Generic name: metronidazole Brand name: Flagyl Preparations: PO 7.

5 mg/kg q6hr (not to exceed 4g/day) CLASSIFICATION: Anti-infectives, Anti-protozoals ACTION: Disrupts DNA and protein synthesis in susceptible organisms Bactericidal, or amebicidal action INDICATION / USES: Amebicide in the management of amebic dysentery COMMON ADVERSE EFFECTS: CNS: seizures, dizziness, headache GI: abdominal pain, anorexia, nausea, diarrhea, dry mouth, furry tongue, glossitis, unpleasant taste, vomiting Hematologic: leukopenia Skin: rashes, urticaria CONTRA-INDICATIONS: hypersensitivity NURSING CONSIDERATIONS: Administer with food or milk to minimize GI irritation. Tablets may be crushed for patients with difficulty swallowing. Instruct patient to take medication exactly as directed evenly spaced times between dose, even if feeling better. Do not skip doses or double up on missed doses. If a dose is missed, take as soon as remembered if not almost time for next dose. May cause dizziness or light-headedness. Caution patient or other activities requiring alertness until response to medication is known. Inform patient that medication may cause an unpleasant metallic taste. Inform patient that medication may cause urine to turn dark. Advise patient to consult health care professional if no improvement in a few days or if signs and symptoms of superinfection (black furry overgrowth on tongue; loose or foulsmelling stools develop).

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metronidazole, Flagyl

Pharmacy Author: Omudhome Ogbru, PharmD Medical and Pharmacy Editor: Jay W. Marks, MD GENERIC NAME: metronidazole BRAND NAME: Flagyl

DRUG CLASS AND MECHANISM: Metronidazole is an antibiotic effective against anaerobic bacteria bacteria are single-celled, living organisms that thrive in environments in which there is little oxygen (a disease in the abdomen (bacterial peritonitis), liver (liver abscess), and pelvis (abscess of the ovaries a lamblia and ameba are intestinal parasites that can cause abdominal pain and diarrhea in infected indi parasite that causes inflammation of the vagina (vaginitis). Metronidazole selectively blocks some of th and the parasites resulting in their death. PRESCRIPTION: Yes GENERIC AVAILABLE: Yes

PREPARATIONS: Tablets: 250 and 500 mg. Tablets, extended release: 750 mg. Capsule: 375 mg. Cream: 0.75% and 1%. Lotion: 0.75%. Gel: 0.75% 1%. Injection: 5 mg/ml

STORAGE: Metronidazole should be stored at room temperature and protected from light.

PRESCRIBED FOR: Metronidazole is used to treat parasitic infections including Giardia infections of th abscess, and amebic dysentery (infection of the colon causing bloody diarrhea), bacterial vaginosis, tri carriers of trichomonas (both sexual partners) who do not have symptoms of infection. Metronidazole i with other antibiotics in treating abscesses in the liver, pelvis, abdomen, and brain caused by susceptib is also used in treating infection of the colon caused by a bacterium called C. difficile. (Many commonly bacteria that inhabit the colon. C. difficile is an anaerobic bacterium that can infect the colon when the are inhibited by common antibiotics. This leads to inflammation of the colon (pseudomembranous colit pain.) Metronidazole also is used in combination with other drugs to treatHelicobacter pylori (H. pylori) ulcers. Metronidazole topical gel is used for treating acne rosacea, and the vaginal gel is used for treat

DOSING: Metronidazole may be taken orally with or without food. In the hospital, metronidazole can be serious infections. The liver is primarily responsible for eliminating metronidazole from the body, and d patients with liver disease and abnormal liver function. Various metronidazole regimens are used. Some examples are listed below.

Amebic dysentery: 750 mg orally 3 times daily for 5-10 days Amebic liver abscess: 500-750 mg orally three times daily for 5-10 days Anaerobic infections: 7.5 mg/kg orally every 6 hours not to exceed 4 grams daily

Bacterial Vaginosis: 750 mg (extended release tablets) once daily for 7 days. One applicator-ful daily for 5 days. Clostridium difficile infection: 250-500 mg orally 4 times daily or 500-750 orally 3 times daily Giardia: 250 mg orally three times daily for 5 days Helicobacter pylori: 800-1500 mg orally daily for several days in combination with other drugs.

Pelvic inflammatory disease (PID): 500 mg orally twice daily for 14 days in combination with oth

Trichomoniasis: 2 g single dose or 1 g twice Rosacea: apply topical gel 0.75-1% once daily Pharmacy Author: Omudhome Ogbru, PharmD Medical and Pharmacy Editor: Jay W. Marks, MD

DRUG INTERACTIONS: Alcohol should be avoided because metronidazole and alcohol together can cause severe nausea, vomiting, cramps, flushing, and headache. Metronidazole can increase the blood thinning effects of warfarin(Coumadin) and increase the risk of bleeding probably by reducing the break down of warfarin. Cimetidine (Tagamet) increases blood levels of metronidazole whilecholestyramine reduces blood levels of metronidazole by reducing its absorption. Metronidazole should not be combined with amprenavir (Agenerase) for treating human immunodeficiency disease (infection with HIV) because amprenavir contains propylene glycol. Metronidazole blocks the breakdown of propylene glycol in the liver leading to accumulation of propylene glycol in blood. Accumulation of propylene glycol could cause seizures, increased heart rate, and lead to kidney failure. Metronidazole increases the blood levels of carbamazepine (Tegretol, Tegretol XR , Equetro, Carbatrol), lithium (Eskalith, Lithobid) and cyclosporine though unknown mechanisms. Serious reactions may occur if these drugs are taken with metronidazole. PREGNANCY: Metronidazole is not used in early pregnancy because of potential adverse effects on the fetus. NURSING MOTHERS: Metronidazole is excreted in breast milk. Nursing mothers, because of potential adverse effects on the newborn, should not use metronidazole. SIDE EFFECTS: Metronidazole is a valuable antibiotic and is generally well tolerated with appropriate use. Minor side effects include nausea, headaches, loss of appetite, a metallic taste, and rarely a rash. Serious side effects of metronidazole are rare. Serious side effects include seizures and damage of nerves resulting in numbness and tingling of extremities (peripheral neuropathy), encephalopathy, and aseptic meningitis. Metronidazole should be stopped if these symptoms appear. GENERIC NAME: METRONIDAZOLE - ORAL (MET-roe-NYE-da-zole) BRAND NAME(S): Flagyl Medication Uses | How To Use | Side Effects | Precautions | Drug Interactions | Overdose | Notes |Missed Dose | Storage

USES: Metronidazole is used to treat a variety of infections. It belongs to a class of antibiotics known as nitroimidazoles. It works by stopping the growth of bacteria and protozoa.This antibiotic only treats bacterial and protozoal infections. It will not work for viral infections (e.g., common cold, flu). Unnecessary use or overuse of any antibiotic can lead to its decreased effectiveness. HOW TO USE: This medication may be taken with food or a full glass of water or milk to prevent stomach upset. Dosage is based on your medical condition, the type of infection being treated, and your response to therapy.Antibiotics work best when the amount of medicine in your body is kept at a constant level. Therefore, take this drug at evenly spaced intervals.Continue to take this medication until the full prescribed amount is finished, even if symptoms disappear after a few days. Stopping the medication too early may allow bacteria/protozoa to continue to grow, which may result in a relapse of the infection.Inform your doctor if your condition persists or worsens. SIDE EFFECTS: Dizziness, headache, diarrhea, nausea, stomach pain, loss of appetite, constipation, changes in taste, and dry mouth may occur. If any of these effects persist or worsen, notify your doctor or pharmacist promptly.This drug may cause urine to darken in color. This is harmless.Remember that your doctor has prescribed this medication because he or she has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor immediately if any of these unlikely but serious side effects occur: unsteadiness, seizures, mental/mood changes (such as confusion), numbness/tingling of hands/feet, painful urination.Tell your doctor immediately if any of these rare but very serious side effects occur: eye pain, severe/persistent headache, sudden vision changes, stiff/painful neck, sore throat, persistent fever, unusual bleeding/bruising, severe stomach pain, persistent nausea/vomiting.Use of this medication for prolonged or repeated periods may result in oral thrush or a new vaginalyeast infection (oral or vaginal fungal infection). Contact your doctor if you notice white patches in your mouth, a change in vaginal discharge, or other new symptoms.A very serious allergic reaction to this drug is unlikely, but seek immediate medical attention if it occurs. Symptoms of a serious allergic reaction may include: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA1088.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345. OVERDOSE: If overdose is suspected, contact your local poison control center or emergency room immediately. US residents can call the US national poison hotline at 1800-222-1222. Canadian residents should call their local poison control center directly. Symptoms of overdose may include nausea, vomiting, severe dizziness, and seizures.

