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148 Cards in this Set

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When are Acyclovir, Valacyclovir, and Famiciclovir the answer to the question?
1) Herpes simplex cases, including genital, cutaneous, and orolabial.
2) Herpes encephalitis: acyclovir (IV)
3) Varicella zoster virus
4) Shingles: Herpes zoster or reactivation of varicela
5) Bell's Palsy
How do Acyclovir, Valacyclovir, and Famiciclovir work?
The medications work through the inhibition of thymidine kinase.
What are Acyclovir, Valacyclovir, and Famiciclovir's most common adverse effects?
The most common adverse effects are nephrotoxicity, presumably from precipitation of the medication in the kidney tubule. Symptoms of neurological toxicity, such as confusion, tremors, and hallucinations, occur rarely.
For which question is rifaximin the correct answer?
Rifaximin is used to treat traveler's diarrhea, such as that from E. coli. Rifaximin is not to be used for invasive diarrhea. An associated fever and bloody diarrhea indicate an invasive pathogen, such as campylobacter. When fever and bloody diarrhea are described, ciprofloxacin is the answer.
How does rifaximin work?
Rifaximin is a nonabsorbed version of the rifamycin antibiotic, rifampin. Rifaximin inhibits ribosomal RNA production of essential proteins.
What are the most common adverse effects of rifaximin?
There are no major adverse effects of rifaximin, because it is not absorbed from the GI tract. It does not cause clostridium difficile colitis and may in fact treat it.
When are daptomycin and linezolid the answer to the question?
These are used for G+ organisms, such as MRSA, streptococci, and vancomycin-resistant enterococci.
Linezolid is the only oral antibiotic for MRSA. They can both be used for vancomycin-resistant organisms. Pay attention when a question indicates MRSA where vancomycin cannot be used or where vancomycin is not in the answer.
How do daptomycin and linezolid work?
Linezolid is an oxazolidinone and inhibits protein synthesis at the ribosomes. Daptomycin is a cyclic lipopeptide and disrupts the cell membrane. These are unique drug classes.
What are the most common adverse effects of daptomycin and linezolid?
Linezolid most commonly causes thrombocytopenia and is a MAO inhibitor (avoid tyramine-containing foods).
Daptomycin caused creatine phosphokinase (CPK) and liver function test (LFT) elevations.
When is tigecycline the answer to the question?
Tigecycline is an extremely broad-spectrum antibiotic that covers (MRSA) as well as G- bacilli. Tigecycline is the answer for complicated hospital or ICU acquired infections.
Tigecycline alone is equivalent to vancomycin and aztreonam in combination.
It is also active against vancomycin-resistant enterococci and penicillin-resistant pneumococcus.
How does tigecycline work?
Tigecycline is a "glycylcycline" antibiotic that binds to the ribosome and inhibits protein syntheisis.
It is virtually unique in that it covers staph, strep, G-, anaerobes and vancomycin resistant organisms.
What are the most common adverse effects of tigecycline?
Tigecycline is hepatotoxic and causes nausea and diarrhea.
What are polymyxin B (PMB) and Colistin?
Polymyxin and colistin are used topically for conjunctivitis, infections of the skin, and otitis externa. They are also the correct answer for multi-drug-resistant gram-negative bacilli that cause ventilator associated pneumonia and sepsis from pseudomas or acinetobacter.
What is the mechanism of action of polymyxin B (PMB) and Colistin?
They work by disrupting phospholipids in the cell wall membrane.
What are the most common adverse effects of polymyxin B (PMB) and Colistin?
Colistin and polymyxin are very toxic to the kidney and to the nerves, so their use is limited to topical applications of the skin, eye, and ear. They are also used for multi-drug-resistant G- bacilli when there are no other therapeutic options.
A mailman comes to the emergency department after having been bitten by a dog.
What is the best therapy?
What is the most likely organism involved in the wound?
Bites are treated with local wound care and tetanus prophylaxis. Antibiotics are NOT currently indicated.
DO answer antibiotics with:
1) Hand-bite wounds
2) Deep puncture wounds
3) Wounds requiring surgical debridement
4) Older patients
5) Bites near prosthetic joint
6) Infected wounds
Use:
1) amoxicillin/clavulanic acid
2) clindamycin and TMP/SMX for penicillin allergic patients.
Dogs and Cats transmit Pasturella multocida.
A dog comes to the ED after having been bitten by a mailman.
What is the best therapy?
What is the most likely organism involved in the wound?
Bites are treated with local wound care and tetanus prophylaxis. Antibiotics are NOT currently indicated.
DO answer antibiotics with:
1) Hand-bite wounds
2) Deep puncture wounds
3) Wounds requiring surgical debridement
4) Older patients
5) Bites near prosthetic joint
6) Infected wounds
Use:
1) amoxicillin/clavulanic acid
2) clindamycin and TMP/SMX for penicillin allergic patients.
Human bites transmit Eikenella corrodens.
A 42 yo male is going to India for a week.
What are the best prophylaxes against malaria?
Mefloquine or atovoquone/proquanil are the best malaria prophylaxes in most of the world.
Doxycycline is use when there is mefloquine resistance.
Chloroquine can be used in those areas in which the malaria is still sensitive to it.
Chloroquine sensitivity is retained in Central America, Caribbean, and some parts of the Middle East.
A 42 yo male is going to India for a week.
What are the adverse effects of the prophylaxes against malaria?
Mefloquine is associated with neuropsychiatric abnormalities, such as psychosis, hallucinations, and seizures. It may cause cardiac rhythm effects, such as bradycardia and QT interval prolongation. If the question describes a person on beta blockers or having an arrhythmia, use atovoquone/proquanil instead of mefloquine.
Doxycycline is associated with a photosensitivity rash
A 28 yo female is visiting you in MA for the first time after coming off a plane from New Zealand. the evening after she arrives, she finds a tick attached to her ankle.
Which treatment should you use?
1) Serology
2) Docycycline
3) Amoxicillin
4) Ceftriaxone
5) Western blot testing
6) Reassurance
Reassurance
This is an asymptomatic tick bite from a country that is not endemic for deer or deer ticks. In addition, the tick has been attached for <24 hours. Ticks, even if infected, need more than 24-36 hours to transmit the organism for Lyme disease.
