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a LANGE medical book

2017
CURRENT
Medical Diagnosis
& Treatment
FIFTY-SIXTH EDITION

Edited by

Maxine A. Papadakis, MD
Professor of Medicine
Associate Dean of Students
School of Medicine
U niversity of California, San Fra ncisco

Stephen J. McPhee, MD
Professor of Medicine, Emeritus
Division of General I nternal Medicine
Department of Medicine
U niversity of California, San Francisco

Associate Editor

Michael W. Rabow, MD
Professor of Medicine and U rology
Division of General I nternal Medicine
Department of Medicine
U niversity of California, San Francisco

With Associate Authors

New York Chicago San Francisco Athens London Madrid Mexico City
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 Contents
Authors v 14. Disorders of Hemostasis, Thrombosis,
Preface xiii & Antithrombotic Therapy 546

Andrew D.Leavitt, MD, & Tracy Minichiello, MD

1. Disease Prevention & Health Promotion 1

Michael Pignone MD, MPH, & Rene Salazar, MD 15. Gastrointestinal Disorders 578

Kenneth R. McQuaid, MD
2. Common Symptoms 19

PaulL. Nadler, MD, & Ralph Gonzales, MD, MSPH 16. Liver, Biliary Tract, & Pancreas
Disorders 674
3. Preoperative Evaluation & Perioperative
Lawrence S. Friedman, MD
Management 45

Hugo Q. Cheng, MD 17. Breast Disorders 734

Armando E. Giuliano, MD, & Sara A. Hurvitz, MD

4. Geriatric Disorders 55

G. Michael Harper, MD, C. Bree Johnston, MD, MPH, 18. Gynecologic Disorders 762
& C. SethLandefeld, MD
Jason Woo, MD, MPH, FACOG,
& Alicia Y. Armstrong, MD, MHSCR
5. Palliative Care & Pain Management 72

Michael W. Rabow, MD, & Steven Z. Pantilat, MD 19. Obstetrics & Obstetric Disorders 797

VanessaL. Rogers, MD, & Kevin C. Worley, MD

6. Dermatologic Disorders 95

Kanode Shinkai, MD, PhD, &Lindy P. Fox, MD 20. Rheumatologic, Immunologic,

& Allergic Disorders 826
7. Disorders of the Eyes & Lids 164
David B. Hellmann, MD, MACP,
Paul Riordan-Eva, FRCOphth & John B. Imboden Jr., MD

8. Ear, Nose, & Throat Disorders 200 21. Electrolyte & Acid-Base Disorders 884
Lawrence R.Lustig, MD, & Joshua S. Schindler, MD Kerry C. Cho, MD

9. Pulmonary Disorders 241 22. Kidney Disease 913

Mark S. Chesnutt, MD, & Thomas J. Prendergast, MD Suzanne Watnick, MD, & Tonja C. Dirkx, MD

10. Heart Disease 322 23. Urologic Disorders 953

Thomas M. Bashore, MD, Christopher B. Granger, MD, Maxwell V. Meng, MD, FACS,
Kevin P. Jackson, MD, & Manesh R. Patel, MD Thomas J. Walsh, MD, MS, & Thomas D. Chi, MD

11. Systemic Hypertension 439 24. Nervous System Disorders 977

Michael Sutters, MD, MRCP (UK) Michael J. Aminoff, MD, DSc, FRCP,
& Vanja C. Douglas, MD
12. Blood Vessel & Lymphatic Disorders 472
25. Psychiatric Disorders 1050
Christopher D. Owens, MD, MSc,
Warren J. Gasper, MD, & Meshell D. Johnson, MD Nolan Williams, MD,
& Charles DeBattista, DMH, MD
13. Blood Disorders 499
26. Endocrine Disorders 1108
Lloyd E. Damon, MD,
& Charalambos Babis Andreadis, MD, MSCE Paul A. Fitzgerald, MD

iii
 iv CMDT 201 7 CONTENTS

27. Diabetes Mellitus & Hypoglycemia 1210 40. Inherited Disorders 1676

Umesh Masharani, MB, BS, MRCP(UK) Reed E. Pyeritz, MD, PhD

28. Lipid Disorders 1259 41. Sports Medicine & Outpatient

Orthopedics 1685
Robert B. Baron, MD, MS
Anthony Luke, MD, MPH, & C. Benjamin Ma, MD

29. Nutritional Disorders 1268

e1. Anti-Infective Chemotherapeutic
Robert B. Baron, MD, MS & Antibiotic Agents Online*

B. Joseph Guglielmo, PharmD

30. Common Problems in Infectious
Diseases & AntimicrobialTherapy 1287
e2. Fundamentals of Human
Peter V. Chin-Hong, MD, Genetics & Genomics Online*
& B. Joseph Guglielmo, PharmD
Reed E. Pyeritz, MD, PhD

31. HIV Infection & AIDS 1330

e3. Diagnostic Testing & Medical
Mitchell H. Katz, MD Decision Making Online*

C. Diana Nicoll, MD, PhD, MPA,

32. Viral & Rickettsial Infections 1363 & Chuanyi MarkLu, MD
Wayne X. Shandera, MD,
& Natalie J. M. Dailey Garnes, MD, MPH e4. Information Technology in
Patient Care Online*
33. Bacterial & Chlamydiallnfections 1441 Russ Cucina, MD, MS

Brian S. Schwartz, MD
e5. Integrative Medicine Online*

34. Spirochetal Infections 1488 Kevin Barrows, MD, & Sanjay Reddy, MD

Susan S. Philip, MD, MPH

e6. Podiatric Disorders Online*

35. Protozoal & Helminthic Infections 1507 Monaro Dini, DPM, & Nina Babu, DPM

Philip J. Rosenthal, MD
e7. Women's Health Issues Online*

36. Mycotic Infections 1547 Megan McNamara, MD, MSc,

& Judith Walsh, MD, MPH
Samuel A. Shelburne, Ill, MD, PhD,
& Richard J. Hamill, MD
e8. Lesbian & Bisexual
Women's Health Online*
37. Disorders Related to Environmental
Juno Obedin-Maliver, MD, MPH,
Emergencies 1561
& Patricia A. Robertson, MD
Jacqueline A. Nemer, MD, FACEP,
& Melissa C. Clark, MD
e9. Transgender Health & Disease
Prevention Online*
38. Poisoning 1577
Madeline B. Deutsch, MD, MPH
Kent R. Olson, MD
e10. Appendix: Therapeutic Drug Monitoring,
39. Cancer 1607 Laboratory Reference Intervals, &
Pharmacogenetic Testing Online*
Patricia A. Cornett, MD,
& Tiffany 0. Dea, PharmD C. Diana Nicoll, MD, PhD, MPA,
& Chuanyi MarkLu, MD
Index 1719

