>AIDS (Acquired immuno deficiency syndrome)

AIDS Introduction

AIDS stands for: Acquired Immune Deficiency Syndrome

AIDS is a medical condition. A person is diagnosed with AIDS when their immune system is too weak to fight off infections.
Since AIDS was first identified in the early 1980s, an unprecedented number of people have been affected by the global AIDS epidemic. Today, there are an estimated 33.4 million people living with HIV and AIDS and each year around two million people die from AIDS related illnesses.

Causes of AIDS:

AIDS is caused by HIV.

HIV and Immune cells

HIV is a virus that gradually attacks immune system cells. As HIV progressively damages these cells, the body becomes more vulnerable to infections, which it will have difficulty in fighting off.  It is at the point of very advanced HIV infection that a person is said to have AIDS. It can be years before HIV has damaged the immune system enough for AIDS to develop.

Symptoms of AIDS:

A person is diagnosed with AIDS when they have developed an AIDS related condition or symptom, called an opportunistic infection, or an AIDS related cancer. The infections are called ‘opportunistic’ because they take advantage of the opportunity offered by a weakened immune system.
It is possible for someone to be diagnosed with AIDS even if they have not developed an opportunistic infection. AIDS can be diagnosed when the number of immune system cells (CD4 cells) in the blood of an HIV positive person drops below a certain level.

Is there a cure for AIDS?

Worryingly, many people think there is a 'cure' for AIDS - which makes them feel safer, and perhaps take risks that they otherwise wouldn’t. However, there is still no cure for AIDS. The only way to stay safe is to be aware of how HIV is transmitted and how to prevent HIV infection.

How many people have died from AIDS?

Since the first cases of AIDS were identified in 1981, more than 25 million people have died from AIDS. An estimated two million people died as a result of AIDS in 2008 alone.
Although there is no cure for AIDS, HIV infection can be prevented, and those living with HIV can take antiretroviral drugs to delay the onset of AIDS. However, in many countries across the world access to prevention and treatment services is limited. Global leaders have pledged to work towards universal access to HIV prevention and care, so that millions of deaths can be averted.

Treatment of AIDS:

 
A community health worker gives an HIV positive patient antiretroviral drugs, Kenya 

Antiretroviral treatment can prolong the time between HIV infection and the onset of AIDS. Modern combination therapy is highly effective and someone with HIV who is taking treatment could live for the rest of their life without developing AIDS.
An AIDS diagnosis does not necessarily equate to a death sentence. Many people can still benefit from starting antiretroviral therapy even once they have developed an AIDS defining illness. Better treatment and prevention for opportunistic infections have also helped to improve the quality and length of life for those diagnosed with AIDS.
Treating some opportunistic infections is easier than others. Infections such as herpes zoster and candidiasis of the mouth, throat or vagina, can be managed effectively in most environments. On the other hand, more complex infections such as toxoplasmosis, need advanced medical equipment and infrastructure, which are lacking in many resource-poor areas.
It is also important that treatment is provided for AIDS related pain, which is experienced by almost all people in the very advanced stages of HIV infection.

Why do people still develop AIDS today?

Even though antiretroviral treatment can prevent the onset of AIDS in a person living with HIV, many people are still diagnosed with AIDS today. There are four main reasons for this:

• In many resource-poor countries antiretroviral treatment is not widely available. Even in wealthier countries, such as America, many individuals are not covered by health insurance and cannot afford treatment. 
• Some people who became infected with HIV in the early years of the epidemic before combination therapy was available, have subsequently developed drug resistance and therefore have limited treatment options.
• Many people are never tested for HIV and only become aware they are infected with the virus once they have developed an AIDS related illness. These people are at a higher risk of mortality, as they tend to respond less well to treatment at this stage.
• Sometimes people taking treatment are unable to adhere to, or tolerate the side effects of drugs.

Caring for a person with AIDS:

In the later stages of AIDS, a person will need palliative care and emotional support. In many parts of the world, friends, family and AIDS organisations provide home based care. This is particularly the case in countries with high HIV prevalence and overstretched healthcare systems.
End of life care becomes necessary when a person has reached the very final stages of AIDS. At this stage, preparing for death and open discussion about whether a person is going to die often helps in addressing concerns and ensuring final wishes are followed.

