(3L\T0XA@ S

MID-ATLANTICOutstanding opportunity! Seeking dynamic Pediatrician to direct clinical activities of newfreestanding Pediatric After Hours Urgent Care Center in South Jersey area. FT, 40hour/week. Requires leadership, excellent interpersonal skills and desire to grow a newservice. Must have current NJ license, BC/BE. PALS certification desired. Additional PT/moonlighting positions also available to staff center. Excellent salary, comprehensive ben-efits, malpractice insurance, flexible scheduling and no on-call! Fax CV with cover letterto: Director of Clinical Services, (856) 988-0367, or mail to P.O. Box 1707, Voorhees, NJ08043.

SOUTHEASTFlorida Keys - Pediatrician sought. Highly Competitive Base Salary and benefits package.Practice in Paradise 365 days a year. For information on other positions in the state of

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I thfroug Innovation

Mayo Foundation is an afl7rmnative action and equal opportunity educator and employer.

Child Abuse PediaicianFT Faculty - Pediatrics Child Protecton TeamThe University of Miami Child Protection Team is seekinga BC/BE pediatrician and full-time faculty to be part ofa multidisciplinary team charged with assessing forensicchild abuse treatment. Salary commensurate withexperience. Candidates must have or be eligible for aFlorida Medical License.Please send CV to: Walter F. UIEITYOFLambert, IU.D., University of X IMiami, CPT, 1150 NIW 14 Street, l lSuite 21:2, Miami, Florida 33136._Tel: (305) 243-7550; E-mall: SHO FMDCNwiambert*med.miami.edu; COLOFMDCNor Fax: (305) 243-7548. VWW^.Miami.edu/jobs

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42 AAP News www.aapnews.org July 2002

MAYO CLINIC

CHILD ABUSE PROGRAM DIRECTORMayo Clinic

Mayo Medical SchoolRochester, Minnesota

The Mayo Clinic seeks a physician Director for our Child Abuse Program. The Director wouldcoordinate other physicians, psychologists, and nurse practitioners on the Child Abuse/NeglectAdvisory Team. The well-established program has an experienced LICSW serving as the ChildAbuse Coordinator with whom the Director will work. Clinical and educational opportunitiesexist with Mayo's Pediatric, Family Medicine, Psychiatry, Psychology, and Emergency Medicinefaculty and residents, as well as with Mayo Medical School students and allied health staff. Thecandidate will represent Mayo in child abuse/neglect related matters on a regional, state, andnational level.

Mayo Clinic provides excellent career opportunities through our large outpatient clinical practice;the comprehensive Mayo Eugenio Litta Children's Hospital, and our commitment to educationand research. Mayo Clinic offers the advantages of a renowned medical center with a successfulintegrated group practice in a very attractive Midwestern locale with a population of 125, 000.

The position would be divided between the Child Abuse Program and clinical work in theprimary specialty area in which the candidate is trained. Candidates may come from one of thefollowing clinical disciplines: Pediatrics, Psychiatry, Family Medicine, Behavior/Development,or Emergency Medicine.

Qualified individuals should forward their curriculum vitae and letters of interest to the chair ofthe search committee:

Jay L. Hoecker, M.D.Interim-Director, Mayo Child Abuse Program and Search Committee Chair

Mayo Clinic200 First Street, SW

Rochester, MN 55905

(507) 284-5247(Fax: 507-284-9744)

The WVIRELESSalarmn that wakes

the BEDW"ETTER...not the whole house!

k,f I Lj*A iO [:_> A_>; , I lU ~LD )

ZITHROMAX°{azithromycin for oral suspension)

BRIEF SUMMARYINDICATIONS AND USAGE

ZITHROMAXI (azithromycin) is indicated for the treatment of paients vvth mild to moderate infections (pneumonia:see WARNINGS) caused by susceptible strains of the desigae microorganisms in the specific conditions listedbelowv. As recommended doae.drton ftea.an plcbeptient --pultions vary among these infec-tions. please see DOSAGEAND AMINISTAION for spcfcdsng recommendations.

Acute otitis media caused by Haemophilus influenzae, Moraxella catarthalis, or Streptococcuspneumoniae.(For specific dosage recommendation, see DOSAGEAND ADMINISTRATION.)