*Free access t o online chapters at www. accessmedicine.com/cmdt

 Authors

N. Franklin Adkinson, Jr., MD Kevin Barrows, MD

Professor of Medicine, Johns Hopkins Asthma & Allergy Clinical Professor of Family and Community Medicine,
Center, Baltimore, Maryland Director of Mindfulness Programs, Osher Center for
[email protected] Integrative Medicine; Department of Family and
Allergic & Immunologic Disorders (in Chapter 20) Community Medicine, University of California,
San Francisco
Diana Alba, MD Kevin. [email protected]
Fellow, Division of Endocrinology and Metabolism, CMDT Online-Integrative Medicine
University of California, San Francisco
References Thomas M. Bashore, MD
Professor of Medicine; Senior Vice Chief, Division of
Michael J. Aminoff, MD, DSc, FRCP Cardiology, Duke University Medical Center, Durham,
Distinguished Professor and Executive Vice Chair, North Carolina
Department of Neurology, University of California, [email protected]
San Francisco; Attending Physician, University of Heart Disease
California Medical Center, San Francisco
[email protected] Brook Calton, MD, MHS
Nervous System Disorders Assistant Professor of Clinical Medicine, Division of
Geriatrics, Department of Medicine, University of
Charalambos Babis Andreadis, MD, MSCE California, San Francisco
Associate Professor of Clinical Medicine, Division of References
Hematology/Oncology, University of California,
San Francisco Amy D. Chen, MD
[email protected] Clinical Instructor, Division of Hospital Medicine,
Blood Disorders University of California, San Francisco
References
Alicia Y. Armstrong, MD, MHSCR
Medical Officer, Contraceptive Discovery and Hugo Q. Cheng, MD
Development Branch, Eunice Kennedy Shriver Clinical Professor of Medicine, University of California,
National Institute for Child Health and Human San Francisco
Development, National Institutes for Health, [email protected]
Rockville, Maryland Preoperative Evaluation & Perioperative Management
[email protected]
Gynecologic Disorders Mark S. Chesnutt, MD
Clinical Professor, Pulmonary & Critical Care Medicine,
Nina Babu, DPM Dotter Interventional Institute, Oregon Health &
Assistant Clinical Professor, Department Science University, Portland, Oregon; Director, Critical
of Orthopaedic Surgery, University of California, Care, Portland Veterans Affairs Health Care System
San Francisco [email protected]
CMDT Online-Podiatric Disorders Pulmonary Disorders

David M. Barbour, PharmD, BCPS Thomas D. Chi, MD

Pharmacist, Denver, Colorado Assistant Professor, Department of Urology, University of
[email protected] California, San Francisco
Drug References [email protected]
Urologic Disorders
Robert B. Baron, MD, MS
Professor of Medicine; Associate Dean for Graduate and Peter V. Chin-Hong, MD
Continuing Medical Education; Vice Chief, Division of Professor, Division of Infectious Diseases, Department of
General Internal Medicine, University of California, Medicine, University of California, San Francisco
San Francisco [email protected]
[email protected] Common Problems in Infectious Diseases & Antimicrobial
Lipid Disorders; Nutritional Disorders Therapy

v
 vi CMDT 201 7 AUTHORS

Kerry C. Cho, MD Charles DeBattista, DMH, MD

Associate Clinical Professor of Medicine, Division of Professor of Psychiatry and Behavioral Sciences, Director:
Nephrology, University of California, San Francisco Depression Clinic and Research Program Director of
[email protected] Medical Student Education in Psychiatry, Stanford
Electrolyte & Acid-Base Disorders University School of Medicine, Stanford, California
[email protected]
Pelin Cinar, MD, MS Psychiatric Disorders
Clinical Assistant Professor of Medicine in Oncology,
University of California San Francisco; Director of Madeline B. Deutsch, MD
Quality Improvement, UCSF Helen Diller Family Assistant Clinical Professor, Clinical Director, Center of
Comprehensive Cancer Center Excellence for Transgender Health, Department of
[email protected] Family & Community Medicine, University of
Alimentary Tract Cancers (in Chapter 39) California, San Francisco
[email protected]
Melissa C. Clark, MD CMDT Online-Transgender Health & Disease Prevention
Assistant Clinical Professor, Department of Emergency
Medicine, University of California, San Francisco, Monara Dini, DPM
San Francisco General Hospital Assistant Clinical Professor, Chief of Podiatric Surgery
[email protected] Division, Department of Orthopedic Surgery,
Disorders Related to Environmental Emergencies University of California, San Francisco
[email protected]
Patricia A. Cornett, MD CMDT Online-Podiatric Disorders
Professor of Medicine, University of California,
San Francisco; Chief, Hematology/Oncology, Tonja C. Dirkx, MD
San Francisco Veterans Affairs Health Care System, Associate Professor of Medicine, Division of Nephrology,
San Francisco, California Department of Medicine, Oregon Health and Sciences
[email protected] University, Portland, Oregon; Renal Clinic Director,
Cancer Portland Veterans Affairs Health Care System
[email protected]
Russ Cucina, MD, MS Kidney Disease
Associate Professor of Hospital Medicine; Chief Health
Information Officer, UCSF Health System; University Vanja C. Douglas, MD
of California, San Francisco Sara & Evan Williams Foundation Endowed
[email protected] Neurohospitalist Chair, Associate Professor of Clinical
CMDT Online-Information Technology in Neurology, Department of Neurology, University of
Patient Care California, San Francisco
Vanj [email protected]
Natalie J. M. Dailey Garnes, MD, MPH Nervous System Disorders
Clinical Postdoctoral Fellow, Division of Pediatric
Infectious Diseases, Department of Pediatrics and Paul A. Fitzgerald, MD
Medicine, Baylor College of Medicine, Clinical Professor of Medicine, Department of Medicine,
Houston, Texas Division of Endocrinology, University of California,
[email protected] San Francisco
Viral & Rickettsial Infections [email protected]
Endocrine Disorders
Lloyd E. Damon, MD
Professor of Clinical Medicine, Department of Medicine, Lindy P. Fox, MD
Division of Hematology/Oncology; Director of Adult Associate Professor, Department of Dermatology,
Hematologic Malignancies and Blood and Marrow University of California, San Francisco
Transplantation, Deputy Chief of the Division of [email protected]
Hematology and Medical Oncology, University of Dermatologic Disorders
California, San Francisco
[email protected] Lawrence S. Friedman, MD
Blood Disorders Professor of Medicine, Harvard Medical School; Professor
of Medicine, Tufts University School of Medicine,
Tiffany 0. Dea, PharmD, BCOP Boston, Massachusetts; The Anton R. Fried, MD, Chair,
Oncology Pharmacist, Veterans Affairs Health Care Department of Medicine, Newton-Wellesley Hospital,
System, San Francisco, California; Adjunct Professor, Newton, Massachusetts; Assistant Chief of Medicine,
Thomas J. Long School of Pharmacy and Health Massachusetts General Hospital, B oston, Massachusetts
Sciences, Stockton, California [email protected]
[email protected] Liver, Biliary Tract, & Pancreas Disorders; Hepatobiliary
Cancer Cancers (in Chapter 39)
 AUTHORS CMDT 201 7 vii

Warren J. Gasper, MD David B. Hellmann, MD, MACP

Assistant Professor of Clinical Surgery, Division of Aliki Perroti Professor of Medicine; Vice Dean for Johns
Vascular and Endovascular Surgery, Department of Hopkins Bayview; Chairman, Department of Medicine,
Surgery, University of California, Johns Hopkins Bayview Medical Center, Johns Hopkins
San Francisco University School of Medicine, Baltimore, Maryland
[email protected] [email protected]
Blood Vessel & Lymphatic Disorders Rheumatologic, Immunologic, & Allergic Disorders

Armando E. Giuliano, MD, FACS, FRCSEd Sara A. Hurvitz, MD

Executive Vice Chair of Surgery, Associate Director of Associate Professor; Director, Breast Oncology Program,
Surgical Oncology, Cedars-Sinai Medical Center, Division of Hematology/Oncology, Department of
Los Angeles, California Internal Medicine, University of California, Los Angeles
[email protected] [email protected]
Breast Disorders Breast Disorders

