group 3

Question 1

what does MRSA stand for

Answer 1

Methicillin-Resistant Staphylococcus Aureus

Question 2

what is MRSA

Answer 2

a type of bacteria that is resistant to certain
antibiotics. Staphylococcus (Staph) is a bacteria that lives on the skin or in the nose of a healthy person.
Staph can cause infections ranging from minor skin infections such as pimples or boils and abscesses, to
life threatening conditions such as sepsis, pneumonia, meningitis, or Toxic Shock Syndrome (TSS).

Question 3

treatment of MRSA

Answer 3

Once diagnosed, it is important to take the ENTIRE course of prescribed antibiotics. If the patient is
still experiencing symptoms after the course of antibiotics, please have them call the office so further
treatment may be recommended.
Prescribe a chlorhexidine gluconate 4% antiseptic solution (called Hibiclens). This is an over-the-counter
soap to thoroughly cleanse the skin. Use this as a body wash every day for 3 days, then 3 times a week
until the infection is fully resolved.
Prescribe Bactroban (Mupirocin) ointment. This is used to decrease the colonization (multiplying) of
the bacteria. Patient instructions are to place a small amount on a cotton swab and apply to the inside of
the nostrils twice a day for 5 days. Do not insert the cotton swab further than the cotton tip.

Question 4

Orbital and Periorbital Cellulitis clinical manifestations

Answer 4

Both preseptal and orbital cellulitis can present with swelling and erythema.
• Preseptal and orbital (postseptal) cellulitis occurs most commonly in children.
• These conditions may be difficult to distinguish clinically, and because orbital cellulitis may be
sight- and life-threatening, diagnostic imaging (and at times surgical exploration) may be
required to confirm the diagnosis.
o Pain with eye movement is more common in orbital cellulitis but can also occur in
preseptal cellulitis.
o Chemosis (conjunctival swelling) is far more common in orbital cellulitis but has been
observed in severe preseptal cellulitis.
o Orbital cellulitis, but not preseptal cellulitis causes the following: (CT warranted if any of
the following symptoms are present)
• Proptosis
• Globe displacement
• Limitation of eye movements
• Double vision
• Vision loss (indicates orbital apex involvement)

Question 5

treatment of orbital and periorbital cellulitis

Answer 5

Milder cases of preseptal cellulitis in adults and children, older than one year of age:
o May be managed on an outpatient basis, provided the patient has no signs of systemic
toxicity, has been adequately immunized for H. influenzae and S. pneumoniae, and close
follow-up is feasible.
o In these cases, we recommend treatment with broad-spectrum oral antibiotics:
▪ Amoxicillin-clavulanate 875 mg every 12 hours in adults; 90 mg/kg per day
amoxicillin and 6.4 mg/kg per day of clavulanate in two divided doses in children
▪ Cefpodoxime 200 mg every 12 hours in adults; 10 mg/kg per day divided every
12 hours in children, maximum daily dose 400 mg
▪ Cefdinir 600 mg daily in adults; 14 mg/kg per day divided every 12 hours in
children, maximum daily dose 600 mg
▪ Duration of therapy — Although there have been no controlled trials examining
the duration of antimicrobial therapy in preseptal cellulitis, treatment
recommendations are based on clinical case series, generally for a duration of 7
to 10 days. Occasional patients will continue to have local signs of cellulitis at
the end of treatment, in which cases continued oral antibiotic therapy is
recommended until resolution of all erythema has occurred.
• Pediatric patients (<1 year of age) and all patients with more severe preseptal cellulitis should
be managed as for orbital cellulitis with a CT scan, intravenous broad-spectrum antibiotics, and
hospital observation.

