25, 26. Infectious Diseases Flashcards Preview

Pharmacy > 25, 26. Infectious Diseases > Flashcards

Flashcards in 25, 26. Infectious Diseases Deck (217):
1

A patient presents with symptoms of a common cold: runny nose, sore throat, sneezing, and coughing. What is the most likely cause of the patient's cold?

A. Rhinovirus
B. Staphylococcus aureus
C. Group B Streptococci
D. Adenovirus
E. Multiple organisms are likely
 

A. Of the over 200 viruses that can cause the common cold, rhinovirus is the most common. Other symptoms of the common cold can include mild body aches and headache. Antibiotics will not help a viral infection.

2

Choose the correct term for the lowest drug concentration that will inhibit the growth of an organism:

A. Minimum bactericidal concentration
B. Post antibiotic effect
C. Minimum inhibitory concentration
D. Resistance
E. Intermediate sensitivity
 

C. The minimum inhibitory concentration (MIC) is the lowest concentration of an antimicrobial drug that will inhibit the visible growth of a microorganism. Minimum inhibitory concentrations are important to determine resistance of microorganisms to an antimicrobial agent and to monitor activity of antimicrobial agents.

3

A patient with a urinary tract infection has asked for advice on a product for painful urination. Her doctor wrote the name phenazopyridine down on a sheet of paper. Which of the following patient counseling points are correct regarding phenazopyridine? (Select ALL that apply.)

A. Take this medication with food and 8 oz of water to minimize stomach upset.
B. She can purchase the over the counter product Azo.
C. She should use the product as long as she has symptoms.
D. This medication is effective in treating a bacterial urinary tract infection.
E. This product will cause red-orange coloring of the urine and can stain clothing.
 

A, B, E. Phenazopyridine (Azo, generics) is a urinary analgesic. Phenazopyridine should not be used longer than two days because an antibacterial agent should be working and the painful symptoms should have subsided. If the pain has not subsided, the patient should return to the physician. Phenazopyridine causes a harmless, red-orange coloring of the urine and other body fluids. Contact lenses and clothes could be stained. Take with food and 8 oz of water to minimize stomach upset.

4

An otherwise healthy patient comes in with a gram-positive and gram-negative foot infection. The doctor would like to use a cephalosporin for treatment of the patient's infection. Which of the following statements regarding cephalosporins is correct?

A. Cefazolin is an oral cephalosporin that is considered to be the most effective therapy for mild-moderate gram-negative foot infections.
B. Cefixime is the only oral cephalosporin with gram-negative and enteric anaerobic coverage.
C. Cephalexin is an oral, second-generation cephalosporin with sufficient gram-negative and gram-positive coverage for moderate severity foot infections.
D. Cefuroxime is an oral, second-generation cephalosporin with adequate gram-negative and gram-positive coverage for mild-moderate foot infections.
E. Cefpodoxime is an intravenous, third-generation cephalosporin with adequate gram-positive and gram-negative coverage for severe foot infections.
 

D. Cefazolin is an intravenous cephalosporin. Cefixime is not effective for enteric anaerobes. Cephalexin is a first generation cephalosporin and cefpodoxime is an oral, third-generation cephalosporin. Cefuroxime is a second generation cephalosporin and is effective in treating MSSA and gram-negative bacteria associated with mild-moderate foot infections.

Cefotetan & cefoxitin are second generation cephalosporins that have anaerobic activity.

5

Which of the following statements is correct regarding linezolid? (Select ALL that apply.)

A. Linezolid is associated with bone marrow suppression.
B. Linezolid is part of the streptogramin class of antibiotics.
C. Linezolid should be dose adjusted in renal impairment.
D. Linezolid is a weak MAO inhibitor.
E. Linezolid oral suspension should not be refrigerated.
 

A, D, E. Linezolid is part of the oxazolidinone class of antibiotics and does not need to be dose adjusted in renal impairment. The oral suspension should be stored at room temperature.

6

A nurse calls the pharmacy to ask about crushing ciprofloxacin tablets and giving it via the nasogastric tube. The pharmacist should respond:

A. Ciprofloxacin is only available in an IV formulation.
B. Hold tube feedings at least 1 hour before and 2 hours after the administration of ciprofloxacin.
C. Give ciprofloxacin and flush the nasogastric tube immediately with water; in this manner it is safe to give with tube feedings.
D. There is no interaction between ciprofloxacin and tube feedings.
E. There is no formulation of ciprofloxacin that can be used for nasogastric tube administration.
 

B. For feeding tube administration, crush immediate-release ciprofloxacin tablets and mix with water. Hold tube feeds for 1 hour before and 2 hours after administration. Enteral feedings can significantly decrease plasma concentrations of ciprofloxacin. There is a suspension but it cannot be used with feeding tubes.

7

A patient gave the pharmacist a prescription for Ceftin 500 mg BID #20. Which of the following is an appropriate generic substitution for Ceftin?

A. Cefprozil
B. Cefpodoxime
C. Doripenem
D. Cefuroxime
E. Cefdinir
 

D. The generic name of Ceftin is cefuroxime.

Cefprozil (Cefzil) - 2nd generation, PO

Cefpodoxime (Vantin) - 3rd generation, PO

Doripenem (Doribax) - carbapenem, IV

Cefdinir (Omnicef) - 3rd generation, PO

8

Chief Complaint:  “I’m out of my inhaler and I can’t breath"

History of Present Illness:  KS is a 30 y/o female who comes to the ER today for worsening shortness of breath and cough.  She is out of her albuterol inhaler.  She occasionally lives on the street, but has been staying in the local homeless shelter for 3 nights.  She reports fatigue, but denies night sweats and hemoptysis.  Her cough is nonproductive. KS has mild right lower extremity cellulitis extending from right ankle to right calf.  Patient states she scraped her leg on a fence and it has not healed.  KS has not been treated with antibiotics.  

Allergies:  NKDA

Past Medical History: HIV x 5 years, PCP pneumonia 5 years ago when she was diagnosed with HIV, asthma, and dyslipidemia

Medications: Truvada 1 tablet daily, Tivicay 50 mg once daily, albuterol inhaler 1 puff 3-4 times daily as needed, Flovent Diskus 100 mcg BID, simvastatin 20 mg HS

Physical Exam / Vitals: 

Height: 5’2”  Weight: 105 pounds   

BP: 122/72 mmHg  HR: 71 BPM  RR: 18 BPM Temp: 103.2°F  Pain: 3/10 

General: Pleasant ill appearing female 

Lungs: decreased breath sounds bilaterally – right worse than left.  Mild wheezing. 

