Antibiotic man

Question 1

Management of meningitis?

Answer 1

• Ceftriaxone 2g IV BD
  + Dexamethasone 10mg IV QDS.
  + Amoxicillin IV 2g 4-hourly if >60 or immunocompromised (listeria).

Question 2

Common causes of bacterial meningitis?

Answer 2

• Strep. pneumoniae.
• Neisseria meningitidis.
• HiB.
• Group B Strep. (e.g. agalactiae).
• Listeria.
• Gram negatives e.g. Enterobacter, Enterococci, E. coli.
• Staph. aureus, Staph. epidermidis.
• Pseudomonas.

Question 3

When should dexamethasone be continued in bacterial meningitis?

Answer 3

If confirmed pneumococcal cause.

Question 4

What would you add to the treatment regime?
- Bacterial meningitis.
+ Recent travel to a country with high rates of penicillin resistant pneumococci.

Answer 4

Vancomycin IV (aim for pre-dose level of 15-20mg/L).
OR
Rifampicin IV/PO 600mg BD.

(Countries such as turkey, spain, italy, greece, china, poland, canada, mexico, USA, croatia).

Question 5

Pathogens associated with ventriculitis and meningitis-shunt associated or post-operative?

Answer 5

• Pseudomonas.
• Gram-negatives.
• Staph. aureus, Staph. epidermidis.
• Propionibacterium sp.

Question 6

Pathogens associated with meningitis post-trauma?

Answer 6

• Pneumococci.
• H. influenzae.
• Streptococci.
• Anaerobes.
  (Often URTI pathogens)

Question 7

Management of meningitis post-trauma?

Answer 7

• Ceftriaxone IV 2g BD

+ Metronidazole IV 500mg TDS.

Question 8

Management of brain abscess?

Answer 8

Ceftriaxone IV 2g BD.
+ Metronidazole IV 500mg 8-hourly.
+ if staph. suspected, then add IV Flucloxacillin or Vancomycin if allergic or MRSA.
TREAT FOR 4 WEEKS MINIMUM.

Question 9

Pathogens associated with brain abscess?

Answer 9

• Streptococci.

- Bacteroids.

Question 10

Pathogens associated with viral encephalitis?

Answer 10

• Herpes virus (HSV, Varicella Zoster, CMV, EBV).
• Enteroviruses (Coxsackie, poliovirus).
• Flaviviruses (West Nile, Japanese encephalitis, tick-borne, Dengue).
• Paramyxovirus (mumps, measles, RSV).
• Arboviruses (spread by ticks and mosquitos).
• Parvovirus B19.
• Adenovirus.
• Influenza.

Question 11

Management of viral encephalitis?

Answer 11

IV Aciclovir 10mg/kg 8-hourly for 14 days then repeat LP.
(21 days if immunocompromised).
> HSV PCR +ve then continue treatment and weekly PCR until negative.

Question 12

Causes of viral meningitis?

Answer 12

• Enteroviruses.
• Herpes simplex.
• Varicella zoster.
• Paramyxovirus.

Question 13

How is viral meningitis managed?

Answer 13

As per community acquired bacterial meningitis.

- Manage symptomatically (stop all other treatment) if enteroviral or mumps meningitis confirmed.

Question 14

Management of epiglottitis/ supraglottitis?

Answer 14

Ceftriaxone IV 2g OD.

Question 15

Management of mild/moderate CAP (CURB 0-2)?

Answer 15

Amoxicillin IV/PO 1g TDS.
- Doxycycline PO 200mg on day 1, then 100mgOD if pen-allergic OR IV Clarithromycin if NBM.

5 days total IV/PO.

Question 16

Management of severe CAP (CURB 3-5)?

Answer 16

• Co-amoxiclav IV 1.2g TDS + Doxycycline PO 100mg BD.

OR if pen-allergic Levofloxacin IV 500mg BD.

TOTAL IV/PO - 7 days..

Question 17

ALL patients with severe CAP should be stepped down to?

