Acne

Acne

Acne is a common skin condition that afflicts most people, to a varying degree, during the teen years. However, the disease is by no means restricted to this age group; adults in their 20's or 30's may have acne. Don't think that because acne is common, treatment is unnecessary. Waiting to "outgrow" acne can be a serious mistake. Medical treatment can improve your appearance and self esteem, and prevent the development of lifelong scars.The Cause of AcneAcne is actually caused by a combination of several factors:

Rising hormone levels during adolescence cause enlargement and over activity of the oil glands in the skin.

The canals that bring this oil to the surface become blocked with keratin (a protein that is part of the skin).

When these oil glands are overactive and the canals are blocked, the bacteria that normally live on the skin and in the oil become trapped. They subsequently multiply, and cause inflammation and irritation.Cleansing and CosmeticsEven though you may be told to wash frequently, acne is not a disease caused by dirt. For example, the blackness of a blackhead is not dirt, but is due to the accumulation of the normal skin pigment in the oil gland ducts.Wash your face with a mild antibacterial soap recommended by your dermatologist twice a day. If one's skin is very oily, it may be washed more often. Over washing or scrubbing tends to irritate the skin and will make acne worse. Therefore, do not use any abrasive cleaners or cleansing pads.Shampooing is also important in acne therapy. The oilier your hair is, the more often you should shampoo it. Also, it is best to keep hair off the face as much as possible to avoid hair oils.For covering blemishes, many preparations have been formulated to match skin color. These cosmetics should be water based (i.e. the first ingredient on the label should be water). Most cosmetics and skin products that are safe to use on acne-prone skin will say “non-comedogenic”, “oil free” or “won’t clog pores.”Look for these labels on your facial products. Greasy applications such as Vaseline, cocoa butter, cold cream, and vitamin E oil should be avoided. If the face is dry, your dermatologist can recommend a moisturizer for your type skin.

Diet : The idea that acne can be brought on by an unhealthy diet has been debated for years. For the last 30 years the conventional wisdom has been that diet plays no role in most cases of acne. While many Dermatologists still believe this to be true, another view is emerging. Doctors were surprised to learn that acne is virtually unknown in some remote jungle tribes. These people live off the land without the modern staples of beef, dairy, wheat and sugar. On the other hand, the age when acne first emerges is getting younger for teens in the USA along with the age of puberty.Could something in the modern diet be the culprit? Some say yes, because eating the wrong things can let loose the wrong kind of hormones.These hormones activate the oil glands in your face. High levels of hormones are present in cows milk, since most dairy cattle are pregnant. The idea that milk is an essential part of everyone's diet is probably wrong. You can easily get your calcium, vitamin D and protein from other foods, or from supplements. It may take 6 months off all dairy products before any improvement can be seen, but about 1 in 3 say this helps their acne quite a bit.

Another theory blames sugar and excess carbohydrates. These push your body to pump out insulin, which can throw off other hormones as a result. Someoverweight women with acne have hormone imbalances and excess insulin. In these women bringing the insulin level down corrects the hormone levels and acne. While there is no proof sugar and carbohydrates are important in most cases of acne, there is also no doubt sugar and excessive carbohydrates are not good for you. Eating healthy foods is a good ideafor acne sufferers.There are still others who blame particular foods for their acne. Chocolate and nuts are commonly mentioned, but these don't seem to play arole in most people's acne. The importance of diet may vary between individuals, but the idea that diet plays no role in acne is probably on the way out.

Treatment of Acne :

Acne need not be feared as something untreatable. In recent years many effective forms of therapy have been developed. Dermatologists want to prevent scars that acne can leave. Years of untreated acne can leave a lifelong imprint on a person's face and can have an effect on his or her self-image. While acne may not be curable, it is usually controllable.Since acne has many forms, your dermatologist designs an individual approach to care for successful control. Thus, the course of therapy will vary according to such factors as type of acne, it's severity and extent, and the patient's day-to-day activities.

