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Good filling of the treated coronary artery branches should be noted before cardiopulmonary bypass is weaned cheap fosamax 70mg with amex. Aortic Valve Insufficiency Whether the anomalous coronary is unroofed or reimplanted discount 35 mg fosamax with amex, the commissure between the left and right aortic sinuses may needs to be partially dissected away from P 70mg fosamax visa. It must be subsequently resuspended to the aortic wall or patch to prevent aortic valve dysfunction. Cardioplegia During the procedure, additional doses of cardioplegic solution are delivered directly into the coronary ostia with an olive-tipped cannula. Difficult Anatomy If inspection of the anomalous coronary anatomy suggests a technically difficult transfer or disruption of the intercoronary commissure by an unroofing procedure, the aorta should be closed and coronary bypass graft considered (the left or both internal thoracic arteries to the left system or the right internal thoracic artery to the right coronary). The consultative attending intensivist may not need any training, because their practice needs are not such that it is required. For the active frontline intensivist, the Competence Statement is a good guide for the scope of practice, with additional skills added according to interest and practice requirements. Competence should be defined by the scope of practice, but in some situations, there is an added layer of complexity. The hospital credentialing committee must grant the privilege to perform critical care ultrasonography. If the clinician has achieved competence during fellowship training as defined by their program director, hospital credentialing committees routinely grant privileges. This may not be the case for attending level intensivists, where other physician specialists perceive economic or political threat to granting the privilege to a physician who is not a radiologist or cardiologist. In this case, the intensivist may be competent, and yet be blocked from performing within their scope of practice. One solution to this problem is to provide strong evidence of training, such that the credentialing committee cannot but grant privileges. This evidence would include a comprehensive log of all scanning activity, cognitive training, image review, and course attendance. The American College of Chest Physicians has designed a training program to provide competence and to fulfil requirements to obtain hospital privileges. Limitations of Critical Care Ultrasonography Competence in critical care ultrasonography requires an understanding of its limitations. Related to patient factors: Obesity, heavy musculature, and edema may degrade the ultrasonography image to a major extent. The presence of subcutaneous air may block transmission of ultrasound, so that deeper structures cannot be visualized. For example, most critically ill patients are supine, so that posterior structures may be difficult to image. Related to the physics of ultrasonography: the physics of ultrasound limit the resolution and penetration of ultrasound in body tissues, and artifacts are common that may mimic abnormalities. Ultrasound is blocked by air owing to intense reflection such that the presence of air precludes any visualization of underlying structures. Structures in the lung that are completely surrounded by air are invisible, ribs block visualization of the heart or brain, whereas gas-filled intestine blocks visualization of abdominal structures. Related to the operator: the intensivist who performs critical care ultrasonography is responsible for all the aspects of image acquisition, interpretation, and application of the results to the clinical problem at hand. A limitation of critical care ultrasonography relates to the need for the intensivist to be fully trained and therefore competent in those aspects that are relevant to their practice needs. Rather than having several stand-alone chapters summarizing various aspects of ultrasonography, the editors have embedded ultrasonography in a disease- or procedure-specific manner that is clinically relevant to the frontline intensivist. The accompanying video library serves to provide guidance for a wide variety of critical care ultrasonography applications. Cholley, B: International expert statement on training standards for critical care ultrasonography Expert Round Table on Ultrasound in. Assessing the Effectiveness of Pain Relief Critically ill patients often are incapable of communicating their feelings because of delirium, obtundation, or endotracheal intubation. After a single or a few bolus injections, these medications are typically short acting because of rapid redistribution out of the brain. Hypoalbuminemia, common in critical illness, decreases protein binding and increases free-drug concentration. Because free drug is the only moiety available to tissue receptors, decreased protein binding increases the pharmacologic effect for a given plasma concentration. Aging leads to (1) a decrease in total body water and lean body mass; (2) an increase in body fat and, hence, an increase in the volume of distribution of lipid-soluble drugs; and (3) a decrease in drug clearance rates, because of reductions in liver mass, hepatic enzyme activity, liver blood flow, and renal excretory function. There is a progressive, age- dependent increase in pain relief and electroencephalographic suppression