Disease treatment in horses encompasses a range of medical interventions and management strategies aimed at addressing various health conditions affecting equine species. These treatments can include pharmacological approaches, such as the administration of antibiotics, anti-inflammatory drugs, and antiparasitic medications, as well as non-pharmacological methods like physical therapy, dietary adjustments, and surgical procedures. The selection of appropriate treatments depends on the specific disease, its severity, and the individual needs of the horse. This topic brings together peer-reviewed research studies and scholarly articles that explore the efficacy, safety, and advancements in therapeutic options for equine diseases, providing insights into best practices and emerging trends in equine veterinary medicine.
Dubey JP, Howe DK, Furr M, Saville WJ, Marsh AE, Reed SM, Grigg ME.Equine protozoal myeloencephalitis (EPM) is a serious disease of horses, and its management continues to be a challenge for veterinarians. The protozoan Sarcocystis neurona is most commonly associated with EPM. S. neurona has emerged as a common cause of mortality in marine mammals, especially sea otters (Enhydra lutris). EPM-like illness has also been recorded in several other mammals, including domestic dogs and cats. This paper updates S. neurona and EPM information from the last 15 years on the advances regarding life cycle, molecular biology, epidemiology, clinical signs, diagnosis, treat...
Marx C, Silveira MD, Beyer Nardi N.Mesenchymal stem cells, considered one of the most promising cell types for therapeutic applications due to their capacity to secrete regenerative bioactive molecules, are present in all tissues. Stem cells derived from the adipose tissue have been increasingly used for cell therapy in humans and animals, both as freshly isolated, stromal vascular fraction (SVF) cells, or as cultivated adipose-derived stem cells (ASCs). ASCs have been characterized in different animal species for proliferation, differentiation potential, immunophenotype, gene expression, and potential for tissue engineering. W...
The intestinal tract is a rich and complex environment and its microbiota has been shown to have an important role in health and disease in the host. Several factors can cause disruption of the normal intestinal microbiota, including antimicrobial therapy, which is an important cause of diarrhea in horses. This study aimed to characterize changes in the fecal bacterial populations of healthy horses associated with the administration of frequently used antimicrobial drugs. Results: Twenty-four adult mares were assigned to receive procaine penicillin intramuscularly (IM), ceftiofur sodium IM, tr...
de Grauw JC, Visser-Meijer MC, Lashley F, Meeus P, van Weeren PR.Intra-articular (IA) injection of corticosteroids with or without hyaluronate (HA) has been used for decades in equine practice for treatment of noninfectious synovitis and osteoarthritis. However, to date, no large-scale randomised equine field trials have been reported that address the supposed superior clinical efficacy of the combination of corticosteroid + HA compared with IA injection of corticosteroid alone. Objective: To compare the clinical efficacy of IA triamcinolone acetonide (TA, 12 mg) compared with IA TA (12 mg) + high molecular weight HA (20 mg) in horses with clinical jo...
van Eps AW, Orsini JA.Digital hypothermia may be effective for laminitis prophylaxis and therapy, but the efficacy of cooling methods used in clinical practice requires evaluation. Objective: To use hoof wall surface temperature (HWST) to compare several cooling methods used in clinical practice. Methods: Experimental crossover design with a minimum washout period of 72 h. Methods: Seven cooling methods (commercially available ice packs, wraps and boots) and one prototypical dry-sleeve device were applied to a single forelimb in 4 horses for 8 h, during which HWST of the cooled forelimb and the uncooled (contro...
Srivastava A, Singh BN, Deepak D, Rawat AK, Singh BR.The discovery of quorum-sensing (QS) systems regulating antibiotic resistance and virulence factors (VFs) has afforded a novel opportunity to prevent bacterial pathogenicity. Dietary molecules have been demonstrated to attenuate QS circuits of bacteria. But, to our knowledge, no study exploring the potential of colostrum hexasaccharide (CHS) in regulating QS systems has been published. In this study, we analyzed CHS for inhibiting QS signaling in Staphylococcus aureus. We isolated and characterized CHS from mare colostrum by high-performance thin-layer chromatography (HPTLC), reverse-phase hig...