Ralph Gonzales, MD, MSPH John B. Imboden, Jr., MD

Associate Dean, Clinical Innovation and Chief Innovation Alice Betts Endowed Chair for Arthritis Research;
Officer, UCSF Health; Professor of Medicine, Division Professor of Medicine, University of California,
of General Internal Medicine, Department of Medicine, San Francisco; Chief, Division of Rheumatology,
University of California, San Francisco San Francisco General Hospital
[email protected] [email protected]
Common Symptoms Rheumatologic, Immunologic, & Allergic Disorders

Christopher B. Granger, MD Kevin P. Jackson, MD

Professor of Medicine; Director, Cardiac Care Unit, Duke Assistant Professor of Medicine, Director of
University Medical Center, Duke Clinical Research Electrophysiology, Duke Raleigh Hospital, Duke
Institute, Durham, North Carolina University Medical Center, Durham, North Carolina
[email protected] [email protected]
Heart Disease Heart Disease

B. Joseph Guglielmo, PharmD Jane Jih, MD, MPH, MAS

Professor and Dean, School of Pharmacy, University of Assistant Professor of Medicine, Division of General
California, San Francisco Internal Medicine, Department of Medicine, University
[email protected] of California, San Francisco
Common Problems in Infectious Diseases & Antimicrobial j [email protected]
Therapy; CMDT Online-Anti-Infective References
Chemotherapeutic & Antibiotic Agents
Meshell D. Johnson, MD
Elan L. Guterman, MD Associate Professor of Medicine, Division of Pulmonary
Neurology Resident, Department of Neurology, University and Critical Care Medicine, Department of Medicine,
of California, San Francisco University of California, San Francisco
References meshell.j [email protected]
Blood Vessel & Lymphatic Disorders; Alcohol Use Disorder
Richard J. Hamill, MD (Alcoholism) (in Chapter 25)
Professor, Division of Infectious Diseases, Departments of
Medicine and Molecular Virology & Microbiology, C. Bree Johnston, MD, MPH
Baylor College of Medicine, Houston, Texas Medical Director of Palliative and Supportive Care,
[email protected] PeaceHealth St. Joseph Medical Center, B ellingham,
Mycotic Infections Washington; Clinical Professor of Medicine, University
of Washington
G. Michael Harper, MD bj [email protected]
Professor, Division of Geriatrics, Department of Medicine, Geriatric Disorders
University of California San Francisco School of
Medicine; San Francisco Veterans Affairs Health Care Mitchell H. Katz, MD
System, San Francisco, California Clinical Professor of Medicine, Epidemiology &
[email protected] Biostatistics, University of California, San Francisco;
Geriatric Disorders Director of Health Services, Los Angeles County
[email protected]
HIV Infection & AIDS
 viii CMDT 201 7 AUTHORS

C. Seth Landefeld, MD Umesh Masharani, MB, BS, MRCP(UK)

Professor of Medicine; Chair, Department of Medicine Professor of Medicine, Division of Endocrinology and
and Spencer Chair in Medical Science Leadership, Metabolism, Department of Medicine, University of
University of Alabama at Birmingham California, San Francisco
[email protected] [email protected]
Geriatric Disorders Diabetes Mellitus & Hypoglycemia

David C. Lange, MD Megan McNamara, MD, MSc

Clinical Fellow, Division of Cardiology, Department of Associate Professor of Medicine, Case Western Reserve
Internal Medicine, Cedars-Sinai Medical Center, University School of Medicine; Louis Stokes Cleveland
Los Angeles, California Veterans Affairs Medical Center
References [email protected]
CMDT Online-Womens Health Issues
Andrew D. Leavitt, MD
Professor, Departments of Medicine (Hematology) and Kenneth R. McQuaid, MD
Laboratory Medicine; Medical Director, UCSF Adult Chief, Gastroenterology and Medical Service,
Hemophilia Treatment Center, University of California, San Francisco Veterans Affairs Medical Center;
San Francisco Professor of Clinical Medicine, Marvin H. Sleisenger
[email protected] Endowed Chair and Vice-Chairman, Department of
Disorders of Hemostasis, Thrombosis, & Anti thrombotic Medicine, University of California,
Therapy San Francisco
[email protected]
Chuanyi Mark Lu, MD Gastrointestinal Disorders; Alimentary Tract Cancers
Professor, Department of Laboratory Medicine, University (in Chapter 39)
of California, San Francisco; Chief, Hematology,
Hematopathology & Molecular Diagnostics, Maxwell V. Meng, MD, FACS
Laboratory Medicine Service, Veterans Affairs Health Professor, Chief of Urologic Oncology, Department of
Care System, San Francisco, California Urology, University of California, San Francisco
[email protected] [email protected]
CMDT Online-Appendix: Therapeutic Drug Monitoring Urologic Disorders; Cancers of the Genitourinary Tract
& Laboratory Reference Intervals, & Pharmacogenetic (in Chapter 39)
Testing; CMDT Online-Diagnostic Testing & Medical
Decision Making Tracy Minichiello, MD
Clinical Professor of Medicine, University of California,
Anthony Luke, MD, MPH San Francisco; Chief, Anticoagulation and Thrombosis
Professor of Clinical Orthopaedics, Department of Services, San Francisco Veterans Affairs Medical
Orthopaedics; Director, UCSF Primary Care Sports Center
Medicine; Director, Human Performance Center at the [email protected]
Orthopaedic Institute, University of California, Disorders of Hemostasis, Thrombosis, & Anti thrombotic
San Francisco Therapy
[email protected]
Sports Medicine & Outpatient Orthopedics Paul L. Nadler, MD
Clinical Professor of Medicine; Director, Screening and
Lawrence R. Lustig, MD Acute Care Clinic, Division of General Internal
Howard W. Smith Professor and Chair, Department of Medicine, Department of Medicine, University of
Otolaryngology-Head & Neck Surgery, Columbia California, San Francisco
University Medical Center & New York Presbyterian [email protected]
Hospital, New York, New York Common Symptoms
lrl2 [email protected]
Ear, Nose, & Throat Disorders Jacqueline A. Nemer, MD, FACEP
Professor of Emergency Medicine, Director of
C. Benjamin Ma, MD Advanced Clinical Skills, Department of Emergency
Associate Professor, Department of Orthopaedic Surgery; Medicine, University of California,
Chief, Sports Medicine and Shoulder Service, San Francisco
University of California, San Francisco j [email protected]
[email protected] Disorders Related to Environmental Emergencies
Sports Medicine & Outpatient Orthopedics
 AUTHORS CMDT 201 7 ix