The global AIDS epidemic

Around 2.7 million people became infected with HIV in 2008. Sub-Saharan Africa has been hardest hit by the epidemic; in 2008 over two-thirds of AIDS deaths were in this region.

 

Parc de l'espoir - AIDS Memorial Park in Montreal, Canada

The epidemic has had a devastating impact on societies, economies and infrastructures. In countries most severely affected, life expectancy has been reduced by as much as 20 years. Young adults in their productive years are the most at-risk population, so many countries have faced a slow-down in economic growth and an increase in household poverty. In Asia, HIV and AIDS causes a greater loss of productivity than any other disease. An adult’s most productive years are also their most reproductive and so many of the age group who have died from AIDS have left children behind. In sub-Saharan Africa the AIDS epidemic has orphaned nearly 12 million children.
In recent years, the response to the epidemic has been intensified; in the past ten years in low- and middle-income countries there has been a 6-fold increase in spending for HIV and AIDS. The number of people on antiretroviral treatment has increased, the annual number of AIDS deaths has declined, and the global percentage of people infected with HIV has stabilised.
However, recent achievements should not lead to complacent attitudes. In all parts of the world, people living with HIV still face AIDS related stigma and discrimination, and many people still cannot access sufficient HIV treatment and care. In America and some countries of Western and Central and Eastern Europe, infection rates are rising, indicating that HIV prevention is just as important now as it ever has been. Prevention efforts that have proved to be effective need to be scaled-up and treatment targets reached. Commitments from national governments right down to the community level need to be intensified and subsequently met, so that one day the world might see an end to the global AIDS epidemic.

>HIV(Human immuno deficiency virus)

Introduction of HIV

HIV and Immune cells

HIV stands for: Human Immunodeficiency Virus

HIV is a virus. Viruses such as HIV cannot grow or reproduce on their own, they need to infect the cells of a living organism in order to replicate (make new copies of themselves). The human immune system usually finds and kills viruses fairly quickly, but HIV attacks the immune system itself – the very thing that would normally get rid of a virus.

With around 2.7 million people becoming infected with HIV in 2008, there are now an estimated 33 million people around the world who are living with HIV, including millions who have developed AIDS.

The Structure of HIV:

In this computer generated image, the large object is a human CD4+ white blood cell, and the spots on its surface and the spiky blue objects in the foreground represent HIV particles. 

HIV virus structure

Outside of a human cell, HIV exists as roughly spherical particles (sometimes called virions). The surface of each particle is studded with lots of little spikes.
An HIV particle is around 100-150 billionths of a metre in diameter. That's about the same as:

• 0.1 microns
• 4 millionths of an inch
• one twentieth of the length of an E. coli bacterium
• one seventieth of the diameter of a human CD4+ white blood cell.

Unlike most bacteria, HIV particles are much too small to be seen through an ordinary microscope. However they can be seen clearly with an electron microscope.

HIV particles surround themselves with a coat of fatty material known as the viral envelope (or membrane). Projecting from this are around 72 little spikes, which are formed from the proteins gp120 and gp41. Just below the viral envelope is a layer called the matrix, which is made from the protein p17.

The proteins gp120 and gp41 together make up the spikes that project from HIV particles, while p17 forms the matrix and p24 forms the core.

The viral core (or capsid) is usually bullet-shaped and is made from the protein p24. Inside the core are three enzymes required for HIV replication called reverse transcriptase, integrase and protease. Also held within the core is HIV's genetic material, which consists of two identical strands of RNA.

Viral class of HIV:

HIV belongs to a special class of viruses called retroviruses. Within this class, HIV is placed in the subgroup of lentiviruses. Other lentiviruses include SIV, FIV, Visna and CAEV, which cause diseases in monkeys, cats, sheep and goats. Almost all organisms, including most viruses, store their genetic material on long strands of DNA. Retroviruses are the exception because their genes are composed of RNA (Ribonucleic Acid).

RNA has a very similar structure to DNA. However, small differences between the two molecules mean that HIV's replication process is a bit more complicated than that of most other viruses.

Number of genes of HIV:

HIV has just nine genes (compared to more than 500 genes in a bacterium, and around 20,000-25,000 in a human). Three of the HIV genes, called gag, pol and env, contain information needed to make structural proteins for new virus particles. The other six genes, known as tat, rev, nef, vif, vpr and vpu, code for proteins that control the ability of HIV to infect a cell, produce new copies of virus, or cause disease.

