25, 26. Infectious Diseases Flashcards
A patient presents with symptoms of a common cold: runny nose, sore throat, sneezing, and coughing. What is the most likely cause of the patient’s cold?
A. Rhinovirus
B. Staphylococcus aureus
C. Group B Streptococci
D. Adenovirus
E. Multiple organisms are likely
A. Of the over 200 viruses that can cause the common cold, rhinovirus is the most common. Other symptoms of the common cold can include mild body aches and headache. Antibiotics will not help a viral infection.
Choose the correct term for the lowest drug concentration that will inhibit the growth of an organism:
A. Minimum bactericidal concentration
B. Post antibiotic effect
C. Minimum inhibitory concentration
D. Resistance
E. Intermediate sensitivity
C. The minimum inhibitory concentration (MIC) is the lowest concentration of an antimicrobial drug that will inhibit the visible growth of a microorganism. Minimum inhibitory concentrations are important to determine resistance of microorganisms to an antimicrobial agent and to monitor activity of antimicrobial agents.
A patient with a urinary tract infection has asked for advice on a product for painful urination. Her doctor wrote the name phenazopyridine down on a sheet of paper. Which of the following patient counseling points are correct regarding phenazopyridine? (Select ALL that apply.)
A. Take this medication with food and 8 oz of water to minimize stomach upset.
B. She can purchase the over the counter product Azo.
C. She should use the product as long as she has symptoms.
D. This medication is effective in treating a bacterial urinary tract infection.
E. This product will cause red-orange coloring of the urine and can stain clothing.
A, B, E. Phenazopyridine (Azo, generics) is a urinary analgesic. Phenazopyridine should not be used longer than two days because an antibacterial agent should be working and the painful symptoms should have subsided. If the pain has not subsided, the patient should return to the physician. Phenazopyridine causes a harmless, red-orange coloring of the urine and other body fluids. Contact lenses and clothes could be stained. Take with food and 8 oz of water to minimize stomach upset.
An otherwise healthy patient comes in with a gram-positive and gram-negative foot infection. The doctor would like to use a cephalosporin for treatment of the patient’s infection. Which of the following statements regarding cephalosporins is correct?
A. Cefazolin is an oral cephalosporin that is considered to be the most effective therapy for mild-moderate gram-negative foot infections.
B. Cefixime is the only oral cephalosporin with gram-negative and enteric anaerobic coverage.
C. Cephalexin is an oral, second-generation cephalosporin with sufficient gram-negative and gram-positive coverage for moderate severity foot infections.
D. Cefuroxime is an oral, second-generation cephalosporin with adequate gram-negative and gram-positive coverage for mild-moderate foot infections.
E. Cefpodoxime is an intravenous, third-generation cephalosporin with adequate gram-positive and gram-negative coverage for severe foot infections.
D. Cefazolin is an intravenous cephalosporin. Cefixime is not effective for enteric anaerobes. Cephalexin is a first generation cephalosporin and cefpodoxime is an oral, third-generation cephalosporin. Cefuroxime is a second generation cephalosporin and is effective in treating MSSA and gram-negative bacteria associated with mild-moderate foot infections.
Cefotetan & cefoxitin are second generation cephalosporins that have anaerobic activity.
Which of the following statements is correct regarding linezolid? (Select ALL that apply.)
A. Linezolid is associated with bone marrow suppression.
B. Linezolid is part of the streptogramin class of antibiotics.
C. Linezolid should be dose adjusted in renal impairment.
D. Linezolid is a weak MAO inhibitor.
E. Linezolid oral suspension should not be refrigerated.
A, D, E. Linezolid is part of the oxazolidinone class of antibiotics and does not need to be dose adjusted in renal impairment. The oral suspension should be stored at room temperature.
A nurse calls the pharmacy to ask about crushing ciprofloxacin tablets and giving it via the nasogastric tube. The pharmacist should respond:
A. Ciprofloxacin is only available in an IV formulation.
B. Hold tube feedings at least 1 hour before and 2 hours after the administration of ciprofloxacin.
C. Give ciprofloxacin and flush the nasogastric tube immediately with water; in this manner it is safe to give with tube feedings.
D. There is no interaction between ciprofloxacin and tube feedings.
E. There is no formulation of ciprofloxacin that can be used for nasogastric tube administration.
B. For feeding tube administration, crush immediate-release ciprofloxacin tablets and mix with water. Hold tube feeds for 1 hour before and 2 hours after administration. Enteral feedings can significantly decrease plasma concentrations of ciprofloxacin. There is a suspension but it cannot be used with feeding tubes.
A patient gave the pharmacist a prescription for Ceftin 500 mg BID #20. Which of the following is an appropriate generic substitution for Ceftin?
A. Cefprozil
B. Cefpodoxime
C. Doripenem
D. Cefuroxime
E. Cefdinir
D. The generic name of Ceftin is cefuroxime.
Cefprozil (Cefzil) - 2nd generation, PO
Cefpodoxime (Vantin) - 3rd generation, PO
Doripenem (Doribax) - carbapenem, IV
Cefdinir (Omnicef) - 3rd generation, PO
Chief Complaint: “I’m out of my inhaler and I can’t breath”
History of Present Illness: KS is a 30 y/o female who comes to the ER today for worsening shortness of breath and cough. She is out of her albuterol inhaler. She occasionally lives on the street, but has been staying in the local homeless shelter for 3 nights. She reports fatigue, but denies night sweats and hemoptysis. Her cough is nonproductive. KS has mild right lower extremity cellulitis extending from right ankle to right calf. Patient states she scraped her leg on a fence and it has not healed. KS has not been treated with antibiotics.
Allergies: NKDA
Past Medical History: HIV x 5 years, PCP pneumonia 5 years ago when she was diagnosed with HIV, asthma, and dyslipidemia
Medications: Truvada 1 tablet daily, Tivicay 50 mg once daily, albuterol inhaler 1 puff 3-4 times daily as needed, Flovent Diskus 100 mcg BID, simvastatin 20 mg HS
Physical Exam / Vitals:
Height: 5’2” Weight: 105 pounds
BP: 122/72 mmHg HR: 71 BPM RR: 18 BPM Temp: 103.2°F Pain: 3/10
General: Pleasant ill appearing female
Lungs: decreased breath sounds bilaterally – right worse than left. Mild wheezing.
CV: RRR – no murmurs
GI: Normal bowel sounds
Ext: Mild right lower extremity cellulitis with some purulence
Labs:
Na (mEq/L) = 129 (135 – 145)
WBC (cells/mm3) = 10.4 (4 – 11 x 10^3)
K (mEq/L) = 3.5 (3.5 – 5)
Hgb (g/dL) = 13.4 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 103 (95 – 103)
Hct (%) = 40.1 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 24 (24 – 30)
Plt (cells/mm3) = 202 (150 – 450 x 10^3)
BUN (mg/dL) = 12 (7 – 20)
PMNs (%) = 92 (45 – 73)
SCr (mg/dL) = 0.9 (0.6 – 1.3)
Bands (%) = 7 (3 – 5)
Glucose (mg/dL) = 118 (100 – 125)
Eosinophils (%) = 3 (0 – 5)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Basophils (%) = 0 (0 – 1)
Mg (mEq/L) = 1.8 (1.3 – 2.1)
Lymphocytes (%) = 29% (20 – 40)
PO4 (mg/dL) = 3.6 (2.3 – 4.7)
Monocytes (%) = 2 (2 – 8)
AST (IU/L) = 62 (10 – 40)
ALT (IU/L) = 58 (10 – 40)
Albumin (g/dL) = 3.1 (3.5 – 5)
Tests:
Chest Xray: bilateral upper lobe cavitary lesions. Recommend chest CT for further evaluation.
Plan: Obtain CD4+ count and viral load. Admit for IV antibiotics and additional diagnostic work-up.
Question:
Based on chest Xray, KS will be treated empirically for PCP. A physician calls the pharmacist for assistance in determining a dosing regimen for Bactrim. He would like to use Bactrim 20 mg/kg orally. Which of the following is correct?
A. Bactrim SS 2 tabs BID
B. Bactrim SS 2 tabs TID
C. Bactrim DS 1 tab TID
D. Bactrim DS 2 tabs BID
E. Bactrim DS 2 tabs TID
E. 105 pounds = 47.7 kg. 47.7 kg x 20 mg/kg = 954 mg Bactrim/day. Bactrim is dosed from the TMP component and DS tabs have 160 mg TMP per tab. KS would need 6 tabs per day (954 mg Bactrim / 160 mg TMP per tab) to treat her infection. To avoid errors, mg/kg doses should reference the TMP component. When using higher SMX/TMP doses like this, monitor the patient carefully for side effects.
Molly is an 82 year-old female with a Pseudomonas aeruginosa infection. The clinical pharmacist is rounding with the infectious disease team. The pharmacist is asked to explain the potential advantages of extended-interval, or once-daily, aminoglycoside dosing. Choose the correct statement:
A. If the random gentamicin serum level is elevated, the dosing interval should be decreased.
B. Extended-interval dosing is more cost effective, and helps to reduce nephrotoxicity risk.
C. The peak and trough levels should be measured around the third dose for extended-interval dosing.
D. Extended-interval dosing for gentamicin is 15 mg/kg/day.
E. If the random gentamicin serum level is elevated, the dose should be decreased.
B. Extended Interval (formerly known as “Once Daily Dosing”) for gentamicin and tobramycin is 4-7 mg/kg/day. The dose in the answer choice (15 mg/kg/day) is generally used for once-daily dosing of amikacin. Extended-interval dosing can help preserve renal function (the primary toxicity) and is more cost-effective than administering the medication via conventional dosing.
A patient has been taking antibiotics for one week and develops severe diarrhea. Which of the following medications has a boxed warning regarding the risk of causing severe and possibly fatal colitis?
