Lower Respiratory Infections

W8-T.Lower Respiratory Infections IRAT AND APP: 1.In the absence of a complicating bacterial infection, which of the following is the most appropriate approach to treating acute bronchitis? A. Prescribing broad-spectrum antibiotics B. Routinely recommending non-prescription cough and cold preparations C. Providing symptomatic and supportive care D. Discouraging hydration and bed rest 2. Which of the following is true regarding chronic bronchitis? A. The majority of patients who suffer from chronic bronchitis have a negative smoking history. B.N-acetylcysteine should be routinely prescribed to treat associated bronchospasm. C. Given the low incidence of bacterial resistance; broad-spectrum antibiotics are rarely employed. D. During acute exacerbations, the use of antimicrobial is controversial; however, patients with prominent symptoms may benefit. 3. Community-acquired bacterial pneumonia is most commonly caused by: A.Staphylococcus aureus B. Listeria monocytogenes C. Legionella species D.Streptococcus pneumoniae 4. _______________antimicrobial therapy for pneumonia should consist of antibiotic regimens targeting presumed causative pathogens based on clinical presentation and patient-specific characteristics, local epidemiology, and resistance patterns. A.Definitive B.Empiric 5. ________(a)______________ is the most common cause of acute bronchiolitis, an infection that mostly affects infants during their first year of life. In the well infant, bronchiolitis usually is a _____(b)________ viral illness. A.(a) Influenza - (b) fatal B.(a) Influenza - (b) self limiting C.(a) Respiratory syncytial virus - (b) fatal D.(a) Respiratory syncytial virus - (b) self limiting 1.SB (NKDA) is a 50 YOF with HTN. She presented to an ambulatory clinic for shortness of breath and her chest x-ray revealed a trace of infiltration at the left lower lobe. She was afebrile and her vital signs were stable/normal. What is the best antimicrobial regimen? A.Augmentine B.Levaquin C.Tygacil D. Zithromax 2.RH is a 63-year-old female who presents to the clinic with productive cough, shortness of breath, fever of 102.7°F, chills, and pleuritic chest pain. Physical Exam reveals absent breath sounds in the right lower lobe, and a chest X-ray shows a consolidation of the right lower lobe. RH is using mealtime insulin to control her blood sugars and recently underwent a CABG six months ago for coronary artery disease. What is the best outpatient antimicrobial regimen? A.Amoxicillin B.Amoxicillin/clavulanate + Azithromycin C. Ceftriaxone + Azithromycin D.Ceftriaxone + Levofloxacin E.Vancomycin + Cefepime 3.LS is a 74-year-old male (NKDA) from home who presents to urgent care with a productive cough, and pleuritic chest pain. He is alert (3/3) and was admitted for antibiotic treatment. His PMH is significant for hypertension, coronary heart disease, and chronic rhinosinusitis for which he completed a 10-day course of amoxicillin 3 weeks ago. Chest X-ray shows significant infiltration at his lungs. Vital Signs are as follows. Temperature 102 F, HR=80 BPM, BP= 123/78, RR= 20. O2 saturation 96%, BMP is as follows. Na=140, K=4.4, Cl=101, BUN=22, Serum Creatinine=1.1, Glucose=155, CO2=24. WBC 15K, PLT 125K, Hgb 12, HCT 35% What would be the best empiric antimicrobial therapy? A.Amoxicillin B.Amoxicillin/clavulanate + Azithromycin C. Ceftriaxone + Azithromycin D. Ceftriaxone + Levofloxacin E.Vancomycin + Cefepime 4.JB is a 68-year-old male who presents to the ER with