among elderly patients receiving the same dose of opioid as younger patients. To provide a proper anesthetic, medications should be selected according to the nature of the procedure and titrated according to the patient’s response to surgical stimuli. In addition, specific disease states should be considered in order to maximize safety and effectiveness. Head Trauma Head-injured patients require a technique that provides effective yet brief anesthesia, so that the capacity to assess neurologic status is not lost for extended periods of time. In contrast, if the medications last too long, there may be difficulty in making an adequate neurologic assessment following the procedure. Accordingly, sufficient analgesia should be provided during and after invasive procedures to reduce plasma catecholamine and stress hormone levels. Renal and/or Hepatic Failure the association between sepsis and acute renal failure has been recognized for many years. The risk of an adverse drug reaction is at least three times higher in azotemic patients than in those with normal renal function. This risk is magnified by excessive unbound drug or drug metabolite(s) in the circulation and changes in the target tissue(s) induced by the uremic state. Liver failure alters the volumes of distribution of many drugs by impairing synthesis of the two major plasma-binding proteins, albumin and α1-acid glycoprotein. In addition, reductions in hepatic blood flow and hepatic enzymatic activity decrease the clearance rates of many drugs. Midazolam is rarely used alone as a hypnotic; however, its profound anxiolytic and amnestic effects render it useful in combination with other agents. Dexmedetomidine does not reliably produce unconsciousness; however, its sedation is not accompanied by ventilatory depression and it potentiates opioid analgesia, thereby permitting lower opioid doses. The required doses will be higher in patients with tolerance, and should be reduced in elderly patients and in patients with decreased cardiovascular function. Propofol Description Propofol is a hypnotic agent associated with pleasant emergence and hangover characteristics. It is extremely popular because it is readily titratable and has more rapid onset and offset kinetics than midazolam. Thus, patients emerge from anesthesia more rapidly after propofol than after midazolam, a factor that may make propofol the preferred agent for sedation and hypnosis in general, and in particular for patients with altered level of consciousness. The ventilatory response to rebreathing carbon dioxide during a maintenance propofol infusion is similar to that induced by other sedative drugs (i. Nevertheless, spontaneously breathing patients anesthetized with propofol are able to maintain normal end-tidal carbon dioxide values during most minor surgical procedures.

Ethylene glycol poisoning often results in higher anion gaps than other causes of this abnormality [56 discount 35mg fosamax with visa,43 order 35mg fosamax mastercard,80 buy fosamax 35mg amex,81]. The differential diagnosis of an increased anion gap metabolic acidosis is discussed above (see “Alcoholic Ketoacidosis” section). In young children, child abuse and inborn errors of organic acid metabolism should be considered in the differential diagnosis [78,82]. Calcium levels are initially normal but may drop significantly as calcium complexes with oxalic acid to form calcium oxalate. The osmol gap (refer to Chapters 97, 137, and 198) is frequently used as a diagnostic test in the evaluation of these patients. First, the serum osmolality should be measured by the freezing point depression, as vapor pressure osmometry will not detect methanol, ethanol, and isopropanol. Although an osmol gap greater than 10 mOsm is often sought as indirect evidence of the presence of an exogenous alcohol or glycol, failure to find an elevated osmol gap does not rule out significant alcohol or glycol ingestion [80]. Cumulative measurement error in the formula parameters, variations of the formula itself, and the natural variability in the osmol gap at baseline contribute to imprecision in the calculated osmol gap [30,85,86]. Furthermore, as the parent alcohol or glycol is oxidized to the toxic-charged metabolite, the osmol gap disappears. Conversely, an elevated osmol gap is not specific for alcohols or glycols, as lactic acidosis, ketoacidosis, and sepsis can also increase the osmol gap [80]. In studies of various control populations not exposed to methanol, isopropanol, or ethylene glycol, osmol gaps averaged approximately −1 to −2 mOsm per kg [31,87,88]. Thus, although an arbitrary upper limit of 10 mOsm per kg has historically been used for the normal osmol gap, an osmol gap of 10 mOsm per kg in a patient whose usual baseline gap is 0 could represent substantial serum concentrations of ethylene glycol (62 mg per dL) or methanol (32 mg per dL) [81]. One patient with an osmol gap of only 11 mOsm per kg had an ethylene glycol level of 38 mg per dL and subsequently developed renal failure [43], whereas another patient with an osmol gap of 7. Thus, an elevated osmol gap may suggest the presence of an alcohol or glycol, but a normal gap does not rule out a small ingestion or a late presentation. Microscopic examination of the urine for crystals is another indirect diagnostic test frequently recommended. Calcium oxalate monohydrate (needle-shaped) and calcium oxalate dihydrate (envelope-shaped) crystals