CV:  RRR – no murmurs 

GI: Normal bowel sounds 

Ext: Mild right lower extremity cellulitis with some purulence

Labs:

Na (mEq/L) = 129 (135 – 145)              

WBC (cells/mm3) = 10.4 (4 – 11 x 10^3)       

K (mEq/L) = 3.5 (3.5 – 5)                      

Hgb (g/dL) = 13.4 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 103 (95 – 103)                

Hct (%) = 40.1 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 24 (24 – 30)              

Plt (cells/mm3) = 202 (150 – 450 x 10^3)

BUN (mg/dL) = 12 (7 – 20)                  

PMNs (%) = 92 (45 – 73)

SCr (mg/dL) = 0.9 (0.6 – 1.3)                

Bands (%) = 7 (3 – 5) 

Glucose (mg/dL) = 118 (100 – 125)      

Eosinophils (%) = 3 (0 – 5)

Ca (mg/dL) = 8.8 (8.5 – 10.5)                

Basophils (%) = 0 (0 – 1)

Mg (mEq/L) = 1.8 (1.3 – 2.1)                

Lymphocytes (%) = 29% (20 – 40)

PO4 (mg/dL) = 3.6 (2.3 – 4.7)                

Monocytes (%) = 2 (2 – 8)

AST (IU/L) = 62 (10 – 40) 

ALT (IU/L) = 58 (10 – 40) 

Albumin (g/dL) = 3.1 (3.5 – 5)

Tests: 

Chest Xray: bilateral upper lobe cavitary lesions.  Recommend chest CT for further evaluation.   

Plan:  Obtain CD4+ count and viral load.  Admit for IV antibiotics and additional diagnostic work-up.  

Question: 

Based on chest Xray, KS will be treated empirically for PCP.  A physician calls the pharmacist for assistance in determining a dosing regimen for Bactrim.  He would like to use Bactrim 20 mg/kg orally.  Which of the following is correct? 

A. Bactrim SS 2 tabs BID

B. Bactrim SS 2 tabs TID

C. Bactrim DS 1 tab TID

D. Bactrim DS 2 tabs BID

E. Bactrim DS 2 tabs TID

E. 105 pounds = 47.7 kg. 47.7 kg x 20 mg/kg = 954 mg Bactrim/day. Bactrim is dosed from the TMP component and DS tabs have 160 mg TMP per tab. KS would need 6 tabs per day (954 mg Bactrim / 160 mg TMP per tab) to treat her infection. To avoid errors, mg/kg doses should reference the TMP component. When using higher SMX/TMP doses like this, monitor the patient carefully for side effects.

9

Molly is an 82 year-old female with a Pseudomonas aeruginosa infection. The clinical pharmacist is rounding with the infectious disease team. The pharmacist is asked to explain the potential advantages of extended-interval, or once-daily, aminoglycoside dosing. Choose the correct statement:

A. If the random gentamicin serum level is elevated, the dosing interval should be decreased.
B. Extended-interval dosing is more cost effective, and helps to reduce nephrotoxicity risk.
C. The peak and trough levels should be measured around the third dose for extended-interval dosing.
D. Extended-interval dosing for gentamicin is 15 mg/kg/day.
E. If the random gentamicin serum level is elevated, the dose should be decreased.
 

B. Extended Interval (formerly known as "Once Daily Dosing") for gentamicin and tobramycin is 4-7 mg/kg/day. The dose in the answer choice (15 mg/kg/day) is generally used for once-daily dosing of amikacin. Extended-interval dosing can help preserve renal function (the primary toxicity) and is more cost-effective than administering the medication via conventional dosing.

10

A patient has been taking antibiotics for one week and develops severe diarrhea. Which of the following medications has a boxed warning regarding the risk of causing severe and possibly fatal colitis?

A. Maxipime
B. Biaxin
C. Cipro
D. Cleocin
E. Cancidas
 

D. Cleocin (clindamycin) has a boxed warning regarding the risk of severe and possibly fatal colitis. When counseling, tell patients to report watery and/or frequent diarrhea immediately as the patient may require treatment for pseudomembranous colitis.

11

A patient has a prosthetic mitral valve and needs to have some extensive dental work done. The patient is noted to have allergies to Keflex and Unasyn. Which of the following statements is the best recommendation to give this patient?

A. Take amoxicillin 2 grams 1 hour prior to dental appointment.
B. Take cefadroxil 2 grams 30 minutes prior to dental appointment.
C. Take clindamycin 600 mg 1 hour prior to dental appointment.
D. Take azithromycin 500 mg 30 minutes after dental appointment.
E. This patient does not need antibiotics for his dental work.
 

C. Clindamycin 600 mg can be used as an alternative for endocarditis prophylaxis in a patient with a beta-lactam allergy.

Dental procedures & IE prophylaxis:

An artificial heart valve or heart valve repaired with artificial material.

A history of endocarditis

A heart transplant with abnormal heart valve function

Congenital heart defects

12

A patient is receiving Bactrim SS therapy. Which of the following strengths and ingredients are in Bactrim SS tablets?

A. 400 mg sulfamethoxazole and 80 mg trimethoprim
B. 80 mg sulfamethoxazole and 400 mg trimethoprim
C. 16 mg sulfamethoxazole and 80 mg trimethoprim
D. 240 mg sulfamethoxazole and 40 mg trimethoprim
E. 100 mg sulfamethoxazole and 50 mg trimethoprim
 

A. The ratio of sulfamethoxazole to trimethoprim is always 5:1. The single strength tablet of Bactrim contains 400 mg sulfamethoxazole and 80 mg trimethoprim.

13

A patient gave the pharmacist a prescription for Augmentin 875 mg Q12H #20. Which of the following is an appropriate generic substitution for Augmentin?

A. Ampicillin/clavulanate
B. Ampicillin/tazobactam
C. Amoxicillin/clavulanate
D. Amoxicillin/tazobactam
E. Imipenem/cilastatin
 

C. Amoxicillin/clavulanate is the generic name of Augmentin. Clavulanic acid, or claculanate, inactivates beta lactamase enzymes, which extends the activity (or coverage) of the drug.

Ampicillin/clavulanate (does not exist)
Ampicillin/tazobactam (does not exist)
Amoxicillin/tazobactam (does not exist)
Imipenem/cilastatin (Primaxin)

14

A patient gave the pharmacist a prescription for Z-Pak. Which of the following is the generic name and an appropriate dosing regimen for Z-Pak?

