By J. Julio. Montana State University-Northern Havre. 2018.

Beta-lactam antibacterials derive their name from the beta- Despite the common element of a beta-lactam ring buy 50 mg fildena with amex icd-9 erectile dysfunction diabetes, char- lactam ring that is part of their chemical structure purchase fildena 150 mg overnight delivery erectile dysfunction self test. An intact acteristics of beta-lactam antibiotics differ widely because beta-lactam ring is essential for antibacterial activity. The drugs may gram-positive and gram-negative bacteria produce beta- differ in antimicrobial spectrum of activity, routes of ad- lactamase enzymes that disrupt the beta-lactam ring and ministration, susceptibility to beta-lactamase enzymes, and inactivate the drugs. Beta-lactam antibiotics include penicillins, microorganisms acquire resistance to beta-lactam antibiotics. The latter acteristics of selected drugs are listed in Table 34–1 and characteristic may help to explain the development of mu- routes and dosage ranges are listed in the Drugs at a Glance tant strains of microorganisms exposed to the drugs. Mechanism of Action PENICILLINS Beta-lactam antibacterial drugs inhibit synthesis of bacter- ial cell walls by binding to proteins (penicillin-binding pro- The penicillins are effective, safe, and widely used anti- teins) in bacterial cell membranes. The group includes natural extracts from defective cell wall that allows intracellular contents to leak the Penicillium mold and several semisynthetic derivatives. In sub-bactericidal con- When penicillin G, the prototype, was introduced, it was centrations, the drugs may inhibit growth, decrease viability, (text continues on page 515) 512 SECTION 6 DRUGS USED TO TREAT INFECTIONS Drugs at a Glance: Penicillins Routes and Dosage Ranges Generic/Trade Name Adults Children Penicillins G and V Penicillin G potassium and sodium IM 300,000–8 million U daily IM, IV 50,000–300,000 U/kg/d in divided (Pfizerpen) IV 6–20 million U daily by continuous or intermittent doses q4h infusion q2–4h. For direct IV injec- Weight > 40 kg: Same as adults tion, the dose should be well diluted and given Weight ≤ 40 kg: PO, IM, IV 50–100 mg/kg/d in over 10–15 min. In severe infections, Weight > 20 kg: Same as adults (Principen) doses up to 2 g q4h may be given IV. Weight ≤ 20 kg: PO, IM, IV 50–200 mg/kg/d in divided doses q6h Amoxicillin PO 250–500 mg q8h Weight > 20 kg: Same as adults (Amoxil) Weight ≤ 20 kg: 20–40 mg/kg/d in divided doses q8h Extended-Spectrum (Antipseudomonal) Penicillins Carbenicillin indanyl sodium PO 382–764 mg four times daily PO 30–50 mg/kg/d in divided doses q6h (Geocillin) Ticarcillin IM, IV 1–3 g q6h. IM injections should not exceed Weight < 40 kg: 100–300 mg/kg/d q6–8h (Ticar) 2 g/injection. Mezlocillin IM, IV 200–300 mg/kg/d in four to six divided Age 1 mo–12 y: 150–300 mg/kg/d in six divided (Mezlin) doses. Usual adult dosage, 3 g q4h or 4 g q6h doses, q4h Piperacillin IV, IM 200–300 mg/kg/d in divided doses q4–6h. Age < 12 y: Dosage not established (Pipracil) Usual adult dosage, 3–4 g q4–6h; maximal daily dose, 24 g Penicillin/Beta-Lactamase Inhibitor Combinations Ampicillin/sulbactam IM, IV 1. Can also be given parenterally PO 250 mg q12h; severe infec- >12 y, same as adults; (Ceftin) 2. Available only in tablet form tions, 500 mg q12h; urinary <12 y, 125 mg q12h 3. The tablet may be crushed and tract infection, 125 mg q12h Otitis media, >2 y, 250 mg q12h, added to a food (eg, applesauce), <2 y, 125 mg q12h but the crushed tablet leaves a strong, bitter, persistent aftertaste. Loracarbef A synthetic drug similar to cefaclor PO 200–400 mg q12h PO 15–30 mg/kg/d in divided (Lorabid) doses q12h Third Generation Cefdinir Indicated for bronchitis, pharyngitis, PO 300 mg q12h or 600 mg ≥13 y: PO Same as adults (Omnicef) and otitis media caused by strep- q24h for 10 d 6 mo–12 y: PO 7 mg/kg q12h tococci or H. Indicated for bronchitis, otitis media, PO 400 mg daily for 10 d Oral suspension with 90 mg/5 mL (Cedax) pharyngitis, or tonsillitis caused by Renal impairment: 10 kg: 5 mL daily streptococci or H. Available in a capsule for oral use CrCl 5–29 mL/min, 100 mg q24h Above 45 kg: Same as adults and an oral pediatric suspension Oral suspension with that comes in two concentrations 180 mg/ 5 mL (90 mg/5 mL and 180 mg/5 mL). Antimicrobial spectrum similar to IV, IM 1 g daily (q24h) (Monocid) other second-generation