Question 6

age for treatrment consent for reproductive health and STI testing

Answer 6

any

Question 7

age for treatment consent for mental health and chemical dependency

Answer 7

14

Question 8

age for tx consent for all other medical and dental services

Answer 8

15

Question 9

Legal and Best Practice Concerns Based on Age:

Answer 9

Providers are expected to involve parents by the end of the minor’s mental health, drug or
alcohol treatment unless: The parent refuses involvement; Clear clinical indications to the
contrary exist and are documented in the treatment record; There is identified sexual abuse; or
The minor has been emancipated and/or separated from the parent for at least 90 days.
• When a minor self-consents for health care services, providers are encouraged to use their best
clinical judgment in deciding whether to share information with the parent or guardian (ORS
109.650), and NUNM expects providers to obtain a signed Proxy for such cases.
• Providers should be aware of barriers to confidentiality related to medical billing and
Explanation of Benefits by insurance companies, as well as access to Open Notes through
MyChart.
• American Academy of Pediatrics (AAP) recommends starting conversation about sexual health
and substance use at age 11 without parents in the room.
• Adolescents may legally consent to medical care for STIs without parental notification in all 50
states and Washington D.C.1

Question 10

Well-Child Screening Guidelines and Questionnaires:

Answer 10

ASQ: Asymptomatic developmental screening at 9-mo, 18-mo, and 24-30-mo visits, and symptomatic
evaluation at any age until 60 months of age. Documents available on Moodle.
M-CHAT: Autism Screening to be done at 18 and 24 month visits. Multiple languages here:
http://mchatscreen.com/mchat-rf/translations/
Edinburgh Depression Screen: Used for Postnatal Depression. To be given at EVERY office visit during
the first year of life. Consider screening all caregivers for depression, not just birth-mother. Responses
are entered into the pediatric patient’s chart under ‘Flowsheets’. Multiple languages here:

Question 11

Adolescent Mental Health and Substance Use Screening Questionnaires:

Answer 11

PHQ-Adolescents: Yearly depression screening and monitoring for patients age 12-18.
• SCARED: Anxiety assessment and monitoring for symptomatic children age 8-18 years. Both
Child and Parent versions available. More languages are here:
http://www.pediatricbipolar.pitt.edu/content.asp?id=2333
• CRAFFT: Alcohol and substance use screening. Recommend yearly screening starting at age 11,
or in younger patients if history suggests risk. Multiple languages available here:
http://www.ceasar-boston.org/CRAFFT/selfCRAFFT.php
• Vanderbilt Questionnaire: Assess for ADHD for 6-18 year of age, although some use as young as
4 years. To be completed by parents and teachers. Intended to assess when concerns are
present, and NOT as a screening tool.

Question 12

Depression in Adolescents

Answer 12

If suicidality is present, a discussion about standard of care treatment should be held, including
a consideration of a combination of pharmaceuticals and psychotherapy. Black box warning
regarding an increased risk of suicidality in adolescent patients should be discussed.
• For pediatric psychological prescribing support, call OPAL (Oregon Psychiatric Access Line) 503-
346-1000
• See information above regarding age of consent for Mental Health services.
• Offer adolescent-specific crisis lines and resources:
o Teen2Teen: 4pm – 9pm, Monday - Friday
▪ Phone Line: (877) 968- 8491
▪ Text: 839 863
o 24-Hour Text Crisis Line: 741 741

Question 13

When to Send Suicidal Patients to the Emergency Department:

Answer 13

Unable or unwilling to create a safety plan
• Suicidal in the context of family situation, and has to go home
• Suicidal and not thinking clearly, such as a patient who is high or psychotic
• Significant risk factors
• You do not believe the patient can remain safe
• The patient’s family does not believe they can keep them safe

Question 14

Mandatory Reporting of Suspected Child Abuse (Non-Accidental Trauma/ NAT): what to report

Answer 14

Physical, sexual, or emotional abuse
• Neglect
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• Domestic Violence - when children are in the family or potentially exposed (otherwise report DV
concerns to law enforcement)
• Parental substance abuse (legal or illegal) that causes intoxication and inability to care for the
child

Question 15

Mandatory Reporting of Suspected Child Abuse (Non-Accidental Trauma/ NAT): obtaining disclosure

Answer 15

Ask non-leading questions
• Children will need to give a detailed account of the abuse to authorities – don’t press them to
give you details beyond what is necessary to initiate the report, and attempt to minimize the
number of times the child is questioned about abuse-related incidents.
• Record as close to verbatim as possible.