A. Erythromycin 250 mg Q AM, for 5 days
B. Azithromycin 250 x 2 on day 1, then 250 mg x 1 on days 2-5
C. Azithromycin 250 mg x 1, for 5 days
D. Clarithromycin 250 mg Q AM, for 5 days
E. Azithromycin 250 mg x 2, for 5 days
 

B. Azithromycin is the generic for Z-Pak. A common doing regimen is two 250 mg tablets x 1 on the first day, then one 250 mg tablet for days 2-5.

15

Danny is diagnosed with a giardia infection.  Which of the following medications would be best to recommend for treatment of giardiasis?

A. Metronidazole
B. Cefuroxime
C. Doxycycline
D. Erythromycin
E. Clindamycin
 

A. Giardiasis is a diarrheal illness caused by the parasite, Giardia intestinalis. It can be treated with metronidazole or tinidazole.

16

A patient is receiving vancomycin 2 grams IV Q12H for treatment of MRSA. The nurse asks how long to infuse the medication. Which is the best recommendation to give the nurse regarding the infusion of this vancomycin dose?

A. The vancomycin should be infused over a minimum of 2 hours
B. The vancomycin should be infused over a maximum of 2 hours
C. The vancomycin should be infused over a minimum of 1 hour
D. The vancomycin should be infused over a maximum of 1 hour
E. The vancomycin should be given via a bolus dose
 

A. Vancomycin can cause serious side effects if infused too quickly. Given the patient is receiving 2 grams, vancomycin should be infused over a minimum of 2 hours. Often, the infusion is given over a longer time period.

Each 500mg of vancomycin should be infused over at least 30 minutes.  Hence 2000mg (2 grams) would require at least 2 hours of infusion time.

17

Tanya comes to the pharmacy to pick up her prescription for Valtrex for treatment of her recurrent herpes simplex virus. Which of the following statements would be best to include during patient counseling?

A. This medication is very effective and will cure your herpes infection.
B. You should start therapy within one day of symptom onset to experience maximum benefit from the drug.
C. This medication should be taken with food.
D. It is safe to continue sexual contact with your partner when you have symptoms or a herpes outbreak.
E. This product is effective only when you have developed genital lesions.
 

B. Antivirals used to treat herpes simplex virus decrease the duration of the infection. Antivirals should be started within 24 hours of symptom onset of a recurrence for maximal benefit.

A. Valtrex only treats the recurrent infection, it does not cure it.

C. Valtrex can be taken with or without food.

D. It is not safe to continue sexual contact when you have symptoms or a herpes outbreak.

E. It is effective for both oropharyngeal disease as well.

18

A 36 year-old female is nine weeks pregnant. She presents to the pharmacy with symptoms of a vaginal fungal infection. She has vaginal itching and a white, curd-like discharge. She had similar symptoms a few months ago and went to the free clinic for help. She was examined and given one dose of fluconazole 150 mg x 1. She was instructed to purchase an over the counter product the next time she has these types of symptoms. She is asking for advice on an over-the-counter product. Choose the correct agent:

A. Terbinafine x 7 days
B. Clotrimazole x 7 days
C. Butenafine x 3 days
D. Miconazole x 1 day
E. Tioconazole x 3 days
 

B. Since the patient is now pregnant, the drug of choice is a topical azole product for 7 days duration.

19

A patient is picking up VFEND at the pharmacy and asks to be counseled by the pharmacist. Which of the following counseling points regarding VFEND are correct? (Select ALL that apply.)

A. This medication should be taken with meals, preferably breakfast and dinner.
B. This medication can cause lymphomas with prolonged use.
C. This medication can cause visual changes; care is advised when driving and driving at night should be avoided.
D. This medication can damage your liver and liver function tests may need to be monitored.
E. This medication is associated with many drug interactions.
 

C, D, E. Visual disturbances (abnormal vision, color vision change and/or photophobia) occur in about 20% of voriconazole-treated patients. Voriconazole is taken on an empty stomach 1 hour before or 1 hour after meals. Check for drug interactions; there are many.

A. This medication is taken on an empty stomach, at least 1 hour before or 1 hour after meals, usually every 12 hours or as directed.

B. Common SEs: QT prolongation, visual changes, CNS toxicity (hallucinations), photosensitivity.

Drug of choice for Aspergillosis

20

Manny comes to the urgent care center with a large cellulitis wound. The doctor wants to prescribe something orally that covers MRSA. Which of the following medications fit this description?

A. Tygacil
B. Zyvox
C. Doribax
D. Synercid
E. Vancocin
 

B. Zyvox covers MRSA and comes in both an intravenous and oral formulation. The other medications listed are only available intravenously (oral vancomycin is not absorbed and is not appropriate for MRSA coverage.)

Tygacil (tigecycline)

Doribax (doripenem)

Synercid (quinupristin/dalfopristin)

Vancocin (vancomycin)

21

Which of the following statements are correct regarding patient counseling advice on Bactrim? (Select ALL that apply.)

A. Take this medication with 8 oz of water.
B. This medication must be taken with food.
C. This medication can increase your risk of sunburn.
D. This medication can cause a rash; if you develop a serious rash, seek medical help right away.
E. This medication should not be used if the patient has a sulfa allergy.
 

A, C, D, E. Bactrim works best if given on an empty stomach. However, if GI upset is present, patients can take the medication with a light snack. It has a sulfa moiety and is associated with allergic reactions. It is also associated with photosensitivity.

22

Sarah presents to the emergency department with fever, chills, nausea, cough, and fatigue. She reports feeling awful for the past week and appears confused. Her previous doctor started her on amoxicillin. Sarah's white blood cell count was found to be elevated today. Her past medical history is significant for COPD, hypertension, dyslipidemia, and atrial fibrillation. She is taking lisinopril, lovastatin, procainamide, amoxicillin and some inhalers. The doctor would like to start broad empiric coverage for her infectious process. Which of the following oral broad spectrum medication/s would be most appropriate to treat Sarah given her history?

A. Cefdinir + doxycycline
B. Moxifloxacin
C. Tigecycline
D. Telithromycin
E. Aztreonam
 

A. Tigecycline is a broad spectrum IV antibiotic that would not be appropriate for outpatient treatment. Moxifloxacin is not an appropriate option due to the risk of QT prolongation when used in combination with class Ia anti-arrhythmics (like procainamide). Telithromycin can increase the risk of QT prolongation in patients taking procainamide. Aztreonam is only active against gram-negative pathogens. An oral beta-lactam + doxycycline is the regimen of choice for treating possible drug-resistant Strep. pneumoniae for which this patient is at risk.