Community-acquired pneumonia due to Chlamydiapneumoniae, Haemophilus infiuenzae, Mycoplasmapneumoniae, or Streptococcuspneumoniaie in patients appropriate for oral therapy (For specific dosage recom-mendation, see DOSAGE AND ADMINISTRATION.)

NOTE: Azithromycin should not be used in peifiatriic paeients with pneumonia who are judged to bei ate for oral therapy because of moderate to severe illness or risk hetors such as

an fteflwn:patients with cysticfibrosis, patients with nosocomially acquired infec-tion,ptiens wth kownor suspected bacteremia,rptents requiring hospitalization, orpatens ilhsiniicnt mderlying healthprolemis fat mavcompromise their ability to

respon toIerIlns(including immunodeficiency or functional asplenia).PharyngitisSonsillitis caue by Streptococcuspygenesas an altemative to first-line therapv in

individuais who cannot use firstln therapy. (For specific dosage recommendation, see DOSAGE'AND ADMINIS-TRATION.)

NOTE: PenicillinIb the intramuscular routeJ is the usual drug of choice in the treatment of Streptococcuspogenes infectio-n-the prophylaxis of rheurmatic fever. ZITHROMAX" is often effective in the eradication of suscep-tible strains of Streptococcuspyoenesfrom the nasopharynx. Because some strains are resistantto ZITHROMAXI,susceptibility tests should be performed when patients are treated with ZITHROMAX". Data establishing efficacy ofazithromycin in subsequent prevention of rheumatic fever are not available.

Appropriate culture and susceptibility tests should be performed before treatment to determine the causativeorganism andJ its susceptibility to azithromycin~. Therapy vvith ZITHROMAXI may be initiated before results of thesetests are known; once the results become available, antimicrobial therapy should be adjusted accordingly.

CONTRIWNDICATIONSZITHROMAXI is contraindicated in patients with knowfn hypersensitivity to azithromycin, erythromycin oranymacrolide antibiotic.

WARNINGSSerious allergic reactions, including angioedema, anaphyiaxis, and dermatologic reactions including StevensJohnonSndrme ad toic pidermal necrolysis have been reported rarely in patients on azithromycin therapy.Altougrae, atlites aveben reported. (See CONTRAINDICATIONS.) Despite initially successful sympto-matcteamen o th alericsymptoms, vvhen symptomatic therapy was discontinued, the allergic symptomsrecrrdsonth0eaterinsome patients wihoutfurther azthrmmycinexposure. These patients required

prolonged periods of observation and symptomatic treatment. The relationship of these episodes to the long tissuealf-iffe of azithromycin and subsequent prolonged exposure to antigen is unknowvn at present.

If an allergic reaction occurs, the drug should be discontinued ancd appropriate therapy should be instituted.Physicians snould be awvare that reappearance of the allergic symptoms may occur when symptomatic therapy isdiscontinued.

In the _vuet of pneumonia, azithromycin has only been shown to be safe and effective in thetreabn0n of commnwniy-acquired pneumonia due to CW-mydiapnoumnwMi Haeoph9usin*^waMt1oplasm2 p,aeumonsm, or Sctpoccus _ nptesaprriefooalhrpyAzRhmmycin should not be used In p iatetwihpemnahoreuddtob aporat fororal therpy because of moderate to seeeilnsorik factors sc sayo h oom:ptetwith cysticfibrosis, patients with nosocomially.acuied infections,painswl known orsupcebacteremia,peat reqluiring hospiaizto, eldrl or deiiatdpte nsorpt s vwihhsgiicant underlying health problems thtmaycomprms hi blt orsodt hi illness {nldnimmunodeficienc or fuinction al asplenia).

Pseudomembora-nouscolitis has been reported withnnedyall antibacteial agents ad may range insevritfom ildtolif-treatening. Therefre, it is important to considertis diagnosis in patientswhoresntwth iarheasubsequenttothe administration of antibacterial agents.Treamentwithantiacteia agents alters the normal flora of the colon and may permit overgrowth of clostridia.

