BCGP / Infectious disease

Answer D. Primary treatment for stenotrophomonas maltophilia is SMX-TMP. Meropenem, ciprofloxacin, and vancomycin have no coverage.
Reference:
Gilbert D. The Sanford Guide to Antimicrobial Therapy 2014. Sperryville, Va.: Antimicrobial Therapy; 2014

Answer D. Advanced age, previous antimicrobial usage, duration of hospitalization, cancer chemotherapy, GI surgery, tube feeding, and use of acid-suppressing medications.
Reference:
Cohen S, Gerding D, Johnson S et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults: 2010 Update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA). Infection Control and Hospital Epidemiology. 2010;31(5):431-455. Doi: 10.1086/651706

Answer B. Ceftaroline covers MRSA, but it does not cover pseudomonas. Ertapenem does not cover pseudomonas. Cefepime has pseudomonas coverage.
Reference:
Gilbert D. The Sanford Guide to Antimicrobial Therapy 2014. Sperryville, Va.: Antimicrobial Therapy; 2014

Answer A. Meropenem is the drug of choice for ESBL empirically due to higher percentage of sensitivity. It can be de-escalated once culture and sensitivity available.
Reference:
Gilbert D. The Sanford Guide to Antimicrobial Therapy 2014. Sperryville, Va.: Antimicrobial Therapy; 2014

Answer C. A is wrong because ampicillin-sulbactam covers Acinetobacter and piperacillin-tazobactam has variable coverage for Acinetobacter. B. is wrong because neither ampicillin-sulbactam nor piperacillin-tazobactam covers ESBL. D. is wrong because both ampicillin-sulbactam and piperacillin-tazobactam cover anaerobes.
Reference:
Gilbert D. The Sanford Guide to Antimicrobial Therapy 2014. Sperryville, Va.: Antimicrobial Therapy; 2014.

Answer B. Purulent skin soft tissue infection are most likely caused by Staph. Aureus. Empiric antibiotic should be targeted to Staph. Aureus. Streptococcus is normally found from the Nonpurulent necrotizing Infections. E. Coli is normally found in the UTI and intra-abdominal infection. Pseudomonas aeruginosa is found in Diabetic wound and infections associated with burns.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer B. The IDSA SSTI treatment guidelines recommends treating empirically with doxycycline or SMX/TMP in patients presenting with moderate purulent SSTI. Since this patient has a sulfa allergy SMX/TMP cannot be used in this patient. Doxycycline is the drug of choice here. Linezolid would be appropriate if the patient was presenting with a severe purulent SSTI indicated by meeting SIRS criteria or previously failing antibiotic therapy.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer A. The ISDA SSTI guidelines recommend covering for MRSA in patients with an abscess who have failed initial antibiotic treatments or have SIRS. This patient has failed antibiotic treatment and meets the SIRS criteria. SMX/TMP cannot be used in this patient due to the patient’s allergy. Vancomycin with zosyn is not recommend for this type infection and clindamycin may be resisted since the patient has already failed the first round of treatment.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer B. Vancomycin, Linezolid, and SMX/TMP have MRSA coverage; Dicloxacillin does not. This patient happens to be allergic to sulfa drugs, which would include SMX/TMP. Vancomycin unfortunately has a very low bioavailability, so low in fact it cannot be used orally to treat an infection outside the GI tract; it would have to be given IV for this patient’s infection. Linezolid is the only option here because it can be absorbed through oral administration, has MRSA coverage, and does not contain a sulfa component.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer A. This patient is displaying signs of a severe case of cellulitis. Severe cellulitis is defined as having one of the following: failed oral antibiotic treatment, immunocompromised, clinical signs of deeper infection, or meeting the SIRS criteria. Based on this patient’s presentation they have failed antibiotic treatment and meet SIRS criteria. For severe cellulitis, IDSA SSTI guidelines recommend using Vancomycin along with Zosyn.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer A. This patient is showing signs of erysipelas. The patient does not appear to have a systemic infection, this indicates the infection is mild and can be treated effectively with oral medication in the outpatient setting. Linezolid and vancomycin are not recommended because MRSA is not suspected in this patient. Cephalexin has the most specific (narrow) coverage for streptococcus out of these antibiotics.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer C. The IDSA SSTI guidelines recommends using Doxycycline with either ceftriaxone or cefotaxime when the culture results show Vibrio vulnificus as the culprit.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer E. Cefazolin or an antistaphylococcal penicillin (oxacillin or nafcillin) is recommended for this patient because the C&S results indicate MSSA. Since the patient develops a rash to penicillins, it would be acceptable to use cefazolin in this case.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer C. For this type of infection, doxycycline, dicloxacillin, or cephalexin would be appropriate outpatient therapy. Since the patient has already been treated for a week, a minimum of 7 additional days of therapy is recommended. There is no need to give dicloxacillin for 21 days since IDSA recommends 2-3 weeks of therapy, also because the patient has an allergy to penicillins it is not recommended. Since the patient is improving on cefazolin, cephalexin is an appropriate oral medication to discharge the patient on.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer D. The IDSA guidelines recommend preemptive antimicrobial therapy in patients that are immunocompromised, asplenic, have advanced liver disease, have moderate to severe injuries, have injuries that may have penetrated the periosteum or joint capsule, or, as in this patient, has resultant edema of the affected area. The duration of this treatment is recommended for 3-5 days.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer E. The IDSA guidelines state that Pasteurella species are commonly cultured from animal bites, purulent and non-purulent.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer A. The IDSA guidelines recommends Augmentin for the initial treatment of an infection caused by an animal bite. Augmentin covers most of the aerobic and anaerobic bacteria that cause the infection. The other antibiotics listed here are not recommended, though ampicillin-sulbactam is recommended in the case of an infection caused by a human bite.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer A. The IDSA SSTI guidelines recommends antimicrobial agents active against gram-negative bacteria and anaerobes, such as cephalosporins or fluoroquinolones, to be used in combination with metronidazole when treating a surgical site infection following an operation on the axilla, GI tract, perineum, or, as with this patient, female genital tract. The patient is allergic to fluoroquinolones, so ciprofloxacin should not be used for this patient.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.

Answer D. The IDSA SSTI guidelines recommends the use of a first generation cephalosporin or an antistaphylococcal penicillin in patient with a surgical site infection. If MRSA is suspected vancomycin, linezolid, daptomycin, telavancin, or ceftaroline can be used. In this patient MRSA is not suspected so vancomycin is not needed. The other antibiotics listed here are used in cases following a surgical operation on the axilla, GI tract, perineum, or female genital tract.
Reference:
Stevens, Dennis L., et al. "Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America." Clinical Infectious Diseases (2014): ciu296. Available at: https://academic.oup.com/cid/article/59/2/e10/2895845/Practice-Guidelines-for-the-Diagnosis-and Management of Skin and Soft Tissue Infection.