23

A pharmacist is working in the emergency department. A medical intern asks how to treat a patient who has tested positive for syphilis. The intern explains that the patient does not know how long he has had the disease and has stated that he has had multiple sexual partners over the last few years. Which regimen would be best to treat this patient's syphilis?

A. Ceftriaxone 250 mg IM x 1
B. Azithromycin 1 gram PO x 1
C. Aqueous penicillin G 3-4 million units IV Q4H x 10 days
D. Penicillin G benzathine 2.4 million units IM x 1
E. Penicillin G benzathine 2.4 million units IM weekly x 3 weeks
 

E. Since the patient has had syphilis for an unknown duration, it is best to treat with penicillin G benzathine weekly for 3 weeks.

Penicillin G benzathine 2.4 million units IM x 1 is used for primary, secondary or early latent syphilis (<1 year duration).

Penicillin G benzathine 2.4 million units IM weekly x 3 weeks is used for late latent (>1 year duration), tertiary, or latent syphilis of unknown duration.

24

A patient gave the pharmacist a prescription for Levaquin. Which of the following is an appropriate generic substitution forLevaquin?

A. Levofloxacin
B. Ciprofloxacin
C. Azithromycin
D. Linezolid
E. Telavancin
 

A. The generic name of Levaquin is levofloxacin.


Ciprofloxacin (Cipro)
Azithromycin (Zithromax)
Linezolid (Zyvox)
Telavancin (Vibativ)

25

Which of the following statements are true regarding pyrazinamide? (Select ALL that apply.)

A. This medication is used to reduce the risk of peripheral neuropathies in patients taking isoniazid.
B. This medication is contraindicated in patients with acute gout.
C. This medication can cause significant ototoxicity.
D. This medication should not be used if the patient has a sulfa allergy.
E. This medication can cause hepatotoxicity.
 

B, E. Pyrazinamide is an antitubercular agent used in the initial treatment of tuberculosis. It is contraindicated in patients with acute gout and severe hepatic damage.

26

Patty has contracted trichomoniasis. Which of the following options would be preferred treatments for trichomoniasis?

A. Metronidazole 2 grams PO x 1
B. Ciprofloxacin 1 gram PO x 1
C. Azithromycin 2 grams PO x 1
D. Penicillin G benzathine 2.4 million units IM x 1
E. Penicillin G benzathine 2.4 million units IM x 3 weekly doses
 

A. Trichomoniasis, caused by the parasite Trichomonas vaginalis, can be treated with metronidazole or tinidazole 2 grams PO x 1. Sexual partners should be treated as well.

Azithromycin 2 grams PO x 1 treats both gonorrhea and chlamydial infections

Penicillin G benzathine 2.4 million units IM treats syphilis.

27

A 62 year-old female patient came into the pharmacy to get an influenza shot. It was her first time receiving the annual vaccine. Three days later, she came back complaining of a hacking cough, mild weakness, stuffy nose and a sore throat. She is afebrile and has no muscle aches or pains. She states the shot gave her the flu. What is the most likely reason for the patient's illness?

A. She has a cold.
B. She has an influenza infection.
C. She has mild illness due to the shot, but it's not likely an influenza infection.
D. She was allergic to the influenza vaccine.
E. None of the above.
 

A. The patient has classic symptoms of a cold (cough, mild weakness, stuffy nose and sore throat, without fever). Symptoms of influenza include a sudden onset, high fever (usually 3-4 days duration), dry cough, prominent headache, muscle aches and pains (myalgia), weakness, fatigue (which can last for weeks), with occasional stuffy nose and sore throat. The influenza shot is inactivated and cannot cause influenza; it may cause a mild illness for a day or two afterwards. If patients get these symptoms, do not treat in advance or at the time of the shot as this may reduce the vaccine effectiveness. If symptoms develop afterwards the patient can self-treat at that time.

28

Which of the following oral suspensions should be refrigerated? (Select ALL that apply.)

A. Augmentin
B. Ceftin
C. Levaquin
D. Zmax
E. Septra
 

A, B. Ceftin and Augmentin oral suspensions should be refrigerated, the others should not.

Refrigeration required: amoxicillin/clavulanate (Augmentin), ceprozil, cefuroxime (Ceftin), cephalexin (Keflex), erythromycin ethylsuccinate/sulfisoxazole (E.S.P.), penicillin VK

Do Not Refrigerate: azithromycin (Zmax), cefdinir, clarithromycin (Biaxin-bitter taste, thickening/gels), clindamycin (Cleocin-thickening, crystallize), ciprofloxacin (Cipro), doxycycline (Vibramycin), fluconazole (Diflucan), levofloxacin (Levaquin), linezolid (Zyvox), sulfamethoxazole/trimethoprim (Septra, Sulfatrim), voriconazole (VFEND)

29

Which of the following statements is correct regarding the appropriate use of metronidazole? 

A. Alcohol can be consumed 12 hours after the last dose of metronidazole.
B. The IV:PO dosing ratio is 1:1.
C. Metronidazole is an azole antifungal agent.
D. The extended release formulation should be taken with food to increase absorption.
E. The brand name is Tequin.
 

B. Metronidazole is an amebicide, antiprotozoal antibiotic. Patients must wait 3 days after the last dose of metronidazole before commencing alcohol consumption.

E. Brand name is Flagyl

Tequin is gatifloxacin

30

A patient comes to the clinic with fever, chills, muscle aches and a severe headache. She was recently on a week-long camping trip in South Carolina with her extended family. The patient appears to have a tick bite and is diagnosed with Rocky Mountain spotted fever. Which of the following medications is the best treatment option for this patient?

A. Rifampin 300 mg x 5 days
B. Metronidazole 1 gram x 7 days
C. Tobramycin 5 mg/kg/d divided Q8H x 7 days
D. Doxycycline 100 mg BID x 7 days
E. Acyclovir 400 mg TID x 10 days
 

D. Treatment of Rocky Mountain spotted fever involves careful removal of the tick from the skin and antibiotics to eliminate the infection. Doxycycline or tetracycline are the drugs of choice and are used for both confirmed and suspected cases.

31

Which of the following statements is correct regarding nafcillin? 

A. Nafcillin does not have activity against methicillin-susceptible Staphylococcus aureus (MSSA).
B. Nafcillin is a vesicant.
C. Nafcillin should be dose adjusted in renal impairment.
D. Nafcillin is compatible with NS only.
E. Nafcillin cannot be used in a sulfa allergic patient.
 

