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Cruzacalle 5 x 7 Full Color. Postcards 4x6 Full Color 16Pts Entrega Gratis Puerto Rico. Mediante este servicio virtual usted se podrá matricular y tomar curso de Corredor de Bienes Raíces de la Florida de 72 horas a Distancia por Internet desde cualquier parte y o desde la comodidad de su hogar. Este curso es totalmente en inglés y por Internet y está disponible para tomarlo las 24 horas los 7 días de la semana.

Career Real Estate College está siempre a la vanguardia con la Educación a Distancia. Una vez terminado este curso, usted tendrá la confianza y el conocimiento necesario para aprobar el examen estatal y lanzar su carrera en el sector inmobiliario en la Florida. Career Real Estate College Florida mantiene un alto nivel de educación de calidad, confiabilidad y experiencia durante años que lo ha convertido en la Escuela de Bienes Raíces más grande de Puerto Rico.

18 años o más Diploma de Escuela Superior o su equivalente Número de Seguro Social Los Asociados de Ventas deben haber tomado el Curso Post Licencia Post I 45 horas Huellas Dactilares Tomar y aprobar el Curso de 72 horas El solicitante debe tener la experiencia requerida. Cursos Florida. Con el fin de obtener una licencia como corredor de bienes raíces, el solicitante deberá ser titular Una licencia activa del Asociado de Ventas de bienes raíces por lo menos 24 meses durante los 5 años anteriores en la oficina de uno o más corredores de bienes raíces con licencia en este estado o cualquier otro estado, territorio o jurisdicción de los Estados Unidos o en cualquier jurisdicción nacional extranjera, o Una licencia válida y vigente de asociado de ventas de bienes raíces por lo menos 24 meses durante los 5 años anteriores en el servicio de una agencia gubernamental por un sueldo y la realización de las funciones atribuidas en el Capítulo 475 de los Estatutos de la Florida, para las licencias de bienes raíces, o Una licencia de Corredor de Bienes Raíces actual y válida durante al menos 24 meses durante los 5 años precedentes en cualquier otro estado o jurisdicción de los Estados Unidos o en cualquier jurisdicción nacional extranjero.

Vendedor POST I Curso Post Lic. Corredor POST II Curso Reactivación 28 horas. Tiene alguna duda o pregunta, estamos para servirle. Vendedor de Bienes Raíces Corredor de Bienes Raíces Curso Vendedor Online Curso Corredor Online Educación Continua Post Lic. Curso de Corredor de Bienes Raíces de la Florida Online. Roosevelt 1105 San Juan, PR 00921.

Customs requirements. The New Zealand Customs Service external link protects New Zealand s borders. Customs protecting the New Zealand border. Its job is to make sure that all goods and people entering and exiting New Zealand do so according to New Zealand laws and regulations. The New Zealand Customs Service website provides information on.

Travel to and from NZ external link - information for travellers planning to visit, or return home, to NZ. Arriving in New Zealand external link - information about the incoming Passenger Arrival Card and items you must declare. Duty free shopping allowances external link - information about the duty and GST you may need to pay on items you bring into NZ. Prohibited and restricted items external link - items you can t bring into NZ, or which require approval to import.

Moving to NZ permanently external link - information about bringing your household contents, vehicles, pets and animals to NZ. Importing goods personal external link - information about the duty and GST that may apply to items you import into NZ. Biosecurity at the border. Importing goods business external link - information about import documentation, clearance and requirements.

The Ministry for Primary Industries MPI external link looks after New Zealand s biosecurity system. Their work includes facilitating international trade, protecting the health of New Zealanders and ensuring the welfare of our environment, flora and fauna, marine life and Maori resources. What you must declare external link - including information about filling in your Passenger Arrival Card.

Bringing your pet to New Zealand external link - what you need to do when importing or exporting pets. Bringing goods into New Zealand external link - the biosecurity requirements that must be met before your goods are cleared to enter NZ. NZeTA - a new travel requirement for visitors to NZ. Importation of prescription medication. The New Zealand Government has introduced a new travel requirement for some transit passengers.

It s called the NZeTA New Zealand Electronic Travel Authority and travellers need to request theirs via the official mobile app or website. Colombian and Ecuadorian passport holders transiting through New Zealand on their way to another country need an NZeTA before they board their plane. Approval can take up to 72 hours, so get it before you go. Visit the official government website Immigration New Zealand - NZeTA external link or mobile app search for NZeTA on your phone.

For information on this process visit Immigration New Zealand - Visa options external link. Colombian and Ecuadorean passport holders travelling to New Zealand will need a visa. Cómo usar hielo y compresas frías. Generalidades del tema Información relacionada Créditos. Contenidos del tema. Generalidades del tema. El hielo y las compresas frías pueden aliviar el dolor, la hinchazón y la inflamación causados por lesiones y otras afecciones, como la artritis. Tipos de hielo y compresas frías.

Toalla helada. Moje una toalla con agua fría y exprímala hasta que solo esté húmeda. Doble la toalla, métala en una bolsa de plástico y congélela durante 15 minutos. Saque la toalla de la bolsa y colóquela en la zona lesionada o dolorida. 5 kg de hielo en una bolsa de plástico o en una compresa de hielo que se compra en la tienda. Coloque alrededor de 1 libra 0. Vierta el agua necesaria para cubrir apenas el hielo. Compresa de hielo.

