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Bactrim suspension trimethoprim and sulfamethoxazole. This was also found to be associated with Phentermine 37.5mg 60 pills US$ 260.00 US$ 4.33 a greater incidence of pneumonia (odds ratio [OR] 1.8, purchase phentermine online cheap 95% CI 1.0–3.8) than the combination of cephalexin, clindamycin, and imipenem. Although Bactrim was associated with a modest (OR 1.6, 96% CI 0.9–3.6) increased risk of hospitalization for pneumonia, this was not statistically significant. The authors concluded that they could not rule out the possibility that Bactrim may be associated with adverse events related to its use, but they noted that the difference between ORs from combination of cephalexin, clindamycin, and imipenem from the Bactrim-only group was statistically significant. As Bactrim is a long-acting antibiotic with limited shelf life, it is essential that patients and clinicians be aware of the potential for serious adverse events when patients try to use Bactrim without other antibiotics. A Cochrane systematic review of 10 randomized double-blind control trials conducted between 1990 and 2011 identified 10 case reports of serious adverse reactions to Bactrim between 1997 and 2004 (13, 15, 16, 34, 35, 36, 37, 38). These data supported the safety of Bactrim in preventing pneumonia. As a result of this work, the Centers for Disease Control issued a policy statement on pneumococcal infections for adults in April 2007 (39) recommending that "patients with uncomplicated pneumococcal infections who receive Bactrim should be advised to take an additional dose of the antibiotic" (i.e., cephalexin or clindamycin). The new policy statement also recommended that "patients with suspected pneumococcal infections should receive a second dose of cephalexin or clindamycin if antibiotic therapy is stopped within the first 24 hours of administration" (40). In October 2013, the FDA issued a public health advisory about the risk of adverse events associated with short-term Bactrim discontinuation, noting that Cheapest carisoprodol online "Bactrim may cause serious adverse events" (i.e., gastrointestinal upset, rash, fever, arthralgia) when not taken as recommended (41). The FDA has not updated their policy regarding Bactrim discontinuation, but the CDC issued a statement in 2015 indicating that they had "identified a new risk" associated with Bactrim discontinuation (42). The statement cited a report that "three people who took Bactrim as directed, but had not been treated appropriately, were seriously ill due to a severe, potentially life-threatening allergic reaction to the drug" (43). The CDC recommended that clinicians not use Bactrim for patients who present with a fever >38°C, or who may have had a severe allergic reaction to the antibiotic. In addition, it recommended that clinicians not treat patients with a fever >38°C or rash of unknown cause who received Bactrim and had not been adequately cured of pneumococcal infection. Patients With Pneumococcal Disease In addition to the above recommendations for use of cephalexin or clindamycin, there are a number of recommendations for the treatment pneumonia and sepsis with antibiotics. The American College of Physicians has issued a set of guidelines that recommend the use of cephalexin or clindamycin for the treatment of pneumonia and sepsis (44). These guidelines state that "cephalexin or clindamycin should be administered in groups of at least 6, or in combination with other antimicrobials as indicated" (44). The ACP Guideline also states that "the use of antibiotics is rarely indicated in patients with pneumonia and/or sepsis, particularly in patients with active infection who are at risk for disseminated infections" (44). The American Society of Microbiology Guidelines for the Management of Patients with Antibiotic-Related Infections advises that antibiotic treatment should be started when bacterial cultures are negative for the pathogen, clinical presentation of infection is stable, and the patient considered to be at high risk of disseminated infection (45). Infectious Diseases Society of America recommendations for the management of pneumococcal and respiratory disease in adults state that "the most appropriate treatment is usually empiric therapy with multiple antibiotics and antibiotic prophylaxis for as long indicated" (46). Pneumococcal Disease Associated with the Use of Imipenem The recent outbreak of pneumococcal meningitis in New York City, Washington, D.C., and Maryland reported by the CDC in 2013 suggested that use of imipenem to treat pneumococcal meningitis was associated with an increased risk of pneumococcal infection and mortality (4, 47).

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