">",
" Do not take 2 doses at the same time or extra doses.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2696457",
" </span>",
" </span>",
" <span class=\"content\">",
" Do not change the dose or stop this drug. Talk with the doctor.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyi-os drugH1Div\" id=\"F10016436\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" How do I store and/or throw out this drug?",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699336",
" </span>",
" </span>",
" <span class=\"content\">",
" Store at room temperature.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b498:s2699266",
" </span>",
" </span>",
" <span class=\"content\">",
" Store in a dry place. Do not store in a bathroom.",
" </span>",
" </li>",
" </ul>",
" </div>",
" <div class=\"ord-stmt yyj-os drugH1Div\" id=\"F10016437\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" General drug facts",
" </span>",
" <ul class=\"statements\" style=\"list-style-type:none;\">",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b259:s2699675",
" </span>",
" </span>",
" <span class=\"content\">",
" If your symptoms or health problems do not get better or if they become
worse, call your doctor.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b259:s2699673",
" </span>",
" </span>",
" <span class=\"content\">",
" Do not share your drugs with others and do not take anyone else's drugs.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b259:s2699678",
" </span>",
" </span>",
" <span class=\"content\">",
" Keep all drugs out of the reach of children and pets.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b259:s2699709",
" </span>",
" </span>",
" <span class=\"content\">",
" If you have any questions about this drug, please talk with your doctor,
pharmacist, or other health care provider.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b259:s3302581",
" </span>",
" </span>",
" <span class=\"content\">",
" In Canada, take any unused drugs to the pharmacy. Also, visit
file://www.hc-sc.gc.ca/hl-vs/iyh-vsv/med/disposal-defaire-eng.php#th to learn about
the right way to get rid of unused drugs.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b259:s2699677",
" </span>",
" </span>",
" <span class=\"content\">",
" Keep a list of all your drugs (prescription, natural products, vitamins,
OTC) with you. Give this list to your doctor.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b259:s2699671",
" </span>",
" </span>",
" <span class=\"content\">",
" These are not all of the side effects that may occur. If you have questions
about side effects, call your doctor. Call your doctor for medical advice about
side effects.",
" </span>",
" </li>",
" <li class=\"statement\">",
" <span class=\"attributes\" style=\"display:none;\">",
" <span class=\"entity\">",
" &bull;",
" </span>",
" <span class=\"link\">",
" urn:lims:b259:s2699683",
" </span>",
" </span>",
" <span class=\"content\">",
" Talk with the doctor before starting any new drug, including prescription
or OTC, natural products, or vitamins.",
" </span>",
" </li>",
" </ul>",
" </div>",
" </div>",
" <div id=\"topicAgreement\">",
" Use of UpToDate is subject to the",
" <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
target=\"_blank\">",
" Subscription and License Agreement",
" </a>",
" .",
" </div>",
" <div id=\"topicVersionRevision\">",
" Topic 12459 Version 35.0",
" </div>",
" </div>",
" <div id=\"footer\">",
" <div id=\"supportFooter\">",
" <span class=\"sfInfo\">",
" &copy; 2013 UpToDate, Inc. All rights reserved.",
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" Support Tag: [1005-197.136.42.3-E1899EF4C7-S244013.14]",
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" <h1>",
" TOPIC OUTLINE",
" </h1>",
" <div id=\"outline\">",
" <ul>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#F169505\">",
" Brand Names: U.S.",
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" <li class=\"plainItem\">",
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" Brand Names: Canada",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#F10016428\">",
" What is this drug used for?",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#F10016427\">",
" What do I need to tell my doctor before I take this drug?",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#F10016432\">",
" What are some things I need to know or do while I take this drug?",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#F10016433\">",
" What are some side effects of this drug?",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#F10016435\">",
" What are some side effects that I need to call my doctor about right away?",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#F10016430\">",
" How is this drug best taken?",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#F10016431\">",
" What do I do if I miss a dose?",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#F10016436\">",
" How do I store and/or throw out this drug?",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#F10016437\">",
" General drug facts",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" RELATED TOPICS",
" </h1>",
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" <ul>",
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" <a class=\"drug drug_general\" href=\"UTD.htm?7/4/7238?
source=related_link\">",
" Exemestane: Drug information",
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var title_f0_30_486="Levodopa-benserazide: Drug information";
var content_f0_30_486=[" <noscript>",
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JavaScript is required in order for our site to behave correctly. Please enable
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" <!-- TC:TOPIC_PAGE -->",
" <div id=\"topicContent\">",
" <div id=\"drugTitle\">",
" Levodopa-benserazide: Drug information",
" </div>",
" <div id=\"lexiTitleImg\">",
" <img height=\"17\" src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\"
width=\"71\"/>",
" </div>",
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" </div>",
" <div id=\"drugCopy\">",
" Copyright 1978-2013 Lexicomp, Inc. All rights reserved.",
" </div>",
" <div id=\"topicText\">",
" (For additional information",
" <a class=\"drug drug_patient\" href=\"UTD.htm?18/17/18709?source=see_link\">",
" see \"Levodopa-benserazide: Patient drug information\"",
" </a>",
" )",
" <br/>",
" For abbreviations and symbols that may be used in Lexicomp (",
" <a class=\"graphic graphic_table\" href=\"UTD.htm?23/39/24183\">",
" show table",
" </a>",
" )",
" <div class=\"list cbnlist drugH1Div drugBrandNames\" id=\"F139718\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Brand Names: Canada",
" </span>",
" <ul>",
" <li>",
" Prolopa&reg;",
" </li>",
" </ul>",
" </div>",
" <div class=\"ex_sect_xr thclist drugH1Div drugBrandNames\" id=\"F139728\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pharmacologic Category",
" </span>",
" <ul>",
" <li>",
" Anti-Parkinson's Agent, Dopamine Agonist",
" </li>",
" </ul>",
" </div>",
" <div class=\"block doa drugH1Div\" id=\"F139721\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Adult",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" <b>",
" Parkinson's disease:",
" </b>",
" Oral:",
" <b>",
" Note:",
" </b>",
" Dosage expressed as levodopa/benserazide. Dosage should be introduced
gradually, individualized, and continued for 3-6 weeks before assessing benefit.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <i>",
" Patients currently receiving levodopa therapy:",
" </i>",
" Discontinue levodopa &ge;12 hours prior to the initiation of therapy; start
at 15% of previous levodopa dose.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <i>",
" Patients",
" <b>",
" NOT",
" </b>",
" on levodopa therapy:",
" </i>",
" Initial: 100/25 mg 1-2 times/day; increase dose by 100/25 mg every 3-4 days
until therapeutic effect; usual optimal dosage: 400/100 mg to 800/200 mg divided
into 4-6 doses",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" <b>",
" Note:",
" </b>",
" The 200/50 mg capsules should be used only when maintenance therapy is
reached. The 50/12.5 mg capsules should be used to decrease adverse effects when
adjusting dose. Total daily dose during the first year of therapy should not exceed
1000-1200 mg of levodopa. After 1 year of therapy, the maximum recommended daily
dose of levodopa is 600 mg/day.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <i>",
" Patients experiencing dystonia:",
" </i>",
" Dosage reduction is recommended",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <i>",
" Brief interruption of therapy:",
" </i>",
" Reinitiate therapy at previous dose when patient is able to resume
treatment.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <i>",
" Extended interruption of therapy:",
" </i>",
" Reinitiate therapy at a lower dose and adjust gradually when patient is able
to resume treatment",
" </p>",
" </div>",
" <div class=\"block doe drugH1Div\" id=\"F2564095\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Geriatric",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Refer to adult dosing.",
" </p>",
" </div>",
" <div class=\"block dor drugH1Div\" id=\"F13301007\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Renal Impairment",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" There are no dosage adjustments provided in manufacturer's labeling. Use in
decompensated renal disease is contraindicated.",
" </p>",
" </div>",
" <div class=\"block doh drugH1Div\" id=\"F13301006\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosing: Hepatic Impairment",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" There are no dosage adjustments provided in manufacturer's labeling. Use in
decompensated hepatic disease is contraindicated.",
" </p>",
" </div>",
" <div class=\"block foccan drugH1Div\" id=\"F5950025\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dosage Forms: Canada",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Excipient information presented when available (limited, particularly for
generics); consult specific product labeling.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Capsule:",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Prolopa&reg;:",
" </p>",
" <p style=\"text-indent:-2em;margin-left:6em;text-align:justify;\">",
" 50-12.5: Levodopa 50 mg and benserazide 12.5 mg",
" </p>",
" <p style=\"text-indent:-2em;margin-left:6em;text-align:justify;\">",
" 100-25: Levodopa 100 mg and benserazide 25 mg",
" </p>",
" <p style=\"text-indent:-2em;margin-left:6em;text-align:justify;\">",
" 200-50: Levodopa 200 mg and benserazide 50 mg",
" </p>",
" </div>",
" <div class=\"block prod-avail drugH1Div\" id=\"F11217268\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Product Availability",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Not available in U.S.",
" </p>",
" </div>",
" <div class=\"block adm drugH1Div\" id=\"F139697\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Administration",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Administer with or immediately after meals. Capsules should be swallowed
whole; do not crush, chew, open, or dissolve in liquid.",
" </p>",
" </div>",
" <div class=\"block use drugH1Div\" id=\"F139696\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Use",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Treatment of Parkinson's disease (except drug-induced Parkinsonism)",
" </p>",
" </div>",
" <div class=\"block ars drugH1Div\" id=\"F139726\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Adverse Reactions Significant",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Frequency not defined.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Cardiovascular: Arrhythmias, chest pain, edema, ECG changes (nonspecific),
flushing, hypertension, orthostatic hypotension, pallor, phlebitis",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Central nervous system: Agitation, anxiety, ataxia, bruxism, confusion,
delusions, dementia, depression, euphoria, faintness, fatigue, fever, gait
abnormalities, hallucinations (mostly visual), headache, impulse control symptoms
(including pathological gambling), insomnia, lethargy, malaise, neuroleptic
malignant-like syndrome, nightmares, oculogyric crisis, on-off phenomena, paranoid
ideation, psychotic episodes, sedation, seizures, somnolence, suicidal
tendencies/behavior, temporal disorientation, trismus",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Dermatological: Alopecia, pruritus, rash",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Endocrine &amp; metabolic: Libido increased, protein-bound iodine increased,
uric acid increased",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Gastrointestinal: Abdominal distress or pain, anorexia, burning sensation on
tongue, constipation, diarrhea, duodenal ulcer, dysphagia, epigastric pain,
eructation, flatulence, GI bleeding, nausea, sialorrhea, taste alterations,
vomiting, weight gain/loss, xerostomia",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Genitourinary: Discoloration of urine, hematuria, nocturia, urinary
frequency, urinary retention or incontinence",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Hematologic: Agranulocytosis, hemolytic anemia (rare), leukopenia
(transient), Positive Coombs' test, thrombocytopenia",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Hepatic: Alkaline phosphatase increased, bilirubin increased, LDH increased,
transaminases increased",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Neuromuscular &amp; skeletal: Akinesia paradoxica, choreiform and involuntary
movements, dystonia, end-of-dose akinesia, hand tremor, low back pain, muscle spasm
and twitching, musculoskeletal pain, numbness, torticollis, weakness",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Ocular: Activation of latent Horner's syndrome, blepharospasm, blurred
vision, diplopia, diluted pupils",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Renal: BUN increased",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Respiratory: Bizarre breathing pattern, cough, hoarseness, postnasal drip",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Miscellaneous: Diaphoresis, discoloration of sweat, hiccups, hypersensitivity
reactions, lip/mouth/tongue tightness",
" </p>",
" </div>",
" <div class=\"block coi drugH1Div\" id=\"F139700\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Contraindications",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Hypersensitivity to benserazide, levodopa, sympathomimetics, or any component
of the formulation; use with or within 14 days of MAO inhibitors; patients with
clinical laboratory evidence of uncompensated cardiovascular, endocrine, renal,
hepatic, hematologic, or pulmonary disease; patients with decompensated endocrine,
renal, hepatic, cardiac disorders, psychiatric disorders, narrow-angle glaucoma, or
closed-angle glaucoma; patients &lt;25 years of age (due to possibility of skeletal
abnormalities from benserazide); pregnancy or use in women of childbearing
potential without adequate contraception",
" </p>",
" </div>",
" <div class=\"block war drugH1Div\" id=\"F139683\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Warnings/Precautions",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Concerns related to adverse effects:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; CNS effects:",
" <b>",
" [Canadian Boxed Warning]:",
" </b>",
" Patients have reported falling asleep while engaging in activities of daily
living and sometimes without significant warning signs. Monitor for daytime
somnolence or pre-existing sleep disorder; discontinue if significant daytime
sleepiness or episodes of falling asleep occur. Patients must be cautioned about
performing tasks which require mental alertness (eg, operating machinery or
driving). Use with caution in patients receiving other CNS depressants or
psychoactive agents. Effects with other sedative drugs or ethanol may be
potentiated.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Impulse control disorders: Dopamine agonists used for
Parkinson&rsquo;s disease or restless legs syndrome have been associated with
compulsive behaviors and/or loss of impulse control, which has manifested as
pathological gambling, libido increases (hypersexuality), and/or binge eating.
Causality has not been established, and controversy exists as to whether this
phenomenon is related to the underlying disease, prior behaviors/addictions and/or
drug therapy. Dose reduction or discontinuation of therapy has been reported to
reverse these behaviors in some, but not all cases.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Increased growth hormone levels: May increase human growth hormone
levels.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Melanoma: Risk for melanoma development is increased in
Parkinson&rsquo;s disease patients; drug causation or factors contributing to risk
have not been established. Patients should be monitored closely and periodic skin
examinations should be performed.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Disease-related concerns:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Cardiovascular disease: Use with caution in patients with
cardiovascular disease (MI, atrial, nodal, or ventricular arrhythmias); initiate in
a monitored setting.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Diabetes: Use with caution in patients with diabetes mellitus;
antidiabetic agents may require dose adjustment.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Glaucoma: Use with caution in patients with chronic wide-angle
glaucoma; monitor IOP carefully in patients with wide-angle glaucoma.
Contraindicated in patients with narrow-angle and closed-angle glaucoma.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Hepatic impairment: Use with caution in patients with hepatic
impairment;. contraindicated in decompensated hepatic disease.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Peptic ulcer disease: Use with caution in patients with peptic ulcer
disease.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Psychotic disorders: Use with extreme caution in patients with
psychotic disorders; observe patients closely for development of depression with
concomitant suicidal tendencies.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Renal impairment: Use with caution in patients with renal impairment;.
contraindicated in decompensated renal disease.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Seizure disorder: Use with caution in patients with a history of
seizure disorder.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Concurrent drug therapy issues:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Current levodopa therapy: If patient is already receiving levodopa,
discontinue levodopa at least 12 hours before starting levodopa/benserazide and
begin at 15% of previous amount of levodopa.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Phenothiazines: Use with caution in patients receiving
phenothiazines.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Tricyclic antidepressants (TCAs): Use with caution in patients
receiving TCAs.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Special populations:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Elderly: Use with caution in the elderly; may be more sensitive to CNS
effects of levodopa.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" <b>",
" <i>",
" Other warnings/precautions:",
" </i>",
" </b>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Appropriate use: Not indicated in management of intention tremor,
Huntington's chorea, or drug-induced extrapyramidal symptoms. Administer in careful
increments and observe closely for development of abnormal involuntary movements.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Dietary protein: Distribute dietary protein throughout the day to
avoid fluctuations in levodopa absorption.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Discontinuation of therapy: Dopaminergic agents have been associated
with a syndrome resembling neuroleptic malignant syndrome (NMS) on abrupt
withdrawal or significant dosage reduction after long-term use.",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" &bull; Patient information: Patient must be instructed to resume normal
activities gradually (rapid mobilization may increase risk of injury).",
" </p>",
" </div>",
" <div class=\"block cyt drugH1Div\" id=\"F13298828\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Metabolism/Transport Effects",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" None known.",
" </p>",
" </div>",
" <div class=\"block dri drugH1Div\" id=\"F139687\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Drug Interactions",
" </span>",
" <br/>",
" <br/>",
" <div class=\"lexi\" id=\"lexiInteractAddInfo\">",
" (For additional information:",
" <a class=\"dip\" href=\"./drug-interaction\" target=\"_blank\">",
" Launch Lexi-Interact&trade; Drug Interactions Program",
" </a>",
" )",
" </div>",
" <div class=\"lexi\" id=\"lexiInteractImgB\">",
" <img border=\"0\" height=\"17\"
src=\"./../images/lexiComp/Lexicomp_2012_71x17.myextg\" width=\"71\"/>",
" </div>",
" <div class=\"clear\">",
" </div>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Antipsychotics (Atypical): May diminish the therapeutic effect of Anti-
Parkinson's Agents (Dopamine Agonist). Management: Consider using an alternative
antipsychotic agent when possible in patients with Parkinson's disease. If an
atypical antipsychotic is necessary, consider using clozapine or quetiapine, which
may convey the lowest interaction risk.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Antipsychotics (Typical): Anti-Parkinson's Agents (Dopamine Agonist) may
diminish the therapeutic effect of Antipsychotics (Typical). Antipsychotics
(Typical) may diminish the therapeutic effect of Anti-Parkinson's Agents (Dopamine
Agonist). Management: Avoid concomitant therapy if possible and monitor for
decreased effects of both agents when these combinations cannot be avoided.
