key: cord-350024-whne0l19
authors: Anderson, Victoria L.; Miskinis-Hilligoss, Dianne
title: Choosing the Right Antibiotic in Ambulatory Care
date: 2006-11-28
journal: J Nurse Pract
DOI: 10.1016/j.nurpra.2006.09.009
sha: 
doc_id: 350024
cord_uid: whne0l19

The goal of this article is to be a quick guide for the nurse practitioner practicing in an ambulatory setting for making the right antibiotic choice for the right infection. With the use of a system-based approach, this article defines the most common infections seen in ambulatory care and their most common causative organisms and gives antibiotic options with respect to efficacy, common side effects, and cost. We provide recommendations for length of therapy and follow-up, as well.

approximately 20-to 1400-m thick.The dermis, lying deeper to the epidermis, houses sweat glands, nerves, blood vessels, and lymphatics.

Diagnoses of skin infections, rashes, or both are made by history and examination, and at times a skin biopsy is needed.The medical history and the history of the injury will help in choosing what organisms might be involved or to what extent one or both of these structures are involved. Nurse practitioners can diagnose and manage most of these skin infections; however, in the case of necrotizing fasciitis this is a surgical emergency and requires immediate referral and hospitalization.The following clinical entities most commonly seen in outpatient care are described: cellulitis, impetigo, folliculitis, furuncles and carbuncles, necrotizing fasciitis, paronychia, onychomycoses, lice, scabies, and Lyme disease.

Definition. An acute inflammatory spreading response of the skin characterized by superficial swelling, pain, erythema, and warmth that often extends in the subcutaneous tissues. 2 Diagnosis. Rapidly spreading cellulitis, evidence of systemic response, or association with asplenia, neutropenia, cardiac or renal failure, cirrhosis, preexisting edema, or immunodeficiencies are indications for admission and treatment with an intravenous antibiotic (cefazolin or vancomycin for patients allergic to penicillin). In a diabetic host, a clinician should consider broader coverage to include gram-negative and anaerobe coverage that includes an intravenous (carbapenem, meropenem, or imipenem-cilastatin) and a penicillinase-penicillin such as ampicillin-sulbactam. Differential diagnosis.

• Contact dermatitis: intense pruritus and a history of an exposure help to differentiate this usually erythematous rash that can spread from the point of exposure. • Erysipelas: superficial, red, and tender,"St.Anthony's fire" rash with well-demarcated edges caused mostly by group A ␤-hemolytic streptococci. • Panniculitis: defined as an inflammation of the adipose layer of the skin and can be septate or lobular and includes such entities as erythema nodosum (multiple, scattered erythematous lesions that are painful), erythematous nodules of idiopathic or varied cause such as infection, drug reaction, sarcoidosis, ulcerative colitis. • Sweet's syndrome or acute febrile dermatosis. • Insect bites or stings: the history, pruritus, and lack of response to antimicrobials may help to distinguish this from cellulitis. • Kerions of the scalp because of tinea capitis can appear erythematous, indurated, and painful but is caused by a fungus instead of bacteria so will not respond to antibiotics, and cultures from drainage will be negative for bacteria but may be positive on the wet mount. • Folliculitis: see discussion below. • Superficial thrombophlebitis and deep vein thrombosis (DVT): a tender cord and a history of venous catheter will help with the differential for superficial thrombophlebitis. Engorgement of superficial veins in the extremity of a DVT and a history of risk factors toward a DVT and a lowerextremity ultrasound scan will help to differentiate this from cellulitis. 2 Cause. Usually trauma related. Most common sites are legs and digits; rarely seen are the face, hands, torso, neck, and buttocks. 3 Common bacterial organisms. Gram-positive organisms: Streptococcus pyogenes, Staphylococcus aureus. If saltwater or brackish water injuries lead to cellulitis, consider Vibrio vulnificus. Treatment. Heat and elevation of an extremity; support hose for patients with chronic edema, analgesics (acetaminophen or ibuprofen), and antibiotics. Antibiotics. Duration is typically 10 to 14 days.

