Infectious disease - part 1

JP has a blood culture report showing Gram-positive cocci resembling Streptococci, enteric Gram-negative rods and anaerobes. Which of the following medications would provide adequate coverage for these organisms? A Ertapenem B Rifaximin C Metronidazole D Fosfomycin E Ciprofloxacin

A - Carbapenems (e.g., ertapenem, which is Invanz) cover all of these organisms. Rifaximin is not absorbed from the GI tract and is not used for systemic infections. Fosfomycin is used for uncomplicated UTI. Ciprofloxacin lacks reliable coverage of Streptococci. Metronidazole offers insufficient coverage.

Which of the following statements is correct regarding linezolid? A Linezolid is associated with bone marrow suppression. B Linezolid covers MRSA but not VRE. C Linezolid should be dose adjusted in renal impairment. D Linezolid is a strong CYP 1A2 inhibitor. E Linezolid is associated with hemolytic anemia in patients with G6PD deficiency.

A - Linezolid is part of the oxazolidinone class of antibiotics that covers MRSA and VRE. It does not need to be dose adjusted in renal impairment and has no notable CYP enzyme interactions. With longer treatment courses, patients should be monitored for thrombocytopenia, as well as anemia and leukopenia.

Which of the following statements are correct with regard to sulfamethoxazole/trimethoprim? (Select ALL that apply.) A It is a potent hepatic enzyme inducer resulting in reduced drug concentrations. B It has excellent bioavailability, thus can transition from intravenous to oral formulations in a 1:1 fashion. C It is active against many Gram-positive pathogens, including Staphylococci, Gram-negative pathogens, and opportunistic pathogens. D This drug should be used with caution in a patient with G6PD deficiency. E A negative Coombs test with sulfamethoxazole/trimethoprim indicates hemolytic anemia.

B, C, D - TMP/SMX is a potent CYP 2C9 inhibitor (not inducer). It has 1:1 conversion from IV:PO dosing. It is a broad spectrum agent with excellent Gram-positive, Gram-negative (not Pseudomonas) and opportunistic pathogen coverage. It is partially cleared by the kidney and should be dosed reduced for CrCl < 30 mL/min. A positive Coombs test in the labs (along with decreasing hemoglobin/hematocrit) would indicate the presence of hemolytic anemia and Bactrim should be discontinued.

Which of the following can interfere with coagulation laboratory assays? (Select ALL that apply.) A Bactrim B Daptomycin C Linezolid D Oritavancin E Telavancin

B, D, E - Unfractionated heparin is contraindicated within 120 hours (5 days) of oritavancin due to false elevations of the aPTT. Daptomycin and telavancin can cause increased PT/INR results.

A patient has been taking antibiotics for one week and develops severe diarrhea with painful abdominal cramps. Which of the following medications has a boxed warning regarding the risk of causing severe and possibly fatal colitis? A Cefepime B Biaxin C Cipro D Clindamycin E Cancidas

D - Although clindamycin carries a boxed warning for risk of severe and possibly fatal colitis, all antibiotics carry a warning for risk of superinfections including risk of C. difficile-associated diarrhea. When counseling, tell patients to report watery and/or frequent diarrhea immediately as the patient may require treatment for pseudomembranous colitis.

Azithromycin is commonly used in treatment of all of the following EXCEPT: A Chlamydia B Gonorrhea C Mycobacterium avium complex D Toxoplasmosis E Travelers' diarrha

D - Azithromycin is also used in community-acquired pneumonia and COPD exacerbations.

Which of the following abx can interfere with coguation therapy

Vibativ (televancin) orbactiv (oritavancin)

Aminopenicillins

amoxicillin ampicillin adds gram - (HNPEK)

time dependent

beta lactams (penicillin, cephalosporins, carbapenems) Goal: maintain drug level (shorter dosing intervals, extended/continuous infusions)

4th gen cepholosporin

cefepime

5th gen cepholorsporin

ceftaroline

`All of the following have activity against pseudomonas except

ertapenam

Which of the following statements regarding linezolid is correct?

it is a MAO inhibitor and should be avoided with serotonergic drugs

antistaphylococcal

nafcillin, oxacillin adds mssa coverage

extended spectrum + betalactamase inhibitors

piperacillin/tazobactam adds CAPES, pseudomonas

Amoxicillin (Amoxil)

prophylxais dental procedures dose: 2 grams X1

Penicillin VK

strep

Amoxicillin (Amoxil)

used for AOM (otitis media) dose: 80-90 mg/kg

Amoxicillin/clauvulanate (Augmentin)

used for AOM (otitis media) dose: 90 mg/kg

Protein synthesis inhibitors

1. AG 2. macrolides 3. tetracyclines 4. clindamycin 5. linezolid, tedizolid 6. Quinupristin/dalfopristin

Concentration dependent

1. AG 2. quinolones 3. daptomycin Goal: high peak (large doses, long intervals)

Cell wall inhibitors

1. beta-lactams (penicillins, cephalosporins, carbapenems) 2. monobactams (aztreonam) 3. Vancomycin, dalbavancin, televancin, oritavancin

