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Ear Infection [Otitis Media]

Ear Infection

What is an ear infection?

Ear infections can affect the ear canal or the middle ear.

Acute otitis externa (AOE) is the scientific name for an infection of the ear canal, which is also called swimmer’s ear.

Middle ear infections are called Otitis Media, and there are two types of middle ear infections:

  • Otitis Media with Effusion (OME) occurs when fluid builds up in the middle ear without pain, pus, fever, or other signs and symptoms of infection.
  • Acute Otitis Media (AOM) occurs when fluid builds up in the middle ear and is often caused by bacteria, but can also be caused by viruses.

 

How are ear infections caused and how can they be prevented?

Bacteria

AOM is often caused by bacteria, and Streptococcus pneumoniae is a common bacterial cause of AOM.

→ Ensure your child is up to date on vaccinations, including the pneumococcal vaccination which protects against Streptococcus pneumoniae. Breast feeding exclusively until your baby is 6 months old and continuing to breastfeed for at least 12 months can protect your baby from infections, including AOM.

Be Antibiotics Aware: Smart use, Best Care

On This Page

  • What is an ear infection?
  • How are ear infections caused and how can they be prevented?
  • How are ear infections treated?

Anatomy of the ear showing where fluid builds up in the middle ear and puts pressure, or pushes, on the ear.

Cold and Flu Season 

AOM often occurs after a cold. Viruses cause OME (fluid in the middle ear), and then bacteria can grow in the fluid leading to AOM.

  • Ensure your child is up to date on vaccinations and gets a flu vaccine every year.

Injury to the Ear 

Foreign objects, like cotton swabs and bobby pins, can cause cuts and bruises in the ear canal that can get infected, causing acute otitis external AOE.

  • Avoid putting foreign objects in the ear.

Cigarette Smoke 

Exposure to cigarette smoke can lead to more colds and more AOM.

  • Avoid smoking and exposure to secondhand smoke.

Family History

The tendency to develop AOM can run in families.

  • Family history is not preventable. Instead, focus on other prevention methods, like staying up to date on vaccinations, breast feeding, and avoiding smoke.

How are ear infections treated?

  • AOE is usually treated with antibiotic ear drops.
  • OME usually goes away on its own and does not benefit from antibiotics.
  • AOM may not need antibiotics in many cases because the body’s immune system can fight off the infection without help from antibiotics, but sometimes antibiotics are needed.

Watchful Waiting

  • Mild AOM often will get better on its own without antibiotic treatment, so your healthcare professional may recommend watchful waiting before prescribing antibiotics to you or your loved one. This means that your provider may wait a few days before deciding whether to prescribe
    antibiotics, while treating the symptoms of AOM. Watchful waiting gives your or your child’s own immune system time to fight off the infection first
    before starting antibiotics. If you or your child don’t get better in 2–3 days or get worse, your healthcare professional can recommend starting antibiotics.
  • Another form of watchful waiting is delayed prescribing. This means that your healthcare professional may give you an antibiotic prescription, but
    ask you to wait 2–3 days to see if you or your child are still sick with fever, ear pain, or other symptoms before filling the prescription.

Symptom Relief

There are ways to relieve symptoms associated with ear infections – like ear pain – whether or not antibiotics are needed. Consider using acetaminophen
or ibuprofen to relieve pain or fever. Ask your healthcare professional or pharmacist what medications are safe for you or your loved one to take.

Antibiotics, such as amoxicillin, are used to treat severe ear infections or ear infections that last longer than 2–3 days.

If your child has a fever of 102.2°F (39°C) or higher, discharge or fluid coming from the ear, symptoms are much worse, or symptoms last for more than two or three days for AOM, you should contact your healthcare professional. If your child has symptoms of OME for more than one month or hearing loss, contact your healthcare professional.

 

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E.coli (Escherichia coli)

Escherichia coli (abbreviated as E. coli) are bacteria found in the environment, foods, and intestines of people and animals. E. coli are a large and diverse group of bacteria. Although most strains of E. coli are harmless, others can make you sick. Some kinds of E. coli can cause diarrhea, while others cause urinary tract infections, respiratory illness and pneumonia, and other illnesses.

Symptoms

Symptoms of Shiga toxin-producing E. coli (STEC) infection vary for each person, but often include severe stomach cramps, diarrhea (often bloody), and vomiting. Some people may have a fever, which usually is not very high (less than 101˚F/38.5˚C). Most people get better within 5 to 7 days. Some infections are very mild, but others are severe or even life-threatening.

Most people with a STEC infection start feeling sick 3 to 4 days after eating or drinking something that contains the bacteria. However, illnesses can start anywhere from 1 to 10 days after exposure. Contact your healthcare provider if you have diarrhea that lasts for more than 3 days or is accompanied by high fever, blood in the stool, or so much vomiting that you cannot keep liquids down and you pass very little urine.

Hemolytic Uremic Syndrome (HUS)

About 5 to 10% of people who are diagnosed with STEC infection develop a potentially life-threatening complication known as hemolytic uremic syndrome (HUS). HUS develops about 7 days after symptoms first appear, when diarrhea is improving. Clues that someone is developing HUS include decreased frequency of urination, feeling very tired, and losing pink color in cheeks and inside the lower eyelids. People with HUS should be hospitalized because their kidneys may stop working and they may develop other serious problems. Most people with HUS recover within a few weeks, but some suffer permanent damage or die.

Prevention

Escherichia coli (abbreviated as E. coli) are bacteria found in the environment, foods, and intestines of people and animals.

Most E. coli are harmless and are actually an important part of a healthy human intestinal tract. However, some E. coli can cause diarrhea, urinary tract infections, respiratory illness, bloodstream infections, and other illnesses. The types of E. coli that can cause illness can be transmitted through contaminated water or food, or through contact with animals or people.

What are Shiga toxin-producing E. coli?

Some kinds of E. coli bacteria cause disease when they make a toxin called Shiga toxin. The bacteria that make these toxins are called “Shiga toxin-producing E. coli,” or STEC for short.

How can I prevent a STEC infection?

someone washing hands

  • Know your chances of getting food poisoning. People with higher chances for foodborne illness are pregnant women, newborns, children, older adults, and those with weak immune systems, such as people with cancer, diabetes, or HIV/AIDS.
  • Practice proper hygiene, especially good handwashing.
    • Wash your hands thoroughly after using the bathroom and changing diapers.
    • Wash your hands thoroughly before and after preparing or eating food.
    • Wash your hands thoroughly after contact with animals or their environments (at farms, petting zoos, fairs, even your own backyard).
    • Wash your hands thoroughly before preparing and feeding bottles or foods to an infant or toddler, before touching an infant or toddler’s mouth, and before touching pacifiers or other things that go into an infant or toddler’s mouth.
    • Keep all objects that enter infants’ and toddlers’ mouths (such as pacifiers and teethers) clean.
    • If soap and water aren’t available, use an alcohol-based hand sanitizer with at least 60% alcohol (check the product label to be sure). These alcohol-based products can quickly reduce the number of germs on hands in some situations, but they are not a substitute for washing with soap and running water.
  • Follow the four steps to food safety when preparing food: cleanseparatecook, and chill.
  • Wash fruits and vegetables well under running water, unless the package says the contents have already been washed.

  • Cook meats thoroughly:
    • To kill harmful germs, cook beef steaks and roasts to an internal temperature of at least 145°F (62.6˚C) and allow to rest for 3 minutes after you remove meat from the grill or stove.
    • Cook ground beef and pork to a minimum internal temperature of 160°F (70˚C).
    • Always use a food thermometer to check that the meat has reached a safe internal temperature because you can’t tell whether meat is safely cooked by looking at its color.
  • Don’t cause cross-contamination in food preparation areas. Thoroughly wash hands, counters, cutting boards, and utensils after they touch raw meat.
  • Avoid raw milk, unpasteurized dairy products, and unpasteurized juices (such as fresh apple cider).
  • Don’t swallow water when swimming and when playing in lakes, ponds, streams, swimming pools, and backyard “kiddie” pools.

 

Thromboembolism (Blood Clots)

Venous thromboembolism (VTE), also known as blood clots, is an underdiagnosed and serious, but preventable medical condition. It is important to know about VTE because it can happen to anybody at any age and cause serious illness, disability, and in some cases, death. The good news is that VTE can be prevented and treated if discovered early.

Basics

Blood clot

Deep Vein Thrombosis and Pulmonary Embolism (DVT/PE) are often underdiagnosed and serious, but preventable medical conditions.

Deep vein thrombosis (DVT) is a medical condition that occurs when a blood clot forms in a deep vein. These clots usually develop in the lower leg, thigh, or pelvis, but they can also occur in the arm.

It is important to know about DVT because it can happen to anybody and can cause serious illness, disability, and in some cases, death. The good news is that DVT is preventable and treatable if discovered early.

Complications of DVT

The most serious complication of DVT happens when a part of the clot breaks off and travels through the bloodstream to the lungs, causing a blockage called pulmonary embolism (PE). If the clot is small, and with appropriate treatment, people can recover from PE. However, there could be some damage to the lungs. If the clot is large, it can stop blood from reaching the lungs and is fatal.