A. Maxipime
B. Biaxin
C. Cipro
D. Cleocin
E. Cancidas
D. Cleocin (clindamycin) has a boxed warning regarding the risk of severe and possibly fatal colitis. When counseling, tell patients to report watery and/or frequent diarrhea immediately as the patient may require treatment for pseudomembranous colitis.
A patient has a prosthetic mitral valve and needs to have some extensive dental work done. The patient is noted to have allergies to Keflex and Unasyn. Which of the following statements is the best recommendation to give this patient?
A. Take amoxicillin 2 grams 1 hour prior to dental appointment.
B. Take cefadroxil 2 grams 30 minutes prior to dental appointment.
C. Take clindamycin 600 mg 1 hour prior to dental appointment.
D. Take azithromycin 500 mg 30 minutes after dental appointment.
E. This patient does not need antibiotics for his dental work.
C. Clindamycin 600 mg can be used as an alternative for endocarditis prophylaxis in a patient with a beta-lactam allergy.
Dental procedures & IE prophylaxis:
An artificial heart valve or heart valve repaired with artificial material.
A history of endocarditis
A heart transplant with abnormal heart valve function
Congenital heart defects
A patient is receiving Bactrim SS therapy. Which of the following strengths and ingredients are in Bactrim SS tablets?
A. 400 mg sulfamethoxazole and 80 mg trimethoprim
B. 80 mg sulfamethoxazole and 400 mg trimethoprim
C. 16 mg sulfamethoxazole and 80 mg trimethoprim
D. 240 mg sulfamethoxazole and 40 mg trimethoprim
E. 100 mg sulfamethoxazole and 50 mg trimethoprim
A. The ratio of sulfamethoxazole to trimethoprim is always 5:1. The single strength tablet of Bactrim contains 400 mg sulfamethoxazole and 80 mg trimethoprim.
A patient gave the pharmacist a prescription for Augmentin 875 mg Q12H #20. Which of the following is an appropriate generic substitution for Augmentin?
A. Ampicillin/clavulanate
B. Ampicillin/tazobactam
C. Amoxicillin/clavulanate
D. Amoxicillin/tazobactam
E. Imipenem/cilastatin
C. Amoxicillin/clavulanate is the generic name of Augmentin. Clavulanic acid, or claculanate, inactivates beta lactamase enzymes, which extends the activity (or coverage) of the drug.
Ampicillin/clavulanate (does not exist)
Ampicillin/tazobactam (does not exist)
Amoxicillin/tazobactam (does not exist)
Imipenem/cilastatin (Primaxin)
A patient gave the pharmacist a prescription for Z-Pak. Which of the following is the generic name and an appropriate dosing regimen for Z-Pak?
A. Erythromycin 250 mg Q AM, for 5 days
B. Azithromycin 250 x 2 on day 1, then 250 mg x 1 on days 2-5
C. Azithromycin 250 mg x 1, for 5 days
D. Clarithromycin 250 mg Q AM, for 5 days
E. Azithromycin 250 mg x 2, for 5 days
B. Azithromycin is the generic for Z-Pak. A common doing regimen is two 250 mg tablets x 1 on the first day, then one 250 mg tablet for days 2-5.
Danny is diagnosed with a giardia infection. Which of the following medications would be best to recommend for treatment of giardiasis?
A. Metronidazole
B. Cefuroxime
C. Doxycycline
D. Erythromycin
E. Clindamycin
A. Giardiasis is a diarrheal illness caused by the parasite, Giardia intestinalis. It can be treated with metronidazole or tinidazole.
A patient is receiving vancomycin 2 grams IV Q12H for treatment of MRSA. The nurse asks how long to infuse the medication. Which is the best recommendation to give the nurse regarding the infusion of this vancomycin dose?
A. The vancomycin should be infused over a minimum of 2 hours
B. The vancomycin should be infused over a maximum of 2 hours
C. The vancomycin should be infused over a minimum of 1 hour
D. The vancomycin should be infused over a maximum of 1 hour
E. The vancomycin should be given via a bolus dose
A. Vancomycin can cause serious side effects if infused too quickly. Given the patient is receiving 2 grams, vancomycin should be infused over a minimum of 2 hours. Often, the infusion is given over a longer time period.
Each 500mg of vancomycin should be infused over at least 30 minutes. Hence 2000mg (2 grams) would require at least 2 hours of infusion time.
Tanya comes to the pharmacy to pick up her prescription for Valtrex for treatment of her recurrent herpes simplex virus. Which of the following statements would be best to include during patient counseling?
A. This medication is very effective and will cure your herpes infection.
B. You should start therapy within one day of symptom onset to experience maximum benefit from the drug.
C. This medication should be taken with food.
D. It is safe to continue sexual contact with your partner when you have symptoms or a herpes outbreak.
E. This product is effective only when you have developed genital lesions.
B. Antivirals used to treat herpes simplex virus decrease the duration of the infection. Antivirals should be started within 24 hours of symptom onset of a recurrence for maximal benefit.
A. Valtrex only treats the recurrent infection, it does not cure it.
C. Valtrex can be taken with or without food.
D. It is not safe to continue sexual contact when you have symptoms or a herpes outbreak.
E. It is effective for both oropharyngeal disease as well.
A 36 year-old female is nine weeks pregnant. She presents to the pharmacy with symptoms of a vaginal fungal infection. She has vaginal itching and a white, curd-like discharge. She had similar symptoms a few months ago and went to the free clinic for help. She was examined and given one dose of fluconazole 150 mg x 1. She was instructed to purchase an over the counter product the next time she has these types of symptoms. She is asking for advice on an over-the-counter product. Choose the correct agent:
A. Terbinafine x 7 days
B. Clotrimazole x 7 days
C. Butenafine x 3 days
D. Miconazole x 1 day
E. Tioconazole x 3 days
B. Since the patient is now pregnant, the drug of choice is a topical azole product for 7 days duration.
A patient is picking up VFEND at the pharmacy and asks to be counseled by the pharmacist. Which of the following counseling points regarding VFEND are correct? (Select ALL that apply.)
A. This medication should be taken with meals, preferably breakfast and dinner.
B. This medication can cause lymphomas with prolonged use.
C. This medication can cause visual changes; care is advised when driving and driving at night should be avoided.
D. This medication can damage your liver and liver function tests may need to be monitored.
E. This medication is associated with many drug interactions.
C, D, E. Visual disturbances (abnormal vision, color vision change and/or photophobia) occur in about 20% of voriconazole-treated patients. Voriconazole is taken on an empty stomach 1 hour before or 1 hour after meals. Check for drug interactions; there are many.
A. This medication is taken on an empty stomach, at least 1 hour before or 1 hour after meals, usually every 12 hours or as directed.
B. Common SEs: QT prolongation, visual changes, CNS toxicity (hallucinations), photosensitivity.
Drug of choice for Aspergillosis
Manny comes to the urgent care center with a large cellulitis wound. The doctor wants to prescribe something orally that covers MRSA. Which of the following medications fit this description?
A. Tygacil
B. Zyvox
C. Doribax
D. Synercid
E. Vancocin
B. Zyvox covers MRSA and comes in both an intravenous and oral formulation. The other medications listed are only available intravenously (oral vancomycin is not absorbed and is not appropriate for MRSA coverage.)
Tygacil (tigecycline)
Doribax (doripenem)
Synercid (quinupristin/dalfopristin)
Vancocin (vancomycin)
Which of the following statements are correct regarding patient counseling advice on Bactrim? (Select ALL that apply.)
A. Take this medication with 8 oz of water.
B. This medication must be taken with food.
C. This medication can increase your risk of sunburn.
D. This medication can cause a rash; if you develop a serious rash, seek medical help right away.
E. This medication should not be used if the patient has a sulfa allergy.
A, C, D, E. Bactrim works best if given on an empty stomach. However, if GI upset is present, patients can take the medication with a light snack. It has a sulfa moiety and is associated with allergic reactions. It is also associated with photosensitivity.
Sarah presents to the emergency department with fever, chills, nausea, cough, and fatigue. She reports feeling awful for the past week and appears confused. Her previous doctor started her on amoxicillin. Sarah’s white blood cell count was found to be elevated today. Her past medical history is significant for COPD, hypertension, dyslipidemia, and atrial fibrillation. She is taking lisinopril, lovastatin, procainamide, amoxicillin and some inhalers. The doctor would like to start broad empiric coverage for her infectious process. Which of the following oral broad spectrum medication/s would be most appropriate to treat Sarah given her history?
A. Cefdinir + doxycycline
B. Moxifloxacin
C. Tigecycline
D. Telithromycin
E. Aztreonam
A. Tigecycline is a broad spectrum IV antibiotic that would not be appropriate for outpatient treatment. Moxifloxacin is not an appropriate option due to the risk of QT prolongation when used in combination with class Ia anti-arrhythmics (like procainamide). Telithromycin can increase the risk of QT prolongation in patients taking procainamide. Aztreonam is only active against gram-negative pathogens. An oral beta-lactam + doxycycline is the regimen of choice for treating possible drug-resistant Strep. pneumoniae for which this patient is at risk.
A pharmacist is working in the emergency department. A medical intern asks how to treat a patient who has tested positive for syphilis. The intern explains that the patient does not know how long he has had the disease and has stated that he has had multiple sexual partners over the last few years. Which regimen would be best to treat this patient’s syphilis?
A. Ceftriaxone 250 mg IM x 1
B. Azithromycin 1 gram PO x 1
C. Aqueous penicillin G 3-4 million units IV Q4H x 10 days
D. Penicillin G benzathine 2.4 million units IM x 1
E. Penicillin G benzathine 2.4 million units IM weekly x 3 weeks
E. Since the patient has had syphilis for an unknown duration, it is best to treat with penicillin G benzathine weekly for 3 weeks.