Atypical antipsychotics such as clozapine and quetiapine may be less likely to
reduce the effects of anti-Parkinson's agents.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Fosphenytoin: May diminish the therapeutic effect of Levodopa.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Glycopyrrolate: May decrease the serum concentration of Levodopa.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Iron Salts: May decrease the serum concentration of Levodopa. Only applies to
oral iron preparations. Management: Consider separating doses of the agents by 2 or
more hours to minimize the effects of this interaction. Monitor for decreased
therapeutic effects of levodopa during concomitant therapy, particularly if doses
cannot be separated.",
" <b>",
" Exceptions:",
" </b>",
" Ferric Gluconate; Ferumoxytol; Iron Dextran Complex; Iron Sucrose.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" MAO Inhibitors: Levodopa may enhance the adverse/toxic effect of MAO
Inhibitors. Of particular concern is the development of hypertensive reactions when
levodopa is used with nonselective MAOI.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" MAO Inhibitors: May enhance the orthostatic hypotensive effect of Orthostatic
Hypotension Producing Agents.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Methionine: May diminish the therapeutic effect of Levodopa. Probably only
with large doses of methionine. Data was generated using 4.5gm daily.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Methylphenidate: May enhance the adverse/toxic effect of Anti-Parkinson's
Agents (Dopamine Agonist).",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Metoclopramide: May diminish the therapeutic effect of Anti-Parkinson's
Agents (Dopamine Agonist).",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Multivitamins/Minerals (with ADEK, Folate, Iron): May diminish the
therapeutic effect of Levodopa. Multivitamins/Minerals (with ADEK, Folate, Iron)
may decrease the serum concentration of Levodopa. Only applies to oral iron-
containing preparations. Management: Separate doses of these agents by 2 or more
hours. Monitor for decreased levodopa effects, particularly if doses cannot be
separated. Concurrent use of a multivitamin and levodopa (without carbidopa)
should be avoided.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Phenytoin: May diminish the therapeutic effect of Levodopa.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Pyridoxine: May diminish the therapeutic effect of Levodopa. Management: The
concomitant use of pyridoxine and levodopa (in the absence of a dopa decarboxylase
inhibitor (DDI)) should be avoided. Use of a DDI (e.g., carbidopa) with levodopa
will essentially eliminate the risk of this interaction.",
" <i>",
" Risk D: Consider therapy modification",
" </i>",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;\">",
" Sapropterin: May enhance the adverse/toxic effect of Levodopa.",
" <i>",
" Risk C: Monitor therapy",
" </i>",
" </p>",
" </div>",
" <div class=\"block foi drugH1Div\" id=\"F139713\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Ethanol/Nutrition/Herb Interactions",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Food: High-protein diets may decrease effect of levodopa; food impairs or
reduces the rate and extent of levodopa absorption (15% to 30%). Iron salts
(ferrous sulfate) may decrease the absorption of levodopa.",
" </p>",
" </div>",
" <div class=\"block pri drugH1Div\" id=\"F139703\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pregnancy Implications",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Teratogenic effects have been observed with levodopa in animal reproduction
studies; use is contraindicated in pregnant women and women of childbearing age
without proper contraception.",
" </p>",
" </div>",
" <div class=\"block lac drugH1Div\" id=\"F139724\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Lactation",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Excretion in breast milk unknown/not recommended",
" </p>",
" </div>",
" <div class=\"block brc drugH1Div\" id=\"F139704\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Breast-Feeding Considerations",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Breast-feeding is not recommended since occurrence of skeletal malformations
in infants cannot be excluded.",
" </p>",
" </div>",
" <div class=\"block dic drugH1Div\" id=\"F139705\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Dietary Considerations",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" High-protein diets may decrease effect of levodopa.",
" </p>",
" </div>",
" <div class=\"block mop drugH1Div\" id=\"F139692\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Monitoring Parameters",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Regular assessment of cardiovascular, hepatic, hematopoietic, and renal
function; monitor blood glucose in patients with diabetes; symptoms of psychosis
and dystonia",
" </p>",
" </div>",
" <div class=\"list fbnlist drugH1Div drugBrandNames\" id=\"F139706\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" International Brand Names",
" </span>",
" <ul>",
" <li>",
" Levazide (ID);",
" </li>",
" <li>",
" Levoben (ID);",
" </li>",
" <li>",
" Levopar (DE, ID);",
" </li>",
" <li>",
" Levopar Plus (IL);",
" </li>",
" <li>",
" Madopar (AR, AT, AU, CH, CL, CO, CZ, DE, DK, EE, ES, FI, GB, GR, HK, HN, ID,
IE, IT, KP, MX, MY, NL, NO, NZ, PE, PH, PK, PL, PT, RU, SG, TH, TR, TW, VE);",
" </li>",
" <li>",
" Madopar-F (IN);",
" </li>",
" <li>",
" Madopark (SE);",
" </li>",
" <li>",
" Modopar (FR);",
" </li>",
" <li>",
" Prolopa (BE, BR, CN, PY, UY);",
" </li>",
" <li>",
" Seler (PY);",
" </li>",
" <li>",
" Tonotil (UY);",
" </li>",
" <li>",
" Vopar (HK, TH)",
" </li>",
" </ul>",
" </div>",
" <div class=\"block pha drugH1Div\" id=\"F139682\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Mechanism of Action",
" </span>",
" <p style=\"text-indent:0em;display:inline\">",
" Symptoms of Parkinson&rsquo;s disease are due to a lack of striatal dopamine.
Levodopa crosses into the blood-brain barrier (BBB) and is converted to dopamine by
striatal enzymes. Benserazide inhibits the peripheral plasma breakdown of levodopa
by inhibiting its decarboxylation and therefore increases levodopa availability at
the BBB.",
" </p>",
" </div>",
" <div class=\"block phk drugH1Div\" id=\"F139699\"
xmlns=\"file://www.w3.org/1999/xhtml\">",
" <span class=\"drugH1\">",
" Pharmacodynamics/Kinetics",
" </span>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Absorption: Benserazide: 66% to 74% from GI tract",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Distribution:",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Benserazide: Does not cross the blood-brain barrier; mainly concentrated in
kidneys, liver, lungs, and small intestine",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Levodopa: 57 L; crosses the blood-brain barrier and not bound to plasma
proteins",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Metabolism:",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Benserazide: Hydroxylated to trihydroxybenzylhydrazine, a potent inhibitor of
decarboxylase",
" </p>",
" <p style=\"text-indent:-2em;margin-left:4em;text-align:justify;\">",
" Levodopa: Major pathways: Decarboxylation and O-methylation; Minor pathways;
Transamination and oxidation",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Bioavailability: Levodopa: 98% (range: 74% to 112%)",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Half-life elimination: Levodopa: 1.5 hours; 3-O-methyldopa (major
metabolite): 15 hours",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Time to peak, serum: ~1 hour",
" </p>",
" <p style=\"text-indent:-2em;margin-left:2em;text-align:justify;\">",
" Excretion: Benserazide: Urine (64%); feces (24%)",
" </p>",
" </div>",
" </div>",
" <div id=\"topicAgreement\">",
" Use of UpToDate is subject to the",
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Gambling in Parkinson's Disease: A Behavioral Manifestation of Pharmacologic
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" </div>",
" <div class=\"lgnd\">",
" The ultrasound images were performed six months apart and show rapid (&gt;0.5
cm)&nbsp;expansion of an abdominal aortic aneurysm (AAA) (A to B)&nbsp;and
advancing hydronephrosis (white arrow) (C to D).&nbsp;Perianeurysmal fibrosis with
secondary progressive ureteral obstruction, as would be seen with an inflammatory
aneurysm,&nbsp;could explain these findings.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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var outline_f0_30_487=null;
var title_f0_30_488="Folliculitis in dark skin";
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" &copy;2013 UpToDate",
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" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
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" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
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" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 524px\">",
" <div class=\"ttl\">",
" Folliculitis",
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" Small inflammatory papules and pustules are present in this patient with
folliculitis. Erythema is difficult to appreciate due to dark skin pigmentation.
Postinflammatory hyperpigmentation is also present.",
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Inc.",
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var title_f0_30_489="Principles of infection control in long-term care facilities";
var content_f0_30_489=[" <noscript>",
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" <div id=\"topicContent\">",
" <div id=\"topicTitle\">",
" Principles of infection control in long-term care facilities",
" </div>",
" <div id=\"topicContributors\">",
" <div>",
" <a id=\"authors\">",
" </a>",
" <a class=\"contributor contributor_credentials contributorType\"
href=\"UTD.htm?0/30/489/contributors\">",
" Author",
" </a>",
" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/30/489/contributors\">",
" Michael J Richards, MD, FRACP",
" </a>",
" <br/>",
" </div>",
" <div>",
" <a class=\"contributor contributor_credentials contributorType\"
href=\"UTD.htm?0/30/489/contributors\">",
" Section Editor",
" </a>",
" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/30/489/contributors\">",
" Anthony Harris, MD, MPH",
" </a>",
" <br/>",
" </div>",
" <div>",
" <a class=\"contributor contributor_credentials contributorType\"
href=\"UTD.htm?0/30/489/contributors\">",
" Deputy Editor",
" </a>",
" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/30/489/contributors\">",
" Elinor L Baron, MD, DTMH",
" </a>",
" <br/>",
" </div>",
" </div>",
" <div id=\"disclosures\">",
" <a href=\"UTD.htm?0/30/489/contributor-disclosure\" target=\"_blank\">",
" Disclosures",
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" is complete.",
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" </div>",
" <div id=\"literatureReviewDate\">",
" <span class=\"emphasis\">",
" Literature review current through:",
" </span>",
" Oct 2013.",
" <span class=\"pipeSpace\">",
" |",
" </span>",
" <span class=\"emphasis\">",
" This topic last updated:",
" </span>",
" Nov 2, 2012.",
" </div>",
" <div id=\"topicText\">",
" <p class=\"headingAnchor\" id=\"H1\">",
" <span class=\"h1\">",
" INTRODUCTION",
" </span>",
" &nbsp;&mdash;&nbsp;Rather than being just \"old folks homes,\" long-term care
facilities (LTCFs) represent a complex group of ever-evolving health care systems
that serve persons from all age groups and provide variable levels of care to
individuals unable to care for themselves. This diverse group of facilities
includes skilled-nursing facilities providing post-acute care, nursing homes,
assisted living facilities, retirement homes, rehabilitation centers, long-term
care hospitals, long-term psychiatric facilities, and institutions for those with
intellectual disabilities.",
" </p>",
" <p>",
" These facilities provide a unique environment favoring the transmission of
infections to residents. Infection control practices should allow for the fact that
these facilities are a home for many residents as well as a place of nursing,
medical",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" psychosocial care for their residents. Facilities differ considerably, and an
effective infection control program should be designed around the specific needs
and risks of the residents as well as available resources.",
" </p>",
" <p>",
" The general issues involved in infection control in LTCFs will be reviewed
here, emphasizing the more important and topical areas of this expanding field.
Such infections are a form of non-nosocomial (outpatient) healthcare associated
infections as opposed to hospital-acquired (nosocomial) healthcare associated
infections.",
" </p>",
" <p>",
" Specific sites and pathogens responsible for infections in these facilities
are discussed separately. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?25/34/26152?
source=see_link\">",
" \"Important sites and pathogens causing infections in long-term care
facilities\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H2\">",
" <span class=\"h1\">",
" EPIDEMIOLOGY",
" </span>",
" &nbsp;&mdash;&nbsp;As the population ages and technology improves to care for
patients with previously fatal conditions, both the number and proportion of
persons in LTCFs will increase. Approximately 2.5 million Americans now live in
these facilities. Five percent of Americans over the age of 65 currently reside in
nursing homes, and up to 43 percent of those turning 65 in the United States will
be admitted to a nursing home before they die. In Norway, there were twice as many
long-term care beds in 2000 as compared to 1984 [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/1\">",
" 1",
" </a>",
" ]. Changes in acute care practices are moving more acutely ill persons from
hospitals into LTCFs, resulting in changes in both the composition and number of
persons in LTCFs. Residents of LTCFs may now occasionally have central venous lines
and even require mechanical ventilation.",
" </p>",
" <p>",
" The incidence of nosocomial infections in LTCFs is comparable to that in acute
care hospitals in both total number and rate of infections [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/2\">",
" 2",
" </a>",
" ]. The incidence of nosocomial infections ranges from 2.6 to 14 infections per
1000 resident-days [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/2,3\">",
" 2,3",
" </a>",
" ]. Infections contribute to 63 percent of deaths in LTCFs and are the primary
reason for 25 to 50 percent of transfers to acute care hospitals [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/4\">",
" 4",
" </a>",
" ]. Residents average at least one serious infection per year. Infections may
be sporadic, endemic or epidemic and transmitted in a variety of ways.",
" </p>",
" <p>",
" Residents of these institutions are subject to infections circulating in the
community, those normally considered to be healthcare-associated, and those unique
to persons with a wide range of disabilities (",
" <a class=\"graphic graphic_table graphicRef62996 \" href=\"UTD.htm?
22/21/22875\">",
" table 1",
" </a>",
" ). Infection is facilitated by:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Immunosenescence",
" </li>",
" <li>",
" Underlying chronic medical illnesses",
" </li>",
" <li>",
" Fecal and urinary incontinence",
" </li>",
" <li>",
" Depressed mental state",
" </li>",
" <li>",
" Protracted use of devices such as urinary catheters and nasogastric tubes",
" </li>",
" <li>",
" Medications that suppress the immune system or the central nervous system",
" </li>",
" <li>",
" Advanced age",
" </li>",
" <li>",
" Factors that promote person-to-person transmission such as crowding and
sharing of meals",
" </li>",
" </ul>",
" </p>",
" <p>",
" Antibiotic-resistant bacteria are frequently present in LTCFs, and 25 to 75
percent of antibiotic use may be inappropriate [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/5\">",
" 5",
" </a>",
" ]. Antibiotic-resistant organisms can be easily transferred between LTCFs and
acute care hospitals and vice versa because patients typically move back and forth
between the two facilities. LTCFs often lack adequate infection control programs
and sufficient space for handwashing and isolation of patients.",
" </p>",
" <p>",
" Infection control in these settings is a fascinating mix of hospital and
community public health. The Association for Practitioners in Infection Control
(APIC) has developed guidelines for infection prevention and control in LTCFs [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/6\">",
" 6",
" </a>",
" ], which are among the most complete recommendations to date.",
" </p>",
" <p class=\"headingAnchor\" id=\"H3\">",
" <span class=\"h1\">",
" HISTORY OF INFECTION CONTROL PROGRAMS IN LTCFS",
" </span>",
" &nbsp;&mdash;&nbsp;A number of past problems with infection control programs
in LTCFs have been improved through regulations, studies, and concerted efforts on
the part of the facilities.",
" </p>",
" <p class=\"headingAnchor\" id=\"H4\">",
" <span class=\"h2\">",
" Past deficiencies",
" </span>",
" &nbsp;&mdash;&nbsp;Studies in the United States in the 1980s indicated major
deficiencies in infection control practices and programs in LTCFs, but also growing
interest in this area [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/7,8\">",
" 7,8",
" </a>",
" ]. A picture emerged of institutions with high patient-staff ratios,
considerable non-professional staffing with high turnover, and few infection
control policies. As examples:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" In 53 Maryland nursing homes, more than half had insufficient or no
isolation policies for infected decubitus ulcers or acute diarrhea, although
employee health issues were more adequately addressed [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/8\">",
" 8",
" </a>",
" ].",
" </li>",
" <li>",
" In a North Carolina study of 12 facilities in 1985, none of the Infection
Control Practitioners (ICPs) had attended an infection control education course,
and the ICP spent an average of only two hours per week on infection control [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/9\">",
" 9",
" </a>",
" ].",
" </li>",
" </ul>",
" </p>",
" <p>",
" Many LTCFs failed to perform systematic surveillance, lacked isolation
facilities, had a shortage of sinks, and had deficiencies in employee and resident
health care programs.",
" </p>",
" <p class=\"headingAnchor\" id=\"H5\">",
" <span class=\"h2\">",
" The present",
" </span>",
" &nbsp;&mdash;&nbsp;The present situation appears to be improving [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/10\">",
" 10",
" </a>",
" ]. Training opportunities for LTCF ICPs are being developed. A two-day
training in basic skills developed in Nebraska has been evaluated and shown to be
effective in producing improvements in knowledge and implementation of recommended
infection control practices in LTCFs [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/11\">",
" 11",
" </a>",
" ]. A Connecticut study of skilled nursing facilities in 1990 showed almost all
ICPs had received some training in IC, and had worked in the field for an average
of 3.5 years. More than half had a link with hospital ICPs [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/12\">",
" 12",
" </a>",
" ].",
" </p>",
" <p>",
" In a survey of northeastern United States LTCFs, 98 percent of facilities had
ICPs spending a median of 8 hours per week on infection control activities. Fifty
two percent of these personnel had formal training in infection control [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/3\">",
" 3",
" </a>",
" ]. In contrast, British nursing homes usually do not have a designated
infection control nurse [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/13\">",
" 13",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H6\">",
" <span class=\"h1\">",
" REGULATORY REQUIREMENTS",
" </span>",
" &nbsp;&mdash;&nbsp;Regulatory requirements add impetus to these changes.
Skilled nursing facilities are required by the OBRA act of 1987 to have an
infection control program. LTCFs must comply with OSHA guidelines, particularly
aimed at prevention of transmission of blood borne pathogens to healthcare workers.
Facilities participating in Medicare and Medicaid programs are required by the HCFA
Centers for Medicare and Medicaid Services (CMS) to establish policy and procedures
to investigate infections in the facility. Requirements of the program have been
published [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/14\">",
" 14",
" </a>",
" ].",
" </p>",
" <p>",
" Veterans Affairs Nursing Homes must be accredited by the Joint Commission of
Healthcare Organizations (JCAHO), which requires an effective facility wide program
oversight, and written policies, procedures for surveillance, prevention, and
control of infection for all patients and staff [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/15\">",
" 15",
" </a>",
" ]. In 1996 the JCAHO long-term care standards were issued requiring a
coordinated infection control process [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/16\">",
" 16",
" </a>",
" ]. State requirements for LTCFs vary widely.",
" </p>",
" <p class=\"headingAnchor\" id=\"H7\">",
" <span class=\"h1\">",
" STRUCTURE OF AN INFECTION CONTROL PROGRAM",
" </span>",
" &nbsp;&mdash;&nbsp;A designated infection control practitioner (ICP) and an
Infection Control Committee (ICC) are fundamental components of an infection
control program. The program requires interdisciplinary cooperation, with
contributions from the facility administration, medical director, the staff and the
local health department. The APIC guidelines suggest for maximal efficiency that an
ICC consist of the ICP, administrator and medical director [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/6\">",
" 6",
" </a>",
" ]. The ICC should oversee the infection control program. The functions of an
infection control program are listed in Table 2 (",
" <a class=\"graphic graphic_table graphicRef71795 \" href=\"UTD.htm?