In addition, nearly one-third of people who have a DVT will have long-term complications caused by the damage the clot does to the valves in the vein called post-thrombotic syndrome (PTS). People with PTS have symptoms such as swelling, pain, discoloration, and in severe cases, scaling or ulcers in the affected part of the body. In some cases, the symptoms can be so severe that a person becomes disabled.

For some people, DVT and PE can become a chronic illness; about 30% of people who have had a DVT or PE are at risk for another episode.

Risk Factors for DVT

Almost anyone can have a DVT. However, certain factors can increase the chance of having this condition. The chance increases even more for someone who has more than one of these factors at the same time.

Everyone Is at Risk. Some Factors Can Increase This Risk. 

Following is a list of factors that increase the risk of developing DVT:

  • Injury to a vein, often caused by:
    • Fractures,
    • Severe muscle injury, or
    • Major surgery (particularly involving the abdomen, pelvis, hip, or legs).
  • Slow blood flow, often caused by:
    • Confinement to bed
      (e.g., due to a medical condition or after surgery);
    • Limited movement (e.g., a cast on a leg to help heal an injured bone);
    • Sitting for a long time, especially with crossed legs; or
    • Paralysis.
  • Increased estrogen, often caused by:
    • Birth control pills
    • Hormone replacement therapy, sometimes used after menopause
    • Pregnancy, for up to 6 weeks after giving birth
  • Certain chronic medical illnesses, such as:
    • Heart disease
    • Lung disease
    • Cancer and its treatment
    • Inflammatory bowel disease (Crohn’s disease or ulcerative colitis)
  • Other factors that increase the risk of DVT include:
    • Previous DVT or PE
    • Family history of DVT or PE
    • Age (risk increases as age increases)
    • Obesity
    • A catheter located in a central vein
    • Inherited clotting disorders

Preventing DVT

female running

The following tips can help prevent DVT:

  • Move around as soon as possible after having been confined to bed, such as after surgery, illness, or injury.
  • If you’re at risk for DVT, talk to your doctor about:
    • Graduated compression stockings (sometimes called “medical compression stockings”)
    • Medication (anticoagulants) to prevent DVT.
  • When sitting for long periods of time, such as when traveling for more than four hours:
    • Get up and walk around every 2 to 3 hours.
    • Exercise your legs while you’re sitting by:
      • Raising and lowering your heels while keeping your toes on the floor
      • Raising and lowering your toes while keeping your heels on the floor
      • Tightening and releasing your leg muscles
    • Wear loose-fitting clothes.
  • You can reduce your risk by maintaining a healthy weight, avoiding a sedentary lifestyle, and following your doctor’s recommendations based on your individual risk factors.

Symptoms

Know the Signs. Know your Risk. Seek Care.

Everybody should know the signs and symptoms of DVT/PE, their risk for DVT/PE, to talk to their health care provider about their risk, and to seek care immediately if they have any sign or symptom of DVT/PE.

DVT

Downloadable slideshow on DVT

DVT Slideshow widget thumbnailThis narrated slideshow describes the risk factors, signs, and symptoms of DVT/PE.

About half of people with DVT have no symptoms at all. The following are the most common symptoms of DVT that occur in the affected part of the body:

  • Swelling
  • Pain
  • Tenderness
  • Redness of the skin

If you have any of these symptoms, you should see your doctor as soon as possible.

PE

You can have a PE without any symptoms of a DVT.

Signs and symptoms of PE can include:

  • Difficulty breathing
  • Faster than normal or irregular heart beat
  • Chest pain or discomfort, which usually worsens with a deep breath or coughing
  • Coughing up blood
  • Very low blood pressure, lightheadedness, or fainting

If you have any of these symptoms, you should seek medical help immediately.

Diagnosis of DVT and PE

The diagnosis of DVT or PE requires special tests that can only be performed by a doctor. That is why it is important for you to seek medical care if you experience any of the symptoms of DVT or PE.

Learn more about diagnosis »

Treatments for DVT and PE

DVT

Medication is used to prevent and treat DVT. Compression stockings (also called graduated compression stockings) are sometimes recommended to prevent DVT and relieve pain and swelling. These might need to be worn for 2 years or more after having DVT. In severe cases, the clot might need to be removed surgically.

PE

Immediate medical attention is necessary to treat PE. In cases of severe, life-threatening PE, there are medicines called thrombolytics that can dissolve the clot.  Other medicines, called anticoagulants, may be prescribed to prevent more clots from forming. Some people may need to be on medication long-term to prevent future blood clots.

Learn more about treatments »

Did you know?

DVT does not cause heart attack or stroke. There are two main types of blood clots.
How a clot affects the body depends on the type and location of the clot:

  • A blood clot in a deep vein of the leg, pelvis, and sometimes arm, is called deep vein thrombosis (DVT). This type of blood clot does not cause heart attack or stroke.
  • A blood clot in an artery, usually in the heart or brain, is called arterial thrombosis. This type of blood clot can cause heart attack or stroke.

Both types of clots can cause serious health problems, but the causes and steps you can take to protect yourself are different. To learn more about arterial thrombosis, visit CDC’s information about heart disease and stroke prevention.

C. neoformans Infection

C. neoformans Infection

Cryptococcus neoformans is a fungus that lives in the environment throughout the world. People can become infected with C. neoformans after breathing in the microscopic fungus, although most people who are exposed to the fungus never get sick from it. C. neoformans infections are extremely rare in people who are otherwise healthy; most cases occur in people who have weakened immune systems, particularly those who have advanced HIV/AIDS.

Definition of C. neoformans Infection

A photomicrograph of Cryptococcus neoformans using a light India ink staining preparation.

A photomicrograph of C. neoformans stained with India ink.

Cryptococcus neoformans (abbreviated C. neoformans) is a fungus that lives in the environment throughout the world. People can become infected with C. neoformans after breathing in the microscopic fungus, although most people who are exposed to the fungus never get sick from it.

Infection with the fungus Cryptococcus (either C. neoformans or C. gattii) is called cryptococcosis. Cryptococcosis usually affects the lungs or the central nervous system (the brain and spinal cord), but it can also affect other parts of the body. Brain infections due to the fungus Cryptococcus are called cryptococcal meningitis.

C. neoformans infections are extremely rare in people who are otherwise healthy. Most cases of C. neoformans infection occur in people who have weakened immune systems, particularly those who have advanced HIV/AIDS.

Symptoms of C. neoformans Infection

A woman coughing

Cough is a common symptom of Cryptococcus infection in the lungs.

C. neoformans usually infects the lungs or the central nervous system (the brain and spinal cord), but it can also affect other parts of the body. The symptoms of the infection depend on the parts of the body that are affected.14

In the lungs

A C. neoformans infection in the lungs can cause a pneumonia-like illness. The symptoms are often similar to those of many other illnesses, and can include:

  • Cough
  • Shortness of breath
  • Chest pain
  • Fever

In the brain (cryptococcal meningitis)

Cryptococcal meningitis is an infection caused by the fungus Cryptococcus after it spreads from the lungs to the brain. The symptoms of cryptococcal meningitis include:

Man holding head.  Man holding neck.

Headache, fever, and neck pain are common symptoms of cryptococcal meningitis.

  • Headache
  • Fever
  • Neck pain
  • Nausea and vomiting
  • Sensitivity to light
  • Confusion or changes in behavior

If you have symptoms that you think may be due to a C. neoformans infection, please contact your healthcare provider.

C. neoformans Infection Risk & Prevention

C. neoformans infections are extremely rare among people who are otherwise healthy. Most cases of C. neoformans infection occur in people who have weakened immune systems13, such as people who:

  • Have advanced HIV/AIDS,
  • Have had an organ transplant, or
  • Are taking corticosteroids, medications to treat rheumatoid arthritis, or other medications that weaken the immune system.

No. The infection can’t spread between people or between people and animals.

Yes. Pets can get C. neoformans infections, but it is very rare, and the infection cannot spread between animals and people.45 If you’re concerned about your pet’s risk of getting a C. neoformans infection, or if you think that your pet has the infection, please talk to a veterinarian.

It’s difficult to avoid breathing in C. neoformans because it’s thought to be common in the environment. Most people who breathe in C. neoformans never get sick from it. However, in people who have weakened immune systems, C. neoformans can stay hidden in the body and cause infection later when the immune system becomes too weak to fight it off. This leaves a window of time when the silent infection can be detected and treated early, before symptoms develop (see “Detecting silent cryptococcal infection in people who have HIV/AIDS”).

One approach to prevent cryptococcal meningitis is called “targeted screening.” Research suggests that C. neoformans is able to live in the body undetected, especially when a person’s immune system is weaker than normal. In a targeted screening program, a simple blood test is used to detect cryptococcal antigen (an indicator of cryptococcal infection) in HIV-infected patients before they begin taking antiretroviral treatment (ART). A patient who tests positive for cryptococcal antigen can take fluconazole, an antifungal medication, to fight off the silent fungal infection and prevent it from developing into life-threatening meningitis.