Penicillin G benzathine 2.4 million units IM x 1 is used for primary, secondary or early latent syphilis (<1 year duration).
Penicillin G benzathine 2.4 million units IM weekly x 3 weeks is used for late latent (>1 year duration), tertiary, or latent syphilis of unknown duration.
A patient gave the pharmacist a prescription for Levaquin. Which of the following is an appropriate generic substitution forLevaquin?
A. Levofloxacin
B. Ciprofloxacin
C. Azithromycin
D. Linezolid
E. Telavancin
A. The generic name of Levaquin is levofloxacin.
Ciprofloxacin (Cipro)
Azithromycin (Zithromax)
Linezolid (Zyvox)
Telavancin (Vibativ)
Which of the following statements are true regarding pyrazinamide? (Select ALL that apply.)
A. This medication is used to reduce the risk of peripheral neuropathies in patients taking isoniazid.
B. This medication is contraindicated in patients with acute gout.
C. This medication can cause significant ototoxicity.
D. This medication should not be used if the patient has a sulfa allergy.
E. This medication can cause hepatotoxicity.
B, E. Pyrazinamide is an antitubercular agent used in the initial treatment of tuberculosis. It is contraindicated in patients with acute gout and severe hepatic damage.
Patty has contracted trichomoniasis. Which of the following options would be preferred treatments for trichomoniasis?
A. Metronidazole 2 grams PO x 1
B. Ciprofloxacin 1 gram PO x 1
C. Azithromycin 2 grams PO x 1
D. Penicillin G benzathine 2.4 million units IM x 1
E. Penicillin G benzathine 2.4 million units IM x 3 weekly doses
A. Trichomoniasis, caused by the parasite Trichomonas vaginalis, can be treated with metronidazole or tinidazole 2 grams PO x 1. Sexual partners should be treated as well.
Azithromycin 2 grams PO x 1 treats both gonorrhea and chlamydial infections
Penicillin G benzathine 2.4 million units IM treats syphilis.
A 62 year-old female patient came into the pharmacy to get an influenza shot. It was her first time receiving the annual vaccine. Three days later, she came back complaining of a hacking cough, mild weakness, stuffy nose and a sore throat. She is afebrile and has no muscle aches or pains. She states the shot gave her the flu. What is the most likely reason for the patient’s illness?
A. She has a cold.
B. She has an influenza infection.
C. She has mild illness due to the shot, but it’s not likely an influenza infection.
D. She was allergic to the influenza vaccine.
E. None of the above.
A. The patient has classic symptoms of a cold (cough, mild weakness, stuffy nose and sore throat, without fever). Symptoms of influenza include a sudden onset, high fever (usually 3-4 days duration), dry cough, prominent headache, muscle aches and pains (myalgia), weakness, fatigue (which can last for weeks), with occasional stuffy nose and sore throat. The influenza shot is inactivated and cannot cause influenza; it may cause a mild illness for a day or two afterwards. If patients get these symptoms, do not treat in advance or at the time of the shot as this may reduce the vaccine effectiveness. If symptoms develop afterwards the patient can self-treat at that time.
Which of the following oral suspensions should be refrigerated? (Select ALL that apply.)
A. Augmentin
B. Ceftin
C. Levaquin
D. Zmax
E. Septra
A, B. Ceftin and Augmentin oral suspensions should be refrigerated, the others should not.
Refrigeration required: amoxicillin/clavulanate (Augmentin), ceprozil, cefuroxime (Ceftin), cephalexin (Keflex), erythromycin ethylsuccinate/sulfisoxazole (E.S.P.), penicillin VK
Do Not Refrigerate: azithromycin (Zmax), cefdinir, clarithromycin (Biaxin-bitter taste, thickening/gels), clindamycin (Cleocin-thickening, crystallize), ciprofloxacin (Cipro), doxycycline (Vibramycin), fluconazole (Diflucan), levofloxacin (Levaquin), linezolid (Zyvox), sulfamethoxazole/trimethoprim (Septra, Sulfatrim), voriconazole (VFEND)
Which of the following statements is correct regarding the appropriate use of metronidazole?
A. Alcohol can be consumed 12 hours after the last dose of metronidazole.
B. The IV:PO dosing ratio is 1:1.
C. Metronidazole is an azole antifungal agent.
D. The extended release formulation should be taken with food to increase absorption.
E. The brand name is Tequin.
B. Metronidazole is an amebicide, antiprotozoal antibiotic. Patients must wait 3 days after the last dose of metronidazole before commencing alcohol consumption.
E. Brand name is Flagyl
Tequin is gatifloxacin
A patient comes to the clinic with fever, chills, muscle aches and a severe headache. She was recently on a week-long camping trip in South Carolina with her extended family. The patient appears to have a tick bite and is diagnosed with Rocky Mountain spotted fever. Which of the following medications is the best treatment option for this patient?
A. Rifampin 300 mg x 5 days
B. Metronidazole 1 gram x 7 days
C. Tobramycin 5 mg/kg/d divided Q8H x 7 days
D. Doxycycline 100 mg BID x 7 days
E. Acyclovir 400 mg TID x 10 days
D. Treatment of Rocky Mountain spotted fever involves careful removal of the tick from the skin and antibiotics to eliminate the infection. Doxycycline or tetracycline are the drugs of choice and are used for both confirmed and suspected cases.
Which of the following statements is correct regarding nafcillin?
A. Nafcillin does not have activity against methicillin-susceptible Staphylococcus aureus (MSSA).
B. Nafcillin is a vesicant.
C. Nafcillin should be dose adjusted in renal impairment.
D. Nafcillin is compatible with NS only.
E. Nafcillin cannot be used in a sulfa allergic patient.
B. Nafcillin is a vesicant. If extravasation occurs, use cold packs and hyaluronidase injections to treat.
Harry is a 71 year old male who has been in the intensive care unit for several weeks and is now being treated for aPseudomonas infection. His weight is 213 pounds and height is 6’1”. His current serum creatinine is 2.4 mg/dL. Based on the culture sensitivities, the medical team decides to start tobramycin at 2.5 mg/kg. They ask the pharmacist to write the order and administer the first dose at 8:00 AM. Which of the following is the correct tobramycin regimen for this patient?
A. Tobramycin 500 mg IV then monitor levels
B. Tobramycin 200 grams IV Q24H
C. Tobramycin 200 mg IV Q8H
D. Tobramycin 240 mg IV Q24H
E. Tobramycin 240 mg IV Q8H
D. Tobramycin is dosed anywhere from 1-2.5 mg/kg for traditional dosing. Since this patient is very ill, the team was correct to go with the upper limit. Aminoglycosides are dosed using total body weight, unless the patient is > 130% of IBW (then use adjusted body weight). 2.5 mg/kg x 96.8 kg = 242 mg; round to 240 mg. Harry’s estimated creatinine clearance is between 30-40 mL/min regardless of which weight was used to calculate it (you should use his adjusted body weight in this case), so his dosing interval should be Q24 hours. Administering the drug every 8 hours would be too frequent for someone with this degree of renal impairment.
Susan is prescribed Avelox for a community-acquired pneumonia infection. What is the mechanism of action for Avelox?
A. Binds to pencillin binding proteins to inhibit cell wall synthesis
B. Binds to the 30s ribosomal subunit, inhibiting protein synthesis
C. Inhibits DNA topoisomerase IV, thereby blocking DNA gyrase
D. Inhibits synthesis of Beta (1,3)-D-glucan
E. Binds to the 50s ribosomal subunit, inhibiting protein sythesis
C. Avelox (moxifloxacin) is a fluoroquinolone and works by binding to topoisomerase IV to inhibit DNA gyrase and the double helical coiling of the DNA.
Aminoglycosides and tetracyclines bind to the 30s ribosomal subunit, inhibiting protein synthesis
Macrolides, clindamycin, linezolid, and Synercid bind to the 50s ribosomal subunit, inhibiting protein sythesis
Derek has developed candidemia after 3 weeks in the intensive care unit. He is currently being treated with micafungin. Which of the following statements is correct regarding micafungin?
A. Micafungin is available orally and can cause pulmonary edema.
B. Micafungin is Pregnancy Category X.
C. Micafungin requires premedication prior to administration.
D. Micafungin can cause histamine-related symptoms.
E. Micafungin is an azole antifungal agent.
D. Micafungin, an echinocandin, can cause histamine-mediated symptoms such as rash, pruritus, facial swelling, flushing, and hypotension. To decrease the potential of a histamine reaction, infuse over 1 hour. Micafungin is Pregnancy Category C and is only available intravenously.
The mother of a 2 year-old daughter has been given a prescription for an acute otitis media infection. The child has no known drug allergies. This is the first time the child has received treatment for this condition. What is the drug of choice for this condition?
A. Azithromycin suspension 30 mg/kg/day given daily
B. Amoxicillin 80-90 mg/kg/day, divided Q 12 hours
C. Clarithromycin suspension, divided Q 12 hours
D. Amoxicillin 40 mg/kg/day, divided Q 12 hours
E. Cephalexin suspension, divided Q 12 hours
B. Amoxicillin (80-90 mg/kg/day) is a drug of choice for acute otitis media, which is most commonly caused by resistantStreptococcus pneumoniae.
A patient is taking nitrofurantoin for treatment of a urinary tract infection. Which of the following statements regarding nitrofurantoin are correct?
