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James E. Tisdale, PharmD, BCPS, FCCP, FAPhA, FAHA

Professor, College of Pharmacy, Purdue University, West Lafayette
Adjunct Professor, School of Medicine, Indiana University, Indianapolis, Indiana

https://www.phpr.purdue.edu/directory/jtisdale

Predicting acute uncomplicated urinary tract infection in women: a systematic review of the diagnostic accuracy of symptoms and signs blood pressure levels good cheap 45 mg midamor with visa. The review also examined the diagnostic value of individual symptoms and signs combined with dipstick test results in terms of clinical decision making hypertension 12080 purchase 45 mg midamor with visa. Diagnostic accuracy improves considerably when combined with dipstick tests blood pressure changes cheap midamor 45 mg with mastercard, particularly tests for nitrites arteria renal cheap 45 mg midamor amex. This supports the use in this flowchart of a stepwise approach, using symptoms initially, moving on to urine dipsticks if there are fewer discriminatory symptoms and signs. The presence of vaginal discharge combined with a negative result for combined nitrites and leucocyte-esterase dipstick test reduces the post-test probability further to 15%. Other infectious causes include urethritis, sexually transmitted infections, and vaginitis. An initial targeted history includes features of a local cause (for example, vaginal or urethral irritation), risk factors for a complicated urinary tract infection (for example, men, pregnancy, presence of urologic obstruction, recent procedure), and symptoms of pyelonephritis. The syndrome may include but is not limited to genital symptoms of dryness, burning, and irritation; sexual symptoms of lack of lubrication, discomfort or pain, and impaired function; and urinary symptoms of urgency, dysuria and recurrent urinary tract infections. Six simple physiological parameters form the basis of the scoring system: Last review: Nov 2018. The recommendations state that advice should be given on self-care to all those with expected pyelonephritis. Advice is given on antibiotic choice and administration and to reassess if symptoms worsen rapidly or significantly at any time, or do not start to improve within 48 hours of taking the antibiotic, taking account of: other possible diagnoses any symptoms or signs suggesting a more serious illness or condition, (such as sepsis) previous antibiotic use, which may have led to resistant bacteria Admission should be considered in those aged 16 years and over with acute pyelonephritis if they are significantly dehydrated or unable to take oral fluids and medicines, or are pregnant, or have a higher risk of developing complications. Self-care advice includes the use of paracetamol for pain relief and drinking enough fluids to avoid dehydration. The negative predictive value when nitrite, leukocytes, and blood are all negative was 76%. The positive predictive value for having nitrite and either blood or leukocytes was 92%. The authors conclude that although dipsticks can moderately improve diagnostic precision, they are poor at ruling out infection. What is the predictive value of urinary symptoms for diagnosing urinary tract infection in women The subjects comprised 343 women 14 years of age or older who consulted their family physician for incident urinary tract symptoms. The decision aid took into account 4 diagnostic criteria: the presence of burning or pain on urination symptoms present for 1 day the presence of leukocytes (greater than a trace amount) and the presence of nitrites (any positive, including trace amounts) Total antibiotic prescriptions, unnecessary prescriptions and recommendations for urine culture results were determined and compared with management. Three of the original decision aid variables (dysuria, the presence of leukocytes [greater than a trace amount], and the presence of nitrites [any positive]) were associated with having a positive urine culture result, but 1 variable (symptoms for 1 day) was not. A simplified decision aid incorporating the 3 significant variables had a sensitivity of 80. Following decision aid recommendations would have reduced antibiotic prescriptions by 23. Clinical relevance of laboratory-reported antibiotic resistance in acute Last review: Nov 2018. Symptomatic treatment of uncomplicated lower urinary tract infections in the ambulatory setting: randomised, double blind trial. The primary outcome was resolution of symptoms at day 3 (72 hours after randomisation and 12 hours after intake of the last study drug). The pre-specified principal secondary outcome was the