Catawba College. P. Gambal, MD: "Buy online Malegra FXT - Best online Malegra FXT no RX".
Perceived priorities of key public health stakeholders in Europe on the use of health communication for the prevention and control of communicable diseases cheap 140mg malegra fxt with amex erectile dysfunction protocol foods. Paper presented at meeting organised by the Directorate General for Health & Consumers; 2011 discount malegra fxt online visa erectile dysfunction doctor brisbane. A total of nine reviews [1-9] were undertaken to collate and synthesise current evidence in the area of health communication with particular relevance to the prevention and control of communicable diseases in the European context order malegra fxt 140 mg with visa erectile dysfunction middle age. Three types of review were undertaken: rapid review of reviews of evidence [1-3] purchase generic malegra fxt on-line erectile dysfunction treatment protocol, literature reviews [4-7], and systematic literature reviews [8-9]. Evidence review: social marketing for the prevention and control of communicable disease . Literature reviews Four literature reviews were undertaken: A literature review on health information-seeking behaviour on the web: a health consumer and health professional perspective . A literature review of trust and reputation management in communicable disease public health . Health communication campaign evaluation with regard to the prevention and control of communicable diseases in Europe . A literature review on effective risk communication for the prevention and control of communicable diseases in Europe . Systematic literature reviews Two systematic literature reviews were undertaken: Systematic literature review of the evidence for effective national immunisation schedule promotional communications . Systematic literature review to examine the evidence for the effectiveness of interventions that use theories and models of behaviour change: towards the prevention and control of communicable diseases . All reviews involved a search of the relevant databases using relevant, specified search terms, for English language literature and included both published and grey literature. For details of the specific search strategy pertaining to each review see the review reports [1-9]. The results are presented in the form of a matrix of the strengths and weakness of the evidence base for each of the topic areas. The series of reviews represents three distinct approaches ranging from more descriptive reviews of literature to more analytical systematic reviews. This is reflected in the matrices with some analysis presented in a more descriptive format while others are more analytical. Please see Appendix 2 to view the strengths and weaknesses matrix template and the accompanying explanation of key domain categories. Strengths • Health literacy has been defined as the degree to which individuals have the capacity to obtain, process and understand the basic health information and services needed to make appropriate health decisions . Models & theories Were there any models, theories or frameworks identified in the review? Strengths A number of frameworks exist, including Coulter & Ellins’  classification of a typography which proposes four types of health literacy interventions: • written health information interventions; • alternative format interventions; • low literacy initiatives; and • targeted mass media campaigns. Weaknesses • Most interventions have a focus which is limited to the accessibility of written information and alternative formats for the provision of information. Tools Did the review identify any tools that facilitate step by step practical application? Weaknesses • The existing measures all operate at the functional level of literacy and are criticised for measuring literacy rather than health literacy. Evidence What evidence was identified in the review and what was the quality of the evidence? Strengths The interventions in the reviews included: randomised control trials, complex interventions, controlled and uncontrolled experimental designs. The criteria which were used included: • adequacy of study population • comparability of participants • validity of the literacy measurement • reliability of the literacy measurement • maintenance of comparable groups • appropriateness of the outcome measure • appropriateness of statistical analysis • control of confounders • eligibility criteria specified • outcome assessor blinded for all primary outcomes • point estimates and measure of variability given for all primary outcomes • intention-to-treat analysis • a priori sample size calculation • a participant flow diagram. Quality • Two of the five reviews did not apply quality criteria to the included interventions [18, 19]. Behavioural and other changes • Changes in self-efficacy and/or confidence relating to health and/or health behaviour. Weaknesses