11/49/12060\">",
" table 2",
" </a>",
" ). The Medical Director should review the program at least annually.",
" </p>",
" <p class=\"headingAnchor\" id=\"H8\">",
" <span class=\"h2\">",
" Infection control practitioner",
" </span>",
" &nbsp;&mdash;&nbsp;The ICP is usually a registered nurse with other
responsibilities. The requirements of the ICP include [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/17\">",
" 17",
" </a>",
" ]:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Specific training in infection control",
" </li>",
" <li>",
" Personal skills in interactions with hospital staff, medical personnel,
residents, and their families",
" </li>",
" <li>",
" Knowledge and experience in resident assessment and chart review",
" </li>",
" <li>",
" Knowledge of geriatric infectious diseases and basic microbiologic culture
techniques",
" </li>",
" <li>",
" Educational skills, since education is vital, particularly for nursing aides
who have frequent resident contacts",
" </li>",
" <li>",
" Support from the administration for appropriate educational opportunities
and resources including expert consultation in infectious diseases and infection
control",
" </li>",
" </ul>",
" </p>",
" <p>",
" How large an institution should be to justify a full-time ICP has not been
investigated and will depend upon the nature of patients in the facility. Lack of
time for the ICP to adequately fulfill infection control responsibilities was
identified as a problem in early studies. An effective infection prevention program
can provide the foundation for expanding performance improvement throughout the
LTCF, where initiatives share similar methods and principles [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/18\">",
" 18",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H9\">",
" <span class=\"h1\">",
" SURVEILLANCE",
" </span>",
" &nbsp;&mdash;&nbsp;The primary and most significant use of surveillance data
in LTCFs is in the detection of outbreaks, increases in infection rates, and
problems requiring some type of specific infection control intervention [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/19\">",
" 19",
" </a>",
" ]. Monitoring of disease patterns over time may provide information on the
effectiveness of changes in infection control practices and policies. Surveillance
may also indicate the need for additional training and staff education. In the
United States, routine illness surveillance within a LTCF is required by HCFA [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/14\">",
" 14",
" </a>",
" ].",
" </p>",
" <p>",
" Surveillance systems should be relatively simple in order to be effective
since the ICP usually has only a few hours per week for infection control
activities. The basic components of a surveillance system include:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" A mechanism for data collection",
" </li>",
" <li>",
" A schedule and procedure for routinely evaluating data and making
comparisons",
" </li>",
" <li>",
" A means for disseminating the results of those evaluations to those who have
a need to know",
" </li>",
" </ul>",
" </p>",
" <p>",
" Hospital designed surveillance techniques may be inappropriate and unworkable
in LTCFs because available time, laboratory data, and medical records differ.",
" </p>",
" <p class=\"headingAnchor\" id=\"H10\">",
" <span class=\"h2\">",
" Data collection",
" </span>",
" &nbsp;&mdash;&nbsp;Surveillance definitions for infections among residents of
LTCFs serving the elderly have been developed but have not been validated [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/19\">",
" 19",
" </a>",
" ]. Simple definitions of nosocomial infections are required. Several groups
have recommended surveillance data collection through periodic rounds rather than
chart reviews [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/17\">",
" 17",
" </a>",
" ]. Conversations with unit nursing staff and residents, and clinical
observations are important components of these rounds. Although data can be
collected through periodic review of charts, laboratory reports and other records,
the amount and quality of information is often considerably less than from these
same sources in hospitals. The frequency of data collection depends upon how much
new information is likely to be available. Weekly surveillance has been recommended
as a minimum [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/17\">",
" 17",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H11\">",
" <span class=\"h2\">",
" Infection rates",
" </span>",
" &nbsp;&mdash;&nbsp;Crude infection rates for different sites of infection may
be calculated using the number of infections as the numerator and daily census as
the denominator. These rates may help to identify outbreaks. However, these rates
should not be used to compare one institution to another. To accomplish this latter
goal, additional data must be collected to facilitate calculating infection rates
with risk adjustment. While risk adjusted infection rates are the most accurate for
interfacility comparisons, they are time consuming to perform.",
" </p>",
" <p>",
" One method used for interfacility comparison of infection rates created a
standardized regional data set to provide an external benchmark for interfacility
comparisons [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/20\">",
" 20",
" </a>",
" ]. Infection rates in particular groups of residents (eg, patients with
urinary catheters or other risk factors) may be more useful for comparisons with
other units within the facility. It may be more useful to express these rates in
terms of specific exposures (eg, catheter-days) rather than using an overall census
denominator. With difficulty in determining infections in long-term care
facilities, antibiotic use may be a useful surrogate measure. Studies using
antibiotic use as a surrogate, demonstrate substantial interfacility variation
although after adjusting for case mix, these rates are primarily driven by
infection rates [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/21\">",
" 21",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H12\">",
" <span class=\"h2\">",
" Data use, analysis and presentation",
" </span>",
" &nbsp;&mdash;&nbsp;Information can be organized into a line list (an ongoing
list of individuals meeting surveillance criteria for suffering a nosocomial
infection). Computerized spreadsheet programs can be very helpful in maintaining
and organizing surveillance information. These should be augmented with a list of
locally notifiable diseases and conditions, which can be obtained from state or
local health departments.",
" </p>",
" <p>",
" The frequency of evaluation depends upon the size of the facility. Larger
facilities should examine data at least weekly, while smaller facilities can use a
biweekly or monthly interval. The purpose of evaluation is to detect sentinel or
trigger events; mechanisms for action and follow-up should be planned in advance.
Examples of sentinel events might include the identification of a resident with
scabies crustosa (Norwegian scabies) or detection of two cases of diarrheal illness
among residents of the same unit within one week. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?28/2/28712?
source=see_link\">",
" \"Scabies\"",
" </a>",
" .)",
" </p>",
" <p>",
" More subtle problems such as increases in respiratory or urinary tract
infections (UTI) are best detected by comparisons with previous weeks. Information
on trends should be provided back to units and employees.",
" </p>",
" <p class=\"headingAnchor\" id=\"H13\">",
" <span class=\"h2\">",
" Reporting of notifiable diseases",
" </span>",
" &nbsp;&mdash;&nbsp;Consideration should be given to state and local notifiable
disease reporting. State and local health officers and licensing officials may be
contacted for input in determining sentinel events.",
" </p>",
" <p class=\"headingAnchor\" id=\"H14\">",
" <span class=\"h2\">",
" Outbreaks of infectious diseases",
" </span>",
" &nbsp;&mdash;&nbsp;Outbreaks may be broadly defined as an unusual increase in
illness above baseline levels. In LTCFs, respiratory and gastrointestinal viral
infections are relatively frequent and may attack a large proportion of the
residents and healthcare workers. These outbreaks may range in severity from mild
upper respiratory tract or diarrhea to life threatening dehydration or pneumonia.
Although we often think of outbreaks in terms of several cases, in some instances,
a single event may be sufficient to initiate a response. Examples of such
situations include scabies, meningococcal meningitis to infections with certain
antibiotic-resistant pathogens such as methicillin-resistant Staphylococcus aureus
(MRSA) and vancomycin-resistant enterococci (VRE).",
" </p>",
" <p>",
" A real function of surveillance is to promptly identify increases, so that
control measures may be instituted in a timely fashion. The development of written
procedures for managing outbreaks will contribute to timely interventions.
Procedures should be developed for initial management of outbreaks involving common
sites or pathogens. These may be determined on the basis of experience",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" consultation with local licensing and health officials. Issues that need to be
considered in an outbreak management plan include those of screening, isolation,
contact identification and prophylaxis. Provisions should be made for obtaining the
necessary authorization for specimen collection and prophylaxis.",
" </p>",
" <p class=\"headingAnchor\" id=\"H15\">",
" <span class=\"h1\">",
" PREVENTION PRACTICES",
" </span>",
" &nbsp;&mdash;&nbsp;While a good surveillance program will identify problems
and a well-designed management plan will help institute timely and effective
control measures, it is those policies and procedures that are implemented on a
daily basis that prevent problems in the first place.",
" </p>",
" <p class=\"headingAnchor\" id=\"H16\">",
" <span class=\"h2\">",
" Written procedures and guidelines",
" </span>",
" &nbsp;&mdash;&nbsp;Written procedures and guidelines should address topics
such as immunizations, handwashing, changing catheters and dressings, management of
spills of blood and body fluids, handling of linens, cleaning and disinfection.
Staff training and monitoring is a key component to an effective infection control
program. Training should be formal and informal, sufficiently frequent to address
needs arising from staff turnover, and should be readily understandable by all
employees. This may be especially difficult since turnover rates among nurses'
aides, the major direct care givers, may range from 70 to 100 percent [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/22\">",
" 22",
" </a>",
" ]. Orientation for aides should include assessment of residents for
infections, handwashing, modes of transmission of infection, staff hygiene, and
employee health. Mechanisms for monitoring and evaluating staff performance and for
promoting infection control policies should be developed.",
" </p>",
" <p class=\"headingAnchor\" id=\"H17\">",
" <span class=\"h2\">",
" Isolation precautions",
" </span>",
" &nbsp;&mdash;&nbsp;LTCFs often lack private rooms and rooms with appropriate
ventilation for patient isolation. Contact precautions generally adopted in
hospitals may be used with modification in LTCFs. These involve:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Wearing gloves if making contact with mucous membranes or non intact skin",
" </li>",
" <li>",
" Hand hygiene with soap and water or with alcohol based hand rubs",
" </li>",
" <li>",
" Private rooms for residents where possible",
" </li>",
" <li>",
" Barriers to protect healthcare workers from body substances",
" </li>",
" </ul>",
" </p>",
" <p>",
" Some of these precautions may be difficult to implement in LTCFs. Guidelines
for glove, mask and gown use have been developed by APIC [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/6\">",
" 6",
" </a>",
" ]. If adequate isolation facilities are not available, residents may need to
be transferred to acute hospitals for some conditions, particularly tuberculosis
and transmissible infections with antibiotic-resistant bacteria [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/23\">",
" 23",
" </a>",
" ]. Clear communication between the LTCF and the hospital at the time of
transfer is essential, especially about potentially transmissible pathogens.
Guidelines for disinfectants, patient care equipment, linen and transportation have
been developed for patients with antibiotic-resistant organisms [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/23\">",
" 23",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H18\">",
" <span class=\"h2\">",
" Hand hygiene",
" </span>",
" &nbsp;&mdash;&nbsp;Hand hygiene is the",
" <strong>",
" single most important",
" </strong>",
" infection control measure. Non-medicated bar or liquid soaps are adequate.
Alcohol-based hand hygiene product (eg, foams, gels, disposable towelettes, or soap
substitutes) may be used if no visible soiling or debris are present on hands and
especially during procedures with multiple patient contacts. Hand hygiene should be
performed:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Before and after each contact with a resident",
" </li>",
" <li>",
" After any contact with blood or body fluids",
" </li>",
" <li>",
" After removing gloves",
" </li>",
" <li>",
" After contact with surfaces or equipment that may be contaminated with
antibiotic- resistant organisms",
" </li>",
" <li>",
" After assisting with feeding",
" </li>",
" <li>",
" After leaving an isolation room",
" </li>",
" <li>",
" After handling dressings, bedpans, catheters or urinals",
" </li>",
" <li>",
" After prolonged contact with dry and intact skin",
" </li>",
" <li>",
" After personal use of the toilet",
" </li>",
" <li>",
" After blowing or wiping the nose",
" </li>",
" <li>",
" Upon completion of duty",
" </li>",
" </ul>",
" </p>",
" <p>",
" Visitors should be instructed to wash their hands before and after contact
with a resident, after contact with body fluids, and before and after feeding
residents.",
" </p>",
" <p>",
" Handwashing is recommended for procedures such as insertion of an intravenous
line or a urinary catheter. Major deficiencies in handwashing persist. As an
example, use of gloves and adherence to handwashing guidelines were examined in one
study of 230 staff-resident contacts in a 255 bed LTCF [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/9\">",
" 9",
" </a>",
" ]. Handwashing occurred 63 percent of the time after but only 27 percent
before and 0 percent during a contact with a patient. It was estimated from this
study that transmission of an organism was possible in 158 of 193 (82 percent)
evaluable interactions.",
" </p>",
" <p class=\"headingAnchor\" id=\"H19\">",
" <span class=\"h2\">",
" Sharp injuries",
" </span>",
" &nbsp;&mdash;&nbsp;Practices for avoiding sharp injuries and the disposal of
sharps in LTCFs should be similar to those used in acute care facilities.
Needlestick injuries occur in nursing homes and are often related to needle
recapping [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/24\">",
" 24",
" </a>",
" ]. Needles should not be manually recapped. In the 1990s increasing numbers of
patients with human immunodeficiency virus (HIV) infection have been cared for in
LTCFs. An outbreak of hepatitis B was reported related to sharps from reusable
fingerstick blood sampling instruments in LTCFs [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/25\">",
" 25",
" </a>",
" ]. A protocol should be developed with arrangements for urgent access to
expert help and appropriate medication after needlestick accidents.",
" </p>",
" <p class=\"headingAnchor\" id=\"H20\">",
" <span class=\"h1\">",
" ANTIBIOTIC USE",
" </span>",
" &nbsp;&mdash;&nbsp;Antibiotics are used extensively in LTCFs. The probability
of receiving at least one course of systemic antibiotics during a one year period
is greater than 50 percent for a resident of an LTCF [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/26,27\">",
" 26,27",
" </a>",
" ]. Antibiotics are frequently given for protracted periods and for
inappropriate indications, particularly for urinary tract colonization associated
with catheter use and for pressure sores that are not infected. Antibiotics are
often prescribed over the telephone. Some studies report that 25 to 75 percent of
systemic antimicrobials were prescribed inappropriately [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/27-29\">",
" 27-29",
" </a>",
" ].",
" </p>",
" <p>",
" Diagnosis of infection can be difficult in the elderly. Symptoms can be
nonspecific, and laboratory and radiology support limited. Many patients with
pneumonia do not have a chest radiograph taken. Asymptomatic bacteriuria is common
in the elderly, and a positive urine culture is thus not strongly predictive of
urinary tract infection as the cause of fever in the setting. The Society for
Hospital Epidemiology of America (SHEA) has developed a position paper to address
the need to promote optimal antibiotic use in LTCFs, including recommendations for
empiric therapy and an approach to the management of upper respiratory, lower
respiratory, skin and soft tissue infections, diarrhea, and fever of unknown origin
[",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/30-32\">",
" 30-32",
" </a>",
" ].",
" </p>",
" <p>",
" Further recommendations involve reporting, educational and other approaches
used in acute care facilities such as:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Review of antimicrobial utilization in the infection control program using a
multidisciplinary approach, involving physicians, pharmacists, nursing staff, the
medical director, as well as the ICP",
" </li>",
" <li>",
" Monitoring antibiotic dosage, duration, and costs, and reviewing data on a
regular basis",
" </li>",
" <li>",
" Developing and promoting programs for judicious antibiotic use",
" </li>",
" <li>",
" Consideration of using antibiotic order forms, automatic stop orders, and
limited susceptibility reporting",
" </li>",
" <li>",
" Developing guidelines for the use of antimicrobial agents in patients in
whom \"comfort measures only\" are being provided",
" </li>",
" </ul>",
" </p>",
" <p>",
" In selected facilities, more intensive programs should be undertaken,
including assessment of antibiotic appropriateness, and plans for response if high
levels of inappropriate use are identified.",
" </p>",
" <p class=\"headingAnchor\" id=\"H21\">",
" <span class=\"h2\">",
" Antibiotic resistant bacteria in LTCFs",
" </span>",
" &nbsp;&mdash;&nbsp;The emergence of antibiotic resistant bacteria in LTCFs is
a concern to health care providers, public health officials, and facility
administrators [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/33,34\">",
" 33,34",
" </a>",
" ]. An extraordinarily high incidence of antimicrobial resistant isolates has
been reported from some LTCFs [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/35\">",
" 35",
" </a>",
" ]. This incidence varies widely. Rapid dissemination of antimicrobial
resistant strains of bacteria may occur, and once established, these bacteria may
persist in these institutions. Contributing factors include:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Two-way traffic of residents and patients between LTCFs and hospitals,
transferring antibiotic resistant bacteria with the patients. One study of VRE
colonization in a regional health system including acute care facilities and LTCFs
reported that the incidence was higher in the acute care facilities (7 versus 2
percent), but colonized LTCF patients were significantly more likely than non-
colonized residents to have been hospitalized at one of the acute care facilities
(63 versus 18 percent) [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/36\">",
" 36",
" </a>",
" ]. The LTCFs may be seen as \"amplifiers and reservoirs\" of antibiotic
resistant bacteria by the hospitals, leading to concern by the acute care
facilities when patients are transferred.",
" </li>",
" <li>",
" Selection and mutation of antibiotic resistant bacteria in the facility. In
one study, after 70 percent of 63 courses of antibiotics for UTI in patients with
indwelling catheters, bacteriuria developed that was resistant to the initial
antibiotic [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/37\">",
" 37",
" </a>",
" ].",
" </li>",
" <li>",
" Plasmid transfer between species and genus of bacteria has been documented
in nursing home outbreaks.",
" </li>",
" <li>",
" High rates of person-to-person transmission, facilitated by community
activities with direct contacts between residents or via staff with inadequate
training or handwashing. In a study of 50 nursing homes in Canada and the United
States, increased staffing, more sinks, and use of antimicrobial soap was
associated with reduced antimicrobial resistance [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/38\">",
" 38",
" </a>",
" ].",
" </li>",
" <li>",
" Long-term use of urinary catheters and other invasive devices or foreign
bodies [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/39\">",
" 39",
" </a>",
" ]",
" </li>",
" <li>",
" Outbreaks of resistant organisms in long-term care facilities",
" </li>",
" <li>",
" Higher rates of antibiotic resistant S. pneumoniae in long-term care
residents than in the community [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/40\">",
" 40",
" </a>",
" ]",
" </li>",
" </ul>",
" </p>",
" <p>",
" Resistant organisms in the facility may directly cause increased morbidity and
also lead to greater antibiotic expenditures because of the need to move to more
expensive antimicrobial agents. Isolation procedures can also increase costs
(gloves, gowns, single rooms), and may considerably limit the mobility and
socialization of residents. The LTCF should have a policy dealing with resistant
bacteria such as MRSA and VRE. The recommendations of the Society for Hospital
Epidemiology of America (SHEA) are listed in Table 1 (",
" <a class=\"graphic graphic_table graphicRef70780 \" href=\"UTD.htm?