use of any antibiotic (including norfloxacin and fosfomycin as trial drugs) up to day 30. Effectiveness of 5 different approaches in management of urinary tract infection: randomised controlled trial. Inpatient therapy is recommended for patients who have severe illness or in whom a complication is suspected. Patients often present with acute onset of irritative (for example dysuria, urinary fre quency, urinary urgency) or obstructive (for example hesitancy, incomplete voiding, straining to urinate, weak stream) voiding symptoms. Suprapubic, rectal, or perineal pain, painful ejaculation, hematospermia, and painful defecation may be present as well. Systemic symptoms, such as fever, chills, nausea, emesis, and malaise, commonly and occur and should indicate the need to consider sepsis. The physical examination should include abdominal, genital, and digital rectal examination to assess for a tender, enlarged, or boggy prostate. Diagnosis is predominantly made based on history and physical examination, but may be aided by urinalysis. Management of acute bacterial prostatitis should be based on severity of symptoms, risk factors, and local antibiotic resistance patterns. Urine cultures should be obtained in all patients who are suspected of having acute bacterial prostatitis to determine the responsible bacteria and its antibiotic sensitivity pattern. The evidence review for the prostatitis guidelines summarizes some of the more recent evidence around the diagnosis of prostatitis. Diagnostics for acute bacterial prostatitis include a mid-stream urine sample for dipstick testing, then culture for bacteria and antibiotic sensitivity. Therefore, other conditions with similar presentations should also be considered when making a diagnosis of acute prostatitis. They were investigated by excretory urography, cysto urethroscopy, uroflowmetry, digital rectal examination and measurement of post-void residual urine volume by abdominal ultrasonography. In all, surgically correctable disorders were found in 20 patients, of whom 15 had previously unrecognised abnormalities. To reveal abnormalities of clinical importance, any urological evaluation should primarily be focused on the lower urinary tract. Evaluation of the nitrite and leukocyte esterase activity tests for the diagnosis of acute symptomatic urinary tract infection in men. The missing nitrite and leucocyte test data may be secondary to the fact that, according to the general practitioner guidelines in the Netherlands, the leucocyte test should not be performed when results of the nitrite test are positive. Findings indicated that for all patients for whom both the nitrite test and the leucocyte test were performed, the sensitivity of the nitrite test was 47%, and the specificity was 98%. Women who presented with urinary symptoms were divided into 2 age groups (45 to 54 years, n = 102, mean age 48. There was a positive correlation between being older and reporting urine urgency, painful voiding (dysuria), incontinence, low back-pain, and lower abdominal pain. Older women reported more generalised unspecific symptoms (lower abdominal pain, lower back pain, chills, constipation, and diarrhoea) and incontinence issues. Symptoms were grouped as voiding-related symptoms, local constant symptoms, and generalised symptoms. A diagnostic and treatment algorithm was implemented in the multifaceted intervention, suggesting that urine cultures should be ordered if there is a fever of over 37. Antibiotics should only be prescribed in cases of systemic symptoms of infection with an in-situ catheter. Fewer courses of antimicrobials were prescribed in the intervention nursing homes than in the usual care homes (weighted mean difference 0. Development of minimum criteria for the initiation of antibiotics in residents of long term-care facilities: results of a consensus conference. Using a modified delphi approach, a questionnaire and selected relevant articles were sent to participants who were asked to rank individual signs and symptoms with respect to their relative importance. Using the results of the weighting by participants, a modification of the nominal group process was used to achieve consensus. They also all exhibited a fever and had some collecting device that provided clear clinical pointers to the diagnosis. During the course of this study the death rate in this institution dropped to about half of what was anticipated, and returned to previous levels following completion of the study. Infection can be recognized at a very early stage despite an atypical geriatric presentation, and early treatment reduces morbidity and mortality.

