Adolescent medicine (Philadelphia, Pa.)最新文献

Invasive disease due to group A beta-hemolytic streptococci (GABHS) can be divided into 3 categories of disease: streptococcal toxic shock syndrome (strepTSS), necrotizing fasciitis, and other invasive GABHS disease. Patients with strepTSS may have multiorgan failure within hours of presentation. Clindamycin and penicillin G should be used in combination for treatment of invasive GABHS disease. The mortality rate for menstrual staphylococcal toxic shock syndrome has decreased with early recognition and treatment, and removal of hyperabsorbent tampons from the market. Kawasaki syndrome (KS) is the most common cause of acquired heart disease in children in the U. S., and atypical forms have a higher mortality rate than typical KS. Hantavirus pulmonary syndrome is a zoonosis with an 80% mortality rate if the diagnosis is not made on first presentation and patients return to the hospital in shock. Children and adolescents with Lyme disease have an excellent prognosis and respond well to antimicrobial therapy. Cat scratch disease (CSD) is caused by Bartonella henselae and is transmitted by flea-infested kittens. CSD lymphadenopathy typically resolves spontaneously in 2ñ3 months; however, there is a 50% likelihood of resolution in 1 month if patients receive a 5-day treatment course with azithromycin.

The striking, widespread increase in bacterial resistance to antibiotics is an issue of great concern. Worldwide emergence of antibiotic resistances in our common gram-positive coccal pathogens is probably the most serious problem we have in the realm of bacterial infections. The most important of these organisms are penicillin-resistant Streptococcus pneumoniae, vancomycin-resistant Enterococcus, and methicillin- (and now vancomycin-) resistant Staphylococcus aureus. Although known by the above names, all of these organisms are multidrug-resistant. Beta-lactam and vancomycin resistances in gram-positive cocci are caused by altered cell wallñbinding sites with decreased affinity for the drug. Another serious problem is that of resistance in certain gram-negative bacilli due to extended-spectrum beta-lactamase production. These antibiotic resistances in common pathogens have made antimicrobial therapy of many infections extremely difficult or virtually impossible in some instances. The extensive, and often inappropriate, use of antibiotics in the U.S. and worldwide is the major factor in the emergence and spread of antimicrobial resistance. Microbial mechanisms, epidemiology, clinical importance, treatment, and prevention of these antibiotic resistance problems are discussed.

Urinary symptoms in adolescents are common, particularly in females. Urinary tract infections (UTIs) cause many of these symptoms. For uncomplicated UTIs, both lower and upper tract, therapy is straightforward. Commonly used antibiotics are trimethoprim/sulfamethoxazole (TMP/SMX), cefixime, and ciprofloxacin (off-label use) for 3 days for lower tract infections and 10ñ14 days for upper tract infections. Adolescent UTIs are markers for sexual activity, just as UTIs in younger children are often markers for anatomic defects, e.g., congenital abnormalities. Adolescents with upper and lower UTIs often have concurrent sexual activity or a complication of that activity. Issues among adolescents with UTIs are more similar to those of young adults than to those of younger children. It is as important to counsel adolescents about sexual activity and its consequences as it is to treat the UTIs. All adolescents with UTIs should be queried for sexual activity; evidence of sexually transmitted diseases (STDs) should be sought; and counseling for STDs and responsible sexual activity is recommended. Complicated UTIs include those in patients who have grown into adolescence after a childhood of infections or who have anatomic abnormalities, recurrent infections, reflux and reflux nephropathy, spina bifida and neurogenic bladder, transplanted kidneys, diabetes, and urolithiasis. These patients require individualized medical programs, unique for their condition, history, and microbiology.

While upper respiratory tract infections (URTIs) cause much infectious morbidity in infants and young children, adolescents are not immune to infections. Adolescents experience two to four episodes of viral nasopharyngitis annually. In addition to group A streptococcus (GAS), pharyngitis may occur with other streptococci, Arcanobacterium haemolyticum, Epstein-Barr virus, Neisseria gonorrhoeae, and other pathogens. Uvulits, typically in association with GAS, occurs occasionally. Peritonsillar abscess is the most common deep neck space infection seen in adolescents, but retropharyngeal and parapharyngeal abscesses also occur, causing major morbidity. Adolescents experience fewer cases of otitis media than younger children. Rhinosinusitis occurs commonly in adolescents, occasionally leading to chronic sinusitis and serious sequelae such as osteomyelitis. This article reviews the major URTIs likely to be encountered by physicians caring for adolescents. For each entity there is a brief description of the epidemiology, morbidity, microbiology, clinical and laboratory features, treatment, and prevention.

Human immunodeficiency virus (HIV) infection, once largely confined to adolescents with hemophilia, has come to involve the general adolescent population. Individuals younger than 22 years comprise up to 25% of the people newly infected with HIV. Unsafe sexual practices, intravenous drug abuse, homelessness, psychiatric disorders, and inadequate psychosocial support are only some of the factors that have contributed to the epidemic. Present data indicate that interventions have had a positive impact on adolescent behavior in preventing the continuing spread of the disease, but more needs to be accomplished before we consider the problem controlled. Although proper medical treatment and providing adequate psychological and social support to adolescents who are already infected constitute an important aspect of care, the true solution of the problem lies in altering the behavior and practices that lead to the acquisition of this infection.