Mild acne is treated with one or a combination of topical medications. The purpose of these is not only to treat existing acne lesions, but to prevent new blemishes from forming. Therefore, these are applied over most of your face, not just directly on the present pimples. In addition, in some people these creams may cause the face to become a little dry, pink or feel taught. This is normal. If your face becomes too irritated or 'raw' feeling, don't stop the creams, just decrease the frequency of application (i.e. apply every second or third day).Moderate and severe acne is usually treated by topical medicines with the addition of oral antibiotics. Since different combinations work better for some patients than others, you are usually evaluated every four to six weeks until the acne is well controlled.In addition to this conventional therapy, your dermatologist may recommend one or more of these treatments to speed healing and clearing of your acne:

Acne Surgery: This procedure greatly speeds acne clearing and appearance by manually removing blackheads and whiteheads. A round loop extractor is used to apply uniform smooth pressure to dislodge the material. Inserting a pointed instrument to carefully expose the contents loosens lesions that offer resistance. This may be combined with microdermabrasion, which helps to remove dead skin on the face and open up smaller blocked pores.

Intralesional Corticosteroid Therapy: If one or several painful acne cysts develop, fast relief is available with this relatively painless procedure. Each cyst is given a single injection of a dilute cortisone solution, using a very tiny needle.

Accutane Therapy: In 1982 a new oral medication, isotretinoin (Accutane), became available for the treatment of patients with severe acne not responsive to conventional treatments. The duration of treatment is usually five to six months, and one such course is often curative of severe acne forever. Use of this medication does require a thorough understanding of its side effects and precautions (e.g. the prevention of pregnancy).Treatment of Acne ScarringPrior to correcting acne scarring, it is generally advisable to wait until acne activity has been low or absent for several months. Scars improve with time as the body softens their appearance. The color contrast is often the most troublesome aspect of resolving large acne blemishes. These lesions may leave a flat or depressed red scar that is so obvious, patients mistake the mark for an active lesion. The color will fade and approach skin tones in 4 to 12 months. Many patients are self-conscious about the pitted and crater like scars that do not fade. These remain as a permanent record of previous severe acne. Your dermatologist may a variety of procedures to you to remove or revise these marks:

Chemical Peel: Superficial acne scarring, and irregular pigmentation of the skin are easily treated with this technique. Chemical agents are applied to the skin, which cause the outer layer to be removed. Different chemicals and concentrations are used, depending on ones skin type and degree of scarring.

Laser Resurfacing: More prominent scarring from acne is best treated by this technique. The top several layers of skin are removed with this high energy light. This action evens out the skin to give it a smoother, more pleasing contour.

Punch Excision and/or Grafting: Some narrow pitted scars are too deep to be removed by dermabrasion. These can be removed with a surgical instrument called a punch. The resulting defect is closed, either primarily or with a tiny skin graft, with gratifying results. Sometimes this procedure is followed by chemical peel or laser resurfacing for patients with a mixed type of scarring.

Collagen Implantation: Patients with a few soft depressed scars with smooth edges respond well to collagen. This natural protein is injected under the lesion to elevate it to the level of the skin.A Final WordTreatment of acne is a continuing process if the disorder is to be controlled successfully. You must follow your dermatologist's instructions, since you are the only one who can accomplish the necessary daily care. If you are willing to spend the time and extend the effort, you can expect a pleasing result.

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Excessive Sweating

Excessive Sweating :Known medically as Hyperhidrosis :About 1% and some say 2% of people all over the world complain of excessive sweating , and because this is a high percentage , we will talk about this problem , its presentation , causes and treatment.


Presentation : The typical presentation is an excessive sweating that commonly affects : hands "palmer" , feet "planter" and armpits "axillary" and less commonly face , forehead and other areas. It could occur without any identified reason (such as heat , hyperactivity , anxiety or emotional stress).
Sweating usually subsides during sleeping and comes back again after waking up .

Sweating is embarrassing, it stains clothes, and it complicates business and social interactions. Severe cases can have serious practical consequences as well, making it hard for people who suffer from it to hold a pen, grip a steering wheel, or shake hands.

Causes :
Many diseases can cause excessive sweating , such as hyperthyroidism , but patients in this case have other complaints for example : heat intolerance , weight loss , diarrhea ... etc.
TB and Malignancies cause night sweating not day sweating. Emotional stress can trigger sweating but it subsides once the cause of the stress goes.


In general most cases of occur in people who are otherwise healthy , and it tends to affect more than one member of the same family which means that hereditary factors have a role.


