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GEORGIA DEPARTMENT OF CORRECTIONS
Floyd Veterans Memorial Building
Room 952 - East Tower
Atlanta, Georgia 30334
Sonny Perdue
Governor

MEMORANDUM

TO:
Medical Directors, Medical Administrators, & Health Care Personnel State & Private Prisons, Boot Camps, Transitional and Detention Centers Jerry Buttelwerth, MSN, CFNP, CCHP Clinical Services Consultant Clinical Update 03.02: Practice Guidelines for Managing Skin Infections Caused by Methicillin Resistant Staphylococcus aureus (MRSA) Madie LaMarre, MSN, CFNP, Statewide Clinical Services Supervisor Harris Hodges, Interim Division Director, Programs William P. Kissel, Health Services Director Joseph E. Paris, PhD, MD, GDC Statewide Medical Director Office of Health Services Management and Clinical Teams Jennifer Taussig, MPH, Statewide Public Health Coordinator Ed Bailey, DO, GCHC Statewide Medical Director Charles Peterson, Pharm D, Director of Pharmacy, GCHC Nick Munhofen, Director of Operations, GCHC Lynn Bill, BSN, MPA, Director of Patient Care Services, GCHC Kathleen E. Toomey, MD, MPH, Director, Georgia Division of Public Health Paul Blake, MD, MPH, Georgia State Epidemiologist OFFICE OF HEALTH SERVICES
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Fax: 404-651-6414
GEORGIA DEPARTMENT OF CORRECTIONS
Floyd Veterans Memorial Building

Room 952 - East Tower
Atlanta, Georgia 30334
SONNY PERDUE
GOVERNOR


CLINICAL UPDATE 03:02
TO:
Medical and Nursing Directors, Health Administrators State and Private Prisons, Boot Camps, Transitional & Detention Centers Notifiable Diseases Section, Epidemiology Branch Division of Public Health, Georgia Department of Human Resources Notifiable Diseases Section, Epidemiology Branch Division of Public Health, Georgia Department of Human Resources Practice Guidelines for Managing Skin Infections Caused by Methicillin Resistant Staphylococcus aureus (MRSA) I. Background
Staphylococcus aureus, a type of bacterium often simply referred to as "staph," is commonly
found on the skin and in the nose of healthy persons. Occasionally, staph also can cause minor
infections such as pimples, boils (furuncles), or hair bumps (folliculitis), or serious infections
such as blood infections (bacteremia). Some staph are resistant to antibiotics in both the
penicillin class (e.g., Methicillin) and the cephalosporins class (e.g., Keflex). These staph are
known as Methicillin-resistant Staphylococcus aureus (MRSA). MRSA may be resistant to other
types of antibiotics as well, especially macrolides such as erythromycin.
OFFICE OF HEALTH SERVICES
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MRSA has been common in hospitals for approximately 20 years, but only recently has become
an increasingly common cause of community-onset infections. In addition, outbreaks of skin
boils caused by MRSA in correctional settings have been reported in several states, including
Georgia. Based on Statewide reports of MRSA skin infections, carriage of MRSA without
symptoms may be widespread among inmates in Georgia jails and prisons, and guidelines are
needed to slow its spread and minimize MRSA infections.
These guidelines are divided into four (4) parts: prevention, recognition, diagnosis and
treatment (including recurrent lesions in an individual), and outbreak control. All facilities should
ensure that prevention measures are in place and diagnostic testing is available. Facilities
affected by MRSA will need to implement treatment and outbreak control measures.
II. Prevention
Four basic measures are critical to minimize the spread of MRSA in correctional facilities.
These include:
1. Minimizing unnecessary antibiotic use 3. Optimizing hygiene, especially hand washing among inmates 4. Controlling drainage from infected lesions
Appropriate Antibiotic Use
Use of antibiotics for any reason may kill susceptible staph on the skin and in the nose, but
MRSA may survive. Selective survival of MRSA increases the risk of MRSA transmission and
MRSA infections in the population and the individual. For this reason, it is important to
always use antibiotics responsibly and to consider carefully whether antibiotics are
necessary before prescribing them.
Published guidelines exist for appropriate antibiotic use
for common respiratory tract infections in adults, including sore throat, sinus symptoms, and
cough illness. A one-page summary of these guidelines is attached (see Attachment A). Taken
from, "Guidelines for Appropriate Antibiotic Use for Treatment of Acute Respiratory Tract
Infections in Adults," Annals of Internal Medicine, 2001, 134:479-529.
