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If you are returning products to several retailers, you should distribute the products accordingly and send the products to those retailers who shipped them to you initially. Otitis media OM is the single most frequent condition causing pediatric patients to be taken to a healthcare provider and to be given antibiotics [86]. Acute OM with effusion is the clinical variant of OM most likely to have a bacterial etiology and, as a result, most likely to benefit from antimicrobial therapy [87, 88] Table Streptococcus pneumoniae, nontypeable Haemophilus influenzae , and Moraxella catarrhalis are the most common bacterial causes of OM, with S.

Turicella otitidis and Staphylococcus auricularis are emerging pathogens thought to cause OM, but additional studies are needed to determine the true significance of these organisms [89, 90]. Chronic suppurative OM is associated with a higher rate of complications than acute OM.

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Pseudomonas aeruginosa and S. A variety of respiratory viruses are known to cause OM; however, there exists no pathogen specific therapy and as a result, there is little reason to attempt to establish an etiologic diagnosis in patients with a viral etiology. Efforts to determine the cause of OM are best reserved for patients likely to have a bacterial etiology recent onset, bulging tympanic membrane, pain, or exudate who have not responded to prior courses of antimicrobial therapy, patients with immunological deficiencies, and acutely ill patients [86, 88].

The only representative specimen is middle ear fluid obtained either by tympanocentesis or, in patients with otorrhea or myringotomy tubes, by collecting drainage on mini-tipped swabs directly after cleaning the ear canal. Cultures of the pharynx, nasopharynx, anterior nares, or nasal drainage material are of no value in attempting to establish an etiologic diagnosis of bacterial OM Table 16 [92].

The etiological agents of rhinosinusitis vary based upon the duration of symptoms and whether it is community acquired or of nosocomial origin Table Streptococcus pneumoniae , nontypeable H. The role of respiratory viruses in sinusitis needs further study, but most patients with acute sinusitis have an upper respiratory virus detectable early in the illness [93].

Staphylococcus aureus , gram-negative bacilli, Streptococcus spp, and anaerobic bacteria are associated more frequently with subacute, chronic, or healthcare-associated sinusitis [94]. The role of fungi as etiological agents is more controversial, possibly due to numerous publications that used poor sample collection methods and thus did not recover the fungal agents. In immunocompetent hosts, fungi are associated most often with chronic sinusitis, though the significance of fungal presence in chronic sinusitis is frequently uncertain [93, 95, 96].

Invasive sinusitis due to fungal infections in severely immunocompromised persons or uncontrolled diabetic patients is often severe and carries a high mortality rate. Attempts to establish an etiologic diagnosis of sinusitis are typically reserved for patients with complicated infections or chronic disease patients who are seriously ill, immunocompromised, continue to deteriorate clinically despite extended courses of antimicrobial therapy, or have recurrent bouts of acute rhinosinusitis with clearing between episodes.

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Swabs are not recommended for collecting sinus specimens since an aspirate is much more productive of the true etiologic agent s and is the specimen of choice. Endoscopically obtained swabs can recover bacterial pathogens but rarely detect the causative fungi [92, 97, 98]. In maxillary sinusitis, antral puncture with sinus aspiration though seldom done and, in adults, swabs of material draining from the middle meatus obtained under endoscopic guidance represent the only adequate specimens.

Cultures of middle meatus drainage specimens are not recommended for pediatric patients due to colonization with normal microbiota, which overlaps with potential respiratory tract pathogens.

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Examination of nasal drainage material is of no value in attempting to determine the cause of maxillary sinusitis. Surgical procedures are necessary to obtain specimens representative of infection of the frontal, sphenoid, or ethmoid sinuses. To establish a fungal etiology, an endoscopic sinus aspirate is recommended [98] but is often unproductive for a fungal agent.

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Tissue biopsy may be more productive. Acute pharyngitis accounts for roughly 1. Differences between the epidemiology of various infectious agents related to the age of the patient, the season of the year, accompanying signs and symptoms, and the presence or absence of systemic disease are insufficient to establish a definitive etiologic diagnosis on clinical and epidemiologic grounds alone [].