CDC is assisting areas of the world where the prevalence of cryptococcal infections is high, such as sub-Saharan Africa and Southeast Asia, to prevent deaths from cryptococcal infections by helping implement targeted screening programs to detect early cryptococcal disease in HIV-infected persons. Because many of the countries in these areas of the world often don’t have the resources needed to detect Cryptococcus as the underlying cause of meningitis, CDC is also helping these countries build their laboratory capacity. Early identification of cryptococcal-infected patients in resource-limited settings may lead to more timely treatment, reduced mortality due to cryptococcal meningitis, and overall improved quality of life.

Sources of C. neoformans

Where does C. neoformans live?

C. neoformans lives in the environment throughout the world. The fungus is typically found in soil, on decaying wood, in tree hollows, or in bird droppings.

How does someone get a C. neoformans infection?

C. neoformans infections are not contagious. Humans and animals can get the infection after inhaling the microscopic fungus from the environment. Some research suggests that people may be exposed to C. neoformans in the environment when they are children.3 Most people who breathe in C. neoformans never get sick from it. However, in people who have weakened immune systems, C. neoformans can stay hidden in the body and cause infection later when the immune system becomes too weak to fight it off.

Diagnosis and Testing for C. neoformans Infection

This 800X magnification photomicrograph shows a sample of lung tissue infected with Cryptococcus fungal organisms.

Your healthcare provider may take a sample of blood to test for cryptococcal antigen.

How is a C. neoformans infection diagnosed?

Healthcare providers rely on your medical history, symptoms, physical examinations, and laboratory tests to diagnose a C. neoformans infection.

Your healthcare provider will take a sample of tissue or body fluid (such as blood, cerebrospinal fluid, or sputum) and send the sample to a laboratory to be examined under a microscope, tested with an antigen test, or cultured. Your healthcare provider may also perform tests such as a chest x-ray or CT scan of your lungs, brain, or other parts of the body.

Treatment for C. neoformans Infection

How are C. neoformans infections treated?

People who have C. neoformans infection need to take prescription antifungal medication for at least 6 months, often longer. The type of treatment usually depends on the severity of the infection and the parts of the body that are affected.

  • For people who have asymptomatic infections (e.g., diagnosed via targeted screening) or mild-to-moderate pulmonary infections, the treatment is usually fluconazole.
  • For people who have severe lung infections or infections in the central nervous system (brain and spinal cord), the recommended initial treatment is amphotericin B in combination with flucytosine. After that, patients usually need to take fluconazole for an extended time to clear the infection.

The type, dose, and duration of antifungal treatment may differ for certain groups of people, such as pregnant women, children, and people in resource-limited settings. Some people may also need surgery to remove fungal growths (cryptococcomas).

Bacterial Meningitis

On This Page

  • Causes
  • Risk Factors
  • How it Spreads
  • Signs & Symptoms
  • Diagnosis
  • Treatment
  • Prevention
  • Reference

Español: Meningitis bacteriana

Bacterial meningitis is very serious and can be deadly. Death can occur in as little as a few hours. Most people recover from meningitis. However, permanent disabilities (such as brain damage, hearing loss, and learning disabilities) can result from the infection.

There are several types of bacteria that can cause meningitis. Leading causes in the United States include

  • Streptococcus pneumoniae
  • Group B Streptococcus
  • Neisseria meningitidis
  • Haemophilus influenzae
  • Listeria monocytogenes

On average, bacterial meningitis caused about 4,100 cases and 500 deaths in the United States each year between 2003 and 2007.

These bacteria can also be associated with another serious illness, sepsis. Sepsis is the body’s overwhelming and life-threatening response to infection that can cause tissue damage, organ failure, and death.

Causes

Common causes of bacterial meningitis vary by age group:

  • Newborns: Group B Streptococcus, Streptococcus pneumoniae, Listeria monocytogenes, Escherichia coli
  • Babies and children: Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), group B Streptococcus
  • Teens and young adults: Neisseria meningitidis, Streptococcus pneumoniae
  • Older adults: Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae type b (Hib), group B Streptococcus, Listeria monocytogenes

 

Risk Factors

Certain people are at increased risk for bacterial meningitis. Some risk factors include:

  • Age
    • Babies are at increased risk for bacterial meningitis compared to people in other age groups. However, people of any age can develop bacterial meningitis. See section above for which bacteria more commonly affect which age groups.
  • Community setting
    • Infectious diseases tend to spread where large groups of people gather together. College campuses have reported outbreaks of meningococcal disease, caused by N. meningitidis.
  • Certain medical conditions
    • There are certain medical conditions, medications, and surgical procedures that put people at increased risk for meningitis.
  • Working with meningitis-causing pathogens
    • Microbiologists routinely exposed to meningitis-causing bacteria are at increased risk for meningitis.
  • Travel
    • Travelers may be at increased risk for meningococcal disease, caused by N. meningitidis, if they travel to certain places, such as:
      • The meningitis belt in sub-Saharan Africa, particularly during the dry season
      • Mecca during the annual Hajj and Umrah pilgrimage

How it Spreads

Generally, the germs that cause bacterial meningitis spread from one person to another. Certain germs, such as Listeria monocytogenes, can spread through food.

How people spread the germs often depends on the type of bacteria. It is also important to know that people can carry these bacteria in or on their bodies without being sick. These people are “carriers.” Most carriers never become sick, but can still spread the bacteria to others.

Here are some of the most common examples of how people spread each type of bacteria to each other:

  • Mothers can pass group B Streptococcus and Escherichia coli to their babies during labor and birth.
  • People spread Hib and Streptococcus pneumoniae by coughing or sneezing while in close contact with others, who breathe in the bacteria.
  • People spread Neisseria meningitidis by sharing respiratory or throat secretions (saliva or spit). This typically occurs during close (coughing or kissing) or lengthy (living in the same household) contact.
  • People can get Escherichia coli by eating food prepared by people who did not wash their hands well after using the toilet.

People usually get sick from Escherichia coli and Listeria monocytogenes by eating contaminated food.

Signs and Symptoms

Pregnancy

Pregnant women are at increased risk of developing listeriosis, an infection caused by the bacteria Listeria monocytogenes. Pregnant women with listeriosis typically experience only fever and other flu-like symptoms, such as fatigue and aches. Infection during pregnancy can lead to miscarriage, stillbirth, premature delivery, or life-threatening infection of the newborn, including meningitis. Pregnant women can reduce their risk of meningitis caused by Listeria monocytogenes. You can reduce the risk that you and your baby will get meningitis caused by Listeria monocytogenes by avoiding certain foods and safely preparing others.

Pregnant women can pass group B Streptococcus (group B strep) to their baby during labor and delivery. A newborn infected with group B strep can develop meningitis or other life-threatening infections soon after birth. Talk with your doctor or midwife about getting a group B test when you are 35 to 37 weeks pregnant. Doctors give antibiotics (during labor) to women who test positive in order to prevent infection in newborns.

Meningitis symptoms include sudden onset of fever, headache, and stiff neck. There are often other symptoms, such as

  • Nausea
  • Vomiting
  • Photophobia (increased sensitivity to light)
  • Altered mental status (confusion)

In newborns and babies, the meningitis symptoms of fever, headache, and neck stiffness may be absent or difficult to notice. The baby may be irritable, vomit, feed poorly, or appear to be slow or inactive. In young babies, doctors may also look for a bulging fontanelle (soft spot on infant’s head) or abnormal reflexes. If you think your baby or child has any of these symptoms, call the doctor right away.

Symptoms of bacterial meningitis can appear quickly or over several days. Typically they develop within 3 to 7 days after exposure

Later symptoms of bacterial meningitis can be very serious (e.g., seizures, coma). For this reason, anyone who thinks they may have meningitis should see a doctor as soon as possible.

Diagnosis

If a doctor thinks you have meningitis, they will collect samples of blood or cerebrospinal fluid (fluid near the spinal cord). A laboratory will test the samples to see what is causing the infection. It is important to know the specific cause of meningitis so the doctors know how to treat it.

Treatment

Doctors treat bacterial meningitis with a number of antibiotics. It is important to start treatment as soon as possible.

Prevention

The most effective way to protect you and your child against certain types of bacterial meningitis is to get vaccinated. There are vaccines for three types of bacteria that can cause meningitis:

  • Neisseria meningitidis
  • Streptococcus pneumoniae
  • Hib

Make sure you and your child are vaccinated on schedule.

Like with any vaccine, the vaccines that protect against these bacteria are not 100% effective. The vaccines also do not protect against all the types (strains) of each bacteria. For these reasons, there is still a chance you can develop bacterial meningitis even if you were vaccinated.

Pregnant women should talk to their doctor or midwife about getting tested for group B Streptococcus. Women receive the test when they are 35 to 37 weeks pregnant. Doctors give antibiotics (during labor) to women who test positive in order to prevent passing group B Strep to their newborns.

Pregnant women can also reduce their risk of meningitis caused by Listeria monocytogenes. Women should avoid certain foods during pregnancy and safely prepare others.

