Isolation of virus from the throat is more likely to be associated with disease than isolation from the stool since virus is shed for shorter periods from the throat. Concern about smallpox has recently increased because of the threat of bioterrorism (Chap. The patient usually guards against palpation and limits movement, pressure, and stretch around the bubo. Lice have a life span of only a few weeks, feed at frequent intervals, and survive only a few days off the human host. Today, the typical patient is using a ventilator, has a slowly progressive infiltrate, and has been colonized with P. Second-generation cephalosporins (cefuroxime, cefoxitin) also offer substantial coverage. Isoniazid is bacteriostatic against resting bacilli and bactericidal against rapidly multiplying organisms, both extracellularly and intracellularly. Temperaturepulse dissociation (relative bradycardia) occurs in typhoid fever, brucellosis, leptospirosis, some drug-induced fevers, and factitious fever. Symptoms include an extremely sore throat, foul breath, and a bad taste accompanied by fever and a sensation of choking. Tender enlargement of the spleen and liver frequently occurs in the acute phase of illness. The cause of the ulceration is unknown, although a viral etiology has been postulated. Its mechanism of action involves inhibition of mycolic acid cell-wall synthesis via oxygen-dependent pathways such as the catalase-peroxidase reaction. As mentioned above, these unique features of actinomycosis mimic malignancy, with which it is often confused. Epidemiologic studies have demonstrated an association between serologic evidence of C. Tetanus vaccine became part of the routine childhood immunization schedule in the late 1940s. The newer fluoroquinolones gatifloxacin, moxifloxacin, and gemifloxacin have excellent in vitro activity against N. The fulminant form may reflect the same basic disease process seen in necrotizing fasciitis, but with the necrotizing inflammatory process extending into the muscles themselves rather than remaining limited to the fascial layers. Antibacterial drugs should be reserved for the treatment of bacterial complications of acute influenza, such as secondary bacterial pneumonia. Other microorganisms causing infection after cat bites are similar to those causing dog bite-wound infections. Specific antiviral therapy is available for influenza (Table 88-2): the neuraminidase inhibitors zanamivir and oseltamivir for both influenza A and influenza B and the adamantane agents amantadine and rimantadine for influenza A (Chap. Patients with this condition produce a thick, eosinophilic mucus with the consistency of peanut butter that contains sparse fungal hyphae on histologic examination. Demonstrating that therapeutic agents for sepsis have consistent, reproducible efficacy has been extremely difficult, even within well-defined patient populations. Immunocompetent hosts can develop localized cutaneous infection in surgical or traumatic wounds, from contaminated injections, or after body piercing. In the setting of acute primary infection patients may experience a syndrome of headache, photophobia, and meningismus. Transmission of the organism by ticks and tabanid flies takes place mainly in the spring and summer.
Other anaerobic bacteria, frequently mixed with aerobic organisms, may produce gas. Findings on chest radiography are useful for assessing the severity of illness in that they identify multilobar involvement and permit monitoring of disease progression. In European cases, there is less expansion of the antibody response, and no single set of criteria for the interpretation of immunoblots results in high levels of sensitivity and specificity in all countries. The presence of symbiotic microorganisms, including algae, amebas, ciliated protozoa, and other waterdwelling bacteria, promotes the growth of L. Adhesins comprise a wide range of surface structures, not only anchoring the microbe to a tissue and promoting cellular entry where appropriate, but also eliciting host responses critical to the pathogenic process (Table 2-1). Considerable progress has been made in recent years in the development of such tests, which are now widely available for a number of viral infections. Dysphagia or stiffness or pain in the neck, shoulder, and back muscles appears concurrently or soon thereafter. Vegetations become smaller with effective therapy, but at 3 months after cure, half are unchanged and 25% are slightly larger. The continued development and testing of vaccine combinations aim to mitigate these concerns. At presentation during the first 3 days of illness, only 3% of patients exhibit the classic triad of fever, rash, and history of tick exposure. Recent studies have estimated there to be about 110,000 patients with bronchiectasis in the United States. The onset of disease is usually sudden and is associated with tender bleeding gums, foul breath, and a bad taste. Patients with peptic ulcer disease or gastric adenocarcinoma are more likely than persons without these conditions to be colonized by cag PaI-positive strains. In younger children, persistent effusions and decreased hearing can be associated with impairment of language acquisition skills. Blood lactate levels rise early because of increased glycolysis as well as impaired clearance of the resulting lactate and pyruvate by the liver and kidneys. It is a disorder that typically affects older individuals; approximately two-thirds of patients are women. Pneumonia results in a