Weight of Mechanistic Evidence Pollard and Selby (1978) appear to present evidence of vaccine rechal lenge leading to symptoms of peripheral neuropathy in a patient heart attack bar generic midamor 45mg with visa, subse quently diagnosed with a spontaneously relapsing remitting neuropathy blood pressure form buy cheap midamor 45 mg line, who developed symptoms in association with acute viral infections; how ever arrhythmia center of connecticut buy midamor 45 mg fast delivery, the authors did not rule out other possible causes and did not provide 2J hypertension orthostatic discount 45 mg midamor. The spontaneous development of peripheral neuropathy makes it diffcult to conclude that the tetanus toxoid vaccines were the causative agent. Furthermore, Hughes and colleagues (1996) do not report the latency between adminis tration of the additional tetanus toxoid vaccines and the development of peripheral neuropathy. Latencies considered to be long would reduce the association of the development of symptoms with the administration of the vaccine. The observed number of cranial nerve disorders in the Tdap cohort (126 events) was greater than the historical Td cohort (100. The authors concluded that the risk of cranial nerve disorders following Tdap vaccination is not signifcantly higher than the risk following Td vaccination, which only provides information on the safety of the acellular pertussis antigen component. Weight of Mechanistic Evidence While rare, infection with Clostridium tetani or Corynebacterium diph theria has been associated with facial nerve palsy (MacGregor, 2010; Reddy and Bleck, 2010). Mechanistic Evidence the committee identifed 11 publications describing clinical, diagnostic, or experimental evidence of anaphylaxis after the administration of vac cines containing diphtheria toxoid, tetanus toxoid, and acellular pertussis antigens alone or in combination. Two publications reported a temporal association between administration of a tetanus containing vaccine and development of symptoms, but the committee did not consider the symp toms to be defnitive anaphylaxis (Bohlke et al. Four publications reported anaphylaxis after vaccination but did not report a time frame between vaccination and development of symptoms (Nakayama and Onoda, 2007; Peng and Jick, 2004; Pollock and Morris, 1983; Thierry-Carstensen et al. Described below are fve publications that contributed to the weight of mechanistic evidence. Bhatia (1985) described a 12-year-old boy presenting with a deep wound on a lower limb. Due to a family history of allergy, a test dose of a 1:10 dilution of tetanus toxoid was administered intradermally. Within a few minutes the patient developed local pain and itching increasing to generalized urticaria, a rapid thready pulse, and severe bronchospasm. Bilyk and Dubchik (1978) described the case of a 38-year-old patient Copyright National Academy of Sciences. Two to three minutes after receiving purifed and adsorbed tetanus toxoid the patient developed dizzi ness, tinnitus, nausea, vomiting, erythematous skin rash, tachycardia, and breathing diffculty. Mandal and colleagues (1980) described the case of a 21-year-old woman (case 1) presenting with restlessness, itching over the tongue ini tially and then the whole body, a sensation of warmth, inspiratory diffculty with rhonchi, tightness in the throat with voice change, pain in the lower back and abdomen, erythema and swelling of the face and neck, and an urticarial rash on the limbs 2 to 3 minutes after receiving the second dose of a tetanus toxoid vaccine. Mansfeld and colleagues (1986) describe two cases of anaphylaxis after exposure to a tetanus toxoid vaccine. Case 1 describes a 33-year-old woman presenting with a severe anaphylactic reaction involving wheezing, facial edema, and peripheral urticaria 5 minutes after skin prick testing to full-strength tetanus toxoid. Furthermore, at the age of 4 years the patient developed an urticarial rash and fever after receiving tetanus toxoid and tetanus antitoxin. Case 2 (case 3 in the publication) describes a 23-year old highly atopic man who collapsed after experiencing wheezing and generalized itching after skin prick testing with full-strength tetanus toxoid. Zaloga and Chernow (1982) reported the case of a 20-year-old man presenting with dyspnea, wheezing, lightheadedness, stridor, and the loss of consciousness within minutes of receiving purifed fuid tetanus toxoid. The patient recovered after treatment with two doses of epinephrine and diphenhydramine hydrochloride. Weight of Mechanistic Evidence the publications, described above, presented clinical evidence suffcient for the committee to conclude the vaccine was a contributing cause of ana phylaxis after administration of a tetanus toxoid vaccine. The clinical de scriptions establish a strong