If someone has bacterial meningitis, a doctor may recommend antibiotics to help prevent other people from getting sick. Doctors call this prophylaxis.  CDC recommends prophylaxis for:

  • Close contacts of someone with meningitis caused by Neisseria meningitidis
  • Family members, especially if they are at increased risk, of someone with a serious Hib infection

Your doctor or local health department will tell you if you or someone in your house needs prophylaxis.

You can also help protect yourself and others from bacterial meningitis by maintaining healthy habits:

  • Don’t smoke and avoid cigarette smoke
  • Get plenty of rest
  • Avoid close contact with people who are sick

This is especially important for people at increased risk for disease, including:

  • Young babies
  • Older adults
  • People with weak immune systems
  • People without a spleen or a spleen that doesn’t work the way it should (functional asplenia)

 


Reference

  1. Thigpen MC, Whitney CG, Messonnier NE, Zell ER, Lynfield R, Hadler JL, et al. Emerging Infections Programs Network. Bacterial meningitis in the United States, 1998-2007. N Engl J Med. 2011;364:2016-25.

Aortic Aneurysm

Aortic Aneurysm

An aortic aneurysm is a balloon-like bulge in the aorta, the large artery that carries blood from the heart through the chest and torso.

This image shows a normal aorta, and next to it shows a thoracic aortic aneurysm. It also shows an abdominal aortic aneurysm that is located below the arteries that supply blood to the kidneys.On the right, Figure A shows a normal aorta. Figure B shows a thoracic aortic aneurysm located behind the heart. Figure C shows an abdominal aortic aneurysm located below the arteries that supply blood to the kidneys. (Image courtesy of the National Heart, Lung, and Blood Institute)

Aortic aneurysms work in two ways:

  • The force of blood pumping can split the layers of the artery wall, allowing blood to leak in between them. This process is called a dissection.
  • The aneurysm can burst completely, causing bleeding inside the body. This is called a rupture.
  • Dissections and ruptures are the cause of most deaths from aortic aneurysms.

Aortic Aneurysm in the United States

  • Aortic aneurysms were the primary cause of 9,863 deaths in 2014 and a contributing cause in more than 17,215 deaths in the United States in 2009.1,2
  • About two-thirds of people who have an aortic dissection are male.3
  • The U.S. Preventive Services Task Force recommends that men aged 65–75 years who have ever smoked should get an ultrasound screening for abdominal aortic aneurysms, even if they have no symptoms.4

Types of Aortic Aneurysm

Thoracic Aortic Aneurysms

A thoracic aortic aneurysm occurs in the chest. Men and women are equally likely to get thoracic aortic aneurysms, which become more common with increasing age.5

Thoracic aortic aneurysms are usually caused by high blood pressure or sudden injury. Sometimes people with inherited connective tissue disorders, such as Marfan syndrome and Ehlers-Danlos syndrome, get thoracic aortic aneurysms.

Signs and symptoms of thoracic aortic aneurysm can include

  • Sharp, sudden pain in the chest or upper back.
  • Shortness of breath.
  • Trouble breathing or swallowing.

Abdominal Aortic Aneurysms

Man clutching his stomach.An abdominal aortic aneurysm occurs below the chest. Abdominal aortic aneurysms happen more often than thoracic aortic aneurysms.

Abdominal aortic aneurysms are more common in men and among people aged 65 years and older. Abdominal aortic aneurysms are less common among blacks compared with whites.6

Abdominal aortic aneurysms are usually caused by atherosclerosis (hardened arteries), but infection or injury can also cause them.7

Abdominal aortic aneurysms often don’t have any symptoms. If an individual does have symptoms, they can include

  • Throbbing or deep pain in your back or side.
  • Pain in the buttocks, groin, or legs.

Other Types of Aneurysms

Aneurysms can occur in other parts of your body. A ruptured aneurysm in the brain can cause a stroke. Peripheral aneurysms—those found in arteries other than the aorta—can occur in the neck, in the groin, or behind the knees. These aneurysms are less likely to rupture or dissect than aortic aneurysms, but they can form blood clots. These clots can break away and block blood flow through the artery.

Risk Factors for Aortic Aneurysm

Diseases that damage your heart and blood vessels also increase your risk for aortic aneurysm. These diseases include

Some inherited connective tissue disorders, such as Marfan syndrome and Ehlers-Danlos syndrome, can also increase your risk for aortic aneurysm. Your family may also have a history of aortic aneurysms that can increase your risk.

Unhealthy behaviors can also increase your risk for aortic aneurysm, especially for people who have one of the diseases listed above. Tobacco use is the most important behavior related to aortic aneurysm. People who have a history of smoking are 3 to 5 times more likely to develop an abdominal aortic aneurysm.8

Treating Aortic Aneurysm

The two main treatments for aortic aneurysms are medicines and surgery. Medicines can lower blood pressure and reduce risk for an aortic aneurysm. Surgery can repair or replace the injured section of the aorta.

CDC’s Public Health Efforts Related to Aortic Aneurysm

Web Sites with More Information About Aortic Aneurysm

For more information about aortic aneurysms, visit the following Web sites:

References

  1. Centers for Disease Control and Prevention. Underlying Cause of Death 1999-2013 on CDC WONDER Online Database, released 2015. Data are from the Multiple Cause of Death Files, 1999-2013, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. http://wonder.cdc.gov/ucd-icd10.html. Accessed on Feb 3, 2015.
  2. Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, et al. Heart disease and stroke statistics—2013 update: a report from the American Heart Association. Circulation. 2013;127:e6–e245.
  3. Ramanath VS, Oh JK, Sundt TM, Eagle KA. Acute aortic syndromes and thoracic aortic aneurysm. Mayo Clin Proc. 2009;84(5):465–81.
  4. Fleming C, Whitlock EP, Bell TL, Lederle FA. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2005;142:203–11.
  5. Clouse WD, Hallett JW Jr, Schaff HV, Gayari MM, Ilstrup DM, Melton LJ 3rd. Improved prognosis of thoracic aortic aneurysms: a population-based study. JAMA. 1998;280:1926–9.
  6. Guirguis-Blake J, Wolff TA. Screening for abdominal aortic aneurism. Am Fam Physician. 2005;71:2154–5.
  7. Creager MA, Loscalzo J. Diseases of the aorta. In: Fauci AS, Braunwald E, Kasper DL, et al., editors. Harrison’s Principles of Internal Medicine. 17th edition. Columbus, OH: McGraw-Hill; 2008.
  8. Fleming C, Whitlock EP, Bell TL, Lederle FA. Screening for abdominal aortic aneurysm: a best-evidence systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2005;142:203–11.

Anaplasmosis

Anaplasmosis is a disease caused by the bacterium Anaplasma phagocytophilum. These bacteria are spread to people by tick bites primarily from the blacklegged tick (Ixodes scapularis) and the western blacklegged tick (Ixodes pacificus).

People with anaplasmosis will often have fever, headache, chills, and muscle aches. Doxycycline is the drug of choice for adults and children of all ages with anaplasmosis.

Transmission

Figure 1: Estimated geographic distribution of blacklegged ticks (above) and western blacklegged ticks (below)

Anaplasmosis is a tickborne disease caused by the bacterium Anaplasma phagocytophilum.

  • Tick bites
  • Blood transfusion
    • In rare cases, A. phagocytophilum has been spread by blood transfusion.

Anaplasmosis is most commonly reported in the Northeastern and upper Midwestern states.

Signs and Symptoms

  • Signs and symptoms of anaplasmosis typically begin within 1–2 weeks after the bite of an infected tick.
    • Tick bites are usually painless, and many people do not remember being bitten.
  • See your healthcare provider if you become ill after having been bitten by a tick or having been in the woods or in areas with high brush where ticks commonly live.

Early Illness

Early signs and symptoms (days 1-5) are usually mild or moderate and may include:

  • Fever, chills
  • Severe headache
  • Muscle aches
  • Nausea, vomiting, diarrhea, loss of appetite

Late Illness

Rarely, if treatment is delayed or if there are other medical conditions present, anaplasmosis can cause severe illness. Prompt treatment can reduce your risk of developing severe illness.

 Signs and symptoms of severe (late stage) illness can include:

  • Respiratory failure
  • Bleeding problems
  • Organ failure
  • Death

 Risk factors for severe illness:

  • Delayed treatment
  • Age: being older puts you at risk
  • Weakened immune system: People with weakened immune systems (such as those receiving some cancer treatments, individuals with advanced HIV infection, prior organ transplants, or people taking some medications) are at risk for severe illness

Diagnosis and Testing

  • Your healthcare provider can order certain blood tests to look for evidence of anaplasmosis or other illnesses that cause similar symptoms.
  • Test results may take several weeks.
  • If your healthcare provider thinks you have anaplasmosis, or another tickborne infection, he or she may prescribe antibiotics while you wait for test results.

Treatment

  • Early treatment with the antibiotic doxycycline can prevent death and severe illness.

Doxycycline is the recommended antibiotic treatment for anaplasmosis in adults and children of all ages.

Doxycycline saves lives! A good reason to smile: Doxycycline is the #1 recommended treatment for suspected rickettsial infextions in patients of all ages.

