Posts tagged "Treatment"

Treatment of Nail Fungus Infection

Fungus infects nails and more commonly toe nails (less frequently finger nails). Fungal infection of nails may be very difficult to treat properly for complete cure. Fungal infection of nails (both toe nails and finger nails) begins as a white or yellow spot under the tip of fingernail or toenail. The infected nail/nails may become discolored, thick and have crumbling edges, as the fungal infection spreads to the deeper into nail. The condition may become painful, which prompt most patients to seek medical attention. The infection may also recur after successful treatment, especially if you continue to get exposed to conditions favorable for fungus growth and infection such as warm, moist conditions.

There are several different forms of treatment of fungal infection of nails; including over-the-counter medications antifungal nail creams and ointments, although they are not very effective. Ideally the over-the-counter antifungal medications should be avoided, as they can not be relied upon, for a complete cure.

The antifungal antibiotics are very effective in curing and eliminating the fungal infection of nails, although they can do little to prevent re-infection. The most effective antifungal antibiotics for treatment of fungal infection of nails are terbinafine (available as Lamisil) and itraconazole (available as Sporanox). These antifungal antibiotics are taken orally and highly effective for complete cure.

The oral antifungal antibiotics are used when patient has certain medical conditions such as diabetes mellitus, history of cellulites, or if the infection is severe and unlikely to be cured by topical agents.

Other treatment options in fungal infection of nails include topical medications (if the fungal infection is mild to moderate severity), surgery (for extremely severe and painful conditions) etc.

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Posted by - August 26, 2010 at 11:59 am

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Treatment of Pneumonia Caused by Pneumococcus

The most common cause of community acquired pneumonia is pneumococcus and empirical therapy for community acquired pneumonia should always include an antibiotic which is effective against local strains of pneumococcus. But the ideal way of treatment is to start with an antibiotic which is not resistant to local strains and send for blood culture and antibiotic sensitivity test. After the antibiotic sensitivity test report is available, the antibiotic can be changed if required or continued if it is sensitive to the pneumococcus.

Generally antibiotics for treatment of pneumococcal pneumonia can be given by oral route or by parenteral route. Commonly used oral antibiotics are amoxicillin (1 gram every 8 hourly), a quinolone such as levofloxacin (500 mg once a day) and Telithromycin (800 mg once a day). Parenteral treatment of pneumonia can be either by ampicillin (1-2 gram IV or intravenously every 6 hourly), ceftriaxone (1 gram IV once or twice a day), quinolone such as gatifloxacin (400 mg IV every 24 hours), Imipenem (500 mg IV every 6 hourly) etc.

How long pneumococcal pneumonia should be treated?

There is no clear cut guideline for optimal treatment of pneumococcal pneumonia. The duration of therapy is generally guided by the response of the patient to the antibiotic therapy. And in absence of a clear cut guideline most of the doctors treat pneumococcal pneumonia for 5-7 days. Most experienced physician’s advice to start treatment with parenteral therapy, followed by oral antibiotic and observation of the patient for not more than 5 days once fever subsides. In this way duration of treatment do not generally cross 5-7 days.

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Posted by - April 23, 2010 at 3:43 pm

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Treatment of Syphilis

The causative agent for syphilis is Treponema pallidum, a spirochete. Syphilis is still fairly common disease (it is a sexually transmitted disease), despite presence of very effective antibiotics such as penicillin. At present globally more than 10 million people contact syphilis, annually. But there is a sharp decline of more than 95% in the past 50 years in the incidence of syphilis after advent of penicillin therapy to treat syphilis effectively.

The antibiotic of choice for treatment of syphilis is still penicillin for all the stages of syphilis. There is no reported incidence of resistance of Treponema pallidum to penicillin and hence still the drug of choice.

The CDC has given a guideline for treatment of syphilis in the year 2006 which is given below:

  • Treatment of syphilis in Primary, secondary, and early latent phase of syphilis is Penicillin G benzathine (a single dose of 2.4 million units intramuscularly).
  • Late latent phase, or cardiovascular involvement, CSF (cerebrospinal fluid) analysis should be done. If CSF is normal Penicillin G benzathine 2.4 million units intramuscularly weekly for 3 weeks. If CSF is abnormal it should be treated as neurosyphilis.
  • Neurosyphilis, either symptomatic or asymptomatic is to be treated with aqueous penicillin G, 18–24 million units intravenously, given every 4 hourly (3–4 million units) or by continuous intravenous infusion. Alternative regimen is aqueous penicillin G procaine, 2.4 million units intramuscularly plus oral probenecid (500 mg every 6 hourly), both for 10–14 days.
  • During pregnancy the treatment is same as with general population and according to stages.
  • If patient is sensitive to penicillin, alternative includes Tetracycline hydrochloride (500 mg orally 4 times a day) or doxycycline (100 mg orally two times a day) for 14 days. Penicillin sensitive pregnant patients or patients with neurosyphilis have to be treated with penicillin after desensitization.

