2. Bacterial Infection

Question 1

Viral infections should not be treated with antibacterials unless…

Answer 1

Antibacterials are being used to treat bacterial infections secondary to a viral infection

Question 2

In regards to spectrum, which type of antibacterials are preferred

Answer 2

Generally narrow-spectrum antibacterials are preferred to broad-spectrum antibacterials unless there is a clear clinical need, such as sepsis

Question 3

Infections treated over a prolonged period

Answer 3

Tuberculosis, osteomyelitis

Question 4

Adverse reactions related to cephalosporins

Answer 4

Superinfection due to the selection of resistant organisms, e.g fungal infections or pseudomembranous colitis. Further problems related to superinfection include vaginitis and pruritus

Question 5

Broad spectrum antibiotics

Answer 5

Aminoglycosides
Amoxicillin & Ampicillin
Quinolones
Tetracyclines
Cephalosporins
Carbapenems
Chloramphenicol

(Arteries Are Always Quickly Travelling Cellular Critical Components)

Question 6

Narrow spectrum antibiotics

Answer 6

Benzylpenicillin
Clindamycin
Glycopeptides
Metronidazole
Nitrofurantoin
Phenoxymethylpenicillin
Linezolid

(Blood Clotting Generates Many New Plate-Lets)

Question 7

Notifiable diseases medical professionals are responsible for notifying

Answer 7

Acute encephalitis
Acute infectious hepatitis
Acute meningitis
Acute poliomyelitis
Anthrax
Botulism
Brucellosis
Cholera
COVID-19
Diphtheria
Enteric fever (typhoid or paratyphoid fever)
Food poisoning
Haemolytic uraemic syndrome (HUS)
Infectious bloody diarrhoea
Invasive group A streptococcal disease
Legionnaires’ disease
Leprosy
Malaria*
Measles*
Meningitis*
Meningococcal septicaemia
Monkeypox
Mumps
Plague
Rabies*
Rubella
Severe Acute Respiratory Syndrome (SARS)*
Scarlet fever*
Smallpox
Tetanus
Tuberculosis*
Typhus
Viral haemorrhagic fever (VHF)
Whooping cough*
Yellow fever

Question 8

Signs and symptoms of sepsis

Answer 8

S - slurred speech or confusion
E - extreme dizziness or muscle pain
P - passing no urine
S - severe breathlesness
I - it feels like you’re going to die
S - skin discoloured

Question 9

Signs and symptoms of an infection

Answer 9

Malaise, aches, pain, inflammation, swelling, pus

Confusion in elderly, worsening renal function, breathing difficulties

Question 10

Clinical biomarkers for infection

Answer 10

Raised CRP, temperature respiration rate, glucose concentration (impacts diabetics)

Reduced blood pressure

Question 11

Management of early sepsis

Answer 11

In community aqcuired septicaemia:
1st line: broad spectrum antipseudomonal penicillin: ticarillin or piperacillin
Or broad spectrum cephalosporin: ceftazidime

In hospital acquired septicaemia:
1st line: broad spectrum antipseudomonal beta lactam: penicillin, cephalosporin, carbapenem or monobactam.
if MRSA is suspected: ADD vancomycin to treatment
If anaerobic bacteria is suspected: ADD metronidazole to treatment

Question 12

If source of infection is identified in septic patient vs if it is not identified

Answer 12

If source of infection is identified, treat in line with local antibacterial guidance or susceptibility results.
If source of infection is not identified, treat with IV antibiotics from local formulary in line with national guidelines

Question 13

How frequently are risk septic patients monitored

Answer 13

No less than every 30 minutes

Question 14

Apropriateness of antibiotics in pregnancy

Answer 14

Metronidazole
Chloramphenicol (grey baby), Quinolones (arthropathy) Aminoglycosides
Nitrofurantoin (should be avoided during 3rd trimester )
Tetracyclines
Trimethoprim/co-trimaxazole (avoided in first trimester)

MCQANTT

Question 15

Consequences of a superinfection

Answer 15

• Candidiasis
• Colitis (caused by clindamycin, and broad spectrum antibiotics: amoxicillin, ampicillin, 3rd and 4th gen cephalosporins, quinolones)

Question 16

Alternative drugs for patients allergic to with immediate hypersensitivity to penicillins

