Medex

Jean-Pierre Ya red, MD

• Director, Critical Care Medicine in the Heart and Vascular Institute
• Cleveland Clinic Foundation
• Cleveland, Ohio

In megaloblastic erythropoiesis hiv infection africa discount 5 mg medex with mastercard, the nucleus and cytoplasm do not mature at the same rate so that nuclear maturation lags behind cytoplasmic hemoglobinization antiviral use in pregnancy buy medex toronto. Formation of white blood cells (Leucopoiesis) Granulopoiesis and Monocytopoiesis Neutrophils and monocytes hiv infection undetectable discount medex 1 mg overnight delivery, which evolve into macrophages when they enter the tissues hiv symptoms three months after infection medex 1mg with visa, are arise form a common committed progenitor hiv infection rates new zealand generic 5mg medex visa. The myeloblast is the earliest recognizable precursor in the granulocytic series that is found in the bone marrow antiviral brandon cronenberg cheap medex amex. This concomitant cell division and maturation sequence continues form promyelocytes to early myelocytes, late myelocytes, and they metamyelocytes, which are no longer capable of cell division. Subsequent segmentation of the nucleus gives rise to the mature neutrophil or polymorphonuclear leucocyte. The average interval from the initiation of granulopoiesis to the entry of the mature neutrophil into the circulation is 10 to 13 days. The mature neutrophil remains in the circulation for only about 10 to 14 hours before entering the tissue, where it soon dies after performing its phagocytic function. It has a thin nuclear membrane and finely dispersed, granular, purplish, pale chromatin with well-demarcated, pink, evenly distributed parachromatin: 2-5 light blue-gray nucleoli surrounded by dense chromatin are seen. Cytoplasm: the cytop la sm ic m a ss is sm a llin comparison to the nucleus, producing a nuclear/ cytoplasmic ratio of 7:1. It stains basophilic (bluish) and shows a small indistinct, paranuclear, lighter staining halo (golgi apparatus). It is round or oval, eccentric, possibly slightly indented, and surrounded by a thin membrane. With in the finely of granular purplish pale chromatin, 1-3 nucleoli may be faintly visible. Cytoplasm: It is pale blue; it is some what large in area than in myeloblast, so the nuclear/cytoplasmic ratio is 4:1 or 5:1. The non-specific, peroxidase-containing 26 Hematology azurophilic granules are characteristic of the promyelocyte stage of development. Cytoplasm: Light pink and contains neutrophilic granules (brownish) that may cover the nucleus and are coarse in the younger cells but become finer as the cell matures. Metamyelocyte (Juvenile cell) the last cell of the granulocyte series capable of mitotic division; further stage in the development are caused by maturation and non-division. The nuclear membrane is thick and heavy, and the chromatin is concentrated into irregular thick and thin areas. Band Granulocyte (Stab Cell) the juvenile cell or the band cell are the youngest granulocytes normally found in the peripheral blood. Cytoplasm: contains specific and a few non-specific granules and is pink or colorless. The ratio of segmented to band forms is of clinical significance and is normally about 10:1. Cytoplasm: abundant and slightly eosinophilic (pinkish) or colorless and contains specific granules. The neutrophilic granules are very fine in texture and do not overlay the nucleus. Eosinophilic Granulocyte and Precursors Eosinophils mature in the same manner as neutrophils. In the eosinophilic promyelocyte in the Wright-Giemsa stained preparation the granule are at first bluish and later mature into orange granules, which are larger than neutrophilic granules are round or ovoid and are prominent in the eosinophilic myelocyte. Nucleus: usually bilobed, rarely singleor tri-lobed and 29 Hematology contains dense chromatin masses. Eosinophils with more than two nuclear lobes are seen in vitamin B12 and folic acid deficiency and in allergic disorders. Cytoplasm: densely filled with orange-pink granules so that its pale blue color can be appreciated only if the granules escape. Basophilic Granulocyte and Precursors the early maturation of the basophilic granulocyte is similar to that of the neutrophlic granulocyte. It is difficult to see the nucleus because it contains less chromatin and is masked by the cytoplasmic granules. Cytoplasm: Pale blue to pale pink and contains granules that often overlie the nucleus but do not fill the cytoplasm as completely as the eosinophilis granules do. The chromatin is delicate blue to purple stippling with small, regular, pink, pale or blue parachromatin areas. Cytoplasm: Relatively large in amount, contains a few azurophile granules, and stains