Apriete la bolsa para sacarle el aire y séllela. Envuelva la bolsa en una toalla húmeda y colóquela en la zona afectada. Compresas frías. Las bolsas de arvejas chícharos o maíz elotes congelados son baratas, duran de 10 a 20 minutos y se adaptan bien al cuerpo. Mezcle 3 tazas 710 ml de agua y 1 taza 235 ml de alcohol isopropílico de frotar en una bolsa para congelador.

Selle la bolsa y colóquela en el congelador hasta que se forme aguanieve. Vuelva a congelar la bolsa cuando se derrita el aguanieve. También puede comprar compresas frías que pueden reutilizarse. Guárdelas en el congelador. Algunas están diseñadas para envolverlas alrededor de una zona lesionada, como un brazo o una rodilla. Cómo usar hielo o compresas frías. Colóquese hielo o una compresa fría en la zona lesionada o dolorida al menos 3 veces al día mientras tenga dolor, hinchazón e inflamación.

Después de eso, use hielo por entre 15 y 20 minutos, 3 veces al día por la mañana, por la tarde después del trabajo o la escuela y media hora antes de acostarse. Además, colóquese hielo después de cualquier actividad prolongada o ejercicio vigoroso. Ponga siempre un paño entre la piel y la compresa de hielo, y presione firmemente contra todas las curvas de la zona afectada. No se coloque hielo por más de 15 a 20 minutos seguidos y no se quede dormido con el hielo sobre la piel.

Las compresas frías comerciales son demasiado pesadas y voluminosas para usarlas en el ojo o alrededor de este. Tenga cuidado alrededor del ojo para evitar una quemadura química en el ojo si la compresa tiene una fuga. Información relacionada. Lesiones de los dedos del pie, de los pies y de los tobillos Problemas y lesiones en la espalda Problemas y lesiones en las rodillas Use Heat or Ice to Relieve Low Back Pain Lumbalgia Problemas y lesiones en los hombros Problemas en los dedos de los pies, pies y tobillos, no relacionados con lesiones.

Revisado 26 junio, 2019. Autor El personal de Healthwise Evaluación médica William H. MD, FACEP - Medicina de emergencia Adam Husney MD - Medicina familiar Kathleen Romito MD - Medicina familiar Joan Rigg PT, OCS - Terapía física. Evaluación médica William H. Esta información no reemplaza el consejo de un médico. Healthwise, Incorporated, niega toda garantía y responsabilidad por el uso de esta información.

El uso que usted haga de esta información implica que usted acepta los Términos de Uso. Aprenda cómo desarrollamos nuestro contenido. Para aprender más sobre Healthwise, visite Healthwise. Healthwise, Healthwise para cada decisión de la salud, y el logo de Healthwise son marcas de fábrica de Healthwise, Incorporated. Durante las primeras 72 horas, colóquese hielo por 10 minutos, una vez cada hora.

Feline Friday. Sacramento SPCA. Vaccinate My Pet. Spay Neuter EXPANSION project. Spay Neuter My Pet. Train My Pet. Learn About End of Life Services. Report a Lost Pet. Report Cruelty or Neglect. Visit the Sacramento SPCA. Read Success Stories. Work at the SPCA. Meet Corporate Partners. Surrender My Pet. DATOS SOBRE EL PARVOVIRUS. Que Es Parvovirus. Leer En Español. Parvovirus canino, o parvo, como es generalmente conocido, es un virus que usualmente ataca el tracto intestino canino parvovirus enteritis y, en casos raros, el corazon myocarditis.

Primero identifcado a fines de los1970 s, el virus es uno de los mas resistentes conocidos; puede resistir el calor, frio y los mos comunes desinfectantes. Parvo es transmitido por el excremento y vomito de perros y perritos infectados. El virus puede vivir en el excremento por mas o menos dos semanas y puede existir en el ambiente en los pisos o jaulas por muchos meses.

Porque es tan dificil de matar, el virus se transmite facilmente por fomentos como las manos, ropa, o zapatos de la persona quien tiene contacto con el virus. Sintomas de esta enfermedad aparesen despues del periodo de incubacion. El periodo de incubacion puede ser desde 3 a 12 dias despues de tener contacto, pero usualmente ocure entre 5 a 7 dias despues de exposicion.

Cuales Son Los Sintomas. Estos sintomas aveces son acompanados con excremento gris o amarillo con mal olor, o diarrea rayada con sangre. Unos perros infectados con el virus no tienen sintomas y nunca se enferman, mientras otros ensenan pocas sintomas y se alevian pronto. Otros se ponen muy enfermos y mueren entre 48 a 72 horas despues de los primer sintomas. A Que Perros Les Da. Los primeros signos del parvo incluyen la perdida de apetito, vomito, deshidratacion, letargo, fiebre, y depresion.

Aunque el virus puede atacar a perros y perritos de cualquier edad, el virus es mas comun en perros menores de un ano. El incidente mas alto se ve en perritos entre la edad de 6 a 24 semanas. Generalmente, perritos son protejedos por imunidad materna hasta las 6 semanas. Muchos perros adultos tienen imunidad porque fueron vacunados o fueron expuestos a la enfermedad cuando jovenes. Varios estudios sujeten que ciertas razas, incluyendo Dobermans y Rottweilers, puede ser mas susceptibles a la enfermedad que otras razas.