C. Diana Nicoll, MD, PhD, MPA Manesh R. Patel, MD

Clinical Professor and Vice Chair, Department of Associate Professor of Medicine, Division of Cardiology,
Laboratory Medicine; Associate Dean, University of Department of Medicine; Director of Interventional
California, San Francisco; Chief of Staff and Chief, Cardiology, Duke University Medical Center, Durham,
Laboratory Medicine Service, San Francisco Veterans North Carolina
Affairs Health Care System [email protected]
[email protected] Heart Disease
CMDT Online-Appendix: Therapeutic Drug Monitoring
& Laboratory Reference Intervals, & Pharmacogenetic Susan S. Philip, MD, MPH
Testing; CMDT Online-Diagnostic Testing & Medical Assistant Clinical Professor, Division of Infectious
Decision Making Diseases, Department of Medicine, University of
California, San Francisco; Disease Prevention and
Juno Obedin-Maliver, MD, MPH Control Branch, Population Health Division,
Clinical Research Fellow, Women's Health, San Francisco San Francisco Department of Public Health,
Veterans Affairs Medical Center; Clinical Instructor, San Francisco, California
Department of Obstetrics, Gynecology, and [email protected]
Reproductive Sciences, University of California Spirochetal Infections
San Francisco; Founder and Investigator, Lesbian, Gay,
Bisexual, and Transgender Medical Education Michael Pignone, MD, MPH
Research Group, Stanford University School of Professor of Medicine; Chief, Division of General Internal
Medicine, Stanford, California Medicine, Department of Medicine, University of
Juno. [email protected] North Carolina, Chapel Hill
CMDT Online-Lesbian & Bisexual Womens Health [email protected]
Disease Prevention & Health Promotion
Kent R. Olson, MD
Thomas J. Prendergast, MD
Clinical Professor of Medicine, Pediatrics, and Pharmacy,
Clinical Professor of Medicine, Oregon Health and
University of California, San Francisco; Medical
Science University; Pulmonary Critical Care Section
Director, San Francisco Division, California Poison
Chief, Portland Veterans Affairs Health Care System,
Control System
Portland, Oregon
[email protected]
[email protected]
Poisoning
Pulmonary Disorders
R. Anthony Orden, MD Reed E. Pyeritz, MD, PhD
Clinical Fellow, Division of Allergy & Clinical William Smilow Professor of Medicine and Genetics,
Immunology, Johns Hopkins Asthma & Allergy Center, Raymond and Ruth Perelman School of Medicine of
Baltimore, Maryland the University of Pennsylvania, Philadelphia
rorden [email protected] [email protected]
Allergic & Immunologic Disorders (in Chapter 20) Inherited Disorders; CMDT Online-Fundamentals of
Human Genetics & Genomics
Christopher D. Owens, MD, MSc
Associate Professor of Surgery, Division of Vascular and Michael W. Rabow, MD, FAAHPM
Endovascular Surgery, Department of Surgery, Helen Diller Family Chair in Palliative Care, Professor of
University of California, San Francisco; Chief, Clinical Medicine and Urology, Division of General
Vascular Surgery, San Francisco Veteran's Affairs Internal Medicine, Department of Medicine; Director,
Medical Center Symptom Management Service, Helen Diller Family
[email protected] Comprehensive Cancer Center, University of
Blood Vessel & Lymphatic Disorders California, San Francisco
[email protected]
Steven Z. Pantilat, MD Palliative Care & Pain Management
Professor of Medicine, Department of Medicine; Kates­
Burnard and Hellman Distinguished Professor of Sanjay Reddy, MD
Palliative Care; Director, Palliative Care Program, Assistant Clinical Professor of Medicine, Division of
University of California, San Francisco Hospital Medicine, Department of Medicine.
[email protected] University of California, San Francisco
Palliative Care & Pain Management [email protected]
CMDT Online-Integrative Medicine
 X CMDT 201 7 AUTHORS

Paul Riordan-Eva, FRCOphth Yiwey Shieh, MD

Consultant Ophthalmologist, King's College Hospital, Primary Care Research Fellow, Division of General
London, United Kingdom Internal Medicine, Department of Medicine, University
[email protected] of California, San Francisco
Disorders of the Eyes & Lids References

Patricia A. Robertson, MD Kanade Shinkai, MD, PhD

Professor, Department of Obstetrics, Gynecology, and Associate Professor, Department of Dermatology,
Reproductive Sciences, University of California, University of California, San Francisco
San Francisco [email protected]
[email protected] Dermatologic Disorders
CMDT Online-Lesbian & Bisexual Womens Health
Scott J. Steiger, MD, FACP, FASAM
Vanessa L. Rogers, MD Assistant Professor of Clinical Medicine, Division of
Associate Professor, Obstetrics and Gynecology, General Internal Medicine, Department of Medicine,
University of Texas Southwestern Medical Center, University of California, San Francisco
Dallas, Texas [email protected]
[email protected] Opioids for Chronic, Noncancer Pain (in Chapter 5)
Obstetrics & Obstetric Disorders
Michael Sutters, MD, MRCP(UK)
Philip J. Rosenthal, MD Attending Nephrologist, Virginia Mason Medical Center,
Professor, Department of Medicine, University of Seattle, Washington; Affiliate Assistant Professor of
California, San Francisco; Associate Chief, Division of Medicine, Division of Nephrology, University of
HIV, Infectious Diseases, and Global Health, Washington School of Medicine, Seattle, Washington
San Francisco General Hospital [email protected]
[email protected] Systemic Hypertension
Protozoal & Helminthic Infections
PhilipTiso
Rene Salazar, MD
Principal Editor, Division of General Internal Medicine,
Associate Professor of Clinical Medicine, Division of University of California, San Francisco
General Internal Medicine, Department of Medicine, References
University of California, San Francisco
[email protected] Judith Walsh, MD, MPH
Disease Prevention & Health Promotion Professor of Clinical Medicine, Division of General
Internal Medicine, Women's Health Center of
Joshua S. Schindler, MD
Excellence, University of California, San Francisco
Associate Professor, Department of Otolaryngology,
[email protected]
Oregon Health & Science University, Portland, Oregon;
CMDT Online-Womens Health Issues
Medical Director, OHSU-Northwest Clinic for Voice
and Swallowing
Thomas J. Walsh, MD, MS
[email protected] Associate Professor, Department of Urology, University
Ear, Nose, & Throat Disorders of Washington School of Medicine, Seattle,
Brian S. Schwartz, MD Washington
Associate Professor, Division of Infectious Diseases, [email protected]
Department of Medicine, University of California, Urologic Disorders
San Francisco Sunny Wang, MD
[email protected] Assistant Clinical Professor of Medicine, Division of
Bacterial & Chlamydia/ Infections Hematology and Oncology, University of California,
San Francisco; San Francisco Veterans Affairs
Wayne X. Shandera, MD
Health Care System
Assistant Professor, Department of Internal Medicine,
[email protected]
Baylor College of Medicine, Houston, Texas
Lung Cancer (in Chapter 39)
[email protected]
Viral & Rickettsial Infections
Suzanne Watnick, MD
Samuel A. Shelburne, Ill, MD, PhD Professor of Medicine, Division of Nephrology and
Associate Professor, Department of Infectious Diseases Hypertension, Oregon Health & Science University,
and Department of Genomic Medicine, The University Portland; Portland Veterans Affairs Health Care
of Texas MD Anderson Cancer Center, Houston, Texas System, Portland, Oregon
[email protected] [email protected]
Mycotic Infections Kidney Disease
 CMDT 201 7 xi

Nolan Williams, MD Kevin C. Worley, MD

Instructor, Department of Psychiatry, Stanford University Associate Professor of Obstetrics and Gynecology,
School of Medicine, Stanford, California Department of Obstetrics and Gynecology, Division of
[email protected] Maternal-Fetal Medicine, University of Texas
Psychiatric Disorders Southwestern Medical Center, Dallas, Texas
[email protected]
CAPT Jason Woo, MD, MPH, FACOG Obstetrics & Obstetric Disorders
Medical Officer, Office of Generic Drugs, Center for Drug
Evaluation and Research, U.S. Food and Drug Bree Zimmerman, MD
Administration, Silver Spring, Maryland Chief Resident, Department of Dermatology, University
[email protected] of California, San Francisco
Gynecologic Disorders References
This page intentionally left blank
 Preface

Current Medical Diagnosis & Treatment 201 7 (CMDT 201 7) is the 56th edition of this single-source reference for practitio­
ners in both hospital and ambulatory settings. The book emphasizes the practical features of clinical diagnosis and patient
management in all fields of internal medicine and in specialties of interest to primary care practitioners and to subspecial­
ists who provide general care.
Our students have inspired us to look at issues of race and justice, which surely impact people's health. We have therefore
reviewed the content of our work to ensure that it contains the dignity and equality that every patient deserves.