A 7 year old boy goes to camping in the woods in CT. A week after he returns, he develops a circular, erythematous rash with central clearing that is >5cm in diameter.
Which treatment should you use?
1) Serology
2) Doxycycline
3) Amoxicillin
4) Ceftriaxone
5) Western blot testing
6) Reassurance
Amoxicillin
A large, round, erythematous rash is consistent with Lyme disease. There is no need to perform serologic testing when the rash is characteristic. Lyme rash is typically >5cm in diameter. Doxycycline and amoxicillin are equally efficacious, bu ther is no reason to use doxycycline in a child less than 8 yo when there is an acceptable alternative therapy.
A 43 yo administrative assistant comes to your office with myalgia, fever, cough, headache, arthralgia, and sore throat for the last 24-36 hours.
What therapy will you offer the patient?
Oseltamivir and zanamivir are neuraminidase inhibitors that can be used to treat both influenza A and B within 48 hours of the development of symptoms. They shorten the duration of illness 1-2 days.
A 43 yo administrative assistant comes to your office with myalgia, fever, cough, headache, arthralgia, and sore throat for the last 24-36 hours.
How does the primary treatment work?
The inhibition of neuraminidase prevents the release of the virus from the cell surface.
A 43 yo administrative assistant comes to your office with myalgia, fever, cough, headache, arthralgia, and sore throat for the last 24-36 hours.
What are the most common adverse effects of the primary treatment?
Zanamivir may cause some wheezing, because it is administered by inhalation.
A man with AIDS comes to the emergency department with blurry vision. He is found to have a retinal lesion. His CD4 count is <50.
What are the best initial therapies?
CMV retinitis is the most common cause of retinal lesions in patients with AIDS and low CD4 counts.
The best therapies for CMV are valganciclovir, ganciclovir, foscarnet, or .cidofovir
Because it can be used orally, valganciclovir is the drug of choice.
A man with AIDS comes to the emergency department with blurry vision. He is found to have a retinal lesion. His CD4 count is <50.
How do the best initial therapies work?
valganciclovir, ganciclovir, foscarnet, or cidofovir interfere with viral replication of CMV.
A man with AIDS comes to the emergency department with blurry vision. He is found to have a retinal lesion. His CD4 count is <50.
What are the most common adveres effects of the best initial therapies?
Ganciclovir: Neutropenia
Foscarnet: Nephrotoxicity, urethral ulcers, hypocalcemia, hypomagnesemia
Cidofovir: Nephrotoxicity
Valganciclovir: seizures, neutropenia
When is drotecogin the answer?
Drotrecogin is used to treat severe sepsis with multiorgan dysfunction and a high APACHE II score.
It reduces the mortality of sepsis and is used in addition to antibiotics, fluids, and possible pressors such as norepinephrine. If the question describes a patient with hypotension, tachycardia, hyperventilation, and hypoxia from sepsis leading to ventilator dependence, then drotrecogin is indicated.
How does drotecogin work?
Drotecogin is an activated Protein C analog. It has fibrinolytic and anti-inflammatory properties.
What are the most common adverse effects of drotrecogin?
The most common adverse effect of drotrecogin is bleeding.
A 27 yo intern gets stuck by a needle that she had just used to draw blood from a patient with AIDS.
What is the next best step in management?
HIV-infected needle-stick injuries should be treated prophylactically:
1) Zidovudine, lamivudine, and a protease inhibitor
OR
2) Tenofovir, emtricitabine, and a protease inhibitor.

The recommended protease inhibitor is lopinavir/ritonavir.
Alternatives are atazanavir, fosamprenavir, or nelfinavir
A 27 yo intern gets stuck by a needle that she had just used to draw blood from a patient with AIDS.
What is the risk of transmission without therapy?
The risk of transmission is 0.3 percent or 1 in 300.
A 27 yo intern gets stuck by a needle that she had just used to draw blood from a patient with AIDS.
What are the adverse effects of therapy?
Nausea and vomiting are the most common adverse effects of therapy.
A 25 yo nurse has been stuck by a needle from a hepatitis B surface-antigen-positive patient.
What should you do first?
What is the most appropriate postexposure prophylaxis?
1) Check hepB vaccination status.
2) If the injured person has protective levels of antibody, then NO further postexposure prophylaxis is needed. The presence of surface antibodies indicates that the person is protected. If the injured person does NOT have a protective level of antibody, then he or she should receive hepatitis immune globulin and a full course of hepatitis B vaccine
A 52 yo trauma surgeon has been lacerated by a scapel with blood from a patient who has hepatitis C.
What should you do first?
What is the most appropriate postexposure prophylaxis?
Nothing
There is no postexposure prophylaxis for hepatitis C. Immune globulin will not work, and there is no hepatitis C vaccine.
A child wakes up in the middle of the night to find a bat flying around the room. The bat flies out, and no injury is noted. It is unknown how long the bat was there.
What is the most appropriate treatement?
Bats are the most common vector for the transmission of rabies in the US.
Prophylaxis is indicated with rabies immune globulin and rabies vaccine for any level of injury, including bites, scratches, and mucous membrane exposure.
Prophylaxis is also indicated if the bat is found in a room while someone is sleeping and it is not known if contact occurred. Any unattended child should be given prophylactic treatment.
A man finds his neighbor's dog ruining his garden. When the man chases the dog out, the dog bites him.
What is the most appropriate treatment?
Rabies prophylaxis does not need to be given for dog bites, if the dog is known and is healthy.
If the dog is wild or unknown, then the dog should be observed for ten days. If abnormal behavior develops, then prophylaxis should be offered.
Patients with bites from a dog with abnormal behavior at any time should receive rabies immune globulin and vaccine.
A 42 yo female is working on a construction site and is accidentally hit by a nail from a nail gun. The nails were lying around in the dirt before use. She has received no vaccines since childhood.
What is the first best step in treatment?
1) Prophylaxis for tetanus should be given with ANY wound if more than ten years have passed since the last vaccination. If a vaccination has been given previously, prophylaxis consists only of tetanus toxoid.
2) If the person has NEVER been vaccinated, then BOTH tetanus toxoid and tetanus immune globulin should be given. Only people who have never been vaccinated should receive immune globulin.
3) If the person has received a dirty would, then a booster of tetanus toxoid should be given if more than FIVE years have passed since the last booster. Clean wounds are protected for ten years, dirty wounds for five years.