• ␤-Lactamase-resistant penicillin.Augmentin: adult, 875 mg orally every 12 hours; pediatric, 30 to 40 mg/kg divided every 12 hours. • First-generation cephalosporin. Keflex: adult, 250 mg every 6 hours or 500 mg every 12 hours; pediatric, 25 to 50 mg/kg per day in divided doses every 6 hours. • Azithromycin (Zithromax): adult, 500 mg day 1 and 250 mg days 2 to 5, may increase to 10 days depending on host and extent of disease; pediatric, 10 mg/kg day 1, followed by 5 mg/kg days 2 to 5. • Fluoroquinolones. Levofloxacin: adult, 500 mg orally every day; pediatric use is not approved for those aged younger than 18 years. 

A primarily pediatric entity, this superficial infection of the corneal layer of the dermis presents as a unilocular, vesicular rash that often erupts, leaving a serous drainage that is golden yellow and crusting. Occurs mostly on the face or cheek and chin and is usually associated with trauma but can be a secondary infection from a herpetic lesion or angular chelitis. It can be bullous or nonbullous and is highly infectious, often in families and institutional childcare settings. Differential diagnosis.

• Varicella: crusts of varicella are darker and harder.

• Herpes simplex: fluid is more turbid and lacks the golden yellow hue.

• Acute palmar pustulosis: palms and soles are more commonly affected and are sterile and self-limited associated with pharyngitis. Causative organisms. S aureus, gram-positive organism commonly found in the environment. Treatment. Hand washing, topical Bactroban, and systemic antibiotics.

• Azithromycin: adult, 500 mg day 1 and 250 mg days 2 to 5; pediatric, 10 mg/kg day 1, followed by 5 mg/kg days 2 to 5. ation. Diagnosis is made by physical examination, because lesions often are pustular with a hair follicle in the center. Most common causative organism. S aureus. Treatment. Folliculitis usually resolves spontaneously; however, in significant cases or in immune-compromised or diabetic patients, you may want to treat with topical agents and watch closely.

• Topical therapy with cleansing with Hibiclens or antibacterial soap, application of topical anti-infective agent such as benzoyl peroxide. If needed, you can use an application of topical erythromycin, clindamycin as Cleocin, mupirocin, or Bactroban. Follow-up. If there is a change in the rash or development of systemic symptoms, follow-up is immediate; otherwise, it is as needed.

Definition. Folliculitis that extends beyond the hair follicle creates a furuncle, a walled off mass with pustular material inside. Multiple furuncles that coalesce into a large mass is a carbuncle.A carbuncle will drain through multiple sinus tracts. 5 Most common causative organisms. S aureus. Treatment. Incision and drainage are usual in an otherwise healthy host and addition of a systemic antibiotic. Any evidence of associated cellulitis with an ill-appearing patient or one who has an immune defect, diabetes, cirrhosis, chronic steroid use, burns, or obesity should lead to a high index of suspicion toward a necrotizing fasciitis. Antibiotics.

• First-generation cephalosporin. Keflex: adult, 250 mg every 6 hours or 500 mg every 12 hours; pediatric, 25 to 50 mg/kg per day in divided doses every 6 hours. • Augmentin: adult, 875 mg orally every 12 hours; pediatric, 30 to 40 mg/kg divided every 12 hours. Follow-up. If change in rash or development of systemic symptoms, the follow-up is immediate; otherwise, it is 3 to 5 days for a compromised host or as needed in a healthy host.

Definition and cause. This surgical emergency is described as a necrosis of the fascia and the subcutaneous tissue. It may occur from an injury to the skin or from a preexisting skin rash, but in most cases it has no identifiable cause. 6 Evidence suggests that predisposing factors, such as age older than 50 years, diabetes, cirrhosis, immunosuppression, chronic renal failure, or cardiac disease, may attribute to developing necrotizing fasciitis. Diagnosis. It can occur on any part of the body, but the perineum, extremities, and truncal areas are most involved. Presenting symptoms are swelling that may evolve into tense erythema that may progress to a dusky blue and pain out of proportion to what is visible. Palpable crepitus from air formation and soft tissue air on X-ray is also pathogonomic but not always present. Local symptoms may be accompanied by systemic symptoms of sepsis and shock. Common bacterial organisms. Usually the cause is polymicrobial with both anaerobic and aerobic gram-positive and gram-negative organisms to include Vibrio, group A and B streptococci, enterococci, staphylococci, Escherichia coli, Pseudomonas, Proteus, Serratia, Clostridium, and rarely fungal organisms, including Aspergillus, Zygomycetes, and Candida. Treatment. Treatment is immediate referral for surgical debridement and hospitalization for intravenous antibiotics and supportive treatment for sepsis.