Question 16

Mandatory Reporting of Suspected Child Abuse (Non-Accidental Trauma/ NAT): who to contact

Answer 16

Child Abuse Hotline: 1-855-503-SAFE (7233)
• Call CARESNW or the Emergency Department for consult on suspected child abuse.
o 503-276-9000,

Question 17

Transgender Care for Pediatric Patients

Answer 17

• Refer patients to pediatric endocrinology at OHSU to assess if they are a good fit for GnRH
agonists for puberty suppression.
• Offer mental health support and family involvement.
• Provide an internal referral to a trans-specific shift, where they may consider hormone-related
care for adolescents over the age of 15.

Question 18

ADHD Management Guidelines for the Pediatric Patient:

Answer 18

• Vanderbilt questionnaire completed by parent and teacher
• Other biomedical causes for symptoms ruled out via laboratory evaluation
• Refer for full neuropsychological evaluation (consider Pacific University)
• Requirements for stimulant medication management:
o Diagnosis of ADHD from neuropsychological evaluation or previous records
o Controlled-substance contract signed by parent(s) and child, including agreement to
random UAs, pill counts, and consistent prescriber and pharmacy
o Concomitant behavior therapy instated
o Verify script each month in the Prescription Drug Monitoring Program
o Offer 1 month of medication at a time
o Goals of treatment (long and short term)
▪ Regular follow-ups with lab monitoring if indicated
▪ Bi-annual reassessment
▪ Medication/treatment efficacy
▪ Minimize long-term amphetamine use
▪ Changes to diagnosis or additional symptoms

Question 19

review pediatric vital signs

Answer 19

review

Question 20

Stage 1 pediatric hTN

Answer 20

1. If the BP reading is at the stage 1 HTN level (click link for Table 3) and the patient is
   asymptomatic, provide lifestyle counseling and recheck the BP in 1 to 2 weeks by auscultation.
2. If the BP reading is still at the stage 1 level, upper and lower extremity BP should be checked
   (right arm, left arm, and 1 leg), and BP should be rechecked in 3 months by auscultation.
   Nutrition and/or weight management referral should be considered as appropriate; and
3. If BP continues to be at the stage 1 HTN level after 3 visits, ambulatory blood pressure
   monitoring should be ordered (if available), diagnostic evaluation should be conducted, and
   treatment should be initiated. Subspecialty referral should be considered (click link for Table
   11).

Question 21

stage 2 pediatric HTN

Answer 21

1. If the BP reading is at the stage 2 HTN level (click link for Table 3), upper and lower extremity BP
   should be checked (right arm, left arm, and 1 leg), lifestyle recommendations given, and the BP
   measurement should be repeated within 1 week. Alternatively, the patient could be referred to
   subspecialty care within 1 week;
2. If the BP reading is still at the stage 2 HTN level when repeated, then diagnostic evaluation,
   including ambulatory blood pressure monitoring, should be conducted and treatment should be
   initiated, or the patient should be referred to subspecialty care within 1 week (click link for
   Table 11); and
3. If the BP reading is at the stage 2 HTN level and the patient is symptomatic, or the BP is >30
   mm Hg above the 95th percentile (or >180/120 mm Hg in an adolescent), refer to an immediate
   source of care, such as an emergency department (ED).