A. This medication may cause your urine to turn blue in color.
B. This medication can be used in patients with severe renal impairment.
C. This medication is not absorbed when taken concurrently with food.
D. This medication can be used for complicated cystitis.
E. This medication may rarely cause serious pulmonary problems.
E. Nitrofurantoin is contraindicated in patients with a creatinine clearance less than 60 mL/min. Nitrofurantoin should be taken with food to enhance absorption. Long term use can lead to serious and fatal pulmonary toxicity. Nitrofurantoin is only indicated for uncomplicated cystitis as serum levels are not adequate to treat systemic/complicated UTIs.
Which of the following auxiliary labels should be placed on a prescription for cephalexin oral suspension?
A. Take with at least 8 ounces of water
B. Keep the medication refrigerated
C. Use caution when operating heavy machinery or while driving a car
D. Do not shake prior to use
E. Do not use if you are pregnant
B. Cephalexin oral suspension should be refrigerated and used within 14 days. Shake well. Take with food if stomach upset occurs.
Refrigeration required: amoxicillin/clavulanate (Augmentin), ceprozil, cefuroxime (Ceftin), cephalexin (Keflex), erythromycin ethylsuccinate/sulfisoxazole (E.S.P.), penicillin VK
Do Not Refrigerate: azithromycin (Zmax), cefdinir, clarithromycin (Biaxin-bitter taste, thickening/gels), clindamycin (Cleocin-thickening, crystallize), ciprofloxacin (Cipro), doxycycline (Vibramycin), fluconazole (Diflucan), levofloxacin (Levaquin), linezolid (Zyvox), sulfamethoxazole/trimethoprim (Septra, Sulfatrim), voriconazole (VFEND)
Which of the following medications should be avoided in children younger than 8 years old due to discoloration of teeth and bone growth retardation?
A. Telavancin
B. Tigecycline
C. Telithromycin
D. Tinidazole
E. Rifaximin
B. Tigecycline is a derivative of minocycline and should not be used in pregnant women or in children younger than 8 years old due to teeth discoloration and bone growth retardation.
Four T’s of Tigecycline:
T – related to Tetracycline: teeth discoloration and bone growth retardation ages <8 years
T – concentrates in Tissues (lipophilic). Avoid use in bloodstream infection because it won’t have the concentration since it stays in tissues.
T – Three Gram negative pathogens not covered: Psuedomonas, Proteus, Providencia
T – Tummy side effects N/V/D
Remember Tiger: when reconstituted, it becomes orange/yellow like a tiger; discard if not this color.
Chief Complaint: “I’m out of my inhaler and I can’t breath”
History of Present Illness: KS is a 30 y/o female who comes to the ER today for worsening shortness of breath and cough. She is out of her albuterol inhaler. She occasionally lives on the street, but has been staying in the local homeless shelter for 3 nights. She reports fatigue, but denies night sweats and hemoptysis. Her cough is nonproductive. KS has mild right lower extremity cellulitis extending from right ankle to right calf. Patient states she scraped her leg on a fence and it has not healed. KS has not been treated with antibiotics.
Allergies: NKDA
Past Medical History: HIV x 5 years, PCP pneumonia 5 years ago when she was diagnosed with HIV, asthma, and dyslipidemia
Medications: Truvada 1 tablet daily, Tivicay 50 mg once daily, albuterol inhaler 1 puff 3-4 times daily as needed, Flovent Diskus 100 mcg BID, simvastatin 20 mg HS
Physical Exam / Vitals:
Height: 5’2” Weight: 105 pounds
BP: 122/72 mmHg HR: 71 BPM RR: 18 BPM Temp: 103.2°F Pain: 3/10
General: Pleasant ill appearing female
Lungs: decreased breath sounds bilaterally – right worse than left. Mild wheezing.
CV: RRR – no murmurs
GI: Normal bowel sounds
Ext: Mild right lower extremity cellulitis with some purulence
Labs:
Na (mEq/L) = 129 (135 – 145)
WBC (cells/mm3) = 10.4 (4 – 11 x 10^3)
K (mEq/L) = 3.5 (3.5 – 5)
Hgb (g/dL) = 13.4 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 103 (95 – 103)
Hct (%) = 40.1 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 24 (24 – 30)
Plt (cells/mm3) = 202 (150 – 450 x 10^3)
BUN (mg/dL) = 12 (7 – 20)
PMNs (%) = 92 (45 – 73)
SCr (mg/dL) = 0.9 (0.6 – 1.3)
Bands (%) = 7 (3 – 5)
Glucose (mg/dL) = 118 (100 – 125)
Eosinophils (%) = 3 (0 – 5)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Basophils (%) = 0 (0 – 1)
Mg (mEq/L) = 1.8 (1.3 – 2.1)
Lymphocytes (%) = 29% (20 – 40)
PO4 (mg/dL) = 3.6 (2.3 – 4.7)
Monocytes (%) = 2 (2 – 8)
AST (IU/L) = 62 (10 – 40)
ALT (IU/L) = 58 (10 – 40)
Albumin (g/dL) = 3.1 (3.5 – 5)
Tests:
Chest Xray: bilateral upper lobe cavitary lesions. Recommend chest CT for further evaluation.
Plan: Obtain CD4+ count and viral load. Admit for IV antibiotics and additional diagnostic work-up
Question:
KS is diagnosed with PCP and stabilized. She is ready for discharge. Her provider is concerned that the cellulitis has not healed as well as he had hoped. He asks the pharmacist about a single dose glycopeptide for bacterial skin and skin structure infections that he heard about. He thinks KS would be a good candidate for this drug. Which drug is he referring to?
A. Vancomycin
B. Dalbavancin
C. Oritavancin
D. Tedizolid
E. Polymyxin
C. Oritavancin and dalbavancin are lipoglycopeptides that were FDA-approved in 2014. Both have activity againstStaphylococci (MSSA and MRSA) and Streptococci. Oritavancin is a one-time dose and dalbavancin is given as two doses (one week apart).
Remember “O” for one dose oritavancin (Orbactiv) and “D” for double dose dalbavancin (Dalvance).
A hospitalized patient with no known drug allergies has cellulitis and the physician ordered vancomycin 1,000 mg IV Q12H and imipenem-cilastatin 1,000 mg IV Q8H. Both medications were administered at the same time. The patient had a profound drop in blood pressure. Her upper body, mostly in the trunk area, was covered with an erythematous rash. The patient’s breathing became labored. What is the likely cause of the patient’s symptoms?
A. She likely had an anaphylactic reaction to cilastatin.
B. It is likely the infusion rate of vancomycin was too rapid.
C. The reaction was due to the combination of imipenem-cilastatin and vancomycin; the dosing should be separated by several hours.
D. These are side effects of the cilastatin component, which has not been reduced for renal insufficiency.
E. It is unlikely that this reaction is due to one of these medications.
B. The patient has experienced symptoms of Redman’s Syndrome, a reaction due to a fast infusion of vancomycin. Symptoms can include a sudden or profound decrease in blood pressure, an erythematous rash, angioedema, pruritus, erythema, and trouble breathing (dyspnea, wheezing).
The erythematous rash usually starts in the trunk area and moves upward towards the head and face during Redman’s Syndrome.
Jack has been in the intensive care unit for the past two weeks. He was initially admitted for an asthma exacerbation requiring mechanical ventilation. Over the course of the hospitalization, he developed ventilator-associated pneumonia and was treated with broad-spectrum antibiotics. His blood cultures are now positive for VRE faecium. Which of the following antibiotics provide coverage for VRE faecium bacteremia?
A. Synercid
B. Vancocin
C. Ketek
D. Invanz
E. Avelox
A. Synercid (quinupristin/dalfopristin) covers VRE faecium.
Agents used for VRE faecium: daptomycin (DoC), linezolid, Synercid, tigecycline
Agents used for VRE faecalis: Pen G or ampicillin (DoC), linezolid, daptomycin, tigecycline
Dual VRE coverage: daptomycin, linezolid, tigecycline
Ketek (telithromycin)
Invanz (ertapenem)
Avelox (moxifloxacin)
A patient taking isoniazid is at risk for peripheral neuropathy. Which of the following medications can be given to reduce the risk of peripheral neuropathy?
A. Vitamin B1
B. Vitamin B2
C. Vitamin B6
D. Vitamin E
E. Vitamin B12
C. Vitamin B6, or pyridoxine, 25-50 mg PO daily can be given to patients taking isoniazid to decrease the risk of peripheral neuropathy.
Vitamin B1 (Thiamine) Vitamin B2 (Riboflavin) Vitamin B6 (Pyridoxine) Vitamin E (Tocopherol) Vitamin B12 (Cyanocobalamin)
Janis has a blood culture report showing gram-positive cocci resembling streptococci, enteric gram-negative bacilli and anaerobes. Which of the following medications would provide adequate coverage for these organisms?
A. Ertapenem
B. Rifaximin
C. Metronidazole
D. Fosfomycin
E. Ciprofloxacin
A. Carbapenems (e.g., ertapenem) cover all of these organisms.
A patient with an active tuberculosis infection will receive ethambutol therapy as part of their combination drug therapy. The patient will require counseling regarding the possibility of the following adverse effect:
A. Vision problems
B. Shortness of breath
C. Thyroid dysfunction
D. Appetite suppression
E. Hearing loss
A. Ethambutol can cause optic neuritis, which can decrease visual acuity and may cause blindness. Patients should be counseled to report any changes in vision to their physician promptly.
A 30 year-old female patient is 12 weeks pregnant and presents to the physician with symptoms of urinary urgency, burning and frequency. She is diagnosed with a urinary tract infection. Her only medications are a daily prenatal vitamin and a calcium supplement. She has no drug allergies. Which is the best medication to recommend for this patient?
A. Ciprofloxacin
B. Doxycycline
C. Tobramycin
D. Cephalexin
E. Vancomycin
D. Cephalexin can be used safely in pregnancy as long as the patient does not have an allergy to penicillins or cephalosporins. It may not cover the organism, in which case symptoms would persist and an alternative agent would need to be used.