NOTES: Do not share this medication with others.Treatment of certain infections (trichomoniasis) may require that sexual partners be treated as well to avoid reinfection. During therapy, refrain from sexual intercourse or always use a condom.This medication has been prescribed for your current condition only. Do not use it later for another infection unless told to do so by your doctor. A different medication may be necessary in those cases.Laboratory and/or medical tests (e.g., blood counts) should be performed from time to time to monitor your progress or check for side effects. Consult your doctor for more details. MISSED DOSE: If you miss a dose, take it as soon as you remember. If it is near the time of the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up. STORAGE: Tablets should be stored at room temperature below 77 degrees F (25 degrees C) away from light. Capsules should be stored at or below room temperature between 59-77 degrees F (15-25 degrees C). Do not store in the bathroom. Keep all medicines away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company for more details about how to safely discard your product. PRECAUTIONS: Before taking metronidazole, tell your doctor or pharmacist if you are allergic to it; or to other nitroimidazoles such as tinidazole; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: liver problems, nervous system disorders (e.g., seizures), blood disorders, Crohn's disease.Avoid alcoholic beverages while taking this medication and for at least 1 day (3 days if you are taking the oral capsules) after finishing this medicine because drinking alcohol may result in severe stomach upset/cramps, nausea, vomiting, headache and flushing.This drug may make you dizzy. Do not drive, use machinery, or do any activity that requires alertness until you are sure you can perform such activities safely.The elderly may be at greater risk for side effects while using this drug.Tell your doctor if you are pregnant before using this drug. It should not be used during the first 3 months of pregnancy and used only with caution during the last 6 months, unless your infection has not improved on other antibiotics.This medication passes into breast milk. Discuss the risks and benefits with your doctor before breast-feeding. If you are prescribed the single-dose treatment, your doctor may direct you to interrupt breast-feeding for a short time after the dose. Consult your doctor for more details. DRUG INTERACTIONS: Your healthcare professionals (e.g., doctor or pharmacist) may already be aware of any possible drug interactions and may be monitoring you for it. Do not start, stop or change the dosage of any medicine before checking with them first.This drug should not be used with the following medications because very serious interactions may occur: alcohol-containing products (e.g., cough and cold syrups,

aftershave),amprenavir oral solution, disulfiram, lopinavir/ritonavir oral solution.If you are currently using any of these medications listed above, tell your doctor or pharmacist before starting metronidazole.Before using this medication, tell your doctor or pharmacist of all prescription and nonprescription/herbal products you may use, especially of: "blood thinners" (e.g., warfarin), busulfan, cimetidine, fluorouracil, lithium, mebendazole, live bacterial vaccines, drugs for seizures (e.g., phenobarbital, phenytoin).Although most antibiotics probably do not affect hormonal birth control such as pills, patch, or ring, some antibiotics may decrease their effectiveness. This could cause pregnancy. Examples include rifamycins such as rifampin or rifabutin. Be sure to ask your doctor or pharmacist if you should use additional reliable birth control methods while using this antibiotic.This medication may interfere with certain laboratory tests (including liver function tests, blood triglyceride levels), possibly causing false test results. Make sure laboratory personnel and your doctors know you use this drug.This document does not contain all possible interactions. Therefore, before using this product, tell your doctor or pharmacist of all the products you use. Keep a list of all your medications with you, and share the list with your doctor and pharmacist.

Community-acquired pneumonia
From Wikipedia, the free encyclopedia
Community-acquired pneumonia (CAP) is a term used to describe one of several diseases in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. CAP occurs throughout the world and is a leading cause of illness and death. Causes of CAP include bacteria, viruses, fungi, and parasites. CAP can be diagnosed by symptoms and physical examination alone, though x-rays, examination of the sputum, and other tests are often used. Individuals with CAP sometimes require treatment in a hospital. CAP is primarily treated with antibioticmedication. Some forms of CAP can be prevented by vaccination.[1]

[edit]Signs

and symptoms

Symptoms of CAP commonly include: dyspnea coughing that produces greenish or yellow sputum a high fever that may be accompanied with sweating, chills, and uncontrollable shaking sharp or stabbing chest pain rapid, shallow breathing that is often painful

Less common symptoms include:

the coughing up of blood (hemoptysis) headaches (including migraine headaches) loss of appetite excessive fatigue blueness of the skin (cyanosis) nausea vomiting diarrhea joint pain (arthralgia) muscle aches (myalgia)

The manifestations of pneumonia, like those for many conditions, might not be typical in older people. They might instead experience: new or worsening confusion hypothermia falls*

Additional symptoms for infants could include: being overly sleepy yellowing of the skin (jaundice) difficulties feeding[2]

[edit]Cause
There are over a hundred microorganisms which can cause CAP. The most common types of microorganisms are different among different groups of people. Newborn infants, children, and adults are at risk for different spectrums of disease causing microorganisms. In addition, adults with chronic illnesses, who live in certain parts of the world, who reside in nursing homes, who have recently been treated with antibiotics, or who are alcoholics are at risk for unique infections. Even when aggressive measures are taken, a definite cause for pneumonia is only identified in half the cases.

[edit]Infants
Newborn infants can acquire lung infections prior to being born either by breathing infected amniotic fluid or by blood-borne infection across the placenta. Infants can also inhale (aspirate) fluid from thebirth canal as they are being born. The most important infection

in newborns is caused by Streptococcus agalactiae, also known as Group B Streptococcus or GBS. GBS causes at least 50% of cases of CAP in the first week of life.[3] Other bacterial causes in the newborn period include Listeria monocytogenes and tuberculosis. Viruses can also be transferred from mother to child; herpes simplex virus is the most common and life-threatening, but adenovirus, mumps, and enterovirus can also cause disease. CAP in older infants reflects increased exposure to microorganisms. Common bacterial causes include Streptococcus pneumoniae, Escherichia coli, Klebsiella pneumoniae, Moraxella catarrhalis, andStaphylococcus aureus. A unique cause of CAP in this group is Chlamydia trachomatis, which is acquired during birth but which does not cause pneumonia until 24 weeks later. Maternally-derivedsyphilis can be a cause of CAP in this age group. Common viruses include respiratory syncytial virus (RSV), metapneumovirus, adenovirus, parainfluenza, influenza, and rhinovirus. RSV in particular is a common source of illness and hospitalization.[4] Fungi and parasites are not typically encountered in otherwise healthy infants.

[edit]Children
For the most part, children older than one month of life are at risk for the same microorganisms as adults. However, children less than five years are much less likely to have pneumonia caused byMycoplasma pneumoniae, Chlamydophil pneumoniae, or Legionella pneumophila. In contrast, older children and teenagers are more likely to acquire Mycoplasma pneumoniae and Chlamydophila pneumoniae than adults.[5]

[edit]Adults
The full spectrum of microorganisms is responsible for CAP in adults. Several important groups of organisms are more common among people with certain risk factors. Identifying people at risk for these organisms is important for appropriate treatment. Viruses Viruses cause 20% of CAP cases. The most common viruses are influenza, parainfluenza, respiratory syncytial virus, metapneumovirus, and adenovirus. Less common viruses causing significant illness include chicken pox, SARS, avian flu, and hantavirus.[6] Atypical organisms The most common bacterial causes of pneumonia are the so-called atypical bacteria Mycoplasma pneumoniae and Chlamydophila pneumoniae. Legionella pneumophila is considered atypical but is less common. Atypical organisms are more difficult to grow, respond to different antibiotics, and were discovered more recently than the typical bacteria discovered in the early twentieth century.

Streptococcus pneumoniae

Streptococcus pneumoniae is a common bacterial cause of CAP (most common cause in UK). Prior to the development of antibiotics and vaccination, it was a leading cause of death. Traditionally highly sensitive to penicillin, during the 1970s resistance to multiple antibiotics began to develop. Current strains of "drug resistant Streptococcus pneumoniae" or DRSP are common, accounting for twenty percent of all Streptococcus pneumoniae infections. Adults with risk factors for DRSP

including being older than 65, having exposure to children in day care, having alcoholism or other severe underlying disease, or recent treatment with antibiotics should initially be treated with antibiotics effective against DRSP.[7]

Hemophilus influenzae

Hemophilus influenzae is another common bacterial cause of CAP. First discovered in 1892, it was initially believed to be the cause of influenza because it commonly causes CAP in people who have suffered recent lung damage from viral pneumonia. Enteric Gram negative bacteria

The enteric Gram negative bacteria such as Escherichia coli and Klebsiella pneumoniae are a group of bacteria that typically live in the human intestines. Adults with risk factors for infection including residence in a nursing home, serious heart and lung disease, and recent antibiotic use should initially be treated with antibiotics effective against Enteric Gram negative bacteria.

