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FY1 Antimicrobial Prescribing

Assessment

Name of FY1 Doctor …………………………………

Questions Summary

Short questions Mark Pass/Fail

Question 1
Question 2
Question 3
Question 4
Question 5
Question 6
Question 7
Question 8

Overall mark: PASS / FAIL


Antimicrobial Prescribing Assessment

As part of the Trust’s mandatory induction training, all new FY1 doctors are
required to complete an Antimicrobial Prescribing Assessment during their
induction.

All completed assessments should be returned to Rebecca Greaves


(FY1 Programme Administrator) in by 4th August 2017.

FY1s who fail to complete the assessment within the given timescale will be
sent a reminder and be expected to complete and return the assessment
within a week of receiving this reminder. Failure to complete the assessment
will be notified to the FY1’s Supervisor for extra support and guidance.

All FY1s must PASS this assessment. Any FY1 who does not pass will be
required to re-take the assessment. A second failure will result in remedial
training and probable direct supervision of their prescribing until deemed
competent by their supervisor.

Form of assessment:

The following assessment is a set of short answer questions that can be


answered by referring to the Antimicrobial Formulary.

These questions are based on the Appropriate Antibiotic Prescribing for


Tomorrow’s Doctor Project, supported by the British Society for Antimicrobial
Chemotherapy and the University of Dundee Medical School.

Questions have been adapted to suit the Blackpool, Fylde and Wyre NHS
Foundation Trust Antimicrobial Formulary.

Time allowance:

The assessment should take no longer than 45 minutes to complete.

Resources available:

The Antimicrobial Formulary/ ‘App’ is accessible from the homepage of the


Trust Intranet or via the ‘app’ is available via this link:

http://www.bfwh.nhs.uk/mobile/amformulary/index.shtml

BNF is also available on the Trust Intranet.


Short Questions

1). A 65-year-old man has been unwell for 5 days. He developed a high fever
and productive cough with small amounts of sputum. Over the next 2 days he
deteriorated becoming mildly confused and short of breath. He was given
amoxicillin by his GP. His condition did not improve and his wife became
increasingly concerned. His GP is worried that he may have community-
acquired pneumonia (CAP) and has requested urgent assessment and
inpatient care if appropriate.

PMH: hypertension
SH: smoker 20 cigarettes/day, occasional beer 8 units/week
FH: Nil
DH:
Amoxicillin 500mg tds for 5 days from GP (has had 2 days),
Bendroflumethiazide 2.5mg od
Perindopril 4mg on

On examination:
Pyrexia, temp 39ºC
Mild dehydration
Slight confusion
Pulse 96bpm
RR 26/min
BP160/80
CXR – right basal consolidation

Investigations:
Ur 8.3 mmol/L Cr 90μmol/L
WCC 13.5 x 109/L
CRP 230mg/L

Imp: Community Acquired Pneumonia

(a) What is the severity of this patient’s pneumonia? (2 marks)

(b) What antibiotic treatment would you recommend for this patient?
(2 marks)

(c) What are the most likely causative organisms for this patient’s
pneumonia? (2 marks)
One week later, the gentleman has completed his course of antibiotics and
has been much improved. A few days later you are asked to review the
patient when he has suddenly deteriorated, with shortness of breath, pyrexia,
cough, raised WCC and RR 35/min, oxygen saturation 90% on room air.

(d) What is the likely diagnosis? (2 marks)

(e) What antibiotic treatment would you recommend for this patient?
(2 marks)
2) You are working on a general surgical ward. A patient is admitted for
emergency splenectomy, following a road traffic accident. The patient is on
cefuroxime and metronidazole as surgical prophylaxis (standard one dose at
induction, and two doses post-op). After his operation, the patient is
transferred to HDU. On day 2, the Nurse asks you whether the patient should
continue on antibiotics, the patient is currently NBM. The patient has no signs
of infection, fever, or raised infection markers.

(a) Does surgical prophylaxis need to be continued in this patient?


(1 mark)

(b) Does this patient require antibiotics for any other reason, if yes, what
would you recommend? (1 mark)

After a few days the patient is transferred to a general surgical ward and is
now able to eat and drink.

(c) What changes would you make to this patient’s antibiotic therapy?
(1 mark)

(d) How long will this patient have to continue taking antibiotics for?
(1 mark)

(e) What vaccinations doses this patient require post splenectomy?


(5 marks)

(f) When can these vaccines be given in the event of an emergency


splenectomy? (1 mark)
3). A 75-year-old woman is diagnosed by the surgical team with a superficial
wound infection following internal fixation of a fractured neck of femur. On
admission a wound swab is taken, this has grown MRSA. The patient is
septic, and the Consultant Microbiologist recommends treatment with IV
vancomycin. The patient weighs 57kg, and her serum creatinine is 98 μmol/L.

(a) What is this patient’s estimated creatinine clearance (mL/min)?


(1 mark)

(b) What dose of vancomycin should she receive and how often?
(1 mark)

(c) What monitoring does this patient’s vancomycin therapy require?


(1 mark)

You prescribe an appropriate dose of IV vancomycin.