Animales quien han sido castrado probablamento fueron vacunados y debido a eso tienen menos probabledad de andar de vagos, asi reduciendo el riesgo de tener contacto con el virus. Estudios tambien indican que perros no castrados llevan mas riesgo que los que han sido castrados. Como Se Trata El Parvo. TratamIento usualmente incluye hospitalizacion, rebastecimiento de liquidos intravenos, y medicina para controlar el vomito, diarrea y infeciones secundarias.

Como Se Previene El Parvo. El mejor modo de prevenir el parvo es vacunarlos contra el virus y tenerlos en control; perros permitidos andar de vagos corren mas riesgo de tener contacto con el virus. This item appears in. We are located at. Refugios pueden prevenir un brote al institutar un programa de vacuna; asegurando que las jaulas sean disinfectadas con un producto asegurado de matar viruses; evaluando y vigilando con mucho cuidado a todos los animales; minamizando el tramite de fomentos ; y educando al personal y publico sobre la enfermedad.

7387 Phone 916. Tax ID number 94-1312343. Low-Cost Vaccine Wellness Clinic Hours Mon - Tues 11am 3pm Adoption Center Hours Wed Sun 11am 6pm Animal Intake Hours Wed Sun By Appointment Low-Cost Spay Neuter Clinic Hours Mon Sat By Appointment. Thank you, your submission has been received. Transit Visas in China Visas de Transito en la China. Sweet Travel Blog.

Tips tricks from a traveler Astucias de una viajera. In a previous post I explained how China requires a visa for most citizens to enter the country, however, there s a small loophole to that. China has in place a 72-hour and 144-hour transit visas. The really interesting visa is the 144 hours one, equal to 6 days, and was implemented to increase tourism in the area. The policy was put into place this year 2016 and covers only the cities of Shanghai, Jiangsu, and Zhejiang.

However, only nationals of certain countries can enjoy this special transit visa. The downside of this visa is that you cannot leave the city it was delivered in, but on the other hand, Shanghai is big and interesting enough for you to spend 6 days there. The 72-hour policy only includes 18 cities for the moment, and you are required to leave through the same airport you entered.

Three days might seem short, but if you re wanting to visit say, Beijing, while avoiding all the visa hassle it may already seem like the better option. One important thing is that, upon arrival in order to obtain either visa you must make sure you have a ticket confirming your flight to your final destination. So if you re thinking about traveling to an Asian country, you might consider making a layover in China, and checking one more country off your traveling list.

72-hour VISA 144-hour VISA. Below are links with more details on each visa and the list of countries that can benefit from them. Sweet Travels. En la entrada previa, expliqué como la China requiere a casi todas las nacionalidades una visa para entrar al país, sin embargo existe un tecnicismo a esto. China tiene unos visados de transito de 72-horas y 144-horas. La mas interesantes de estas es la de 144-horas, igual a 6 días, la cual fue puesta en lugar para augmenter el turismo.

La ley se implementó este año 2016 y cubre las ciudades de Shanghai, Jiangsu, y Zhejiang. Desafortunadamente solo nacionales de ciertos países pueden disfrutar de estas visas. Otra desventaja, es que con esta visa no se puede salir de la ciudad que te emitió el visado, pero la verdad Shanghai es lo suficiente grande e interesante para pasar 6 días completos allí. La visa de 72-horas solo incluye 18 ciudades por el momento, y estas obligado a salir por el mismo aeropuerto por el cual entraste.

Tal vez tres días parezca poco, pero si has querido visitar digamos, Beijing, y al mismo tiempo evitarte todo el enredo de la visa, esta podría ser una mejor opción. Algo muy importante es que a la llegada, para poder obtener ambas visas, deberas mostrar una confirmación de tu pasaje de vuelo al destino final. Así que si estas pensando viajar a un país oriental, te recomiendo considerar hacer transito en la China, y poder chulear un país mas de tu lista.

Acá abajo les dejo unos enlaces con mas detalles sobre la visa y la lista de países que se pueden beneficiar de estas. VISA de 72-horas VISA de 144-horas. Dulces Viajes. Month December 2016. br - Desentupidora Higitec Desentupidora 24 horas em São Paulo. br has ranked N A in N A and 2,124,998 on the world. Provided by Alexa ranking, higitec. br reaches roughly 1,465 users per day and delivers about 43,952 users each month. The domain higitec. br uses a Commercial suffix and it s server s are located in N A with the IP number 104.

List of domain same IP 104. hagitec japan. hagitec conduit. hagitec distributors. 10 and it is a. hightech grafix. hightech signs. hygitech usa inc 60 broad street suite 3502. Search Results related to higitec. br on Search Engine. Desentupidora Higitec - Mais de 50 ANOS de sucesso oferecendo serviços emergenciais 24 horas para desentupir qualquer tipo de encanamento. Líder de mercado, a Desentupidora Higitec possui uma cessionária em cada bairro para lhe atender com maior rapidez e eficiência.

Todas as cessionárias da Desentupidora Higitec são devidamente licenciadas pelos órgãos competentes. DA 52 PA 36 MOZ Rank 1. HIGITEC se fundó en el año 1990 con el fin de aportar sus conocimientos y experiencia adquiridos en el ámbito de la Higiene Pública y Alimentaria. En el ámbito de la higiene y seguridad alimentaria, realizamos Planes de Autocontrol APPCC en todas las actividades posibles.

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See photos, tips, similar places specials, and more at Higitec Desentupimento e Dedetização. Business Service in São Paulo, SP. Foursquare uses cookies to provide you with an optimal experience, to personalize ads that you may see, and to help advertisers measure the results of their ad campaigns. DA 93 PA 75 MOZ Rank 83. Find out what works well at HIGITEC from the people who know best. Get the inside scoop on jobs, salaries, top office locations, and CEO insights.