3rd gen cepholosporin

1. cefdinir(omnicef) 2. ceftriaxone (rocephin) 3. cefotaxime 4. ceftazidime

2nd gen cepholosporin

1. cefuroxime (Ceftin) 2. cefotetan 3. cefoxitin

first gen cepholosporins

1. cephalexin (keflex) 2. cefazolin (Ancef)

Cell membrane inhibitors

1. polymyxin (colistimethate) 2. daptomycin 3. telavancin 4. oritavancin

DNA/RNA inhibitors

1. quinolones 2. Metronidazole, tinidazole 3. rifampin

Folic Acid synthesis inhibitors

1. sulfonamides 2. trimethoprim 3. daposne

AUC: MIC dependent

1. vanco 2. macrolides 3. tetracyclines

A patient is receiving Bactrim DS therapy. Which of the following strengths and ingredients are in Bactrim DS tablets?

A

Which of the following statements is correct regarding the appropriate use of metronidazole? A Side effects include a metallic taste in the mouth. B The IV:PO dosing ratio is 0.5:1. C Metronidazole is an azole antifungal agent. D Metronidazole is available in IV and PO formulations only. E Alcohol should not be consumed for 7 days after the last dose.

A - Metronidazole is an amebicide, antiprotozoal antibiotic. Topical and vaginal formulations are also available. Alcohol should be avoided during therapy and for 3 days after the last dose to avoid flushing, abdominal cramping and N/V.

A patient is receiving vancomycin 2 grams IV Q12H for treatment of MRSA osteomyelitis. The nurse asks how long to infuse the medication. Which is the best recommendation to give the nurse regarding the infusion of this vancomycin dose? A The vancomycin should be infused over a minimum of 2 hours B The vancomycin should be infused over a maximum of 2 hours C The vancomycin should be infused over a minimum of 1 hour D The vancomycin should be infused over a maximum of 1 hour E The vancomycin should be given via a bolus dose

A - Vancomycin can cause serious side effects if infused too quickly. Given the patient is receiving 2 grams, vancomycin should be infused over a minimum of 2 hours. Often, the infusion is given over a longer time period.

DM is diagnosed with a Giardia infection. Which of the following medications would be best to recommend for treatment of giardiasis? A Metronidazole B Cefuroxime C Doxycycline D Erythromycin E Clindamycin

A -Giardiasis is a diarrheal illness caused by the parasite, Giardia intestinalis. It can be treated with metronidazole or tinidazole.

Which of the following antimicrobial agents have activity against Bacteroides fragilis? (Select ALL that apply.) A Meropenem B Metronidazole C Ampicillin/sulbactam D Cefoxitin E Cefepime

A, B, C, D

Levofloxacin and azithromycin share which of the following pharmacokinetic characteristics? (Select ALL that apply.) A Lipophilic agents B Large volume of distribution C Low intracellular concentrations D Excellent tissue penetration E Nephrotoxicity

A, B, D - Drugs like quinolones and macrolides penetrate tissue well (part of the rationale for use in pneumonia, where penetration into lung tissue is needed). These drugs are also active against atypical pathogens, as they work intracellularly, rather than on the cell wall. Beta-lactams and aminoglycosides are examples of hydrophilic drugs.

A prescription for generic minocycline is filled. Which of the following statements regarding minocycline are correct? (Select ALL that apply.) A This medication has been associated with drug-induced lupus. B Take on an empty stomach 1 hour before or 2 hours after meals. C This medication may increase the risk of sunburn. D This medication should be separated when given with antacids. E This medication does not interact with other medications.

A, C, D - Minocycline should not be used in children younger than 8 years old or in patients who are pregnant due to the risk of tooth discoloration, bone growth retardation and reduced skeletal development. Phosphate binders like fosrenol also decrease minocycline absorption.

Which of the following statements are correct regarding patient counseling advice on Bactrim for toxoplasmosis prophylaxis? (Select ALL that apply.) A Take this medication with 8 oz of water. B The pharmacist should contact the prescriber. Bactrim should not be used for toxoplasmosis prophylaxis. C This medication can increase risk of sunburn. D This medication can cause a rash; if patient develop a serious rash, seek medical help right away. E This medication should not be used if the patient has a sulfa allergy.

A, C, D, E - Bactrim works best if given on an empty stomach. However, if GI upset is present, patients can take the medication with a light snack. It has a sulfa moiety and is associated with allergic reactions. It is also associated with photosensitivity.

Which of the following statements are true regarding Zyvox? (Select ALL that apply.) A Myelosuppression can occur with use of Zyvox. B It is cleared primarily by the kidney requiring dose adjustments in the setting of renal impairment. C Monitor for serotonin syndrome when used with SSRI antidepressants. D Nephrotoxicity is a common toxicity with prolonged use. E It has excellent bioavailability, thus can transition from intravenous to oral formulations in a 1:1 fashion.

A, C, E - It is primarily cleared by the liver, not the kidney. It is a MAO inhibitor. It is contraindicated within 2 weeks of MAO inhibitors and should be used with caution with serotonergic agents such as SSRI antidepressants (monitoring is recommended). Myelosuppression (e.g., thrombocytopenia) is a duration related toxicity, not nephrotoxicity. Zyvox has excellent bioavailability; transition from IV:PO in a 1:1 fashion and it requires no adjustment for renal impairment.