pale blue or gray. The cytoplasm filling the nucleus indentation is lighter in color than the surrounding cytoplasm. Promonocyte the earliest monocytic cell recognizable as belonging to the monocytic series is the promonocyte, which is capable of mitotic division. Its product, the mature 31 Hematology monocyte, is only capable of maturation into a macrophage. The chromatin network consists of fine, pale, loose, linear threads producing small areas of thickening at their junctions. Cytoplasm: Ab unda nt,op a que,gra y-b lue,a nd unevenly stained and may be vacuolated. Lymphopoiesis 32 Hematology the precursor of the lymphocyte is believed to be the primitive mulipotential stem cell that also gives rise to the pluirpotenital myeloid stem cell for the granulocytic, erythyroid, and megakaryocytic cell lines. Lymphoid precursor cells travel to specific sites, where they differentiate into cells capable of either expressing cellmediated immune responses or secreting immunoglobulins. The influence for the former type of differentiation in humans is the thymus gland; the resulting cells are defined as thymus-dependent lymphocytes, or T cells. The site of the formation of lymphocytes with the potential to differentiate into antibody-producing cells has not been identified in humans, although it may be the tonsils or bone marrow. In chickens it is the bursa of Fabricius, and for this reason these bursa-dependent lymphocytes are called B cells. The nuclear membrane is distinct and 33 Hematology one or two pink nucleoli are present and are usually well outlined. Cytoplasm: there is a thin rim of basophlic, homogeneous cytoplasm that may show a few azurophilic granules and vacuoles. Lymphocytes There are two varieties and the morphologic difference lies mainly in the amount of cytoplasm, but functionally most small lymphocytes are T cells and most large lymphocytes are B cells. Cytoplasm: It is basophilic and forms a narrow rim around the nucleus or at times a thin blue line only. Formation of platelets (Thrombopoiesis) Platelets are produced in the bone marrow by fragmentation of the cytoplasm of megakaryocytes. The precursor of the megakaryocyte-the megakaryoblastarises by a process of differentiation for the hemopoietic s t e m c e l l. T h e m e g a k a r y o b l a s t p r o d u c e s megakaryocytes, distinctive large cell that are the 35 Hematology source of circulating platelets. The final stage of platelet production occurs when the mature megakaryocyte sends cytoplasmic projections into the marrow sinusoids and sheds platelets into the circulation. It takes approximately 5 days from a megakaryoblast to become a mature megakaryocyte. Cytoplasm: the cytoplasm form s a scanty, bluish, patchy, irregular ring around the nucleus. The chromatin appears to have coarse heavily stained strands and may show clumping. The total number of nucleoli is decreased and they are more difficult to see than in the blast cell. Cytoplasm: intensely basophilic, filled with increasing 37 Hematology numbers of azurophilic granules radiating from the golgi apparatus toward the periphery sparing a thin peripheral ring that remains blue in color. Cytoplasm: a large amount of polychromatic cytoplasm produces blunt, smooth, pseudopodia-like projections that contain aggregates of azurophilic granules surrounded by pale halos. In Wright Giemsa stained films, platelets appear as 38 Hematology small, bright azure, rounded or elongated bodies with a delicately granular structure. What are the hemopoietic tissues during fetal life, in infancy, in childhood and in adulthoodfi What are the effects of the hormone erythropoietin on red cell development and maturation 4. Blood must be collected with care and adequate safety precautions to ensure test results are reliable, contamination of the sample is avoided and infection from blood transmissible pathogens is prevented. The proper collection and reliable 41 Hematology processing of blood specimens is a vital part of the laboratory diagnostic process in hematology as well as other laboratory disciplines. Unless an appropriately designed procedure is observed and strictly followed, reliability can not be placed on subsequent laboratory results even if the test itself is performed carefully. All material of human origin should be regarded as capable of transmitting infection. The operator is also strongly advised to cover any cuts, abrasions or skin breaks on the hand with adhesive tape and wear gloves. Care must be taken when handling especially, syringes and needles as needle-stick injuries are the most commonly encountered accidents. Should a needle-stick injury occur, immediately remove gloves and vigorously squeeze the wound while flushing the bleeding with