Surveillance for MRSA
Surveillance permits early recognition of MRSA in the facility and improves treatment. The
following guidelines should be implemented:
1. Establish and maintain a skin infection log (see Attachment B) of skin infections, OFFICE OF HEALTH SERVICES
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ƒ type/location of lesion ƒ date of culture (or visit date if not cultured) ƒ culture results (microorganism detected) ƒ antibiotics ƒ if MRSA, antibiotic susceptibility to (erythromycin, TMP/SMX, clindamycin, Evaluate antibiotic-resistance patterns of all isolates to identify common patterns and to guide empiric therapy. 2. Encourage inmates with skin lesions to come to medical (through the sick call or urgent/emergent care access) before spread to other inmates or personnel occurs. When inmates are transferred to another facility, they should be interviewed about the presence of skin lesions, and examined if lesions are reported. In many outbreaks, inmates have mistaken early lesions for spider bites, so encouraging inmates with spider bites to be evaluated may improve early recognition of a potential MRSA skin infection. 3. Obtain a culture from all draining skin lesions. If a lesion contains pus but is not
draining, drainage should be established through sterile incision and drainage (I&D) or warm soaks, and lesion exudates should be cultured.
Personal Hygiene
All staph skin infections, including MRSA, spread easily between people, most commonly by
direct skin contact. Transmission is particularly common under crowded conditions and in warm
weather. Good hygiene, with use of soap and water, is very important in reducing the risk
of spread by removing bacteria on the skin.
Waterless hand sanitizers also work well, if
hands are not visibly soiled. All facilities should ensure convenient access to soap and water
for inmates, and encourage daily showers and regular hand washing (e.g., before meals and
after using restroom facilities). Installation of liquid soap dispensers near sinks may improve
access to soap and compliance with hand hygiene.
Any break in the skin could lead to a staph infection. Minor wounds and chronic skin diseases
need to be treated appropriately and in a timely manner. Activities that lead to breaks in the
skin such as tattooing should be discouraged.
Environmental Cleaning
1. Environmental surfaces should be cleaned regularly with a dilute bleach solution (i.e., 1 tbsp. household bleach per gallon of water) or other disinfectant-based solution. Special attention should be given to surfaces frequently touched by hands. 2. Laundry should be washed and thoroughly dried, using hot settings when possible. 3. Bed sheets, towels and clothing should be laundered regularly. OFFICE OF HEALTH SERVICES
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Control of Infectious Body Fluids
Draining skin lesions may contain millions of infectious bacteria, and may be an important
source of transmission and environmental contamination. If a lesion contains pus, drainage
is essential for rapid improvement, but draining lesions must be covered with absorptive
dressings. Dressings must be changed frequently and disposed of carefully to prevent
spread.
III. Recognition

Efforts to improve diagnosis of MRSA skin infections in correctional facilities include active
programs for disease recognition, including inmate screening during diagnostic intake,
intrasystem transfer and during periodic physical exams.
Screening Inmates
Improved recognition of MRSA can be done through interviewing and examining inmates during
intakes, transfers, and physical exams done for other purposes.
Health care staff should obtain medical history information related to the presence of
current or previous skin infections. Particular attention should be given to patients with a
history of prior MRSA, HIV, diabetes, or known recent contact with a MRSA case, or
recent hospitalization.
The clinician should document culture positive MRSA skin infection information
on the Problem List.