temporal relationship between administration of a tetanus toxoid vaccine and anaphylaxis. In addition, two publications reported the development of symptoms after either skin prick or intrader mal testing with either a full strength or dilution of a tetanus toxoid vaccine suggesting the presence of IgE to one or more components in the vaccine. The committee assesses the mechanistic evidence regarding an as sociation between tetanus toxoid vaccine and anaphylaxis as strong based on six cases presenting temporality and clinical symptoms consistent with anaphylaxis. Mechanistic Evidence the committee did not identify literature reporting clinical, diagnostic, or experimental evidence of chronic urticaria after the administration of vaccines containing diphtheria toxoid, tetanus toxoid, and acellular pertus sis antigens alone or in combination. Weight of Mechanistic Evidence Autoantibodies, complement activation, IgE hypersensitivity, and mo lecular mimicry may contribute to the development of chronic uriticaria; however, the committee did not identify literature reporting evidence of these mechanisms after administration of vaccines containing diphthe ria toxoid, tetanus toxoid, and acellular pertussis antigens alone or in combination. Mechanistic Evidence the committee identifed one publication reporting clinical, diagnos tic, or experimental evidence of serum sickness after the administration of vaccines containing diphtheria toxoid and tetanus toxoid antigens alone or in combination. Daschbach (1972) described a 7-year-old boy present ing with typical serum sickness 3 days after administration of a diphtheria and tetanus toxoid vaccine while being treated for a burn. Weight of Mechanistic Evidence the publication did not present clinical evidence suffcient for the committee to conclude the vaccine may be a contributing cause of serum sickness after administration of a diphtheria toxoid and tetanus toxoid vac cine. The presence of precipitins to tetanus could cause immune complexes in vivo, which are a known mechanism of serum sickness. The committee assesses the mechanistic evidence regarding an as sociation between diphtheria toxoid or tetanus toxoid vaccine and serum sickness as weak based on one case. The committee assesses the mechanistic evidence regarding an as sociation between acellular pertussis vaccine and serum sickness as lacking. A self-report questionnaire was sent to the cases and controls to assess ex posures in the 10 years before disease onset; 64. The cases were di agnosed with rheumatoid arthritis by a rheumatologist and were identifed at rheumatology units in Sweden. Controls were selected from the national population register and matched to cases on age, sex, and residential area. A questionnaire was given to the cases and controls to report vaccination histories in the 5 years before disease onset. A total of 1, 998 (95 percent) cases and 2, 252 (81 percent) controls completed the questionnaire and were included in the analysis. The major weakness of the study was that it employed no independent verifcation of reported immunizations, and past studies have suggested that many people do not keep careful written records nor do they have accurate memories of past immunizations. The odds ra tio for rheumatoid arthritis diagnosis within 5 years of administration of tetanus toxoid vaccine was 1. The authors concluded that tetanus toxoid or diphtheria vaccination does not increase the risk of rheumatoid arthritis. Weight of Epidemiologic Evidence the two studies described above had serious limitations and low preci sion. Also, there was no assessment of pertussis antigen exposure, which is a component of many vaccines for diphtheria and tetanus toxoid administered in the United States. See Table 10-4 for a summary of the studies that contributed to the weight of epidemiologic evidence. The committee has limited confdence in the epidemiologic evi dence, based on two studies that lacked validity and precision, to assess an association between diphtheria toxoid or tetanus toxoid vaccine and chronic arthritis. The epidemiologic evidence is insuffcient or absent to assess an association between acellular pertussis vaccine and arthropathy. Adverse Effects of Vaccines: Evidence and Causality 569 Copyright National Academy of Sciences. Adverse Effects of Vaccines: Evidence and Causality 570 Copyright National Academy of Sciences. Sidebotham and Lenton (1996) did not provide clinical, diagnostic, or experimental evidence of causality, including the latency between administration of a diphtheria and tetanus toxoid vaccine and development of joint aches after vaccina tion. In addition, four publications reported the concomitant administration of vaccines, making it diffcult to determine which, if any, vaccine could have been the precipitating event (Aksu et al.

