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We considered one full attack to take place from the onset of fghting to the moment when the mother separated the cubs; if the cubs initiated another bout of fghting that would be considered another attack cheap 50 mg azathioprine with visa spasms thoracic spine. We calculated the number of attacks for each fght in Eurasian lynx litters (median=5; min=2; max=18; n=6) and in Iberian lynx litters (median=3 buy azathioprine 50mg otc muscle relaxant in anesthesia. Ag e o F A g g r e s s o r in ib e r i A n ly n x F i g h t (mother-r A i s e d A n d h A n d -r A i s e d litters) order azathioprine 50mg amex zanaflex muscle relaxant. Ag e o F F i g h t A n d d u r A t i o n o F A g g r e s s i v e p e r i o d in ib e r i A n ly n x litters, n At u r A l A n d h A n d - bR I s a y bR e z o 24 r A i s e d. In one Eurasian lynx litter a new fght emerged nine days after the frst one, but the cubs were not aggressive during the period between both fghts. Eurasian lynx cubs were separated only on one occasion, after the frst fght was observed, and the cubs were checked afterwards for aggressiveness toward littermates. Five days after the fght they were still aggressive, but aggressiveness was not present on the 9th day after the frst fght. Iberian lynx cubs were separated by keepers when fghting escalated to a point of concern, and they were later reunited at different time intervals after the fghts (4-14 days), once the cubs seemed to have calmed down. Analysis did not reveal a husbandry infuence on the duration of aggression between cubs. Thus, the aggressive period in Iberian lynx lasted, in average, until postnatal day 63 (min=45; max=144). Although females were aggressors in 65% of the fghts (m:f=6:11), the sex ratio of aggressors did not differ from the overall sex ratio of all Eurasian lynx litters (naidenko and Antonevich, this book). In the mother-raised Iberian lynx litters, aggressors were males in 67% cases (m:f=6:2). In hand-raised cubs sex ratio was 6:2 (m:f), taking the bobcat female into account, but all the hand-raised pairs were of the same sex (four male combinations in 2008 and one constant female pair in 2006). Although all pairs had fghts, the small sample size does not allow us to analyze the sex ratio of aggressors. Similarly, in mother-raised Iberian litters the aggressor was larger than the victim in 86% of the fghts (6/7 litters). Re s P o n s e o f m o t h e R s t o fIghtIng o f f s P R I n g Females tried to stop cub fghts as soon as they emerged. Eurasian lynx mothers used their forelegs and mouth to separate cubs in a very rough way. One of the females, Adelfa, used her paws to prevent the aggressive cubs from contacting each other, but not to break up a fght between cubs. In both species, females would sometimes use their body to keep cubs apart, licking away the aggressor to move it further from the victim. Sibling aggression in other mammalian species tends to emerge during moments of highest competition between sibs, such as nursing, eating, etc. It has been argued that the lack of resources seems to be the underlying mechanism of litter size restrictions that cause aggression in larger litters (Hofer and East, 2008). Yet, in both lynx species early fghts were spontaneous and did not appear to be the result of any direct competition. This characteristic distinguishes lynx fghts from early aggression in other taxa (Fraser and Thompson, 1991; Drummond, 2006). The number of attacks per fght was slightly higher for Eurasian lynx encounters than for Iberian lynx ones, but the duration of the aggressive period for the Eurasian lynx was much shorter than for the Iberian species. These differences could be caused by the separation of viciously fghting cubs of the endangered species, so the fght was left unresolved and no behavioral asymmetry was established (Antonevich and naidenko, 2008). We can also expect species-specifc differences to exist in some characteristics of fghts like the ways that mothers use to stop cubs from fghting. There is no evidence that sex infuences the role of the cub in the fght, but data indicates that size does in both species. Although several characteristics differ between Eurasian and Iberian lynx fghts, this phenomenon is similar in both species but differs from sibling aggression in other species of animals. En el periodo transcurrido entre diciembre de 2003 y diciembre de 2008, se llevaron a cabo 318 inmovilizaciones en 126 individuos, 60 de ellos de vida libre. En la mayora de los casos los animales fueron capturados con jaula trampa y para la anestesia se emple la combinacin de ketamina y medetomidina, que fue suplementada con isofurano cuando fue necesario prolongar el procedimiento. En el mismo periodo se realizaron 52 necropsias, 38 en animales de vida libre, revelando que el atropello es la principal causa de muerte. El seguimiento intensivo de la poblacin de vida libre ha puesto de manifesto que las enfermedades infecciosas (leucemia felina, tuberculosis, moquillo canino, panleucopenia felina) suponen una seria amenaza para la supervivencia