Mechanism :As we know we have in our bodies the autonomous nervous system. This system on which we have no control affects blood pressure, heart rate, anxiety level and many other functions.. it's divided into 2 parts : the sympathatic "that trigger sweating" and the parasympathetic.
In hyperhidrosis patient has over activation of the Sypmathatic nervous system.


Treatment :1) Local treatment with Aluminium chloride containing antiperspirants such as ANHYDROL solution : it's very effective mainly in the axillary area . You have to use it for 4 times in the first week "once per day" to notice the results , then use it 2 times in the second week and 1 time for every week later.
Aluminium chloride causes sever skin irritation so to avoid this side effect you have to ensure that your armpits are totally dry before using it, then apply a very thin layer of the agent over the targeted area "armpit" and keep your arms raised or put your hands behind your head and lie on the bed until it dries completely "it takes 5 - 10 minutes" .
It's advised to use it just before going to bed because the parasympathetic system takes the lead over the sympathetic system during sleeping and there will be no sweating and no skin irritation , then washing it after waking up by taking a hot bath.

2) Injections of botulinum toxin type A, under the brand names Botox or Dysport, are used to disable the sweat glands.The effects may persist from four to nine months depending on the site of injection. This procedure has been approved by the U.S. Food and Drug Administration (FDA) to treat underarm sweating. It's also most effective in the axillary area.

3) Surgical procedures

Sweat gland removal or destruction is one surgical option available for axillary hyperhidrosis. There are multiple methods for sweat gland removal or destruction such as sweat gland suction, retrodermal currettage, and axillary liposuction, Vaser, or Laser Sweat Ablation. Sweat gland suction is a technique adapted from liposuction, in which approximately 30% of the sweat glands are removed, with a proportionate reduction in sweat.

There are other choices of treatment but less effective.

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Hair Loss

Hair Loss

Introduction : The normal cycle of hair growth lasts for 2 to 3 years. Each hair grows approximately 1 centimeter per month during this phase. About 90 percent of the hair on your scalp is growing at any one time. About 10 percent of the hair on your scalp, at any one time, is in a resting phase. After 3 to 4 months, the resting hair falls out and new hair starts to grow in its place.

It is normal to shed some hair each day as part of this cycle. However, some people may experience excessive (more than normal) hair loss. Hair loss of this type can affect men, women and children.

What causes excessive hair loss?

A number of things can cause excessive hair loss. For example, about 3 or 4 months after an illness or a major surgery, you may suddenly lose a large amount of hair. This hair loss is related to the stress of the illness and is temporary. 

Hormonal problems may cause hair loss. If your thyroid gland is overactive or underactive, your hair may fall out. This hair loss usually can be helped by treatment thyroid disease. Hair loss may occur if male or female hormones, known as androgens and estrogens, are out of balance. Correcting the hormone imbalance may stop your hair loss.

Many women notice hair loss about 3 months after they've had a baby. This loss is also related to hormones. During pregnancy, high levels of certain hormones cause the body to keep hair that would normally fall out. When the hormones return to pre-pregnancy levels, that hair falls out and the normal cycle of growth and loss starts again. 

Some medicines can cause hair loss. This type of hair loss improves when you stop taking the medicine. Medicines that can cause hair loss include blood thinners (also called anticoagulants), medicines used for gout, high blood pressure or heart problems, vitamin A (if too much is taken), birth control pills and antidepressants.

Certain infections can cause hair loss. Fungal infections of the scalp can cause hair loss in children. The infection is easily treated with antifungal medicines.

Finally, hair loss may occur as part of an underlying disease, such as lupus or diabetes. Since hair loss may be an early sign of a disease, it is important to find the cause so that it can be treated.

Can certain hairstyles or treatments cause hair loss?

Yes. If you wear pigtails or cornrows or use tight hair rollers, the pull on your hair can cause a type of hair loss called traction alopecia (say: “al-oh-pee-sha”). If the pulling is stopped before scarring of the scalp develops, your hair will grow back normally. However, scarring can cause permanent hair loss. Hot oil hair treatments or chemicals used in permanents (also called "perms") may cause inflammation (swelling) of the hair follicle, which can result in scarring and hair loss.

What is common baldness?

"Common baldness" usually means male-pattern baldness, or permanent-pattern baldness. It is also called androgenetic alopecia. Male-pattern baldness is the most common cause of hair loss in men. Men who have this type of hair loss usually have inherited the trait. Men who start losing their hair at an early age tend to develop more extensive baldness. In male-pattern baldness, hair loss typically results in a receding hair line and baldness on the top of the head.

