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The random question you didn't think you had to study..
100
MRSA and Pseudomonas
These two virulent pathogens must be covered if treating a patient in the ICU for CAP.
100
Moxifloxacin Levofloxacin
What are the respiratory FQ?
100
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
1. 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?
100
CXR with infiltrates
This is the gold standard when it comes to clinical diagnosis of PNA. BONUS: What must be present?
100
Early onset (less than 4 days) VAP
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?
200
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
What are 3 atypical pathogens that can cause atypical PNA? BONUS: name 2 atypical presentation signs and symptoms
200
Pip/Tazo Cefepime Carbapenems-Dori, Imi, Mero-NOT ERTA!
Name 3 anti-pseudomonal beta lactams
200
a. Noninvasive b. No risk to patient c. May aid in diagnosis and choice of empirical therapy in CAP
Name 3 advantages of getting a sputum culture for a patient with CAP
200
a. Sputum b. Blood c. Endotracheal culture 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
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?
200
a. Late onset HAP b. Pseudomonas, MRSA
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?
300
7-8 days
What is the treatment duration for HAP/VAP with the two exceptions for relapse being P.A. and Acinetobacter
300
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)
Give 2 P.A. regimens for CAP
300
a. < 25 neutrophils b. > 10 squamous epithelial cells
What are the qualifications for a contaminated sputum culture in terms of neutrophils and squamous epithelial cells?
300
5 days MRSA/P.A. are 10-14 days
3. What is the treatment duration for CAP? Bonus: What are the exceptions?
400
a. Late onset HAP b. Psuedomonas, MRSA
MM is a 76 year old female who was admitted 10/26 for acute pyelonephritis after being treated initially with fosfomyxin 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?
400
Cefepime/Ceftazidime + Cipro/Levo + Vanco/Linezolid
Give an example late onset MDR treatment regimen using at least 1 cephalosporin and FQ.
400
a. Legionella and Pneumococcal (Legionella in water)
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?
400
Sputum, Legionella UAT, Pneumococcal UAT
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?
400
Carbapenems-Dori, Imi, Mero
What are the drugs of choice for ESBL
500
a. Azithromycin-yes b. Levofloxacin-yes c. Amoxicillin/Clavulanate-N ~ use this in combo with Azithro when resistance with strep is >35%--Strep is gram positive, makes sense we would use a gram positive covering agent with the beta lactamase d. Ceftriaxone-NO gram+/- NOT pseudomonas e. Linezolid-no, Gram + only
5. Which of these drugs covers atypical pathogens (name all that apply) a. Azithromycin b. Levofloxacin c. Amoxicillin/Clavulanate d. Ceftriaxone e. Linezolid
500
a. Carbapenems-Mero, Dori, Imi b. Polymixin-Colistin, Polymixin B c. Sulbactam
Name the 3 treatment options for resistant Acinetobacter strains
500
Moxifloxacin
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
500
a. Sputum b. Blood c. Endotracheal culture d. BAL-not improving with treatment and P.A might be a concern
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?
500
Polymixins Aminoglycosides Tigecycline
Name a treatment option for CRE