1. Therapeutics III Tutoring February 13 th 2016 Lisa Hayes lhayes3@uthsc.edu

2. Outline Febrile Neutropenia CNS Infections Vector Borne/Miscellaneous Infections

3. Febrile Neutropenia

4. Key Points to Remember Be able to define fever Be able to define neutropenia Be able to calculate ANC Know when to treat for fungal infections Know who is high/low risk – Type of cancer, MASCC score Know empiric therapy for high and low risk Know how to de-escalate (infx v no infx) Prophylaxis

5. Which of the following is defined as a “fever” in a neutropenic patient? A- single oral temp of 38C B- sustained oral temp of 39C over 1 hour period C- single axillary temp of 101F D- sustained oral temp of 38C over 30 minutes

6. Calculate the ANC for patient JJ. WBC: 0.8 Segs: 27% Bands: 23% A- 450 B- 300 C- 400 D- 250

7. Is GY a high risk or low risk patient based on the following information? ANC: 100; line appears infected; MASCC score 18 A- high risk B- low risk

8. Recommend an appropriate empiric regimen for GY. Additional information – history of positive MRSA nasal swab. A- Zosyn only B- Cefepime + Vancomycin C- Cipro + Metronidazole D- Vancomycin only

9. Patient GY receives antibiotics for 4 days. She is still febrile, and the blood cultures are still negative. What should be done now? A- redraw blood culture B- continue current antibiotics until afebrile C- change current coverage D- add antifungal coverage

10. Which of the following is NOT an option for antifungal coverage? A- Fluconazole B- Amphotericin B C- Ciprofloxacin D- Mycamine

11. You are never able to discover the source of infection for GY. However, she is now afebrile and has been afebrile for 24 hours. How long should you recommend continuing the abx? A- 10-14 days total B- Until 48 hours afebrile and ANC is over 500 C- DC abx now D- change to oral after 72 hours afebrile

12. What is the drug of choice for prophylaxis of pneumocystitis jiroveci pneumonia? A- Cipro B- Doxycyline C- Septra D- Clindamycin

13. Bacterial Meningitis

14. Things to Know for Bacterial Meningitis Etiology by Age Etiology by Co-Morbid condition Know what the LP will show if bacterial meningitis is present Most common deficits as result of dx Acute v Subacute v Chronic Drug Induced Aseptic Meningitis Drug Penetration Empiric Treatment (and by age) Duration of Treatment based on organism identified Steroids! Prophylaxis – what did she tell you would need to know for exam?

15. Which age is most predisposed to meningitis? A – 25-50 years old B – 15-18 years old C – under 5 years old D – over 60 years old

16. Which organism is more common in those who are exposed to cigarette smoking? A – S. pneumo B – H. flu C – N. meningitidis D – Listeria

17. In what age groups must we cover empirically for LISTERIA? A – 4 – 12 wks + 0-4 wks B – over 50 years and 18-50 years C – 3mo-18 years and 0-4 wks D – 0-4wks and over 50 years

18. When should S. aureus coverage be provided empirically? A – immunocompromised B – CSF shunts, intracranial manipulation C – basilar skull fracture D – partially treated meningitis

19. Match the following to the appropriate definition. A – Acute meningitis B – Subacute meningitis C – chronic meningitis D – partial treatment meningitis 1 – meningitis with symptoms lasting over 7 days (usually means viral picture) 2 – antibiotics given prior to meningitis diagnosis 3 – meningitis with neurologic s/s developing over 1-7 days 4 – presentation within 24 hours of onset of s/s

20. Which organism has a characteristic non-blanching rash? A – S. pneumo B – H. flu C – N. meningitidis D – Listeria

21. A LP is performed on a 4 year old with suspected meningitis. The results are below. His serum glucose is 85mg/dL. Which of the following are characteristic of a bacterial CNS infection? LP results – WBC: 3K – Protein: 250 – Glucose: 25mg/dL A – none indicate CNS infection B- all indicate CNS infection C – only glucose D – only WBC

22. Which of the following drugs is NOT typically associated with aseptic meningitis? A – doxycyline B – TMP-SMX C – lamotrigine D – ibuprofen

23. The most common type of meningitis is secondary to S. pneumo. What is a common morbidity of this disease? A – B – paralysis C – loss of hearing D – loss of eyesight

24. The gram stain from the LP fluid in a patient, KK, results with gram-positive cocci. Which of the following regimens would be appropriate for empiric treatment? A – PCN G B – Ampicillin + AMG C – Ceftriaxone + AMG D – Vanc + Ceftriaxone

25. A patient EW is 3 weeks old and presents with a bulging fontanel. She is diagnosed with likely meningitis. Which is appropriate treatment given her age? A – Vanc + Ampicillin + ceftriaxone B – Vanc + cefotaxime C – Ampicillin + cefotaxime D – Vanc + ceftriaxone