Surgical prophylaxis, IV, IM 1 g cephalosporins 1 h before procedure 2. Effective against most organisms IV, IM 1–2 g q12h for 5–10 d; (Cefotan) except Pseudomonas maximum dose, 3 g q12h in 2. Highly resistant to beta-lactamase life-threatening infections enzymes Perioperative prophylaxis, IV 1–2 g 30–60 min before surgery Cefoxitin 1. The first cephamycin (derived from a IV 1–2 g q4–6h IV 80–160 mg/kg/d in divided (Mefoxin) different fungus than Surgical prophylaxis, IV 1 or 2 g doses q4–6h. Penetrates cerebrospinal fluid in 30–60 min before initial skin Bacterial meningitis, IV 200– presence of inflamed meninges incision 240 mg/kg/d in divided doses q6–8h, reduced to 100 mg/kg/d on clinical improvement Third Generation Cefoperazone 1. Active against gram-negative and IV, IM 2–4 g/d in divided doses Dosage not established (Cefobid) gram-positive organisms, including q8–12h gram-negative organisms resistant to earlier cephalosporins 2. Excreted primarily in bile; half-life prolonged in hepatic failure Cefotaxime 1. Antibacterial activity against most IV, IM 1 g q6–8h; maximum Weight > 50 kg: same as adults (Claforan) gram-positive and gram-negative dose, 12 g/24h Weight < 50 kg and age > 1 mo: IV, bacteria, including several strains IM 50–180 mg/kg/d, in divided resistant to other antibiotics. Recommended for serious Neonates: ≤ 1 wk, IV 50 mg/kg infections caused by susceptible q12h; 1–4 wk, IV 50 mg/kg q8h microorganisms CHAPTER 34 BETA-LACTAM ANTIBACTERIALS: PENICILLINS, CEPHALOSPORINS, AND OTHERS 515 Drugs at a Glance: Parenteral Cephalosporins (continued) Routes and Dosage Ranges Generic/Trade Name Characteristics Adults Children Ceftazidime 1. Active against gram-positive and IV, IM 1 g q8–12h 1 mo to 12 y: IV 30–50 mg/kg (Fortaz) gram-negative organisms q8h, not to exceed 6 g/d 2. Especially effective against gram- <1 mo: IV 30 mg/kg q12h negative organisms, including P.

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Repaglinide (Prandin) Onset of action discount fildena 100mg with mastercard erectile dysfunction homeopathic drugs, within 30 min; peak order fildena 25mg otc erectile dysfunction doctor in nj, PO 1–2 mg 15–30 min. Combination Drug* Glyburide/metformin (Glucovance) Available in preparations with 1. Patients previously treated with glyburide or mg glyburide and 500 mg metformin; other sulfonylurea plus metformin: Initially, PO 2. States, may play a role in the development of diabetes Jean Watson, a 52-year-old type 2 diabetic, has been managed for and atherosclerosis. If so, beneficial effects of a supple- the last 3 years on 500 mg of metformin (Glucophage) bid. Watson is sched- study of pregnant women and older adults with marginal uled for an intravenous pyelogram (IVP) to evaluate a series of re- levels of chromium, administration of a supplement im- cent urinary tract infections. Watson comes in for her test, she mentions that her blood glucose was elevated that morn- proved glucose tolerance. At present, there is insufficient ing, so she took her metformin as usual with a sip of water but did evidence to recommend routine chromium supplementa- not eat breakfast as instructed. Some clinical trials have been done, but peo- ple with diabetes were excluded. Some sources report no known effects on blood Glucosamine, as indicated by animal studies, may cause glucose; others report a decrease in animals and hu- impaired beta cell function and insulin secretion similar mans. Some researchers also reported increased serum to that observed in humans with type 2 diabetes. Long- insulin and improvement in liver glycogen storage after term effects in humans are unknown, but the product is garlic administration. There is a potential for additive considered potentially harmful to people with diabetes hypoglycemic effects with antidiabetic drugs, although or impaired glucose tolerance (prediabetes). Several studies (generally small and not well- tidiabetic medications have not been reported. How- designed) indicate that ginseng lowers blood glucose ever, blood sugar should be monitored carefully. It may chondroitin, which is often taken with glucosamine for be useful in preventing diabetes or complications of dia- osteoarthritis, there is no information about effects on betes. However, larger and longer studies are needed be- blood sugar, use by diabetic clients, or interactions with fore general use can be recommended for diabetics or