1. Therapeutics 3 Tutoring
2/27/17
Melanie

2. Topics
Sepsis
Endocarditis
Vector borne diseases

3. SEPSIS

4. 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

5. 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

6. 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

7. 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.

8. 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

9. 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

10. endocarditis

11. 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

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

13. 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??

14. 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

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

16. zoonoses

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

18. 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

19. 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 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

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

21. 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

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

23. 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

24. 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

25. 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