INTENDED AUDIENCE FOR CMDT

House officers, medical students, and all other health professions students will find the descriptions of diagnostic and
therapeutic modalities, with citations to the current literature, of everyday usefulness in patient care.
Internists, family physicians, hospitalists, nurse practitioners, physicians' assistants, and all primary care providers will
appreciate CMDT as a ready reference and refresher text. Physicians in other specialties, pharmacists, and dentists will find
the book a useful basic medical reference text. Nurses, nurse-practitioners, and physicians' assistants will welcome the
format and scope of the book as a means of referencing medical diagnosis and treatment.
Patients and their family members who seek information about the nature of specific diseases and their diagnosis and
treatment may also find this book to be a valuable resource.

NEW IN THIS EDITION OF CMDT

Updated treatment recommendations for direct -acting oral anticoagulants ( dabigatran, rivaroxaban, apixaban, and
edoxaban)
New combination therapy (sacubitril plus valsartan) to improve clinical outcome in heart failure with reduced left ven­
tricular ej ection fraction
New information on Zika virus and infection caused by Elizabethkingia species
Alternative, noninvasive diagnostic tests for the diagnosis of cirrhosis
Diagnosis of Clostridium difficile by PCR tests, including newly recognized NAP 1 hypervirulent strains
Treatment of recurrent C difficile infections with fidaxomicin
Revised USPSTF recommendations for cardiovascular prevention methods
New information on proprotein convertase subtilisin/kexin type 9 (PCSK9) inhibitors for hypercholesterolemia
Latest antiviral regimens for chronic hepatitis C and treatment of autoimmune hepatitis
New pneumococcal, meningococcal vaccines
Update on influenza vaccines
Update on MMR and HPV vaccines
New FDA-approved medications for diabetes mellitus
Update on anti-TNF and immunomodulatory therapies of inflammatory bowel disease
New pharmacologic treatment for schizophrenia and bipolar disorder
Updated recommendations regarding appendicitis
New table summarizing 2 0 1 5 Revised Jones Criteria for rheumatic fever
New table outlining European Society of Cardiology guidelines for defining and diagnosing pericarditis
Latest information on treatment options for obesity
Updated information on dilated cardiomyopathy and Tako-Tsubo cardiomyopathy
Extensive revision of Disorders of Hemostasis, Thrombosis, & Anti thrombotic Therapy chapter
Revised treatment recommendations for infective endocarditis
Information on increasing deaths due to opioid overdose
Update on predictors of acute coronary syndrome
Updated and new treatment recommendations for HIV
Latest treatment recommendations for latent tuberculosis in HIV-positive and HIV-negative patients
Substantial revision of Nervous System Disorders chapter
The combination of PET and CT imaging in preoperative staging and role of programmed cell-death - 1 (PD- 1 )
inhibitors (nivolumab and pembrolizumab) for non-small cell lung cancers
Pharmacologic treatment for female hyposexual desire disorder

xiii
 xiv CMDT 201 7 PREFACE

• Extensively revised section on Alcohol Use Disorder (Alcoholism)

• Updated treatment options for hepatitis C-associated renal disease and focal segmental glomerulosclerosis
Revised treatment options for Cushing syndrome and hypercortisolism
• Latest revision of recommended adult immunization schedule from the Centers for Disease Control
• Two new online chapters: Lesbian & Bisexual Women's Health and Transgender Health & Disease Prevention
• Expanded online Podiatry chapter

OUTS TANDING FEATUR ES OF CMDT

• Medical advances up to time of annual publication
• Detailed presentation of primary care topics, including gynecology, obstetrics, dermatology, ophthalmology, otolaryn­
gology, psychiatry, neurology, toxicology, urology, geriatrics, orthopedics, women's health, preventive medicine, and
palliative care
• Concise format, facilitating efficient use in any practice setting
• More than 1 000 diseases and disorders
• Annual update on HIV IAIDS and other newly emerging infections.
• Specific disease prevention information
• Easy access to medication dosages, with trade names indexed and costs updated in each edition
• Recent references, with unique identifiers (PubMed, PMID numbers) for rapid downloading of article abstracts and, in
some instances, full-text reference articles
CMDT Online (www.AccessMedicine.com) provides full electronic access to CMDT 201 7 plus expanded basic science
information and ten additional chapters. The ten online-only chapters (Anti-Infective Chemotherapeutic & Antibiotic
Agents, Fundamentals of Human Genetics & Genomics, Diagnostic Testing & Medical Decision Making, Information
Technology in Patient Care, Integrative Medicine, Podiatric Disorders, Women's Health Issues, Lesbian & Bisexual Women's
Health, Transgender Health & Disease Prevention, and Appendix: Therapeutic Drug Monitoring & Laboratory Reference
Intervals, & Pharmacogenetic Testing) are available at www.AccessMedicine.com/CMDT. CMDT Online is updated
throughout the year and includes an expanded, dedicated Media Gallery as well as links to related Web sites. Subscribers
also receive access to Diagnosaurus with 1 000+ differential diagnoses, Guide to Diagnostic Tests, Quick Medical Diagnosis
& Treatment, and CURRENT Practice Guidelines in Primary Care.

ACKNOWLEDGMENTS

We wish to thank our associate authors for participating once again in the annual updating of this important book. We are
especially grateful to Timothy G. Berger, MD, Patrick F. Fogarty, MD, J. Daniel Kelly, MD, Geoffrey A. Kerchner, MD, PhD, and
Cynthia A. Luu, DPM who are leaving CMDT this year. We have all benefited from their clinical wisdom and commitment.
Many students and physicians also have contributed useful suggestions to this and previous editions, and we are grateful.
We continue to welcome comments and recommendations for future editions in writing or via electronic mail. The editors'
e-mail addresses are below and author e-mail addresses are included in the Authors section.
Maxine A. Papadakis, MD
[email protected]
Stephen J. McPhee, MD
[email protected]
Michael W. Rabow, MD
[email protected]
San Francisco, California
 From inability to let alone; from too much zeal for the new and con­
tempt for what is old; from putting knowledge before wisdom, and
science before art and cleverness before common sense; from treating
patients as cases; and from making the cure of the disease more
grievous than the endurance of the same, Good Lord, deliver us.

