Chapter 8 part 1: ID

D.M. is a 21-year-old university student who presents to the emergency department with the worst headache of his life. During the past few days, he has felt slightly ill but has been able to go to class regularly and eat and drink adequately. This morning, he awoke with a terrible headache and pain whenever he moved his neck. He has no significant medical history and takes no medications. He cannot remember the last time he received a vaccination. On physical examination, he is in extreme pain (10/10) with the following vital signs: temp 102.4°F (39.1°C), HR 110 bpm, respiratory rate 18 breaths/minute, and bp 130/75 mm Hg. His laboratory values are wnl, except for WBC 22,500 cells/mm3 (82 poly- morphonuclear leukocytes, 11 band neutrophils, 5 lymphocytes, and 2 monocytes). A computed tomography scan of the head is normal, so a lumbar puncture is performed with the following results: glucose 44 mg/dL (peripheral, 110), protein 220 mg/dL, and WBC 800 cells/mm3 (85% neutrophils, 15% lymphocytes). Which is the best empiric therapy for D.M.? A. Penicillin G 4 million units intravenously every 4 hours. B. Ceftriaxone 2 g intravenously every 12 hours. C. Ceftriaxone 2 g intravenously every 12 hours plus dexamethasone 10 mg intravenously every 6 hours. D. Ceftriaxone 2 g intravenously every 12 hours plus vancomycin 1000 mg intravenously every 8 hours plus dexamethasone 10 mg intravenously every 6 hours.

D Bacterial meningitis: protein > 150, glucose <0.4 blood, WBC high w/ dominant neutrophil Vanco for pen-resistant S.peneu Dexa include in empiric Vanco+dexa can be dc if rule out pneumococcal

B.P. is a 66-y/o woman who underwent a 2-vessel CABG 8 days ago and has been on a ventilator in the surgical intensive care unit since then. Her temperature is now rising and her chest radiograph reveals a new infiltrate in the right lower lobe. Her medical history includes CAD with a MI 2 years ago, COPD, and hypertension. All antipseudomonal antibiotics in the institution are active against at least 90% of strains. B.P. has no known drug allergies. Which is the best empiric therapy for B.P.? A. Ceftriaxone 1 g intravenously every 24 hours plus gentamicin 7 mg/kg intravenously every 24 hours plus linezolid 600 mg intravenously every 12 hours. B. Piperacillin/tazobactam 4.5 g intravenously every 6 hours. C. Levofloxacin 750 mg intravenously every 24 hours plus linezolid 600 mg intravenously every 12 hours. D. Cefepime 2 g intravenously every 8 hours plus tobramycin 7 mg/kg intravenously every 24 hours plus vancomycin 15 mg/kg intravenously every 12 hours.

D Hospitalized > 5d: Pseudo coverage (most guidelines recommend double coverage even though antipseudomonal abx active againse >90%)

T.S. is a 48-year-old man who presents to the emergency department with fever, chills, nausea and vomiting, anorexia, lymphangitis in his right hand, and lower back pain. He has no significant medical history except for kidney stones 4 years ago. He has NKDA. He is homeless and was a person with SUD (intravenous heroin) for the past year but quit 2 weeks ago. On physical examination, he is alert and oriented, with the following vital signs: temperature 100.8°F (38°C), heart rate 114 beats/minute, respiratory rate 12 breaths/minute, and blood pressure 127/78 mm Hg. He has a faint systolic ejection murmur, and his right hand is erythematous and swollen. His laboratory values are all within normal limits. He had an HIV test 1 year ago, which was negative. One blood culture was obtained in the emergency department that later grew MSSA. Two more cultures were obtained 24 hours after the first culture and are now both growing gram-positive cocci in clusters. A transesophageal echocardiogram reveals vegetation on the mitral valve. Which is the best therapeutic regimen for T.S.? A. Nafcillin therapy for 7-10 days. B. Nafcillin plus rifampin plus gentamicin therapy for 6 weeks or longer. C. Nafcillin plus gentamicin therapy for 2 weeks of both antibiotics. D. Nafcillin therapy for 6 weeks.

