Download Therapeutics III Tutoring February 13th 2016

Therapeutics III Tutoring
February 13th 2016
Lisa Hayes
[email protected]
Outline
• Febrile Neutropenia
• CNS Infections
• Vector Borne/Miscellaneous Infections
Febrile Neutropenia
Key Points to Remember
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Be able to define fever
Be able to define neutropenia
Be able to calculate ANC
Know when to treat for fungal infections
Know who is high/low risk
– Type of cancer, MASCC score
• Know empiric therapy for high and low risk
• Know how to de-escalate (infx v no infx)
• Prophylaxis
Which of the following is defined as a
“fever” in a neutropenic patient?
• A- single oral temp of 38C
• B- sustained oral temp of 39C over 1 hour
period
• C- single axillary temp of 101F
• D- sustained oral temp of 38C over 30 minutes
Calculate the ANC for patient JJ.
WBC: 0.8
Segs: 27%
Bands: 23%
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A- 450
B- 300
C- 400
D- 250
Is GY a high risk or low risk patient
based on the following information?
ANC: 100; line appears infected;
MASCC score 18
• A- high risk
• B- low risk
Recommend an appropriate empiric
regimen for GY. Additional information
– history of positive MRSA nasal swab.
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A- Zosyn only
B- Cefepime + Vancomycin
C- Cipro + Metronidazole
D- Vancomycin only
Patient GY receives antibiotics for 4
days. She is still febrile, and the blood
cultures are still negative. What should
be done now?
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A- redraw blood culture
B- continue current antibiotics until afebrile
C- change current coverage
D- add antifungal coverage
Which of the following is NOT an
option for antifungal coverage?
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A- Fluconazole
B- Amphotericin B
C- Ciprofloxacin
D- Mycamine
You are never able to discover the source of infection for GY.
However, she is now afebrile and has been afebrile for 24 hours.
How long should you recommend continuing the abx?
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A- 10-14 days total
B- Until 48 hours afebrile and ANC is over 500
C- DC abx now
D- change to oral after 72 hours afebrile
What is the drug of choice for
prophylaxis of pneumocystitis jiroveci
pneumonia?
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A- Cipro
B- Doxycyline
C- Septra
D- Clindamycin
Bacterial Meningitis
Things to Know for Bacterial
Meningitis
• Etiology by Age
• Etiology by Co-Morbid condition
• Know what the LP will show if bacterial meningitis is
present
• Most common deficits as result of dx
• Acute v Subacute v Chronic
• Drug Induced Aseptic Meningitis
• Drug Penetration
• Empiric Treatment (and by age)
• Duration of Treatment based on organism identified
• Steroids!
• Prophylaxis – what did she tell you would need to
know for exam?
Which age is most predisposed to
meningitis?
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A – 25-50 years old
B – 15-18 years old
C – under 5 years old
D – over 60 years old
Which organism is more common in
those who are exposed to cigarette
smoking?
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A – S. pneumo
B – H. flu
C – N. meningitidis
D – Listeria
In what age groups must we cover
empirically for LISTERIA?
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A – 4 – 12 wks + 0-4 wks
B – over 50 years and 18-50 years
C – 3mo-18 years and 0-4 wks
D – 0-4wks and over 50 years
When should S. aureus coverage be
provided empirically?
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A – immunocompromised
B – CSF shunts, intracranial manipulation
C – basilar skull fracture
D – partially treated meningitis
Match the following to the appropriate
definition.
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A – Acute meningitis
B – Subacute meningitis
C – chronic meningitis
D – partial treatment
meningitis
• 1 – meningitis with
symptoms lasting over 7
days (usually means viral
picture)
• 2 – antibiotics given prior
to meningitis diagnosis
• 3 – meningitis with
neurologic s/s developing
over 1-7 days
• 4 – presentation within
24 hours of onset of s/s
Which organism has a characteristic
non-blanching rash?
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A – S. pneumo
B – H. flu
C – N. meningitidis
D – Listeria
A LP is performed on a 4 year old with suspected
meningitis. The results are below. His serum glucose is
85mg/dL. Which of the following are characteristic of a
bacterial CNS infection?
• LP results
– WBC: 3K
– Protein: 250
– Glucose: 25mg/dL
• A – none indicate CNS
infection
• B- all indicate CNS
infection
• C – only glucose
• D – only WBC
Which of the following drugs is NOT typically associated
with aseptic meningitis?
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A – doxycyline
B – TMP-SMX
C – lamotrigine
D – ibuprofen
The most common type of meningitis
is secondary to S. pneumo. What is a
common morbidity of this disease?
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A–
B – paralysis
C – loss of hearing
D – loss of eyesight
The gram stain from the LP fluid in a patient, KK, results
with gram-positive cocci. Which of the following
regimens would be appropriate for empiric treatment?
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A – PCN G
B – Ampicillin + AMG
C – Ceftriaxone + AMG
D – Vanc + Ceftriaxone
A patient EW is 3 weeks old and presents with a bulging
fontanel. She is diagnosed with likely meningitis. Which
is appropriate treatment given her age?
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A – Vanc + Ampicillin + ceftriaxone
B – Vanc + cefotaxime
C – Ampicillin + cefotaxime
D – Vanc + ceftriaxone
Pick the pair which does NOT have a
correct duration of treatment.