27/41/28315\">",
" table 3",
" </a>",
" ).",
" </p>",
" <p>",
" For LTCFs with a low rate of endemic infections caused by antimicrobial
resistant pathogens (less than one case per 1000 resident days), additional control
measures recommended include:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Monthly analysis of surveillance data to identify cross infection or
colonization",
" </li>",
" <li>",
" Residents with resistant organisms should not be placed in rooms with
debilitated, non-ambulatory residents at greatest risk of becoming colonized or
infected",
" </li>",
" <li>",
" Single rooms or cohorting strategies should be used judiciously to minimize
dissemination of resistant organisms into the environment from residents shedding
large numbers of bacteria",
" </li>",
" </ul>",
" </p>",
" <p>",
" However, for LTCFs with high rates of endemic infection (&gt;1 case per 1000
resident days) or an outbreak, consultation with an experienced epidemiologist is
recommended.",
" </p>",
" <p class=\"headingAnchor\" id=\"H22\">",
" <span class=\"h1\">",
" HEALTH POLICIES FOR RESIDENTS AND EMPLOYEES",
" </span>",
" &nbsp;&mdash;&nbsp;The APIC guidelines suggest that resident and employee
health programs be part of infection control activities in LTCF facilities. Issues
for the residents such as immunization, prevention of aspiration, skin care,
tuberculosis screening and UTIs should be included in these programs. These are
discussed separately. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?25/34/26152?
source=see_link\">",
" \"Important sites and pathogens causing infections in long-term care
facilities\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H23\">",
" <span class=\"h2\">",
" Immunizations for residents",
" </span>",
" &nbsp;&mdash;&nbsp;An aggressive approach to immunization should be part of
every infection control program in LTCFs. The use of standing orders for
vaccination of LTCF residents is recommended [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/41\">",
" 41",
" </a>",
" ]. The three most important vaccines for elderly residents of these facilities
are influenza vaccine, pneumococcal vaccine and tetanus-diphtheria toxoids [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/42\">",
" 42",
" </a>",
" ].",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Influenza vaccine is effective in elderly persons and should be given
annually in the autumn. However, influenza outbreaks can occur in long-term care
facilities even when &ge;80 percent of residents are vaccinated. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?36/8/37002?
source=see_link&amp;anchor=H14#H14\">",
" \"Seasonal influenza vaccination in adults\", section on 'Elderly
patients'",
" </a>",
" .)",
" </li>",
" <li>",
" Pneumococcal vaccine should be given at age 65 or on admission to the LTCF
if the patient is over 65 years, unless the resident has been recently immunized.
(See",
" <a class=\"medical medical_review\" href=\"UTD.htm?21/12/21705?
source=see_link\">",
" \"Pneumococcal vaccination in adults\"",
" </a>",
" .)",
" </li>",
" <li>",
" Recommendations for tuberculosis are discussed separately. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?25/34/26152?
source=see_link\">",
" \"Important sites and pathogens causing infections in long-term care
facilities\"",
" </a>",
" .)",
" </li>",
" <li>",
" Tetanus and diphtheria vaccine should be offered every ten years. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?6/54/7014?
source=see_link\">",
" \"Tetanus-diphtheria toxoid vaccination in adults\"",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H24\">",
" <span class=\"h2\">",
" Employee health policies",
" </span>",
" &nbsp;&mdash;&nbsp;Employees in LTCFs are less likely than health care workers
in acute care facilities to have formal education or previous professional
experience in healthcare.",
" </p>",
" <p class=\"headingAnchor\" id=\"H25\">",
" <span class=\"h3\">",
" Initial assessment",
" </span>",
" &nbsp;&mdash;&nbsp;All employees should have an initial assessment of their
medical history, health status, and immunizations. A history of past varicella,
measles, hepatitis, and recurrent skin infections should be sought.",
" </p>",
" <p class=\"headingAnchor\" id=\"H26\">",
" <span class=\"h3\">",
" Vaccinations",
" </span>",
" &nbsp;&mdash;&nbsp;Vaccination against influenza and hepatitis B should be
offered to those who are not immune. The efficacy of this approach was illustrated
in three randomized trials in the United Kingdom in which health care workers were
offered influenza vaccination at intervention LTCFs, and were not offered
vaccination at control sites [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/43-45\">",
" 43-45",
" </a>",
" ]. Employee vaccination rates in the intervention facilities ranged from 48 to
61 percent. During years of influenza activity, the mortality rates for patients in
the institutions in which influenza vaccine was administered were significantly
lower in all three studies: 13.6 versus 22.4 percent [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/43\">",
" 43",
" </a>",
" ]; 10 versus 17 percent [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/44\">",
" 44",
" </a>",
" ]; and 11.2 versus 15.3 percent [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/45\">",
" 45",
" </a>",
" ].",
" </p>",
" <p>",
" Influenza-like illness in intervention sites was lower in two studies [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/44,45\">",
" 44,45",
" </a>",
" ], although the incidence of influenza infection as determined by virologic
surveillance among residents did not differ in the third [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/43\">",
" 43",
" </a>",
" ]. Thus, immunizing even one-half of the health care worker population reduces
mortality and influenza illness in residents of LTCFs.",
" </p>",
" <p class=\"headingAnchor\" id=\"H27\">",
" <span class=\"h3\">",
" Tuberculosis",
" </span>",
" &nbsp;&mdash;&nbsp;The risks of transmission of tuberculosis in these
institutions should be explained. A program should be instituted for preemployment
Mantoux testing, chest radiographs for unexplained positive reactors, and annual
testing of nonreactors.",
" </p>",
" <p class=\"headingAnchor\" id=\"H28\">",
" <span class=\"h3\">",
" Blood borne infections",
" </span>",
" &nbsp;&mdash;&nbsp;Surveys suggest that in the past personnel in LTCFs may
have been relatively uninformed about transmission of HIV infection [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/46\">",
" 46",
" </a>",
" ]. Education on precautions to reduce the risk of transmission of blood borne
pathogens, including disposal of sharps (see above), and body substance isolation
should be offered to all employees with contact with residents. There should be an
established rapid mechanism for access to appropriate post exposure prophylaxis if
the staff have an incident of potential HIV or hepatitis B or C exposure [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/489/abstract/47\">",
" 47",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H29\">",
" <span class=\"h3\">",
" Hand hygiene",
" </span>",
" &nbsp;&mdash;&nbsp;Instruction in the method and role of hand hygiene in the
prevention of disease transmission should be given (see above).",
" </p>",
" <p class=\"headingAnchor\" id=\"H30\">",
" <span class=\"h3\">",
" Reporting of ill health",
" </span>",
" &nbsp;&mdash;&nbsp;Employees should report significant communicable diseases,
and cough, rash or diarrhea. They should not have contact with residents or their
food while potentially infectious.",
" </p>",
" <p class=\"headingAnchor\" id=\"H31\">",
" <span class=\"h1\">",
" THE FUTURE",
" </span>",
" &nbsp;&mdash;&nbsp;The awareness of the risks of nosocomial infections to LTCF
residents, concerns over the potential risks to a wider community from antibiotic-
resistant pathogens that may be amplified in nursing homes, increasing community
expectations for quality assessment, new research findings, and improvements in
information technology that will make data collection and analysis more accessible,
should accelerate improvements in infection control practices in LTCFs. Financial
restraints, particularly as a larger proportion of the population use these
facilities, may retard this progress, since basic engineering needs for sinks and
single rooms, and increased educational requirements and skills for staff will add
to the costs of care.",
" </p>",
" <p class=\"headingAnchor\" id=\"H23872926\">",
" <span class=\"h1\">",
" SUMMARY",
" </span>",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" The encompassing term &ldquo;long-term care facility&rdquo; (LTCF) includes
skilled-nursing facilities providing post-acute care, nursing homes, assisted
living facilities, retirement homes, rehabilitation centers, long-term care
hospitals, long-term psychiatric facilities, and institutions for those with
intellectual disabilities. Residents of these institutions are subject to
infections circulating in the community, those normally considered to be
healthcare-associated, and those unique to persons with a wide range of
disabilities (",
" <a class=\"graphic graphic_table graphicRef62996 \" href=\"UTD.htm?
22/21/22875\">",
" table 1",
" </a>",
" ). LTCF often lack adequate infection prevention and control programs, and
have high rates of inappropriate antibiotic use, but the situation is improving.
(See",
" <a class=\"local\" href=\"#H1\">",
" 'Introduction'",
" </a>",
" above and",
" <a class=\"local\" href=\"#H2\">",
" 'Epidemiology'",
" </a>",
" above.)",
" </li>",
" <li>",
" A designated infection control practitioner (ICP) and Infection Control
Committee (ICC) are fundamental components of an infection control program. The
major functions of such programs include the following (",
" <a class=\"graphic graphic_table graphicRef71795 \" href=\"UTD.htm?
11/49/12060\">",
" table 2",
" </a>",
" ):",
" </li>",
" </ul>",
" </p>",
" <p>",
" <ul class=\"hyphen-block\">",
" <li>",
" Surveillance of prespecified infections to aid in the detection of
outbreaks, increases in infection rates, and problems that may require a specific
infection control intervention. The surveillance program should be relatively
simple, as resources are usually quite limited. Certain infections may need to be
reported to public health or governmental infection control agencies. (See",
" <a class=\"local\" href=\"#H9\">",
" 'Surveillance'",
" </a>",
" above.)",
" </li>",
" <li>",
" Establishment and enforcing of policies to prevent the acquisition and
spread of infections, including isolation precautions, hand hygiene policies, and
practices to avoid sharps injuries. (See",
" <a class=\"local\" href=\"#H15\">",
" 'Prevention practices'",
" </a>",
" above.)",
" </li>",
" <li>",
" Review of antimicrobial utilization and development of programs for
judicious antibiotic use. This is particularly important to curb the emergence of
antibiotic resistant bacteria in LTCFs. (See",
" <a class=\"local\" href=\"#H20\">",
" 'Antibiotic use'",
" </a>",
" above.)",
" </li>",
" <li>",
" Institution of health policies for residents and employees, such as
immunization against vaccine preventable diseases, to reduce the risk of infection.
(See",
" <a class=\"local\" href=\"#H22\">",
" 'Health policies for residents and employees'",
" </a>",
" above.)",
" </li>",
" </ul>",
" </p>",
" </div>",
" <div id=\"topicAgreement\">",
" Use of UpToDate is subject to the",
" <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
target=\"_blank\">",
" Subscription and License Agreement",
" </a>",
" .",
" </div>",
" <div class=\"headingAnchor\" id=\"references\">",
" <h1>",
" REFERENCES",
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" McKibben LJ, Stange PV, Sneller VP, et al. Use of standing orders programs
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" </li>",
" </ol>",
" </div>",
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" Topic 3807 Version 8.0",
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" <ul>",
" <li>",
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" <span>",
" SUMMARY",
" </span>",
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" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H1\">",
" INTRODUCTION",
" </a>",
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" <a class=\"outlineLink\" href=\"#H2\">",
" EPIDEMIOLOGY",
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" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H3\">",
" HISTORY OF INFECTION CONTROL PROGRAMS IN LTCFS",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H4\">",
" Past deficiencies",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H5\">",
" The present",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H6\">",
" REGULATORY REQUIREMENTS",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H7\">",
" STRUCTURE OF AN INFECTION CONTROL PROGRAM",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H8\">",
" Infection control practitioner",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H9\">",
" SURVEILLANCE",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H10\">",
" Data collection",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H11\">",
" Infection rates",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H12\">",
" Data use, analysis and presentation",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H13\">",
" Reporting of notifiable diseases",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H14\">",
" Outbreaks of infectious diseases",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H15\">",
" PREVENTION PRACTICES",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H16\">",
" Written procedures and guidelines",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H17\">",
" Isolation precautions",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H18\">",
" Hand hygiene",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H19\">",
" Sharp injuries",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H20\">",
" ANTIBIOTIC USE",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H21\">",
" Antibiotic resistant bacteria in LTCFs",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H22\">",
" HEALTH POLICIES FOR RESIDENTS AND EMPLOYEES",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H23\">",
" Immunizations for residents",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H24\">",
" Employee health policies",
" </a>",
" </li>",
" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H25\">",
" - Initial assessment",
" </a>",
" </li>",
" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H26\">",
" - Vaccinations",
" </a>",
" </li>",
" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H27\">",
" - Tuberculosis",
" </a>",
" </li>",
" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H28\">",
" - Blood borne infections",
" </a>",
" </li>",
" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H29\">",
" - Hand hygiene",
" </a>",
" </li>",
" <li class=\"dashItem\">",
" <a class=\"outlineLink\" href=\"#H30\">",
" - Reporting of ill health",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H31\">",
" THE FUTURE",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H23872926\">",
" SUMMARY",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a href=\"#references\">",
" REFERENCES",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" <div class=\"openRelatedGraphics\" id=\"ID/3807\" rel=\"outline_link\">",
" GRAPHICS",
" <a class=\"graphics_icon\" href=\"#\" title=\"View All Related Graphics\">",
" View All",
" </a>",
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" </h1>",
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" <div class=\"openRelatedGraphics\" id=\"ID/3807|TAB\">",
" <a href=\"#\" title=\"TABLES\">",
" TABLES",
" </a>",
" </div>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"graphic graphic_table\" href=\"UTD.htm?22/21/22875\" title=\"table
1\">",
" Infections in residents of LTCF",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"graphic graphic_table\" href=\"UTD.htm?11/49/12060\" title=\"table
2\">",
" LTCF IC program guidelines",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"graphic graphic_table\" href=\"UTD.htm?27/41/28315\" title=\"table
3\">",
" Resistant bacteria in LTCFs",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" RELATED TOPICS",
" </h1>",
" <div id=\"relatedTopics\">",
" <ul>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?25/34/26152?
source=related_link\">",
" Important sites and pathogens causing infections in long-term care
facilities",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?21/12/21705?
source=related_link\">",
" Pneumococcal vaccination in adults",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?28/2/28712?
source=related_link\">",
" Scabies",
" </a>",
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source=related_link\">",
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source=related_link\">",
" Tetanus-diphtheria toxoid vaccination in adults",
" </a>",
" </li>",
" </ul>",
" </div>",
" </div>"].join("\n");
var title_f0_30_490="Screening for sexually transmitted infections";
var content_f0_30_490=[" <noscript>",
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" Screening for sexually transmitted infections",
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0/30/490/contributors\">",
" Heidi Swygard, MD, MPH",
" </a>",
" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/30/490/contributors\">",
" Myron S Cohen, MD",
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href=\"UTD.htm?0/30/490/contributors\">",
" Section Editors",
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0/30/490/contributors\">",
" Noreen A Hynes, MD, MPH, DTM&amp;H",
" </a>",
" <br/>",
" <a class=\"contributor contributor_credentials\" href=\"UTD.htm?
0/30/490/contributors\">",
" Robert H Fletcher, MD, MSc",
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href=\"UTD.htm?0/30/490/contributors\">",
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0/30/490/contributors\">",
" Allyson Bloom, MD",
" </a>",
" <br/>",
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" Literature review current through:",
" </span>",
" Oct 2013.",
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" This topic last updated:",
" </span>",
" Sep 6, 2012.",
" </div>",
" <div id=\"topicText\">",
" <p class=\"headingAnchor\" id=\"H1\">",
" <span class=\"h1\">",
" INTRODUCTION",
" </span>",
" &nbsp;&mdash;&nbsp;Sexually transmitted infections (STIs) are a major public
health problem in developed and developing countries. Complications of untreated
STIs include upper genital tract infections, infertility, cervical cancer, and
enhanced transmission and acquisition of the human immunodeficiency virus (HIV).",
" </p>",
" <p>",
" The approach to STI diagnosis and management is based upon disease or symptom-
specific syndromes, including vaginal discharge, urethral discharge, ulcerative
genital disease, nonulcerative genital disease, and pelvic pain. However, many
patients have asymptomatic disease, which increases the risk of complications and
sustained transmission in the community. Unfortunately, routine screening of all
patients is cost-prohibitive, particularly in resource-poor countries [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/1\">",
" 1",
" </a>",
" ]. Targeted screening of asymptomatic patients in specified risk groups is
important and has been shown to be effective.",
" </p>",
" <p>",
" STI screening, including targeted screening and prevention, will be discussed
here. In its 2010 guidelines on the treatment of sexually transmitted infections,
the United States Centers for Disease Control and Prevention (CDC) also made
recommendations on screening [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. The recommendations in this topic are largely consistent with those
guidelines.",
" </p>",
" <p>",
" The approaches to patients with specific genitourinary symptoms and signs are
discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?35/49/36633?
source=see_link\">",
" \"Approach to women with symptoms of vaginitis\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/0/1032?
source=see_link\">",
" \"Clinical features and diagnosis of pelvic inflammatory disease\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?12/15/12538?
source=see_link\">",
" \"Approach to the patient with genital ulcers\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?13/15/13561?
source=see_link\">",
" \"Acute uncomplicated cystitis and pyelonephritis in women\"",
" </a>",
" .) The prevention of STIs is discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?34/12/35018?
source=see_link\">",
" \"Prevention of sexually transmitted infections\"",
" </a>",
" .)",
" </p>",
" <p>",
" Information on the clinical presentation, diagnosis, and treatment of specific
STIs are reviewed in detail separately. (See related topics). Sexually transmitted
infections and HIV infection in adolescents are also discussed separately. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?36/51/37689?
source=see_link\">",
" \"Sexually transmitted diseases: Overview of issues specific to
adolescents\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/44/1737?
source=see_link\">",
" \"The adolescent with HIV infection\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H2\">",
" <span class=\"h1\">",
" TAKING A SEXUAL HISTORY",
" </span>",
" &nbsp;&mdash;&nbsp;In the assessment of sexually transmitted infection (STI)
risk, it is important to obtain a thorough sexual history including:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Any new sexual partner(s)",
" </li>",
" <li>",
" History of multiple sexual partners",
" </li>",
" <li>",
" History of genital ulceration (which can increase the risk of HIV
acquisition)",
" </li>",
" <li>",
" History of sexual intercourse with trauma (which can increase the risk of
acquisition of hepatitis B or C)",
" </li>",
" <li>",
" Types of sexual exposures (which will guide decisions about which mucosal
sites to test diagnostically)",
" </li>",
" <li>",
" Frequency of condom use",
" </li>",
" </ul>",
" </p>",
" <p>",
" The history should be straightforward and non-judgmental with appropriate
counseling regarding risk-taking behaviors, as necessary [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/3\">",
" 3",
" </a>",
" ]. Some medical providers do not routinely obtain a sexual history. In one
study, only 70 percent reported \"always\" or \"almost always\" obtaining a sexual
history in adolescent females [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/4\">",
" 4",
" </a>",
" ]. One reason for this omission may be related to provider comfort with this
part of the patient interview [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. Suggestions for open-ended, non-judgmental questions, as suggested by the
Centers for Disease Control and Prevention (CDC), are found in the following table
(",
" <a class=\"graphic graphic_table graphicRef61677 \" href=\"UTD.htm?