antidiabetic drugs. For nondiabetics who use ginseng, the herb may need to be taken with a meal to prevent unintentional hypoglycemia. For diabetics, use of ginseng should be very cautious (if at all), with frequent monitoring Supplements that May Decrease of blood glucose and signs of hypoglycemia, because of Blood Glucose Levels possible additive effects with antidiabetic medications. Its use should also be accompanied by proper diet, physical Basil, which is commonly used in cooking, is also avail- activity, and antidiabetic medication. The amounts used in Glucomannan, which is promoted as a diet aid and laxa- cooking are unlikely to affect blood sugar, but larger tive, has hypoglycemic effects and should be avoided amounts may cause hypoglycemia or increase the hypo- or used very cautiously by people with diabetes. If used, blood glucose Guar gum is a type of fiber that becomes gel-like upon levels should be closely monitored. It is used as a Bay leaf is commonly used in cooking (it should be re- thickening agent in foods and drugs and is an ingredi- moved from the food before eating) and is also avail- ent in some over-the-counter weight loss products. It increases should be used cautiously, if at all, by people with dia- the effects of insulin and is sometimes recommended by betes because it has hypoglycemic effects and slows nutritionists for diabetic diets. It may increase production of in- sulin receptors and insulin binding to the receptors, thereby increasing insulin effectiveness, lowering Nursing Process blood glucose levels, and decreasing insulin require- ments in people with diabetes. It also may have ben- Assessment eficial effects on serum cholesterol levels. Ankle edema may indi- ment, occurrence of complications such as ketoacidosis, cate venous insufficiency or impaired cardiac function. Clients with diabetes have a prepares the food, what factors help in following the high incidence of atherosclerosis, which makes them diet, what factors interfere with following the diet, the susceptible to hypertension, angina pectoris, myocardial current weight, and whether there has been a recent infarction, peripheral vascular disease, and stroke. Also ask if herbal or other dietary sup- Therefore, check blood pressure and ask about chest plements are used. If so, list each one by name and fre- pain and pain in the legs with exercise (intermittent quency of use. Ask the client to describe usual activities of have kidney and bladder problems.

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Conditions that decrease the number or function so less is available for reuse in the formation of LDL cholesterol; of receptors (eg buy fildena 100 mg visa erectile dysfunction caused by lipitor, high dietary intake of cholesterol quality 100 mg fildena erectile dysfunction drugs recreational use, saturated fat, or and inhibiting cellular uptake of LDL cholesterol. Nonreceptor uptake occurs in various cells, es- tors, smoking, and some medications (eg, steroids and beta block- pecially when levels of circulating LDL cholesterol are high. HDL cholesterol levels are example, macrophage cells in arterial walls can attach LDL, not directly affected by diet. CHAPTER 58 DRUGS FOR DYSLIPIDEMIA 853 Total serum cholesterol (mg/dL) excessive caloric intake (excessive dietary fats are stored Normal or desirable = less than 200 in adipose tissue; excessive proteins and carbohydrates Borderline high = 200 to 239 are converted to triglycerides and also stored in adipose tis- High = 240 or above sue) and obesity. High caloric intake also increases the LDL cholesterol (mg/dL) conversion of VLDL to LDL cholesterol, and high dietary Optimal = less than 100 intake of triglycerides and saturated fat decreases the ac- Near or above optimal = 100–129 tivity of LDL receptors and increases synthesis of choles- Borderline high = 130 to 159 terol. Very high triglyceride levels are associated with High = 160 to 189 acute pancreatitis. Very high = 190 or above Dyslipidemia may be primary (ie, genetic or familial) or HDL cholesterol (mg/dL) secondary to dietary habits, other diseases (eg, diabetes mel- High = more than 60 litus, alcoholism, hypothyroidism, obesity, obstructive liver Low = less than 40 disease), and medications (eg, beta blockers, cyclosporine, Triglycerides (mg/dL) oral estrogens, glucocorticoids, sertraline, thiazide diuretics, Normal or desirable = less than 150 