JG, a 46 year-old male, is found to have vancomycin-resistant E. faecalis (VRE) on his recent blood cultures. Which of the following regimens is the best option for treatment of his VRE infection? A Daptomycin B Vancomycin C Colistimethate D Quinupristin-dalfopristin E Cefazolin

A- Daptomycin is indicated for the treatment of vancomycin-resistant E. faecalis whereas the other medications do not cover this pathogen.

JR has been in the intensive care unit for the past two weeks. He was initially admitted for an asthma exacerbation requiring mechanical ventilation. Over the course of the hospitalization, he developed ventilator-associated pneumonia and was treated with broad-spectrum antibiotics. His blood cultures are now positive for E. faecium which is vancomycin-resistant (VRE). Which of the following antibiotics provide coverage for vancomyin-resistant E. faecium bacteremia? A Synercid B Vancocin C Tygacil D Invanz E Avelox

A- Synercid covers VRE faecium. Tygacil is active against VRE, but should be avoided for treatment of bloodstream infections. It is lipophilic and distributes rapidly to the tissues, resulting in low serum concentrations.

Aminopenicillin + betalactamase inhibitors

Amoxicillin/clavulanate ampicillin/sulbactam adds MSSA, more resistant strains of HNPEK, anaerobes (mouth & B. Fragilis)

Which of the following formulations is not available? A Aztreonam for inhalation B Amoxicillin/clavulanate injectable C Gentamicin topical ointment D Tobramycin opthalmic solution E Tobramycin for inhalation

B - Amoxicillin/clavulanate is not available for IV use in the U.S. Aztreonam for inhalation is used in cystic fibrosis and is called Cayston. Tobramycin for inhalation (also used in CF) is called TOBI.

The pharmacist should counsel a patient to use sunscreen when taking with of the following abx?

Avelox (moxifloxacin)

A patient gave the pharmacist a prescription for Z-Pak. Which of the following is the generic name and an appropriate dosing regimen for Z-Pak? A Erythromycin 250 mg Q AM, for 5 days B Azithromycin 250 x 2 on day 1, then 250 mg x 1 on days 2-5 C Azithromycin 250 mg x 1, for 5 days D Clarithromycin 250 mg Q AM, for 5 days E Azithromycin 250 mg x 2, for 5 days

B

A nurse calls the pharmacy to ask about crushing ciprofloxacin tablets and giving it via the nasogastric tube. The pharmacist should respond: Ciprofloxacin is only available in an IV formulation. B Hold tube feedings at least 1 hour before and 2 hours after the administration of ciprofloxacin. C Give ciprofloxacin and flush the nasogastric tube immediately with water; in this manner it is safe to give with tube feedings. D There is no interaction between ciprofloxacin and tube feedings. E There is no formulation of ciprofloxacin that can be used for nasogastric tube administration.

B - For feeding tube administration, crush immediate-release ciprofloxacin tablets and mix with water. Hold tube feeds for 1 hour before and 2 hours after administration. Enteral feedings can significantly decrease plasma concentrations of ciprofloxacin. There is a suspension but it cannot be used with feeding tubes because it is oil-based and adheres to the tubing.

NA is a 42 year-old female who was a victim of a house fire. She acquired third degree burns requiring skin grafting. Unfortunately her course has been complicated by post-operative Acinetobacter wound infection and acute kidney injury. She has no known drug allergies. Which of the following antibacterials would be considered first line in her case as a single agent? A Vancomycin B Meropenem C Ampicillin D Fosfomycin E Linezolid

B - Meropenem is a drug of choice for treating Acinetobacter.

Which of the following medications should be avoided in children younger than 8 years old due to discoloration of teeth and bone growth retardation? A Telavancin B Minocycline C Telithromycin D Tinidazole E Rifaximin

B - Minocycline should not be used in children younger than 8 years old or pregnant or breastfeeding women due to teeth discoloration and bone growth retardation in the child.

Which of the following statements is correct regarding nafcillin? A Nafcillin is active against MRSA. B Nafcillin is a vesicant. C Nafcillin should be dose adjusted in renal impairment. D Nafcillin is compatible with NS only. E Nafcillin cannot be used in a sulfa allergic patient.

B - Nafcillin is a vesicant. If extravasation occurs, use cold packs and hyaluronidase injections to treat. Ampicillin, ampicillin/sulbactam and ertapenem are compatible with NS only.

Which two antibiotics should be separated from multivitamin supplements? A Flagyl and Ceftin B Minocycline and levofloxacin C Avelox and Amoxil D Bactrim and Zithromax E Biaxin and Zyvox

B - Tetracyclines and fluoroquinolones should be separated from divalent cations (e.g., calcium, iron, magnesium, zinc) as they may inhibit absorption through chelation.