Avoid ciprofloxacin due to cartilage problems in pregnancy.
Avoid doxycycline due to bone growth retardation in pregnancy.
Tobramycin and vancomycin would require IV.
A prescription for generic doxycycline is filled. Which of the following statements regarding doxycycline are correct? (SelectALL that apply.)
A. This medication should not be used in children younger than 8 years old.
B. Take on an empty stomach 1 hour before or 2 hours after meals.
C. This medication may increase the risk of sunburn.
D. This medication should be separated when given with antacids.
E. This medication does not interact with other medications.
A, C, D. Doxycycline should not be used in children younger than 8 years old or in patients who are pregnant due to the risk of tooth discoloration, bone growth retardation and reduced skeletal muscle development.
Joshua is going to the operating room for repair of his hernia. He has no known drug allergies. Which of the following medications should be used for antibiotic prophylaxis?
A. Doripenem
B. Ticarcillin
C. Metronidazole
D. Cefazolin
E. Ciprofloxacin
D. Peri-operative antibiotic prophylaxis is recommended for patients undergoing surgery. First and second generation cephalosporins are typically the drugs of choice for most procedures.
Chief Complaint: “I’m out of my inhaler and I can’t breath”
History of Present Illness: KS is a 30 y/o female who comes to the ER today for worsening shortness of breath and cough. She is out of her albuterol inhaler. She occasionally lives on the street, but has been staying in the local homeless shelter for 3 nights. She reports fatigue, but denies night sweats and hemoptysis. Her cough is nonproductive. KS has mild right lower extremity cellulitis extending from right ankle to right calf. Patient states she scraped her leg on a fence and it has not healed. KS has not been treated with antibiotics.
Allergies: NKDA
Past Medical History: HIV x 5 years, PCP pneumonia 5 years ago when she was diagnosed with HIV, asthma, and dyslipidemia
Medications: Truvada 1 tablet daily, Tivicay 50 mg once daily, albuterol inhaler 1 puff 3-4 times daily as needed, Flovent Diskus 100 mcg BID, simvastatin 20 mg HS
Physical Exam / Vitals:
Height: 5’2” Weight: 105 pounds
BP: 122/72 mmHg HR: 71 BPM RR: 18 BPM Temp: 103.2°F Pain: 3/10
General: Pleasant ill appearing female
Lungs: decreased breath sounds bilaterally – right worse than left. Mild wheezing.
CV: RRR – no murmurs
GI: Normal bowel sounds
Ext: Mild right lower extremity cellulitis with some purulence
Labs:
Na (mEq/L) = 129 (135 – 145)
WBC (cells/mm3) = 10.4 (4 – 11 x 10^3)
K (mEq/L) = 3.5 (3.5 – 5)
Hgb (g/dL) = 13.4 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 103 (95 – 103)
Hct (%) = 40.1 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 24 (24 – 30)
Plt (cells/mm3) = 202 (150 – 450 x 10^3)
BUN (mg/dL) = 12 (7 – 20)
PMNs (%) = 92 (45 – 73)
SCr (mg/dL) = 0.9 (0.6 – 1.3)
Bands (%) = 7 (3 – 5)
Glucose (mg/dL) = 118 (100 – 125)
Eosinophils (%) = 3 (0 – 5)
Ca (mg/dL) = 8.8 (8.5 – 10.5)
Basophils (%) = 0 (0 – 1)
Mg (mEq/L) = 1.8 (1.3 – 2.1)
Lymphocytes (%) = 29% (20 – 40)
PO4 (mg/dL) = 3.6 (2.3 – 4.7)
Monocytes (%) = 2 (2 – 8)
AST (IU/L) = 62 (10 – 40)
ALT (IU/L) = 58 (10 – 40)
Albumin (g/dL) = 3.1 (3.5 – 5)
Tests:
Chest Xray: bilateral upper lobe cavitary lesions. Recommend chest CT for further evaluation.
Plan: Obtain CD4+ count and viral load. Admit for IV antibiotics and additional diagnostic work-up.
Question:
Based on chest Xray, KS will be treated empirically for PCP. An order is received for Bactrim 20 mg/kg/day IV divided Q6H. What is the correct dose for KS?
A. Bactrim 26 mg IV Q6H
B. Bactrim 160 mg IV Q6H
C. Bactrim 240 mg IV Q6H
D. Bactrim 300 mg IV Q6H
E. Bactrim 950 mg IV Q6H
C. 105 pounds = 47.7 kg. 47.7 kg x 20 mg/kg = 954 mg Bactrim per day divided Q6H. Approximately 238.5 mg IV Q6H, so the dose is rounded to 240 mg IV Q6H.
A patient is prescribed isoniazid for treatment of tuberculosis. Which of the following statements regarding isoniazid are correct? (Select ALL that apply.)
A. It is an hepatic enzyme inducer.
B. It should be taken on an empty stomach.
C. Store the oral solution in the refrigerator.
D. It can turn the urine a reddish color.
E. It is associated with hepatitis and liver function tests may need to be monitored.
B, E. Isoniazid is an hepatic inhibitor and needs to be taken on an empty stomach. The oral solution is stored at room temperature. Monitor liver function.
A healthy, 25 year-old male is traveling to the Baja Peninsula in Mexico to visit a friend. He has never traveled to Mexico before and is concerned that he may acquire traveler’s diarrhea. Recommend an appropriate prophylactic medication:
A. Levofloxacin 500 mg daily x 1-3 days
B. Azithromycin 500 mg daily x 1-3 days
C. Loperamide 2 mg BID x 1-3 days
D. Bismuth subsalicylate
E. Ciprofloxacin XR 1,000 mg daily x 1-3 days
D. Prophylaxis with antibiotics for traveler’s diarrhea (TD) is not recommended, except perhaps for short-term travelers who are high-risk (such as those who are immunocompromised) or who are taking critical trips during which even a short bout of diarrhea could impact the purpose of the trip. Loperamide is used for treatment, not prophylaxis. Bismuth subsalicylate, such as in Pepto-Bismol, can be used for prophylaxis if the patient wishes.
A physician is unfamiliar with rifaximin and asks for information on the drug. Which of the following points would be accurate to describe rifaximin?
A. Rifaximin can be used to treat traveler’s diarrhea caused by non-invasive E. coli.
B. Rifaximin requires renal dose adjustments.
C. Rifaximin is a strong hepatic enzyme inducer similar to rifampin.
D. Rifaximin is an antiprotozoal agent.
E. Rifaximin is an effective agent for treating C. difficile infections.
A. Rifaximin is an antibacterial agent indicated for the treatment of non-invasive E. coli and for reduction in the risk of overt hepatic encephalopathy. Since systemic drug absorption is minimal, it is not a strong hepatic enzyme inducer.
A patient gave the pharmacist a prescription for Solodyn 1 tab daily #30. Which of the following is an appropriate generic substitution for Solodyn?
A. Minocycline
B. Doxycycline
C. Erythromycin
D. Telithromycin
E. Itraconazole
A. The generic name for Solodyn is minocycline.
Doxycycline (Vibramycin)
Erythromycin (many brand names)
Telithromycin (Ketek)
Itraconazole (Sporanox)
A patient with severe renal impairment (creatinine clearance less than 30 mL/min) is in the hospital for treatment of an infection. Blood cultures are positive for Candida krusei. Which of the following medications is best to treat the patient’s infection?
A. Tigecycline 100 mg IV x 1; then 50 mg IV every 12 hours
B. Amphotericin B deoxycholate 3 mg/kg IV daily
C. Caspofungin 70 mg IV x 1, then 50 mg IV daily
D. Fluconazole 200 mg IV daily
E. Ketoconazole 400 mg PO daily
C. Caspofungin is effective against Candida species such as C. krusei and C. glabrata. Fluconazole, in typical doses, would not cover C. krusei. Infuse caspofungin slowly, over 1 hour. Echinocandins do not require dose adjustment in renal impairment.
Remember the name “Echinocandins” have “-candin” in it so it treats Candidiasis better than other drugs.
A patient is being discharged home from the hospital. The patient was getting fluconazole 400 mg IV daily for the treatment of his fungal infection. The physician would like to continue with oral fluconazole therapy. What is the equivalent oral dose?
A. 800 mg
B. 600 mg
C. 400 mg
D. 200 mg
E. 100 mg
C. The fluconazole IV to oral ratio is 1:1.
Jenna is a 36 year-old female who is diagnosed with community acquired pneumonia as an outpatient. She has no medical problems and is not on any prescription medications. Jenna has no known drug allergies. Which of the following medications would be most appropriate to recommend for treatment?
A. Moxifloxacin
B. Tetracycline
C. Azithromycin
D. Amoxicillin
E. Vancomycin
C. Outpatient treatment of community acquired pneumonia in healthy individuals with no co-morbidities should be initiated with a macrolide antibiotic or doxycycline.
Joseph is on tobramycin IV every 8 hours for treating a gram negative infection and his levels are reported as a peak of 8.3 mcg/mL and a trough of 2.1 mcg/mL. Which of the following recommendations should the pharmacist make to the medical team?
A. Increase the dose of tobramycin
B. Reduce the dose of tobramycin
C. Extend the dosing interval of tobramycin
D. Reduce the dose and extend the interval of tobramycin
E. Shorten the dosing interval of tobramycin
C. The peak of tobramycin is within range, but the trough level is too high (it should be less than 2 mcg/mL and ideally less than 1.5 mcg/mL). By extending the dosing interval, the trough level will decrease and the toxicity risk is lowered.
Jackson, a 46 year old male, is found to have VRE faecalis on his recent blood cultures. Which of the following regimens is the best option for treatment of VRE faecalis?
