UK national guidelines on the management of syphilis 2008. // Cited by NGC-7153

Major Recommendations

Definitions for the level of evidence (I-IV) and grade of recommendation (A-C) are provided at the end of the "Major Recommendations" field.

Screening for syphilis is recommended for all asymptomatic patients attending a United Kingdom (UK) genitourinary (GU) clinic. There are no controlled studies to support this statement but the recent increase in infectious syphilis in the UK and other European countries supports screening as part of good clinical practice. Apart from the public health benefit of detecting infectious syphilis, screening will detect non-infectious stages of syphilis, which will benefit the individual patient.

Patients with syphilitic lesions will require further investigation as outlined below.

Recommended Tests

Serological Screening Tests

• Treponema pallidum (T. pallidum) enzyme immunoassay (EIA). (Evidence Level IIb; Grade of Recommendation B). There are a number of different EIA's to detect anti-treponemal antibodies and very few have been subject to peer review evaluation so it is important to establish satisfactory performance of any EIA used; this applies to all types of serological test.
• EIA's that detect both immunoglobulin G (IgG) and immunoglobulin M (IgM) are recommended as they tend to be more sensitive in primary infection. (Evidence Level IIb; Grade of Recommendation B).
• The T. pallidum particle assay (TPPA) is recommended in preference to the T. pallidum haemagglutination assay (TPHA). (Evidence Level IV; Grade of Recommendation C).
• Screening with either EIA alone (Evidence Level IIb; Grade of Recommendation B) or the TPPA alone (Evidence Level IV; Grade of Recommendation C) is recommended (the TPPA is more sensitive than the TPHA in primary infection).
• The TPHA can be used in combination with a cardiolipin antigen/reagin test such as Venereal Disease Research Laboratory (VDRL) or Rapid Plasma Reagin (RPR) to maximize the detection of primary infection on screening. (Evidence Level III; Grade of Recommendation B)

Additional and Confirmatory Serological Tests (Evidence Level IV; Grade of Recommendation C)

• An EIA IgM test should be performed in addition to routine screening tests in all cases of genital ulceration as well as in those who are known contacts of syphilis (see below).
  Note: The rationale for this is that IgM becomes detectable in the serum 2 to 3 weeks after infection and IgG 4 to 5 weeks after infection. Therefore there will be a window of 1 to 2 weeks when routine screening tests may be negative.
• A quantitative TPPA should be used to confirm a positive EIA.
• An EIA should be used to confirm a positive TPPA.
• An additional test such as immunoblotting based on recombinant antigens or the fluorescent antibody absorbed (FTA-abs) test can be used in the case of a discrepancy between the EIA and TPPA.
• An EIA for anti-treponemal IgM should be performed on all sera reactive in one or more of the screening tests.
• Quantitative VDRL/RPR tests should be performed before therapy.

Note: In patients who have previously been treated for syphilis a fourfold increase in VDRL/RPR titre and/or a change in the EIA IgM from negative to positive (confirmed on a second specimen) suggests re-infection or relapse.