can both be seen, but the monohydrate may be confused with uric or hippuric acid crystals [43,90]. The dihydrate crystals tend to occur at higher concentrations and convert to the monohydrate form within 24 hours [91], but are also nonspecific and can be found in the urine after ingestion of oxalate-containing foods such as rhubarb. Other nonspecific urinary findings can include low specific gravity, proteinuria, hematuria, and pyuria. Some antifreeze manufacturers add fluorescein to their products to facilitate the detection of radiator leaks. Wood’s lamp examination of the urine or gastric aspirate to detect fluorescence is unreliable and should not be used to make or exclude the diagnosis. Other drugs, food products, toxins, and even endogenous compounds cause urine to fluoresce, as do the containers used to collect urine [92,93]. The caveats noted under ethylene glycol for the evaluation and interpretation of these parameters apply equally to methanol. Lactic acidosis may be seen late in the course of methanol poisoning and may result from inhibition of the mitochondrial electron transport system or from poor tissue perfusion [42]. Amylase elevations and pancreatitis can occur in up to one-half of severely poisoned patients [66,94]. Computed tomography scanning can demonstrate cerebral edema, as well as frontal lobe and basal ganglia hemorrhages and infarcts associated with poor clinical outcomes. Antidotal therapy, cofactor therapy, and hemodialysis may be necessary in addition to supportive care to achieve these goals. Gastric aspiration via a nasogastric tube may be beneficial when performed within an hour of an intentional ingestion. Oral activated charcoal is ineffective, but may be considered when coingestants are suspected [95,96]. First, unlike the metabolites in lactic acidosis and ketoacidosis, the metabolites of ethylene glycol and methanol cannot be transformed to regenerate bicarbonate [43], and the acidosis must be corrected with exogenous alkali. Second, increasing the serum pH enhances the ionization of acid metabolites, making them less diffusible, trapping them in the blood and extracellular fluid, and limiting their tissue penetration [42]. Third, urinary alkalinization may increase excretion of acid metabolites through ion trapping, provided renal function remains normal [35,90]. In ethylene glycol poisoning, however, the hypocalcemia that occurs as calcium complexes with oxalate may be worsened by alkali administration. Calcium chloride/gluconate should be administered to correct symptomatic hypocalcemia including seizures, but the indiscriminate use of calcium salts to correct a laboratory value should be avoided because it may increase the precipitation of calcium oxalate crystals [97]. Cerebral edema should be managed acutely with hyperventilation, mannitol (provided renal function is intact), and potentially intracranial pressure monitoring and decompression. Indications for antidotal therapy in cases of known or possible methanol or ethylene glycol intoxication are outlined in Table 99. Although most sources recommend administering sufficient ethanol to maintain serum ethanol concentrations between 100 and 150 mg per dL [63], limited data support this target concentration. Targeting a 1:4 molar ratio [42,101] a serum ethanol concentration of 100 mg per dL should suffice for methanol concentrations as high as 257 mg per dL or ethylene glycol as high as 540 mg per dL. Perhaps the most important limitation is the toxicity of ethanol itself, including coma, airway compromise, respiratory depression, and agitation [16,102,103]. Subsequent behavioral effects and severe mental status depression may require interventions, such as sedation and endotracheal intubation shortly after initiation of therapy. The need for these interventions as well as the continuous infusion of ethanol itself can complicate and delay interfacility transfer. Maintaining an adequate ethanol level can be difficult and interindividual variation in metabolism and removal during hemodialysis necessitate frequent monitoring of serum concentrations and dosage adjustments [102]. This allows for more opportunity for ethanol-related medication errors, such as excessive ethanol dose, inadequate monitoring, and inappropriate antidote duration, as compared with fomepizole therapy [104]. Finally, ethanol therapy is relatively contraindicated in patients on disulfiram or similar medications, patients with hepatic disease, and patients with alcohol addiction. Admission to an intensive care setting is considered mandatory for an individual receiving ethanol therapy. Despite these advantages, ethanol should not be overlooked as a viable treatment option during mass outbreaks or times of limited resources or drug availability [109]. Currently, fomepizole is only available in a parenteral formulation, although oral administration of this same formulation has similar pharmacokinetics and efficacy [110]. Highly selected patients treated with fomepizole may also avoid hemodialysis (discussed later), intensive care unit admission, or even interfacility transfer [48,49,90,95,106,107,110–115]. These advantages are even more important in the setting of mass epidemics and in pediatric exposures [116]. Adverse drug events associated with fomepizole therapy are infrequent, but include rash, eosinophilia, minimal hepatic transaminase elevations, nausea, vomiting, and abdominal pain [121].