No identified indicators of success at the interactive or critical levels of health literacy. Application What has been applied into practice in the area of health literacy for the prevention and control of communicable diseases? Strengths • This evidence review identified five reviews with a total of 84 studies [15, 16, 17, 18, 19]. European An evolving body of North American evidence at functional literacy level with possible application to the European context. In addition, many of the studies were mainly located in North America, thus reviews may only be generalised in a limited way to other contexts and health systems. Targeting including hard-to-reach populations No focus on disadvantaged populations – some authors noted the exclusion of some disadvantaged populations . The references cited in this matrix table and upcoming tables are listed in Appendix 3. Strengths • In the context of public health, advocacy strives to optimise health by addressing the environmental, social, political and economic factors that impact on health . Weaknesses • The word advocacy and its underlying concept do not translate directly into other languages [25, 22]. Models & theories Were there any models, theories or frameworks identified in the review? Strengths • A number exist – as an example, this review includes one relating to physical activity developed by Shilton . Weaknesses To date, little focus on developing models and theories specifically for communicable diseases. Commonly included in the toolkits are guides to: • public speaking • designing an advocacy campaign • generating media interest and • lobbying. Weaknesses No evidence of formal or systematic evaluation of health advocacy interventions was identified in this review. Evidence What evidence was identified in the review and what was the quality of the evidence? Public health campaigns to change industry practices that damage health: an analysis of 12 case studies. Two campaigns from each of the six target industries were chosen, reviewed, analysed and coded with the aim to: • examine the interactions between advocacy campaigns and their industry targets; • explore the roles of government, researchers and media; and • identify those characteristics of campaigns that succeed in changing health-damaging practices . However, recent developments, particularly in the application of a theory of change, have strengthened the knowledge base [33, 34]. Behavioural and other changes • No interventions in the review by Freudenberg et al. Behavioural and other changes • None of the interventions in the review by Freudenberg et al. Application What has been applied into practice in the area of health advocacy for the prevention and control of communicable diseases? Focus • The interventions included in the review of health advocacy initiatives were focused on changing the health-damaging practices related to alcohol, automobiles, firearms, food and beverages, pharmaceuticals and tobacco corporations. No evidence review of health advocacy interventions has been carried out in Europe. Focus No evidence review of health advocacy interventions in communicable diseases in Europe was found.
May be associated with leading edge of subepithelial fibrosis or Salzmann nodular degeneration e cheap malegra fxt 140mg visa erectile dysfunction doctor in hyderabad. May be quiescent with less dilated vessels and little growth or "active" with dilated vessels and progressive growth centrally on the cornea f buy malegra fxt cheap erectile dysfunction causes alcohol. Punctate staining or dellen formation may be present central to the cap on the cornea g order generic malegra fxt canada erectile dysfunction vascular disease. Restriction of ocular mobility may occur buy malegra fxt without prescription erectile dysfunction statistics canada, especially on lateral gaze with extensive lesions or lesions recurrent after prior surgeries 2. May occur in any meridian and is non-adherent to the limbus so a probe can be passed beneath it 2. Usually appears morphologically different, lacks radial orientation and vascular straightening associated with pterygium B. Ultraviolet B blocking eyeglasses or sunglasses may have a role in reducing the likelihood of progression or recurrence B. Excision of pinguecula in rare cases when chronically inflamed, interferes with contact lens wear, or for cosmetic reasons. Occurs most frequently following simple excision leaving bare sclera and least frequently with primary closure, conjunctival grafting, amniotic membrane transplantation with/without mitomycin C application b. Dellen formation related to inadequate smoothing at limbus or a thickened conjunctival graft 4. Irregular astigmatism - less likely with avulsion of the head from the cornea or blunt dissection 6. Corneal and/or scleral melting following treatment with mitomycin C or radiation C. Limbal versus conjunctival autograft transplantation