Compare pay for popular roles and read about the team s work-life balance. Uncover why HIGITEC is the best company for you. DA 24 PA 35 MOZ Rank 29. Brands of the World is the world s largest library of brand logos in vector format available to download for free. BotW is also a great place for designers to showcase their work.

DA 94 PA 20 MOZ Rank 77. HighTec has teamed up with HiRain Technologies for the sales and support of HighTec s products in China. HiRain is a well established player on the market, offering a wide range of development tools for embedded applications through their tools division. DA 90 PA 96 MOZ Rank 51. With over 40 years of experience, Hagitec s customer centric staff can offer insight on your tubing projects. Find out more about our ever growing applications. DA 82 PA 22 MOZ Rank 4. Title Desentupidora Higitec Desentupidora 24 horas em São Paulo Tips Description Tips Keywords Tips Viewport width device-width, initial-scale 1 Tips Icon UTF-8.

Host Type Class TTL Extra higitec. br HINFO IN 3788 Cpu RFC8482 Os. Copyright c Nic. 10 Domain infomation Error No appropriate Whois server found for higitec. htmlbeing prohibited its distribution, commercialization or reproduction, in particular, to use it for advertising or any similar purpose. domain higitec. 2020-09-12T23 50 42-03 00 - IP 66. br owner LMA Servi os de Limpeza e Manuten o Eireli owner-c SIDAN37 tech-c MADAT nserver ken.

com nsstat 20200910 AA nslastaa 20200910 nserver megan. com nsstat 20200910 AA nslastaa 20200910 created 19970804 50117 changed 20190911 expires 20230804 status published. nic-hdl-br MADAT person Manuten o de Dom nios - Atuart created 20070622 changed 20180414. Security and mail abuse issues should also be addressed to cert. brrespectivelly to email protected and email protected whois. br accepts only direct match queries.

Types of queries are domain. nic-hdl-br SIDAN37 person Sirley Damasceno Andrade created 20190909 changed 20200730. brregistrant tax IDticket, provider, CIDR block, IP and ASN. br has ranked N A in N A and 2,122,625 on the world. br reaches roughly 1,467 users per day and delivers about 44,001 users each month. DA 52 PA 76 MOZ Rank 69. DA 62 PA 21 MOZ Rank 15. DA 96 PA 48 MOZ Rank 11.

DA 81 PA 98 MOZ Rank 48. Higitec logo vector. Download free Higitec vector logo and icons in AI, EPS, CDR, SVG, PNG formats. DA 20 PA 91 MOZ Rank 9. DA 38 PA 32 MOZ Rank 89. DA 25 PA 44 MOZ Rank 93. DA 97 PA 74 MOZ Rank 54. DA 12 PA 84 MOZ Rank 29. 2020-09-14T10 54 49-03 00 - IP 66. brrespectivelly to email protected and mail- email protected whois. Diagnosis and Treatment of Acute Pyelonephritis in Women. Am Fam Physician. RICHARD COLGAN, MD, and MOZELLA WILLIAMS, MD, University of Maryland School of Medicine, Baltimore, Maryland.

2011 Sep 1;84 5 519-526. JOHNSON, MD, University of Minnesota, Minneapolis, Minnesota. Abstract Epidemiology Clinical Diagnosis Inpatient vs. Article Sections. Outpatient Treatment Diagnostic Tests Choice of Antibiotics Monitoring Response to Therapy References. Acute pyelonephritis is a common bacterial infection of the renal pelvis and kidney most often seen in young adult women. History and physical examination are the most useful tools for diagnosis.

Most patients have fever, although it may be absent early in the illness. Flank pain is nearly universal, and its absence should raise suspicion of an alternative diagnosis. A positive urinalysis confirms the diagnosis in patients with a compatible history and physical examination. Urine culture should be obtained in all patients to guide antibiotic therapy if the patient does not respond to initial empiric antibiotic regimens.

Escherichia coli is the most common pathogen in acute pyelonephritis, and in the past decade, there has been an increasing rate of E. Imaging, usually with contrast-enhanced computed tomography, is not necessary unless there is no improvement in the patient s symptoms or if there is symptom recurrence after initial improvement. coli resistance to extended-spectrum beta-lactam antibiotics. Outpatient treatment is appropriate for most patients.

Inpatient therapy is recommended for patients who have severe illness or in whom a complication is suspected. Practice guidelines recommend oral fluoroquinolones as initial outpatient therapy if the rate of fluoroquinolone resistance in the community is 10 percent or less. If the resistance rate exceeds 10 percent, an initial intravenous dose of ceftriaxone or gentamicin should be given, followed by an oral fluoroquinolone regimen.

Oral beta-lactam antibiotics and trimethoprim sulfamethoxazole are generally inappropriate for outpatient therapy because of high resistance rates. Several antibiotic regimens can be used for inpatient treatment, including fluoroquinolones, aminoglycosides, and cephalosporins. Acute pyelonephritis is one of the most common serious bacterial infections in young adult women.

Because of the frequency and severity of the infection, physicians must be familiar with approaches to effective management. This includes making an accurate diagnosis, deciding between inpatient and outpatient management, and selecting an appropriate antimicrobial regimen that is consistent with expert guidelines and local susceptibility data. SORT KEY RECOMMENDATIONS FOR PRACTICE. Clinical recommendation Evidence rating Reference.

