At long last an improvement

Recently my pain has improved and i feel much better, the recent changes i have made are:-

Vitamin D

Apple Cider Vinegar

taken every morning in conjunction with my other supplements which are below:-

Soluable Vitamin C

Multivitamins

Glucomsomine Sulphate

Cod Liver Oil

My prescribed medication

Naproxen 500mg

I was supposed to take this 2 twice a day, but i am taking 2 once a day, as i feel that is sufficient.

And Copper Insoles.

The question is is it one of the above or a combination of above.................

The Doctor also prescribed me 

Co Codamol (30mg/500mg)

To take as and when needed but since i have been taking the above, i have not needed to take them.

Miracle Drug

When i went to the Doctors the Co-codomol he prescribed was

Solpadol 30mg/500mg capsules (Codein Phosphate and Paracetamol)

I have taken this when my pain became unbearable, and the difference was extreme, the relief was incredible.

Solpadol

Main use	Active ingredient	Manufacturer
Severe pain	Paracetamol 500mg, codeine phosphate 30mg (co-codamol)	Sanofi-Aventis

How does it work?

Solpadol caplets, capsules and effervescent tablets all contain two active ingredients, paracetamol and codeine phosphate. This combination of medicines is often referred to as co-codamol. (NB. Co-codamol is also available without a brand name, ie as the generic medicine.)
Paracetamol is a simple painkilling medicine used to relieve mild to moderate pain. Despite its widespread use for over 100 years, we still don't fully understand how paracetamol works to relieve pain. However, it is now thought that it works by reducing the production of prostaglandins in the brain and spinal cord.
The body produces prostaglandins in response to injury and certain diseases. One of the effects of prostaglandins is to sensitise nerve endings, causing pain (presumably to prevent us from causing further harm to the area). As paracetamol reduces the production of these nerve sensitising prostaglandins it is thought it may increase our pain threshold, so that although the cause of the pain remains, we can feel it less.
Codeine is a stronger painkiller known as an opioid. Opioid painkillers work by mimicking the action of naturally occurring pain-reducing chemicals called endorphins. Endorphins are found in the brain and spinal cord and reduce pain by combining with opioid receptors.
Codeine mimicks the action of natural endorphins by combining with the opioid receptors in the brain and spinal cord. This blocks the transmission of pain signals sent by the nerves to the brain. Therefore, even though the cause of the pain may remain, less pain is actually felt.
Solpadol caplets, capsules and effervescent tablets contain 30mg of codeine, which in combination with the paracetamol, is effective at relieving severe pain.

What is it used for?

• Severe pain.

Warning!

• This medication may cause drowsiness. If affected do not drive or operate machinery. Avoid alcoholic drink.
• Do not take this medicine with any other products that contain paracetamol. Many over-the-counter painkillers and cold and flu remedies contain paracetamol. It is important to check the ingredients of any medicines you buy without a prescription before taking them in combination with this medicine. Seek further advice from your pharmacist.
• An overdose of paracetamol is dangerous and capable of causing serious damage to the liver and kidneys. You should never exceed the dose stated in the information leaflet supplied with this medicine. Immediate medical advice should be sought in the event of an overdose with this medicine, even if you feel well, because of the risk of delayed, serious liver damage.
• Alcohol increases the risk of liver damage that can occur if an overdose of paracetamol is taken. The hazards of paracetamol overdose are greater in persistant heavy drinkers and in people with alcoholic liver disease.
• If this medicine is taken regularly for long periods of time, the body can become tolerant to it and it may become less effective at relieving pain. With prolonged use, the body may also become dependent on the codeine. As a result, withdrawal symptoms such as restlessness and irritability may occur if the medicine is then stopped suddenly. If you find you need to use this medicine all the time you should consult your doctor for advice.
• Consult your doctor if your symptoms persist despite taking this medicine.
• Taking a painkiller for headaches too often or for too long can actually make the headaches worse.

Use with caution in

• Elderly people
• Weak or debilitated people
• Decreased kidney function
• Decreased liver function
• Asthma
• Chronic obstructive pulmonary disease (COPD)
• Epilepsy
• Underactive thyroid gland (hypothyroidism)
• Low blood pressure (hypotension)
• Narrowing of the urethra, causing difficulty passing urine
• Enlarged prostate gland (prostatic hypertrophy)
• People at risk of bowel obstruction, eg due to constipation
• Inflammatory bowel disease such as ulcerative colitis or Crohn's disease
• Biliary tract disorders, eg recent surgery on the biliary tract
• Underproduction of natural steroid hormones by the adrenal glands (Addison's disease)
• Myasthenia gravis.
• Solpadol effervescent tablets contain sodium. They should be avoided in people with kidney problems and those on a low sodium diet.

Not to be used in

• Children under 12 years of age
• Slow, shallow breathing (respiratory depression)
• People having an asthma attack
• Alcohol intoxication (acute alcoholism)
• People with a head injury or raised pressure inside the skull (raised intracranial pressure)
• Paralysis or inactivity in the intestines that prevents material moving through the gut (paralytic ileus).
• Solpadol effervescent tablets contain sorbitol and are not suitable for people with rare hereditary problems of fructose intolerance.

This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy.

If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.

Label warnings

• Do not take more than 2 at any one time. Do not take more than 8 in 24 hours.
• Do not take this medication with any other products containing paracetamol.
• This medication may cause drowsiness. If affected do not drive or operate machinery. Avoid alcoholic drink.

Side effects

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Just because a side effect is stated here does not mean that all people using this medicine will experience that or any side effect.

• Constipation.
• Nausea and vomiting.
• Dizziness.
• Lightheadedness.
• Drowsiness.
• Shortness of breath.
• Confusion.
• Mood changes.
• Difficulty in passing urine (urinary retention).
• Skin rash.
• Dry mouth.
• Slowed heart rate.
• Contraction of the pupils.

The side effects listed above may not include all of the side effects reported by the drug's manufacturer.

For more information about any other possible risks associated with this medicine, please read the information provided with the medicine or consult your doctor or pharmacist.

How can this medicine affect other medicines?