B. Nafcillin is a vesicant. If extravasation occurs, use cold packs and hyaluronidase injections to treat.

32

Harry is a 71 year old male who has been in the intensive care unit for several weeks and is now being treated for aPseudomonas infection. His weight is 213 pounds and height is 6'1". His current serum creatinine is 2.4 mg/dL. Based on the culture sensitivities, the medical team decides to start tobramycin at 2.5 mg/kg. They ask the pharmacist to write the order and administer the first dose at 8:00 AM. Which of the following is the correct tobramycin regimen for this patient?

A. Tobramycin 500 mg IV then monitor levels
B. Tobramycin 200 grams IV Q24H
C. Tobramycin 200 mg IV Q8H
D. Tobramycin 240 mg IV Q24H
E. Tobramycin 240 mg IV Q8H
 

D. Tobramycin is dosed anywhere from 1-2.5 mg/kg for traditional dosing. Since this patient is very ill, the team was correct to go with the upper limit. Aminoglycosides are dosed using total body weight, unless the patient is > 130% of IBW (then use adjusted body weight). 2.5 mg/kg x 96.8 kg = 242 mg; round to 240 mg. Harry's estimated creatinine clearance is between 30-40 mL/min regardless of which weight was used to calculate it (you should use his adjusted body weight in this case), so his dosing interval should be Q24 hours. Administering the drug every 8 hours would be too frequent for someone with this degree of renal impairment.

33

Susan is prescribed Avelox for a community-acquired pneumonia infection. What is the mechanism of action for Avelox?

A. Binds to pencillin binding proteins to inhibit cell wall synthesis
B. Binds to the 30s ribosomal subunit, inhibiting protein synthesis
C. Inhibits DNA topoisomerase IV, thereby blocking DNA gyrase
D. Inhibits synthesis of Beta (1,3)-D-glucan
E. Binds to the 50s ribosomal subunit, inhibiting protein sythesis
 

C. Avelox (moxifloxacin) is a fluoroquinolone and works by binding to topoisomerase IV to inhibit DNA gyrase and the double helical coiling of the DNA.

Aminoglycosides and tetracyclines bind to the 30s ribosomal subunit, inhibiting protein synthesis

Macrolides, clindamycin, linezolid, and Synercid bind to the 50s ribosomal subunit, inhibiting protein sythesis

34

Derek has developed candidemia after 3 weeks in the intensive care unit. He is currently being treated with micafungin. Which of the following statements is correct regarding micafungin?

A. Micafungin is available orally and can cause pulmonary edema.
B. Micafungin is Pregnancy Category X.
C. Micafungin requires premedication prior to administration.
D. Micafungin can cause histamine-related symptoms.
E. Micafungin is an azole antifungal agent.
 

D. Micafungin, an echinocandin, can cause histamine-mediated symptoms such as rash, pruritus, facial swelling, flushing, and hypotension. To decrease the potential of a histamine reaction, infuse over 1 hour. Micafungin is Pregnancy Category C and is only available intravenously.

35

36

The mother of a 2 year-old daughter has been given a prescription for an acute otitis media infection. The child has no known drug allergies. This is the first time the child has received treatment for this condition. What is the drug of choice for this condition?

A. Azithromycin suspension 30 mg/kg/day given daily
B. Amoxicillin 80-90 mg/kg/day, divided Q 12 hours
C. Clarithromycin suspension, divided Q 12 hours
D. Amoxicillin 40 mg/kg/day, divided Q 12 hours
E. Cephalexin suspension, divided Q 12 hours
 

B. Amoxicillin (80-90 mg/kg/day) is a drug of choice for acute otitis media, which is most commonly caused by resistantStreptococcus pneumoniae.

37

A patient is taking nitrofurantoin for treatment of a urinary tract infection. Which of the following statements regarding nitrofurantoin are correct? 

A. This medication may cause your urine to turn blue in color.
B. This medication can be used in patients with severe renal impairment.
C. This medication is not absorbed when taken concurrently with food.
D. This medication can be used for complicated cystitis.
E. This medication may rarely cause serious pulmonary problems.
 

E. Nitrofurantoin is contraindicated in patients with a creatinine clearance less than 60 mL/min. Nitrofurantoin should be taken with food to enhance absorption. Long term use can lead to serious and fatal pulmonary toxicity. Nitrofurantoin is only indicated for uncomplicated cystitis as serum levels are not adequate to treat systemic/complicated UTIs.

38

Which of the following auxiliary labels should be placed on a prescription for cephalexin oral suspension?

A. Take with at least 8 ounces of water
B. Keep the medication refrigerated
C. Use caution when operating heavy machinery or while driving a car
D. Do not shake prior to use
E. Do not use if you are pregnant
 

B. Cephalexin oral suspension should be refrigerated and used within 14 days. Shake well. Take with food if stomach upset occurs.

Refrigeration required: amoxicillin/clavulanate (Augmentin), ceprozil, cefuroxime (Ceftin), cephalexin (Keflex), erythromycin ethylsuccinate/sulfisoxazole (E.S.P.), penicillin VK

Do Not Refrigerate: azithromycin (Zmax), cefdinir, clarithromycin (Biaxin-bitter taste, thickening/gels), clindamycin (Cleocin-thickening, crystallize), ciprofloxacin (Cipro), doxycycline (Vibramycin), fluconazole (Diflucan), levofloxacin (Levaquin), linezolid (Zyvox), sulfamethoxazole/trimethoprim (Septra, Sulfatrim), voriconazole (VFEND)

39

Which of the following medications should be avoided in children younger than 8 years old due to discoloration of teeth and bone growth retardation?

A. Telavancin
B. Tigecycline
C. Telithromycin
D. Tinidazole
E. Rifaximin
 

B. Tigecycline is a derivative of minocycline and should not be used in pregnant women or in children younger than 8 years old due to teeth discoloration and bone growth retardation.

Four T's of Tigecycline:

T – related to Tetracycline: teeth discoloration and bone growth retardation ages <8 years

T – concentrates in Tissues (lipophilic). Avoid use in bloodstream infection because it won't have the concentration since it stays in tissues.

T – Three Gram negative pathogens not covered: Psuedomonas, Proteus, Providencia

T – Tummy side effects N/V/D

Remember Tiger: when reconstituted, it becomes orange/yellow like a tiger; discard if not this color.