catabolic state in a patient already nutritionally at risk. The usual setting for epidemic typhus is a site of war or natural disaster in which people are exposed to body lice. The major noninfectious etiologies that should be included in the differential diagnosis of acute encephalitis are nonvasculitic autoimmune meningoencephalitis, which may or may not be associated with serum antithyroid microsomal and antithyroglobulin antibodies; limbic encephalitis associated with antineuronal antibodies; limbic encephalopathy not associated with cancer; acute disseminated encephalomyelitis and related fulminant demyelinating disorders; and lymphoma. Recently, however, they have fallen out of favor because of the time required to obtain a final result for the convalescent-phase sample. The illnesses caused by respiratory viruses traditionally have been divided into multiple distinct syndromes, such as the "common cold," pharyngitis, croup (laryngotracheobronchitis), tracheitis, bronchiolitis, bronchitis, and pneumonia. Other rare complications include encephalitis, peripheral nerve abnormalities, myelitis, facial palsy, and granulomatous hepatitis or splenitis. Routine surveillance among neutropenic patients for infections with filamentous fungi, such as Aspergillus and Fusarium, helps hospitals to determine whether they are facing unduly extensive environmental risks. Antibody to some of these proteins is generally present in serum of children >4 years old; however, colonizing or disease-causing isolates may survive in serum despite this naturally present antibody and complement. For patients with track-site infection, successful therapy without catheter removal is unusual. In the female partner, it is important to confirm ovulation and assess tubal patency.
Schedules for immunization are ultimately derived from careful consideration of the many relevant variables and may ultimately depend on the best opportunities to reach the target groups. The clinical history and/or setting can often identify cases of acute anaerobic bacterial sinusitis, acute fungal sinusitis, or sinusitis from noninfectious causes. Pulmonary signs in primary pneumonic plague may indicate involvement of a single lobe in the early stage, with rapidly developing segmental consolidation before bronchopneumonic spread to other lobes of the same and opposite lungs. Most of these health problems are minor: only 5% require medical attention, and <1% require hospitalization. Mild white matter hypodensity is also seen adjacent to the frontal horns of the lateral ventricles. These patients present with fever, faint or no murmur, and (in 75% of cases) prominent pulmonary findings related to septic emboli, including cough, pleuritic chest pain, nodular pulmonary infiltrates, and occasionally pyopneumothorax. A pericardial rub is heard throughout the respiratory cycle, whereas a pleural rub disappears when respiration is suspended. Chloramphenicol and tetracycline have been used successfully for treatment of the acute stages of tularemia but have been associated with higher relapse rates (up to 20%) than conventionally used agents. Treatment of asymptomatic catheter-associated bacteriuria may be of greatest benefit to elderly women, who most often develop symptoms if left untreated. Symptoms of upper respiratory tract infection are not prominent, although mild sore throat, pharyngitis, and cervical adenopathy are often documented; on occasion, the last may be the only manifestation of illness. These infections include empyema, adult epiglottitis, pericarditis, cellulitis, septic arthritis, osteomyelitis, endocarditis, cholecystitis, intraabdominal infections, urinary tract infections, mastoiditis, aortic graft infection, and bacteremia without a detectable focus. In compromised hosts, disseminated lesions may appear as a result of bacteremic spread. Studies with monoclonal antibodies and nucleotide sequencing of the major outer-membrane protein have delineated at least 20 serotypes of C. To differentiate between true urethritis and functional symptoms among symptomatic patients or to make a presumptive diagnosis of C. The coexistence of cirrhosis in patients with tuberculous peritonitis complicates the diagnosis. These techniques may be superior to echocardiography in detecting loculated pericardial effusions, pericardial thickening, and the presence of pericardial masses. Disruption of the cytoskeleton results in loss of cell shape, adherence, and tight junctions, with consequent fluid leakage. Impaired host defense mechanisms are often involved in the predisposition to recurrent infections. Uncommon infections include ophthalmic infection and peritonitis associated with continuous ambulatory peritoneal dialysis. Precautions for the care of patients with potentially contagious clinical syndromes. Patients with slowly progressive involvement of multiple cranial nerves and/or spinal nerve roots are likely to have chronic meningitis. Missense mutations or deletion of katG is also associated with reduced catalase and peroxidase activity. An adverse event can be either a true vaccine reaction or an event whose occurrence is temporally related to a vaccine dose but is entirely unrelated to the vaccine itself. A special type of contiguous-focus osteomyelitis occurs in the setting of peripheral vascular disease and nearly always involves the small bones of the feet of adults with diabetes. Occasionally, hypoesthesia and/or weakness of the lower extremities persists for many months. Another study