A. Daptomycin
B. Vancomycin
C. Colistimethate
D. Quinupristin-dalfopristin
E. Cephalexin
A. Daptomycin is indicated for the treatment of VRE faecalis whereas the other medications do not cover this pathogen.
Agents used for VRE faecium: daptomycin (DoC), linezolid, Synercid, tigecycline
Agents used for VRE faecalis: Pen G or ampicillin (DoC), linezolid, daptomycin, tigecycline
Dual VRE coverage: daptomycin, linezolid, tigecycline
A 25 year-old female has been to see her primary care physician. She is planning to become pregnant and wanted a “clean bill of health”. She was found to be infected with gonorrhea. Which of the following statements is the best recommendation for this patient?
A. She should be treated with cefixime 400 mg PO x 1.
B. She should be treated with ceftriaxone 250 mg IM x 1.
C. She should be treated with ceftriaxone 250 mg IM x 1 and azithromycin 1 gram PO x 1.
D. She should be treated with penicillin G 2.4 million units IM x 3.
E. Therapy should be withheld until a pregnancy test can be obtained.
C. Treat all sexual partners to prevent re-infection.
Lucas is receiving ampicillin for the treatment of a Proteus mirabilis bacteremia. The doctor wants to know how ampicillin works. Which of the following best characterizes the pharmacodynamic properties of ampicillin?
A. Ampicillin exhibits concentration-dependent bacterial killing
B. Ampicillin exhibits concentration-above-MIC-dependent killing
C. Ampicillin exhibits colonic concentration bacterial killing
D. Ampicillin exhibits post antibiotic effect for bacterial killing
E. Ampicillin exhibits time-above-MIC-dependent bacterial killing
E. Ampicillin, a penicillin, exhibits time-dependent killing. The drug level in the blood must be above the MIC of the organism in order to inhibit bacterial cell growth. Therefore, the amount of time spent above the MIC leads to maximal effectiveness of ampicillin.
T>MIC: beta-lactams (penicillins, cephalosporins)
Cmax:MIC: aminoglycosides, fluoroquinolones, daptomycin, colistin
AUC:MIC: vancomycin, macrolides, tetracyclines
Helen is a 68 year-old female who comes to the clinic for an urgent appointment. She has been feeling awful due to her “flu-like” symptoms and she cannot get any rest because of her coughing. Her past medical history is significant for heart failure, status-post breast cancer, peptic ulcer disease and gout. Helen is diagnosed with community acquired pneumonia. Which is the best treatment regimen for her community acquired pneumonia?
A. Clarithromycin 500 mg PO Q12H
B. Cefpodoxime 500 mg PO Q12H
C. Doxycycline 100 mg PO Q12H
D. Moxifloxacin 400 mg PO daily
E. Patient should be admitted to the hospital for intravenous therapy
D. A respiratory fluoroquinolone is a treatment of choice for patients at risk for drug resistant S. pneumonia community acquired pneumonia. Helen is at risk due to her age and co-morbidities. A beta-lactam plus a macrolide is another treatment option.
Julie comes to the emergency department with a large wound that is oozing pus on her lower right leg. She has diabetes and did not want to see a doctor earlier because she does not have medical insurance. It is presumed that the infection is due to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Which of the following oral medications can be used to treat CA-MRSA? (Select ALL that apply.)
A. Clindamycin
B. Sulfamethoxazole/trimethoprim
C. Ciprofloxacin
D. Linezolid
E. Quinupristin/dalfopristin
A, B, D. Ciprofloxacin does not have activity against CA-MRSA and quinupristin-dalfopristin is not available as an oral agent.
CA-MRSA coverage: Bactrim DS, doxycycline, minocycline, clindamycin, linezolid, daptomycin, tigecycline, caftaroline, vancomycin, telavancin, dalbavancin, tedizolid
Nosocomial MRSA coverage: vancomycin, linezolid, Synercid, daptomycin, ceftaroline, telavancin, tigecycline, dalbavancin, tedizolid, rifampin (in combination), SMX/TMP
Chief Complaint: “I need something for pain”
History of Present Illness: KA is a 62 y/o Hispanic male who was admitted to the hospital on 10/16/14 complaining of severe pain that has worsened over 2 days. The pain is in the center of his abdomen. He vomited once today, but it did nothing to help the pain. The pain is a 9 out of 10. KA has never experienced anything like this before. He reports no trauma and has no fever. He admits to social alcohol and tobacco use. KA’s past medical history is significant for hypertension, osteoarthritis, type 2 diabetes, and hypothyroidism.
Allergies: NKDA
Medications: Benicar 40 mg daily, Byetta 10 mcg SC BID, Synthroid 75 mcg daily, Tylenol 650 every 6 hours and Glucosmine & Chondroitin capsules
Physical Exam / Vitals:
Height: 5’11” Weight: 226 pounds
BP: 146/89 mmHg HR: 88 BPM RR: 16 BPM Temp: 98.9°F Pain: 9/10
Labs on 10/16/14:
Na (mEq/L) = 137 (135 – 145)
WBC (cells/mm3) = 7.3 (4 – 11 x 10^3)
K (mEq/L) = 3.7 (3.5 – 5)
Hgb (g/dL) = 16.5 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 100 (95 – 103)
Hct (%) = 48.4 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 28 (24 – 30)
Plt (cells/mm3) = 302 (150 – 450 x 10^3)
BUN (mg/dL) = 16 (7 – 20)
AST (IU/L) = 35 (10 – 40)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
ALT (IU/L) = 32 (10 – 40)
Glucose (mg/dL) = 120 (100 – 125)
Albumin (g/dL) = 4.1 (3.5 – 5)
Ca (mg/dL) = 9.2 (8.5 – 10.5)
A1C (%) = 8.7
Mg (mEq/L) = 1.9 (1.3 – 2.1)
PO4 (mg/dL) = 3.2 (2.3 – 4.7)
Tests on 10/16/14:
CT Abdomen: acute pancreatitis
Plan: Discontinue Byetta and manage with insulin. Control pain with IV opioids.
10/18/14
Vitals: BP: 142/85 mmHg HR: 80 BPM RR: 15 BPM Temp: 102.4°F Pain: 3/10
Labs on 10/18/14:
Na (mEq/L) = 137 (135 – 145)
WBC (cells/mm3) = 13.1 (4 – 11 x 10^3)
K (mEq/L) = 3.8 (3.5 – 5)
Hgb (g/dL) = 14.6 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 99 (95 – 103)
Hct (%) = 43.5 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 28 (24 – 30)
Plt (cells/mm3) = 300 (150 – 450 x 10^3)
BUN (mg/dL) = 15 (7 – 20)
AST (IU/L) = 33 (10 – 40)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
ALT (IU/L) = 22 (10 – 40)
Glucose (mg/dL) = 108 (100 – 125)
Albumin (g/dL) = 4.1 (3.5 – 5)
Ca (mg/dL) = 9.2 (8.5 – 10.5)
A1C (%) = 8.5
Mg (mEq/L) = 1.9 (1.3 – 2.1)
PO4 (mg/dL) = 3.1 (2.3 – 4.7)
Tests on 10/18/14:
CT abdomen: resolving pancreatic inflammation
Chest xray: right lower lobe infiltrate
Question:
Which of the following antimicrobial regimens is best to initiate for KA on 10/18/14 based on the suspected pathogens?
A. Azithromycin monotherapy
B. Linezolid monotherapy
C. Ampicillin/sulbactam monotherapy
D. Vancomycin + meropenem
E. Piperacillin/tazobactam + ciprofloxacin
C. KA is 48 hours into his hospital stay. Common pathogens for early HAP are similar to CAP with increased prevalence of enteric Gram-negatives and decreased prevalence of atypical pathogens.
Many hospitalized patients with MRSA skin and soft tissue infections are typically treated with IV therapy and transitioned to an oral agent to allow ease of use and discharge from the hospital. Prior to sending patients home on clindamycin, what test should be performed to ensure clindamycin’s effectiveness?
A. Hodge test
B. D-test
C. E-test
D. Synergy test
E. MBC test
B. The “D-test” is used to determine the presence of constitutive (already present) resistance in MRSA. The Hodge test detects carbapenemase production. E-tests are drug strips that determine minimal inhibitory concentrations of an antibiotic and bacteria. Synergy tests determine if the effects of combining two antibiotics is greater than the sum of the individual agent. MBC test is minimal bactericidal concentration needed to kill bacteria.
A patient has an MRSA wound infection. She has heart failure and impaired renal function with an estimated creatinine clearance of 40 mL/min. Her current medications include Toprol XL, Zestril and Lasix. She is going to receive intravenous vancomycin while in the hospital. Choose the correct statement:
A. Vancomycin should not be used in patients with heart failure.
B. She should receive the vancomycin orally due to the risk of further renal insufficiency.
C. She is at an elevated risk of ototoxicity due to the concurrent use of furosemide.
D. The trough is not important; only vancomycin peaks should be monitored.
E. She should receive ceftazidime instead of vancomycin.
C. Oral vancomycin is not absorbed and could not treat a systemic infection. Nephrotoxicity and ototoxicity are the primary toxicities that can occur with vancomycin therapy, and the risk is increased with concomitant medications that have these same side effects such as loop diuretics and aminoglycosides.
Which of the following statements concerning bronchitis are correct? (Select ALL that apply.)
A. Most cases of acute bronchitis are viral; antibiotics will not help
B. In mild-moderate cases of acute bronchitis, treatment is generally supportive.
C. It is best to suppress a cough that brings up mucus.
D. Antibiotics may be considered for patients who meet the definition of acute exacerbation of chronic bronchitis.
E. Antibiotics are utilized when fever is present.
A, B, D. It is best not to suppress a cough that brings up mucus. Breathing in warm, moist air can be helpful and a humidifier will be useful in cold weather if the heating unit is drying out the air in the home. This can be particularly beneficial during sleep. Drinking adequate fluids and getting enough rest are important. Antibiotic use is not indicated in uncomplicated bronchitis.