At either end of each strand of RNA is a sequence called the long terminal repeat, which helps to control HIV replication.

HIV life cycle:

Entry

HIV can only replicate (make new copies of itself) inside human cells. The process typically begins when a virus particle bumps into a cell that carries on its surface a special protein called CD4. The spikes on the surface of the virus particle stick to the CD4 and allow the viral envelope to fuse with the cell membrane. The contents of the HIV particle are then released into the cell, leaving the envelope behind.

Reverse Transcription and Integration

Once inside the cell, the HIV enzyme reverse transcriptase converts the viral RNA into DNA, which is compatible with human genetic material. This DNA is transported to the cell's nucleus, where it is spliced into the human DNA by the HIV enzyme integrase. Once integrated, the HIV DNA is known as provirus.

Transcription and Translation

HIV provirus may lie dormant within a cell for a long time. But when the cell becomes activated, it treats HIV genes in much the same way as human genes. First it converts them into messenger RNA (using human enzymes). Then the messenger RNA is transported outside the nucleus, and is used as a blueprint for producing new HIV proteins and enzymes.

Assembly, Budding and Maturation

 

This electron microscope photo shows newly formed HIV particles budding from a human cell.

Among the strands of messenger RNA produced by the cell are complete copies of HIV genetic material. These gather together with newly made HIV proteins and enzymes to form new viral particles, which are then released from the cell. The enzyme protease plays a vital role at this stage of the HIV life cycle by chopping up long strands of protein into smaller pieces, which are used to construct mature viral cores.

The newly matured HIV particles are ready to infect another cell and begin the replication process all over again. In this way the virus quickly spreads through the human body. And once a person is infected, they can pass HIV on to others in their bodily fluids.

Connection between HIV and AIDS:

HIV causes AIDS by damaging the immune system cells until the immune system can no longer fight off other infections that it would usually be able to prevent.

It takes around ten years on average for someone with HIV to develop AIDS. However, this average is based on the person with HIV having a reasonable diet, and someone who is malnourished may well progress from HIV to AIDS more rapidly.

Transmission of HIV:

HIV is found in the blood and the sexual fluids of an infected person, and in the breast milk of an infected woman. HIV transmission occurs when a sufficient quantity of these fluids get into someone else's bloodstream.

There are various ways a person can become infected with HIV:

• Unprotected sexual intercourse with an infected person: Sexual intercourse without a condom carries the risk of HIV infection.
• Contact with an infected person's blood: If sufficient blood from somebody who has HIV enters someone else's body, then HIV can be passed on in the blood.
• Use of infected blood products: Many people in the past have been infected with HIV by the use of blood transfusions and blood products which were contaminated with the virus. In much of the world this is no longer a significant risk, as blood donations are routinely tested for HIV.
• Injecting drugs: HIV can be passed on when injecting equipment that has been used by an infected person is then used by someone else. In many parts of the world, often because it is illegal to possess them, injecting equipment or works are shared.
• From mother to child: HIV can be transmitted from an infected woman to her baby during pregnancy, delivery and breastfeeding.

Certain groups of people, such as injecting drug users, sex workers, prisoners, and men who have sex with men have been particularly affected by HIV. However, HIV can infect anybody, and everyone needs to know how they can and can’t become infected with HIV.

HIV symptoms:

Some people experience a flu-like illness, develop a rash, or get swollen glands for a brief period soon after they become infected with HIV. However, although these are hiv symptoms they are also common symptoms of other less serious illnesses, and do not necessarily mean that a person has HIV.

Often people who are infected with HIV don’t have any symptoms at all. It is important to remember that a person who has HIV can pass on the virus immediately after becoming infected, even if they feel healthy. It’s not possible to tell just by looking if someone has been infected with HIV.

The only way to know for certain if someone is infected with HIV is for them to be tested.

Testing for HIV:

 

A sign promoting HIV testing in Livingstone, Zambia 

 

It is important for a person to get an HIV test if they think they may have been at risk of HIV infection.

There are various types of HIV test, but the most commonly used - the antibody or ELISA test - detects HIV antibodies in a person’s blood. It is necessary to wait at least 3 months after the last possible exposure before having an HIV antibody test, to be certain of an accurate result.