It is important to tell your doctor or pharmacist what medicines you are already taking, including those bought without a prescription and herbal medicines, before you start treatment with this medicine. Similarly, check with your doctor or pharmacist before taking any new medicines while taking this one, to ensure that the combination is safe.
You should not take other medicines that contain paracetamol in combination with this medicine, as this can easily result in exceeding the maximum recommended daily dose of paracetamol. Many cold and flu remedies and over-the-counter painkillers contain paracetamol, so be sure to check the ingredients of any other medicines before taking them with this one.
This medicine should not be taken at the same time as, or within 14 days of taking a monoamine oxidase inhibitor (MAOI), for example the antidepressants phenelzine, tranylcypromine or isocarboxacid.
There may be an increased risk of drowsiness and sedation if this medicine is taken with any of the following (which can also cause drowsiness):

• alcohol
• antipsychotics, eg haloperidol
• barbiturates, eg phenobarbital, amobarbital
• benzodiazepines, eg diazepam, temazepam
• other opioid painkillers, eg morphine, dihydrocodeine
• sedating antihistamines, eg chlorphenamine, hydroxyzine
• sleeping tablets, eg zopiclone
• tricyclic antidepressants, eg amitriptyline.

Cholestyramine reduces the absorption of paracetamol from the gut. It should not be taken within an hour of taking paracetamol or the effect of the paracetamol will be reduced.
Metoclopramide and domperidone may increase the absorption of paracetamol from the gut.
Long-term or regular use of paracetamol may increase the anti-blood-clotting effect of warfarin and other anticoagulant medicines, leading to an increased risk of bleeding. This effect does not occur with occasional pain-killing doses. If you are taking an anticoagulant medicine and you are also taking co-codamol regularly, your blood clotting time (INR) should be regularly monitored.

Doctors.......Waste of time

Well today i saw Dr Lake again, and as i predicted it was a complete waste of time.
He had the results of the X Ray and confirmed Moderate Arthritis in Right Knee, Left Knee not quite so bad Minor to Moderate Arthritis, NO Arthritis in Hips and Back.  Which is as i expected, however, if it is only moderate and if it isthis pain ful and immobilising, what will it be like if it is severe.

However, most of the discussion centred around my weight and he said they couldn't do anything until i lost weight, he explored my history of weight loss and diet.  And said he would refer me to a dietician and to the Gym, well hopeless, but we will see.

He prescribed me
Co Codamol (30mg/500mg)
Naproxen 500mg

He said there was no point in him seeing me again, as he would get reports, so i have to ration my medication i guess.


Naproxen (naprosyn)¹ is one of the nonsteroidal anti-inflammatory drugs (NSAIDs)² used to treat certain types of arthritis. Naproxen tablets were approved by the FDA in 1976. On January 11, 1994, the FDA approved naproxen in a nonprescription form.

What is the availability of naproxen?

Naproxen is currently available as an over-the-counter drug by either its generic name or by several brand names. Prescription-strength naproxen comes as a regular tablet, enteric-coated tablet, extended-release tablet, and as a liquid suspension to take orally.
The usual dose of naproxen is 250 mg, 375 mg, or 500 mg -- twice a day in the morning and evening for conditions like rheumatoid arthritis, osteoarthritis, or ankylosing spondylitis. Enteric-coated naproxen is usually taken in doses of 375 or 500 mg twice a day. Your doctor can adjust your dose based on how you are responding to the drug.

When is naproxen prescribed?

Naproxen is prescribed to relieve signs and symptoms of osteoarthritis³ and rheumatoid arthritis⁴. It is primarily used to reduce inflammation⁵, stiffness, and pain.

Are there any special instructions regarding how to take naproxen?

Many doctors instruct patients to take naproxen with food. Some resources say that naproxen can be taken with or without food. Other resources suggest taking it with a full glass of water. To prevent stomach upset, you can take it with food or milk. If stomach upset occurs, consult your doctor. He may recommend that you take an antacid.

Are there patients who should not take naproxen?

Patients who had episodes of asthma, rhinitis, or nasal polyps after taking aspirin or other NSAIDs should not take naproxen. Aspirin-sensitive patients should not take naproxen.
Be sure your doctor knows about any previous drug reactions. Patients who have had ulcers, stomach bleeding, severe kidney problems, or severe liver problems may not be candidates for treatment with naproxen.

What common side effects can occur with naproxen?

Diarrhea, constipation, gas, mouth sores, headache, dizziness, thirst, lightheadedness, drowsiness, tingling in arms and legs, cold symptoms, ringing in the ears, hearing problems, and trouble falling or staying asleep are all possible side effects associated with naproxen.

What special warnings and precautions are associated with naproxen?

Problems with stomach ulcers and stomach bleeding can occur with any NSAID, and naproxen is no exception. Typically, these problems are tied to long-term use of the drug but not always -- short-term use of naproxen or other NSAIDs can be problematic for some patients. Stomach ulcers and bleeding can occur without warning. Some people do get signs and warnings by experiencing burning stomach pain, black stools, or vomiting. Call your doctor if you are experiencing these symptoms.
Liver damage can occur in people taking NSAIDs like naproxen. Warning signs include nausea, vomiting, fatigue, appetite loss, itching, yellowing of the skin or eyes, and dark urine.
Naproxen can cause fluid retention and swelling in the body. NSAIDs like naproxen have also been linked to increased blood pressure.
NSAIDs, including naproxen, are associated with an increased risk of adverse cardiovascular events, including heart attack, stroke, and new onset or worsening of pre-existing hypertension⁶ (high blood pressure). The cardiovascular risk may be increased with duration of use of naproxen or other NSAIDs or pre-existing cardiovascular risk factors or disease.

Are there drug interactions associated with naproxen?

Naproxen can have serious adverse reactions with certain drugs. Drugs which can cause interactions include:

• Aspirin⁷
• ACE inhibitors
• Blood-thinning medications
• Furosemide
• Lithium
• Methotrexate⁸

Steven is Home

On the 16th August Steven was admitted to Queen Elizabeth Hospital in King's Lynn, he was diagnosed with Endocarditis, an infection of the heart valve.  After antibiotic care in the Hospital, the decision was made to transfer him to Papworth Hospital, in Cambridge, to assess the condition of his heart valve and maybe replacing it if necessary.

Today after 6 weeks in hospital Steven was eventually discharged in spite of reluctance from the registrar because his INR was so low.

Steven will have to self administer Clexane, and have to have blood tests taken every other day, in about 2 weeks time Steven will have to have another blood culture done to make sure there is no infection,  Steven has to take care in case of a secondary infection.

Papworth Visit

After work today we collected Jude and went to visit Steven in Papworth for the first time, it was an easy journey, with no problem, finding our way round Papworth was interesting but we made it.

This was not a happy visit, Papworth is not a nice hospital, very dated, the staff are good and the food is an improvement on King's Lynn, but the environment itself was very poor and dated and didn't look very hygienic.

