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Your patient has bloody diarrhea. DDx?
SEECSY: Salmonella, Escherichia coli (hemorrhagic and enterotoxigenic strains), Entamoeba histolytica, Campylobacter jejuni, Shigella, Yersinia enterocolitica
Name as many anti-pseudomonal Abx as you can
Ticarcillin, Piparacillin Ceftazadime, Cefepime, Aztreonam, Imipenem, Meropenem, Ciprofloxacin, Levofloxicin, Polymyxin E, Tobramycin, Amikacin, Gentamycin
1You receive a culture from a patient’s sputum that you suspect has an extensive pneumonia & it’s positive for enterobacter cloacae. The sensitivities show that it is sensitive to gentamycin, oxacillin & pipercillin-tazobactim. You are about to write orders to initiate treatment with one of these when your preceptor tells you that those medications wont work because of SPICE. What is he talking about??
SPICE stands for a group of organisms that often appear susceptible with conventional susceptibility testing, resistance during therapy with the agent may occur and lead to clinical failure. It is therefore recommended that combination antimicrobial therapy (i.e. beta-lactam/beta-lactamase inhibitor plus an aminoglycoside or fluoroquinolone) or a carbapenem alone be used when treating serious or deep-seated infections (such as pneumonia, meningitis, osteomyelitis, or sepsis) with these organisms.
• Serratia spp.
• Pseudomonas aeruginosa
• Indole positive Proteae (Proteus vulgaris, Morganella morganii, Providencia spp.)
• Citrobacter spp.
• Enterobacter cloacae
What carbapenem does not have pseudomonas coverage?
A) Imipenem B) Meropenem C) Ertapenem D) Doripenem E) Neither A or B has pseudomonas coverage
B, ertapenem does not have pseudomonas coverage. Both imipenem & meropenem are excellent antibiotic choices for pseudomonas, along with broad spectrum coverage.It should be noted, however, that the carbapenems class should be used sparingly to avoid resistance because they are key to killing klebsiella and there is little other antibiotics that can do that job!
What is the Centor criteria and what is it used for?
The Centor Criteria are a set of criteria which may be used to identify the likelihood of a bacterial infection in patients complaining of a sore throat. They were developed as a method to quickly diagnose the presence of GAS. The patients are judged on four criteria, with one point added for each positive criterion:
• History of fever
• Tonsillar exudates
• Tender anterior cervical adenopathy
• Absence of cough
If they have 3 or 4 of these then you are to treat with antibiotics & no other testing is needed!
Name 3 infections that need to be treated with Beta-lactams.
Syphilis, GAS, dental infections
Which of the following etiologic agents is considered an “atypical” pneumonia?
A. Haemophilus influenzae
B. Streptococcus pneumoniae
C. Pseudomonas aeruginosa
D. Legionella pneumophila
D. Legionella pneumophila
What is the treatment for bacterial vaginosis?
A. Doxycycline
B. Ceftriaxone
C. Flagyl
D. Penicillin
C. Flagyl (note to self, or others that want brownie points: Add dosage here____)
A 32 y.o. woman who is 20 weeks gestation comes to your office c/o fever, HA, malaise, myalgia, N/V, and a rash. When examined, the rash can be described as erythemtous macules that are 1-5 mm in diameter. She tells you that she first noticed the rash on her wrists and ankles, but now has noticed that the rash has spread to her chest and back. History also tells you that she loves the outdoors and was recently on a camping trip with her family in Wisconsin.
What is the BEST treatment?
A. Penicillin
B. Doxycycline
C. Doxyrubicin
D. Chloramphenicol
D. Chloramphenicol
A 32 y.o. HIV+ patient comes to your office with a CD4 count of 180. What should be prescribed?
A. Metronidazole
B. TMP/SMX
C. Efavirenz
D. Amphotericin B
B. TMP/SMX
Which infection is otherwise known as Human Herpes Virus 8?