Women may develop female-pattern baldness. In this form of hair loss, the hair can become thin over the entire scalp.

Can my doctor do something to stop hair loss?

Perhaps. Your doctor will probably ask you some questions about your diet, any medicines you're taking, whether you've had a recent illness and how you take care of your hair. If you're a woman, your doctor may ask questions about your menstrual cycle, pregnancies and menopause. Your doctor may want to do a physical exam to look for other causes of hair loss. Finally, blood tests or a biopsy (taking a small sample of cells to examine under a microscope) of your scalp may be needed.

Is there any treatment for hair loss?

Depending on your type of hair loss, treatments are available. If a medicine is causing your hair loss, your doctor may be able to prescribe a different medicine. Recognizing and treating an infection may help stop the hair loss. Correcting a hormone imbalance may prevent further hair loss.

Medicines may also help slow or prevent the development of common baldness. One medicine, minoxidil (brand name: Rogaine), is available without a prescription. It is applied to the scalp. Both men and women can use it. Another medicine, finasteride, is available with a prescription. It comes in pills and is only for men. It may take up to 6 months before you can tell if one of these medicines is working.

If adequate treatment is not available for your type of hair loss, you may consider trying different hairstyles or wigs, hairpieces, hair weaves or artificial hair replacement.

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Treatment of community-acquired pneumonia in adults in the outpatient setting

INTRODUCTION — Community-acquired pneumonia (CAP) is defined as an acute infection of the pulmonary parenchyma in a patient who has acquired the infection in the community, as distinguished from hospital-acquired (nosocomial) pneumonia. A third category of pneumonia, designated "healthcare-associated pneumonia," is acquired in other healthcare facilities such as nursing homes, dialysis centers, and outpatient clinics.

CAP is a common and potentially serious illness. It is associated with considerable morbidity and mortality, particularly in elderly patients and those with significant comorbidities 

The treatment of CAP in adults in the outpatient setting will be reviewed here. A variety of other important issues related to CAP are discussed separately. These include:

 • The diagnostic approach to patients with CAP.

 • How one makes the decision to admit patients with CAP to the hospital. 

 • Treatment recommendations for CAP in patients requiring hospitalization. 

 • Treatment recommendations for patients with healthcare-associated pneumonia. 

 • The evidence for efficacy of different antibiotic medications in the empiric treatment of CAP and issues related to drug resistance. 

 • The epidemiology and microbiology of CAP. 

 • Pneumonia in special populations, such as aspiration pneumonia and immunocompromised patients. 

INDICATIONS FOR HOSPITALIZATION — Determination of whether a patient with CAP can be safely treated as an outpatient or requires hospitalization is essential before selecting an antibiotic regimen. Severity of illness is the most critical factor in making this determination, but other factors should also be taken into account. These include ability to maintain oral intake, likelihood of compliance, history of substance abuse, cognitive impairment, living situation, and patient functional status. These issues with appropriate references are discussed in detail elsewhere. 

Summarized briefly, prediction rules have been developed to assist in the decision of site of care for CAP. The two most commonly used prediction rules are the Pneumonia Severity Index (PSI) and CURB-65. The PSI is better studied and validated, but requires a more complicated assessment.

CURB-65 uses five prognostic variables:

 • Confusion (based upon a specific mental test or disorientation to person, place, or time)

 • Urea (blood urea nitrogen in the United States) >7 mmol/L (20 mg/dL)

 • Respiratory rate >30 breaths/minute

 • Blood pressure [BP] (systolic <90 mmHg or diastolic <60 mmHg)

 • Age >65 years

The authors of the original CURB-65 report suggested that patients with a CURB-65 score of 0 to 1, who comprised 45 percent of the original cohort and 61 percent of the later cohort, were at low risk and could probably be treated as outpatients; those with a score of 2 should be admitted to the hospital, and those with a score of 3 or more should be assessed for ICU care, particularly if the score was 4 or 5.

A simplified version (CRB-65), which does not require testing for blood urea nitrogen, may be appropriate for decision-making in primary care practitioners' offices. With either version, admission to the hospital is recommended if one or more points are present.