The prospect of receiving a positive test result (meaning that a person is infected with HIV) may be daunting, but learning that you are HIV positive is the first step to getting support and staying healthy. HIV testing is also very important for stopping the spread of HIV, as somebody who is aware of their HIV status can take steps to ensure they do not pass on the virus.

Treatment of HIV:

 

An HIV positive South African woman holding her antiretroviral drugs 

 

Antiretroviral drugs keep the levels of HIV in the body at a low level, so that the immune system is able to recover and work effectively. Antiretroviral drugs enable many HIV positive people to live long and healthy lives.

Starting antiretroviral treatment for HIV infection involves commitment – drugs have to be taken every day, and for the rest of a person’s life. Adhering to HIV treatment is important, particularly because not doing so increases the risk of drug resistance. Side effects to the HIV drugs can make adherence difficult, and are sometimes very severe. There are ways of reducing the impact of these side effects, but sometimes it is necessary to change to an alternative HIV treatment regime.

There are more than 20 antiretroviral drugs approved for the treatment of HIV infection in the US and Europe, as well as many new HIV drugs currently undergoing trials. Although treatment for HIV has become more widely available in recent years, access to antiretroviral treatment is limited in some parts of the world due to a lack of funding.

Prevention of HIV:

Despite considerable investment and research, there is currently no vaccine for HIV, and microbicides (designed to prevent HIV being passed on during sex) are still undergoing trials. However, there are other ways that people can protect themselves from HIV infection, which are the basis of HIV prevention efforts around the world.

Education about HIV and how it is spread is an essential part of HIV prevention. HIV education needs to be culturally appropriate and can take place in various settings, for example lessons at school, media campaigns, or peer education.

Preventing sexual transmission of HIV

 

HIV and AIDS education for Scouts in the Central African Republic 

 

If a person has sexual intercourse with someone who has HIV they can become infected. ‘Safer sex’ refers to things that a person can do to minimise their risk of HIV infection during sexual intercourse; most importantly, using condoms consistently and correctly.

A person can be certain that they are protected against HIV infection by choosing not to have sex at all, or by only doing things that do not involve any blood or sexual fluid from one person getting into another person's body. This kind of sexual activity is the only thing that can be considered ‘safe sex’.

Effective sex education is important for providing young people with the knowledge and skills to protect themselves from sexual transmission of HIV. Comprehensive sex education should develop skills and attitudes that encourage healthy sexual relationships, as well as provide detailed information about how to practise ‘safer sex’.

Preventing transmission of HIV through blood

A person can protect him or herself against HIV infection by ensuring that HIV infected blood does not enter their body.

Injecting drug users who share injecting equipment or works are at risk of HIV infection. Needle exchange programmes can help to prevent HIV transmission among drug users by providing clean needles and disposing of used ones.

Health care workers can be exposed to HIV infected blood while at work. The most effective way to limit their risk of HIV infection is to use universal precautions with every patient, for example washing hands and wearing protective barriers (gloves, aprons, goggles). In the event that a healthcare worker is exposed to potentially HIV infected blood at work, PEP (Post exposure prophylaxis) is recommended as an HIV prevention measure.

Preventing mother to child transmission of HIV

Mother to child transmission of HIV can be prevented by using antiretroviral drugs, which reduce the chances of a child becoming infected with HIV from around 25% to less than 2%. Once a child is born, safer infant feeding practices can also greatly reduce the risk of HIV being passed on from mother to child.

For these precautions to be taken, an HIV positive mother must firstly be aware of her status. This is why HIV testing in pregnancy is a crucial prevention measure.

The full story of HIV and AIDS

HIV is only half the story…

What happens when HIV develops into AIDS? Why are approximately 2 million people dying from AIDS each year? What are the effects of the global AIDS epidemic?

Learn about AIDS and get the full story.

>Anthrax

Introduction of Anthrax

Microscopic picture of anthrax

Anthrax is described in the early literature of the Greeks, Romans, and Hindus. The fifth plague, described in the book of Genesis, may be among the earliest descriptions of anthrax.

Anthrax is caused by exposure to the spores of the bacteria Bacillus anthracis that become entrenched in the host body and produce lethal poisons. It is primarily a disease of grazing animals such as cattle, sheep, goats, and horses. Pigs are more resistant, as are dogs and cats. Birds usually are naturally resistant to anthrax. Buzzards and vultures are naturally resistant to anthrax but may transmit the spores on their talons and beaks.