found that chronic fatigue did not develop after typical upper respiratory infections but did in some individuals after infectious mononucleosis. As recently as 2004, chromosomal mutations accounted for resistance to penicillin, tetracycline, or both in 12% of strains surveyed in the United States. Maximal recommended doses of antimicrobial drugs should be given intravenously, with adjustment for impaired renal function when necessary. However, these latter recommendations were placed on hold in the wake of increased concerns of the use of variola virus as a biologic weapon and thus the need to maintain an active program of defensive research. Burns predispose to infection by damaging the protective barrier function of the skin, thus facilitating the entry of pathogenic microorganisms, and by inducing systemic immunosuppression. The epidemic that peaked in 1990 predominantly involved African-American heterosexual men and women and occurred largely in urban areas, where infectious syphilis was correlated significantly with the exchange of sex for crack cocaine. Accordingly, the American Dental Association and the American Academy of Orthopaedic Surgeons do not recommend antibiotic prophylaxis for nedasalamatebook@gmail.
As noted above, the number of licensed vaccines and the strategies for their best use change constantly as new products, new indications, and new information become available. If antibiotic therapy is stopped earlier, lesions often continue to heal, but the relapse rate is higher. Examples include, but are not limited to , the following: Bacillary angiomatosis Candidiasis, oropharyngeal (thrush) Candidiasis, vulvovaginal; persistent, frequent, or poorly responsive to therapy Cervical dysplasia (moderate or severe)/cervical carcinoma in situ Constitutional symptoms, such as fever (38. The synovial fluid should be examined for crystals, because gout and pseudogout can resemble septic arthritis clinically, and infection and crystal-induced disease occasionally occur together. Infection with this fastidious gram-negative rod typically presents after a dog bite as fever, chills, myalgia, vomiting, diarrhea, dyspnea, confusion, and headache. A second level of specificity is provided by the fact that the acyclovir nedasalamatebook@gmail. Staphylococcus aureus, coagulase-negative staphylococci, enterococci, Streptococcus pneumoniae, other streptococci, other gram-positive bacteria. The skin-test antigen, which is not commercially available, can boost titers of agglutinating antibody. Cross-reactions also occur with the O chains of some other gram-negative bacteria, including Escherichia coli O157, Francisella tularensis, Salmonella enterica group N, Stenotrophomonas maltophilia, and Vibrio cholerae. There are no known risks for pregnant women who travel to high-altitude destinations and stay for short periods. In the patient who is allergic to -lactam drugs, chloramphenicol is a suitable alternative; chloramphenicol-resistant meningococci have been reported from Vietnam and France. However, antibodies neither enhance lysis by complement nor inhibit intracellular multiplication within phagocytes. The affected lymph nodes may become fluctuant and drain spontaneously, but usually the condition resolves with effective treatment. Very few organisms and a strong cellular response are observed in patients with acute Q fever, whereas many organisms and a moderate cellular response are seen in chronic Q fever. Pain is often absent in slowly developing tuberculous, postirradiation, neoplastic, or uremic pericarditis. For example, after receptor binding and fusion, herpesvirus nucleocapsids are released into the cytoplasm along with tegument proteins. Anterior osteophytes eventually develop, but vertebral destruction or impingement on the spinal cord is rare and usually suggests tuberculosis (Table 58-1). Diphtheritic ulcers occasionally-but not consistently- have a punched-out appearance. In most cases, the illness becomes shorter and milder and the afebrile intervals longer with each relapse. The vast majority of cases in the United States are streptobacillary, whereas Spirillum infection occurs mainly in Asia. A pattern of relapsing infection in a middle-aged man strongly suggests chronic bacterial prostatitis. The infection may be initiated by the use of catheters for bladder drainage and is favored by the prolonged stasis of urine in the bladder. Fortunately, granulocytopenic patients are likely to be infected with certain types of organisms (Table 11-4); thus the selection of an antibiotic regimen is somewhat easier than it might otherwise be (see "Antibacterial Therapy" later in the chapter). The diagnosis of clostridial myonecrosis can be established by frozen-section biopsy of muscle. Wet mount for fungus and parasites, India ink preparation and culture, culture for fastidious bacteria and fungi, assays for cryptococcal antigen and oligoclonal immunoglobulin bands, and cytology should be performed. Most gastrointestinal side effects can be minimized by reducing the dose or using slow-release formulations. During the acute phase of viral hepatitis, antibodies to smooth muscle and other cell constituents may be present, and low titers of rheumatoid factor, nuclear antibody, and heterophil antibody can also be found occasionally. In eastern Europe, incidence increased during the 1990s because of deterioration in socioeconomic conditions and the health care infrastructure; however, after peaking in 2001, incidence has recently stabilized.