Martínez-Boví R, Cuervo-Arango J.Haemorrhagic anovulatory follicle is the most common pathological anovulatory condition in the mare, but its cause remains unknown. An experimental model to induce luteinised unruptured follicles (LUF) with flunixin-meglumine (FM) has been developed. Luteinised unruptured follicles share similar morphological and hormonal characteristics with haemorrhagic anovulatory follicles. Objective: To test the effect of intrafollicular administration of prostaglandins PGE2 and PGF2α during the periovulatory period on ovulation and pregnancy in FM-treated mares. Methods: In vivo experiment in a crossove...
Di Stefano DA, Greco GB, Cinci L, Pieri L.The present work describes a horizontal ridge augmentation in which a titanium mesh was preshaped by adapting it to a stereolithographic model of the patient's jaw that was fabricated from CT scans. Guided bone regeneration (GBR) involves covering the augmentation site with a long-lasting barrier to protect it from the invasion of surrounding soft tissues. Among barriers, titanium meshes may provide a successful outcome, but the intraoperatory time needed to shape them is a disadvantage. The 54-year-old patient, missing the right mandibular second bicuspid, first molar, and second molar, had h...
Miszczak F, Pronost S, Vabret A.Equine arteritis virus (EAV) is the causative agent of equine viral arteritis, a disease observed only in equids. EAV is the prototype of the family Arteriviridæ within the order Nidovirales. EAV is an enveloped, positive-sense, single-stranded RNA virus with a considerable variation in the genome as observed in other RNA viruses. During natural infections, EAV may cause abortion and persistent subclinical infections in stallions which can shed the virus in the semen for years, or even lifetime. Chronically infected stallions represent the natural reservoir of the virus. They ensure the persi...
Gilkerson JR, Bailey KE, Diaz-Méndez A, Hartley CA.Many viral agents have been associated with respiratory disease of the horse. The most important viral causes of respiratory disease in horses are equine influenza and the equine alphaherpesviruses. Agents such as equine viral arteritis virus, African horse sickness virus, and Hendra virus establish systemic infections. Clinical signs of disease resulting from infection with these agents can manifest as respiratory disease, but the respiratory tract is not the major body system affected by these viruses. Treatment of viral respiratory disease is generally limited to supportive therapies, where...
Underwood C, Collins SN, Mills PC, Van Eps AW, Allavena RE, Medina Torres CE, Pollitt CC.Pharmaceutical agents with potential for laminitis prevention have been identified. Many of these, including the MMP inhibitor marimastat, are impractical for systemic administration. This study compared local delivery of marimastat by regional limb perfusion (RLP) to systemic intravenous bolus dosing (SIVB), and established whether RLP results in local lamellar drug delivery. Six adult horses received 0.23 mg/kg of marimastat by RLP followed by 0.23 mg/kg marimastat by SIVB, with a 24-h washout period. Lamellar ultrafiltration probes sampled lamellar interstitial fluid as lamellar ultrafiltra...
Salter MM, Seeto WJ, DeWitt BB, Hashimi SA, Schwartz DD, Lipke EA, Wooldridge AA.To isolate and characterize endothelial colony-forming cells (ECFCs; a subtype of endothelial progenitor cells) from peripheral blood samples of horses. Methods: Jugular venous blood samples from 24 adult horses. Methods: Blood samples were cultured in endothelial cell growth medium. Isolated ECFCs were characterized by use of functional assays of fluorescence-labeled acetylated low-density lipoprotein (DiI-Ac-LDL) uptake and vascular tubule formation in vitro. Expression of endothelial (CD34, CD105, vascular endothelial growth factor receptor 2, and von Willebrand factor) and hematopoietic (C...
Rickert M, Rauschmann M, Fleege C, Behrbalk E, Harms J.The development of interbody fusion now stretches over many decades and is still not complete. Conclusions: Due to the lack of appropriate implants, the initial fusions were performed via decortication of the dorsal and lateral structures of the spine, followed by placement of an autograft. Despite acceptable fusion results, better primary stability and higher fusion rates were desired. In addition, it became known that the primary load-bearing of the spine is located ventrally in the area of the corpus of the vertebrae. These considerations led to the development of the PLIF technique that wa...