Definition and cause. Scabies is a highly contagious dermatosis caused by a mite, Sarcoptes scabiei. Diagnosis and differential diagnosis. Common diagnoses include atopic dermatitis, dyshidrotic eczema, urticaria, pityriasis rosea, impetigo, and contact dermatitis. Symptoms are intense pruritus caused by the immune response of the mites' excretions and their burrowing in the skin.The pathognomonic sign is the burrow of the scabies that can be linear, curved, or Sshaped and pink-white to gray colored in appearance. Lesions are often in web spaces of fingers and wrists, in extensor surfaces of the elbows and knees, sides of hands and feet, axillary areas, buttocks, and waistline. Skin scraping to look for mites and eggs using mineral oil on a glass slide under microscopy is helpful, but without a positive finding it is not conclusive. Treatment. All household members and close contacts should be treated whether they are symptomatic.

• Permethrin (Elmite or Acticin) cream 1% is applied from head to toe and everywhere in between for an 8-to 14-hour period and then washed off.This treatment should be reapplied in 1 week.All household bedding should be washed in hot water

The Journal for Nurse Practitioners -JNP and dried on a hot cycle or dry cleaned. Once cleaned all bedding should not be used for 72 hours. Follow-up. If there is a change in rash or development of systemic symptoms, the follow-up is immediate; otherwise, it is 3 to 5 days for a compromised host or as needed in a healthy host.

Definition and cause. Infestation of the hairy parts of the body with 2 of the 560 species of arthropods that suck blood and feed on mammals. 7 Pediculus humanus and Phthirus pubis are those 2 species that cause human lice. Diagnosis. Clinical observation of nits or lice. Treatment.

• Malathion (Ovide) available by prescription is the most effective treatment, and no evidence shows development of resistance to this product to date, whereas resistance to permethrin or Nix has been shown. Use 1 of these 3 products on dry hair (as lice can hold their breath under water for 8 to 12 hours) for 30 minutes and follow by combing the hair with a fine-tooth comb to remove the nits. Use of wet-combing or use of petroleum, mayonnaise, and pomades is alternative to insecticides to kill lice but must be reapplied every 4 weeks until all nits hatch and can be removed. Follow-up. Most schools will exclude children with lice, so letters may need to be written to explain when children can return, usually after the first treatment despite the presence of nits.

Definition. Infection of the skin bordering the nail.The infection will lead to swelling, erythema, and pain. Paronychia can be acute or chronic. Cause. Acute paronychia is most readily caused by nail biting, nail trauma, and thumb sucking, whereas chronic paronychia is caused by chronic exposure to water or irritants. Causative bacterial organisms. Acute paronychia is caused by S aureus, streptococci, Pseudomonas, and anaerobes; chronic paronychia is caused by atypical mycobacteria, Candida, and gram-negative rods. Treatment. Acute paronychia: warm soaks, incision, and drainage as needed, and antibiotics. Chronic paronychia: avoidance of overexposure to water or irri-tants by wearing rubber gloves, emollients, topical steroids, soaks in acetic acid, or occasional oral antibiotics used for acute paronychia or referral to a dermatologist or surgeon for chronic paronychia for nail removal or eponychial marsupialization. 8 • Antibiotics for acute paronychia.Augmentin: adult, 875 mg orally every 12 hours; pediatric, 30 to 40 mg/kg divided every 12 hours. • Clindamycin: adult, 150 to 450 mg orally four times a day; pediatric, 8 to 20 mg/kg per day orally divided three times a day or four times a day. Follow-up. If change in rash or development of systemic symptoms, follow-up is immediate; otherwise, it is as needed.

