Tuesday, March 20, 2012

Urinary Tract Infection

Urinary tract infection (UTI) is the most common bacterial infection encountered in the ambulatory setting in the US. By the age of 32 years, half of all women have reported at least one UTI. Young healthy women have a 25% chance of recurrence within six months.

Risk factors for uncomplicated UTI include sexual intercourse, new sex partner (within past year), use of spermicides, previous UTI and history of urinary tract infections in a first degree relative (mother, sister, daughter). There is no association with precoital or postcoital voiding patterns, daily beverage consumption, frequency of urination, delayed voiding habits, wiping patterns, tampon use, douching, use of hot tubs, type of underwear, or body mass index.

Urinary tract infections rarely progress to pyelonephritis (kidney infection). However, UTI is associated with considerable discomfort and antimicrobial drugs are prescribed to rapidly resolve the symptoms. Short courses of antibiotics are recommended as first-line treatment. The physician will choose a medication n the basis of the patient’s allergy and compliance history, local practice patterns, the prevalence of resistance in the local community, availability, cost, and patient and physician threshold for failure (choosing the wrong medication).

The key to management of UTI is to improve the quality of life while minimizing antimicrobial exposure.

The New England Journal of Medicine has an excellent review of uncomplicated UTI.

Sunday, March 11, 2012

Nontraditional Cardiovascular Risk Factors

We have several risk models to try to assess which patients are at highest risk for heart disease. The traditional models use the widely accepted parameters such as cholesterol levels, smoking, diabetes, hypertension, and family history. Much of the collected data stems from the Framingham model. (Quick calculation)

In order to further refine risk assessment, the AHRQ (Agency for Health Care Research and Quality) has evaluated some non-traditional risk factors and issued recommendations. These recommendations are aimed at asymptomatic adults with an intermediate risk (10-20%) of future heart disease as determined by multiple traditional risk factors (such as the Framingham or ATPIII models).

There is agreement that measurement of cardiac C-reactive protein (CRP) may be reasonable in persons who have an intermediate risk and it is uncertain as to the use of preventive therapies such as starting cholesterol-lowering medications.

There is also agreement that lipid studies beyond the standard fasting profile are not recommended. The non-recommended screening tests include lipoprotein subclasses, apolipoproteins, particle size and density. However, these tests might be helpful in identifying susceptible individuals where there is a strong family history.  An emerging test, lipoprotein-associated phospholipase A2 (Lp-PLA2) might be helpful; data is still pending.

There is no evidence that homocysteine level screening is helpful. Measurement of natriuretic peptide is not recommended in asymptomatic adults. Fibrinogen and white blood cells are independent markers of cardiovascular risk, but there is insufficient evidence for the use in screening.

For the full AHRQ report.

Friday, March 2, 2012

2012 Adult Immunization Schedule

There are some new recommendations for adult immunizations – anyone over 18 years old.

The “new” tetanus shot (Tdap) includes protection against pertussis (whooping cough) as well at tetanus and diphtheria.
·         Tdap vaccine is recommended for all persons who are close contacts of infants younger than 12 months of age (e.g., parents, grandparents, and child-care providers) and who have not received Tdap previously.
·         Tdap vaccine is recommended for pregnant women during later pregnancy (>20 weeks gestation).
·         Other adults who are close contacts of children younger than 12 months of age continue to be recommended to receive a one-time dose of Tdap vaccine.

The human papillomavirus is associated with cervical cancer, mouth cancer and penile cancer. The previous recommendation for HPV immunization was for females younger than 26 years. The update includes routine vaccination of males 11–12 years of age, with catch-up vaccination recommended for males 13–21 years of age. Also now recommended for previously unvaccinated males 22–26 years of age who are immunocompromised, or who test positive for human immunodeficiency virus (HIV) infection, or who have sex with men.

All children are now immunized against hepatitis B. The updated recommendation is to vaccinate adults younger than 60 years old who have diabetes as soon as possible after diabetes is diagnosed. Also now recommended, at the discretion of the treating clinician, for adults with diabetes who are 60 years or older based on a patient’s likely need for assisted blood glucose monitoring, likelihood of acquiring hepatitis B, and likelihood of immune response to vaccination.

The “shingles shot” (Zoster vaccine) was recently approved by the FDA for administration to persons 50 years or old, the Advisory Committee on Immunization Practices continues to recommend that vaccination begin at age 60 years.

Read the full article in the MMWR.