ID

Question 0

What agents cause, and what is empiric treatment for nursing-home acquired pneumonia?

Answer 0

MRSA, pseudomonas.

Inpatient tx should include 3 drugs:

1) anti-pseudomonal cefalosporin, carbapenim or extended spectrum beta lactam/lactamase inhibitor
2) anti-pseudomonal flouroquinolone or aminoglycoside
3) anti-MRSA agent

Reasonable outpt tx would be ceftriaxone and azithro or levoquine alone.

Question 1

What is the treatment for acute mononucleosis?

Answer 1

Treatment is supportive and includes hydration, NSAIDs and throat sprays or lozenges. Corticosteroids do not have a role unless there is airway compromise. There is no evidence to support the use of antihistamines, acyclovir or bed rest. Nearly all patients will have an enlarged spleen and it is recommended that they abstain from contact or collision type activities for 3 to 4 weeks.

Question 2

Name as many anti-pseudomonal drugs as you can

Answer 2

Cephs: cefepime, ceftazidine, ceftriaxone

Monobactam: aztreonam
Carbapenems: imipenem, meropenem, doripenem

B-lactam/lactamase inhibitors: piperacillin/tazobactam, ticarcillin/clavulanate

Flouroquinolones: llevofloxacin (respiratory), cipro

Aminoglycosides: gent, tobra, amikacin (usually used as adjunctive rather than as monotherapy) .

Question 3

What drugs may be effective for multi-drug resistant pseudomonas?

Answer 3

IV colistin or polymixin B

Colistin is at least mildly nephrotoxic.

Question 4

What are the clinical features of cerebral malaria?

Answer 4

There is a prodrome of delirium or erratic behavior, coma following a generalized convulsion, fever, and lack of focal neurological signs in the presence of a diffuse symmetric encephalopathy. Laboratory findings would include hemolytic anemia with indirect bilirubinemia, dark red urine positive for hemoglobin, and a peripheral blood smear showing normochromic normocytic anemia with Plasmodium Falciparum trophozoites and schizonts.

Question 5

What are the revised Jones criteria for diagnosis of rheumatic fever?

Answer 5

A previous Group A strep infection combined with two major manifestations or one major and two minor manifestations as follows.

Major manifestations include carditis, polyarthritis, Sydenham chorea, erythema marginatum, and subcutaneous nodules.

Minor manifestations include arthralgia, fever, elevated acute phase reactants, and prolonged PR interval on EKG.

Question 6

What is trichiriasis?

Answer 6

It is caused by a nematode (Trichirus trichiura) infecting the large intestine. The organism is also called whipworm. It has a large egg output of about 200 eggs per gram making the detection of eggs in and over and parasite examinations unproblematic. The ova are characteristically barrel or lemon shaped with a thick shell and translucent polar prominences. Infection with this nematode is mainly asymptomatic. Heavily infected individuals may present with a mild microcytic anemia, bloody diarrhea, growth retardation, or rectal prolapse. Mebendazole or Vermox is the treatment of choice.

Question 7

What is ascariasis?

Answer 7

It is caused by a nematode (Ascaris lumbricoides) and does not produce the perianal and peroneal pruritis seen in enterobiasis. The ova are easily detected in the stool by routine O&P exam. The worm burden is usually large and the female worm produces 200,000 ova daily. Problems with this nematode arise in its ability to cause obstruction of the lumen of the small bowel as well as the biliary duct. Patients usually presents with acute epigastric pain, nausea, and vomiting. Larval migration through the lungs can cause pneumonitis. Certain conditions can cause the worms to migrate to other tissues or organs, and they can even migrate out of the anus and/or nose. Mebendazole/Vermox is the treatment of choice.

Question 8

What is ankylostomiasis?

Answer 8

It is also called hookworm infection (Acylpstoma duodenale and Necator americanus). A low degree of prevalence of the infection still exists in the southeastern United States. The larvae are in the soil and penetrate the skin where they travel to the lungs, penetrate the alveolar walls and make their way up the trachea to be swallowed and carried to their final habitat in the small intestine. Disease manifestations may occur early during the course of infection with “ground itch”, intense pruritus and erythema at the site of the larval penetration. The major clinical manifestations of Hookworm disease are iron deficiency anemia and chronic protein-energy malnutrition. Eggs are detected by O&P exam and are ovoidal and thin shelled, measuring 58 x 36 µm.

Question 9

Describe the clinical features of pertussis.