Direct Detection of T. pallidum in First and Second Degree Syphilis

• Dark ground/dark field microscopy (DGM) of lesion exudate or lymph nodes should be performed by experienced clinicians. (Evidence Level IV; Grade of Recommendation C) Because of interference from commensal spirochaetes that are found in the normal flora of the genital and rectal mucosae, DGM is considered to be less reliable in examining rectal and non-penile genital lesions. DGM is not suitable for examining oral lesions.
  Note: To obtain lesion exudates from a presumptive syphilitic chancre for DGM, the ulcer should be cleaned with sterile saline using a gauze swab. Any crust on the ulcer surface should first be removed. The ulcer should then be squeezed for sufficient time to produce sufficient serous fluid to be collected by a loop or other suitable instrument and placed on a glass microscope slide. The exudate should have a coverslip placed over it and DGM performed within 10 minutes in order to look for the characteristic morphology and motility of T. pallidum organisms. Other sites from which exudative material can be examined include skin lesions (after removal of the epithelial surface) and condylomata lata. Material from enlarged lymph nodes can be aspirated using a sterile 23 gauge needle and syringe filled with 0.2 ml of sterile saline.
• If the initial examination is negative DGM should be repeated daily for at least three days: antibiotics should be withheld during this period - local saline lavage may be used to reduce local sepsis. (Evidence Level IV; Grade of Recommendation C)
• Testing of material submitted on dry swabs by the polymerase chain reaction (PCR) is recommended for oral or other lesions where contamination with commensal treponemes is likely. (Evidence Level IV; Grade of Recommendation C)
• PCR is also useful in the diagnosis of primary syphilis and is available via local laboratories sending samples to the Sexually Transmitted Bacteria Reference Laboratory (STBRL) at the Health Protection Agency (stbrl@hpa.org.uk). (Evidence Level IV; Grade of Recommendation C)

Recommended Sites for Testing

• Clotted blood (all patients)
• Ulcer material (primary syphilis)
• Lesion material (secondary syphilis)

Factors Which Alter Tests Recommended or Sites Tested

Genital or extra-genital lesions (including oral) that could be due to primary syphilis or a history of sexual contact with a patient known to have syphilis are the only factors which would influence the recommended tests or sites tested. In these circumstances an anti-treponemal IgM EIA should be performed in addition to the routine tests (see above).

Other aspects of sexual history (e.g., oral sex, unprotected sex with multiple partners, past history of STD, sexual assault) will not alter tests or sites but factors such as unprotected oral, vaginal or anal sex with multiple partners and sexual assault may influence the frequency of repeat testing (see below – "Recommendation for Frequency of Repeat Testing in an Asymptomatic Patient").

Risk Groups

• Men who have sex with men (MSM) (no alteration to standard recommendation)
• Sex workers (no alteration to standard recommendation)
• 'Young' (under 25) patients (no alteration to standard recommendation)

Other

• Pregnant women (no alteration to standard recommendation)
• Women with history of hysterectomy (no alteration to standard recommendation)
• Patients who are known contacts of the infection need a request for an anti-treponemal IgM EIA on the blood specimen submitted for standard screening.

Recommendation for Frequency of Repeat Testing in an Asymptomatic Patient (Evidence Level IV; Grade of Recommendation C in each case)

• The frequency of repeat testing depends on the sexual history, particularly type of sexual exposure and number of sexual partners.
• A 'high risk' exposure would include unprotected oral, anal or vaginal intercourse with a 'high risk' partner (e.g., partner with suspected or proven syphilis, homosexual male with multiple partners, anonymous partner(s) in saunas and other venues, commercial sex worker, partner just arrived from or living in a country where the prevalence ofsyphilis is known to be high).
• No further testing is recommended if the patient had a single 'low risk' episode more than six weeks previously (this is a pragmatic approach but is based on the scientific premise that the average pre-patent period is three weeks and IgG production starts around the fourth week of infection).
• A repeat screening test is recommended three months after exposure if the patient had a single 'high risk' exposure less than six weeks prior to attending the clinic.
• Routine screening as well as specific EIA-IgM tests should be repeated at six weeks and three months for patients who:
  1. Have had multiple 'high risk' exposures
  2. Have DGM negative ulcerative lesions that could be due to primary syphilis
  3. Are contacts of a suspected or proven case of syphilis, regardless of whether they have received epidemiological treatment for syphilis
• Patients with 'high risk' exposures should be informed about the symptoms of primary or secondary syphilis and encouraged to return immediately if these develop before the next serological screening visit.