de la especie. El conocimiento cientfco generado por los diferentes procedimientos clnicos, anlisis y seguimientos se aplica en la gestin y en la conservacin de la especie. Three hundred and eighteen anesthesias of 126 individuals were carried out during the period between December 2003 and December 2008, 60 of them belonged to the free-ranging population. Fifty two necropsies were performed in the same period, 38 of them on free-ranging animals, revealing road-kills as the main cause of mortality. Intensive monitoring of the free-ranging population has shown that infectious diseases (feline leukemia, tuberculosis, canine distemper, feline panleukopenia) can be a serious threat to the survival of the species. A preventive medicine programme is being implemented with the captive breeding population. Scientifc knowledge generated through the various clinical procedures, tests, and monitoring programs is applied to the management and conservation of this species. The development of 169 a health programme that allows studying biomedical aspects and evaluating the incidence, as well as prevalence of infectious pathogens and diseases, is one of the most relevant aspects that need to be taken into account when designing a long-term conservation plan for any species including the Iberian lynx. The document is developed by a Breeding Committee, and is reviewed on an annual basis. The committee consists of several working groups specialized on different disciplines, including health aspects (Vargas et al. The group works in close collaboration with other groups of the Breeding Committee. Its main goals include the following: Development and implementation of working protocols (Iberian lynx clinical manual, Iberian lynx hand- rearing manual, Iberian lynx necropsy manual) These protocols are considered to be living documents that are periodically revised based on experience, scientific information and programme needs. The protocols standardize work processes, and aim at maximizing the information that can be obtained each time a lynx, either alive or dead, is handled. Anesthesia, clinical examination, and sample collection Procedures where anesthesia is needed include: quarantine examinations; health and reproductive examinations (Roldan et al. In addition to the equipment necessary at each breeding center, specifc equipment to anesthetize free-ranging individuals exists both in Sierra Morena and Doana. The duplicate gear helps to avoid the risk of transmitting infectious agents between in situ and ex situ populations. At least two veterinarians participate in any Iberian lynx anesthesia: one of them exclusively monitors the animal, while the other is in charge of the clinical examination and sample collection. Independently of the reasons for the anesthesia, biological samples are systematically 171 collected whenever possible according to protocol (Iberian lynx clinical manual).

By contrast cheap azathioprine 50mg online spasms after surgery, competition between B cell clones for producing anity-matured anti- bodies appears to depend on the dynamic rates of association between Bcellreceptors and antigens generic 50mg azathioprine mastercard muscle relaxant exercises. The sixth section compares the cross-reactivity of an in vivo buy azathioprine 50 mg free shipping spasms coughing, poly- clonal immune response with the cross-reactivity of a puried, mono- clonal antibody. Polyclonal immune responses raise antibodies against many epitopes on the surface of an antigen. Cross-reactivity declines lin- early with the number of amino acid substitutions between variant anti- gens because each exposed amino acidcontributes only a small amount to the total binding between all antibodies and all epitopes. By contrast, amonoclonal antibody usually binds to a single epitope on the antigen surface. Cross-reactivity declines rapidly and nonlinearly with the num- ber of amino acid substitutions in the target epitope because a small number of amino acids control most of the binding energy. The seventh section discusses the specicity and cross-reactivity of Tcellresponses. The eighth section lists the ways in which hosts vary genetically in their responses to antigens. The germline genesthatcontribute to the T cellreceptor have some poly- morphisms that inuence recognition, but the germline B cell receptor genes do not carry any known polymorphisms. Each specic subset of an antigenic molecule recognized by an antibody or a T cell receptor denes an epitope. For example, insulin, a dimeric protein with 51 amino acids, has on its surface at least 115 antibody epitopes (Schroer et al. Nearly the entire surface of an antigen presents many overlapping domains that antibodies can discriminate as distinct epitopes (Benjamin et al. Epitopes have approximately 15 amino acids when dened by spatial contact of antibody and epitope during binding (Benjamin and Perdue 1996). Almost all naturally occurring antibody epitopes studied so far are composed of amino acids that are discontinuous in the primary se- quence but brought together in space by the folding of the protein. The relative