Other causes for concern was Stevens test result haven't been sent from King's Lynn, and won't arrive till beginning of next week, most frustrating and disorganised to say the least.

The surgeon is also not happy with the risk involved in the operation, because it is rare to replace a replacement mitral valve there is very little information available, thus the risks are quite high.  Once the results arrive and the surgeon can study them, he might be able to make an informed decision about the treatment plan, but we continue the waiting game :(

Steven has been put on a new antibiotic Teicoplanin, which believe it or not was the anitbiotic tested on the culture taken, so why wasn't that the one he was put on ugh

Teicoplanin is an antibiotic used in the prophylaxis and treatment of serious infections caused by Gram-positive bacteria, including methicillin-resistant Staphylococcus aureus and Enterococcus faecalis. It is a glycopeptide antibiotic extracted from Actinoplanes teichomyceticus, with a similar spectrum of activity to vancomycin. Its mechanism of action is to inhibit bacterial cell wall synthesis.
Teicoplanin is marketed by Sanofi-Aventis under the trade name Targocid.
Oral teicoplanin has been demonstrated to be effective in the treatment of pseudomembranous colitis and Clostridium difficile-associated diarrhoea, with comparable efficacy with vancomycin.^[1]

I went Doctors............................

Bob made me an appointment to see the Doctor, i saw Dr Lake and he was very nice, i cannot fault him.

However, his comments were as predicted, weight problem, prescribed co-codamol, and is organising an Xray on both knees and left hip.  He said there is signs of arthritis in both knees but none in hip so it could be referred pain.

My prescription medication is Kapake

Kapake (co-codamol)

Main use	Active ingredient	Manufacturer
Severe pain	Paracetamol 500mg, codeine phosphate 30mg (co-codamol)	Galen

How does it work?

Kapake tablets and capsules contain two active ingredients, paracetamol and codeine phosphate. This combination of medicines is often referred to as co-codamol. (NB. Co-codamol is also available without a brand name, ie as the generic medicine.)
Paracetamol is a simple painkilling medicine used to relieve mild to moderate pain. Despite its widespread use for over 100 years, we still don't fully understand how paracetamol works to relieve pain. However, it is now thought that it works by reducing the production of prostaglandins in the brain and spinal cord.
The body produces prostaglandins in response to injury and certain diseases. One of the effects of prostaglandins is to sensitise nerve endings, causing pain (presumably to prevent us from causing further harm to the area). As paracetamol reduces the production of these nerve sensitising prostaglandins it is thought it may increase our pain threshold, so that although the cause of the pain remains, we can feel it less.
Codeine is a stronger painkiller known as an opioid. Opioid painkillers work by mimicking the action of naturally occurring pain-reducing chemicals called endorphins. Endorphins are found in the brain and spinal cord and reduce pain by combining with opioid receptors.
Codeine mimicks the action of natural endorphins by combining with the opioid receptors in the brain and spinal cord. This blocks the transmission of pain signals sent by the nerves to the brain. Therefore, even though the cause of the pain may remain, less pain is actually felt.
Kapake tablets and capsules contain 30mg of codeine, which in combination with the paracetamol, is effective at relieving severe pain.

What is it used for?

• Severe pain.

Warning!

• This medication may cause drowsiness. If affected do not drive or operate machinery. Avoid alcoholic drink.
• Do not take this medicine with any other products that contain paracetamol. Many over-the-counter painkillers and cold and flu remedies contain paracetamol. It is important to check the ingredients of any medicines you buy without a prescription before taking them in combination with this medicine. Seek further advice from your pharmacist.
• An overdose of paracetamol is dangerous and capable of causing serious damage to the liver and kidneys. You should never exceed the dose stated in the information leaflet supplied with this medicine. Immediate medical advice should be sought in the event of an overdose with this medicine, even if you feel well, because of the risk of delayed, serious liver damage.
• Alcohol increases the risk of liver damage that can occur if an overdose of paracetamol is taken. The hazards of paracetamol overdose are greater in persistant heavy drinkers and in people with alcoholic liver disease.
• If this medicine is taken regularly for long periods of time, the body can become tolerant to it and it may become less effective at relieving pain. With prolonged use, the body may also become dependent on the codeine. As a result, withdrawal symptoms such as restlessness and irritability may occur if the medicine is then stopped suddenly. If you find you need to use this medicine all the time you should consult your doctor for advice.
• Consult your doctor if your symptoms persist despite taking this medicine.
• Taking a painkiller for headaches too often or for too long can actually make the headaches worse.

Use with caution in

• Elderly people.
• Weak or debilitated people.
• Decreased kidney function.
• Decreased liver function.
• Asthma.
• Chronic obstructive pulmonary disease (COPD).
• Epilepsy.
• Underactive thyroid gland (hypothyroidism).
• Underproduction of natural steroid hormones by the adrenal glands (Addison's disease).
• Low blood pressure (hypotension).
• Narrowing of the urethra, causing difficulty passing urine.
• Enlarged prostate gland (prostatic hypertrophy).
• People at risk of bowel obstruction, eg due to constipation.
• Inflammatory bowel disease such as ulcerative colitis or Crohn's disease.
• Biliary tract disorders, eg recent surgery on the biliary tract.
• Myasthenia gravis.

Not to be used in

• Children under 12 years of age.
• Slow, shallow breathing (respiratory depression).
• People having an asthma attack.
• Alcohol intoxication (acute alcoholism).
• People with a head injury or raised pressure inside the skull (raised intracranial pressure).
• Paralysis or inactivity in the intestines that prevents material moving through the gut (paralytic ileus).

This medicine should not be used if you are allergic to one or any of its ingredients. Please inform your doctor or pharmacist if you have previously experienced such an allergy.

If you feel you have experienced an allergic reaction, stop using this medicine and inform your doctor or pharmacist immediately.

Label warnings

• Do not take more than 2 at any one time. Do not take more than 8 in 24 hours.
• Do not take this medication with any other products containing paracetamol.
• This medication may cause drowsiness. If affected do not drive or operate machinery. Avoid alcoholic drink.

Side effects

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects that are known to be associated with this medicine. Just because a side effect is stated here does not mean that all people using this medicine will experience that or any side effect.

• Constipation.
• Nausea and vomiting.
• Dizziness.
• Lightheadedness.
• Drowsiness.
• Shortness of breath.
• Confusion.
• Mood changes.
• Difficulty in passing urine (urinary retention).
• Skin rash.
• Dry mouth.
• Slowed heart rate.
• Contraction of the pupils.