Definition. Fungal infection in the nail beds, nail matrix, or plate. 9 Although mostly a cosmetic problem, mobility can be affected, indirectly adding to morbidity of persons with diabetes and venous stasis. Causative bacterial organisms. Trichophyton rubrum and Trychophyton mentagrophytes Differential diagnosis. Psoriasis, lichen planus, contact dermatitis, trauma, nail bed trauma, yellow nail syndrome. Treatment.

• Fluconazole: one 150 mg tablet each week for 9 months. • Itraconazole: 200 mg/day for 12 weeks for toenails and 200 mg/day for 6 weeks for fingernails, or pulse dosing of 400 mg/day for first week of the month for 2 to 3 pulses for fingernails and 3 to 4 pulses for toenails. • Terbinafine: 250 mg/day for 12 weeks for toenails and 10 weeks for fingernails. Follow-up. Special note:These drugs all have significant drug interactions in that they induce the cytochrome P-450 enzymes, changing the metabolism of many concomitant drugs. Laboratory evaluation of liver enzymes is warranted at baseline and then at 6 weeks for terbinafine.

Definition. Multisystem inflammatory disease caused by an infection, which is spread by a tick bite. Causative organisms. Spirochete Borrelia burgdorferi. Diagnosis and differential diagnosis. The diagnosis of Lyme disease is often made clinically and occasionally www.npjournal.org

The Journal for Nurse Practitioners -JNP 687 supported by appropriate laboratory testing (serum antibodies to ␤ burgdorferi). Lyme disease has been described using 3 phases of infection.

• Early localized disease: erythema migrans (EM), often called a bull's-eye rash and associated symptoms • Early disseminated disease: multiple EM and associated symptoms, Lyme carditis, neurologic features, including facial palsies, lymphocytic meningitis, and radiculoneuropathies • Late disease: neurologic features, including peripheral neuropathies, chronic encephalopathies, arthritis, and migratory polyarthritis or monoarthritis (Sigal) The transmission of disease from tick to human can take place only after the tick has been attached to the host for 24 to 48 hours and has had at least one blood meal.This is important to know because many patients will want antibiotic treatment after finding a tick.There are several different approaches to treatment. Empiric antibiotic prophylaxis is not recommended for patients who are not symptomatic. Persons who develop a skin lesion or other illness within 1 month after removing a tick should be instructed to seek medical attention to rule out any tick-borne diseases (Lyme disease, Rocky Mountain spotted fever, ehrlichiosis, tularemia, babesiosis, or Colorado tick fever). Lyme disease is the most common and is endemic to the Mid-North Atlantic states and in areas of the Great Lakes.

The Infectious Diseases Society of America has published guidelines to assist clinicians in the decisions about the treatment of patients diagnosed with possible Lyme disease. One option is to treat with antimicrobials only if the person is at risk because of a prolonged attachment. Another option is to treat only if the person develops or presents with EM or other systemic symptoms. All persons who exhibit late disease symptoms, seroconvert from negative to positive (serum antibodies to B burgdorferi), or both should be treated with a full 21-day course of antibiotics and receive follow-up evaluations. 

The respiratory system infections discussed herein include upper and lower respiratory tract infections, including otitis media, pharyngitis, sinusitis, bronchitis, and pneumonia. Most of these infections are usually viral in nature; however, they often become secondarily infected with a bacterial organism.We strongly recommend culture verification (as feasible) to determine organism and resistance patterns to guide antibiotic choices and changes but understand that empiric regimens must be started at the time of visit, and it is in that frame we make recommendations for empiric antibiotics regimens.

