Ciprofloxacin
Vancomycin
Trimethoprim-sulfamethoxazole
Ceftriaxone
Ceftazidime
1
Oral trimethoprim-sulfamethoxazole
Oral azithromycin
Oral levofloxacin
Oral cefuroxime axetil
Intravenous vancomycin
Streptococcus bovis
Streptococcus meliri
Staphylococcus aureus
Coagulase-negative staph.
Enterococcus faecium
Azithromycin
2.
Vancomycin
3.
Ceftazidime
4.
Trimethoprim-sulfamethoxazole
5.
Ciprofloxacin
Campylobacter jejuni
2.
Salmonella typhi
3.
Shigella dysenteriae
4.
5.
Salmonella typhimurium
Plesiomonas shigelloides
10
A 29-year-old man who currently uses injection drugs presents with fever
and rigors. On physical examination, his temperature is 40 C. There are
hemorrhagic papular lesions on his distal left index finger and right great
toe and petechiae in the palpebral conjunctivae. The lungs are clear.
Cardiac examination shows a grade 2/6 systolic ejection murmur and a
grade 2/4 diastolic murmur at the upper right and lower left sternal border.
Abdominal examination is unremarkable, and there are no joint effusions or
tenderness. Leukocyte count is 19,000/L, and serum creatinine is 1.2
mg/dL. Four sets of blood cultures grow gram-positive cocci in clusters,
and vancomycin and gentamicin are begun. The next day, the blood
isolates are identified as methicillin-susceptible Staphylococcus aureus.
You choose to continue gentamicin.
Which of the following changes should also be made in the antibiotic
regimen?
1.
2.
3.
4.
5.
Continue vancomycin
Change vancomycin to nafcillin
Change vancomycin to ceftriaxone
Change vancomycin to ciprofloxacin
Add rifampin
11
12
A 66-year-old man with a history of significant renal failure due to poorly controlled
hypertension is admitted to the intensive care unit following a large subarachnoid
hemorrhage. He required intubation on arrival and has remained ventilated for 3
weeks. Seven days after admission, he developed a catheter-associated urinary tract
infection due to Escherichia coli, which was treated with ceftriaxone for 7 days. Two
days ago (4 weeks after admission), he developed a fever to 39.2 C, and thick,
purulent sputum was suctioned from his endotracheal tube. A chest radiograph
showed evidence of a new right lower lobe infiltrate. A Gram's stain of an
endotracheal tube aspirate showed abundant polymorphonuclear cells and gramnegative rods. Blood samples were obtained for culture, and the patient was started
on empiric therapy with ceftriaxone.
This morning, the patient is still febrile and requires vasopressors to maintain his
blood pressure. You receive a call from the microbiology laboratory to tell you that the
patient's blood cultures are positive for gram-negative rods. The microbiologist also
informs you that the endotracheal aspirate is growing E. coli with the following
sensitivity pattern:
Ampicillin:Resistant
Cefazolin:Resistant
Cefuroxime:Resistant
Ceftriaxone:Sensitive
Ceftazidime:Resistant
Gentamicin:Sensitive
Trim-sulfa:Resistant
Ciprofloxacin:Resistant
Imipenem:Sensitive
What should you do next to manage this patient's infection?
1. Continue the ceftriaxone
2. Discontinue the ceftriaxone and start gentamicin
3. Continue the ceftriaxone and add gentamicin
4. Discontinue the ceftriaxone and start imipenem
5. Continue the ceftriaxone and add imipenem
13
14
An 80-year-old woman is admitted to the coronary care unit following a large inferior
myocardial infarction. She required immediate intubation and ventilatory assistance. One
week after her admission, she developed pneumonia, for which she was treated with a 2week course of imipenem. During this time, she also developed moderate renal failure,
which was believed to be due to poor renal perfusion, and an indwelling urinary catheter
was inserted to monitor her urine output.
Her clinical status gradually improved, and she was extubated 4 weeks after admission.