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A – S. pneumo: 10-14 days
B – N. meningitidis: 7 days
C – Listeria: 10-14 days
D – H. flu – 7 days
GB is a patient whose gram stain results show a beta-lactamase
positive strain of H. flu. Which antibiotic would be most
appropriate?
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A – Ceftriaxone
B – Ampicillin
C – AMG
D – Vancomycin
Steroids (dexamethasone) are used to help with the
morbidity of meningitis (hearing loss). Which of the
following patients would be a good candidate for
steroid therapy?
• A – AA, a 4 week old infant
• B – BB, a 3 year old who presented to the ED
within 12 hours of noticing symptoms and has
received no medications yet
• C – CC, a 35 year old patient who was partially
treated last week before returning today
• D – DD, a 68 year old patient who has arrived to
the neurocritical care unit after receiving 2 doses
of antibiotic in the ED
You selected the correct patient, BB. Now, select the
appropriate dose of dexamethasone and when it
should be given. Pt weight: 18kg
• A – 11mg IV four times daily for 4 days, give first
dose with first antibiotic
• B – 2.7mg IV four times daily for 4 days, give first
dose 1 hour before first antibiotic
• C – 11mg IV daily for duration of antibiotic
therapy, give first dose 1 hour before first
antibiotic
• D – 2.7mg IV four times daily for duration of
antibiotic therapy, give first dose with start of
antibiotics
Vector Borne/Misc Illness
Need to Know for Vector Borne Illness
• Know KEY characteristics of disease
– Including which vector is responsible (tick,
mosquito, etc)
• Know treatment and prevention for each dx
• Know which medications to avoid in dx
JH is a patient who reports recently traveling to Africa. She
returned 7 days ago. She now reports flulike symptoms
accompanied by eye pain. Diagnose her and recommend
treatment.
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A – Dengue, supportive treatment
B – Malaria, Atovaquone
C – West Nile virus, supportive treatment
D – Rocky Mountain Spotted Fever,
Doxycycline
Which type of Plasmodium species is
responsible for the most severe disease?
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A – P. vivax
B – P. ovale
C – P. malariae
D – P. falciparum
Which of the following is not a
recommended treatment for Malaria?
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A – Malarone
B – Quinine + Ciprofloxacin
C – Mefloquine
D – Artemether-lumefantrine
HT is a 25 year old patient who presents with prominent
lymphadenopathy, a maculopapular rash that he reports started
on his chest and moved to his arms and legs. Pertinent labs
include WBC 3K and elevated LFT. Which vector borne illness is
most likely + what drug should you recommend?
• A – Rocky Mountain Spotted Fever,
Chloramphenicol
• B – Erlichiosis, Septra
• C – Rocky Mountain Spotted Fever,
Clindamycin
• D – Erlichiosis, Doxycycline
Which of the following is the drug of
choice for Tularemia?
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A – Gentamicin
B – Ciprofloxacin
C- Streptomycin
D – Levofloxacin
An 8year old patient GE presents with the classic triad of Rocky Mountain
Spotted Fever. The attending in the ER wishes to start the appropriate
treatment. Allergies: PCN Provide a recommendation.
• A – Ciprofloxacin, despite the risk of tendon
rupture
• B – Doxycycline despite the risk of tooth
discoloration
• C – Chloramphenicol – despite history of fatal
outcomes
• D – Cefdinir, recommend monitoring for crosssensitivity
What is the characteristic sign of Lyme disease?
What is the DOC for prophylaxis? Do most
patients require prophylaxis?
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A – maculopapular rash, Cipro, yes
B – Bull’s eye rash, Doxycyline, no
C – maculopapular rash, Ceftin, yes
D – Bull’s eye rash, Amoxicillin, no
Which animal borne disease can be
carried in the stool for up to 5 weeks?
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A - Bartonella
B – Crytposporidium
C – Salmonella
D - Hantavirus
Select the appropriately matched
vector to disease.
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A – Bartonella: cat
B – Cryptosporidium: rodent
C – Hantavirus: cat
D – Brucellosis: bird
A patient tells you he takes Truvada and that he has
been having terrible diarrhea for the last few weeks
after his return from travel abroad. What is most likely?
Treatment?
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A – Salmonella, Septra if at risk for bacteremia
B – Cryptospordium, Nitazoxanide
C – Leptospirosis, Doxycycline
D – Cdiff, Metronidazole
GB is a young otherwise patient who presents to your
clinic with complaints of a painful knot on her calf that
appeared about 1 week after being scratched by her
male kitten. It appears she has Bartonella (cat scratch
fever). Allergies: Septra.
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A – no treatment, will correct on its own
B – Erythromycin 500mg QID x 6wk + rifampin
C – Doxycycline 100mg bid x 6wk
D - Z-pack
A patient has possibly been exposed to rabies via a
rabid squirrel she was trying to feed. She is 4 months
pregnant. What should you recommend?
• A – Wound infiltration with rabies immune
globulin only
• B – 3 rabies vaccine series + choice A
• C – 5 rabies vaccines series + choice A
• D – counseling on not feeding squirrels