Question 22

vaccines

Answer 22

NUNM providers will present the ACIP/CDC vaccine schedule and provide caregivers with
information, focusing on informed consent, offering a thorough PARQ. ACIP/CDC vaccine
schedule can be found here: https://www.cdc.gov/vaccines/schedules/index.html
• NUNM providers should discuss vaccines at every well child visit and document accordingly
• Detailed vaccine information, including contraindications can be found in the CDC Pink
Book: https://www.cdc.gov/vaccines/pubs/pinkbook/index.html
• For any vaccines that parents decline:
o Have parents sign the NUNM Vaccine Refusal Form - document in the chart that it was
signed and send to be scanned.
o Do not sign the medical exemption form unless we have the administered a vaccine and
observed an adverse reaction. If an adverse reaction occurs, document in VAERS.
https://vaers.hhs.gov/index
o If families have a philosophical exemption, NUNM providers do not sign Vaccine
Education Certificate. Instead, direct parents to educate themselves through the videos
on the Oregon State Public Health Lab (OSPHL) website and advise them to print off
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necessary certificate of completion for school. Note that parents must have access to
internet and a printer to complete these trainings.
http://www.oregon.gov/oha/PH/PreventionWellness/VaccinesImmunization/GettingIm
munized/Pages/non-medical-exemption.aspx
• VFC Provider Agreement states that: For the vaccines identified and agreed upon in the provider
profile, I will comply with immunization schedules, dosages, and contraindications that are
established by the Advisory Committee on Immunization Practices (ACIP) and included in the VFC
program unless:
o In the provider’s medical judgement, and in accordance with accepted medical practice,
the provider deems such compliance to be medically inappropriate for the child;
o The particular requirements contradict state law, including laws pertaining to religious
and other exemptions.

Question 23

Newborn Screening (NBS)

Answer 23

Recommended testing is at 2 days and 2 weeks of age, although samples can be sent to the
OSPHL until 6 months of age if not performed earlier.
• Providers who see children under 6 months of age should request records of NBS results to
confirm normal findings.
• Educate the parents extensively about the risks of opting out of this testing. Provide thorough
PARQ conference.
• If parents decline the NBS, have them sign the NUNM Newborn Screening Refusal Form
(available on the NUNM Health Center Moodle page). One copy should be scanned into the
chart, one given to the parents, and another copy sent to the OSPHL.
• More information can be found through the OHPSL:
http://www.oregon.gov/oha/ph/LaboratoryServices/NewbornScreening/Pages/index.aspx
• After performing a Newborn Screening, it is essential to follow up with the OSPHL for results.

Question 24

Lead Screening:

Answer 24

Screening Protocols for Children per the Oregon Health Authority: All children should be
assessed for risk of lead poisoning at 1 and 2 years of age, or between 3-5 years if not
previously screened. To screen, administer the Oregon Lead Risk Assessment Questionnaire
(form posted on Moodle). If any response is “Yes” or “Don’t know,” the patient should be
referred to the Oregon Lead Line for capillary blood lead testing, or venipuncture can be
performed at the NUNM Lab.
• Blood lead testing should also be considered as part of a diagnostic work-up of any individual
regardless of age with the following symptoms:
o Behavioral problems (applies to children): aggression, hyperactivity, attention deficit,
school problems, learning disabilities, excessive mouthing or pica behavior and other
behavior disorders. Investigative Guidelines 7 Sept, 2016
o Developmental problems (applies to children): growth, speech and language delays
and/or hearing loss. Symptoms or signs consistent with lead poisoning: irritability,
headaches, vomiting, seizures or other neurological symptoms, anemia, loss of appetite,
abdominal pain/cramping or constipation. Ingestion of foreign body.
• Per AAP Guidelines, consider screening patients who are immigrants and refugees upon arrival,
and then again 3-6 months later.

Question 25

Pneumonia – Community Acquired Pneumonia (CAP) in ADULTS – Most commonly causative organisms for outpatient community acquired pneumonia
are:

Answer 25

Streptococcus pneumoniae,
• Mycoplasma pneumoniae,
• Chlamydia pneumoniae,
• influenza virus,
• parainfluenza virus,
• respiratory syncytial virus
o Haemophilus influenzae and Legionella pneumoniae are less common

Question 26

Pneumonia – Community Acquired Pneumonia (CAP) in ADULTS – Requirements for Hospital Admission:

Answer 26

C – confusion to person, place, and time, or based upon a specific mental test.
R – respiratory rate greater than 30 bpm.
B – blood pressure less than 90mmHg systolic or 60mmHg diastolic.
65 – age greater than 65 years.
Each of the four items is worth one point. It is recommended that patients with a score of one (1) or
more be admitted to the hospital.
• Living situation, mental status, functional status, probable compliance with treatment, ability to
maintain oral intake, history of substance use, must also be considered in the decision not to
admit.

