By Z. Ashton. Hillsdale College. 2018.

Congenital during a bleed clozapine 25 mg mastercard, he is asked to clean the nose Telangiectasia (Osler-Weber-Rendu which is then pinched for about 10 minutes clozapine 25 mg on line. The area is anaesthetised by local nasal sinuses xylocaine pack and cauterisation done 100 mg clozapine with visa. Exanthematous fevers like measles, Nasal packing Every attempt should be made mumps, typhoid to control the bleeding without packing the g. Hodgkin’s disease nose, as this causes further trauma to the nasal 182 Textbook of Ear, Nose and Throat Diseases mucosa, is troublesome for the patient, and nose is packed, as packing disturbs the nasal delays recovery. Various packing is needed when bleeding is haemostatic preparations like adenochrome, profuse and does not stop on pinching the vitamin C and K, and calcium preparations nose. A lubricated or medicated gauze is play only an adjuvant role in stopping the used for this purpose although nowadays bleeding. Packing Alternatively, nasal packing may be should never be done with a dry gauze. In such cases ligation continuous in spite of proper anterior nasal of the blood vessels supplying the nose may packing, then posterior nasal pack may be be the only alternative. This can be done under general The nose is mostly supplied by the external or local anaesthesia supplemented by carotid artery through its sphenopalatine sedation. The threads of artery in the neck or the internal maxillary the pack are attached to the ends of the artery in the sphenopalatine fossa arrests catheters which are then withdrawn into bleeding. The pack is guided by fingers from the area supplied by the anterior ethmoid behind the soft palate. The ligation of ethmoid vessels is done rubber catheter are tied on a rubber piece through a periorbital incision in the medial at the columella. A separate thread attached to the Besides these measures of controlling gauze pack is brought out through the bleeding from the nose, attention should be mouth. Racial: The deflections are more common in Europeans than in Asian or African Deviations of the nasal septum are commonly races. Age: Deflections are uncommon in anatomical, physiological and pathological children. Hereditary: Heredity may be a factor in its Various theories and factors have been put causation. High arched palate: Lack of descent or broadening of the palate as occurs normally during infancy may be a factor. Injury ruptures the chondro- osseous joint capsule of the septum and causes dislocations and fracture of the premaxillary wings. Birth moulding theory: Prolonged and forceful stress during the birth process affects the nose and causes dislocations and deformations. Cosmetic deformity: The dislocated ante- The deviated septum, depending on its loca- rior end may project out into the nasal tion and degree, is the most common cause of vestibule or cause deformity of the tip. Pain due to pressure on the anterior breathing with consequent dryness of the ethmoidal nerve. These predispose An external nasal deformity affecting the to recurrent attacks of sore throat, common cartilaginous part of the nose may be present. Impairment of The anterior end of the cartilaginous septum drainage of the sinuses may occur due to may project into one of the nasal vestibules mechanical obstruction of septal deviations or (called dislocation of anterior end of the by compensatory hypertrophy of turbinates. Anterior rhinoscopy Headache and facial neuralgia might occur shows deflection of the cartilaginous or bony because of defective aeration and impinge- septum or combination of both. This occurs because of stretching the mucosal vessels complicated with dryness of the mucosa and associated nose picking. Treatment of Deviated Nasal Septum Surgical correction is done to relieve the patient of symptoms. Diseases of the Nasal Septum 185 Submucous Resection of Septum the septum and also to reduce bleeding during surgery. Deviated nasal septum producing symp- Steps of Operation toms like nasal obstruction. When the deviated septum is a predis- cutaneous junction, usually on the posing factor for sinusitis or recurrent convex side of the deflection. With an elevator the mucoperichond- ing to the poor development of the teeth rial flap is elevated and the cartilage and mouth. Deviated septum preventing access for cartilage anteriorly leaving a strip for removal of polypi or ethmoidectomy. The incision is made operation may be needed for complete to the subperichondrial space of the other removal of the polypi. To gain, access for other intranasal rated from the mucoperichondrium of operations, for example trans-sphenoidal the other side without tearing the flap. To reduce the roominess in unilateral retract two mucoperichondrial flaps atrophic rhinitis. A ribbon gauze pack soaked then removed with Ballenger’s knife or in xylocaine is packed into the nose with an Luc’s forceps.

