NSG 533 EXAM 2 LIVE SESSION

Question 1

A 65-year-old male presents to your ER with mental status changes, a few falls and violent delirium. He is also a chronic alcoholic. His CrCl is 45 mL/min. He does not have a fever and does not complain of dysuria or pain.

1. What other tests should you order?

UA and urine culture, CBC, CMP, renal and liver function tests

2. What diagnosis do you suspect?

UTI

3. His UA comes back indicative of UTI. What does his UA probably say?

pyuria, bacteremia greater than 10^3 CFU/mL, positive nitrites,

4. What would you use to treat this patient and for how long?

CrCl means no nitrofurantoin. So sulfa/trim x 7 days or cipro x 7 days.

Answer 1

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Question 2

The attending decides to admit the patient. He develops a pressure ulcer while hospitalized. You order a culture ASAP and a referral to your hospital’s wound nurse for documentation and ulcer scoring. It takes 3 days for the culture to come back, meanwhile, the ulcer continues to worsen. The culture comes back positive for MSSA but they did not test for pathogen susceptibility due to lab error.

1. What regimen would you choose for this patient while hospitalized to treat MSSA?

Pip/tazo

2. He gets discharged 3 days later after showing marked improvement. What Rx would you send the patient home on and for how long? When would you follow up with the patient’s caregiver?

Oral rx for amo/clav (Augmentin) x10-14 days. Follow up minimum 1 month.

Answer 2

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Question 3

1. After going through module 8, I am wondering if you can elaborate the treatment for previously healthy vs immunocompromised for cellulitis or what I should focus on? Table 73-3 is very confusing to follow, and the book does not do a great job at explaining it.

Answer 3

Well try to think of it as another way to say with or without comorbidities. Table 73-3 is a mess in my opinion. I hate it. I would focus on first-line for each MSSA and MRSA for patients previously healthy (without comorbidities or previous infection) and immunocompromised (with comorbidities) and have an alternative in mind if they had a pcn allergy or previous antibiotic coverage. I would not focus on mild vs mod/severe because if you need IV antibiotics for MRSA it’s going to be vanc first line.

So:

healthy (no comorb) MSSA = dicloxacillin, cephalexin, and everything you can use in mrsa /

MRSA = sulfa/trimeth, clindamycin, doxycycline, linezolid (reserved for hospitalized or failed every other oral option)

immuno/DM (cellulitis with comorb) MSSA = augmentin, levofloxacin, moxifloxacin, clindamycin /

MRSA = dual therapy see table below

Question 4

While reading the treatment for UTI, you stated during the live session that fluoroquinolones should not be given to children, does that statement only apply to the treatment of UTIs? Just curious because a fluoroquinolone is recommended for treatment of ARBS in children.

Answer 4

That statement applies to all fluoroquinolones in all humans under the age of 18. It does list moxifloxacin and levofloxacin as options in the chapter but they should be reserved for adults for ARBS.

Question 5

3. UTI- you had mentioned that male UTIs are always considered complicated and that a longer treatment duration is necessary. The TMP-SMX is a 3-day treatment, and nitrofurantoin is a 5 day treatment, but is recommended for uncomplicated UTI- which treatment would then be suggested for Males?

Answer 5

nitrofurantoin is the only med for UTI where the length of treatment doesn’t change between complicated and uncomplicated, so it is five days minimum for everybody. For every other medication for male UTI they need a minimum of 7 days of treatment.

Question 6

4. UTI- nitrofurantoin and bactrim both are not good for the elderly, what would be recommended as a treatment for them?

Answer 6

I would recommend for acute UTI (not recurrent) amox/clav, cefdinir, cefaclor, or low dose (250mg) of ciprofloxacin before falling back to those two. While they are not great for the elderly they are not absolutely contraindicated, just cautioned against. So if they fail all other options, or after an actual culture, those are the only ones that work you have no choice. You can also decrease the dose of both to half of the normal adult dose to minimize ADRs too.

Question 7

5. I don’t see in the book that 3g is the max dose for the elderly, for exam purposes, should we be going by that maximum amount in elderly patients?

Answer 7

Yes, use the 3 gram max for elderly patients for the exam for APAP.

Question 8

6. Oxycodone- the book states that it is used for moderate pain but in the SG you had mentioned its used more for severe pain.

Answer 8

I would save it for severe like in the study guide and consider hydrocodone for moderate pain. Here is a pretty good infographic for potencies. The way I look at it is everything in the blue for moderate and orange for severe.

Question 9

7. Conversions- do we need to memorize table 34-3 for the exam?

Answer 9

absolutely not. You will be given the information needed for any calculation problem. What you need to know is the process of converting.

Question 10

8. amitriptyline is the only medication listed that does not have FDA approved indication listed, so would you not use it?