D Only strep can be treated for 2 weeks No rifampin+genta for native valve

O.R. is a 73-year-old man who presents to the emergency department with a 3-day history of fever, chills, frequency, urgency, and perineal pain. A urinalysis reveals many bacteria. A rectal examination reveals a swollen, tender prostate. He is given a diagnosis of acute bacterial prostatitis. Which is the best regimen for this patient? A. Amoxicillin/clavulanate 875 orally twice daily for 7 days. B. Trimethoprim/sulfamethoxazole double strength orally twice daily for 14 days. C. Cefprozil 500 mg orally twice daily for 21 days. D. Ciprofloxacin 500 mg orally twice daily for 28 days.

D Prostatis: 4wks FQ of Bactrim only

H.W. is a 38-year-old woman who presents with a fever, malaise, dry cough, nasal congestion, and severe headaches. Her symptoms began suddenly 3 days ago, and she has been in bed since then. She reports no other illness in her family, but several people have recently called in sick at work. It is influenza season. Which is best for H.W.? A. Azithromycin 500 mg, followed by 250 mg daily orally for 4 more days. B. Amoxicillin/clavulanic acid 875 mg orally twice daily for 5 days. C. Oseltamivir 75 mg twice daily orally for 5 days. D. Symptomatic treatment only.

D dry cough, high temp, malaise, nasal congestion, severe HA: influenza Oseltamivir: only 48hs

B.K. is a 58-year-old woman (height 66 inches, weight 82 kg) who is scheduled to undergo a total knee replacement tomorrow. She has no significantmedical history and no drug allergies. Which is the best surgical prophylaxis regimen for this patient? A. Cefazolin 2 g within 1 hour of the incision and no doses postoperatively. B. Cefazolin 2 g within 4 hours of the incision and three doses every 8 hours postoperatively. C. Cefazolin 1 g within 1 hour of the incision and three doses every 8 hours postoperatively. D. Cefazolin 1 g within 4 hours of the incision and no doses postoperatively.

A

B.Y. is an 85-year-old woman who is bedridden and lives in a nursing home. She is chronically catheterized, and her urinary catheter was last changed 3 weeks ago. Today, her urine is cloudy, and a UA reveals many bacteria. B.Y. is not noticing any symptoms. A urine culture is obtained. Which option is best for B.Y.? A. No therapy because she is chronically catheterized and has no symptoms. B. No antibiotic therapy, but the catheter should be changed. C. Ciprofloxacin 500 mg orally twice daily for 7 days and a new catheter. D. Ciprofloxacin 500 mg orally twice daily for 14-21 days without a change in catheter.

A Chronically catheterized: no therapy, asymptomatic - no need to replace catheter if initiate abx: 7d

W.A. is a 55-year-old man who presents with weight loss, malaise, and severe back pain and spasms that have progressed during the past 2 months. He has also experienced loss of sensation in his lower extremities. Four months before this admission, he had surgery for a fractured tibia, followed by an infection treated with unknown antibiotics. W.A. has hypertension and a history of diverticulitis. On PE, he is alert and oriented, with the following vital signs: temperature 99.4°F (37.4°C), HR 88 bpm, RR 14 bpm, and blood pressure 130/85 mm Hg. His laboratory values are wnl, except for WBC 14,300 cells/mm3, ESR 89 mm/hour, and CRP 12 mg/dL. MRI reveals bony destruction of lumbar vertebrae 1 and 2, which is confirmed by a bone scan. A CT-guided bone biopsy reveals Gr(+) cocci in clusters. Which is the best therapy for W.A.? A. Vancomycin 15 mg/kg intravenously every 12 hours for 6 weeks. B. Nafcillin 2 g intravenously every 6 hours for 2 weeks. C. Levofloxacin 750 mg orally every 24 hours for 6 weeks. D. Ampicillin/sulbactam 3 g intravenously every 6 hours for 2 weeks.