running tap water and then thoroughly scrub the wound with cotton balls soaked in 0. Used disposable syringes and needles and other sharp items such as 42 Hematology lancets must be placed in puncture-resistant container for subsequent decontamination or disposal. Three general procedures for obtaining blood are (1) Skin puncture, (2) venipuncture, and (3) arterial puncture. The technique used to obtain the blood specimen is critical in order to maintain its integrity. The composition of venous blood varies and is dependent on metabolic activity of the perfused organ or tissue. Venous blood is oxygen deficient relative to arterial blood, but also differs in pH, carbon dioxide concentration, and packed cell volume. Blood obtained by skin puncture is an admixture of blood from arterioles, venules, and capillaries. Increased pressure in the arterioles yields a specimen enriched in arterial blood. Cold sites should not be punctured as samples collected from cold sites give falsely high results of hemoglobin and cell counts. Rub the site vigorously with a gauze pad or cotton moistened with 70% alcohol to remove dirt and epithelial debris and to increase blood circulation in the area. If the heel is to be punctured, it should first be warmed by immersion in a warm water or applying a hot towel compress. A deep puncture is no more painful than a superficial one and makes repeated punctures unnecessary. The site should not be squeeze or pressed to get blood since this dilutes it with fluid from the tissues. Rather, a freely flowing blood should be taken or a moderate pressure some distance above the puncture site is allowable. Stop the blood flow by applying slight pressure with 46 Hematology a gauze pad or cotton at the site. Venous Blood Collection A venous blood sample is used for most tests that require anticoagulation or larger quantities of blood, 47 Hematology plasma or serum. The veins in the antecubital fossa of the arm are the preferred sites for venipuncture. They are larger than those in the wrist or ankle regions and hence are easily located and palpated in most people. Puncture of the external jugular vein in the neck region and the femoral vein in the inguinal area is the procedure of choice for obtaining blood. Attach the needle so that the bevel faces in the same direction as the graduation mark on the syringe.

Dactylariosis Clinical signs and lesions: this is a neurotrophic mycotic disease of turkey poults hiv infection statistics us order medex pills in toronto, quail chicks and young chickens antiviral condoms purchase generic medex online, with many of the clinical and pathologic features of aspergillosis antiviral supplements for hpv order medex 5mg free shipping. Signs of dactylariosis are incoordination antiviral and antibiotics buy medex 5 mg low price, tremors hiv infection rates washington dc generic medex 1 mg fast delivery, torticollis antiviral for cold sores order discount medex online, circling, recumbency due to mycotic lesions in the brain, and death. In the brain lesions involve the cerebellum and cerebrum as large, hardened, grayish, and circular or as focal areas of red colors. Cause, transmission, and epidemiology: the etiological agent is Dactylaria gallopava; it grows naturally in old sawdust, which often is used as chicken litter. Occurrence of this disease is associated with contaminated litter (wood chip and sawdust) and egg incubators. Colonies are velvety, gray-brown with a flat or wrinkled surface, and the reverse side of the colony is a deep purple-red. Recovery: Cases will re-occur if fungi can grow in incubators or litter on the farm because it is not handled properly. If, however, the cause of the contamination is corrected and/or the source removed, there is no residual risk to new birds. Clinical signs and lesions: this is an acute viral disease of ducks, geese and swans characterized by weakness, thirst, diarrhea, short course, high mortality, and by lesions of the vascular, digestive, and lymphoid systems. In adult ducks there is sudden, high, persistent rate of death and a marked drop in egg production. Sick birds show inappetence, weakness, ataxia, photophobia, adhered eyelids, nasal discharge, extreme thirst, prolapsed penis, and watery diarrhea. Hemorrhages are present at many sites and there may be free blood in body cavities, gizzard or intestines. Hemorrhages often occur on the liver, in mucosa of the gastrointestinal tract (including the esophageal-provetricular junction), throughout the heart, and in the pericardium and ovary. There may be elevated, crusty plaques in the esophagus, ceca, rectum, cloaca or bursa of Fabricius. Hemorrhage and/ or necrosis in the annular bands discs of lymphoid tissue along the intestines