anti–human immunodeficiency virus protease inhibitors). Borderline high = 150 to 199 Types of dyslipidemias (also called hyperlipoproteinemias High = 200 to 499 because increased blood levels of lipoproteins accompany Very high = 500 or above increased blood lipid levels) are described in Box 58–2. Overall, the most effective blood lipid profile for preven- Although hypercholesterolemia is usually emphasized, tion or management of atherosclerosis and its sequelae is high hypertriglyceridemia is also associated with most types of HDL cholesterol, low LDL cholesterol, and low total choles- hyperlipoproteinemia. The National Cholesterol Education Program recommends management of clients according to their blood levels of total DYSLIPIDEMIA and LDL cholesterol and their risk factors for cardiovascular disease (Table 58–1). Note that both dietary and drug therapy Dyslipidemia (also called hyperlipidemia) is associated are recommended at lower serum cholesterol levels in clients with atherosclerosis and its many pathophysiologic effects who already have cardiovascular disease or diabetes mellitus. Ischemic heart disease has a Guidelines include the following: high rate of morbidity and mortality. Elevated total choles- • Assess for, and treat, if present, conditions known to terol and LDL cholesterol and reduced HDL cholesterol are increase blood lipids (eg, diabetes mellitus, hypo- the abnormalities that are major risk factors for coronary thyroidism). Elevated triglycerides also play a role in car- • Stop medications known to increase blood lipids, if diovascular disease. BOX 58–2 TYPES OF DYSLIPIDEMIAS Type I is characterized by elevated or normal serum cholesterol, usually occurs in middle-aged adults (40 to 60 years) and is elevated triglycerides, and chylomicronemia. This rare condition associated with accelerated coronary and peripheral vascular may occur in infancy and childhood. Type IIa (familial hypercholesterolemia) is characterized by a Type IV is characterized by normal or elevated cholesterol lev- high level of low-density lipoprotein (LDL) cholesterol, a normal els, elevated triglycerides, and increased levels of VLDL. This level of very–low-density lipoprotein (VLDL), and a normal or type usually occurs in adults and may be the most common form slightly increased level of triglycerides. Type IV is often secondary to obesity, is a definite risk factor for development of atherosclerosis and excessive intake of alcohol, or other diseases. Type IIb (combined familial hyperlipoproteinemia) is charac- Type V is characterized by elevated cholesterol and triglyc- terized by increased levels of LDL, VLDL, cholesterol, and eride levels with an increased level of VLDL and chylomicrone- triglycerides and lipid deposits (xanthomas) in the feet, knees, and mia. Instead, it is associated Type III is characterized by elevations of cholesterol and with fat and carbohydrate intolerance, abdominal pain, and pan- triglycerides plus abnormal levels of LDL and VLDL. This type creatitis, which are relieved by lowering triglyceride levels. It is essential that diet therapy continue as the 30% of calories from fat, less than 10% of calories from benefits of diet and drug therapy are additive. A Step II diet contains no more than 30% of calories from fat, less than 7% of calo- DRUG THERAPY OF DYSLIPIDEMIA ries from saturated fat, and less than 200 mg of choles- terol per day. The Step II diet is more stringent and may Dyslipidemic drugs are used to decrease blood lipids, to pre- be used initially in clients with more severe dyslipidemia, vent or delay the development of atherosclerotic plaque, pro- cardiovascular disease, or diabetes mellitus. It can de- mote the regression of existing atherosclerotic plaque, and crease LDL cholesterol levels by 8% to 15%. The drugs act by altering the production, metabo- levels, and they lower HDL cholesterol concentrations. Drug therapy is • Use the Mediterranean diet, which includes moderate recommended when approximately 6 months of dietary and amounts of monounsaturated fats (eg, canola and olive other lifestyle changes fail to decrease dyslipidemia to an ac- oils) and polyunsaturated fats (eg, safflower, corn, cot- ceptable level. It is also recommended for clients with signs tonseed, sesame, soybean, sunflower oils), to also de- and symptoms of coronary heart disease, a strong family his- crease risks of cardiovascular disease.