A urine culture and antimicrobial susceptibility testing should be performed in women with suspected acute pyelonephritis. Initial empiric therapy should be selected based on the likely infecting uropathogen and local antibiotic sensitivity patterns. Treatment options for women with acute pyelonephritis not requiring hospitalization include 500 mg of oral ciprofloxacin Cipro twice per day for seven days; 1,000 mg of extended-release ciprofloxacin once per day for seven days; or 750 mg of levofloxacin Levaquin once per day for five days.

Oral trimethoprim sulfamethoxazole Bactrim, Septra at a dosage of 160 mg 800 mg twice per day for 14 days is an appropriate treatment choice for women with acute pyelonephritis if the uropathogen is known to be susceptible. These options are appropriate in areas where the prevalence of resistance to fluoroquinolones does not exceed 10 percent. Initial treatment of women with acute pyelonephritis who require hospitalization should include an intravenous antimicrobial regimen, such as a fluoroquinolone, an aminoglycoside with or without ampicillinan extended-spectrum cephalosporin or penicillin with or without an aminoglycosideor a carbapenem.

The choice of agents should be based on local resistance data, and the regimen should be tailored based on susceptibility results. A consistent, good-quality patient-oriented evidence; B inconsistent or limited-quality patient-oriented evidence; C consensus, disease-oriented evidence, usual practice, expert opinion, or case series. By definition, acute pyelonephritis is an infection of the renal pelvis and kidney that usually results from ascent of a bacterial pathogen up the ureters from robo de opções binarias gratis iq option 2020 bladder to the kidneys.

It is estimated that acute pyelonephritis accounts for approximately 250,000 office visits and 200,000 hospital admissions each year in the United States, and approximately 11 hospitalizations per 10,000 Canadian women each year. 1 3 The incidence of acute pyelonephritis is highest in otherwise healthy women 15 to 29 years of age, followed by infants and older persons. 4 Although acute pyelonephritis also occurs in men, children, and pregnant women, these groups account for only a small percentage of cases.

Accordingly, this review focuses on diagnosis and treatment of acute pyelonephritis in nonpregnant women. In 80 percent of acute pyelonephritis cases, Escherichia coli is the responsible pathogen in women, although it is not as common in older persons. coliless common causative organisms include other Enterobacteriaceae, Pseudomonas aeruginosagroup B streptococci, and enterococci. Causative Organisms in Acute Pyelonephritis. Organism Prevalence. The spectrum of pathogens involved in acute pyelonephritis is similar to that of cystitis but with a lower frequency of Staphylococcus saprophyticus Table 14.Proteus species, Enterobacter species.

Other Enterobacteriaceae e. Information from reference 4. During the previous decade, community-acquired bacteria particularly E. ANTIBIOTIC RESISTANCE. coli that produce extended-spectrum beta-lactamases have emerged as a cause of acute pyelonephritis worldwide. The most common risk factors for contracting these uropathogens include visits to health care centers, recent use of antimicrobial agents particularly cephalosporins and fluoroquinolonesolder age, and presence of comorbid conditions, such as diabetes mellitus and recurrent urinary tract infections UTIs.

4510 Older women, women who are menopausal or pregnant, and women who have preexisting urinary tract structural abnormalities or obstructions have a higher risk of UTI, but not necessarily of acute pyelonephritis. UNCOMPLICATED ACUTE PYELONEPHRITIS. COMPLICATED VS. Uncomplicated acute pyelonephritis typically occurs in healthy, young women without structural or functional urinary tract abnormalities and without relevant comorbidities.

Complicated acute pyelonephritis occurs in patients with a structurally or functionally abnormal genitourinary tract, or a predisposing medical condition. Compared with uncomplicated acute pyelonephritis, complicated acute pyelonephritis is characterized by a broader spectrum of clinical presentations, a wider variety of infecting organisms including a greater likelihood of antimicrobial resistanceand a greater risk of progression to a complication, such as intrarenal or perinephric abscess or emphysematous pyelonephritis.

Clinical Diagnosis. History and physical examination are the most helpful tools for diagnosing acute pyelonephritis Table 2 12. Physicians should consider acute pyelonephritis in women presenting with lower urinary tract symptoms e.urinary frequency, urgency, dysuria accompanied by fever, nausea, vomiting, or flank pain. Flank pain is nearly universal in patients with acute pyelonephritis; its absence should raise suspicion of an alternative diagnosis. On physical examination, the key finding is tenderness to palpation of the costovertebral angle.

Patients with nephrolithiasis and ureterolithiasis, which also cause flank pain, do not usually present with costovertebral angle tenderness. Clinical and Robo de opções binarias gratis iq option 2020 Findings in Patients with Acute Pyelonephritis. Category Findings. Lower urinary tract symptoms e.frequency, urgency, dysuria. Upper urinary tract symptoms e. Constitutional symptoms e. Gastrointestinal symptoms e.fever, chills, malaise.nausea, vomiting, anorexia, abdominal pain.

Fever temperature 100. 0 Ctachycardia, hypotension. Costovertebral angle tenderness. Possible abdominal or suprapubic tenderness. Urinalysis showing positive leukocyte esterase test, microscopic pyuria or hematuria, or white blood cell casts. Peripheral blood smear showing leukocytosis, with or without left shift. Positive blood culture in 15 to 30 percent of cases.