40

Chief Complaint:  “I’m out of my inhaler and I can’t breath"

History of Present Illness:  KS is a 30 y/o female who comes to the ER today for worsening shortness of breath and cough.  She is out of her albuterol inhaler.  She occasionally lives on the street, but has been staying in the local homeless shelter for 3 nights.  She reports fatigue, but denies night sweats and hemoptysis.  Her cough is nonproductive. KS has mild right lower extremity cellulitis extending from right ankle to right calf.  Patient states she scraped her leg on a fence and it has not healed.  KS has not been treated with antibiotics.  

Allergies:  NKDA

Past Medical History: HIV x 5 years, PCP pneumonia 5 years ago when she was diagnosed with HIV, asthma, and dyslipidemia

Medications: Truvada 1 tablet daily, Tivicay 50 mg once daily, albuterol inhaler 1 puff 3-4 times daily as needed, Flovent Diskus 100 mcg BID, simvastatin 20 mg HS

Physical Exam / Vitals: 

Height: 5’2”  Weight: 105 pounds   

BP: 122/72 mmHg  HR: 71 BPM  RR: 18 BPM Temp: 103.2°F  Pain: 3/10 

General: Pleasant ill appearing female 

Lungs: decreased breath sounds bilaterally – right worse than left.  Mild wheezing. 

CV:  RRR – no murmurs 

GI: Normal bowel sounds 

Ext: Mild right lower extremity cellulitis with some purulence

Labs:

Na (mEq/L) = 129 (135 – 145)              

WBC (cells/mm3) = 10.4 (4 – 11 x 10^3)       

K (mEq/L) = 3.5 (3.5 – 5)                      

Hgb (g/dL) = 13.4 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 103 (95 – 103)                

Hct (%) = 40.1 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 24 (24 – 30)              

Plt (cells/mm3) = 202 (150 – 450 x 10^3)

BUN (mg/dL) = 12 (7 – 20)                  

PMNs (%) = 92 (45 – 73)

SCr (mg/dL) = 0.9 (0.6 – 1.3)                

Bands (%) = 7 (3 – 5) 

Glucose (mg/dL) = 118 (100 – 125)      

Eosinophils (%) = 3 (0 – 5)

Ca (mg/dL) = 8.8 (8.5 – 10.5)                

Basophils (%) = 0 (0 – 1)

Mg (mEq/L) = 1.8 (1.3 – 2.1)                

Lymphocytes (%) = 29% (20 – 40)

PO4 (mg/dL) = 3.6 (2.3 – 4.7)                

Monocytes (%) = 2 (2 – 8)

AST (IU/L) = 62 (10 – 40) 

ALT (IU/L) = 58 (10 – 40) 

Albumin (g/dL) = 3.1 (3.5 – 5)

Tests: 

Chest Xray: bilateral upper lobe cavitary lesions.  Recommend chest CT for further evaluation.   

Plan:  Obtain CD4+ count and viral load.  Admit for IV antibiotics and additional diagnostic work-up


Question: 
KS is diagnosed with PCP and stabilized.  She is ready for discharge.  Her provider is concerned that the cellulitis has not healed as well as he had hoped.  He asks the pharmacist about a single dose glycopeptide for bacterial skin and skin structure infections that he heard about.  He thinks KS would be a good candidate for this drug.  Which drug is he referring to?

A. Vancomycin
B. Dalbavancin
C. Oritavancin
D. Tedizolid
E. Polymyxin
 

C. Oritavancin and dalbavancin are lipoglycopeptides that were FDA-approved in 2014. Both have activity againstStaphylococci (MSSA and MRSA) and Streptococci. Oritavancin is a one-time dose and dalbavancin is given as two doses (one week apart).

Remember "O" for one dose oritavancin (Orbactiv) and "D" for double dose dalbavancin (Dalvance).

41

A hospitalized patient with no known drug allergies has cellulitis and the physician ordered vancomycin 1,000 mg IV Q12H and imipenem-cilastatin 1,000 mg IV Q8H. Both medications were administered at the same time. The patient had a profound drop in blood pressure. Her upper body, mostly in the trunk area, was covered with an erythematous rash. The patient's breathing became labored. What is the likely cause of the patient's symptoms?

A. She likely had an anaphylactic reaction to cilastatin.
B. It is likely the infusion rate of vancomycin was too rapid.
C. The reaction was due to the combination of imipenem-cilastatin and vancomycin; the dosing should be separated by several hours.
D. These are side effects of the cilastatin component, which has not been reduced for renal insufficiency.
E. It is unlikely that this reaction is due to one of these medications.
 

B. The patient has experienced symptoms of Redman's Syndrome, a reaction due to a fast infusion of vancomycin. Symptoms can include a sudden or profound decrease in blood pressure, an erythematous rash, angioedema, pruritus, erythema, and trouble breathing (dyspnea, wheezing).

The erythematous rash usually starts in the trunk area and moves upward towards the head and face during Redman's Syndrome.

42

Jack has been in the intensive care unit for the past two weeks. He was initially admitted for an asthma exacerbation requiring mechanical ventilation. Over the course of the hospitalization, he developed ventilator-associated pneumonia and was treated with broad-spectrum antibiotics. His blood cultures are now positive for VRE faecium. Which of the following antibiotics provide coverage for VRE faecium bacteremia?

A. Synercid
B. Vancocin
C. Ketek
D. Invanz
E. Avelox
 

A. Synercid (quinupristin/dalfopristin) covers VRE faecium.

Agents used for VRE faecium: daptomycin (DoC), linezolid, Synercid, tigecycline

Agents used for VRE faecalis: Pen G or ampicillin (DoC), linezolid, daptomycin, tigecycline

Dual VRE coverage: daptomycin, linezolid, tigecycline

Ketek (telithromycin)

Invanz (ertapenem)

Avelox (moxifloxacin)

43

A patient taking isoniazid is at risk for peripheral neuropathy. Which of the following medications can be given to reduce the risk of peripheral neuropathy?

A. Vitamin B1
B. Vitamin B2
C. Vitamin B6
D. Vitamin E
E. Vitamin B12
 

C. Vitamin B6, or pyridoxine, 25-50 mg PO daily can be given to patients taking isoniazid to decrease the risk of peripheral neuropathy.

Vitamin B1 (Thiamine)
Vitamin B2 (Riboflavin)
Vitamin B6 (Pyridoxine)
Vitamin E (Tocopherol)
Vitamin B12 (Cyanocobalamin)

44

Janis has a blood culture report showing gram-positive cocci resembling streptococci, enteric gram-negative bacilli and anaerobes. Which of the following medications would provide adequate coverage for these organisms?