In immunocompromised hosts, varicella vesicles may lack the characteristic erythematous base or may appear hemorrhagic. The animal vaccine used in a given area should contain the serovars known to be present in that area. Research is needed to develop adjunctive agents that can damp the septic response before organ dysfunction or hypotension occurs. The choice of empirical antibiotics for the anaerobes in mixed infections can nearly always be made reliably, since patterns of antimicrobial susceptibility are usually predictable (Chap. Adoption of new guidelines for shorter-course therapy will not undermine the care of patients, many unnecessary complications and expenses will be avoided, and the useful life of these valuable drugs will perhaps be extended. Abdominal Infection Klebsiella causes a spectrum of abdominal infections similar to that caused by E. Before rifampin is prescribed for any patient, a review of concomitant drug therapy is essential. If the biotyping approach is automated and the reading process is coupled to computer-based data analysis, rapidly growing organisms (such as Enterobacteriaceae) can be identified within hours of detection on agar plates. In practice, however, high-dose induction therapy has not yielded higher sustained response rates. One clinical feature that has been used to help guide diagnostic and therapeutic decision making is illness duration. This disease, which is caused by bacteria of the Mycobacterium tuberculosis complex, usually affects the lungs, although other organs are involved in up to one-third of cases. For children, furazolidone has been the recommended agent and trimethoprim-sulfamethoxazole the second choice. Although the newer quinolones exhibit increased in vitro activity against staphylococci, it is uncertain whether this increase translates into enhanced in vivo activity. Patients may experience constitutional signs and symptoms or may develop an opportunistic disease abruptly 1 0. Suppression of recurrent genital herpes: Oral acyclovir (200-mg capsules tid or qid, 400 mg bid, or 800 mg qd), famciclovir (250 mg bid), or valacyclovir (500 mg daily) is effective. Under these circumstances of routine testing, although desirable, pretest counseling may not always be built into the testing process. The comparative genomics of singlenucleotide polymorphisms support the likelihood that four distinct strains exist, having originated in East Africa or Central Asia. Serologic methods generally fall into two categories: those that determine protective antibody levels and those that measure changing antibody titers during infection. Routine varicella vaccination of children and susceptible employees can markedly decrease risk and frequency of exposures. The infection is acquired during or shortly before birth from the colonized maternal genital tract. Eruptive xanthomas may appear on the back, the buttocks, and the extensor surfaces of the arms and legs. The conversion from environmental saprophyte to a pathogen involves the coordinate regulation of bacterial determinants of pathogenesis that mediate entry into cells, intracellular growth, and cellto-cell spread. Experimental inoculation of the fallopian tubes of lower primates has shown that repeated exposure to C. Reactivation rates are 40% for allogeneic recipients and 25% for autologous recipients. Routine premarital serologic testing for syphilis is controversial because of low yield. Removal of the thickened visceral pleura (decortication) is occasionally necessary to improve lung function. The white blood cell count is generally somewhat elevated, with few immature cells. Histologically, interstitial infiltrates of lymphocytes and plasma cells in a perivascular and peribronchial distribution are present.
Aloysia triphylla (Lemon Verbena). Wellbutrin SR.