Susceptibility—Illness occurs most frequently with increasing age (most cases are at least 50) purchase clozapine 25mg, especially in patients who smoke and those with diabetes mellitus 25mg clozapine fast delivery, chronic lung disease 25mg clozapine for sale, renal disease or malignancy; and in the immunocompromised, particularly those receiving corticoste- roids or who had an organ transplant. Preventive measures: Cooling towers should be drained when not in use, and mechanically cleaned periodically to remove scale and sediment. Appropriate biocides should be used to limit the growth of slime-forming organisms. Maintaining hot water sys- tem temperatures at 50°C (122°F) or higher may reduce the risk of transmission. Control of patient, contacts and the immediate environment: 1) Report to local health authority: In many countries, not a reportable disease, Class 3 (see Reporting). Initiate an investiga- tion for a hospital source should a single confirmed nosoco- mial case be identified. Epidemic measures: Search for common exposures among cases and possible environmental sources of infection. Decon- tamination of implicated sources by chlorination and/or super- heating water supplies has been effective. Identification—A polymorphic protozoan disease of skin and mucous membranes caused by several species of the genus Leishmania. These protozoa exist as obligate intracellular parasites in humans and other mammalian hosts. The disease starts with a macule then a papule that enlarges and typically becomes an indolent ulcer in the absence of bacterial infection. Lesions may heal spontaneously within weeks to months, or last for a year or more. In some individuals, certain strains (mainly from the Western Hemisphere) can disseminate to cause mucosal lesions (espundia), even years after the primary cutaneous lesion has healed. These sequelae, which involve nasopharyngeal tissues, are char- acterized by progressive tissue destruction and often scanty presence of parasites and can be severely disfiguring. Recurrence of cutaneous lesions after apparent cure may occur as ulcers, papules or nodules at or near the healed original ulcer. Diagnosis is through microscope identification of the nonmotile, intra- cellular form (amastigote) in stained specimens from lesions, and through culture of the motile, extracellular form (promastigote) on suitable media. An intradermal (Montenegro) test with leishmanin, an antigen derived from the promastigotes is usually positive in established disease; it is not helpful with very early lesions, anergic disease or immunosuppressed patients. Occurrence—2 million new cases per year: China (recently), India and Pakistan; south-western Asia, including Afghanistan and the Islamic Republic of Iran; southern regions of former Soviet Union, the Mediterra- nean littoral; the sub-Saharan African savanna and Sudan, the highlands of Ethiopia and Kenya, Namibia; the Dominican Republic, Mexico (especially Yucatan), south central Texas, all of central America and every country of South America except Chile and Uruguay; leishmania have recently been reported among kangaroos in Australia. Numerous cases of diffuse cutaneous leishmaniasis have been reported in the past from the Dominican Republic and Mexico. In some areas in the eastern hemisphere, urban population groups, including children, are at risk for anthroponotic cutaneous leishmaniasis due to L. In the western hemisphere, disease is usually restricted to special groups, such as those working in forested areas, those whose homes are in or next to a forest, and visitors to such areas from nonendemic countries. Reservoir—Locally variable; humans (in anthroponotic cutaneous leishmaniasis), wild rodents (gerbils), hyraxes, edentates (sloths), marsu- pials and domestic dogs (considered victims more than real reservoirs); unknown hosts in many areas. Mode of transmission—In zoonotic foci, from the animal reservoir through the bite of infective female phlebotomines (sandflies). Motile promastigotes develop and multiply in the gut of the sandfly after it has fed on an infected mammalian host; in 8–20 days, infective parasites develop and are injected during biting. In humans and other mammals, the organisms are taken up by macrophages and transform into amastigote forms, which multiply within the macrophages until the cells rupture, enabling spread to other macrophages. In anthroponotic foci person-to- person transmission occurs through sandfly bites and, very rarely, through transfusion. Period of communicability—Not directly transmitted from per- son to person, but infectious to sandflies as long as parasites remain in lesions in untreated cases, usually a few months to 2 years. Factors responsible for late mutilating disease, such as espundia, are still partly unknown; occult infections may be activated years after the primary infection. The most important factor in immunity is the development of an adequate cell- mediated response. Control measures vary according to the habits of mammalian hosts and phlebotomine vectors; they include the following: 1) Case management: Detect cases systematically and treat rapidly. This applies to all forms of leishmaniasis and is one of the important measures to prevent development of de- structive mucosal lesions in the western hemisphere and “recidivans form” in the eastern hemisphere, particularly where the reservoir is largely or solely human. Phle- botomine sandflies have a relatively short flight range and are highly susceptible to control by systematic spraying with residual insecticides. Spraying must cover exteriors and interiors of doorways and other openings if transmission occurs in dwellings.