This review focuses on the diagnosis and treatment of common sexually transmitted diseases (STDs) encountered among adolescents in the U.S. and other developed countries. Included are new recommendations for the treatment of primary and recurrent genital herpes, management of pelvic inflammatory disease, and a revised approach to the care of adolescent victims of sexual assault. Diagnosis begins with a classification based on major clinical findings: genital ulcers with lymphadenitis, urethritis, vaginal discharge, pelvic inflammatory disease, and male STD syndromes. Appropriate laboratory evaluation for each of these clinical presentations is detailed and treatment options are summarized. Preventive interventions along with suggestions for an approach to the preadolescent well care visit, generally scheduled at age 11ñ12 years, are offered. Routine preventive therapy after a sexual assault takes into account difficulty in follow-up and the need to reassure adolescents and their families that all prophylaxis for possible infection has been provided.

Musculoskeletal infections are uncommon disorders in adolescents and represent unique diagnostic and therapeutic challenges to the clinician. The pathogenesis, treatment, and prognosis of many musculoskeletal infections vary markedly in children compared to adults based in part on behavioral differences, bone growth, and changing vascularity patterns. Since adolescents can exhibit manifestations of infection common to either age range, a familiarity with the differences is essential for successful management. This article reviews common musculoskeletal infections affecting normal adolescent population, but also includes special considerations. Hematogenous osteomyelitis and suppurative arthritis are reviewed in detail, including pathogenesis, etiology, signs and symptoms, diagnosis, laboratory tests, radiologic imaging, and treatment. Also discussed are contiguous osteomyelitis with and without vascular insufficiency, puncture wound osteomyelitis, vertebral osteomyelitis, osteomyelitis with sickle cell disease, chronic osteomyelitis, pyomyositis, acute bacterial myositis, and nonstreptococcal myonecrosis.

Lower respiratory tract infections are an important cause of morbidity and occasional mortality in adolescents. This article reviews lower respiratory tract infections by anatomic location. Laryngotracheitis, tracheitis, bronchitis, pneumonia, and parapneumonic effusions are discussed. Specific viral, bacterial, mycoplasmal, and chlamydial etiologies are discussed. The epidemiology and clinical manifestations of lower respiratory tract infections in adolescents are presented according to anatomic site. Treatment for the spectrum of lower respiratory tract infections is also reviewed. Treatment options include supportive care, humidification, corticosteroids, antivirals, antibiotics, and appropriate drainage. Appropriate drainage of parapneumonic effusions includes thoracentesis, closed-tube thoracostomy, and surgery (thoracoscopy or thoracotomy). Imaging modalities include conventional radiography, computed tomography, and ultrasonography. Emphasis is placed on the common lower respiratory tract infections that affect the normal adolescent population.

This article reviews the following gastrointestinal infections: esophagitis, gastritis, duodenitis including duodenal ulcers, and enteritis (gastroenteritis). The epidemiology, risk factors, microbiology and pathogenesis, diagnosis, treatment, morbidity/mortality, and prevention are discussed in relation to the most important pathogens. The symptoms and pathogenesis of esophagitis caused by Candida albicans and herpes simplex are contrasted with the symptoms of esophagitis caused by Helicobacter pylori and gastroesophageal reflux disease (GERD). The incidence of gastritis and gastric and duodenal ulcers caused by H. pylori is discussed. The treatment regimens of H. pylori infection recommended by the CDC are presented. Endoscopic findings in esophagitis, gastritis, and duodenal ulcers are presented and discussed. The difference in symptoms caused by viral agents (Norwalk virus), bacterial agents (enterotoxigenic E. coli), and parasites (Giardia lamblia and Cryptosporidium parvum) are compared and contrasted. The symptoms of infections of the terminal small bowel caused by Salmonella and Campylobacter jejuni and the symptoms of pure colonic infection, dysentery, caused by Shigella and enteroinvasive E. coli and Entamoeba histolytica are discussed. The treatment regimens for enteritis are presented.

Viral hepatitis is the most common cause of acute and chronic hepatitis. The term viral hepatitis generally refers to infections resulting from one of the hepatotrophic viruses: hepatitis A, B, C, D, and E. The last 10 years have brought many important advances in understanding the epidemiology, pathogenesis, molecular biology, and immunoprophylaxis of infections caused by hepatotrophic viruses. Development of sensitive and specific immunoassays has enabled detection of specific agents. This has allowed for identification of infected patients and monitoring response to therapy. Additionally, serologic markers have allowed for isolation of contaminated blood products and a reduction in the spread of disease. The remaining challenge is the application of this knowledge to the treatment and prevention of viral hepatitis. This article explores the risk factors, epidemiology, microbiology, clinical and laboratory diagnosis, treatment, and prevention of the hepatotrophic viral infections.