Ptx Iii - Exam 2

Front 1

Which of the following represents the best classification of S. aureus and E. Coli?
A. S. aureus is an aerobic gram-positive bacilli and E. Coli is an aerobic gram-negative bacilli
B. S. aureus is an aerobic gram-positive cocci and E. Coli is an anaerobic gram-negative bacilli
C. S. aureus is an anaerobic gram-positive cocci and E. Coli is an aerobic gram-negative bacilli
D. S. aureus is an aerobic gram-positive cocci and E. Coli is an aerobic gram-negative bacilli

Back 1

D. S. aureus is an aerobic gram-positive cocci and E. Coli is an aerobic gram-negative bacilli

Both organisms are aerobes; S. aureus is classified as an aerobic gram-positive cocci and E. Coli is an aerobic gram-negative bacilli making answer D correct and all the others false.

Front 2

Which of the antibiotics listed in the Susceptibility report above does not require renal dose adjustments?
A. Trimethoprim/sulfamethoxazole (Septra, Bactrim)
B. Ciprofloxacin (Cipro) and Ceftriaxone (Rocephin)
C. Ceftriaxine (Rocephin) and oxacillin
D. Ceftazidime (Fortaz and Ceftriaxone (Rocephin)

Back 2

C. Ceftriaxine (Rocephin) and oxacillin

All beta-lactams except for ceftriaxone, nafcillin and oxacilin require renal
adjustments as a result answer choice C is correct and D is incorrect as ceftazidime requires dose adjustment for impaired renal function. All fluoroquinolones apart from moxifloxacin require renal adjustments making answer choice B incorrect. SMX/TMP also requires renal adjustments making A incorrect as well.

Front 3

JP is a 22 year-old male college student presenting to the emergency department with a chief complaint of a two day history of severe headache, nausea, vomiting, and photophobia. When questioned about his recent health, he mentions having no prior
concerns or medical conditions. He lives in a fraternity and actively participates in intramural sports, but mentions his roommate was recently very ill. The ER physician is
concerned JP’s presentation seems indicative of acute bacterial meningitis. The physician is bedside, ready to perform a lumbar puncture and is waiting for the pharmacist's antibiotic recommendations.
With acute bacterial meningitis suspected, which of the following would be the
most appropriate course of action in JP’s treatment?
A. lumbar puncture, administer empiric antibiotics, take blood cultures, narrow antibiotic spectrum
B. administer empiric antibiotics, lumbar puncture, take blood cultures, narrow antibiotic spectrum
C. lumbar puncture, take blood cultures, administer empiric antibiotics, narrow antibiotic spectrum
D. administer empiric antibiotics, take blood cultures, narrow antibiotic spectrum, lumbar puncture

Back 3

C. lumbar puncture, take blood cultures, administer empiric antibiotics, narrow antibiotic spectrum

Answer C is correct. As stated in the patient case, there is no delay in obtaining a lumbar puncture, thus antibiotic administration can be done in a timely manner. At the same time as obtaining the lumbar puncture, you would also obtain blood cultures. From there you would administer empiric antibiotics, await results of the lumbar puncture and blood cultures, and narrow antibiotic spectrum as appropriate.

Front 4

Based on JP’s presentation and background, what would be the most appropriate recommendation to the physician for empiric therapy and why?
A. Ceftriaxone (Rocephin) and vancomycin, because Neisseria meningitidis is the most likely pathogen
B. Ceftazidime (Fortaz) and vancomycin because Neisseria meningitidis is the most likely pathogen
C. Ceftriaxone (Rocephin) and vancomycin because Haemophilus influenzae is the most likely pathogen
D. Ceftazidime (Fortaz), vancomycin, and ampicillin because Streptococcus pneumoniae is the most likely pathogen

Back 4

A. Ceftriaxone (Rocephin) and vancomycin, because Neisseria meningitidis is the most likely pathogen

The most common pathogen in patients between 4 and 29 years of age is Neisseria meningitidis, thus ruling out answers C & D. Answer B is incorrect because ceftazidime is reserved for use when Pseudomonas aeruginosa
infections are suspected. P. aeruginosa is suspected mainly in patients who have had recent antibiotic or healthcare exposures, which our patient did not have. Answer A is correct because empiric therapy for suspected Neisseria meningitidis infections is a 3rd generation cephalosporin (ceftriaxone/cefotaxime) plus vancomycin.

Front 5

NP is a 35 year old female who presents to the hospital with complaints of severe abdominal pain, perfuse diarrhea and a high fever. NP is currently taking clindamycin 300 mg orally twice daily for 7 days to treat bacterial vaginosis. NP’s stool culture revealed Clostridium difficile.

What would be the most appropriate recommendation for NP?
A. Vancomycin 125mg i.v. q.i.d.
B. Metronidazole (Flagyl) 250mg p.o. q.i.d.
C. This type of infectious diarrhea is usually self-limited and she can take loperamide (Imodium) to decrease the stool frequency
D. Discontinuation of the offending agent (clindamycin), then initiate metronidazole (Flagyl) 250mg qid.

Back 5

D. Discontinuation of the offending agent (clindamycin), then initiate metronidazole (Flagyl) 250mg qid.

Clindamycin should be discontinued as it is the offending agent. Metronidazole is the DOC. ORAL vancomycin is appropriate when the patient does not respond to oral metronidazole.

Front 6

TZ is a 5-month-old male who was brought to the urgent care clinic by his mother. The mother states that after she picked up her son from daycare 2 days ago; he has been very irritable and has not stopped tugging on his right ear. TZ has a temperature of 101°F and his right tympanic membrane is erythematous and immobile. Patient with no drug allergies.

What antibiotic would be most appropriate for initial therapy?
A. Cefpodoxime (Vantin®) 10 mg/kg PO daily
B. Amoxicillin (Amoxil®) 90 mg/kg/day divided BID
C. Azithromycin (Zithromax®) 500 mg PO x 1, then 250 mg PO daily x 4 days
D. Cefuroxime (Ceftin®) 30 mg/kg/day divided BID

Back 6

B. Amoxicillin (Amoxil®) 90 mg/kg/day divided BID

Front 7

TZ and his mother return 3 days later with no improvement after the initial therapy.
What is the most appropriate recommendation?
A. Continue cefpodoxime (Vantin®) 10 mg/kg PO daily
B. Continue amoxicillin (Amoxil®) 90 mg/kg/day divided BID
C. Change to amoxicillin/clavulanate (Augmentin ES®) 90 mg/kg/day divided BID
D. Change to erythromycin (E-mycin®) 500 mg PO BID x 3 days

Back 7

C. Change to amoxicillin/clavulanate (Augmentin ES®) 90 mg/kg/day divided BID

Front 8

LB is a very ill appearing 52 year-old female that presents to the ER with fever, cough with productive sputum, tachypnea and severe shortness of breath. She states that he has
been sick and has been out of work for several days due to “the flu. She is diagnosed with severe community-acquired pneumonia and her physician would like you to assist with the care plan.
PMH: Asthma
PSH: Splenectomy following motor vehicle crash in 1993

Which of the following groups contain pathogens most likely responsible for LB’s community-acquired pneumonia?
A. Klebsiella pneumoniae, Pseudomonas aeruginosa, Hafnia alvei
B. Mycoplasma pneumoniae, Streptococcus pyogenes, Listeria monocytogenes
C. Influenza A, Streptococcus pneumoniae, Enterococcus faecalis
D. Methicillin-resistant Staphylococcus aureus, Haemophilus influenza, Streptococcus pneumoniae
E. None of the above

Back 8

D. Methicillin-resistant Staphylococcus aureus, Haemophilus influenza, Streptococcus pneumoniae

Correct. H. flu and S. pneumoniae are both encapsulated pathogens that are
common causes of CAP, especially in splenectomized patients. In addition,
since he has such severe pneumonia associated with a post-influenza period,
CA-MRSA must be included as a possible cause.
Hafnia alvei, K. pneumoniae and P. aeruginosa are infrequent
causes in CAP. While mycoplasma is responsible for CAP, it is usually a milder form. Enterococcus and group A streptococcus are not common causes of pneumonia. Influenza A and S. pneumoniae are potential causes for CAP.
Enterococcus is not.

Front 9

Select the most appropriate therapeutic care plan for LB:
A. Hospitalize LB. Obtain blood and sputum cultures and initiate therapy with IV cefotaxime (Claforan), IV azithromycin (Zithromax), and IV linezolid (Zyvox). Once patient clinically stable transition to oral therapy & administer pneumococcal vaccine.
B. Hosptialize LB. Obtain sputum cultures and begin therapy with IV ceftriaxone (Rocephin). Once patient clinically stable, administer pneumococcal vaccine.
C. Treat as an outpatient with amoxicillin/clavulanic acid (Augmentin) for 7 days.
D. Admit patient. Obtain sputum cultures. Begin high-dose IV ciprofloxacin (Cipro). Once patient clinically stable transition to oral therapy to complete a 5 day course. Administer pneumococcal vaccine.

Back 9

A. Hospitalize LB. Obtain blood and sputum cultures and initiate therapy with IV cefotaxime (Claforan), IV azithromycin (Zithromax), and IV linezolid (Zyvox). Once patient clinically stable transition to oral therapy & administer pneumococcal vaccine.

Ceftriaxone alone does not provide adequate coverage of atypical
organisms. 3rd generation cephalosporins must be combined with a macrolide for appropriate empiric CAP coverage. In addition, given the severity of the pneumonia, CA-MRSA should be empirically covered. This patient is severely ill. Even though we do not have enough information to calculate a PSI, she is diagnosed with severe CAP. She should at least be admitted for observation and a short course of IV antibiotics. High-dose ciprofloxacin is reserved for HAP involving P. aeruginosa. Ciprofloxacin also will not provide adequate S. pneumoniae
coverage. In addition, given the severity of the pneumonia, CA-MRSA should
be empirically covered.

Front 10

Which of the following are risk factors for the involvement of multidrug resistant pathogens in health-care associated pneumonia?
A. Resident of a nursing home
B. Liver transplant on immunosuppressive medications
C. Hospitalized for more than two days within the proceeding 90 days
D. A and C
E. A, B and C

Back 10

E. A, B and C

Front 11

RH is a 64 year-old female hospitalized for bilateral knee replacement surgery. During the surgery, a foley catheter is placed to allow for adequate bed rest following the procedure. Five days following her surgery, she develops a low-grade fever and chills. The nurse taking care of the patient notes that her foley catheter bag contains cloudy, foul smelling urine. A specimen is obtained and sent for urinalysis and quantitative culture and she is started empirically on Septra (trimethoprim/sulfamethoxazole) 1 DS tablet PO BID.

Which of the following organisms are associated with hospital-acquired urinary tract infections?
A. Escherichia coli
B. Staphylococcus saprophyticus
C. Pseudomonas aeruginosa
D. A and C
E. A, B and C

Back 11

D. A and C

E. coli and P. aeruginosa are commonly implicated in nosocomial
UTIs. E. coli remains the most common cause of UTIs, even in hospitalized patients. S. saprophyticus is primarily is involved in uncomplicated cystitis in otherwise healthy young females.

Front 12

RH’s urinalysis is conducted and the following results are available:
Cloudy, amber urine
pH: 7.0
WBC: 79
Nitrite: negative
Bacteria: Many
RH’s culture: 10,000 – 100,000 Pseudomonas aeruginosa

Which of the following is the best therapeutic plan for RH?
A. Continue therapy with Septra (trimethoprim/sulfamethoxazole) but change to equivalent intravenous dose as this is a hospital acquired infection requiring IV antibiotics.
B. Remove foley catheter. Discontinue Septra (trimethoprim/sulfamethoxazole). Initiate therapy with ceftriaxone (Rocephin) 1 gram IV every 12 hours. Replace foley after first dose.
C. Remove foley catheter and encourage use of bedside commode. Discontinue Septra (trimethoprim/sulfamethoxazole) and begin treatment with cefepime (Maxipime) at 500mg IV every 12 hours.
D. Initiate therapy with doxycycline 100 mg IV BID. After 5 days of therapy remove the foley catheter and discontinue the doxycycline.

Back 12

C. Remove foley catheter and encourage use of bedside commode. Discontinue Septra (trimethoprim/sulfamethoxazole) and begin treatment with cefepime (Maxipime) at 500mg IV every 12 hours.

TMP-SMX does not have significant activity against P. aeruginosa. In addition, not all hospital acquired infections require IV antibiotic therapy. Ceftriaxone does not provide adequate anti-pseudomonal activity. Also the dose of ceftriaxone is wrong at 1 gram q12h. The foley catheter should be removed/exchanged as soon as possible followed by a short course of antipseudomonal antibiotics.
Doxycyline does not provide anti-pseudomonal activity and is not an ideal urinary tract antiinfective due to limited renal clearance compared with
other alternatives. While this may be effective at reducing the colony burden, it is unlikely to be successful as this patient had symptoms consistent with a true infection (fevers, chills) and a positive UA.

Front 13

MS is a 48 year old obese female with Type 2 diabetes mellitus. She presents to her physician with left foot swelling and an ulcer on the ball of her left foot. She states that she noticed the ulcer about 4 weeks ago. The physician notices extensive inflammation and the patient has signs of systemic toxicity (e.g. tachycardia and fever). She has been treated for infections of her left foot several times over the past year and has had Pseudomonas aeruginosa grow from a few of the cultures in the past. The patient will be admitted to the hospital for IV antibiotic treatment of a diabetic foot infection.

Which of the following antibiotic combinations provides appreciable coverage for Pseudomonas aeruginosa and would be appropriate for initial treatment of this patient?
A. Daptomycin (Cubicin) + Ampicillin/sulbactam (Unasyn)
B. Vancomycin + Ertapenem (Invanz)
C. Ticarcillin/clavulanate (Timentin)+ Clindamycin
D. Piperacillin/tazobactam (Zosyn) + Linezolid (Zyvox)

Back 13

D. Piperacillin/tazobactam (Zosyn) + Linezolid (Zyvox)

A-Ampicillin/sulbactam does not provide coverage for Pseudomonas
aeruginosa, B-Ertapenem does not provide adequate coverage for Pseudomonas aeruginosa, C-Clindamycin not a first-line option to cover methicillin-resistant
Staphylococcus aureus

Front 14

JB is a 48 year old male with chronic hepatitis C infection. His viral load was 10,000,000 IU/mL and his genotype is 3a. He is currently on treatment with pegylated interferon and ribavirin and is in for a follow-up visit at during the 13th week of his therapy. He had a viral load done the week prior (week 12) and it was 10,000 copies/mL.

What would be the most appropriate recommendation at this time?
A. Discontinue therapy as patient has not had an adequate response (< 2 log decrease in viral load)
B. Continue therapy, reassess at week 24, if week 24 viral load undetectable, continue therapy for additional 24 weeks
C. Continue therapy, reassess at week 24, if week 24 viral load detectable, continue therapy for additional 24 weeks
D. Continue therapy, reassess at week 24, if week 24 viral load undetectable, stop therapy and check viral load 24 weeks after end of treatment

Back 14

D. Continue therapy, reassess at week 24, if week 24 viral load undetectable, stop therapy and check viral load 24 weeks after end of treatment

A-patient has had > 2 log decrease in viral load (< 100,000), B-
Duration of therapy for genotype 3 is 24 weeks, C-If viral load is detectable at 24
weeks, therapy is considered to have failed so would not be continued regardless of genotype.