binding of a native and a mutant antigen to a puried (monoclonal) antibody denes one common measure of cross-reactivity. C50mut is the concentration of the mutant antigen required to cause 50% inhibi- tion of the reaction between the native antigen and the antibody. Simi- larly, C50nat is the concentration of the native antigen required to cause 50% inhibition of the reaction between the native antigen and the an- tibody (self-inhibition). Then the relative equilibrium binding constant for the variant antigen, C50nat/C50mut,measurescross-reactivity (Ben- jamin and Perdue 1996). Site-directed mutagenesis has been used to create epitopes that vary by only a single amino acid. Studies dier considerably in the methods used to identify the amino acid sites dening an epitope, the choice of sites to mutate, the amino acids used for substitution, and the calculation of changes in equilibrium binding constants or the free- energy of binding. Benjamin and Perdue (1996) discuss these general issues and summarize analyses of epitopes on four proteins. First, approximately 5 of the 15 amino acids in each epitope strongly inuence binding. Certain substitutions at each of these strong sites can reduce the relative binding constant by two or three orders of magnitude. These strong sites may contribute about one-half of the total free-energy of the reaction (Dougan et al. Second, the other 10 or so amino acids in contact with the antibody may each inuence the binding constant by up to one order of magni- tude. Third, the consequences of mutation at a particular site depend, not surprisingly, on the original aminoacidandtheamino acid used for substitution. Fourth, theoretical predictions about the free-energy consequences of substitutions based on physical structure and charge can sometimes be highly misleading. This problem often occurs when the binding location between the antibody and a particular amino acid is highly accessible to solvent, a factor that theoretical calculations have had diculty incor- porating accurately. Fifth, antibodies raised against a particular epitope might not bind optimally to that epitopethe antibodies sometimes bind more strongly to mutated epitopes. In addition, antibodies with low anity for an antigen can have higher anity for related antigens (van Regenmortel 1998). Each antibody binding site denes a paratope, composed of the particular amino acids of that antibody that physically bind to a specic epitope. Approximately 50 variable amino acids make up the potential binding area of an antibody (van Regenmortel 1998). However, in both epitope and paratope, substitutions both in and away from the binding site can change the spatial conformation of the binding region and aect the binding reaction (Wedemayer et al. The antibodys 50 or so variable amino acids in its binding region dene many overlapping groups of 15 amino acids. A paratope does not dene asinglecomplementary epitope; rather it presents certain molecular characteristics that bind antigenic sites with varying anity. First, an antibody can have two completely independent binding sites (paratopes) for unrelated epitopes (Richards et al. Bhattachar- jee and Glaudemans (1978) showed that two puried mouse antibodies (M384 and M870) each bind methyl D-galactopyranoside and phos- phorylcholine at two dierent sites in the antigen-binding region of the antibody. Second, an antibody presumably has many overlapping paratopes that can potentially bind to a variety of related or unrelated epitopes. I did not, however, nd any studies that dened for a particular antibody the paratope map relative to a set of variable epitopes. The potential distribution of paratopes may change as a B cell clone matures in re- sponse to challenge by a matching antigenI take this up in the next section (4. Third, a single paratope can bind two unrelated epitopes (mimotopes, Pinilla et al. X-ray diraction of three competing peptides showed that they all bound to the same site on the antibody (Keitel et al. Fourth, a particular epitope can be recognized by two dierent par- atopes with no sequence similarity. The two antibodies also have dierent patterns of cross- reactivity with other antigens. Experimental studies of specicity frequently compare pairwise ani- ties between an epitope and various paratopes or between a paratope and various epitopes. In these pairwise measures, one rst raises anti- body to a monomorphic (nonvarying) antigenic molecule and then iso- lates a single epitope-paratope bindingin other words, one raises a monoclonal antibody that binds to a single antigenic site. Variations in anity are then measured for dierent epitopes holding the paratope constant or for dierent paratopesholding the epitope constant. Alternatively, one can challengeahost with a polymorphic popula- tion of antigens. One controlled approach varies the antigens only in asmall region that denes a few epitopes (Gras-Masse et al. If exact replicas of each epitope occur rarely, then antibodies will be se- lected according to their binding anity for the aggregate set of varying epitopes (mixotopes) to which they match.