Answer 16

• Macrolides
• Metronidazole (dental infections)

Question 17

Nephrotoxic antibiotics

Answer 17

Aminoglycosides
Glycopeptides
Tetracyclines (except doxycycline and minocycline)
Nitrofurantoin (as it depends on renal clearance, patients must have a certain level of eGFR )

Question 18

Hepatotoxic antibiotics

Answer 18

Tetracyclines
Rifampicin
Co-amoxiclav (causes choleostatic jaundice)
Flucloxacillin (causes chleostatic jaundice)

Question 19

Antibiotics which are typically used for the following bacteria

1. Staphylocci
2. MRSA
3. Streptocci
4. Anaerobic bacteria
5. Pseudomonal aeruginosa

Answer 19

1. Flucloxacillin
2. Vancomycin (or Teicoplanin) (or Linezolid for certain infections)
3. Phenoxymethylpenicillin sore throats commonly caused by steptococci
4. Metronidazole, dental infections are commonly caused by anaerobic bacteria
5. Gentamicin or an Antipseudomonal penicillin

Question 20

Common gastro-intestinal infections

Answer 20

Gastro-enteritis is a stomach bug and causes diarrhoea and vomiting. Typically caused by food poisioning from salmonella or E.coli or rotavirus or norovirus.
It is self-limiting and does not need to be treated with an antibiotic.

C.difficile is a bowel infection. It causes water diarrhoea. Occurs when the gut flora is supressed, allowing C.difile producing bacteria to multiply. Commonly occurs with clindamycin, quinolones, amipicillin,amoxicillin and 3rd/4th gen cephalosporins. Patients over 65 years, taking PPI’s or in hospital for a long time.

Question 21

How do you treat First episode of mild, moderate, or severe C. difficile infection

Answer 21

Gastro-enteritis is self-limiting and does not require antibiotics.

C.dificile treatment:
1st line: oral vancomycin
2nd line: fidaxomicin

In further episodes:
If its been <12 weeks since last episode: fidoxamicin

If its been >12 weeks since last episode: fidoxamicin OR oral vancomycin

Life threatening infections: treated by specialists
ORAL vancomycin with IV metronidazole

Question 22

Common cardiovascular infections

Answer 22

Endocarditis, where the linining of the heart (endocardium) becomes infected. Caused by bacteria entering the blood stream and entering the heart. Risk is increased with parenteral procedures or dental infection.
Caused by stapphylococci, streptococci, enterococci and HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, and Kingella: all HACEK members are fastidious Gram-negative bacteria)

Question 23

Treatment of common cardiovascular conditions

Answer 23

Endocarditis treatment:
Treatment will depend on if the patient has a natural or artificial heart valve and causative organisms.

BLIND THERAPY
Natural heart valve:
1st line; Broad spectrum penicillin: Ampicillin or amoxicillin +/- low-dose Gentamicin

If patient is allergic to penciillin, vancomycin +/- low-dose Gentamicin

Prosthetic heart valve:
Vancomycin AND Rifampicin AND low dose gentamicin

When culture and sensitivity test comes back and the organism is identified, specific antibiotics are then given.

If causative organism is:
MRSA- vancomycin
Staphylococci- Flucloxacillin
Streptococci - Benzylpenicillin

Follows general principles

Question 24

Common respiratory tract infections

Answer 24

Coughs caused by cold and flu viruses

Pneumonia, a lung infection where the alveoli become inflammed and fill with fluid.

Signs and symptoms include: breathing difficulty, chest pain, fever and cough. Commonly caused by streptococci pneumoniae and H.influenzae.
HAP - if contracted after 48 hrs in hospital
CAP - if contracted less than 48 hrs in hospital