A patient is starting quadruple therapy for treatment of active tuberculosis. Rifampin is part of the regimen. Which of the following is correct regarding rifampin therapy?
A. This medication should be taken with meals.
B. This medication is a potent inhibitor of many hepatic enzymes leading to many drug interactions.
C. This medication can cause orange-red discoloration of body secretions and stain contact lenses.
D. This medication can cause optic neuritis.
E. This medication is taken three times daily.
C. Rifampin is a potent inducer of many hepatic enzymes and will lead to many drug interactions. It is important to take on an empty stomach; food decreases absorption.
Isoniazid is a potent inhibitor of hepatic enzymes.
Ethambutol causes optic neuritis.
Rifampin and isoniazid are taken once daily on an empty stomach.
All tuberculosis drugs are taken once daily.
The clinical pharmacist is preparing for rounds. He calls the laboratory to see if the cultures are ready on Mr. Jones. The laboratory states that the Gram stain is purple in color. What class of organisms appears purple on a Gram stain?
A. Gram-positive organisms
B. Gram-negative organisms
C. Fungal organisms
D. Atypical organisms
E. Viral organisms
A. Gram staining is an empirical method of differentiating bacterial species into two large groups, Gram-positive and Gram-negative. Gram-positive organisms stain purple (bluish-purple) while gram-negative organisms stain pink (reddish-pink). The pharmacist can recommend “empiric” therapy. Once the specific organisms have been identified, the empiric therapy should be changed to directed therapy that targets only the identified organism/s.
Chief Complaint: “I need something for pain”
History of Present Illness: KA is a 62 y/o Hispanic male who was admitted to the hospital on 10/16/14 complaining of severe pain that has worsened over 2 days. The pain is in the center of his abdomen. He vomited once today, but it did nothing to help the pain. The pain is a 9 out of 10. KA has never experienced anything like this before. He reports no trauma and has no fever. He admits to social alcohol and tobacco use. KA’s past medical history is significant for hypertension, osteoarthritis, type 2 diabetes, and hypothyroidism.
Allergies: NKDA
Medications: Benicar 40 mg daily, Byetta 10 mcg SC BID, Synthroid 75 mcg daily, Tylenol 650 every 6 hours and Glucosmine & Chondroitin capsules
Physical Exam / Vitals:
Height: 5’11” Weight: 226 pounds
BP: 146/89 mmHg HR: 88 BPM RR: 16 BPM Temp: 98.9°F Pain: 9/10
Labs on 10/16/14:
Na (mEq/L) = 137 (135 – 145)
WBC (cells/mm3) = 7.3 (4 – 11 x 10^3)
K (mEq/L) = 3.7 (3.5 – 5)
Hgb (g/dL) = 16.5 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 100 (95 – 103)
Hct (%) = 48.4 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 28 (24 – 30)
Plt (cells/mm3) = 302 (150 – 450 x 10^3)
BUN (mg/dL) = 16 (7 – 20)
AST (IU/L) = 35 (10 – 40)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
ALT (IU/L) = 32 (10 – 40)
Glucose (mg/dL) = 120 (100 – 125)
Albumin (g/dL) = 4.1 (3.5 – 5)
Ca (mg/dL) = 9.2 (8.5 – 10.5)
A1C (%) = 8.7
Mg (mEq/L) = 1.9 (1.3 – 2.1)
PO4 (mg/dL) = 3.2 (2.3 – 4.7)
Tests on 10/16/14:
CT Abdomen: acute pancreatitis
Plan: Discontinue Byetta and manage with insulin. Control pain with IV opioids.
10/18/14
Vitals: BP: 142/85 mmHg HR: 80 BPM RR: 15 BPM Temp: 102.4°F Pain: 3/10
Labs on 10/18/14:
Na (mEq/L) = 137 (135 – 145)
WBC (cells/mm3) = 13.1 (4 – 11 x 10^3)
K (mEq/L) = 3.8 (3.5 – 5)
Hgb (g/dL) = 14.6 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 99 (95 – 103)
Hct (%) = 43.5 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 28 (24 – 30)
Plt (cells/mm3) = 300 (150 – 450 x 10^3)
BUN (mg/dL) = 15 (7 – 20)
AST (IU/L) = 33 (10 – 40)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
ALT (IU/L) = 22 (10 – 40)
Glucose (mg/dL) = 108 (100 – 125)
Albumin (g/dL) = 4.1 (3.5 – 5)
Ca (mg/dL) = 9.2 (8.5 – 10.5)
A1C (%) = 8.5
Mg (mEq/L) = 1.9 (1.3 – 2.1)
PO4 (mg/dL) = 3.1 (2.3 – 4.7)
Tests on 10/18/14:
CT abdomen: resolving pancreatic inflammation
Chest xray: right lower lobe infiltrate
Question:
Which of the following infections does KA most likely have based on his labs and tests on 10/18/14?
A. Cellulitis
B. Peritonitis
C. Bronchitis
D. Meningitis
E. Pneumonia
E. Pneumonia is diagnosed with a chest xray. KA’s increased white blood cell count and temperature also support the clinical picture of an infection.
Itraconazole is used for a variety of fungal infections including blastomycosis, histoplasmosis, aspergillosis and onychomycosis. Itraconazole cannot be used with certain drugs. Which of the following drugs is contraindicated with the use of itraconazole?
A. Cetirizine
B. Quinidine
C. Zafirlukast
D. Azithromycin
E. Amphotericin B
B. Itraconazole is a strong 3A4 inhibitor. Use with certain drugs has been associated QT prolongation and ventricular arrhythmias.
Cetirizine (Zyrtec)
Quinidine (Quinidex)
Zafirlukast (Accolate)
Amphotericin B (Fungizone)
Liposomal amphotericin B (AmBisome)
In patients with infective endocarditis who are receiving traditional dosing of gentamicin in combination with vancomycin, what is the peak goal for gentamicin?
A. 1 mcg/mL
B. 2 mcg/mL
C. 4 mcg/mL
D. 5 mcg/mL
E. 10 mcg/mL
C. Gentamicin peak goal for synergy in infective endocarditis is 3-4 mcg/mL. Traditional dosing of gentamicin is recommended for this condition.
A patient is taking Moxatag for treatment of strep throat. Which of the following statements is correct regarding Moxatag?
A. Moxatag can be used in patients with a creatinine clearance less than 30 mL/min.
B. Moxatag should be administered within 1 hour of finishing a meal.
C. Moxatag should be stored in the refrigerator.
D. Moxatag is an extended release product delivered by the osmotic-controlled release oral delivery system (OROS).
E. Moxatag is safe to use in a patient who has a penicillin allergy.
B. Moxatag is extended-release amoxicillin indicated for pharyngitis caused by Streptococcus pyogenes. It is taken once daily within 1 hour of finishing a meal. Moxatag should not be used in patients with a creatinine clearance less than 30 mL/min.
Many patients test positive for tuberculosis (TB). Which of the following patients should be given treatment for latent tuberculosis if the Mantoux tuberculin skin test has an induration of 8 mm? (Select ALL that apply.)
A. Persons with a close contact of a known TB case.
B. HIV-infected persons.
C. Healthcare worker.
D. Patients without any known risk factors who are over 35 years of age.
E. Persons who are immunocompromised.
A, B, E. The Mantoux tuberculin skin test is the standard method of determining whether a person is infected with TB. It is performed by injecting 0.1 mL of tuberculin purified protein derivative (PPD) into the inner surface of the forearm. An induration of 5 mm or more is positive in immunocompromised patents or those with close contacts of a known TB patient. If there are no known risk factors, an induration greater than 15 mm is positive.
How long should peri-operative antibiotic prophylaxis be continued for most surgeries?
A. 5 days
B. 7 days
C. 10 days
D. 1 day or less
E. 2 days
D. Most surgeries require only 1 day (or less, sometimes just 1 dose) of antibiotic use for prevention of infections. Cardiac bypass surgery requires 2 days of prophylactic antibiotic therapy.
Roger is a 58 year-old male who is in the medical intensive care unit with a severe Pseudomonas aeruginosa infection. He is on ciprofloxacin and cefepime and his infection does not seem to be clearing. Which of the following medications should be used to replace the current therapy?
A. Doribax
B. Invanz
C. Zyvox
D. Minocycline
E. Tygacil
A. All the carbapenems, except Invanz, cover Pseudomonas aeruginosa. Ciprofloxacin and cefepime often cover Pseudomonas aeruginosa, but perhaps this infection is resistant.
Doribax (doripenem)
Invanz (ertapenem)
Zyvox (linezolid)
Minocycline (Solodyn)
Tygacil (tigecycline), does not cover Pseudomonas, Proteus, Providencia (Remember Four T’s of Tygacil)
Which of the following are common components of Antimicrobial Stewardship Programs? (Select ALL that apply.)
A. Antimicrobial pre-authorization policy
B. Open formulary policy
C. Intravenous to oral switching protocol
D. De-escalation of therapy
E. Disease care pathways or protocols
A, C, D, E. Allowing for an open formulary means that drugs are not restricted in any way and are available for prescribing. All other options encourage judicious prescribing.
Linezolid will most likely have a drug-drug interaction with which of the following medications?
A. Venlafaxine
B. Metoprolol
C. Enalapril
D. Calcium carbonate
E. Ampicillin
A. Linezolid is a reversible monoamine oxidase inhibitor and it interacts with anti-depressants such as SSRIs, SNRIs (venlafaxine), TCAs, and other drugs potentially causing serotonin syndrome.