Sending Facility – In addition to the standard measures taken for preparing a patient for transfer out of the facility (chart preparation, medications, etc.), health care staff should document the MRSA skin infection information where appropriate and communicate with receiving facility. Health care staff at the receiving facility should review the health record and interview the patient. If the patient has new skin lesions, the nurse should either telephone the clinician or refer the patient to the clinician for skin lesion management orders/instructions. • Other Physical Exams At the time of the physical exam, the clinician should review the Problem List and health record to determine if the patient has a current or past history of skin infections. Particular attention should be given to patients with a history of prior MRSA, HIV, diabetes, or known recent contact with a MRSA case, or recent hospitalization. OFFICE OF HEALTH SERVICES
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Diagnosis and Treatment of MRSA Skin Infections

The type and severity of skin infection should be defined. The following is a list of common skin
lesions accompanied by their definition:
Folliculitis (hair bumps): a skin infection involving the hair follicle and its immediate
surroundings. It presents as a series of raised, painful reddish lesions with a swollen base, each of them being centered on a hair follicle. • Furuncle (boil): aggressive, deeper form of folliculitis that extends into the skin. It
appears as an acute, localized abscess of the skin and subcutaneous tissue around a hair follicle, resulting in a tender, inflammatory nodule containing pus. • Carbuncle: aggregate of multiple, connected furuncles with spread of infection under
the skin, resulting in deep abscess, often accompanied by extensive local sloughing, slow healing, and a large scar. • Cellulitis: diffuse, spreading, acute inflammation of the skin and of subcutaneous
tissue, characterized by redness, inflammation, and swelling without necrosis, pus or drainage.
Treatment of skin and soft tissue infections differs according to the type of infection, and the
host. In general, minor skin infections, such as folliculitis or furuncles usually require
only local care once drainage is assured by warm soaks or incision and drainage
.
However, a furuncle with surrounding cellulitis, or fever, or one located about the midface
should be treated with antibiotics. Diffuse or recurrent furuncles may require antibiotics. In
immunocompromised patients, such as those with HIV infection, diabetes or steroid use, many
practitioners prefer to use antibiotics even for minor infections, but data do not support this.
More serious infections, such as carbuncles and cellulitis generally require antibiotics, and if
progressive, may require intravenous therapy. If serious or systemic infection is suspected or
underlying disease complicates treatment, infectious disease (ID) consultation is warranted.
Managing Furuncles or Other Draining Lesions
• Clinicians should educate patients with draining lesions regarding frequent hand washing, particularly if a lesion is touched. • Patients should be cautioned NOT to squeeze or touch their own or others’ lesions. • Patients with draining lesions must keep a dry dressing over the area. Dressings should be changed often enough to prevent seepage, in a supervised setting, and disposed of carefully in biohazard bags. • Warm soaks, when used, should be performed in a supervised setting to ensure proper disposal of materials. To ensure proper technique and evaluate condition of wounds, medical staff should perform or supervise all dressing changes when possible. Inmates OFFICE OF HEALTH SERVICES
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should be given extra dressings and proper means to dispose of soiled ones (in biohazard bags) for emergencies. • Inmates with infections, who continue to practice poor hygiene, should be isolated or cohorted with other infected patients. Isolation may involve placing the inmate in a regional infirmary. If infirmary placement is medically indicated, the medical staff should contact Utilization Management for a bed/infirmary assignment. Cohorting would involve placing infected inmates together in a separate housing unit. • For uncomplicated furuncles in the normal host, adequate drainage (i.e., through
warm soaks or surgical incision) and wound care are considered primary therapy
and also provide the mechanism to diagnose MRSA through culture.
All facilities
should identify a mechanism to provide incision and drainage when needed, and to
culture all draining lesions; swabbing of skin is not adequate. While clinical judgment
is important, many experts feel that once drainage is assured, antibiotics are
unnecessary and do not speed resolution of uncomplicated furuncles.
To ensure
resolution, medical follow up is important. If incision and drainage is planned, the
American Heart Association (AHA) recommends prophylactic antibiotics before the
procedure in persons with certain cardiac conditions. (Dajani, A.S. et al. Circulation
1997;96:358-366.)
• In the correctional setting, clinicians may choose to treat with antibiotics to reduce the likelihood of transmission, but data to support this practice are unavailable. When
antibiotics are prescribed, directly observed therapy (DOT) should be considered to
ensure compliance and prevent the diversion of drugs with possible street value.
Prolonged therapy is not necessary if lesions are responding, and does not
eradicate colonization. Treatment duration depends on clinical response, but
seven days is usually sufficient.
If wounds are not resolving within this period,
evaluate for complicating factors (undrained pus, noncompliance) and consider
consulting with an infectious disease specialist.

When the clinician determines that antibiotics are necessary for treatment of skin
infections (i.e., carbuncles, cellulitis or furuncles in an immunocompromised
patient), treating empirically requires knowing if MRSA is the likely pathogen.
This
requires surveillance and monitoring of the skin log.