Calvo-Pinilla E, de la Poza F, Gubbins S, Mertens PP, Ortego J, Castillo-Olivares J.Previous studies show that a recombinant modified vaccinia Ankara (MVA) virus expressing VP2 of AHSV serotype 4 (MVA-VP2) induced virus neutralising antibodies in horses and protected interferon alpha receptor gene knock-out mice (IFNAR -/-) against challenge. Follow up experiments indicated that passive transfer of antiserum, from MVA-VP2 immune donors to recipient mice 1h before challenge, conferred complete clinical protection and significantly reduced viraemia. These studies have been extended to determine the protective effect of MVA-VP2 vaccine-induced antiserum, when administered 48h be...
Rendle DI, Hughes KJ, Doran GS, Edwards SH.To determine the pharmacokinetics of pergolide after IV administration to horses. Methods: 8 healthy adult horses. Methods: Pergolide mesylate was administered IV at a dose of 20 μg/kg (equivalent to 15.2 μg of pergolide/kg) to each horse, and blood samples were collected over 48 hours. Pergolide concentrations in plasma were determined by means of high-performance liquid chromatography-tandem mass spectrometry, and pharmacokinetic parameters were determined on the basis of noncompartmental methods. Results: After IV administration of pergolide, mean ± SD clearance, elimination half-life, a...
Ching PK, de los Reyes VC, Sucaldito MN, Tayag E, Columna-Vingno AB, Malbas FF, Bolo GC, Sejvar JJ, Eagles D, Playford G, Dueger E, Kaku Y....During 2014, henipavirus infection caused severe illness among humans and horses in southern Philippines; fatality rates among humans were high. Horse-to-human and human-to-human transmission occurred. The most likely source of horse infection was fruit bats. Ongoing surveillance is needed for rapid diagnosis, risk factor investigation, control measure implementation, and further virus characterization.
Larsdotter S, Nostell K, von Euler H.Serum thymidine kinase (sTK) activity is a tumour marker used as a prognostic indicator for lymphoma in humans, dogs and cats. The aim of this study was to evaluate the clinical utility of sTK as a biomarker for lymphoma in horses. Serum samples were collected from clinically normal horses (n = 37), horses with lymphoma (n = 23), horses with non-haematopoietic neoplasia (n = 9) and horses with inflammatory disease (n = 14). sTK was measured using a radioenzyme assay. A reference cut-off value of <2.7 U/L (mean + 2 standard deviations, SDs) was established using data fro...
Johns IC, Adams EL.This study aimed to identify changing antimicrobial resistance patterns in isolates commonly obtained from equine clinical submissions. Laboratory records from 1999 to 2012 were searched for equine samples from which Escherichia coli or Streptococcus species was isolated. Susceptibility to enrofloxacin, ceftiofur, gentamicin, penicillin G, trimethoprim sulfamethoxazole (TMPS) and tetracyclines was noted. Isolates were divided into those identified between 1999 and 2004 (Early) and between 2007 and 2012 (Late). The proportion of isolates resistant to each antimicrobial and multiple drug-resista...
Hildebrand F, Venner M, Giguère S.Gamithromycin is active in vitro against the bacterial agents most commonly associated with bronchopneumonia in older foals. However, the clinical efficacy and safety of this drug have not been investigated. Objective: Gamithromycin is effective for the treatment of bronchopneumonia in foals. Methods: One hundred and twenty-one foals on a farm endemic for infections caused by Rhodococcus equi. Methods: In a controlled, randomized, and double blinded clinical trial, foals with ultrasonographic evidence of pulmonary abscesses (abscess score 8.0-20 cm) were randomly allocated in 3 treatment group...
Klier J, Lehmann B, Fuchs S, Reese S, Hirschmann A, Coester C, Winter G, Gehlen H.Recurrent airway obstruction (RAO), an asthma-like disease, is 1 of the most common allergic diseases in horses in the northern hemisphere. Hypersensitivity reactions to environmental antigens cause an allergic inflammatory response in the equine airways. Cytosine-phosphate-guanosine-oligodeoxynucleotides (CpG-ODN) are known to direct the immune system toward a Th1-pathway, and away from the pro-allergic Th2-line (Th2/Th1-shift). Gelatin nanoparticles (GNPs) are biocompatible and biodegradable immunological inert drug delivery systems that protect CpG-ODN against nuclease degeneration. Prelimi...