A nine year-old girl has an acute otitis media infection. Her mother has received a prescription for antibiotics and was told to watch the girl first to see if she improves, prior to filling the prescription. The mother is fine with this plan, but wants something now to treat the child’s ear pain. Which of the following are acceptable options for her daughter’s ear pain? (Select ALL that apply.)
A. Acetaminophen
B. Aspirin
C. Ibuprofen
D. Topical benzocaine otic drops
E. Debrox
A, C, D. Systemic acetaminophen or ibuprofen can be used. Acetaminophen or ibuprofen is preferred, however, topical benzocaine otic drops can be used. The concern with the use of the otic medications is that they can mask worsening illness. If topical drops are used, the patient should be re-evaluated after 2 days to check for improvement. Aspirin should not be used in children.
YS is an 8 year old male who was found to be colonized with methicillin-resistant Staphylococcus aureus. He was seen at an outpatient clinic for his first ever skin infection, a pustule and probable cellulitis. What is the most appropriate oral antibiotic therapy for YS?
A. Cetriaxone
B. Ciprofloxacin
C. Clindamycin
D. Vancomycin
E. Minocycline
C. Tetracyclines like minocycline should not be used in children younger than 8 years old. Ciprofloxacin is not effective in treating MRSA. Ceftriaxone does not come in an oral formulation. Oral vancomycin will not achieve appreciable systemic levels to treat skin infections. Clindamycin is a viable oral option due to efficacy and the lack of contraindications.
When should peri-operative antibiotic prophylaxis with cefazolin be initiated in patients undergoing elective surgeries such as hip arthroplasty?
A. Within 1 hour of incision
B. Within 2 hours of incision
C. Within 3 hours of incision
D. Within 2 hours after the surgery is over
E. Immediately after the surgery is over
A. Cefazolin is typically infused over 30 minutes and distributes throughout the body within 30 minutes to prevent surgery related infections. Infusing antibiotics after surgery does not effectively prevent infections.
A 42 year-old female patient is choosing an OTC product for a vaginal fungal infection. She has had three vaginal fungal infections in three months. She is overweight and is eating a candy bar. She should be recommended to have the following conditions tested:
A. Diabetes and HIV
B. Cancer and neoplasm
C. Hypothyroidism and hepatitis
D. Sinusitis and otitis media
E. Bipolar and schizophrenia
A. Frequent fungal infections can indicate more serious conditions. She should be tested for both diabetes and HIV.
PM is a 70 year old man who was recently diagnosed as having a severe case of Clostridium difficile infection (CDI). He has a serum white blood cell count of 24,000 cells/mm3 and a SCr of 2.2 mg/dL with 6-7 loose bowel movements per day. What is the most appropriate therapy for PM?
A. Metronidazole 500 mg IV QID
B. Vancomycin 125 mg PO QID and metronidazole 500 mg IV Q8H
C. Metronidazole 500 mg PO TID
D. Vancomycin 500 mg IV QID
E. Vancomycin 125 mg PO QID
E. Severe, uncomplicated CDI episodes should be treated with oral vancomycin monotherapy.
Mild-mod: metronidazole 500mg PO TID x 10-14 days
Severe uncomplicated: vancomycin 125mg PO QID x 10-14 days
Severe complicated: vancomycin 500mg PO QID + metronidazole 500mg IV Q8H
Chief Complaint: “I need something for pain”
History of Present Illness: KA is a 62 y/o Hispanic male who was admitted to the hospital on 10/16/14 complaining of severe pain that has worsened over 2 days. The pain is in the center of his abdomen. He vomited once today, but it did nothing to help the pain. The pain is a 9 out of 10. KA has never experienced anything like this before. He reports no trauma and has no fever. He admits to social alcohol and tobacco use. KA’s past medical history is significant for hypertension, osteoarthritis, type 2 diabetes, and hypothyroidism.
Allergies: NKDA
Medications: Benicar 40 mg daily, Byetta 10 mcg SC BID, Synthroid 75 mcg daily, Tylenol 650 every 6 hours and Glucosmine & Chondroitin capsules
Physical Exam / Vitals:
Height: 5’11” Weight: 226 pounds
BP: 146/89 mmHg HR: 88 BPM RR: 16 BPM Temp: 98.9°F Pain: 9/10
Labs on 10/16/14:
Na (mEq/L) = 137 (135 – 145)
WBC (cells/mm3) = 7.3 (4 – 11 x 10^3)
K (mEq/L) = 3.7 (3.5 – 5)
Hgb (g/dL) = 16.5 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 100 (95 – 103)
Hct (%) = 48.4 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 28 (24 – 30)
Plt (cells/mm3) = 302 (150 – 450 x 10^3)
BUN (mg/dL) = 16 (7 – 20)
AST (IU/L) = 35 (10 – 40)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
ALT (IU/L) = 32 (10 – 40)
Glucose (mg/dL) = 120 (100 – 125)
Albumin (g/dL) = 4.1 (3.5 – 5)
Ca (mg/dL) = 9.2 (8.5 – 10.5)
A1C (%) = 8.7
Mg (mEq/L) = 1.9 (1.3 – 2.1)
PO4 (mg/dL) = 3.2 (2.3 – 4.7)
Tests on 10/16/14:
CT Abdomen: acute pancreatitis
Plan: Discontinue Byetta and manage with insulin. Control pain with IV opioids.
10/18/14
Vitals: BP: 142/85 mmHg HR: 80 BPM RR: 15 BPM Temp: 102.4°F Pain: 3/10
Labs on 10/18/14:
Na (mEq/L) = 137 (135 – 145)
WBC (cells/mm3) = 13.1 (4 – 11 x 10^3)
K (mEq/L) = 3.8 (3.5 – 5)
Hgb (g/dL) = 14.6 (13.5 – 18 male, 12 – 16 female)
Cl (mEq/L) = 99 (95 – 103)
Hct (%) = 43.5 (38 – 50 male, 36 – 46 female)
HCO3 (mEq/L) = 28 (24 – 30)
Plt (cells/mm3) = 300 (150 – 450 x 10^3)
BUN (mg/dL) = 15 (7 – 20)
AST (IU/L) = 33 (10 – 40)
SCr (mg/dL) = 1.1 (0.6 – 1.3)
ALT (IU/L) = 22 (10 – 40)
Glucose (mg/dL) = 108 (100 – 125)
Albumin (g/dL) = 4.1 (3.5 – 5)
Ca (mg/dL) = 9.2 (8.5 – 10.5)
A1C (%) = 8.5
Mg (mEq/L) = 1.9 (1.3 – 2.1)
PO4 (mg/dL) = 3.1 (2.3 – 4.7)
Tests on 10/18/14:
CT abdomen: resolving pancreatic inflammation
Chest xray: right lower lobe infiltrate
Question:
Several days later on 10/20/14, KA is improving on IV antibiotics. One of the medical students on the team caring for KA suggests a “respiratory fluoroquinolone” for outpatient management of KA’s infection. Which of the following correctly lists the three respiratory fluoroquinonlones and explains why they are called “respiratory fluoroquinolones”?
A. Gatifloxacin, gemifloxacin, and moxifloxacin; because they have enhanced Gram-negative and anaerobic activity.
B. Ciprofloxacin, levofloxacin, and norfloxacin; because they have enhanced Gram-positive and anaerobic coverage.
C. Gemifloxacin, levofloxacin, and moxifloxacin; because they have enhanced Gram-positive and atypical coverage.
D. Ciprofloxacin, levofloxacin, and ofloxacin; because they have enhanced Gram-positive and anaerobic activity.
E. Levofloxacin, gatifloxacin, and moxifloxacin; because they have enhanced Gram-negative and atypical coverage.
C.
They are referred to as respiratory fluoroquinolones due to enhanced coverage of Streptococcus pneumoniae and atypical coverage.
Ryan is a 70-year-old male who lives in a skilled nursing facility. He has been complaining about urinary urgency and painful urination. His laboratory tests are negative for all sexually transmitted diseases, but positive for an Extended Spectrum Beta-Lactamase (ESBL) producing Klebsiella pneumoniae. What empiric antimicrobial regimen would you recommend for Ryan?
A. Zosyn
B. Invanz
C. Timentin
D. Maxipime
E. Teflaro
B. Carbapenems are the drugs of choice for Extended Spectrum Beta-Lacatamsase (ESBL) producing bacteria.
Zosyn (piperacillin/tazobactam)
Invanz (ertapenem)
Timentin (ticarcillin/clavulanate)
Maxipime (cefepime) - 4th generation
Teflaro (ceftaroline) - 5th generation
A man with chills and a fever sneezes and coughs inside a crowded bus. The other passengers in the bus may have been put at risk of contracting the following conditions which are transmitted by aerosolized droplets, via sneezing or coughing: (Select ALL that apply.)
A. Tuberculosis
B. Varicella
C. Clostridium difficile
D. Trichomoniasis
E. Influenza
A, B, E. Influenza and tuberculosis are both airborne diseases; they are spread by sneezing, coughing or talking. Varicella can be transmitted person to person or via droplet particles (airborne).
Jeannie is being transitioned from ciprofloxacin intravenous to ciprofloxacin oral suspension. Which of the following statements regarding ciprofloxacin oral suspension are true? (Select ALL that apply.)
A. This agent may prolong the QT interval.
B. The patient’s blood sugar may be affected.
C. This medication should not be given through feeding tubes.
D. This agent can cause peripheral neuropathies.
E. This medication should be shaken prior to use.
A, B, C, D, E. Ciprofloxacin oral suspension should not administered through feeding tubes since the suspension is oil-based and adheres to the tubing. Hypo (especially if on hypoglycemics) or hyperglycemia may occur; monitor BG levels in at-risk patients. FQs have a warning regarding peripheral neuropathies.