Question 25

Treatment of common respiratory tract infections

Answer 25

Coughs caused by cold and flu viruses are usually self-limiting and do not require treatment ------------------------------- Community acquired pneumonia (CAP) treatment: **Low severity OR moderate severity** 1st line: Amoxicillin 500mg- 1g TDS (5 days). This is the adult dose. ***Child 1–11 months** 125 mg 3 times a day for 5 days; increased if necessary up to 30 mg/kg 3 times a day. **Child 1–4 years** 250 mg 3 times a day for 5 days; increased if necessary up to 30 mg/kg 3 times a day. **Child 5–11 years** 500 mg 3 times a day for 5 days; increased if necessary up to 30 mg/kg 3 times a day (max. per dose 1 g 3 times a day). **Child 12–17 years** 500 mg 3 times a day for 5 days; increased if necessary up to 1 g 3 times a day.* Penicillin allergy: Macrolides: Clarithromycin or Doxycycline. If patient is pregnant, erythromycin is preferred. **High severity:** 1st line: Co-amoixiclav AND Clarithromycin OR Erythromycin if patient is pregnant In penicilliin allergy: Levofloxacin ----------------------------------------------------- **HOSPITAL ACQUIRED PNEUMONIA** Non-severe HAP/Patients NOT at a higher risk of resistance: 1st line: Co-amoxiclav In penicillin allergy; Doxycycline or Cefalexin Severe HAP/Patients AT a high risk of resistance: 1st line: Piperacillin AND Tazobactam

Question 26

Common central nervous system infections

Answer 26

Meningitis is characterised by the inflammation of the meninges. Signs and symptoms include: Headache, seizures, stiff neck, drowsiness or unresponsiveness, dislike of bright nights, blotchy rash, high temperature (fever) over 37.5. This is a MEDICAL EMERGENCY.

Question 27

Treatment of common central nervous system infections

Answer 27

Treatment of meningitis Blind therapy: 1st line: Benzylpenicillin In penicillin allergy: Cefotaxime Patients with an immediate hypersensitivty: Chloramphenicol ## Footnote Cefotaxime may be an alternative in penicillin allergy; chloramphenicol may be used if history of immediate hypersensitivity reaction to penicillin or to cephalosporins.

Question 28

Common muscoskeletal infections

Answer 28

Oseteomyelitis is a bone infection Septic arthritis is a joint infection, which may occur following an open fracture or during surgery.

Question 29

Treatment of common muscoskeletal infections

Answer 29

Osteomyelitis and Septic arthritis treatment 1st line: Flucloxacillin In penicillin allergy: Clindamycin. If MRSA is suspected, offer vancomycin Osteomyelitis ~ 6 weeks: Rifampicin OR Fuscidic acid for 2 weeks Septic arthritis ~ 4-6 weeks Cefotaxime (ceftriaxone) if gonoccoal or gram negative is suspected

Question 30

Common skin infections

Answer 30

Impetigo - contagious superficial skin infection, common in young children. Can also be a secondary complication from eczema or chicken pox, due to scratching Two types bullous vs non-bullous Cellulitis - inflammation in the subcutaenous infection. Infections spreading around the wound, or lower leg infections are usually cellulitis. Skin infections are usually caused by stapphylococci aureus. Animal and human bites are also another common skin infection.

Question 31

Treatment of common skin infections

Answer 31

**Impetigo non-bullous AND restricted to small area** 1st line: hydrogen peroxide cream. Canot be used near the eyes. Alternatively: Fuscidic acid cream. **Impetigo non-bullous AND widespead** 1st line: Flucloxacillin OR Fuscidic acid **If a patient is systemically unwell, have a high risk of complications of have bullous impetigo:** 1st line: Flucloxacillin In penicillin allergy: Clarithromycin or Erythromycin if they are pregnant ---------------------------------------------------- **Cellulitis** First line: Flucloxacillin oral/IV In penicillin allergy: Clarithromycin or Erythromycin in pregnant patients OR Doxycicline **If the cellulitis is near the eyes or nose:** 1st line: Co-amoxiclav oral/IV In penicllin allergy: Clarithromycin + Metronidazole ----------------------------------------------- **Animal and human bites** 1st line: Co-amoxiclav oral IV In penicilllin allergy: Doxycicline + Metronidazole

Question 32

What are common dental infections

Answer 32

Are commonly caused by anaerobic bacteria * Gingivitis Acute necrotizing ulcerative gingivitis (ANUG) - painful infection of the gums. * Pericoronitis - inflammation of the gum tissue around your wisdom teeth. * Periapical abscess - a pocket of infection (pus) around your tooth root. * Periodontal abscess - is a pocket of pus in the tissues of the gum * Periodonitis - severe infalmmation of the gums. It is a gum disease.