What are the indications for the influenza vaccine?
1) Everyone over 50
2) Health care workers
3) Anyone with chronic heart, lung, liver, or kidney dz; diabetes; HIV; or who uses steroids, has no spleen, or is a resident of a chronic care facility.
4) Pregnant women
How does the influenza vaccine work?
Influenza vaccine is constructed yearly with viral surface antigens from the previous years' most important strains.
How often is the influenza vaccine given?
Given yearly
What are the most common adverse effects of the influenza vaccine?
It can induce a mild fever and mild muscle soreness.
Very rarely it is associated with Guillian-Barre syndrome.
In whom is the influenza vaccine contraindicated?
It is contraindicated when the patient is allergic to eggs.
The live attenuated intranasal vaccine should not be given to pregnant or immunocompromised patients.
What are the indications for the pneumococcal vaccination?
1) Everyone over 65
2) Anyone with chronic heart, lung, liver, or kidney dz; diabetes; HIV; or who has no spleen, uses steroids, or resides in a chronic care facility.
3) Alcoholics
4) People with cochlear implants
How does pneumoccal vaccination work?
Vaccine is derived from the capsular polysaccharide from the surface of the pneumococcus.
How often is the pneumococcal vaccine given?
Most patients over age 65 receive a single injection. A second inection is given after five years only in immunocompromised patients and those in whom the first injection was before age 65.
What are the most common adverse effects of the pneumococcal vaccine?
Pneumococcal vaccine is extremely safe.
Local muscle soreness is the only significant adverse effect.
In whom is the pneumoccal vaccine contraindicated?
There are no contraindications for pneumococcal vaccination.
What condition do you treat with clindamycin?
Infections that are predominantly anaerobic.
1) Lung
2) Aspiration pneumonia
Clindamycin is also very useful for treating G+ organisms, such as staphylococci and streptococci. Although it is not as effective as a beta lactam, like penicillin or cephalosporin, it is used when the patient has a life-threatening anaphylactic reaction to penicillins
1) Cellulitis, erysipelas, and impetigo
2) Oral infections
3) Pelvic infections
Other second-line uses include:
1) Pneumocystis pneumonia
2) Bacterial vaginosis
3) Toxoplasmosis
4) Methicillin resistant staphaureus
How does clindamycin work?
Clindamycin is a lincosamide antibiotic. It inhibits the ribosome
What are the most common adverse effects of clindamycin?
Clindamycin often leads to diarrhea from Clostridium dificile.
When do you treat a patient with metronidazole?
Anaerobic G- bacilli found in the abdomen.
1) Clostridium difficile colitis
2) Diverticulitis in combination with a quinolone
3) Perforated abdominal organs
4) Pelvic infections
Also effective for protozoal ornganisms including:
1) Giardia
2) Entamoeba histolytica
3) Trichomonas
How does metronidazole work?
Inhibits bacterial mitochondria
Interferes with numerous cytosolic products, and blocks DNA production.
It generates free radicals that are toxic to the cell.
What are the most common adverse effects of metronidazole?
1) Metallic taste
2) Disulfiram reaction with alcohol
3) Rarely can cause seizures and neurological disorders
A patient with acute leukemia has recently undergone an allogeneic bone marrow transplantation. After two weeks of fever and neutropenia, she delivers a lung infection diagnosed as aspergillus.
What is the best therapy for this patient?
Voriconazole is superior to amphotericin in the mgmt of aspergillus.
Voriconazol results in greater survival with fewer adverse effects than amphotericin.
Itraconazole is not powerful enough in severe cases.
Echinocandins (caspofungin) are used as salvage if the patient fails to respond to amphotericin or voriconazole.
Vorconazole will not treat mucormycosis
A patient with acute leukemia has recently undergone an allogeneic bone marrow transplantation. After two weeks of fever and neutropenia, she delivers a lung infection diagnosed as aspergillus.
How does this best therapy work?
Imidazoles and triazoles inhibit microsomal cP450 enzymes.
This impairs the biosynthesis of ergosterol for the cytoplasmic membrane.
Amphotericin is a polyene antifungal that interferes with sterol production in the cell membrane.
A patient with acute leukemia has recently undergone an allogeneic bone marrow transplantation. After two weeks of fever and neutropenia, she delivers a lung infection diagnosed as aspergillus.
What are the most common adverse effects of the best therapy?
Amphotericin will raise the creatinine level and cause a distal renal tubular acidosis with hypokalemia.
Voriconazole can be hepatotoxic like azoles. It can also prolong the QT on an EKG.
The most unique adverse effect of voriconazole is a transient visual disturbance.
List three echinocandins.
Caspofungin
Micafungin
Anidulafungin
What conditions to echinocandins treat?
Fever and neutropenia who are still febrile after using bacterial antibiotics. Echinocandins are at least as efficacious as amphotericin and much less toxic. Echinocandins are used to treat:
1) Candida infections
2) Esophageal candidiasis
3) Aspergillus, especially if other therapies fail.
What organism is NOT affected by echinocandins?
Echinocandins do NOT affect Cryptococcus.
How do echinocandins work?
Echinocandins, block 1, 3-D-glucan. This is a polysaccharide in the fungal wall that does not exist in humans.
What are the most common adverse effects of echinocandins.
These medications have very few adverse effects. Minor histamine release with flushing, headache, urticaria, and pruritus has been reported.
When do you treat with posaconazole?
Posaconazole is used as empiric therapy for patients with fever and neutropenia who have not responded to empiric treatment with antibacterial coverage.
Accepted empiric coverage is with imipenem, cefepime, or piperacillin/tazobactam.
It is not known whether posaconazole is superior to the other echinocandins or voriconazole for febrile neutropenia. Used for these conditions:
1) Candida
2) Aspergillus
3) Mucormycosis
4) Cryptocococcus, histoplasmosis, coccidioidomycosis
How does posaconazole work
Azole antifungals block ergosterol synthesis.
What are the most common adverse effects of posaconazole?
Adverse effects are very few.
Rarely liver toxicity or QT prolongation may occur
A 25 yo medical student is entering his residency. His purified protein derivative (PPD) has 12 millimeters of induration. He had Bacille Calmette-Guerin (BCG) as a child. He has no symptoms and his chest X-ray is normal.