The lowest concentration of antibiotic at which no bacterial growth is seen is correctly called what? A Minimum bactericidal concentration B Minimum inhibitory concentration C Resistance point D Serum concentration E Susceptibility breakpoint

B - The minimum inhibitory concentration (MIC) is the lowest concentration of antibiotic tested that inhibits growth of the organism. The MIC is often reported on the culture and susceptibility report, which lists the results for multiple antibiotics. If the MIC is </= the susceptibility breakpoint (set by CLSI), it is reported as S-susceptible.

A hospitalized patient with no known drug allergies has cellulitis and the physician ordered vancomycin 1,000 mg IV Q12H and imipenem-cilastatin 1,000 mg IV Q8H. The medications were administered at the same time over 30 minutes. During the infusion, the patient experienced a profound drop in blood pressure. Her upper body, mostly in the trunk area, was covered with an erythematous rash. The patient's breathing became labored. What is the likely cause of the patient's symptoms? A She likely had an anaphylactic reaction to cilastatin. B Rapid administration of vancomycin caused red man syndrome. C The reaction was due to the combination of imipenem-cilastatin and vancomycin; the administration should be separated by several hours. D These are side effects of the cilastatin component, which has not been reduced for renal insufficiency. E It is unlikely that this reaction is due to one of these medications.

B - The patient has experienced symptoms of red man syndrome, a reaction due to a rapid infusion of vancomycin. Symptoms can include rash, pruritus, erythema and, less frequently, hypotension or angioedema. Infusions should be limited to no more than 1 gram per hour.

BF is a 52 y/o male patient who has been hospitalized in the ICU of a major trauma center for 26 days. He has had multiple abdominal surgeries secondary to traumatic injuries sustained in a farming accident. He subsequently developed a bloodstream infection. Blood Culture and Susceptibility Report: E. coli Amikacin - R Ciprofloxacin - R Gentamicin - R Tobramycin - I Levofloxacin - R Piperacillin/tazobactam - R Cefepime - R Imipenem - S SMX/TMP - R Extended-spectrum beta-lactamase + Which of the following strategies is best to manage BF's infection? A Ceftaroline 600 mg IV Q12H B Meropenem 1 g IV Q8H C Cefepime 2 g IV Q8H D Piperacillin/tazobactam 4.5 g IV Q8H (4 hour infusions) E Polymixin 15,000 units/kg/dose IV Q12H

B - This isolate is ESBL positive, which indicates that the beta-lactamase enzyme is capable of inactivating penicillins (even with beta-lactamase inhibitors like Zosyn) and most cephalosporins . Carbapenems are a good choice for ESBL + infections. The cephalosporin/beta-lactamase inhibitors (Zerbaxa and Avycaz) are active against ESBL producers as well.

MP presents to the urgent care center with a large cellulitis wound on his left lower extremity. The patient has a history of MRSA infection 2 months prior and the practitioner wants to prescribe something orally that covers MRSA. Which of the following medications fit this description?

B - Zyvox covers MRSA and comes in both an intravenous and oral formulation. The other medications listed are only available intravenously (oral vancomycin is not absorbed and is not appropriate for MRSA coverage).

Which of the following statements regarding the IV formulations of Bactrim is/are correct?

Bactrim IV is compatible with Dextrose 5% (D5W)

DH is a 42 year-old male being treated with Synercid for a complicated VRE and MRSA infection. Which of the following are common toxicities of Synercid? A Infusion reactions, electrolyte abnormalities, nephrotoxicity B Arthralgias/myalgias, nephrotoxicity, neurological disturbances C Infusion reactions, arthralgias/myalgias, hyperbilirubinemia D Hyperbilurbinemia, neurological disturbances, arthralgias/myalgias E Electrolyte abnormalities, nephrotoxicity, infusion reactions

C

Which of the following abx is not matched with a possible side effect/warning/interaction: a. daptomycin- increased CPK/myopathy b. televancin- fetal risk c. vanco - seizures d. metronidazole- disulfiram like rxn with alcohol e. doripenem- dec valproic acid conc

C

Which of the following has a REMS program regarding fetal abnormalities? A Azithromycin B Fosfomycin C Telavancin D Vancomycin E Ceftaroline

