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Actinomycosis

(A israelii most common also A naeslundn. A viscosus. A odontolyticus, A meyeri, A geiencsenae)

Cervicofacial, pulmonary, abdominal, cerebral. & rarely pericarditis (IDCP 12:233. 2004)

Classically abdominal aclino presents as inloiabdominal or pubic mass abscess, fistula Itacl (Dis Catvi Rectum 48:575, 2005) years alter surgery & may mimic cancer (World J Gaslto 11 1722. 2005). Fino needle aspuale ot ceivicolacial actino established dx in 15 pts in Spain JMed Oral Pal ol Oral Ciro Bucal 9 467. 2004)

Ampicillin 50 mg per kg per day IV times 4-6 wks. then 0 5 gm amoxicillin po til! OR Penicillin G 10-20 million units per day IV times 4-6 wks, then penicillin V 2-4 grn pet day po Duration individualized, esp with surgical dobulking. lolal duration 3-6 mos. usually adequate lor thoiacic & abdominal & 3-6 wks toi cervicofacial (CID 38 444. 2004).

Doxycycllne or ceftriaxone or clindamycin or erythromycin Chloramphenicol 12.5-15 mg pet kg IV/po q6h lias been recommended tor CNS infection in pen-allergic pts

Tuboovarlan abscesses may complicate lUDs. Removal ot IUD is primary rx With abscesses intlammalory mass or (istulao. surgery otten required While penicillin G and ampicillin IV have been effective, with homo IV therapy, agents given q24h eg. cetlnaxone. are more practical (CID 19:161. f994) Surgery may tie necessary loi hemoptysis (An Thot Surg 74 185. 2002)

Aspergillosis IA lumigalus most common, also A tlavus and others) (CID 30 696, 20001

Aspergillosis IA lumigalus most common, also A tlavus and others) (CID 30 696, 20001

1 aspergillosis (ABPA)

, wilti asthma & 115% wilh cystic fibrosis

Allergic bronchopulmonary

ABPA found in 1 -2% of pts wilti fCID 37 (Suppl 3):37. 2003] Clinical manifestations- wheezing, putmon ary Infiltiates. bronchiectasis & librosis Airway colonization assoc. with T blood eosinophils t seium IgE,1 spectlic serum antibodies Allergic fungal sinusitis relapsing chronic sinusitis, nasal polyps wilhoul bony invasion, asthma, eczema or allergic rhinitis. T IgE levels and isolation ol Aspeigillus sp or other demaliaceous sp (Allotnana, Cladosporium, etc)

Acute asthma attacks associated with ABPA Corticosteroids

Rx ol ABPA Itraconazole'

200 mg po q24h limesl 6 wks or longer (Allergy 60:1004. 2005)

In 2 PRCTs\ lira I number ol exacerbations requiring corticosteioids (p ■ 0 03), improved immunological markers (eosinophils in spulum & I arum IgE levels), & in 1 study improved lung tunction & exercise tolerance (NEJM 342.756, 2000: Cochrane Database Syst flev 3CD001108, 20041

Rx controversial: systemic cortico steroids + surgical debridement (80% respond but 2/3 relapse) (Otolaryn Head Neck Su/g 131.704. 2004)

For latluros try itra' 200 mg po bid Ilmes12 mos (CID 31: 203. 2000) Flucon nasal spiay benetited 12/16 pis (EOT/83:

In 1 report, fungal elements identilied by hislopalhology in up to 93% ot cases ot "chronic sinusitis" & in a DBPCT in 24 pts, intranasal amplio was assoc with a I In mucosal thickening ot 8.6% by CT scan vs Î ol 2 5% in placebo (LnlD 4:257. 2004) Conlioveisial aiea a (fungus bsll) (J Resp Dis 23:300.

Efficacy ol anliinicrobial agents not proven Itraconazole (|)o) benelll (oponed srvr.uli .11,' [J Am A::,:! : • "•". ' : >■ — '>

Voriconazole 6 nig pa kg IV ql2h on day 1. then eithet (4 mg per kg IVq!2h) or (200 mg po ql2h lor body weight >40 kg. but 100 mg po q12h tor body weight <40 kg) OR Lipid-based ampho B may be as effective and less nephiotoxic than standard ampho 6 but much more expensive (see footnote' for dosages). Some authorities now preler lipid-based ampho B over standard ampho B as initial rx (CID 32: 415. 2003) OR Ampho B (see footnote' page 76) Rapid increase lo 1 mg per ka (1-1 25 mg per kg it neutropenic) IV q24h Tola! dose of 2-2.5 gm tec. by some but data to support this lacking OR Combination rx: Vori On above dosages) - csspo (dosage t>e/ow) are cuuenlly preferred initial treatment in many bone marrcrw transplant units, esp in pts receiving high doses ot corticosteroids (Abstracts in Heme & One 8 11. 2005)