confusion, fever, dyspnea, pleuritic chest pain, and productive cough. His PMH is significant for hospitalization a month ago for a complicated UTI and was treated with Rocephin. Chest X-ray shows significant infiltration at his lungs (multi-focal). Vital Signs are as follows. Temperature 102.7 F, HR=100 BPM, BP= 90/60, RR= 32. BMP is as follows. Na=140, K=4.4, Cl=101, BUN=32, Serum Creatinine=1.1, Glucose=155, CO2=24. WBC = 14K. PLT = 250K. He is hospitalized. What is the best antimicrobial treatment? A. Amoxicillin B.Amoxicillin/clavulanate + Azithromycin C.Ceftriaxone + Azithromycin D. Levofloxacin E.Vancomycin + Cefepime + Azithromycin 5.JB from question #4 is on empiric antimicrobial therapy day 3 of Linezolid and Zosyn. JB’s MRSA nasal PCR came back negative. His blood cultures, sputum cultures, and urine cultures had no growth. He has been afebrile for 48 hours; other vital signs are stable and normal. WBC = 11K. PLT 230K. Na=144, K=4.4, Cl=101, BUN=15, Serum Creatinine=1.0, Glucose=145, CO2=24. How would you modify his antimicrobial therapy? A.Switch Linezolid to Vancomycin B.De-escalate to Ceftriaxone after discontinuing Linezolid, Zosyn C.Switch Zosyn to Ertapenem D.Add Levofloxacin 6.JB from Question 5 was hospitalized and is currently on Day 5 of empiric CAP therapy. · His S/S improved significantly. · VS : RR=18, Pulse =67 bpm, Tmax = 97F, BP = 125/67 mmHg, O2 saturation 97% in room air · Labs: SCR = 0.7 mg/dL, BUN = 15 mg/dL, Blood glucose = 108 mg/dL, WBC = 9.5K, PLT= 150K, Procalcitonin < 0.1 How will you modify his antimicrobial therapy? A.Switch IV Antimicrobials to PO B.Discontinue Antimicrobials C. Add Vancomycin D.Add Zosyn 1.A 65 YOM presents with STEMI, and is intubated upon arrival to the ED and emergently taken to the cath lab for PCI where he was found to have multi-vessel CAD. On 6/27, the patient was admitted and transferred to ICU. On 6/30, his WBC increased, he developed a fever, and broad-spectrum antibiotics were initiated with suspicion of pneumonia. PMH: DM, HTN, ESRD on HD, HLD, and anxiety/depression Labs: WBC=14.9K, Hgb=10, PLT=229K, Scr=13.4, BUN=61, Troponin=2.33 Tmax 102 °F Chest X-ray revealed upper lobe pulmonary infiltrates. What is the most appropriate empiric antimicrobial therapy? A.Cubicin + Zosyn B.Zyvox + Invanz C.Vancomycin + Maxipime D.Fortaz + Levaquin 2. Continued Case, Scenario 1 for the patient in Question 1, On 6/30, empiric antimicrobial therapy was initiated as follows. Vancomycin IV once weekly + Zosyn 3.375g IV q 12 hrs (4 hr extended infusion) Sputum culture on 6/30 grew ESBL negative Klebsiella pneumoniae resistant to ampicillin but susceptible to amikacin, cefepime, ceftriaxone, ciprofloxacin, levofloxacin, gentamicin, tobramycin, meropenem, piperacillin/tazobactam, and TMP/SMX MRSA nasal screening test negative The patient is afebrile and S/S stable How will you modify the antimicrobial therapy? A.Switch vancomycin to linezolid. B.Discontinue vancomycin and Zosyn, and start ceftriaxone C.Add ciprofloxacin D.Switch zosyn to meropenem 3. Scenario 2 for the patient in Question 1 On 6/30, empiric antimicrobial therapy was initiated as follows. Vancomycin IV once weekly + Zosyn 3.375g IV q 12 hrs (4 hr extended infusion) MRSA nasal screening test negative Sputum culture on 6/30 grew ESBL (+) Klebsiella pneumoniae resistant to ampicillin, cefazolin, cefepime, ceftriaxone, ciprofloxacin, levofloxacin, gentamicin, tobramycin, SMX/TMP, but susceptible to amikacin, meropenem, piperacillin/tazobactam How will you modify the