Urine culture growing 10 5 colony-forming units per mL of urine. Information from reference 12. Fever greater than 100. 0 C is characteristic of acute pyelonephritis, but it may be absent in persons with early or mild cases. Fever may also be absent in frail, older persons or in immunocompromised persons, who also may not exhibit other classic manifestations of acute pyelonephritis.

Physicians should consider other disorders that may robo de opções binarias gratis iq option 2020 from or mimic acute pyelonephritis Table 3 12. Intrarenal and perinephric abscesses, which usually are complications of acute pyelonephritis, are more common than emphysematous pyelonephritis, which is a necrotizing infection that produces intraparenchymal gas within the kidney that is identifiable by renal imaging.

13 This disorder occurs most often in older women with diabetes. Additional complications of acute pyelonephritis that may benefit from urologic or infectious disease subspecialty consultation are listed in Table 4. Diagnoses to Consider in Patients with Flank Pain and Costovertebral Angle Tenderness. Disorder Flank pain Costovertebral angle tenderness Fever and leukocytosis. Basilar pleural processes. Lower rib fractures. Noninfectious renal disorders including urolithiasis.

Renal corticomedullary necrosis. Renal vein thrombosis. Retroperitoneal disorders e.hemorrhage, abscess. Splenic abscess or infarct. Urinary tract obstruction. Finding typically presenttypically absentor variably present. Complications of Acute Pyelonephritis That May Benefit from Subspecialty Consultation. Complication Relevant diagnostic test Relevant subspecialty. Blood cultures, antimicrobial susceptibility testing.

Urinary tract imaging. Infectious diseases, interventional radiology, urology. Extensively drug-resistant organism. Blood and urine cultures, antimicrobial susceptibility testing. Perinephric or intrarenal abscess. Interventional radiology, urology. Previous antibiotic treatment, although not diagnostically relevant, is important to consider when choosing a treatment regimen.

For this reason, it should be included in the patient history when considering acute pyelonephritis. Inpatient vs. Outpatient Treatment. However, patients who appear ill may have severe pyelonephritis or a complication of acute pyelonephritis and should be considered for hospitalization and further evaluation Table 5 14. The possibility of urinary obstruction or an alternative diagnosis should be considered in these patients. Considerations for Hospitalization in Patients with Acute Pyelonephritis.

Comorbid conditions e.renal dysfunction, urologic disorders, diabetes mellitus, advanced liver or cardiac disease. Metabolic derangement e.renal dysfunction, acidosis. Severe flank or abdominal pain. Unable to take liquids by mouth. Very high fever 103 F 39. Physicians must be alert for the presence of severe sepsis and septic shock, which require urgent specialized management that is beyond the scope of this review.

Information from reference 14. Most cases of uncomplicated acute pyelonephritis can be managed in the outpatient setting. Diagnostic Tests. Urine dipstick testing, microscopic urinalysis, or both are commonly used in diagnosing UTI, including acute pyelonephritis. Most women with acute pyelonephritis have marked pyuria or a positive leukocyte esterase test, which often is accompanied by microscopic hematuria or a positive heme dipstick test.

In contrast, gross hematuria is rare in patients with acute pyelonephritis and is more common in patients with acute uncomplicated cystitis. The presence of white blood cell casts indicates renal-origin pyuria, supporting the diagnosis of acute pyelonephritis, but casts are not often seen. URINE CULTURE. All patients with suspected acute pyelonephritis should have a urine culture and antimicrobial susceptibility testing to guide possible adjustment of the initial antimicrobial regimen if there is no improvement and selection of step-down oral therapy for patients treated initially with intravenous therapy.

A midstream urine specimen after proper cleansing of the vulva is often recommended. Several studies, however, found no significant differences in the number of contaminated or unreliable culture results when voided urine specimens were collected with or without preparatory cleansing. 16 18 Obtaining a urine sample by catheterization is unnecessary. Studies have shown no differences in colony counts or organisms between samples collected by catheterization versus midstream voiding.

More than 95 percent of women with uncomplicated acute pyelonephritis will have greater than 10 5 colony-forming units of a single gram-negative organism per mL of urine. 19 Urine Gram stain, if available, may aid in the choice of empiric antimicrobial therapy pending culture results. If gram-positive cocci are observed, Enterococcus species or S. saprophyticus may be the causative organism. Posttreatment urinalysis and urine culture are unnecessary in patients who are asymptomatic after therapy.

However, repeat urine culture is advised if symptoms do not improve substantially within two to three days of initiation of therapy, or if symptoms recur within two weeks of treatment. These patients should also undergo urinary tract imaging. Most women with acute pyelonephritis do not need imaging studies unless symptoms do not improve or there is a recurrence.

21 The purpose of imaging is to identify an underlying structural abnormality, such as occult obstruction from a stone or an abscess 2122 Figure 1 23. Although renal ultrasonography and magnetic resonance imaging are sometimes used, computed tomography with contrast media is considered the imaging modality of choice for nonpregnant women. Abdominal computed tomography with intravenous contrast media in a patient with acute pyelonephritis demonstrates a large right perinephric abscess crescentic low-density collection identified by arrow.

Radiography of urological infections. Reprinted with permission from Tanagho E. In Tanagho EA, McAninch JW, eds. Smith s General Urology. New York, NY McGraw-Hill; 2008 525. Because of the risk of contrast nephropathy, caution is needed when administering contrast media to patients taking metformin Glucophage or to those with renal insufficiency. However, patients with acute pyelonephritis and an acutely elevated baseline serum creatinine level may sometimes warrant computed tomography imaging as part of the evaluation to look for obstruction.