Clinical judgment should be used for all patients, incorporating the prediction rule scores as a component of the decision for hospitalization or intensive care unit admission, but not as an absolute determinant .

PRINCIPLES OF ANTIMICROBIAL THERAPY — CAP can be caused by a variety of pathogens, with bacteria being the most common identifiable cause . The choice of initial therapy is complicated by the emergence of antibiotic resistance among Streptococcus pneumoniae, the most common bacterium responsible for CAP. 

Empiric therapy — Antibiotic therapy is typically begun on an empiric basis, since the causative organism is not identified in an appreciable proportion of cases of CAP treated in the outpatient setting . In addition, the clinical features and chest radiographic findings are not sufficiently specific to determine etiology and influence treatment decisions. The sputum Gram stain can be useful for directing the choice of initial therapy if performed on a good quality sample and interpreted by skilled examiners using appropriate criteria .

The 2007 Infectious Diseases Society of America/American Thoracic Society (IDSA/ATS) guidelines on the management of community-acquired pneumonia suggest that routine tests to identify an etiology for CAP are optional for patients who do not require hospitalization . This recommendation is based in part upon the low rate of failure of empiric therapy in patients with CAP treated in the outpatient setting. The efficacy of empiric therapy was illustrated in a study of over 700 ambulatory patients treated for CAP in one of six emergency departments seen from November 2000 through April 2001, in which empiric antibiotics (a macrolide or fluoroquinolone in >88 percent) were almost universally effective, with only 2.2 percent requiring hospitalization within three weeks of initial emergency department visit .

In contrast, testing for a microbial diagnosis is important in clinical or epidemiologic settings suggesting possible infection with an organism that requires treatment different from standard empiric regimens. These include Legionella species, Mycobacterium tuberculosis, influenza A and B or avian influenza, community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), or agents of bioterrorism .

The selection of antimicrobial regimens for empiric therapy is based upon a number of factors, including:

 • The most likely pathogen(s). 

 • Clinical trials proving efficacy.

 • Risk factors for antimicrobial resistance. The choice of empiric therapy must take into account the emergence of antibiotic resistance among Streptococcus pneumoniae, one of the most common bacteria responsible for CAP. 

 • Medical comorbidities that may influence the likelihood of a specific pathogen and may be a risk factor for treatment failure.

Additional factors that may affect the choice of antimicrobial regimen include the potential for inducing antimicrobial resistance, pharmacokinetic and pharmacodynamic properties, safety profile, and cost .

Common pathogens — Although a variety of bacterial pathogens can cause CAP, a limited number are responsible for the majority of cases

With respect to patients treated in the outpatient setting, the most frequently isolated pathogens are Streptococcus pneumoniae, Mycoplasma pneumoniae, Chlamydophila pneumoniae, and respiratory viruses (eg, influenza, parainfluenza, respiratory syncytial virus) . Legionella pneumoniae and Haemophilus influenzae are less common. The "atypical" pathogens are not often identified in clinical practice because there are not specific, rapid, or standardized tests for their detection, with the exception of L. pneumophila.

Patients with CAP due to Staphylococcus aureus, Enterobacteriaceae, and Pseudomonas aeruginosa are typically sicker and require admission to the hospital. 

Risk factors for drug resistance — Risk factors for and other issues related to drug resistance in patients with CAP are discussed in detail elsewhere. 

Summarized briefly, risk factors for drug-resistant S. pneumoniae in adults include:

 • Age >65 years

 • Beta-lactam, macrolide, or fluoroquinolone therapy within the past three to six months

 • Alcoholism

 • Medical comorbidities

 • Immunosuppressive illness or therapy

 • Exposure to a child in a day care center

Recent therapy or a repeated course of therapy with beta-lactams, macrolides, or fluoroquinolones is a risk factor for pneumococcal resistance to the same class of antibiotic.

The impact of discordant drug therapy, which refers to treatment of an infection with an antimicrobial agent to which the causative organism has demonstrated in vitro resistance, appears to vary with antibiotic class and possibly with specific agents within a class. Most studies have been performed in patients with S. pneumoniae infection and suggest that current levels of beta-lactam resistance generally do not cause treatment failure when appropriate agents (eg, amoxicillin, ceftriaxone, cefotaxime) and doses are used. Of the beta-lactams, cefuroxime is a possible exception. In addition, there appears to be an increased risk of macrolide failure in patients with macrolide-resistant S. pneumoniae. 