36/21/37212\">",
" table 1",
" </a>",
" ) [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]&nbsp;.",
" </p>",
" <p class=\"headingAnchor\" id=\"H3\">",
" <span class=\"h1\">",
" RISK FACTORS",
" </span>",
" &nbsp;&mdash;&nbsp;Risk factors for sexually transmitted infections include
[",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/5-12\">",
" 5-12",
" </a>",
" ]:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Young age (15 to 24 years old)",
" </li>",
" <li>",
" African-American race",
" </li>",
" <li>",
" Unmarried status",
" </li>",
" <li>",
" Geographical residence",
" </li>",
" <li>",
" New sex partner in past 60 days",
" </li>",
" <li>",
" Multiple sexual partners",
" </li>",
" <li>",
" History of a prior STI",
" </li>",
" <li>",
" Illicit drug use",
" </li>",
" <li>",
" Admission to correctional facility or juvenile detention center [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/8\">",
" 8",
" </a>",
" ]",
" </li>",
" <li>",
" Meeting partners on the internet [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/7\">",
" 7",
" </a>",
" ]",
" </li>",
" <li>",
" Contact with sex workers",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H4\">",
" <span class=\"h1\">",
" GENERAL PRINCIPLES",
" </span>",
" &nbsp;&mdash;&nbsp;All patients who seek screening for sexually transmitted
infections (STIs) should receive testing and counseling for HIV infection. (See",
" <a class=\"local\" href=\"#H6\">",
" 'Human immunodeficiency virus (HIV)'",
" </a>",
" below.)",
" </p>",
" <p>",
" The optimal interval for screening of STIs is uncertain. For women with prior
negative screening, the interval for reevaluation will be influenced by a change in
risk factor profile. For previously infected women, rescreening at three to four
months is appropriate due to high rates of reinfection [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/5\">",
" 5",
" </a>",
" ]. The incidence of reinfection was examined in 2419 men and women who were
evaluated in three urban STI clinics [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/13\">",
" 13",
" </a>",
" ]. Patients had follow-up visits scheduled at 3, 6, 9, and 12 months with the
following results [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/13\">",
" 13",
" </a>",
" ]:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Among 1236 women, 26 percent had acquired one or more new infections
(including C. trachomatis, N. gonorrhea and T. vaginalis).",
" </li>",
" <li>",
" Among 1183 men, 15 percent had acquired one or more new infections
(including C. trachomatis and N. gonorrhea).",
" </li>",
" <li>",
" Furthermore, 66 percent of patients with new infections were asymptomatic.",
" </li>",
" </ul>",
" </p>",
" <p>",
" The authors concluded that men and women with newly diagnosed chlamydial,
gonococcal, or trichomonas infections should be rescreened in three months for new
asymptomatic infections. Clinicians should also consider the characteristics of the
communities they serve when determining appropriate screening strategies for their
particular patient population. Local public health authorities can be a source of
valuable information regarding local patterns of infection and disease
prevalence.",
" </p>",
" <p>",
" The advent of urine-based tests and utility of self-collected vaginal swabs
has increased the acceptance of STI screening among patients and providers since it
allows for routine specimen collection without a pelvic examination [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/14,15\">",
" 14,15",
" </a>",
" ]. Urine screening has also led to increased screening of men.",
" </p>",
" <p>",
" Other clinical considerations for STI screening include the diagnosis of an
STI in the sex partner.",
" </p>",
" <p class=\"headingAnchor\" id=\"H5\">",
" <span class=\"h1\">",
" PATHOGENS",
" </span>",
" </p>",
" <p class=\"headingAnchor\" id=\"H6\">",
" <span class=\"h2\">",
" Human immunodeficiency virus (HIV)",
" </span>",
" &nbsp;&mdash;&nbsp;All patients being evaluated for sexually transmitted
infections (STIs) should be offered counseling and referral for HIV testing [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2,16-18\">",
" 2,16-18",
" </a>",
" ]. Counseling provides an opportunity for risk reduction education as well as
diagnosis of HIV infection. Diagnosis of HIV benefits the patient who may need to
initiate antiretroviral therapy due to advanced immunosuppression and the public's
health when the source patient is counseled regarding preventive measures.",
" </p>",
" <p>",
" Recommendations for HIV screening in the Centers for Disease Control (CDC)
guidelines include opt-out screening and annual screening for those at high risk
for HIV infection. For pregnant women, HIV testing is recommended in the first
trimester and again in the third trimester in areas with increased rates of HIV
infection [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. These recommendations are discussed in detail elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?10/34/10793?
source=see_link\">",
" \"Serologic screening for HIV infection\"",
" </a>",
" .)",
" </p>",
" <p>",
" Antibody screening can be accomplished either through a rapid test or enzyme
immunoassay (EIA). Reactive antibody tests need to be confirmed by supplemental
testing. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?19/55/20345?
source=see_link\">",
" \"Diagnostic assays for HIV infection\"",
" </a>",
" .)",
" </p>",
" <p>",
" It is important to recognize that some patients with STIs may also have very
recently acquired HIV infection (acute HIV). Patients with acute HIV infection
often have complaints of a fever, \"mono-like illness\", or diarrhea not common
among STI patients. Diagnosis of acute HIV infection during this \"window period\"
is made by measuring HIV RNA [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/19\">",
" 19",
" </a>",
" ]. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?22/17/22808?
source=see_link\">",
" \"Acute and early HIV infection: Treatment\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H7\">",
" <span class=\"h2\">",
" Gonorrhea",
" </span>",
" &nbsp;&mdash;&nbsp;During 2008, a total of 336,742 cases of gonorrhea were
reported in the United States; the reported gonorrhea rate among women (119.4 per
100,000) was greater than that reported for men (103 per 100,000) [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/6\">",
" 6",
" </a>",
" ]. In the United States, the highest attack rates are seen in sexually active
15- to 19-year-old women (636.8 cases per 100,000) and 20- to 24-year-old men
(433.6 cases per 100,000). Overall, rates in African-Americans continue to decline
but are still 20 times higher than those seen in whites.",
" </p>",
" <p>",
" Gonococcal infection can lead to urethritis, cervicitis, pharyngitis, and
anorectal infection. Since untreated gonococcal infection can lead to serious
complications in women, including pelvic inflammatory disease and infertility,
testing for Neisseria gonorrhoeae should be performed annually in asymptomatic
women with one or more of the following risk factors [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Sexually active women younger than 25 years",
" </li>",
" <li>",
" Inconsistent condom use",
" </li>",
" <li>",
" A history of multiple partners or a partner with multiple contacts",
" </li>",
" <li>",
" Sexual contact with a partner with culture-proven STI",
" </li>",
" <li>",
" A history of repeated episodes of STI",
" </li>",
" <li>",
" Sex work or drug use",
" </li>",
" <li>",
" Pregnancy",
" </li>",
" </ul>",
" </p>",
" <p>",
" Most gonorrhea infections in men produce overt symptoms that lead to medical
evaluation. While less common, asymptomatic disease in men contributes to sustained
transmission in women. Among symptomatic heterosexual men, gonorrhea prevalence can
be as high as 28 percent in some settings; however, the prevalence drops to 1.5
percent in asymptomatic men [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/20\">",
" 20",
" </a>",
" ].",
" </p>",
" <p>",
" The US Preventive Services Task Force (USPSTF) found insufficient evidence to
argue for or against routine gonorrhea screening in men [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/21\">",
" 21",
" </a>",
" ]. However, some high-risk groups, such as MSM, may benefit from routine
screening. (See",
" <a class=\"local\" href=\"#H17\">",
" 'Screening special populations'",
" </a>",
" below.)",
" </p>",
" <p>",
" Regardless of symptoms, sexual partners should be evaluated, tested, and
treated if they had sexual contact with the index patient during the 60 days
preceding onset of symptoms or diagnosis of chlamydia [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ].",
" </p>",
" <p>",
" Current methods for the diagnosis of genital gonococcal infections include
urethral Gram stain, culture on Thayer-Martin media, DNA probes, and DNA
amplification techniques. The use of these tests is discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?25/35/26166?
source=see_link&amp;anchor=H11473906#H11473906\">",
" \"Diagnosis of gonococcal infections\", section on 'General background'",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H8\">",
" <span class=\"h2\">",
" Chlamydia",
" </span>",
" &nbsp;&mdash;&nbsp;Chlamydia trachomatis is the most commonly reported STI in
the United States, with 1,210,523 infections reported in 2008, a case rate of 401.3
per 100,000 population, a nearly 10 percent increase from 2007 (367.5 cases per
100,000) [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/6\">",
" 6",
" </a>",
" ]. Chlamydia infection can lead to urethritis, cervicitis, epididymitis, and
proctitis. Untreated infections in women can lead to tubal pregnancy, infertility,
and chronic pelvic pain [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/6,22\">",
" 6,22",
" </a>",
" ]. In men, chlamydial infection can result in infertility, chronic
prostatitis, reactive arthritis, and urethral strictures.",
" </p>",
" <p>",
" Since the majority of infected women do not exhibit clinical symptoms, the
USPSTF and the CDC recommend annual screening of asymptomatic women for Chlamydia
trachomatis infection in the following risk groups [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/6,16,23\">",
" 6,16,23",
" </a>",
" ]:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" All sexually active women age 25 years or younger (including pregnant
women)",
" </li>",
" <li>",
" Sexually active women older than 25 years with risk factors (eg, a new sex
partner in prior 60 days, more than one sex partner, inconsistent condom use,
unmarried, or history of STI)",
" </li>",
" </ul>",
" </p>",
" <p>",
" Screening programs have been demonstrated to decrease rates of pelvic
inflammatory disease [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/24\">",
" 24",
" </a>",
" ]. The USPSTF made no recommendation for or against routine screening of
asymptomatic low-risk women in the general population and cited insufficient
evidence for or against routine screening of asymptomatic men. The USPSTF clinical
practice guideline for screening for chlamydial infection, as well as other USPSTF
guidelines, can be accessed through the website for the Agency for Healthcare
Research and Quality at",
" <a class=\"external\" href=\"file://www.ahrq.gov/clinic/uspstfix.htm\">",
" www.ahrq.gov/clinic/uspstfix.htm",
" </a>",
" . (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?8/13/8408?
source=see_link\">",
" \"Screening for Chlamydia trachomatis\"",
" </a>",
" .)",
" </p>",
" <p>",
" The CDC suggests focused screening of sexually active men in settings
associated with a high prevalence of chlamydia infections (eg, correctional
facilities and STI clinics) [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. Screening of sexually active men who have sex with men (MSM) can also be
considered. (See",
" <a class=\"local\" href=\"#H19\">",
" 'Men who have sex with men'",
" </a>",
" below.)",
" </p>",
" <p>",
" Testing for chlamydia infection can be performed with nucleic acid
amplification techniques (NAAT) on cervical or urine specimens [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. Diagnosis and treatment of chlamydial infections is discussed elsewhere.
(See",
" <a class=\"medical medical_review\" href=\"UTD.htm?18/18/18728?
source=see_link\">",
" \"Genital Chlamydia trachomatis infections in men\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?41/46/42728?
source=see_link\">",
" \"Genital Chlamydia trachomatis infections in women\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H9\">",
" <span class=\"h2\">",
" Trichomoniasis",
" </span>",
" &nbsp;&mdash;&nbsp;Trichomoniasis is caused by the protozoan T. vaginalis.
Symptoms can include urethritis in males and diffuse malodorous vaginal discharge
with vulvar irritation in females.",
" </p>",
" <p>",
" Infection can also be asymptomatic in men and women [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. One prospective, multicenter study among male partners of women with
trichomoniasis demonstrated that 72 percent of male partners were infected with T.
vaginalis, and of those infected, the vast majority (77 percent) were asymptomatic
[",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/25\">",
" 25",
" </a>",
" ]. Detection of this organism in the male partners was optimized using PCR of
urine samples; urine cultures detected 8 percent of infections compared to 70
percent with PCR-based techniques. The only factor that predicted T. vaginalis
infection in the male partner was a high vaginal pH in the female partner; the
mechanism by which pH alterations might enhance T. vaginalis acquisition or
transmission is unknown.",
" </p>",
" <p>",
" The CDC recommends screening for T. vaginalis in women: a) with new or
multiple partners; b) with a history of STIs; c) who trade sex for drugs or money;
d) who use injection drugs [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. The diagnosis of trichomonas in a female patient can be made by microscopy,
rapid antigen testing, nucleic acid amplification testing, and culture. Among men,
microscopy has poor sensitivity; culture or NAATs is preferred for male patients
[",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. Diagnostic testing is discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/53/1881?
source=see_link\">",
" \"Trichomonas vaginalis\"",
" </a>",
" .)",
" </p>",
" <p>",
" Some studies have suggested that vaginal trichomoniasis is also a risk factor
for HIV acquisition:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" In one study, 1335 HIV-seronegative women in Kenya were monitored for a
median of 566 days for HIV seroconversion and acquisition of T. vaginalis [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/26\">",
" 26",
" </a>",
" ]. There were 806 incident T. vaginalis infections and 265 women
seroconverted to HIV. Trichomoniasis was associated with a 1.5-fold (95% CI 1.04-
2.24-fold) increased risk of HIV acquisition after adjustment for potential
confounding factors. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/53/1881?
source=see_link\">",
" \"Trichomonas vaginalis\"",
" </a>",
" .)",
" </li>",
" <li>",
" In another longitudinal study performed in Uganda and Zimbabwe, PCR testing
for T. vaginalis infection was performed on cervical samples from 213 women who
experienced HIV seroconversion (cases) and in cervical samples from 4450 HIV-
uninfected women (controls) [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/27\">",
" 27",
" </a>",
" ]. In a multivariate analysis controlling for hormonal contraception, other
STIs, and behavioral and demographic factors, the adjusted odds ratio for HIV
acquisition was 2.7 for women who had evidence of T. vaginalis infection.",
" </li>",
" </ul>",
" </p>",
" <p>",
" Diagnosis and treatment is discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?35/49/36633?
source=see_link\">",
" \"Approach to women with symptoms of vaginitis\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/53/1881?
source=see_link\">",
" \"Trichomonas vaginalis\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?18/18/18728?
source=see_link\">",
" \"Genital Chlamydia trachomatis infections in men\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H10\">",
" <span class=\"h2\">",
" Syphilis",
" </span>",
" &nbsp;&mdash;&nbsp;Data from the CDC demonstrated that there was an almost 20
percent increase in the number of cases of primary and secondary syphilis from 2007
to 2008 (up from 11,466 to 13,500 cases) [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/6\">",
" 6",
" </a>",
" ]. Among men who have sex with men (MSM), the case rate increased 15 percent
(6.6 cases per 100,000 in 2007 to 7.6 cases in 2008) while the rate increased 36
percent among women (1.1 cases to 1.5 cases per 100,000). The rates increased among
all",
" <span class=\"nowrap\">",
" race/ethnicities",
" </span>",
" with the exception of American",
" <span class=\"nowrap\">",
" Indian/Alaskan",
" </span>",
" natives [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/6\">",
" 6",
" </a>",
" ]. There is also a relatively high rate of HIV coinfection in persons with
syphilis. (See",
" <a class=\"local\" href=\"#H21\">",
" 'HIV-infected patients'",
" </a>",
" below.)",
" </p>",
" <p>",
" The following groups are at increased risk for syphilis and should be screened
[",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/28,29\">",
" 28,29",
" </a>",
" ]:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" All pregnant women at the first prenatal visit (and during the third
trimester and at delivery for women in high-risk groups). (See",
" <a class=\"local\" href=\"#H18\">",
" 'Pregnant women'",
" </a>",
" below.)",
" </li>",
" <li>",
" Commercial sex workers",
" </li>",
" <li>",
" Persons in correctional facilities",
" </li>",
" <li>",
" Persons diagnosed with another STI",
" </li>",
" <li>",
" MSM who engage in high-risk behaviors",
" </li>",
" </ul>",
" </p>",
" <p>",
" Syphilis testing has classically consisted of an initial, inexpensive
nontreponemal test (eg, RPR, VDRL) with confirmation using a more specific
treponemal test (eg, MHA-TP, FTA-ABS).",
" </p>",
" <p>",
" However, for cost reasons, some high-volume laboratories have begun testing
with the more specific (and automated) treponemal testing first, followed by
testing with the nontreponemal test (when the treponemal test is positive). This
reversal of procedures has lead to questions about test interpretation [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/30\">",
" 30",
" </a>",
" ]. This non-traditional testing algorithm is discussed in detail elsewhere.
(See",
" <a class=\"medical medical_review\" href=\"UTD.htm?38/44/39624?
source=see_link\">",
" \"Diagnostic testing for syphilis\"",
" </a>",
" .)",
" </p>",
" <p>",
" The Task Force recommended against routine screening of asymptomatic persons
who are not at increased risk of syphilis, since most positive tests in this
setting represent false positives. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?38/44/39624?
source=see_link&amp;anchor=H13#H13\">",
" \"Diagnostic testing for syphilis\", section on 'Testing algorithms'",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H11\">",
" <span class=\"h2\">",
" Herpes simplex virus type 1 and type 2",
" </span>",
" &nbsp;&mdash;&nbsp;An estimated 25 percent of the US population has
serological evidence of herpes infection [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/31\">",
" 31",
" </a>",
" ]. Asymptomatic shedding of the virus is not uncommon, although many infected
patients are also unaware of being infected [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/32\">",
" 32",
" </a>",
" ].",
" </p>",
" <p>",
" Since active disease causes ulcerative lesions, herpes infection is believed
to increase the risk of HIV transmission and acquisition. However, the USPSTF
recommends against routine serological screening for herpes in asymptomatic persons
[",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/33\">",
" 33",
" </a>",
" ].",
" </p>",
" <p>",
" HSV-2 has also been associated with other sexually transmitted infections. In
one prospective study of Kenyan sex workers, prevalent HSV-2 infection was linked
to prevalent bacterial vaginosis, although the direction of causality could not be
determined [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/34\">",
" 34",
" </a>",
" ]. HSV-2 was also co-incident with gonorrhea, trichomoniasis, and syphilis
infections.",
" </p>",
" <p>",
" The diagnosis of HSV infection can be confirmed by viral culture, polymerase
chain reaction (PCR), direct fluorescence antibody, Tzanck preparation, and type-
specific serologic tests. The choice of test varies with the clinical presentation.
(See",
" <a class=\"medical medical_review\" href=\"UTD.htm?9/10/9386?
source=see_link\">",
" \"Epidemiology, clinical manifestations, and diagnosis of genital herpes
simplex virus infection\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H12\">",
" <span class=\"h2\">",
" Hepatitis A",
" </span>",
" &nbsp;&mdash;&nbsp;Although hepatitis A is more commonly a cause of food-borne
outbreaks, it can be transmitted through some forms of intimate and sexual contact.