Recommendation for Test of Cure

• Quantitative VDRL/RPR tests are recommended (Evidence Level III; Grade of Recommendation B) and should be performed with the same antigen (Manufacturer) and in the same laboratory. (Evidence Level IV; Grade of Recommendation C)
• VDRL/RPR tests should be performed monthly for three months and at 6 and 12 months for early (infectious) syphilis. (Evidence Level IV; Grade of Recommendation C)
• VDRL/RPR tests should be performed every six months until negative/serofast for late (non-infectious) syphilis. (Evidence Level IV; Grade of Recommendation C)
• HIV positive patients should have repeat treponemal serology performed yearly, or more frequently if at risk of re-infection with syphilis through their sexual activity (see above – recommendations for frequency of repeat testing). (Evidence Level IV; Grade of Recommendation C)
• Lumbar punctures are not normally taken in early syphilis. If lumbar puncture is taken in accordance with appropriate guidelines then the cerebrospinal fluid (CSF) should be tested on a 6 monthly basis until the cell count is normal. (Evidence Level IV; Grade of Recommendation C)

Definitions:

Levels of Evidence

Ia: Evidence obtained from meta-analysis of randomised controlled trials

Ib: Evidence obtained from at least one randomised controlled trial

IIa: Evidence obtained from at least one well designed controlled study without randomisation

IIb: Evidence obtained from at least one other type of well designed quasi-experimental study

III: Evidence obtained from well designed non-experimental descriptive studies

IV: Evidence obtained from expert committee reports or opinions and/or clinical experience of respected authorities

Grading of Recommendations

1. Evidence at level Ia or Ib
2. Evidence at level IIa, IIb, or III
3. Evidence at level IV

Clinical Algorithm(s)

None provided

Full Summary, NGC

헬리코박터 파일로리 감염의 진단 및 치료 가이드라인, 대한소화기학회지 2009

1.1.0 헬리코박터 제균을 위해 양성자펌프억제제(proton pump inhibitor, PPI)를 포함한 3제 요법이 주로 사용된 2005년 이후 헬리코박터 재감염률이 현저히 감소하였고 헬리코박터 유병률도 점차 떨어지고 있다. 따라서 지금까지의 견해 즉 “우리나라에서의 헬리코박터 유병률과 재감염률이 높기 때문에 제균 대상을 제균 적응증에 엄격하게 국한시켜야 한다”는 논리는 재고되어야 한다(증거 수준: 중등도, 권고 등급: 중등도).

2.1.3 헬리코박터 진단을 위한 검사로는 요소분해효소 검사가 추천된다. 그러나 요소분해효소 검사는 위음성 가능성이 있기 때문에 Giemsa 염색법 혹은 Warthin-Starry은 염색법을 위한 조직검사가 필요할 수 있다. 염색법을 위한 조직검사로는 전정부 및 체부에서 각각 조직을 채취하는 것이 바람직하나 조직검사를 되도록 적게 해야 하는 상황에서는 체부에서 조직을 채취하는 것이 권장된다(증거 수준: 높음, 권고 등급: 높음).

2.4.0 제균 치료 후 헬리코박터가 제균되었는지 확인하는 것이 바람직하다. 특히 모든 위궤양 환자, 합병증을 동반한 십이지장 궤양 환자, 조기 위암 환자, 변연부 B세포 림프종(MALT type) 환자와 치료 후 증상이 남아 있거나 증상이 재발된 십이지장궤양 환자에서는 추적 검사를 시행하여 제균 치료 성공 여부, 위암 여부, 궤양 병변의 재발 여부를 각각 확인하여야 한다(증거 수준: 높음, 권고 등급: 높음).

제균 확인 검사는 최소한 제균 치료 종료 2주 경과 후에 시행한다. 제균 확인 검사로는 요소호기 검사가 가장 유용하나 위궤양 치료 후 위암과의 감별을 위해 내시경이 필요한 경우는 전정부와 체부에서 내시경 생검 조직을 이용한 요소분해효소 검사 및 조직 검사(Giemsa 염색법 혹은 Warthin-Starry 은 염색법)를 추천한다(증거 수준: 높음, 권고 등급: 높음).