Answer 17

Doxycycline PO 100mg BD.

TOTAL IV/PO 7 days.

Question 18

Likely causative organisms of epiglottitis?

Answer 18

• H. influenzae.

- Streptococci.

Question 19

Likely causative organisms of tonsillitis?

Answer 19

Group A Strep. (pyogenes, agalactiae).

Question 20

Likely causative organisms of sinusitis?

Answer 20

Pneumococcus.

Question 21

Likely causative organisms of acute otitis media?

Answer 21

• Pneumococcus.

- H. influenzae.

Question 22

Management of non-severe hospital acquire pneumonia?

Answer 22

• PO Amoxicillin 1g TDS 5 days.
  OR Doxycycline 100mg BD.

TOTAL - 5 days.

Question 23

Management of severe hospital acquired pneumonia?

Answer 23

IV amoxicillin 1g TDS.
+ IV Gentamicin.

(if pen-allergic then Co-trimoxazole 960mg BD + Gentamicin).

Question 24

Step-down of severe hospital acquired pneumonia?

Answer 24

PO Co-trimoxazole 960mg BD.

- Total IV/PO 7 days.

Question 25

Why use amoxicillin?

Answer 25

- Beta-lactam, bactericidal - inhibits cell wall . - Active against gram positives (Strep., Enterococci, Listeria, Clostridium) and some gram negatives (Bacteroides, H. influenzae, Neisseria, E. coli).

Question 26

Why use gentamicin?

Answer 26

- Aminoglycoside, bactericidal - binds to ribosomes inhibiting protein synthesis. - Active against gram negatives e.g. coliforms (E. coli, Enterobacter, Klebsiella, Proteus) and Pseudomonas.

Question 27

Why use metronidazole?

Answer 27

- Inhibits nucleic acid synthesis. | - Active against anaerobes e.g. C. diff, trichomoniasis, Gardnerella (bacterial vaginosis), amoebiasis.

Question 28

MRSA is resistant to?

Answer 28

Beta-lactams (penicillins, flucloxacillin, piperacillin-tazobactam, cephalosporins and meropenem).

Question 29

What are the beta-lactam antibiotic groups?

Answer 29

- Penicillins. - Flucloxacillin. - Pip-taz. - Cephalosporins. - Meropenem.

Question 30

Why use Cephalosporins?

Answer 30

Beta-lactams - Bactericidal - inhibit cell wall synthesis by preventing cross-linking of peptido-glycan. - High CSF concentration in meningitis. - High tissue levels good for epiglottitis (life-threatening + potential amoxicillin resistance).

Question 31

Why use Flucloxacillin?

Answer 31

Narrow spec - staph and strep. - Especially in skin, soft tissue, wound infection, cellulitis. STAPH. AUREUS = FLUCLOX.

Question 32

Amoxicillin is ineffective against organisms that produce?

Answer 32

Beta-lactamase.

Question 33

What is co-amoxiclav?

Answer 33

Amoxicillin + clavulanic acid (beta-lactamase inhibitor).

Question 34

Co-amoxiclav is not active against?

Answer 34

Pseudomonas, some E. coli and MRSA.

Question 35

Co-amoxiclav is active against anaerobes - true or false?

Answer 35

True so negates need for Metronidazole.

Question 36

Beta-haemolytic streps (group A, C, G) are sensitive to?

Answer 36

Penicillin and Flucloxacillin.

Question 37

Pip-taz will treat almost everything apart from?

Answer 37

- MRSA. | - ESBL (very resistant coliforms)

Question 38

ESBLs are sensitive to?

Answer 38

- Temocillin. - Pivmecillinam. - Meropenem.

Question 39

Management of native valve indolent (subacute) endocarditis?

Answer 39

Amoxicillin IV 2g 4-hourly + Gentamicin 1mg/kg BD (use actual body weight - max 120mg/dose).

Question 40

Management of native valve acute, severe sepsis?