The side effects listed above may not include all of the side effects reported by the medicine's manufacturer. For more information about any other possible risks associated with this medicine, please read the information provided with the medicine or consult your doctor or pharmacist.

An interesting thing was he gave me was a copy of my MRI results from 30th May 2009.

It never mentioned Arthritis but said shows intramensical degeneration but no tear.

Meaning - You have damaged/worn, but not torn, your meniscus

In anatomy, a meniscus (from Greek μηνίσκος meniskos, "crescent"^[1]) is a crescent-shaped fibrocartilaginous structure that, in contrast to articular disks, only partly divides a joint cavity.^[2] In humans it is present in the knee, acromioclavicular, sternoclavicular, and temporomandibular joints;^[3] in other organisms they may be present in other joints (e.g., between the forearm bones of birds). A small meniscus also occurs in the radio-carpal joint.
It usually refers to either of two specific parts of cartilage of the knee: The lateral and medial menisci. Both are cartilaginous tissues that provide structural integrity to the knee when it undergoes tension and torsion. The menisci are also known as 'semi-lunar' cartilages — referring to their half-moon "C" shape — a term which has been largely dropped by the medical profession, but which led to the menisci being called knee 'cartilages' by the lay public.

Latest News

Yesterday when visiting Steven, he was bubbling and cantankerous and being a nuisance, up to his usual self, trying to escape.

We had Miles overnight whild Jude worked and he was very good.  This morning i ran Junior Church and we worked on Night and Day and the creation. Then we all had a Roast Dinner, and while mum had the children, me and Jude went to the hospital.

Steven was not quite as bright today, he looked and felt weary, however, he is now eating which is good.

This evening Steven's INR was very low, so he has to be on Clexne tonight.

Clexane injection contains the active ingredient enoxaparin, which is a type of medicine called a low molecular weight heparin. It is used to stop blood clots forming within the blood vessels.

Tonight i watched

X Factor

Series 9 - Episode 3

Gary Barlow, Nicole Scherzinger, Tulisa and Louis Walsh continue their tour of six major cities, giving their verdicts on another line-up of would-be chart stars, from genuine hopefuls to the completely hopeless. Mel B joins the panel in Manchester and Anastacia is a guest judge in Glasgow as hundreds of hopefuls try to prove they have what it takes to be the next pop sensation. The judges have already spotted some great potential this year, such as songwriter Ella Henderson and shy supermarket worker Jahmene Douglas, while other contestants have entertained for all the wrong reasons. Dermot O'Leary offers words of encouragement backstage as well as a shoulder to cry on for those who fail to impress.

Inspector George Gently

Series 5 - 2. Gently with Class

2/4. Ellen Mallam is left to drown in an upturned car by its driver, but the young woman's connection to James Blackstone, an aristocratic family's heir apparent, impedes Gently and Bacchus's investigation. The chief inspector discovers that the son's future has been carefully mapped out since birth by his implacable mother Alethea, and she will not countenance any interference in her plans. However, an astonishing twist causes the detectives to reconsider the case in its entirety. Sixties-set detective drama, starring Martin Shaw and Lee Ingleby, with Geraldine Somerville, James Norton, Roger Lloyd Pack, Christopher Fairbank and Ebony Buckle.

Update on Steven

Steven has not had a good week, it has been quite worrying, he has not eaten and slept a lot of the time.

During the week, Steven went to Theatre and had a PICC Line inserted

Peripherally inserted central catheter is a form of IV access. The catheter is inserted in a vein usually located in the arm with the catheter tip terminating in a large vein close to the heart. While in the hospital, nurses will care for the PICC line. They will assess the insertion site, inspect the dressing, check for leakage, perform flushing maintenance and act according to the outcomes. The PICC can be a long term IV access device and patients may be discharged home with the PICC in place to continue with treatments instead of requiring additional hospitalization. Therefore, the patient must be informed of general PICC line care so he is comfortable with it and is aware of circumstances that require alerting healthcare professionals of possible complication.

this is where he now has his antibiotic.

He has also come off of the antibiotics

Vancomycin
Gentamicin

And he has now been put on the antibiotic

Daptomycin

This medication is an antibiotic used to treat serious bacterial infections. It works by stopping the growth of bacteria.

 SIDE EFFECTS: Nausea, vomiting, constipation, diarrhea, headache, dizziness, trouble sleeping, anxiety, or pain/redness/swelling at the injection site may occur.

The reason for this change in medication is that Steven has High Renal Levels which could mean Kidney problems.

Steven has seen a Dental surgeon and hopefully will get his dental problems sorted while in hospital.


Steven was looking and sounding so much better tonight, i felt a lot happier.

Streptococcus Infective Endocarditis

Stevens diagnosis is confirmed as  Streptococcus Infective Endocarditis.

What is endocarditis?

Endocarditis is a serious infection of one of the four heart valves.(It is on Stevens Mitral Valve, his artificial valve)

What causes endocarditis?

Endocarditis is caused by a growth of bacteria on one of the heart valves, leading to an infected mass called a "vegetation". The infection may be introduced during brief periods of having bacteria in the bloodstream, such as after dental work, colonoscopy, and other similar procedures.

What are the symptoms of endocarditis?

Patients with endocarditis can develop:

• fever,
• fatigue,
• chills,
• weakness
• aching joints and muscles,
• night sweats,
• edema (fluid collection) in the leg(s), foot (feet), and abdomen,
• malaise,
• shortness of breath, and
• occasionally, scattered small skin lesions.

In endocarditis, blood cultures can often detect the bacteria causing the endocarditis. Patients can also develop anemia, blood in urine, elevated white blood cell count, and a new heart murmur.

Who is at risk for endocarditis?

People with existing diseases of the heart valves (aortic stenosis, mitral stenosis, mitral regurgitation, etc.) and people who have undergone heart valve replacements are at an increased risk of developing endocarditis. These people are usually given antibiotics prior to any procedure which may introduce bacteria into the bloodstream. This includes routine dental work, minor surgery, and procedures that may traumatize body tissues such as colonoscopy and gynecologic or urologic examinations. Examples of antibiotics used include oral amoxicillin (Amoxil) and erythromycin (Emycin, Eryc,PCE), as well as intramuscular or intravenous ampicillin, gentamicin, and vancomycin.

How is endocarditis diagnosed?