3.1.3 헬리코박터는 위암과 연관성이 높으므로 헬리코박터에 감염되어 있는 조기 위암 환자에서는 위암 치료 후 제균 치료를 추천한다(증거 수준: 중등도, 권고 등급: 높음).

3.1.4 위암의 가족력이 있는 경우, 헬리코박터에 감염된 가족에 대하여 제균 치료를 추천한다(증거 수준: 중등도, 권고 등급: 중등도)

3.2.2 헬리코박터의 1차 치료제로는 PPI (standard dose bid) + clarithromycin (0.5 g bid) + amoxicillin (1 g bid) 조합의 1주 내지 2주 투여가 가장 적합하다(증거 수준: 높음, 권고 등급: 높음)

3.2.3 헬리코박터의 2차 치료제로는 PPI (standard dose bid) + metronidazole (0.5 g tid) + bismuth (120 mg qid) + tetracycline (0.5 g qid) 조합의 1주 내지 2주 투여가 적합하다(증거 수준: 중등도, 권고 등급: 높음)

Full Text

Antiviral Therapy for Herpes Zoster

Results  Intent-to-treat analysis did not detect statistically significant differences for valacyclovir vs famciclovir on resolution of zoster-associated pain (hazard ratio, 1.02; 95% confidence interval, 0.84-1.23; P = .84). Furthermore, no differences were evident between treatments on rash healing rates and on a range of analyses of postherpetic neuralgia. Safety profiles for valacyclovir and famciclovir were similar, with headache and nausea being the more common adverse events.


Conclusions  Valacyclovir treatment is comparable to famciclovir treatment in speeding the resolution of zoster-associated pain and postherpetic neuralgia. Current wholesale prices indicate that valacyclovir is the more cost-effective treatment for herpes zoster ($83.90 vs $140.70 per course).
Full Text, Arch Fam Med 2000 Sep; 9: 863 -869.

Updated Recommendations for Prevention of Invasive Pneumococcal Disease Among Adults Using the 23-Valent Pneumococcal Polysaccharide Vaccine (PPSV23), CDC 2010

Recommendations for Use of PPSV23

At its June and October 2008 meetings, ACIP approved new and revised recommendations for the use of PPSV23 to prevent IPD among adults aged <65 years. ACIP concluded that asthma is an independent risk factor for IPD and should be included in the group of chronic pulmonary diseases (e.g., COPD and emphysema) that are indications for PPSV23 (Table); thus, ACIP recommended that persons aged 19--64 years who have asthma should receive a single dose of PPSV23 (Box). ACIP also concluded that adults who smoke cigarettes are at significantly increased risk for IPD and recommended that persons aged 19--64 years who smoke cigarettes should receive a single dose of PPSV23 and smoking cessation guidance (Box). ACIP also revised its recommendation for use of PPSV23 among American Indians and Alaska Natives. Routine use of PPSV23 is no longer recommended for persons aged <65 years in these populations unless they have a medical condition or other indication for PPSV23. However, in certain situations, public health authorities may recommend PPSV23 for Alaska Natives and American Indians aged 50--64 years who are living in areas where the risk for IPD is increased. All persons should be vaccinated with PPSV23 at age 65 years. Those who received PPSV23 before age 65 years for any indication should receive another dose of the vaccine at age 65 years or later if at least 5 years have passed since their previous dose. Those who receive PPSV23 at or after age 65 years should receive only a single dose. PPSV23, CDC, 2010

CDC 1997

UK national guidelines on the management of syphilis, 2008

BASHH, 2008

NGC summary

Treatment of Herpes Simplex Infection, 2008 Archives of Internal Medicine

Treatment of Herpes Simplex Infection, 2008 Archives of Internal Medicine

Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study -- Amir et al. 314 (7097): 1800 -- BMJ

Treatment of herpes simplex gingivostomatitis with aciclovir in children: a randomised double blind placebo controlled study -- Amir et al. 314 (7097): 1800 -- BMJ

Acute diarrhea

1. Clinical assessment and diagnosis of hypovolemia (dehydration) in children, 2009 Utdol

2. Treatment of hypovolemia (dehydration) in children, 2009 Utdol


3. Evaluation of diarrhea in children, 2009 Utdol

4. Epidemiology, pathogenesis, clinical presentation and diagnosis of viral gastroenteritis in children, 2009 Utdol

5. Clinical presentation and diagnosis of rotavirus infection, 2009 Utdol

Acute Otitis Media Mx. and Tx.