Pseudomonas aeruginosa

Pseudomonas aeruginosa is an uncommon cause of CAP but is a particularly difficult bacteria to treat. Individuals who are malnourished, have a lung disease called bronchiectasis, are oncorticosteroids, or have recently had strong antibiotics for a week or more should initially be treated with antibiotics effective against Pseudomonas aeruginosa.[8] Many less common organisms cause CAP. They are typically identified because an individual has special risk factors or after treatment for the common causes has failed. These rarer causes are covered in more detail in their specific pages: bacterial pneumonia, viral pneumonia, fungal pneumonia, and parasitic pneumonia.

[edit]Risk

factors

Some people have an underlying problem which increases their risk of getting an infection. Some important situations are covered below: Obstruction When part of the airway (bronchi) leading to the alveoli is obstructed, the lung is not able to clear fluid when it accumulates. This can lead to infection of the fluid resulting in CAP. One cause of obstruction, especially in young children, is inhalation of a foreign object such as a marble or toy. The object is lodged in the small airways and pneumonia can form in the trapped areas of lung. Another cause of obstruction is lung cancer, which can grow into the airways block the flow of air. Lung disease People with underlying lung disease are more likely to develop CAP. Diseases such as emphysema or habits such as smoking result in more frequent and more severe bouts of CAP.

In children, recurrent episodes of CAP may be the first clue to diseases such as cystic fibrosis or pulmonary sequestration. Immune problems People who have immune system problems are more likely to get CAP. People who have AIDS are much more likely to develop CAP. Other immune problems range from severe immune deficiencies of childhood such as Wiskott-Aldrich syndrome to less severe deficiencies such as common variable immunodeficiency.[9]

[edit]Pathophysiology
The symptoms of CAP are the result of both the invasion of the lungs by microorganisms and the immune system's response to the infection. The mechanisms of infection are quite different for virusesand the other microorganisms.

Viruses

Viruses must invade cells in order to reproduce. Typically, a virus will reach the lungs by traveling in droplets through the mouth and nose with inhalation. There, the virus invades the cells lining the airways and the alveoli. This invasion often leads to cell death either through direct killing by the virus or by self-destruction through apoptosis. Further damage to the lungs occurs when the immune system responds to the infection. White blood cells, in particular lymphocytes, are responsible for activating a variety of chemicals (cytokines) which cause leaking of fluid into the alveoli. The combination of cellular destruction and fluid-filled alveoli interrupts the transportation of oxygen into the bloodstream. In addition to the effects on the lungs, many viruses affect other organs and can lead to illness affecting many different bodily functions. Viruses also make the body more susceptible to bacterial infection; for this reason, bacterial pneumonia often complicates viral CAP.

Bacteria and fungi

Bacteria and fungi also typically enter the lung with inhalation, though they can reach the lung through the bloodstream if other parts of the body are infected. Often, bacteria live in parts of the upper respiratory tract and are constantly being inhaled into the alveoli. Once inside the alveoli, bacteria and fungi travel into the spaces between the cells and also between adjacent alveoli through connecting pores. This invasion triggers the immune system to respond by sending white blood cells responsible for attacking microorganisms (neutrophils) to the lungs. The neutrophils engulf and kill the offending organisms but also release cytokines which result in a general activation of the immune system. This results in the fever, chills, and fatigue common in CAP. The neutrophils, bacteria, and fluid leaked from surrounding blood vessels fill the alveoli and result in impaired oxygen transportation. Bacteria often travel from the lung into the blood stream and can result in serious illness such as septic shock, in which there is low blood pressure leading to damage in multiple parts of the body including the brain, kidney, and heart.

Parasites

There are a variety of parasites which can affect the lungs. In general, these parasites enter the body through the skin or by being swallowed. Once inside the body, these parasites travel to the lungs, most often through the blood. There, a similar combination of cellular destruction and immune response causes disruption of oxygen transportation.

[edit]Diagnosis
Individuals with symptoms of CAP require further evaluation. Physical examination by a health provider may reveal fever, an increased respiratory rate (tachypnea), low blood pressure (hypotension), a fast heart rate (tachycardia), and/or changes in the amount of oxygen in the blood. Feeling the way the chest expands (palpation) and tapping the chest wall (percussion) to identify dull areas which do not resonate can identify areas of the lung which are stiff and full of fluid (consolidated). Examination of the lungs with the aid of a stethoscope can reveal several things. A lack of normal breath sounds or the presence of crackling sounds (rales) when the lungs are listened to (auscultated) can also indicate consolidation. Increased vibration of the chest when speaking (tactile fremitus) and increased volume of whispered speech during auscultation of the chest can also reveal consolidation.[10]

Pneumonia. Chest x-ray showing increased shadowing in lungs

Pneumonia. Same lungs post treatment

X-rays of the chest, examination of the blood and sputum for infectious microorganisms, and blood tests are commonly used to diagnose individuals with suspected CAP based upon symptoms and physical examination. The use of each test depends on the severity of illness, local practices, and the concern for any complications resulting from the infection. All patients with CAP should have the amount of oxygen in their blood monitored with a machine called apulse oximeter. This helps determine how well the lungs are able to work despite infection. In some cases, analysis of arterial blood gas may be required to accurately determine the amount of oxygen in the blood. Complete blood count (CBC), a blood test, may reveal extra white blood cells, indicating an infection. Chest x-rays and chest computed tomography (CT) can reveal areas of opacity (seen as white) which represent consolidation. A normal chest x-ray makes CAP less likely; however, CAP is sometimes not seen on x-rays because the disease is either in its initial stages or involves a part of the lung not easily seen by x-ray. In some cases, chest CT can reveal a CAP which is not present on chest x-ray. X-rays can often be misleading, as many other diseases can mimic CAP such as heart problems or other types of lung damage.[11]

Main symptoms of infectious pneumonia

Several tests can be performed to identify the cause of an individual's CAP. Blood cultures can be drawn to isolate any bacteria or fungi in the blood stream. Sputum Gram's stain and culture can also reveal the causative microorganism. In more severe cases, a procedure wherein a flexible scope is passed through the mouth into the lungs (bronchoscopy) can be used to collect fluid for culture. Special tests can be performed if an uncommon microorganism is suspected (such as testing the urine for Legionella antigen when Legionnaires' disease is a concern).

[edit]Treatment
CAP is treated by administering an antibiotic which is effective in killing the offending microorganism as well as managing any complications of the infection. If the causative microorganism is unidentified, different antibiotics are tested in the laboratory in order to identify which medication will be most effective. Often, however, no microorganism is ever identified. Also, since laboratory testing can take several days, there is some delay until an organism is identified. In both cases, a person's risk factors for different organisms must be remembered when choosing the initial antibiotics (called empiric therapy). Additional consideration must be given to the setting in which the individual will be treated. Most people will be fully treated after taking oral pills while other people need to be hospitalized for intravenous antibiotics and, possibly, intensive care. In general, all therapies in older children and adults will include treatment for atypical bacteria. Typically this is a macrolide antibiotic such as azithromycin or clarithromycin although a fluoroquinolone such as levofloxacin can substitute. Doxycycline is now the

antibiotic of choice in the UK for complete coverage of the atypical bacteria. This is due to increased levels of clostridium difficile seen in hospital patients being linked to the increased use of clarithromycin.

[edit]Newborns
Most newborn infants with CAP are hospitalized and given intravenous ampicillin and gentamicin for at least ten days. This treats the common bacteriaStreptococcus agalactiae, Listeria monocytogenes, and Escherichia coli. If herpes simplex virus is the cause, intravenous acyclovir is administered for 21 days.