The infection on the valve can cause build up of nodules on the valves called "vegetations". These valve vegetations can be detected by echocardiography (an ultrasound examination of the heart). The most accurate method of detecting valve vegetations is with a procedure called transesophageal echocardiography (TEE). In this procedure an echo-transducer is placed on the tip of a flexible endoscope. The endoscope is inserted through the mouth into the esophagus. The transducer at the tip of the endoscope is then able to take sound wave "pictures" of the heart valves located adjacent to the lower esophagus. It is important to realize that endocarditis may exist without visible vegetations on the heart valve; the exact diagnosis is made by the identification of bacteria in a blood culture, in the appropriate clinical setting.

How is endocarditis treated?

The mainstay of treatment is aggressive antibiotics, generally given intravenously, usually for 4-6 weeks. The duration and intensity of treatment depends on the severity of the infection and the type of bacterial organism responsible. In cases where the valve has been severely damaged by the infection, resulting in severe valve dysfunction, surgical replacement of the valve may be necessary. Response to treatment is indicated by a reduction in fever, negative blood bacterial cultures, and findings on echocardiography.

http://www.medicinenet.com/endocarditis/article.htm


Infective Endocarditis (IE)


IE produces both intracardiac effects, eg valvular insufficiency and a wide variety of systemic effects, both from emboli (sterile and infected) and a variety of immunological mechanisms.

It is a disease that is easily overlooked or misdiagnosed and clinicians should be vigilant and well versed in the manifestations of IE to avoid missing the diagnosis.

Epidemiology

The incidence of infective endocarditis is approximately 1.7-6.2 cases per 100,000 patient years, although rates are higher in at-risk cohorts such as intravenous drug users.^[1] Incidence has remained constant for 50 years despite changes in the factors affecting incidence.^[2]

Figures for incidence are similar between countries. It is 3 times more common in men and increasing in elderly patients (25-50% of cases occur in the over 60s) often associated with other disease, eg diabetes, cancer, alcoholism.

Risk factors

• Previous IE with valvular damage
• Invasive vascular procedures
• Recreational drug abuse
• Rheumatic heart disease (fewer than 20% of cases of IE)
• Elderly patients with calcific aortic stenosis
• Congenital heart disease accounts for 15% of cases (bicuspid aortic valve being the most common)
• Prosthetic valve implants

Pathogenesis

All cases have a nonbacterial thrombotic endocarditis (a sterile fibrin-platelet vegetation) as the prerequisite for adhesion and invasion. The site of this thrombus is influenced by the Venturi effect, with deposition of thrombus on the low pressure side.
There are differences in the different clinical situations:

• Acute IE:
  The thrombus may be produced either by the invading organism or by valvular trauma (pacing wires, catheters, etc.).
• Subacute IE:
  Sufficient inoculum of bacteria required to allow invasion of the thrombus, bacteria clumping with production of agglutinating antibodies.
• Nonbacterial thrombotic endocarditis:
  This can result from, for example, renal failure, neoplasia, systemic lupus erythematosus (SLE) or malnutrition.

The valves most commonly affected by infective endocarditis are (in decreasing order of frequency):

• Mitral valve
• Aortic valve
• Combined mitral and aortic valve
• Tricuspid valve
• Pulmonary valve - rare

Note: mechanical and bioprosthetic valves are affected equally.

The organisms responsible for infective endocarditis

• Staphylococcus aureus:
  The most common cause of IE overall (acute and subacute); most common with prosthetic valves, acute IE, and IE related to intravenous drug abuse. High mortality rate.
  Coagulase negative S. aureus: causes subacute disease similar to Streptococcus viridans. Accounts for 30% of IE associated with prosthetic valves.
• Streptococci:
  • S. viridans:
    50-60% of subacute IE cases.
  • Group D streptococci:
    Usually subacute and the third most common cause of IE.
  • Streptococcus intermedius:
    Acute and subacute infection. Causes 15% of all cases of IE.
  • Group A, C and G streptococci:
    Acute IE is similar to that with S. aureus. High mortality (up to 70%).
  • Group B streptococci:
    Acute disease, high mortality often requiring valve replacement. Occurs in pregnancy and the elderly particularly.
• Pseudomonas aeruginosa:
  Usually acute IE and requires surgery for cure.
• HACEK organisms (Haemophilus aphrophilus, Actinobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens, Kingella kingae):
  Usually subacute disease and about 5% of all IE.
• Fungi:
  Cause subacute disease.
• Enterococci.

Presentation

• Early disease subtle and nonspecific
• Indolent process which may include:
  • Fatigue
  • Low-grade fever
  • Flu-like illness
  • Polymyalgia-like symptoms
  • Loss of appetite
  • Back pain
  • Pleuritic pain
  • Abdominal symptoms (may be pain, vomiting and appendicitis-like symptoms)
  • Symptoms akin to rheumatic fever
  • Weight loss
• Cerebrovascular accident - less common
• Congestive cardiac failure - less common
• May be history of:
  • Invasive procedures (see above)
  • Recreational drug use
  • Dental disease
  • Gingivitis - most cases caused by transient bacteraemia from this
  • Symptoms usually arise 2 weeks after invasive procedures but diagnosed after 6 weeks
  • Fewer than half of patients have previously-diagnosed valvular disease
• Developing disease produces a myriad of further clinical features of embolic or immunological origin when treatment/diagnosis delayed for weeks/months:
  • Acute meningitis - signs and symptoms but with sterile CSF
  • Hemiplegia from emboli in the middle cerebral artery (50% of patients may be first manifestation; has high mortality)
  • Renal infarcts causing painless haematuria
  • Splenic infarction causing pain
  • Blindness from retinal artery occlusion
  • Myocardial infarction from emboli in the coronary artery
  • Pulmonary emboli
  • Interstitial nephritis or proliferative glomerulonephritis from deposition of circulating immune complexes
  • Renal failure may result
  • Musculoskeletal symptoms (nearly half of patients) often from immunologically mediated synovitis
  • Immune-mediated vasculitis (causing Osler's nodes and Roth's spots)
  • Palpitations from immune-mediated myocarditis
  • Back pain (15% of patients) may have origin in immune complex deposition in disc spaces

Examination

• Fever: elderly, chronically ill patients with subacute IE may not have fever, but the majority do
• Heart murmurs:
  • Most patients have a murmur
  • Exception is right-sided IE where one third have murmurs
  • Only 15% have the classic 'changing murmur'
  • Most common murmur is aortic regurgitation
• Petechiae:
  • Conjunctivae
  • Hands and feet (dorsum)
  • Chest and abdominal wall
  • Oral mucosae and soft palate
• Splinter or subungual haemorrhages: Linear and red
• Osler's nodes: small tender red-to-purple nodules pulp of terminal phalanges fingers and toes
• Clubbing: only 10% of cases and usually in longstanding subacute IE
• Roth's spots: retinal haemorrhages with pale centres
• Janeway's lesions: irregular painless erythematous macules on the thenar and hypothenar eminence (usually with acute IE and S. aureus)
• Arthritis:
  • With subacute IE usually asymmetric and up to 3 joints affected (fluid sterile)
  • Acute IE can give acute septic monoarticular arthritis
• Splenomegaly: most often observed in longstanding subacute disease and often persists after treatment
• Meningism/meningitis: purulent disease occurs in acute IE and aseptic variety in subacute IE

Differential diagnosis

The differential diagnosis could include all those conditions which occur as a complication or with progression of the disease.