Industrially order 25 mg clozapine visa, sodium chlorate is synthesized from the electrolysis of a hot sodium chloride solution in a mixed electrode tank: NaCl + 3H O - NaClO + 3H2 3 2 It can also be synthesized by passing chlorine gas into a hot sodium hydroxide solution order clozapine 50 mg mastercard. Waterborne Diseases ©6/1/2018 527 (866) 557-1746 Chemical Oxygen Generation Chemical oxygen generators order 50mg clozapine overnight delivery, such as those in commercial aircraft, provide emergency oxygen to passengers to protect them from drops in cabin pressure by catalytic decomposition of sodium chlorate. Barium peroxide (BaO ) is used to absorb the chlorine which is a minor product in the decomposition. Iron2 powder is mixed with sodium chlorate and ignited by a charge which is activated by pulling on the emergency mask. Similarly, the Solidox welding system used pellets of sodium chlorate mixed with combustible fibers to generate oxygen. Toxicity in Humans Due to its oxidative nature, sodium chlorate can be very toxic if ingested. The oxidative effect on hemoglobin leads to methaemoglobin formation, which is followed by denaturation of the globin protein and a cross-linking of erythrocyte membrane proteins with resultant damage to the membrane enzymes. Therapy with ascorbic acid and methylene blue are frequently used in the treatment of methemoglobinemia. The treatment will consist of exchange transfusion, peritoneal dialysis or hemodialysis. Developmental and Reproductive Effects Several epidemiology studies have reported a possible association between disinfection byproducts and adverse reproductive outcomes, including spontaneous abortion (miscarriage). The Research Foundation for Health and Environmental Effects, a tax-exempt foundation established by the Chlorine Chemistry Division of the American Chemistry Council, sponsored a set of animal studies (Christian et al. Waterborne Diseases ©6/1/2018 528 (866) 557-1746 Formulations Sodium chlorate comes in dust, spray and granule formulations. There is a risk of fire and explosion in dry mixtures with other substances, especially organic materials, and other herbicides, sulfur, phosphorus, powdered metals, strong acids. If accidentally mixed with one of these substances it should not be stored in human dwellings. Marketed formulations contain a fire retardant, but this has little effect if deliberately ignited. Most commercially available chlorate weedkillers contain approximately 53% sodium chlorate with the balance being a fire depressant such as sodium metaborate or ammonium phosphates. Sodium Chlorite Sodium chlorite, like many oxidizing agents, should be protected from inadvertent contamination by organic materials to avoid the formation of an explosive mixture. The chemical explodes on percussive impact, and will ignite if combined with a strong reducing agent. Toxicity Sodium chlorite is a strong oxidant and can therefore be expected to cause clinical symptoms similar to the well-known sodium chlorate: methemoglobinemia, hemolysis, renal failure. From the analogy with sodium chlorate, even small amounts of about 1 gram can be expected to cause nausea, vomiting and even life-threatening hemolysis in Glucose- 6-Phosphate Dehydrogenase deficient persons. However, the corresponding sodium salt, sodium chlorite, NaClO is stable and inexpensive enough to be commercially available. The chlorine dioxide is then absorbed into an alkaline solution and reduced with hydrogen peroxide (H O ), yielding sodium chlorite. Closely related to the genus Memnoniella, most Stachybotrys species inhabit materials rich in cellulose. Depending on the length of exposure and volume of spores inhaled or ingested, symptoms can manifest as chronic fatigue or headaches, fever, irritation to the eyes, mucous membranes of the mouth, nose and throat, sneezing, rashes, and chronic coughing. In severe cases of exposure or cases exacerbated by allergic reaction, symptoms can be extreme including nausea, vomiting, and bleeding in the lungs and nose. In addition to controlling disease- causing organisms, chlorination offers a number of benefits including:  Reduces many disagreeable tastes and odors;  Eliminates slime bacteria, molds and algae that commonly grow in water supply reservoirs, on the walls of water mains and in storage tanks;  Removes chemical compounds that have unpleasant tastes and hinder disinfection; and  Helps remove iron and manganese from raw water. As importantly, only chlorine-based chemicals provide “residual disinfectant” levels that prevent microbial re-growth and help protect treated water throughout the distribution system. The Risks of Waterborne Disease Where adequate water treatment is not readily available, the impact on public health can be devastating. Even where water treatment is widely practiced, constant vigilance is required to guard against waterborne disease outbreaks. A striking example occurred in May 2000 in the Canadian town of Walkerton, Ontario. A report published by the Ontario Ministry of the Attorney General concludes that, even after the well was contaminated, the Walkerton disaster could have been prevented if the required chlorine residuals had been maintained. Some emerging pathogens such as Cryptosporidium are resistant to chlorination and can appear even in high quality water supplies. Cryptosporidium was the cause of the largest reported drinking water outbreak in U. Waterborne Diseases ©6/1/2018 530 (866) 557-1746 The Benefits of Chlorine Potent Germicide Chlorine disinfectants can reduce the level of many disease-causing microorganisms in drinking water to almost immeasurable levels. Chlorine is added to drinking water to destroy pathogenic (disease-causing) organisms.