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Posted by - March 9, 2010 at 1:09 pm

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Treatment of Epididymitis

Epididymitis is a sexually transmitted infection in men. Most of the sexually transmitted epididymitis are acute and generally affect only on one side. Epididymitis causes pain, tenderness (pain on pressure to that part), swelling of epididymis and these symptoms may or may not be accompanied by signs and symptoms of urethritis (infection/inflammation of urethra).

What are the causative organisms of acute sexually transmitted epididymitis?

Most commonly the causative organisms of acute sexually transmitted epididymitis is Clamydia trachomatis and less commonly due to N. gonorrhea, especially in case of males below 35 years of age and sexually active.

Other conditions which should be differentiated from acute epididymitis are torsion of testis, trauma or due to tumor. In torsion of testis, which is a surgical emergency there is sudden onset of pain, the testicle is located in the scrotal sac, there is rotation of the epididymis from a posterior to an anterior position. In torsion of testis on Doppler study there is absence of blood flow to the testis. If symptoms do not subside after complete treatment with appropriate antibiotics, it suggests tumor or a granulomatous disease like tuberculosis. In trauma there is history of trauma.

Treatment of epididymitis:

The treatment of choice for acute epididymitis is ceftriaxone 250 mgs single dose intramuscularly followed by doxycycline 100 mg orally two times a day for next 10 days. This regime cures acute epididymitis due to Clamydia trachomatis as well as due to N. gonorrhea. Previously fluoroquinolones like ciprofloxacin were used, but at present not recommended due to emergence of resistance against fluoroquinolones.  Levofloxacin is used sometimes if the causative organism of epididymitis is found to be Enterobacteriaceae, but it is not useful if epididymitis is due to other organisms.

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Posted by - January 25, 2010 at 12:36 am

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Treatment of Urethritis in Men

Urethritis in men is caused by many different types of organisms and ideal treatment would be to identify the infecting organism and treat it with specific antibiotics highly effective in treating such infection. But it may not be possible in every cases of urethritis. In practice after diagnosing a case of urethritis in men, initially Gram’s staining is done, if it reveals gonococci, treatment for gonococci is done and if it does not reveal gonococci than treatment for NGU (nongonococcal urethritis) is done.

Treatment of gonococci infection:

Gonococci infection is treated with cephalosporin antibiotics. Among cephalosporin antibiotics ceftriaxone (125 mg intramuscularly single dose), cefpodoxime (400 mg orally single dose) or cefixime (400 mg orally single dose) can be used.

If no diagnostic test is available or performed in a patient with urethritis, than treatment regimen should be single-dose regimen for gonorrhea (as above) plus azithromycin (1 gram orally as single dose) or doxycycline (100 mg twice a day for 7 days) for treatment of clamidial infection (C. tracomatis) which occurs frequently in patients suffering from urethritis due to gonococci.

If gonococci are not demonstrated by Gram’s staining, it should be treated as NGU (nongonococcal urethritis) like azithromycin (1 g orally in a single dose) or doxycycline (100 mg orally 2 times a day for 7 days).

How to treat recurrent cases of urethritis?

Recurrent cases of urethritis should be treated with the same regimen as before if they did not comply with the earlier treatment or if they are reexposed to same infection. If the patient was treated appropriately previously, than an intraurethral swab specimen and a first-voided morning urine sample should be tested (culture of the swabs and antibiotic sensitivity done). If compliance to the initial treatment can be confirmed and reexposure excluded (in persistent cases) the treatment should include metronidazole or tinidazole (2 gram orally in a single dose) plus azithromycin (1 gram orally in a single dose).

N.B.- The sexual partner/partners (should be tested for gonorrhea and chlamydial infection) also should be treated with the same regimen as given to the male urethritis patient.

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Posted by - January 19, 2010 at 3:45 pm

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Specific Treatment of Indigestion

If the cause of indigestion can be identified, treatment of indigestion should be directed to correct the cause if possible. If the cause can not be identified, treatment has to be symptomatic and based on general principle of management.The common causes of indigestion are GERD (gastro-esophageal acid reflux disease) and functional dyspepsia (can not be treated satisfactorily unlike GERD).

