http://www.cdc.gov/nchhstp/newsroom/docs/2012/GonorrheaTreatmentGuidelinesFactSheet8-9-2012.pdf
A few days ago the CDC sent out a notice informing providers that due to increasing resistance, cefexime (Suprax) is no longer the first line of therapy for gonorrhea. Many of you all will recall not too long ago
the fluoroquinolones lost favor as therapy due to resistance. As such, the current mainstay of suspected gonorrhea is ceftriaxone (Rocephin) injected.
Please remember that due to high coinfection rates, if you clinically suspect gonorrhea enough to treat for it, you should "assume" coinfection with chlamydia, and also prescribe zithromax or doxycycline. Depending on the study you cite, as many as 20-40% of people who are positive for gonorrhea will also test positive for chlamydia. So, thinking of one should lead to the other.
Of course, don't forget these are all notifiable diseases once the labs return. Use the standard health department report form and fax it to 919-250-3945. The most crucial item to fill out on the form is to be sure to tell the health department if the patient was treated.
This change will impact many of our express cares, as many providers liked Suprax as a "non shot" alternative to rocephin. The CDC article admits an ultra low chance of resistance, but when a "standard of care", precedent setting group like the CDC changes its first line therapy, all providers should be aware, since a second line treatment should include documentation as to why the first line was not used.
Saturday, August 11, 2012
Wednesday, August 8, 2012
One "gal" you don't want to date....
http://www.medscape.com/viewarticle/768306?src=mp&spon=38
Major thanks to Sara Hubbell, nurse practitioner, for I suspect the most succinct summary of this emerging disease that will bring dangerous anaphylaxis to our doorsteps.
When anaphylaxis comes our way and we quickly scamper around with our medicines and 911 calls, we often try to question the alarmed patient about the "usual suspects" pine nuts, pineapple, shrimp, and the like. Note though that a new and rather novel entity, involving tick bites (mainly the Lone Star tick), anaphylaxis and red meat exposure has emerged. By red meat, this includes beef, pork, lamb, and venison. Most patients maintain a tolerance (no reation to)chicken, turkey and fish.
The presumed mechanism of action is thought to start with a Lone Star tick bite. The tick bite triggers production of IgE antibodies to the carbohydrate galactose-alpha-1,3-galactose, known thankfully as the shorter, "alpha-gal".
Sadly for the patient, the "alpha-gal" moiety is a common item in mammalian meat glycoproteins and glycolipids. As such, from the initial tick bite the patient becomes anaphylactic to red meats. As the case studies mention, the allergists can order an antibody test for IgE alpha-gal, which is usually elevated.
https://www.google.com/search?q=lone+star+tick&hl=en&prmd=imvns&tbm=isch&tbo=u&source=univ&sa=X&ei=46siUJPHNsaQ2QXepoHQCQ&ved=0CFgQsAQ&biw=1024&bih=585
Some crux urgent care points (the above link is to pictures of the Lone Star tick for all you wannabe entomologists):
- The alpha-gal anaphylaxis usually occurs 3-6 hours after eating the red meat, which is a bit delayed compared to the usual anaphylaxis reactions where the triggering event is mostly within the last 15-60 minutes.
- The alpha-gal anaphylaxis carries all the pitfalls of usual anaphylaxis, such as hypotension, syncope and hives. The treament is the same, with the mainstay being epinephrine.
- Because many allergists also will do an allergy panel to specific meats, the alpha-gal workup is best done by an allergist/immunologist. From an urgent care standpoint, it may help to remind the patient as they go to the ER to be sure to fill their epinephrine precription and consider an allergist workup. Parents also would appreciate this advice at a scary time.
Again the article is very concise. It is worth the Medscape registration if you have not done so previously, and the cases are enlightening.
The cynical side of me says this is actually a government made vector unleased on the public to combat the obesity epidemic (making red meat have the potential to kill you), but then again I know the fast food lobby is much too strong in Washington DC to have allowed that to happen.....
Comments are welcome....
Major thanks to Sara Hubbell, nurse practitioner, for I suspect the most succinct summary of this emerging disease that will bring dangerous anaphylaxis to our doorsteps.
When anaphylaxis comes our way and we quickly scamper around with our medicines and 911 calls, we often try to question the alarmed patient about the "usual suspects" pine nuts, pineapple, shrimp, and the like. Note though that a new and rather novel entity, involving tick bites (mainly the Lone Star tick), anaphylaxis and red meat exposure has emerged. By red meat, this includes beef, pork, lamb, and venison. Most patients maintain a tolerance (no reation to)chicken, turkey and fish.
The presumed mechanism of action is thought to start with a Lone Star tick bite. The tick bite triggers production of IgE antibodies to the carbohydrate galactose-alpha-1,3-galactose, known thankfully as the shorter, "alpha-gal".
Sadly for the patient, the "alpha-gal" moiety is a common item in mammalian meat glycoproteins and glycolipids. As such, from the initial tick bite the patient becomes anaphylactic to red meats. As the case studies mention, the allergists can order an antibody test for IgE alpha-gal, which is usually elevated.
https://www.google.com/search?q=lone+star+tick&hl=en&prmd=imvns&tbm=isch&tbo=u&source=univ&sa=X&ei=46siUJPHNsaQ2QXepoHQCQ&ved=0CFgQsAQ&biw=1024&bih=585
Some crux urgent care points (the above link is to pictures of the Lone Star tick for all you wannabe entomologists):
- The alpha-gal anaphylaxis usually occurs 3-6 hours after eating the red meat, which is a bit delayed compared to the usual anaphylaxis reactions where the triggering event is mostly within the last 15-60 minutes.
- The alpha-gal anaphylaxis carries all the pitfalls of usual anaphylaxis, such as hypotension, syncope and hives. The treament is the same, with the mainstay being epinephrine.
- Because many allergists also will do an allergy panel to specific meats, the alpha-gal workup is best done by an allergist/immunologist. From an urgent care standpoint, it may help to remind the patient as they go to the ER to be sure to fill their epinephrine precription and consider an allergist workup. Parents also would appreciate this advice at a scary time.
Again the article is very concise. It is worth the Medscape registration if you have not done so previously, and the cases are enlightening.
The cynical side of me says this is actually a government made vector unleased on the public to combat the obesity epidemic (making red meat have the potential to kill you), but then again I know the fast food lobby is much too strong in Washington DC to have allowed that to happen.....
Comments are welcome....
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