[edit]Children
Treatment of CAP in children depends on both the age of the child and the severity of his/her illness. Children less than five do not typically receive treatment to cover atypical bacteria. If a child does not need to be hospitalized, amoxicillin for seven days is a common treatment. However, with increasing prevalence of DRSP, other agents such as cefpodoxime will most likely become more popular in the future.
[12]

Hospitalized children should receive intravenous ampicillin,ceftriaxone,

or cefotaxime. According to a recent meta-analysis a 3 days course of antibiotics seems to be sufficient for most cases of mild to moderate CAP in children.[1]

[edit]Adults
In 2001, the American Thoracic Society, drawing on work by the British and Canadian Thoracic Societies, established guidelines for the management of adults with CAP which divided individuals with CAP into four categories based upon common organisms encountered.[13] Healthy outpatients without risk factors

This group, the largest, is composed of otherwise healthy patients without risk factors for DRSP, enteric Gram negative bacteria, Pseudomonas, or other less common causes of CAP. The primary microoganisms in this group are viruses, atypical bacteria, penicillin sensitive Streptococcus pneumoniae, and Hemophilus influenzae. Recommended management is with a macrolide antibiotic such as azithromycin or clarithromycin for seven[2] to ten days. Outpatients with underlying illness and/or risk factors

This group does not require hospitalization; its members either have underlying health problems (such as emphysema or congestive heart failure) or is at risk for DRSP and/or enteric Gram negative bacteria. Treatment is with a fluoroquinolone active against Streptococcus pneumoniae such as levofloxacin or a beta-lactam antibiotic such

as cefpodoxime, cefuroxime, amoxicillin, oramoxicillin/clavulanate plus a macrolide antibiotic such as azithromycin or clarithromycin for seven to ten days.[3] Hospitalized individuals not at risk for Pseudomonas

This group requires hospitalization and administration of intravenous antibiotics. Treatment is with either an intravenous fluoroquinolone active against Streptococcus pneumoniae such aslevofloxacin or beta-lactam antibiotic such as cefotaxime, ceftriaxone, ampicillin/sulbactam, or high-dose ampicillin plus an intravenous macrolide antibiotic such as azithromycin or clarithromycin for seven to ten days. Individuals requiring intensive care at risk for Pseudomonas

Individuals being treated in an intensive care unit with risk factors for infection with Pseudomonas aeruginosa require specific antibiotics targeting this difficult to eradicate bacteria. One possible regimen is an intravenous antipseudomonal beta-lactam such as cefepime, imipenem, meropenem, or piperacillin/tazobactam plus an intravenous antipseudomonal fluoroquinolone such aslevofloxacin. Another recommended regimen is an intravenous antipseudomonal beta-lactam such as cefepime, imipenem, meropenem, or piperacillin/ tazobactam plus an intravenous aminoglycoside such as gentamicin or tobramycin plus either an intravenous macrolide such azithromycin or an intravenous nonpseudomonal fluoroquinolone such as ciprofloxacin. For mild to moderate community-acquired pneumonia shorter courses of antibiotics (37 days) seem to be sufficient according to a recent meta-analysis.[1]

[edit]Hospitalize
Some people with CAP require hospitalization and more intensive care than the majority. In general, a discussion between the individual and his or her health care provider determines the need for hospitalization. Clinical prediction rules, such as the pneumonia severity index and CURB-65 have been developed to help guide the decision.[14] Factors which increase the need for hospitalization include age greater than 65; underlying chronic illnesses; a respiratory rate greater than thirty breaths per minute; a systolic blood pressure less than 90 mmHg; a heart rate greater than 125 per minute; temperature less than 35 or greater than 40C; confusion; and evidence of infection outside the lung. Laboratory results which increase the need for hospitalization include arterial oxygen tension less than 60 mm Hg, carbon dioxide of greater than 50 mmHg, or pH less than 7.35 while breathing room air; hematocrit less than 30%; creatinine greater than 1.2 mg/dl or blood urea nitrogengreater than 20 mg/ dl; white blood cell count less than 4 10^9/L or greater than 30 10^9/L; and absolute neutrophil count less than 1 x 10^9/L. X-ray findings which increase the need for hospitalization include involvement of more than one lobe of the lung, presence of a cavity, and the presence of a pleural effusion.

[edit]Prognosis
Individuals who are treated for CAP outside of the hospital have a mortality rate less than 1%. Fever typically responds in the first two days of therapy and other symptoms resolve in the first week. The x-ray, however, may remain abnormal for at least a month, even when CAP has been successfully treated. Among individuals who require hospitalization, the mortality rate averages 12%

overall, but is as much as 40% in people who have bloodstream infections or require intensive care.[15] Factors which increase mortality are the same as those which increase the need for hospitalization and are listed above. When CAP does not respond as expected, there are several possible causes. A complication of CAP may have occurred or a previously unknown health problem may be playing a role. Both situations are covered in more detail below. Additional causes include inappropriate antibiotics for the causative organism (i.e. DRSP), a previously unsuspected microorganism (such as tuberculosis), or a condition which mimics CAP (such as Wegener's granulomatosis). Additional testing may be performed and may include additional radiologic imaging (such as a computed tomography scan) or a procedure such as a bronchoscopy or lung biopsy.

[edit]Complications
Despite appropriate antibiotic therapy, severe complications can result from CAP, including:

[edit]Sepsis
Sepsis can occur when microorganisms enter the blood stream and the immune system responds. Sepsis most often occurs with bacterial pneumonia; Streptococcus pneumoniae is the most common cause. Individuals with sepsis require hospitalization in an intensive care unit. They often require medications and intravenous fluids to keep their blood pressure from going too low. Sepsis can cause liver, kidney, and heart damage among other things.

[edit]Respiratory

failure

Because CAP affects the lungs, often individuals with CAP have difficulty breathing. If enough of the lung is involved, it may not be possible for a person to breathe enough to live without support. Non-invasive machines such as a bilevel positive airway pressure machine may be used. Otherwise, placement of a breathing tube into the mouth may be necessary and a ventilator may be used to help the person breathe.

[edit]Pleural

effusion and empyema

Occasionally, microorganisms from the lung will cause fluid to form in the space surrounding the lung, called the pleural cavity. If the microorganisms themselves are present, the fluid collection is often called an empyema. If pleural fluid is present in a person with CAP, the fluid should be collected with a needle (thoracentesis) and examined. Depending on the result of the examination, complete drainage of the fluid may be necessary, often with a chest tube. If the fluid is not drained, bacteria can continue to cause illness because antibiotics do not penetrate well into the pleural cavity.

[edit]Abscess
Rarely, microorganisms in the lung will form a pocket of fluid and bacteria called an abscess. Abscesses can be seen on an x-ray as a cavity within the lung. Abscesses typically occur in aspiration pneumonia and most often contain a mixture of anaerobic bacteria. Usually antibiotics are able to fully treat abscesses, but sometimes they must be drained by a surgeon or radiologist.

[edit]Epidemiology

CAP is a common illness in all parts of the world. It is a major cause of death among all age groups. In children, the majority of deaths occur in the newborn period, with over two million worldwide deaths a year. In fact, the WHO estimates that one in three newborn infant deaths are due to pneumonia.[16] Mortality decreases with age until late adulthood; elderly individuals are particularly at risk for CAP and associated mortality. More cases of CAP occur during winter months than during other times of the year. CAP occurs more commonly in males than females and in blacks than Caucasians. Individuals with underlying illnesses such as Alzheimer's disease, cystic fibrosis, emphysema, tobacco smoking, alcoholism, or immune system problems are at increased risk for pneumonia.[17]

[edit]Prevention In addition to treating any underlying illness which can increase a person's risk for CAP, there are several additional ways to prevent CAP. Smoking cessation is important not only for treatment of any underlying lung disease, but also because cigarette smoke interferes with many of the body's natural defenses against CAP. Vaccination is important in both children and adults. Vaccinations against Haemophilus influenzae and Streptococcus pneumoniae in the first year of life have greatly reduced their role in CAP in children. A vaccine against Streptococcus pneumoniae is also available for adults and is currently recommended for all healthy individuals older than 65 and any adults with emphysema, congestive heart failure, diabetes mellitus, cirrhosis of the liver, alcoholism, cerebrospinal fluid leaks, or who do not have a spleen. A repeat vaccination may also be required after five or ten years.[18] Influenza vaccines should be given yearly to the same individuals as receive vaccination against Streptococcus pneumoniae. In addition, health care workers, nursing home residents, and pregnant women should receive the vaccine.[19] When an influenza outbreak is occurring, medications such as amantadine, rimantadine, zanamivir, and oseltamivir have been shown to prevent cases of influenza.[20]

Community-acquired pneumonia (CAP) is one of the most common infectious diseases addressed by clinicians. CAP is an important cause of mortality and morbidity worldwide. A number of pathogens can give rise to CAP. Typical bacterial pathogens that cause the condition include Streptococcus pneumoniae (penicillin-sensitive and -resistant strains), Haemophilus influenzae (ampicillin-sensitive and -resistant strains), and Moraxella catarrhalis (all strains penicillinresistant). These 3 pathogens account for approximately 85% of CAP cases.[1] CAP is usually acquired via inhalation or aspiration of pulmonary pathogenic organisms into a lung segment or lobe. Less commonly, CAP results from secondary bacteremia from a distant source, such as Escherichia coli urinary tract infection and/or bacteremia.