GUIDELINES — A number of medical societies have issued guidelines for the treatment of CAP . The antibiotic regimens advocated by a collaboration between the Infectious Disease Society of America and the American Thoracic Society (IDSA/ATS) in 2007 , and guidelines from the British Thoracic Society (BTS) in 2009 are summarized here .

The following discussion will review antibiotic therapy in ambulatory patients with CAP. Guideline recommendations for therapy of patients with CAP treated in the inpatient setting are presented separately.

 • The regimens chosen by the IDSA/ATS guidelines mainly rely on macrolides (with or without a beta-lactam) or newer fluoroquinolones for outpatient therapy . The guidelines promote the use of macrolides to provide coverage for both S. pneumoniae and atypical pathogens (particularly, M. pneumoniae and C. pneumoniae), which account for the majority of cases of CAP in ambulatory patients . In studies from different regions of the world, atypical pathogens account for 20 to 30 percent of cases of CAP .

 • The BTS guidelines tend to select older antibiotics than those recommended in North America .

North American approach — The macrolides, which are effective against the atypical pathogens, are recommended in the absence of significant risk factors for macrolide-resistant S. pneumoniae. Experience in North America, suggests that macrolide-resistant S. pneumoniae is less significant for patients without comorbidities or risk factors compared to patients with risk factors . Recent use of macrolide antibiotics is considered a risk factor for resistant S pneumoniae; thus, monotherapy with a macrolide is not recommended for persons who received a macrolide antibiotic in the preceding three months. coccus pneumoniae to the macrolides, azalides, lincosamines, and ketolides".)

BTS approach — In the 2009 British Thoracic Society guidelines, the preferred drug for outpatient management is amoxicillin (500 mg orally three times daily), with doxycycline or clarithromycin as alternatives, including for those with penicillin allergy .

The rationale is that amoxicillin at these doses is effective against most strains of S. pneumoniae with decreased susceptibility to penicillin. Most of the macrolide-resistant S. pneumoniae in Europe is erm-mediated high-level resistance. As a result, the macrolides are not optimal first-line empiric agents.

Coverage of atypical pathogens — The BTS approach places less significance than the North American approach on the need to treat the atypical pathogens empirically in ambulatory patients. Initial empiric therapy that covers M. pneumoniae is considered unnecessary, since the pathogen exhibits epidemic periodicity every four to five years and largely affects younger persons.

Although the clinical course of M. pneumoniae or C. pneumoniae infection is often self-limited, these pathogens can cause severe CAP. As a result, it has been argued that appropriate treatment for even mild CAP due to Mycoplasma reduces both morbidity and the duration of symptoms.

The efficacy of empiric coverage of atypical pathogens was evaluated in a 2005 meta-analysis that evaluated 18 randomized trials of over 6700 patients with mild to moderate CAP who were assigned to treatment with either a beta-lactam or an antibiotic active against atypical pathogens . There was no overall advantage to covering atypical pathogens in terms of the rate of failure to achieve clinical cure or improvement (relative risk 0.97, 95% CI 0.87-1.07) but, in a subgroup analysis, there was a significantly lower failure rate for Legionella infection with such a regimen (relative risk 0.40, 95% CI 0.19-0.85). These trials were not designed to compare the time to response with the different regimens.

TREATMENT REGIMENS — Treatment regimens for outpatients with CAP are based upon studies of the effectiveness of antibiotics, the severity of illness, the presence of comorbid conditions, and the prevalence of risk factors for drug resistant S. pneumoniae (DRSP). 

We suggest the following approach to empiric antimicrobial therapy. 

No comorbidities or recent antibiotic use — For uncomplicated pneumonia in patients who do not require hospitalization, have no significant comorbidities and/or use of antibiotics within the last three months, and where there is not a high prevalence of macrolide-resistant strains, we recommend any one of the following oral regimens:

 • Azithromycin (500 mg on day one followed by four days of 250 mg a day); 500 mg a day for three days, or 2 g single dose (microsphere formulation) are acceptable alternative regimens

 • Clarithromycin XL (two 500 mg tablets once daily) for five days or until afebrile for 48 to 72 hours

 • Doxycycline (100 mg twice a day) for seven to 10 days

There is concern that widespread use of fluoroquinolones in outpatients will promote the development of fluoroquinolone-resistance among respiratory pathogens (as well as other colonizing pathogens) and may lead to an increased incidence of C. difficile colitis . In addition, empiric use of fluoroquinolones should not be used for patients at risk for Mycobacterium tuberculosis without an appropriate assessment for tuberculosis infection. The administration of a fluoroquinolone in patients with tuberculosis has been associated with a delay in diagnosis, increase in resistance, and poor outcomes. 