Burton AJ, Giguère S, Berghaus LJ, Hondalus MK, Arnold RD.Rhodococcus equi, a facultative intracellular pathogen and an important cause of pneumonia in foals, is highly susceptible to killing by gentamicin in vitro. However, gentamicin is not effective in vivo, due to its poor cellular penetration. Encapsulation of drugs in liposomes enhances cellular uptake. The objectives of this study were to compare liposomal gentamicin and free gentamicin with respect to their uptake by equine macrophages and intracellular colocalization with R. equi and to compare the efficacies of liposomal gentamicin, free gentamicin and clarithromycin with rifampin for the r...
Van Der Vekens N, Decloedt A, Ven S, De Clercq D, van Loon G.Different cardiac troponin I (cTnI) assays give different results. Only 1 manufacturer has marketed troponin T (cTnT) assays. Therefore, cTnT often is preferred for detection of myocardial infarction in human patients. Studies of cTnT in horses are limited. Objective: To compare a cTnI and a high-sensitive cTnT assay (hs-cTnT) in horses. Methods: Cardiac troponin I and cTnT were determined in 35 healthy horses (group 1), 23 horses suspected to have primary myocardial damage (group 2a), and 41 horses with secondary myocardial damage caused by structural heart disease (group 2b). Methods: All cT...
Burton AG, Clark KC, Borjesson DL, Carrade DD, Burges J, Owens SD.Volume reduction and RBC depletion of equine bone marrow specimens are necessary processing steps for the immediate therapeutic use of bone marrow (BM)-derived mesenchymal stem cells (MSC), and for MSC expansion in culture. Objective: The purpose of the study was to evaluate the ability of the PrepaCyte-CB processing system to reduce volume, deplete RBC, and recover mononuclear cells (MNC) from equine BM specimens. Methods: One hundred and twenty mL of heparinized BM were obtained from each of 90 horses. A CBC was performed on the BM pre- and post-PrepaCyte-CB processing. Volume and RBC reduct...
Stewart AJ, Cuming RS.Fungal respiratory disease is a rare occurrence in horses. Fungal organisms are ubiquitous in the equine environment; however, there is a geographic predisposition for disease development, with fungal respiratory infections seen more commonly by practitioners working in tropical or subtropical environments. Diagnosis and treatment of fungal respiratory infections pose a challenge for the equine practitioner, and the prognosis for complete resolution of infection is often guarded; however, new antifungal medications are likely to improve treatment success. This article summarizes the available ...
Hines SA, Ramsay JD, Kappmeyer LS, Lau AO, Ojo KK, Van Voorhis WC, Knowles DP, Mealey RH.The apicomplexan hemoparasite Theileria equi is a causative agent of equine piroplasmosis, eradicated from the United States in 1988. However, recent outbreaks have sparked renewed interest in treatment options for infected horses. Imidocarb dipropionate is the current drug of choice, however variation in clinical response to therapy has been observed. Methods: We quantified the in vitro susceptibility of two T. equi isolates and a lab generated variant to both imidocarb dipropionate and a bumped kinase inhibitor compound 1294. We also evaluated the capacity of in vitro imidocarb dipropionate ...
Misra KK, Roy S, Choudhury A.Trypanosoma (Trypanozoon) evansi is a causative agent of the dreadful mammalian disease trypanosomiasis or 'Surra' and carried as a latent parasite in domestic cattle but occasionally proves fatal when transmitted to horses and camel. Sporadic outbreak of 'Surra' to different animals (beside their natural hosts) reminds that T. evansi may be zoonotic, as their close relative cause sleeping sickness to human being. This haemoflagellate is mechanically transmitted by horse fly and its effect on different host varies depending on certain factors including the effectiveness of transmission by mech...
Patel JR, Heldens JG.Since the refinement of tissue culture techniques for virus isolation and propagation from the mid 1960s onwards, veterinary virology has received much academic and industrial interest, and has now become a major global industry largely centred on vaccine development against economically important virus diseases of food animals. Bio-tech approaches have been widely used for improved vaccines development. While many viral diseases are controlled through vaccination, many still lack safe and efficacious vaccines. Additional challenges faced by academia, industry and governments are likely to com...
Roberts SM.Vision is a marvelous sense, critical to the well-being and functional use of horses. Anatomic, optical, and visual acuity generalities are presented. The constituents of unsoundness due to equine ocular disease are discussed, and recommendations are made.