A. Ertapenem
B. Rifaximin
C. Metronidazole
D. Fosfomycin
E. Ciprofloxacin
 

A. Carbapenems (e.g., ertapenem) cover all of these organisms.

45

A patient with an active tuberculosis infection will receive ethambutol therapy as part of their combination drug therapy. The patient will require counseling regarding the possibility of the following adverse effect:

A. Vision problems
B. Shortness of breath
C. Thyroid dysfunction
D. Appetite suppression
E. Hearing loss
 

A. Ethambutol can cause optic neuritis, which can decrease visual acuity and may cause blindness. Patients should be counseled to report any changes in vision to their physician promptly.

46

A 30 year-old female patient is 12 weeks pregnant and presents to the physician with symptoms of urinary urgency, burning and frequency. She is diagnosed with a urinary tract infection. Her only medications are a daily prenatal vitamin and a calcium supplement. She has no drug allergies. Which is the best medication to recommend for this patient?

A. Ciprofloxacin
B. Doxycycline
C. Tobramycin
D. Cephalexin
E. Vancomycin
 

D. Cephalexin can be used safely in pregnancy as long as the patient does not have an allergy to penicillins or cephalosporins. It may not cover the organism, in which case symptoms would persist and an alternative agent would need to be used.

Avoid ciprofloxacin due to cartilage problems in pregnancy.

Avoid doxycycline due to bone growth retardation in pregnancy.

Tobramycin and vancomycin would require IV.

47

A prescription for generic doxycycline is filled. Which of the following statements regarding doxycycline are correct? (SelectALL that apply.)

A. This medication should not be used in children younger than 8 years old.
B. Take on an empty stomach 1 hour before or 2 hours after meals.
C. This medication may increase the risk of sunburn.
D. This medication should be separated when given with antacids.
E. This medication does not interact with other medications.
 

A, C, D. Doxycycline should not be used in children younger than 8 years old or in patients who are pregnant due to the risk of tooth discoloration, bone growth retardation and reduced skeletal muscle development.

48

Joshua is going to the operating room for repair of his hernia. He has no known drug allergies. Which of the following medications should be used for antibiotic prophylaxis?

A. Doripenem
B. Ticarcillin
C. Metronidazole
D. Cefazolin
E. Ciprofloxacin
 

D. Peri-operative antibiotic prophylaxis is recommended for patients undergoing surgery. First and second generation cephalosporins are typically the drugs of choice for most procedures.

49

Chief Complaint:  “I’m out of my inhaler and I can’t breath"

History of Present Illness:  KS is a 30 y/o female who comes to the ER today for worsening shortness of breath and cough.  She is out of her albuterol inhaler.  She occasionally lives on the street, but has been staying in the local homeless shelter for 3 nights.  She reports fatigue, but denies night sweats and hemoptysis.  Her cough is nonproductive. KS has mild right lower extremity cellulitis extending from right ankle to right calf.  Patient states she scraped her leg on a fence and it has not healed.  KS has not been treated with antibiotics.  

Allergies:  NKDA

Past Medical History: HIV x 5 years, PCP pneumonia 5 years ago when she was diagnosed with HIV, asthma, and dyslipidemia

Medications: Truvada 1 tablet daily, Tivicay 50 mg once daily, albuterol inhaler 1 puff 3-4 times daily as needed, Flovent Diskus 100 mcg BID, simvastatin 20 mg HS

Physical Exam / Vitals: 

Height: 5’2”  Weight: 105 pounds   

BP: 122/72 mmHg  HR: 71 BPM  RR: 18 BPM Temp: 103.2°F  Pain: 3/10 

General: Pleasant ill appearing female 

Lungs: decreased breath sounds bilaterally – right worse than left.  Mild wheezing. 

CV:  RRR – no murmurs 

GI: Normal bowel sounds 

Ext: Mild right lower extremity cellulitis with some purulence

Labs:

Na (mEq/L) = 129 (135 – 145)              

WBC (cells/mm3) = 10.4 (4 – 11 x 10^3)       

K (mEq/L) = 3.5 (3.5 – 5)                      

Hgb (g/dL) = 13.4 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 103 (95 – 103)                

Hct (%) = 40.1 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 24 (24 – 30)              

Plt (cells/mm3) = 202 (150 – 450 x 10^3)

BUN (mg/dL) = 12 (7 – 20)                  

PMNs (%) = 92 (45 – 73)

SCr (mg/dL) = 0.9 (0.6 – 1.3)                

Bands (%) = 7 (3 – 5) 

Glucose (mg/dL) = 118 (100 – 125)      

Eosinophils (%) = 3 (0 – 5)

Ca (mg/dL) = 8.8 (8.5 – 10.5)                

Basophils (%) = 0 (0 – 1)

Mg (mEq/L) = 1.8 (1.3 – 2.1)                

Lymphocytes (%) = 29% (20 – 40)

PO4 (mg/dL) = 3.6 (2.3 – 4.7)                

Monocytes (%) = 2 (2 – 8)

AST (IU/L) = 62 (10 – 40) 

ALT (IU/L) = 58 (10 – 40) 

Albumin (g/dL) = 3.1 (3.5 – 5)

Tests: 

Chest Xray: bilateral upper lobe cavitary lesions.  Recommend chest CT for further evaluation.   

Plan:  Obtain CD4+ count and viral load.  Admit for IV antibiotics and additional diagnostic work-up. 


Question: 
Based on chest Xray, KS will be treated empirically for PCP.  An order is received for Bactrim 20 mg/kg/day IV divided Q6H.  What is the correct dose for KS? 

A. Bactrim 26 mg IV Q6H
B. Bactrim 160 mg IV Q6H
C. Bactrim 240 mg IV Q6H
D. Bactrim 300 mg IV Q6H
E. Bactrim 950 mg IV Q6H
 

C. 105 pounds = 47.7 kg. 47.7 kg x 20 mg/kg = 954 mg Bactrim per day divided Q6H. Approximately 238.5 mg IV Q6H, so the dose is rounded to 240 mg IV Q6H.

50

A patient is prescribed isoniazid for treatment of tuberculosis. Which of the following statements regarding isoniazid are correct? (Select ALL that apply.)

A. It is an hepatic enzyme inducer.
B. It should be taken on an empty stomach.
C. Store the oral solution in the refrigerator.
D. It can turn the urine a reddish color.
E. It is associated with hepatitis and liver function tests may need to be monitored.
 

B, E. Isoniazid is an hepatic inhibitor and needs to be taken on an empty stomach. The oral solution is stored at room temperature. Monitor liver function.