Because of these concerns, the use of fluoroquinolones is discouraged in ambulatory patients with CAP without comorbid conditions or recent antimicrobial use, unless it is known that there is a high prevalence of high-level macrolide-resistant S. pneumoniae in the local community. When such resistance is present, the regimen for patients with comorbidities or recent antibiotic use described in the next section can be followed.

Despite these recommendations, fluoroquinolones continue to be given, often inappropriately, for CAP. In one report of 768 ambulatory patients with CAP seen in an emergency department in 2000 and 2001, 245 (32 percent) were treated with levofloxacin; one-half of these patients did not meet the criteria for appropriate fluoroquinolone therapy .

Telithromycin is NOT recommended as a first-line empiric regimen because of concerns about toxicity. 

Although erythromycin is the least expensive macrolide, we rarely use this drug for three reasons: multiple daily doses over several days are required; compliance is limited by gastrointestinal side effects, as well as dosing; and there is a risk of sudden cardiac death due to QT interval prolongation, particularly when other drugs metabolized by CYP3A4 are taken concurrently . The drugs noted above are as effective, more convenient to use, and less toxic.

Comorbidities or recent antibiotic use — The presence of significant comorbidities (ie, chronic obstructive pulmonary disease [COPD], liver or renal disease, cancer, diabetes, chronic heart disease, alcoholism, asplenia, or immunosuppression), and/or use of antibiotics within the prior three months, increases the risk of infection with more resistant pathogens. We recommend one of the following oral regimens for such patients:

 • A respiratory fluoroquinolone (gemifloxacin 320 mg daily, levofloxacin 750 mg daily, or moxifloxacin 400 mg daily) for a minimum of five days.

 • Combination therapy with a beta-lactam effective against S. pneumoniae (high-dose amoxicillin, 1 g three times daily or amoxicillin-clavulanate 2 g twice daily or cefpodoxime 200 mg twice daily or cefuroxime 500 mg twice daily) PLUS either a macrolide (azithromycin 500 mg on day one followed by four days of 250 mg a day or clarithromycin 250 mg twice daily or clarithromycin XL 1000 mg once daily) or doxycycline (100 mg twice daily). Treatment should be continued for a minimum of five days. 

These regimens are also appropriate where there is a high prevalence of "high-level" macrolide-resistant S. pneumoniae, even in the absence of comorbidity or recent antimicrobial use. When choosing between fluoroquinolones, in vitro studies of moxifloxacin and gemifloxacin show more activity against penicillin-resistant pneumococci strains than levofloxacin; the clinical significance of these findings is not yet clear .

Gemifloxacin causes a rash in 2.8 percent of patients overall, but a higher rate (14 percent) in women under 40 years of age who received the drug for seven or more days. The rash is generally mild, occurs after the fifth day of therapy, and resolves with discontinuation of the agent. The rash is not associated with phototoxicity or hypersensitivity and does not preclude the use of other fluoroquinolones in the future, although repeated courses of gemifloxacin should be avoided in such patients. 

Telithromycin should be reserved as an option for patients at risk for drug-resistant pneumococcal infection in whom alternative agents are not appropriate. However, it should NOT be prescribed in patients with known liver disease. 

Pathogen-directed therapy — Once the etiology of CAP has been identified using reliable microbiologic methods, antimicrobial therapy should be directed at that pathogen .

Treatment duration and response — With respect to treatment duration, we generally agree with the 2007 IDSA/ATS guidelines. Ambulatory patients with CAP should be treated for a minimum of five days; because of the prolonged half-life of azithromycin, a shorter duration of drug administration may be indicated for this agent.

Support for this recommendation comes from a meta-analysis of 15 randomized controlled trials of almost 2800 patients with mild to moderate CAP, which found comparable clinical outcomes with less than seven days compared to more than seven days of antimicrobial therapy . Antibiotic therapy should not be stopped until the patient is afebrile for 48 to 72 hours and is clinically stable. 