What is the next best step in the mgmt of this patient?
The student has a purified protein derivative (PPD) with >10 mm of induration and a normal chest X-ray. He should receive nine months of isoniazid.
The history of BCG is not important.
You cannot distinguish a true positive from tuberculosis exposure in the past from a false positive from BCG vaccination.
A 25 yo medical student is entering his residency. His purified protein derivative (PPD) has 12 millimeters of induration. He had Bacille Calmette-Guerin (BCG) as a child. He has no symptoms and his chest X-ray is normal.
What is the risk that the student will become ill?
A positive PPD confers a 10% lifetime risk of tuberculosis. Most reactivation occurs within the first two years of exposure.
A 25 yo medical student is entering his residency. His purified protein derivative (PPD) has 12 millimeters of induration. He had Bacille Calmette-Guerin (BCG) as a child. He has no symptoms and his chest X-ray is normal.
What effect will the treatment have?
Isoniazid reduces this 10% risk by 80-90%.
A 25 yo medical student is entering his residency. His purified protein derivative (PPD) has 12 millimeters of induration. He had Bacille Calmette-Guerin (BCG) as a child. He has no symptoms and his chest X-ray is normal.
What are the common advere effects of treatment?
Isoniazid can cause hepatotoxicity. Routine monitoring of liver function is not necessary, unless underlying liver disease or alcoholism is present.
A 42 yo homeless, alcoholic, immigrant, health care worker in a nursing home presents with fever, cough, sputum, and weight loss over three months. Her chest X-ray has an apical infiltrate, and her sputum is positive for acid-fast bacilli.
What is the next best step in the management of this patient?
TB cases should be placed on respiratory isolation and started on four tuberculosis medications. A positive smear is sufficient to initiate therapy.
Isoniazid (INH), rifampin, pyrizinamide, and ethambutal are the medications for initial therapy.
A 42 yo homeless, alcoholic, immigrant, health care worker in a nursing home presents with fever, cough, sputum, and weight loss over three months. Her chest X-ray has an apical infiltrate, and her sputum is positive for acid-fast bacilli.
What is the duration of therapy?
Isoniazid, rifampin, pyrizinamide, and ethambutal should all be used for the first two months. After sensitivities are known, ethambutal and pyrizinamide can be stopped. INH and rifampin should continue for four more months for a total of six months' therapy.
A 42 yo homeless, alcoholic, immigrant, health care worker in a nursing home presents with fever, cough, sputum, and weight loss over three months. Her chest X-ray has an apical infiltrate, and her sputum is positive for acid-fast bacilli.
Who needs prolonged therapy?
Standard therapy is six months of therapy. Treatment is prolonged if the patient has the following conditions:
1) Osteomyelitis
2) Meningitis
3) Pregnancy
4) Miliary tuberculosis
Your patient comes in for follow-up care for tuberculosis. He complains of blurry vision, and you notice that he has lost color vision. He is on isoniazid, rifampin, pyrizinamide, and ethambutal.
What is the most appropriate mgmt of the patient?
STOP the ethambutal. Ethambutal causes optic neuritis and can cause blurry vision. Color vision abnormalities can be the first symptoms.
Your patient shows no symptoms but has developed hyperuricemia after six weeks of TB medications.
What is the most appropriate management of the patient?
Hyperuricemia is most likely from pyrizanamide. However, because the patient is asymptomatic, you should not stop the medication. Prizinamide is essential to shorten the duration of therapy from nine months to six months.
A 50 year old man with AIDS come to the emergency department with shortness of breath, dry cough, increased LDH, a pO2 of 64, and a chest X-ray with bilateral interstitial infiltrates. He has a CD4 count 105 and is on no medications.
What is the best initial therapy?
Pneumocystis pneumonia (PCP) is initially treated with intravenous trimethoprim/sulfamethoxazole. Milder cases of PCP without severe hypoxia can be treated with atovoquone.
A 50 year old man with AIDS come to the emergency department with shortness of breath, dry cough, increased LDH, a pO2 of 64, and a chest X-ray with bilateral interstitial infiltrates. He has a CD4 count 105 and is on no medications.
What are the most common adverse effects of this treatment?
The most common adverse effect of TMP/SMX is a rash. Bone marrow suppression secondary to its ability to inhibit folate metabolism and renal insufficiency can also occur.
A 50 year old man with AIDS come to the emergency department with shortness of breath, dry cough, increased LDH, a pO2 of 64, and a chest X-ray with bilateral interstitial infiltrates. He has a CD4 count 105 and is on no medications.
What is an alternative medication?
If the patient is allergic to sulfa medications, pentamidine is the alternative for severe PCP.
A 50 year old man with AIDS come to the emergency department with shortness of breath, dry cough, increased LDH, a pO2 of 64, and a chest X-ray with bilateral interstitial infiltrates. He has a CD4 count 105 and is on no medications.
When is the use of steroids indicated?
Steroids are added for severe PCP. Severe is defined as a pO2 <70 or an A-a gradient >35.
A 24 yo male comes to the clinic with urethral discharge.
What is the most appropriate therapy for each case?
1) Urethritis is treated for both chlamydia as well as gonorrhea.
2) For chlamydia, use single-dose azithromycin or doxycycline for a week.
3) For gonorrhea, use single-dose cefixime or ceftriaxone.
A pregnant woman is found to have cervicitis.
What is the most appropriate therapy for each case?
1) Cervicitis is managed in the same way as urethritis.
2) Pregnant women, however, should not receive doxycycycline or quinolones.
3) In pregnancy, use azithromycin and ceftriaxone.
A woman comes to the emergency department with lower abdominal pain and tenderness, fever, and cervical motion tenderness. The pregnancy test is negative.
What is the most appropriate outpatient therapy?
Outpatient therapy for pelvic inflammatory disease (PID) consists of levofloxacin alone for two weeks of ofloxacin with metronidazole.
An alternate outpatient therapy is ceftrixone (or cefoxitin) with doxycycline for two weeks
A woman comes to the emergency department with lower abdominal pain and tenderness, fever, and cervical motion tenderness. The pregnancy test is negative.
What is the most appropriate inpatient therapy?
Inpatient therapy for PID consists of cefoxitin (or cefotetan) with doxycycline.