for advanced and recurrent pterygium. Low-dose intraoperative mitomycin-C versus conjunctival autograft in primary pterygium surgery: long term follow-up. A comparative study of recurrent pterygium surgery: limbal conjunctival autograft transplantation versus mitomycin C with conjunctival flap. Expression in pterygium by immunohistochemical analysis: a series report of 127 cases and review of the literature. Salzmann nodules may develop due to enzymatic disruption of the Bowman layer, anterior migration and proliferation of keratocytes, and secondary deposition of extracellular matrix B. Treatment only indicated if one of the criteria listed above is met Additional Resources 1. Morphologic and confocal investigation on Salzmann nodular degeneration of the cornea. Chronic exposure to mercurial vapors or to mercurial preservatives in ophthalmic medications vi. Fine, dust like deposits in Bowman layer in the horizontal interpalpebral fissure zone i. Peripheral clear zone between the limbus and the peripheral edge of the band keratopathy 2. Horizontal band of dense calcific plaque across interpalpebral zone of the cornea, varying in color from beige-gray to chalky white b. Superficial stromal dystrophies such as Reis-Bucklers corneal dystrophy and Thiel-Behnke corneal dystrophy 5. Solution poured inside optical zone marker, trephine, or similar reservoir that is held onto corneal surface, or applied to corneal surface with soaked cellulose sponge ii. Bandage soft contact lens and antibiotic drops until epithelial defect has resolved 3. Considered for vision-limiting calcific deposits that remain after scraping and chelation b. Transepithelial ablation or ablation after epithelium has been removed (with a masking agent) c. Bandage soft contact lens and antibiotic drops until epithelial defect has resolved V. Uncertain role of prophylactic antibiotics, although topical antibacterial agent should be considered until epithelial defect has resolved b. Irregular corneal surface secondary to different rates of ablation between calcium and corneal stroma a. Probability of recurrence and necessity for repeat removals Additional Resources 1. Conjunctival pigmentation associated with skin complexion (also called benign epithelial melanosis or racial melanosis) a. Ocular melanocytosis (melanosis oculi) and oculodermal melanocytosis (nevus of Ota) 3. Kayser-Fleischer ring associated with copper deposition in Wilson disease Additional Resources 1. History of previous ocular inflammation - "red eyes", "infection", or "light sensitivity" 2. Chemical agents alter the levels of highly reactive hydrogen and hydroxyl ions in affected tissues 2. Raise pH of tissues causing saponification of fatty acids in cell membranes and cellular disruption b. Surface epithelial damage allows penetration of alkali into corneal stroma destroying proteoglycan ground substance and collagen fibers of stroma matrix c. Secondary protease expression by corneal cells and leukocytes and penetration into anterior chamber can then occur causing tissue damage and inflammation e. Damage to limbal stem cells can lead to disruption of normal repopulation of corneal epithelium, resulting in: i. Lower pH of tissues and cause denaturing and precipitation of proteins in tissues b. Cause less injury than alkalis due to buffering capacity of tissues and barrier formed by precipitated proteins c. Can cause severe inflammation leading to upregulation of protease expression resulting in damage to corneal matrix B. Amount of scleral and limbal ischemia or blanching (predictor of progression to limbal stem cell failure) b. Immediate and copious irrigation of the ocular surface with water or normal saline or any nontoxic solution that is not grossly contaminated i. Removal of particulate matter from the ocular surface with cotton-tip applicators and forceps i. Topical corticosteroids in the acute phase (inhibit leukocytes) (during first 2 weeks) b. Oral tetracyclines, citric acid (chelate calcium in the plasma membrane of leukocytes) c. Oral vitamin C (high dose, approximately 2 g per day) (ascorbic acid is a cofactor in collagen synthesis) (monitor renal status) b. Limbal stem cell replacement (cadaveric keratolimbal or living-donor conjunctival-limbal allograft) iii.
Purchase 140 mg malegra fxt. How To Cure Erectile Dysfunction Naturally || How To Get Harder and Thicker Erection At Home By This.