is present. Later it may be bile-stained and contain scattered small, white foci, as well as many hemorrhages. Microscopically there may be intranuclear inclusion bodies in degenerating hepatocytes, epithelial cells of the digestive tract, and in reticuloendothelial cells. Differential diagnosis: Duck enteritis must be differentiated from duck viral hepatitis, pasteurellosis (fowl cholera), Newcastle disease, avian influenza, coccidiosis, and other causes of enteritis. Cause, transmission, and epidemiology: the etiologic agents are variable strains of herpesviruses that are immunologically similar and non-hemagglutinating. The virus grows well on chorioallantoic membrane of 9-14 day-old embryonating duck eggs or on duck embryo fibroblasts. The virus produces intranuclear inclusion bodies in a variety of cells of infected waterfowl. The virus can be transmitted when susceptible birds contact infected birds or an environment (particularly water) contaminated by them. Perhaps carrier birds under stress shed virus intermittently, thus exposing susceptible birds. It is suspected that viremic birds may transmit infection through feeding arthropods. All age groups and many varieties are susceptible; however, mostly adult ducks are affected. Diagnosis: Typical clinical signs and lesions (especially demonstration of intranuclear inclusion and the virus in tissues using fluorescent antibody technique) are diagnostic. Acute and convalescent sera can be used to demonstrate an increasing antibody titer to duck virus enteritis. Prevention: Prevent cohabitation or contact of domestic ducks with wild waterfowl. All appropriate quarantine and sanitary practices should be followed to prevent the introduction of this disease. Onset and spread within a flock are very rapid and most mortality occurs within 1 week of onset. Within a short time they squat with their eyes partially closed, fall on their side, kick spasmodically, and soon die. In older or partially immune ducklings, signs and losses may be so limited that the disease may go unrecognized. Microscopically there may be areas of hepatic necrosis, bile duct proliferation, and some degree of inflammatory response. Differential diagnosis: the disease must be differentiated from duck viral enteritis, Newcastle disease, avian influenza through susceptibility to chloroform and haemagglutination of erythrocytes. It is chloroform resistant and does not hemagglutinate, features that help separate it from most other viral diseases of ducks. Antibodies for prophylactic use may also be obtained from the yolk of eggs produced by immune breeders, or from the eggs of chicken hyperimmunized with the virus. The virus is excreted by recovered ducklings for up to 8 weeks after onset of infection. Susceptible ducklings can be infected by contact with infected ducklings or their contaminated pens. The virus can survive for 10 weeks in contaminated brooders and for 37 days in feces. Wild birds have been suspected of acting as mechanical carriers of virus over short distances. The viruses do not appear to be transmitted through the egg, and there are no known vectors of the disease. Unexposed ducklings can be actively immunized using a chicken embryo-adapted apathogenic vaccine. Ectoparasites found on poultry are in the phylum Arthropoda, which is characterized by segmented bodies, jointed appendages and chitinous exoskeleton. The phylum is divided into two classes: the Insecta that includes the orders Phthiraptera (lice), Siphonaptera (fleas) and Diptera (flies and mosquitoes); and the Arachnida with the order Acarina (ticks and mites). Ectoparasites are very common in free-range systems, and usually controlled in commercial systems. Although they are believed to occur in many family poultry, only a few African countries have published information on their prevalence or occurrence. They feed on the epithelial debris of the skin of the host, or on feathers of birds. The mesoand metathorax are fused to form one piece behind the prothorax, which is a distinct and separate segment. Lice species affecting chickens are Menacanthus stramineus, Menopon gallinae, Cuclotogaster heterographus, Lipeurus caponis, Goniodes gigas and Goniocoites gallinae. It occurs on those parts of the body which are not densely feathered, like the breast, thigh, and around the vent. It has small palpi and a pair of foursegmented antennae folded into grooves in the head. It occurs on the underside of the large wing feathers and moves about very little. The legs are narrow and, characteristically, the hind legs are about twice as long as the first the two pairs. There are characteristic small angular projections on the head in front of the antennae. Goniodes gigas are large brown