Front 15

Which of the following best represents the classification of Bacteroides fragilis?
A. Atypical bacteria
B. Anaerobic gram-negative bacilli
C. Aerobic gram-negative bacilli
D. Anaerobic gram-positive cocci

Back 15

B. Anaerobic gram-negative bacilli

Front 16

Which of the following antibiotics is the drug of choice for treatment of Bacteroides fragilis?
A. Trimethorpim/sulfamethoxazole (Septra®)
B. Gentamicin (Garamycin®)
C. Metronidazole (Flagyl®)
D. Ciprofloxacin (Cipro®)

Back 16

C. Metronidazole (Flagyl®)

None of the other antibiotics listed have appreciable anaerobic activity.

Front 17

AJ is a 5 year old female who is brought to the emergency room by her mother. Her mother states that AJ has had a fever, headache, sensitivity to light, and decreased appetite for the past 2 days. After physical examination of AJ, the physician is concerned about meningitis and orders a lumbar puncture which reveals WBCs 650 (many PMNs), elevated protein and decreased glucose. Gram stain of CSF (cerebrospinal fluid) shows
gram-negative coccobacilli. The child does not attend daycare and is home-schooled along with her sister (age 8) and brother (age 11). The children have not received any of the recommended routine childhood immunizations since their parents are concerned about vaccine side effects.

What is the most likely pathogen causing meningitis in this patient?
A. Haemophilus influenzae
B. Listeria monocytogenes
C. Streptococcus pneumoniae
D. Neisseria meningitides

Back 17

A. Haemophilus influenzae

Listeria monocytogenes is a gram-positive rod, Streptococcus
pneumoniae is a gram-positive cocci, Neisseria meningitides is a gram-negative cocci

Front 18

AS is an 8 month old female who is brought to her pediatrician with a 2-day history of fever, decreased appetite, irritability, and tugging of her left ear. . On physical exam, there is a left middle ear effusion; her tympanic membrane is erythematous, bulging, and is immobile to pneumatic otoscopy. She has a temperature of 39.5°C (10.3.1°F). She is diagnosed with acute otitis media. She has no known drug allergies and has not received antibiotics in the past month.
What is the most appropriate recommendation?
A. Have mom monitor for worsening signs and symptoms and return to the office in
1 week.
B. Treat with ceftriaxone (Rocephin®) 200 mg/kg qd IM x 1 day
C. Treat with amoxicillin (Amoxil®) 90mg/kg/day divided q12h x 10 days
D. Treat with azithromycin (Zithromax®) 20 mg/kg po qd x 10 days

Back 18

C. Treat with amoxicillin (Amoxil®) 90mg/kg/day divided q12h x 10 days

Patient has severe symptoms and certain diagnosis so initial observation is not recommended: The recommended regimen for initial treatment in patient who has not had antibiotics in the prior month and who is not penicillin allergic is high dose amoxicillin. Additionally, ceftriaxone and azithromycin are dosed incorrectly.

Front 19

After 3 days of therapy, mom brings AS back to the clinic stating that she does not seem to be getting better. She is still febrile and her ear exam has not improved. What change in therapy (assume original therapy will be discontinued with this change) should you recommend and which pathogen(s) will this provide enhanced coverage against?

A. Amoxicillin/clavulanate (Augmentin ES®) 90mg/kg/day divided q12h-Moraxella cattarhalis and Streptococcus pneumoniae
B. Ceftriaxone (Rocephin®) 500 mg/kg qd x 3 days-Moraxella cattarhalis, Streptococcus pneumoniae, and Haemophilus influenzae
C. Amoxicillin/clavulanate (Augmentin ES®) 90mg/kg/day divided q12h-Moraxella cattarhalis and Haemophilus influenzae
D. Cefuroxime (Ceftin®) 30 mg/kg qd-Haemophilus influenzae and Streptococcus pneumoniae

Back 19

C. Amoxicillin/clavulanate (Augmentin ES®) 90mg/kg/day divided q12h-Moraxella cattarhalis and Haemophilus influenzae

Recommendation for treatment failure after 3 days in a patient who has not received antibiotics in the prior month and does not have a penicillin allergy is amoxicillin/clavulanate high dose which provides enhanced activity versus beta-
lactamase producing organisms such as some Haemophilus influenzae and most
Moraxella cattarhalis.
Cefuroxime is dosed incorrectly and doesn’t provide enhanced activity versus
Streptococcus pneumoniae compared to high dose amoxicillin. Ceftriaxone is dosed incorrectly.

Front 20

PJ is an 18 year old female who presents to her physician’s office with a 3 day history of sore throat. She has no cough but has a temperature of 38.9°C (102°F). On exam, her pharynx is erythematous. A rapid Strep test is positive for Streptococcus pyogenes (Group A Streptococcus, GAS). She has an allergy to penicillin (anaphylaxis) as a child. What is the most appropriate recommendation?
A. Await the results of throat culture, there are often false positive results with the rapid Strep test in adults.
B. Place the patient on erythromycin base (E-mycin®) 500 mg po qd x 10 days
C. Give the patient ceftriaxone (Rocephin®) 125 mg IM x 1 dose
D. Place the patient on azithromycin (Zithromax®) 500 mg po x 1 dose then 250 mg po x 4 days

Back 20

D. Place the patient on azithromycin (Zithromax®) 500 mg po x 1 dose then 250 mg po x 4 days

Rapid strep test is positive so do not need to wait on a culture; patient
should not receive ceftriaxone due to history of anaphylaxis to penicillin; erythromycin or azithromycin are both options except the erythromycin dose is incorrect.

Front 21

Which of the following markers would be positive in a patient who is an inactive
carrier of the hepatitis B virus?
A. Hepatitis BeAg (envelope antigen)
B. Hepatitis BcAb IgM (core antibody)
C. Hepatitis B DNA viral load
D. Hepatitis BsAg (surface antigen)

Back 21

D. Hepatitis BsAg (surface antigen)

Positive hepattis B eAg and positive hepatitis B DNA viral load are
present with chronic active hepatitis B infections. Hepatitis B Cab IgM is indicative of acute hepatitis B infection.

Front 22

RJ is a 58 year old male who reports to the emergency department with a human bite wound on his right hand. He states that he was a enjoying a night out at a local bar with his girlfriend when another bar patron began harassing her. He states that he had no choice but to defend her and a fight ensued. His right hand is bleeding and he has multiple puncture wounds which appear to be secondary to a human bite. He has no known drug allergies. What antibiotic would be most appropriate?
A. No antibiotic therapy is indicated; human bite wounds rarely get infected and should not be treated with pre-emptive antibiotics
B. Clindamycin (Cleocin®)
C. Azithromycin (Zithromax®)
D. Amoxicllin/clavulanate (Augmentin®)

Back 22

D. Amoxicllin/clavulanate (Augmentin®)

Most human bites eventually become infective and pre-emptive antibiotic therapy with amoxicillin/clavulanate is recommended (directed against Staphylococcus epidermidis and aurues, Eikenella corrodens, and anaerobes).

Front 23

JD is a 55 year-old male who presents to the emergency department with a 2 day history of severe abdominal pain, nausea, and vomiting. He is an alcoholic and has been unsuccessful with several attempts to quit. He reports that he binge drank this past weekend (approximately 18 beers per day Saturday and Sunday) since his
girlfriend left him stating that she could not take his drinking any longer. He has had 2 prior episodes of pancreatitis (last episode 4 weeks prior). On physical exam he is found to have abdominal guarding, rebound tenderness, and fever (39°C, 102.2°F). A CT Scan reveals a pancreatic abscess. What is the most appropriate recommendation?
A. Cefepime (Maxipime®) 2g iv q12h + metronidazole (Flagyl®) 500 mg
iv q12h
B. Ceftriaxone (Rocephin®) 1g iv q24h
C. Ciprofloxacin (Cipro®) 400 mg iv q12h + gentamicin (dosed by
weight/renal function)
D. Piperacillin/tazobactam (Zosyn®) 4.5 g iv q8h + metronidazole (Flagyl®)
500 mg iv q12h

Back 23

A. Cefepime (Maxipime®) 2g iv q12h + metronidazole (Flagyl®) 500 mg
iv q12h

Since patient has intra-abdominal abscess, need to coverage versus gram-negative rods and anaerobes. Answers B and C do not provide appreciable anaerobic coverage and answer D provides redundant anaerobic coverage.

Front 24

RM is a very ill appearing 38 year-old male that presents to the emergency room with fever, cough with productive, blood-tinged sputum, and severe shortness of breath. He states that he has been sick and has been out of work for several days due to “the flu”.
He is diagnosed with severe community-acquired pneumonia (PSI class IV) and his physician would like you to assist with the care plan.
PMH: Asthma
PSH: Splenectomy following motor vehicle crash in 1991

Which of the following group contains pathogens that are most likely responsible for RM’s community-acquired pneumonia?
A. E. coli, Pseudomonas aeruginosa, Streptococcus pneumoniae
B. Community-acquired methicillin-resistant Staphylococcus aureus, Haemophilus influenza, Streptococcus pneumoniae
C. Mycoplasma pneumoniae, Enterococcus faecalis, Streptococcus pyogenes
D. Influeza A, Proteus mirabilis, Serratia marcescens

Back 24

B. Community-acquired methicillin-resistant Staphylococcus aureus, Haemophilus influenza, Streptococcus pneumoniae

H. flu and S. pneumoniae are both encapsulated pathogens that are
common causes of CAP, especially in splenectomized patients. In addition,
since he has such severe pneumonia associated with a post-influenza period,
CA-MRSA must be included as a possible cause.
S. pneumoniae is the most common cause of CAP but E. coli and
P. aeruginosa are rarely implicated
While mycoplasma is responsible for CAP, it is usually a milder form. Enterococcus and group A streptococcus are not common causes of pneumonia.
Influenza A is a potential cause for CAP. Proteus and serratia are
not.

Front 25

Select the most appropriate therapeutic care plan for RM:'
A. Treat as an outpatient with azithromycin (Zithromax)
B. Hosptialize RF. Obtain sputum cultures and begin therapy with IV ciprofloxacin. Once patient clinically stable, administer pneumococcal vaccine. Treat patient for 14 days.
C. Admit patient to hospital. Obtain blood and sputum cultures. Begin high-dose IV ampicillin. Once patient clinically stable transition to oral therapy. Administer influenza and pneumococcal vaccines.
D. Treat as an outpatient with 14-day course of oral levofloxacin (Levaquin) 750 mg.
E. Admit RF to hospital. Obtain blood and sputum cultures and initiate therapy with IV ceftriaxone (Rocephin), IV azithromycin (Zithromax), and IV vancomycin. Once patient clinically stable transition to oral therapy. Administer influenza, pneumococcal, and meningococcal vaccines.

Back 25

E. Admit RF to hospital. Obtain blood and sputum cultures and initiate therapy with IV ceftriaxone (Rocephin), IV azithromycin (Zithromax), and IV vancomycin. Once patient clinically stable transition to oral therapy. Administer influenza, pneumococcal, and meningococcal vaccines.

This patient is severely ill. Even though we do not have enough
information to calculate a PSI, he is diagnosed with severe CAP. He should at least be admitted for observation and a short course of IV antibiotics. Ciprofloxacin does not provide adequate coverage of S. pneumoniae.
In addition, given the severity of the pneumonia, CA-MRSA should be
empirically covered. In addition, since he is asplenic, he should be given
pneumococcal and influenza vaccines to prevent pneumonia as well as
meningococcal vaccine to prevent meningococcal meningitis. High-dose ampicillin does not provide adequate coverage of atypical
organisms. In addition, given the severity of the pneumonia, CA-MRSA should be empirically covered.

Front 26

Risk factors that would qualify a patient as having health-care associated pneumonia
include which of the following? Select best answer.
A. Resident in a nursing home
B. Hospitalized for more than two days within the proceeding 90 days
C. Chronic Hemodialysis
D. Both A and C
E. A, B and C

Back 26

E. A, B and C

Front 27

Which of the following is not a host defense mechanism that serves to protect against urinary tract infections?
A. Vesicoureteral reflux
B. Secretory IgA in the urine
C. Micturition (urination)
D. Mucosal lining of the genitourinary tract
E. Low urinary pH.

Back 27

A. Vesicoureteral reflux
This is not a host defense mechanism. In vesicoureteral reflux,
some urine goes back up into the ureters and possibly up to the kidneys. Reflux exposes the kidneys to infection.

The downward flow of urine serves to
clear the urine of pathogens.
This lining is bactericidal.
Many bacteria cannot effectively grow in the lower pH environment of the human urine.

Front 28

DA is a 46 year-old female hospitalized for hip arthroplasty. During the surgery, a foley catheter is placed to allow for adequate bed rest following the procedure. Three days following her surgery, she develops a low-grade fever and chills. The nurse taking care of the patient notes that her foley catheter bag contains cloudy, foul smelling urine. A specimen is obtained and sent for urinalysis and quantitative culture and she is started empirically on Unasyn® (ampicillin/sulbactam)1.5 gm IV QID.

Which of the following organisms are associated with hospital-acquired urinary tract
infections? Select the best answer.
A. Torulopsis glabrata
B. Bacteroides fragilis
C. Pseudomonas aeruginosa
D. Both A and C
E. A, B and C

Back 28

D. Both A and C

T. glabrata and P. aeruginosa are commonly implicated in
nosocomial UTIs. B. fragilis is an anaerobe that primarily is involved in
intraabdominal infections.

Front 29

DA’s urinalysis is conducted and the following results are available:
Cloudy, amber urine
pH: 6.9
WBC: 29
Nitrite: negative
Bacteria: Many
DA’s culture: 10,000 – 100,000 Pseudomonas aeruginosa

Which of the following is the best therapeutic plan for DA?
A. Continue therapy with Unasyn® (ampicillin/sulbactam) but increase dose to 3 gm IV every 8 hours.
B. Remove foley catheter. Discontinue Unasyn® (ampicillin/sulbactam). Initiate therapy with oxacillin 1 gram IV every 6 hours.
C. Remove foley catheter. Discontinue Unasyn® (ampicillin/sulbactam) and begin treatment with tobramycin at 3 mg/kg IV every 24 hours.
D. Discontinue Unasyn® (ampicillin/sulbactam). Initiate ciprofloxacin 400 mg IV BID. After 5 days of therapy remove the foley catheter and discontinue the ciprofloxacin.
E. Discontinue Unasyn® (ampicillin/sulbactam). No therapy is necessary in this case. The foley catheter should be exchanged and the infection will resolve on its own.

Back 29

C. Remove foley catheter. Discontinue Unasyn® (ampicillin/sulbactam) and begin treatment with tobramycin at 3 mg/kg IV every 24 hours.