A Possible Staph Duration: 4-6 wks

You are a pharmacist who works closely with the surgery department to optimize therapy for patients undergoing surgical procedures at your institution. The surgeons provide you with principles of surgical prophy- laxis that they believe are appropriate. Which is the best practice for optimizing surgical prophylaxis? A. Antibiotics should be redosed for extended surgical procedures; redose if the surgery lasts longer than 4 hours or involves considerable blood loss. B. All patients should be given antibiotics for 24 hours after the procedure; this will optimize prophylaxis. C. Preoperative antibiotics can be given up to 4 hours before the incision; this will make giving the antibiotics logistically easier. D. Vancomycin is the antibiotic of choice for surgical wound prophylaxis because of its long half-life and activity against MRSA.

A must be given w/in 2h

D.M.'s CSF cultures grew N. meningitidis, and now there is concern about prophylaxis. Which is the best recommendation for meningitis prophylaxis? A. The health care providers in close contact with D.M. should receive rifampin 600 mg orally every 12 hours for four doses. B. Everyone in D.M.'s dormitory and in all of his classes should receive rifampin 600 mg orally every 24 hours for 4 days. C. Everyone in the emergency department at the time of D.M.'s presentation should receive the meningococcal conjugate vaccine. D. Everyone in the emergency department at the time of D.M.'s presentation should receive rifampin 600 mg orally every 12 hours for four doses.

A only close contact

V.E. is a 44-year-old man who presents to the ED with a warm, erythematous, and painful right lower extremity. There is no raised border at the edge of the infection. 3 days ago, he scratched his leg on a barbed wire fence on his property (no puncture wound associated with the fence). His temperature has been as high as 101.8°F (38°C) with chills. Doppler studies of his lower extremity are negative. Blood cultures are negative. Which is the best empiric therapy for V.E.? A. Cefazolin 1 g intravenously every 8 hours. B. Penicillin G 2 million units intravenously every 4 hours. C. Piperacillin/tazobactam 3.375 g intravenously every 6 hours. D. Enoxaparin 80 mg subcutaneously twice daily and warfarin 5 mg daily orally.

A penicillin: ok for erysipelas, not cellulitis

P.E. is a 56-year-old man who comes to the clinic with a 3-day history of fever, chills, pleuritic chest pain, malaise, and productive cough. In the clinic, his temperature is 102.1°F (38.9°C) (all other vital signs are normal). His chest radiograph reveals consolidation in the right lower lobe. His WBC is 14.4k cells/mm3, but all other laboratory values are normal. He is given a diagnosis of CAP. He has not received any antibiotics in 5 years and has no chronic disease states. Which is the best empiric therapy for P.E.? A. Doxycycline 100 mg orally twice daily. B. Cefuroxime axetil 250 mg orally twice daily. C. Levofloxacin 750 mg orally daily. D. Trimethoprim/sulfamethoxazole double strength orally twice daily.

A (CURB: 1 at most) DOC: macrolide or doxy

R.K. is a 72-year-old man who presents to the emergency department with a 2-day history of redness and swelling of his upper right extremity. He scraped his arm while clearing some brush in his yard. Although the scratch was initially healing, the area around the injury has become red and warm to the touch over the past few days, and the redness appears to be spreading. His medical history includes GERD, HTN, hyperlipidemia, and osteoarthritis. R.K. is taking pantoprazole 40 mg orally daily, lisinopril 20 mg orally daily, atorvastatin 40 mg orally daily, and acetaminophen 500 mg orally prn. R.K. has no known drug allergies. R.K. is hospitalized and sent home after a few days with a prescription for oral clindamycin for his cellulitis. Two weeks after completing therapy for his cellulitis, R.K. has watery diarrhea. R.K. goes to the emergency department, and his C. difficile toxin is positive. His WBC is 24,500 cells/mm3, albumin is 2.8 g/dL, and SCr is 1.74 mg/dL (normally around 0.90 mg/dL). Which is the best therapeutic regimen for R.K.? A. Metronidazole 500 mg orally three times daily for 7 days. B. Vancomycin 125 mg orally four times daily for 10 days. C. Fidaxomicin 200 mg orally twice daily for 14 days. D. Rifaximin 400 mg orally twice daily for 7 days.