lice, about 3 mm in length, and occur on body feathers. The head is concave posteriorly, producing marked angular corners at the posterior margins, and carries two large bristles projecting from each side of its dorsal surface. Goniocoites gallinae is the smallest lice found on poultry, with adults measuring 1 to 1. The head is rounded, carrying two large bristles that project from each side of its dorsal surface. The antennae have five segments Clinical signs and pathology: On the host, lice cause pruritus, scratching, excoriation, secondary feather damage (as birds pluck their feathers) and irritation, which lead to selfwounding and resultant formation of inflamed and scab covered skin. This constant irritation causes the bird to become nervous and behave abnormally, causing a general unthriftness and unkempt appearance. Infestation in birds also leads to a drop in egg production, decreased hen weight, decreased clutch size, and death in young birds. Menacanthus stramineus can cause anemia by puncturing soft feather quills and feeding on the blood that oozes out. Heavy infestations may cause feather damage and irritation but more importantly, are a sign of debility and poor husbandry. Life cycle and epidemiology: Lice are permanent ectoparasites, spending their entire life cycle on their host. They tend to remain with single host bird throughout their lives; they are unable to survive for more than 1-2 days off their host. As many as 60 eggs are laid by adult female louse and are glued to the host feathers. Diagnosis: this is based on clinical signs and identification of lice in plumage, and their eggs (nits) attached to feathers. Treatment and control: Control of poultry lice requires treating the birds, since lice remain on the bird throughout its life. Birds may be sprayed, dusted or dipped with an appropriate insecticide like permethrin, carbaryl, malathion, or rotenone. Because lice live only a few days off the host, emptying a shed or yard for a week will clean it. It may infest a wide variety of birds and mammals; poultry, rodents, rabbits, canids, felids, horses, and occasionally humans may all become infested. Poultry may develop clusters of the fleas around the eyes, comb, wattles, and other bare spots. On the head behind the antennae are two setae, and in females, a well developed occipital lobe. Mouthparts appear large, extending the length of the forecoxae and projecting from the head conspicuously. The skin over the nodules often becomes ulcerated, and young birds may be killed by heavy infestations. Life cycle and epidemiology: On fertilization, the female fleas burrow into the skin of the fowl, mainly on the comb, wattles and around the eyes of the birds, resulting in the formation of nodules in which eggs are laid. The female lays up to 20 eggs at a time and about 400-500 total during her lifetime. Larvae drop to the ground to develop in soil around chicken cages, pupating in two weeks. Diagnosis: this is based on history, clinical signs, and identification of fleas or flea feces on birds. Both the host bird and the environment must be treated at the same time to be effective. Control the fleas by treating the birds, removing them from the infested area for three weeks, and treating the area (removing fecal droppings and litter, and spraying a suitable insecticide) and birds (again) before returning them. A range of insecticides can be used, namely; organophosphates, carbamates, pyrethrins, and pyrethroids for flea control on the birds. Most of these insects are found in poultry houses, where some feed on birds and other animals (including humans) especially at night. Clinical signs, pathology and economic importance: the majority of these flies irritate the host by biting and sucking blood. Their greatest importance lies in their role as intermediate hosts or as mechanical vectors of disease. Black flies and biting midges are intermediate hosts of the protozoa Leucocytozoon spp. Biting midges are vectors for fowl pox, avian infectious synovitis, and Haemoproteus spp. Flies in the family Muscidae may transfer Newcastle disease virus, Heterakis gallinarum, Pasteurella multocida, and Mycobacterium avium to non-infected birds. Diagnosis: Clinical signs and identification of feeding flies, especially at night. Traps can be used to collect and identify flying insects in the vicinity of poultry. Argas persicus (fowl tick) commonly affects chickens, turkeys, pigeons, ducks and geese in tropical and sub-tropical countries. They are found on the skin (especially nymphs and larval stages), but most of the time the ticks hide in cracks in chicken or human houses, market stalls and sheds, or under the tree bark, away from the host. Etiological Characteristics: the unfed adult tick is pale yellow, turning reddish brown when fed. The margin of the body appears to be composed of irregular quadrangular plates or cells, and the hypostome is notched at the tip. Clinical signs and pathology: Argas persicus causes severe blood loss leading to progressive lowered production. Ornithodoros species (the eyeless tampan) affects poultry and other domestic and wild animals. They are found on the skin, but most of the time, the ticks hide in cracks or under the tree bark, away from the host. Etiological Characteristics: the integument has wrinkled patterns that run continuously over the dorsal and ventral surfaces. These parasites are known to transmit Borrelia anserina and Aegyptinella pullorum. Life cycle and epidemiology of these tick species: Females lay eggs in the cracks and crevices they occupy, usually in batches of 30 to 100 or more; they lay several batches of eggs and produce an average of 700 to 800 eggs during their lifetime. Adults are extremely resistant to starvation, and can live more than a year without a blood meal.

Human metapneumovirus and respiratory syncytial virus in hospitalized danish children with acute respiratory tract infection hiv infection time buy discount medex 5 mg online. A randomized crossover study of disposable thermometers for prevention of Clostridium difficile and other nosocomial infections hiv infection rate liberia discount generic medex canada. Notice to Readers: Additional options for preventive treatment for persons exposed to inhalational anthrax hiv infection rates us cities 5mg medex for sale. Effectiveness of influenza vaccine in health care professionals: a randomized trial hiv primo infection symptoms order discount medex on-line. Nosocomial pertussis: costs of an outbreak and benefits of vaccinating health care workers antiviral imdb cheap generic medex uk. Recommended adult immunization schedule -United States highest hiv infection rate by country purchase medex online from canada, October 2005-September 2006. To gown or not to gown: the effect on acquisition of vancomycin-resistant enterococci. Streptococcal meningitis complicating diagnostic myelography: three cases and review. Alpha-hemolytic streptococci: a major pathogen of iatrogenic meningitis following lumbar puncture. Iatrogenic Streptococcus salivarius meningitis after spinal anaesthesia: need for strict application of standard precautions. Surgical face masks are effective in reducing bacterial contamination caused by dispersal from the upper airway. Respiratory syncytial viral infection in children with compromised immune function. Prolonged shedding of multidrug-resistant influenza A virus in an immunocompromised patient. Attempts to eradicate methicillin-resistant Staphylococcus aureus from a long-term-care facility with the use of mupirocin ointment. High rate of false-negative results of the rectal swab culture method in detection of gastrointestinal colonization with vancomycin-resistant enterococci. Persistent contamination of fabric-covered furniture by vancomycin-resistant enterococci: implications for upholstery selection in hospitals. Impact of implementing a method of feedback and accountability related to contact precautions compliance. Evaluation of the contribution of isolation precautions in prevention and control of multi-resistant bacteria in a teaching hospital. The impact of bedside behavior on catheter-related bacteremia in the intensive care unit. Regional dissemination and control of epidemic methicillin-resistant Staphylococcus aureus. In: the 16th annual scientific meeting of the Society for Healthcare Epidemiology of America. Epidemiology and prevention of pediatric viral respiratory infections in health-care institutions. Role of environmental contamination as a risk factor for acquisition of vancomycin-resistant enterococci in patients treated in a medical intensive care unit. Patient-to-patient transmission of hepatitis C virus through the use of multidose vials during general anesthesia. Parainfluenza virus infections after hematopoietic stem cell transplantation: risk factors, response to antiviral therapy, and effect on transplant outcome. Herpes zoster causing varicella (chickenpox) in hospital employees: cost of a casual attitude. Secondary measles vaccine failure in healthcare workers exposed to infected patients. A cluster of primary varicella cases among healthcare workers with false-positive varicella zoster virus titers. Smallpox in Tripolitania, 1946: an epidemiological and clinical study of 500 cases, including trials of penicillin treatment. Acquisition of coccidioidomycosis at necropsy by inhalation of coccidioidal endospores. Acute hemorrhagic conjunctivitis outbreak caused by