Statistics Canada estimates that major chronic diseases and injuries account for 3 over 33% of direct health care costs purchase 140mg malegra fxt with amex erectile dysfunction treatment ayurveda. In Ontario purchase cheapest malegra fxt and malegra fxt erectile dysfunction psychological causes, chronic diseases account for 55% of direct and indirect health costs cheap 140 mg malegra fxt overnight delivery erectile dysfunction at 55, which includes years of healthy life lost from premature death and lost productivity from disability as well as direct health 3 3٫4 care costs order discount malegra fxt on-line erectile dysfunction treatment medscape. Moreover, Ontarians with multiple serious chronic conditions consume disproportionately more health care than others with chronic conditions. Death rates, and in some cases, prevalence rates (diagnosed cases in the population), have been declining for some chronic diseases but increasing for others in recent years. A decline in death rates (crude rates, 1995 to 1999) has been seen for breast cancer (12%) and asthma (8%) while an increase has been 5 seen for lung cancer (5%). Hospitalizations for cardiovascular diseases are predicted to continue to decrease and, while some risk factors for this group of diseases are falling (e. The health care costs of diabetes and associated 7 conditions are estimated to rise by as much as 48% over the next decade. Chronic Disease can be Prevented, Detected and Managed Although chronic diseases are among the most common and costly health problems facing Canadians, they are also among the most preventable. Major chronic diseases such as cardiovascular disease (heart disease and stroke), diabetes, arthritis, asthma, and osteoporosis share common risk factors and conditions. A small group of modifiable behaviours and intermediate biological factors/risk conditions (e. These modifiable factors are influenced and shaped by societal, economic and physical conditions. Changing health behaviors and biological factors have the potential to reduce chronic disease in Ontario significantly. For example: A tobacco-free society would prevent more than 90% of lung cancer deaths 8 and 30% of all other cancer deaths. Interventions to reduce risk factors and prevent chronic disease can be extremely successful. One compelling example is the comprehensive community-based program in North Karelia, Finland, that brought cardiovascular disease and lung cancer rates in the region into line with national levels by reducing smoking rates, blood pressure, and cholesterol rates in the population through a broad mix of social and medical initiatives. For example: If 70% of women between the ages of 50 and 69 underwent mammography screening, there would be about one-third fewer breast cancer deaths over a 10 ten-year period. With the right treatment and support, people diagnosed with a chronic disease can improve their health and quality of life. Management typically involves multi- 5 faceted interventions providing integrated social and medical support for people 12 with chronic conditions. For example: People with diabetes who attended an interdisciplinary, community-based self-care clinic experienced an average 14% drop in blood glucose levels 13 within one year. A New Approach to Chronic Disease The current health care system was designed to address acute ‘Clients’ in this paper are individuals who use illness rather than chronic health care and other health services, and disease. As a result, medical includes healthy individuals and those suffering from disease. Care tends to be reactive – responding to acute health problems when they present. As a result: Medical practitioners rely on clients to contact the system Patients are usually passive while medical practitioners administer treatment 17 Visits are symptom focused versus patient-centred Promoting the client’s overall health, preventing disease, injury, disability, and ensuring continuity of care across providers are not system priorities. These features render the prevailing model of care inappropriate for tackling chronic disease. For example, in Ontario: 58% of diabetes patients are tested for HbA1C, and of those tested, less 18 than 50% had optimal blood glucose levels. A more responsive approach to chronic disease would recognize that chronic disease: Is ongoing, and therefore warrants pro-active, planned, integrated care within a system that clients can easily navigate Involves clients living indefinitely with the disease and its symptoms, requiring them to be active partners in managing their condition, rather than passive recipients of care Requires multi-faceted care which calls for clinicians and non-clinicians from multiple disciplines to work closely together, to meet the wide range of needs of the chronically ill Can be prevented and therefore warrants health promotion and disease prevention strategies targeted to the whole population, especially those at high risk for chronic disease. Internationally and within Canada there is growing interest in redesigning health care organizations and practice to improve the quality of care and to close the gap in care between what is known to improve outcomes, and what is practiced. This will require health care organizations to re-think current approaches to chronic disease management while exploring ways to build health promotion and disease prevention into health care