B C.diff: low albumin, elevated SCr?

A study is designed to assess the risk of pneumococcal pneumonia in older adults 10 years or more after receiving their last pneumococcal vaccination, compared with older adults who have never received any pneumococcal vaccinations. Which study design is best? A. Case series. B. Case-control study. C. Prospective cohort study. D. Randomized controlled trial.

B Case control: most ethical, cost-effective, timely method Prospective cohort: need too many ppl bc of low incidence, costly

G.N. is a 62-year-old woman who presents to the emergency department with a 3-day history of urinary frequency and dysuria. During the past 24 hours, she has had n/v, and flank pain. G.N. has a hx of DM, which is poorly controlled, with some diabetes-related complications. G.N. also has HTN and a hx of several episodes of DVT. Her medications include glyburide 5 mg orally daily, enalapril 10 mg orally twice daily, warfarin 3 mg orally daily, and metoclopramide 10 mg orally four times daily. On PE, she is alert and oriented, with the following vital signs: temperature 102.8°F (39°C), heart rate 120 beats/minute, respiratory rate 16 breaths/minute, supine blood pressure 140/75 mm Hg, and standing blood pressure 110/60 mm Hg. Her laboratory values are WNL except for elevated INR 2.7, BUN 26 mg/dL, SCr 1.88 mg/dL, and WBC 12,000 cells/mm3 (78 polymorphonuclear leukocytes, 7 band neutrophils, 10 lymphocytes, and 5 monocytes). Her urinalysis reveals turbidity, 2+ glucose, pH 7.0, protein 100 mg/dL, 50-100 WBCs, positive nitrites, 3-5 red blood cells, and many bacteria and positive for casts. Which is the best empiric therapy for G.N.? A. Trimethoprim/sulfamethoxazole double strength orally twice daily for 7 days. Monitor INR carefully. B. Ciprofloxacin 400 mg intravenously twice daily and then 500 mg orally twice daily for a total of 7 days. Monitor INR carefully. C. Gentamicin 140 mg intravenously every 24 hours for 3 days. D. Tigecycline 100 mg once, then 50 mg intravenously every 12 hours and then doxycycline 100 mg orally twice daily for a total of 10 days.

B PO Bactrim: not appropriate for complicated UTI, also interact w/warfarin Tigecycline: not appropriated for cUTI

6 months after treatment of his endocarditis, T.S. is visiting his dentist for a tooth extraction. Which antibiotic is best for prophylaxis? A. Tooth extractions do not warrant endocarditis prophylaxis. B. Administer amoxicillin 2 g 1 hour before the extraction. C. Administer amoxicillin 3 g 1 hour before the extraction and 1.5 g 6 hours for four doses after the extraction. D. T.S. is not at increased risk of endocarditis and does not need prophylactic antibiotics.

B Tooth extractions warrant prophylaxis

J.M.isa72-year-old woman with a hix of a.fib, HTN, a right total hip replacement 8 months earlier, and Crohn disease. She has no drug allergies. She presents to the hospital with increasing pain in her prosthetic hip over the past month. There is concern about hip osteomyelitis. Bone cultures are growing MSSA. J.M. has normal renal function and no known drug allergies. Which is the best antibiotic regimen for this patient with a prosthetic hip infection? A. Vancomycin 1000 mg intravenously every 12 hours plus rifampin 300 mg orally twice daily for 2 weeks. B. Cefazolin 2 g intravenously every 8 hours plus rifampin 300 mg orally twice daily for 6 weeks followed by long-term oral antibiotics. C. Nafcillin 1 g intravenously every 4 hours for 6 weeks. D. Daptomycin 6 mg/kg intravenously daily for 6 weeks followed by long-term oral antibiotics.