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In addition best fosamax 70 mg, aberrations in for example around the limits of viability discount 35 mg fosamax, and post term effective 35mg fosamax. It is generally the case that assessment of gestational age in late pregnancy is less accurate than late pregnancy dating. This is because fetal ultrasound measurements are associated with a larger absolute error with advanc- Measurement of the fetus ing gestation, and because fetal growth disturbances become more prevalent, meaning that an abnormally the most common methods for estimating fetal size at small fetus could be misjudged to have lower gestational any one time are by measuring fetal biometry using ultra- age (while a macrosomic fetus may be ascribed a more sound; or clinically, but also less accurately, by measure- advanced gestational age). It has been shown that relevance in women who attend for their first antenatal universal third‐trimester ultrasound (compared with care visit late in pregnancy and where no other reliable selective ultrasound, which is only carried out based on estimation of gestational age is available. Thus, the potential for error failed to demonstrate benefit of routine late pregnancy should be taken into account in order to ensure safe ultrasound in low‐risk or unselected populations, in terms obstetric practice: for example, in preterm labour where of perinatal mortality, preterm birth less than 37 weeks, late estimation of gestational age suggests a value above caesarean section rates, and induction of labour rates [11]. First, the earliest reliable ultrasound scan taken using standard ultrasonographic planes. The landmarks are (1) centrally positioned, continuous midline echo (falx cerebri); (2) midline echo broken anteriorly at one‐third of its length by the cavum septum pellucidum; (3) thalami located symmetrically on each side of the midline. The landmarks are (1) a short segment of umbilical vein in the anterior third of the abdomen; (2) the stomach bubble is visible; (3) the (c) spine is seen. Note that the bladder and kidneys should not be visible in this axial cross‐section. The marked heterogeneity in these studies is helpful in counselling parents and enabling paediatri- thought to be due to the variety of methodologies cians to make management decisions), there are disad- applied, including the use of different fundal height vantages of using only a single summary measure of size. The single randomized pounded, resulting in 95% confidence intervals for ran- trial in the literature, involving 1639 women, showed no dom error in the region of 14% of birthweight. A more difficult scenario occurs in fetuses that exhibit a relative decrease in size over time by ‘cross- ing centiles’ but which remain above this cut‐off of the Summary box 3. In these cases careful clinical assessment is required; it is not known how many centiles (or standard ● Fetal growth charts should be based on ultrasound, deviations) can be crossed before the risk of adverse out- not on charts of birthweight; this is because in birth- come increases significantly. Birthweight charts should not be used for should be assessed using prescriptive standards which assessment of fetuses. This is because in birthweight show how fetuses should grow when nutritional, envi- charts those with poor growth are over‐represented at ronmental and health constraints on growth are mini- preterm gestations, even when excluding those births that mal. This is different from references that represent the are indicated for growth restriction; in other words, babies distribution of biometry within a population. However, this too is not the World Health Organization recommends the use 5000 of standards to assess human growth [23]. While refer- ences describe how fetuses (or newborns or infants) have grown at a particular time and/or place, standards 4000 describe how they should grow when nutritional, envi- ronmental and health constraints on growth are mini- mal. Thus, standards are prescriptive: they demonstrate 3000 how growth should occur under near optimal condi- tions. It is important to note that the distribution of biometry within a population does not constitute a 2000 standard; this is because populations at high risk may exhibit growth that is suboptimal and is associated 1000 with higher rates of adverse perinatal outcome. While the concept of growth standards has been widely accepted in paediatrics [24], until recently there has 0 been a relative lack of knowledge regarding optimal 26 28 30 32 34 36 38 40 fetal growth. Selection was firstly based at population was applied to measure the weight, length and head cir- level: eight diverse urban populations living in demar- cumference of all newborns born in the entire popula- cated geographical or political areas were selected based tion [26]. Infants were then followed up to the age of 2 on healthy environments free from pollutants, altitude years for detailed assessment of growth and less than 1600m, and