Most patients with CAP begin to improve soon after the initiation of appropriate antibiotic therapy as evidenced by resolution of symptoms, physical findings, and laboratory signs of active infection . However, some symptoms often persist as the patient convalesces . This was illustrated in a study of sequential interviews in 134 ambulatory patients with CAP . The median time to resolution ranged from three days for fever to 14 days for both cough and fatigue. At least one symptom (eg, cough, fatigue, dyspnea) was still present at 28 days in one-third of patients. In another report, 76 percent had at least one symptom at 30 days, most commonly fatigue, compared to 45 percent by history in the one month prior to the onset of CAP .

These symptoms are usually not sufficient to interfere with work as illustrated in a review of 399 ambulatory patients with CAP in which the median time of return to work was six days even though one-third had at least one persistent symptom at 14 days. 

Persistence of such symptoms is not an indication to extend the course of antibiotic therapy as long as the patient has demonstrated some clinical response to treatment .

Follow-up chest radiograph — Chest x-ray findings usually clear more slowly than clinical manifestations  Routine chest x-rays for follow-up of CAP patients who are responding clinically are unnecessary. Some authorities recommend a follow-up chest x-ray at 7 to 12 weeks after treatment for selected patients who are over age 40 years or are smokers, to document resolution of the pneumonia and exclude underlying diseases, such as malignancy .

Among patients with CAP, nonresponse is primarily seen in those who require hospitalization, occurring in 6 to 15 percent of such patients. The incidence of treatment failure is not well defined in ambulatory patients with CAP because population-based studies would be required.

VACCINATION — Patients with CAP should be appropriately vaccinated for influenza and pneumococcal infection. Screening for influenza vaccination status is warranted during influenza season (eg, from October through March in the northern hemisphere) in all patients. Screening for pneumococcal vaccination status is warranted in patients age 65 or older or with other indications for vaccination. Vaccination can be performed during outpatient treatment. 

SMOKING CESSATION — Smoking cessation should be a goal for patients with CAP who smoke.

SUMMARY AND RECOMMENDATIONS

 • Most initial treatment regimens for community-acquired pneumonia (CAP) are empiric. A limited number of pathogens are responsible for the majority of cases of CAP .

 • Emerging drug-resistant S. pneumoniae (DRSP) complicates the use of empiric treatment. Treatment failures have been demonstrated with use of macrolides for macrolide-resistant organisms. We recommend not prescribing macrolide monotherapy for patients who have received a macrolide antibiotic within the preceding three months.

 • Despite in vitro resistance, penicillin-resistant pneumococci may respond to higher dose beta-lactams, other than cefuroxime. Drug toxicity limits the use of telithromycin which should be reserved for patients with "high-level" macrolide-resistant CAP in whom other agents are contraindicated. 

 • North American and British guidelines differ in their recommendations for first-line therapy for outpatient pneumonia. British guidelines promote amoxicillin and place less significance on atypical pathogens. North American guidelines advocate treating both atypical pathogens and pneumococcus, and suggest macrolides when antibiotic resistance is not anticipated. 

 • We support the IDSA/ATS guideline recommendations for empiric treatment of CAP in non-hospitalized patients:

     - For uncomplicated pneumonia in patients who have no significant comorbidities and/or use of antibiotics within the last three months, we suggest treatment with an advanced macrolide . Regimens include azithromycin (500 mg on day one followed by four days of 250 mg a day, or 500 mg for three days, or 2 g as single dose microsphere regimen) or clarithromycin XL (two 500 mg tablets once daily). We suggest NOT using fluoroquinolones for uncomplicated ambulatory patients with CAP . Alternative regimens are acceptable. 

     - For non-hospitalized patients with comorbidities or recent antibiotic use, we suggest treatment with a fluoroquinolone as monotherapy, or combination therapy with a beta-lactam plus a macrolide .

 • We recommend antibiotic treatment for a minimum of five days, although a shorter duration may be indicated with azithromycin because of its prolonged half-life. Therapy should not be stopped until the patient is afebrile for 48 to 72 hours and is clinically stable. When this is achieved, the persistence of other symptoms (eg, dyspnea, cough) is not an indication to extend the course of antibiotic therapy.

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