B combination 2 abx 2-6 wks IV, then 3 months oral

N.L. is a 28-year-old woman with no significant medical history. She reports to the ED with fever and severe right lower quad-rant pain. The pain had been dull for the past few days, but it suddenly became severe during the past 8 hours. Her temperature is 103.5°F (39.7°C),and she has rebound tenderness on abdominal examination. She is taken to surgery immediately, where a perforated appendix is diagnosed and repaired. Which is the best follow-up antibiotic regimen? A. Vancomycin 1000 mg intravenously every 12 hours plus metronidazole 500 mg intrave- nously every 8 hours. B. Cefazolin 1 g intravenously every 8 hours plus ciprofloxacin 400 mg intravenously every 12 hours. C. Ceftriaxone 1 g intravenously every 24 hours plus metronidazole 500 mg intravenously every 8 hours. D. No antibiotics needed after surgical repair of a perforated appendix.

C

R.L. is a 68-y/o man who presents to the ED with coughing and SOB. His symptoms, which began 4 days ago, have worsened during the past 24 hours. He is coughing up yellow-green sputum, and he has chills, with a temperature of 102.4°F (39°C). His medical history includes CAD with a MI 5 years ago, CHF, HTN, and osteoarthritis. He rarely drinks alcohol and has not smoked since his myocardial infarction. He lives at home with his wife. His medications on admission include lisinopril 10 mg/day, hydrochlorothiazide 25 mg/day, and acetaminophen 650 mg four times/day. On physical examination, he is alert and oriented, with the following vital signs: temperature 101.8°F (38°C), heart rate 100 beats/minute, respiratory rate 32 breaths/minute, and blood pressure 142/94 mm Hg. His laboratory results are normal except for blood urea nitrogen (BUN) 32 mg/dL (serum creatinine [SCr] 1.23 mg/dL). A chest radiograph reveals infiltrates in the right lower lobe. A sputum specimen is not available. If R.L. were hospitalized, which would be the best empiric therapy for him? A. Ampicillin/sulbactam 1.5 g intravenously every 6 hours. B. Piperacillin/tazobactam 4.5 g intravenously every 6 hours plus gentamicin 180 mg intravenously every 12 hours. C. Ceftriaxone 1 g intravenously every 24 hours plus azithromycin 500 mg intravenously every 24 hours. D. Doxycycline 100 mg intravenously every 12 hours.

C

S.C. is a 46-year-old woman who presents to the clinic with purulent nasal discharge, nasal and facial congestion, headaches, fever, and dental pain. Her symptoms began about 10 days ago, improved after about 4 days, and then worsened again a few days later. Which is the best empiric therapy for S.C.? A. Cefpodoxime proxetil 200 mg orally twice daily. B. Clindamycin 300 mg orally four times daily. C. Amoxicillin/clavulanate 875 mg/125 mg orally twice daily. D. No antibiotic therapy needed because this is a typical viral infection.

C Bacterial: 2 major (2 peak fever) + few minor Combination: cefpodoxime + clinda: alt for pen allergy

L.G. is a 49-year-old woman with a history of mitral valve prolapse. She presents to her physician's office with malaise and a low-grade fever. Her physician notes that her murmur is louder than usual and orders blood cultures and an echocardiogram. A large vegetation is observed on L.G.'s mitral valve, and her blood cultures are growing Enterococcus faecalis (susceptible to all antibiotics). Which is the best therapy for L.G.? A. Penicillin G plus gentamicin for 2 weeks. B. Vancomycin plus ceftriaxone for 2 weeks. C. Ampicillin plus ceftriaxone for 4-6 weeks. D. Cefazolin plus gentamicin for 4-6 weeks.