Question 27

Pneumonia – Community Acquired Pneumonia (CAP) in ADULTS – Regimens and Guidelines for Empiric Therapy:

Answer 27

Pharmacotherapy should be utilized in cases of pneumonia of presumed, non-viral etiology:
• Empiric therapy is considered rational and appropriate in CAP patients who do not require
hospitalization. In general, CAP outpatients should be treated for a minimum of five days.
• Macrolide monotherapy is appropriate for patients in whom: there is an absence of
comorbidities, complications or antibiotic use in the last three months, and locales where the
prevalence of macrolide-resistant strains is not high. Recommended regimens:
1) Azithromycin PO, 500mg day 1, then 250mg days 2, 3, 4, and 5
OR 500mg/day for three consecutive days
OR 2g single dose
2) Clarithromycin XL PO, 1000mg/day for 5 days or until afebrile for 48-72 hours
3) Doxycycline PO, 100 mg/twice daily for 7 to 10 days.
• In patients with a recent history of antibiotic use (3 months or less), or comorbidities (such as
diabetes, COPD, chronic heart disease, immunosuppression, cancer, liver or kidney disease,
asplenism, or alcoholism), or in areas where there is high prevalence of macrolide resistant S.
pneumoniae, recommended oral regimens include:
1) gemifloxacin 320mg/d, levofloxacin 750mg/day or moxifloxacin 400mg/day for a minimum of
5 days.
2) combination therapy with a beta-lactam effective against S. pneumonia (amoxicillin 1g three
times daily; amoxicillin/clavulanate 2g twice daily; cefpodoxime 200mg twice daily or
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cefuroxime 500mg twice daily) PLUS a macrolide (azithromycin 500mg day 1 and 250mg days 2-
5 or clarithromycin 250mg twice daily) or doxycycline (100mg twice daily) for a minimum of five
days.

Question 28

Associated interventions, Pneumonia – Community Acquired Pneumonia (CAP) in ADULTS

Answer 28

Smoking cessation should be the goal in any CAP patient who is a smoker.
• Screening and vaccination against influenza is recommended for all patients.
• Screening and vaccination against pneumococcus is recommended in patients whom are
smokers, whom have comorbidities (COPD, DM, etc.), or whom are over age 65.

Question 29

Pneumonia – Community Acquired Pneumonia (CAP) in ADULTS, Timelines to Follow Up:

Answer 29

24-48 hours in person or by phone after initiation of treatment.
• Daily, in progressive, worsening, or recalcitrant cases
• 1-2 weeks after initiation of treatment in uncomplicated cases.

Question 30

Pneumonia – Community Acquired Pneumonia (CAP) in ADULTS: Monitoring Each visit should include:

Answer 30

Vital signs
• Pulse Oximetry, resting and three-minutes ambulatory
• Clinical pulmonary physical examination
• White blood cell count
• Blood Urea Nitrogen level
• CRB65 – or another validated hospitalization admission criteria
• Exams, laboratories, imaging, etc. appropriate to relevant co-morbid conditions

Question 31

Chlamydia treatment

Answer 31

Treatment should be initiated when a patient’s screening test is positive or empirically in patients who
present with symptoms suggestive of infection (cervicitis, PID, urethritis).
• Azithromycin – 1 gram single dose
• Doxycycline 100 mg bid x 7 days (C/I in pregnancy)

Question 32

chlamydia alternative therapies

Answer 32

Ofloxacin 300 mg orally twice daily for seven days

Levofloxacin 500 mg orally once daily for seven day

HIV-positive persons with chlamydia should receive the same treatment as those who are HIV negative.
All sex partners should be evaluated, tested, and treated. Persons with chlamydia should abstain from
sexual intercourse for 7 days after single dose antibiotics or until completion of a 7-day course of
antibiotics, to prevent spreading the infection to partners.
CDC recommends retesting 3 months after treatment