Prevention

  • There is no vaccine to prevent anaplasmosis. Prevent illness by preventing tick bites,  preventing ticks on your pets,  and preventing ticks in your yard.
  • Ticks live in grassy, brushy, or wooded areas, or even on animals, so spending time outside camping, gardening, or hunting will bring you in close contact with ticks. Protect yourself, your family, and your pets. Here’s how:
  • Ticks can be active year-round, but ticks are most active during warmer months (April-September).

Tick exposure can occur year-round, but ticks are most active during warmer months (April-September). Know which ticks are most common in your area.

Before You Go Outdoors

  • Know where to expect ticks. Ticks live in grassy, brushy, or wooded areas, or even on animals. Spending time outside walking your dog, camping, gardening, or hunting could bring you in close contact with ticks. Many people get ticks in their own yard or neighborhood.
  • Treat clothing and gear with products containing 0.5% permethrin. Permethrin can be used to treat boots, clothing and camping gear and remain protective through several washings.
  • Use Environmental Protection Agency (EPA)-registered insect repellents containing DEET, picaridin, IR3535, Oil of Lemon Eucalyptus (OLE), para-menthane-diol (PMD), or 2-undecanone. EPA’s helpful search tool can help you find the product that best suits your needs. Always follow product instructions.
    • Do not use insect repellent on babies younger than 2 months old.
    • Do not use products containing OLE or PMD on children under 3 years old.
  • Avoid Contact with Ticks
    • Avoid wooded and brushy areas with high grass and leaf litter.
    • Walk in the center of trails.

After You Come Indoors

Check your clothing for ticks. Ticks may be carried into the house on clothing. Any ticks that are found should be removed. Tumble dry clothes in a dryer on high heat for 10 minutes to kill ticks on dry clothing after you come indoors. If the clothes are damp, additional time may be needed. If the clothes require washing first, hot water is recommended. Cold and medium temperature water will not kill ticks.

Shower soon after being outdoors. Showering within two hours of coming indoors has been shown to reduce your risk of getting Lyme disease and may be effective in reducing the risk of other tickborne diseases. Showering may help wash off unattached ticks and it is a good opportunity to do a tick check.

Check your body for ticks after being outdoors. Conduct a full body check upon return from potentially tick-infested areas, including your own backyard. Use a hand-held or full-length mirror to view all parts of your body. Check these parts of your body and your child’s body for ticks:

  • Under the arms
  • In and around the ears
  • Inside belly button
  • Back of the knees
  • In and around the hair
  • Between the legs
  • Around the waist

Examine gear and pets. Ticks can ride into the home on clothing and pets, then attach to a person later, so carefully examine pets, coats, and daypacks.

Epidemiology and Statistics

  • Anaplasmosis is a disease caused by the bacterium Anaplasma phagocytophilum.
  • This organism was previously known by other names, including Ehrlichia equi and Ehrlichia phagocytophilum, and the disease was previously known as human granulocytic ehrlichiosis (HGE).
  • However, a taxonomic change in 2001 identified that this organism belonged to the genus Anaplasma, and resulted in a change in the name of the disease to anaplasmosis.
  • In the United States, anaplasmosis was first recognized as human disease in the mid-1990s, but did not become nationally notifiable until 1999.
  • CDC compiles the number of cases reported by state and local health departments and reports national trends.

At a glance

  • The number of anaplasmosis cases reported to CDC has increased steadily since the disease became reportable, from 348 cases in 2000, to 4,151 cases in 2016.
  • The incidence (the number of cases for every million persons) of anaplasmosis has also increased, from 1.4 cases per million persons in 2000 to 6.1 cases per million persons in 2010.
  • The case fatality rate (i.e., the proportion of anaplasmosis patients that reportedly died as a result of infection) has remained low, at less than 1%.

Figure 1 – Number of U.S. anaplasmosis cases reported to CDC, 2000–2016

The graph displays the number of human cases of anaplasmosis reported to CDC annually from 2000 through 2016. *From 2000 to 2008, anaplasmosis was included in the reporting category “human granulocytic ehrlichiosis” in reports to NNDSS. **Since 2008, anaplasmosis has been reported to NNDSS in its own reporting category called “Anaplasma phagocytophilum”. Cases of anaplasmosis have generally increased from 350 cases in 2000, when the disease became nationally notifiable, to 1,163 cases in 2009, and 4,151 cases in 2016. The number of cases increased 14% between 2015 and 2016.The graph displays the number of human cases of anaplasmosis reported to CDC annually from 2000 through 2016. *From 2000 to 2008, anaplasmosis was included in the reporting category “human granulocytic ehrlichiosis” in reports to NNDSS. **Since 2008, anaplasmosis has been reported to NNDSS in its own reporting category called “Anaplasma phagocytophilum”. Cases of anaplasmosis have generally increased from 350 cases in 2000, when the disease became nationally notifiable, to 1,163 cases in 2009, and 4,151 cases in 2016. The number of cases increased 14% between 2015 and 2016.

Seasonality

  • Although cases of anaplasmosis can occur during any month of the year, the majority of cases reported to the CDC have an illness onset during the summer months and a peak in cases typically occurs in June and July.
  • This period is the season for increased numbers of nymphal blacklegged ticks, which is the primary life stage of this tick that bites humans and can transmit the pathogen.
  • A second, smaller peak occurs in October and November and corresponds with the period of adult blacklegged tick activity.

Figure 2 – Number of reported anaplasmosis cases by month of onset, 2000–2016

The figure shows the number of cases reported from 2000 through 2016 by month of onset to give the seasonality of cases. There are cases reported in each month of the year, however most are reported in June and July. More than 50% of all cases occur in June and July. The figure shows the number of cases reported from 2000 through 2016 by month of onset to give the seasonality of cases. There are cases reported in each month of the year, however most are reported in June and July. More than 50% of all cases occur in June and July.

Geography

  • Anaplasmosis is most frequently reported from the upper midwestern and northeastern United States.
  • These areas correspond with the known geographic distribution of the blacklegged tick (Ixodes scapularis), the primary tick vector of A. phagocytophilum.
  • This tick also transmits the agents of Lyme disease (Borrelia burgdorferi) and other human pathogens; co-infections with these organisms have occasionally been reported.
  • The geographic range of anaplasmosis appears to be increasing, which is consistent with the blacklegged tick’s expanding range.
  • Increasing ranges for the blacklegged tick have been documented along the Hudson River Valley, Michigan, and Virginia.
  • Eight states (Vermont, Maine, Rhode Island, Minnesota, Massachusetts, Wisconsin, New Hampshire, and New York) account for 90% of all reported cases of anaplasmosis.
  • Occasionally, anaplasmosis cases are reported in other parts of the United States, including southeastern and south-central states where the organism has not been commonly found.
  • Some of these cases might be due to patient travel to states with higher levels of disease, or misdiagnosis of anaplasmosis in patients actually infected with another closely related tickborne disease, ehrlichiosis.

Figure 3 – Annual reported incidence (per million population) for anaplasmosis – United States, 2016. (NN= Not notifiable)

Map of the United States that shows the incidence of anaplasmosis cases by state in 2016 per million persons. Anaplasmosis was not notifiable in Alaska, Colorado, the District of Columbia, Hawaii, Idaho, or New Mexico in 2016. The incidence rate was zero for Arizona, Georgia, Indiana, Louisiana, Mississippi, Montana, Nevada, South Carolina, Utah, Washington, and West Virginia. Incidence ranged from > 0 to 3.0 cases per million persons in California, Kentucky, Oregon, Florida, Ohio, Illinois, Michigan, Oklahoma, Nebraska, Alabama, Maryland, South Dakota, Kansas, North Carolina, Wyoming, Tennessee, Virginia, Missouri, and Iowa. Incidence ranged from > 3 to 26 cases per million persons in Delaware, Pennsylvania, Arkansas, New Jersey and North Dakota. Incidence ranged from > 26 to 130 cases per million persons in Connecticut, New York, New Hampshire, Wisconsin, and Massachusetts. The highest incidence rates, greater than 130 cases per million persons, were found in Minnesota, Rhode Island, Maine, and Vermont.The figure shows the incidence of anaplasmosis cases by state in 2016 per million persons. Anaplasmosis was not notifiable in Alaska, Colorado, the District of Columbia, Hawaii, Idaho, or New Mexico in 2016. The incidence rate was zero for Arizona, Georgia, Indiana, Louisiana, Mississippi, Montana, Nevada, South Carolina, Utah, Washington, and West Virginia. Incidence ranged from > 0 to 3.0 cases per million persons in California, Kentucky, Oregon, Florida, Ohio, Illinois, Michigan, Oklahoma, Nebraska, Alabama, Maryland, South Dakota, Kansas, North Carolina, Wyoming, Tennessee, Virginia, Missouri, and Iowa. Incidence ranged from > 3 to 26 cases per million persons in Delaware, Pennsylvania, Arkansas, New Jersey and North Dakota. Incidence ranged from > 26 to 130 cases per million persons in Connecticut, New York, New Hampshire, Wisconsin, and Massachusetts. The highest incidence rates, greater than 130 cases per million persons, were found in Minnesota, Rhode Island, Maine, and Vermont.