practice and the lives of their clients. It supports health care system changes from one that is designed for episodic, acute illness to one that will support the prevention and management of chronic disease. In practice, jurisdictions have found that simply adding new elements such as self-management programs or client registries to a system solely focused on episodic, acute care does not change delivery of care substantially or improve health outcomes. Changing delivery of care to improve outcomes requires fundamental system changes in the design of practice and provision of self-management supports. The Framework is a ‘roadmap’ to a chronic care delivery system that provides effective care and better health outcomes. The Framework can be applied to both specific and generic chronic disease practice, and to different types of health care organizations. The Framework’s roadmap for effective chronic disease management addresses the distinct needs of clients with chronic conditions as it aims to provide multi- faceted, planned, pro-active seamless care in which the clients are full participants in managing their care and are supported to do this at all points by the system. Ontarians with chronic conditions will experience a change both in their care and their disease management. They will become equal partners in their own health and full collaborators in managing their conditions, and they will be supported in this. Their care will be organized and delivered to give the expert care they need when and where they need it, without their having to struggle through the system on their own, bounced from provider to provider. Their care will be planned and based on the best evidence, and both providers and clients will be supported in following through with the plan. Effective chronic disease management includes the implementation of prevention measures to halt the disease’s progress and to prevent complications and co-morbidities. Prevention in the Charter includes interventions both to reduce the risk of disease among chronically ill individuals and individuals at high risk of developing disease, as well as broad initiatives to improve health 9 within the population as a whole and prevent new cases of chronic disease from occurring. The Charter identifies five action areas in which to do this: Development of personal skills necessary to staying healthy Re-orientation of health services to greater health promotion and disease prevention Building public policies that promote health and prevent disease Creating environments supportive to health Strengthening community action. Actions in these areas not only address the risk factors for an Determinants of health: individuals’ health, but also • Income and social status address the full range of factors • Education and literacy that determine the populations’ • Social support networks health. The determinants of • Employment/working conditions health range from individual • Social environments genetic make-up to socio- • Physical environments economic factors such as • Personal health practices and coping skills income and education. Community agencies deliver much of the promotion/prevention in Ontario, especially promotion/prevention directed at populations of individuals. The Framework makes community providers important partners, linking them with health care providers – through systematic referrals, collaborations to reach underserved populations – for example, to exploit fully the capacity and resources of both sectors to deliver quality care, support client self-management, and prevent chronic disease. The Framework also promotes broader community strategies – led by individuals, families, advocates, and/or agencies – to improve health and reduce the incidence of disease among Ontarians through activities that address the determinants of health. These outcomes will result from both increased prevention/promotion in clinical practice and in the community, as well as improved delivery of chronic disease care. The improved delivery of care will not only ensure quality care in the appropriate setting by the appropriate provider at the right time, but will also increase efficiency in the system. Evidence also indicates that the Framework’s approach will save health care system resources by reducing hospitalizations and use of emergency departments, reducing duplication of services, and helping Ontarians to stay healthy. As indicated earlier, major chronic diseases and injuries account for 33% of 3٫ 4 direct health care costs and 55% of direct and indirect health costs in Ontario. A high proportion of these costs are consumed by the relatively small proportion of individuals with multiple serious chronic conditions. Studies in British Columbia found that in that province, individuals with very high co-morbidity used seven times the inpatient hospital days, four times the physician visits, five times the home care (nursing, rehab), and two and a half times the home support 25٫ 26 services as the population average.