Treatment of GERD:

Treatment of gastro-esophageal acid reflux disease should be started with PPI (proton pump inhibitor) drugs like omeprazole, pentoprazole, lansoprazole etc. PPIs are the first line and most effective drugs in treatment of GERD. Less potent but useful drugs are histamine H2 antagonists such as cimetidine, ranitidine, famotidine etc. and these drugs are generally used for treatment of mild to moderate GERD. If GERD is severe, proton pump inhibitors must be used and for very long duration. Patient can be put on histamine H2 antagonists such as cimetidine, ranitidine if treatment with PPI is giving good response. Combination therapy with a proton pump inhibitor and an H2 antagonist are not required but has been proposed for some refractory cases.

Eradication of H. pylori may also be required and helpful in many cases of indigestion as H. pylori is one of the causative factors of peptic ulcer and peptic ulcer is a common cause of indigestion. Many combination drugs are available for eradication of H. pylori. Most of the combinations include 10–14 days of a proton pump inhibitor with 2 antibiotics like metronidazole, clarithromycin and amoxicillin (any two of these three antibiotics). Eradication of H. pylori infection is associated with reduced prevalence of GERD, especially in the elderly patients.

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Posted by - July 24, 2009 at 12:11 am

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Principles of Treatment of Indigestion

Some general principles of treatment of indigestion should be followed. For example if the cause (e.g. GERD, lactase deficiency, biliary colic etc.) of indigestion can be identified, the therapy should be directed towards the cause of indigestion. If the cause can not be identified, than treatment should be directed towards symptomatic relief of the patient for improving patients’ health.

General principle of treatment of indigestion:

For mild indigestion, reassurance may be the only intervention needed, (especially mentioning the patient of indigestion that a careful evaluation revealed no serious organic disease). Medicines that can cause acid reflux or dyspepsia should be avoided and stopped (if already using) if possible. Patients with GERD (gastro-esophageal reflux disease) should limit alcohol, caffeine, chocolate, and tobacco use because of the effects of these substances on the LES (lower esophageal sphincter) is usually relaxing, which causes easy acid reflux to esophagus. Other measures like consumption of a low-fat diet, avoiding snacks before bedtime, and elevating the head of the bed should be taken as general measure.

Specific therapies for organic disease (if present) should be offered when possible and if the disease can be identified. Examples of specific therapies are surgery, which is appropriate in disorders like biliary colic, while diet changes are indicated for lactase deficiency or celiac disease. Some illnesses such as peptic ulcer disease may be cured by specific medical regimens. However, as most indigestion is caused by GERD or functional dyspepsia, medications that reduce gastric acid, stimulate motility, or blunt gastric sensitivity are indicated.

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Posted by - July 23, 2009 at 11:27 am

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Treatment of Constipation

Constipation is persistent, difficult, infrequent, or seemingly incomplete defecation. It is very difficult to define constipation precisely due to the wide range of normal bowel habits. For treatment of constipation, the cause of constipation should be identified. Treatment of constipation is based on the cause of it.

Patients with slow-transit constipation are treated with laxatives. The examples of laxatives are bulk, osmotic, prokinetic, secretory, and stimulant laxatives including fiber, psyllium, milk of magnesia, lactulose, polyethylene glycol (colonic lavage solution), lubiprostone, and bisacodyl. There is also newer treatment modality aiming at enhancing motility and secretion and may have application in special circumstances such as constipation-predominant IBS (irritable bowel syndrome) in females or in severe constipation.

If a 3 to 6 months trial of medical therapy fails with above treatment regimes and patients continues to have documented slow-transit constipation which is not associated with obstructed defecation, the patients should be considered for laparoscopic colectomy (resection or part of colon) with ileorectostomy (joining of ileum and rectum surgically).  But these operations should not be done if there is continued evidence of an evacuation disorder or a generalized GI dysmotility. Referral to a specialized center for further tests of colonic motor function should be done in these cases.

The presence of megacolon and megarectum is indication for surgical intervention in constipation. But there may be unacceptable complications after surgery like small-bowel obstruction and fecal soiling, particularly at night during the first postoperative year. Frequency of defecation is 3–8 per day during the first year and 1–3 per day from the second postoperative year onwards.

Patients with severe slow-transit constipation require aggressive medical or surgical treatment. However, approximately only 60% of patients with severe constipation are found to have such a physiologic disorder (colonic transit delay and evacuation disorder). Patients with spinal cord injuries or other neurological disorders require a bowel regime that includes rectal stimulation, enema therapy, and carefully timed laxative therapy. 

Patients with evacuation and transit/motility disorder should pursue pelvic floor retraining (biofeedback and muscle relaxation), psychological counseling, and dietary modification first, and than colectomy and ileorectosomy (if colonic transit studies do not normalize and symptoms are intractable despite biofeedback and optimum medical therapy). If patient only has pelvic floor dysfunction, biofeedback training has a 70–80% success rate which is measured by regaining of comfortable stool habits.