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In patients troubled by se- vere nocturnal pruritus generic 50mg azathioprine with amex muscle relaxant of choice in renal failure, a sedative antihistamine such as hydroxyzine 25 mg may be indi- cated 50mg azathioprine for sale muscle relaxant recreational use. However azathioprine 50 mg without a prescription spasms gelsemium semper, patients should be warned that impairment of cognitive function may be a problem the following morning (Pirisi, 2000). Patients with autoimmune chronic urticaria may respond poorly to the above antihis- tamine regime. Systemic steroids are unsuitable as long term treatment for chronic ur- ticaria although short tapering courses may be useful to meet specifc contingencies. In patients with recalcitrant autoimmune chronic urticaria, which is causing signifcant disability, ciclosporin may be efective (Grattan et al. The dosage for an adult is 34 mg / kg / day for three to four months on a tapering schedule. About one-third of patients remain in remission afer ciclosporin has been withdrawn; one-third relapse but only mildly and one-third relapse to their former pre- treatment level of disease activity and may have to be recontinued on ciclosporin. Authors experiences suggest that patients with functional autoantibodies are more likely to respond well than those without. Chronic autoimmune urticaria is not a licensed indication for ciclosporin and the usual precautions regarding renal function, blood pressure monitoring and unwanted interactions with other concurrently administered drugs metabolised via the cytochrome P450 enzyme pathway have to be considered. We have previously reported positive results using more aggressive forms of immuno- therapy including intravenous immunoglobulin (ODonnell et al. We ought to em- phasise that these treatment modalities are temporary symptom-relieving rather than cu- rative. Nevertheless, it is noteworthy that histamine releasing activity of treated patients decreased or diminished in accordance with urticarial symptoms afer the treatments, en- dorsing the pathological role of autoantibodies and rationales for immunotherapies for chronic autoimmune urticaria. Greaves 10 10 Chronic Urticaria as an Autoimmune Disease 367 368 Clive Grattan, Michihiro Hide, and Malcolm W. Greaves More selective immunotherapeutic strategies might include administration of block- ing humanized structure-based peptides recognizing the antibody-binding sites on the -chain. Understanding the mechanism of action of omalizumab in urticaria should pro- vide further insights into the pathogenesis of the disease. References Adachi J, Aoki T, Yamatodani A (1994) Demonstration of sweat allergy in cholinergic urticaria. Ann Allergy Asthma Immunol 74:155159 Erbagci Z (2002) The leukotriene receptor antagonist montelukast in the treatment of chronic id- iopathic urticaria: a single-blind, placebo-controlled, crossover clinical study. Allergy Clin Immunol Internat 13:2326 Hayashi S Hashimoto S (1999) Anti-infammatory actions of new antihistamines. Springer, Verlag Berlin Heidelberg Herxheimer A (1956) The nervous pathway mediating cholinergic urticaria. Eur J Immunol 29:11391148 Juhlin L, Michaelsson G (1969) Cutaneous reactions to kallikrein, bradykinin and histamine in healthy subjects and in patients with urticaria. Histamine release from mast cells dispersed from skin, lung, adenoids, tonsils and colon in response to IgE-dependent and non-immunological stimuli. Br J Der- matol 140:853858 Ohnishi-Inoue Y, Mitsuya K, Horio T (1998) Aspirin-sensitive urticaria: provocation with a leu- kotriene receptor antagonist. A double-blind, placebo-controlled comparison of treatment with montelu- kast and cetirizine in patients with chronic urticaria with intolerance to food additive and/or acetylsalicylic acid. Allergy 50:289291 Pirisi A (2000) Antihistamines impair driving as much as alcohol. J Allergy Clin Immunol 103:484493 372 Clive Grattan, Michihiro Hide, and Malcolm W. Br J Dermatol 160:426428 Tanaka T, Kameyoshi Y, Hide M (2006) Analysis of the prevalence of subtypes of urticaria and angioedema. Allergy 64:141726 Lichen Planus, Lichenoid Eruptions and Cutaneous 11 Graft-Versus-Host-Reaction Mikls Simon Jr. In 1869 Er- asmus Wilson described the cutaneous leichen planus in 50 case histories and recorded oral lesions in 3 of his patients (Wilson, 1869). It appears initially during the ffh or sixth decade and afect women preferentially. Evidence points to the possibility that an al- teration of epidermal cell antigens (bacterial/viral infections, contact sensitizers, trauma etc. The colloid bodies fuoresced brightly with IgM and with other immuno- globulins and complement components (Barthelmes & Haustein, 1970; Baart de la Faille- Kuyper & Baart de la Faille, 1974; Simon jr et al. Tese proteins and oligosaccha- rides may be identifed immunohistochemically by monospecifc antibodies and high-af- fnity lectins, respectively. Shortly afer the appearance of Langerhans cells, basal keratinocytes undergo fattening and hydropic changes, and their nuclei become injured at an early phase of the mitotic cycle. In the