Therapeutics 3 Tutoring 2/27/17 Melanie JAEGER-MJAEGER3@UTHSC.EDU

Topics Sepsis Endocarditis Vector borne diseases

SEPSIS

1. Which of the following statements is false? Nitric oxide formation is responsible for vasodilation seen in sepsis. An example of an intravascular source of bacteremia is endocarditis. Peptidoglycan in gram negative organisms is responsible for the initiation of the SIRS response. Patients can have SIRS without any infection. C

2. PH arrives to the ed with suspected sepsis 2. PH arrives to the ed with suspected sepsis. Which of the following statements is true about initial resuscitation for ph? Colloids are the fluid of choice. Fluids should be given at 30 mL/kg. Target MAP is 80 Fluids must be started within 1 hour. B

3. Which of the following iv antibiotic regimens would be appropriate for empiric therapy for ph? Zosyn started within 3 hours Vancomycin plus ampicillin/sulbactam within 1 hour Meropenem started within 2 hours Cefazolin started within 1 hour B

4. Ph has received a substantial amount of fluids but map is still 55 4. Ph has received a substantial amount of fluids but map is still 55. what should be the next step in therapy? Norepinephrine Dobutamine Vasopressin Dopamine A.

5. PH has now received fluids and NE 5. PH has now received fluids and NE. MAP is still not to goal, and the physician wants to limit further doses of ne. What would you suggest as the next step in therapy? Dopamine Low dose vasopressin High dose vasopressin steroids B

6. PH is still not responding to therapy after fluids and pressors 6. PH is still not responding to therapy after fluids and pressors. What would you recommend for the next step in therapy? Methylprednisolone 250 mg IV Methylprednisolone 500 mg IV Hydrocortisone 100 mg IV Hydrocortisone 500 mg IV C

endocarditis

7. Which of these statements about endocarditis is true? Mechanical heart valves are higher risk than bio-prosthetic valves after the first year. IV drug users are at greater risk of mitral valve endocarditis than tricuspid valve. Osler’s nodes are one of the major criteria for diagnosis of IE. Patients with a prosthetic valve undergoing oral surgery should receive one dose of amoxicillin 2 grams as prophylaxis for IE. D

8. The most common cause of native valve ie is..? Enterococcus S. aureus CoNS strep pyogenes B

9. The most common cause of prosthetic valve ie from 2-12 months is..? Enterococcus S. aureus CoNS strep pyogenes C What about after 12 months for prosthetic valves??

10. SM is found to have MSSA endocarditis 10. SM is found to have MSSA endocarditis. She has a pmh significant for valve replacement 3 years ago. What is the most appropriate treatment option for her? A. Nafcillin 12g daily + cefazolin 6g daily for 6 weeks B. Vancomycin 30 mg/kg q24 + rifampin 300 mg q8hrs for 6 weeks C. Nafcillin 12g daily + rifampin q8hrs for 6 weeks + 2 weeks of gentamicin D. Ceftriaxone 2g IV q24hrs for 6 weeks + 2 weeks of gentamicin C

11. Enterococcus endocarditis should be treated with..? Vancomycin+gentamicin Zosyn+tobramycin Vancomycin+streptomycin ceftriaxone A

zoonoses

12. The drug of choice for erlichiosis is..? Ceftriaxone Doxycycline Ciprofloxacin amoxicillin B doxycycline 100 mg q12h

13. Patient kl presents with a rash on his hands and feet which appeared a couple days after having a fever. What is the most likely diagnosis based on these symptoms? Tularemia Lyme disease Babesiosis Rocky mountain spotted fever D

14. KL is diagnosed with rocky mountain spotted fever 14. KL is diagnosed with rocky mountain spotted fever. What is the doc for his treatment? Amoxicillin 500 mg q8 x 14-21 days Azithromycin 500 mg q24 x 7-10 days Doxycycline 100 mg daily x 14 days Doxycycline 100 mg q12 x 7-14 days D

15. Which of the following is characterized by arthritis symptoms and erythema migrans? Rabies Salmonellosis Lyme disease tularemia C (late) lyme disease

16. Which of these options would be an appropriate regimen for malaria prophylaxis? Doxycycline 100 mg daily, starting 1-2 days before and continuing for 2 weeks after Atovaquone 1 tablet daily, starting 1-2 days before and continuing 7 days after Chloroquine 1 tablet weekly, starting 2 weeks before and continuing 2 weeks after Mefloquine 1 tablet once daily, starting 2 weeks before and continuing 4 weeks after B

17. Which of these diseases is characterized by flulike symptoms and asymmetric paralysis? Yellow fever West nile Brucellosis malaria B

18. Match the disease with the vector Tularemia Malaria Erlichiosis SARS Mosquito Lone Star tick Rabbit Animals/humans Tularemia-rabbit Malaria-mosquito Erlichiosis-tick SARS-animals/humans

Tips for febrile neutropenia Know how to calculate ANC ANC=WBCx(%segs+%bands)/100 Know definition of fever and neutropenia Know MASCC>21 is low risk, <21 is high risk Know when you can de-escalate therapy No fever for 48 hours and ANC>100 and rising

Tips for tb Drug-resistant TB: resistant to INH/rifampin, any FQ, and at least one of 3 injectable 2nd line-->treat with 4-5 drugs it’s susceptible to Everyone is going to get RIPE the first two months Hepatotoxicity can be occurring due to INH without any rise in AST-> maybe monitor AST more often Vit B6 for INH peripheral neurotoxicity Phenytoin DDI: on rifampin (inducer) and INH (inhibitor) rifampin wins out-> increase the dose of phenytoin Pt with HIV gets rifabutin instead of rifampin New treatment option: INH 900 mg + rifapentine 900 mg once WEEKLY for 3 months Traditional: INH 300 mg daily x 9 months Get less hepatotoxicity and better treatment compliance with combo