Baptiste KE, Naylor JM, Bailey J, Barber EM, Post K, Thornhill J.Athletic animals must keep their brains cool during exertion because this organ can be damaged irreversibly by hyperthermia. But how horses do this has remained a mystery, as they don't appear to have thermoregulatory dervices like those found in other animals. They do, however, have a unique anatomical arrangement of their internal carotid arteries, which supply blood to the brain: these are enveloped by a pair of air-filled guttural pouches. Here we show that horses use their guttural pouches to cool these important arteries during exercise, keeping the brain from overheating.
Mathis SC, Slone DE, Lynch TM, Hughes FE, Clark CK.To evaluate the relationship of colonic luminal pressure (CLP) measurements to outcome in horses with large colon volvulus (LCV) after either manual correction or large colon resection and anastomosis (LCRA). Methods: Retrospective study. Methods: Horses (n=57) that had LCV. Methods: Records for horses with LCV (March 1997-December 2003) were reviewed. Inclusion criteria were strangulating LCV proximal to the cecocolic ligament (>270 degrees), recorded CLP, and successful recovery from anesthesia. CLP measurements and survival/mortality rates were compared between horses that had manual correc...
Fugazzola M, Nissinen MT, Jäntti J, Tuppurainen J, Plomp S, Te Moller N, Mäkelä JTA, van Weeren R.Strategies for articular cartilage repair need to take into account topographical differences in tissue composition and architecture to achieve durable functional outcome. These have not yet been investigated in the equine stifle. Objective: To analyse the biochemical composition and architecture of three differently loaded areas of the equine stifle. We hypothesise that site differences correlate with the biomechanical characteristics of the cartilage. Methods: Ex vivo study. Methods: Thirty osteochondral plugs per location were harvested from the lateral trochlear ridge (LTR), the distal int...
Bergfelt DR, Woods JA, Ginther OJ.Characteristics of spontaneous embryonic loss in 21 mares were compared with those of 52 contemporary mares that maintained pregnancy. Embryonic losses were, in retrospect, grouped according to day of loss and length of the interovulatory interval, respectively, as follows: group 1, less than or equal to day 20 and less than or equal to 30 days (n = 10); group 2, less than or equal to day 20 and greater than 30 days (n = 3); and group 3, greater than day 20 and greater than 30 days (n = 8); ovulation was day 0. Mean diameter of the embryonic vesicle in group 1 was smaller (P less than 0.05) on...
Culp WT, Weisse C, Berent AC, Getman LM, Schaer TP, Solomon JA.CASE DESCRIPTION-5 Dogs, 1 goat, and 1 horse underwent percutaneous endovascular retrieval of intravascular foreign bodies between 2002 and 2007. CLINICAL FINDINGS-Foreign bodies were IV catheters in 4 dogs, the horse, and the goat and a piece of a balloon valvuloplasty catheter in 1 dog. Location of the foreign bodies included the main pulmonary artery (1 dog), a branch of a pulmonary artery (4 dogs), the right ventricle (the goat), and a jugular vein (the horse). TREATMENT AND OUTCOME-The procedure of percutaneous endovascular retrieval of the foreign body was easy to perform in all instance...
Staempfli HR, Prescott JF, Carman RJ, McCutcheon LJ.Ten healthy ponies from a single herd were found by repeated fecal culture to be free of Salmonella species and Clostridium cadaveris. In a preliminary study, four ponies administered a single oral dose of 10 mg/kg lincomycin did not develop idiopathic colitis when the drug was administered alone. Four other ponies were administered 10 mg/kg lincomycin by stomach tube together with 0.45 L of colonic content from a horse with idiopathic colitis induced earlier by lincomycin alone. Two of the four ponies were treated with 25 g oral zinc bacitracin premix (110 g/kg active ingredient) 24 h later. ...
Saba C, Eggleston R, Parks A, Peroni J, Sjoberg E, Rice S, Tyma J, Williams J, Grosenbaugh D, Leard AT.Sarcoid tumors are common in horses and may negatively impact the performance and value of the horse. No known treatment is reliably successful. Objective: To determine tolerability, overall response rate, time to response, and progression-free survival of horses with biopsy-confirmed or suspected sarcoids treated with ALVAC-fIL2. Methods: Client-owned horses with measurable, presumed- or biopsy-confirmed sarcoid tumors. Methods: Prospective pilot study. One milliliter of ALVAC-fIL2 was injected into 4 to 5 areas of the sarcoid(s) in each horse (week 0); this treatment was repeated in weeks 1,...