People at Risk

  • The frequency of reported cases of anaplasmosis is highest among males and people over 40 years of age.
  • People with weakened immune systems (such as those occurring due to cancer treatments, advanced HIV infection, prior organ transplants, or some medications) might be at increased risk of severe outcome.
  • People who live near or spend time in known tick habitats might be at increased risk for infection.

Trichomoniasis

Trichomoniasis

Some infected men have symptoms of urethritis, epididymitis, or prostatitis, and some infected women have vaginal discharge that might be diffuse, malodorous, or yellow-green with or without vulvar irritation. However, most infected persons (70%–85%) have minimal or no symptoms, and untreated infections might last for months to years (86,639,648,649). Although partners might be unaware of their infection, it is readily passed between sex partners during penile-vaginal sex (650). Among persons who are sexually active, the best way to prevent trichomoniasis is through consistent and correct use of condoms during all penile-vaginal sexual encounters (22). Partners of men who have been circumcised might have a somewhat reduced risk of T. vaginalis infection (56,651). Douching is not recommended because it might increase the risk for vaginal infections, including trichomoniasis (652).

T. vaginalis infection is associated with two- to threefold increased risk for HIV acquisition (653-656), preterm birth, and other adverse pregnancy outcomes among pregnant women. Among women with HIV infection, T. vaginalis infection is associated with increased risk for PID (657-659). Routine screening of asymptomatic women with HIV infection for T. vaginalis is recommended because of the adverse events associated with asymptomatic trichomoniasis and HIV infection.

Diagnostic testing for T. vaginalis should be performed in women seeking care for vaginal discharge. Screening might be considered for persons receiving care in high-prevalence settings (e.g., STD clinics and correctional facilities) and for asymptomatic persons at high risk for infection (e.g., persons with multiple sex partners, exchanging sex for payment, illicit drug use, or a history of STD). However, data are lacking on whether screening and treatment for asymptomatic trichomoniasis in high prevalence settings or persons at high risk can reduce any adverse health events and health disparities or reduce community burden of infection. Decisions about screening might be informed by local epidemiology of T. vaginalis infection.

Whether the rectum can be a reservoir for T. vaginalis infection is unclear; data are needed to clarify whether this occasional finding might reflect recent depositing contamination in up to 5% of persons reporting recent receptive anal sex (660,661). Further, the efficacy, benefit, and cost-effectiveness of rectal screening are unknown; therefore, rectal testing for T. vaginalis is not recommended. Similarly, oral testing for T. vaginalis is not recommended because of a lack of evidence for oral infections. T. vaginalis infection is not a nationally notifiable condition in the United States (118,662).

Diagnostic Considerations

The use of highly sensitive and specific tests is recommended for detecting T. vaginalis. Among women, NAAT is highly sensitive, often detecting three to five times more T. vaginalis infections than wet-mount microscopy, a method with poor sensitivity (51%–65%) (663,664). The APTIMA T. vaginalis assay (Hologic Gen-Probe, San Diego, CA) is FDA-cleared for detection of T. vaginalis from vaginal, endocervical, or urine specimens from women. This assay detects RNA by transcription-mediated amplification with a clinical sensitivity of 95.3%–100% and specificity of 95.2%–100% (665,666). Among women, vaginal swab and urine have up to 100% concordance (663). As analyte-specific reagents, this assay can be used with urine or urethral swabs from men if validated per CLIA regulations. The sale, distribution, and use of analyte-specific reagents are allowed under 21 C.F.R. 809.30 pertaining to in vitro diagnostic products for human use. For T. vaginalis diagnosis in men, the sensitivity of self-collected penile-meatal swabs was higher than that of urine in one study (80% and 39%, respectively) (667). The BD Probe Tec TV Qx Amplified DNA Assay (Becton Dickinson, Franklin Lakes, New Jersey) is FDA-cleared for detection of T. vaginalis from endocervical, vaginal, or urine specimens from women. Although it might be feasible to perform these tests on the same specimen used for chlamydia and gonorrhea screening, the epidemiology of trichomoniasis is distinct and should not be overlooked in older adults.

Other FDA-cleared tests to detect T. vaginalis in vaginal secretions include the OSOM Trichomonas Rapid Test (Sekisui Diagnostics, Framingham, MA), an antigen-detection test using immunochromatographic capillary flow dipstick technology that can be performed at the point of care, and the Affirm VP III (Becton Dickinson, Sparks, MD), a DNA hybridization probe test that evaluates for T. vaginalis, G. vaginalis, and Candida albicans. The results of the OSOM Trichomonas Rapid Test are available in approximately 10 minutes, with sensitivity 82%–95% and specificity 97%–100% (666,668). Self-testing might become an option, as a study of 209 young women aged 14–22 years found that >99% could correctly perform and interpret her own self-test using the OSOM assay, with a high correlation with clinician interpretation (96% agreement, κ = 0.87) (669). The results of the Affirm VP III are available within 45 minutes. Sensitivity and specificity are 63% and 99.9%, respectively, compared with culture and TMA; sensitivity might be higher among women who are symptomatic (670,671). Neither the OSOM nor the Affirm VP III test is FDA-cleared for use with specimens obtained from men.

Culture was considered the gold standard method for diagnosing T. vaginalis infection before molecular detection methods became available. Culture has a sensitivity of 75%–96% and a specificity of up to 100% (475). In women, vaginal secretions are the preferred specimen type for culture, as urine culture is less sensitive (475,672,673). In men, culture specimens require a urethral swab, urine sediment, and/or semen. To improve yield, multiple specimens from men can be used to inoculate a single culture.

The most common method for T. vaginalis diagnosis might be microscopic evaluation of wet preparations of genital secretions because of convenience and relatively low cost. Unfortunately, the sensitivity of wet mount is low (51%–65%) in vaginal specimens (475,666) and lower in specimens from men (e.g., urethral specimens, urine sediment, and semen). Clinicians using wet mounts should attempt to evaluate slides immediately because sensitivity declines as evaluation is delayed, decreasing by up to 20% within 1 hour after collection (674, 675). When highly sensitive (e.g., NAAT) testing on specimens is not feasible, a testing algorithm (e.g., wet mount first, followed by NAAT if negative) can improve diagnostic sensitivity in persons with an initial negative result by wet mount (475). Although T. vaginalis may be an incidental finding on a Pap test, neither conventional nor liquid-based Pap tests are considered diagnostic tests for trichomoniasis, because false negatives and false positives can occur.

Treatment

Treatment reduces symptoms and signs of T. vaginalis infection and might reduce transmission. Likelihood of adverse outcomes in women with HIV also is reduced with T. vaginalis therapy.

Recommended Regimen
  • Metronidazole 2 g orally in a single dose
    OR
  • Tinidazole 2 g orally in a single dose
Alternative Regimen
  • Metronidazole 500 mg orally twice a day for 7 days

Alcohol consumption should be avoided during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.

The nitroimidazoles are the only class of antimicrobial medications known to be effective against T. vaginalis infections. Of these drugs, metronidazole and tinidazole have been cleared by FDA for the oral or parenteral treatment of trichomoniasis. Tinidazole is generally more expensive, reaches higher levels in serum and the genitourinary tract, has a longer half-life than metronidazole (12.5 hours versus 7.3 hours), and has fewer gastrointestinal side effects (676-678). In randomized clinical trials, recommended metronidazole regimens have resulted in cure rates of approximately 84%–98% (679-681), and the recommended tinidazole regimen has resulted in cure rates of approximately 92%–100% (680,682-685). Randomized controlled trials comparing single 2 g doses of metronidazole and tinidazole suggest that tinidazole is equivalent or superior to metronidazole in achieving parasitologic cure and resolution of symptoms (686).

Metronidazole gel does not reach therapeutic levels in the urethra and perivaginal glands. Because it is less efficacious than oral metronidazole, it is not recommended.

Other Management Considerations

Providers should advise persons infected with T. vaginalis to abstain from sex until they and their sex partners are treated (i.e., when therapy has been completed and any symptoms have resolved). Testing for other STDs including HIV should be performed in persons infected with T vaginalis.

Follow-up

Because of the high rate of reinfection among women treated for trichomoniasis (17% within 3 months in one study) (86), retesting for T. vaginalis is recommended for all sexually active women within 3 months following initial treatment regardless of whether they believe their sex partners were treated (see Diagnostic Considerations). Testing by nucleic acid amplification can be conducted as soon as 2 weeks after treatment (687,688). Data are insufficient to support retesting men.

Management of Sex Partners

Concurrent treatment of all sex partners is critical for symptomatic relief, microbiologic cure, and prevention of transmission and reinfections. Current partners should be referred for presumptive therapy to avoid reinfection. Partners should be advised to abstain from intercourse until they and their sex partners have been adequately treated and any symptoms have resolved. EPT might have a role in partner management for trichomoniasis (97,98,689) and can be used in states where permissible by law; however, no one partner management intervention has been shown to be superior in reducing reinfection rates. Though no definitive data exist to guide treatment for partners of persons with persistent or recurrent trichomoniasis in whom nonadherance and reinfection are unlikely, partners benefit from undergoing evaluation and receiving the same regimen as the patient (see Persistent or Recurrent Trichomoniasis).