1. Diagnosis and Management of Acute Otitis Media, 2004 NGC

2-1. Acute Otitis Media: Part I. Improving Diagnostic Accuracy, 2000 AAFP

2-2. Acute Otitis Media: Part II. Treatment in an Era of Increasing Antibiotic Resistance, 2000 AAFP

Epstein-Barr Virus Infectious Mononucleosis - October 1, 2004 - American Family Physician

Epstein-Barr Virus Infectious Mononucleosis - October 1, 2004 - American Family Physician

Treatment of enterococcal infections, UpToDate 2009

Enterococcal species can cause a variety of infections, including urinary tract infections, bacteremia, endocarditis, and meningitis. The antimicrobial agents available for treatment of enterococcal infection are reviewed here, followed by treatment approaches for clinical syndromes caused by enterococci. Other issues related to enterococci are discussed in detail separately. (See "Mechanisms of antibiotic resistance in enterococci" and "Epidemiology and prevention and control of vancomycin-resistant enterococci" and "Microbiology of enterococci".)... Authorized only

Extended-spectrum beta-lactamases, UpToDate 2009

Extended-spectrum beta-lactamases (ESBL) are enzymes that confer resistance to most beta-lactam antibiotics, including penicillins, cephalosporins, and the monobactam aztreonam. Infections with ESBL-producing organisms have been associated with poor outcomes.
Community-acquired ESBL producing Enterobacteriaceae are prevalent worldwide [1]. Reliably identification of ESBL-producing organisms in clinical laboratories is difficult, so their prevalence is likely underestimated. Carbapenems are the best antimicrobial agent for infections caused by such organisms.... Authorized only

Clinical manifestations; diagnosis; and treatment of acute pyelonephritis, UpToDate 2009

Acute pyelonephritis is a urinary tract infection that has progressed from the lower urinary tract to the upper urinary tract. Most episodes of acute pyelonephritis are uncomplicated but hospitalization may be required [1].
Acute uncomplicated pyelonephritis typically occurs in healthy, young women and must be distinguished from acute complicated pyelonephritis and from chronic pyelonephritis:
Acute complicated pyelonephritis is progression of upper urinary tract infection to emphysematous pyelonephritis, renal corticomedullary abscess, perinephric abscess, or papillary necrosis. (See 'Acute complicated pyelonephritis' below.)
Chronic pyelonephritis is an uncommon cause of chronic tubulointerstitial disease due to recurrent infection, such as infection in association with a chronically obstructing kidney stone (possibly producing xanthogranulomatous pyelonephritis) or vesicoureteral reflux. Affected patients can present with weeks to months of insidious symptoms. (See "Xanthogranulomatous pyelonephritis" and "Presentation, diagnosis, and clinical course of vesicoureteral reflux".)
The clinical features, diagnosis, and treatment of acute uncomplicated and complicated pyelonephritis will be reviewed here. The microbiology and pathogenesis of acute pyelonephritis are discussed separately. (See "Microbiology and pathogenesis of acute pyelonephritis".)... Authorized only

