D&D Integrated Exam I

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D&D Integrated Exam I
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  1. Most common sites of microbial entry:
    MUCOSAL SURFACES
  2. Gram Positive Cocci in Pairs and chains
    • Streptococcus
    • Enterococcus
  3. Gram positive cocci in clusters
    • S. aureus
    • S. epidermidis
  4. Gram Positive Bacilli
    • Listeria
    • Corynebacterium
  5. Gram Negative Cocci
    • Nisseria spp.
    • Moraxella
  6. Gram Negative Bacilli
    • Enterobacteriaciae
    • Pseudomonas
    • Haemophilus
  7. "SPACE" bugs
    Enterobacteriaciae family:

    • Serratia
    • Proteus
    • Acinetobacter
    • Citrobacter
    • Enterobacter
    • E.coli
    • Klebsiella
  8. Gram Positive ANAEROBIC cocci
    • peptococcus
    • peptostreptococcus

    both are oral
  9. Gram positive ANAEROBIC bacilli
    • Clostridium perfringens
    • Clostrdium tetani
    • Clostridium difficile
  10. Gram Negative ANAEROBIC BACILLI
    • B. fragilis
    • B. melaninogenicus
    • Fusobacterium
    • Prevotella
  11. Atypical bacteria missing cell wall
    Mycoplasma: two mentioned

    • 1. Mycobacterium tuberculosis
    • PPD(+)
    • latency
    • 2. Mycobacterium avium intracellulare (MAI)
    • HIV patients get this ===> Mycobacterium Avium Complex (MAC)
  12. Atypical bacteria with no peptidoglycan layer
    • Chlamydia
    • -gram negative obligate intracellular parasite
  13. Fungi known as mold,
    bone marrow transplant patients most affected
    Aspergillus
  14. Fungus
    -most common type
    -vaginal infections
    -diabetics more at risk
    -located throughout alimentary track
    Candida
  15. Fungus:
    -HIV patients
    -CNS symptoms
    -not to be considered if patient is relatively healthy
    Cryptococcus
  16. Fungus:
    -Athlete's foot
    Tinea
  17. More serious hepatitis virus
    • HepB
    • -stays in liver
  18. Herpes
    HS1 ==> cold sores; latency; stays in dermatomes, in nerves

    HS2 ==> Genital tract; latency

    Use suppressive therapy to keep viral load low
  19. Elevated temperature
    normal = 37-37.2 degrees C

    Fever = 37.3 (99.9) or > 38 (100.4)
  20. WBC Differential
    1. Neutrophils: Segs (mature); Bands/Stabs (immature)

    2. Basophils

    3. Eosinophils
  21. Bademia or "Shift to the left"
    • new neutrophils are being made
    • sign of new infection
    • usually when Bands > 10% differential
  22. Normal WBC Count
    4,500 - 10,000

    • Basophils = 0.4-1%
    • Lymphocytes = 25-35%
    • Monocytes = 4-6%
    • Neutrophils = 50-70%
    • Eosinophils = 1-3%
    • Bands (Stabs) = 3-5%
  23. Contaminated sources of cultures
    • Stools
    • Throat Swabs
    • Vaginal/Cervical swabs
  24. Useful for staining fungi
    Calcoflour
  25. Acid Fast Stain
    Rules out Mycobacteria (e.g. TB, MAI)

    • need THREE specimens
    • -LOW sensitivity (need 5000-10000 bacilli/mL to be reliably positive)

    if culture grows, it is specified by PCR
  26. Alternate test for Influenza A and B
    Antigen N/P swab
  27. Alternate test for RSV
    antigen N/P swab
  28. Legionella Alternate test
    Urine Antigen
  29. S. pneumoniae alternate test
    urine antigen
  30. C. difficile alternate test
    Toxin A/Toxin B analysis
  31. Two Major Automated Culture Systems used in hospitals
    • 1. Vitek
    • 2. Microscan
  32. Sputum Culture
    • Rule out pneumonia
    • Gram Stain must have < 25 epithelial cells
  33. CNS cultures
    high opening pressure (>600 mmHg)

    WBC Count ==> 1000 - 5000 mm^3 (mainly neutrophils)

    Decreased Glucose levels (<40 mg/dL)

    Elevated Protein levels
  34. Urine Cultures
    < 10,000 CFU/mL ==> insignificant skin contamination