A pre-dose vancomycin level is taken and is 20.8mg/L. Her renal function


remains stable.

(d) Do you need to make any changes to this patient’s vancomycin


therapy, if so, what? (1 mark)

(e) What is the maximum rate of infusion for IV vancomycin and what
problems are associated with rapid administration? (2 marks)
After a couple of weeks on IV vancomycin therapy, the patient’s condition is
much improved. Her CRP is now within range, and the wound is healing well.
Your SHO asks you to discharge the patient on oral antibiotics for a further
two weeks.

(f) Is oral antibiotics recommended for discharge? Explain your reason. ( 2


marks)

(g) Nurse suggested oral vancomycin treatment, is this appropriate for this
patient’s infection? Explain your answer. ( 2 marks)

4). A patient has been receiving co-amoxiclav and clarithromycin for severe
Community Acquired Pneumonia and has developed a florid rash. The rash is
a likely adverse drug reaction to antibiotic therapy.

(a) Which of the two drugs is most likely to be responsible for the rash? (5
marks)

(b) Which of the following drug(s) may the patient also be allergic to?
(5marks)
a. Amoxicillin
b. Flucloxacillin
c. Ciprofloxacin
d. Tazocin® (Piperacillin-tazobactam)
e. Cefuroxime
f. Vancomycin
5). A 56 year old woman is receiving gentamicin for severe sepsis associated
with pyelonephritis. She weighs 63kg, and her serum creatinine is 80mmol/L.
She was prescribed 300mg gentamicin once daily and has received 1 dose.
Klebsiella has been grown from blood cultures; this is sensitive to gentamicin.
The Microbiologist wishes gentamicin to continue, and recommends that you
monitor her renal function and gentamicin levels. A blood sample is taken
one hour after her second dose, and the result is 12.6mg/L.

Consult the local Antimicrobial formulary and Once Daily Dosing Gentamicin
Monitoring Guidelines Summary.

(a) What is the significance of this gentamicin result? ( 2 marks)

(b) When should gentamicin levels have been taken in a patient receiving
once daily gentamicin therapy (according to the Antimicrobial
Formulary)? (2 mark)

A blood sample is taken immediately pre-3rd dose. The result is 1.5mg/L.

(c) What is the significance of this gentamicin result? Would you make
any changes to the patient’s gentamicin regime? If so, what? (4 marks)

(c) When would you recommend that gentamicin levels are repeated? (2
marks)
6) A 78 year old man has a long term catheter following a stroke. Six weeks
ago the Nurses noted that his urine was unusually smelly and sent a sample
for culture, which grew E.coli sensitive to co-amoxiclav, but resistant to
trimethoprim. He was afebrile with normal pulse, respiratory rate and white
cell count. He was treated with oral co-amoxiclav and developed severe
diarrhoea 5 days later. A stool sample was taken, and tested positive for
Clostridium difficile toxin. He was treated with metronidazole for 10 days for
his clostridium difficile infection. The co-amoxiclav was continued to complete
the intended 7 day course in total.

His diarrhoea improved on metronidazole but recurred when it was stopped.


He received a second 14 day course of metronidazole. A few days later he
again has persistent diarrhoea and mildly raised white cell count and some
abdominal tenderness, but continues to be afebrile with normal pulse and
respiratory rate. There are no signs of colonic dilatation or ileus.

(a) Does the patient meet the criteria for giving oral vancomycin? (2 mark)

(b) What treatment should be prescribed? (5 marks)

(c) Was the original prescription for co-amoxiclav justified? ( 3 marks)

7. One of the Nurses mentions that Pharmacy have left a message saying
that linezolid is a restricted antimicrobial and you cannot prescribe it. What
course of action do you take if you wish to prescribe linezolid?
8). A 75 year old male is admitted to the Clinical Decision Unit with
exacerbation of COPD over the bank holiday weekend.

Past medical history: epilepsy, AF, COPD

Drug history: Tegretol MR 400mg bd


Bisoprolol 2.5mg od
Warfarin usual dose 4mg od (target INR 2.5 for AF)
Symbicort 400/12 1 bd
Salbutamol inhaler 2 prn
Had ciprofloxacin from GP in Glasgow

He is allergic to penicillin – severe rash, swelling of lips, difficulties in


breathing. Similar reaction with cephalosporins

U+Es, LFTs normal, WCC raised slightly


INR 2.4 on admission and day 3 INR 2.9

The on-call doctor prescribed empiric intravenous ciprofloxacin IV 400mg bd


on admission and the patient has been receiving this for the last 3 days (and
no check by pharmacist or microbiologist).

a) What would you counsel your patient on regarding the use of


ciprofloxacin side effect? ( 2 marks)

b) s ciprofloxacin safe to use in someone on Tegretol? (2 marks)

Your patient then develops diarrhoea and stool sample came back as
clostridium difficile toxin positive .

c) What is the likely cause? (2 marks)

The sputum has grown Haemophilus influenzae which is sensitive to


doxycycline, co-amoxiclav.

d) List any change you would like to make to the current treatment plan if
necessary. (4 marks)