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Recommendations for renal dose adjustment are made according to estimated creatinine clearance (CrCl) calculated using the Cockroft-Gault equation arrhythmia getting worse midamor 45 mg overnight delivery, which is used in practice arrhythmia signs and symptoms buy cheap midamor 45mg. Recommendations for renal dose adjustment in the table below are for modifications of the maintenance doses; no adjustments are required for loading doses where applicable blood pressure medication dehydration buy generic midamor on-line. Please consult your local pharmacy department for guidance in patients receiving peritoneal dialysis blood pressure machine name generic midamor 45 mg, continuous veno venous hemofiltration, continuous veno-venous hemodiafiltration or continuous renal replacement therapy. In critically ill patients (ex: sepsis), antimicrobial pharmacokinetics can be significantly altered and unstable potentially resulting in sub-optimal dosing. Oral Suspension Treatment of invasive fungal infections: 400 mg q12h or 200 mg four times daily for patients unable to tolerate a meal or nutritional supplement Therapeutic drug monitoring may be 6 mg/kg q12h x 2 Accumulation & resultant toxicity of the diluent can occur if CrCl less than 50 mL/min. Non beta-lactam alternatives may be: less effective, more toxic, broader spectrum, more expensive and more likely to 4, 13, 15, 16, 17 lead to infection or colonization with resistant organisms. Practice however is changing because allergies have been better defined and the role of the chemical structure on the likelihood of cross-reactivity is now better understood. Immunologic reactions to medications are generally classified according to the Coombs and Gell 5, 9 classification of hypersensitivity reactions (see table 2). The onset and presentation of the reaction can be used to help classify the reaction and determine whether or not a beta-lactam antibiotic may be 5, 9 used (table 2). Penicillins 20, 21, 22 Penicillin is the most frequently reported drug allergy and is reported in 5-10% of the population. Studies have shown that between 80 and 95% or more of those patients reporting a penicillin allergy 52 do not in fact have true hypersensitivity reactions and the vast majority of these patients can tolerate 1, 10, 21, 22, 23, 24, 25 beta-lactams. The use of penicillins can be associated with a nonimmediate, nonpruritic, nonurticarial rash in up to 5, 26 10% of patients that is unlikely to be IgE-mediated and most often idiopathic or T-cell mediated. The time passed since the reaction is useful because 50-80% of penicillin allergic patients lose their sensitivity after 5 and 10 years 2, 29, 30 respectively. Cephalosporins Cephalosporin-induced skin reactions, described as urticarial, rash, exanthema and pruritus, occur in 31 approximately 1 to 3% of patients. This, accompanied with possible penicillin contamination in early cephalosporin 5, 9 production, resulted in overestimations of cross-sensitivity. The American Academy of Pediatrics states that the likelihood of a penicillin allergic 53 patient reacting to a cephalosporin with a different side chain is similar to that of a non-penicillin 5 allergic patient. The public would be better served by warnings that the use of cephalosporins, particularly third or higher generation parenteral cephalosporins, is associated with an increased risk of C difficile infection within 38 90 days. Therefore, if a patient has a cephalosporin allergy, one can 34 safely prescribe another cephalosporin that has dissimilar side chains at both C-3 and C-7 positions. A prospective study evaluating the possibility of using alternative cephalosporins in patients with confirmed cephalosporin allergy demonstrated that cephalosporin allergies are not a class effect, and that patients with confirmed cephalosporin allergy can safely receive cephalosporins with dissimilar 37 side chains. Desensitization will not prevent non-IgE mediated reactions and should never be attempted in patients with reactions involving major organs or severe cutaneous reactions. Usually the 28 procedure is complete within hours and starts in the microgram range. When the desensitization process is complete, treatment with the select beta-lactam should be started immediately and