Severe encephalitis

http://www.soonak.com/PDF/guideline%20encephalitis%20revised.pdf

HIV Treatment Guidelines for Adults and Adolescents Updated

The Department of Health and Human Services (DHHS) Panel ในสหรัฐอเมริกา ได้ updated recommendations Antiretroviral Guidelines for Adults and Adolescents based on current evidence.

"Antiretroviral therapy (ART) for the treatment of [HIV] infection has improved steadily since the advent of potent combination therapy in 1996," the guidelines authors write. "New drugs have been approved that offer new mechanisms of action, improvements in potency and activity even against multidrug-resistant viruses, dosing convenience, and tolerability."

Topics covered in the updated and in previous guidelines have included baseline evaluation, treatment goals, indications for starting ART, choosing initial therapy in ART-naive patients, drugs or combinations to be avoided, managing adverse effects and drug interactions, managing treatment failure, and ART-related considerations directed to specific patient populations.

A new section in the updated guidelines addresses HIV diagnosis and treatment considerations in older patients with HIV infection, who often have more comorbid conditions, which complicates treatment. A new table lists the monthly average wholesale price for US Food and Drug Administration–approved brand and generic antiretroviral (ARV) drugs, including fixed-dose combination products.

Key updates to existing sections of the guidelines include the following:

• Starting ART in treatment-naive patients:
  • ART is recommended for all HIV-infected individuals, but the strength of this recommendation varies according to CD4 cell count before treatment.
  • Regardless of CD4 count, starting ART is strongly recommended for patients who are pregnant or who have a history of an AIDS-defining illness, HIV-associated nephropathy, or coinfection with hepatitis B virus.
  • ART should be offered to infected patients, particularly heterosexuals, who are at risk of transmitting HIV to sexual partners.
  • Patients starting ART should understand the benefits and risks and be willing and able to adhere to treatment. On a case-by-case basis, clinicians may decide to defer therapy because of specific clinical and/or psychosocial factors.
• HIV-infected women: The update explains the use of hormonal contraception in HIV-infected women, including interactions between combined oral contraceptives and ARV drugs and a possible association between hormonal contraceptive use and HIV acquisition or transmission.
• HIV/hepatitis C virus (HCV) coinfection: The update highlights the newly approved HCV NS3/4A protease inhibitors boceprevir and telaprevir, their interactions with ART, available evidence regarding ongoing research in HIV/HCV coinfected patients, and preliminary recommendations on administering these drugs with ART.
• Mycobacterium tuberculosis disease with HIV coinfection: The update includes recommendations about when to start ART in HIV-infected patients diagnosed with tuberculosis but not yet receiving ART. Specific recommendations are based on CD4 counts and severity of major clinical disease.
• Drug interaction tables: Based on recent pharmacokinetic data, key updates include:
  • a change in the recommendation on rifabutin dosing with HIV protease inhibitors;
  • a new recommendation not to use HIV protease inhibitors and nonnucleoside reverse transcriptase inhibitors with rifapentine;
  • additional information and recommendations on interactions of boceprevir and telaprevir with different ARV drugs; and
  • updated interactions between different ritonavir-boosted protease inhibitors and HMG-CoA reductase inhibitors.
• Prevention of secondary HIV transmission: The update describes the role of effective ART in preventing HIV transmission and evidence-based interventions to facilitate identifying and counseling patients with high-risk behaviors.

Some of the study authors report various financial relationships with Bristol-Myers Squibb, Genentech/Roche, Janssen Therapeutics (formerly Tibotec Therapeutics), Merck, Abbott, Gilead, ViiV, GlaxoSmithKline, Hoffmann-La Roche, Tobira, Sanofi Pasteur, Abbott, RAPID Pharmaceuticals, Sangamo Biosciences, MedImmune, ViroStatics, Tai-Med, Medicines Dev Ltd, Pfizer, Virionyx Corp Ltd, Avexa, Human Genome Sciences, Oncolys, Roche, Vertex, VIRxSYS, Ardea Biosciences Avexa, Monogram Biosciences, Pain Therapeutics, Serono, Teva, Argos, BMS, and/or Boehringer Ingelheim.