Aspiration pneumonia is the only form of CAP caused by multiple pathogens (eg, aerobic/anaerobic oral organisms).

Severe CAP
Severe CAP develops in patients with cardiopulmonary disease, diminished splenic function, and/or pathogenic virulence. Even in young and/or healthy hosts, however, severe CAP can develop if the causative pathogen is sufficiently virulent. For example, influenza, severe acute respiratory syndrome (SARS), Hantavirus pulmonary syndrome (HPS), and Legionnaires disease may present as severe CAP.[2, 3, 4, 5] Patients with severe CAP should have the benefit of an infectious disease specialist to assist in the underlying cause of their condition.

CAP-associated complications
Complications in CAP depend on the infecting pathogen and patient health. For example, empyema can occur with Streptococcus pneumoniae, Klebsiella pneumoniae, and group A streptococcal CAP. (K pneumoniaeinfections occur in patients with chronic alcoholism.) Cavitation is not a feature of pneumococcal pneumonia, but it is a normal part of the disease process in K pneumoniae infections. Myocardial infarction can be precipitated by fever due to community-acquired pneumonia (CAP). Patients with CAP who have impaired splenic function may develop overwhelming pneumococcal sepsis, potentially leading to death within 12-24 hours, regardless of the antimicrobial regimen used.

Morbidity and mortality

CAP morbidity and mortality are highest in elderly patients and in immunocompromised hosts. Other factors that predict an increased risk of mortality in patients with CAP include the presence of significant comorbidities, an increased respiratory rate, hypotension, fever, multilobar involvement, anemia, and hypoxia.[6] For more information, see the following:

Mycoplasma Pneumonia Bacterial Pneumonia Viral Pneumonia Imaging Pneumocystis Carinii Pneumonia Aspiration Pneumonia Nosocomial Pneumonia Ventilator-Associated Pneumonia Pneumocystis (carinii) jiroveci Pneumonia Fungal Pneumonia Immunocompromised Pneumonia Nursing Home Acquired Pneumonia Chlamydial Pneumonia Lymphocytic Interstitial Pneumonia Imaging Typical Bacterial Pneumonia Imaging Atypical Bacterial Pneumonia Imaging Viral Pneumonia

Lipid profile
From Wikipedia, the free encyclopedia

This article does not cite any references or sources. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (November 2011)
Lipid profile or lipid panel, is the collective term given to the estimation of, typically, total cholesterol, highdensity lipoprotein cholesterol, low-density lipoprotein cholesterol, and triglycerides. An extended lipid profile may include very low-density lipoprotein. This is used to identify hyperlipidemia (various disturbances of cholesterol and triglyceride levels), many forms of which are recognized risk factors for cardiovascular disease and sometimes pancreatitis. It is recommended that healthy adults with no other risk factors for heart disease be tested with a fasting lipid profile once every five years.[citation needed] Individuals may also be screened using only a cholesterol test and not a full lipid profile. However, if the cholesterol test result is high, there may be the need to have follow-up testing with a lipid profile.[citation needed] If there are other risk factors or the individual has had a high cholesterol level in the past, regular testing is needed and the individual should have a full lipid profile.[citation needed] For children and adolescents at low risk, lipid testing is usually not ordered routinely. However, screening with a lipid profile is recommended for children and youths who are at an increased risk of developing heart disease as adults. Some of the risk factors are similar to those in adults and include a family history of heart disease or health problems such as diabetes, high blood pressure (hypertension), or being overweight. High-risk children should have their first lipid profile between 2 and 10 years old, according to the American Academy of Pediatrics. Children younger than 2 years old are too young to be tested.[citation needed] A total cholesterol reading can be used to assess an individual's risk for heart disease, however, it should not be relied upon as the only indicator. The individual components that make up total cholesterol reading - LDL, HDL, and VLDL - are also important in measuring risk.[citation needed] For instance, one's total cholesterol may be high, but this may be due to very high good (HDL) cholesterol levels - which can actually help prevent heart disease. So, while a high total cholesterol level may help give an indication that that there is a problem with cholesterol levels, the components that make up total cholesterol should also be measured.[citation needed] A lipid profile may also be ordered at regular intervals to evaluate the success of lipid-lowering lifestyle changes such as diet and exercise or to determine the effectiveness of drug therapy such as statins.[citation needed]

Pseudomonas

From Wikipedia, the free encyclopedia

Pseudomonas

P. aeruginosa colonies on an agar plate.

Scientific classification Domain: Phylum: Class: Order: Family: Genus: Bacteria Proteobacteria Gammaproteobacteria Pseudomonadales Pseudomonadaceae Pseudomonas
Migula 1894

Type species Pseudomonas aeruginosa Species P. aeruginosa group P. aeruginosa

P. alcaligenes P. anguilliseptica P. argentinensis P. borbori P. citronellolis P. flavescens P. mendocina P. nitroreducens P. oleovorans P. pseudoalcaligenes P. resinovorans P. straminea P. P. agarici P. asplenii P. aurantiaca P. aureofaciens P. chlororaphis P. corrugata P. fragi P. lundensis P. taetrolens P. P. antarctica P. azotoformans 'P. blatchfordae' P. brassicacearum P. brenneri P. cedrina P. corrugata P. fluorescens P. gessardii

P. libanensis P. mandelii P. marginalis P. mediterranea P. meridiana P. migulae P. mucidolens P. orientalis P. panacis P. proteolytica P. rhodesiae P. synxantha P. thivervalensis P. tolaasii P. veronii P. P. denitrificans P. pertucinogena P. P. cremoricolorata P. fulva P. monteilii P. mosselii P. oryzihabitans P. parafulva P. plecoglossicida P. putida P. P. balearica P. luteola P. stutzeri

P. P. amygdali P. avellanae P. caricapapayae P. cichorii P. coronafaciens P. ficuserectae 'P. helianthi' P. meliae P. savastanoi P. syringae 'P. tomato' P. viridiflava incertae P. abietaniphila P. acidophila P. agarici P. alcaliphila P. alkanolytica P. amyloderamosa P. asplenii P. azotifigens P. cannabina P. coenobios P. congelans P. costantinii P. cruciviae P. delhiensis P. excibis P. extremorientalis P. frederiksbergensis P. fuscovaginae

P. gelidicola P. grimontii P. indica P. jessenii P. jinjuensis P. kilonensis P. knackmussii P. koreensis P. lini P. lutea P. moraviensis P. otitidis P. pachastrellae P. palleroniana P. papaveris P. peli P. perolens P. poae P. pohangensis P. protegens P. psychrophila P. psychrotolerans P. rathonis P. reptilivora P. resiniphila P. rhizosphaerae P. rubescens P. salomonii P. segitis P. septica P. simiae P. suis P. thermotolerans

P. toyotomiensis P. tremae P. trivialis P. turbinellae P. tuticorinensis P. umsongensis P. vancouverensis P. vranovensis P. xanthomarina

Pseudomonas is a genus of gammaproteobacteria, belonging to the family Pseudomonadaceae containing 191 validly described species.[1] Recently, 16S rRNA sequence analysis has redefined the taxonomy of many bacterial species.[2] As a result, the genus Pseudomonas includes strains formerly classified in the genera Chryseomonas and Flavimonas.
[3]

Other strains previously classified in the genus Pseudomonas are now classified in the

genera Burkholderia and Ralstonia.[4][5]