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In a medium-sized mixing bowl fildena 25 mg with amex erectile dysfunction drugs in bangladesh, combine the mint cheap fildena 150mg visa erectile dysfunction treatment ayurvedic, jalapeño peppers, the other 1/ teaspoon soy sauce, cilantro, vinegar, and cucumber and stir well. Serving suggestion: Serve chicken with *Spicy Thai Salsa and sautéed spinach and shiitake mushrooms. Remove the breasts from the marinade and grill for 6 minutes on each side or until fully cooked. CHICKEN AND SHIITAKE MUSHROOM BURGER This is a real staple in the Ultimate New York Body Plan because its versa- tility allows it to be used as an entrée with spinach or broccoli or as a midafternoon snack. Heat a skillet over medium heat and coat with nonfat vegetable cooking spray. Place the onion in the skillet and sauté until soft—approximately 1 to 2 minutes. BARE BONES LOW-FAT CHICKEN SALAD One of the Madison Square Club MVPs, this chicken salad is versatile and quick and easy to prepare. In another bowl, whisk Dijon mustard, chicken stock, and hot pepper sauce together until well blended. Place a medium-sized, nonstick, ovenproof skillet over medium heat and coat with nonfat vegetable cooking spray. Add the onions, red pepper, marjo- ram, black pepper, cayenne pepper, and salt and sauté until soft—approxi- mately 3 minutes. Place chicken over vegetable mixture, cover, and bake for about 40 min- utes or until chicken is cooked through. Either as a snack or for lunch with a nice tossed green salad, this is quite a dish! Lightly coat a nonstick cookie sheet with nonfat vegetable cooking spray. Place eggplant and zucchini slices on the sheet, cover with foil, and bake for about 15 minutes or until slices are soft. Heat a skillet over medium heat and coat with nonfat vegetable cooking spray. Place ground turkey, coriander, black pepper, and cayenne pepper in the skillet and sauté until brown—approximately 3 to 4 minutes. Lasagna assembly: Lightly spray an ovenproof baking dish with nonfat vegetable cooking spray. Alternate layers of baked eggplant, ground turkey, marinara sauce, and baked zucchini. TURKEY CHILI The all-time favorite at the Madison Square Club is brought back here by popular demand. Cook for 2 to 3 minutes, breaking up the turkey into pieces, until browned all over. Serving suggestion: Use one tablespoon of *Red Pepper Almond Pesto instead of ketchup to add some zip to your burger. In a medium-sized mixing bowl, combine turkey, scallion, oregano, and thyme. Fill the red pepper with the ground turkey mixture and place into a baking dish. Optional variation: Before baking, place one tablespoon of *Marinara Sauce on top of the ground turkey. MEXICAN TURKEY BURGER WITH JALAPEÑO PEPPERS AND MEXICAN SALSA My favorite ethnic food has got to be Mexican—can never really get enough salsa! The salsa can also be used for your egg dishes and anything else that might need to be a little caliente. In another medium-sized bowl, combine turkey, scallion, jalapeño pepper, garlic, chili powder, cumin, and salt and mix thoroughly. Grill turkey burger for 4 to 5 minutes on each side until cooked through.

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Amantadine has also been associ- lihood of cross-sensitivity reactions between amprenavir and ated with exacerbations of preexisting seizure disorders and other sulfonamides is unknown cheap 100mg fildena fast delivery erectile dysfunction mayo clinic. Amantadine is teratogenic in animals purchase 25mg fildena otc erectile dysfunction young male causes, tains high concentrations of vitamin E, and patients using this and neither drug has been established as safe for pregnant drug should be cautioned against taking any additional vita- women. Oseltamivir (Tamiflu) and zanamivir (Relenza) are ap- proved for treatment of influenza A or B in clients with symp- Combination Drugs toms for 2 days or less. Oseltamivir In HIV infection, as in many other conditions, the use of is an oral drug; zanamivir is a powder form for oral inhala- combination drugs is increasing. Zanamivir may cause mens are complex and involve the ingestion of many pills bronchospasm in clients with asthma or chronic obstructive daily. Adherence to the regimens is difficult but critical in pulmonary disease. Combivir (lamivudine and zidovudine), Trizivir (abacavir, Drug for Respiratory Syncytial Virus lamivudine, and zidovudine), and Kaletra (lopinavir and Respiratory Tract Infections ritonavir) are currently available. Kaletra is a combination of two protease inhibitors in which ritonavir is added to Ribavirin is used for the treatment of bronchiolitis or pneu- increase serum concentrations of lopinavir. The drug is not recommended for clients on ventilators be- Drugs for Influenza A cause it precipitates and may block breathing tubes, includ- ing endotracheal tubes. Deterioration of pulmonary function Amantadine and rimantadine inhibit replication of the in- is a common