    10,000 - < 100,000 CFU/mL ==> strongly suggestive

    >100,000 CFU/mL ==> Definitive UTI
  35. UTI
    • CA UTI ==> 85% E.coli
    • HA UTI ==> more evenly split (E. coli; Proteus; Enterobacter; Pseudomonas; Acinetobacter; Serratia; Fungal)
  36. Catheter Tips
    Breakpoint for "infection" ==> > 15 colnies

    TLC ==> Triple Lumen Catheter (3 separate tubes in one catheter to keep everything flowing)
  37. DOC for normal healthy pt. with lower UTI
    Bactrim, oral
  38. Antibiograms
    Hospital compilation of data of all specimens that went to lab in that year

    institution-specific

    helps in developing dosing strategies
  39. Conditions with diminished blood flow at site and need prolonged therapy (4-6 weeks)
    Endocarditis

    Septic Arthritis

    Osteomyelitis

    Abscess
  40. DOC for enterococcus
    Ampicillin

    may add gentamicin for synergystic effect (monitor for nephrotoxicity)
  41. Most accurate method of measuring renal function
    24 hour urine output collection
  42. CVVH
    Continuous Veno-Venous Hemodialysis

    in ICU

    pt. is connected 24/7, unlike outpatient hemodialysis
  43. Child-Pugh Score
    Hepatic Function in Children

    • Total serum bilirubin
    • Serum albumin
    • INR
    • Ascites
    • Encephalopathy

    • Class A ===> 5-6 points
    • Class B ===> 7-9 points
    • Class C ===> 10-15 points
  44. Cardiovascular Patients; must have this checked before administering certain drugs
    SODIUM CONTENT (CHF patients are already on diuretics (e.g. furosemide) that are already hgih in sodium
  45. Seizure Disorder risk
    Carbapenems ===> Primaxin (Imipenem and Cilistatin) is most severe risk
  46. Which carbapenem does NOT cover P. aeruginosa?
    Ertepenem (Invanz)
  47. Can cause HYPO or HYPER Glycemia
    Fluoroquinolones
  48. RS is 80 yo female in MICU for 10 days so far.

    Temp = 39
    Cough, sputum production

    Want to cover HAP with MRSA pneumonia... what therapy?
    Vancomycin and 4th generation cephalosporin (Cefepime)

    Carbapenems (except Ertepenem, which doesn't cover P. aeruginosa)

    • What about Unasyn instead of the cephalosporin with Vancomycin?
    • -Unasyn (Ampicillin and Sulbactam) does not cover P. aeruginosa
  49. What generations of Cephalosporins can enter CNS?
    3rd and 4th generations
  50. Which one would have the highest dose of ceftriaxone?
    - UTI
    -Pneumonia
    -Meningitis
    Meningitis (needs large enough dose to reach the CNS to be effective)
  51. Treatment of Abscess
    DRAINAGE and systemic antibiotic appropriate for the site of infection
  52. PICC Catheter
    Peripheral insertion central line catheter

    can stay in for weeks
  53. Femoral Lines
    groin area insertion

    can be used in emergency

    but are highly susceptible to infection
  54. Antibiotic Lock Therapy
    Salvaging a catheter

    place some systemic IV antibiotic in the lumen of the catheter in an attempt to disinfect the line

    sometimes this is necessary when it is worse to remove and replace a catheter (e.g. chemotherapy patients that are already immunosupressed and have had multiple catheter insertions already
  55. LOCK Dose
    SMALLER (~ 1/10) compared to usual systemic dose of antibiotic
  56. Concentration-Dependent Antibiotics
    • AGs (e.g.Gentamicin, etc.)
    • FQs
    • Ketolides
    • Metronidazole
    • Amphotericin B
    • Daptomycin
  57. Time-Dependent Antibiotics
    • ß-Lactams
    • Macrolides
    • Oxazolidinones
    • Flucytosine
    • Glycopeptides
  58. Drugs that are very expensive in community setting...
    Oral from of Vancomycin

    Linezolid
  59. Pseudomonas coverage
    Cipro and Levo (NOT used for CA pneumonia b/c it has limited gram positive coverage)

    Cipro is excellent for HA Pneumonia b/c it is very gram negative

    • Aminoglycosides
    • Carbapenems (except Ertepenem)
  60. Enterococcus Coverage
    • Ampicillin
    • Vanco
    • Dapto
  61. UTI ===> do we use Avelox (moxifloxacin)?
    NO, Avelox (moxifloxacin) is cleared by liver, NOT kidneys and thus does not reach urinary tract in significant amounts
  62. -84 yo female with UTI
    -culture positive for Pseudomonas aeruginosa, Pan-sensitive
    -patient has penicillin allergy
    -what antibiotic do we use?
    • Ceftriaxone?
    • -NO, does not cover P. aeruginosa
    • -Cefepime would work though