[edit]Classification

History

Like most bacteria genera the pseudomonad[note 1] last common ancestor lived hundreds of million years ago, however they were classified by humans at the end of the 19th century. Because of their widespread occurrence in water and in plant seeds such as dicots, the pseudomonads were observed early in the history of microbiology. The generic name Pseudomonas created for these organisms was defined in rather vague terms by Walter Migula in 1894 and 1900 as a genus of Gram-negative, rod-shaped and polar-flagella bacteria with some sporulating species,[6][7] the latter statement was later proved incorrect and was due to refractive granules of reserve materials.[8] Despite the vague description, the type species, Pseudomonas pyocyanea (basonym of Pseudomonas aeruginosa), proved the best descriptor.[8] Additionally, the etymology of the name was not provided and first appeared in the 7th edition of Bergey's manual (=top authority in bacterial nomeclature) asGreek pseudes () "false" and -monas ( / ) "a single unit", which can mean false unit, but there is also the possibility that Migula intended it as false Monas, a nanoflagellate protist.[8] Subsequently, the term "monad" was used in the early history of microbiology to denote single-celled organisms. Soon afterwards, species matching Migula's description were isolated from many natural niches and many were originally assigned to the genus. New methodology and the inclusion of approaches based on the studies of conservative macromolecules have reclassified many strains.[9]

Pseudomonas aeruginosa is increasingly recognized as an emerging opportunistic pathogen of clinical relevance. Several different epidemiological studies indicate antibiotic resistance is increasing in clinical isolates.[10] In the year 2000, the complete genome sequence of a Pseudomonas species was determined; more recently, the sequence of other strains have been determined, including P. aeruginosa strains PAO1 (2000), P. putida KT2440 (2002), P. fluorescens Pf-5 (2005), P. syringae pathovar tomato DC3000 (2003),P. syringae pathovar syringae B728a (2005), P. syringae pathovar phaseolica 1448A (2005), P. fluorescens PfO-1 and P. entomophila L48.[9] An article published in the journal Scientific American in 2008 showed Pseudomonas may be the most common nucleator of ice crystals in clouds, thereby being of utmost importance to the formation of snow and rain around the world.[11]

[edit]Characteristics
Members of the genus display the following defining characteristics:[12]

Rod shaped Gram-negative One or more polar flagella, providing motility Aerobic Nonspore forming positive catalase test positive oxidase test.

Other characteristics which tend to be associated with Pseudomonas species (with some exceptions) include secretion of pyoverdine, a fluorescent yellow-green siderophore[13] under iron-limiting conditions. Certain Pseudomonas species may also produce additional types of siderophore, such as pyocyanin byPseudomonas aeruginosa[14] and thioquinolobactin by Pseudomonas fluorescens,.
[15]

Pseudomonas species also typically give a positive result to theoxidase test, the absence of gas formation

from glucose, glucose is oxidised in oxidation/fermentation test using Hugh and Leifson O/F test, beta hemolytic(on blood agar), indole negative, methyl red negative, VogesProskauer test negative, and citrate positive. The members of the genus demonstrate a great deal of metabolic diversity, and consequently are able to colonise a wide range of niches.[16] Their ease of culture in vitro and availability of an increasing number of Pseudomonas strain genome sequences has made the genus an excellent focus for scientific research; the

best studied species include P. aeruginosa in its role as an opportunistic human pathogen, the plant pathogen P. syringae, the soil bacterium P. putida, and the plant growth promoting P. fluorescens.

[edit]Biofilm

formation

All species and strains of Pseudomonas are Gram-negative rods, and have historically been classified as strict aerobes. Exceptions to this classification have recently been discovered in Pseudomonas biofilms.[17] A significant number of cells can produce exopolysaccharides known as biofilms. Secretion ofexopolysaccharide such as alginate, makes it difficult for pseudomonads to be phagocytosed by mammalian white blood cells.[18] Exopolysaccharide production also contributes to surfacecolonising biofilms which are difficult to remove from food preparation surfaces. Growth of pseudomonads on spoiling foods can generate a "fruity" odor. Pseudomonas have the ability to metabolise a variety of diverse nutrients. Combined with the ability to form biofilms, they are thus able to survive in a variety of unexpected places. For example, they have been found in areas where pharmaceuticals are prepared. A simple carbon source, such as soap residue or cap lineradhesives is a suitable place for them to thrive. Other unlikely places where they have been found include antiseptics, such as quaternary ammoniumcompounds, and bottled mineral water.

[edit]Antibiotic

resistance

Being Gram-negative bacteria, most Pseudomonas spp. are naturally resistant to penicillin and the majority of related beta-lactam antibiotics, but a number are sensitive to piperacillin, imipenem, ticarcillin, tobramycin, or ciprofloxacin.[18] This ability to thrive in harsh conditions is a result of their hardy cell wall that contains porins. Their resistance to most antibiotics is attributed to efflux pumps, which pump out some antibiotics before the antibiotics are able to act. Pseudomonas aeruginosa is a highly relevant opportunistic human pathogen. One of the most worrying characteristics of P. aeruginosa is its low antibioticsusceptibility. This low susceptibility is attributable to a concerted action of multidrug efflux pumps with chromosomally-encoded antibiotic resistance genes (e.g. mexAB-oprM, mexXY, etc.,[19]) and the low permeability of the bacterial cellular envelopes. Besides intrinsic resistance, P. aeruginosa easily develops acquired resistance either by mutation in chromosomallyencoded genes, or by the horizontal gene transfer of antibiotic resistance determinants. Development of multidrug resistance by P. aeruginosa isolates requires several different genetic events that include acquisition of different mutations and/or horizontal transfer of antibiotic resistance genes. Hypermutation favours the selection of mutation-driven antibiotic resistance in P. aeruginosa strains producing chronic infections, whereas the clustering of several different antibiotic resistance genes in integrons favours the concerted acquisition of antibiotic resistance determinants. Some recent studies have shown phenotypic

resistance associated to biofilm formation or to the emergence of small-colony-variants may be important in the response of P. aeruginosa populations to antibiotic treatment.[9]

[edit]Taxonomy
The studies on the taxonomy of this complicated genus groped their way in the dark while following the classical procedures developed for the description and identification of the organisms involved in sanitary bacteriology during the first decades of the 20th century. This situation sharply changed with the proposal to introduce as the central criterion the similarities in the composition and sequences of macromoleculars components of the ribosomal RNA. The new methodology clearly showed the genus Pseudomonas, as classically defined, consisted in fact of a conglomerate of genera that could clearly be separated into five so-called rRNA homology groups. Moreover, the taxonomic studies suggested an approach that might proved useful in taxonomic studies of all otherprokaryotic groups. A few decades after the proposal of the new genus Pseudomonas by Migula in 1894, the accumulation of species names assigned to the genus reached alarming proportions. At present, the number of species in the current list has contracted more than 90%. In fact, this approximated reduction may be even more dramatic if one considers the present list contains many new names, i.e., relatively few names of the original list survived in the process. The new methodology and the inclusion of approaches based on the studies of conservative macromolecules other than rRNA components, constitutes an effective prescription that helped to reduce Pseudomonas nomenclatural hypertrophy to a manageable size.[9]

[edit]Pathogenicity [edit]Animal

pathogens

Main article: Pseudomonas infection Infectious species include P. aeruginosa, P. oryzihabitans, and P. plecoglossicida. P. aeruginosa flourishes in hospital environments, and is a particular problem in this environment since it is the second most common infection in hospitalized patients(nosocomial infections). This pathogenesis may in part be due to the proteins secreted by P. aeruginosa. The bacterium possesses a wide range of secretion systems, which export numerous proteins relevant to the pathogenesis of clinical strains.[20]

[edit]Plant

pathogens

P. syringae is a prolific plant pathogen. It exists as over 50 different pathovars, many of which demonstrate a high degree of host plant specificity. There are numerous other Pseudomonas species that can act as plant pathogens, notably all of the other members of the P. syringae subgroup, but P. syringae is the most widespread and best studied.

Although not strictly a plant pathogen, P. tolaasii can be a major agricultural problem, as it can cause bacterial blotch of cultivated mushrooms.[21] Similarly,P. agarici can cause drippy gill in cultivated mushrooms.[22]

[edit]Use

as biocontrol agents

Since the mid 1980s, certain members of the Pseudomonas genus have been applied to cereal seeds or applied directly to soils as a way of preventing the growth or establishment of crop pathogens. This practice is generically referred to as biocontrol. The biocontrol properties of P. fluorescens strains (CHA0 or Pf-5 for example) are currently best understood, although it is not clear exactly how the plant growth-promoting properties of P. fluorescens are achieved. Theories include: that the bacteria might induce systemic resistance in the host plant, so it can better resist attack by a true pathogen; the bacteria might out compete other (pathogenic) soil microbes, e.g. by siderophores giving a competitive advantage at scavenging for iron; the bacteria might produce compounds antagonistic to other soil microbes, such as phenazine-type antibiotics or hydrogen cyanide. There is experimental evidence to support all of these theories.[23] Other notable Pseudomonas species with biocontrol properties include P. chlororaphis, which produces a phenazine-type antibiotic active agent against certain fungal plant pathogens,[24] and the closely related species P. aurantiaca which produces di-2,4-diacetylfluoroglucylmethane, a compound antibioticallyactive against Gram-positive organisms.[25]

[edit]Use

as bioremediation agents

Some members of the genus Pseudomonas are able to metabolise chemical pollutants in the environment, and as a result can be used for bioremediation. Notable species demonstrated as suitable for use as bioremediation agents include:

P. alcaligenes, which can degrade polycyclic aromatic hydrocarbons.[26] P. mendocina, which is able to degrade toluene.[27] P. pseudoalcaligenes is able to use cyanide as a nitrogen source.[28] P. resinovorans can degrade carbazole.[29] P. veronii has been shown to degrade a variety of simple aromatic organic compounds.[30][31] P. putida has the ability to degrade organic solvents such as toluene.[32] At least one strain of this bacterium is able to convert morphine in aqueous solution into the stronger and somewhat expensive to manufacture drug hydromorphone (Dilaudid).