C

Chief Complaint: "I'm out of my inhaler and I can't breathe". History of Present Illness: KS is a 30 year-old female who comes to the ER today for worsening shortness of breath and cough. She is out of her albuterol inhaler. She occasionally lives on the street, but has been staying in the local homeless shelter for 3 nights. She reports fatigue, but denies night sweats and hemoptysis. Her cough is nonproductive. A mild right lower extremity cellulitis extending from right ankle to right calf is noted. Patient states she scraped her leg on a fence and it has not healed. She has not been treated with antibiotics. Allergies: NKDA Past Medical History: HIV x 5 years, PCP pneumonia 5 years ago when she was diagnosed with HIV, asthma, and dyslipidemia Medications: Truvada 1 tablet daily, Tivicay 50 mg once daily, albuterol inhaler 1 puff 3-4 times daily as needed, Flovent Diskus 100 mcg BID, simvastatin 20 mg QHS Physical Exam / Vitals: Height: 5'2" Weight: 105 pounds BP: 122/72 mmHg HR: 71 BPM RR: 18 BPM Temp: 103.2°F Pain: 3/10 General: Pleasant, ill-appearing female Lungs: decreased breath sounds bilaterally - right worse than left. Mild wheezing CV: RRR - no murmurs GI: Normal bowel sounds Ext: Mild right lower extremity cellulitis with some purulent drainage Labs: Na (mEq/L) = 129 (135 - 145) WBC (cells/mm3) = 10.4 (4 - 11 x 103) K (mEq/L) = 3.5 (3.5 - 5) Hgb (g/dL) = 13.4 (13.5 - 18 male, 12 - 16 female) Cl (mEq/L) = 103 (95 - 103) Hct (%) = 40.1 (38 - 50 male, 36 - 46 female) HCO3 (mEq/L) = 24 (24 - 30) Plt (cells/mm3) = 202 (150 - 450 x 103) BUN (mg/dL) = 12 (7 - 20) PMNs (%) = 92 (45 - 73) SCr (mg/dL) = 0.9 (0.6 - 1.3) Bands (%) = 7 (3 - 5) Glucose (mg/dL) = 118 (100 - 125) Eosinophils (%) = 3 (0 - 5) Ca (mg/dL) = 8.8 (8.5 - 10.5) Basophils (%) = 0 (0 - 1) Mg (mEq/L) = 1.8 (1.3 - 2.1) Lymphocytes (%) = 29% (20 - 40) PO4 (mg/dL) = 3.6 (2.3 - 4.7) Monocytes (%) = 2 (2 - 8) AST (IU/L) = 62 (10 - 40) ALT (IU/L) = 58 (10 - 40) Albumin (g/dL) = 3.1 (3.5 - 5) Tests: Chest X-ray: Bilateral infiltrates with ground glass appearance. Recommend chest CT for further evaluation. Plan: Obtain CD4+ count and viral load. Admit for IV antibiotics and additional diagnostic work-up. Based on chest X-ray, KS will be treated empirically for PCP. An order is received for Bactrim 20 mg/kg/day IV divided Q6H. What is the correct dose? A Bactrim 26 mg IV Q6H B Bactrim 160 mg IV Q6H C Bactrim 240 mg IV Q6H D Bactrim 300 mg IV Q6H E Bactrim 950 mg IV Q6H

C - 105 pounds = 47.7 kg. 47.7 kg x 20 mg/kg = 954 mg Bactrim per day divided Q6H. Approximately 238.5 mg IV Q6H, so the dose is rounded to 240 mg IV Q6H.

SN is prescribed Avelox for a community-acquired pneumonia infection. What is the mechanism of action for Avelox? A Binds to pencillin binding proteins to inhibit cell wall synthesis B Binds to the 30s ribosomal subunit, inhibiting protein synthesis C Inhibits DNA topoisomerase IV, thereby blocking DNA gyrase D Inhibits synthesis of Beta (1,3)-D-glucan E Binds to the 50s ribosomal subunit, inhibiting protein sythesis

C - Avelox is a fluoroquinolone and works by binding to topoisomerase IV to inhibit DNA gyrase and the double helical coiling of the DNA.

CP is a 22 year-old female who has been started on Macrobid for a five day treatment course of a urinary tract infection. Counseling on Macrobid should include the following points? A Do not take antacids or calcium supplements at the same time as your Macrobid dose. B This medication should be taken four times daily in evenly spaced intervals (every 6 hours). C This medication may cause the urine to turn dark yellow or brown in color. This is usually a harmless, temporary effect and will disappear when the medication is stopped. D This medicine can make the skin more sensitive to the sun, and the patient can burn more easily. Use sunscreen and protective clothing. E This drug should be taken on an empty stomach.

C - Nitrofurantoin (Macrobid) is dosed twice daily, hence the brand name MacroBID. Nitrofurantoin does not have chelation interactions and does not cause photosensitivity. It is associated with GI upset and should be taken with food.

KS is diagnosed with PCP and stabilized. She is ready for discharge. Her provider is concerned that the cellulitis has not healed as well as he had hoped. He asks the pharmacist about a single dose medication for bacterial skin and skin structure infections that he heard about. He thinks this patient would be a good candidate for this drug. Which drug is he referring to? A Vancomycin B Telavancin C Oritavancin D Tedizolid E Polymyxin

C - Oritavancin (Orbactiv) and dalbavancin (Dalvance) are lipoglycopeptides with similar spectrum of activity to vancomycin: both have activity against Staphylococci (MSSA and MRSA) and Streptococci. Oritavancin and dalbavancin are a one-time dose.

VK is a 67 year-old female with diabetes, overactive bladder and hypothyroidism who has been started on Cipro for treatment of a urinary tract infection, based on susceptibility testing. Which of the following counseling points are not appropriate for VK? A This medication can cause confusion. B This medicine should be taken 2 hours before or 6 hours after taking Maalox C Cipro is associated with occurrence of muscle aches. D This medicine can make the skin more sensitive to the sun, and the patient can burn more easily. Use sunscreen and protective clothing. E Monitor blood glucose carefully while taking this medication.