course of examining keratinocyte-lymphocyte interactions in vitro, Nickolof et al. In addition, solu- ble mediators of cell damage produced by T-cells may induce keratinocyte apoptosis and formation of colloid bodies. The close interaction between lymphocytes and basement membrane leeds to release of certain metalloproteinases produced by lymphocytes to alter extracellular ma- trix proteins, and the process eventuates in basement membrane disruption, apoptosis, and subepidermal clef formation. This positive lymphocytotoxicity is probably generated by sensitized efector lymphocytes via specifc recognition of foreign antigenic structures on syngeneic oral target cells (Simon jr et al. A network of fne white lines or puncta referred to as Wickham striae is present in many well-developed papules (Fig. Nail changes include longitudinal ridging and splitting of the nail plate, onycholysis, ptery- gium formation, or complete loss of the nail plate. Mucous membranes are in more than half of the patients additional sites of involvement. The linear pattern may develop secondary to trauma in zosteriform or segmental arrange- ment or even in the site of healed herpes zoster. Annular lesions are common on the penis and scrotum but may occur on the trunk or extremities. The bullae, which appear mostly on the extremities with mild constitu- tional symptoms, usually resolve in a few month. The le- sions on the feet tend not to heal but have a defnite risk of development of a squamous cell carcinoma in the chronic ulcerations. The lesions are ofen symmetric, sometimes show accentuated, elevated follicle swellings and chalky hyperkeratoses. Tese lesions can coalesce and form larger plaques most com- monly on the trunk or lower extremities. Sites of predilection in- clude the trunk, neck, sacral region, and the proximal extremities. Perifollicular er- ythema and acuminate keratotic plugs are characteristic features. The extremely pruritic papular lesions are hyperpigmented with violaceous-brown color, which frequently show annular confguration. As the sole man- ifestation of the disease, it makes up 15% to 35% of the patient populace. The buccal mu- cosa (bilateral) and the tongue are most ofen afected but the gums, foor of the mouth, palate, and lips have also been documented.

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Patients should also have assessment of oxygenation by pulse oximetry or arterial blood gas measurement within 8 hours of admission buy azathioprine 50 mg without prescription spasms after stent removal. There should also be a docu- mented infiltrate on chest x-ray or other imaging study in all patients except those with decreased immune function that might not be able to mount an inflammatory response (A-I) azathioprine 50mg on line muscle relaxant jaw clenching. Smoking is the biggest risk factor for pneumococcal bacteremia in immunocompetent cheap 50 mg azathioprine with amex muscle relaxant walmart, non- elderly adults. Prevention Influenza All persons older than the age of 50 years or younger patients with risk factors for pneumonia should receive a yearly inactivated influenza vaccine each fall (strong rec- ommendation, level I evidence). The live, attenuated vaccine should not be used in those with asthma or immunodeficiency. The influenza vaccine should be offered to at-risk patients on hospital discharge, or outpatient encounters in the late fall or early winter. High-risk patients include patients with diabetes, cardiovascular disease, lung disease, 14 J. Patients should receive a repeat vaccination in 5 years if they received their first dose younger than 65 years of age. American Thoracic Society Guidelines for the Management of Community Acquired Pneumonia. Although a broad variety of differential diagnoses must be considered, ranging from infectious or inflammatory etiology to traumatic or neoplastic processes, the vast majority of these symptoms derive from either a viral or bacterial source. The physician must narrow the differential, decide which clinical and laboratory data may be helpful, select the most appropriate management plan for the patients symptoms and disease process, and prevent further complications. Reportedly, 50 to 75% of all cases of pharyngitis are currently treated with antibiotic therapy, approximately 40% of which use broad-spectrum antibiotics or antibiotics that are not indicated. Wilson Pathophysiology Pharyngitis is an inflammation of the pharynx that can lead to a sore throat. Etiologic agents are passed through person-to-person contact, most likely via droplets of nasal secretions or saliva. Symptoms often manifest after an incubation period ranging from 1 to 5 days, and occur most commonly in the winter or early spring. Outbreaks of pharyngitis may occur in households or classrooms, and, infrequently, may be linked to food or animal sources. These bacteria possess protein M, a potent virulence factor that inhibits bacterial phagocytosis, as well as a hyaluronic acid capsule that enhances its ability to invade tissues. Cocci may be detected on cultures (grown on blood agar), latex agglutination tests, or rapid tests using labeled