-Sir Robert Hutchison

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 CMDT 201 7 1

Disease Prevention &

Health Promotion

M ic h a e l Pignone M D, M P H1
Rene Sa l aza r, M D

G E N E RAL A P P ROAC H TO T H E PATI E N T Patient reasons for nonadherence include simple for­
getfulness, being away from home, being busy, and changes
The medical interview serves several functions. I t i s used to in daily routine. Other reasons include psychiatric disor­
collect information to assist in diagnosis (the "history" of ders (depression or substance abuse), uncertainty about the
the present illness), to understand patient values, to assess effectiveness of treatment, lack of knowledge about the
and communicate prognosis, to establish a therapeutic consequences of poor adherence, regimen complexity, and
relationship, and to reach agreement with the patient about treatment side effects.
further diagnostic procedures and therapeutic options. It Patients seem better able to take prescribed medications
also serves as an opportunity to influence patient behavior, than to adhere to recommendations to change their diet,
such as in motivational discussions about smoking cessa­ exercise habits, or alcohol intake or to perform various self­
tion or medication adherence. Interviewing techniques care activities (such as monitoring blood glucose levels at
that avoid domination by the clinician increase patient home). For short-term regimens, adherence to medications
involvement in care and patient satisfaction. Effective clini­ can be improved by giving clear instructions. Writing out
cian-patient communication and increased patient involve­ advice to patients, including changes in medication, may
ment can improve health outcomes. be helpful. B ecause low functional health literacy is com­
mon (almost half of English-speaking US patients are
..... Patient Adherence unable to read and understand standard health education
For many illnesses, treatment depends on difficult funda­ materials) , other forms of communication-such as illus­
mental behavioral changes, including alterations in diet, trated simple text, videotapes, or oral instructions-may be
taking up exercise, giving up smoking, cutting down drink­ more effective. For non-English-speaking patients, clini­
ing, and adhering to medication regimens that are often cians and health care delivery systems can work to provide
complex. Adherence is a problem in every practice; up to culturally and linguistically appropriate health services.
50% of patients fail to achieve full adherence, and one-third To help improve adherence to long-term regimens, cli­
never take their medicines. Many patients with medical nicians can work with patients to reach agreement on the
problems, even those with access to care, do not seek appro­ goals for therapy, provide information about the regimen,
priate care or may drop out of care prematurely. Adherence ensure understanding by using the "teach-back" method,
rates for short-term, self-administered therapies are higher counsel about the importance of adherence and how to
than for long-term therapies and are inversely correlated organize medication-taking, reinforce self-monitoring,
with the number of interventions, their complexity and provide more convenient care, prescribe a simple dosage
cost, and the patient's perception of overmedication. regimen for all medications (preferably one or two doses
As an example, in HIV-infected patients, adherence to daily), suggest ways to help in remembering to take doses
antiretroviral therapy is a crucial determinant of treatment (time of day, mealtime, alarms) and to keep appointments,
success. Studies have unequivocally demonstrated a close and provide ways to simplify dosing (medication boxes).
relationship between patient adherence and plasma HIV Single-unit doses supplied in foil wrappers can increase
RNA levels, CD4 cell counts, and mortality. Adherence adherence but should be avoided for patients who have dif­
levels of more than 95% are needed to maintain virologic ficulty opening them. Medication boxes with compart­
suppression. However, studies show that over 60% of ments (eg, Medisets) that are filled weekly are useful.
patients are less than 90% adherent and that adherence Microelectronic devices can provide feedback to show
tends to decrease over time. patients whether they have taken doses as scheduled or to
notify patients within a day if doses are skipped. Remind­
1 Dr. Pignone is a member of the US Preventive Services Task ers, including cell phone text messages, are another effec­
Force (USPSTF). The views expressed in this chapter are his and tive means of encouraging adherence. The clinician can
Dr. Salazar's and not necessarily those of the USPSTF. also enlist social support from family and friends, recruit
 2 CMDT 201 7 C H A PTER 1

an adherence monitor, provide a more convenient care

O'Connor PJ et al. Randomized trial of telephone outreach to
environment, and provide rewards and recognition for the improve medication adherence and metabolic control in
patient's efforts to follow the regimen. Collaborative pro­ adults with diabetes. Diabetes Care. 2014 Dec;37(12):33 1 7-24.
grams that utilize pharmacists to help ensure adherence are [PMID: 253 1 5207]
also effective. Zillich AJ et al. A randomized, controlled pragmatic trial of tel­
Adherence is also improved when a trusting doctor­ ephonic medication therapy management to reduce hospital­
ization in home health patients. Health Serv Res. 2 0 1 4
patient relationship has been established and when patients
Oct;49(5) : 1 537-54. [PMID: 247 12335]
actively participate in their care. Clinicians can improve
patient adherence by inquiring specifically about the behav­
iors in question. When asked, many patients admit to
incomplete adherence with medication regimens, with H EALTH MAI N T E N A N C E & D I S EA S E
advice about giving up cigarettes, or with engaging only in PREVENTION
"safer sex" practices. Although difficult, sufficient time must
be made available for communication of health messages. Preventive medicine can be categorized a s primary, sec­
Medication adherence can be assessed generally with a ondary, or tertiary. Primary prevention aims to remove or
single question: "In the past month, how often did you take reduce disease risk factors ( eg, immunization, giving up or
your medications as the doctor prescribed?" Other ways of not starting smoking) . Secondary prevention techniques
assessing medication adherence include pill counts and promote early detection of disease or precursor states ( eg,
refill records; monitoring serum, urine, or saliva levels of routine cervical Papanicolaou screening to detect carci­
drugs or metabolites; watching for appointment nonatten­ noma or dysplasia of the cervix) . Tertiary prevention mea­
dance and treatment nonresponse; and assessing predict­ sures are aimed at limiting the impact of established
able drug effects, such as weight changes with diuretics or disease ( eg, partial mastectomy and radiation therapy to
bradycardia from beta-blockers. In some conditions, even remove and control localized breast cancer) .
partial adherence, as with drug treatment of hypertension Tables 1 - l and l -2 give leading causes of death in the
and diabetes mellitus, improves outcomes compared with United States and estimates of deaths from preventable
nonadherence; in other cases, such as HIV antiretroviral causes. Mortality rates continue to decline overall, but
therapy or treatment of tuberculosis, partial adherence recent data suggest increased rates of death, mainly from
may be worse than complete nonadherence. suicide and substance misuse, among less well-educated
middle-aged white adults.
..... Guiding Principles of Care Many effective preventive services are underutilized,
and few adults receive all of the most strongly recom­
Ethical decisions are often called for in medical practice, at mended services. Several methods, including the use of
both the "micro" level of the individual patient -clinician provider or patient reminder systems (including interac­
relationship and at the "macro'' level of the allocation of tive patient health records) , reorganization of care environ­
resources. Ethical principles that guide the successful ments, and possibly provision of financial incentives to
approach to diagnosis and treatment are honesty, benefi­ clinicians (though this remains controversial), can increase
cence, justice, avoidance of conflict of interest, and the
pledge to do no harm. Increasingly, Western medicine
involves patients in important decisions about medical
care, eg, which colorectal screening test to obtain or which
modality of therapy for breast cancer or how far to proceed Table 1 - 1 . Leading causes of death in the United
with treatment of patients who have terminal illnesses (see States, 20 1 3.
Chapter 5).
The clinician's role does not end with diagnosis and Category Esti mate
treatment. The importance of the empathic clinician in All causes 2,596,993
helping patients and their families bear the burden of seri­
1 . Diseases of the heart 6 1 1 , 1 05
ous illness and death cannot be overemphasized. "To cure
sometimes, to relieve often, and to comfort always" is a 2. Malignant neoplasms 584,881
French saying as apt today as it was five centuries ago-as 3. Chronic l ower respi ratory d i seases 1 49,205
is Francis Peabody's admonition: "The secret of the care of
4. Accidents (uni ntentional inju ries) 1 30,557
the patient is in caring for the patient:' Training to improve
mindfulness and enhance patient-centered communica­ 5. Cerebrovascu lar d i seases 1 28,978
tion increases patient satisfaction and may also improve 6. Alzheimer d i sease 84,767
clinician satisfaction. 7. Dia betes mellitus 75,578
8. I nfl uenza and pneumonia 56,979
Choudhry NK et al. Improving adherence to therapy and clinical
outcomes while containing costs: opportunities from the 9. Neph ritis, nephrotic synd rome, 47,1 1 2
greater use of generic medications: best practice advice from and nephrosis
the Clinical Guidelines Committee of the American College
1 0. I ntentional self-harm (suicide) 41 , 1 49
of Physicians. Ann Intern Med. 2 0 1 6 Jan 5; 1 64( 1 ) : 4 1 -9.
[PMID: 265948 1 8]
Data from Natio n a l Center for Health Statistics 20 1 5 .
 D I S EASE P R EVENTION & H EA LTH P ROMOTI O N CMDT 201 7 3