C - Quinolones penetrate the CNS and can cause many CNS toxicities (including seizures) and are associated with photosensitivity. They should be separated from divalent cations to avoid chelation and reduced absorption. Quinolones can cause hypoglycemia or hyperglycemia, so patients with diabetes should monitor bloood glucose closely during therapy. Quinolones are associated with tendon rupture (primarily Achilles), not muscle aches.

Choose the correct term for the lowest drug concentration that will inhibit the growth of an organism: A Minimum bactericidal concentration B Post antibiotic effect C Minimum inhibitory concentration D Resistance E Intermediate sensitivity

C - The minimum inhibitory concentration (MIC) is the lowest concentration of an antimicrobial drug that will inhibit the visible growth of a microorganism. Minimum inhibitory concentrations are important to determine susceptibility of microorganisms to an antimicrobial agent and to monitor activity of antimicrobial agents.

BJ is on tobramycin IV every 8 hours for treating a gram-negative infection and his levels are reported as a peak of 8.3 mcg/mL and a trough of 2.4 mcg/mL. Which of the following recommendations should the pharmacist make to the medical team? A Increase the dose of tobramycin B Reduce the dose of tobramycin C Extend the dosing interval of tobramycin D Reduce the dose and extend the interval of tobramycin E Shorten the dosing interval of tobramycin

C - The peak of tobramycin is within range, but the trough level is above the goal level (it should be less than 2 mcg/mL and ideally less than 1.5 mcg/mL). By extending the dosing interval, the trough level will decrease and the toxicity risk is lowered without decreasing the peak for this concentration-dependent drug.

A patient gave the pharmacist a prescription for Augmentin 875 mg Q12H #20. Which of the following should be dispensed? A Ampicillin/clavulanate B Ampicillin/tazobactam C Amoxicillin/clavulanate D Amoxicillin/tazobactam E Imipenem/cilastatin

C -Amoxicillin/clavulanate is the generic name of Augmentin. Clavulanic acid, or clavulanate, inactivates beta lactamase enzymes, which extends the activity (or coverage) of the drug.

A patient gave the pharmacist a prescription for Ceftin 500 mg BID #14. Which of the following is an appropriate generic substitution for Ceftin? A Cefprozil B Cefpodoxime C Doripenem D Cefuroxime E Cefdinir

D

An otherwise healthy patient presents with a foot infection that developed 1 week after stepping on a child's toy. The wound culture is growing Gram-positive and Gram-negative bacteria; Pseudomonas is not suspected. The physician would like to use a cephalosporin for treatment of the patient's infection. Which of the following statements regarding cephalosporins is correct? A Cefazolin is an oral cephalosporin that is considered to be the most effective therapy for mild-moderate Gram-negative foot infections. B Cefixime is the only oral cephalosporin with Gram-negative and enteric anaerobic coverage. C Cephalexin is an oral, second-generation cephalosporin with sufficient Gram-negative and Gram-positive coverage for moderate severity foot infections. D Cefuroxime is an oral, second-generation cephalosporin with adequate Gram-negative and Gram-positive coverage for mild-moderate foot infections. E Cefpodoxime is an intravenous, third-generation cephalosporin with adequate Gram-positive and Gram-negative coverage for severe foot infections.

D - Cefazolin is an intravenous cephalosporin. Cefixime is not effective for enteric anaerobes. Cephalexin is a first generation cephalosporin and cefpodoxime is an oral, third-generation cephalosporin. Cefuroxime is a second generation cephalosporin and is effective in treating Streptococci, MSSA and Gram-negative bacteria associated with mild-moderate foot infections.

TM is a 42 year-old male who has been started on Biaxin for treatment of pneumonia. Which of the following medications does not pose a drug interaction with the antibiotic treatment? A Amiodarone B Methadone C Simvastatin D Sucralfate E Voriconazole

D - Clarithromycin (as well as erythromycin) is a strong CYP3A4 inhibitor and is contraindicated with simvastatin (and lovastatin) and can cause increased concentrations of methadone and voriconazole. Macrolides are associated with QT interval prolongation, which would be additive with amiodarone, methadone and voriconazole. Macrolides do not have chelation issues with sucralfate.

MS is a 62 year-old male with primary lung cancer admitted to the hospital for weakness. On hospital day 8 the patient was diagnosed with hospital-acquired pneumonia. The team would like to cover for Gram-negative pathogens with meropenem and an additional agent for MRSA coverage. Allergies include vancomycin (angioedema, hypotension) and clindamycin (diarrhea). Which of the following intravenous agents should the pharmacist recommend in this case? A Daptomycin B Tigecycline C Vancomycin D Zyvox E Ceftaroline

D - Daptromycin (Cubicin) is not indicated for pneumonia as it is inactivated by lung surfactant. Tygacil has activity against MRSA, however there is limited data supporting it's use for pneumonia and more importantly the FDA has issued a boxed warning noting that it should be reserved for situations when alternate treatments are not suitable (due to increased mortality in studies compared to other agents). Ceftaroline is a 5th generation cephalosporin with broad coverage and duplicates coverage of meropenem. Zyvox is the best option in this case to provide targeted coverage of MRSA.