must not be 2, 28 interrupted during the treatment course. For a graduated challenge for an intravenous antibiotic, 1% of the full dose is administered, then 10 % of the full dose, then the full 2, 3 dose, separated by 30 minutes to 1 hour each and under careful observation. The decision to use a graduated challenge is based on the risk of cross-reactivity and the description and remoteness of the allergic reaction in question. Treatment options requiring desensitization or graduated challenge should be avoided in severe infections (ex. A multicenter prospective trial demonstrated that antimicrobial stewardship pharmacists performing beta-lactam allergy skin testing and graduated challenge at the point of care was 55 associated with greater use of preferred beta-lactam therapy without increasing the risk of adverse 40 drug reactions. Did the patient have any other ongoing medical problem at the time of the reaction Knowing the specific antimicrobial which caused the reaction can help in determining safe alternatives. Beta-lactams, as a class, are generally safe; allergic and adverse reactions are over diagnosed and over reported. Fearing a potential anaphylaxis secondary to beta-lactam use, many clinicians will over diagnose penicillin allergy or 2 simply accept a diagnosis of penicillin allergy from patients without a proper history of the reaction. Usually flat, barely following the initial raised, erythematous patches (one to several mm in diameter). Classical presentation spares shaded areas, such as under the chin, under the nose, behind the ears. Duration: N/A Morphology: Often resembles exaggerated sunburn, sometimes with blisters. More details: Mechanism not always clear Stevens-Johnson Onset: Delayed Region(s) affected: Less than 10% of the body surface is affected. Morphology: Often begins with dusky red, flat lesions (sometimes target-like, similar to erythema multiforme), progressing to bullae Duration: Up to 6 and necrotic lesions. Morphology: See Stevens-Johnson Syndrome; eventually can Duration: Up to 6 resemble extensive second degree burns weeks More details: Is accompanied by any (or all) of: high fever, fatigue, vomiting, diarrhea, malaise, myalgia, angina, arthralgia, headache, ocular involvement, painful stomatitis A medical emergency; in-hospital mortality more than 30% 62 Type of skin reaction Chronology Description Urticaria Onset: Immediate, Region(s) affected: Can occur in any location. Key to achieving this goal is: appropriate dosing timely administration of first dose antimicrobial within 60 to 120 minutes of surigical incision repeat dosing for prolonged procedures or in the event of major blood loss. Some agents, such as fluoroquinolones and vancomycin, require administration over one to two hours; therefore, the administration of these agents should begin within 120 minutes before surgical incision. Approximately 10% of the population report having a penicillin allergy; however, greater then 90% of these individuals are not truly allergic. For example, there is an increasing rate of gram-positive resistance to clindamycin. There is only significant risk of cross-reactivity among penicillins and between penicillins and cephalosporins with similar side-chains. Cephalosporin allergic patients may safely receive another cephalosporin with dissimilar side chains. Increasing the dose to 3 g for those weighing 120 kg or more can easily be justified. Adjust the dose if necessary immediately; do not wait for a confirmatory trough level. After that, vancomycin trough levels should be obtained once a week before dialysis. Recommendations regarding the prophylactic or as needed use of antibiotics are beyond the scope of these guidelines, please consult a local infectious disease specialist for recommendations. A single dose of Haemophilus influenzae type b (HiB) conjugate vaccine is recommended in all patients who are functionally or anatomically asplenic and greater than 5 years of age regardless of previous Hib 5, 6 6 immunization. This is despite limited efficacy data and a low overall risk of Haemophilus influenzae sepsis in patients greater than 5 6 years of age. Booster doses are recommended every 3 5 years in individuals vaccinated at 6 years of age or 6 younger and every 5 years for individuals vaccinated at greater than 6 years of age.