Coxsackievirus A24-Puerto Rico, 2003. An outbreak of epidemic keratoconjunctivtis in a pediatric unit due to adenovirus type 8. Hepatitis A outbreak in a neonatal intensive care unit: risk factors for transmission and evidence of prolonged viral excretion among preterm infants. Increased risk of illness among nursery staff caring for neonates with necrotizing enterocolitis. A recent outbreak of adenovirus type 7 infection in a chronic inpatient facility for the severely handicapped. Concurrent outbreaks of rhinovirus and respiratory syncytial virus in an intensive care nursery: epidemiology and associated risk factors. Molecular epidemiology of staphylococcal scalded skin syndrome in premature infants. For areas where knowledge gaps exist, recommendations for further research are listed. The categorization scheme used in this guideline is presented in Table 1 in the Summary of Recommendations and described further in the Methods section. The Implementation and Audit section includes a prioritization of recommendations. The Appendices also contain a clearly delineated search strategy that will be used for periodic updates to ensure that the guideline remains a timely resource as new information becomes available. Use urinary catheters in operative patients only as necessary, rather than routinely. Examples of Inappropriate Uses of Indwelling Catheters As a substitute for nursing care of the patient or resident with incontinence As a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void For prolonged postoperative duration without appropriate indications. Consider using alternatives to indwelling urethral catheterization in selected patients when appropriate. Intermittent catheterization is preferable to indwelling urethral or suprapubic catheters in patients with bladder emptying dysfunction. Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site. In the acute care hospital setting, insert urinary catheters using aseptic technique and sterile equipment. Use sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleaning, and a single-use packet of lubricant jelly for insertion. If ultrasound bladder scanners are used, ensure that indications for use are clearly stated, nursing staff are trained in their use, and equipment is adequately cleaned and disinfected in between patients. Use Standard Precautions, including the use of gloves and gown as appropriate, during any manipulation of the catheter or collecting system. Silicone might be preferable to other catheter materials to reduce the risk of encrustation in long-term catheterized patients who have frequent obstruction. Further research is needed on the use of methenamine to prevent encrustation in patients requiring chronic indwelling catheters who are at high risk for obstruction. Obtain large volumes of urine for special analyses (not culture) aseptically from the drainage bag. Guidelines and protocols for nurse-directed removal of unnecessary urinary catheters 3. Provide and implement evidence-based guidelines that address catheter use, insertion, and maintenance. Ensure that supplies necessary for aseptic technique for catheter insertion are readily available. Ensuring that documentation is accessible in the patient record and recorded in a standard format for data collection and quality improvement purposes is suggested. In addition, quality improvement programs should be implemented as an active approach to accomplishing these recommendations and when process and outcome measure goals are not being met based on internal reporting. Risks and benefits of suprapubic catheters as an alternative to chronic indwelling urethral catheters b. Use of new prevention strategies such as bacterial interference in patients requiring chronic catheterization c. Spatial separation of patients with urinary catheters (in the absence of epidemic spread or frequent cross-infection) to prevent transmission of pathogens colonizing urinary drainage systems 21 V. An external catheter is a urine containment device that fits over or adheres to the genitalia and is attached to a urinary drainage bag. The time period for follow-up surveillance after catheter removal also has been shortened from 7 days to 48 hours to align with other device-associated infections. The prevalence of urinary catheter use in residents in long-term care facilities in the United States is on the order of 5%, representing 18 approximately 50,000 residents with catheters at any given time. However, even with the closed drainage system, 23 bacteriuria inevitably occurs over time either via breaks in the sterile system or via the 24 25,26 extraluminal route. Formation of biofilms by urinary pathogens on the surface of the catheter and drainage system 28 occurs