Consequently, the results of laboratory tests play a central role in guiding therapeutic decisions Table Antimicrobial therapy is warranted only in patients with pharyngitis with a proven bacterial etiology []. Several laboratory tests, including culture, rapid antigen tests, and molecular methods, have been used to establish an etiologic diagnosis of pharyngitis due to this organism [, ].

During the past few decades, rapid antigen tests for S. Such tests are technically nondemanding, generally reliable, and often performed at the point of care. For any of these methods, accuracy and clinical relevance depend on appropriate sampling technique. There is a consensus among the professional societies that negative rapid antigen tests for S. Although this is generally not necessary for negative test results in adults due to the lower risk of complications, new guidelines suggest that either conventional culture or confirmation of negative rapid antigen test results by culture should be used to achieve maximal sensitivity for diagnosis of S.

Laboratories accredited by the College of American Pathologists are required to back up negative rapid antigen tests with culture. Rapid, Clinical Laboratory Improvement Amendments CLIA —waived methods for molecular group A Streptococcus testing provide improved sensitivity and may not require culture confirmation [, ], though they have not yet been incorporated into consensus guidelines. However, many healthcare providers consider these organisms to be of significance and base therapeutic decisions on their detection.

Rare cases of poststreptococcal glomerulonephritis after infection with these species have been reported. Recovery of the same organism from multiple patients during an outbreak should be investigated. Arcanobacterium haemolyticum also causes pharyngitis but less commonly. It occurs most often in teenagers and young adults and causes a highly suggestive scarlatina-form rash in some patients.

Neisseria gonorrhoeae and Corynebacterium diphtheriae , in very specific patient and epidemiologic settings, may also cause pharyngitis [].

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Respiratory viruses are the most common cause of pharyngitis in both adult and pediatric populations; however, it is unnecessary to define a specific etiology in patients with pharyngitis due to respiratory viruses since there exists no pathogen-directed therapy for these agents. Recent studies have shown a relationship between Fusobacterium necrophorum and pharyngitis in some patients. In this case, throat infection could be a prelude to Lemierre syndrome. Fusobacterium necrophorum is an anaerobic organism and, as such, will require additional media and the use of anaerobic isolation and identification procedures, which most laboratories are not prepared to use with throat specimens.

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Notify the laboratory of the suspected diagnosis and the etiologic agent so that appropriate procedures can be available. In the absence of anaerobic capability of the laboratory, this would be sent out to a reference laboratory [—]. Respiratory tract infections are among the most common infectious diseases.

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  7. The list of causative agents continues to expand as new pathogens and syndromes are recognized. This section describes the major etiologic agents and the microbiologic approaches to the diagnosis of bronchitis and bronchiolitis; community-acquired pneumonia CAP ; hospital-acquired pneumonia HAP and ventilator-associated pneumonia VAP ; infections of the pleural space; bronchopulmonary infections in patients with cystic fibrosis; and pneumonia in the immunocompromised host.

    The reader is referred to various practice guidelines that have been written in recent years by the Infectious Diseases Society of America, the American Thoracic Society, and the American Society for Microbiology, among other clinical practice groups that describe the clinical features, diagnostic approaches, and patient management aspects of many of these syndromes.

    The table below summarizes some important caveats when obtaining specimens for the diagnosis of respiratory infections. Table 19 lists the etiologic agents and diagnostic approaches for bronchiolitis, acute bronchitis, acute exacerbation of chronic bronchitis, and pertussis, clinical syndromes that involve inflammation of the tracheobronchial tree [, ]. Bronchiolitis is the most common lower respiratory infection in children [, ]. Viruses, alone or in combination, constitute the major causes of the syndrome characterized by bronchospasm wheezing resulting from acute inflammation, airway edema, and increased mucus production [, ].

    Acute bronchitis is largely due to viral pathogens and is less frequently caused by Mycoplasma pneumoniae and Chlamydia pneumoniae. Pertussis, classically known as whooping cough, caused by Bordetella pertussis, should be considered in an adolescent or young adult with paroxysmal cough. NAATs in combination with culture are the recommended tests of choice for B.