By C. Hengley. Knox Theological Seminary. 2018.

She lacked so many of the symptoms of depression purchase nicotinell 17.5mg fast delivery quit smoking hypnosis seminars in my area, foremost being that she never felt depressed discount nicotinell 35 mg with visa quit smoking advertisements. I thought I was following her in the world in which she found herself, namely, a world filled with physical symptoms. She was the first patient with whom all I really did was listen and talk. If such a result could happen with someone as complex as Florence, it could also happen with a lot of other patients. Te experience encour- aged me to continue my exploration of patients who had symptoms but no definable medical disease. By then my belief that there is not a disease behind every symptom was absolute. Tere is just a series of connected thoughts, actions, conflicts, and stress. Any misplaced diagnosis will prevent discovery of the underlying causes. When I was able to find a medical disease to explain the symptoms of a patient in this group, I excluded that patient from further analysis. From 1973 to 1976, I saw 150 patients in whom I failed to find a medical disease to explain the symptoms. Seventy-two of these pa- tients had coexisting and defined medical diseases; however, none of the diseases could reasonably explain the symptoms the patients complained of. Examples of those I excluded were patients with hypertension, simple goiters, gallstones, hemorrhoids, varicose veins, and similar diagnoses. Although these patients had SUOs, I wanted a pure sample of people for whom there was no demon- strable disease after a thorough medical workup. Using micro- 81 82 Symptoms of Unknown Origin biology as a metaphor, I wanted a pure culture: patients with symp- toms but with no known medical diseases. I have struggled with appropriate nomenclature for many years to avoid perpetuating the mind-body dichotomy. I do not want to make a distinction between a disease of psychological origin and one whose origin is a physically definable agent or substance. Here, I will use the terms medical disease or objectively definable dis- ease or diagnosable disease interchangeably. For my analysis, I excluded patients with any disease with ob- jective findings for which there is a code in the International Clas- sification of Diseases manual. I also excluded from the analysis patients with depression, although I did not exclude any of the so- matizing disorders. I prefer the term SUO, since it has no im- plications, psychiatric or otherwise. I also did not exclude patients with errors of refraction or caries of the teeth. Grouping the Patients I was left with seventy-eight patients who had symptoms but no di- agnosable or coexisting medical disease to explain the symptom. A colleague (and a wag) who was puzzled by my interest said I had a pure culture of clinical nothingness. For several weeks, I thumbed through the cards trying to find some method to group patients with similar charac- Symptoms Without Disease 83 teristics. At first, it seemed I had accumulated a series of chaotic clinical experiences. However, I knew each patient extremely well; visions and memories of my encounters came to mind as I exam- ined each card. Using no preconceived logic or defined charac- teristic but instead a kind of overall gestalt, I starting dealing the cards into two piles, A and B. Soon I had divided the entire group of seventy-eight patients into piles of A-ness and B-ness. I began reflecting on what characteristics made a patient A rather than B.

Journal of Neurophysiology nicotinell 17.5 mg low cost quit smoking humor, 89 purchase nicotinell 52.5 mg fast delivery quit smoking 40, 1299– Effect of motor cortex stimulation on spinal interneu- 307. In Motor Control: Concepts contribute to cyclical modulation of the soleus H-reflex and Issues, ed. This tem,suchasspinalcordinjuriesanddiseases,multi- descending control is exerted on all interneurones, plesclerosis,braininjuries,strokeandcerebralpalsy. Even though These alterations contribute to the pathophysiologi- its contribution to the motor disability of patients calmechanismsunderlyingmovementdisordersfol- needs to be revisited (see pp. Atonicimbalancebetweendescending (i) it is the component of the upper motor neurone excitatory and inhibitory inputs on various spinal (or corticofugal, see below) syndrome most acces- pathways accounts for the changes in muscle tone sible to therapy; and (ii) it remains a key dividing of spasticity and parkinsonian rigidity at rest. On point among major schools of physiotherapy, with the other hand, the loss of the normal descending some aiming at inhibiting spasticity (see Bobath, modulation of these pathways during motor tasks, 1990) and other at encouraging it (see Brunnstrom,¨ together with the abnormal descending command 1970). Methods used in clinical neu- but so far not demonstrated, that analyses of the rophysiology help determine the extent to which pathophysiological mechanisms underlying spas- spinalpathwaysmalfunctionafteralesionofthecen- ticity provided by clinical neurophysiological stud- tral nervous system. If this were so, accu- involvement of spinal pathways in the pathophysi- rate evaluation of the mechanisms underlying spas- ology of other motor disorders, such as dystonia, has ticity in individual patients would become increas- been discussed in previous chapters. These thera- pies include: botulinum toxin injection, blockade Spasticity of peripheral nerves by alcohol or phenol, intrathe- cal and oral medication, and physical/occupational Spasticity is one of the components of the upper therapy (for review, see Satkunam, 2003). Moreover, motor neurone syndrome, and occurs in a variety clinical neurophysiological techniques may provide 556 Spasticity 557 the objective and quantitative data necessary for to have a