adverse effect. The drug is absorbed systemi- fluenza A virus and are used to prevent or treat influenza A cally after administration by aerosol. Most infants and chil- CHAPTER 39 ANTIVIRAL DRUGS 585 dren with RSV infections have mild, self-limited disease that • For clients receiving systemic antiviral drugs, monitor does not involve the lower respiratory tract and therefore serum creatinine and other tests of renal function, com- does not require hospitalization or ribavirin therapy. Nursing Process • For clients with HIV infection, monitor for changes in baseline data during each contact; prevent opportunistic Assessment infections (eg, CMV retinitis, herpes infections) when possible; and manage signs and symptoms, disease com- • Assessment varies with the type of viral infection and may plications, and adverse effects of drug therapy to promote include signs and symptoms of influenza or other viral in- quality of life. Baseline data may include • Interview outpatients regarding their compliance with in- vital signs, weight and nutritional status, signs and symp- structions for taking antiviral drugs. Nursing Diagnoses PRINCIPLES OF THERAPY • Anxiety related to a medical diagnosis of HIV infection, genital herpes, or CMV retinitis Prevention of Viral Infections • Altered Sexuality Patterns related to sexually transmitted viral infections (HIV infection, genital herpes) General preventive measures include vaccination, hand wash- • Disturbed Body Image related to sexually transmitted ing, teaching infected clients to cover their mouth and nose infection when coughing or sneezing, treatment of symptoms, and • Social Isolation related to a medical diagnosis of HIV recognition and treatment of complications. Of the sexually infection or genital herpes transmitted viral infections, genital herpes can be prevented • Deficient Knowledge: Disease process and methods of by avoiding sex when skin lesions are present and using con- spread; availability of vaccines and other prophylactic in- doms; HIV infection can be prevented by the consistent use of terventions condoms and use of clean needles by IV drug abusers. Vaccines for prevention of poliomyelitis, measles, • Be safeguarded against new or recurrent infection rubella, mumps, smallpox, chickenpox, and yellow fever and • Act to prevent spread of viral infection to others and re- for protection against influenza and rabies are available (see currence in self Chap. Live attenuated viral vaccines are generally safe and • Avoid preventable adverse drug effects nontoxic. However, they should not be used in patients who • Receive emotional support and counseling to assist in cop- are pregnant, immunodeficient, receiving corticosteroids, ing with HIV infection or genital herpes antineoplastic or immunosuppressive drugs, or irradiation. The multiplicity of rhinoviruses (common cold), enteroviruses, • Assist clients to maintain immunizations against viral and respiratory viruses hinders development of practical, infections. Thus, whenever possible, techniques to ✔ Ask a health care provider for information about manag- prevent viral infections should be employed. For example, treatment of genital herpes does not Use of Antibacterial Drugs ness similar to influenza, with fever, chills, and muscle in Viral Infections aches that may last for several weeks. This period is usually followed by a quiescent phase, which may last Antibacterial drugs should not be used to treat viral infections. The period after the initial Use of Antiretroviral Drugs in HIV Infection infection is characterized by a partially effective im- mune system response, which decreases viral replica- 1. However, some viral replication and destruction improving quality of life, decreasing viral load to un- of lymphoid tissue continue during this period. Early detectable levels in plasma (<400 copies/mL) as long treatment reduces viral load and may delay progression as possible, halting disease progression, and restoring of the disease and development of clinical signs and immune function. Guidelines for drug therapy in adults and adolescents, mendations change often as new drugs and research as developed by the Panel on Clinical Practices for reports become available. Thus, when possible, clini- Treatment of HIV Infection (convened by the Depart- cians with expertise in the care of HIV-infected clients ment of Health and Human Services and the Henry J. Kaiser Family Foundation), include the following: Clinicians caring for HIV-seropositive patients should a. Treatment is recommended for symptomatic patients, patients with CD4+ cell counts <350 cells/mm3, or always consult current treatment guidelines before initiating therapy. Combination antiretroviral therapy is standard of and energy by therapists and their patients. A commonly used 3-drug regimen includes must keep abreast of new developments and monitor pa- 2 NRTIs and a protease inhibitor.

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