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A Bug's Life
I prefer you call me Dr.
PharmD, D as in Drugs
The good the bad and the ugly
I didn't think to study that..
100
These two virulent pathogens must be covered if treating a patient in the ICU for CAP.
What is MRSA and PA
100
This is the gold standard when it comes to clinical diagnosis of PNA. BONUS: What must be present?
What is CXR with infiltrates
100
These are the respiratory FQ
What are Moxi and Levo
100
MJ is a 48 year old patient who presented to BWH ED on 10/15 with a work related wound injury that got infected. She was in the hospital for one day and discharged on vancomycin. She has been going to an outpatient clinic to receive her IV antibiotic treatment due to the severity of the wound. Today, 11/3, she presents to BWH ED with a fever, productive cough, and chills. What classification of PNA is this?
What is HCAP i. Hospitalized for 2 or more days within 90 days of infection ii. Residence in long-term care facility (including nursing homes) iii. Recent IV antibiotic therapy iv. Recent chemotherapy v. Wound care within 30 days of infection vi. Attended hospital or hemodialysis clinic
100
GT is a 46 year old with a PMH of IVDU admitted into the ICU after being rushed to Tufts ED with subsequent intubation following a heroin overdose. 3 days into his ICU stay, the attending notes pulmonary infiltrates accompanied by a fever of 101.2. What type (classification and onset) of PNA is this?
What is Early onset VAP
200
What are 3 atypical pathogens that can cause atypical PNA? BONUS: name 2 atypical presentation signs and symptoms
a. Mycoplasma pneumoniae (lacks cell wall) b. Chlamydophila pneumoniae c. Legionella species (> 90% pneumophila) d. 10 days onset, non productive cough, no chest pain, WBC<10,000
200
PZ is a 45 year old male admitted for CAP on 11/1 being treated with Moxifloxacin 400mg IV. Overnight on 11/3, he decompensates and becomes hypotensive (78/40), febrile (103.1) and tachycardic (124)with O2 saturation into the 70s requiring intubation and ICU transfer. What kinds of diagnostics would you obtain at this time? Induced sputum, Blood, ET, BAL
a. Induced Sputum-no; endotracheal will test for sputum since he is intubated b. Blood-yes, systemic symptoms c. Endotracheal culture, yes intubated and this can easily obtain sputum d. NOT a BAL—invasive and can cause patient to become hypoxic, also not on broad spectrum therapy so an endotracheal culture could help narrow therapy
200
Name 3 anti-pseudomonal beta lactams
What is Pip/tazo, cefepime, cetazidime, meropenem, doripenem, imipenem..NOT ERTA!
200
Name 3 advantages of getting a sputum culture for a patient with CAP
a. Noninvasive b. No risk to patient c. May aid in diagnosis and choice of empirical therapy in CAP
200
What is the treatment duration for CAP? Bonus: What are the exceptions?
What is 5 days (MRSA/PA 10-14 days)
300
the treatment duration for HAP/VAP with the two exceptions for relapse being P.A. and Acinetobacter?
What is 7-8 days
300
JS is a 75 year old female whose daughter brings her to Mass General with subjective reports of labored breathing, confusion and disorientation. Upon exam, her vitals are T 100.3, HR 100, RR 32, and 102/74. Her labs are notable for Scr 1.5, Na 130, K 3.3, and BUN 21. What is her CURB 65 score? BONUS: Where would she classify to be treated? (In/Outpatient)
What is 4 and inpatient
300
Give 2 P.A. regimens for CAP
a.Basic principle: 2 agents with pseudomonal activity + atypical coverage I. Anti-pneumococcal, anti-pseudomonal beta-lactam (piperacillin-tazobactam, cefepime, imipenem, meropenem) + Ciprofloxacin or levofloxacin ii. Anti-pneumococcal, anti-pseudomonal beta-lactam + aminoglycoside + azithromycin iii. Anti-pneumococcal, anti-pseudomonal beta-lactam + Aminoglycoside + antipneumococcoal quinolone (levo)
300
What are the qualifications for a contaminated sputum culture in terms of neutrophils and squamous epithelial cells?
a. < 25 neutrophils b. > 10 squamous epithelial cells
300
What would an empiric treatment regimen entail if a patient was presenting with CAP to a hospital with >25% resistance to Strep Pneumo? BONUS: Why the double whammy?
a. Amox/Clav + Azithro; Respiratory FQ b. Why-because S. pneumo is gram positive-used the Beta lactamase as extra gram positive coverage and the Azithro for atypical coverage
400
MM is a 76 year old female who was admitted 10/26 for acute pyelonephritis after being treated initially with fosfomycin 3g x1 and subsequently ciprofloxacin 250mg BID. Although she was anxious to be discharged, the last 2 days she has been coughing up sputum, is febrile of 101.3, and is experiencing labored breathing (RR 30). Her CXR shows pulmonary infiltrates. What type (classification and onset) of PNA is this? BONUS: When evaluating empiric treatment options, what bugs are you looking to cover?
Late onset VAP P.A. and MRSA
400
EM is a 29 year old female with no PMH who was given a Z-pack for CAP. She finished the course 2 days ago but reports no improvement of symptoms. What kinds of tests would you perform to aid in the diagnosis and identification of the microbiology behind EM’s symptoms?
What is Sputum, Legionella UAT, Pneumococcal UAT
400
Give an example late onset MDR treatment regimen using at least 1 cephalosporin and FQ
What is cefepime/Ceftazidime + Cipro/Levo + Vanco/Linezolid
400
A UAT detects which pathogens that may not be positive in a sputum or blood culture, or be more beneficial if the specimen is contaminated? BONUS: Where does one of the pathogens incubate?
What are legionella (water) and pneumococcal
400
Name the drugs of choice for ESBL
What is Carbapenems-Dori Imi Mero NOT ERTA
500
Which of these drugs covers atypical pathogens (select all that apply) Azithromycin Levofloxacin Amox/Clav Ceftriaxone Linezolid
a. Azithromycin-yes b. Levofloxacin-yes c. Amoxicillin/Clavulanate-N ~ use this in combo with Azithro when resistance with strep is >25%--Strep is gram positive, makes sense we would use a gram positive covering agent with the beta lactamase d. Ceftriaxone-NO gram+/- NOT P.A. e. Linezolid-no; MRSA
500
KB is a 56 year old male with a history of COPD who presented 3 days ago and was subsequently intubated and admitted to ICU with fever 102.6, BP 90/56, HR 105, RR 30. He was treated with ciprofloxacin 400mg IV BID and ceftriaxone 1g Q24H. Today, he remains febrile and the nurse reports yellow colored sputum. What kinds of diagnostics would you obtain at this time? Induced sputum, Blood, ET, BAL
a. Induced Sputum-no, he is intubated so ET will suffice b. Blood c. Endotracheal culture d. BAL-not improving with treatment and P.A might be a concern
500
Nme the 3 treatment options for resistant acinetobacter strains
What are the carbepenems-Dori, Imi, Mero Polymixins Sulbactam
500
In a patient with PCN allergy and resistant S. Pneumo, what would be the best treatment option for CAP? a. Vancomycin b. Pip/Tazo c. Moxifloxacin
What is Moxi
500
Name a treatment option for CRE
What are polymixins, Aminoglycosides, Tigecycline