Therapeutics 3 Tutoring Melanie Jaeger

Exam 2 Tutoring CAP HAP Some UTI and URTI Some Catheter- related infections Some antimicrobial prophylaxis in surgery

CAP

1. JH has suspected pneumonia 1. JH has suspected pneumonia. Gram positive diplococci are found on his sputum gram stain. Which organism is the most likely cause of JH’s Pneumonia? H. flu Klebsiella Staph Strep pneumo D. Strep pneumo

2. Ac is a 68 yo wm presenting to the ED 1/10/17 with altered mental status. Bun 33, RR 24, BP 85/55. What is his curb-65 score? 2 3 4 5 C

3. What level of care is ac (from the previous question) most likely going to need based on his curb-65 score? Treat outpatient Admit to ICU Admit to general ward B. ICU

4. CF is a 60 yo aaf who presents to her pcp with a high fever and productive cough. Her physician suspects pneumonia. Labs: Bun 18, rr 18, bp 87/50. her pmh includes dm type 2. Which of these treatment options is best for her? Treat outpatient with azithromycin Treat outpatient with levofloxacin Treat outpatient with ciprofloxacin Treat inpatient, non-ICU with moxifloxacin Curb-65 score: 1 (BP) treat outpatient B. Treat outpatient with levofloxacin (a respiratory fluoroquinolone)

5. Which of these drugs/ drug combos would be appropriate for treating pneumonia in an inpatient, non-icu setting? Levofloxacin ceftriaxone Ceftriaxone + levofloxacin azithromycin A. Levofloxacin (or moxifloxacin) OR a beta lactam + macrolide (ex. Ceftriaxone + azithromycin)

Zosyn (piperacillin-tazobactam) cefepime 6. A physician consults you for help with choosing treatment for one of his patients with pneumonia. Pseudomonas is a concern. The physician would like to use levofloxacin plus a beta lactam. Which of these beta lactams would not be a good choice? Imipenem ceftriaxone Zosyn (piperacillin-tazobactam) cefepime B. Ceftriaxone

7. What kind of antimicrobial coverage does azithromycin add to cephalosporins?

8. What kind of additional coverage does levofloxacin add to azithromycin plus a cephalosporin?

9. Patients with severe cap admitted through the ed should receive their first antibiotic dose within what time-frame in order to reduce mortality? Within 1 hour of arrival to the ED. Within 4 hours of arrival to the ED. Within 8 hours of arrival to the ED. While still in the ED. D. While still in the ED This is a tricky question. Study shows that patients that received antibiotics within 4 hours had lower mortality, but his slide specifically says to GIVE WHILE IN THE ED.

10. DL Is being treated outpatient for cap 10. DL Is being treated outpatient for cap. Which of these regimens is most appropriate for initial treatment? Levofloxacin 750 mg x 7 days Levofloxacin 750 mg x 5 days Levofloxacin 250 mg x 5 days Levofloxacin 1 g x 3 days B. Levo 750 mg x 5 days

Nosocomial pneumonia

11. At what threshold can pneumonia be diagnosed using a bronchoscopic bal? 103 104-105 106 108 B. Bronchoscopic BAL 104-105 Endotracheal catheter 106 (less specific)

Mycoplasma pneumoniae MRSA 12. KL is a 35 yo wm admitted to roh 1/11/17 with dka. On 1/13/17 kl’s physician suspects that he has contracted pneumonia. A bronchoscopic bal confirms the diagnosis. Which of the following pathogens Is most likely the cause of kl’s pneumonia? KL is not at risk of MDR organisms. P. aeruginosa H. flu Mycoplasma pneumoniae MRSA B. H. flu Don’t have to cover for atypicals in VAP

13. Which of the following antibiotics would be the best empiric choice for KL (from the previous question)? Zosyn Vancomycin Ciprofloxacin Ceftriaxone D. Ceftriaxone OR respiratory FQ OR unasyn (ideally beta lactam first) Ceftriaxone covers PCN-resistant strep pneumo FQ’s cover pcn and cef resistant strep pneumo

14. KL’s cultures come back positive for MSSA 14. KL’s cultures come back positive for MSSA. Which of the following antibiotics is the best treatment option for him? Ceftriaxone Vancomycin Nafcillin Bactrim C. Nafcillin

15. Patient ck is diagnosed with VAP 15. Patient ck is diagnosed with VAP. He was treated with iv antibiotics for a diabetic foot infection 45 days ago. Which of the following drug combos is Not appropriate for his treatment? Cefepime + ciprofloxacin + vancomycin Meropenem + gentamicin + vancomycin Zosyn + gentamicin + linezolid Imipenem + moxifloxacin + vancomycin D. Moxifloxacin does not cover pseudomonas; cipro >>>> levo

Continue AMG for 5 days due to risk of pseudomonas. 16. Cultures for patient ck (from previous question) came back negative. Temp 39 C, bp 130/80, RR 18. ck’s cough has gotten worse. ck has already received 3 days of zosyn+ ciprofloxacin+ vancomycin. What is the best next step in kl’s therapy? Continue AMG for 5 days due to risk of pseudomonas. Switch zosyn to meropenem since treatment has been ineffective, and continue antibiotic therapy for a total of 14 days. Stop all antibiotics. De-escalate therapy by d/c vancomycin. Continue meropenem and cipropfloxacin for another 4 days, for a total of 7 days of therapy. C. Stop all antibiotics. If cultures are negative, you can stop all empiric antibiotics since CK is clinically stable, even though he still has symptoms.