Penicillin-allergic patients can receive clindamycin with gentamicin.
A woman comes to the emergency department with lower abdominal pain and tenderness, fever, and cervical motion tenderness. The pregnancy test is negative.
Who needs to be admitted?
Admission criteria include failure or intolerance of oral therapy or fever or severe pain, which may indicate the presence of an abscess.
List ten protease inhibitors.
Nelfinavir
Ritonavir
Lopinavir
Indinavir
Amprenavir
Saquinavir
Atazanavir
Fosamprenavir
Darunavir
Tipranavir
What are protease inhibitors?
Protease inhibitors are a highly active antiretroviral therapy.
How do protease inhibitors work?
They work by inhibiting the protease enzyme, which is essential for the virus to be packaged as it buds off of a CD4 cell and leaves to infect other T cells.
What are the most common adverse effects of protease inhibitors?
All protease inhibitors cause hyperlipidemia and hyperglycemia in addition to being hepatotoxic. Indinavir has the unique adverse effect of causing kidney stones (nephrolithiasis).
When is a protease inhibitor the answer?
Protease inhibitors are part of the best initial therapy for HIV when the CD4 count goes below 350 cells or the patient has had an opportunistic infection.
The other most common question for protease inhibitors describes a patient who develops either an increased lipid level or kidney stones and asks which medication you should stop.
What is dapsone?
Dapsone is a sulfonamide antibiotic with very selective use against leprosy and as an alternative medication for pneumocystis pneumonia (PCP).
How does dapsone work?
It is a folic acid synthesis inhibitor.
What are dapsone's most common adverse effects?
The most common adverse effect is a rash.
It also can cause hemolysis with glucose 6 phosphate dehydrogenase deficiency.
Methemoglobinemia can also occur.
Aplastic anemia can happen with all folic acid inhibitors
When is dapsone the answer?
Dapsone is used to treat the following conditions
1) PCP and toxoplasmosis prophylaxis when the patient is intolerant of TMP/SMX
2) Leprosy
3) Autoimmune skin disorders such as bullous pemphigoid, lichen planus, and dermatitis herpetiformis
A 43 yo female comes to the emergency department having had a fever, a headache, and photophobia for the last six hours. Her lumbar puncture shows 1400 white cells that are predominantly neutrophils.
What is the best therapy?
The best initial therapy for bacterial meningitis is CEFTRIAXONE, VANCOMYCIN, and STEROIDS.
A 43 yo female comes to the emergency department having had a fever, a headache, and photophobia for the last six hours. Her lumbar puncture shows 1400 white cells that are predominantly neutrophils.
What is the mechanism of action of the best initial therapy?
Ceftriaxone and vancomycin both inhibit the cell wall of bacteria and are bactericidal.
Ceftriaxone is a beta lactam antibiotic that inhibits peptidoglycan cross-linking.
Vancomycin is a glycopeptide antibiotic.
Glycopeptides inhibit the disaccharide precursors to peptidoglycans.
Steroids presumably decrease inflammation of the central nervous system and decrease mortality in acute bacterial meningitis.
A 43 yo female comes to the evergency department having had a fever, a headache, and photophobia for the last six hours. Her lumbar puncture shows 1400 white cells that are predominantly neutrophils.
When do you add ampicillin?
Ampicillin is added to these other medications when the patient may have a Listeria infection.
Listeria monocytogenes occurs more frequently in the elderly, neonates, and those who are immunocompromised, such as patients on steroids or chemotherapy, asplenic patients, and those whith HIV.
A man has been in the hospital for the last 10 days on a ventilator for pneumonia. He develops diarrhea, and the stool toxin is positive for C diff.
What is the best initial therapy?
What are its most common adverse effects?
What will you do next if he does not improve?
1) Metronidazole should be used orally. IV metronidazole should only be used if oral treatment is not possible.
2) Metronidazole gives a disulfiram-like reaction with alcohol, resulting in vomiting. It can also cause a metallic taste in the mouth and peripheral neuropathy.
3) The small percentage of patients who do not respond to oral metronidazole should be switched to oral vancomycin. Vancomycin cannot be used intravenously for colitis.
A man is readmitted for a recurrence of his colitis from C.diff.
What is the therapy for the recurrence of his colitis?
Recurrent episodes of colitis can be treated with oral metronidazole, if the patient responded to oral metronidazole the first time.
A 48 yo injection drug user comes to the ED with a fever. On PE, he has a pan-systolic murmur heard best at the lower left sternal border. The murmur increases with inspiration.
Which valve is most likely involved?
Tricuspid valve endocarditis occurs more often in IVDU because of the constant bathing of the R side of the heart with staphylococcus.
Tricuspid regurgitation is best heard at the lower left sternal border, and all right-sided lesions will tend to increase in loudness with inspiration, which increases venous retrun to the right side of the heart.
A 48 yo injection drug user comes to the ED with a fever. On PE, he has a pan-systolic murmur heard best at the lower left sternal border. The murmur increases with inspiration.
What would you do first in the management of this patient?
The best initial step with presumed acute endocarditis is to draw blood cultures and start empiric therapy. The best empiric therapy for endocarditis is vancomycin and gentamicin.
A 48 yo injection drug user comes to the ED with a fever. On PE, he has a pan-systolic murmur heard best at the lower left sternal border. The murmur increases with inspiration.
What is the mechanism of action of the therapy?
Vancomycin inhibits the cell wall, and aminoglycosides like gentamicin inhibit the ribosome.
A 48 yo injection drug user comes to the ED with a fever. On PE, he has a pan-systolic murmur heard best at the lower left sternal border. The murmur increases with inspiration.
What are the most common adverse effects of the therapy?
Vancomycin can result in "red man syndrome" from a rapid infusion. This flushing from histamine release provoked by the vancomycin.
Aminoglycosides are nephrotoxic.
As you are leaving an expensive sushi restaurant, you lean over to kiss your date. You begin to vomit and have severe diarrhea. In addition, you have a rash, angioedema, wheezing, and flushing.
What is the most likely diagnosis?
Scombroid fish poisoning is characterized by the sudden onset of diarrhea, vomiting, wheezing, and flushing. Scombroid fish poisoning occurs form certain types of fish, such as tuna, mackerel, bonita, and mahi-mahi.