Unasyn® does not have significant activity against P. aeruginosa. In addition, the foley catheter must be removed/exchanged. Oxacillin is an anti-staphylococcal penicillin. Not only does it not cover P. aeruginosa, it has no role in the management of urinary tract infections as it is primarily cleared hepatically. The foley catheter should be removed/exchanged as soon as
possible followed by a short course of antipseudomonal antibiotics. While this may be effective at reducing the colony burden, it is unlikely to be successful as this patient had symptoms consistent with a true
infection (fevers, chills) and a positive UA.

Front 30

Which of the following statements regarding vancomycin is TRUE?
A. Vancomycin exhibits concentration-dependent bacterial killing.
B. Vancomycin peak concentrations are the best predictor of efficacy.
C. Vancomycin trough concentrations should be between 15 – 20 mg/L.
D. Vancomycin is not effectively removed by high-flux hemodialysis.
E. None of the above.

Back 30

Vancomycin exhibits concentration-independent killing. Peak
concentrations are not correlated with efficacy whereas trough
concentrations do correlate with efficacy. Trough concentrations should be
between 15 – 20 mg/L (minimum of 10 mg/L). Vancomycin is effectively
removed by high-flux hemodialysis but is not removed by conventional
dialysis (cellulose membranes)

Front 31

Which of the following antibiotics has appreciable coverage against MRSA
(methicillin resistant staph aureus)?
A. Imipenem/Cilastatin (Primaxin)
B. Tigecycline (Tygacil)
C. Cefepime (Maxipime)
D. Azithromycin (Zithromax)

Back 31

B. Tigecycline (Tygacil)

A, C, and D covers MSSA but not MRSA.

Front 32

SB is a 56 year-old male that presents to the emergency room with complaints of subjective fevers with chills, dysuria, and urinary urgency. He states that the symptoms began approximately 4 days ago and have progressively worsened to the point that today he is feeling nauseous and has developed new onset right flank pain.
PMH: Hypertension, hyperlipidemia, BPH
Allergies: Sulfadiazine causes urticaria

Which of the following is the most appropriate therapeutic plan for SB?

A. Order a urinalysis and urine culture. Initiate empiric therapy with moxifloxacin (Avelox) 400 mg IV QD. Treat for at least 14 days.
B. Initiate immediate empiric therapy with levofloxacin (Levaquin) 500 mg PO BID.
B. Obtain urine cultures after 3 days to assess bacterial eradication. If negative, treat for 48 more hours and then discontinue.
C. Order a urinalysis and urine culture. Initiate therapy with nitrofurantoin 100 mg PO QID. Treat for 14 days.
D. After prostate exam performed, initiate patient on trimethoprim/sulfamethoxazole (Bactrim) 1 DS tablet PO BID. Treat for 28 days.
E. Start the patient empirically on ceftriaxone (Rocephin) 1 gm IV QD. Treat for 7-14 days.

Back 32

E. Start the patient empirically on ceftriaxone (Rocephin) 1 gm IV QD. Treat for 7-14 days.

Moxifloxacin is not recommended for treatment of UTI’s as it is
primarily hepatically metabolized.
Urine is rapidly cleared after antibiotics are initiated. This patient has suspected pyelonephritis – treat for at least 7-14 days. Also the dose for
levofloxacin is 250 – 500 mg once daily.
This patient has symptoms consistent with pyelonephritis. Nitrofurantoin is contraindicated in pyelonephritis and therefore, not an option. It is reserved for cystitis.
This patient has reported uritcaria with sulfadiazine. He should not
receive medications that contain sulfa. In addition, he does not necessarily
have prostatitis, even if he did, prostate exam is contraindicated if prostatitis is
suspected. Obstruction due to his BPH likely did contribute to his UTI however
would not need to extend treatment to 28 days unless prostatitis.

Front 33

LS is a 37 year-old female with a history of more than 3 episodes of uncomplicated cystitis per year. She presents to her primary care physician with recurrent UTI. She is prescribed an appropriate course of ciprofloxacin (Cipro) and her physician wants to start her on prophylactic antibiotics once this course is complete. Which of the following is an appropriate prophylactic regimen for LK?
A. Trimethoprim-Sulfamethoxazole (Septra) 1 SS tablet PO QD.
B. Cephalexin (Keflex) 250 mg PO QD.
C. Nitrofurantoin (Macrodantin) 100 mg PO QD.
D. A&C
E. All of the above

Back 33

E. All of the above
Any of the above may suffice. Factors that may sway the decision is tolerability, known infecting pathogen(s), and resistance.

Front 34

CH is a 58 year-old male admitted to the intensive care unit 9 days ago for medical management following a subarachnoid hemorrhage. The patient has been intubated on a ventilator since admission for airway protection. This morning the patient has new onset of fever at 40.2, increased production of purulent sputum, and WBC of 17.1, up from 8.4 yesterday. Chest X-ray reveals a new infiltrate in the right middle lobe. The medicine team orders appropriate cultures and decides to start the patient on therapy for presumed late onset ventilator-associated pneumonia.
Weight = 83 kg; Ht = 69 inches. SCr = 0.8 mg/dL; No known allergies

Which of the following represents an appropriate empiric antibiotic regimen?
A. Piperacillin/Tazobactam (Zosyn) 4.5 gm IV q6h, Amikacin 1.6 gm IV q24h, and Vancomycin 1.25 gm IV q12h.
B. Initiate therapy with Cefepime (Maxipime) 2 gm IV q12h, Levofloxacin (Levaquin) 500 mg IV q24h, and Daptomycin (Cubicin) 500 mg IV q24h.
C. Begin Ciprofloxacin (Cipro) to 400 mg IV q12h, Gentamicin 580 mg IV q24h,and Linezolid 600 mg IV BID.
D. Initiate therapy with vancomycin at 1 gm IV q12h, ertapenem (Invanz) 1 gm IV q24h, and tobramycin 580 mg IV q24h
E. Meropenem (Merrem) 1 gm IV q8h, Linezolid 600 mg IV q12h, and Azithromycin (Zithromax) 500 mg IV q24h

Back 34

A. Piperacillin/Tazobactam (Zosyn) 4.5 gm IV q6h, Amikacin 1.6 gm IV q24h, and Vancomycin 1.25 gm IV q12h.

Amikacin dose is 20 mg/kg of TBW (83 kg) as patient’s TBW is not > 20% IBW.
Daptomycin, while possessing excellent MRSA activity, has no role
in the management of pneumonia as it is inactivated by pulmonary surfactant.
Also the dose of levofloxacin is too low. The recommended dose is 750 mg.
Ciprofloxacin should not be used at this dose for the treatment of VAP and a cell wall active agent should be used. An aminoglycoside plus a fluoroquinolone is not recommended for empiric treatment of VAP.
Ertapenem should not be used in the empiric management of late
onset VAP due to its lack of pseudomonal activity. Also vancomycin is slightly underdosed at 12 mg/kg.
Empiric atypical coverage with macrolides is not recommended in the management of late onset VAP.

Front 35

JB is a 19 year old college football player with an allergy to sulfa medications (caused hives as a child). He presents to his team physician with recurrent boils on his left thigh
and groin area. He states that they initial improved with the application of warm compresses but they are now worsening. The physician observers multiple boils (some with visible pus) and notices that the upper part of his left thigh is warm and erythematous and is concerned about cellulitis.

Which is the most likely pathogen causing this infection [(assume that the cellulitis is
an extension of the originating infection (i.e. furunculosis)]?
A. Group A Streptococcus
B. Staphylococcus aureus
C. Pseudomonas aeruginosa
D. Staphylococcus epidermidis

Back 35

B. Staphylococcus aureus

Cellulitis is most commonly caused by Staphylococcus aureus or
Group A Streptococcus. Since patient has furuncles that have led to the cellulitis, pathogen is most likely Staphylococcus aureus.

Front 36

What treatment would be most appropriate for this patient?
A. Trimethoprim/suflamethoxazole DS 1-2 tabs po bid
B. Clindamycin 300 mg po bid
C. Minocycline 100 mg po bid
D. Vancomycin 150 mg po qid

Back 36

C. Minocycline 100 mg po bid

A-incorrect since patient has history of significant sulfa allergy, B-not
first line due to potential for resistance, D-oral vancomycin not absorbed and should not be used for systemic infections.

Front 37

What duration of therapy would be most appropriate (all assuming patient clinically improving on regimen)?
A. 3 days
B. 5 days
C. 7 days
D. 14 days

Back 37

C. 7 days

Recommended duration of therapy for cellulitis is 7-10 days.

Front 38

KJ is a 35 year old female who is at a new primary care provider’s office to establish care after recently moving to a new town. During a review of her history, she states that she has hepatitis B but says that she was told that she is “just a carrier”. Which of the
following scenarios in a patient with consistently normal liver enzymes, would be most consistent with a person who is considered an asymptomatic carrier of hepatitis B?
A. HBsAg (+), HBeAg (-), Anti-HBs (-), Anti-HBc (-), HBV DNA viral laod (+)
B. Anti-HBs (+), Anti-HBc (+), HBsAg (-), HBeAg (-)
C. HBsAg (-), HBeAg (-), Anti-HBs (+), Anti-HBc (-)
D. HBsAg (+), HBeAg (-), Anti-HBs (-), Anti-HBc (-), HBV DNA viral load (-)

Back 38

D. HBsAg (+), HBeAg (-), Anti-HBs (-), Anti-HBc (-), HBV DNA viral load (-)

A-Most consistent with HBeAg (-) chronic active hepatitis B; B-Most consistent with past infection with recovery/immunity; C-Most consistent with prior vaccination; D-Most consistent with asymptomatic carrier state

Front 39

Which of the following medications was once considered an option to use as monotherapy in the treatment of hepatitis B in patients co-infected with HIV due to lack of HIV activity but has since been found to have anti-HIV activity and is no longer recommended as monotherapy in this setting?
A. Emtricitabine (Emtriva®)
B. Entecavir (Baraclude®)
C. Lamivudine (Epivir®)
D. Pegylated interferon (Pegasys®)

Back 39

B. Entecavir (Baraclude®)

Emtricitabine and Lamivudine were first approved for HIV, pegylated interferon can be used as monotherapy in HIV-co infected patients since it does not have specific anti-HIV activity and would not lead to cross-resistance to any antiretrovirals. Entecavir monotherapy can lead to M184V HIV mutation which causes cross-resistance to emtricitabine and lamivudine

Front 40

HM is a 36-year-old male complaining of a headache, facial pain, and continuous
nasal discharge. He states he caught a cold about 2-3 weeks prior to today’s visit and has
had symptoms ever since. Patient with a penicillin allergy.
What antibiotic is the most appropriate recommendation for initial therapy?
A. Cefpodoxime (Vantin®)
B. Amoxicillin (Amoxil®)
C. Trimethoprim/sulfamethoxazole (Septra®)
D. Amoxicillin/clavulanate (Augmentin®)

Back 40

C. Trimethoprim/sulfamethoxazole (Septra®)

Front 41

SR is a 35-year-old female who complains of a sore throat, cough, and diarrhea for
the past 2 days. Patient reports no known drug allergies. (-) RADT.
What antibiotic is the most appropriate recommendation for initial therapy?
A. Erythromycin (E-mycin®)
B. Clindamycin (Cleocin®)
C. Amoxicillin/clavulanate (Augmentin®)
D. Azithromycin (Zithromax®) 500 mg PO x 1, then 250 mg PO daily x 4 days
E. Antibiotic therapy is not warranted in this patient.

Back 41

E. Antibiotic therapy is not warranted in this patient.

Front 42

AJ is a 25 year old male who went Joes Crab Shack to participate in the all you can
eat seafood contest. AJ brought home the first place prize after indulging in shrimp,
prawn, lobster, crayfish, crab, clam, mussels, oyster, and scallops. Two days later AJ
presents to the clinic with symptoms of diarrhea, dehydration and nausea and vomiting.
What organism is most likely causing AJ’s diarrhea?
A) Rotavirus
B) Cholera
C) Campylobacter
D) Shigellosis

Back 42

B) Cholera

Cholera causative agent is ingestion of shellfish.

Front 43

AW is a 70 year old white male who presents with generalized abdominal pain nausea and vomiting. An emergency operation was performed for localized peritonitis attributed to acute perforated appendicitis. Antibiotic therapy is needed to cover
Bacteroides fragilis and streptococcus.

What antibiotic therapy would be most appropriate for AW?
A) Ertapanem (Invanz)
B) Ciprofloxacin (Cipro) plus metronidazole (Flagyl)
C) Ciprofloxacin (Cipro)
D) Cefepime (Maxipime)

Back 43

B) Ciprofloxacin (Cipro) plus metronidazole (Flagyl)

Ciprofloxacin plus metronidazole is recommended because anaerobe
coverage is needed.

Front 44

What is the drug of choice for treatment of Neisseria meningitidis?
A. Ampicillin/sulbactam (Unasyn®)
B. Ceftriaxone
C. Imipenem/cilastatin (Primaxin®)
D. Rifampin (Rifadin®)

Back 44

B. Ceftriaxone

Neisseria meningitidis has remained susceptible to penicillin so more broad spectrum agents such as Ampicillin/sulbactam and Imipenem are not necessary. Rifampin is used for chemoprophylaxis for contacts of a case of meningococcal meningitis.

Front 45

JP is a 65 year old diabetic female with a 20 year history of Type 2 diabetes mellitus.
She has a history of hypertension and chronic renal insufficiency (estimated
Creatinine clearance = 25 mL/min).
You would expect to need a reduced dose of which of the following antibiotics in this
patient?
A. Ceftriaxone (Rocephin®)
B. Azithromycin (Zithromax®)
C. Amoxicillin/clavulanate (Augmentin®)
D. Doxycycline (Vibramycin®)

Back 45

C. Amoxicillin/clavulanate (Augmentin®)

None of the other antibiotics listed require dosage reductions for renal dysfunction.

Front 46

Which of the following statements regarding antimicrobial susceptibility testing is true?
A. The antibiotic with the lowest MIC by the E-test method is the most active antibiotic versus the pathogen being tested
B. An antibiotic with a zone size of 8 mm is more active than an antibiotic with a zone size of 2 mm by the Kirby-Bauer disk diffusion method (both antibiotics have the same breakpoints)
C. A major disadvantage of the macrodilution technique is that there is less flexibility in the antibiotics tested
D. Macrodilution technique is less labor intensive and provides quicker results in comparison to the microdilution technique

Back 46

B. An antibiotic with a zone size of 8 mm is more active than an antibiotic with a zone size of 2 mm by the Kirby-Bauer disk diffusion method (both antibiotics have the same breakpoints)

Answer A-depends on breakpoints for susceptibility for the bug and drug combos being tested ( established by Clinical Laboratory Standards Institute); Answer C- This is a disadvantage of microdilution technique; Answer D-
Macrodilution technique is more labor intensive and takes longer.

Front 47

ST is a 58 year old female patient who is in the surgical intensive care unit following neurosurgery for repair of an arteriovenous malformation. One week post-op, her CSF fluid shows the following: 200 WBCs, many PMNs, elevated protein and decreased glucose.