The bacteria that cause anthrax are able to go into a dormant phase, in which they form spores. Spores can exist in the environment for decades. Under the right conditions, the dormant spores can germinate and multiply.

If terrorists were to use the anthrax spores, they would most likely want to disperse it into the air for mass effect. As was seen in October 2001, terrorists could also deliver anthrax by other means, such as placing spores in letters or packages to be opened and inhaled and handled by unsuspecting recipients.People of any age may be affected. Most cases are mild and go away with treatment. Anthrax, however, can be lethal. There are several ways anthrax can cause illness. These are the 3 main ways anthrax affects humans:

Cutaneous (skin) anthrax

• Cutaneous (skin) anthrax causes a characteristic sore on the skin and results from exposure to the spores after handling sick animals or contaminated animal wool, hair, hides, or bone meal products. It is an occupational hazard for veterinarians, farmers, and people who handle animal products. Where the bacteria are common, human infection remains uncommon. Humans are relatively resistant, but the spores may gain access through even tiny breaks in the skin. Cutaneous anthrax is easy to cure if it is treated early with appropriate antibiotics.
• Inhalational anthrax results from breathing anthrax spores into the lungs. People who handle animal hides infested with spores may develop inhalational anthrax, known as woolsorter's disease. Once inhaled, the organisms multiply and may spread their toxins to the bloodstream and many other organs. Infection may spread from the liver, spleen, and kidneys back into the bloodstream, thus causing an overwhelming infection and death. This type of infection (known as septicemic anthrax) most commonly follows inhalational anthrax.
  
• Gastrointestinal anthrax results from eating meat products that contain anthrax. Gastrointestinal anthrax is difficult to diagnose. It can produce sores in the mouth and throat. A person who has eaten contaminated products may feel throat pain or have difficulty swallowing. This form of anthrax has a very high death rate.

Causes of Anthrax:

Anthrax is caused by the bacteria B anthracis. These are rod-shaped germs that can change from "normal" bacteria into spores (or single-celled seeds that can reproduce the bacteria).

Skin lesion of anthrax on face.

Signs and Symptoms of Anthrax:

• Cutaneous (skin) anthrax
  • Cutaneous anthrax occurs 1-7 days (usually 2-5) after spores enter the body through breaks in the skin.
  • This form most commonly affects the exposed areas of the arms and, to a lesser extent, the head and neck.
  • The infection may spread throughout the body in up to 20% of untreated cases.
  • Cutaneous anthrax begins as a small pimplelike lesion (a sore) that enlarges in 24-48 hours to form a "malignant pustule" at the site of the infection. This sore (about 2-3 cm or about an inch) is round with a raised edge. The sore is not painful. The central area of infection is surrounded by small blisters filled with bloody or clear fluid containing many bacteria. A black scab forms at the site of the sore in 7-10 days and lasts for 7-14 days before separating. The surrounding area may be swollen and painful and may last long after the scab forms.
  • Sores that affect the neck may cause swelling that could affect breathing.
  
  
• Inhalational anthrax
  • Inhalational anthrax begins abruptly, 1-60 days (usually 1-3 days) after inhaling large amounts of anthrax spores. The size of the spores is extremely important when it comes to causing disease, and this depends upon the techniques of the person producing the spores. Spores that are too small are inhaled but then immediately exhaled and do not remain in the lungs to cause disease. Spores that are made too large do not remain suspended in the air when released and drop to the ground and are thus never inhaled in the first place. Optimal sized spores for an anthrax biological weapon measure 1-5 micrograms in diameter.
  • A person may initially have no specific respiratory or breathing symptoms but might have a low-grade fever and a nonproductive cough. An exposed person may feel chest pain early in the illness and improve temporarily before rapidly progressing to having severe breathing problems.
  • Inhalational anthrax progresses rapidly with high fever, severe shortness of breath, rapid breathing, bluish color to the skin, a great deal of sweating, vomiting blood, and chest pain that may be so severe as to seem like a heart attack.
  • Inhalational anthrax usually causes death when the poisonous toxins produced by the bacteria overwhelm the body systems.
• Intestinal anthrax
  • Swallowing spores may cause intestinal anthrax 2-5 days later.
  • People with intestinal anthrax may have nausea, vomiting (also vomit blood), tiredness, no appetite, abdominal pain, and bloody diarrhea, plus a fever.
  • Intestinal anthrax is difficult to recognize. Shock and death may occur 2-5 days after it begins.
• Oropharyngeal (mouth and throat) anthrax
  • Swallowing of spores may result in anthrax appearing in the mouth and throat 2-7 days after exposure.
  • People with this type of anthrax may have a sore throat on one side or difficulty swallowing.
  • Death may occur because the person's throat may swell and cause difficulty breathing.
• Septicemic (bloodstream) anthrax
  • Septicemic anthrax refers to an overwhelming blood infection by anthrax. This can be a complication of inhalational anthrax.
  • Internal organs may become darkly colored with widespread bleeding. The bacteria multiply in the blood and overwhelm the red blood cells. The term anthrax is derived from the Greek word for coal and was descriptive in that the lesions produced turned black.
  • Most cases of septicemic anthrax occur following inhalational anthrax. The number of organisms released from the liver or spleen into the bloodstream overwhelm the body's defenses and produce massive amounts of lethal toxin that result in shock and death.
• Anthrax meningitis
  • This type of anthrax may complicate any form of anthrax and spread throughout the central nervous system and to the brain.