Definition. Inflammation or infection and fluid in the middle ear accompanied by acute signs and symptoms of illness. Causative bacterial organisms. Most common are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis. Diagnosis and differential diagnosis. A large percentage of AOM is caused by viruses (respiratory syncytial virus [RSV], rhinovirus, influenza virus, and adenovirus). Because of this, one treatment option recommended by the American Academy of Pediatrics (AAP) and the American Academy of Family Physicians (AAFP) is an observation period of 48 to 72 hours and limiting treatment to only symptomatic relief. Symptomatic relief may consist of pain management and antihistamines or decongestants.This decision should be based on the child's age (must be older than 6 months), severity of illness, and diagnostic certainty. A clinician should confirm a history of acute onset, identify signs of middle ear effusion, and evaluate for the presence of signs and symptoms of middle ear inflammation. Treatment. Analgesics, antihistamines, decongestants, and antibiotics. HIV) . GAS is the most common bacterial cause and requires treatment with antibiotics; therefore, the main objective in evaluating a patient in the primary care setting is to identify, rule out, and treat GAS. Many clinicians use the "Centor Criteria," which include fever, tonsillar exudate, tender anterior cervical lymphadenopathy, and absence of cough.All adult patients with pharyngitis should be clinically screened using these criteria. Patients with none or one of these criteria should not be cultured or treated with antibiotics. Patients with 2 or more of these criteria should have their throat cultured for GAS, and antibiotics should be reserved for those with positive results. Patients with 3 or 4 of these criteria should be treated with antibiotics without the need for throat culture results. 

Definition. Characterized by inflammation of the bronchi causing cough, usually with sputum production, and evidence of concurrent upper airway infection. Causative bacterial organisms. M pneumoniae, C pneumoniae, and Bordetella pertussis. It is suspected that the bacterial pathogens that cause pneumonia can also cause acute bronchitis (S pneumoniae, H influenzae, S aureus, group A Streptococcus, M catarrhalis, anaerobes, and aerobic gram-negative bacteria), but no evidence is convincing to support this concept of "acute bacterial bronchitis." Diagnosis and differential diagnosis. The usual causes of acute bronchitis are viral infections that affect the upper airways (influenza A and B virus; parainfluenza type 1, 2, and 3; coronavirus; rhinovirus; RSV; and human meta-pneumovirus). Cough is the most common symptom. Fever is relatively unusual.A chest X-ray can distinguish pneumonia from bronchitis. Patients that complain of a chronic cough, defined as lasting for longer than 3 weeks, can include noninfectious entities such as postnasal drip, asthma, and gastroesophageal reflux.The indications for a chest X-ray in patients with an acute cough to rule out pneumonia are patients with abnormal vital signs (increased respiratory rate, difficulty in respiratory effort, stridor or tachypnea, and oxygen saturations below 92%) or crackles on chest examination.The main treatment issue in cases of acute bronchitis is the use of antibiotics.

Multiple studies indicate that patients with acute bronchitis do not benefit from antibiotics because bacteria are not usually responsible. Treatment. Analgesics, decongestants, antipyretics, antitussives, vaporizers, ␤-agonist inhalers, and antibiotics. Antibiotics for suspected or proven M pneumoniae, C pneumoniae, or B pertussis include • Azithromycin: adult (5-day regimen), 500 mg once daily for 1 day, then 250 mg orally for 4 days; pediatric, 10 mg/kg per day for 1 day, then 5 mg/kg per day for 4 days. • Doxycycline: adult, 100 mg orally twice daily for 10 to 14 days; pediatric (<45 kg), 2.2 mg/kg every 12 hours for 10 to 14 days. • Levofloxacin: 500 mg orally once daily for 10 to 14 days; not recommended for pediatric patients, Follow-up. No follow-up is necessary unless symptoms do not resolve; immediate follow-up is needed if the patient develops worsening complaints. 10, [23] [24] [25] [26] Community-acquired pneumonia (CAP) Definition. Acute infection of the lung parenchyma in a patient that has acquired the infection in the community rather than the hospital setting. Causative bacterial organisms. Typical organisms are S pneumoniae, H influenzae, S aureus, GAS, M catarrhalis, anaerobes, and aerobic gram-negative bacteria.Atypical organisms include C pneumoniae, Legionella, M pneumoniae. Diagnosis and differential diagnosis. Viruses such as influenza, RSV, parainfluenza virus, rhinovirus, adenovirus, varicella, and severe acute respiratory syndrome (SARS) are estimated to be the cause in up to 31% in adult patients with CAP, and, in young children, viruses are the most common cause.The diagnosis of CAP is based on the following clinical criteria: acute symptoms November/December 2006 690

The Journal for Nurse Practitioners -JNP associated with infection of the lower respiratory tract (fever, cough, tachypnea), presence of acute lung infiltrate on chest X-ray, auscultatory findings consistent with pneumonia, and lack of hospitalization or residence in a long-term facility in the past 2 weeks before infection.