26. Pick the pair which does NOT have a correct duration of treatment. A – S. pneumo: 10-14 days B – N. meningitidis: 7 days C – Listeria: 10-14 days D – H. flu – 7 days

27. GB is a patient whose gram stain results show a beta-lactamase positive strain of H. flu. Which antibiotic would be most appropriate? A – Ceftriaxone B – Ampicillin C – AMG D – Vancomycin

28. Steroids (dexamethasone) are used to help with the morbidity of meningitis (hearing loss). Which of the following patients would be a good candidate for steroid therapy? A – AA, a 4 week old infant B – BB, a 3 year old who presented to the ED within 12 hours of noticing symptoms and has received no medications yet C – CC, a 35 year old patient who was partially treated last week before returning today D – DD, a 68 year old patient who has arrived to the neurocritical care unit after receiving 2 doses of antibiotic in the ED

29. You selected the correct patient, BB. Now, select the appropriate dose of dexamethasone and when it should be given. Pt weight: 18kg A – 11mg IV four times daily for 4 days, give first dose with first antibiotic B – 2.7mg IV four times daily for 4 days, give first dose 1 hour before first antibiotic C – 11mg IV daily for duration of antibiotic therapy, give first dose 1 hour before first antibiotic D – 2.7mg IV four times daily for duration of antibiotic therapy, give first dose with start of antibiotics

30. Vector Borne/Misc Illness

31. Need to Know for Vector Borne Illness Know KEY characteristics of disease – Including which vector is responsible (tick, mosquito, etc) Know treatment and prevention for each dx Know which medications to avoid in dx

32. JH is a patient who reports recently traveling to Africa. She returned 7 days ago. She now reports flulike symptoms accompanied by eye pain. Diagnose her and recommend treatment. A – Dengue, supportive treatment B – Malaria, Atovaquone C – West Nile virus, supportive treatment D – Rocky Mountain Spotted Fever, Doxycycline

33. Which type of Plasmodium species is responsible for the most severe disease? A – P. vivax B – P. ovale C – P. malariae D – P. falciparum

34. Which of the following is not a recommended treatment for Malaria? A – Malarone B – Quinine + Ciprofloxacin C – Mefloquine D – Artemether-lumefantrine

35. HT is a 25 year old patient who presents with prominent lymphadenopathy, a maculopapular rash that he reports started on his chest and moved to his arms and legs. Pertinent labs include WBC 3K and elevated LFT. Which vector borne illness is most likely + what drug should you recommend? A – Rocky Mountain Spotted Fever, Chloramphenicol B – Erlichiosis, Septra C – Rocky Mountain Spotted Fever, Clindamycin D – Erlichiosis, Doxycycline

36. Which of the following is the drug of choice for Tularemia? A – Gentamicin B – Ciprofloxacin C- Streptomycin D – Levofloxacin

37. An 8year old patient GE presents with the classic triad of Rocky Mountain Spotted Fever. The attending in the ER wishes to start the appropriate treatment. Allergies: PCN Provide a recommendation. A – Ciprofloxacin, despite the risk of tendon rupture B – Doxycycline despite the risk of tooth discoloration C – Chloramphenicol – despite history of fatal outcomes D – Cefdinir, recommend monitoring for cross- sensitivity

38. What is the characteristic sign of Lyme disease? What is the DOC for prophylaxis? Do most patients require prophylaxis? A – maculopapular rash, Cipro, yes B – Bull’s eye rash, Doxycyline, no C – maculopapular rash, Ceftin, yes D – Bull’s eye rash, Amoxicillin, no

39. Which animal borne disease can be carried in the stool for up to 5 weeks? A - Bartonella B – Crytposporidium C – Salmonella D - Hantavirus

40. Select the appropriately matched vector to disease. A – Bartonella: cat B – Cryptosporidium: rodent C – Hantavirus: cat D – Brucellosis: bird

41. A patient tells you he takes Truvada and that he has been having terrible diarrhea for the last few weeks after his return from travel abroad. What is most likely? Treatment? A – Salmonella, Septra if at risk for bacteremia B – Cryptospordium, Nitazoxanide C – Leptospirosis, Doxycycline D – Cdiff, Metronidazole

42. GB is a young otherwise patient who presents to your clinic with complaints of a painful knot on her calf that appeared about 1 week after being scratched by her male kitten. It appears she has Bartonella (cat scratch fever). Allergies: Septra. A – no treatment, will correct on its own B – Erythromycin 500mg QID x 6wk + rifampin C – Doxycycline 100mg bid x 6wk D - Z-pack

43. A patient has possibly been exposed to rabies via a rabid squirrel she was trying to feed. She is 4 months pregnant. What should you recommend? A – Wound infiltration with rabies immune globulin only B – 3 rabies vaccine series + choice A C – 5 rabies vaccines series + choice A D – counseling on not feeding squirrels