Answer 9

There is a prodromal phase that lasts one to two weeks and is indistinguishable from a viral upper respiratory infection. It progresses to a more severe cough after the second week. The cough is paroxysmal and maybe severe enough to cause vomiting or fracture ribs. Patients are rarely febrile, but may have increased lacrimation and conjunctival injection. The incubation period is long compared to a viral infection, usually 7 to 10 days.

Question 10

What syndrome is associated with infection with E. coli O:157?

Answer 10

There is a 10 to 15% risk of developing hemolytic uremic syndrome.

Question 11

What is the treatment for enterohemorrhagic E. coli infection?

Answer 11

Supportive care and monitoring for the development of microangiopathic complications, such as hemolytic uremic syndrome. Anti-peristaltic agents increase the risk of systemic complications and should be avoided. Antibiotics appear to increase the risk for hemolytic uremic syndrome and should also be avoided.

Question 12

How is the diagnosis of herpes definitively made?

Answer 12

DNA polymerase chain reaction testing is 95% sensitive as long as an ulcer is present and has a specificity of 90%. The diagnosis is established by culturing the virus from an infected lesion.

Question 13

How should Pneumocystis carinii pneumonia be treated in a patient with AIDS?

Answer 13

Trimethoprim/sulfamethoxazole is the treatment of choice for acute pneumocystis pneumonia. Adjunctive corticosteroids should also be started in any patient whose initial PO2 on room air is less than 70. Other possible effective antibiotics include pentamidine, dapsone, atovaquone, or clindamycin and primaquine.

Question 14

What other organisms should be considered in a male patient with a persistent urethral discharge and dysuria who has already been treated with azithromycin and ceftriaxone? What should the treatment be?

Answer 14

Consideration should be given to obtaining cultures for mycoplasma or Ureaplasma and for Trichomonas. Treatment should include azithromycin 500 mg daily for five days, doxycycline 100 mg b.i.d. for seven days, plus metronidazole 2 g orally as a single dose.

Question 15

What agent causes cat scratch disease? What is its treatment?

Answer 15

Bartonella henselae. Azithromycin is the drug of choice. Other effective antibiotics include rifampin, ciprofloxacin, trimethoprim/sulfamethoxazole, and gentamicin. Ceftriaxone, amoxicillin/clavulanate, doxycycline, and clindamycin are not effective.

Question 16

Streptococcus bovis bacteremia or endocarditis is associated with a high incidence of what other diseases?

Answer 16

Colorectal malignancies. It may also occur with upper G.I. cancers.

Question 17

What is the presentation for Rocky Mountain spotted fever? What is its treatment?

Answer 17

Sudden onset fever, chills and headache; pink blanching rash that covers most of the body including palms and soles but not the face. Recent outdoor activity.

Treatment is doxycycline 100 mg b.i.d. for 10 days

Question 18

What treatments have been shown to shorten hospital stays in children with croup?

Answer 18

Oral or intramuscular dexamethasone, 0.6 mg per kilogram as a single dose, and nebulized budesonide have been shown to reduce croup scores and shorten hospital stays. Racemic epinephrine may be used acutely, but rebound can occur. Albuterol has not been shown to be helpful.

Question 19

What are the typical features of a respiratory syncytial virus infection in a child?

Answer 19

RSV is the most common cause of pneumonia in children age four months to four years. The peak incidence of respiratory syncytial virus is between two and seven months old. Wheezing and profuse rhinorrhea are characteristic, and the disease typically occurs in mid winter or early spring epidemics. Children often have mild fevers, cough almost continuously, yet do not appear acutely ill.

Question 20

What are the three main agents that cause otitis media in children?

Answer 20

Streptococcus pneumoniae, H influenza, and Moraxella catarrhalis.

Question 21

Which children should get antibiotics for otitis media?

Answer 21

All infants less than six months old should be treated with antibiotics if there is a reasonable probability of acute otitis media. Children six months to two years old should be treated with antibiotics if the diagnosis of acute otitis media is certain or if the diagnosis is uncertain or there is severe illness with moderate to severe otalgia and fever greater than or equal to 39° C.

Observation is an option if diagnosis is not certain and illness is not severe.

Overage to children should be treated with antibiotics give the diagnosis of acute otitis media is certain and the illness is severe.

Observation is an option if the diagnosis is certain but the illness is not severe or in patients with an uncertain diagnosis and no signs of severe illness.

Question 22

What is the best antibiotic choice for acute otitis media and children?