Microbiology and pathogenesis of acute pyelonephritis, UpToDate, 2009

Urinary tract infections (UTIs) are common, especially in young children and sexually active women. By convention, UTI is defined as an infection either of the lower tract (acute cystitis) or upper tract (acute pyelonephritis and other renal infections). (See "Acute cystitis in women".)
Despite the upper tract involvement in acute pyelonephritis, most episodes are generally considered to be uncomplicated. A complicated urinary tract infection, whether localized to the lower or upper tract, is associated with an underlying condition that increases the risk of failing therapy (such as obstruction, urologic dysfunction, or a multiply-resistant uropathogen).
At the time of presentation, it is difficult to determine whether a patient with pyelonephritis or cystitis has a complicated or uncomplicated infection. However, an uncomplicated urinary tract infection is generally defined as one occurring in a healthy, ambulatory nonpregnant woman; all other urinary tract infections may be considered complicated. Multiple factors are associated with complicated urinary tract infection that generally warrants both a broader spectrum antimicrobial for empiric therapy and, infrequently, consideration of surgical intervention.
Acute pyelonephritis also must be distinguished from chronic pyelonephritis. Chronic pyelonephritis is an uncommon cause of chronic tubulointerstitial disease due to recurrent infection, such as infection in association with a chronically obstructing kidney stone, or vesicoureteral reflux (VUR). VUR in children can cause repeated episodes of acute, often asymptomatic, infection, and produce renal scarring and, in some cases, progressive renal failure. (See "Presentation, diagnosis, and clinical course of vesicoureteral reflux".)
The epidemiology, microbiology, and pathogenesis of acute pyelonephritis will be reviewed here. The clinical manifestations, diagnosis, and treatment of uncomplicated and complicated infections are discussed separately. (See "Clinical manifestations; diagnosis; and treatment of acute pyelonephritis".)... Authorized only

Management of Sepsis NEJM 2006

A better understanding of the inflammatory, procoagulant, and immunosuppressive aspects of sepsis has contributed to rational therapeutic plans from which several important themes emerge. First, rapid diagnosis (within the first 6 hours) and expeditious treatment are critical, since early, goaldirected therapy can be very effective. Second, multiple approaches are necessary in the treatment of sepsis. Third, it is important to select patients for each given therapy with great care, because the efficacy of treatment — as well as the likelihood and type of adverse results — will vary, depending on the patient... Autorized only

DIC, Current Concept, NEJM, 1999

DISSEMINATED intravascular coagulation is characterized by the widespread activation of coagulation, which results in the intravascular formation of fibrin and ultimately thrombotic occlusion of small and midsize vessels. Intravascular coagulation can also compromise the blood supply to organs and, in conjunction with hemodynamic
and metabolic derangements, may contribute to the failure of multiple organs. At the same time, the use and subsequent depletion of platelets and coagulation proteins resulting from the ongoing coagulation may induce severe bleeding (Fig. 1). Bleeding may be the presenting symptom in a patient with disseminated intravascular coagulation, a factor that can complicate decisions about treatment... Authorized only

Treatment of herpes zoster and postherpetic neuralgia

Herpes zoster (shingles) affects up to half of all people who live to 85 years of age and can lead to long term morbidity. Appropriate treatment controls acute symptoms and reduces the risk of longer term complications. The most common complication in immunocompetent patients is distressing and sometimes intractable chronic pain. Prevention and treatment should be priorities. Most cases of zoster can be managed in primary care and a full understanding of the condition is essential. A previous BMJ editorial focused on variability of estimates of prevalence.1 Here we present an update on the treatment of herpes zoster and postherpetic neuralgia.

1. Authorized only (Treatment of herpes zoster and postherpetic neuralgia, BMJ, 2006)
2. Varicella Zoster Virus: Natural History and Current Therapies of Varicella and Herpes Zoster, IHMF 2007
3. Zoster-associated Pain: What is Known, Who is at Risk and How Can it be Managed?, IHMF 2007

결핵

결핵 진료지침, 대한 결핵 및 호흡기 학회 2005 (요약본)

결핵 진료 지침, 결핵 진료지침 개발위원회, 질병관리본부 2011

Treatment of tuberculosis,4th ed., WHO 2010

Pneumonia treatment, IDSA/ATS, AAFP

Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults, 2007 Chigago Journal

Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults, 2007 NGC

Community-Acquired Pneumonia in Infants and Children, 2003 AAFP