• In facilities where MRSA is not suspected, empiric therapy with a first-generation cephalosporin such as Keflex, or a macrolide such as erythromycin is appropriate, when antibiotics are deemed necessary. If MRSA is likely, appropriate oral antibiotics should be prescribed (see Table 1). Managing Recurrent Furuncles in a Patient Patients with recurrent skin lesions may have nasal colonization, or another source of relapse. The following process should be used to evaluate recurrent skin infections: OFFICE OF HEALTH SERVICES
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1. The clinician should check for an unresolved source of recurrent disease, (e.g., open wound, undrained abscess or infected medical prosthesis). 2. The clinician should check for colonization by rubbing the cotton surface of a culturette firmly over the mucosa of both anterior nares, and send the specimen for culture and susceptibility testing. The results should then be recorded on the skin log. 3. If a nasal culture is positive, attempt decolonization* of the patient by conducting the a. Provide chlorhexidine for thorough daily showers for 5 days. Advise the patient to avoid getting chlorhexidine in the eyes. b. Apply mupirocin (bactoban) nasal ointment in both nares twice a day for five (5) days. Ointment should be massaged well into nares, and should be done by DOT when possible. * The goal of decolonization is to eradicate staph from the anterior nares. Although widespread use of chlorhexidine may be considered during outbreaks, use of mupirocin in the wider population is not advised because it is only useful in nasal carriers and resistance evolves rapidly.
V. Outbreak

In addition to the recommendations in this document, suspected outbreaks should be reported
to the county, district, or state health departments (number for the Georgia Division of Public
Health: 404-657-2588).
Surveillance
• Health care staff should encourage inmates to be seen in medical for “spider bites”, or • If feasible, waive co-pay charges to enhance complete patient identification. • If an outbreak is extensive or prolonged, investigate undiagnosed reservoirs of infection in the general population by actively screening inmates for lesions. OFFICE OF HEALTH SERVICES
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• Nursing staff should provide and emphasize facility-wide education for inmates and staff • Inmates should have access to soap and water, preferably by providing liquid soap dispensers at bathroom sinks and shower facilities. Waterless hand sanitizers are also effective if hands are not visibly soiled, but may be expensive. Hand sanitizers have residual antibacterial effects. • Inmates should be encouraged to shower using soap, with extra attention to body parts that contain many hair follicles and oil glands; the scalp, underarms, chest, groin and buttocks. • Frequent hand washing must be emphasized. Most staph infections are transmitted by • Inmates should avoid sharing personal items (e.g., comb, razor, clothing, towels, etc.). • With assistance from public health, consider an investigation of risk factors for disease • Environmental surfaces should be cleaned regularly with a dilute bleach solution (1 tbsp. household bleach per gallon of water) or other disinfectant-based solutions. Special attention should be given to surfaces frequently touched by hands. • Laundry should be washed and thoroughly dried, using the hot setting. • Fresh washcloths and towels should be provided frequently (preferably daily). Disposable materials may be substituted, if preferable. • Fresh undergarments should be worn daily. • Bed sheets and clothing should be laundered regularly (e.g., daily or twice weekly). • Health care staff should educate patients with draining lesions about frequent hand washing, particularly if a lesion is touched. • Patients must NOT squeeze or touch their own or others’ lesions. • Patients with draining lesions must keep a dry dressing over the lesion. Dressings should be changed in a supervised setting, often enough to prevent seepage, and Deleted: , and
disposed of carefully. Warm soaks, when used, should be provided in a supervised OFFICE OF HEALTH SERVICES
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setting to ensure proper disposal of materials. Inmates should be given extra dressings and proper means to dispose of soiled ones (biohazard bags) for emergencies. • For prolonged or extensive outbreaks, chlorhexidine soap for daily showers for five days in the affected dorm or population should be considered, but caution is required to keep it out of the eyes. Chlorhexidine and waterless hand sanitizers have a residual antibacterial effect. • Isolate (in a regional infirmary if necessary) patients with poor hygiene and MRSA. Inmates with poor hygiene are those who are likely to spread MRSA either due to poor control of wound drainage, or inadequate hand hygiene. • Inmates with food handling work duties should not work if they have any lesions on their hands. Assuming good hygiene, and limited skin contact with others, limitation of work and other activities for other inmates is not indicated.