Persistent or Recurrent Trichomoniasis

Persistent or recurrent infection caused by antimicrobial-resistant T. vaginalis or other causes should be distinguished from the possibility of reinfection from an untreated sex partner. Although most recurrent T. vaginalis infections are thought to result from reinfection, some infections might be attributed to antimicrobial resistance. Metronidazole resistance occurs in 4%–10% of cases of vaginal trichomoniasis (690,691), and tinidazole resistance in 1% (691). In general, T. vaginalis isolates have lower minimum lethal concentrations to tinidazole than metronidazole (692). Emerging nitroimidazole-resistant trichomoniasis is concerning, because few alternatives to standard therapy exist. Single-dose therapy should be avoided for treating recurrent trichomoniasis that is not likely a result of reinfection. If treatment failure has occurred with metronidazole 2 g single dose and reinfection is excluded, the patient (and their partner[s]) can be treated with metronidazole 500 mg orally twice daily for 7 days. If this regimen fails, clinicians should consider treatment with metronidazole or tinidazole at 2 g orally for 7 days. If several 1-week regimens have failed in a person who is unlikely to have nonadherence or reinfection, testing of the organism for metronidazole and tinidazole susceptibility is recommended (693). CDC has experience with susceptibility testing for nitroimidazole-resistant T. vaginalis and treatment management of infected persons and can provide assistance (telephone: 404–718–4141; website: https://www.cdc.gov/laboratory/specimen-submission/detail.html?CDCTestCode=CDC-10239). Higher dose tinidazole at 2–3g for 14 days, often in combination with intravaginal tinidazole, can be considered in cases of nitroimidazole-resistant infections; however, such cases should be managed in consultation with an expert.

Alternative regimens might be effective but have not been systematically evaluated; therefore, consultation with an infectious-disease specialist is recommended. The most anecdotal experience has been with intravaginal paromomycin in combination with high-dose tinidazole (694-696); clinical improvement has been reported with other alternative regimens including intravaginal boric acid (697,698) and nitazoxanide (699). The following topically applied agents have shown minimal success (<50%) and are not recommended: intravaginal betadine (povidone-iodine), clotrimazole, acetic acid, furazolidone, gentian violet, nonoxynol-9, and potassium permanganate (700). No other topical microbicide has been shown to be effective against trichomoniasis (701).

Special Considerations

Allergy, Intolerance, and Adverse Reactions

Metronidazole and tinidazole are both nitroimidazoles. Patients with an IgE mediated-type allergy to a nitroimidazole can be managed by metronidazole desensitization according to a published regimen (702) and in consultation with a specialist.

Pregnancy

T. vaginalis infection in pregnant women is associated with adverse pregnancy outcomes, particularly premature rupture of membranes, preterm delivery, and delivery of a low birthweight infant (658,703-705). Although metronidazole treatment produces parasitologic cure, certain trials have shown no significant difference in perinatal morbidity following metronidazole treatment. One trial suggested the possibility of increased preterm delivery in women with T. vaginalis infection who received metronidazole treatment (706), yet study limitations prevented definitive conclusions regarding the risks of treatment. More recent, larger studies have shown no positive or negative association between metronidazole use during pregnancy and adverse outcomes of pregnancy (634,707-710). If treatment is considered, the recommended regimen in pregnant women is metronidazole 2 g orally in a single dose. Symptomatic pregnant women, regardless of pregnancy stage, should be tested and considered for treatment. Treatment of T. vaginalis infection can relieve symptoms of vaginal discharge in pregnant women and reduce sexual transmission to partners. Although perinatal transmission of trichomoniasis is uncommon, treatment also might prevent respiratory or genital infection of the newborn (711,712). Clinicians should counsel symptomatic pregnant women with trichomoniasis regarding the potential risks for and benefits of treatment and about the importance of partner treatment and condom use in the prevention of sexual transmission.

The benefit of routine screening for T. vaginalis in asymptomatic pregnant women has not been established. However, screening at the first prenatal visit and prompt treatment, as appropriate, are recommended for pregnant women with HIV infection, because T. vaginalis infection is a risk factor for vertical transmission of HIV (713). Pregnant women with HIV who are treated for T. vaginalis infection should be retested 3 months after treatment.

Although metronidazole crosses the placenta, data suggest that it poses a low risk to pregnant women (317). No evidence of teratogenicity or mutagenic effects in infants has been found in multiple cross-sectional and cohort studies of pregnant women (708-710,714). Women can be treated with 2 g metronidazole in a single dose at any stage of pregnancy.

Metronidazole is secreted in breast milk. With maternal oral therapy, breastfed infants receive metronidazole in doses that are lower than those used to treat infections in infants, although the active metabolite adds to the total infant exposure. Plasma levels of the drug and metabolite are measurable, but remain less than maternal plasma levels (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT). Although several reported case series found no evidence of adverse effects in infants exposed to metronidazole in breast milk, some clinicians advise deferring breastfeeding for 12–24 hours following maternal treatment with a single 2-g dose of metronidazole (635). Maternal treatment with metronidazole (400 mg three times daily for 7 days) produced a lower concentration in breast milk and was considered compatible with breastfeeding over longer periods of time (636,637).

Data from studies involving human subjects are limited regarding use of tinidazole in pregnancy; however, animal data suggest this drug poses moderate risk. Thus, tinidazole should be avoided in pregnant women, and breastfeeding should be deferred for 72 hours following a single 2-g dose of tinidazole (http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm).

HIV Infection

Up to 53% of women with HIV infection also are infected with T. vaginalis (715,716). T. vaginalis infection in these women is significantly associated with PID (659), and treatment of trichomoniasis is associated with significant decreases in genital-tract HIV viral load and viral shedding (717,718). For these reasons, routine screening and prompt treatment are recommended for all women with HIV infection; screening should occur at entry to care and then at least annually thereafter. A randomized clinical trial involving women with HIV infection and T. vaginalis infection demonstrated that a single dose of metronidazole 2 g orally was less effective than 500 mg twice daily for 7 days (719). Thus, to improve cure rates, women with HIV infection who receive a diagnosis of T. vaginalis infection should be treated with metronidazole 500 mg orally twice daily for 7 days (rather than with a 2-g single dose of metronidazole). Factors that might interfere with standard single-dose treatment for trichomoniasis in these women include high rates of asymptomatic BV co-infections, use of antiretroviral therapy, changes in vaginal ecology, and impaired immunity (656,720,721).

Treatment

Treatment reduces symptoms and signs of T. vaginalis infection and might reduce transmission. Likelihood of adverse outcomes in women with HIV is also reduced with T. vaginalis therapy.

Recommended Regimen for Women with HIV Infection
  • Metronidazole 500 mg orally twice daily for 7 days

In women with HIV infection who receive a diagnosis of T. vaginalis infection, retesting is recommended within 3 months following initial treatment; NAAT is encouraged because of higher sensitivity of these tests. Data are insufficient to recommend routine screening, alternative treatment regimens of longer duration, or retesting in men.

Bacterial Vaginosis

Bacterial Vaginosis

BV is a polymicrobial clinical syndrome resulting from replacement of the normal hydrogen peroxide producing Lactobacillus sp. in the vagina with high concentrations of anaerobic bacteria (e.g., Prevotella sp. and Mobiluncus sp.), G. vaginalis, Ureaplasma, Mycoplasma, and numerous fastidious or uncultivated anaerobes. Some women experience transient vaginal microbial changes, whereas others experience them for longer intervals of time. Among women presenting for care, BV is the most prevalent cause of vaginal discharge or malodor; however, in a nationally representative survey, most women with BV were asymptomatic (203).

BV is associated with having multiple male or female partners, a new sex partner, douching, lack of condom use, and lack of vaginal lactobacilli; women who have never been sexually active are rarely affected (589). The cause of the microbial alteration that precipitates BV is not fully understood, and whether BV results from acquisition of a single sexually transmitted pathogen is not known. Nonetheless, women with BV are at increased risk for the acquisition of some STDs (e.g., HIV, N. gonorrhoeae, C. trachomatis, and HSV- 2), complications after gynecologic surgery, complications of pregnancy, and recurrence of BV (590-593). BV also increases the risk for HIV transmission to male sex partners (594). Although BV-associated bacteria can be found in the male genitalia, treatment of male sex partners has not been beneficial in preventing the recurrence of BV (595).

Diagnostic Considerations

BV can be diagnosed by the use of clinical criteria (i.e., Amsel’s Diagnostic Criteria) (596) or Gram stain. A Gram stain (considered the gold standard laboratory method for diagnosing BV) is used to determine the relative concentration of lactobacilli (i.e., long Gram-positive rods), Gram-negative and Gram-variable rods and cocci (i.e., G. vaginalis, Prevotella, Porphyromonas, and peptostreptococci), and curved Gram-negative rods (i.e., Mobiluncus) characteristic of BV. Clinical criteria require three of the following symptoms or signs:

  • homogeneous, thin, white discharge that smoothly coats the vaginal walls;
  • clue cells (e.g., vaginal epithelial cells studded with adherent coccobacilli) on microscopic examination;
  • pH of vaginal fluid >4.5; or
  • a fishy odor of vaginal discharge before or after addition of 10% KOH (i.e., the whiff test).