Answer 10

In real life, not without some documentation to back it up because using things off-label will bite you in an audit from insurance companies these days without documentation as to why you chose this for this patient. For the test and this chapter, they have listed it as an adjuvant so it’s ok to use if the patient doesn’t have issues which would preclude them from use, like conditions where an anticholinergic is contraindicated/cautioned against.

Question 11

9. Table 34-5, do we need to know the dosing?

Answer 11

No, just which medications can help certain opioid adverse effects.

Question 12

10. Table 35-3- triptans- is there anything specific we should look at?

Answer 12

I would look at the last two columns (hepatic/renal considerations and potential drug interactions).

Question 13

11. OP- the chart in the book says its defined as less than -2.5, but also says OP is diagnosed with levels -2.5 to -4.0?

Answer 13

I honestly do not like the way they worded it, but the more negative a number is, and the less it is, the higher the number after the negative number. So -2.5 is OP and everything more negative is too, like -2.6, -3.0, and -4.0.
-4 OP, -3 OP, -2.6 OP, -2.5 OP

-2.4 osteopenic, -.1.9 penic, -2.2 penic

Question 14

12. While going through chapter 59, should we know the specific types of cyp3a4 inhibitors and p-glycoproteins?

Answer 14

I wouldn’t say you have to memorize them but I would know the most common. Like anything that ends in “vir”.

Question 15

13. What is considered to be a urate overproducer? Would it be considered over the normal range of 6.8? Or is it a higher number?

Answer 15

A urate overproducer consistently has a UA level higher than 6.8, even after undergoing a low purine diet. Although, most never realize until blood work is done.

Question 16

14. Can you elaborate on amoxicillin and that it lacks coverage for b lactamase producers?

Answer 16

bacteria have developed enzymes called beta lactamases to attack the beta lactam ring on penicillins to destroy the antibiotic before it can get inside and break down the bacterial cell wall. This form of resistance is getting more prevalent sadly. Therefore, clavulanic acid is added because it is a beta lactamase inhibitor. It is the shield so the sword can stab if you will.

Question 17

15. Figure 69-1- should we only focus on viridans streptococci and streptococcus pneumoniae?

Answer 17

In figure 69-1, I would focus on what is normal flora for each body section, not just those two. For example, where does E.coli reside as normal flora?

Question 18

16. ABRS- the book states that cephalosporins should only be given with clindamycin and vice versa, is this the same for AOM?

Answer 18

Regarding the cephalosporin plus clindamycin thing; it only applies to two specific cephalosporins (cefixime and cefpodoxime proxetil). It increases spectrum and decreases resistance risk. Honestly this recommendation may change in real life depending on local resistance patterns, but for this course it’s just these two.

Question 19

17. clarify about the treatments for cellulitis. The chart in the textbook is challenging to understand as it seems poorly organized to me. I understand that we need to know an immense amount of knowledge for our boards, but I am trying to narrow down the information for the test in terms of first line treatment, second line treatment, etc.

Answer 19

First line for previously healthy MSSA is dicloxacillin. But you can also do cephalexin and clindamycin. For MRSA it is sulfa/trimeth, doxy and clindamycin.

Firstline for comorbid conditions MSSA is amox/clav. But you can also do levofloxacin, moxifloxacin, clindamycin. For MRSA it is MSSA TX plus either sulfa/trim, doxy or clindamycin unless need hospitalized then it is vancomycin. Linezolid is reserved for last line, after all other oral options have failed or a wound culture shows it is the only thing it is susceptible to.

Question 20

18. In the “previously healthy section” for cellulitis treatment, it states if CA-MRSA is suspected OR there is an allergy to penicillins; Clindamycin, Bactrim, Doxycycline, or Linezolid could be used.

Answer 20

first line for MSSA are all penicillins. If you suspect MRSA or they have an allergy to pcn those would work.

Question 21

19. Are these antibiotics listed in order of primary choice? So for example, for the above criteria, clindamycin would be first choice antibiotic (if no allergies to that med exist)?

Answer 21

No they are not. Honestly clindamycin is last choice because of resistance rates increasing and risk of c.diff. First line would be sulfa/trim then doxy…unless they have a sulfa allergy then that limits what they can have to doxy or clinda.

Question 22

20. Also, the criteria states “if allergic to penicillins”. Does this mean that any of these medications could be used instead of dicloxacillin for MSSA treatment? That is the only penicillin class medication I see on the table that would need replacement if the patient has an allergy. If not, what medication could be used for MSSA if the person has a penicillin allergy?

Answer 22

You’re right for oral therapies, there are a few penicillin IV choices too. Orally, the patient could do any of the three MRSA choices or a cephalosporin.

Question 23

21. In the recorded live lecture, you mention some discrepancies with the “immunocompromised, DM, etc.” section. Would you be able to clarify the primary treatments for the etiologic bacteria for that section please?