Question 33

Gonorrhea treatment

Answer 33

Treatment - pharmacological intervention should be initiated with a positive test (Culture, DNA probe,
NAAT (preferred testing choice by CDC urethral {swab or urine}, vaginal, cervical {swab or on liquid
based pap} or gram stain)
Urogenital & Pharyngeal infections
Recommended regimens — The dosage and administration of combination therapy for uncomplicated
gonococcal infections are outlined below:
• Ceftriaxone 250 mg intramuscular in a single dose for treatment of gonococcal infection
PLUS
• Azithromycin (1 gram in a single do

Question 34

Gonorrhea Alternative therapies

Answer 34

If an injectable cephalosporin is not an option, oral cephalosporin therapy can be considered.
Cefixime (400 mg orally in a single dose or 400 mg by suspension) PLUS 1 gram azithromycin
orally (single dose) was shown to lead to microbiologic cure in 96 percent of patients with
uncomplicated gonorrhea.
Azithromycin monotherapy — While a higher dose of azithromycin monotherapy (i.e. 2 g single dose)
would treat both gonorrhea and chlamydia infections, it is not a recommended regimen due to the
frequency of gastrointestinal side effects, high cost, and concerns regarding increasing gonococcal drug
resistance to azithromycin [30]. Monotherapy with azithromycin is not recommended by the CDC for the
treatment of gonorrhea, except in patients with severe penicillin allergy who cannot undergo beta
lactam desensitization protocols or in pregnant women

Question 35

Conjunctivitis due to Gonorrhea

Answer 35

Single 1 gram IM injection of ceftriaxone to be effective [37]. All patients should also be treated
presumptively for Chlamydia infection as well with either azithromycin or doxycycline

Question 36

Epididymitis

Answer 36

Treatment of epididymitis depends upon clinical suspicion of the etiology.
• For acute epididymitis most likely caused by sexually transmitted GC and CT: Ceftriaxone (250
mg intramuscularly) and oral treatment for chlamydia with doxycycline (100 mg twice for 10
days) is recommended in these patients.
• For acute epididymitis most likely caused by sexually-transmitted GC and CT and enteric
organisms (men who practice insertive anal sex) : ceftriaxone 250 mg IM in a single dose PLUS
levofloxacin 500 mg orally 1x/day for 10 days OR ofloxacin 300 mg orally 2x/day for 10 days.

Question 37

serological tests for Syphilis

Answer 37

see notes

Question 38

Syphilis treatment

Answer 38

Treatment must be initiated with positive testing for syphilis – initial serologic testing, non-treponemal
tests (RPR, VRDL, TRUST) followed by treponemal tests (FTA-ABS, MHA-TP, TP-EIA, TP-PA).
Antibiotic treatment is necessary per CDC recommendations:
Primary & secondary syphilis
• Doxycycline – 200 mg po bid x 14 days (updated 1/22/16 rd)
• Tetracycline – 500 mg po qid x 14 days
All stages required as 1st line treatment IM penicillin G – 2.4 million units single dose IM Bicillin
(benzathine penicillin G)

Question 39

Follow-up labs and testing for Syphillis

Answer 39

Serologic monitoring is critically important during follow-up of treated syphilis, since clinical symptoms
or signs (e.g., chancre) may resolve without therapy and infection can progress insidiously to later stages
of infection (e.g., neurosyphilis). Non-treponemal tests are usually assessed at 3, 6, and 12-month
intervals after treatment, and antibody titers are compared with the pretreatment baseline. It is
Non-treponemal test (e.g. RPR)
Reactive
Reactive
Non-treponemaltest(e.g.RPR)
Second Treponemal test (e.g. FTA-ABS)
Reactive
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important that the same testing assay (e.g., RPR or VDRL) be used for all follow-up examinations, and be
performed by the same laboratory since titers may vary by 1 to 2 dilutions if different tests are used.