What are the most likely pathogens causing meningitis in this patient?
A. Group B Streptococcus, Listeria monocytogenes, Pseudomonas aeruginosa
B. Neisseria meningitides, Streptococcus pneumoniae, Escherichia coli
C. Enterococcus faecalis, Streptococcus pyogenes, Staphylococcus aureus
D. Staphylococcus aureus, Pseudomonas aeruginosa, Staphylococcus epidermidis

Back 47

D. Staphylococcus aureus, Pseudomonas aeruginosa, Staphylococcus epidermidis

Patient has a hospital-acquired meningitis following a neurosurgical
procedure. The most likely pathogens are best described in answer D.

Front 48

What would be the most appropriate recommendation as empiric therapy for this patient (patient has normal renal function)?
A. Ampicillin 2g iv q12h + gentamicin (Garamycin®) (dosed by weight/renal function)
B. Ceftriaxone (Rocephin®) 2g iv q24h + vancomycin (Vancocin®) (dosed by weight/renal function)
C. Ceftazidime (Fortaz®) 2g iv q24h + gentamicin (dosed by weight/desired peak)
D. Cefepime (Maxipime®) 2g iv q8h + vancomycin (Vancocin®) (dosed by weight/renal function)

Back 48

D. Cefepime (Maxipime®) 2g iv q8h + vancomycin (Vancocin®) (dosed by weight/renal function)

Coverage should include Pseudomonas aeruginosa, Staphylococcus epidermidis and Staphylococcus aureus. Answer D is the only option that appropriately covers these pathogens.

Front 49

JP is a 20 year old nursing student at UF who presents to the infirmary with complaints of nasal congestion, runny nose, sneezing, and fatigue for the past 5 days. She states that she has been using an over the counter cough and cold product (Drixoral®) without relief. She complains of a severe headache which started yesterday and left-sided facial pain and tenderness. Her temperature is 103°F. She has not received antibiotics in the past month and has no known drug allergies.

What is the most appropriate recommendation?
A. Withhold antibiotics unless symptoms persist for longer than 7-10 days and treat patient symptomatically (e.g. topical or oral decongestants, steam inhalation)
B. Treat patient with moxifloxacin (Avelox®) 400 mg po bid
C. Treat patient with amoxicillin/clavulanate (Augmentin XR) 2000 mg po qd
D. Treat patient with amoxicillin (Amoxil®) 875 mg po bid

Back 49

D. Treat patient with amoxicillin (Amoxil®) 875 mg po bid

Patient has severe symptoms (facial pain, fever) so should not wait until 7 days to treat. Recommended options for patient who has not received antibiotics in the prior month and who does not have a penicillin allergy are
amoxicillin UD or HD, amoxicillin/clavulanate, cefdinir,
cefpodoxime, cefuroxime. Option D is the best option. Additionally, moxifloxacin and amoxicillin/clavulanate are dosed incorrectly.

Front 50

BJ is a 48 year-old male with chronic active hepatitis B infection who is being treated with pegylated interferon (Pegasys). Which of the following is NOT a potential adverse effect of interferon for which he should be monitored??
A. Hyperkalemia
B. Thyroid dysfunction
C. Leukopenia
D. Flu-like symptoms

Back 50

A. Hyperkalemia

B, C, D are all potential adverse effects of interferon products including pegylated interferon. These agents are not known to cause hyperkalemia.

Front 51

Which of the following hepatitis B medications is similar to an HIV medication and has the potential to cause nephrotoxicity?
A. Adefovir (Hepsera®)
B. Entecavir (Baraclude®)
C. Telbivudine (Tyzeka®)
D. Lamivudine (Epivir HB®)

Back 51

A. Adefovir (Hepsera®)

Adefovir is similar to the HIV medication tenofovir and both of these
medications can cause nephrotoxicity. Lamivudine is the same as a medication used for HIV but it is not known to cause nephrotoxicty.

Front 52

MS is a 45 year old obese female with Type 2 diabetes mellitus. She presents to her physician’s office with left foot swelling and a large ulcer on the ball of her left foot. She is febrile with a vand the physician considers the infection to be limb-threatening. She has no known drug allergies and has normal renal function.

What is the most appropriate recommendation?
A. Cefotetan (Cefotan®) 1 g iv q12h
B. Ceftriaxone (Rocephin®) 1g iv q24h + metronidazole (Flagyl®) 500 mg iv q12h
C. Cefepime (Maxipime®) 1g iv q24h + metronidazole (Flagyl®) 500 mg iv qd +
vancomycin (Vancocin®) (dosed by weight and renal function)
D. Meropenem (Merrem®) 500 mg iv q8h + vancomycin (Vancocin®) 1g iv q12h

Back 52

D. Meropenem (Merrem®) 500 mg iv q8h + vancomycin (Vancocin®) 1g iv q12h

Since wound is severe, recurrent, and limb-threatening, should include coverage against Pseudomonas aeruginosa as well as methicillin resistant Staphylococcus aureus (MRSA). Option C would provide coverage versus these
pathogens but the cefepime and metronidazole are both underdosed.

Front 53

J is a 24 year old pharmacy student who went out to the bars with his classmates after taking their Pharmacotherapy III exam. As per their usual routine, they stopped by Taco Bell on their way home. He ordered a Mexican Pizza with extra green onions while his friends ordered soft tacos. They heard in the news that there were some recent cases of a severe infectious diarrhea that were linked to Taco Bell but they like to think outside the bun and decided to take the risk. Some of these cases in the news reportedly lead to hemolytic uremic syndrome. Two days later, AJ developed severe abdominal cramping, nausea, vomiting, and had 10 bloody looses stools in a single day.

What is the most likely pathogen causing infectious diarrhea in this patient and the other Taco Bell patrons?
A. Escherichia coli (0157:H7 strain)
B. Salmonella sp.
C. Clostridium difficile
D. Rotavirus sp.

Back 53

A. Escherichia coli (0157:H7 strain)

The signs and symptoms listed (particularly the link to cases of
hemolytic uremic syndrome) are consistent with infectious diarrhea due to Escherichia coli (0157:H7).

Front 54

What is the most appropriate recommendation for AJ?
A. This type of infectious diarrhea is usually self-limited and he can take
loperamide (Imodium®) to decrease the stool frequency
B. Metronidazole (Flagyl®) 500 mg po tid, avoid antimotility agents
C. Ciprofloxacin (Cipro®) 500 mg po bid x 7 days plus loperamide (Imodium®) to decrease stool frequency
D. He should report to his physician’s office or the emergency department immediately for evaluation and supportive care (rehydration therapy)

Back 54

D. He should report to his physician’s office or the emergency department immediately for evaluation and supportive care (rehydration therapy)

Since patient has bloody diarrhea, antimotility agents are contraindicated which rules out answers A and C. Metronidazole does not have
appreciable activity versus E. coli and anti-infectives are generally avoided due to the potential to increase risk of hemolytic uremic syndrome.

Front 55

BB is a 61 year-old female admitted to the intensive care unit 9 days ago for medical management following a subarachnoid hemorrhage. The patient has been intubated on a ventilator since admission for airway protection. This morning the patient has new onset
of fever at 40.1°C (104.1°F), increased production of purulent sputum, and WBC of 17.1, up from 8.4 yesterday. Chest X-ray reveals a new infiltrate in the right middle lobe. The
medicine team orders appropriate cultures and decides to start the patient on therapy for presumed ventilator-associated pneumonia.
BB weighs 66 kg; SCr = 0.8 mg/dL; No known allergies

Which of the following represents the most appropriate empiric antibiotic regimen?
A. Begin Piperacillin/Tazobactam (Zosyn®) 4.5 grams IV q6h, Azithromycin (Zithromax®) 500 mg IV q24h, and Linezolid (Zyvox®) 600 mg IV BID
B. Initiate therapy with Cefepime (Maxipime®) 2 gm IV q12h, Tobramycin 460 mg IV q24h, and Vancomycin 20 mg/kg IV q12h
C. Begin ciprofloxacin (Cipro®) to 500 mg IV q12h, Gentamicin 460 mg IV q24h, and Linezolid (Zyvox®) 600 mg IV BID
D. Initiate therapy with vancomycin at 1 gm IV q12h, ertapenem (Invanz®) 1 gm IV q24h, and ciprofloxacin (Cipro®) 400 mg IV q8h
E. Begin imipenem/cilastatin (Primaxin®) 500 mg IV q8h, Gentamicin 460 mg IV q24h, and Amikacin 1.3 grams IV q24h

Back 55

B. Initiate therapy with Cefepime (Maxipime®) 2 gm IV q12h, Tobramycin 460 mg IV q24h, and Vancomycin 20 mg/kg IV q12h

Azithromycin has no role in the management of suspected ventilator associated pneumonia. An additional antipseudomonal agent (i.e. FQ or AG) should be added.
Ciprofloxacin should not be used at this dose for the treatment of VAP and a cell wall active agent should be used. An aminoglycoside plus a fluoroquinolone is not recommended for empiric
treatment of VAP
Ertapenem should not be used in the empiric management of late
onset VAP due to its lack of pseudomonal activity.
This regimen contains two aminoglycosides and no anti-MRSA agent

Front 56

EM is a 56 year-old male that presents to the emergency room with complaints of subjective fevers with chills, dysuria, and urinary urgency. He states that the symptoms began approximately 4 days ago and have progressively worsened to the point that today he is feeling nauseous and has developed new onset right flank pain.
PMH: Hypertension, hyperlipidemia, BPH
Allergies: Sulfadiazine causes urticaria

Which of the following is the most appropriate therapeutic plan for EM?
A. Start the patient empirically on levofloxacin (Levaquin®) 250 mg PO BID. Treat for 5 days.
B. Order a urinalysis and urine culture. Initiate empiric therapy with cefuroxime (Ceftin®) 750 mg IV every 8 hours. Treat for at least 14 days.
C. Initiate immediate empiric therapy with ciprofloxacin (Cipro®) 500 mg PO BID. Obtain urine cultures after 3 days to assess bacterial eradication. If negative, treat for 48 more hours and then discontinue.
D. Order a urinalysis and urine culture. Initiate therapy with nitrofurantoin (Macrobid®) 100 mg PO BID. Treat for 14 days.
E. After prostate exam performed, initiate patient on Trimethoprim- Sulfamethoxazole (Septra®) 1 DS tablet PO BID. Treat for 28 days.

Back 56

B. Order a urinalysis and urine culture. Initiate empiric therapy with cefuroxime (Ceftin®) 750 mg IV every 8 hours. Treat for at least 14 days.

This patient has symptoms consistent with pyelonephritis. His symptoms a severe enough to warrant higher doses of antibiotics, preferably initially intravenous given his symptoms, for at least 7-14 days. In addition, levofloxacin should not be dosed 250 mg twice daily.
Urine is rapidly cleared after antibiotics are initiated. This patient has suspected pyelonephritis – treat for at least 7-14 days.
This patient has symptoms consistent with pyelonephritis. Nitrofurantoin is contraindicated in pyelonephritis and therefore, not an option. It is reserved for cystitis.
This patient has reported urticaria with sulfadiazine. He should not receive medications that contain sulfa. In addition, he does not necessarily have prostatitis, even if he did, prostate exam is contraindicated if prostatitis is suspected. Obstruction due to his BPH likely did contribute to his UTI however would not need to extend treatment to 28 days unless prostatitis.

Front 57

RG is a 35 year old female admitted to the hospital and diagnosed with acute pyelonephritis.
Her symptoms include nausea, vomiting, fever, and dysuria. She has no history of urologic
structural or functional problems. Which empiric therapy is the most appropriate?
a. Piperacillin/tazobactam
b. Amoxicillin/clavulanate
c. Ceftriaxone
d. Vancomycin
e. Nitrofurantoin

Back 57

c. Ceftriaxone

A is wrong because Pseudomonas coverage is not needed
B is wrong because it is only available PO and patient should receive IV
D is wrong only covers gram positive and E coli is the most common organism
E does not have adequate concentrations for kidney infections

Front 58

After 48 hours of the above antibiotic RG is asymptomatic, afebrile and tolerating an oral diet.
The culture returns positive for > 100,000 E coli with the following susceptibility:
Ampicillin R
Ampicillin/sulbactam R
Ceftriaxone S
Levofloxacin S
Gentamicin S
Nitrofurantoin S
Trimethoprim/Sulfamethoxazole R
On which antibiotic would you send the patient home?
a. Ceftriaxone
b. Ciprofloxacin
c. Nitrofurantoin
d. Trimethoprim/sulfamethoxazole
e. Gentamicin

Back 58

b. Ciprofloxacin

A is wrong because it would have to be given IV
C is wrong because nitrofurantoin should not be used for acute pyelo
D is wrong because TMP/SMX is resistant
E is wrong because it would have to be given IV and monitored

Front 59

What is the minimum duration of treatment recommended for RG?
a. 1 day
b. 3 days
c. 7 days
d. 14 days
e. 4 weeks

Back 59

c. 7 days

A is wrong as this is only studied in cystitis
B is wrong as this is only studied in cystitis
D is wrong because FQ can be used for shorter durations 14 days is for beta-lactams
E is the duration for prostatitis

Front 60

PB is a 24 year old female diagnosed with acute uncomplicated cystitis by her primary care physician. Which of the following statements are FALSE in regards to the treatment of uncomplicated cystitis?
a. For fluoroquinolones and trimethoprim/sulfamethoxazole 7 day treatment is significantly better than 3 day treatment
b. The duration of treatment of cystitis with beta-lactams should last 7 days
c. The urinary concentrations of fluoroquinolones and trimethoprim/sulfaethoxazole are significantly higher than serum concentrations
d. The choice of fluoroquinolone or trimethoprim/sulfamethoxazole for the empiric treatment
of cystitis depends on local susceptibilities of E coli.

Back 60

a. For fluoroquinolones and trimethoprim/sulfamethoxazole 7 day treatment is significantly better than 3 day treatment
B is wrong because the recommendation for treatment is 7 days if a beta lactam is used
C is wrong because FQ and TMP/SMX concentrate in the urine
D is wrong because in some areas E coli are more likely susceptible to FQ or to TMP/SMX

Front 61

AB is a 68 y/o male who presents to the ER c/o loose bowel movements, 5 per day X 4 days.
PMH:
HTN
DM-2
Recurrent sinusitis – most recent 1 week ago treated with Augmentin
Dyslipidemia
Vitals in the ER:
BP 130/85
P 80
R 20
T 100.6
Pain 0/10
02 Sat 98% on RA
Ht: 5’7’’
Wt: 80kg
Pertinent Labs in the ER:
WBC = 20 K
N = 89%
SCr = 1.1
BUN = 12
All other WNL

What is the most appropriate initial therapy for AB for possible Clostridium difficile colitis.
a. Vancomycin 1000mg IVPB Q12H
b. Metronidazole 250mg PO QID
c. Vancomycin 125mg PO QID
d. Clindamycin 600mg PO Q8H

Back 61

b. Metronidazole 250mg PO QID

A- Incorrect as IV Vancomycin dose not have adequate penetration into the GI tract to be used for
C.diff infections
B- Correct: 1st line agent is C.diff infections
C- Incorrect: Vancomycin PO is reserved for patient’s who failed or can not tolerate Flagyl
D- Incorrect: Clindamycin has no coverage against C.diff and is commonly the cause of the
infection.