What NOT to do in an outbreak
• Widespread or generalized nasal swabbing is usually not indicated. • Environmental swabbing is usually not indicated. • Prolonged antibiotic therapy is not indicated and not helpful. • Widespread use of mupirocin for the population at risk is not advisable due to likely rapid OFFICE OF HEALTH SERVICES
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Table 1: Oral Antibiotics for Empiric Treatment of suspected MRSA Skin Infections,
When Antibiotics Are Deemed Necessary*
Useful for
Antibiotic
Comments
Infection
Preferred drug. Significant side effects (allergic rash) may occur. Side effects more common in HIV-infected persons. Tetracyclines:
Bacteriostatic. Photosensitivity, GI side effects. Avoid Bacteriostatic. Erythromycin-resistant strains of MRSA may appear to be clindamycin-susceptible, but have an inducible form of clindamycin-resistance. This problem varies geographically. Resistance can develop on monotherapy. Do not use Fluoroquinolones:
alone. Avoid in pregnancy. **May combine with
Rifampin.
Resistance develops quickly on monotherapy. Do not use alone. ***May combine with Ciprofloxacin.
Penicillins:
MRSA are resistant to all beta-lactam antibiotics. Cephalosporins:
MRSA are resistant to all beta-lactam antibiotics. Macrolides:
Bacteriostatic. Many community strains and most hospital strains of MRSA are macrolide-resistant. * When antibiotic susceptibility results are known, they should be used to guide choice of antibiotic therapy. Knowing the predominant strains of staph in an institution and studying the resistance patterns by keeping a skin log and culturing all lesions can assist in the empiric choice of antibiotics while susceptibility results are pending.
VI. References

1.
APIC. "Infection Control and Epidemiology in the Correctional Facility," From APIC Text of Infection Control and Epidemiology, Pfeiffer, J.A. (Ed.), 2000. CDC. Issues in Health Care Settings – Antimicrobial Resistance: MRSA Information for Patients. Available at www.cdc.gov/ncidod/hip/Aresist/mrsafaq. CDC. Issues in Health Care Settings – Antimicrobial Resistance: MRSA Information for Health Care Personnel. See web site listed above. OFFICE OF HEALTH SERVICES
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CDC. "Methicillin-Resistant Staphylococcus aureus Skin or Soft Tissue Infections in a
State Prison – Mississippi, 2002," MMWR, 2000:Vol.50 (42), pp. 919-922.
Garner, J.S., "Hospital Infection Control Practices Advisory Committee: Guidelines for
Isolation Precautions in Hospitals," Infection Control Hospital Epidemiology, 1996,
Vol.17, pp. 53-80.
Georgia Department of Human Resources, Division of Public Health, Epidemiology Branch. Memorandum to Colwell Probation Detention Center, Blairsville, GA. September 7, 2001. Georgia Department of Human Resources, Division of Public Health, Epidemiology Branch. Memorandum to Colwell Probation Detention Center, Blairsville, GA. August 31, 2001. Gibson, D.N., Moellering, R.C., & Sande, M.A. The Sanford Guide to Antimicrobial
Therapy, 2001
, 31st Edition, page 36.
Pierce County (WA) Antibiotic Resistance Task Force and Tacoma-Pierce County (WA) Health Department. "Controlling Antibiotic Resistance – A practical Guide for Health Care Providers, Schools, Residential & Correctional Facilities, Dentists and Veterinarians." Available at www.tpchd.org/antibiotic/manualwithLinks.pdf, January 2002, pp. 27-28. State of California Department of Corrections. Memorandum to Health Care Managers, Chief Medical Officers, Public Health Staff/Designees. Swartz, M.N. "Cellulitis and Subcutaneous Tissue Infections." In Mandell, G.L., Bennett,
J.E., & Dolin, R. Principals and Practice of Infectious Diseases, 2000, 5th Edition,
page 1040.
Texas Department of Criminal Justice, Health Service Division. Infection Control Manual, Number B-14-16. January 15, 1999.
VII. Appendices
1.
Appendix A: Adult Appropriate Antibiotic Use Summary Appendix B: Georgia Department of Corrections Skin Infection Log OFFICE OF HEALTH SERVICES
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Appendix A.