Answer 22

Amoxicillin 80 to 90 mg per kilogram per day. Amoxicillin clavulanate for those who have been treated with antibiotics in the last 30 days, those with concurrent conjunctivitis, or those taking prophylactic amoxicillin for recurrent otitis media.

If the child is penicillin allergic but had no urticaria or anaphylaxis, cephalosporins can be used these would include cefdinir 14 mg per kilogram per day, cefpodoxime 10 mg per kilogram per day, cefuroxime 3 mg per kilogram per day or ceftriaxone 50 mg per kilogram IM or IV.

If the child is penicillin allergic and had urticaria or anaphylaxis, the treatment would be macrolides including erythromycin and sulfamethoxazole, azithromycin, and clarithromycin. Another choice would be clindamycin.

Treatments that are not recommended due to resistance include trimethoprim sulfamethoxazole and levofloxacin.

Question 23

What are the indicators for bacterial rhinosinusitis?

Answer 23

Duration of seven or more days, purulent nasal discharge, maxillary tooth or facial pain, unilateral maxillary sinus tenderness, and especially worsening of symptoms after initial improvement.

Question 24

What are appropriate drugs for community acquired MRSA?

Answer 24

Clindamycin, doxycycline, minocycline, and trimethoprim sulfamethoxazole. MRSA is resistant to beta-lactam’s and macrolides and is showing increasing resistant to fluoroquinolones.

Question 25

What is the clinical picture of giardiasis?

Answer 25

The most characteristic symptoms include: foul-smelling, soft, or loose stools; foul-smelling flatus; belching; marked abdominal distention; and the virtual absence of mucus or blood in the stool. Stool is usually mushy between exacerbations, though constipation may occur. Eosinophilia is not usually a feature of this disease.

Question 26

What organism rarely causes bacteremia and fatal sepsis after animal bites, especially in asplenic patients or those with underlying hepatic disease?

Answer 26

Capnocytophaga canimorsus

Question 27

What is the presentation and treatment of streptococcal disease of the perineum?

Answer 27

The epidemiology of group A streptococcal disease of the perineum is similar to that of group A streptococcal pharyngitis, and the two often coexist. The average age of this disease varies from 1 to 11 years, with a mean of five years. girls and boys are almost equally affected. It is theorized that either auto inoculation from mouth to hand to perineum, or that it is transmitted through the gastrointestinal tract. incidence peaks in March April and May and North America. The condition usually presents with itching and a beefy redness around the anus and/or Volvo and will not clear with medications used to treat candidal infections.

Question 28

What is the standard treatment for Pneumocystis carinii pneumonia?

Answer 28

Trimethoprim/sulfamethoxazole is the treatment of choice for acute pneumocystis pneumonia. Adjunctive corticosteroid should also be started in any patient whose initial PO2 on room air is less than 70 mm. Other effective antibiotics include pentamadine, dapsone, atovaquone, and clindamycin.

Question 29

What is the initial recommended workup for men with urethritis?

Answer 29

Gonorrhea and chlamydia testing of the penile discharge or urine, urinalysis with microscopy if no discharge is present, VDRL or RPR testing for syphilis, and HIV and hepatitis B testing.

Question 30

What is a positive urinalysis for urethritis in a man?

Answer 30

Positive leukocyte esterase or greater than or equal to 10 wbc’s per high-powered field the first void urine sediment.

Question 31

What is presumptive treatment for urethritis in a male?

Answer 31

Azithromycin 1 g orally as a single dose, or doxycycline 100 mg orally twice a day for seven days. In addition ceftriaxone 125 mg IM, or cefixime 400 mg orally as a single dose, should be given.

Question 32

What actions should be taken and treatment given in a male with a history of treated urethritis who presents with the same complaints within three months and has not changed partners?

Answer 32

The same tests as at first visit should be repeated including gonorrhea and chlamydia testing of the penile discharge or urine. Consideration should also be given to obtaining cultures for Mycoplasma, Ureaplasma and trichomonas from the urethra or urine. Treatment should include azithromycin 500 mg orally once daily for five days or doxycycline 100 mg orally twice daily for seven days plus metronidazole 2 g orally as a single dose.

Question 33

What patients should be given the pneumococcal vaccine before the age of 65?

Answer 33

Institutionalized individuals over the age of 50, those with chronic cardiac or pulmonary disease, diabetes mellitus, anatomic asplenia, chronic liver disease, kidney failure, and healthcare workers it is recommended that those receiving the vaccine before the age of 65 receiving additional dose at age 65 or five years after the first dose, whichever is later

Question 34

What is the treatment of recurrent Clostridium difficile infection?

