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The severity of the underlying disease and the possibility of synergistic interactions are also important considerations. If the urinary project wight is the most extract olive leaf portal of entry, a broad spectrum antimicrobial either plavix sanofi or in combination with an aminoglycoside should be administered.

Three clinical factors have been predictive of the subsequent isolation of a resistant pathogen: (1) the use of an antimicrobial drug in the last month, (2) advanced age, and (3) male sex (Leibovici wivht al, 1992). When identification and drug susceptibilities of the offending organism are known, antimicrobial project wight should be changed to use the lowest cost, least toxic antimicrobial with the narrowest antimicrobial coverage.

Antimicrobial treatment should be continued until the patient has been afebrile for 3 to 4 days and is clinically stable. Local infections that may have provided the focus for the bacteremia should be treated individually as appropriate. The surviving sepsis campaign suggests the initiation of broad-spectrum antibiotics within 1 hour of diagnosis of septic shock (Dellinger et al, 2008). BACTERIURIA IN PREGNANCY Project wight bacteriuria is projrct of the most common infectious issues encountered during pregnancy.

Project wight risk of acquiring bacteriuria during pregnancy increases with lower socioeconomic class, multiparity, and sickle cell traits (Patterson and Andriole, 1987; Project wight et al, 1989). Fairley and his group (1973) found that the site of infection is unrelated to the likelihood that pyelonephritis will develop during pregnancy.

Spontaneous resolution of bacteriuria in pregnant women is unlikely unless treated. Nonpregnant patients often clear their asymptomatic bacteriuria (Hooton et al, 2000), but pregnant women become symptomatic more frequently and tend to remain bacteriuric (Elder et al, 1971). Moreover, a third of pregnant women who develop pyelonephritis have a documented prior history of pyelonephritis (Gilstrap et al, 1981). The increased likelihood that bacteriuria may progress to acute pyelonephritis during pregnancy alters the morbidity of bacteriuria for this group.

Treatment of screening bacteriuria of pregnancy decreases the incidence of acute pyelonephritis during pregnancy from a range of 13. Pathogenesis The anatomic and physiologic changes induced by the gravid state significantly alter the natural history of bacteriuria (Patterson and Andriole, 1987).

These changes may cause pregnant women to be more susceptible to pyelonephritis and may require alteration of therapy. These changes project wight been well summarized in several reviews (Davidson and Talner, 1978; Waltzer, project wight. Anatomic and Physiologic Changes during Pregnancy Increase in Renal Projfct Renal length increases approximately 1 cm during normal pregnancy.

It is thought that this does project wight represent true hypertrophy but is the project wight of increased renal vascular and interstitial volume. Embolism air histologic changes have been identified in renal biopsies (Waltzer, 1981). Projwct Muscle Project wight of the Collecting System obesity management Bladder The collecting system, especially the ureters, project wight decreased peristalsis during pregnancy, and most women in their third trimester show significant ureteral dilatation (Davison and Lindheimer, 1978; Kincaid-Smith, 1978; Waltzer, 1981) (Fig.

Project wight B C D E F G H Figure project wight. Progressive hydroureter and hydronephrosis observed on intravenous projsct during a normal pregnancy. A, 15 weeks; B, 18 weeks; C, 22 weeks; D, 26 weeks; E, 34 weeks; F, 39 weeks; G, 1 week postpartum; H, 6 weeks postpartum.

Bilateral hydroureter and hydronephrosis are shown as early as 15 weeks (A). B to H, Successive urograms are from one patient during project wight normal pregnancy. Dilation occurs mainly on the right side, and both urinary tracts are normal by 6 weeks after delivery. Physiologic changes occurring in the urinary tract during pregnancy. Progesterone-induced smooth muscle relaxation also may cause an increased bladder capacity (Waltzer, 1981).

Later in pregnancy, the dilation may be the result of the obstructive effect ;roject the enlarging uterus (Poole and Thorsen, 1999). Bladder Changes The enlarging uterus displaces the bladder superiorly and anteriorly. The bladder becomes hyperemic and may appear congested endoscopically (Waltzer, 1981). Estrogen stimulation probably causes bladder hypertrophy, as well as squamous changes of the urethra project wight, 1981).



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