She was transferred to a medical ward 3 days later. Five weeks after admission, the
patient developed a fever and rigors, and blood cultures grew methicillin-resistant
Staphylococcus aureus , which was believed to have originated from an infected peripheral
intravenous catheter site. The catheter was removed, and she was treated with a 2-week
course of vancomycin.
She continued to improve slowly with daily physical and occupational therapy. Six weeks
after admission, a urine specimen was taken from the indwelling catheter as it was being
changed and was sent for culture. Forty-eight hours later, the following identification and
sensitivity report was issued from the microbiology laboratory:
Identification:Enterococcus faecium
Ampicillin:Resistant
Gentamicin:Resistant
Streptomycin:Resistant
Teicoplanin:Sensitive
Vancomycin:Resistant
The patient denies fevers, chills, and dysuria. Her neutrophil count is within normal limits.
Your next action should be to:
1. Start ciprofloxacin and doxycycline
2. Remove the catheter and observe the patient
3. Obtain and start teicoplanin
4. Start linezolid
5. Start quinupristin/dalfopristin
15
16
3.
4.
5.
17
A 68-year-old diabetic man was recently discharged from the hospital after treatment
for congestive heart failure. While in the hospital, he was found to be colonized with
methicillin-resistant Staphylococcus aureus (MRSA) and received chlorhexidine baths
and intranasal mupirocin. He was also found to have peripheral neuropathy and a
chronic, inactive, small ulcer over the head of the right metatarsal.
The patient's son calls this morning to tell you that his hather is very confused,
feverish, and sweaty and that his right foot is swollen and red. You ask him to bring
him to the hospital, and you meet him in the emergency room. On physical
examination, the patient's right foot is inflamed and foul-smelling.
Laboratory studies:
Leukocyte count 13,000/L Hemoglobin 11.8 g/dL Blood glucose16 mol/dL Gram's
stain of a specimen from the foot ulcer Gram-negative bacilli, gram-positive cocci in
chains, and gram-positive cocci in clusters
Which of the following is the best therapy for this patient?
1.
2.
3.
4.
5.
Imipenem
Cefazolin and metronidazole
Nafcillin, ceftriaxone, and metronidazole
Vancomycin, ceftriaxone, and metronidazole
Quinupristin/dalfopristin
18
2.
3.
4.
19
A 29-year-old man is admitted to the hospital with communityacquired pneumonia. Blood cultures yield Streptococcus
pneumoniae resistant to penicillin (MIC = 4.0 g/mL).
Azithromycin
Ceftriaxone
Amoxicillin
Levofloxacin
Trimethoprim-sulfamethoxazole
20
A 68-year-old paraplegic man is transferred to the hospital from the nursing home
because he has fever and mild confusion. His general physical examination is
unchanged since his last office visit, except that over the sacrum he has a deep
decubitus ulcer that has developed and progressed rapidly. The admitting
physician performs local dbridement and wound care and prescribes imipenem
for possible sepsis. On the third hospital day, the patient is clinically better, and a
blood culture from admission and deep-tissue cultures from the dbridement both
show Klebsiella pneumoniae with the following resistance phenotype:
Ampicillin-Resistant
Cefazolin-Resistant
Ceftriaxone-Susceptible
Ceftazidime-Resistant
Imipenem-Susceptible
Ciprofloxacin-Resistant
Tobramycin-Susceptible
Which of the following treatment choices is most reasonable at this point?
1.
Continue imipenem
2.
Change to ceftriaxone; add anaerobic coverage
3.
Change to tobramycin; add anaerobic coverage
4.
Change to moxifloxacin alone for broader-spectrum fluoroquinolone coverage
5.
Stop antibiotics, as dbridement has removed the source of the infection
21
1.
2.
3.
4.
22
2.
3.
4.
24
2.
3.
4.
25
29
30
31
1.
2.
3.
4.
5.
32
Mycobacterium tuberculosis
Staphylococcus aureus
Pseudomonas aeruginosa
Klebsiella pneumoniae
Mixed alpha streptococci and anaerobes
33