Some of the more unusual diseases which may also have similar complex and varied manifestations are:

• SLE
• Atrial myxoma and other cardiac neoplasms
• Lyme disease
• Antiphospholipid syndrome
• Polymyalgia rheumatica
• Reactive arthritis

Investigations

Blood cultures

• Blood cultures are used to demonstrate bacteraemia of 30 minutes or more duration
• Draw 3 to 5 sets of blood cultures over 24 hours
• In acute IE, 3 sets drawn from different venepuncture sites over 30 minutes demonstrates continuous bacteraemia
• If cultures are negative 24 hours after stopping antibiotics, repeat after 7 days and, if still negative, reconsider IE diagnosis
• Blood should not be drawn from IV lines (unless diagnosing line infection when simultaneous line and peripheral vein sampling may be used)
• Prior use of antibiotics commonly gives false negative results
• Probably 50% of culture results are estimated to be falsely positive
• Fastidious organisms may require special culture media or prolonged incubation
• HACEK organisms may require 3 weeks of culture and brucella organisms up to 6 weeks

Serological tests

These may be necessary to detect some organisms, eg legionella, chlamydia, brucella and coxiella species.

Imaging studies

Echocardiography is the indirect investigative method of choice. Note in general terms that:

• Echocardiography is particularly useful in the elderly
• Echocardiography is especially of use when clinical picture of IE but negative cultures
• Echocardiography is useful to predict complications such as embolisation:
  • Larger vegetations (>10 mm diameter)
  • Multiple vegetations
  • Pedunculated vegetations
  • Prolapsing vegetations
• Diagnosis of IE can never be excluded with negative echocardiogram (of whatever type)
• Echocardiography should not be used to screen for IE because of high (15% plus) false positive rate (caused by thickened valves, etc.)

Transthoracic echocardiography (TTE):

• TTE is the initial technique of choice for investigating infective endocarditis.^[1]
• Can detect vegetations in 60% of native valve endocarditis but much less often in prosthetic valves
• TTE is good enough for most cases of IE

Transoesophageal echocardiography (TEE):

• In high risk groups, TEE, with its higher sensitivity and specificity, may be needed if the TTE is normal and suspicion of infective endocarditis remains high^[1]
• Was developed to visualise prosthetic valves and right-sided pathology
• It detects over 90% of all vegetations
• TEE is better at detecting myocardial abscesses and vegetations on pacemaker leads

Two dimensional cardiac ultrasound Doppler studies have been a helpful advance providing more information on vegetations:

• This may help in diagnosis but also in predicting risk of embolisation
• Useful for visualising jet lesions and cusp perforation

Radionucleotide studies are of little value except for detecting splenic abscesses which are refractory to antibiotic treatment.
Electrocardiogram is useful to detect the 10% of patients who will develop conduction defects.

Diagnostic criteria

The Duke criteria - for definitive clinical diagnosis requires either 2 major or 1 major and 3 minor or 5 minor criteria from the list below:^[3]

• Major blood culture criteria:
  • 2 positive blood cultures for typical IE organisms
  • Persistently positive cultures for such organisms drawn >12 hours apart
  • 3 or more positive cultures drawn at least 1 hour apart
• Major echocardiographic criteria:
  • Positive result and no alternative explanation
  • Myocardial abscess
  • Partial dehiscence of prosthetic valve
  • New valvular regurgitation
• Positive molecular assays for specific gene targets
• Positive serology for Coxiella burnetii, Bartonella spp., or Chlamydophila psittaci
• Minor criteria:
  • Predisposing cardiac condition
  • Intravenous drug use
  • Fever (38°C or over)
  • Elevated C-reactive protein or erythrocyte sedimentation rate
  • Vascular lesions
  • Immunological phenomenon
  • Positive cultures less than 'major'
  • Positive echocardiographic results but insufficient for major criteria
• Definitive pathological diagnosis from tissue

Management

Have a high index of suspicion:

• Admit the patient to hospital for full investigation:
  • Blood cultures
  • Temperature records
  • Basic haematology and biochemistry investigations
  • ECG and CXR
  • Comprehensive TTE
• Blood cultures:
  • With a sick patient (acute IE) take 3 sets of cultures at >1 hour intervals.
  • Less obvious IE (sub-acute presentation) requires 6 sets of cultures over 24-48 hours.
  • Cultures negative for the commoner organisms should be checked for unusual slow-growing organisms and fungi.
• Referral:
  • When blood cultures are positive to a cardiologist.
  • At the outset to a microbiologist.
• TTE or TEE:
  • If TTE difficult or suboptimal.
  • In order further to assess vegetations, abscesses or valvular perforations.
  • In all patients with prosthetic valve endocarditis (PVE).
• Serological testing:
  • If the diagnosis is still suspected but cultures negative after 7 days.
  • Tests for Coxiella burnetii, Bartonella spp. and chlamydial organisms are available and should be performed.
• Testing of biopsied tissue with special techniques to identify bacteria and fungi are being developed.

Antimicrobial therapy

Stevens antibiotic treatment is Vancomycin, Gentamicin, Rifampicin, lasting for 6 weeks, in hospital via drip.