BLOOD CULTURES. Blood cultures are commonly obtained from patients with acute pyelonephritis who are ill enough to warrant hospital admission, although they may not routinely be necessary in patients with uncomplicated acute pyelonephritis. 2526 Approximately 15 to 30 percent of patients with acute pyelonephritis are found to be bacteremic; older persons and those with complicated acute pyelonephritis are more likely to have bacteremia and sepsis.

However, blood cultures may be the only method of identifying the causative organism in cases of suspected acute pyelonephritis that turn out to be another disorder, such as endometritis, intraabdominal or psoas abscess, or cholangitis. There is no evidence that patients with a positive blood culture should be treated differently from those with negative blood cultures with respect to agent, route, or duration of antimicrobial therapy; hospital admission; or length of hospital stay if admitted to the hospital.

OTHER DIAGNOSTIC TESTS. The baseline evaluation of acute pyelonephritis should include a basic metabolic panel, most importantly to assess renal function. If the diagnosis is not clear, other laboratory tests e.lipase, transaminase, and beta subunit of human chorionic gonadotropin levels may be appropriate to clarify the differential diagnosis. Choice of Antibiotics. In 2010, the Infectious Diseases Society of America updated its 1999 guidelines on the treatment of acute uncomplicated cystitis and pyelonephritis in women.

15 The guidelines include recommendations for antimicrobial regimens in patients with acute pyelonephritis. When choosing an antibiotic, physicians should consider the effectiveness, risk of adverse effects, and resistance rates in the local community. Because urine culture yields a causative organism in almost all cases of acute pyelonephritis, a positive blood culture is diagnostically redundant. Risk factors for acute pyelonephritis in nonpregnant women include sexual intercourse three or more times per week during the previous 30 days, UTIs in the previous 12 months, diabetes, stress incontinence in the previous 30 days, a new sex partner in the previous year, recent spermicide use, and a history of UTIs in the patient s mother.

OUTPATIENT REGIMENS. Fluoroquinolones are the preferred empiric antimicrobial class in communities where the local prevalence of resistance of community-acquired E. coli is 10 percent or less. Although not all clinical microbiology laboratories serving outpatient medical practices provide reports on the source of specimens tested for antibiotic resistance i.community-acquired versus hospital-acquiredphysicians should consider contacting their local laboratory to obtain the best available susceptibility data.

If the prevalence of fluoroquinolone resistance among relevant organisms does not exceed 10 percent, patients not requiring hospitalization can be treated with oral ciprofloxacin Cipro; 500 mg twice per day for seven daysor a once-daily oral fluoroquinolone, such as ciprofloxacin 1,000 mg, extended-release, for seven days or levofloxacin Levaquin; 750 mg for five days. 15 These can be given with or without an initial intravenous dose of the corresponding agent e.400 mg ciprofloxacin or 500 mg levofloxacin.

An initial intravenous dose is appropriate in patients experiencing nausea or vomiting. Table 6 summarizes outpatient treatment options for nonpregnant women with acute pyelonephritis. Outpatient Treatment Options for Nonpregnant Women with Acute Pyelonephritis. Drug class Antibiotic Dosage. 500 mg orally, twice per day for seven days. 1,000 mg orally, once per day for seven days. 750 mg orally, once per day for five robo de opções binarias gratis iq option 2020.

Trimethoprim sulfamethoxazole Bactrim, Septra. 160 mg 800 mg orally, twice per day for 14 days. Use when prevalence of fluoroquinolone resistance among Escherichia coli isolates is known to be 10 percent or less. If resistance prevalence exceeds 10 percent, see inpatient recommendations in Table 7. There is good evidence for use from at least one properly randomized controlled trial. There is moderate evidence for use from at least one well-designed clinical trial, without randomization; from cohort or case-control analytic studies preferably from more than one center ; from multiple time-series; or from dramatic results from uncontrolled experiments.

Use if pathogen is known to be susceptible to trimethoprim sulfamethoxazole. If susceptibility profile is unknown, see inpatient recommendations in Table 7. Information from reference 15. Because of the generally high prevalence of resistance to oral betalactam antibiotics and trimethoprim sulfamethoxazole Bactrim, Septrathese agents usually are reserved for cases where susceptibility results for the urine isolate are known and indicate likely activity.allergy history, potential drug-drug interactions, drug availability may require the empiric use of an oral beta-lactam antibiotic or trimethoprim sulfamethoxazole before susceptibility is known.

In such cases, a long-acting, broad-spectrum parenteral drug such as ceftriaxone Rocephin; 1 g or gentamicin 5 mg per kg should be given concurrently as a one-time dose or longer to cover for possible resistance until sensitivities of the organism are known. Likewise, if the local fluoroquinolone resistance prevalence in E. coli exceeds 10 percent, an initial intravenous dose of ceftriaxone or gentamicin is recommended, followed by an oral fluoroquinolone regimen.

INPATIENT REGIMENS. 15 However, additional factors e. For women with acute pyelonephritis who require hospitalization, initial intravenous antimicrobial therapy is recommended Table 7. 15 Pregnant women with acute pyelonephritis should be hospitalized and treated initially with a second-or third-generation cephalosporin, and then assessed to determine whether further treatment as an outpatient is appropriate.