Hepatitis A screening should be offered to MSM and injection drug users (IDU). If
susceptible, vaccination should be offered in these patient groups. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/38/1641?
source=see_link\">",
" \"Hepatitis A virus vaccination and postexposure prophylaxis\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?34/12/35018?
source=see_link\">",
" \"Prevention of sexually transmitted infections\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H13\">",
" <span class=\"h2\">",
" Hepatitis B",
" </span>",
" &nbsp;&mdash;&nbsp;Hepatitis B is efficiently transmitted by percutaneous or
mucous membrane exposure to infected blood or body fluids that contain blood.
Hepatitis B screening (hepatitis B surface antigen with anti-HBc or anti-HBs)
should be offered to patients with multiple sex partners, MSM, and injection drug
users. If the patient is susceptible, vaccination should be offered. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?30/60/31690?
source=see_link\">",
" \"Hepatitis B virus vaccination\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?34/12/35018?
source=see_link\">",
" \"Prevention of sexually transmitted infections\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?41/18/42279?
source=see_link\">",
" \"Serologic diagnosis of hepatitis B virus infection\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H14\">",
" <span class=\"h2\">",
" Hepatitis C",
" </span>",
" &nbsp;&mdash;&nbsp;Sexual transmission of hepatitis C is much less efficient
than through injection drug use. Risk factors for sexual transmission include
exposure to an infected partner or exposure to multiple sex partners. Case reports
of acute hepatitis C among HIV-positive MSM have suggested that the risk of HCV
transmission may be increased in the setting of genital ulcerative disease (eg,
syphilis). (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?29/32/30218?
source=see_link\">",
" \"Epidemiology, natural history, and diagnosis of hepatitis C in the HIV-
infected patient\"",
" </a>",
" .)",
" </p>",
" <p>",
" Hepatitis C antibody testing is recommended for routine screening in
asymptomatic persons based on their risk for infection or recognized exposure (eg,
IDU, hemodialysis) [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. Another setting in which HCV antibody screening may be considered is the
sex partner of a patient who has been diagnosed with hepatitis C, particularly if
there is a history of traumatic anal receptive sexual intercourse. Screening for
hepatitis C is discussed in detail elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?40/55/41849?
source=see_link&amp;anchor=H2#H2\">",
" \"Screening for and diagnosis of chronic hepatitis C virus infection\",
section on 'Who should be tested'",
" </a>",
" .)",
" </p>",
" <p>",
" No vaccine is available for hepatitis C. Those individuals who are HCV-
seropositive should be referred for further evaluation to determine if their
disease is active. Information should also be given regarding transmission to
decrease the risk of HCV transmission to others. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?2/7/2169?
source=see_link\">",
" \"Epidemiology and transmission of hepatitis C virus infection\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H15\">",
" <span class=\"h2\">",
" Human papillomavirus",
" </span>",
" &nbsp;&mdash;&nbsp;Persistent viral infection with specific high-risk
genotypes of human papillomavirus (HPV) causes virtually all cancers of the cervix.
In the United States, guidelines issued by various professional organizations
strongly recommend screening for cervical cancer, although there are minor
differences in the recommended screening parameters (",
" <a class=\"graphic graphic_table graphicRef82951 \" href=\"UTD.htm?
24/21/24925\">",
" table 2",
" </a>",
" ). Cervical cancer screening policies in other countries also differ by
starting age, stopping age, and frequency (",
" <a class=\"graphic graphic_table graphicRef72903 \" href=\"UTD.htm?
11/32/11790\">",
" table 3",
" </a>",
" ). These recommendations are discussed in detail elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?37/16/38154?
source=see_link&amp;anchor=H32#H32\">",
" \"Screening for cervical cancer: Rationale and recommendations\", section on
'Recommendations of professional organizations'",
" </a>",
" .)",
" </p>",
" <p>",
" Specific screening recommendations for HIV-infected women are also discussed
elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?36/4/36934?
source=see_link\">",
" \"Screening for cervical cancer in HIV infected women\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?16/35/16954?
source=see_link&amp;anchor=H15#H15\">",
" \"HIV and women\", section on 'Abnormal cervical cytology'",
" </a>",
" .)",
" </p>",
" <p>",
" If a woman (aged &gt;21) has not had a Pap test within the recommended
screening interval, cervical screening should be considered at the time of
evaluation for an STI [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2,35\">",
" 2,35",
" </a>",
" ]. In a review of 1000 female STI clinic attendees who had a Pap smear
performed as part of their clinical evaluation, 5.7 percent had an abnormal result
[",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/36\">",
" 36",
" </a>",
" ]. Increasing age, genital warts, and chlamydia infections were independently
associated with an abnormal Pap smear in multivariate analysis.",
" </p>",
" <p>",
" The presence of a mucopurulent discharge should not delay cervical cytologic
examination; women who are menstruating should return for screening at the earliest
opportunity [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. The sequence of Pap testing in relation to collection of other
cervicovaginal specimens does not appear to influence the Pap test results.",
" </p>",
" <p>",
" Women between the ages of 9 and 26 years are recommended to receive",
" <a class=\"drug drug_general\" href=\"UTD.htm?42/35/43574?source=see_link\">",
" human papillomavirus vaccine",
" </a>",
" to prevent cervical dysplasia and cervical cancer. Routine vaccination is
recommended for females between the ages of 11 and 12 years, but the vaccination
series may be started as early as nine years, and females age 13 to 26 years can
benefit from the vaccine as well [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/37,38\">",
" 37,38",
" </a>",
" ]. Pap smears and HPV DNA or antibody testing is not required before starting
the series. However, clinicians need to be aware that HPV immunization is NOT
effective in clearing cytologically evident disease or infection. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?19/17/19738?
source=see_link\">",
" \"Recommendations for the use of human papillomavirus vaccines\"",
" </a>",
" .)",
" </p>",
" <p>",
" Quadrivalent HPV vaccine can also be used in males and females aged 9 to 26
years to prevent genital warts and anogenital cancers.",
" </p>",
" <p class=\"headingAnchor\" id=\"H16\">",
" <span class=\"h1\">",
" SCREENING SEXUALLY ACTIVE PATIENTS",
" </span>",
" &nbsp;&mdash;&nbsp;As noted above, all sexually active men and women should be
offered routine testing for HIV infection. Also serologic screening for hepatitis B
should be performed; if the patient has no evidence of prior exposure or
vaccination, then immunization against hepatitis B should be offered. (See",
" <a class=\"local\" href=\"#H6\">",
" 'Human immunodeficiency virus (HIV)'",
" </a>",
" above and",
" <a class=\"local\" href=\"#H13\">",
" 'Hepatitis B'",
" </a>",
" above.)",
" </p>",
" <p>",
" Women with a history of unprotected sex or multiple sex partners should be
screened annually for gonorrhea and chlamydia. Annual cervical screening should
also be included. Females between the ages of 9 and 26 years should be offered",
" <a class=\"drug drug_general\" href=\"UTD.htm?42/35/43574?source=see_link\">",
" human papillomavirus vaccine",
" </a>",
" . (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?19/17/19738?
source=see_link\">",
" \"Recommendations for the use of human papillomavirus vaccines\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?8/13/8408?
source=see_link\">",
" \"Screening for Chlamydia trachomatis\"",
" </a>",
" .)",
" </p>",
" <p>",
" Men with a history of unprotected sex or multiple sex partners should be
screened annually for chlamydia. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?8/13/8408?
source=see_link\">",
" \"Screening for Chlamydia trachomatis\"",
" </a>",
" .)",
" </p>",
" <p>",
" Some proponents have argued that school-based health centers should implement
systematic screening programs in adolescents, who are at high risk of STI
acquisition [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/39\">",
" 39",
" </a>",
" ].",
" </p>",
" <p>",
" Because of high rates of reinfection, patients diagnosed with gonorrhea should
be advised to retest in three months; for patients who fail to be retested in that
time period, clinicians should consider repeating gonorrhea testing in the 12
months following the initial diagnosis. Retesting should not be confused with a
test of cure; test of cure is not recommended [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H17\">",
" <span class=\"h1\">",
" SCREENING SPECIAL POPULATIONS",
" </span>",
" &nbsp;&mdash;&nbsp;Screening recommendations vary by risk group.",
" </p>",
" <p class=\"headingAnchor\" id=\"H18\">",
" <span class=\"h2\">",
" Pregnant women",
" </span>",
" &nbsp;&mdash;&nbsp;Intrauterine or perinatally transmitted sexually
transmitted infections (STIs) can have severely debilitating effects on pregnant
women, their partners, and their fetuses. Infections of concern include herpes,
hepatitis B, chlamydia and gonorrhea, syphilis, HIV and hepatitis C [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/40\">",
" 40",
" </a>",
" ]. Screening for these infections is discussed elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?41/1/42010?
source=see_link\">",
" \"Initial prenatal assessment and patient education\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H19\">",
" <span class=\"h2\">",
" Men who have sex with men",
" </span>",
" &nbsp;&mdash;&nbsp;The following screening tests should be offered to sexually
active men who have sex with men (MSM) on at least an annual basis [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" HIV antibody",
" </li>",
" <li>",
" Urethral or urine test (culture or nucleic acid amplification) for gonorrhea
and chlamydia. The choice of test will depend on issues of cost, convenience, and
feasibility, which may vary in different settings.",
" </li>",
" <li>",
" Pharyngeal culture for gonorrhea in men with history of oral-genital
exposure; testing for chlamydia pharyngeal infection is not recommended.",
" </li>",
" <li>",
" Rectal gonorrhea and chlamydia screening in MSM who have had receptive anal
intercourse in the past year.",
" </li>",
" <li>",
" Syphilis serology",
" </li>",
" </ul>",
" </p>",
" <p>",
" More frequent screening (eg, every three to six-month intervals) is
recommended by the Centers for Disease Control (CDC) for MSM who have multiple or
anonymous partners.",
" </p>",
" <p>",
" One study determined the proportion of gonorrhoeae infections in MSM that
would be missed if only urethral or urine specimens were tested. Over a seven-year
period, 7333 MSM attending a STI clinic in the United States underwent culture",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" NAAT sampling of multiple sites [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/41\">",
" 41",
" </a>",
" ]. The study demonstrated that one-third of the total number of gonorrhoeae
cases would have been missed if only urethral or urine samples were tested. Similar
findings have been reported in HIV-infected MSM [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/42\">",
" 42",
" </a>",
" ].",
" </p>",
" <p>",
" Screening for evidence of past hepatitis B and hepatitis A infection should
also be performed in this population as well; if the patient is seronegative,
immunization with both vaccines should be offered. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?30/60/31690?
source=see_link\">",
" \"Hepatitis B virus vaccination\"",
" </a>",
" and",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/38/1641?
source=see_link\">",
" \"Hepatitis A virus vaccination and postexposure prophylaxis\"",
" </a>",
" .)",
" </p>",
" <p>",
" Patients should also be offered testing for hepatitis C antibody, since there
is increasing evidence of sexual transmission among MSM [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/43\">",
" 43",
" </a>",
" ]. For those MSM who are HIV-infected, ongoing screening for hepatitis C is
warranted to detect acute infection. (See",
" <a class=\"local\" href=\"#H21\">",
" 'HIV-infected patients'",
" </a>",
" below.)",
" </p>",
" <p>",
" More frequent screening may be needed in those at highest risk (patients who
acknowledge having multiple anonymous partners or having sex in conjunction with
drug use) [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ].",
" </p>",
" <p>",
" Routine testing for anal cytologic abnormalities or anal HPV infection is not
recommended until more data are available on the reliability of screening methods
[",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H20\">",
" <span class=\"h2\">",
" Women who have sex with women",
" </span>",
" &nbsp;&mdash;&nbsp;The risk of infection with STIs among women who have sex
with women varies widely, depending upon number of partners, if the patient is
bisexual, and specific sexual practices. As an example, practices involving
digital-vaginal or digital-anal contact, particularly with shared penetrative sex
items, are a possible means for transmission of infection.",
" </p>",
" <p>",
" Diagnostic testing for sexually transmitted infections should be performed in
women with symptoms and annual screening for chlamydia and syphilis should be
performed among WSW who are sexually active [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ]. &nbsp;",
" </p>",
" <p>",
" HPV DNA has been detected from the cervix, vagina, and vulva in approximately
one-third of women who have sex with women and high and low-grade squamous
intraepithelial lesions have been reported [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/44\">",
" 44",
" </a>",
" ]. Thus, women who have sex with women should undergo routine cervical cancer
screening and HPV immunization according to standard guidelines [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2\">",
" 2",
" </a>",
" ].",
" </p>",
" <p>",
" This topic is discussed elsewhere (see",
" <a class=\"medical medical_review\" href=\"UTD.htm?24/33/25113?
source=see_link\">",
" \"Medical care of women who have sex with women\"",
" </a>",
" ).",
" </p>",
" <p class=\"headingAnchor\" id=\"H21\">",
" <span class=\"h2\">",
" HIV-infected patients",
" </span>",
" &nbsp;&mdash;&nbsp;High rates of STIs have been found through screening
programs of HIV-infected patients in the United States and abroad [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/45\">",
" 45",
" </a>",
" ]. As examples:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" In a study of routine screening for syphilis, gonorrhea, and chlamydia among
814 asymptomatic HIV-infected patients, 1.8 percent of patients were diagnosed with
syphilis and 10 percent were diagnosed with chlamydia or gonorrhea; 88 percent of
these cases occurred at nonurethral sites [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/46\">",
" 46",
" </a>",
" ].",
" </li>",
" <li>",
" In a 10-year prospective study of female sex workers in Kenya, 238 women of
a cohort of 1215 subjects had documented HIV seroconversion [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/47\">",
" 47",
" </a>",
" ]. HIV infection was associated with a significantly higher incidence of
genital ulcer disease, which increased with progressive levels of
immunosuppression.",
" </li>",
" <li>",
" The estimated rate of primary and secondary syphilis in persons with HIV is
higher than that of the general population. Of 6862 reported cases of syphilis in
2002 in the United States, 25 percent occurred in persons coinfected with HIV [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/48\">",
" 48",
" </a>",
" ].",
" </li>",
" </ul>",
" </p>",
" <p>",
" Routine STI screening of HIV-infected patients in order to reduce the spread
of STIs is recommended, particularly because STIs in turn can increase HIV
transmission. Specifically, testing for the following infections is recommended [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/2,49\">",
" 2,49",
" </a>",
" ]:",
" </p>",
" <p>",
" <ul class=\"bulletCompact-block\">",
" <li>",
" Neisseria gonorrhoeae, at initial evaluation then annually",
" </li>",
" <li>",
" Chlamydia trachomatis, at initial evaluation then annually",
" </li>",
" <li>",
" Syphilis, at initial evaluation then annually",
" </li>",
" <li>",
" Hepatitis A (for MSM, those who are chronically infected with hepatitis B",
" <span class=\"nowrap\">",
" and/or",
" </span>",
" C, and injection drug users), at initial evaluation with vaccination if
susceptible",
" </li>",
" <li>",
" Hepatitis B, at initial evaluation with vaccination if susceptible",
" </li>",
" <li>",
" Hepatitis C, at initial evaluation with antibody testing with at least
annual screening for MSM, active injection drug or intranasal cocaine users, those
who engage in unprotected sex, and those undergoing hemodialysis",
" </li>",
" </ul>",
" </p>",
" <p>",
" In areas of high STI prevalence, biannual STI testing may be prudent. More
frequent screening for gonorrhea, chlamydia, and syphilis is indicated in HIV-
infected MSM who have multiple or anonymous partners, as well as in patients who
exchange sex for money, drugs or basic needs. (See",
" <a class=\"local\" href=\"#H19\">",
" 'Men who have sex with men'",
" </a>",
" above.)",
" </p>",
" <p>",
" However, up to 42 percent of healthcare providers (HCP) providing HIV care
reported \"never\" or \"almost never\" performing initial STI screening in HIV-
infected patients, and many healthcare providers do not ask patients about ongoing
risk-taking behaviors [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/50\">",
" 50",
" </a>",
" ]. Of the 58 percent reporting some initial STI screening, almost one-third of
these same HCP reported \"never\" to \"almost never\" performing annual gonorrhea
or chlamydia testing in their HIV-infected women and men, respectively [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/51\">",
" 51",
" </a>",
" ].",
" </p>",
" <p>",
" Sexual transmission of hepatitis C among HIV-infected MSM has increased
internationally [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/52-55\">",
" 52-55",
" </a>",
" ]. Ongoing periodic screening in these men with liver function tests (LFTs)
followed by hepatitis C antibody (HCV Ab) and RNA testing if abnormal is
recommended to identify acute infection, which has a higher response rate to
therapy than in the chronic setting. In a cost-effectiveness analysis, a screening
strategy with yearly HCV Ab testing and LFTs with reflex RNA every six months was
cost effective when the incidence of hepatitis C is below 1.25 percent [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/56\">",
" 56",
" </a>",
" ]. When the incidence is above 1.25 percent, screening with LFTs every three
months was most cost effective.",
" </p>",
" <p>",
" The incidence of anal cancer is also increasing among HIV-infected MSM.
Screening is discussed in detail elsewhere. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/33/1562?
source=see_link\">",
" \"Anal intraepithelial neoplasia: Diagnosis, screening, prevention, and
treatment\"",
" </a>",
" .)",
" </p>",
" <p>",
" Women with HIV should have cervical screening twice in the first year after
diagnosis of HIV infection, and if the results are normal, annually thereafter.
Women with abnormal cytology should be managed with colposcopy and gynecological
consultation. (See",
" <a class=\"medical medical_review\" href=\"UTD.htm?16/35/16954?
source=see_link\">",
" \"HIV and women\"",
" </a>",
" .)",
" </p>",
" <p class=\"headingAnchor\" id=\"H22\">",
" <span class=\"h1\">",
" HEALTH DEPARTMENT NOTIFICATION",
" </span>",
" &nbsp;&mdash;&nbsp;Local and state public health practices of partner
notification and disease reporting are important in addition to individual sexually
transmitted disease case management. Notifiable infections include chancroid,
chlamydia trachomatis, gonorrhea, acute hepatitis B, acute hepatitis C, HIV, and
syphilis [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/57\">",
" 57",
" </a>",
" ].",
" </p>",
" <p class=\"headingAnchor\" id=\"H23\">",
" <span class=\"h1\">",
" PARTNER NOTIFICATION",
" </span>",
" &nbsp;&mdash;&nbsp;Partners should be notified, examined, and treated for the
sexually transmitted infection (STI) identified or suspected in the index patient.