Table 1 -2. Deaths from all causes attributable to common preventable risk factors. (Numbers given in the thousa nds.)
Risk Factor Male (95% (1} Female (95% Cl) Both Sexes (95% Cl)

Tobacco smoking 248 (226-269) 2 1 9 ( 1 96-244) 467 (436-500)

H i g h blood pressu re 1 64 ( 1 53-1 75) 2 3 1 (21 3-249) 395 (372-4 1 4)
Overweig ht-obesity (high BMI) 1 1 4 (95- 1 28) 1 02 (80-1 1 9) 2 1 6 ( 1 88-237)
Physical i nactivity 88 (72- 1 05) 1 03 (80-1 28) 1 9 1 ( 1 64-222)
H i g h blood g l u cose 1 02 (80-1 22) 89 (69- 1 08) 1 90 ( 1 63-2 1 7)
H i g h LDL cholesterol 60 (42-70) 5 3 (44-59) 1 1 3 (94-1 24)
H i g h d i etary salt (sod i u m ) 49 (46-5 1 ) 5 4 (50-57) 1 02 (97-1 07)
Low d i etary omega-3 fatty acids (seafood) 45 (37-52) 3 9 (31 -47) 84 (72-96)
H i g h d i etary trans fatty acids 46 (33-58) 3 5 (23-46) 82 (63-97)
Alcohol use 45 (32-49) 20 ( 1 7-22) 64 (51 -69)
Low intake of fruits and vegeta bles 33 (23-45) 24 ( 1 5-36) 5 8 (44-74)
Low d i etary polyu nsatu rated fatty acids 9 (6-1 2) 6 (3-9) 1 5 ( 1 1 -20)
(in place of satu rated fatty acids)

B M I , body mass index; Cl, confidence i nterva l ; LDL, low-de n s ity l i po p rote i n .
N ote: N u m bers o f deaths can not b e s u m med across categ ories.
U sed, with permission, fro m Danaei G et al. The p reventa ble causes of death i n the U n ited States: co m pa rative risk assessment of d i eta ry,
l ifestyle, a n d meta bolic risk facto rs. P LoS Med. 2009 A p r 28;6(4) :e 1 000058.

utilization of preventive services, but such methods have schedules for children and adolescents can be found online
not been widely adopted. at http:/ /www.cdc.gov/vaccines/schedules/hcp/ child -ado­
lescent.html, and the schedule for adults is outlined in
Table 30-7. Substantial vaccine-preventable morbidity and
Case A et al. Rising morbidity and mortality in midlife among
mortality continue to occur among adults from vaccine­
white non-Hispanic Americans in the 2 1 st century. Proc
Nat! Acad Sci U S A. 2 0 1 5 Dec 8; 1 1 2(49) : 1 5078-83. [PMID:
preventable diseases, such as hepatitis A, hepatitis B, influ­
2657563 1 ] enza, and pneumococcal infections.
Forman-Hoffman V L e t al. Disability status, mortality, and lead­ Evidence suggests annual influenza vaccination is
ing causes of death in the United States community popula­ safe and effective with potential benefit in all age groups,
tion. Med Care. 2 0 1 5 Apr;53(4):346-54. [PMID: 2 5 7 1 9432] and the Advisory Committee on Immunization Practices
Johnson NB et al; Centers for Disease Control and Prevention
(ACIP) recommends routine influenza vaccination for all
(CDC). CDC National Health Report: leading causes of mor­
bidity and mortality and associated behavioral risk and pro­
persons aged 6 months and older, including all adults.
tective factors-United States, 2005-20 1 3 . MMWR Surveil! When vaccine supply is limited, certain groups should be
Summ. 2 0 1 4 Oct 3 1 ;63(Suppl 4):3-27. [PMID: 25356673] given priority, such as adults 50 years and older, individu­
Kochanek KD et al. Mortality in the United States, 2 0 1 3 . NCHS als with chronic illness or immunosuppression, and preg­
Data Brief. 2014 Dec;( l 78) : 1 -8. [PMID: 25549 1 8 3 ] nant women. An alternative high-dose inactivated vaccine
Ma J e t al. Temporal trends in mortality in the United States,
is available for adults 65 years and older. Adults 65 years
1 969-20 1 3 . JAMA. 20 1 5 Oct 27;3 1 4 ( 1 6) : 1 73 1 -9. [PMID:
26505597]
and older can receive either the standard-dose or high­
Yoon PW et al; Centers for Disease Control and Prevention dose vaccine, whereas those younger than 65 years should
(CDC) . Potentially preventable deaths from the five leading receive a standard-dose preparation.
causes of death-United States, 2008-20 1 0 . MMWR Morb The ACIP recommends two doses of measles, mumps,
Mortal Wkly Rep. 2 0 1 4 May 2;63 ( 1 7) : 3 69-74. [PMID: and rubella (MMR) vaccine in adults at high risk for expo­
24785982]
sure and transmission (eg, college students, health care
workers). Otherwise, one dose is recommended for adults
PREVENTION OF I N FECTIOUS DISEASES aged 1 8 years and older. Physician documentation of dis­
ease is not acceptable for evidence of MMR immunity.
Much of the decline i n the incidence and fatality rates o f Routine use of 1 3 -valent pneumococcal conjugate vac­
infectious diseases i s attributable t o public health mea­ cine (PCV13) is recommended among adults aged 65 and
sures-especially immunization, improved sanitation, and older. Individuals 65 years of age or older who have never
better nutrition. received a pneumococcal vaccine should first receive PCV 1 3
Immunization remains the best means of preventing followed b y a dose o f 23-valent pneumococcal polysaccha­
many infectious diseases. Recommended immunization ride vaccine (PPSV23) 6-12 months later. Individuals who
 4 CMDT 201 7 C H A PTER 1