Front 62

TR is a 40 year old male initiated on vancomycin for a Staphylococcus infection in his leg. He is ready for discharge and the following culture and sensitivity (C&S) is available.
Tissue Culture Gram-positive cocci
Staphylococcus aureus
Oxacillin S
Cefazolin S
Cephalexin S
Clindamycin R
Erythromycin S
Linezolid S
Vancomycin S
TMP/SMX R

What is the most appropriate medication for the oral treatment at home?
a. Vancomycin PO
b. Clindamycin because even though resistant erythromycin is sensitive so the organism is
considered susceptible to clindamycin.
c. Linezolid PO
d. Cephalexin PO

Back 62

d. Cephalexin PO

A is wrong because vanco is not absorbed orally and cannot be used for a systemic infection
B is wrong because if clinda is resistant then it doesn’t matter if erythromycin is S or R
C is wrong because of cost and the choice can be more streamlined.

Front 63

SB is a 65 year female with a Pseudomonal infection and decreased renal function. The patient is receiving ciprofloxacin and cefepime. The doses need to be adjusted for decreased renal
function. Which of the following is correct?
a. A. Decrease ciprofloxacin dose because it is considered to have time-dependent killing and keep the frequency the same.
b. Lengthen the frequency of ciprofloxacin and keep the mg dose the same because
ciprofloxacin demonstrates concentration-dependent killing.
c. Decrease cefepime dose and maintain frequency because cefepime demonstrates
concentration-dependent killing.
d. Lengthen the frequency of cefepime and maintain the dose because cefepime demonstrates
time-dependent killing
e. Both B and D are correct

Back 63

b. Lengthen the frequency of ciprofloxacin and keep the mg dose the same because
ciprofloxacin demonstrates concentration-dependent killing.

A is wrong because cipro demonstrates concentration-dependent killing
C is wrong because cefepime is time-dependent killing
D is wrong because the frequency should remain the same and the dose decreased if a drug has timedependent
killing like cefepime.

Front 64

MB is a 45 year old male with an intra-abdominal infection post surgery. Preliminary cultures show an Enterobacter sp and Pseudomonas sp. Based on culture results inducible Amp C betalactamases
are suspected in the Enterobacter. Which of the following antibiotics is the most appropriate choice?
a. Meropenem
b. Ertapenem
c. Ceftazidime
d. Ampicillin-sulbactam

Back 64

a. Meropenem

B is wrong because it does not cover Pseudomonas
C is wrong because even if the C&S indicated Ceftazidime as S it should not be used due to its ability to induce beta-lactamases
D is wrong because it does not cover Pseudomonas

Front 65

DK is a 70 yo, 187 lb, 5’10” WM who is a patient admitted to your medical ward over the
weekend. The medicine team covering the patient is concerned about an ulcer on the medial aspect of his left heel with (+) tract to bone.
PMH is significant for hypertension, DM type 2, CVA, hyperlipidemia, PVD, pressure ulcers, hypothyroidism, GERD, and a recent UTI treated with ciprofloxacin.

Current Medications:
APAP 975 mg q6h
bisacodyl 10 mg twice daily
isosorbide mononitrate 60 mg daily
levothyroxine 0.025 mg daily
metoprolol 12.5 mg q 12 hours
omeprazole 20 mg daily
Percocet 1-2 tabs q 4 hours prn
simvastatin 20 mg daily metformin 1 g twice daily
Na 140 mEq/L Hgb 12.1 g/dL WBC 12.2 x 103/mm3
K 4.3 mEq/L Hct 34% Neutrophils 67%
Cl 102 mEq/L Plt 220 x 103/mm3 Bands 5%
CO2 22 mEq/L ESR 87 mm/hr Lymphs 16%
BUN 31 mg/dL Glu 101 mg/dL Monos 12%
SCr 1.2 mg/dL
Radiological findings:
3-phase bone scan: “Delayed bone scan images demonstrate a linear focus of increased response in the posterior inferior left calcaneal cortex.”
What is the initially recommended duration of treatment for this type of infection?
a. 7-10 days
b. 2-3 weeks
c. 4-6 weeks
d. 3 to 6 months

Back 65

c. 4-6 weeks
Osteomyelitis typically requires at least 4-6 weeks of therapy,
particularly in patients who have poor vascular supply (DM, PVD). Answer B is the usual treatment duration for DFIs not involving osteomyelitis. Answer D represents a length of therapy used infrequently and only in patients who respond poorly or very slowly to initial
antibiotic therapy (i.e. poor/slow response at 4-6 weeks of therapy).

Front 66

Given the above information, and based on what you know about the most likely
causative organisms, which of the following is the most appropriate plan of action?
a. Oxacillin 12 g/day by continuous infusion
b. Vancomycin 1 g IV twice daily, dose adjusted based on steady-state trough levels
c. Daptomycin 4 mg/kg IV administered over 30 minutes once every 24 hours
d. Ciprofloxacin 750 mg PO twice daily
e. Ceftazidime 2 g IV q 8 hours

Back 66

b. Vancomycin 1 g IV twice daily, dose adjusted based on steady-state trough levels

Vancomycin is 1st line therapy for osteomyelitis infections given that S. aureus is the
most common causative organism (both overall and in contiguous infections). It should be
assumed that S. aureus strains are methicillin-resistant until proven otherwise.
Oxacillin is the drug-of-choice for infections caused by methicillin-sensitive S.
aureus. However, anti-MRSA choices are better initial agents until MSSA has been
documented.
Daptomycin is a reasonable alternative, but is considered 2nd line therapy after
vancomycin.
Ciprofloxacin can be used in osteomyelitis when there is a strong concern for P.
aeruginosa infections. Additionally, given that this patient will be treated on an inpatientbasis
as well as his poor vascular supply (DM + PVD), it would be reasonable to initiate IV
therapy, at least initially.
Ceftazidime can also be used in osteomyelitis cases, but again only when there is a
strong indication for P. aeruginosa infection.

Front 67

SK is a 27 yo female presenting to her local ED with complaints of left lower-extremity pain, swelling, tenderness, and warmth. Ultrasound is (-) for DVT. She is diagnosed with mild-tomoderate uncomplicated cellulitis. Her vital signs are normal and labs are WNL. Cultures are
taken and the gram stain shows gram (+) cocci in clusters, suggesting S. aureus as the causative
agent. You also recently perused your local antibiogram which shows relatively high levels of
resistance to penicillin, erythromycin and oxacillin. D-test was positive. The patient reports a sulfonamide allergy from childhood.
Which of the following is the most appropriate empiric oral antimicrobial agent for
treating this infection?
a. Dicloxacillin
b. Trimethoprim-sulfamethoxazole
c. Clindamycin
d. Linezolid

Back 67

d. Linezolid
Linezolid is the only option with good MRSA coverage and no obvious
contraindication in the above patient.

Dicloxacillin has excellent coverage of MSSA but does not cover MRSA. Given the
high local levels of MRSA, it would be inappropriate to not empirically cover for this
pathogen.
Trimethoprim-sulfamethoxazole has MRSA coverage, but should be avoided in a patient with sulfonamide allergies.
High levels of erythromycin suggest the need for a D-test prior to using empiric
clindamycin. A positive D-test is indicative of inducible resistance to clindamycin and it is
unlikely clindamycin will maintain susceptibility and should therefore be avoided as empiric therapy.

Front 68

Which of the following is considered “1st-line” therapy in a 28-month old child
diagnosed with AOM (via tympanocentesis) who is also exhibiting a low-grade fever of
38.2°C and mild-to-moderate otalgia? The child has NKDA.
a. Observation period, 48-72 hours
b. Amoxicillin (HD), 80-90 mg/kg/day
c. Amoxicillin-clavulanic acid (HD), 90 mg/kg/day of amoxicillin component
d. Ceftriaxone IM 1 g every 24 hours

Back 68

a. Observation period, 48-72 hours

Any child > 2 years should be observed initially for 48-72 hours unless there are
signs/symptoms of severe infection (T > 39°C and/or severe otalgia), even when certain of diagnosis as in this case.
Amoxicillin would be an appropriate 1st-line therapy if this child were 6 mo – 2
years old and diagnosis was certain (i.e. via tympanocentesis) or in any child < 6 months old
regardless of certainty of diagnosis.
Amox-clav would be appropriate only if the child is having signs/symptoms of
severe infection or if the child has failed 48-72 hours of treatment with amoxicillin.
Ceftriaxone is reserved for children with severe infections who have previously
failed Amoxicillin-clavulanate or as alternative therapy in non-type I penicillin allergies.

Front 69

T.R. is a 35 yo wm presenting to PCP with persistent fever and cough. He was well until 3 days earlier when he developed nasal stuffiness, mild sore throat, and a cough productive of small amounts of clear sputum. He presents to the office today because of a temperature of 38.3°C
at home last night and spasms of coughing that produce purulent secretions. He has also noted
a few flecks of bright-red blood in his sputum on one occasion.
PMH: No history of familial illness, hospitalizations or trauma.
SH: Lives at home with wife and 4 children (ages 3-11); the children are all fully immunized,
but the 11-yo child is recovering from a “nagging” cough that persisted 10-14 days; (+)
tobacco [1ppd x 20 years]; social EtOH; denies illicits.
All: NKDA
Current Medications: Acetaminophen 500 mg prn headaches (“a few times per month”)
PE: VS: BP 119/78; P 110 beats/min; T 38.9°C; RR 18; O2 sat (room air) 93%
HEENT: PERRLA; EOMI; mild erythema of the mucosa of the nose and posterior
Oropharynx
Lungs: Inspiratory rales heard at the right lung base.
Labs: BMP – wnl
CBC: WBC 12.2 x 103/mm3; Neutrophils 82%; Bands 11%; Lymphs 7%
Radiological Exam:
Chest X-ray documents bilateral lower lobe infiltrates that are more pronounced on the right side; no pleural effusions noted.

Using the Pneumonia Severity Index (see attached) or CURB-65 to assess severity of this
community-acquired pneumonia infection, in which setting would this patient be most
appropriately treated?
a. Outpatient
b. Brief inpatient followed by outpatient
c. Inpatient (medical ward)
d. Inpatient (ICU)

Back 69

a. Outpatient

This is an uncomplicated pneumonia case in which the PSI score is 35,
suggesting very low mortality risk and outpatient treatment. Likewise a CURB-65 score of 0
suggests outpatient treatment.

Front 70

Based on your knowledge of CAP and the information provided above, which pathogens are most likely to be implicated in this infection?
a. S. pneumoniae and Legionella spp.
b. S. pneumoniae, Chlamydia pneumoniae, H. influenza
c. S. pneumoniae, S. aureus, enteric gram(-) rods (e.g. E. coli, K. pneumoniae)
d. Viral (e.g. rotavirus, influenza, parainfluenza, RSV)

Back 70

a. S. pneumoniae and Legionella spp.

S. pneumo, H. influenzae, and atypicals (C. pneumoniae, M. pneumoniae, L.
pneumophila) are the most commonly implicated pathogens in uncomplicated outpatient cases.
S. aureus and enteric gram(-) rods are found primarily in ICU-treated patients and
generally infrequently, although CA-MRSA cases are on the rise.
Viruses account for approximately 10% of community-acquired pneumonia cases.

Front 71

Which of the following would be the most appropriate initial antimicrobial therapy for
T.R.?
a. Dicloxacillin 500 mg PO q 6 hours
b. Clarythromycin extended-release 1000 mg PO once daily
c. Levofloxacin 750 mg PO once daily
d. Cefpodoxime 200 mg PO q 12 hours

Back 71

b. Clarythromycin extended-release 1000 mg PO once daily

Respiratory macrolides are 1st-line therapy for outpatient treatment of mild-tomoderate
CAP.
Although dicloxacillin has reasonable coverage of S. pneumo it does not offer any
atypical coverage.
Fluoroquinolones are generally reserved for patients with risk-factors for drugresistant
S. pneumo (e.g. recent antibiotic use or certain comorbidities) or for combination use in more severe cases requiring hospital admission.

Front 72

B.B., a 3-year old, 13.5kg BM is brought into his pediatrician office by his mother who is
concerned that he may have “caught something at his day-care center.” He has been
experiencing a runny nose and low-grade fever and has been generally cranky for the past 24 hours. The mother thinks it may be the “flu” because one of the employees there said it has been going around the office. You just finished reading CDC influenza surveillance data
suggesting high-levels of influenza B infections in your region with low levels of resistance to antivirals. The pediatrician has asked for your recommendation on treating B.B.

Which of the following is the most appropriate drug and dose for treating this suspected
influenza infection?
a. Zanamivir 10 mg (2 inhalations) twice daily
b. Rimantidine 100 mg PO twice daily
c. Amantadine 35 mg/3.5 mL PO twice daily (based on 5mg/kg/day dosing)
d. Oseltamivir 30 mg PO twice daily
e. Zanamivir 5 mg (1 inhalation) twice daily

Back 72

d. Oseltamivir 30 mg PO twice daily

Oseltamivir is indicated for the treatment of children ≥ 1 year and covers influenza B
strains. Given the low-levels of local resistance, this would be the drug of choice.
Zanamivir covers influenza B strains, but is not indicated for treating children
under 7 years because of concerns over their ability to properly use the inhaler.
Rimantidine is not indicated for treatment of children < 13 years nor does it cover
influenza B strains.
Amantadine is indicated for treatment in younger children, but does not cover
influenza B strains.

Front 73

Which of the following is not a risk factor for nosocomial pneumonia?
a. Age > 70 years
b. Medications which raise the gastric pH (e.g. PPIs, H2 antagonists)
c. Absence of proper vaccination (e.g. pneumococcal, influenza)
d. Previous antibiotic exposure
e. Chronic lung disease (e.g. COPD)

Back 73

c. Absence of proper vaccination (e.g. pneumococcal, influenza)

Unlike with CAP, S. pneumo is not the most common pathogen causing
nosocomial pneumonias. Similarly, viral infections make up for only a small amount of
nosocomial pneumonia cases in immunocompetent patients. Thus, the absence of
pneumococcal/influenza vaccination are not expected to appreciably alter the risk of
developing nosocomial pneumonia whereas the other choices are expected to.

Front 74

Jessica is an 18 year old college freshman who is brought to the local ER by her roommate. Her recent
complains of headaches and neck stiffness for the last 24 hours have progressed to a fever of 102.3°F
and now confusion according to the roommate. The following medical assessments have been
completed:
WBC: 23,000
Head CT- normal
Chest X-ray: normal
Spinal tap:
CSF: Protein: 300 mg/dL glucose: 30mg/dL
Gram stain: gram-negative cocci in pairs (diplococci)
Culture & sensitivity: pending
All other labs: WNL

What would you recommend for Jessica’s empiric therapy?
a. Ampicillin 2g q4h, Vancomycin 500mg q6h, ceftriaxone 2g q12h; dexamethasone 10mg IV
with the first dose and q6hrs for 4 days
b. Nafcillin 2g q4h, ceftriaxone 2g q12h, dexamethasone 10mg IV with the first dose and q6hrs
for 4 days
c. Vancomycin 500mg q6h, ceftriaxone 2g q12h; Dexamethasone 10mg IV with the first dose
and q6hrs for 4 days
d. Ampicillin 2g q4h, Ceftriaxone 2g q12h; Dexamethasone 10mg IV with the first dose and
q6hrs for 4 days

Back 74

c. Vancomycin 500mg q6h, ceftriaxone 2g q12h; Dexamethasone 10mg IV with the first dose
and q6hrs for 4 days

Your patient should be offered empiric therapy that covers Streptococcus pneumoniae
(gram positive cocci) and N. meningitidis (gram negative diplococci)
a. Use of Ampicillin is not necessary in this patient as she is not immunocompromised
b. Nafcillin is recommended for treatment of MSSA and not used in this patient population
c. Correct answer
d. Use of Ampicillin is not necessary in this patient because she is not immunocompromised and
Vancomycin should be added until drug resistance Streptococcus pneumoniae has been ruled out.