Only one form of tic may be present order clozapine 100mg on line, or there may be a combination of tics which are carried out simultaneously cheap 50mg clozapine with visa, alternatively or consecutively cheap clozapine 100 mg visa. Includes head-banging, spasmus nutans, rocking, twirling, finger-flicking mannerisms and eye poking. Such movements are particularly common in cases of mental retardation with sensory impairment or with environmental monotony. Of nonorganic origin: Of nonorganic origin: Hypersomnia Nightmares Insomnia Night terrors Inversion of sleep rhythm Sleepwalking Excludes: narcolepsy (347) when of unspecified cause (780. Of nonorganic origin: Of nonorganic origin: Infantile feeding Overeating disturbances Pica Loss of appetite Psychogenic vomiting Excludes: anorexia: nervosa (307. Sometimes the child will have failed to gain bladder control and in other cases he will have gained control and then lost it. Sometimes the child has failed to gain bowel control, and sometimes he has gained control but then later again became encopretic. There may be a variety of associated psychiatric symptoms and there may be smearing of faeces. Encopresis (continuous) (discontinuous) of nonorganic origin Excludes: encopresis of unspecified cause (787. Most of the items listed in the inclusion terms are not indicative of psychiatric disorder and are included only because such terms may sometimes still appear as diagnoses. Catastrophic stress Exhaustion delirium Combat fatigue Excludes: adjustment reaction (309. The category of mixed disorders should only be used when there is such an admixture that this cannot be done. Such disorders are often relatively circumscribed or situation- specific, are generally reversible, and usually last only a few months. They are usually closely related in time and content to stresses such as bereave- ment, migration or separation experiences. In children such disorders are associated with no significant distortion of development. For example, an adolescent grief reaction resulting in aggressive or antisocial disorder would be included here. Excludes: neuroses, personality disorders, or other nonpsychotic conditions occurring in a form similar to that seen with functional disorders but in association with a physical condition; code to 300. There is a general diminution of self-control, foresight, creativity and spontaneity, which may be manifest as increased irritability, selfishness, restlessness and lack of concern for others. Conscientiousness and powers of concentration are often diminished, but measurable deterioration of intellect or memory is not necessarily present. The overall picture is often one of emotional dullness, lack of drive and slowness; but, particularly in persons previously with energetic, restless or aggressive characteristics, there may be a change towards impulsiveness, boastfulness, temper outbursts, silly fatuous humour, and the development of unrealistic ambitions; the direction of change usually depends upon the previous personality. A considerable degree of recovery is possible and continue over the course of several years. These states are often associated with old age, and may precede more severe states due to brain damage classifiable under dementia of any type (290. Mood may fluctuate, and quite ordinary stress may produce exaggerated fear and apprehension. There may be marked intolerance of mental and physical exertion, undue sensitivity to noise, and hypochondriacal preoccupation. The symptoms are more common in persons who have previously suffered from neurotic or personality disorders or when there is a possibility of compensation. This syndrome is particularly associated with the closed type of head injury when signs of localized brain damage are slight or absent, but it may also occur in other conditions. Postcontusional syndrome (encephalopathy) Post-traumatic brain syndrome, nonpsychotic Status postcommotio cerebri Excludes: frontal lobe syndrome (310. It should be used for abnormal behavior, in individuals of any age, which gives rise to social disapproval but which is not part of any other psychiatric condition. To be included, the behavior--as judged by its frequency, severity and type of associations with other symptoms--must be abnormal in its context. Disturbances of conduct are distinguished from an adjustment reaction by a longer duration and by a lack of close relationship in time and content to some stress. They differ from a personality disorder by the absence of deeply ingrained maladaptive patterns of behavior present from adolescence or earlier. Where the emotional disorder takes the form of a neurotic disorder described under 300. Overanxious reaction of childhood and adolescence Excludes: abnormal separation anxiety (309.