low correlation with the briskness of the clinical trials and longitudinal studies and to follow tendon jerks (Fellows, Ross & Thilmann, 1993), and the progress of individual patients. Either the description was too simplistic, paper by Landau (1980) who pointed out the care- and therefore unhelpful, or the participants could less use of the word spasticity, emphasising that it not agree on the detailed quantitative features of the is only a facet of the upper motor neurone syn- exaggeratedstretchreflexinspastichypertonia. Con- drome, not necessarily the one that causes the great- flicting views were presented concerning the domi- estdisability. How- ever, attractive as it may be, it must be recognised Definition that this proposition has not echoed as much, and the term upper motor neurone syndrome continues Spasticity and stretch reflex exaggeration to be used in the literature. The tonic stretch reflex has been shown pathways involved by the lesion are different after 558 Pathophysiology of movement disorders cerebral and spinal lesions, it is not surprising that contracting muscle, and is only demonstrable clin- the pathophysiology of spasticity is different after ically for the quadriceps muscles, where the range stroke and spinal cord injury (pp. There are other decreaseintheresistancetostretchthatoccurswhen features of spasticity, such as clonus and the clasp- a dynamic reflex response subsides as movement knife phenomenon, but these are not invariably slowsorceases. Thus, the relaxation of a vigorous reflex con- In neurological practice, the crucial question about traction stretches muscle spindle endings and can spasticity is the extent to which it contributes to produce a volley that, given the hyperactivity of the the motor impairment and limitation of activity in reflex arc, is sufficient to trigger another reflex con- patients with a corticofugal syndrome. The presence of clonus is directly related assumed that a voluntary movement that stretches to the tendon jerk hyperreflexia, and whether it can a spastic muscle might be expected to produce be elicited depends on the skill of the examiner who reflex activity that would oppose the movement. As clonus subsides, the spin- depends both on the exaggeration of the stretch dle discharge produced by relaxation of the twitch reflex and changes in the transmission in spinal contractiongraduallybecomesdispersed. Spasticity 559 Spastic restraint–adebated proposition reflex threshold (Powers, Marder-Meyer & Rymer, 1988), increased stretch reflex gain (Thilmann, The contribution of spasticity to motor impair- Fellows & Garms, 1991), but no evidence for abnor- ment has been the subject of vigorous discussion, mal stretch reflex (Dietz et al. However, the prevailing view concluded that the increased resistance to stretch is that the exaggeration of stretch reflexes in some of spastic muscles mainly results from changes in of these patients may give rise to crucial restraint non-neuralfactors(see pp. Accordingly, ferent results may be obtained in patients with dif- the usefulness of reducing spasticity is now gener- ferent lesions of the central nervous system, and/or ally accepted (using, e. Patients with spinal cord lesions Stroke patients In patients with spinal cord lesions, in particular In stroke patients, there is evidence that the in spinal cord compression, chronic myelopathies increased resistance to stretch in the triceps surae or hereditary spastic paraparesis, there is evi- is due to mechanical rather than reflex causes (Perry dence that exaggerated stretch reflexes can disrupt et al. Thatreductionofspasticitywillimprove in favour of a neural origin of spastic hyperto- gait remains to be firmly established (Landau, 2003; nia than of changes in the muscle itself. More Cramer, 2004) and, on the contrary, its reduction recently, unwanted stretch reflex activity in the mightbecounterproductiveasspasticityoftenhelps antagonisttriggeredbythedynamicconcentriccon- support the body during locomotion (see Dietz, traction of the agonist has been shown to limit the 2003). Conflicting results have been obtained con- amplitude and/or to slow down the movement of cerning the resistance opposed by the biceps brachii knee muscles (Knutsson, Martensson & Gransberg,˚ to voluntary elbow extension: decreased stretch 1997). However, the exaggeration of the brate rigidity immediately follows the causal lesion, tonic stretch reflex has only a low correlation with while spasticity takes days, often weeks to develop. Moreover, the This gives time for rearrangements to occur at spinal increased resistance to stretch is also, and perhaps level (see pp. The contribution of exaggerated stretch reflexes to motor disability of Possible spinal mechanisms underlying patients with corticofugal lesions has been overes- the pathophysiology of spasticity at rest timated, and varies with the underlying cause, being more important in patients with spinal cord lesions As indicated in Fig. Reduction of spasticity accompanies selective (ii) Why do spinal pathways malfunction? In fact, the excitability of the the main feature of both is the increased reactivity stretch reflex depends on an intact reflex arc and to a stretch stimulus which is (i) more pronounced on several excitatory and inhibitory mechanisms. It was there- itation of an inhibitory one will reduce the stretch fore presumed that the same spinal mechanisms reflex, even though its exaggeration (spasticity) is might be responsible for the stretch reflex exagger- caused by other mechanisms. In decere- brate rigidity of the cat, the mechanisms include Hyperexcitability of motoneurones hyperexcitability, over-activity, suppression of Ib inhibition, closure of pathways mediating FRA Here,anormal stretch-induced reflex volley would inhibition to extensor motoneurones, and possibly produceanexaggeratedresponsebecausemotoneu- opening of pathways mediating oligosynaptic Ia and rones are closer to their discharge threshold.