Question 40

Trichomoniasis (Trichomonas vaginalis) treatment

Answer 40

Positive finding on wet prep, rapid diagnostic kits using DNA probes and monoclonal antibodies (OSOM,
AFIRM VP III), liquid based pap tests
All nonpregnant women with symptoms or asymptomatic trichomonas should be treated
• Metronidazole 2 g po single dose or Tinidazole 2 g po sd.
• Metronidazole 500 mg po bid x 7 days
Pregnancy: Metronidazole is CI in 1st trimester. Use cautiously in 2nd & 3rd for symptomatic cases
• Must treat partner concurrently

Question 41

PID CDC Diagnostic Criteria

Answer 41

PID should be suspected & treatment initiated if:
• Patient is at risk for PID
o Being a sexually active woman younger than 25 years old
o Having more than one sexual partner
o Being in a sexual relationship with a person who has more than one sex partner
o Having sex without a condom
o Having had an IUD inserted recently
o Douching regularly, which upsets the balance of good versus harmful bacteria in the
vagina and may mask symptoms that might otherwise cause you to seek early treatment
o Having a history of pelvic inflammatory disease or a sexually transmitted infection
AND
• Patient has uterine tenderness, adnexal tenderness, or CMT with no other apparent cause.
o Individually – each of these have very high sensitivities compared with histologically
confirmed endometritis.
o Findings that support the diagnosis:
▪ Cervical or vaginal mucopurulent (green/yellow) d/c
▪  ESR (>15mm/hr) or  CRP
▪ Lab finding of CT or GC infection
▪ Oral temp of  101F(38.3C)
▪ WBC on wet prep (10) – has high sensitivity & positive predictive value for
diagnosis of PID.

Question 42

PID Treatment

Answer 42

Criteria for Inpatient Treatment of PID
• Failure to improve after 3 days of outpatient tx
• Inability to follow or tolerate oral antibiotics
• Pregnancy
• Severe illness (i.e., high fever, vomiting or tubo-ovarian abscess)
• Surgical emergency cannot be excluded
• Immunodeficiency, incl. HIV infection with low CD4 count, cancer therapies, transplant pt

Question 43

PID Parental and Oral Regimes

Answer 43

CDC- 2015-recommended oral/IM regimen A (updated 1/22/2015 rd)
• Ceftriaxone 250 mg IM in a single dose, PLUS
• Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
• Metronidazole 500 mg orally 2 times a day for 14 days
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CDC – 2015-recommended oral/IM regimen B
• Cefoxitin 2 g IM in a single dose PLUS
• Probenecid 1 g orally in a single dose, PLUS
• Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
• Metronidazole 500 mg orally 2 times a day for 14 days
CDC- 2010 - recommended oral/IM regimen C
• Other parenteral third-generation cephalosporin (e.g., Ceftizoxime, Cefotaxime), PLUS
• Doxycycline 100 mg orally 2 times a day for 14 days
With or Without
• Metronidazole 500 mg orally 2 times a day for 14 days

Question 44

PID Parental treatment NOT an option or available the following treatment option should be used:

Answer 44

Vantin 400 mg single dose, PLUS
• Doxycycline 100 mg po 2 times a day for 14 days, PLUS
• Metronidazole 500 mg orally 2 times a day for 14 days

Question 45

Multnomah County Health Department Recommendations (5/2007):PID

Answer 45

• Quinolones are no longer recommended by CDC as 1st line treatment of GC (24% resistance in
U.S. – 2005)
• If quinolones are used – test for cure in one week
• Pregnancy – use azithromycin * 2 gm – single dose – test for cure in 1 wk.
• Cefpodoxime (Vantin)* – 400 mg po single dose – for uncomplicated anogenital GC (only as an
alternative if injectable antibiotics are not an option)

Question 46

PID Follow-up

Answer 46

• Patients should show substantial improvement in 72 hours – have them RTC & repeat exam –
vitals & pelvic exam. Patients who do not improve usually required hospitalization
• Repeat CT testing if (+) at initial diagnosis – 4-6 weeks after treatment
• HIV testing recommended to all women diagnosed with acute PID

Question 47

PID Partner Management

Answer 47

All male sexual partners who have had sexual contact with pt. 60 days prior to patient’s onset of
symptoms should be examined & treated
• Partners should be treated for GC/CT even if women did not have a positive test for either