Initial and Step-Down Inpatient Treatment Options for Nonpregnant Women with Acute Pyelonephritis. 15 Options include a fluoroquinolone, an aminoglycoside with or without ampicillinan extended-spectrum cephalosporin or penicillin with or without an aminoglycosideor a carbapenem. Phase of therapy Antibiotic Dosage. 400 mg IV, twice per day. 250 to 500 mg IV, once per day.

1,000 mg IV, once per day. 5 mg per kg IV, once per day. 500 mg IV every six hours. Listed in order of priority. Continue treatment until clinical improvement or until susceptibilities are known. If symptoms do not improve, another diagnosis or a complication of acute pyelonephritis should be considered. There is moderate evidence for use from opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Gentamicin or tobramycin Tobrex. Depending on renal function. Maximum dosage of 4 g per day. Use if fluoroquinolone resistance is known to be 10 percent or less, or if the isolate s fluoroquinolone susceptibility is known. Use if the isolate s trimethoprim sulfamethoxazole susceptibility is known. Monitoring Response to Therapy. Therapy with appropriate empiric antibiotics should produce improvement within 48 to 72 hours. If the patient does not improve as expected i.no progressive reduction in, or resolution of, the local and systemic signs and symptoms that led to the diagnosisstrong consideration should be given to a complication of acute pyelonephritis or an alternative diagnosis, and appropriate additional testing should be performed.

Get immediate access, anytime, anywhere. Choose a single article, issue, or full-access subscription. Earn up to 6 CME credits per issue. Already a member or subscriber. Get Full Access. Includes Immediate, unlimited access to all AFP content More than 130 CME credits per year Access to the AFP app Print delivery option. Access This Issue. Includes Immediate access to this issue CME credits in this issue.

Access This Article. Includes Immediate access to this article. The Authors. RICHARD COLGAN, MD, is an associate professor and director of medical student education in the Department of Family and Community Medicine at the University of Maryland School of Medicine in Baltimore. MOZELLA WILLIAMS, MD, is an assistant professor and assistant director of medical student education in the Department of Family and Community Medicine at the University of Maryland School of Medicine.

JOHNSON, MD, is a professor of medicine and senior associate director of the Infectious Diseases Fellowship Program at the University of Minnesota in Minneapolis, and director of the Molecular Epidemiology Unit at the Minneapolis VA Medical Center. Address correspondence to Richard Colgan, MD, University of Maryland School of Medicine, 29 South Paca St.Baltimore, MD 21201 e-mail rcolgan som.

Reprints are not available from the authors. Author disclosure Dr. Johnson receives research support from Merck, Inc.to perform molecular analysis of antibiotic-resistant Escherichia coli. The research is not directly related to the topic of this article, and thus is not disqualifying. The other authors have no relevant financial affiliations to disclose. Epidemiology of urinary tract infection. Foxman B, Klemstine KL, Brown PD.

Acute pyelonephritis in US hospitals in 1997 hospitalization and in-hospital mortality. Ann Epidemiol. Nicolle LE, Friesen D, Harding GK, Roos LL. Hospitalization for acute pyelonephritis in Manitoba, Canada, during the period from 1989 to 1992; impact of diabetes, pregnancy, and aboriginal origin. Clin Infect Dis. Czaja CA, Scholes D, Hooton TM, Stamm WE.

Population-based epidemiologic analysis of acute pyelonephritis. Scholes D, Hooton TM, Roberts PL, Gupta K, Stapleton AE, Stamm WE. Risk factors associated with acute pyelonephritis in healthy women. Ann Intern Med. Zahar JR, Lortholary O, Martin C, Potel G, Plesiat P, Nordmann P. Addressing the challenge of extended-spectrum beta-lactamases. Curr Opin Investig Drugs. Oteo J, Pérez-Vázquez M, Campos J. Extended-spectrum beta -lactamase producing Escherichia coli changing epidemiology and clinical impact.

Curr Opin Infect Dis. Rooney PJ, O Leary MC, Loughrey AC, et al. Nursing homes as a reservoir of extended-spectrum beta-lactamase ESBL -producing ciprofloxacin-resistant Escherichia coli. J Antimicrob Chemother. Rodríguez-Baño J, Alcalá JC, Cisneros JM, et al. Community infections caused by extended-spectrum beta-lactamase-producing Escherichia coli. Arch Intern Med. Epidemiology of urinary tract infections incidence, morbidity, and economic costs.

Complicated pyelonephritis unresolved issues. Curr Infect Dis Rep. Shoff WH, Green-McKenzie J, Edwards C, Behrman AJ, Shepherd SM. Acute pyelonephritis the differential diagnosis and workup. March 5, 2010. Accessed January 17, 2011. Michaeli J, Mogle P, Perlberg S, Heiman S, Caine M. Emphysematous pyelonephritis. Johns Hopkins Medical Center Abx Guide. Acute uncomplicated pyelonephritis. September 15, 2008.

org diagnosis genitourinary pyelonephritis subscription required. Accessed December 17, 2010. Gupta K, Hooton TM, Naber KG, et al. International clinical practice guidelines for the treatment of acute uncomplicated cystitis and pyelonephritis in women a 2010 update by the Infectious Diseases Society of America and the European Society for Microbiology and Infectious Diseases. Bradbury SM. Collection of urine specimens in general practice to clean or not to clean.

J R Coll Gen Pract. Immergut MA, Gilbert EC, Frensilli FJ, Goble M. Regardless of which antibiotic is chosen for initial empiric therapy, the regimen should be revised as necessary after urine culture susceptibility results are available. Bray PA, Corry MF.

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