universally with prolonged duration of catheterization. Over time, the urinary catheter becomes colonized with microorganisms living in a sessile state within the biofilm, rendering them resistant to antimicrobials and host defenses and virtually impossible to eradicate without removing the catheter. Resistance of gram-negative pathogens to other agents, including 5 third-generation cephalosporins and carbapenems, was also substantial. The proportion of organisms that were multidrug-resistant, defined by non-susceptibility to all agents in 4 classes, 29 was 4% of P. Literature Search Following the development of the key questions, search terms were developed for identifying literature relevant to the key questions. For the purposes of quality assurance, we compared these terms to those used in relevant seminal studies and guidelines. The detailed search strategy used for identifying primary literature and the results of the search can be found in Appendix 1B. Three evidence tables were developed, each of which represented one of our key questions. Meta-analyses were performed only where their use was deemed critical to a recommendation, and only in circumstances where multiple studies with sufficiently homogenous populations, interventions, and outcomes could be analyzed. Before exclusion, data from the primary studies that we originally captured were abstracted into the evidence tables and reviewed. We also excluded systematic reviews that analyzed primary studies that were fully captured in a more recent systematic review. To ensure that all relevant studies were captured in the search, the bibliography was vetted by a panel of clinical experts. Grading of Evidence First, the quality of each study was assessed using scales adapted from existing methodology checklists, and scores were recorded in the evidence tables. Low further research is very likely to affect confidence in the estimate of effect and is likely to change the estimate 4. In some instances, multiple recommendations emerged from a single narrative evidence summary. For clinicians: Different choices will be appropriate for different patients, and clinicians must help each patient to arrive at a management decision consistent with her or his values and preferences. If the latter was the case, those critical outcomes will be noted at the end of the relevant evidence summary. Our evidence-based recommendations were cross-checked with those from guidelines identified in our original systematic search. Recommendations from previous guidelines for topics not directly addressed by our systematic review of the evidence were included in our "Summary of Recommendations" if they were deemed critical to the target users of this guideline. Unlike recommendations informed by our literature search, these recommendations are not linked to a key question. For operative patients, low-quality evidence suggested a benefit of avoiding urinary 37-44,47-49 catheterization. The most common surgeries studied were urogenital, gynecological, laparoscopic, and orthopedic surgeries. Our search did not reveal data on the impact of catheterization on peri-operative hemodynamic management. Avoid use of urinary catheters in patients and nursing home residents for management of incontinence. Further research is needed on the benefit of using a urethral stent as an alternative to an indwelling catheter in selected patients with bladder outlet obstruction. Consider alternatives to chronic indwelling catheters, such as intermittent catheterization, in spinal cord injury patients. To answer this question, we reviewed the quality of evidence for those risk factors examined in more than one study. For bacteriuria, multiple risk factors were identified; there was high quality evidence for prolonged catheterization and moderate quality evidence for female sex, positive meatal cultures, and lack of antimicrobial exposure. Our search did not reveal data on adverse events and antimicrobial resistance associated with antimicrobial use, although one observational study found that the protective effect of antimicrobials lasted only for the first four days of catheterization, and that antimicrobial exposure led to changes in the epidemiology of bacterial flora in the urine. Low-quality evidence suggested that older age, higher severity of illness, and being on an internal medicine service compared to a surgical service were independent risk factors for mortality in patients with indwelling urinary catheters. Minimize urinary catheter use and duration in all patients, particularly those who may be at higher risk for mortality due to catheterization, such as the elderly and patients with severe illness.

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