Guidelines have been produced for treating IE.^[

Treatment of infective endocarditis: guidelines from the RCP.
Type or variety of IE/ organism	Antibiotic	Dose/route	Duration of treatment
IE due to penicillin-sensitive viridans streptococci and S. bovis (MIC*<0.1 mg/l) in adults	Benzylpenicillin and gentamicin (b)	Benylpenicillin: 7.2-12 g iv/24 hours in 4-6 divided doses Gentamicin: 3-5 mg/kg iv daily in 2-3 divided doses (max 240 mg/day)	4-6 weeks (a) 2 weeks
As above but allergic to penicillin	Vancomycin and gentamicin (b)	Vancomycin: 30 mg/kg iv in 24 hours infused in 2 divided doses over 2 hours Gentamicin: as above	4 weeks 2 weeks
IE due to penicillin-relative resistant viridans streptococci and S. bovis (MIC*>0.1 mg/l) in adults	Benzylpenicillin and gentamicin (b)	Benzylpenicillin: 12-14 g iv/24 hours in 4-6 divided doses Gentamicin as above	4-6 weeks (a) 2 weeks(a)
As above but allergic to penicillin	Vancomycin and gentamicin (b)	Vancomycin and gentamicin as above	Vancomycin and gentamicin as above
IE due to staphylococci on native valve: penicillin-sensitive (non-beta-lactamase producers)	Benzylpenicillin and gentamicin (b)	Benzylpenicillin: 12-14 g regime as above. Gentamicin as above	6 weeks benzylpenicillin 3-5 days of gentamicin only
IE due to staphylococci on native valve: methicillin-sensitive staphylococci (beta-lactamase producer)	Flucloxacillin and gentamicin (b)	Flucloxacillin: 8-12 g iv/24 hours in 4 divided doses Gentamicin as above	6 weeks flucloxacillin 3-5 days of gentamicin only
IE due to staphylococci on native valve: methicillin-resistant staphylococci (c)	Vancomycin (d) and gentamicin (b)	Vancomycin: 30 mg/kg iv in 24 hours in 2 divided doses (infused over 2 hours) Gentamicin as above	6 weeks vancomycin 3-5 days of gentamicin only
As above but allergic to penicillin	Vancomycin (d) and gentamicin (b)	As above for V and G	As above for V and G
IE due to enterococci in adults: gentamicin-sensitive or low level resistant organism (MIC*<500 mg/l)	Benzylpenicillin or ampicillin or amoxicillin and gentamicin (f), (b)	Benzylpenicillin: 10-12 g iv/24 hours in 4-6 divided doses Amp/amox: 12 g iv/24 hours in 4-6 divided doses Gentamicin as above	All 4-6 weeks with 6 weeks if symptoms for more than 3 months of amox and amp (e)
As above but allergic to penicillin	Vancomycin (d) and gentamicin (b)	As above for V and G	As above for V and G
(a) Adjust duration according to response and microbiologist advice. (b) Check gentamicin levels regularly. (c) Linezolid or Synercid® may be used with MRSA. (d) Monitor peak and trough levels with advice. (e) 6 weeks for symptoms over 3 months. (f) Strains highly resistant to gentamicin seek microbiology advice. *MIC = minimum inhibitory concentration.

Surgical care

Surgery is needed in approximately 50% of patients who develop infective endocarditis and careful timing is essential to ensure a good outcome:^[1]

• In most stable patients surgery is best delayed until antibiotics are completed to reduce the risk of perioperative complications and early prosthetic valve endocarditis.
• Unstable patients with haemodynamic or perivalvular complications have a poor prognosis and are best transferred to a specialist centre at the earliest opportunity.

Complications

These are an inherent part of the progression of the disease. Patients should be monitored for:

• Valve dysfunction
• Myocardial abscesses
• Embolic phenomena
• Heart failure
• Metastatic infection
• Immunological disease and organ dysfunction
• Complications even after bacteriological cure
• Conduction defects (patients with IE should have daily ECGs)

Prognosis

This varies markedly according to a variety of factors. The following outlines the range of prognosis when managed appropriately:

• Native valve endocarditis:
  • S. viridans 98% cure rate
  • S. aureus 60-90% cure rate with worse results in occurring in those NOT abusing intravenous drugs
  • Fungal infections - cure rate less than 50%
• PVE:
  • Cure rates at least 10% lower than above for each variety
  • Surgery needed more often
  •  
  http://www.patient.co.uk/doctor/infective-endocarditis
  
  
  Streptococci are the commonest causes of bacterial endocarditis. However, Streptococcus mutans, a member of this group associated with dental caries which might be expected to be commonly associated with endocarditis, has only rarely been reported. This is possibly because of difficulties in isolation and identification. Differing blood culture media may affect the chances of isolation of these organisms, and, though brain-heart infusion, thiol, tryptic soy, and glucose-brain infusion broths have all proved satisfactory, subcultures may require increased CO2 concentrations for growth. Plemorphism in the resultant colonies and in the individual organisms may give rise to a hazardous misinterpretation of this appearance as contamination. Strep. mutans and the similarly penicillin sensitive Strep. bovis may be differentiated from the penicillin resistant enterococci by their lincomycin sensitivity and intolerance of 6-3 per cent sodium chloride. Precise differentiation of streptococci in bacterial endocarditis is of value both epidemiologically and in the management of the disease.
• 
  
  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC483257/
  
  

Ahh Bless, he is poorly

On Thursday Bob developed a swollen ankle, and had a red rash up his leg, it was sore and itchy, he also had no energy, and had the shakes badly, on Friday it had spread, till he could barely walk.  I did tell him he needed to get it looked at.

This morning Bob went to Burton on Trent to a model train exhibition, staying at his friend Adams overnight, Adam and Andrea agreed with me that he needed to get it looked at, and took him to an NHS walk in centre in Peterborough, where they diagnosed him with Cellulitis, they prescribed him 500mg C-Fluampicil and told him it could be quite serious and if that doesn't clear it up he needs to go to A and E to be admitted and put on an IV, as that is the only cure.  He got the prescription from a late night Asda Pharmacy. The whole thing from start to finish took an hour and half

Wow you wouldn't get such efficient fast treatment round here.

Cellulitis

Skin infection - bacterial

Last reviewed: April 17, 2009.

Cellulitis is a common skin infection caused by bacteria.