Post-transplantation and post-chemotherapy m neutropenic pis |PMN <500 per mm1) but may also present with neutrophil recovery (Mycopatho-logia 159:181. 2005) Most common pneumonia in tiansplanl recipienls Usually a lale (2100 days) complication in allogeneic bone mairow & liver Iransplanlation median survival 36 days, bul overall mortality rates vary from 78-94% iCID 36:46. 2003) May complicate COPD when coilicosteroids used (Clin Micro Inl 11 427. 2005)

Typical x-ray/CT lung lesions ¡halo sign, cavitation. or mycotic lung sequestration) have 90% positive predictive value tor invasive pulmonary aspergillosis in pts with hematologic malignancies (CID 31 859.2000)

An immunologic test thai detects circulating galactomannan is availablo tot dx ol invasive aspergillosis A incent article loviews the stiengths & weaknesses ol the lest ¡CID 41 (Suppl 6J .S38I, (continued on next page)

Oral solution preferred to tablets because of' absorption see Table f IS. page 83) PRCTs Prospective randomized controlled trials Dosages: ABLC 5 mg per kg por day IV over 2 hrs. ABCC 3-4 mg per kg pet day IV given as 1 mg pel kg pel hi liposomal Ampho B 3-5 mg per k

See page 2 lor abbreviations Alt dosage recommendations are lor adults (unless otherwise indicated) and assume norma) renal Lnclion

(continued on next page)

Aspef^ilbs rna^complicate pulmonary sequestration (Eur J Cardio Thor

Voriconazole n,-.ip --r-. ■,:tiv>:- ii-„in ampho B in randomized trial ol 277 rnimunosupptesseo pts with tPA, 53% responded vs 32% rx with ampho B Overall survival belter (71 vs 58%) (NEjM 347 406.2002) Appears particularly advantageous in cetebral aspergillosis (CID 39 603, 2004) & as salvage therapy in those with teliactory infection (Eur J Haematol 73 50. 2004) 40% ol 31 pts survived with vori alone. Von reputed satisfactory results in 11/20 pis with bone involvement (18 lot salvage), lollow-up average ol 3 mos (CID 40 1141, 2005)

Ampho B overall success rate 34-42% (CID 32 358. 2001) in pulmonary aspergillosis in pts rx ?14 days. Success dependent on underlying disease 83% tieatlAidnuy transplants, 54% neutropenic leukemia pts. 33% bone marrow transplant. 20% Irvet transplant (CID 23 608. 1996) 44% ot 398 pts receiving ampho B lipid complex (ABLC) were cuied oi improved & 21% stabilized, most had tailed lo respond to prior antitungal rx (CID 40.S392. 2005) A. terreus Infections particularly resistant to ampho B: in 83 cases. 73.4% mortality with ampho B rx vs 55.8% with voriconazole rx (p <0.01) (CID 39 192. 2004) Use vori!

Caspofungin: Among 83 pts with IPA included in Ihe primary (MITT) analysis. 37 (45%) had turntable response following salvage rx with caspo monotherapy In pts receiving >7 days ol caspo monotherapy, 56% (37/66) responded favorably (CID 39 (563.2004) Response in compassionate use program 44% (J Inl 50:196.2005) Minimal toxicity reported (Transpi/rrfDrs '25. 2002)

Mlcstungin: 57% clinical response in an open-label study ol "deep-seated" intections (Scand J Inl Drs 36 372. 2004)

Combination therapy: To date no controlled patient trials, and they are needed (CID 39 803. 2004) No antagonism between Iriazoles (von & itra), echinocandins (caspo). & ampho B Synergy (continued on next page)

I per day tV given over 1 -2 hrs

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Coping with Asthma

Coping with Asthma

If you suffer with asthma, you will no doubt be familiar with the uncomfortable sensations as your bronchial tubes begin to narrow and your muscles around them start to tighten. A sticky mucus known as phlegm begins to produce and increase within your bronchial tubes and you begin to wheeze, cough and struggle to breathe.

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