Degree of corneal opacification i) Unable to visualize endothelium in cases of corneal opacification 2 purchase malegra fxt mastercard erectile dysfunction medication and heart disease. Mode i) Automated - appropriate when endothelial mosaic well-visualized ii) Manual - appropriate when endothelial cell borders not well visualized or endothelial mosaic interrupted by guttae ii order malegra fxt with american express coke causes erectile dysfunction. Endothelial cell density i) Normal adult endothelial cell density is 2000-3000 cells/mm2 iii cheap malegra fxt 140 mg online erectile dysfunction oral treatment. Endothelial cell morphology - cell shape and size i) Coefficient of variation - Average cell size divided by the standard deviation of the average cell size (i) Normally < 0 purchase malegra fxt american express causes of erectile dysfunction in 50s. Less than 50% hexagonal cells may be an indication of poor cell function Additional Resources 1. Current state of in vivo confocal microscopy in management of microbial keratitis. The relative value of confocal microscopy and superficial corneal scrapings in the diagnosis of Acanthamoeba keratitis. Application of in vivo laser scanning confocal microscopy for evaluation of ocular surface diseases: lessons learned from pterygium, meibomian gland disease, and chemical burns. Presents an illuminated series of concentric rings and views the reflection from the corneal surface (handheld Placido disc, collimating keratoscopes) a. Collects reflected data points from the concentric rings and creates a map of the cornea 3. Uses color-coded map to present the data with warmer (red and orange) colors representing steeper curvature of the cornea and cooler (blue and green) colors representing flatter curvature. Instantaneous radius of curvature (tangential power): better sensitivity to peripheral changes iii. Useful in detecting irregular astigmatism or multifocal corneas- irregular corneal reflex, scissoring reflex 2. Helpful in determining etiology for unexplained decreased vision or unexpected post-surgical results including: under corrected aberrations, induced astigmatism, decentered ablations, irregular astigmatism, etc 9. Quality and reproducibility of images is operator dependent and dependent on quality of tear film 11. Non-standardized data maps; user can manipulate appearance of data by changing scales; colors may be absolute or varied (normalized) 12. Reflex is neutralized using appropriate spherocylindrical lenses yielding information on sphere and astigmatism 4. Non-linear or multiple reflexes that cannot be fully neutralized are seen in irregular astigmatism 5. Decreased light reflex may also indicate cataract or other optic pathway obstruction (i. The front of the cornea acts as a convex mirror whose reflection generates a virtual image of a target 2. The keratometer measures the size of the images reflected from at least four points of the central 2. A vergence formula is used to report the radius of curvature in millimeters or refracting power in diopters 4. Useful in detecting irregular astigmatism or multifocal corneas- irregular corneal reflex, scissoring reflex 2. Not useful for changes outside the central cornea (radial keratotomy, keratoconus) Additional Resources 1. The anterior segment is imaged by a rotating Scheimpflug camera, which measures thousands of elevation points to create a 3D image 2. Wavefront sensing devices measure the cumulative sum of optical aberrations induced by each structure in the visual pathway 3. Light rays from a single (safe) laser beam are aimed into the eye and the light rays reflect back from the retina in parallel rays 5. Aberrations inside the eye cause the light rays to change directions and a wavefront sensor collects this information in front of the cornea 6. Other methods for wavefront sensing: Tscherning and Tracy - measure wavefront as light goes into the eye 7. All wavefront systems give a detailed report of higher order aberrations mathematically. The aberrated wavefront can be described by Zernicke polynomials to quantify spherical aberration, coma, etc. Anterior elevation maps useful for evaluating anterior ectasias, guiding astigmatism treatment, glare symptoms, haze symptoms, unexplained decreased vision, central islands 3. Posterior elevation maps useful for evaluating posterior ectasias, glare symptoms, haze symptoms, unexplained decreased vision 4. Pachymetry map useful in giving measurement of corneal thickness throughout the cornea 5. Allows clinicians to detect subtle variations in power distributions of the anterior corneal surface 10. Helpful in explaining unexpected post-surgical results including: undercorrection, aberrations, induced astigmatism, decentered ablations, etc. Non-standardized data maps; can