The hemagglutination-inhibition rubella antibody test fetal arrhythmia 38 weeks order midamor canada, which previously was the most commonly used method of serologic screening for rubella infection pulse pressure under 25 order 45 mg midamor free shipping, generally has been supplanted by a number of equally or more sensitive assays for determining rubella immunity prehypertension icd 9 discount midamor online visa, including enzyme immunoassays and latex agglutination tests blood pressure chart by age purchase 45 mg midamor. A false-positive IgM test result may be caused by rheumatoid factor, parvovirus IgM, and heterophile antibodies. Low-avidity IgG is associated with recent primary rubella infection, whereas high-avidity IgG is associated with past infection or reinfection. The avidity assay is not a routine test and should be performed in reference laboratories. Most postnatal cases are positive virologically on the day of symptom onset, and most congenital cases are positive virologically at birth. Blood, urine, and cataract specimens also may yield virus, particularly in infants with congenital infection. Contact isolation is indicated for children with proven or suspected congenital rubella until they are at least 1 year of age, unless 2 cultures of clinical specimens obtained 1 month apart after 3 months of age are negative for rubella virus. Children with postnatal rubella should be excluded from school or child care for 7 days after onset of the rash. Caregivers of these infants should be made aware of the potential hazard of the infants to susceptible pregnant contacts. All birth defects in which rubella infection is suspected etiologically should be investigated thoroughly and reported to the Centers for Disease Control and Prevention through local or state health departments. When a pregnant woman is exposed to rubella, a blood speci men should be obtained as soon as possible and tested for rubella antibody (IgG and IgM). An aliquot of frozen serum should be stored for possible repeated testing at a later time. The presence of rubella-specifc IgG antibody in a properly performed test at the time of exposure indicates that the person most likely is immune. Although live-virus rubella vaccine administered after exposure has not been demonstrated to prevent illness, vaccine theoretically could prevent illness if administered within 3 days of exposure. Immunization of exposed nonpregnant people may be indi cated, because if the exposure did not result in infection, immunization will protect these people in the future. Vaccine can be given simultaneously with other vaccines (see Simultaneous Administration of Multiple Vaccines, p 33). Clinical effcacy and challenge studies have demonstrated that 1 dose confers long-term immunity against clinical and asymptomatic infection in more than 90% of immunized people. At least 1 dose of live-attenuated rubella-containing vac cine is recommended for people 12 months of age or older. Routine serologic testing of nonpregnant postpubertal women before immunization is unnecessary and is a potential impediment to protection against rubella, because it requires 2 visits. If a woman is found to be susceptible, rubella vaccine should be administered during the immediate postpartum period before discharge. If vac cine is administered inadvertently or if pregnancy occurs within 28 days of immuniza tion, the patient should be counseled on the theoretical risks to the fetus. Immunizing susceptible children whose mothers or other household contacts are pregnant does not cause a risk. Children with minor illnesses, such as upper respiratory tract infec tion, may be immunized (see Vaccine Safety, p 41). Immunocompromised patients with disorders associated with increased severity of viral infections should not receive live-virus rubella vaccine (see Immunocompromised Children, p 74). The risk of rubella expo sure for patients with altered immunity can be decreased by immunizing their close susceptible contacts. Although small amounts of virus are shed after immunization, no evidence of transmission of vaccine virus from immunized children has been found. For patients who have received high doses of corticosteroids (2 mg/kg or greater or more than 20 mg/day) for 14 days or more and who otherwise are not immunocompromised, the recommended interval before immunization is at least 1 month (see Immunocompromised Children, p 74) after steroids have been discontinued. Salmonella enterica serotypes Typhi, Paratyphi A, Paratyphi B, and certain other uncommon serotypes can cause a protracted bacteremic illness referred to , respectively, as typhoid and paratyphoid fever and collectively as enteric fevers. The onset of enteric fever typically is gradual, with manifestations such as fever, constitutional symptoms (eg, headache, malaise, anorexia, and lethargy), abdominal pain and tenderness, hepato megaly, splenomegaly, dactylitis, rose spots, and change in mental status. Salmonella serotype Typhi is classifed in O serogroup D, along