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Posted by - July 21, 2009 at 11:55 pm

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Treatment of Chronic Diarrhea

If diarrhea continues for more than 4 weeks, it is considered as chronic diarrhea. Chronic diarrhea requires evaluation to rule out underlying pathology. Compared to causes of acute diarrhea, most of the causes of chronic diarrhea are noninfectious.

Principle of treatment of chronic diarrhea:

Treatment of chronic diarrhea depends on the specific cause of diarrhea and it is directed towards the cause of diarrhea, which may be curative, suppressive, or empirical. If the cause can be removed or eradicated, the treatment of chronic diarrhea is curative as with resection of a colorectal cancer, antibiotic administration for Whipple’s disease, or discontinuation of a drug (if any drug is the cause of chronic diarrhea).

For many chronic conditions, diarrhea can be controlled by suppression of the underlying mechanism which is causing the chronic diarrhea. Examples are elimination of dietary lactose for lactase deficiency or gluten (gluten free diet) for celiac sprue, use of glucocorticoids or other anti-inflammatory agents for idiopathic IBDs (inflammatory bowel diseases), adsorptive agents such as cholestyramine for ileal bile acid malabsorption etc. Other examples are use of proton pump inhibitors such as omeprazole for the gastric hypersecretion of gastrinomas, somatostatin analogues such as octreotide for malignant carcinoid syndrome, prostaglandin inhibitors such as indomethacin for medullary carcinoma of the thyroid, and pancreatic enzyme replacement if there is any pancreatic insufficiency.

But if the specific cause or mechanism of chronic diarrhea can not be pinpointed, empirical therapy may be beneficial. For example loperamide, is often helpful in mild or moderate watery diarrhea. For those with more severe diarrhea, codeine or tincture of opium may be beneficial. Such antimotility agents should be avoided with IBD, as there may be precipitation of toxic megacolon. Clonidine, an alpha-2 adrenergic agonist, may allow control of diabetic diarrhea.

General measures:

Fluid and electrolyte replacement is an important and essential component of management for all cases of chronic diarrhea. Replacement of fat-soluble vitamins may also be necessary in patients with chronic steatorrhea (lipids can not be absorbed or fat malabsorption).

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Posted by - July 19, 2009 at 9:34 am

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Treatment of Acute Diarrhea

Diarrhea is loosely defined as passage of abnormally liquid or unformed stools at an increased frequency and with a typical Western diet stool weight of more than 200 grams can be considered as diarrhea. 

Principle of treatment of acute diarrhea:

In acute diarrhea the most important part of treatment is the replacement of lost fluid and electrolytes. Fluid replacement should be gradual and over a period of time. In mild cases of acute diarrhea fluid replacement is all that may be required. Oral sugar-electrolyte solutions used in sports as drinks or designed formulations should be started promptly with severe diarrhea to limit dehydration, as severe ehydration is the major cause of death in severe diarrhea. If dehydration is very severe, especially infants and the elderly, require IV (intravenous) re-hydration for maintaining patients’ health.

If the dehydration is moderate as seen in non-febrile and non-bloody diarrhea, anti-motility and anti-secretory agents such as loperamide can be used. But drugs like loperamide should be avoided if the diarrhea patient is suffering from febrile dysentery, which may cause prolongation of diarrhea.

Role of antibiotics in acute diarrhea:

Use of antibiotics may sometimes reduce the severity and duration of diarrhea in some selected cases. Ciprofloxacin (500 mg twice a day for 3 to 5 days) is used by many doctors’ for treatment of severely ill patients with febrile dysentery empirically without diagnostic evaluation. If the cause of diarrhea is suspected to be due to giardiasis, metronidazole (250 mg 4 times a day for 7 days) can be used successfully. Antibiotic coverage has to be given whether or not a causative organism is discovered in patients who are immune deficient, have mechanical heart valves or recent vascular grafts, or are elderly.

Antibiotic prophylaxis should be given for certain patients traveling to high-risk countries in whom the likelihood or seriousness of acquired diarrhea would be especially high, including those with immunocompromise, IBD (inflammatory bowel disease e.g. ulcerative colitis), hemochromatosis, or gastric achlorhydria (absence of acid in stomach). For prophylaxis the use of trimethoprim/sulfamethoxazole (Bactrim), ciprofloxacin, or rifaximin (rifaximin not be suitable for invasive disease) may reduce bacterial diarrhea in such travelers by 90%. Finally, physicians should be vigilant to identify if an outbreak of diarrheal illness is occurring and to alert the public health authorities promptly, which may reduce the ultimate size of the diarrhea affected population.  

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Posted by - July 17, 2009 at 11:44 am

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