Wright IM, Douglas J.In recent years much attention has been paid to vascular studies of the navicular bone in health and disease; however, the relative importance of these studies has overshadowed biomechanical factors which may yet prove to be of importance. This paper outlines the pertinent anatomy, and discusses current concepts in the aetiology and pathogenesis of the disease. It describes the treatment regimens which are based on biomechanical considerations and compares the results of some currently employed techniques. All aspects of navicular disease remain controversial. This paper is not intended to rev...
Durando MM.Horses have a high prevalence of resting arrhythmias, cardiac murmurs, and valvular regurgitation, and training can increase the prevalence. This makes it challenging for equine veterinarians who are asked to evaluate horses for poor performance to determine the clinical relevance of some findings. In addition, cardiac disease has the potential to cause collapse or sudden death, putting both the horse and rider at risk. Further diagnostics, such as echocardiograms and resting and exercising ECGs can help to sort out the impact of an abnormality found on resting physical examination. However un...
McPherson EA, Lawson GH, Murphy JR, Nicholson JM, Fraser JA, Breeze RG, Pirie HM.Mean normal values for PaO, and max A Ppl for horses were determined. Using 2 standard deviations below (Pa0,) and above (max A Ppl) the mean normal values as a guide, horses affected with COPD were satisfactorily distinguished from other horses in a series of 100 animals. The frequency of occurrence of 20 different clinical parameters in affected, not affected and possibly affected horses was examined statistically. Poor work performance and a history of previous febrile illness occurred more often in COPD horses than in others. The presence of a chronic cough, dyspnoea, double expiratory eff...
Page AE, Slovis NM, Horohov DW.Lawsonia intracellularis is the etiologic agent for equine proliferative enteropathy (EPE), which typically affects weanling and yearling horses. In North America, EPE cases often occur between August and January, although cases outside of this time frame have been reported. Clinical signs of EPE are usually nonspecific and include lethargy, pyrexia, anorexia, peripheral edema, weight loss, colic, and diarrhea. Diagnosis is based on the presence of hypoproteinemia and hypoalbuminemia along with clinical signs and positive commercial serologic and/or molecular testing. Treatment requires the us...
McGurrin MK, Physick-Sheard PW, Kenney DG, Kerr C, Hanna WJ.Conventional treatment of equine atrial fibrillation (AF) involves administration of quinidine salts. Most uncomplicated cases respond to treatment, but pharmacologic cardioversion involves a range of adverse effects, and some horses are unable to tolerate medication. A study was undertaken to develop transvenous electrical cardioversion (TVEC) as an alternative treatment. Safety issues and catheter placement techniques with catheter-integrated cardioversion electrodes were investigated, and responses to shock application were evaluated. After the premortem catheterization of elective-euthanas...
Betancourt A, Lyons ET, Horohov DW.Anthelmintic treatments have been associated with local inflammatory reactions. Since each class of anthelmintic has unique mechanisms of action affecting different subpopulations of parasites, we hypothesised that they will also induce characteristic proinflammatory responses. Objective: To determine the effect of anthelmintic class on the proinflammatory response post treatment. Methods: Ponies naturally infected with cyathostomins and other parasites after pasture grazing were left untreated or treated with representatives of 3 different classes of anthelmintics: fenbendazole (benzimidazole...
Westerman TL, Tornquist SJ, Foster CM, Poulsen KP.To evaluate use of serum amyloid A (SAA) and haptoglobin concentrations as prognostic indicators for horses with inflammatory disease in regard to euthanasia, complications, and hospitalization duration and cost. Methods: 20 clinically normal horses and 53 horses with inflammatory disease. Methods: Total WBC count, neutrophil count, and fibrinogen, SAA, and haptoglobin concentrations were determined for clinically normal horses and horses with suspected inflammatory disease. Clinicopathologic values at admission were compared to test the use of SAA and haptoglobin concentrations in predicting ...
Fielding CL, Magdesian KG.Sepsis and septic shock represent a major cause of morbidity and mortality in equine neonates and in all species. Early recognition of the condition is important, but definitive examination and laboratory variables to predict equine neonatal sepsis are lacking. Early and aggressive treatment should include broad-spectrum antimicrobial coverage, source control, and hemodynamic support. Field practitioners and intensive care clinicians work together in the management of this condition because the recognition and initial treatment should begin as early as possible.