Causes, incidence, and risk factors

Staphylococcus and streptococcus bacteria are the most common causes of cellulitis.
The skin normally has many types of bacteria living on it. When there is a break in the skin, however, bacteria can enter the body and cause infection and inflammation. The skin tissues in the infected area become red, hot, irritated, and painful.
Risk factors for cellulitis include:

• Cracks or peeling skin between the toes
• History of peripheral vascular disease
• Injury or trauma with a break in the skin (skin wounds)
• Insect bites and stings, animal bites, or human bites
• Ulcers from diabetes or a blockage in the blood supply (ischemia)
• Use of corticosteroid medications or medications that suppress the immune system
• Wound from a recent surgery

Symptoms

• Fever
• Signs of infection:
  
  • Chills, shaking
  • Fatigue
  • General ill feeling (malaise)
  • Muscle aches, pains (myalgias)
  • Warm skin, sweating
• Pain or tenderness in the area with the rash or sore
• Skin redness or inflammation that increases in size as the infection spreads
• Skin sore or rash (macule):
  
  • Comes on suddenly
  • Grows quickly in the first 24 hours
  • Usually has sharp borders
• Tight, glossy, "stretched" appearance of the skin
• Warmth over the area of redness

Other symptoms that can occur with this disease:

• Hair loss at the site of infection
• Joint stiffness caused by swelling of the tissue over the joint
• Nausea and vomiting

Signs and tests

During a physical examination, the doctor may find:

• Redness, warmth, and swelling of the skin
• Swelling and drainage if the infection is around a skin wound
• Swollen glands (lymph nodes) near the cellulitis

Your health care provider may mark the edges of the redness with a pen, to see if the redness goes past the marked border over the next several days.
Tests that may be used:

• Blood culture
• Complete blood count (CBC)

Treatment

Cellulitis treatment may require a hospital stay if:

• You are very sick (very high temperature, blood pressure problems, nausea and vomiting that does not go away)
• You have been on antibiotics and the infection is getting worse
• Your immune system is not working well (due to cancer, HIV)
• You have an infection around your eyes

Most of the time, treatment with oral antibiotics and close follow-up is enough. Treatment is focused on controlling the infection and preventing complications.
You may receive antibiotics to control the infection, and analgesics to control pain.
Raise the infected area higher than your heart to reduce swelling. Rest until your symptoms improve.

Expectations (prognosis)

It is possible to be cured with 7 - 10 days of treatment. Cellulitis may be more severe in people with chronic diseases and those who are more prone to infection because their immune system is not working properly (immunosuppressed).
People with fungal infections of the feet may have cellulitis that keeps coming back. The cracks in the skin offer an opening for bacteria to get inside.

Complications

• Bone infection (osteomyelitis)
• Inflammation of the lymph vessels (lymphangitis)
• Meningitis (if cellulitis is on the face)
• Sepsis, shock
• Tissue death (gangrene)

Calling your health care provider

Call your health care provider if:

• You have symptoms of cellulitis
• You are being treated for cellulitis and you develop new symptoms, such as persistent fever, drowsiness, lethargy, blistering over the cellulitis, or red streaks that spread

Seek medical attention immediately if the cellulitis is on your face.

Prevention

Protect your skin by:

• Keeping your skin moist with lotions or ointments to prevent cracking
• Wearing shoes that fit well and provide enough room for your feet
• Learning how to trim your nails to avoid harming the skin around them
• Wearing appropriate protective equipment when participating in work or sports

Whenever you have a break in the skin:

• Clean the break carefully with soap and water
• Cover with a bandage and change it every day until a scab forms
• Watch for redness, pain, drainage, or other signs of infection

Co-fluampicil

Important: co-fluampicil is a type of penicillin antibiotic and it should not be taken by anyone who is allergic to penicillins. Co-fluampicil should be taken when your stomach is empty. This means an hour before food or 2 hours after food. Space the doses evenly throughout the day. Keep taking this medicine until the course is finished, unless you are told to stop.

About co-fluampicil

Type of medicine	Penicillin antibiotic
Used for	Bacterial infections
Also called	Magnapen®
Available as	Capsules, oral liquid, and injection

About co-fluampicil

Co-fluampicil contains two penicillin antibiotics in equal amounts, flucloxacillin and ampicillin.

It is used to treat bacterial infections such as infections of the chest or skin. It works by killing or stopping the growth of bacteria that cause the infection.

Before taking co-fluampicil

Before taking co-fluampicil make sure your doctor or pharmacist knows:

• If you are pregnant or breast-feeding.
• If you have glandular fever.
• If you have liver problems or have ever had liver problems after taking an antibiotic.
• If you have kidney problems.
• If you are taking other medicines, including those available to buy without a prescription, herbal and complementary medicines.
• If you have ever had an allergic reaction to this or any other medicine. It is particularly important that you tell your doctor if you are allergic to any antibiotics.

How to take co-fluampicil

• Before beginning treatment, read the manufacturer's printed information leaflet from inside the pack.
• Take co-fluampicil exactly as your doctor has told you.
• Co-fluampicil is usually taken every six hours. Space the doses evenly throughout the day.
• Keep taking this antibiotic until the course is finished unless you are told to stop. This is to prevent your infection from coming back.
• Take co-fluampicil when your stomach is empty. This means an hour before food or 2 hours after food.
• Try not to miss any doses. If you do forget a dose, take it as soon as you remember unless it is nearly time for your next dose, in which case leave out the missed dose. Do not take two doses together to make up for a forgotten dose.

Getting the most from your treatment

• Some people develop thrush (redness and itching in the mouth or vagina) after taking a course of antibiotics. If you think you have thrush speak with your doctor or pharmacist for advice.
• If you are using oral combined hormonal contraception (the 'pill'), additional contraceptive precautions such as condoms are not required during a course of this antibiotic unless you are sick or have diarrhoea. If you need further advice, speak with your doctor or pharmacist.
• If you are having an operation or dental treatment, tell the person carrying out the treatment that you are taking a penicillin.
• This antibiotic may stop the oral typhoid vaccine from working. If you are having any vaccinations, make sure the person treating you knows that you are taking this medicine.
• If you still feel unwell after completing your course of co-fluampicil, make another appointment to see your doctor.

Can co-fluampicil cause problems?

Along with their useful effects, most medicines can cause unwanted side-effects although not everyone experiences them. These usually improve as your body adjusts to the new medicine, but speak with your doctor or pharmacist if any of the following side-effects continue or become troublesome.

Common side-effects	What can I do if I experience this
Feeling or being sick, stomach ache	Eat little and often and stick to simple or bland foods
Diarrhoea	Drink plenty of water to replace lost fluids. If the diarrhoea is severe or lasts for more than 24 hours, see your doctor
Thrush, skin rash and itching	Speak with your doctor or pharmacist for advice

Important: If you experience any of the following rare symptoms, stop taking co-fluampicil and contact your doctor for advice straight away:

• Swelling of your tongue, mouth, or face, or any problems with your breathing.
• A severe itchy skin rash.
• Jaundice, fever or pain in your joints.
• Severe diarrhoea.

If you experience any other symptoms which you think may be due to this medicine, speak with your doctor or pharmacist.