A. CMV B. EBV C. VZV D. Kaposi sarcoma E. Roseola
D. Kaposi sarcoma
A new pt of yours: HIV+, 26 y.o. male c/o pleuritic chest pain, with a sore throat and swelling in his knees and ankles. He tells you that he has just moved here from Arizona. What is highest on your differential?
A. Histoplasma capsulatum B. Aspergillus fumigatus C. Cryptococcus neoformans D. Coccidiodes immitis
D. Coccidiodes immitis
A 19 y.o. volunteer at a blood bank notes that he thinks one of the sharps containers broke. In his haste to clean it up, he reports that a needle used to draw blood stuck his hand. He was subsequently referred to the employee health service. The pt thinks that he received the HBV vaccine at birth. Which of the following would be the result of his hepatitis panel, if indeed he was vaccinated?
A. HBsAG(-), anti-HBs(-), anti-HBc(-), anti-HBe(-), HBeAg(-)
B. HBsAG(-), anti-HBs(+), anti-HBc(-), anti-HBe(-), HBeAg(-)
C. HBsAG(-), anti-HBs(+), anti-HBc(+), anti-HBe(+), HBeAg(-)
D. HBsAG(+), anti-HBs(-), anti-HBc(+), anti-HBe(-), HBeAg(+)
E. HBsAG(+), anti-HBs(-), anti-HBc(+), anti-HBe(+), HBeAg(-)
B
You order a urine culture on a 36 y.o. woman. The lab result comes back to you as follows:
“30 K mixed gram positive flora including Group B Streptococcus”
Why would this concern you?
A. She has an obvious UTI B. Group B Strep is an important uropathogen C. She is a woman between the ages of 12 and 50 D. Multiple organisms are involved, which means a broader spectrum antibiotic will have to be used
C. She is a woman of child-bearing years (at our lab this was considered 12 to 50)
Which of the following rickettsial diseases is spread primarily by lice, and was also largely influential in stopping Napoleon during his attempted invasion of Russia?
A. R. rickettsia
B. R. akari
C. R. typhi
D. R. prowazekii
D. R. prowazekii
The CXR for your pt. in room 206 shows a patchy infiltrate pattern. What bugs are highest on your differential?
A. Haemophilus influenzae B. Aspergillus C. Mycobacterium tuberculosis D. Influenza virus E. Pneumocystis carinii
D. Influenza virus
You are managing the care of a pt that recently underwent abdominal surgery to remove a tumor, is on ciprofloxacin and cefazolin, and has had a prolonged neutropenia. Prior to the surgery, the pt. was on aggressive chemotherapy. The patient also has had a fulminant case of thrush and has had fevers (102.7) and abdominal pain. Blood cultures x 3 have been sent, and are all negative. The pt. continues to have symptoms. Which of the following is the best course of action?
A. Start the patient on IV vancomycin B. Start the patient on IV fluconazole C. Start the patient on IV imipenem D. Start the patient on IV gentamycin
B. Start IV fluconazole
A 28 y.o. comes to you complaining of headaches, backaches, fevers, chills, malaise, and night sweats. The only thing you found odd in your history was that he likes to hunt rabbits with his friends (who is this guy, Elmer Fudd?!?)
Which of the following is NOT true?
A. The likely culprit is a gram positive rod B. The infection was likely caused by a tick bite C. This infection may play a role in a war, someday… D. Gentamycin is a good treatment option
A. Francisella tularensis - tularemia)
What is the MOA for the macrolides?
A. Inhibition of protein synthesis by binding to the 50S ribosomal subunit
B. Inhibition of protein synthesis by binding to the 30S ribosomal subunit
C. Inhibition of folic acid synthesis
D. Inhibition of cell wall synthesis
A. Inhibition of protein synthesis by binding to the 50S ribosomal subunit
Which of these drug combinations is otherwise known as Zosyn?