Strain KC of P. stutzeri is able to degrade carbon tetrachloride.[33]

[edit]Food

spoilage agents

As a result of their metabolic diversity, ability to grow at low temperatures and ubiquitous nature, many Pseudomonas spp. can cause food spoilage. Notable examples include dairy spoilage by P. fragi,
[34]

mustiness in eggs caused by P. taetrolens and P. mudicolens,[35] and P. lundensis, which causes spoilage

ofmilk, cheese, meat, and fish.[36]

Complete blood count

From Wikipedia, the free encyclopedia

This article needs additional citations for verification. Please help improve this article by adding citations to reliable sources. Unsourced material may be challenged and removed. (February 2007)
"Blood count" redirects here. For the Billy Strayhorn composition, see Blood Count.

Complete blood count

Diagnostics

Schematics (also sometimes called "Fishbones") of shorthand for complete blood count commonly used by clinicians and healthcare providers. The shorthand on the right is used more often in the US. Hgb=Hemoglobin, WBC=White blood cells, Plt=Platelets, Hct=Hematocrit.

MeSH

D001772

MedlinePlus

003642

eMedicine

94020

Reference range

Hgb: 120175 g/L; WBC: 3.511 x 109/L;

Plt: 140450 x 109/L; Hct: 3153%

LOINC

57021-8

HCPCS-L2

G0306

A complete blood count (CBC), also known as full blood count (FBC) or full blood exam (FBE) or blood panel, is a test panel requested by a doctoror other medical professional that gives information about the cells in a patient's blood. A scientist or lab technician performs the requested testing and provides the requesting medical professional with the results of the CBC. Alexander Vastem is widely regarded as being the first person to use the complete blood count for clinical purposes.[citation needed] Reference ranges used today stem from his clinical trials in the early 1960s. The cells that circulate in the bloodstream are generally divided into three types: white blood cells (leukocytes), red blood cells (erythrocytes), and platelets (thrombocytes). Abnormally high or low counts may indicate the presence of many forms of disease, and hence blood counts are amongst the most commonly performed blood tests in medicine, as they can provide an overview of a patient's general health status. A CBC is routinely performed during annual physical examinations in some jurisdictions.

[edit]Methods [edit]Samples

Drawing blood

A phlebotomist collects the sample, drawing the blood into a test tube containing an anticoagulant (EDTA, sometimes citrate) to stop it from clotting. The sample is then transported to a laboratory.

In the past, counting the cells in a patient's blood was performed manually, by viewing a slide prepared with a sample of the patient's blood under amicroscope (a blood film, or peripheral smear). Nowadays, this process is generally automated by use of an automated analyzer, with only approximately 30% of samples now being examined manually.

[edit]Automated

blood count

Complete blood count performed by an automated analyser. Differentials missing.

The blood is well mixed (though not shaken) and placed on a rack in the analyzer. This instrument has many different components to analyze different elements in the blood. The cell counting component counts the numbers and types of different cells within the blood. The results are printed out or sent to a computer for review. Blood counting machines aspirate a very small amount of the specimen through narrow tubing. Sensors count the number of cells passing through the tubing, and can identify the type of cell; this is flow cytometry. The two main sensors used are light detectors and electrical impedance. One way the instrument can tell what type of blood cell is present is by size. Other instruments measure different characteristics of the cells to categorize them. Because an automated cell counter samples and counts so many cells, the results are very precise. However, certain abnormal cells in the blood may not be identified correctly, requiring manual review of the instrument's results and identification of any abnormal cells the instrument could not categorize. In addition to counting, measuring and analyzing red blood cells, white blood cells and platelets, automated hematology analyzers also measure the amount of hemoglobin in the blood and within each red blood cell. This information can be very helpful to a physician who, for example, is trying to identify the cause of a patient's anemia. If the red cells are smaller or larger than normal, or if there is a lot of variation in the size of the red cells, this data can help guide the direction of further testing and expedite the diagnostic process so patients can get the treatment they need quickly.

[edit]Manual

blood count

Counting chambers that hold a specified volume of diluted blood (as there are far too many cells if it is not diluted) are used to calculate the number of red and white cells per litre of blood. To identify the numbers of different white cells, a blood film is made, and a large number of white cells (at least 100) are counted. This gives the percentage of cells that are of each type. By multiplying the percentage with the total number of white blood cells, the absolute number of each type of white cell can be obtained. Manual counting is useful in cases where automated analyzers cannot reliably count abnormal cells, such as those cells that are not present in normal patients and are only seen in peripheral blood with certain haematological conditions. Manual counting is subject to sampling error because so few cells are counted compared with automated analysis. Medical technicians examine blood film via a microscope for 30% of CBCs, not only to find abnormal white cells, but also because variation in the shape of red cells is an important diagnostic tool. Although automated analysers give fast, reliable results regarding the number, average size, and variation in size of red blood cells, they do not detect cells' shapes. Also, some normal patients' platelets will clump in EDTA anticoagulated blood, which causes automatic analyses to give a falsely low platelet count. The technician viewing the slide in these cases will see clumps of platelets and can estimate if there are low, normal, or high numbers of platelets.

[edit]Results
For examples of standard values, see Reference ranges for blood tests#Hematology.

A scanning electron microscope (SEM) image of normal circulating human blood. One can see red blood cells, several knobby white blood cells including lymphocytes, a monocyte, a neutrophil, and many small disc-shaped platelets.

A complete blood count will normally include:

[edit]Red

cells

Total red blood cells The number of red cells is given as an absolute number per litre. Hemoglobin - The amount of hemoglobin in the blood, expressed in grams per decilitre. (Low hemoglobin is called anemia.)

Hematocrit or packed cell volume (PCV) - This is the fraction of whole blood volume that consists of red blood cells.

Red blood cell indices

Mean corpuscular volume (MCV) - the average volume of the red cells, measured in femtolitres. Anemia is classified as microcytic or macrocyticbased on whether this value is above or below the expected normal range. Other conditions that can affect MCV include thalassemia, reticulocytosisand alcoholism.

Mean corpuscular hemoglobin (MCH) - the average amount of hemoglobin per red blood cell, in picograms.

Mean corpuscular hemoglobin concentration (MCHC) - the average concentration of hemoglobin in the cells.

Red blood cell distribution width (RDW) - the variation in cellular volume of the RBC population.

[edit]White

cells

Total white blood cells All the white cell types are given as a percentage and as an absolute number per litre.

A complete blood count with differential will also include:

Neutrophil granulocytes May indicate bacterial infection. May also be raised in acute viral infections. Because of the segmented appearance of the nucleus, neutrophils are sometimes referred to as "segs." The nucleus of less mature neutrophils is not segmented, but has a band or rod-like shape. Less mature neutrophils those that have recently been released from the bone marrow into the bloodstream are known as "bands" or "stabs". Stab is a German term for rod.[1]

Lymphocytes Higher with some viral infections such as glandular fever and. Also raised in chronic lymphocytic leukemia (CLL). Can be decreased by HIV infection. In adults, lymphocytes are the second most common WBC type after neutrophils. In young children under age 8, lymphocytes are more common than neutrophils.[1]

Monocytes May be raised in bacterial infection, tuberculosis, malaria, Rocky Mountain spotted fever, monocytic leukemia, chronic ulcerative colitis and regional enteritis [1]

Eosinophil granulocytes Increased in parasitic infections, asthma, or allergic reaction. Basophil granulocytes May be increased in bone marrow related conditions such as leukemia or lymphoma. [1]

A manual count will also give information about other cells that are not normally present in peripheral blood, but may be released in certain disease processes.