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For example order nicotinell 17.5 mg with visa quit smoking message board, measures that require a time stamp nicotinell 35mg low cost quit smoking 40 days ago, such as administration of antibiotics within one hour prior to surgical incision, are not available within most administrative databases. Not only do they contain measures requir- Data Collection 123 ing a time stamp but some measures also require the data collector to include or exclude patients based on criteria that are not consistently cap- tured in administrative databases. The measure percent of patients with congestive heart failure who are receiving an ACE inhibitor is an exam- ple of this. The use of ACE inhibitors in this population is indicated in all patients with an ejection fraction of less than 40 percent. The ejection frac- tion is not part of the typical administrative database. Hence, accurate reporting of this measure is completely dependent on retrospective chart review, yet it is one of the most critical interventions that a patient with congestive heart fail- ure will receive. A recent consensus document presented to NQF5 sug- gested that clinical importance should rate foremost among criteria for effectiveness and that measures that score poorly on feasibility6 because of the burden of medical record review should not be excluded solely on that basis if their clinical importance is high (National Quality Forum Consumer, Purchaser and Research Council Members 2002). Fourth, focused medical record review is the primary tool for answer- ing the why of given situations, as described above. Suffice it to say that medical record review continues to be a key component of many data col- lection projects, but it needs to be used judiciously because of the time and cost involved. The approach to medical record review involves a series of well- thought-out steps, beginning with the development of a data collection tool and ending with the compilation of collected data elements into a reg- istry or electronic database software for review and analysis. The data collection is commonly completed by nursing staff, dedicated research assistants, or full-time data analysts. The downside to asking nursing staff to perform data collection is that it is an immensely time-consuming task that can distract nurses from their direct patient care responsibilities. Because this will be their only job, the accuracy of data collection is better; if the staff are also responsible for presenting their work to various quality committees, the data are more likely to be rigorously validated. One way to accomplish this is by converting the data collection forms into a scannable format. With this approach, data entry can be as simple as feeding the forms into the scanner and viewing the results on the computer screen. The key to success is careful design of the forms and careful completion to ensure that all of the data elements are captured by the scanner. The most efficient data collection tools follow the actual flow of patient care and medical record documentation whether the data are col- lected retrospectively or prospectively. First, detailed information not routinely available in administrative databases can be gathered. Physiologic parameters can be captured, such as the range of blood pressures for a patient on vasoactive infusions or 24-hour intake and output for patients with heart failure. The timing of administration of clot busters for patients with certain types of stroke can mean the difference between full recovery or no recov- ery, and the window of opportunity for these patients is small, usually within three hours of the onset of symptoms. For patients with acute myocardial infarction, the administration of aspirin and beta-blockers within the first 24 hours is critical to survival. Prospective chart review also allows the data collection staff to spot patient trends as they develop, rather than getting the information in a ret- rospective fashion after the patients have been discharged. For instance, an increasing incidence of ventilator-associated pneumonia may be detected sooner, or an increase in the rate of aspiration in patients with stroke may be spotted as it occurs. Prospective data collection is very costly and time consuming, and it often requires several full-time data analysts. Administrative Databases Administrative databases are a common source of data for quality improve- ment projects. Administrative data refers to information that is collected, Data Collection 125 processed, and stored in automated information systems. This includes enrollment or eligibility information, claims information, and managed care encounters. The claims and encounters may be for hospital and other facil- ity services, professional services, prescription drug services, laboratory services, and so on. Examples of administrative data sources include hospital or physician office billing systems, health plan claims databases, health information man- agement or medical record systems, and registration systems (admission/ discharge/transfer). Ideally, a hospital will also maintain a cost accounting system that not only integrates the previously mentioned systems into one database but also provides the extremely important elements of patient cost. Although each of these sources has its unique characteristics, for the purposes of discussion they will be considered collectively under admin- istrative databases (with the exception of health plan claims databases, which will be covered later in the chapter). Administrative databases are an excellent source of data for report- ing on clinical quality, financial performance, and some patient outcomes.