Rifaximin may be used in management of all of the following EXCEPT: A Hepatic encephalopathy B IBS with diarrhea C Refractory C. difficile D Spontaneous bacterial peritonitis E Travelers' diarrhea

D - Rifaximin (Xifaxin) is an antibacterial agent that is structurally related to rifampin. It is indicated for the treatment of non-invasive E. coli travelers' diarrhea, for reduction in the risk of overt hepatic encephalopathy and for IBS-D. Since systemic drug absorption is minimal, it is not useful for spontaneous bacterial peritonitis (SBP).

HW is a 71 year-old male who has been in the intensive care unit for several weeks and is now being treated for pneumonia, with a lower respiratory culture positive for Pseudomonas aeruginosa. His weight is 225 pounds and height is 6'0". His current serum creatinine is 2.4 mg/dL. Based on the culture sensitivities, the medical team decides to start tobramycin at 2.5 mg/kg. They ask the pharmacist to write the order and administer the first dose at 8:00 AM. Which of the following is the correct tobramycin regimen for this patient? A Tobramycin 500 mg IV then dose per levels B Tobramycin 200 grams IV Q24H C Tobramycin 200 mg IV Q8H D Tobramycin 220 mg IV Q24H E Tobramycin 220 mg IV Q8H

D- Tobramycin is dosed anywhere from 1-2.5 mg/kg for traditional dosing. Since this patient is very ill, the team chose to go with the higher end dose. Aminoglycosides are dosed using adjusted body weight for obese patients. 2.5 mg/kg x 87.47 kg = 218.68 mg; round to 220 mg. His estimated creatinine clearance is between 30-40 mL/min regardless of which weight was used to calculate it (you should use his adjusted body weight in this case), so his dosing interval should be Q24 hours. Administering the drug every 8 hours would be too frequent for someone with this degree of renal impairment.

Extended-infusion piperacillin-tazobactam is a dosing strategy that optimizes which of the following pharmacodynamic parameters? A Peak:MIC ratio B AUC:MIC ratio C Peak concentration D Time above MIC (T > MIC) E Minimum bactericidal concentration

D-As a beta-lactam antibiotic, piperacillin/tazobactam kills or inhibits bacterial growth when drug concentrations exceed the minimum inhibitory concentration (MIC). Extending the infusion (from the traditional 30 minutes to infusing over 4 hours) results in greater T > MIC and is one way to optimize the activity of beta-lactams and effectively treat more resistant (higher MIC) organisms.

Chief Complaint: "I'm out of my inhaler and I can't breathe". History of Present Illness: KS is a 30 year-old female who comes to the ER today for worsening shortness of breath and cough. She is out of her albuterol inhaler. She occasionally lives on the street, but has been staying in the local homeless shelter for 3 nights. She reports fatigue, but denies night sweats and hemoptysis. Her cough is nonproductive. A mild right lower extremity cellulitis extending from right ankle to right calf is noted. Patient states she scraped her leg on a fence and it has not healed. She has not been treated with antibiotics. Allergies: NKDA Past Medical History: HIV x 5 years, PCP pneumonia 5 years ago when she was diagnosed with HIV, asthma, and dyslipidemia Medications: Truvada 1 tablet daily, Tivicay 50 mg once daily, albuterol inhaler 1 puff 3-4 times daily as needed, Flovent Diskus 100 mcg BID, simvastatin 20 mg QHS Physical Exam / Vitals: Height: 5'2" Weight: 105 pounds BP: 122/72 mmHg HR: 71 BPM RR: 18 BPM Temp: 103.2°F Pain: 3/10 General: Pleasant, ill-appearing female Lungs: decreased breath sounds bilaterally - right worse than left. Mild wheezing CV: RRR - no murmurs GI: Normal bowel sounds Ext: Mild right lower extremity cellulitis with some purulent drainage Labs: Na (mEq/L) = 129 (135 - 145) WBC (cells/mm3) = 10.4 (4 - 11 x 103) K (mEq/L) = 3.5 (3.5 - 5) Hgb (g/dL) = 13.4 (13.5 - 18 male, 12 - 16 female) Cl (mEq/L) = 103 (95 - 103) Hct (%) = 40.1 (38 - 50 male, 36 - 46 female) HCO3 (mEq/L) = 24 (24 - 30) Plt (cells/mm3) = 202 (150 - 450 x 103) BUN (mg/dL) = 12 (7 - 20) PMNs (%) = 92 (45 - 73) SCr (mg/dL) = 0.9 (0.6 - 1.3) Bands (%) = 7 (3 - 5) Glucose (mg/dL) = 118 (100 - 125) Eosinophils (%) = 3 (0 - 5) Ca (mg/dL) = 8.8 (8.5 - 10.5) Basophils (%) = 0 (0 - 1) Mg (mEq/L) = 1.8 (1.3 - 2.1) Lymphocytes (%) = 29% (20 - 40) PO4 (mg/dL) = 3.6 (2.3 - 4.7) Monocytes (%) = 2 (2 - 8) AST (IU/L) = 62 (10 - 40) ALT (IU/L) = 58 (10 - 40) Albumin (g/dL) = 3.1 (3.5 - 5) Tests: Chest X-ray: Bilateral infiltrates with ground glass appearance. Recommend chest CT for further evaluation. Plan: Obtain CD4+ count and viral load. Admit for IV antibiotics and additional diagnostic work-up. Question The physician asks the pharmacist on rounds to assist with transitioning the patient to oral Bactrim 20 mg/kg/day in preparation for hospital discharge. What is the correct dose? A Bactrim SS 2 tabs BID B Bactrim SS 2 tabs TID C Bactrim DS 1 tab TID D Bactrim DS 2 tabs BID E Bactrim DS 2 tabs TID

