Therapeutics III Tutoring February 10th, 2016 Lisa Hayes lhayes3@uthsc.edu

Outline Endocarditis Hospital Acquired Pneumonia Catheter Related Infections Surgical Prophylaxis

Things to Remember Symptoms/Signs Duke Criteria/Diagnosis HACEK organisms – importance IVDU – differences Empiric Regimens Diagnostic Regimens TEE v TTE Dental Prophylaxis

Which two valves are affected most by IE? A – mitral and pulmonic B – mitral and tricuspid C – tricuspid and pulmonic D – mitral and aortic D

Which valve is most affected in cases of IVDU? A – mitral B – pulmonic C – tricuspid D - aortic C

Which of the following is not a minor criteria of the Duke Criteria? A - blood culture positive B – Osler’s nodes C – Janeway Lesion D – fever, temp over 38C A

D – Vanc + Gentamicin + Cefepime + Rifampin A patient has not had any valve replacement but is positive for endocarditis based on 2 positive Duke criteria (positive TEE and positive blood culture). He has had symptoms for 3 weeks. Which of the following would be an appropriate regimen? A – Vanc + Rocephin B – Vanc + Unasyn C - Vanc + Cefepime D – Vanc + Gentamicin + Cefepime + Rifampin B

B – Ceftriaxone 2gm IV daily x 6wk A patient has a prosthetic valve. Blood culture results show MSSA. TEE shows extensive vegetation. Recommend appropriate definitive treatment. A – PCN G 24MU divided q4h B – Ceftriaxone 2gm IV daily x 6wk C – Nafcillin 12gm IV divided q6h for 6wk + Rifampin 300mg PO q8h for 6wk + Gent 3mg/kg IV divided q8h for 2wk D – Vancomycin 15mg/kg IV q12h for 6wk + Rifampin 300mg PO q8h for 6wk + Gent 3mg/kg IV divided q8h for 2wk C

A – use tobramycin instead of gentamicin A patient has been diagnosed with E. faecalis endocarditis. The resident thinks he remembers hearing you are supposed to replace the aminoglyoside with another agent. What should you tell him? A – use tobramycin instead of gentamicin B – use ceftriaxone instead of gentamicin C – use cefepime instead of gentamicin D – use clindamycin instead of gentamicin B

A – Amoxicillin 250mg x 1, 24 hours before procedure A patient with a history of infective endocarditis is having all his teeth removed by surgically cutting them out in preparation for receiving dentures. Which of the following regimens would be appropriate for prophylaxis (no allergies to any meds)? A – Amoxicillin 250mg x 1, 24 hours before procedure B – Amoxicillin 2gm x 1, 1 hour before procedure C – Clindamycin 600mg IM x 1, 1 hour before procedure D – Cephalexin 1gm IM x 1, 1 hour before procedure B C isn’t wrong, just not ideal for pt with no allergies D – need 2gm

Hospital Acquired Pneumonia

Which of the following is indicative of a true infection in the bacteriologic strategy? A – PSB: 103 cfu B – BAL: 105 cfu C – A and B C

What is the DOC for PCN-resistant S. pneumo? A – Levaquin B – Rocephin C – ertapenem D – Unasyn B Levaquiin if pnc and ceph resistant

What is NOT a risk factor for MDR pathogen? A – antimicrobial therapy in last 3 months B – hospitalization of 5 days or more C – chronic hemodialysis D – home infusion E – presence in nursing home F – all of the above are risk factors F

GV is a patient from a nursing home. Recommend appropriate PNA coverage. A – Rocephin + Azithromycin B – Zosyn + Moxifloxacin + Daptomycin C – Cefepime + Levaquin + Vancomycin D – Ceftazidime + Ciprofloxacin C

A – Zosyn B – Cefepime C – Meropenem D – Unasyn BAL is taken from GV and Acinetobacter results. Which of the following should be recommended? A – Zosyn B – Cefepime C – Meropenem D – Unasyn C Merrem - DOC but can use Unasyn but it is the sulbactam that actually treats the acinetobacter

A – amikacin B – tobramycin C – gentamicin Aminoglycosides are used for “double coverage” for Pseudomonas. Which one has the highest risk for resistance? A – amikacin B – tobramycin C – gentamicin C FQ’s have MUCH MORE resistance than AMG. If you TRULY need double coverage, use AMG but know you are risking nephrotox

RB has Stentotrophomonas PNA. How should be treated? A – Septra B – Ceftriaxone C – Amikacin D - PCN A

EC has MSSA PNA acquired as a HD patient EC has MSSA PNA acquired as a HD patient. How long should she be treated? A – 10 days B – 7 days C – 14 days D – 5 days B If Pseudomonas – 14 days

Catheter Related Infections

Which of the following is not a risk factor for Candidemia infection? A – pneumonia infection B – total parenteral nutrition C – transplant D - long term antibiotics

A patient with a CVL presents to the ER with a fever, WBC 17, and BP 90/60. What should be your course of action? A – blood culture x 2, monitor B – blood culture x 2, empiric antibiotics C – blood culture x 2, remove CVL D – blood culture x 2, remove CVL, empiric antibiotics D

A – no other recommendation, good therapy B – add fluconazole oral CR is on chronic TPN for short-gut syndrome. He turns up febrile in the ED. He is started on zosyn and vancomycin empirically. What else would you recommend? A – no other recommendation, good therapy B – add fluconazole oral C – add amphotericin IV D – add mycamine D

A – 10 days, vancomycin B – 14 days, daptomycin C – 14 days, linezolid EV had her CVL removed due to fever. It grew out MRSA. How long and with what drug should we treat this patient? A – 10 days, vancomycin B – 14 days, daptomycin C – 14 days, linezolid D – 7 days, vancomycin B

If you don’t know the answer ---- cefazolin might be a good guess….. Surgical Prophylaxis If you don’t know the answer ---- cefazolin might be a good guess…..

How long before the procedure should vancomycin start if it is to be prophylactic antibiotic? A – 30 minutes B – 60 minutes C – 90 minutes D – 120 minutes D

B – cefoxitin + metronidazole C – cefazolin + metronidazole BC requires an emergency appendectomy. Which is the most appropriate recommendation for prophylaxis? A – metronidazole B – cefoxitin + metronidazole C – cefazolin + metronidazole D – cefotetan + clindamycin C Could also do just cefoxitin or just cefotetan

RF is a patient undergoing spinal surgery with hardware RF is a patient undergoing spinal surgery with hardware. The MD has ordered cefazolin. Patient weighs 352pounds. How many grams should be ordered? A – 1 gm B – 2 gm C – 3 gm C

A – continue with plan for cefazolin B – change to cefotetan RF arrives for surgery and you verify his allergies. He says he is allergic to PCN-VK and he had a severe rash. What do you recommend at this time? A – continue with plan for cefazolin B – change to cefotetan C – change to clindamycin D – change to metronidazole C (could be vanc also)

Major break in surgical technique would classify what type of wound? A – Class I B – Class II C – Class III D – Class IV C

Questions ?? lhayes3@uthsc.edu