In some settings, partner delivered patient medication (PDPM) has been used. With
this system, the patient directly provides their sexual contacts with medications
and prescriptions to be filled. The PDPM approach does not give the sexual contact
a chance to ask questions, or receive counseling or additional STD screening, but
does prevent recurrent gonococcal and chlamydial infections [",
" <a class=\"abstract\" href=\"UTD.htm?0/30/490/abstract/58\">",
" 58",
" </a>",
" ]. Clinicians need to be aware that PDPM is not legal in all states.",
" </p>",
" <p>",
" Patients and their sex partners should abstain from sexual intercourse until
seven days after a single-dose treatment or upon completion of a seven-day
regimen.",
" </p>",
" <p class=\"headingAnchor\" id=\"PATIENT_INFORMATION\">",
" <span class=\"h1\">",
" INFORMATION FOR PATIENTS",
" </span>",
" &nbsp;&mdash;&nbsp;UpToDate offers two types of patient education materials,
&ldquo;The Basics&rdquo; and &ldquo;Beyond the Basics.&rdquo; The Basics patient
education pieces are written in plain language, at the 5",
" ^{",
" th",
"}",
" to 6",
" ^{",
" th",
"}",
" grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a
general overview and who prefer short, easy-to-read materials. Beyond the Basics
patient education pieces are longer, more sophisticated, and more detailed. These
articles are written at the 10",
" ^{",
" th",
"}",
" to 12",
" ^{",
" th",
"}",
" grade reading level and are best for patients who want in-depth information
and are comfortable with some medical jargon.",
" </p>",
" <p>",
" Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
&ldquo;patient info&rdquo; and the keyword(s) of interest.)",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" Basics topics (see",
" <a class=\"medical medical_basics\" href=\"UTD.htm?22/52/23362?
source=see_link\">",
" \"Patient information: Chlamydia and gonorrhea (The Basics)\"",
" </a>",
" and",
" <a class=\"medical medical_basics\" href=\"UTD.htm?21/25/21906?
source=see_link\">",
" \"Patient information: Genital herpes (The Basics)\"",
" </a>",
" and",
" <a class=\"medical medical_basics\" href=\"UTD.htm?1/57/1940?
source=see_link\">",
" \"Patient information: Screening for sexually transmitted diseases (The
Basics)\"",
" </a>",
" )",
" </li>",
" <li>",
" Beyond the Basics topics (See",
" <a class=\"medical medical_patient\" href=\"UTD.htm?1/44/1730?
source=see_link\">",
" \"Patient information: Gonorrhea (Beyond the Basics)\"",
" </a>",
" and",
" <a class=\"medical medical_patient\" href=\"UTD.htm?24/14/24802?
source=see_link\">",
" \"Patient information: Chlamydia (Beyond the Basics)\"",
" </a>",
" and",
" <a class=\"medical medical_patient\" href=\"UTD.htm?1/60/1986?
source=see_link\">",
" \"Patient information: Testing for HIV (Beyond the Basics)\"",
" </a>",
" and",
" <a class=\"medical medical_patient\" href=\"UTD.htm?36/3/36916?
source=see_link\">",
" \"Patient information: Genital herpes (Beyond the Basics)\"",
" </a>",
" and",
" <a class=\"medical medical_patient\" href=\"UTD.htm?3/60/4035?
source=see_link\">",
" \"Patient information: Genital warts in women (Beyond the Basics)\"",
" </a>",
" and",
" <a class=\"medical medical_patient\" href=\"UTD.htm?30/45/31447?
source=see_link\">",
" \"Patient information: Hepatitis B (Beyond the Basics)\"",
" </a>",
" and",
" <a class=\"medical medical_patient\" href=\"UTD.htm?17/4/17478?
source=see_link\">",
" \"Patient information: Hepatitis C (Beyond the Basics)\"",
" </a>",
" .)",
" </li>",
" </ul>",
" </p>",
" <p class=\"headingAnchor\" id=\"H25\">",
" <span class=\"h1\">",
" SUMMARY AND RECOMMENDATIONS",
" </span>",
" &nbsp;&mdash;&nbsp;Risk factors for sexually transmitted infection (STI)
acquisition include young age, unmarried status, residence in an urban area, new
sex partner, multiple sex partners, history of STIs, illicit drug use, contact with
sex workers, imprisonment, and meeting partners on the internet. (See",
" <a class=\"local\" href=\"#H3\">",
" 'Risk factors'",
" </a>",
" above.)",
" </p>",
" <p>",
" Our recommendations for screening are consistent with those of the Centers for
Disease Control and Prevention, as outlined in the 2010 treatment guidelines for
STIs:",
" </p>",
" <p>",
" <ul class=\"bullet-block\">",
" <li>",
" All patients being evaluated for STIs should be offered counseling and
testing for HIV. (See",
" <a class=\"local\" href=\"#H6\">",
" 'Human immunodeficiency virus (HIV)'",
" </a>",
" above.)",
" </li>",
" <li>",
" Hepatitis B screening should be offered to men who have sex with men (MSM),
injection drug users (IDU), persons attending an STI clinic or seeking STI
treatment, and persons with a history of multiple sex partners. Patients who are
not immune should be offered vaccination. (See",
" <a class=\"local\" href=\"#H13\">",
" 'Hepatitis B'",
" </a>",
" above.)",
" </li>",
" <li>",
" Hepatitis A screening should be offered to MSM and injection drug users.
Those who are not immune should be offered vaccination. (See",
" <a class=\"local\" href=\"#H12\">",
" 'Hepatitis A'",
" </a>",
" above.)",
" </li>",
" <li>",
" Asymptomatic women with risk factors for STIs should be screened for
gonococcal or chlamydial infection annually. &nbsp;Males and females between the
ages of 9 and 26 years should be offered human papillomavirus vaccination. (See",
" <a class=\"local\" href=\"#H7\">",
" 'Gonorrhea'",
" </a>",
" above and",
" <a class=\"local\" href=\"#H8\">",
" 'Chlamydia'",
" </a>",
" above and",
" <a class=\"local\" href=\"#H15\">",
" 'Human papillomavirus'",
" </a>",
" above.)",
" </li>",
" <li>",
" The following screening tests for sexually active MSM are recommended on at
least an annual basis: HIV antibody, testing for gonorrhea and chlamydia, and
syphilis serology. More frequent screening may be indicated in patients at high
risk. (See",
" <a class=\"local\" href=\"#H19\">",
" 'Men who have sex with men'",
" </a>",
" above.)",
" </li>",
" <li>",
" Syphilis screening is recommended for commercial sex workers, persons who
exchange sex for drugs, and persons in correctional facilities. (See",
" <a class=\"local\" href=\"#H10\">",
" 'Syphilis'",
" </a>",
" above.)",
" </li>",
" <li>",
" Pregnant women should be screened for gonorrhea, chlamydia, HIV, hepatitis
B, and syphilis infections. (See",
" <a class=\"local\" href=\"#H17\">",
" 'Screening special populations'",
" </a>",
" above.)",
" </li>",
" <li>",
" HIV-infected patients should be screened annually for Neisseria gonorrhoeae,
Chlamydia trachomatis, syphilis, and hepatitis B and C. Vaccination against
hepatitis A and B is recommended for nonimmune patients. HIV-infected patients who
actively use injection drugs or intranasal cocaine, engage in unprotected sex, are
men who have sex with men, or are undergoing hemodialysis should have ongoing
screening for hepatitis C. (See",
" <a class=\"local\" href=\"#H21\">",
" 'HIV-infected patients'",
" </a>",
" above.)",
" </li>",
" <li>",
" Local and state public health departments should be kept informed of
notifiable infections, which include chancroid, chlamydia, gonorrhea, acute
hepatitis A, acute hepatitis B, acute hepatitis C, HIV, and syphilis. (See",
" <a class=\"local\" href=\"#H22\">",
" 'Health department notification'",
" </a>",
" above.)",
" </li>",
" <li>",
" Partners should be notified, examined, and treated for the STI identified in
the index patient. Patients and their sex partners should abstain from sexual
intercourse until therapy is completed. (See",
" <a class=\"local\" href=\"#H23\">",
" 'Partner notification'",
" </a>",
" above.)",
" </li>",
" </ul>",
" </p>",
" </div>",
" <div id=\"topicAgreement\">",
" Use of UpToDate is subject to the",
" <a class=\"licenseLink\" href=\"./license\" id=\"sla_in_page\"
target=\"_blank\">",
" Subscription and License Agreement",
" </a>",
" .",
" </div>",
" <div class=\"headingAnchor\" id=\"references\">",
" <h1>",
" REFERENCES",
" </h1>",
" <ol id=\"reference\">",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/1\">",
" Low N, Broutet N, Adu-Sarkodie Y, et al. Global control of sexually
transmitted infections. Lancet 2006; 368:2001.",
" </a>",
" </li>",
" <li>",
" file://www.cdc.gov/std/treatment/2010/default.htm (Accessed on January 03,
2011).",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/3\">",
" Torkko KC, Gershman K, Crane LA, et al. Testing for Chlamydia and sexual
history taking in adolescent females: results from a statewide survey of Colorado
primary care providers. Pediatrics 2000; 106:E32.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/4\">",
" Boekeloo BO, Marx ES, Kral AH, et al. Frequency and thoroughness of STD/HIV
risk assessment by physicians in a high-risk metropolitan area. Am J Public Health
1991; 81:1645.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/5\">",
" Ness RB, Smith KJ, Chang CC, et al. Prediction of pelvic inflammatory
disease among young, single, sexually active women. Sex Transm Dis 2006; 33:137.",
" </a>",
" </li>",
" <li>",
" Centers for Disease Control and Prevention. Sexually Transmitted Disease
Surveillance, 2008. US Department of Health and Human Services, Atlanta, GA 2009.",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/7\">",
" Bernstein KT, Zenilman J, Olthoff G, et al. Gonorrhea reinfection among
sexually transmitted disease clinic attendees in Baltimore, Maryland. Sex Transm
Dis 2006; 33:80.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/8\">",
" Lofy KH, Hofmann J, Mosure DJ, et al. Chlamydial infections among female
adolescents screened in juvenile detention centers in Washington State, 1998-2002.
Sex Transm Dis 2006; 33:63.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/9\">",
" Kerani RP, Handcock MS, Handsfield HH, Holmes KK. Comparative geographic
concentrations of 4 sexually transmitted infections. Am J Public Health 2005;
95:324.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/10\">",
" Niccolai LM, Ethier KA, Kershaw TS, et al. New sex partner acquisition and
sexually transmitted disease risk among adolescent females. J Adolesc Health 2004;
34:216.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/11\">",
" Klausner JD, Kent CK, Wong W, et al. The public health response to epidemic
syphilis, San Francisco, 1999-2004. Sex Transm Dis 2005; 32:S11.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/12\">",
" Kahn RH, Voigt RF, Swint E, Weinstock H. Early syphilis in the United States
identified in corrections facilities, 1999-2002. Sex Transm Dis 2004; 31:360.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/13\">",
" Peterman TA, Tian LH, Metcalf CA, et al. High incidence of new sexually
transmitted infections in the year following a sexually transmitted infection: a
case for rescreening. Ann Intern Med 2006; 145:564.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/14\">",
" Hoebe CJ, Rademaker CW, Brouwers EE, et al. Acceptability of self-taken
vaginal swabs and first-catch urine samples for the diagnosis of urogenital
Chlamydia trachomatis and Neisseria gonorrhoeae with an amplified DNA assay in
young women attending a public health sexually transmitted disease clinic. Sex
Transm Dis 2006; 33:491.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/15\">",
" Hobbs MM, van der Pol B, Totten P, et al. From the NIH: proceedings of a
workshop on the importance of self-obtained vaginal specimens for detection of
sexually transmitted infections. Sex Transm Dis 2008; 35:8.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/16\">",
" Centers for Disease Control and Prevention, Workowski KA, Berman SM.
Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep 2006;
55:1.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/17\">",
" Campos-Outcalt D, Mickey T, Weisbuch J, Jones R. Integrating routine HIV
testing into a public health STD clinic. Public Health Rep 2006; 121:175.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/18\">",
" Branson BM, Handsfield HH, Lampe MA, et al. Revised recommendations for HIV
testing of adults, adolescents, and pregnant women in health-care settings. MMWR
Recomm Rep 2006; 55:1.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/19\">",
" Pilcher CD, Fiscus SA, Nguyen TQ, et al. Detection of acute infections
during HIV testing in North Carolina. N Engl J Med 2005; 352:1873.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/20\">",
" Gaydos CA, Kent CK, Rietmeijer CA, et al. Prevalence of Neisseria
Gonorrhoeae among men screened for Chlamydia Trachomatis in four United States
cities, 1999-2003. Sex Transm Dis 2006; 33:314.",
" </a>",
" </li>",
" <li>",
" US Preventive Services Task Force. Screening for gonorrhea. Agency for
Healthcare Research and Quality, Rockville, MD. Revised January 2006.
file://www.ahrq.gov/clinic/uspstf/uspsgono.htm (Accessed on June 05, 2006).",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/22\">",
" Kohl KS, Markowitz LE, Koumans EH. Developments in the screening for
Chlamydia trachomatis: a review. Obstet Gynecol Clin North Am 2003; 30:637.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/23\">",
" US Preventive Services Task Force. Screening for chlamydial infection:
recommendations and rationale. Am J Prev Med 2001; 20:90.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/24\">",
" Scholes D, Stergachis A, Heidrich FE, et al. Prevention of pelvic
inflammatory disease by screening for cervical chlamydial infection. N Engl J Med
1996; 334:1362.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/25\">",
" Se&ntilde;a AC, Miller WC, Hobbs MM, et al. Trichomonas vaginalis infection
in male sexual partners: implications for diagnosis, treatment, and prevention.
Clin Infect Dis 2007; 44:13.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/26\">",
" McClelland RS, Sangare L, Hassan WM, et al. Infection with Trichomonas
vaginalis increases the risk of HIV-1 acquisition. J Infect Dis 2007; 195:698.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/27\">",
" Van Der Pol B, Kwok C, Pierre-Louis B, et al. Trichomonas vaginalis
infection and human immunodeficiency virus acquisition in African women. J Infect
Dis 2008; 197:548.",
" </a>",
" </li>",
" <li>",
" US Preventive Services Task Force. Screening for syphilis. Agency for
Healthcare Research and Quality, Rockville, MD. Release date 2004.
file://www.ahrq.gov/clinic/uspstf/uspssyph.htm (Accessed on June 05, 2006).",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/29\">",
" Wong W, Chaw JK, Kent CK, Klausner JD. Risk factors for early syphilis among
gay and bisexual men seen in an STD clinic: San Francisco, 2002-2003. Sex Transm
Dis 2005; 32:458.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/30\">",
" Centers for Disease Control and Prevention (CDC). Syphilis testing
algorithms using treponemal tests for initial screening--four laboratories, New
York City, 2005-2006. MMWR Morb Mortal Wkly Rep 2008; 57:872.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/31\">",
" Stanberry L, Cunningham A, Mertz G, et al. New developments in the
epidemiology, natural history and management of genital herpes. Antiviral Res 1999;
42:1.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/32\">",
" Krone MR, Wald A, Tabet SR, et al. Herpes simplex virus type 2 shedding in
human immunodeficiency virus-negative men who have sex with men: frequency,
patterns, and risk factors. Clin Infect Dis 2000; 30:261.",
" </a>",
" </li>",
" <li>",
" US Preventive Services Task Force. Screening for herpes. Agency for
Healthcare Research and Quality, Rockville, MD. Release date 2005.