Adult Appropriate Antibiotic Use Summary
Diagnosis
CDC Principles of Appropriate Antibiotic Use for Upper Respiratory Infections in Adults
The diagnosis of nonspecific upper respiratory tract infections or acute rhinopharyngitis should be used to denote acute infection that is typically viral in origin, and in which sinus, pharyngeal, and lower airway symptoms, although frequently present, are not prominent. Antibiotic treatment of nonspecific upper respiratory infections in adults does not enhance illness resolution or prevent complications, and is therefore not recommended. Purulent secretions in the nares and throat (commonly reported and seen in patients with uncomplicated, upper respiratory tract infection) neither predict bacterial infection nor benefit from antibiotic treatment. Group A beta hemolytic streptococcus (GABHS) is the etiologic agent in approximately 10% of adult cases of pharyngitis. The large majority of adults with acute pharyngitis have a self-limiting illness, which would do well with supportive care only. The benefits of antibiotic treatment of adult pharyngitis are limited to those patients with GABHS infection. All patients with pharyngitis should be offered appropriate doses of analgesics, antipyretics and other supportive care. Limit antibiotic prescriptions to those patients with the highest likelihood of GABHS. Clinically screen all adult patients with pharyngitis for the presence of the 4 Cantor criteria: (1) history of fever, (2) tonsilar exudates, (3) no cough, and (4) tender anterior cervical lymphadenopathy (lymphadenitis). 1. Do not test and do not treat patients with none or only one of these criteria. These patients are 2. For patients with 2 or more criteria, the following strategies are appropriate: ¾ Test patients with 2, 3, or 4 criteria using a rapid antigen test. Limit antibiotic therapy ¾ Test patients with 2 or 3 criteria using a rapid antigen test. Limit antibiotic therapy to patients with a positive test or patients with 4 criteria. ¾ Do not use any diagnostic tests. Limit antibiotic therapy to patients with 3 or 4 criteria. Throat cultures are neither recommended for the routine primary evaluation of adults with pharyngitis, nor for the confirmation of negative rapid antigen tests. Throat cultures may be indicated as a part of investigations of outbreaks of GABHS disease, for monitoring the development and spread of antibiotic resistance, or when pathogens such as gonococcus are being considered. The preferred antibiotic for treatment of acute GABHS pharyngitis is penicillin, or erythromycin for a penicillin-allergic patient. Most cases of acute rhinosinusitis diagnosed in ambulatory care are due to uncomplicated viral, upper respiratory tract infections. Bacterial and viral rhinosinusitis are difficult to differentiate on clinical grounds. The clinical diagnosis of acute bacterial rhinosinusitis should be reserved for patients with rhinosinusitis symptoms lasting 7 days or more and who have maxillary facial/tooth pain or tenderness (especially when unilateral) and purulent nasal secretions. Patients who have rhinosinusitis symptoms for less than 7 days are unlikely to have a bacterial infection. Sinus radiographs are not recommended for diagnosis in routine cases. Acute bacterial rhinosinusitis resolves without antibiotic treatment in the majority of cases. Symptomatic treatment and reassurance is the preferred, initial management strategy for patients with mild symptoms. Antibiotic therapy should be reserved for patients meeting the criteria for the clinical diagnosis of acute bacterial rhinosinusitis who have moderately severe symptoms, and for those with severe rhinosinusitis symptoms – especially those with unilateral face pain – regardless of duration of illness. Initial treatment should be with the most narrow-spectrum agent that is active against likely pathogens Streptococcus pneumoniae and Haemophilus influenzae. The evaluation of adults with an acute cough illness, or with presumptive diagnosis of uncomplicated acute bronchitis, should focus on ruling out pneumonia. In the healthy, non-elderly adult, pneumonia is uncommon in the absence of vital sign abnormalities or asymmetrical lung sounds, and chest radiography is warranted in the absence of other known causes. Routine antibiotic treatment of uncomplicated bronchitis is not recommended, regardless of duration of cough. In the unusual circumstances when pertussis infection is suspected, a diagnostic test should be performed and antimicrobial therapy initiated. Patient satisfaction with care for bronchitis is most dependent on the doctor-patient communication rather than on whether or not an antibiotic is prescribed. OFFICE OF HEALTH SERVICES
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DEPARTMENT
CORRECTIONS
Infection Log
Appendix
If MRSA, Antibiotic Susceptibility
Type/Location
Antibiotics
of Lesion
(visit date if
Prescribed
cultured)
OFFICE OF HEALTH SERVICES
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OFFICE OF HEALTH SERVICES
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