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Forty-two cases were between 3-5 years old effective nicotinell 17.5mg quit smoking ulcerative colitis, 31 cases were between 6-8 years old buy nicotinell 17.5 mg free shipping quit smoking ear treatment, 15 cases were between 9-11 years old, and 16 cases were between 12-14 years old. The course of disease was 1-3 years in 54 cases, 4-6 years in 37 cases, and 7-9 years in 13 cases. These children were all unable to contain themselves, with enuresis during sleep that was frequent and copious and more than one time each evening. Other signs and symptoms included lack of strength, a somber white facial complexion, fear of cold, cold limbs, lack of warmth in the extremities, low back and knee aching and limpness, somewhat less than normal intelli- gence, usually long, clear urination, a pale tongue with thin, white fur, and a fine, deep or slow, deep pulse. Treatment method: Modified Gui Zhi Jia Long Gu Mu Li Tang consisted of: Gui Zhi (Ramulus Cinnamomi), 10g Bai Shao (Radix Paeoniae Albae), 10g mix-fried Gan Cao (Radix Glycyrrhizae), 5g calcined Long Gu (Os Draconis), 15g calcined Mu Li (Concha Ostreae), 15g Ba Ji Tian (Radix Morindae Officinalis), 10g Bu Gu Zhi (Fructus Psoraleae), 10g Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), 10g Sang Piao Xiao (Ootheca Mantidis), 10g Wu Yao (Radix Linderae), 10g Da Zao (Fructus Jujubae), 7 pieces Sheng Jiang (uncooked Rhizoma Zingiberis), 3 slices One packet of these medicinals was decocted in water, divided into four doses, and administered warm per day. While taking these medicinals, all other medicinals and treatments were stopped. If there was inability to wake from sleep, five grams of Dan Nan Chinese Research on the Treatment of Pediatric Enuresis 59 Xing (bile-processed Rhizoma Arisaematis) and seven grams of Shi Chang Pu (Rhizoma Acori Tatarinowii) were added in order to transform phlegm and arouse the spirit. If there was devitalized intake and sloppy stools, 10 grams of earth-fried Bai Zhu (Rhizoma Atractylodis Macrocephalae) and five grams of Sha Ren (Fructus Amomi) were added in order to fortify the spleen and harmonize the center. If there was shortness of breath and laziness to speak, 10 grams each of Huang Qi (Radix Astragali) and Tai Zi Shen (Radix Pseudostellariae) were added in order to boost the qi and support the righteous. If there was spontaneous perspiration or night sweats 15 grams each of Ma Huang Gen (Radix Ephedrae) and Fu Xiao Mai (Fructus Levis Tritici) were added in order to secure the interstices and stop sweating. Among these, 23 cases took seven pack- ets of medicinals, 37 cases took 14 packets of medicinals, and nine cases took 21 packets of medicinals. Discussion: The formula Gui Zhi Jia Long Gu Mu Li Tang first appeared in the Jin Gui Yao Lue (Essentials from the Golden Cabinet). In this clas- sic, it was indicated for vacuity taxation and loss of essence con- ditions. Cheng finds this formula often produces instantaneous results when used to treat the lower origin vacuity cold pattern of enuresis. Gui Zhi Jia Long Gu Mu Li Tang regulates and supple- ments both yin and yang, subdues yang, and promotes absorp- tion. Within the above formula, Bai Ji Tian and Bu Gu Zhi are added to warm yang and supplement the kidneys. Wu Yao forti- fies the spleen, assists in movement, and warms the bladder qi transformation. If yang is secured and yin is stabilized, then the qi transformation of the bladder returns to normal and enure- sis is stopped. From The Treatment of 50 Cases of Pediatric Enuresis with Jia Wei Wu Zi Yan Zong Tang (Five Seeds Increase Progeny Decoction with Added Flavors) by Peng Xi-zhen, Shang Hai Zhong Yi Yao Za Zhi (Shanghai Journal of Chinese Medicine & Medicinals), 1984, #3, p. Treatment method: Jia Wei Wu Zi Yan Zong Tang was composed of: Tu Si Zi (Semen