Question 33

Treatment of common dental infections

Answer 33

**Pericoronitis/ANUG ~ 3 days** 1st line: Metronidazole 400/500mg TDS Alternatively: Amoxicllin 500mg-1g TDS **Periapical OR periodental abscess up to 5 days** 1st line: Phenoxymethylpenicilllin or amoxicillin In penicillin allergy: Clarithromycin If there are signs of spreading infection, ADD metronidazole

Question 34

Common infections of the ear, nose and throat

Answer 34

**Otits externa -** infection of the outer ear canal. Commonly caused by stapphylococcal aureus and pseudomonal aeurginosa **Otitis interna** infection of the middle ear causing a build up of fluid. Commonly caused by haemophilus influenzae, streptococcus pyogenes and pneumoniae **Sinusitis -** inflammation of the sinuses. Commonly caused by streptococcus pneumoniae, haemophilus influenzae. Staphylococcus aureus. **Sore throat -** commonly caused by streptococcus pyogenes. AKA stret throat

Question 35

Treatment for infections of the ear, nose and throat

Answer 35

Ear infections, sinusitis and sore throat are self-limiting. A secondary bacterial infection may arise. **Otitis externa:** 1st line: Flucloxacillin In penicillin allergy: Clarithromycin or Azithromycin. Eryhtromycin if patient is pregnant If pseudomonas is suspected, offer ciprofloxacin or an aminoglycoside (gentamicin) ----------------------------------------------- **Otitis media** 1st line: Amoxicillin If symptoms still worsen after 2/3 days of treatment, offer co-amoxiclav In penicillin allergy: Clarithromycin or Erythromycin if patient is pregnant ----------------------------------------------------- **Sinusitis** 1st line: Phenoxymethylpenicillin If symptoms still worsen after 2/3 days of treatment, offer co-amoxiclav If patient is systemically unwell, has a high risk of complications, has signs of a more serious illness Offer: co-amoxiclav In penicillin allergy: Clarithromycin OR Doxycycline. Erythromycin should be offered if patient is pregnant -------------------------------------------------- **Acute Sore Throat** 1st line: Phenoxymethylpenicillin for 5 - 10 days In penicillin allergy: Clarithromycin. Erythromycin should be offered if patient is pregnant

Question 36

Common genito-urinary infections

Answer 36

Chlamydia - common STD. Caused by chlamydia trachomatis Bacterial vaginosis - caused by excessive growth of bacteria found in the vagina. Increases the risk of contracting an STD. Urinary tract infection - inflammation of the bladder. Commonly caused by E.coli. A lower UTI can develop into an upper UTI where the kidneys become affected.

Question 37

Treatment for common genito-urinary infections

Answer 37

**Chlamydia** 1st line: Doxycyline Alternatively: Azithromycin, the dose is 1g dose on the first day the 500mg dose for the next 2 days **Bacterical vaginosis** 1st line: Metronidazole 2g as single dose OR 400 - 500mg BD for 5 - 7 days Alternatively can be treated with vaginal preparations of metronidazole or clindamycin **Lower-UTI** 1st line: Nitrofuranotin OR trimethoprim (if there is a low risk of resistance) Females: 3 days Males: 7 days If there is no improvement after 48 hours, 2nd line for females: Nitrofurantoin (if this was not previously given) Fosfomycin or Pivmecillinam In men consider an alternative diagnosis such as kidney infection or prostatitis In pregnant woman: Nitrofurantoin for 7 days. Should be AVOIDED at term 2nd line for pregnant woman: Amoxicillin of Cefalexin. Should always treat asymptomatic bacteruria in pregnant woman, can be treated with any of the above antibiotics.

Question 38

What is tuberculosis and what are the signs and symptoms

Answer 38

Tuberculosis is a bacterial ifnection caused by myobacterium tuberculosus and is spread through coughs and sneezes. Symptoms include a cough for over 3 weeks, weight loss, night sweats, loss of apetite and neck swelling

Question 39

Tuberculosis treatment

Answer 39

Active tuberculosis is treated in 2 phases and lasts 6 months in total. In the initial phase, four drugs are taken for 2 months: Rifampicin, Isoniazid, Pyrazinimide, Ethambutol (RIPE). In the continuation phase Rifampicin and Isoniazid are taken for 4 months