monoclonal antibodies. The viruses and other nonstreptococcal bacteria that also can cause pharyngitis are discussed in greater detail below, in the Differential Diagnosis section. If the patient meets two, three, or four of the criteria, a diagnostic laboratory test is indicated. Some physicians will begin antibiotic therapy presumptively for patients with severe symptoms who meet three or four of the Centor criteria, and may not send a diagnostic test in addition to testing. Ultimately, the usefulness of clinical prediction rules depends on the prevalence of disease in a given community. The gold standard of pharyngitis testing remains the throat culture, collected by swabbing the pharynx and peritonsillar region, and growing the sample on a sheeps blood agar plate. Under ideal circumstances, and often using two samples, the sen- sitivity and specificity of such cultures reaches 97% and 99%, respectively. Serology may be collected for presence or absence of streptococcal antibody titers, but this information will not influence the immediate treatment of the patients pharyngitis symptoms. This information is necessary to support a diagnosis of rheumatic fever, but treatment for pharyngitis needs to begin before the return of serology laboratory results. Differential Diagnosis The differential diagnosis for sore throat symptoms is extensive. The patients clinical history and physical examination findings can help distinguish among the several viral, bacterial, and other causes of pharyngitis. Arcanobacterium haemolyticum, formerly known as Corynebacterium haemolyticum, is seen more frequently in teenagers and young adults, and may be accompanied by a scarlatiniform rash. Reported cases of Corynebacterium diphtheriae are very rare because of childhood vaccinations, but patients with this variety of pharyngitis will frequently complain of hoarseness and stridor caused by circulation of the diph- theria exotoxin, and may also experience cervical adenitis and edema. The defining characteristic of this bacteria is the development of a firmly adherent, gray, inflam- matory pseudomembrane across the oropharynx. In addition to the more common viral and bacterial causes of pharyngitis, a number of other causes of sore throat exist. Trauma or throat strain caused by overuse (shouting, for example) should be elicited via the patients history of symptom onset. An abscess would likely cause higher fevers, more discomfort, and persistent symptoms despite typical first-line antibiotic treatment. Airway compromise, hoarseness, or neck swelling may accompany abscesses depending on their location. Wilson For the vast majority of pharyngitis cases, supportive therapy purely for symptom control is the most appropriate strategy. Supportive therapy for pharyngitis includes appropriately dosed analgesic and antipyretic medicines, proper oral hydration, and rest. Acetaminophen or ibuprofen are indicated for all ages for both pain and fever control, whereas aspirin should be avoided in the pediatric population because it can increase the risk of injury to hepatic and renal structures (Reyes Syndrome). Over-the-counter lozenges, sore throat drops, and throat sprays are also available to keep the affected area moisturized or anesthetized. Penicillin-allergic patients should be treated with eryth- romycin or a first-generation cephalosporin. Complications For patients with acute pharyngitis, complications can develop when a bacterial source of infection is not managed properly. Nonsuppurative complications are reflective of streptococcal toxins, streptolysins, and inflammatory processes involving antibodies targeted at the bacteria. Peritonsillar and retropharyngeal abscesses form in <1% of patients complain- ing of sore throat who are treated with antibiotics. Erythromycin stearate Children: 3050 mg/kg/day orally divided three to four times daily for 10 days Adults: 250500 mg orally three to four times daily for 10 days 4. Erythromycin ethyl succinate Children: 3050 mg/kg/day orally divided three to four times daily for 10 days Adults: 400 mg orally four times daily for 10 days 5. Cephalexin Children: 2550 mg/kg/day orally divided twice daily for 1014 days (maximum, 4 g/day) Adults: 500 mg orally twice daily for 1014 days 6. Cefadroxil Children: 30 mg/kg/day orally divided twice daily for 10 days (maximum, 2 g/day) Adults: 12 g orally divided once or twice daily for 10 days 7. Amoxicillin Children >3 months: 2545 mg/kg/day orally divided twice daily or 2040 mg/kg/day orally divided three times daily for 10 days Adults: 500875 mg orally twice daily for 10 days Dosing strategies, recurrent infection or treatment failure 1. Clindamycin Children: 2030 mg/kg/day orally divided three times daily for 10 days (maximum, 1. Amoxicillinclavulanic acid Children >3 months old, but < 40 kg: 2545 mg/kg/day orally divided twice daily or 20 40 mg/kg/day divided three times daily for 10 days Children > 40 kg: dosing similar to adults Adults: 500875 mg orally twice daily for 10 days 3. Penicillin G Dosing identical to initial treatment options even less, but patients do not always present for evaluation until complications have begun.