Practice exam feedback 2019.2 Question 3

Question 3 9 marks High level knowledge required for good answers Referenced Dunn and Therapeutic guidelines “Pass” score 6/9 Pass rate 27.5% Many borderline candidates If everyone had scored an additional 1 mark, pass rate would be 57.5% Suggest you go and have a look at Therapeutic guidelines as many candidates were close but lacked detail

a) State 1 Pro and 1 Con for use of CURB 65 Referenced to Dunn Pro’s Validated Easy to use Can be modified to removed urea (CRB-65) Cons Doesn't include O2 or co-morbidities Overestimates severity in elderly Underestimates severity in young

Common errors Writing more than one answer in each section Not understanding what a Pro is Writing “a risk stratification tool that assists in determining mortality risk and therefore aids decisions on treatment location (admit vs discharge)” This is what the tool is, not why it is good Misusing the terms Sensitivity/Specificity These terms are not appropriate here Getting confused with other scoring systems eg SMART COP

b) List 4 components Confusion Urea >7 Respiratory rate >30 Needed any 4 of these Confusion Urea >7 Respiratory rate >30 Blood pressure: systolic <90 diastolic <60 Age >65

Common errors Having wrong components eg O2 sats Not including the reference range or having the wrong number eg Urea>20 Remember this is a high level knowledge question, as such reference range is required Writing 5 answers – only the first 4 considered.

c) According to Therapeutic Guidelines, prescribe antibiotics for CURB 65 score zero Monotherapy Amoxycillin 1g tds orally, for 5-7 days Monotherapy (if atypical suspected) Doxycycline 100mg bd, for 5-7 days Not required for answer - Combination therapy (if follow up cannot be confirmed or failure of treatment at 48 hrs) Amoxycillin 1g tds plus doxycycline 100mg bd

Common errors Wrong dose amoxycillin Wrong drug No duration of therapy Many wrote 500mg tds Wrong drug Augmentin duo forte is not recommended treatment No duration of therapy If a question asks you to “prescribe” you need to write the same detail that would go on a prescription or medication chart

d) Antibiotic choice for CF patient with lower Resp tract infection Challenging question as there is no specific recommended drug It depends upon the stage of life the patient is, and whether they have been colonized with a resistant organism The most common organism is Pseudomonas, but can have a variety, and abx choice should be targeted to previous sputum results (no one actually mentioned this in their answer) Inhaled antibiotics are often useful in this group, only one person mentioned Tobramycin (did not expect a dose for this drug given how infrequently this is prescribed by ED Physicians I expected you to at least cover Pseudomonas for a patient at high risk of severe infection

Pseudomonas (general treatment, not specific to CF) Ceftazidime 2g tds Or Piperacillin/tazobactam 4.5 g 6hourly Plus for those patients with severe pneumonia or bacteraemia, either of the above with either Gentamicin 3-5mg/kg or Ciprofloxacin 400mg tds IV

Common errors Not recognizing that this patient probably needs more aggressive treatment given background Commencing oral cipro only (probably needs parenteral treatment) Using monotherapy only (probably needs to have Gent/cipro as second agent in this patient) Use of brand name – Tazocin (though this could be argued and some of the other examiners may disagree on this point). Most people charted Pip/Taz as a tds regime, not qid as per therapeutic guidleines Use of ceftriaxone/azithromycin, or meropenum (this last one may be used based on sensitivities of sputum cultures, but should be avoided if possible to prevent further resistance) Wrong doses or no doses

Good luck!