Cuscutae) Gou Qi Zi (Fructus Lycii) Fu Pen Zi (Fructus Rubi) Che Qian Zi (Semen Plantaginis) Wu Wei Zi (Fructus Schisandrae), no amounts given If there was spleen-lung qi vacuity, Dang Shen (Radix Codonopsitis), Yi Zhi Ren (Fructus Alpiniae Oxyphyllae), and Shan Yao (Radix Dioscoreae) were added. Study outcomes: Forty-two cases were cured, three cases improved, and five cases got no improvement. In general, these patients needed to take 8-20 packets to cure their condition. Peng, based on the Chinese medical theory of different diseases, same treatment, uses Wu Zi Yang Zong Tang to treat pediatric enuresis. Within this formula, the sovereign and ministerial medicinals, Tu Si Zi and Fu Pen Zi, have a warm nature and both enter the liver and kidney channels. Gou Qi Zi supplements the kidneys, secures and astringes, nourishes the Chinese Research on the Treatment of Pediatric Enuresis 61 liver and fortifies the spleen. Its nature is cold, and it enters the lung, kidney, and small intestine channel. It is used here to eliminate dampness which might otherwise damage the center and to counteract the slimy nature of the other medicinals. It enters the lung and kidney channels and has the abili- ty to guide the action of the formula to these channels. Wu Wei Zi also has the functions to constrain the lungs, enrich the kidneys and secure and astringe. The addition of Dang Shen, Yi Zhi Ren, and Shan Yao is in order to supplement the lungs and fortify the spleen. From The Therapeutic Effects of Treating 167 Cases of Pediatric Enuresis by Regulating & Supplementing the Spleen & Kidneys by Yang Li-Guo, Zhe Jiang Zhong Yi Xue Yuan Xue Bao (Academic Journal of Zhejiang College of Chinese Medicine), 1993, #5, p.

Apply principles of using macrolides in selected vancomycin in the treatment of pseudo- client situations 35 mg nicotinell visa quit smoking research study. Critical Thinking Scenario You are an infection control nurse who will be providing long-term care nurses with an update on methicillin- resistant Staphylococcus aureus (MRSA) 52.5mg nicotinell overnight delivery quit smoking ear treatment. Because MRSA has been a significant problem over the last decade, especially in long-term care facilities, your goal is to increase knowledge about the development of drug resistance and appropriate measures to prevent spread of this organism. What risks are involved when vancomycin is used consistently to treat MRSA. What infection control practices are necessary to limit the spread of MRSA and other resistant organisms. OVERVIEW sues and fluids and may be bacteriostatic or bactericidal, depending on drug concentration in infected tissues. They The drugs described in this chapter are heterogeneous in are effective against gram-positive cocci, including group their antimicrobial spectra, characteristics, and clinical A streptococci, pneumococci, and most staphylococci. Some are used often; some are used only in specific are also effective against species of Corynebacterium, Tre- circumstances. The macrolides and selected miscellaneous ponema, Neisseria, and Mycoplasma and against some drugs are described in the following sections; names, routes, anaerobic organisms such as Bacteroides and Clostridia. MAC disease is an opportunistic infection that occurs mainly in people with advanced human MACROLIDES immunodeficiency virus infection. Erythromycin, the prototype, is now used less often be- The macrolides, which include erythromycin, azithromycin cause of microbial resistance, numerous drug interactions, and (Zithromax), clarithromycin (Biaxin), and dirithromycin the development of newer macrolides. Erythromycin is me- (Dynabac), have similar antibacterial spectra and mecha- tabolized in the liver and excreted mainly in bile; approxi- nisms of action. They are widely distributed into body tis- mately 20% is excreted