low perinatal morbidity and mor- neurodevelopment. These standards challenge the perception of Fetal biometry was measured every 5 weeks by ultra- optimal fetal growth and also how growth problems sound using highly standardized, blinded and scientifi- should be identified and defined. Screening for fetal growth restriction with universal 2 World Health Organization. A systematic review of the ultrasound Antenatal Care for Uncomplicated Pregnancies. J Epidemiol translucency thickness, free beta‐human chorionic Community Health 2013;67:999–1005. Routine introducing the symphyseal–fundal height‐ ultrasound screening for the prediction of gestational measurement. Ultrasound Obstet Gynecol Cochrane Database of Systematic Reviews 2012, Issue 1999;14:23–28. International standards for early fetal size and pregnancy 17 Royal College of Obstetricians and Gynaecologists. The dating based on ultrasound measurement of crown– Investigation and Management of the Small‐for‐ rump length in the first trimester of pregnancy. Acta Paediatr impact of choice of reference charts and equations on 2015;104:987–996. Broadly, for any medical condition, there should be a Pre‐conception or pre‐pregnancy counselling involves discussion about whether becoming pregnant has risks seeing women several months prior to conception in for the mother or fetus. Pre‐pregnancy counselling will inform women of their risks, empowering them to make an informed decision Purpose of pre‐conception whether or not to proceed with pregnancy. It will allow counselling planning or prevention of pregnancy, and access to the appropriate multidisciplinary specialized services if nec- All women considering having a baby should see their essary. Pre-conception Counselling 39 Who needs pre‐conception Healthcare professionals who counselling? Specialists also have a role, particularly conditions that may be aggravated by pregnancy, in diabetologists, neurologists and cardiologists, who will particular the commoner conditions including epilepsy, be seeing adolescents and women of reproductive age diabetes, congenital or known acquired cardiac disease, for regular checks of their diabetes, epilepsy or heart autoimmune disorders, obesity with body mass index disease. The recommendation especially Unfortunately some specialists may be reluctant to dis- applies to women prior to having assisted reproduction cuss the implications of medical disease and the associ- and other fertility treatments. They are well informed as to the effects vated to see a doctor prior to getting pregnant, even if of various medical diseases in pregnancy and are aware they have a medical illness. Many will clinics or pre‐pregnancy health check clinics would be have dedicated pre‐conception clinics in tertiary care. Many maternal medicine specialists will also be able to Additionally, it is estimated that 25–40% of pregnancies offer detailed contraceptive advice and in many instances are unplanned. Unplanned pregnancies are associated are able to administer long‐acting contraceptives, avoid- with adverse outcomes, including low birthweight ing delay in gaining effective contraception. The average age of first sexual intercourse is 16 years Women intending to conceive should be encouraged to and 0. Two‐thirds of these girls potatoes), protein (lean meat, fish, beans and lentils), undergo a termination of pregnancy [3]. These will assist in increasing the conditions, such as complex congenital heart disease, stores of vitamins, iron and calcium. Continuing a would necessitate a discussion about pregnancy during healthy diet in pregnancy can have beneficial effects on adolescence (12–15 years old) depending on the degree childhood cardiovascular function [2]. This is not to encourage preg- the unpredictability regarding the exact moment a nancy in these teenagers, but to educate them of the risks woman becomes pregnant leads to the recommendation that unintended pregnancy may hold for them. Even a contraceptive agents, including progesterone‐containing planned pregnancy is not detected until 5–6 weeks of implants, intrauterine devices and injections, are 20–100 gestation, at which stage vulnerable organs, particularly times more effective in preventing pregnancy than con- the central nervous system, have already started devel- traceptive pills or barrier methods such as condoms [2]. There is some Food containing pregnancy evidence that the risk of other congenital malformations may be reduced with folate and multivitamin supple- Unpasteurized milk Soft mould‐ripened mentation [9]. High caffeine intake mildly ● skin pigmentation (melanin reduces the absorption increases the risk of fetal growth restriction. A Women with renal disease may not metabolize vitamin higher dose of folic acid (5 mg daily) is required in women: D effectively and will require the use of active vitamin D metabolites instead [11]. It is estimated that if all preg- Subfertility nant women stopped smoking there would be a 10% Miscarriage reduction in fetal and infant deaths.