Studies indicate that a toxin produced by Clostridium difficile is a primary cause of "antibiotic-associated colitis."After the diagnosis of pseudomembranous colifis has been established, therapeutic measures should be initi-

ated. Mild cases of pseuaomembranous colitis usually respond to discontinuation of the drug alone.In moderate to severe cases, consideration should be given to management vvth fluids and electrolytes, protein sup-plementation, and treatment-with an antibacterial druiuclinicallyeffective against Clostridium difficilecolitis.

PRECUIIOIJSGeneral: Because azithromycin is pnincipally eliminated via the liver, caution should be exercised when azithromycinis administered to patients with impzaired hepatic function.

There are no data regardling azithromycin usage in patients with renal impairment, thus, caution should be exer-cised when prescribing azitlhromycin in tnese patients.

The fbllowving adverse eventshave been reported vvth macrolide products: ventricular arrhythmias, includingventricular tachycardia and torsades de pointes, in individuals vvith proloriged O]T intervals.

There has been a spontaneous report trom the post-marketing experience of a patient with previous historv ofarrhythmias wvho experienced torsades de pointes and subsequent myocardial infarction fbllovwng a course ofazithromycin therapyInformation for Paotiet: Zithromaxe oral suspension can be taken vvith or vvthout food.

Patients should also be cautioned not to take aluminum- and magnesium-containing antacids and azithromycinsimultaneously.

The patient should be directed to discontinue azithromycin immediately and contact a physician if any signs of anallergic reaction occur.Drug iadAduminum- and magnesium-contining antacids reduce the peak serum concetrations (rate) but nottheAUC (extent of azithrormyain absor in.

Administration of cimotdine (800 mg) two hours prior to azithromycin had no effect on azithromycin absorption.Azithromycin did not affect the plasma concentrations or pharmacokinetics of theophylline administered as a sin-

gle intravenous dose. The effect of azithromyc'in on the plasma concentrations or pharmacokinetics of theophyllineadministered in muftiple doses resulting in therapeutic steady-state concentrations of theophylline is not knowvn.However, concurrent use of macrolides and theopnylline has been associated Wvth increases in the serum concen-trations of theophylline.Therefore, until further data are available, prudent medical practice dictates careful monitor-ing of plasma theophylline concentrations in patients receiving azithromycin andi theophylline concomitantly.

Azithromycin diu not affect the prothrombin time response to a single aose of warfarin. Howvever, prudent med-ical practice dictates careful monitoring of prothrombin time in all patients treated with azithromycin and warfarinconcomitantly. Concurrent use of macrolides and warfarin in clinical practice has been associatea with increasedanticoagulant effects.

The fbIolovvng druQ interactions have not been reported in clinical trials with azithromycin; howvever, no specificdrug interaction studies have been performed to evaluate potential dnug-drug interaction. Nonetheless, they navebeen observed with macrollide products. Until further data are developed regarding drug interactions whenazithoyi n hs rg r used concomitantly, careful monitoring of patients is advised:

Digoineevatd dioxinconcntrations.Ergoaminordihyroerotaine-acute ergot toxicity characterized by severe peripheral vasospasm and dyses-

Triazolam-decrease the clearance of triazolam and thus may increase the pharmacologic effect of triazolam.Drugs metabolized by the cytDchrome P450 system-elevations of serum carbamazepine,terfenadine,cydlosp(xine,hexcolarbital, and pherytoin concentrations.LbrtrTest Interactions; There are no reported laboratory test interactions.

Crchiiogenesiis, Mutagenesis, Impairment of Fertility long-term studies in animals have not been performedtoevaluate carcinogenic ptential. Azithromycin has shown no mutagenic potential in standard laboratory tests:mousIymhom assy, uman lymphocyte ciastogenic assay, and mouse Done marrow clastogenic assay.No evi-deneoimaird frtiitydueto azithromycin was tound.PregancTeatoeni Efect. Pegnncy Category B: Reproduction studies have been performed in rats and

miceatdsesp t modratey maemaly toxicgdose concentrations (i.e., 200 mgAkg/day). These doses, based

Permanente, P.C., 500 NE Multnomah, Ste.,100, Portland, OR 97232-2099, phone: (800)813-3763; E-mail: Judy.A.Parmenter?kp.org.Visit our Web site at www.kp.org/nw. EOE

Pediatrics for the Practitioner-Big Island ofHawaii, Oct. 14-17, 2002. Sponsored by SaintLuke's Hospital and The Children's MercyHospital of Kansas City. Call (816) 932-2220or send e-mail to cmeOsaint-lukes.org formore information.

on a mg/ml basis, are estimated to be 4 and 2 times, respectively, the human daily dose of 500 mg. In the animalstudies, no evidence of harm to the fetus due to azithromycin vwas found. There are, however, no adequate and well-controlled studies in pregnant women. Because animal reproduction studies are not always predictive of humanrespnseazthrmyci shuldbe sedduring pregnancy only if clearly needed.