Bacteria within the fish result in the production of histamine. Scombroid poisoning has the fastest onset from all forms of food poisoning with symptoms occurring within minutes of ingestion.
As you are leaving an expensive sushi restaurant, you lean over to kiss your date. You begin to vomit and have severe diarrhea. In addition, you have a rash, angioedema, wheezing, and flushing.
What is the best initial therapy?
Treatment for scombroid fish poisoning is with antihistamines, such as diphenhydramine.
Epinephrine is used for very severe cases.
A woman presents with onchymycosis
of her toenail. The KOH of a scraping of the nail shows fungal hyphae.
What is the best therapy for this patient?
Terbinafine is the best therapy for onchomycosis. It has far greater efficacy than griseofulvan.
Terbinafine is used for 6 weeks for fingernails and 12 weeks for toenails.
Itraconazole is also superior to griseofulvan but NOT as efficacious as terbinafine.
A woman presents with onchymycosis of her toenail. The KOH of a scraping of the nail shows fungal hyphae.
What is the mechanism of action of the best therapy?
Terbinafine works by inhibiting squalene epoxidase. This interferes with the production of ergosterol, which is necessary to make the fungal cell wall. Squalene accumulates within the cell wall, which may account for terbinafine's fungicidal activity.
A woman presents with onchymycosis of her toenail. The KOH of a scraping of the nail shows fungal hyphae.
What are the most common adverse effects of the best therapy?
The most common adverse effects of terbinafine are hepatotoxicity and taste disturbance.
A 60 year ole man comes to the ED with SOB, cough, purulent sputum, and temperature of 102F. His white cell count is 18,000. His pO2 is 65 on room air. The chest X-ray shows infiltrates in the right middle and right upper lobes.
Which of the abnormalities described is the most important in determining whether this patient should be admitted.
Severity of Hypoxia.
The white cell elevation, the purulent sputum, and fever do NOT mean that someone needs to be admitted.
Chest X-Ray abnormalities by themselves do NOT indicate a need for admission. It is not the number of lobes involved but rather the LEVEL of hypoxia, hypotension, tachycardia, or confusion that indicates a need for IV therapy.
A 60 year ole man comes to teh ED with SOB, cough, purulent sputum, and temperature of 102F. His white cell count is 18,000. His pO2 is 65 on room air. The chest X-ray shows infiltrates in the right middle and right upper lobes.
What is the best therapy for outpatient pneumonia?
Outpatient pneumonia is best treated with an oral macrolide, such as azithromycin or clarithromycin.
If there is serious underlying lung disease, respiratory fluoroquinolones, such as levofloxacin, gatifloxacin, or moxifloxacin, are the first choice.
A 60 year ole man comes to teh ED with SOB, cough, purulent sputum, and temperature of 102F. His white cell count is 18,000. His pO2 is 65 on room air. The chest X-ray shows infiltrates in the right middle and right upper lobes.
What is the therpy for inpatient pneumonia?
Inpatient pneumonia is treated with the combination of ceftriaxone and azithromycin or with fluoroquinolone as a single agent.
A man comes to clinic with a genital ulcer and surrounding lymphadenopathy. The ulcer is painless with heaped-up, indurated edges. His darkfield examination is positive for spirochetes, and the RPR is negative.
What is the best initial therapy?
A single IM injection of benzathine penicillin is the best intitial therapy for both primary and early secondary syphilis. Symptoms include a chancre, rash, lymphadenopathy, or condylomata lata. RPR can be negative in primary syphilis.
A man comes to clinic with a genital ulcer and surrounding lymphadenopathy. The ulcer is painless with heaped-up, indurated edges. His darkfield examination is positive for spirochetes, and the RPR is negative.
What is the treatment if this patient is allergic to penicillin?
Penicillin-allergic patients with primary and secondary syphilis are best treated with doxycycline or a macrolide. Doxycycline is superior in efficacy.
A man comes to clinic with a genital ulcer and surrounding lymphadenopathy. The ulcer is painless with heaped-up, indurated edges. His darkfield examination is positive for spirochetes, and the RPR is negative.
What are the most common adverse effects of therapy?
Besides an allergic reaction, the most common adverse effect of treatment is the Jarisch-Herxheimer rxn. This consists of fever, rash, myalgias, and headache. This is thought to result form the release of lipopolysaccharide from dying spirochetes. It is treated with aspirin.
A 24 yo pregnant female is in the clinic for routine prenatal care. Her VDRL, or RPR, is reactive at a titer of 1:64, and the FTA-ABS is reactive. She has no symptoms.
What is the best therapy for this patient?
Secondary syphilis of indeterminant duration is referred to as "latent" syphilis. When the serology for syphilis is positive but the duration of the infection is unknown, the syphilis is "latent". These patients have no symptoms. Latent syphilis is treated with THREE IM inections of benzathine penicillin given at weekly intervals. The same treatment is used in pregnancy.
A 24 yo pregant female is in the clinic for routine prenatal care. Her VDRL, or RPR, is reactive at a titer of 1:64, and the FTA-ABS is reactive. She has no symptoms.
What is the best therapy if she is penicillin-allergic?
Pregnant women with syphilis who are allergic to penicillin should undergo desensitization to penicillin. This is true for any stage of syphilis.
A 24 yo woman has vaginal itching and dyspareunia. Her wet mount shows clue cells, and the pH is 6.5
What is the best initial therapy.
How would the therapy differ if she were pregnant?
1) The symptoms of bacterial vaginitis are clue cells and a high vaginal pH. Normal vaginal pH is <4.5.
Metronidazole or clindamycin are the best initial therapy for BV. They can be used orally or locally.
2) BV in pregnancy is best treated with oral medications to prevent preterm delivery. Oral metronidazole is NOT dangerous in pregnancy. Untreated BV is dangerous in pregnancy.
A 34 yo female has vaginal discharge, and the wet mount shows motile forms.
What is the best intitial therapy?
How would the therapy differ if she were pregnant?
1) Trichomoniasis is treated only wiht oral medications.
Oral metronidazole or oral tinidazole are the best meds.
2) Pregnant women with trichomoniasis should receive oral metronidazole. There is no proven teratogenicity of metronidazole.
A 25 yo woman who is HIV positive finds out that she is pregnant. She is on zidovudine, lamivudine, and nelfinavir.
What is the best regimen?