Choosing between inpatient and outpatient treatment is a crucial decision that will influence the medication choice. Clinicians should use clinical judgment and mortality prediction tools (ATS, Infectious Disease Society of America [IDSA], or both) to determine whether a patient should be hospitalized or is able to receive outpatient therapy safely with scheduled followup care (need follow-up chest X-ray in 4 to 6 weeks). Hospitalization should depend on patient age, presence of comorbidities, and severity of presenting disease. Treatment. Analgesics, antipyretics, inhalers, antibiotics, and prevention with immunizations (adult: pneumococcal vaccine and yearly influenza vaccine) are used. Pneumonia is a known complication of rubeola, varicella, pertussis, and H influenzae type B (HIB), which are all part of routine childhood vaccinations.

Antibiotics for outpatient treatment include 

This section discusses infections of the genitourinary tract, including vaginitis, cervicitis, cystitis, and epididymitis with specific reference to the diagnosis and management of sexually transmitted diseases (STDs).

Definition. Bladder infection is usually caused by bacteria that ascend from the urethra, often with presenting symptoms of dysuria, pyuria, bacteriuria, urinary frequency, and urgency often associated with suprapubic tenderness. Differential diagnosis. Urethritis is defined as a lower urinary tract infection or the urethra; symptoms can encompass those of cystitis but may include discharge, burning on urination. Pyelonephritis is defined as infection of the kidney(s) with symptoms of cystitis, flank pain, and fever. Common causative bacterial organisms. E coli, Proteus mirabilis, Pseudomonas species, Klebsiella pneumoniae, Enterobacter species, Candida species. Treatment. Increased fluid intake, cranberry juice, and antibiotics. For uncomplicated cystitis, defined as episodes occurring in healthy nonpregnant females with functionally and anatomically normal urinary tract, antibiotics include 31 • TMP-SMX (sulfamethoxazole) (Bactrim-Septra): adult, 1 DS (800/160) tablet every 12 hours for 3 days. • For sulfa allergy.TMP: 100 mg every 12 hours for 3 days. • Ciprofloxacin 500 mg every 12 hours for 3 days or ciprofloxacin 500 mg extended release (ER) daily for 3 days. Follow-up. No follow-up is needed unless symptoms do not resolve; immediate follow-up is needed if the patient's complaints worsen. Special situations. Pediatric: neonates, uncircumcised boys, and children with functionally or anatomically abnormal urinary tracts are susceptible to urinary tract infections.Their presentations are remarkably different from adults.Young children aged 2 to 5 years may have abdominal complaints with nausea and vomiting and fever. 32 Infants may present with poor feeding, fever, irritability, and malodorous urine. 32 After age 5, typical symptoms will present. Be suspicious of an STD in a sexually active man. Rule out a functional or anatomic urinary tract defect.

The Journal for Nurse Practitioners -JNP 691

• Amoxicillin: 20 to 40 mg/kg per day divided every 8 hours. • TMP-SMX (Bactrim): 8 mg/kg per day as trimethoprim divided every 6 hours. 32

Definition. Vaginal discharge with vulvar itching and irritation. Diagnosis and differential diagnosis. Diagnosis is made on clinical history and physical examination of the vagina and its secretions.Testing of vaginal secretions for pH and with potassium hydroxide for amine testing for bacterial vaginosis and presence of pseudohyphae for Candida and motile protozoa for Trichomonas. Cervicitis may be asymptomatic or present with abdominal pain, dyspareunia, and abnormal menstrual bleeding.The pelvic examination will reveal mucopurulent exudates in the endocervical canal and a friable cervix when touched by a cotton swab. 33 Causative organisms, treatments, and special situations are given in Table 1 .