C Duration: 4-6 Cefazolin: no activity against E.faecalis

R.K. is a 36-year-old woman who presents to the emergency department with a severe headache and neck stiffness. Her temperature is 99.5°F (37.5°C). After a negative computed tomographic scan of the head, a lumbar puncture reveals the following: glucose 54 mg/dL (peripheral, 104 mg/dL), protein 88 mg/dL, and WBC 220 cells/mm3 (100% lymphocytes). The Gram stain reveals no organisms. Which option describes the best therapy for R.K.? A. This is aseptic (probably viral) meningitis, and no antibiotics are necessary. B. Administer ceftriaxone 2 g intravenously every 12 hours until the cerebrospinal fluid (CSF) cultures are negative for bacteria. C. Administer ceftriaxone 2 g intravenously every 12 hours and vancomycin 15 mg/kg intravenously every 12 hours until the CSF cultures are negative for bacteria. D. Administer acyclovir 500 mg intravenously every 8 hours until the CSF culture results are complete.

C Even if believe aseptic: abx must be given until CSF negative (no need dexa?)

G.N. returns to the clinic in 6 months with no urinary symptoms, but her chief concern is now an ulcer on her right foot. She recently returned from a vacation in Florida and thinks she might have stepped on something while walking barefoot on the beach. Her foot is not sore but is red and swollen around the deep ulcer. Her medications are the same as before. Vital signs are stable, and there is nothing significant on PE except for the right foot ulcer. Laboratory values are within normal limits (SCr 0.86 mg/dL). Which is the best empiric therapy for G.N.? A. Nafcillin 2 g intravenously every 6 hours for 6-12 weeks. B. Tobramycin 120 mg intravenously every 12 hours plus levofloxacin 750 mg intravenously every 24 hours for 1-2 weeks. C. Ampicillin/sulbactam 3 g intravenously every 6 hours for 2-3 weeks. D. Below-the-knee amputation followed by ceftriaxone 1 g intravenously every 24 hours for 1 week.

C Nafcillin: ok for Gr(+) but no (-) and anaerobe Toba/levo: no anarobe. Tobra not good choice for long term DM: nephrotox No need for Pseudo (but warm climate, water)

N.R. is a 28-year-old woman who presents to the clinic with a 2-day history of dysuria, frequency, and urgency. She has no significant medical history, and the only drug she takes is oral contracep- tives. Which is the best empiric therapy for N.R.? A. Nitrofurantoin extended release (ER) 100 mg orally twice daily for 3 days. B. Ciprofloxacin 500 mg orally twice daily for 7 days. C. Trimethoprim/sulfamethoxazole double strength orally twice daily for 3 days. D. Cephalexin 500 mg orally four times daily for 3 days.

C Nitro: 5d FQ: not preferred, no need 7 days

A.B. is a 63-year-old woman who presents to the emergency department with left leg pain and erythema. The pain and erythema have worsened over the past 24 hours, and in the ED, large blisters formed and the leg became numb. The left leg is significantly swollen with a large area of erythema and large bullae extending from the thigh to the upper leg. There is crepitus within the soft tissue. A.B. is found to have rapidly progressing necrotizing fasciitis. A.B. has normal renal function and no known drug allergies. Which is the best empiric therapy for A.B.? A. Vancomycin 15 mg/kg intravenously every 12 hours. B. Piperacillin/tazobactam 4.5 g intravenously every 8 hours. C. Vancomycin 15 mg/kg intravenously every 12 hours plus meropenem 1 g intravenously every 8 hours plus clindamycin 900 mg intravenously every 8 hours. D. Linezolid 600 mg intravenously every 12 hours plus ceftriaxone 1 g intravenously every 24 hours plus azithromycin 500 mg IV daily.

C Recommend cover Strep, P.aeruginosa, Clinda: reduce toxin from Strep