in urine. Depending on the specific salt 548 CHAPTER 37 MACROLIDES AND MISCELLANEOUS ANTIBACTERIALS 549 Drugs at a Glance: Macrolides Usual Routes and Dosage Ranges Generic/Trade Name Adults Children Azithromycin (Zithromax) Respiratory and skin infections, PO 500 mg 6 mo and older: Acute otitis media PO, as a single dose on the first day, then 250 mg 10 mg/kg as a single dose (not to exceed once daily for 4 d. Nongonococcal urethritis 500 mg) on the first day, then 5 mg/kg and cervicitis caused by Chlamydia trachomatis, (not to exceed 250 mg) once daily for 4 d give 1 g as a single dose. Azithromycin and Mechanism of Action dirithromycin are excreted mainly in bile, and clarithromycin is metabolized to an active metabolite in the liver, which is The macrolides enter microbial cells and attach to 50S ribo- then excreted in urine. Oph- thalmic and topical preparations are discussed in Chapters 65 and 66. Indications for Use A relative of the macrolides, telithromycin (Ketek), is the first of a new class of antibiotics, named the ketolides. The macrolides are widely used for treatment of respiratory Telithromycin and a similar drug have not yet received tract and skin/soft tissue infections caused by streptococci and Food and Drug Administration (FDA) approval for market- staphylococci. These drugs are expected to offer better activity against stitute in clients who are allergic to penicillin; for prevention multidrug-resistant strains of Streptococcus pneumoniae, an of rheumatic fever, gonorrhea, syphilis, pertussis, and chlamy- 550 SECTION 6 DRUGS USED TO TREAT INFECTIONS Drugs at a Glance: Miscellaneous Antibacterials Routes and Dosage Ranges Generic/Trade Name Adults Children Chloramphenicol (Chloromycetin) PO, IV 50–100 mg/kg/d in four divided doses q6h Children and full-term infants >2 wk: PO 50 mg/kg/d in three or four divided doses q6–8h Clindamycin hydrochloride (Cleocin) PO 150–300 mg q6h; up to 450 mg q6h for PO 8–16 mg/kg/d in three or four divided doses severe infections q6–8h; up to 20 mg/kg/d in severe infections Clindamycin phosphate IM 600 mg–2. Linezolid (Zyvox) PO 400–600 mg q12h Dosage not established IV 600 mg over 30–120 min q12h (for serious infections) Metronidazole (Flagyl) Anaerobic bacterial infection, IV 15 mg/kg (about Dosage not established 1 g for a 70-kg adult) as a loading dose, in- fused over 1 h, followed by 7. Duration usually 7–10 d; maximum dose 4 g/d Surgical prophylaxis, colorectal surgery, IV 15 mg/kg, infused over 30–60 min, infusion to be completed about 1 h before surgery, followed by 7. Spectinomycin IM 2 g in a single dose Dosage not established Vancomycin PO 500 mg q6h or 1 g q12h; maximum dose, PO, IV 40 mg/kg/d in divided doses 4 g/d Infants and neonates: IV 15 mg/kg initially, then IV 2 g/d in two to four divided doses, q6–12h 10 mg/kg q12h for neonates up to 7 d of age, then q8h up to 1 mo of age VREF, vancomycin-resistant Enterococcus faecium. For prevention, clarithromycin may be into body tissues and fluids, including cerebrospinal fluid used alone; for treatment, it is combined with one or two (CSF), but low drug levels are obtained in urine. It is me- other drugs (eg, ethambutol or rifabutin) to prevent the emer- tabolized in the liver and excreted in the urine. Clarithromycin is also Chloramphenicol is rarely used in infections caused used to treat Helicobacter pylori infections associated with by gram-positive organisms because of the effectiveness peptic ulcer disease. Each of the alternate classes of antibiotics Contraindications to Use has a more favorable safety profile and should be consid- ered first, before chloramphenicol. It is indicated for use Macrolides are contraindicated in people who have had hyper- in serious infections for which no adequate substitute sensitivity reactions.

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