have received more than one dose of PPSV23 should receive The rate of tuberculosis in the United States has been
a dose of PCV 1 3 more than 1 year after the last dose of declining since 1 992. Two blood tests, which are not con­
PPSV23 was administered. founded by prior bacillus Calmette-Guerin (BCG) vaccina­
The ACIP recommends routine use of a single dose of tion, have been developed to detect tuberculosis infection
tetanus, diphtheria, and 5-component acellular pertussis by measuring in vitro T-cell interferon-gamma release in
vaccine (Tdap) for adults aged 1 9-64 years to replace the response to two antigens (one, the enzyme-linked immu­
next booster dose of tetanus and diphtheria toxoids vaccine nospot [ELISpot] , [T-SPOT.TB ] , and the other, a quantita­
(Td). Due to increasing reports of pertussis in the United tive ELISA [ QuantiFERON-TB Gold] test) . These
States, clinicians may choose to give Tdap to persons aged T-cell-based assays have an excellent specificity that is
65 years and older (particularly to those who might risk higher than tuberculin skin testing in BCG-vaccinated
transmission to at-risk infants who are most susceptible to populations.
complications, including death), despite limited published Treatment of tuberculosis poses a risk of hepatotoxicity
data on the safety and efficacy of the vaccine in this age and thus requires dose monitoring of liver transaminases.
group. Alanine aminotransferase (ALT) monitoring during the
B oth hepatitis A vaccine and immune globulin provide treatment of latent tuberculosis infection is recommended
protection against hepatitis A; however, administration of for certain individuals (preexisting liver disease, preg­
immune globulin may provide a modest benefit over vac­ nancy, chronic alcohol consumption) . ALT should be
cination in some settings. Hepatitis B vaccine administered monitored in HIV-infected patients during treatment of
as a three-dose series is recommended for all children aged tuberculosis disease and should be considered in patients
0- 1 8 years and high-risk individuals (ie, health care work­ over the age of 35. Symptomatic patients with an ALT ele­
ers, inj ection drug users, people with end-stage renal dis­ vation three times the upper limit of normal or asymptom­
ease) . Adults with diabetes are also at increased risk for atic patients with an elevation five times the upper limit of
hepatitis B infection, and in October 20 1 1 , the ACIP rec­ normal should be treated with a modified or alternative
ommended vaccination for hepatitis B in diabetic patients regimen.
aged 1 9-59 years. In diabetic persons aged 60 and older, The US Preventive Services Task Force (USPSTF) rec­
hepatitis B vaccination should be considered. ommends behavioral counseling for adolescents and adults
Human papillomavirus (HPV) virus-like particle who are sexually active and at increased risk for sexually
(VLP) vaccines have demonstrated effectiveness in pre­ transmitted infections. Sexually active women aged 24 years
venting persistent HPV infections and thus may impact the or younger and older women who are at increased risk for
rate of cervical intraepithelial neoplasia ( CIN) II-III. The infection should be screened for chlamydia.
ACIP recommends routine HPV vaccination (with three HIV infection remains a maj or infectious disease prob­
doses of the 9-valent [9vHPV] , 4-valent [4vHPV] , or lem in the world. The Centers for Disease Control and
2-valent [2vHPV] vaccine) for girls aged 1 1 - 1 2 years. The Prevention (CDC) recommends universal HIV screening
ACIP also recommends that all unvaccinated girls and of all patients aged 1 3 -64, and the USPSTF recommends
women through age 26 years receive the three-dose HPV that clinicians screen adolescents and adults aged 15 to 65
vaccination. Studies suggest that one dose of vaccine may years. Clinicians should integrate biomedical and behav­
be as effective as three. The ACIP recommends the routine ioral approaches for HIV prevention. In addition to reduc­
vaccination with three doses of the 4vHPV or 9vHPV ing sexual transmission of HIV, initiation of antiretroviral
vaccine for boys aged 1 1 or 12 years, males through age therapy reduces the risk for AIDS-defining events and
2 1 years, and men who have sex with men and immuno­ death among patients with less immunologically advanced
compromised men (including those with HIV infection) disease.
through age 26 years. Vaccination of males with HPV may Since sexual contact is a common mode of transmis­
lead to indirect protection of women by reducing transmis­ sion, primary prevention relies on eliminating high-risk
sion of HPV and may prevent anal intraepithelial neoplasia sexual behavior by promoting abstinence, later onset of
and squamous cell carcinoma in men who have sex with first sexual activity, decreased number of partners, and use
men. The use of HPV vaccine in the United States among of latex condoms. D aily preexposure prophylaxis with
women aged 1 8-26 years increased by 22% between 2008 the fixed-dose combination of tenofovir 3 0 0 mg and
and 2012; however, rates of immunization are low, espe­ emtricitabine 200 mg should be considered for people who
cially among Latina women and those with limited access are HIV-negative but at substantial risk for HIV infection.
to care. Interventions addressing personal beliefs and sys­ Studies of men who have sex with men suggest preexpo­
tem barriers to vaccinations may help address the slow sure prophylaxis therapy is very effective in reducing the
adoption of this vaccine. risk of contracting HIV. Patients taking preexposure pro­
Persons traveling to countries where infections are phylaxis should be encouraged to use other prevention
endemic should take the precautions described in Chap­ strategies to maximally reduce their risk, such as consistent
ter 30 and at http://wwwnc. cdc.gov/travel!destinations/ condom use and choosing less risky sexual behaviors (eg,
list. Immunization registries-confidential, population­ oral sex) . Postexposure prophylaxis is widely used after
based, computerized information systems that collect occupational and nonoccupational contact, and it has been
vaccination data about all residents of a geographic estimated to reduce the risk of transmission by approxi­
area-can be used to increase and sustain high vaccina­ mately 80%. Postexposure prophylaxis should be initiated
tion coverage. within 72 hours of exposure.
 D I S EASE P R EVENTION & H EA LTH P ROMOTI O N CMDT 201 7 5

In immunocompromised patients, live vaccines are

Kreimer A R e t al; Costa Rica Vaccine Trial and PATRICIA study
contraindicated, but many killed or component vaccines groups. Efficacy of fewer than three doses of an HPV- 1 6/ 1 8
are safe and recommended. Asymptomatic HIV-infected AS04-adjuvanted vaccine: combined analysis o f data from the
patients have not shown adverse consequences when given Costa Rica Vaccine and PATRICIA trials. Lancet Oncol. 2 0 1 5
live MMR and influenza vaccinations as well as tetanus, Jul; 16(7) :775-86. [PMID: 26071 347]
hepatitis B, H influenza type b, and pneumococcal vaccina­ LeFevre ML. B ehavioral counseling interventions to prevent
sexually transmitted infections: U.S. Preventive Services Task
tions-all should be given. However, if p oliomyelitis
Force recommendation statement. Ann Intern Med. 2 0 1 4
immunization is required, the inactivated poliomyelitis D e c 1 6; 1 6 1 ( 1 2) :894-90 1 . [PMID: 25244227]
vaccine is indicated. In symptomatic HIV-infected patients, LeFevre ML. Screening for Chlamydia and gonorrhea: U.S. Pre­
live-virus vaccines, such as MMR, should generally be ventive Services Task Force recommendation statement. Ann
avoided, but annual influenza vaccination is safe. Intern Med. 2 0 1 4 Dec 1 6; 1 6 1 ( 1 2) :902- 1 0 . [PMID: 25243785]
Herpes zoster, caused by reactivation from previous MacDougall D et a!. Universal tetanus, diphtheria, acellular per­
tussis (Tdap) vaccination of adults: what Canadian health care
varicella zoster virus infection, affects many older adults
providers know and need to know. Hum Vaccin Immunother.
and people with immune system dysfunction. It can cause 2 0 1 5; 1 1 (9):2 1 67-79. [PMID: 2609086 1 ]
postherpetic neuralgia, a potentially debilitating chronic Markowitz L E et a!. Human papillomavirus vaccination: recom­
pain syndrome. A varicella vaccine is available for the pre­ mendations of the Advisory Committee on Immunization
vention of herpes zoster. Several clinical trials have shown Practices (ACIP). MMWR Morb Mortal Wkly Rep Recomm
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