The only true contraindication to immunization with aP or wP is an anaphylactic reaction to a previous dose or to any constituent of the vaccine order 50mg clozapine amex. In young infants with suspected evolving and progressive neurological disease generic 100mg clozapine otc, immunization may be delayed for some months to permit diagnosis in order to avoid possible confusion about the cause of symptoms buy clozapine 100 mg mastercard. Clarithromycin and azithromy- cin are expensive but better tolerated alternatives. Suspected cases should be removed from the presence of young children and infants, especially nonimmunized infants, until the patients have received at least 5 days of a minimum 7-day course of antibiotics. Suspected cases who do not receive antibiotics should be isolated for 3 weeks after onset of paroxysmal cough or till the end of cough, whichever comes first. Passive immu- nization has not been demonstrated to be effective and there is no product currently commercially available. The initiation of active immunization following recent exposure is not effective against infection but should be undertaken to protect the child against further exposure in case it has not been infected. A 7-day course of erythromycin, clarithromycin or azithromy- cin for household and other close contacts, regardless of immunization status and age, is recommended for house- holds where there is a child under 1. Prophylactic antibio- therapy in the early incubation period may prevent disease, but difficulties of early diagnosis, costs involved and con- cerns related to the occurrence of drug resistance all limit prophylactic treatment to selected individual conditions: - children under 1 year and pregnant women in the last 3 weeks of pregnancy (because of the risk of transmission to the newborn); - stopping infection among household members, particularly if there are children aged under 1 and pregnant women in the last 3 weeks of pregnancy. Epidemic measures: A search for unrecognized and unre- ported cases may be indicated to protect preschool children from exposure and to ensure adequate preventive measures for exposed children under 7. Accelerated immunization, with the first dose at 4–6 weeks of age and the second and third doses at 4-week intervals, may be indicated; immunizations should be completed for those whose schedule is incomplete. Disaster implications: Pertussis is a potential problem if introduced into crowded refugee camps with many non-immu- nized children. International measures: Ensure completion of primary immu- nization of infants and young children before they travel to other countries; review need for a booster dose. A scaling painless papule with satellite lymphadenopathy ap- pears 1–8 weeks after infection, usually on the hands, legs or dorsum of the feet. Within 3–12 months a maculopapular, erythematous secondary rash appears and may evolve into tertiary splotches of altered (dyschro- mic) skin pigmentation of variable size. These treponema-containing macules pass through stages of blue to violet to brown pigmentation, finally becoming treponema-free depigmented (achromic) scars. Lesions coexist at different stages of evolution and are most common on the face and extremities. Serological tests for syphilis usually become reactive before or during the secondary rash and thereafter behave as in venereal syphilis. Occurrence—Found only among isolated rural populations living under crowded unhygienic conditions in the American tropics. Mode of transmission—Presumably person-to-person through di- rect and prolonged contact with initial and early dyschromic skin lesions. The location of primary lesions suggests that trauma provides a portal of entry; lesions in children occur in those body areas most scratched. Various biting and sucking arthropods, especially blackflies, are suspected but are not proven as biological vectors. Period of communicability—Unknown; potentially communica- ble while dyschromic skin lesions are active, sometimes for many years. Not highly contagious; several years of intimate contact may be necessary for transmission. Preventive measures: Those applicable to other nonvenereal treponematoses apply to pinta; see Yaws, 9A. Control of patient, contacts and the immediate environment: 1) Report to local health authority: In selected endemic areas; in most countries, not a reportable disease, Class 3 (see Report- ing). Epidemic measures, Disaster implications and International measures: See Yaws, C, D and E. Identification—A specific zoonosis involving rodents and their fleas, which transfer the bacterial infection to various animals and to people. Initial signs and symptoms may be nonspecific with fever, chills, malaise, myalgia, nausea, prostration, sore throat and headache. Lymph- adenitis often develops in those lymph nodes that drain the site of the bite, where there may be an initial lesion. This is bubonic plague, and it occurs more often (90%) in lymph nodes in the inguinal area and less commonly in those in the axillary and cervical areas. All forms, including instances in which lymphadenopathy is not apparent, may progress to septicemic plague with bloodstream dissemination to diverse parts of the body that include the meninges. Secondary involvement of the lungs results in pneumo- nia; mediastinitis or pleural effusion may develop.