Answer 23

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Question 24

22. The only med dosage we need to know is colchicine correct? Should we know labs for contraindication or just have a idea in general eg: poor kidney function avoid this.

Answer 24

Yes. Acute: 1.2 mg at onset and 0.6 mg 1 hour later
Prophylaxis: 0.6 mg QD or BID
No need to know specific labs. Look out for CKD, renal insufficiency, kidney failure, etc.

Question 25

23. which bugs MUST we know? There are so many and there is so much content.

Answer 25

CAP, aspiration pneumo, ARBS, AOM, the gut, the skin, and the soft tissue and UTI.

Question 26

24. The notes for module 5 review says that triptans are avoided in patients with migraine associated with neurological focality. Does that mean APAP, NSAIDS, aspirin, and caffeine are the primary treatment as well as the table 36-4 “oral medications for prophylaxis of migraine” for migraine patients with aura?

Answer 26

Yes, due to risk of stroke with Migraine + aura. Same goes for ergots.

Question 27

Fosfomycin:

• May have lower efficacy compared to 3 or 5 day regimens with other agents.
• No systemic effects, so do not use if pyelonephritis or other systemic infection is suspected or confirmed.

Answer 27

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Question 28

Fos_______:

• May have lower efficacy compared to 3 or 5 day regimens with other agents.
• No systemic effects, so do not use if pyelonephritis or other systemic infection is suspected or confirmed.

Answer 28

Fosfomycin

Question 29

Nitrofurantoin

• No systemic effects, so do not use if pyelonephritis or other systemic infection is suspected or confirmed.
• Use caution in patient with a CrCl less than 30 mL/min.
• Be mindful about different formulations and dosing (Macrodantin vs MacroBID).
• Safe in pregnancy, but avoid at term.

Answer 29

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Question 30

Nitrof________

• No systemic effects, so do not use if pyelonephritis or other systemic infection is suspected or confirmed.
• Use caution in patient with a CrCl less than 30 mL/min.
• Be mindful about different formulations and dosing (Macrodantin vs MacroBID).
• Safe in pregnancy, but avoid at term.

Answer 30

Nitrofurantoin

Question 31

TMP/SMZ (co-trimoxazole)

• reasonable empiric option for outpatients
• Resistance prevalencein the inpatient setting is likely >20%, so would avoid empiricially
• Avoid in severe renal impairment, sulfa allergy, G6PD deficiency
• Monitor potassium and serum creatinine (although this drug can inhibit tubular secretion of creatinine and make it tricky to identify a true AKI…)
• Avoid in 3rd trimester of pregnancy
• Be mindful of choosing this agent if the patient is on warfarin due to a significant drug-drug reaction.

Answer 31

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Question 32

TM_/SM_ (co-trimoxazole)

• reasonable empiric option for outpatients
• Resistance prevalencein the inpatient setting is likely >20%, so would avoid empiricially
• Avoid in severe renal impairment, sulfa allergy, G6PD deficiency
• Monitor potassium and serum creatinine (although this drug can inhibit tubular secretion of creatinine and make it tricky to identify a true AKI…)
• Avoid in 3rd trimester of pregnancy
• Be mindful of choosing this agent if the patient is on warfarin due to a significant drug-drug reaction.

Answer 32

TMP/SMZ

Question 33

Beta-lactams:
(Amoxicillin/clavulanate, cefpodoxime, cephalexin, cefuroxime, cefdinir)

• Considered alternative agents for managing cystitis according to guidelines; however they are widely used clinically and well-tolerated with a low adverse effect profile.
• These specific agents listed should have adequate urinary concentrations

Answer 33

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Question 34

Be__-lact__s:
(Amoxicillin/clavulanate, cefpodoxime, cephalexin, cefuroxime, cefdinir)

• Considered alternative agents for managing cystitis according to guidelines; however they are widely used clinically and well-tolerated with a low adverse effect profile.
• These specific agents listed should have adequate urinary concentrations

Answer 34

Beta-lactams:
(Amoxicillin/clavulanate, cefpodoxime, cephalexin, cefuroxime, cefdinir)

Question 35

Fluoroquinolones:
(ciprofloxacin, levofloxacin)

• consider if other options cannot be used.
• FDA warnings exist regarding fluoroquinolone use for uncomplicated UTIs.
• Avoid moxifloxacin as urinary concentrations are very low.

Answer 35

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Question 36

Fluoroq_________:
(ciprofloxacin, levofloxacin)

• consider if other options cannot be used.
• FDA warnings exist regarding fluoroquinolone use for uncomplicated UTIs.
• Avoid moxifloxacin as urinary concentrations are very low.

Answer 36

Fluoroquinolones:
(ciprofloxacin, levofloxacin)