Front 75

What prophylaxis would you recommend for Jessica’s roommate if the gram-stain organism was
indentified as patient’s infectious pathogen?
a. Ciprofloxacin 250mg orally for 1 dose
b. Ciprofloxacin 500mg orally for 1 dose
c. Rifampin 600mg q12 for 6 doses
d. Rifampin 600mg once daily for 4 days

Back 75

b. Ciprofloxacin 500mg orally for 1 dose

Based upon the gram stain morphology you would suspect Neisseria meningitidis (gram
negative diplococci).
a. The dose of Ciprofloxacin is 500mg orally for 1 dose for adults
b. Correct answer
c. Rifampin for prophylaxis of N. meningitidis is dosed at 600mg q12 for 4 doses
d. Rifampin 600mg once daily for 4 days is prophylaxis against H. influenza

Front 76

JR is a 23 year-old HIV-positive Asian male who was screened for hepatitis at his first HIV appointment. He admits to a past history of IVDU and MSM (men who have sex with men) as risk
factors. What hepatitis treatment (s) and/or prevention method(s) would you recommend based upon
this patient’s serology results if he was not going to be started on HIV medications?
Total HAV: negative
Total HCV: positive
HCV RNA: <0.1 copies/mL (undetectable)
HBsAg: negative
HBcAb: positive
HBsAb: positive
ALTs: 22 IU/L
All other labs: WNL
Weight: 80kg

a. Vaccinate to prevent HAV infection
b. Vaccinate to prevent HAV and Pegylated interferon alfa- 2a at 180mg SC once weekly for 48
weeks
c. Pegylated interferon alfa 2a 180mg SC once weekly with ribavirin orally 600mg BID for 48
weeks.
d. Tenofovir 300mg with emtricitabine 200mg orally daily for 48 weeks for treatment of both HIV
and HBV

Back 76

a. Vaccinate to prevent HAV infection

Your patient is susceptible to HAV, immune to HBV after exposure (HBcAb is positive) and HCV immune after exposure (no vaccine available and no RNA with a positive antibody test).

a. Vaccination with HAV is the correct answer as he is immune to the other forms of hepatitis and
MSM is a risk factor for vaccination
b. Your patient is immune to HCV (undetectable RNA and positive antibody test) so treatment
with interferon for HCV or HBV is not necessary although HAV immunization is recommended.
c. Your patient is immune to HCV (undetectable RNA and positive antibody test) so treatment
with interferon and ribavirin is not necessary.
d. Tenofovir 300mg and emtricitabine 200mg are recommended for treatment of HBV co-infected HIV-positive patients or they can be used as first line agents in HIV positive patients but always in combination with a protease inhibitor or non-nucleoside reverse transcriptase inhibitor. Your patient has immunity to HBV.

Front 77

Which of the following antibiotics would be most appropriate as empiric outpatient
oral therapy for an infection suspected to be due to a community-acquired strain of
Methicillin-resistant Staphylococcus aureus?
A. Azithromycin (Zithromax®)
B. Linezolid (Zyvox®)
C. Vancomycin (Vancocin®)
D. Doxycycline (Vibramycin®)

Back 77

D. Doxycycline (Vibramycin®)

Community-acquired strains of MRSA are usually resistant to macrolides and drugs of
first choice are doxycycline or TMP/SMX. Oral vancomycin cannot be used to treat
systemic infections as it is not absorbed. Linezolid would likely cover a community acquired MRSA strain but is not used first-line.

Front 78

Which of the following pathogens is classified as a gram-positive bacilli?

A. Listeria monocytogenes
B. Streptococcus pneumoniae
C. Neisseria gonorrhea
D. Escherichia coli

Back 78

A. Listeria monocytogenes

Front 79

Which of the following antibiotics has appreciable activity against the anaerobic
pathogen Bacteroides fragilis?
A. Ceftriaxone (Rocephin®)
B. Metronidazole (Flagyl®)
C. Trimethorpim/sulfamethoxazole (Septra®)
D. Amoxacillin (Amoxil®)

Back 79

B. Metronidazole (Flagyl®)

The other antibiotics listed to not provide coverage against this pathogen.

Front 80

Which of the following antibiotics would be considered safest to use in a patient who
reports a history of anaphylaxis to penicillin?
A. Ertapenem (Invanz®)
B. Ceftriaxone (Rocephin®)
C. Aztreonam (Azactam®)
D. Piperacillin/tazobactam (Zosyn®)

Back 80

C. Aztreonam (Azactam®)

The other agents listed are more structurally similar to penicillin and would have a higher
potential for cross-sensitivity. (Highest potential with piperacillin/tazobactam since it is a
penicillin). Aztreonam would be considered safest to use in a patient with penicillin
allergy.

Front 81

Which of the following antibiotics has appreciable activity versus the pathogen
Pseudomonas aeruginosa?

A. Cefotetan (Cefotan®)
B. Ertapenem (Invanz®)
C. Ticarcillin/clavulanate (Timentin®)
D. Daptomycin (Cubicin®)

Back 81

C. Ticarcillin/clavulanate (Timentin®)

The other antibiotics listed due to not provide appreciable coverage against this pathogen.

Front 82

PJ is a 4 year old male who is brought to the emergency department (ED) by his mother
who states that he has a fever, has been crying incessantly and is very irritable. The ED
physician is concerned about meningitis and performs a lumbar puncture which reveals:
WBCs 250 (85% PMNs), protein 155 mg/dL, and glucose 25 mg/dL. Gram stain shows gram-negative coccobacilli.

Based on the CSF and Gram Stain findings, what is the most likely pathogen causing
meningitis in this patient?
A. Group B Streptococcus
B. Haemophilus influenzae
C. Streptococcus pneumoniae
D. Neisseria meningitidis

Back 82

B. Haemophilus influenzae

The most likely pathogens causing meningitis in this patient are B, C, and D. Based on the
gram-stain, Haemophilus influenzae is the most likely. Streptococcus pneumoniae is a gram positive cocci and Neisseria meningitides is a gram negative cocci.

Front 83

What antibiotic regimen would be most appropriate for empiric therapy of meningitis
in this patient (PJ)?
A. Ceftriaxone (Rocephin®) + Vancomycin (Vancocin®)
B. Ampicillin (Omnipen®)
C. Vancomycin (Vancocin®) + Ampicillin (Omnipen®)
D. Penicillin G

Back 83

A. Ceftriaxone (Rocephin®) + Vancomycin (Vancocin®)

Empiric therapy for age 1 month to 50 years is (Ceftriaxone or cefotaxime) + vancomycin. Even if trying to target Haemophilus influenzae, ampicillin and penicillin would not provide adequate empiric coverage of this pathogen since 50% or more produce beta-lactamase.
Empiric therapy is given until organism is identified and results of culture/sensitivity are
available.

Front 84

AJ is a 3 year old female who is brought to her pediatrician’s office in late June with a 2-
day history of fever and tugging at her left ear. On physical exam, she is febrile and her
left tympanic membrane is erythematous, bulging and non-mobile with purulent fluid.
She is diagnosed with acute otitis media. She has not received any antibiotics in the past and has no known drug allergies.

What would be the most appropriate recommendation?
A. Do nothing, acute otitis media occurring in the summer is most likely of viral
origin and antibiotics are not warranted
B. Place patient on amoxicillin/clavulanate HD (Augmentin®) 45 mg/kg/day
divided q6h
C. Place patient on amoxicillin HD (Amoxil®) 90 mg/kg/day divided q12h
D. Place patient on cefpodoxime (Vantin®) 25 mg/kg/day divided q8h

Back 84

C. Place patient on amoxicillin HD (Amoxil®) 90 mg/kg/day divided q12h

Recommended empiric therapy acute OM in a patient without a penicillin allergy who has not received antibiotics in the prior month is amoxicillin HD.

Front 85

After 4 days of appropriate antibiotic therapy, AJ has a mild fever, her left tympanic
membrane is still bulging and erythematous, and fluid remains in the middle ear. What
would be the most appropriate recommendation at this time?
A. Do nothing, it may take up to 6 months for her tympanic membrane to appear
normal
B. Place patient on amoxicillin/clavulanate HD (Augmentin ES®) 90 mg/kg/day
po divided q12h
C. Place patient on azithromycin (Zithromax®) 100 mg/kg po qd
D. Place patient on ceftriaxone (Rocephin®) 250 mg/kg/day IM x 3 days

Back 85

B. Place patient on amoxicillin/clavulanate HD (Augmentin ES®) 90 mg/kg/day

Recommended therapy for acute OM in a patient without a penicillin allergy who has not
received antibiotics in the past month who has clinical failure after 48-72 hours is
amoxicillin/clavulanate HD.

Front 86

LS is a 21 year college student who presents to the infirmary with a 3 day history of
sore throat. He has no cough but has a temperature of 38.5 °C (101.3 °F). On exam, his
pharynx is erythematous. A rapid Strep test is positive for Streptococcus pyogenes
(Group A Streptococcus, GAS) and he is diagnosed with pharyngitis. He reports having
a severe allergy to penicillin as a child. What would be the most appropriate
recommendation?

A. Do nothing, adults with GAS pharyngitis do not need antibiotic therapy and
this only contributes to the development of antibiotic resistance
B. Place the patient on penicillin V (Pen-Vee K®) 500 mg po bid x 10 days
C. Give the patient ceftriaxone (Rocephin®) 125 mg IM x 1 dose
D. Place the patient on erythromycin (E-mycin®) 500 mg po qid x 10 days

Back 86

D. Place the patient on erythromycin (E-mycin®) 500 mg po qid x 10 days

A macrolide is recommended for treatment of GAS pharyngitis in a patient who is
penicillin allergic.

Front 87

RB is a 72 year old male who reports to the clinic with chief complaint of worsening
cough. He has a history of chronic obstructive pulmonary disease (COPD) and chronic
bronchitis. He reports having a cough that has been present daily for the past 2 years but
for the past week, the volume of sputum has increased and it has become thicker. He has
not received antibiotic therapy in the past 6 months. On physical exam he is found to be
febrile and has wheezes bilaterally. A chest x-ray is done and rules out pneumonia and
he is diagnosed with a severe acute exacerbation of chronic bronchitis. What therapy
would be the most appropriate recommendation?

A. Trimethoprim/sulfamethoxazole (Septra®) 1 DS tab po qd
B. Levofloxacin (Levaquin®) 500 mg po qd
C. Erythromycin (E-mycin®) 500 mg po bid
D. Amoxicillin/clavulanate HD (Augmentin®) 875 mg po qid

Back 87

B. Levofloxacin (Levaquin®) 500 mg po qd

Recommended empiric therapies for a severe acute exacerbation of chronic bronchitis are amoxicillin/clavulanate, azithromycin, clarithromycin, oral 2nd/3rd generation ceph, FQ with enhanced gram-positive activity, or telithromycin. So drugs listed in B or D are options but the dose in D is incorrect.

Front 88

RG is a 58 year old previously healthy male who presents to the emergency
department with an abrupt onset of cough with purulent sputum, fever, and shortness of
breath. Chest x-ray shows a left lower lobe infiltrate. He is admitted to the hospital
(general medical ward) with a diagnosis of community-acquired pneumonia. What would
be the most appropriate recommendation?
A. Levofloxacin (Levaquin®) 500 mg iv qd + azithromycin (Zithromax®) 500 mg
iv qd
B. Erythromycin 500 mg iv qid
C. Doxycycline (Vibramycin®) 100 mg iv bid
D. Moxifloxacin (Avelox®) 400 mg iv qd

Back 88

D. Moxifloxacin (Avelox®) 400 mg iv qd

Recommended empiric therapy for CAP in a patient admitted to the general
medical ward is a macrolide (azithro or clarithro) + beta-lactam (cefotaxime or
ceftriaxone usually) OR a fluoroquinolone with enhanced gram-positive activity.
Answer D is the only option that falls into one of those 2 categories.

Front 89

LK is a 31 year-old male admitted to the surgical intensive care unit 7 days ago following
traumatic head injury. The patient has been intubated on a ventilator since admission for
airway protection. This morning the patient has new onset of fever at 39.5 °C (103.1 °F),
increase production of purulent sputum, and WBC of 14.8, up from 8.4 yesterday. Chest
X-ray reveals a new infiltrate in the left lower lobe. The medicine team orders
appropriate cultures and decides to start the patient on therapy for presumed ventilatorassociated
pneumonia.
Current medications are:
Albuterol 2.5 mg nebulized q6h Bisacodyl 10 mg supp rectally QD prn
Docusate 100 mg PO BID Morphine Sulfate 1-4 mg IV q1h prn
Heparin 5,000 units SQ BID Ondansetron (Zofran) 4 mg IV q4h prn
Pantoprazole (Protonix) 40 mg IV q12h
Ciprofloxacin (Cipro) 400 mg IV q12h (started upon admission)
LK weighs 66 kg; SCr = 0.8 mg/dL; No known allergies

Which of the following represents the most appropriate therapeutic plan?
A. Continue the ciprofloxacin (Cipro) at current dose. Add Piperacillin/Tazobactam
(Zosyn) 4.5 grams IV q6h and Linezolid (Zyvox) 600 mg IV BID
B. Discontinue ciprofloxacin (Cipro). Initiate therapy with Cefepime (Maxipime) 2
gm IV q12h, Tobramycin 460 mg IV q24h, and Vancomycin 1 gm IV q12h
C. Increase the dose of ciprofloxacin (Cipro) to 500 mg IV q12h and add Linezolid
(Zyvox) 600 mg IV BID plus Gentamicin 460 mg IV q24h
D. Increase the ciprofloxacin (Cipro) dose to 400 mg IV q8h. Initiate therapy with
ertapenem (Invanz) 1 gm IV q24h and add vancomycin at 1 gm IV q12h.
E. Continue the ciprofloxacin (Cipro) and wait for cultures. Change therapy if
necessary as dictated by the culture and sensitivity analysis.

Back 89

The dose of ciprofloxacin is inappropriate for a
patient with suspected ventilator associated pneumonia. Also would not
want to continue with fluoroquinolone as the patient developed symptoms
while on therapy.
Ciprofloxacin should not be used at this dose for the
treatment of VAP and a cell wall active agent should be used. An
aminoglycoside plus a fluoroquinolone is not recommended for empiric
treatment of VAP.
Ertapenem should not be used in the empiric management of late
onset VAP due to its limited antipseudomonal activity.
This patient has developed infection while on ciprofloxacin. The
organism responsible is either not covered by ciprofloxacin or has developed
resistance. Empiric therapy to cover the most likely pathogens should be
started immediately as reduced morbidity and mortality is associated with
early appropriate empiric therapy.