Definition. Painful scrotal swelling that is often unilateral and can be associated with trauma, urinary tract infection, and STDs.Acute bacterial epididymitis is rare and is often accompanied by prostatitis. 34 Differential diagnosis. Testicular torsion, appendiceal torsion. STDs are of high suspicion in patients with penile discharge and strong history of unprotected sexual exposure. 35 Common bacterial organisms. Pseudomonas and streptococci, organisms that are common if STD is suspected, N gonorrhoeae and Chlamydia trachomatis. 34 Treatment. Antibiotics. Rule out urinary tract functional or anatomic abnormality and STDs.

• Ciprofloxacin: 500 mg orally every 12 hours for 10 days. • Levofloxacin: 500 mg orally daily for 10 days. • Sexually transmitted diseases. Ceftriaxone: 250 mg intramuscularly; doxycycline: 100 mg orally every 12 hours for 10 days.

Diarrhea is discussed in this section, because it is likely to be the most encountered chief complaint in regard to the gastrointestinal system. Diarrhea's cause is first and foremost viral; however, we will present in this section all the common bacterial pathogens and their treatment. Of note, we recognize that many pathologic entities still are not mentioned here, such as acute appendicitis, pancreatitis, or cholecystitis, whose causes could be infectious and are likely to be seen in an ambulatory care setting. However, because most of these entities are very likely to result in a hospital admission, we elected not to discuss them. 

National Ambulatory Medical Care Survey

Lippincotts Prim Care Pract

Common bacterial skin infections

Practice guidelines for the diagnosis and management of soft-tissue infections

Available at: www.bmj

Scabies and pediculosis

Common acute hand infections

Treating onchomycosis

Diagnosis of Lyme disease

The Sanford guide to antimicrobial therapy

Misconceptions about Lyme disease: confusions hiding behind illchosen terminology

Diagnosis of Lyme disease. Available at: www.uptodate

Tick-borne disease

The emergence of Lyme disease

Practice guidelines for the treatment of Lyme disease

Acute otitis media

Practice guidelines: AAP, AAFP release guidelines on the diagnosis and management of acute otitis media

Treatment of acute otitis media. Available at: www.uptodate

Practice guidelines: principles of appropriate antibiotic use: part IV. Acute pharyngitis

Approach to acute pharyngitis in adults. Available at: www.uptodate

Acute sinusitis and rhinosinusitis in adults. Available at: www.uptodate

Macrolides for the treatment of chronic sinusitis, asthma, and COPD

American Academy of Pediatrics: clinical practice guidelines: management of sinusitis

Available at: www.uptodate

Practice guidelines: principles of appropriate antibiotic use: part V. Acute bronchitis

Guidelines for the management of adults with community-acquired pneumonia. Diagnosis, assessment of severity, antimicrobial therapy, and prevention

Diagnosis and treatment of community-acquired pneumonia

Community-acquired pneumonia in infants and children

Urinary tract infections: management rationale for uncomplicated cystitis

Pediatric urinary tract infections

US Department of Health and Human Services

Evaluation of the acute scrotum in adults. Available at: www.uptodate

Important bacterial gastrointestinal pathogens in children: a pathogenesis perspective

Infectious Disease Society of America. Practice guidelines for the management of infectious diarrhea

Acute infectious diarrhea

Principles and practices of infectious diseases

Principles and practices of infectious diseases

Principles and practices of infectious diseases

Rifamycins and macrolides, clindamycin and ketolides

Tetracyclines and chloramphenicol

Sulfonamides and trimethoprim

Principles and practices of infectious diseases

What are restricted duty, light duty, and transitional duty, and the implications of each for case management practices?

Disability prevention principles in the primary care office

Temporary work restrictions: guidelines for the primary care provider

Work restrictions and outcome of non-specific low back pain

Minnesota Workers' Compensation System Report. Minneapolis, Minn: MN Department of Labor and Industry

Occupational medicine practice guidelines

$ indicates no more than $2/dose; $$, = $2-$5/dose; $$$, $5-$10/dose; $$$$, more than $ 10 10, [35] [36] [37] Common antibiotics used in ambulatory care and comparison of their cost, side effects, and spectrum of activity are given in Table 2 . The online home for all 57 titles in The Clinics of North America series, the most trusted sources for clinical reviews.

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