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Necrosis and hemorrhagic inflammation quickly develop buy 70mg fosamax with visa, causing the sudden onset of severe respiratory distress with dyspnea buy 70 mg fosamax with mastercard, cyanosis purchase 70mg fosamax, and diffuse diaphoresis accompanied by fever, tachycardia, and tachypnea. On pulmonary auscultation, moist, crepitating rales are evident, and findings consistent with pleural effusions may be apparent. Chest X-ray demonstrates a widened mediastinum without a definite parenchymal infiltrate. The combination of a widened mediastinum accompanied by pleural effusions should immediately raise the possibility of inhalation anthrax. Thoracentesis reveals hemorrhagic fluid, and Gram stain and culture are both usually positive. Death can be very sudden, and patients have been reported to die “in mid-sentence. Between 1 and 7 days after spores are inoculated into the skin, a small papule develops. The vesicle subsequently ruptures, and a black eschar becomes evident at the base of the ulcer (ure 13. Despite the erythema and swelling, lesions are not painful, but they may be mildly pruritic. Lymphangitis, lymphadenopathy, fever, and malaise may accompany infection of the skin. The arms are the most frequent sites of infection; the face and neck are also commonly involved. A single lesion is usually found, although multiple sites may become infected as a result of simultaneous inoculations. Usually, a single lesion develops on an exposed area of the body, an arm being most common. This disease occurs primarily in developing countries, usually after ingestion of contaminated meat. These symptoms are rapidly followed by acute abdominal pain, hematemesis, and bloody diarrhea. Findings on examination suggest an acute surgical abdomen, and moderate leukocytosis with immature band forms is seen. Rapid progression to toxemia and shock leads to death within 2-5 days after the initial onset of symptoms. Inflammatory lesions that resemble the cutaneous lesions develop on the posterior pharynx, hard palate, or tonsils. Tissue necrosis and edema are accompanied by sore throat, dysphagia, fever, regional lymphadenopathy, and toxemia. Diagnosis A careful epidemiologic history is the single most important means of reaching the diagnosis. In cases of natural infection, a history of contact with herbivores or products from these animals, particularly if the products come from outside the United States, should raise the possibility of anthrax. In the setting of a possible bioterrorist attack, employment history and a history of being present in a contaminated area are important clues. Diagnosis must therefore be presumptive, and the threshold for treatment should be low to prevent progression from mildly symptomatic to life-threatening disease. Nasal swabs are helpful for determining the physical parameters of exposure, but not for deciding individual treatment or prophylaxis. Positive cultures of blood and cerebrospinal fluid usually accompany a fatal outcome. Enzyme-linked immunosorbent assays for antibodies against lethal toxin and edema toxin are available. For epidemiologic purposes, samples from the nose and face can be obtained using rayon-tipped swabs. Cultures from these sites are specific, but insensitive, and, in the individual patient, cannot be used to decide whether to begin treatment. Nasal samples can be used to determine the physical perimeters of exposure, and the resulting data can used to determine who should receive prophylactic antibiotics. The physical appearance of the skin lesions is characteristic, and Gram stains and cultures of the ulcer base are frequently positive. A rise in multiple titers by a factor of four over 4 weeks or in a single titer to 1:32 is considered positive. Treatment Although penicillin has been recommended as the treatment of choice for naturally occurring anthrax, penicillin-resistant natural strains have been reported. Penicillin-resistant strains of anthrax have also been genetically engineered as bioterrorist weapons, and the military protocol recommends intravenous ciprofloxacin (400 mg twice daily) or doxycycline (200 mg loading dose, followed by 100 mg twice daily) as first-line therapy (see Table 13. Penicillin is recommended as an alternative, once sensitivities have been obtained. Because penicillin treatment induces β-lactamase activity, penicillin should be combined with an additional antibiotic. Two other antibiotics that demonstrate activity against anthrax should be combined with any of the above agents in the seriously ill patient, including rifampin, vancomycin, imipenem, meropenem, and clindamycin. Treatment should be continued for 60 days, with a switch to oral antibiotics as the patient’s clinical condition improves. Excision of skin lesions is contraindicated because of the increased risk of precipitating bacteremia. However, after appropriate antibiotic therapy, excision and skin grafting may be necessary. All individuals suspected of exposure should receive prophylaxis: a) Give a fluoroquinolone (ciprofloxacin, levofloxacin, or ofloxacin) or alternatively doxycycline for 60 days. A human monoclonal antibody, raxibacumab, directed against protective antigen has proved efficacious in multiple animal studies, and in monkeys resulted in a 64% survival rate for inhalation anthrax as compared with 0% for the placebo control group. A single dose of 40 mg/kg is recommended for children and adults weighing over 50 kg. Before antibiotics became available, cutaneous disease resulted in a mortality of 10-20%. Despite appropriate antibiotics and respiratory support, inhalation anthrax is frequently fatal. Prophylaxis A killed vaccine derived from a component of the anthrax exotoxin is available and is recommended for all industrial workers at risk of exposure to contaminated animal products. As a result of increased concerns about biologic warfare and bioterrorism, military personnel are now vaccinated. To date, surveillance studies have not detected any serious or unexpected adverse reactions. The regimen of choice is an oral fluoroquinolone or, if fluoro-quinolones are contraindicated, doxycycline (see Table 13.

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