NuringMotersIt s nt kovv vvethr aithomyin s excreted In human milk. Because many drugs areexceteinhumn mlk,cauionshould beeecsdwe ztrmcnis administered to a nursing woman.

Pediatric Use: (See INDICATIONS AND USAGEAND DSGAD ADMINISTRlATION.)Acute Otitis Media (total dosage regimen: 30mg/kg, see DOSAGEAND ADMINISTRtATION): Safety and

effectiveness in the treatment of children with otitis media under 6 months of age have not been established.Community-Acquired Pneumonia (dosage regimen: 10 mg/kg on Day 1 followed by 5 mg/kg on Days 2-5):

Safety and effectiveness in the treatment of children with community-acquired pneumonia under 6 months ofaqe have not been established. Safety and effectiveness for pneumonia duie to ChlamydiapneumoniaeandmRycoplasmapneumoniaewere documented in pediatric clinical trials. Safety and effectiveness for pneumoniadue to Haemophilus influenzaeand Streptococcuspneumoniaewere not documented bacteriologically in thepediatric clinical trial due to difficulty in obtaining specimens. Use of azithromycin for these twvo microorganismsIs supported, however, by evidence from adequate andwell-controlled studies in adults.

Phayngti/Tosilits dosgeregimen: 12mmkg onDaysl1-5): Safety and effectiveness in the treatrnent of chil-dre vt hrnii/oslii under 2 years ofage have not been established.

Studesvalutin theuseof repeated courses of theazhave not been conducted.Genaric se:Pharacoinetc paameers n oder olute7ers(585 vyears old) were similar to those in younger

volunteers (18-40 years old) fo h -a hrpui eie.Dsg dustment does not appear to be necessaryfor older patients with norma rea n eai ucin eevn ramn vth this dosage regimen.

In clinical trials, most of the reported side effects were mild to moderate in severity and were reversible upon dis-continuation of the drua~. Potentially serious side effects of angioedema and cholestatic jaundice were reportedrarelv Anoroximately 0.7% of the patients (adults and children)i from the 5-day multiple-dose clinical trials aiscontin-ued ZITHROMAX" (azithromycin) therapy because of treatmnent-related side effects. In clinical trials in childreniCven30 mg/kg, either as a single aose or over 3 days, discontinuation from the trials due to treatment-related side effcswas approxirnately 1%. (See DOSAGE AND ADMINISTRATION.) Most of the side effects leading to discontinua-tion were related to the gastrointestinal tract, e.g., nausea, vomiting, diarrhea, or abdominal pain.Clinical:Children: Single andMultiple-dose regimens The types of side effects in children were comparable to those seenin adults, with different incidence rates for the dosage regimens recommended in childrer.Acute Otitis Media: Forthe recomnmended total dosage regimen of 30 mg/kq,the mostfrequentside effects(YI1%)attributed to treatment were diarrhea, abdomirnal pain, vomiting, nausea and rash. (See DOSAGEAND ADMINIS-TRATION.)The incidence, based on dosing regimen, is described in the table below.

Dosage Diarrhea, % Abdominal Vomiting,% Nausea, % Rash, %Regimen Pain, %1-day 43% 1A% 49YO 1.0% 1.0%3-day 2.6% 1.7% 2.3% 0.4% 0.6%5-day 1.8% 1.2% 1.1% 0.5% 0.4%

Communitv-Acquired Pneumonia: For the recommended dosage regimen of 10 mg/kg on Day 1 followed by 5 mg/kgonays2-5th mot fequntside effects attributed to treatment were diarrhea/loose stools (5.8%), abdominalpai,vmitng,andnauea 1.% each), and rash 01.6%).