E - 105 pounds = 47.7 kg. 47.7 kg x 20 mg/kg = 954 mg Bactrim/day. Bactrim is dosed from the TMP component and DS tabs have 160 mg TMP per tab. KS would need 6 tabs per day (954 mg Bactrim / 160 mg TMP per tab) to treat her infection. To avoid errors, mg/kg doses should reference the TMP component. When using higher SMX/TMP doses like this, monitor the patient carefully for side effects.

LJ is receiving ampicillin/sulbactam for the treatment of a Proteus mirabilis bacteremia. The physician wants to know how ampicillin/sulbactam works. Which of the following best characterizes the pharmacodynamic properties of ampicillin/sulbactam? Ampicillin/sulbactam exhibits concentration-dependent bacterial killing B Ampicillin/sulbactam exhibits concentration-above-MIC-dependent killing C Ampicillin/sulbactam exhibits AUC:MIC killing D Ampicillin/sulbactam exhibits post antibiotic effect for bacterial killing E Ampicillin/sulbactam exhibits time-dependent bacterial killing

E - Ampicillin, a beta-lactam antibiotic, exhibits time-dependent killing. Therefore, maximizing the amount of time spent at a concentration above the MIC (T > MIC) correlates to optimal effectiveness of ampicillin's ability to inhibit bacterial cell growth. This is why ampicillin/sulbactam is given more frequently (Q6H) than concentration-dependent drugs (e.g., quionolones). Sulbactam is a beta-lactamase inhibitor.

Which of the following groups of pathogens best represents clindamycin's spectrum of activity? Atypicals and anaerobic pathogens B Multidrug-resistant Gram-negative pathogens (Acinetobacter, Pseudomonas) and skin flora (Streptococci, Staphylococci) C Enteric Gram-negative pathogens and anaerobic pathogens D Parasitic and fungal pathogens E Aerobic (Streptococci, Staphylococci) and anaerobic Gram-positive pathogens

E - Clindamycin has excellent coverage for Gram-positive pathogens (Streptococci, Staphylococci, but not Enterococci) and anaerobic pathogens.

Which of the following statements is incorrect regarding daptomycin? A It exhibits concentration-dependent killing. B The intravenous formulation is incompatible with D5W. C It is associated with myopathy/muscle toxicity, thus monitor for creatine kinase. D It requires dose adjustments for moderate to severe renal impairment. E The oral formulation has excellent bioavailability.

E - Daptomycin requires dose adjustments for CrCl < 30 mL/min. It is associated with myopathy and rarely rhabdomyolysis. Creatine kinase should be monitored weekly (more often if renal impairment or on statin). Daptomycin is only available in intravenous formulation which is compatible with normal saline, not with dextrose.

A patient is taking Macrobid for treatment of a urinary tract infection. Which of the following statements regarding Macrobid is correct? A This medication may cause the urine to turn blue in color. B The dose is given Q6H. C This medication is not absorbed when taken concurrently with food. D This medication can be used for pyelonephritis. E This medication should not be used if CrCl is < 60 mL/min.

E - Nitrofurantoin can cause brown urine discoloration. Macrobid is given twice daily (BID). Nitrofurantoin is contraindicated in patients with a creatinine clearance less than 60 mL/min. Nitrofurantoin should be taken with food to enhance absorption and decrease GI upset. Nitrofurantoin is only indicated for uncomplicated cystitis as serum levels are not adequate to treat systemic infections or complicated UTIs. Long term use can lead to serious and fatal pulmonary toxicity.

The Gram-stain of a patient's blood culture reveals Gram-positive cocci in chains. Which organism is consistent with this observation? A H. influenzae B MSSA C Acinetobacter baumannii D Staph. aureus E Strep. pyogenes

E - Strep species tend to organize in pairs or chains. S. pyogenes is also called Group A strep and it can cause "strep throat" as well as more severe diseases, including necrotizing fasciitis. It is not possible to differentiate MRSA from MSSA on the Gram-stain. This is determined by the susceptibility testing. H. influenzae and Acinetobacter are Gram-negatives.

Which one of the following antimicorbials in IV formulation is stable in and preferred to be reconstituted in normal saline

Ertapenem ampicillin

An infection caused by e. coli that produces ESBL could be treated with which of the following abx

Invanz (ertapenam) Zerbaxa(ceftolazane/tazabactam) avycaz(ceftazidime/avibactam

Which of the following abx suspensions should be refridgerated?

Keflex

Which one of the following abx does NOT require dose adjustment in renal impairment?

Nafcillin

Natural penicillins

Penicillin G (dental) mostly gram +/mouth anaerobes