Answer 34

Initially Clostridium difficile infection should be treated with either oral metronidazole or oral vancomycin.Mild recurrent disease can be treated by repeating the course of the original agent. Multiple recurrences or severe disease warrants the use of both agents.

Question 35

What patients with acute bacterial sinusitis should be treated, and when? What antibiotics should be used?

Answer 35

Those with symptoms for at least 10 days without improvement should be treated. Signs and symptoms may include nasal drainage and congestion, facial pressure and/or pain, sinus tenderness and headache.

Recommended antibiotics include amoxicillin alone or amoxicillin/clavulanate. Suggested alternatives include respiratory quinolones or the combination of the third-generation cephalosporin and clindamycin, particularly and persons with penicillin allergy. Do to increasing emergence of resistance of Streptococcus and Haemophilus species, neither TMP/SMX nor macrolides are now recommended.

Question 36

What condition does parvovirus B 19 cause and what is its presentation?

Answer 36

Erythema infectiosum or fifth disease. It is a common childhood illness characterized by a slapped cheek appearance on the face and Elase like erythematous rash on the trunk and extremities. Although adults can develop a rash, it is not as common as in children and the slapped cheek appearance is rare. Children and adults also may experience 1 to 4 days of systemic symptoms prior to the appearance of the rash. Arthropathy affecting the joints of the hands, wrists, knees, and ankles can occur, most commonly in adults. I Thropp at the typically lasts 1 to 2 weeks. The clinical course and immunocompetent children and adults, including pregnant women, generally is self-limited. It may be associated with fetal loss or hydrops fetalis in pregnancy. However there do not appear to be long-term developmental sequelae of infection in children who do not develop hydrops.

Question 37

What are the hallmarks of toxic shock syndrome? What should the treatment be?

Answer 37

Erythroderma, hypotension, and laboratory evidence of end organ involvement such as elevated liver enzymes or kidney function studies, anemia, thrombocytopenia, and elevated creatinine kinase. The CDC case definition is made when patients have a fever over 38.9, hypotension, diffuse Erythroderma, desquamation unless the patient dies before It can occur, and involvement of at least three organ symptoms. Treatment with IV clindamycin, which inhibits toxin synthesis, should be undertaken immediately. However clindamycin has been shown to be more effective in vitro than in vivo. In general treatment is supportive and patients require extensive fluid replacement and possibly vasopressors.

Question 38

What is red man syndrome?

Answer 38

It is the most common adverse reaction to vancomycin. It is an idiopathic in fusion reaction which is not thought to involve drug specific antibodies and therefore may develop with the first administration of vancomycin. It occurs principally with parenteral administration of vancomycin and appears to be associated with a rapid rate of infusion. It is characterized by flushing, erythema, and pruritus, usually affecting the upper body, Mac and face more than the lower body pains and muscle spasms in the back and chest, dyspnea and hypotension may also occur. It is rarely life-threatening, though severe cardiovascular toxicity and even cardiac arrest can occur.

Question 39

How fast should IV vancomycin be infused and why?

Answer 39

It should be infused at a rate no higher than 10 mg per minute or for a 1 g dose over a minimum of 100 minutes, which ever results in a slower infusion. It needs to be infused slowly to avoid the occurrence of red man syndrome.

Question 40

What is the recommended treatment for pertussis?

Answer 40

For children and adults with mild to moderate illness a two week course of oral erythromycin is recommended, principally to halt the spread of the infection.

Question 43

What is the best overall drug for eradication of onychomycosis?

Answer 43

Oral terbinafine or Lamisil. It has the best cure rate and tolerability. It is contraindicated in significant liver disease. Itraconazole is less effective and more toxic, and griseofulvin is significantly less effective.

Question 46

Exposure to which body fluids of an HIV infected patient would require consideration of postexposure prophylaxis?

Answer 46

Blood, semen, vaginal secretions, and breast milk.

Question 47

What underlying condition is the usual cause of tricuspid valve endocarditis? What organism is usually responsible?

Answer 47

IV drug use. Staph aureus.

Question 48

What organisms are likely to be chlorine resistant and to cause a disease outbreaks related to drinking water?

Answer 48

Cryptosporidium, Giardia, hepatitis A virus, and Entamoeba histolytica.

Question 49

What bacterial infection may often cause lymphocytosis with reactive lymphocytes on peripheral blood smear?

Answer 49

Bordetella pertussis. It has been known to cause absolute lymphocyte counts of up to 70,000 per microliter.