manipulate appearance of data by changing scales; colors may be absolute or varied (normalized) 15. Provides similar functions as listed in scanning-slit corneal tomography (items 1-12) 2. Rotating image process helps better identify central cornea and correct for eye movements 3. Higher cost compared with Placido based computerized corneal topography and scanning-slit corneal topography 4. Keratoconus detection program useful in determining what size penetrating keratoplasty button to use due to peripheral corneal thinning 7. Only technology currently available that is able to measure and quantify higher order aberrations 2. Should be useful for all situations where computerized corneal tomography is helpful (see above) 4. Measuring solely corneal aberrations may assist in improving refractive procedure selection 2. Clinical and research applications of anterior segment optical coherence tomography-a review. Recent advances in ophthalmic anterior segment imaging: a new era for ophthalmic diagnosis? Thought to be due to elastotic degeneration and collagenolysis that leads to laxity of the adherence of the conjunctiva to the underlying connective tissue 3. Suggested that enzyme accumulation in the tear film due to delayed tear clearance may lead to degradation of the conjunctiva B. Loose conjunctival folds interposed between the inferior globe and the margin of the lower eyelid a. If the chalasis is nasally located it may cause punctal occlusion and delayed tear clearance 2. Folds may be single or multiple, and may be lower than, equal to, or higher than the tear meniscus 3. With fluorescein or Rose Bengal stain, discrete areas of staining may be present on the redundant bulbar conjunctiva and the adjacent lid margin.
Sulfonamides mimick p-aminobenzoic acid order malegra fxt 140mg visa reflexology erectile dysfunction treatment, a substrate for dihydro- • pteroate synthetase generic 140 mg malegra fxt with amex erectile dysfunction 50. Sensitivity to β-Lactamases • Enzymes that inactivate penicillins by opening β-lactam rings • Allow bacteria to be resistant to penicillin • Transferable between bacterial strains (i buy malegra fxt in india zinc erectile dysfunction treatment. Pseudomonas aeruginosa • Low toxicity • High resistance to β-lactamases • Poor stability in solution (ten times less stable than Pen G) β-Lactamase Inhibitors Clavulanic acid (Beechams 1976)(from Streptomyces clavuligerus) • Weak buy generic malegra fxt 140mg on line erectile dysfunction young age, unimportant antibacterial activity • Powerful irreversible inhibitor of β-lactamases - suicide substrate • Used as a sentry drug for ampicillin • Augmentin = ampicillin + clavulanic acid • Allows less ampicillin per dose and an increased activity spectrum • Timentin = ticarcillin + clavulanic acid Glycopeptide antibiotics: Vancomycin Hubbard & Walsh, Angew. Inhibition of transglycosylation by Vancomycin D D • Vancomycin forms tight hydrogen bonds with the Ala- Ala terminal unit of the pentapeptide, thereby capping the pentapeptides • Vancomycin can form rather stable head-to-tail dimers • Due to the large size of Vancomycin it acts as a steric block preventing access from the transglycosylase and transpeptidase enzymes Structure of the complex between Vacomycin and a tripeptide Knox et al. Originally: Naturally occurring microbial products Today: Any agent used to treat infections 3 Mechanisms of antibiotics • Bacteriostatic • Bactericidal 4 Bacteriostatic antibiotics • Thetracyclines • Spectinomycin • Sulphonamides • Macrolides • Chloramphenicol • Trimethoprim 5 Bactericidal antibiotics • Penicillins • Cephalosporins • Fluoroquinolones (Ciprofloxacin) • Glycopeptides (Vancomycin) • Monobactams • Carbapenems 6 What is antimicrobial resistance I? T h eability ofa m icroorganism to survive ata given concentration ofan antim icrobial agentatwh ich th enorm alpopulation ofth e m icroorganism would bekilled T h isiscalled th e “ Epidem iological breakpoint”. T h eability ofa m icroorganism to survivetreatm entwith a clinical concentration ofan antim icrobial agentin th ebody. Posters for office A poster displayed • avoid treating positive cultures in disturbance, seizure, encephalopathy) in the practice waiting room stating a the absence of signs/symptoms • Hyperkalemia (cotrimoxazole) commitment to reducing antibiotic use • Skin: minor/major (e. Handouts for Patients according to local bacterial prevalence patient due to r bacterial resistance http://healthycanadians. Vancomycin Graphic design: Dealing with Patient’s Expectations & Demands Debbie Bunka, Colette Molloy (designmolloy. Neither the authors nor Saskatoon Health Region nor any other party who has been involved in the preparation or publication of this work warrants or represents that the information contained herein is accurate or complete, and they are not responsible for any errors or omissions or for the result