Phayniti/tnsiliis:Fo te recommended dosage regimen of 12 mg/kg on Days 1-5, the most frequentrshd RNfct attibtdhead rach e n01V. ere diarrhea (5.4%/), vomiting (5.6°%), abdominal pain 13.4%), nausea (2%),

With anv of the treatment regimens, no other treatment-related side effects occurred in children treated withZITHROM vwith afrequency greater thanl1%. Side effects that occurred vvth afrequency ofl1%or less includedthe fbIlowing:Cardiov'ascular Chest pain.Gastrointestinal: Dyspepsia, constipation, anorexia, enteritis, flatulence, gastritis, jaundice, loose stools and oralmoniliasis.

Heaoii adLmhatic: Anemia and leukopenia.Nervous SsmHedche (otitis media dosage), hyperkinesia, di7iness, agitation, nervousness and insomnia.General: Fvr, faeedema, fatiHque, fungal infection, maiaise and pain.Allergic: Rash and allergic reaction.

Repiatry- Cough increased, pharyngitis, pleural effusion and rhinitis.Sknand Appenaages: Eczema, fungal dermatitis, pruritus, sweating, urticaria and vesiculobullous rash.

Special Senses: Conjunctivitis.Post-Marktng Experience: Adverse events reported vvth azithromycin during the post-marketing period inadult and/or pediatric patients for which a causal reiationship may not be establisned include:Alergpic: Arthralgia, edema, urticaria and angioedema.

Ca diovacubar Arrhythmias including ventricular tachycardia and hypotension.Gastontestinal: Anorexia, constipation, dyspepsia! flatulence, vomiting/diarrhea rarely resulting in dehydration,pseudomembranous colitis, pancreatitis, or-arcandidiasis and rare reports of tongue discoloration.General: Asthenia, paresthesia, fatigue, malaise and anaphylaxis (rarely fatal).Genitoufinary Interstitial nephritis and acute renal failure and vaginitis.HmtoiTkcThobctpna.LvrBlayAnrmallvrfntoicudgheats and cholestatic jaundice, as vvell as rare cases of hepatic

necroi n eai failure, some ofwihhv eutdin death.Nerou Syb:Cnvulsions, dizziness/vertigo, headache, somnolence, hyperactivity, nervousness, agitation and

PyharcAggressive reaction and anxiety.ib/pedages: Pruritus, rarely serious skin reactions including erythema multiforme, Stevens-Johnson syn-drmadtxic epidermal necrolysis.

Special Senses: Hearing disturbances including hearing loss, deafness and/or tinnitus and rare reports of tasteperversion.Laboratory AbnormalWdes:Children:One,'Three and hwe Day RegimensLaboratory data collected from comparative clinical trials employing twvo 3-day regimens (30 mg/kg or 60 mg/kg individed doses over 3 days), or twvo b-aay regimens (30 m /g or 60 mg/kg in divided doses over 5 days) were simi-lar for regimens of azithromycin and all comparators combwined, with most clinically significant laboratory abnor-malities occurring at incidences of 1-5%. Laboratorydata for patients receiving 30 mg/kg as a single dose werecollected in one single center trial. In that trial, an absolute neutrophil count between 5001M500 ceCsmml wasobserved in 10/64 patients receiving 30 mg/kg as a single dose, 9/62 patients receiving 30 mg/kq aiven over 3days, and 8/63 comparator patients. No patient had an absolute neutrophil count <500 cells/mm .?See DOSAGEANDADMINISTRATION)In multiple-dose clinical trials involving approximtl 4700 pediatric patients, no patients discontinued therapybecause of treatrnent-related laboratory abnormalites.