A. Amoxicillin + Clavulonate
B. Ticarcillin + Clavulonate
C. Ampicillin + Sulbactam
D. Piperacillin + Tazobactam
D. Piperacillin + Tazobactam
A 30 y.o. man presents with a high fever and chills, HA, nausea, vomiting, and muscle aches. Yesterday he had an episode involving abnormal movements of his right hand and face (focal seizure). He also has difficulty comprehending speech and has olfactory hallucinations. He has no Hx of psychiatric illness.
PE: Fever, tachycardia, mild tachypnea, confused and disoriented, papilledema, mild nuchal rigidity; Kernig sign positive
LP: shows mononuclear pleocytosis, mildly elevated protein, normal glucose
MRI: Chararacteristic changes of encephalitis seen over medial temporal lobes
What is the causative agent?
A. Neisseria meningitidis C. West Nile Virus
B. Herpes simplex virus D. Streptococcus pneumoniae
B - Herpes encephalitis is the most common cause of sporadic viral encephalitis, with a predilection for the temporal lobes and a range of clinical presentations, from aseptic meningitis and fever to a severe rapidly progressive form involving altered consciousness. In adults, herpes simplex virus type 1 (HSV-1) accounts for 95% of all fatal cases of sporadic encephalitis and usually results from reactivation of the latent virus. The clinical findings and neuroimaging appearance are both consistent with spread of the virus from a previously infected ganglion.
Which of the following organisms causes dysentery and has a cystic form that contaminates the water supply through poor handling of human sewage and has been linked to spread through anal intercourse in homosexual men?
A. Vibrio cholera B. Entamoeba histolytica C. Hookworm D. Salmonella sp. E. Giardia lamblia
B. Entamoeba histolytica
Which of the following is the appropriate treatment for acute Clostridium tetani infection?
A. Tetanus Ig, tetanus toxoid, and metronidazole B. Tetanus Ig, and PCN C. Tetanus toxoid, and PCN D. Tetanus Ig, tetanus toxoid, and PCN E. Tetanus Ig, and tetanus toxoid
A or D ..and don’t forget debridement!!
From Uptodate: Metronidazole (500 mg IV every six to eight hours) is the preferred treatment for tetanus, but penicillin G (2 to 4 million units IV every four to six hours) is a safe and effective alternative [8]. We suggest a treatment duration of 7 to 10 days.
Although antibiotics probably play a relatively minor role in the management of tetanus, they are universally recommended. However, is important to emphasize that appropriate antimicrobial therapy may fail to eradicate C. tetani unless adequate wound debridement is performed
An infection of a hair follicle produces a single pus-filled crater with a red rim. This infection can penetrate deep into the subcutaneous tissue to become a(n):
A. Abscess
B. Furuncle
C. Carbuncle
D. Pustule
B
Of the following, which is the most common cause of foodborne acute gastroenteritis?
A. Bacillus cereus B. Staphylococcus aureus C. Rotavirus D. Norovirus E. Anisakis
D. Norovirus
Which of the following forms of anthrax is most common?
A. Inhalational B. Hematogenous C. Cutaneous D. Gastrointestinal E. Congenital
C. Cutaneous
A pt. with known a HIV infection presents with the gradual onset of a cough, SOB on exertion, and a feeling of a ‘catch’ on inspiration. The CXR reveals a lobar infiltrate. His O2 sat is 95% and PPD is negative. CD4 count is 500. What is the most likely etiology?
A. HSV B. Mycobacterium C. Streptococcus pneumoniae D. Pneumocystis jiroveci E. Toxoplasma gondii
C
Pts with HIV are at increased risk for ordinary bacterial pneumonias as their immune systems begin to decline in function. When CD4 counts are in the 200 to 500 range, their risk for pneumococcal pneumonia is 3 to 4 times greater than that of the immunocompetent pt. The clinical picture of lobar infiltrate on X-ray are consistent with typical pneumonia, most often caused by Strep pneumo. Pneumocystis pneumonia is unlikely until the CD4 counts drop below 200. Mycobacterial pneumonia would likely be associated with a more chronic cough and the others are not likely to cause pulmonary disease.