obtained from the use of such information. Readers are encouraged to confirm the information contained herein with other sources. Cough suppressantsm ay be considered form anaging cough,& humidifier to maintain - Humidifier: clean frequently to risk of inhaled bronchodilatorsifw heezing ispresent. There was an ↑ risk of adverse events (nausea, rash, diarrhea) difference in clinicalim provem ent. Itcan also help identify patients pathogens Azithrom ycin: There are concernsw ith using (see ClinicalQ & A) 500m g po daily x 3 days,or m acrolidesasm onotherapy due to w ho m ay require broaderspectrum antibiotics. Due to the long t½ (~68 M onotherapy sufficientform ost,although som e Canadian referencessuggestthe hoursin adults),a 3-day course ofazithrom ycin isin essence providing therapy option ofcom bining doxycycline w ith a beta-lactam due to concernsw ith doxycycline beyond 3 days. Doxycycline (m ax 200m g/day)x 7 -10 days Azithrom ycin 10m g/kg po Day 1 (m ax 500 Itisdifficultforpediatricpatients ClinicalQ & A m g/dose),then 5m g/kg po to produce a sputum sam ple. H ow ever,antibiotics w ho do notrequire diagnostictesting (see below )orantibiotics. Not recommended for symptom management: Controversial as to whether or not asymptomatic carriers with recurrent pharyngitis Routine use of corticosteroids. If patient insists, encourage a Avoid identifying asymptomatic carriers without recurrent pharyngitis. See V iral& bacterialsinusitishave sim ilarsym ptom s,butsym ptom sthat alarm sym ptom son nextpage. Incidence issim ilaram ong those treated w ith antibiotics w orsen orare prolonged (≥10 days)suggestbacterialinvolvem ent. H ow ever,due to lim itationsw ith these,the guidelines saline nasal drops/rinses/irrigation - Anecdotally, nasal drops/sprays may help. In otherw ords,outof1000 patients Most sinusitis cases improve without antibiotics. Watchful waiting should be presenting w ith sinusitis,5 to 20 patientsw ould have bacterialsinusitis, considered in patients who: and 4 to 17 ofthese bacterialcasesw ould resolve w ithoutantibiotics. H ow ever,the addition of x 10 days(m axim um 3g/day) to high-dose am oxicillin, Am oxicillin clavulanate ↑ the risk ofG Iadverse events. Duration oftherapy,ifneeding to treatw ith an antibiotic: - Considerassessm entforallergies,im m unologicdeficiency,orsurgery. O verall,there Alarm Sym ptom sforUrgentReferralto Em ergency Room : w asno difference in adverse events. H ow ever,in the sensitivity analysis(5 vs10 - system ic toxicity;altered m entalstatus;severe headache;sw elling ofthe orbitor days),shortcourseshad few eradverse events(O R 0. In concentration-dependentkilling,an antim icrobialism ore effective ata higherdose. Classificationsare notabsolute -forexam ple,agentsm ay be bacteriostaticin m ostsituationsbutbactericidalathigh concentrations,orbacteriostaticagainstsom e organism sand bactericidalagainstothers. Anaerobiccoverage can be im portantin situationssuch asaspiration pneum onia,intra-abdom inalinfections,and diabeticfootulcers. Antim icrobialsw ith good activity include m etronidazole,clindam ycin,am ox-clav,and m oxifloxacin. Asa result,they cannotbe view ed undera gram stain and are naturally resistantto allbeta-lactam s. Antim icrobialsw ith good activity include m acrolides,fluoroquinolones,and tetracyclines. Com m on beta-lactam ase producersinclude H aem ophilus influenzae,Neisseria gonorrhoeae,M oraxella catarrhalis,Escherichia coli,Proteus,Klebsiella,and Bacteroidesfragilis. H ow ever,today Staph aureusisreliably resistantto penicillin,am oxicillin,and am picillin through beta-lactam ase production. In response,beta-lactam ase-resistantantibioticsw ere invented,like m ethicillin,cloxacillin,and oxacillin. Am oxicillin Considerw atchfulw aiting in acute otitism edia forsuitable children (see page 78). M ax: 1000-4000m g/day $40 risk 2-4/1000 vsbaseline riskof1-2/1000 Excellentbioavailability. M ax: 3000m g/day Cephalosporins:Bindsto penicillin binding proteinson bacterialcellw alls,inhibiting cellw allbiosynthesis. G onorrhea resistance to cefixim e ~ 2% in Canada (com bine cefixim e w ith am acrolide due to resistance + to add chlam ydiacoverage). Riskofallergy cross-sensitivitybetw een cephalosporinsand penicillinsislow -see AntibioticOverview page. Enterobacter; Peds: 8m g/kg po q24h $29 20m g/m Lsusp straw berry Neisseria;Proteus;E. Stearate:250m g po q6h $20 Erythrom cyin Estolate 50m g/m Lsusp ❄ H asbeen used to increase G Im otilitye. Non-estolate: Estolate form ulation:contraindicated in pregnancy ( hepatotoxicity),butbestin kidsasm ostacid stable. Situp aftertaking foratleast30 m inutes,and take w ith a fullglassofw ater,to reduce riskofpillslodging in the esophagusand causing ulceration. Pg 12 OralAntibiotics(continued) Treatw ith adequate dose & appropriate duration © w w w. M ayhave lessabsorption via jejunostom ytube since fluroquinolonesare likelyabsorbed in the duodenum.