    • Aztreonam:
    • -Yes,
    • -also has less side effect than aminoglycosides (e.g. gentamicin) especially important since she is 84
    • -Aminoglycoside may be necessary if she were septic (would use gentamicin for short term treatment (24-48 hours)

    • -Unasyn (ampicillin and sulbactam)?
    • -NO ==> only Piperacillin or Ticarcillin would work
  63. The Big Four pathogens that cause CAP
    Streptococcus pneumoniae (encapsulated); 70-80% of all cases

    H. influenzae (encapsulated); gram negative; smokers/COPD

    Mycoplasma pneumoniae (walking pneumonia in young healthy adults)

    Legionella pneumophila
  64. Pen-sensitive Strep. pneumonia infection
    DO NOT USE CIPRO

    preferred agents ===> pen V or G; Aminopenicillins
  65. What not to use for Intermediate PEN resistant Strep. pneumoniae infections
    MACROLIDES (azithromycin, clarithromycin, erythromycin)
  66. Preferred agent for H. influenzae infection
    ß-lactamase negative ===> Aminopenicillins

    ß-Lactamase positive ===> ß-lactam/BLI combo; FQs; Doxycycline
  67. What to use against atypical pathogens?
    Drugs affecting ribosomes or DNA

    • Macrolides
    • FQs
  68. Mycoplasma pneumonia treatment
    • Macrolides
    •  or
    • Doxycycline
    • or
    • FQs (all FQs work)
  69. Signs/Symptoms and Risk Factors of Legionella pneumonia infection?
    S/S ===> high fever, hyponatremia, CNS manifestations, GI side effects, headache

    Risk Factors ===> age, smoking, immunocompromised conditions
  70. Legionella Treatment
    Erythromycin with or without Rifamin

    Azithromycin or FQ is preferred for severe disease
  71. Pregnant female with pneumonia... DO NOT TREAT WITH...
    DOXYCYCLINE (not used in pregnancy or children < 8 years of age)

    FQs may also be teratogenic
  72. Risk Factors and unique signs/symptoms of legionella pneumonia
    risk factors ===> age, smoking/COPD

    Presentation ===> more systemic (e.g. nausea, vomiting, diarrhea, headache, confusion, hyponatremia)
  73. Agents used to treat legionella
    ANY FQ (moxi, cipro, levo)

    Macrolide (Azithromycin > Erythromycin due to excellent intracellular conc. and legionella is an intracellular microbe)
  74. Treatment of Ambulatory pt. for pneumonia (relatively young and healthy)
    has to cover Strep. Haemophilus, and Atypicals

    FQs monotherapy (UNLESS PREGNANT)

    Doxcycline monotherapy

    Macrolide monotherapy

    Macrolide + Ampicilln/Sulbactam if recently on antibiotics
  75. What empirical antibioitc regimens can be used in patients admitted to the general medical ward for treatment of pneumonia?
    FQs alone (covers strep. haemophilus, and atypicals)

    Macrolide (Azithro IV) ==> with Cephalosporin (Ceftriaxone) OR ß-Lactam/BLI combination
  76. Can cephalosporins be used in patients allergic to penicillins?
    NO ===> IF Type I allergic rxn (anaphylaxis)

    YES ===> IF Type II alergic rxn (delayed type, mild rash)
  77. What antibiotics can be used to treat, empirically, patients in the general medical ward?
    FQs alone

    Combination of Macrolide (IV Azithro) with Cephalosporin (Ceftriaxone)

    ß-Lactam and BLI (Piperacillin/Tazobactam)
  78. Risk factors and unique signs and symptoms of legionella pneumonia
    Risk factors ===> elderly; Smoking or COPD

    Presentation ==> more systemic, other organs involved
  79. Agent used to treat legionella
    Any FQ (moxi, cipro, levo)

    Macrolide (Azithro IV)
  80. Treatment in ambulatory patient (relatively young and healthy) for pneumonia.
    Covers strep, haemophilus, and atypicals

    FQs alone

    Doxycycline alone

    Macrolide alone

    MAcrolide + Ampicillin/Sulbactam (Unasyn) if they have been on Abx recently
  81. Pregnant ambulatory patient with pneumonia
    DO NOT USED FQs or Doxy
  82. What empirical antibiotic regimens can be used in pts. admitted to the general medical ward for treatment of pneumonia?
    FQs alone