Detection of three of these criteria has been correlated with results by Gram stain (597). Other tests, including Affirm VP III (Becton Dickinson, Sparks, MD), a DNA hybridization probe test for high concentrations of G. vaginalis, and the OSOM BV Blue test (Sekisui Diagnostics, Framingham, MA), which detects vaginal fluid sialidase activity, have acceptable performance characteristics compared with Gram stain. Although a prolineaminopeptidase card test is available for the detection of elevated pH and trimethylamine, it has low sensitivity and specificity and therefore is not recommended. PCR has been used in research settings for the detection of a variety of organisms associated with BV, but evaluation of its clinical utility is still underway. Detection of specific organisms might be predictive of BV by PCR (598,599). Additional validation is needed before these tests can be recommended to diagnose BV. Culture of G. vaginalis is not recommended as a diagnostic tool because it is not specific. Cervical Pap tests have no clinical utility for the diagnosis of BV because of their low sensitivity and specificity.

Treatment

Treatment is recommended for women with symptoms. The established benefits of therapy in nonpregnant women are to relieve vaginal symptoms and signs of infection. Other potential benefits to treatment include reduction in the risk for acquiring C. trachomatis, N. gonorrhoeae, T. vaginalis, HIV, and herpes simplex type 2 (592,593,600).

Recommended Regimens
  • Metronidazole 500 mg orally twice a day for 7 days
    OR
  • Metronidazole gel 0.75%, one full applicator (5 g) intravaginally, once a day for 5 days
    OR
  • Clindamycin cream 2%, one full applicator (5 g) intravaginally at bedtime for 7 days

Alcohol consumption should be avoided during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole. Clindamycin cream is oil-based and might weaken latex condoms and diaphragms for 5 days after use (refer to clindamycin product labeling for additional information).

Women should be advised to refrain from sexual activity or use condoms consistently and correctly during the treatment regimen. Douching might increase the risk for relapse, and no data support the use of douching for treatment or relief of symptoms.

Alternative Regimens
  • Tinidazole 2 g orally once daily for 2 days
    OR
  • Tinidazole 1 g orally once daily for 5 days
    OR
  • Clindamycin 300 mg orally twice daily for 7 days
    OR
  • Clindamycin ovules 100 mg intravaginally once at bedtime for 3 days*

*Clindamycin ovules use an oleaginous base that might weaken latex or rubber products (e.g., condoms and vaginal contraceptive diaphragms). Use of such products within 72 hours following treatment with clindamycin ovules is not recommended.

Alcohol consumption should be avoided during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 72 hours after completion of tinidazole.

Alternative regimens include several tinidazole regimens (601) or clindamycin (oral or intravaginal) (602). An additional regimen includes metronidazole (750-mg extended release tablets orally once daily for 7 days); however, data on the performance of this alternative regimen are limited.

Certain studies have evaluated the clinical and microbiologic efficacy of using intravaginal lactobacillus formulations to treat BV and restore normal flora (603-607). Overall, no studies support the addition of any available lactobacillus formulations or probiotic as an adjunctive or replacement therapy in women with BV. Further research efforts to determine the role of these regimens in BV treatment and prevention are ongoing.

Other Management Considerations

All women with BV should be tested for HIV and other STDs.

Follow-Up

Follow-up visits are unnecessary if symptoms resolve. Because persistent or recurrent BV is common, women should be advised to return for evaluation if symptoms recur. Detection of certain BV-associated organisms has been associated with antimicrobial resistance and might be predictive of risk for subsequent treatment failure (608-613). Limited data are available regarding optimal management strategies for women with persistent or recurrent BV. Using a different recommended treatment regimen can be considered in women who have a recurrence; however, retreatment with the same recommended regimen is an acceptable approach for treating persistent or recurrent BV after the first occurrence (614). For women with multiple recurrences after completion of a recommended regimen, 0.75% metronidazole gel twice weekly for 4–6 months has been shown to reduce recurrences, although this benefit might not persist when suppressive therapy is discontinued (615). Limited data suggest that an oral nitroimidazole (metronidazole or tinidazole 500 mg twice daily for 7 days) followed by intravaginal boric acid 600 mg daily for 21 days and then suppressive 0.75% metronidazole gel twice weekly for 4–6 months for those women in remission might be an option for women with recurrent BV (616). Monthly oral metronidazole 2g administered with fluconazole 150 mg has also been evaluated as suppressive therapy; this regimen reduced the incidence of BV and promoted colonization with normal vaginal flora (617).

Management of Sex Partners

Data from clinical trials indicate that a woman’s response to therapy and the likelihood of relapse or recurrence are not affected by treatment of her sex partner(s) (595). Therefore, routine treatment of sex partners is not recommended.

Special Considerations

Allergy, Intolerance, or Adverse Reactions

Intravaginal clindamycin cream is preferred in case of allergy or intolerance to metronidazole or tinidazole. Intravaginal metronidazole gel can be considered for women who are not allergic to metronidazole but do not tolerate oral metronidazole. It is advised to avoid consuming alcohol during treatment with nitroimidazoles. To reduce the possibility of a disulfiram-like reaction, abstinence from alcohol use should continue for 24 hours after completion of metronidazole or 72 hours after completion of tinidazole.

Pregnancy

Treatment is recommended for all symptomatic pregnant women. Studies have been undertaken to determine the efficacy of BV treatment among this population, including two trials demonstrating that metronidazole was efficacious during pregnancy using the 250-mg regimen (618,619); however, metronidazole administered at 500 mg twice daily can be used. One trial involving a limited number of participants revealed treatment with oral metronidazole 500 mg twice daily to be equally effective as metronidazole gel, with cure rates of 70% using Amsel criteria to define cure (620). Another trial demonstrated a cure rate of 85% using Gram-stain criteria after treatment with oral clindamycin (621). Multiple studies and meta-analyses have failed to demonstrate an association between metronidazole use during pregnancy and teratogenic or mutagenic effects in newborns (622,623). Although older studies indicated a possible link between use of vaginal clindamycin during pregnancy and adverse outcomes for the newborn, newer data demonstrate that this treatment approach is safe for pregnant women (624). Because oral therapy has not been shown to be superior to topical therapy for treating symptomatic BV in effecting cure or preventing adverse outcomes of pregnancy, symptomatic pregnant women can be treated with either of the oral or vaginal regimens recommended for nonpregnant women. Although adverse pregnancy outcomes, including premature rupture of membranes, preterm labor, preterm birth, intra-amniotic infection, and postpartum endometritis have been associated with symptomatic BV in some observational studies, treatment of BV in pregnant women can reduce the signs and symptoms of vaginal infection. A meta-analysis has concluded that no antibiotic regimen prevented preterm birth (early or late) in women with BV (symptomatic or asymptomatic). However, in one study, oral BV therapy reduced the risk for late miscarriage, and in two additional studies, such therapy decreased adverse outcomes in the neonate (625).

Treatment of asymptomatic BV among pregnant women who are at high risk for preterm delivery (i.e., those with a previous preterm birth) has been evaluated by several studies, which have yielded mixed results. Seven trials have evaluated treatment of pregnant women with asymptomatic BV at high risk for preterm delivery: one showed harm (626), two showed no benefit (627,628), and four demonstrated benefit (618,619,629,630).

Similarly, data are inconsistent regarding whether treatment of asymptomatic BV among pregnant women who are at low risk for preterm delivery reduces adverse outcomes of pregnancy. One trial demonstrated a 40% reduction in spontaneous preterm birth among women using oral clindamycin during weeks 13–22 of gestation (630). Several additional trials have shown that intravaginal clindamycin given at an average gestation of >20 weeks did not reduce likelihood of preterm birth (628,631-633). Therefore, evidence is insufficient to recommend routine screening for BV in asymptomatic pregnant women at high or low risk for preterm delivery for the prevention of preterm birth (111).

Although metronidazole crosses the placenta, no evidence of teratogenicity or mutagenic effects in infants has been found in multiple cross-sectional and cohort studies of pregnant women (634). Data suggest that metronidazole therapy poses low risk in pregnancy (317).

Metronidazole is secreted in breast milk. With maternal oral therapy, breastfed infants receive metronidazole in doses that are less than those used to treat infections in infants, although the active metabolite adds to the total infant exposure. Plasma levels of the drug and metabolite are measurable, but remain less than maternal plasma levels (http://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT). Although several reported case series found no evidence of metronidazole-associated adverse effects in breastfed infants, some clinicians advise deferring breastfeeding for 12–24 hours following maternal treatment with a single 2-g dose of metronidazole (635). Lower doses produce a lower concentration in breast milk and are considered compatible with breastfeeding (636,637). Data from studies of human subjects are limited regarding the use of tinidazole in pregnancy; however, animal data suggest that such therapy poses moderate risk. Thus tinidazole should be avoided during pregnancy (317).

HIV Infection

BV appears to recur with higher frequency in women who have HIV infection (638). Women with HIV who have BV should receive the same treatment regimen as those who do not have HIV infection.

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