In 50% of the cases effective clozapine 25 mg, however buy cheap clozapine 50 mg on line, pseudomembranes are not present buy 50mg clozapine free shipping, making endoscopy a relatively insensitive test (43). Further, endoscopy should be avoided in patients with severe disease with colonic dilatation due to the risk of perforation. Stool cultures are highly sensitive but the specificity is low because non-disease-causing, non-toxigenic strains of the bacterium would also grow naturally on media. The culture must be accompanied by tissue culture cytotoxin assay or enzyme immunoassay to identify toxigenic strains. However, since stool cultures allow for molecular typing it is an essential tool for monitoring molecular epidemiology and antibiotic susceptibility. However, a positive Clostridium difficile Infection in Critical Care 279 culture result only indicates the presence of the organism, not the toxin production. It has the highest sensitivity of all the tests and can detect as little as 10 pg of toxin B (26). The assay reveals cytopathic effects on cell culture monolayers characterized by rounding of fibroblasts (Fig. Preincubation with neutralizing antibodies against the toxins demonstrates the specificity of the cytotoxicity. The major disadvantage of the cytotoxin assay is that it is technically demanding and expensive, and many laboratories lack the expertise and equipment to provide rapid turnaround (25). The disadvantage is the low sensitivity (70–80%) linked to the fact that it requires a large amount of toxins (100–1000 pg) for detection. The relatively high false-negative rate can be decreased by 5% to 10% by repeating two to three specimens but this also increases the cost. A study by Ticehurst (46) indicate that this two-step method has good sensitivity, specificity, and cost although there is a 24-to 48-hour delay in reporting results. Supportive measures such as intravenous fluid and electrolyte replenishment should be instituted if necessary. Use of antiperistaltic agents, such as narcotics and loperamide, should be avoided as they may promote the development of toxic megacolon (6). Vancomycin, administered via retention enemas, has been shown to be effective in small, uncontrolled case series of patients with severe or fulminant colitis not responding to standard therapy (50). The cost per day with standard dosing (125 mg 4 times daily) is approximately $70 as compared with $2 with metronidazole. Studies have shown that a regimen of 125-mg oral vancomycin administered four times daily (current standard regimen) is as effective as 500 mg four times a day (older standard) (51). Metronidazole, as opposed to oral vancomycin, is virtually 100% absorbed in the small bowel and reaches the colon through biliary excretion and increased exudation across the intestinal mucosa during diarrhea (52). In healthy volunteers without diarrhea, oral and intravenously administered metronidazole achieve low fecal concentrations but usually exceeds the C. Side effects of metronidazole include dose-dependent peripheral neuropathy, nausea, and metallic taste. Metronidazole is typically dosed orally at 500 mg three times daily or 250 mg four times daily. First, it must be emphasized that treatment is not indicated in patients who are asymptomatic even with a positive stool toxin assay. Mild to Moderate Disease For very mild disease, discontinuation of the inducing agent may be sufficient therapy and no further antibiotic therapy needed. Current guidelines recommend oral metronidazole (500 mg 3 times daily or 250 mg 4 times daily) for initial treatment (Table 3). Metronidazole is favored over oral vancomycin in mild to moderate cases due to its lower cost and good efficacy. Empiric therapy is appropriate if clinical suspicion is high and the initial diagnostic assay is pending or negative. One study showed increased mortality among patients who had an initial false-negative toxin (40). The recommended dose for severe disease is 125-mg oral vancomycin four times daily. Response to treatment is generally rapid, with decreased fever within one day and improvement of diarrhea in four to five days. Patients who fail to respond may have alternate diagnoses, lack of compliance, or the inability of drug to reach the colon such as with ileus or megacolon (26). Yet, all studies have shown failures with both metronidazole and vancomycin (*15% failure rates in the randomized controlled trials). Surgery is indicated for patients with peritoneal signs, systemic toxicity, toxic megacolon, perforation, multiorgan failure, or progression of symptoms despite appropriate antimicrobial therapy and Clostridium difficile Infection in Critical Care 283 recommended before serum lactate >5 (54). Select patients with disease clearly limited to the ascending colon have been treated successfully with right hemicolectomy, but intraoperative colonoscopy should be performed to rule out left-sided disease (40). Among patients requiring surgery, mortality rates after colectomy have ranged from 38% to 80% in small series (40).