Front 90

Likely pathogens responsible for this type of infection include:
A. Escherichia coli, Staphylococcus epidermidis, and Pseudomonas aeruginosa
B. Pseudomonas aeruginosa, Streptococcus viridans, and Moraxella cattarhalis
C. Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus
D. Bacteroides fragilis, Pseudomonas aeruginosa, and Streptococcus pneumonia
E. Staphylococcus aureus, Escherichia coli, and Chlamydia pneumoniae

Back 90

C. Klebsiella pneumoniae, Pseudomonas aeruginosa, and Staphylococcus aureus

S. epidermidis is not associated with late onset VAP.
Moraxella cattarhalis and Streptoccocus viridans are not
commonly associated with late onset VAP.
Bacteroides fragilis is not commonly associated with late onset VAP.
Chlamydia pneumoniae is not commonly associated with late
onset VAP.

Front 91

MJ is a 46 year-old female who presents to the clinic with complaints of dysuria, urinary
urgency, and suprapubic heaviness. This is the 4th time MJ has presented to the clinic in
the past 8 months. She most recently presented with similar symptoms approximately 1
month ago and received a 3 day course of sulfamethoxazole-trimethoprim (Septra) at an
unknown dose. She denies any subjective fevers, chills, or associated flank pain. She is
diagnosed with a recurrent urinary tract infection.
A urinalysis is conducted and the following results are available:
Cloudy, amber urine
pH: 6.9
Leukocyte esterase: positive
Nitrite: negative

Which of the following is the best therapeutic plan for MJ at this point?
A. Initiate therapy with sulfamethoxazole-trimethoprim 1 DS (Septra DS) tablet once
daily. Take for 7 days.
B. Send a urine specimen for culture and sensitivity testing. Once infection is
verified and culture results are known, start patient on appropriate therapy. Treat
for 3 days.
C. Obtain a urine specimen for analysis and microbiologic testing. While the results
are pending, start the patient empirically on ciprofloxacin (Cipro) 250 mg PO
BID. Treat for 3 days.
D. Initiate therapy with nitrofurantoin (Macrodantin) 50 mg PO BID. Treat for 3
days.
E. No therapy is necessary in this case. The patient does not have a fever, nitrite is
negative, and she has recently received a course of antibiotics and therefore this is
likely contamination.

Back 91

C. Obtain a urine specimen for analysis and microbiologic testing. While the results
are pending, start the patient empirically on ciprofloxacin (Cipro) 250 mg PO
BID. Treat for 3 days.

The patient should immediately begin empiric therapy with a
broad spectrum agent pending urinalysis and culture and sensitivity testing.
Therapy can be tailored once results are known.
Since this patient has recurrent UTIs and has presumably been
treated in recent weeks, culture and sensitivity testing should be done. In
addition nitrofurantoin should be dosed 100 mg PO QID and should be given for 7 days.
This patient has classic symptoms of a UTI. Since this patient is symptomatic, treatment is necessary.

Front 92

Once current infection is treated, is MJ a candidate for urinary tract infection
prophylaxis? If yes, which of the following represents the most appropriate regimen?
A. No. Prophylaxis is not warranted in this case
B. Yes. Ciprofloxacin (Cipro) 250 mg PO every other day
C. Yes. Amoxicillin (Amoxil) 250 mg PO TID.
D. No. Antibiotic prophylaxis is not warranted but this patient should be advised to
drink cranberry juice every morning after her first void
E. Yes. Nitrofurantoin (Macrodantin) 50 mg PO every night.

Back 92

E. Yes. Nitrofurantoin (Macrodantin) 50 mg PO every night.
This patient would likely benefit from prophylactic therapy as she has had 4 UTIs in the past 8 months.
This is not a recommended prophylactic regimen. The use of fluoroquinolnes in this manner will likely lead to resistance.
This is not a recommended prophylactic regimen. While this
likely will prevent recurrence, this is considered a treatment dose and a TID
prophylactic regimen is not in the patient’s best interest.
While there is limited information that supports the use of cranberry juice in preventing UTIs, there is no data to support use in this manner.

Front 93

All of the following are symptoms associated with pyelonephritis except:
A. Nausea & Vomiting
B. Costovertebral tenderness
C. Nocturia
D. Headache
E. Fever

Back 93

D. Headache

Nausea and vomiting are not uncommon in severe acute
pyelonephritis.
Costovertebral tenderness is commonly described in
pyelonephritis.
Nocturia is common in most types of UTI.
Fever is a hallmark sign of pyelonephritis.

Front 94

Which of the following antibiotics would be most appropriate for treating an infection due to methicillin-resistant Staphylococcus aureus (MRSA)?

A. Linezolid (Zyvox®)
B. Amoxicillin/clavulanate (Augmentin®)
C. Ceftriaxone (Rochephin®)
D. Imipenem (Primaxin®)

Back 94

A. Linezolid (Zyvox®)

Linezolid is the only antibiotic listed with activity versus MRSA. The others listed have activity against Methicillin susceptible Staphylococcus aureus (MSSA).

Front 95

Which of the following antibiotics does not have appreciable activity versus Pseudomonas aeruginosa?

A. Piperacillin/tazobactam (Zosyn®)
B. Ertapenem (Invanz®)
C. Ceftazidime (Fortaz®)
D. Ciprofloxacin (Cipro®)

Back 95

B. Ertapenem (Invanz®)

Ertapenem is the one carbaenem that does not have appreciable activity versus Pseudomonas aerugionsa. All other agents listed have activity against Pseudomonas aeruginosa.

Front 96

3. All of the following antibiotics have appreciable activity versus the atypical pathogens (e.g. Mycoplasma, Chlamydia, Legionella) EXCEPT:

A. Erythromycin (E-mycin®)
B. Doxcycyline (Vibramycin®)
C. Levofloxacin (Levaquin®)
D. Cefuroxime (Ceftin®)

Back 96

D. Cefuroxime (Ceftin®)

The cephalosporins do not have reliable activity versus atypical pathogens.

Front 97

4. Which of the following cephalosporins has appreciable activity against the anaerobic pathogen Bacteroides fragilis?

A. Cefotaxime (Claforan®)
B. Cefpodoxime (Vantin®)
C. Cefepime (Maxipime®)
D. Cefotetan (Cefotan®)

Back 97

D. Cefotetan (Cefotan®)

Cefotetan and cefoxitin are the cephalosporins that have increased anaerobic activity including coverage against Bacteroides fragilis.

Front 98

Which of the following antibiotics would be most appropriate for treatment of an infection due to penicillin-intermediate Streptococcus pneumoniae?

A. Erythromycin (E-mycin®)
B. Trimethoprim-sulfamethoxazole (Septra®)
C. Moxifloxacin (Avelox®)
D. Doxycycline (Vibramycin®)

Back 98

C. Moxifloxacin (Avelox®)

Penicillin-intermediate or resistant Streptococcus pneumoniae is usually resistant to the other antibiotics listed as well.

Front 99

MJ is a 2 week old infant male who is brought to the emergency room by her mother. Her mother states that MJ has had a fever, has been irritable, crying incessantly, and has not been eating. After physical examination of MJ, the physician is concerned about meningitis and orders a lumbar puncture which reveals WBCs 650 (many PMNs), elevated protein and decreased glucose. Gram stain of CSF shows gram-positive bacilli (rods).

What is the most likely pathogen causing meningitis in this patient?

A. Escherichia coli
B. Listeria monocytogenes
C. Streptococcus pneumoniae
D. Neisseria meningitidis

Back 99

B. Listeria monocytogenes

Listeria monocytogenes is the only bacteria listed that is a gram-positive bacilli. Streptococcus pneumoniae not common in those < 1 month old. Eschericia coli is a potential pathogen in newborns but is a gram-negative rod.

Front 100

7. What is the most appropriate empiric therapy for meningitis in this patient?

A. Ampicillin (Omnipen®)+ cefotaxime (Claforan®)
B. Cefotaxime (Claforan®) + vancomycin (Vancocin®)
C. Penicillin G
D. Cefepime (Maxipime®) + vancomycin (Vancocin®)

Back 100

A. Ampicillin (Omnipen®)+ cefotaxime (Claforan®)

Recommended options for meningitis in a newborn are ampicillin + either cefotaxime, ceftriaxone, or an aminoglycoside.

Front 101

DJ is a 40 year old male who is seen at his physician’s office with a 2 week history of nasal congestion with thick greenish/yellow discharge, headache, and sinus pain. He states that he has had a fever for the past 2 days. He reports that he recently had a cold that seemed to get better but his nasal symptoms persisted and continued to worsen. He is diagnosed with acute sinusitis. He has not received antibiotics in the prior month.

What antibiotic therapy would be most appropriate for this patient at this time?

A. Gatifloxacin (Tequin®) 400 mg po bid
B. Amoxicillin (Amoxil®) 500 mg po qd
C. Trimethoprim/sulfamethoxazole (Septra®) DS 1 po tid
D. Amoxicillin/clavulanate (Augmentin®) 875 mg po bid

Back 101

D. Amoxicillin/clavulanate (Augmentin®) 875 mg po bid

Recommended options when antibiotics not received in the prior month are amoxicillin, amoxicillin/clavulanate, cefdinir, cefpodoxime. In addition, doses for other agents listed are incorrect.

Front 102

9. Which of the following regimens would you recommend if DJ had received antibiotics in the past month?

A. Amoxicillin/clavulanate high dose/HD (Augmentin ES®) 500 mg po qid
B. Cefuroxime (Ceftin®) 500 mg po qd
C. Moxifloxacin (Avelox®) 400 mg po qd
D. Amoxicillin HD (Amoxil®) 1000 mg po bid

Back 102

C. Moxifloxacin (Avelox®) 400 mg po qd

Recommended options are amoxicillin/clavulanate (consider high dose) or FQ with enhanced gram-positive activity. Options of those listed are amoxicillin/clavulanate or moxifloxacin; however, dose listed for amoxicillin/clavulanate is incorrect.

Front 103

LS is an 18 year old female you presents to her physician’s office with a 2 day history of sore throat. She has no cough but has a temperature of 39.5C. On exam, her pharynx is erythematous. A rapid Strep test is positive for Streptococcus pyogenes (Group A Streptococcus, GAS). She has a penicillin allergy (she reports rash when she received penicillin as a child). Which of the following is the most appropriate recommendation?

A. Erythromycin (E-mycin®) 500 mg po bid x 3 days
B. Clindamycin (Cleocin®) 300 mg po bid x 10 days
C. Ceftriaxone (Rocephin®) 125 mg IM x 1 dose
D. Azithromycin (Zithromax®) 500 mg po x 1, then 250 mg po qd x 4 days

Back 103

D. Azithromycin (Zithromax®) 500 mg po x 1, then 250 mg po qd x 4 days

D. Azithromycin (Zithromax®) 500 mg po x 1, then 250 mg po qd x 4 days

Front 104

AJ is a 9 month old female who is brought to her pediatrician with a 3-day history of fever, decreased appetite, irritability, and tugging of her left ear. On physical exam, her left tympanic membrane is erythematous, bulging and non-mobile. She has a temperature of 102F. She is diagnosed with acute otitis media. Her mother reports that her daughter attends daycare. AJ has not received any antibiotics in the prior month.

11. What antibiotic therapy is most appropriate for this patient?

A. Amoxicillin/clavulanate (Augmentin ES®) 90 mg/kg/day divided qid
B. Cefuroxime (Ceftin®) 100 mg/kg/day divided tid
C. Amoxicillin (Amoxil®) 90 mg/kg/day divided bid
D. Ceftriaxone (Rocephin®) 150 mg/kg IM

Back 104

C. Amoxicillin (Amoxil®) 90 mg/kg/day divided bid

Recommended options for otitis media in a patient without recent antibiotic therapy are amoxicillin usual dose or high dose. Therefore, correct answer is C. (Doses of other agents listed are also incorrect).

Front 105

The patient is brought back to the clinic on day 3 with worsening symptoms. What is most appropriate for this patient now?

A. Continue current antibiotics, 3 days is not enough time to assess for clinical response for otitis media
B. Change antibiotic to cefuroxime (Ceftin®) 30 mg/kg/day divided bid
C. Change antibiotic to amoxicillin/clavulanate (Augmentin®) 45 mg/kg/day divided bid
D. Change antibiotic to ceftriaxone (Rocephin®) 5 mg/kg IM qd

Back 105

B. Change antibiotic to cefuroxime (Ceftin®) 30 mg/kg/day divided bid

Would change patient to amoxicillin/clavulanate high dose, cefdinir, cefpodoxime, cefprozil, cefuroxime. Dose listed for amoxicillin/clavulanate is too low (dose should be 90 mg/kg/day divided BID). Dose for cefuroxime is correct.

Front 106

AB is a 58 year old male who reports to the clinic with chief complaint of worsening cough. He reports having a cough that has been present daily for the past 3 months but over the past 10 days the sputum has increased in volume, has become thicker. He states that he is short of breath and has had a fever. He has 20 pack-year history of smoking and a past medical history of chronic bronchitis for which he has received repeated courses of antibiotics. Upon exam, he is noted to have a fever of 103 F and an oxygen saturation of 85% on room air. The physician does a chest x-ray which rules out pneumonia and the patient is diagnosed with a severe acute exacerbation of chronic bronchitis.

13. What are the most likely pathogens causing bronchitis in this patient?

A. Viruses, Streptococcus pneumoniae, Staphylococcus aureus, Chlamydia Pneuomoniae
B. Viruses, Streptococcus pneumoniae, Moraxella cattarhalis, Haemophilus influenzae, Mycoplasma pneumoniae
C. Viruses, Streptococcus pneumoniae, Staphylococcus aureus, Chlamydia pneuomoniae, Haemophilus influenzae
D. Viruses, Streptococcus pyogenes, Haemophilus influenzae, Pseudomonas aeruginosa

Back 106

B. Viruses, Streptococcus pneumoniae, Moraxella cattarhalis, Haemophilus influenzae, Mycoplasma pneumoniae

Staphylococcus aureus, Chlamydia pneumonia, Streptococcus pyogenes, are not common pathogens causing acute exacerbation of chronic bronchitis.

Front 107

Which of the following is the most appropriate recommendation?

A. Gatifloxacin (Tequin®) 400 mg po qd
B. Amoxicillin/clavulanate (Augmentin®) 250 mg po bid
C. Doxycycline (Vibramycin®) 500 mg po qd
D. Cephalexin (Keflex®) 500 mg po qid

Back 107

A. Gatifloxacin (Tequin®) 400 mg po qd

Recommended options include amoxicillin/clavulanate, azithromycin, clarithromycin, 2nd/3rd generation oral ceph, FQ. Gatifloxacin is the only one of these options listed at the correct dose.