DOSAGEANDADMINISTRATION (See INDICATilONSAND USAGE)ZithromaxO for oral suspension can be taken vvth or vmthout food.Acute Oddts Media: the recommended dose of ZITHROMAX" for oral suspension for the treatment of childrenvvth acute otitis media is 30 mg/kg given as a single dose or 10 mg/kig once daily for 3 days or 10 mg/kg as a singledose on the first day followved by 5 mg/kg/day on Days 2 through 5. The safety of re-dosing azithromycin in childrenwvho vomit after receiving 30 mg/kg as a singale dose nas not been established. In clinical studies involvin 487patients vvth acute obitis media given a single 30 mg/g dose of azithromycin, eight patients vvho vomite vvthin 30minutes of dosing were re-dosed at the same total, dose.Community-Acquired Pnwmownia:The recommended dose of ZITHROMA)(° for oral suspension forthe treatmentof children vvth community-acquired pneumonia is 10 mg/kg as a single dose on the first day followed by 5 mg/kg on

Pharynis/2Though litis The recommended dose of ZITHROMAX" for children vvth pharyngitis/tonsillitis is12m/gonce daily for 5 days.

Forrnore detalledprouctinfbmationplease referto the fullprescribinginformnation orcall 18W793477.Rev.9 January 2002

17th Annual San Diego Conference on Childand Family Maltreatment, Feb. 3-7, 2003.Chadwick Center for Children and Families,Children's Hospital-San Diego. Develop andenhance skills in the prevention, investigation,diagnosis, treatment, prosecution of family vio-lence. Research-based, best practiceapproaches. Multidisciplinary, internationalaudience. Up to 32 CEUs have been requested.Web site at www.chsd.org/chadwickcenter.Contact: sdconferenceQ?chsd.org or faxname/address to (858) 966-8018 for brochure.

Florida, or nationwide, call Craig West, toll-free (877) 633-1500, ext. 100; or fax to (954)827-0585; e-mail to docheadhunterQ?aol.com.

Primary Care Physicians -The TennesseeDepartment of Health, is sponsoring the 13thAnnual Medical Recruitment Fair on Sept. 19-20, at Cool Springs Conference Center inFranklin, TN. Representatives from communi-ties across Tennessee will be in attendance todiscuss practice opportunities for family prac-tice and preventive medicine, physicians,internists, obstetricians, and pediatricians.Certain expenses associated with RecruitmentFair Attendance will be reimbursed for a lim-ited number of primary care physicians.Practice incentive grants are available to eligi-ble primary care physicians for loan repay-ment and practice start-up costs. For additionalinformation, contact the Office of HealthAccess at (615) 741-0417 or e-mail toJeannette.JacksonEstate .tn us.

Dynamic pediatric group of 4 physicians seeksrecently trained pediatrician to join our active,well-established 1 6-year-old practice. Office islocated in Orlando, Fla., with year-round recre-ational climate. Enjoy excellent reputation inarea and opportunity for immediate summeror fall employment if desired. Excellent salary,malpractice insurance, benefits package andafter- hours nurse -triage service. Bi-Lingual aplus. Submit cover letter and resume to (407)354-5436.

NORTHWESTNeonatologist-Portland,Oregon. NorthwestPermanente, P.C. has an excellent opportun'ityfor a BC/BE Neonatologists in a stimulatingprofessional environment with one of the mostsuccessful and highly-rated quality healthplans in the country; and to enjoy a lifestyleinherent to the beautiful Pacific Northwest!Our physician-managed multispecialty group,which provides care for over 445,000 mem-bers of Kaiser Permanente, has a full-timeposition available for a BC/BE Neonatologist ata state-of-the-art level 3 NICU in. one of ouraffiliated medical centers in suburban Portland.

Duties involve covering level 3 and 2 new-borns in an expanding 30-bed unit, some careof well newborns, as well as co'ordinating new-born services as part of our Department ofPediatrics in the greater Portla-nd area. Callwill be shared with our two Neonatologists.We offer our physicians a competitive salaryand benefits package, which includes a gen-erous retirement program, professional liabil-ity coverage, sabbatical leave and more. Forinformation regarding these exciting opportu-nities, please forward CV to: A.P. Clark,Director, Professional Resources, Northwest

Augmerntin lamoxicillin/clavulanate patassium} is a registered trademark of GbaxoSmithKline.Referenco:1. Data on file. Plfizer Inc., NewYork, W.Z Block SLArrieta A, Seibel M, McLinn S, Eppes SC. Single dose azithmmycin 130 mg/kg) in acute otitis media. Paper presented at Infectious Diseases Society afAmefica 38tAnnual Meeling; September 7-10, 2000, New Orleans, La.Abstractl174.

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July2002 www.aapnews.org AAPNews 43

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