A patient who is already on antiretroviral meds for her own health with a low CD4 cell count in the past should continue on the same therapy.
Do not stop antiretrivirals even during the first trimester if the mother's life is dependent on the medications.
A woman tests positive for HIV as part of routine prenatal care. Her viral load is 300,000, and her CD4 is 85.
What is the best regimen?
Should you perform a C-section?
1) A woman with a low CD4 count (<350) or high viral load (>50,000) should be started immediately on antiretroviral therapy, even if she is pregnant. Antiretrivirals should be started even in the first trimester if the woman needs the meds for her own health. Triple therapy with two nucleoside reverse transcriptase inhibitors and a protease inhibitor should be used and continued lifelong, even after the delivery is complete.
2) C-section should be performed if the patient's viral load is not fully controlled to a level <1000 copies.
Which antiretroviral medication is contraindicated in pregnancy?
Efavirenz is a non-nucleoside reverse transcriptase inhibitor. It is specifically contraindicated in pregnancy because of the risk of neural tube defects.
What treatment should a baby deliverd from an HIV mother receive?
The baby should receive zidovudine (AZT) syrup for at least six weeks after delivery.
An HIV+ man comes to the office with several weeks of worsening difficulty and pain with (odynophagia) swallowing. His last CD4 is 85.
What is the next best step in the management of this patient?
Start treatment with fluconazole.
Dysphagia and odynophagia in a person wiht AIDS and CD4 cells <100 is so often from esophageal candidiasis that there is no need for endoscopy; treatment with fluconazole should be started.
An HIV+ man comes to the office with several weeks of worsening difficulty and pain with (odynophagia) swallowing. His last CD4 is 85.
How does the next step in therapy work?
Imidazoles and triazoles, such as fluconazole, impair the biosynthesis of ergosterol for the cytoplasmic membrane.
An HIV+ man comes to the office with several weeks of worsening difficulty and pain with (odynophagia) swallowing. His last CD4 is 85.
What are the most common adverse effects in the next step in therapy?
Azole antifungals are extremely benign. After prolonged use at high dose, they can be associated with hepatotoxicity.
An HIV+ man comes to the office with several weeks of worsening difficulty and pain with (odynophagia) swallowing. His last CD4 is 85.
What will you do if the next step in therapy fails?
If the condition does not respond to fluconazole, endoscopy should be erformed to diagnose rarer causes of esophageal leasions in HIV+ patients, such as herpes, or CMV
A 34 yo man has been newly diagnosed with AIDS. His CD4 is 20 and his viral load is 450,000. He is currently asymptomatic.
What would you recommend as the best initial therapy?
1) Antiretroviral therapy should be started in most patients with CD4 cells <350 and in all patients with CD4 cells <200.
2) Two nucleoside reverse transcriptase inhibitors (NRTIs) with either efavirenz or a protease inhibitor (PI) should be started.
3) Pneumocystis carinii pneumonia (PCP) prophylaxis with TMP/SMX should be given when the CD4 drops below 200.
4) Azithromycin for Mycobacterium avium intracellulare prophylaxis should be given to patients with CD4 cells <50.
A 34 yo man has been newly diagnosed with AIDS. His CD4 is 20 and his viral load is 450,000. He is currently asymptomatic.
How does the best initial therapy work?
NRTIs inhibit the transcription of HIV RNA into DNA. They terminate the synthesis of DNA chains. Normally, the single-stranded RNA virus is transformed into DNA, which is integrated into the host cell genome.
NRTIs do NOT affect host cell DNA polymerases.
PIs inhibit the viral protease enzyme that is crucial to maturation of HIV, allowing budding from host cells.
A 34 yo man has been newly diagnosed with AIDS. His CD4 is 20 and his viral load is 450,000. He is currently asymptomatic.
What are the most common adverse effects of the best initial therapy?
1) All NRTIs can cause lactic acidosis.
2) All PIs can cause hyperlipidemia and hyperglycemia.
3) Zidovudine can cause anemia.
4) Didanosine and Stavudine can cause pancreatitis and neuropathy.
5) Tenofovir can cause renal insufficiency and Fanconi's syndrome.
A man with peptic ulcer disease is admitted for a perforation of his ulcer. He is febrile, hypotensive, and tachycardic. He is started on imipenem and gentamicin. Three days later, his creatinine rises to 3.0, and he has a seizure.
What is the spectrum of activity of these antibiotics?
Gentamicin, tobramycin, and amikacin are aminoglycoside antibiotics. They are primariy effective against G- bacilli.
2) Imipenem, meropenem, and ertapenem are carbapenem antibiotics. They cover all the aerobic G- bacilli covered by aminoglycosides as well as anaerobes. The anaerobic coverage of carbapenems is equal to that of metronidazole. In addition, carbapenems cover all methicillin or oxacillin sensitive staphylococci and streptococci.
A man with peptic ulcer disease is admitted for a perforation of his ulcer. He is febrile, hypotensive, and tachycardic. He is started on imipenem and gentamicin. Three days later, his creatinine rises to 3.0, and he has a seizure.
What is the mechanism of action of the imipenem and gentamicin?
1) Carbapenems inhibit cell wall synthesis in the same way as penicillin by inhibiting peptidoglycan synthesis. They bind to penicillin-binding proteins.
2) Aminoglycosides inhibit protein synthesis by binding to the 30s ribosomal subunit.
A man with peptic ulcer disease is admitted for a perforation of his ulcer. He is febrile, hypotensive, and tachycardic. He is started on imipenem and gentamicin. Three days later, his creatinine rises to 3.0, and he has a seizure.
What are the most common adverse effects of imipenem and gentamicin?
1) Carbapenems can cause neurotoxicity.
2) Aminoglycosides lead to nephrotoxicity and ototoxicity. Rarely, they cause neuromuscular blockade and produce a myasthenia-like weakness.
A man with peptic ulcer disease is admitted for a perforation of his ulcer. He is febrile, hypotensive, and tachycardic. He is started on imipenem and gentamicin. Three days later, his creatinine rises to 3.0, and he has a seizure.
Why did he have a seizure?
The patient seized as an adverse effect of the imipenem. The level of imipenem rose due to his impaired renal function and, at toxic level, cause a seizure.