Answer 40

Flucloxacillin IV 2g 6-hourly (4-hourly if >85kg).

Question 41

Management of prosthetic valve or suspected MRSA endocarditis?

Answer 41

Vancomycin IV + Gentamicin IV 1mg/kg BD (actual body weight, max. 120mg/dose). + when vancomycin reaches therapeutic levels add Rifampicin PO 600mg BD.

Question 42

Management of non-severe C. diff?

Answer 42

Metronidazole PO 400mg TDS for 10 days.

Question 43

Management of severe C. diff?

Answer 43

Vancomycin 125mg QDS PO / NG +/-IV Metronidazole. FOR 10 DAYS.

Question 44

Management of mild, proven spontaneous bacterial peritonitis?

Answer 44

Co-trimoxazole PO 960mg BD. | FOR 5-7 DAYS.

Question 45

Management of severe, proven spontaneous bacterial peritonitis?

Answer 45

Piperacillin Tazobactam IV 4.5g TDS | Then step down to Co-trimoxazole PO.

Question 46

Management of peritonitis / biliary tract / intra-abdominal sepsis?

Answer 46

IV Amoxicillin 1g TDS + Metronidazole 400mg TDS + Gentamicin. (if pen-allergic > IV Vancomycin + Met + Gent). TOTAL IV/PO 7 DAYS. Step down to PO Co-trimoxazole + Metronidazole.

Question 47

Management for catheterised patients with suspected UTI?

Answer 47

Do not use urinalysis, do not treat unless clinical signs/ symptoms of infection. If definite infection then treat as complicated UTI.

Question 48

Management of complicated UTI / pyelonephritis / urosepsis?

Answer 48

IV Amoxicillin 1g TDS + Gentamicin (or if pen-allergic: IV Co-trimoxazole + Gent). Step down to Co-trimoxazole PO or as per sensitivities. TOTAL IV/PO - 7 DAYS.

Question 49

Management of uncomplicated female lower UTI?

Answer 49

Nitrofurantoin 100mg MR BD (or 50mg QDS) OR Trimethoprim 200mg BD (not in first trimester). treat for 3 days.

Question 50

Management of uncatheterised male UTI?

Answer 50

Nitrofurantoin 100mg MR BD (or 50mg QDS) OR Trimethoprim 200mg BD Treat for 7 days.

Question 51

Management of cellulitis?

Answer 51

Flucloxacillin 1g QDS (oral if mild, IV if sepsis). If pen-allergic: Doxycycline 100mg BD. OR Clindamycin TOTAL IV/PO 7 DAYS.

Question 52

Management of mild diabetic foot infection?

Answer 52

Flucloxacillin 1g QDS PO (pen-allergic: Doxycycline 100mg BD. TOTAL 7 DAYS

Question 53

Management of moderate diabetic foot infection?

Answer 53

Flucloxacillin 1g QDS + Metronidazole 400mg TDS. | pen-allergic: doxycycline 100mg BD + Met

Question 54

Open fracture prophylaxis?

Answer 54

IV Co-amoxiclav 1.2g TDS (or IV Co-trimoxazole 960mg BD). + Metronidazole 500mg TDS Start within 3 hours for a max of 72 hours.

Question 55

Management of acute septic arthritis / osteomyelitis?

Answer 55

Seek ID advice. | - IV Flucloxacillin 2g QDS.

Question 56

Management of severe systemic infection of unknown source?

Answer 56

IV Amoxicillin 1g TDS + Metronidazole 500mg TDS + Gentamicin. Add Staph. aureus cover if PWID - IV Flucloxacillin 2g QDS. IF PEN-ALLERGIC: IV Vancomycin + Metronidazole + gentamicin.

Question 57

Management of acute exacerbation of COPD?

Answer 57

ABx only if purulent sputum or consolidation on CXR or signs of pneumonia. 1. Amoxicillin 500mg TDS. 2. Doxycycline 200mg Day 1, then 100mg OD for 5 days total.