antimicrobial therapy? A.Switch vancomycin to linezolid B.Discontinue vancomycin and zosyn and start meropenem C.Add ciprofloxacin D.Switch zosyn to ertapenem 4. BG (75 YOF) is currently on empiric antimicrobial therapy including vancomycin and Zosyn for septic shock caused by ventilator-associated pneumonia. PMH: h/o Seizure All: NKDA VS: RR=24, Pulse =120 bpm, T 102.5 ◦F, BP = 105/43 mmHg Labs: SCR = 1.2 mg/dL(Baseline = 0.8), BUN = 18 mg/dL, Blood glucose = 136 mg/dL, WBC = 20,500, PLT= 50,000, PCT = 3.5 Medications: vancomycin, Zosyn, tube feedings, lansoprazole, and norepinephrine to maintain MAP> 65 mmHg Scenario 4-1) MRSA screening negative Her sputum grew Pseudomonas aeruginosa, susceptible to piperacillin/tazobactam, cefepime, ceftazidime, tobramycin, meropenem, and ciprofloxacin. How will you modify his antimicrobial therapy? A. Switch vancomycin to linezolid B.Discontinue vancomycin C. Switch zosyn to cefepime D. Add tobramycin 5.BG (75YOF) is currently on empiric antimicrobial therapy including vancomycin and Zosyn for septic shock caused by ventilator-associated pneumonia. PMH : h/o Seizure All : NKDA VS : RR=24, Pulse =120 bpm, T 102.5 ◦F, BP = 105/43 mmHG Labs: SCR = 1.2 mg/dL(Baseline = 0.8), BUN = 18 mg/dL, Blood glucose = 136 mg/dL, WBC = 20,500, PLT= 50,000, PCT = 3.5 Medications: vancomycin, Zosyn, tube feedings, lansoprazole, norepinephrine to maintain MAP> 65 mmHg Scenario 4-2) Her sputum grew MRSA. How will you modify his antimicrobial therapy? A.Switch vancomycin to linezolid B.Discontinue zosyn C.Switch zosyn to cefepime D.Add tobramycin 6. BG (75 YOF) is currently on Zosyn IV (Day #7) + ciprofloxacin IV (Day # 3). Her S/S improved significantly and extubated. VS: RR=18, Pulse =67 bpm, Tmax = 97F, BP = 125/67 mmHG Labs: SCR = 0.7 mg/dL, BUN = 15 mg/dL, Blood glucose = 108 mg/dL, WBC = 9,500, PLT= 150,000, PCT <0.1 CXR showed improvement. How will you modify his antimicrobial therapy? A.Switch IV antimicrobials to PO B.Discontinue antimicrobials C.Switch Zosyn to Ceftriaxone D.Add Linezolid W8-Th. Urinary Tract Infections IRAT: 1.When treating a community-acquired UTI in a treatment naive patient who has never had a UTI before, which of the following organisms should be most highly suspected and targeted when choosing antibiotic therapy? A.Proteus mirabilis B.Staphylococcus saprophyticus C.Escherichia coli D.Enterococcus faecalis 2. Recurrent UTIs are considered either (a) or (b). (a) usually happens more than 2 weeks after the last UTI and is treated as a new uncomplicated UTI. (b) usually happens within 2 weeks of the original infection and is a (b) of the original infection because of unsuccessful treatment of the original infection, a resistant organism, or anatomical abnormalities. A.(a) Relapse - (b) Reinfection B.(a) Reinfection - (b) Relapse 3.Significant bacteriuria has been defined as bacterial counts of greater than (a) organisms (colony-forming unit [CFU])/mL) of a midstream clean catch urine. However, this is too general and significant bacteriuria in patients with symptoms of UTI may be defined as greater than (b) organisms (CFU)/mL. A.(a) 10,000,000 - (b) 100,000 B.(a) 100,000-(b) 100 C.(a) 10,000-(b)100 D.(a)100,000 - (b) 1,000 4. Primary choices of uncomplicated UTI includes ______________, a dose of fosfomycin, and ______________. A.5 days of TMP/SMX, 3 days of nitrofurantoin B.3 days of fluoroquinolones and 3 days of TMP/SMX C.3 days of fluoroquinolones and 5 days of nitrofurantoin D.3 days of TMP/SMX, 5 days of nitrofurantoin