    Macrolide (azithro IV) with either Ceftriaxone or BLA/BLI combination
  83. Can cephalosporins be used in patients who are allergic to penicillin?
    NO (if type I allergic reaction)

    YES (if delayed type II)
  84. What antibiotics can be used to treat (empirically) patients in the general medical ward?
    FQs alone

    Combination of Macrolide (IV Azithromycin) and Cephalosporin (Ceftriaxone)

    BLA/BLI combination
  85. Most severe serotype of influenza
    A
  86. Influenza risk factors
    Children < 2 years old (10 x increased risk of hospitalization due to severe infection)

    Chronic comorbidities

    Transplant patients
  87. Influenza Treatment
    Oseltamivir (Tamiflu) ===> suspension or capsule

    Zanamavir ===> inhalation
  88. young, relatively healthy patient has flu symptoms for 4 days now. What agent do you treat with?
    NONE
  89. Patient is hospitalized. No matter how long he has had symptoms, what can you use?
    Oseltamavir ONLY (reduces risk of death)
  90. Oseltamivir (Tamiflu) Dosing
    75 mg BID x 5 days, initiated within 2 days of symptom onset

    prophylaxis ==> 75 mg QD x 10 days
  91. Zanamivir (Relenza) Dosing
    Two- 5 mg inhalations BID x 5 days
  92. Zanamivir Warning/Precaution
    MUST BE USED WITH SPECIAL PIZZA
  93. What pts. should receive antiviral treatment for influenza?
    • Patients having symptoms in first 48 hours of onset
    • children < 2
    • patients > 65
    • pts. with comorbidities
  94. Watery Diarrhea Main Treatment
    Rehydration Therapy, GLUCOSE BASED
  95. Two Pharmacologic treatments of watery diarrhea
    OTC ===> Loperamide (Immodium)

    • Rx ===> Diphenoxylate/Atropine (Lomotil)
    • (more side effects; anticholinergic; narcotic derivative)
  96. Traveler's Diarrhea OTC Treatment
    Bismuth Subsalicylate (Pepto-Bismol)
  97. Bismuth Subsalicylate (Pepto-Bismol) counseling
    • Aspirin derivative (allergy)
    • disturbs gastric and duodenol ulcers
    • bismuth can discolor tongue and stools
  98. Traveler's diarrhea of Latin America/Africa
    FQs
  99. Traveler's Diarrhea of SE Asia
    Azithromycin Oral (FQs have increased resistance)
  100. Traveler's Diarrhea Prophylaxis
    DISCOURAGED (resistance risk and photosensitivity from FQs)
  101. Meds associated with C. difficile Colitis
    • Ampicillin
    • Clindamycin
    • Cephalosporins
    • FQs
  102. C. difficile colitis treatment
    Metronidazole (DOC) if WBC count < 15000

    Vancomycin (if high white counts/sepsis)
  103. Giardia caused by...
    Protozoa from still fresh water
  104. Giardia Treatment
    Metronidazole (NOT FDA-approved but IS DOC)

    Tindamax or Alinia (FDA-approved drugs but expensive and not carried often by pharmacies)
  105. Metronidazole Counseling
    • Do not drink alcohol (dilsulfuram reaction)
    • Metallic taste possible
    • Neuropathies (tingling of hands/feet, etc.)
  106. Live Vaccines
    • Measles
    • Varicella
    • Herpes Zoster
    • Rotavirus
    • Intranasal Influenza
    • Yellow Fever (no longer used)
    • Oral Typhoid Capsules (no longer used)
  107. Live Vaccine Contraindications
    Immunocompromised conditions

    Pregnancy (may transmit live virus to fetus)
  108. T-Cell INdependent immunity
    Polysaccharide vaccines
  109. Polysaccharide vaccine Disadvantages
    NOT consistently immunogenic for children < 2 years of age

    NO booster effect

    SHORT LIVED immunity
  110. T-Cell DEpendent immunization
    Conjugated Polysaccharide Vaccines
  111. Guidelines to immunizations
    Can administer as many vaccines (live or inactivated)at once as you want

    Live vaccines ==> either all at once or must separate by 4 weeks

    Inactivated Vaccines ==> can be sporadically done (e.g. 2 on monday, 1 on wednesday, 5 on saturday, etc)
  112. Vaccination series guidelines
    okay to give later than normal

    CANNOT give earlier than normal (considered as it never occurred)
  113. Who should receive the seasonal influenza vaccine?
    ALL INDIVIDUALS > 6 MONTHS SHOULD RECEIVE ON A YEARLY BASIS

    ESPECIALLY IF PREGNANT!!
  114. Inactivated Influenza Vaccine (IIV)
    • 3-4 antigens
    • IM injection
    • 90% effective in healthy young adults
    • 50-60% effective in pts. >65
    • 30-40% effective among frail elderly

    CANNOT CAUSE INFLUENZA (it is impossible)

    Well tolerated, high safety
  115. Live Attentuated Influenza Vaccine (LAIV, FluMist)
    covers 2A and 2B viruses (same as IIV)

    COLD-ADAPTED (virus cannot replicate at body temp.)