17. Which of the following antibiotics has an FDA indication for HAP? Telvancin (Vibativ) Ceftolozane/tazobactam (Zerbaxa) Ceftazidime/avibactam (Avycaz) Colistin A. Telvancin (this was from last year’s slides)

Catheter-related infections

18. Which of these is a specific risk factor for candidemia? TPN Meningitis UTI Femoral CVC A. TPN

19. Which of these lab results would be a positive diagnosis of CRBSI? A sonification catheter culture that grew >15 cfu of Enterococcus. A blood culture with two bottles positive for Bacillus. A roll plate catheter culture that grew >10 cfu of Enterococcus. A blood culture with one bottle positive for Micrococcus. B. Need 2 of 4 bottles for Corynebacterium, Bacillus, Micrococcus, and CoNS.

20. In which of these cases of crbsi would you most likely recommend that the cvc not be removed before treatment? Uncomplicated, short-term Candida CRBSI Complicated, long-term CRBSI with endocarditis Uncomplicated, long-term staph aureus CRBSI Uncomplicated, long-term Enterococcus CRBSI D. Can keep CVC in uncomplicated enterococcus CRBSI

Surgical prophylaxis

21. Which gram positive organism is the most common pathogen associated with surgery? CoNS Enterococci S. aureus Streptococci C. S. aureus (19% incidence)

22. Which antibiotic would you recommend for surgical prophylaxis before an appendectomy? Zosyn Cefazolin Metronidazole cefotetan D. Cefotetan (or cefoxitin, or cefazolin+metronidazole)

23. The timing of the first dose of an antimicrobial for surgical prophylaxis is critical. How many minutes before the first surgical incision should the first dose of vancomycin be given? 60 minutes 120 minutes 180 minutes 240 minutes B. 120 minutes (for vancomycin and for FQs)

24.The first dose of cefazolin 2 g is given for surgical prophylaxis at 11:30. At what time should the cefazolin be redosed? 13:30 14:30 15:30 3:30 C. 15:30 (4 hours)

UTI

25. Which of these lab findings is most indicative of UTI? Pyuria Positive leukocyte esterases Positive WBC casts Urine pH of 7 B. Leukocyte esterases

26. Which of the following durations of therapy would be appropriate for acute pyelonephritis? 3 days 5 days 14 days 4 weeks C. 14 days

27. Which of the following drugs/durations would NOT be an appropriate treatment selection for uncomplicated cystitis? Levofloxacin 250 mg daily x 3 days Augmentin 500 mg TID x 7 days Bactrim 800-160 BID x 3 days Nitrofurantoin 100 mg BID x 3 days D. Nitrofurantoin 100 mg BID x3 days (Nitrofurantoin is given x 5 days)

28. Lt is a 28 yo wf presenting to the clinic with a uti 28. Lt is a 28 yo wf presenting to the clinic with a uti. This is her 3rd uti in the last 8 months. what would you recommend for her treatment? Recommend that LT receive a prescription for 14 days of ciprofloxacin. Recommend that LT receive an Rx for 14 days of Augmentin, then Nitrofurantoin 100 mg for daily prophylaxis. Recommend that LT receive an Rx for Nitrofurantoin 100 mg for daily prophylaxis. Recommend that LT receive a prescription for 14 days of ciprofloxacin and that LT receive a standing Rx for Bactrim so that she can self-initiate UTI treatment when she recognizes signs/symptoms in the future. B.

A few notes about UTI.. Make sure you know your treatment options and durations What cant be used in complicated/pyelonephritis Prostatitis duration is longer and only bactrim or quinolone is an option Always check for patient allergies (ex. Sulfa, penicillins) Pregnancy: treat bacteriuria even if asymptomatic- consider trimester and CI drugs Nitrofurantoin and bactrim cannot be used in 3rd trimester NO quinolones! Augmentin is a good, safe option

URTI

29. Which of These pathogens is the most common cause of urtis? Strep pneumo Moraxella catarrhalis H. flu viruses D. viruses-up to 50%

A few things to note about urti.. durations of therapy based on age for AOM when to use antibiotics or observation for AOM Definition of recurrent otitis media Otitis media with effusion: if low-risk do watchful waiting for 3 months If OME lasts >3 months, then do a hearing test Penicillin is gold standard for bacterial pharyngitis Topical/oral decongestants and antihistamines are not recommended for rhinosinusitis nonpharm adjuvant therapy

Questions? EMAIL: mjaeger3@uthsc.edu