Which antibiotic is associated with “Red man syndrome”?
A. Levofloxacin
B. Vancomycin
C. Gentamycin
D. Moxifloxacin
B. Vancomycin
Which organism is associated with struvite crystals?
A. Pseudomonas aeruginosa
B. Prevotella intermedia
C. Peptostreptococcus magnus
D. Proteus mirabilis
D. Proteus mirabilis
A 21 y.o. man comes to your urgent care clinic on a Saturday evening due to abdominal cramps, nausea, and vomiting. He denies diarrhea. He states that he was at a company picnic earlier in the day and mostly Asian foods were served. The patient is a vegetarian and says that he only had rice and vegetables.
What is the most probably etiologic organism?
A. Staphylococcus aureus
B. Streptococcus pyogenees
C. Pseudomonas aeruginosa
D. Bacillus cereus
D. B. cereus
Which of the following is rodent-borne and the cause of hemorrhagic fever and a pulmonary syndrome, which begins with a fever and may rapidly progress to shock and ARDS?
A. Human T-cell lymphotropic virus (HTLV) B. Flavivirus C. Hantavirus D. Filovirus E. Coronavirus
C. Hantavirus
An HIV positive pt with a CD4 count of 225 cells/mL should receive prophylaxis for which of the following opportunistic infections?
A. Pneumocystis jiroveci B. Toxoplasmosis C. Candidiasis D. Mycobacterium avium E. CMV
A. Pneumocystis
Vancomycin would be the LEAST effective against which of the organisms below?
A. Corynebacterium urealyticum
B. Listeria monocytogenes
C. Enterococcus faecalis
D. Burkholderia cepacia
D. Burkholderia cepacia
The most frequent source of infection with Listeria monocytogenes is through which of the following?
A. Human feces B. Livestock C. Raw milk D. Soil E. Ticks
C. Raw milk
Which is the third generation cephalosporin?
A. Cefepime
B. Cefadroxil
C. Cefuroxime
D. Cefotaxime
D. Cefotaxime
Four people have visited your clinic in the past hour. They all were at the same company party the day before. They all claim to have eaten the seafood, which is the only other link in common that you can ascertain. Given the incubation period, and assumption that the food poisoning stems from the seafood, which of the following is the LOWEST on your DDx?
A. Norovirus
B. Hepatitis A
C. Vibrio parahemolyticus
D. Vibrio vulnificus
B. Hepatitis A incubation period averages 30 days (range 15 to 49 days), after which the illness begins with the abrupt onset of prodromal symptoms including, fatigue, malaise, nausea, vomiting, anorexia, fever, and right upper quadrant pain
Which of the following antibiotics interacts with DNA to cause a loss of helical DNA structure and strand breakage resulting in inhibition of protein synthesis and cell death in susceptible organisms?
A. Chloramphenicol
B. Gentamycin
C. Doxycycline
D. Metronidazole
D
Which of the following is the organism responsible for Hand, Foot, and Mouth disease?
A. Rotavirus
B. Coxsackie A virus
C. Coxsackie B virus
D. Adenovirus
B
Pathology from HSV can include all of the following, EXCEPT:
A. Ocular disease
B. Congenital infection
C. Encephalitis
D. Erb’s palsy
D
A 3 y.o. African immigrant woman is brought in to the ED with congestion and a sore throat. Her family has been in the US only 1 month. They were ‘rescued’ from a refugee camp. This is her first medical evaluation. On exam, she is noted to have a low-grade fever; TMs are pearly gray without injection or visible air fluid levels. Throat is erythematous with enlarged tonsils covered by a grayish membrane. Tonsilar nodes are tender. Lungs are CTA. Rapid strep screen is negative. The most likely etiologic agent is:
A. Bordatella pertussis
B. Corynebacterium diphtheriae
C. Streptococcal pyogenes
D. Hemophilus influenza
B.