with many other common serotypes including serotype Enteritidis. In 2009, the most commonly reported human isolates in the United States were Salmonella serotypes Enteritidis, Typhimurium, Newport, Javiana, and Heidelberg; these 5 serotypes generally account for nearly half of all Salmonella infections in the United States ( The major food vehicles of transmission to humans include food of animal origin, such as poultry, beef, eggs, and dairy products. Other modes of transmission include ingestion of contaminated water; contact with infected reptiles or amphibians (eg, pet turtles, iguanas, lizards, snakes, frogs, toads, newts, salamanders) and rodents or other mammals. Chronic human carriers (mostly involving chronic infection of the gall bladder but occasionally involving infection of the urinary tract) constitute the reservoir in areas with endemic infection. Infection with enteric fever serovars implies ingestion of a food or water vehicle contaminated by a chronic carrier or person with acute infection. Nomenclature for Salmonella Organisms Complete Namea Serotypeb Antigenic Formula S enterica a subspecies enterica serotype Typhi Typhi 9, 12, [Vi]:d: S enterica subspecies enterica serotype Typhimurium Typhimurium [1], 4, [5], 12:i:1, 2 S enterica subspecies enterica serotype Newport Newport 6, 8, [20]:e, h:1, 2 S enterica subspecies enterica serotype Paratyphi A Paratyphi A [1], 2, 12:a:[1, 5] S enterica subspecies enterica serotype Enteritidis Enteritidis [1], 9, 12:g, m: aSpecies and subspecies are determined by biochemical reactions. Serotypes are now written nonitalicized with a capital frst letter (eg, Typhi, Typhimurium, Enteritidis). The serotype of Salmonella is determined by its O (somatic) and H (fagellar) antigens and whether Vi is expressed. Every year, nontyphoidal Salmonella organisms are one of the most common causes of laboratory-confrmed cases of enteric disease reported by the Foodborne Diseases Active Surveillance Network (FoodNet [ A potential risk of transmission of infection to others persists for as long as an infected person excretes nontyphoidal Salmonella organisms. Twelve weeks after infection with the most common nontyphoidal Salmonella serotypes, approximately 45% of children younger than 5 years of age excrete organisms, compared with 5% of older children and adults; antimicrobial therapy can prolong excretion. Approximately 1% of adults con tinue to excrete Salmonella organisms for more than 1 year. Diagnostic tests to detect Salmonella antigens by enzyme immunoassay, latex agglutination, and monoclonal anti bodies have been developed, as have assays that detect antibodies to antigens of enteric fever serotypes. The combination of a single blood culture plus culture of bile (collected from a bile-stained duodenal string) is 90% in detecting Salmonella serotype Typhi infection in children with clinical enteric fever. Resistance to these antimicrobial agents is becoming more common, especially in resource-limited countries. In areas where ampicillin and trimethoprim-sulfamethoxazole resistance is common, a fuoroquinolone or azithromycin usually is effective. Multidrug-resistant isolates of Salmonella serotypes Typhi and Paratyphi A and strains with decreased susceptibility to fuoroquinolones are common in Asia and are found increasingly in travelers to areas with endemic infection. Azithromycin is an effective alternative for people with uncomplicated infections. The chronic carrier state may be eradicated by 4 weeks of oral therapy with ciprofoxacin or norfoxacin, antimicrobial agents that are highly concen trated in bile. High-dose parenteral ampicillin also can be used if 4 weeks of oral fuo roquinolone therapy is not well tolerated (see Fluoroquinolones, p 800). These drugs should be reserved for critically ill patients in whom relief of manifestations of toxemia may be life saving. In children with typhoid fever, precautions should be continued until culture results for 3 consecutive stool specimens obtained at least 48 hours after cessation of antimicro bial therapy are negative. Specifc strategies for controlling infection in out-of-home child care include adherence to hygiene practices, including meticulous hand hygiene and limiting exposure to reptiles and rodents (see Children in Out-of-Home Child Care, p 133). When nontyphoidal Salmonella serotypes are identifed in a symptomatic child care attendee or staff member with enterocolitis, older children and staff members do not need to be excluded unless they are symptomatic. Stool cultures are not required for asymptomatic contacts or for return to child care following resolution of illness. Antimicrobial therapy is not recommended for people with asymptomatic nontyphoi dal Salmonella infection or uncomplicated diarrhea or for people who are contacts of an infected person. Vaccine is selected on the basis of age of the child, need for booster doses, and possible contraindications (see Precautions and Contraindications, p 640) and reactions (see Adverse Events, p 640).