    • FOR HEALTHY INDIVIDUALS 2-49 years old
    • NOT FOR HIGH RISK PATIENTS
  116. Patient has legionella pneumonia in hospital, with many comorbidities.

    Do we give the LAIV?
    NO NO NO
  117. Leading cause of CA pneumonia, meningitis, and bacteremia
    Streptococcus pneumoniae
  118. Streptococcus pneumoniae risk factors
    • elderly
    • asplenic
    • Chronic CVD or Respiratory Disease conditions (infection may exacerbate stress on CV system, higher risk of MI)

    • Metabolic Conditions (e.g. diabetes)
    • Immunocompromised
  119. Polysaccharide Pneumococcal Vaccine (PSV)
    • Pneumovax
    • SHORT DOA
    • NOT FOR CHILDREN
    • covers 23 strains
    • better against bacteremia than pneumonia
  120. Polysaccharide Pneumococcal Vaccine Indications
    • ALL ADULTS > 65
    • people 2-65 years with comorbidities
    • adults 19-64 who smoke/have Asthma
  121. Legionnaire patient, 65 years old, smokes, has lung disease. Do we give Polysaccharide Pneumococcal Vaccine?
    YES
  122. Polysaccharide Pneumococcal Vaccine re-vaccination
    ONCE

    people at highest risk of death (asplenic, nephrotic syndrome, immunocompromised; if > 5 years after initial dose)

    People > 65 who received initial dose >5 years ago when they were < 65

    Children who received initial dose > 3 years ago and will be < 10 years old at time of revaccination
  123. PCV13 (Prevnar)
    Conjugated Polysaccharide Pneumococcal Vaccine
  124. PCV13
    • ALL children with vaccine series starting at 2 months of age
    • FDA approved for adults > 50 years old
    • CDC advises for people > 10 years old with immunocompromised condition (given along with the Polysaccharide vaccine)
  125. Whooping Cough (Pertussis)
    Bordetella pertussis

    more severe among children < 5 years old

    susceptible to macrolides (azithromycin)
  126. Tetanus, Diphtheria, Pertussis Vaccinations
    • 1. DTaP
    • -High dose (capital letters)
    • -children at 2 months
    • -with booster doses until 7 years old

    • 2. Tdap
    • -lower doses
    • pts. > 11 years of age
    • ONCE as adult
  127. Legionella pneumonia pt., 65 yrs old, do we give this pt. DTaP?
    NO

    They get Tdap
  128. Most common STD in the world
    Human Papilloma Virus (HPV)
  129. Main HPV types
    High Risk ===> 16 and 18

    Low Risk ===> 6 and 11
  130. HPV vaccine adverse effect
    syncope (sudden loss of consciousness) in 13-16% of pts. withing 15-20 minutes of immunization
  131. Gardasil (Merck)
    inactivated, quadrivalent vaccine

    covers 6, 11, 16, 18

    prevention of cervical, vaginal, and vulvar cancers (female) and genital warts in both females and males

    3-shot series
  132. if patient already has HPV infection, should they still get the Gardasil vaccine?
    yes, it will protect them form the other 3 serotypes they don't have.
  133. Cervarix (GSK)
    inactivated, bivalent vaccine

    covers 16 and 18

    only approved for prevention of cervical cancer in female patients
  134. Varicella Vaccine
    LIVE Vaccine ===> given after first 12 months of age (due to maternal antibodies in infant)

    mild case of chicken pox may occur upon vaccination
  135. Herpes Zoster Vaccine
    Zostavax

    Individuals over 50 years of age (CDC recommends this age to be 60 due to waning of immunity issues)
  136. Meningococcal Disease
    Neisseria meningitidis

    Serotype B ==> less antigenic (no vaccine available)

    vaccine protects 4 of 5 most common serotypes (just not B)

    sub-sahara africa ==> meningitis belt
  137. At risk for meningococcal infection
    college freshmen

    military recruits

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