Front 108

15. MS is a 29 year old male who presents to his physician’s office with a 10 day history of cough with purulent sputum, fever, and shortness of breath. He states that he has been busy preparing his dissertation for his PhD and has not had time to seek medical attention for his symptoms before today. He has a past medical history of allergic rhinitis but has been otherwise healthy. After physical examination, his physician is concerned about pneumonia and would like to initiate antibiotic therapy. Patient will not be admitted to the hospital. What is the most appropriate recommendation?
A. Moxifloxacin (Avelox®) 800 mg po qd
B. Amoxicillin/clavulanate (Augmentin XR®) 2000 mg po bid
C. Trimethoprim/sulfamethoxazole (Septra DS®) 1 po qd
D. Doxycycline (Vibramycin®) 100 mg po bid

Back 108

D. Doxycycline (Vibramycin®) 100 mg po bid

Doxycycline or macrolides are recommended options for treating CAP in otherwise healthy patient. If patient had a recent history of antibiotic use then Macrolide (specifically azithromycin or clarithromycin) + (amoxicillin HD or amoxicillin/clavulanate HD) or FQ with enhanced gram-positive activity could be used. Doxycycline is the only one of these potential options listed at the correct dose.

Front 109

JM is a 45 year old female who has been in the intensive care unit for the past 5 days following complications from a hysterectomy. She has required mechanical ventilation for the past 5 days and has had increased oxygen requirements over the past 24 hours. Her nurse also reports increase in the volume and viscosity of her secretions from her endotracheal tube. She is febrile, hypotensive, and has required vasopressors for the past 12 hours. A chest x-ray shows a new infiltrate in the right lower lobe. The resident is concerned about a severe hospital-acquired pneumonia in this patient and would like to begin empiric antibiotic therapy. There have been a lot of infections due to methicillin-resistant Staphylococcus aureus in the hospital recently. The patient has normal renal function and weighs 65kg.

What is the most appropriate recommendation?
A. Ceftriaxone (Rocephin®) 1 g iv qd + azithromycin (Zithromax®) 500 mg iv qd
B. Gatifloxacin (Tequin®) 400 mg iv qd + linezolid (Zyvox®) 600 mg iv qd
C. Cefepime (Maxipime®) 2g iv q12h + vancomycin (Vancocin®) 1 g iv q12h + ciprofloxacin (Cipro®) 400 mg iv q12h
D. Vancomycin (Vancocin®) 1g iv q12h + cefotaxime (Claforan®)1 g iv q12h + gentamicin (Garamycin®) 450 mg iv qd

Back 109

C. Cefepime (Maxipime®) 2g iv q12h + vancomycin (Vancocin®) 1 g iv q12h + ciprofloxacin (Cipro®) 400 mg iv q12h

Therapy for severe hospital-acquired pneumonia should include coverage against the core pathogens as well as Pseudomonas aeruginosa and Staphylococcus aureus.
Options A, B, D do not provide adequate coverage against a systemic Pseudomonas aeruginosa infection.

Front 110

JM’s sputum cultures grow Pseudomonas aeruginosa that is susceptible to all antibiotics tested. The patient has been improving on the current antibiotic regimen and is being transferred to the general medical ward this afternoon. Which of the following would be the most appropriate for this patient at this time?

A. Ceftriaxone (Rocephin®) 1 g iv qd
B. Gentamicin (Garamycin®) 450 mg iv qd
C. Cefepime (Maxipime®) 2 g iv 12h
D. Gatifloxacin (Tequin®) 400 mg iv q12h

Back 110

C. Cefepime (Maxipime®) 2 g iv 12h

Cefepime is the only option that is listed that is recommended for systemic Pseudomonas aeruginosa infection.

Front 111

. JK is a 26 year old male who presents to his physician’s office with redness and pain
bilaterally on his face. He reports that he recently had a cold which has resolved. He
now reports these symptoms plus low-grade fever. He is diagnosed with Erysipelas.
What is the most likely pathogen?

A. Staphylococcus aureus
B. Streptococcus pneumoniae
C. Staphylococcus epidermidis
D. Group A Streptococcus

Back 111

D. Group A Streptococcus

Group A Streptococcus is the most likely pathogen in erysipelas.

Front 112

19. PJ is a 35 year old male who abuses intravenous drugs. He comes to the Emergency Department with a 5 day history of fever and redness and swelling of his left arm. A bone scan is done which reveals osteomyelitis of the left humerous.

What is the most appropriate recommendation for this patient at this time?
A. Vancomycin (Vancocin®) + ceftriaxone (Rocephin)
B. Oxacillin + cefotaxime (Claforan®)
C. Cefazolin (Kefzol®) + gentamicin (Garamycin®)
D. Ciprofloxacin (Cipro®) + metronidazole (Flagyl)
E. Oxacillin + ciprofloxacin (Cipro®)

Back 112

E. Oxacillin + ciprofloxacin (Cipro®)

Most common pathogens causing osteomyelitis in IVDA are gram-negative rods particularly Pseudomonas aeruginosa, Enterobacter, Serratia. Gram-positive pathogens such as Staphylococcus aureus and Streptococcus pyogenes. Options A, B, C do not adequately cover Pseudomonas aeruginosa; option D does not include reliable coverage against the gram-positive pathogens and provides unnecessary anaerobic coverage.

Front 113

KM is a 7 year old female who is brought to the Emergency Department by her father on Super Bowl Sunday. They had been watching the game at a friend’s house when KM was bitten in the lip by their dog. She is found to have a deep puncture wound of the lip requiring 4 stitches. What is the most appropriate recommendation for this patient at this time?

A. Dog bites rarely become infected so antibiotics are not indicated for this patient
B. Place patient on 5 day course of cephalexin (Keflex®)
C. Place patient on 5 day course of doxycyline (Vibramycin®)
D. Place patient on 5 day course of amoxicillin/clavulanate (Augmentin®)

Back 113

D. Place patient on 5 day course of amoxicillin/clavulanate (Augmentin®)

Dog bite involving a deep puncture window so antibiotics are recommended. Recommended options include amoxicillin/clavulanate or clindamycin + (TMP/SMX or fluoroquinolone). Answer D is the only correct option.

Front 114

WS is a 25 year old female who recently underwent gastric bypass surgery. She is seen in the Emergency Department with complaints of fever and abdominal pain. A CT scan of the abdomen reveals an intra-abdominal abscess. Which of the following is most appropriate for this patient at this time?

A. Metronidazole (Flagyl®)
B. Cefepime (Maxipime®)
C. Aztreonam (Azactam®)
D. Piperacillin/tazobactam (Zosyn®)

Back 114

D. Piperacillin/tazobactam (Zosyn®)

The patient has an intra-abdominal abscess so must provide broad-spectrum coverage with agent or combination of agent that provides coverage against gram-negatives and anaerobes such as Bacteroides. Metronidazole covers anaerobes, cefepime and aztreonam cover gram-negatives but do not provide coverage against Bacteroides.

Front 115

SK is 24 year old female who is seen at the Family Medicine clinic with a 3 day
history of abdominal pain and diarrhea. She states that she has approximately 8
loose stools per day. She is a medical student and is on her last day of a day course of doxycyline (Vibramycin®) that her friend gave her for treatment of an upper respiratory infection. Stool studies are done and are positive for Clostridium difficile. Which of the following is most appropriate for this patient at this time?
A. Do nothing, this is a self-limiting and will resolve upon discontinuation of the doxycycline
B. Treat patient with vancomycin (Vancocin®) 500 mg po qid x 5 days
C. Treat patient with metronidazole (Flagyl®) 500 mg po tid x 10 days
D. Treat patient with clindamycin (Cleocin®) 450 mg po tid x 10 days

Back 115

C. Treat patient with metronidazole (Flagyl®) 500 mg po tid x 10 days

Metronidazole or vancomycin are options for treating Clostridium difficile colitis. Duration of therapy is generally 10 days and vancomycin should not be used first line due to risk for vancomycin-resistant enterococci.

Front 116

JR is a 53 year old female with a history of Type 2 DM, HTN, COPD, and rheumatoid arthritis. She presents to the emergency room with subjective fevers, painful urination, suprapubic heaviness, and bilateral flank tenderness. Pt reports symptoms started approximately 48 hours prior to presentation. Pt reports general malaise and nausea with 4-5 episodes of vomiting during this time. Pt recently admitted to hospital for COPD exacerbation. She was discharged home on an unknown antibiotic 5 days ago. Pt was catheterized during that admission but the catheter was pulled prior to discharge. Pt reports an allergy to sulfa containing drugs.
Vital signs: BP 92/54 P 114 R 20 T 39.2C
Which of the following is the best therapeutic plan for JR?

A. Empirically start patient on ampicillin 500mg IV q12h. Then obtain urine sample for urinalysis and culture and sensitivity testing.
B. Obtain urine sample for urinalysis and culture and sensitivity testing. Once urinalysis and culture are reported, begin targeted antibiotic therapy against known pathogen(s).
C. Obtain urine sample for urinalysis and culture and sensitivity testing. Empirically initiate therapy with cefuroxime 1gm IV every 24 hours.
D. Obtain urine sample for urinalysis and culture and sensitivity testing. Empirically initiate therapy with Timentin 3.1gm IV q6h.

Back 116

D. Obtain urine sample for urinalysis and culture and sensitivity testing. Empirically initiate therapy with Timentin 3.1gm IV q6h.

Timentin is a broad-spectrum agent with anti-pseudomonal activity.
This patient has a hospital acquired pyelonephritis which is unresponsive to an unknown antibiotic. In this case must assume the P. aeruginosa or another inherently resistant organism may be involved. An antipseudomonal agent should be empirically started. Additionally, the urine sample must be obtained prior to the initiation of antibiotics.
It will take at least 24 hours for culture and sensitivity analysis to be finalized. This patient has vital signs that are concerning and she should be started on empiric antibiotics immediately. Once the microbiology results are reported, therapy can then be streamlined to other agents based on known pathogens.

Front 117

JR’s urine is sent for urinalysis and culture and sensitivity testing.

UA reveals the following:

Culture Report:
RBC: 20
Enterococcus faecium 10,000-100,000 col/ml
WBC: 82
Nitrite: Negative
Leukocyte Esterase: Small
Sensitivity analysis:
Bacteria: Moderate
Ampicillin - sensitive
No WBC casts visualized
Penicillin - resistant
Vancomycin – sensitive

. Given these results, what is the most appropriate recommendation at this time?

A. Discontinue empiric antibiotic (if started). Initiate Vancomycin 500mg IV q12h hours. Transition to oral ciprofloxacin 500mg PO BID once patient’s initial symptoms improve. Treat for a total of 7-10 days.
B. Continue empiric antibiotic at current dose. Once patient experiences initial symptom improvement, switch to Septra DS 1 tablet PO BID. Treat for a total of 14 days.
C. Discontinue empiric antibiotic. Initiate ampicillin 1gm IV q6h. Treat for a total of 14 days.
D. Discontinue empiric antibiotic. Initiate ceftriaxone 1gm IV q24h until patient experiences initial symptom improvement. Switch to cefuroxime 500mg PO BID to complete a total of 14 days of therapy.

Back 117

C. Discontinue empiric antibiotic. Initiate ampicillin 1gm IV q6h. Treat for a total of 14 days.

This is an ampicillin sensitive E. faecium pyelonephritis. Ampicillin concentrates extremely well in the urinary tract. Therapy for pyelonephritis is at least 14 days.
Vancomycin does not need to be used in this case. The organism is sensitive to ampicillin and the patient does not have a PCN allergy. Ciprofloxacin should not be used in the management of enterococcal infections. In addition, this patient needs to be treated for at least 14 days for her pyelonephritis.
Timentin does not provide optimal enterococcal coverage. It is much too broad spectrum of an agent given the known pathogen. Therapy should be tailored to as narrow spectrum agent as possible. In addition, cotrimoxazole does not cover enterococcus.
This is an ampicillin sensitive E. faecium pyelonephritis. Ampicillin concentrates extremely well in the urinary tract. Therapy for pyelonephritis is at least 14 days.
Cephalosporins do not cover enterococcus species.

Front 118

DA is a 34 year old male with a history of quadriplegia secondary to diving accident 15 years ago. At his nursing home, patient was found to have dark, foul smelling urine in foley catheter bag. Pt was unable to describe any symptoms due to neurologic injury. Urine was sent for urinalysis and pt was found to have a urinary tract infection. Pt was transferred from nursing home to the hospital for treatment of a urinary tract infection. He requires chronic foley catheter placement. Patient currently has stage 3-4 decubitus ulcers on buttocks. A CT scan was done in the emergency room and upper tract involvement was ruled out. Patient is admitted for management of catheter related urinary tract infection.
What is the most appropriate treatment plan for DA?
A. Begin empiric therapy with ciprofloxacin 500mg PO BID. Remove the catheter 24 hours after initiation of antibiotic and replace with new sterile foley catheter. Treat for a total of 5 days.
B. Pull the foley catheter immediately and place the patient in a diaper. Perform daily urinalysis to ensure that the infection clears.
C. Pull the foley catheter and replace with new sterile catheter then begin empiric antibiotic therapy with Zosyn 3.375gm IV q6h.
D. Initiate empiric therapy with Cefepime 1gm IV q12h. There is no need to remove the foley catheter as Cefepime will rapidly sterilize both the urine and catheter.

Back 118

A. Begin empiric therapy with ciprofloxacin 500mg PO BID. Remove the catheter 24 hours after initiation of antibiotic and replace with new sterile foley catheter. Treat for a total of 5 days.

The patient requires chronic catheterization. It would not be reasonable to pull the foley entirely and place him in a diaper as he has severe decubitus ulcers on his buttocks and this would exposed these ulcers to contaminated urine which could possibly lead to severe infection.
This would not be an option due to his ulcerations and risk of contamination of ulcers with infected urine.
The urine must be sterilized with 24 hours of antibiotic therapy prior to catheter exchange otherwise the new catheter will become colonized in the infected urine.
The foley must be exchanged.

Front 119

SF is a 38 year old female who presents to the clinic with symptoms of dysuria, urinary frequency, suprapubic heaviness. She denies any fevers, nausea/vomiting, or flank pain. She thinks that she has another UTI. This is the 4th time SF has presented to your clinic with these symptoms in the past 11 months. She has returned to the clinic every 2-3 months. She is very frustrated and upset with the frequency at which these infections occur. The physician asks you recommend an antibiotic treatment regimen for her. The physician also asks for your option on UTI prophylaxis and the best prophylactic regimen(s) to use.

Which of the following is the best therapeutic option for SF?
A. Initiate Septra DS 1 tablet PO BID for 3 days. Once treatment is complete, begin prophylactic regimen of Septra SS 1 tablet PO QHS.
B. Initiate treatment with amoxicillin 500mg po BID for 14 days. She should not need a prophylactic regimen once she completes a long course of therapy.
C. Initiate treatment with ciprofloxacin 500mg PO QD for 3 days. This patient is not a candidate for prophylaxis.
D. Pt does not need treatment. Immediately begin prophylactic therapy with nitrofurantoin 100mg PO QHS.

Back 119

A. Initiate Septra DS 1 tablet PO BID for 3 days. Once treatment is complete, begin prophylactic regimen of Septra SS 1 tablet PO QHS.

This is the best option as she is having > 3 infections per year.
These infections represent reinfection, not relapse. A longer treatment course will not likely prevent future reinfections.
This patient is an ideal candidate as she is having at least 4 reinfections per year.
The current infection must first be treated then prophylactic therapy can begin.