Skin lesions of anthrax on neck

Home Care

There is no home care for anthrax before a doctor makes the diagnosis.

When to Seek Medical Care

Anthrax develops rapidly, so immediate medical attention is required. Go to a hospital's emergency department if you have been or think you have been exposed to spores.

Physician Diagnosis:

• The skin lesions will eventually turn black. If you have a painless ulcer (sore) that is suspected to be cutaneous anthrax, the doctor will take a small sample of the fluid and see if it grows under special conditions in the laboratory. Samples will be viewed under a microscope. The anthrax bacteria will look different than other, similar organisms. If anthrax is suspected, laboratory personnel will take special care with the sample because it is considered a biohazard. Anthrax is not contagious from person to person, however, and standard hospital practices of hygiene, known as universal precautions, will prevent spread from one person to another.
  
• If you have cutaneous anthrax and have developed a fever and other symptoms throughout your body, the doctor may test your blood for the bacteria.
  
• If the doctor thinks you may have inhalational anthrax, you will have a chest x-ray or a CT scan. Other tests may be performed, including a lumbar puncture (spinal tap). You will also be admitted to the hospital.
  
• An infectious disease specialist may be among the doctors called in.

Chest x-ray showing widened chest cavity resulting from inhalation anthrax.

Anthrax Treatment:

The preferred way to treat anthrax is with antibiotics. The goal of antibiotics is to destroy the infection and prevent complications and death.

• Many antibiotics are effective against B anthracis and include the following:
  
  
  • Doxycycline (Vibramycin)
    
  • Penicillin
    
  • Amoxicillin (Trimox, Amoxil, Biomox)
    
  • Ampicillin (Marcillin, Omnipen, Polycillin, Principen, Totacillin)
    
  • Ciprofloxacin (Cipro)
    
  • Levofloxacin (Levaquin)
    
  • Gatifloxacin (Tequin)
    
  • Chloramphenicol (Chloromycetin)
• Severely ill people may be given medications through an IV. Treatment may continue for several weeks.
  
• People exposed to anthrax may be given preventive antibiotics usually to be taken for 60 days.

Prognosis and Follow-up:

• Prognosis: If treated early, people with cutaneous anthrax recover. Those with oropharyngeal or intestinal anthrax have a less favorable outcome, and people with inhalational anthrax have the worst outcomes. About one-half of the victims of the fall 2001 anthrax attacks died.
  
• Follow-up: With cutaneous anthrax, 80% of people who are not treated will recover. If treated, they may be given medication and sent home. A permanent circular scar may remain at the site of the original lesion. For others, with inhalational, meningeal, or septicemic anthrax, hospitalization is required.

Prevention:

An anthrax vaccine exists but is not readily available. It consists of a series of 6 immunizations given over 18 months. A booster is then available to be given annually, especially to those who have exposure to anthrax-containing animals or animal products. A skin test can determine if the vaccine is active.

To prevent infection from spores of B anthracis released in the air after a suspected bioterrorist attack, your doctor may prescribe ciprofloxacin or doxycycline for 60 days. Other antibiotics may be used once lab tests return showing which ones are effective.