The initiation of empirical therapy does not mark the end of the diagnostic workup; rather, it commits the physician to continued thoughtful reexamination and evaluation. A subsequent prolonged course of oral antibiotic therapy is often prescribed, especially in the setting of a foreign body, but controlled data for this approach are lacking. Histologic examination reveals massive necrosis and dropout of liver cells of most lobules with extensive collapse and condensation of the reticulin framework. In any setting, patients treated for syphilis need to be carefully monitored to ensure adequate therapy. A potentially important but even more controversial association is with ischemic heart disease and cerebrovascular disease. The clinical presentation may be surprisingly indolent given the extent of disease. Hematogenous abscesses are often multiple, and multiple abscesses often (50%) have a hematogenous origin. However, since 1977, H1N1 and H3N2 viruses have circulated simultaneously, resulting in outbreaks of varying severity. Such media are composed of agar, which is not metabolized by bacteria; nutrients to support the growth of the species of interest; and sometimes substances to inhibit the growth of other bacteria. The finding of a heart murmur-certainly if new-raises concern about endocarditis, a rare but serious complication. The cell frequently misperceives that the receptor has encountered its "normal ligand. All tests may be nonreactive in early primary syphilis, although the treponemal tests have slightly higher sensitivity during this stage. Finally, congenital tuberculosis results from transplacental spread of tubercle bacilli to the fetus or from ingestion of contaminated amniotic fluid. In hospital-acquired meningitis, and particularly meningitis after neurosurgical procedures, staphylococci and gram-negative organisms including P. In all cases, careful follow-up should be assured for any patient treated for syphilis with azithromycin. Sexual dysfunction has been described as a side effect of therapy with beta blockers. Leptospires enter the host through abrasions in the skin or through intact mucous membranes, especially the conjunctiva and the lining of the oro- and nasopharynx. Bites and scratches from cats and other animals may introduce Pasteurella multocida into joints, and bites from humans may introduce Eikenella corrodens or other components of the oral flora. Clinical trials for safety in humans and efficacy in animals are currently underway to evaluate the role of recombinant protective antigen (one of the major components, along with lethal factor and edema factor, of B. Famciclovir is well absorbed orally, has a bioavailability of 77%, and is rapidly converted to penciclovir by deacetylation and oxidation in the intestine and liver. T and B cells in the peripheral blood may reconstitute the immune response if they are transferred in adequate numbers. The meninges, the subarachnoid space, and the brain parenchyma are all frequently involved in the inflammatory reaction (meningoencephalitis). Tuberculous otitis is rare and presents as hearing loss, otorrhea, and tympanic membrane perforation. During a febrile illness, the diurnal variation is usually maintained, but at higher, febrile levels. Vancomycin plus gentamicin is the recommended regimen for infections due to enterococci with high-level intrinsic resistance to -lactams. In its mild form, leptospirosis may present as an influenza-like illness with headache and myalgias.
Dairy products, especially soft cheeses, unpasteurized milk, and ice cream, are the most frequently implicated sources of infection; raw meat and bone marrow may be sources under exceptional circumstances. White-footed mice and white-tailed deer in the United States and red deer in Europe are natural reservoirs for A. Phagocytes appear rapidly at sites of infection in conjunction with the initiation of inflammation. Anaerobic bacteria are not found in appreciable numbers in the normal upper intestine until the distal ileum. If the mass enlarges or the patient becomes more toxic, the abscess should be drained. Molluscum contagiosum is the most common human disease resulting from poxvirus infection and is transmitted by close contact, including sexual intercourse. Passive immunization is used in the treatment of certain illnesses associated with toxins. In general, these patients should receive any killed or inactivated vaccine preparation appropriate to the area they are visiting; this recommendation includes the vaccines for Japanese encephalitis, hepatitis A and B, poliomyelitis, meningococcal infection, and typhoid. No qualitative abnormalities in the virus were detected in most of these patients. However, in most developed countries, including the United States (see above and below), there has been a gradual shift toward heterosexual transmission. The petechiae may coalesce into hemorrhagic bullae or may undergo necrosis and ulcerate. A constant threat during generalized spasms is reduced ventilation or apnea or laryngospasm. Proteus less commonly causes infection at a variety of other extraintestinal sites. Rifabutin is readily absorbed after a single oral dose of 300 mg and reaches peak serum levels (0. Antigen in urine is detectable 3 days after the onset of clinical disease and disappears over 2 months; positivity can be prolonged when patients receive glucocorticoids. This protein modulates the expression of virulence genes in response to environmental signals via a cascade of regulatory proteins. Asymptomatic avian carriers are common, and complete recovery may be followed by continued shedding of the organism for many months. At low bacterial inocula, epithelial cell ingestion and subclinical inflammation are probably efficient means to eliminate pathogens; in contrast, at higher inocula, a proportion of surviving bacterial cells enter host tissue through the damaged mucosal surface and multiply, producing disease. Prolonged prophylaxis (beyond 24 h) merely alters the normal flora and favors infections with organisms resistant to the antibacterial agents used. Emphysematous pyelonephritis is usually characterized by a rapidly progressive clinical course, with high fever, leukocytosis, renal parenchymal necrosis, and accumulation of fermentative gases in the kidney and perinephric tissues. Although given for several weeks longer, the regimens recommended for the treatment of endocarditis involving prosthetic valves (except for staphylococcal infections) are similar to those used to treat native valve infection (Table 19-4). In preliminary clinical trials, moxifloxacin has been matched in potency only by rifampin. Western blots require individual evaluation and are inherently difficult to quantitate or automate. Cardiac findings are compatible with a high-output state; tachycardia and summation gallop are common. In addition, the pathogen can express a carbohydrate that mediates binding to host cells. The extent of the neuromuscular compromise is dependent upon the level of toxemia. In young children with poor natural immunity, hematogenous dissemination may result in fatal miliary tuberculosis or tuberculous meningitis. Pili or fimbriae are commonly used by gram-negative and gram-positive bacteria for attachment to host cells and tissues.