A 23 yo woman with dysuria and white cells in her urine is started on TMP/SMX. She develops a rash and is switched to ciprofloxacin.
What are the spectra of activity of these antibiotics?
1) Ciprofloxacin is broadly active against the majority of G- bacilli. In addition, all fluoroquinolones are active against Mycoplasma, Legionella, and chlamydia pneumonia.
A 23 yo woman with dysuria and white cells in her urine is started on TMP/SMX. She develops a rash and is switched to ciprofloxacin.
What are these antibiotics mechanism of action?
Quinolones, such as ciprofloxacin, exhibit concentration-dependent bactericidal activity by inhibiting the activity of DNA gyrase and topoisomerase, enzymes essential for bacterial DNA replication.
A 23 yo woman with dysuria and white cells in her urine is started on TMP.SMX. she develops a rash and is switched to ciprofloxacin.
What are the most common adverse effects of these antibiotics?
Quinolones can rarely be associated with CNS toxicity. Inhibition of chondroblasts can lead to Achilles tendon rupture. This is why quinolones are contraindicated in pregnancy and children.
Gatifloxacin causes hyperglycemia. Occasionally it prolongs the QT interval.
A 43 yo woman with pyelonephritis and E. coli bacteremia develops anaphylaxis to ampicillin. She is switched to aztreonam.
What are the spectra of activity of these antibiotics?
1) Aztreonam, a mono-bactam and the only drug in its class, is active against G- bacilli. There are no cross-reactivity between aztreonam and penicillin. Hence, aztreonam can be used even if there has been anaphylaxis with penicillin.
A 43 yo woman with pyelonephritis and E. coli bacteremia develops anaphylaxis to ampicillin. She is switched to aztreonam.
What are these antibiotics mechanism of action?
Aztreonam is a beta lactam antibiotic and inhibits cell wall synthesis.
A 43 yo woman with pyelonephritis and E. coli bacteremia develops anaphylaxis to ampicillin. She is switched to aztreonam.
What are the most common adverse effects of these antibiotics?
Aztreonam is generally safe with few adverse effects.
A 64 yo man with diabetes develops an ulcer over his tibia. The X-ray is normal, but the MRI shows osteomyelitis. A bone biopsy is performed, which grows an organism.
What is the best therapy for this patient?
Osteomyelitis cannot be effectively treated without a biopsy of the bone. Staphylococci accounts for only 50-70% of isolates. There is no way to determine the sensitivity of the organism without a biopsy.
1) Staphylococcus aureus: Oxacillin-sensitive organisms are best treated with nafcillin or oxacillin. Ceftriaxone or cefazolin can be used as well. If the patient suffers a rash due to penicillin, cephalosporins can be safely used. Oxacillin resistant organisms are treated with vancomycin, linezolid, or daptomycin
2) G- bacilli: If the organism is sensitive, the drug of choice is a fluoroquinolone, such as ciprofloxacin. Quinolones can be used orally.
A 64 yo man with diabetes develops an ulcer over his tibia. The X-ray is normal, but the MRI shows osteomyelitis. A bone biopsy is performed, which grows an organism.
How will you determine the duration of therapy?
ESR can be used to follow the response to therapy. Most patients are afebrile at the beginning of therapy and have a normal white cell count, so those measures cannot be used to monitor therapy.
You are working in the congressional mail room when 10 envelopes with white poweder arrive marked "Please inhale on opening."
What is the best proplylactic therapy?
Inhalation anthrax spores have been sent via the mail as a weapon of bioterrorism. The best proplylactic medications are ciprofloxacin or doxycycline. Amoxacillin is a second-line agent, used when quinolones or doxycycline are contraindicated.
A 53 yo alcoholic man with cirrhosis and ascites is admitted for fever and abdominal pain. A paracentesis reveals 1,200 white blood cells that are 80% neutrophils.
What are the criteria for treatment of spontaneous bacterial peritonitis?
Spontaneous bacterial peritonitis is treated when the ascitic fluid reveals wither total WBC >500 or neutrophils >250.
A 53 yo alcoholic man with cirrhosis and ascites is admitted for fever and abdominal pain. A paracentesis reveals 1,200 white blood cells that are 80% neutrophils.
What is the drug of choice for SBP?
Cefotaxime is the treatment of choice for SBP.
A 53 yo alcoholic man with cirrhosis and ascites is admitted for fever and abdominal pain. A paracentesis reveals 1,200 white blood cells that are 80% neutrophils.
What is the indication for proplylaxis of SBP?
Proplylaxis is indicated in:
1) Patient has experienced previous SBP
2) Ascites occurs with variceal hemorrhage.
3) Ascitic protein content <1.0 grams/dl.
A 53 yo alcoholic man with cirrhosis and ascites is admitted for fever and abdominal pain. A paracentesis reveals 1,200 white blood cells that are 80% neutrophils.
What is the best proplylactic medication?
The best prophylactic medications is either norfloxacin or TMP/SMX
A child comes to the ED with a sudden onset of severe sore throat, fever and stridor. Her voice is muffled, and she is drooling. An examination in the operating room with direct fiberoptic laryngoscopy reveals epiglottitis.
What is the most urgently needed therapy?
In cases of epiglottitis, securing an airway with nasotracheal intubation is the most urgent step. The airway may close off abruptly, and the examination should occur in the operating room.
A child comes to the ED with a sudden onset of severe sore throat, fever and stridor. Her voice is muffled, and she is drooling. An examination in the operating room with direct fiberoptic laryngoscopy reveals epiglottitis.
What is the drug of choice?
Antibiotic treatment for epiglottitis is with ceftriaxone and clindamycin.
A woman comes to see you for genital warts on her labia majora. They are not uncomfortable, but she would like them removed.
What is the best therapy?
Condylomata accuminata, or genital warts, can be treated with a large number of methods that are approximately equal in efficacy. These are:
1) Cryotherapy
2) Podophyllin
3) Laser removal
4) Trichloroacetic acid
5) Imiquimod; a local immunostimulant that acts by local cytokine induction and leads to sloghing of the lesion very slowly over a period of months.
A woman comes to see you for genital warts on her labia majora. They are not uncomfortable, but she would like them removed.
What are the most common adverse effects of therapy?
All therapies, with the exception of imiquimod, can lead to damage to surrounding healthy tissue.
Podphyllin is teratogenic.