There are multiple reasons for this patient’s osteoporo-sis, including a heavy smoking history, possible alco-holism, and chronic inflammatory disease treated with glucocorticoids. High levels of cytokines from the chronic inflammation activate osteoclasts. Glucocorticoids increase urinary losses of calcium, suppress bone formation, and inhibit intestinal calcium absorption as well as decreasing gonadotropin production, leading to hypogonadism. Man-agement should include measurement of serum testoster-one, calcium, 25(OH)D, and the 24-hour urine calcium and creatinine levels (to verify completeness of collection), with treatment as appropriate for these secondary causes, plus initiation of bisphosphonate or denosumab therapy as primary treatment.
Antimicrobial agents provide some of the most dramatic examples of the advances of modern medicine. Many infectious diseases once considered incurable and potentially lethal can now be treated effectively with antibiotics. The remarkably powerful and specific activity of antimicrobial drugs is due to their selectivity for targets that are either unique to prokaryote and fungal microorganisms or much more important in these organisms than in humans. Among these targets are bacterial and fungal cell wall-synthesizing enzymes (Chapters 43 and 48), the bacterial ribosome (Chapters 44 and 45), the enzymes required for nucleotide synthesis and DNA replication (Chapter 46), and the machinery of viral replication (Chapter 49). The special group of drugs used in mycobacterial infections is discussed in Chapter 47. Cytotoxic antiseptics and disinfectants are discussed in Chapter 50. The clinical uses of many antimicrobial agents are summarized  in Chapter 51.
The major problem threatening the continued success of antimicrobial drugs is the development of resistant organisms. Antibiotic resistance mechanisms existed long before the clinical use of antibiotics, even resistance to synthetic drugs that were created in the 20th century. Because resistance mechanisms are already present in nature, an inevitable consequence of antimicrobial use is the selection of resistant microorganisms. Since the start of the antibiotic era, antibiotic use in patients and animals has fueled a major increase in the prevalence of drug-resistant pathogens. In recent years, highly resistant Gram-negative organisms with novel mechanisms of resistance have been increasingly reported. Some of these strains have spread over vast geographic areas as a result of patients seeking medical care in different countries.
Much attention has been focused on eliminating the misuse of antibiotics to slow the tide of resistance. Antibiotics are misused in a variety of ways, including use in patients who are unlikely to have bacterial infections, use over unnecessarily prolonged periods, and use of multiple agents or broad-spectrum agents when not needed. Large quantities of antibiotics have been used in agriculture to stimulate growth and prevent infection in livestock, and this has added to the selection pressure that results in resistant organisms. In December 2013, the U.S. Food and Drug Administration (FDA) announced a program to phase out the nontherapeutic use of antibiotics in livestock. In 2015, President Obama announced a 5-year National Action Plan with the goals of improving antimicrobial stewardship efforts, tools for diagnosing infectious diseases, and surveillance for resistant organisms. However, even if these programs are successful, it will take years before the benefits are apparent.
Antibiotic resistance has many negative consequences. The prevalence of resistant organisms drives the use of broader-spectrum, less efficacious, or more toxic antibiotics. Not surprisingly, infections caused by antibiotic-resistant pathogens are associated with increased costs, morbidity, and mortality. The Centers for Disease Control and Prevention estimates that every year in the United States at least 2 million people acquire infections due to and 23,000 people die from infections caused by resistant bacteria.