Although these infections are often of mixed etiology, involving both anaerobes and coliforms, pure anaerobic infections without coliform or other facultative bacterial species occur more often in pelvic than in intraabdominal sites and are characterized by drainage of foul-smelling pus or blood from the uterus, generalized uterine or local pelvic tenderness, and continued fever and chills. Plain radiographs obtained early in the course of infection may show soft tissue swelling, but the first change in bone-a periosteal reaction-is not evident until at least 10 days after the onset of infection. In most cases, campylobacters are transmitted to humans in raw or undercooked food products or through direct contact with infected animals. Early-onset nosocomial pneumonia, which manifests within the first 4 days of hospitalization, is most often caused by communityacquired pathogens, such as Streptococcus pneumoniae and Haemophilus species. However, patients with bacteremia should receive both doxycycline and gentamicin, mainly to prevent the development of endocarditis. Anaplasma phagocytophilum causes human granulocytic ehrlichiosis (anaplasmosis), and Ehrlichia chaffeensis causes human monocytic ehrlichiosis. Determining whether multiple isolates from different patients are the same or different is relevant when there is concern that a nosocomial outbreak may have been due to a common point source. Unlike the rash of rubella, the enteroviral rash occurs in the summer and is not associated with lymphadenopathy. In some cases, the presence of an underlying systemic illness points to a specific agent or class of agents as the probable cause. On occasion, individuals with a history of immunization may develop modified measles. Adenoviruses account for ~10% of acute respiratory infections in children but for <2% of respiratory illnesses in civilian adults. When fulfilling criteria of severity, this type of chronic hepatitis, when untreated, may have a 6-month mortality of as high as 40%. Patients with underlying sinusitis frequently have symptoms related to this infection. If a delay in sample processing is expected, Carey-Blair transport medium and/or alkalinepeptone water-enrichment medium should be inoculated as well. Other Manifestations Enteroviruses are an infrequent cause of childhood pneumonia and the common cold. Since medical therapy alone is often sufficient for cure, the challenge for the clinician is to consider the possibility of actinomycosis, to diagnose it in the least invasive fashion, and to avoid unnecessary surgery. For example, brain abscesses that develop as a complication of infective endocarditis are often due to viridans streptococci or S. The patient who aspirates in the hospital may also have a mixed infection involving enteric gram-negative rods. Although no high-titer preparation is available for postexposure protection against non-A, non-B hepatitis, standard human immune serum globulin is efficacious. Identification usually requires confirmation by staining with virus-specific monoclonal antibodies. If there are pulmonary signs or symptoms, bronchoscopy with bronchoalveolar lavage for cultures and cytology should be considered. Regimen is used for contacts of patients with isoniazid-resistant, rifampinsusceptible tuberculosis. These patients tend to be older than those with right-sided endocarditis, their prognosis is worse, and their incidence of complications (including peripheral emboli, cardiac decompensation, and metastatic seeding) is higher. At present, strategies to interrupt latency or to maintain molecular latency in neurons are not available. Pregnant women who received their last Td booster >10 years previously may receive Td during the second or third trimester; those boosted <10 years previously (and as recently as 2 years before) should receive Tdap after delivery. After the start of antimicrobial treatment for leptospirosis, a Jarisch-Herxheimer reaction similar to that seen in other spirochetal diseases may develop. The efficacy of linezolid or daptomycin as an alternative to vancomycin for left-sided, methicillin-resistant S.