file://www.ahrq.gov/clinic/uspstf/uspsherp.htm (Accessed on June 05, 2006).",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/34\">",
" Kaul R, Nagelkerke NJ, Kimani J, et al. Prevalent herpes simplex virus type
2 infection is associated with altered vaginal flora and an increased
susceptibility to multiple sexually transmitted infections. J Infect Dis 2007;
196:1692.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/35\">",
" Kamb ML. Cervical cancer screening of women attending sexually transmitted
disease clinics. Clin Infect Dis 1995; 20 Suppl 1:S98.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/36\">",
" Kanno MB, Nguyen RH, Lee EM, et al. The prevalence of abnormal cervical
cytology in a sexually transmitted diseases clinic. Int J STD AIDS 2005; 16:549.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/37\">",
" Casey C, Vellozzi C, Mootrey GT, et al. Surveillance guidelines for smallpox
vaccine (vaccinia) adverse reactions. MMWR Recomm Rep 2006; 55:1.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/38\">",
" Markowitz LE, Dunne EF, Saraiya M, et al. Quadrivalent Human Papillomavirus
Vaccine: Recommendations of the Advisory Committee on Immunization Practices
(ACIP). MMWR Recomm Rep 2007; 56:1.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/39\">",
" Nsuami M, Taylor SN, Sanders LS, Martin DH. Missed opportunities for early
detection of chlamydia and gonorrhea in school-based health centers. Sex Transm Dis
2006; 33:703.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/40\">",
" Majeroni BA, Ukkadam S. Screening and treatment for sexually transmitted
infections in pregnancy. Am Fam Physician 2007; 76:265.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/41\">",
" Gunn RA, O'Brien CJ, Lee MA, Gilchick RA. Gonorrhea screening among men who
have sex with men: value of multiple anatomic site testing, San Diego, California,
1997-2003. Sex Transm Dis 2008; 35:845.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/42\">",
" Rieg G, Lewis RJ, Miller LG, et al. Asymptomatic sexually transmitted
infections in HIV-infected men who have sex with men: prevalence, incidence,
predictors, and screening strategies. AIDS Patient Care STDS 2008; 22:947.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/43\">",
" G&ouml;tz HM, van Doornum G, Niesters HG, et al. A cluster of acute
hepatitis C virus infection among men who have sex with men--results from contact
tracing and public health implications. AIDS 2005; 19:969.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/44\">",
" Marrazzo JM, Koutsky LA, Kiviat NB, et al. Papanicolaou test screening and
prevalence of genital human papillomavirus among women who have sex with women. Am
J Public Health 2001; 91:947.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/45\">",
" Dang T, Jaton-Ogay K, Flepp M, et al. High prevalence of anorectal
chlamydial infection in HIV-infected men who have sex with men in Switzerland. Clin
Infect Dis 2009; 49:1532.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/46\">",
" Phipps W, Stanley H, Kohn R, et al. Syphilis, chlamydia, and gonorrhea
screening in HIV-infected patients in primary care, San Francisco, California,
2003. AIDS Patient Care STDS 2005; 19:495.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/47\">",
" McClelland RS, Lavreys L, Katingima C, et al. Contribution of HIV-1
infection to acquisition of sexually transmitted disease: a 10-year prospective
study. J Infect Dis 2005; 191:333.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/48\">",
" Chesson HW, Heffelfinger JD, Voigt RF, Collins D. Estimates of primary and
secondary syphilis rates in persons with HIV in the United States, 2002. Sex Transm
Dis 2005; 32:265.",
" </a>",
" </li>",
" <li>",
" file://hab.hrsa.gov/deliverhivaidscare/files/hepccoinfectguide2011.pdf
(Accessed on July 20, 2012).",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/50\">",
" Hall CS, Marrazzo JD. Emerging issues in management of sexually transmitted
diseases in HIV infection. Curr Infect Dis Rep 2007; 9:518.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/51\">",
" Se&ntilde;a AC, Mertz KJ, Thomas D, et al. A survey of sexually transmitted
diseases/HIV coinfection testing and reporting practices among health care
providers in New Jersey. Sex Transm Dis 2005; 32:406.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/52\">",
" van de Laar T, Pybus O, Bruisten S, et al. Evidence of a large,
international network of HCV transmission in HIV-positive men who have sex with
men. Gastroenterology 2009; 136:1609.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/53\">",
" van der Helm JJ, Prins M, del Amo J, et al. The hepatitis C epidemic among
HIV-positive MSM: incidence estimates from 1990 to 2007. AIDS 2011; 25:1083.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/54\">",
" Centers for Disease Control and Prevention (CDC). Sexual transmission of
hepatitis C virus among HIV-infected men who have sex with men--New York City,
2005-2010. MMWR Morb Mortal Wkly Rep 2011; 60:945.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/55\">",
" Taylor LE, Holubar M, Wu K, et al. Incident hepatitis C virus infection
among US HIV-infected men enrolled in clinical trials. Clin Infect Dis 2011;
52:812.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/56\">",
" Linas BP, Wong AY, Schackman BR, et al. Cost-effective screening for acute
hepatitis C virus infection in HIV-infected men who have sex with men. Clin Infect
Dis 2012; 55:279.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/57\">",
" Hopkins RS, Jajosky RA, Hall PA, et al. Summary of notifiable diseases--
United States, 2003. MMWR Morb Mortal Wkly Rep 2005; 52:1.",
" </a>",
" </li>",
" <li>",
" <a class=\"nounderline abstract\" href=\"UTD.htm?0/30/490/abstract/58\">",
" Golden MR, Whittington WL, Handsfield HH, et al. Effect of expedited
treatment of sex partners on recurrent or persistent gonorrhea or chlamydial
infection. N Engl J Med 2005; 352:676.",
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" SUMMARY &amp; RECOMMENDATIONS",
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" INTRODUCTION",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H2\">",
" TAKING A SEXUAL HISTORY",
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" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H3\">",
" RISK FACTORS",
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" <a class=\"outlineLink\" href=\"#H4\">",
" GENERAL PRINCIPLES",
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" PATHOGENS",
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" Human immunodeficiency virus (HIV)",
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" <a class=\"outlineLink\" href=\"#H7\">",
" Gonorrhea",
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" </li>",
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" <a class=\"outlineLink\" href=\"#H8\">",
" Chlamydia",
" </a>",
" </li>",
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" <a class=\"outlineLink\" href=\"#H9\">",
" Trichomoniasis",
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" </li>",
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" <a class=\"outlineLink\" href=\"#H10\">",
" Syphilis",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H11\">",
" Herpes simplex virus type 1 and type 2",
" </a>",
" </li>",
" <li class=\"bulletItem\">",
" <a class=\"outlineLink\" href=\"#H12\">",
" Hepatitis A",
" </a>",
" </li>",
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" <a class=\"outlineLink\" href=\"#H13\">",
" Hepatitis B",
" </a>",
" </li>",
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" Hepatitis C",
" </a>",
" </li>",
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" <a class=\"outlineLink\" href=\"#H15\">",
" Human papillomavirus",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H16\">",
" SCREENING SEXUALLY ACTIVE PATIENTS",
" </a>",
" </li>",
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" SCREENING SPECIAL POPULATIONS",
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" Pregnant women",
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" Men who have sex with men",
" </a>",
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" Women who have sex with women",
" </a>",
" </li>",
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" HIV-infected patients",
" </a>",
" </li>",
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" HEALTH DEPARTMENT NOTIFICATION",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H23\">",
" PARTNER NOTIFICATION",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#PATIENT_INFORMATION\">",
" INFORMATION FOR PATIENTS",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"outlineLink\" href=\"#H25\">",
" SUMMARY AND RECOMMENDATIONS",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a href=\"#references\">",
" REFERENCES",
" </a>",
" </li>",
" </ul>",
" </div>",
" <h1>",
" <div class=\"openRelatedGraphics\" id=\"ID/7596\" rel=\"outline_link\">",
" GRAPHICS",
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1\">",
" Five Ps of sexual history",
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2\">",
" US recs cerv cancer screen",
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3\">",
" Intl cerv cancer screen policies",
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" <h1>",
" RELATED TOPICS",
" </h1>",
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" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_patient\" href=\"UTD.htm?36/3/36916?
source=related_link\">",
" Patient information: Genital herpes (Beyond the Basics)",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_basics\" href=\"UTD.htm?21/25/21906?
source=related_link\">",
" Patient information: Genital herpes (The Basics)",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_patient\" href=\"UTD.htm?3/60/4035?
source=related_link\">",
" Patient information: Genital warts in women (Beyond the Basics)",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_patient\" href=\"UTD.htm?1/44/1730?
source=related_link\">",
" Patient information: Gonorrhea (Beyond the Basics)",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_patient\" href=\"UTD.htm?30/45/31447?
source=related_link\">",
" Patient information: Hepatitis B (Beyond the Basics)",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_patient\" href=\"UTD.htm?17/4/17478?
source=related_link\">",
" Patient information: Hepatitis C (Beyond the Basics)",
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" <a class=\"medical medical_basics\" href=\"UTD.htm?1/57/1940?
source=related_link\">",
" Patient information: Screening for sexually transmitted diseases (The
Basics)",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_patient\" href=\"UTD.htm?1/60/1986?
source=related_link\">",
" Patient information: Testing for HIV (Beyond the Basics)",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?34/12/35018?
source=related_link\">",
" Prevention of sexually transmitted infections",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?19/17/19738?
source=related_link\">",
" Recommendations for the use of human papillomavirus vaccines",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?8/13/8408?
source=related_link\">",
" Screening for Chlamydia trachomatis",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?40/55/41849?
source=related_link\">",
" Screening for and diagnosis of chronic hepatitis C virus infection",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?36/4/36934?
source=related_link\">",
" Screening for cervical cancer in HIV infected women",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?37/16/38154?
source=related_link\">",
" Screening for cervical cancer: Rationale and recommendations",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?41/18/42279?
source=related_link\">",
" Serologic diagnosis of hepatitis B virus infection",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?10/34/10793?
source=related_link\">",
" Serologic screening for HIV infection",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?36/51/37689?
source=related_link\">",
" Sexually transmitted diseases: Overview of issues specific to adolescents",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/44/1737?
source=related_link\">",
" The adolescent with HIV infection",
" </a>",
" </li>",
" <li class=\"plainItem\">",
" <a class=\"medical medical_review\" href=\"UTD.htm?1/53/1881?
source=related_link\">",
" Trichomonas vaginalis",
" </a>",
" </li>",
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var title_f0_30_491="Clinical differential of microcystic adnexal carcinoma";
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" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\">",
" <div class=\"ttl\">",
" Clinical differential diagnosis of microcystic adnexal carcinoma",
" </div>",
" <div class=\"cntnt\">",
" <table cellspacing=\"0\">",
" <tbody>",
" <tr>",
" <td>",
" Basal cell carcinoma, infiltrative or morpheaform type",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Desmoplastic squamous cell carcinoma",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Scar",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Cyst",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Other adnexal carcinomas",
" </td>",
" </tr>",
" </tbody>",
" </table>",
" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
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var title_f0_30_492="Reducing lead absorption";
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" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" ^{",
" &reg;",
"}",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=PEDS
%2F76197&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=5\" onclick=\"\">",
" <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=PEDS
%2F76197&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=5\" onclick=\"\"
title=\"Print this page\">",
" Print",
" </a>",
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" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
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" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\">",
" <div class=\"ttl\">",
" Steps to take to minimize lead absorption in your family",
" </div>",
" <div class=\"cntnt\">",
" <table cellspacing=\"0\">",
" <tbody>",
" <tr>",
" <td>",
" 1. Make sure that your children wash their hands and face before eating
and sleeping.",
" </td>",
" </tr>",
" <tr>",
" <td>",
" 2. Prevent your children from eating things other than food (eg, dirt,
paint).",
" </td>",
" </tr>",
" <tr>",
" <td>",
" 3. Make sure that all surfaces (floors, countertops, tabletops, etc) have
been thoroughly cleaned with a high phosphate detergent. This is especially
important for toddlers since they crawl and lay on the floor and frequently put
their hands in their mouths.",
" </td>",
" </tr>",
" <tr>",
" <td>",
" 4. If your home was built prior to 1977, it is extremely important to
remove any flaking or peeling paint in the house, since older homes frequently were
painted with lead-based paint. Painting over lead-based paint, or applying
wallpaper, are only temporary ways to control exposure, and are not acceptable
means of control. Protective equipment and respirators must be worn in the removal
of lead-based paint from walls and woodwork. Consult a professional experienced in
lead paint removal before doing this work.",
" </td>",
" </tr>",
" <tr>",
" <td>",
" 5. Make sure that your children receive the recommended daily allowance of
multivitamins with iron. They should have well-balanced diets, and drink plenty of
milk (2-3 cups) each day. (Maximum amount of milk - 24 oz/day)",
" </td>",
" </tr>",
" <tr>",
" <td>",
" 6. Do not use herbal or folk medicine (these may contain lead).",
" </td>",
" </tr>",
" <tr>",
" <td>",
" 7. If you are not sure that your pottery does not have a lead glaze, use
it only for decoration.",
" </td>",
" </tr>",
" <tr>",
" <td>",
" 8. Store food in glass, plastic, or stainless steel containers, not in
open cans.",
" </td>",
" </tr>",
" <tr>",
" <td>",
" 9. Use water from the cold tap for cooking and drinking. Let it run for
several minutes before collecting for use.",
" </td>",
" </tr>",
" <tr>",
" <td>",
" 10. Be careful to keep materials for hobbies, such as those used for
making ceramics or stained glass, away from children and areas where they spend
time.",
" </td>",
" </tr>",
" </tbody>",
" </table>",
" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var script_f0_30_492=[""].join("\n");
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var title_f0_30_493="rMPI CP prog";
var content_f0_30_493=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" ^{",
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"}",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=CARD
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" <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=CARD
%2F73446&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=2\" onclick=\"\"
title=\"Print this page\">",
" Print",
" </a>",
" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
" </a>",
" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\">",
" <div class=\"ttl\">",
" Myocardial perfusion imaging for acute chest pain: Prognostic data",
" </div>",
" <div class=\"cntnt\">",
" <table cellspacing=\"0\">",
" <tbody>",
" <tr>",
" <td class=\"subtitle1\" rowspan=\"2\">",
" Study",
" </td>",
" <td class=\"subtitle1\" rowspan=\"2\">",
" N",
" </td>",
" <td class=\"subtitle1\" rowspan=\"2\">",
" Duration of f/u",
" </td>",
" <td class=\"subtitle1\" rowspan=\"2\">",
" Endpoint",
" </td>",
" <td class=\"subtitle1\" colspan=\"3\">",
" Event rate, percent",
" </td>",
" </tr>",
" <tr>",
" <td class=\"subtitle2\">",
" Normal scan",
" </td>",
" <td class=\"subtitle2\">",
" Equivocal scan",
" </td>",
" <td class=\"subtitle2\">",
" Abnormal scan",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Varetto T, Cantalupi D, Altieri A, Orlandi C. Emergency room technetium-
99m sestamibi imaging to rule out acute myocardial ischemic events in patients with
nondiagnostic electrocardiograms. J Am Coll Cardiol 1993; 22:1804.",
" </td>",
" <td>",
" 64",
" </td>",
" <td>",
" 18 m",
" </td>",
" <td>",
" Death, MI, revasc",
" </td>",
" <td>",
" 0",
" </td>",
" <td>",
" N/A",
" </td>",
" <td>",
" 20",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Hilton TC, Thompson RC, Williams HJ, et al. Technetium-99m sestamibi
myocardial perfusion imaging in the emergency room evaluation of chest pain. J Am
Coll Cardiol 1994; 23:1016.",
" </td>",
" <td>",
" 102",
" </td>",
" <td>",
" 3 m",
" </td>",
" <td>",
" Death, MI, revasc",
" </td>",
" <td>",
" 1.4",
" </td>",
" <td>",
" 13",
" </td>",
" <td>",
" 71",
" </td>",
" </tr>",
" <tr>",
" <td rowspan=\"2\">",
" Tatum JL, Jesse RL, Kontos MC, et al. Comprehensive strategy for the
evaluation and triage of the chest pain patient. Ann Emerg Med 1997; 29:116.",
" </td>",
" <td rowspan=\"2\">",
" 1187",
" </td>",
" <td rowspan=\"2\">",
" 12 m",
" </td>",
" <td>",
" MI",
" </td>",
" <td>",
" 0",
" </td>",
" <td rowspan=\"2\">",
" N/A",
" </td>",
" <td>",
" 11",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Death",
" </td>",
" <td>",
" 0",
" </td>",
" <td>",
" 8",
" </td>",
" </tr>",
" <tr>",
" <td rowspan=\"4\">",
" Heller GV, Stowers SA, Hendel RC, et al. Clinical value of acute rest
technetium-99m tetrofosmin tomographic myocardial perfusion imaging in patients
with acute chest pain and nondiagnostic electrocardiograms. J Am Coll Cardiol 1998;
31:1011.",
" </td>",
" <td rowspan=\"4\">",
" 357",
" </td>",
" <td rowspan=\"4\">",
" In-hospital",
" </td>",
" <td>",
" AMI",
" </td>",
" <td>",
" 0.9",
" </td>",
" <td rowspan=\"4\">",
" N/A",
" </td>",
" <td>",
" 12",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Cath",
" </td>",
" <td>",
" 19",
" </td>",
" <td>",
" 33",
" </td>",
" </tr>",
" <tr>",
" <td>",
" CAD",
" </td>",
" <td>",
" 7",
" </td>",
" <td>",
" 23",
" </td>",
" </tr>",
" <tr>",
" <td>",
" Revasc",
" </td>",
" <td>",
" 5",
" </td>",
" <td>",
" 16",
" </td>",
" </tr>",
" <tr>",
" <td rowspan=\"2\">",
" Udelson JE, Beshansky JR, Ballin DS, et al. Myocardial perfusion imaging
for evaluation and triage of patients with suspected acute cardiac ischemia: a
randomized controlled trial. JAMA 2002; 288:2693.",
" </td>",
" <td rowspan=\"2\">",
" 1215",
" </td>",
" <td rowspan=\"2\">",
" 30 d",
" </td>",
" <td>",
" MI",
" </td>",
" <td>",
" 0.6",
" </td>",
" <td>",
" 0.8",
" </td>",
" <td>",
" 10.3",
" </td>",
" </tr>",
" <tr>",
" <td>",
" MI, death, revasc",
" </td>",
" <td>",
" 3",
" </td>",
" <td>",
" 6.1",
" </td>",
" <td>",
" 20.5",
" </td>",
" </tr>",
" </tbody>",
" </table>",
" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" MI: myocardial infarction; revasc: revascularization; CAD: coronary artery
disease.",
" </div>",
" <div class=\"reference\">",
" Soman P, Udelson JE. Imaging patients with chest pain in the emergency
department. In: Nuclear Cardiology: State of the art and future directions, 3rd ed,
Mosby, Philadelphia 2005.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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var title_f0_30_494="Amniochorionic inflammation";
var content_f0_30_494=[" <div id=\"graphicsToolbar\">",
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" <a href=\"?imageKey=OBGYN
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title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=OBGYN
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title=\"Print this page\">",
" Print",
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" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
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" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 470px\">",
" <div class=\"ttl\">",
" Amniochorionic inflammation",
" </div>",
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" </div>",
" <div class=\"lgnd\">",
" <div class=\"footnotes\">",
" CRH: corticotropin releasing hormone; TNF: tumor necrosis factor; IL:
interleukin; PG: prostaglandins.",
" </div>",
" <div class=\"reference\">",
" Courtesy of Charles Lockwood, MD.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
var script_f0_30_494=[""].join("\n");
var outline_f0_30_494=null;
var title_f0_30_495="Adult proximal humerus fracture 2";
var content_f0_30_495=[" <div id=\"graphicsToolbar\">",
" <div id=\"graphicsCopy\">",
" &copy;2013 UpToDate",
" ^{",
" &reg;",
"}",
" </div>",
" <div id=\"graphicsLinks\">",
" <a href=\"?imageKey=EM
%2F59038&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\">",
" <img alt=\"Print this page\" src=\"./../images/icn_print.myextg\"
title=\"Print this page\"/>",
" </a>",
" <a class=\"icontxt textLink\" href=\"?imageKey=EM
%2F59038&amp;source=image_view&amp;view=print&amp;elapsedTimeMs=1\" onclick=\"\"
title=\"Print this page\">",
" Print",
" </a>",
" <a class=\"etacLink\" href=\"#\">",
" <img alt=\"Email graphic(s)\" src=\"./../images/icn_email.myextg\"
title=\"Email graphic(s)\"/>",
" </a>",
" <a class=\"icontxt textLink etacLink\" href=\"#\" title=\"Email graphic(s)\">",
" Email",
" </a>",
" </div>",
" </div>",
" <div class=\"graphic\">",
" <div class=\"figure\" style=\"width: 470px\">",
" <div class=\"ttl\">",
" Displaced (two-part) proximal humerus fracture",
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" </div>",
" <div class=\"lgnd\">",
" This anteroposterior radiograph shows a signficantly displaced fracture of the
humerus at the surgical neck. In the Neer classification system this is categorized
as a two-part fracture. The superior displacement of the distal fragment was
clinically apparent as shortening of the upper arm.",
" <div class=\"footnotes\">",
" </div>",
" <div class=\"reference\">",
" Courtesy of Rebecca Bassett, MD.",
" </div>",
" </div>",
" </div>",
" </div>",
"</div>"].join("\n");
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