[edit]Platelets

Platelet numbers are given, as well as information about their size and the range of sizes in the blood. Mean platelet volume (MPV) - a measurement of the average size of platelets.

[edit]Interpretation
Certain disease states are defined by an absolute increase or decrease in the number of a particular type of cell in the bloodstream. For example:

Type of Cell

Increase

Decrease

Red Blood Cells (RBC)

erythrocytosis or polycythemia anemia or erythroblastopenia

White Blood Cells (WBC): leukocytosis

leukopenia

-- lymphocytes

-- lymphocytosis

-- lymphocytopenia

-- granulocytes:

-- granulocytosis

-- granulocytopenia or agranulocytosi s

-- --neutrophils

-- --neutrophilia

-- --neutropenia

-- --eosinophils

-- --eosinophilia

-- --eosinopenia

-- --basophils

-- --basophilia

-- --basopenia

Platelets

thrombocytosis

thrombocytopenia

All cell lines

pancytopenia

Many disease states are heralded by changes in the blood count:

leukocytosis can be a sign of infection. thrombocytopenia can result from drug toxicity. pancytopenia is generally referred to as the result of decreased production from the bone marrow, and is a common complication of cancer chemotherapy.

Electrolyte
From Wikipedia, the free encyclopedia

This article is about the ionic solution. For the R.E.M. song, see Electrolite. In chemistry, an electrolyte is any substance containing free ions that make the substance electrically conductive. The most typical electrolyte is an ionic solution, but molten electrolytes and solid electrolytes are also possible. Commonly, electrolytes are solutions of acids, bases or salts. Furthermore, some gases may act as electrolytes under conditions of high temperature or low pressure. Electrolyte solutions can also result from the dissolution of some biological (e.g., DNA, polypeptides) and synthetic polymers (e.g., polystyrene sulfonate), termed polyelectrolytes, which contain charged functional groups. Electrolyte solutions are normally formed when a salt is placed into a solvent such as water and the individual components dissociate due to the thermodynamic interactions between solvent and solute molecules, in a process called solvation. For example, when table salt, NaCl, is placed in water, the salt (a solid) dissolves into its component ions, according to the dissociation reaction NaCl(s) Na+(aq) + Cl(aq) It is also possible for substances to react with water producing ions, e.g., carbon dioxide gas dissolves in water to produce a solution which contains hydronium, carbonate, and hydrogen carbonate ions. Note that molten salts can be electrolytes as well. For instance, when sodium chloride is molten, the liquid conducts electricity.

An electrolyte in a solution may be described as concentrated if it has a high concentration of ions, or dilute if it has a low concentration. If a high proportion of the solute dissociates to form free ions, the electrolyte is strong; if most of the solute does not dissociate, the electrolyte is weak. The properties of electrolytes may be exploited using electrolysis to extract constituent elements and compounds contained within the solution.

[edit]Physiological

importance

In physiology, the primary ions of electrolytes are sodium (Na+), potassium (K+), calcium (Ca2+), magnesium (Mg2+), chloride (Cl), hydrogen phosphate (HPO42), and hydrogen carbonate (HCO3). The electric charge symbols of plus (+) and minus () indicate that the substance in question is ionic in nature and has an imbalanced distribution of electrons, the result of chemical dissociation. All known higher lifeforms require a subtle and complex electrolyte balance between the intracellular and extracellular environment. In particular, the maintenance of precise osmotic gradients of electrolytes is important. Such gradients affect and regulate the hydration of the body as well as blood pH, and are critical for nerve and muscle function. Various mechanisms exist in living species that keep the concentrations of different electrolytes under tight control. Both muscle tissue and neurons are considered electric tissues of the body. Muscles and neurons are activated by electrolyte activity between the extracellular fluid or interstitial fluid, and intracellular fluid. Electrolytes may enter or leave the cell membrane through specialized protein structures embedded in the plasma membrane called ion channels. For example, muscle contraction is dependent upon the presence of calcium (Ca2+), sodium (Na+), and potassium (K+). Without sufficient levels of these key electrolytes, muscle weakness or severe muscle contractions may occur. Electrolyte balance is maintained by oral, or in emergencies, intravenous (IV) intake of electrolytecontaining substances, and is regulated by hormones, generally with the kidneys flushing out excess levels. In humans, electrolyte homeostasis is regulated by hormones such as antidiuretic hormone, aldosterone and parathyroid hormone. Serious electrolyte disturbances, such as dehydration andoverhydration, may lead to cardiac and neurological complications and, unless they are rapidly resolved, will result in a medical emergency.

[edit]Measurement
Measurement of electrolytes is a commonly performed diagnostic procedure, performed via blood testing with ion selective electrodes or urinalysis by medical technologists. The interpretation of these values is somewhat meaningless without analysis of the clinical history and is often impossible without parallel measurement of renal function. Electrolytes measured most often are sodium and potassium.

Chloride levels are rarely measured except for arterial blood gas interpretation since they are inherently linked to sodium levels. One important test conducted on urine is the specific gravitytest to determine the occurrence of electrolyte imbalance.

[edit]Rehydration
In oral rehydration therapy, electrolyte drinks containing sodium and potassium salts replenish the body's water and electrolyte levels after dehydration caused by exercise, excessive alcohol consumption, diaphoresis, diarrhea, vomiting, intoxication or starvation. Athletes exercising in extreme conditions (for three or more hours continuously e.g. marathon or triathlon) who do not consume electrolytes risk dehydration (or hyponatremia).[1] A simple electrolyte drink can be home-made by using the correct proportions of water, sugar, salt, salt substitute for potassium, and baking soda.[2] Electrolytes are commonly found in fruit juices, coconut water, sports drinks, milk, and many fruits and vegetables (whole or in juice form) (e.g. potatoes, avocados).

[edit]Electrochemistry
Main article: electrolysis When electrodes are placed in an electrolyte and a voltage is applied, the electrolyte will conduct electricity. Lone electrons normally cannot pass through the electrolyte; instead, a chemical reaction occurs at the cathode consuming electrons from the anode. Another reaction occurs at the anode, producing electrons that are eventually transferred to the cathode. As a result, a negative charge cloud develops in the electrolyte around the cathode, and a positive charge develops around the anode. The ions in the electrolyte neutralize these charges, enabling the electrons to keep flowing and the reactions to continue. For example, in a solution of ordinary table salt (sodium chloride, NaCl) in water, the cathode reaction will be 2H2O + 2e 2OH + H2 and hydrogen gas will bubble up; the anode reaction is 2NaCl 2 Na+ + Cl2 + 2e and chlorine gas will be liberated. The positively charged sodium ions Na+ will react towards the cathode neutralizing the negative charge of OH there, and the negatively charged hydroxide ions OHwill react towards the anode neutralizing the positive charge of Na+ there. Without the ions from the electrolyte, the charges around the electrode would slow down continued electron

flow; diffusion of H+and OH through water to the other electrode takes longer than movement of the much more prevalent salt ions. Also: Electrolytes dissociate in water because water molecules are dipoles and the dipoles orient in an energetically favorable manner to solvate the ions. In other systems, the electrode reactions can involve the metals of the electrodes as well as the ions of the electrolyte. Electrolytic conductors are used in electronic devices where the chemical reaction at a metal/electrolyte interface yields useful effects.

In batteries, two metals with different electron affinities are used as electrodes; electrons flow from one electrode to the other outside of the battery, while inside the battery the circuit is closed by the electrolyte's ions. Here the electrode reactions convert chemical energy to electrical energy.

In some fuel cells, a solid electrolyte or proton conductor connects the plates electrically while keeping the hydrogen and oxygen fuel gases separated.

In electroplating tanks, the electrolyte simultaneously deposits metal onto the object to be plated, and electrically connects that object in the circuit.

In operation-hours gauges, two thin columns of mercury are separated by a small electrolytefilled gap, and, as charge is passed through the device, the metal dissolves on one side and plates out on the other, causing the visible gap to slowly move along.

In electrolytic capacitors the chemical effect is used to produce an extremely thin 'dielectric' or insulating coating, while the electrolyte layer behaves as one capacitor plate.

In some hygrometers the humidity of air is sensed by measuring the conductivity of a nearly dry electrolyte.

Hot, softened glass is an electrolytic conductor, and some glass manufacturers keep the glass molten by passing a large current through it.

[edit]Dry

electrolyte

Dry electrolytes are essentially gels in a flexible lattice framework.[3]