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents

New Guidelines for Rhinosinusitis

เนื่องจากการติดเชื้อที่ไซนัสมักจะติดเชื้อบริเวณโพรงจมูกร่วมด้วย
จึงเปลี่ยน term การวินิจฉัยจาก Sinusitis เป็น Rhinosinusitis
ทาง สมาคม โรคติดเชื้ออเมริกา (Infectious Diseases Society of America)
ได้นำเสนอ guideline สำหรับ diagnosis and management of acute bacterial rhinosinusitis (ABRS) infections โดยใช้ระบบ grading ใหม่เพื่อให้มีความชัดเจนมากขี้น( April 15, 2012, issue of Clinical Infectious Diseases.)
ความจำเป็นที่ต้องมี Guideline เกิดขึ้นเนื่องจาก

• ไม่สามารถแยกทางคลินิกได้อย่างชัดเจนว่าเป็น bacterialหรือ viral acute rhinosinusitis, ทำให้เกิดการใช้ Antibiotic มากเกินความจำเป็นและไม่เหมาะสม;
• การเลือกคนไข้ในการให้ empirical antimicrobial ที่ไม่เหมาะสมทำให้ได้ Evidence base ที่ไม่มีคุณภาพ เกิดช่องว่างต่อองค์ความรู้
  
• เกิดปัญหาเชื้อดื้อยา และปัญหาต่อ antimicrobial susceptibility profiles ของแบคทีเรียที่แยกได้จาก ABRS
• ผลของ conjugated vaccines ต่อ Streptococcus pneumoniae on the emergence of nonvaccine serotypes associated with ABRS

เนื่องจาก Acute Rhinosinusitis พบได้บ่อยมาก โดยพบ 1 ใน 7 ราย ของผู้ใหญ่ แต่เป็น ABRS 2-10 %ของผู้ป่วยที่อาการเข้าได้กับ Acute Rhinosinusitis การพิจารณาให้ Antibiotic ทาง clinician ต้องพิจารณาจาก clinical presentation เพื่อแยก bacterial จาก viral rhinosinusitis. guideline ข้างล่างถ้ามีข้อใดข้อหนึ่ง ควรให้การรักษาแบบ bacteria ดังนี้

• symptoms or signs compatible with acute rhinosinusitis lasting for ≥ 10 days without any evidence of clinical improvement;
• Onset with severe symptoms or signs of high fever (≥ 39°C or 102°F) and purulent nasal discharge or facial pain lasting for at least 3-4 consecutive days at the beginning of an illness; or
• Onset with worsening symptoms or signs characterized by new onset of fever, headache, or increase in nasal discharge following a typical viral upper respiratory infection that lasted 5-6 days and initially improved ("double-sickening").

• Antibiotic Treatment for Rhinosinusitis

  First-line therapy:

  amoxicillin-clavulanate, which has better coverage than amoxicillin.เนื่องจาก

• Increasing prevalence of Haemophilus influenzaeใน respiratory tract infections in children since the introduction of the pneumococcal vaccines; and
• High prevalence of beta-lactamase-producing respiratory pathogens in ABRS among recent respiratory tract isolates, particularly H influenzae.

Second-line therapy:

• Doxycycline may be used as an alternate regimen in adults;
• The following are not recommended because of resistance issues: macrolides, such as clarithromycin and azithromycin; trimethoprim-sulfamethoxazole; and second- and third-generation oral cephalosporins;
• Combination therapy with a third-generation oral cephalosporin plus clindamycin may be used in children with non-type-1 penicillin allergy or who are from geographic regions with high endemic rates of penicillin-nonsusceptible S pneumoniae. Levofloxacin is recommended for children with type-1 penicillin allergy; and
• Respiratory fluoroquinolones may be used in patients in whom first-line therapy failed or who have risk factors for antibiotic resistance.

Length of therapy:

• Adults: 5-7 days for uncomplicated ABRS
• Children: 10-14 days

Adjunct therapy:

• Intranasal saline irrigations with physiologic or hypertonic saline may be helpful in adults but are less likely to be tolerated in children;
• Intranasal corticosteroids are recommended in persons with a history of allergic rhinitis; and
• Topical and oral decongestants and antihistamines are not recommended.