51


A healthy, 25 year-old male is traveling to the Baja Peninsula in Mexico to visit a friend. He has never traveled to Mexico before and is concerned that he may acquire traveler's diarrhea. Recommend an appropriate prophylactic medication:

A. Levofloxacin 500 mg daily x 1-3 days
B. Azithromycin 500 mg daily x 1-3 days
C. Loperamide 2 mg BID x 1-3 days
D. Bismuth subsalicylate
E. Ciprofloxacin XR 1,000 mg daily x 1-3 days
 

D. Prophylaxis with antibiotics for traveler's diarrhea (TD) is not recommended, except perhaps for short-term travelers who are high-risk (such as those who are immunocompromised) or who are taking critical trips during which even a short bout of diarrhea could impact the purpose of the trip. Loperamide is used for treatment, not prophylaxis. Bismuth subsalicylate, such as in Pepto-Bismol, can be used for prophylaxis if the patient wishes.

52

A physician is unfamiliar with rifaximin and asks for information on the drug. Which of the following points would be accurate to describe rifaximin?

A. Rifaximin can be used to treat traveler's diarrhea caused by non-invasive E. coli.
B. Rifaximin requires renal dose adjustments.
C. Rifaximin is a strong hepatic enzyme inducer similar to rifampin.
D. Rifaximin is an antiprotozoal agent.
E. Rifaximin is an effective agent for treating C. difficile infections.
 

A. Rifaximin is an antibacterial agent indicated for the treatment of non-invasive E. coli and for reduction in the risk of overt hepatic encephalopathy. Since systemic drug absorption is minimal, it is not a strong hepatic enzyme inducer.

53

A patient gave the pharmacist a prescription for Solodyn 1 tab daily #30. Which of the following is an appropriate generic substitution for Solodyn?

A. Minocycline
B. Doxycycline
C. Erythromycin
D. Telithromycin
E. Itraconazole
 

A. The generic name for Solodyn is minocycline.

Doxycycline (Vibramycin)

Erythromycin (many brand names)

Telithromycin (Ketek)

Itraconazole (Sporanox)

54

A patient with severe renal impairment (creatinine clearance less than 30 mL/min) is in the hospital for treatment of an infection. Blood cultures are positive for Candida krusei. Which of the following medications is best to treat the patient's infection?

A. Tigecycline 100 mg IV x 1; then 50 mg IV every 12 hours
B. Amphotericin B deoxycholate 3 mg/kg IV daily
C. Caspofungin 70 mg IV x 1, then 50 mg IV daily
D. Fluconazole 200 mg IV daily
E. Ketoconazole 400 mg PO daily
 

C. Caspofungin is effective against Candida species such as C. krusei and C. glabrata. Fluconazole, in typical doses, would not cover C. krusei. Infuse caspofungin slowly, over 1 hour. Echinocandins do not require dose adjustment in renal impairment.

Remember the name "Echinocandins" have "-candin" in it so it treats Candidiasis better than other drugs.

55

A patient is being discharged home from the hospital. The patient was getting fluconazole 400 mg IV daily for the treatment of his fungal infection. The physician would like to continue with oral fluconazole therapy. What is the equivalent oral dose?

A. 800 mg
B. 600 mg
C. 400 mg
D. 200 mg
E. 100 mg
 

C. The fluconazole IV to oral ratio is 1:1.

56

Jenna is a 36 year-old female who is diagnosed with community acquired pneumonia as an outpatient. She has no medical problems and is not on any prescription medications. Jenna has no known drug allergies. Which of the following medications would be most appropriate to recommend for treatment?

A. Moxifloxacin
B. Tetracycline
C. Azithromycin
D. Amoxicillin
E. Vancomycin
 

C. Outpatient treatment of community acquired pneumonia in healthy individuals with no co-morbidities should be initiated with a macrolide antibiotic or doxycycline.

57

Joseph is on tobramycin IV every 8 hours for treating a gram negative infection and his levels are reported as a peak of 8.3 mcg/mL and a trough of 2.1 mcg/mL. Which of the following recommendations should the pharmacist make to the medical team?

A. Increase the dose of tobramycin
B. Reduce the dose of tobramycin
C. Extend the dosing interval of tobramycin
D. Reduce the dose and extend the interval of tobramycin
E. Shorten the dosing interval of tobramycin
 

C. The peak of tobramycin is within range, but the trough level is too high (it should be less than 2 mcg/mL and ideally less than 1.5 mcg/mL). By extending the dosing interval, the trough level will decrease and the toxicity risk is lowered.

58

Jackson, a 46 year old male, is found to have VRE faecalis on his recent blood cultures. Which of the following regimens is the best option for treatment of VRE faecalis?

A. Daptomycin
B. Vancomycin
C. Colistimethate
D. Quinupristin-dalfopristin
E. Cephalexin
 

A. Daptomycin is indicated for the treatment of VRE faecalis whereas the other medications do not cover this pathogen.

Agents used for VRE faecium: daptomycin (DoC), linezolid, Synercid, tigecycline

Agents used for VRE faecalis: Pen G or ampicillin (DoC), linezolid, daptomycin, tigecycline

Dual VRE coverage: daptomycin, linezolid, tigecycline

59

A 25 year-old female has been to see her primary care physician. She is planning to become pregnant and wanted a "clean bill of health". She was found to be infected with gonorrhea. Which of the following statements is the best recommendation for this patient? 

A. She should be treated with cefixime 400 mg PO x 1.
B. She should be treated with ceftriaxone 250 mg IM x 1.
C. She should be treated with ceftriaxone 250 mg IM x 1 and azithromycin 1 gram PO x 1.
D. She should be treated with penicillin G 2.4 million units IM x 3.
E. Therapy should be withheld until a pregnancy test can be obtained.
 

C. Treat all sexual partners to prevent re-infection.

60

Lucas is receiving ampicillin for the treatment of a Proteus mirabilis bacteremia. The doctor wants to know how ampicillin works. Which of the following best characterizes the pharmacodynamic properties of ampicillin?

A. Ampicillin exhibits concentration-dependent bacterial killing
B. Ampicillin exhibits concentration-above-MIC-dependent killing
C. Ampicillin exhibits colonic concentration bacterial killing
D. Ampicillin exhibits post antibiotic effect for bacterial killing
E. Ampicillin exhibits time-above-MIC-dependent bacterial killing
 

E. Ampicillin, a penicillin, exhibits time-dependent killing. The drug level in the blood must be above the MIC of the organism in order to inhibit bacterial cell growth. Therefore, the amount of time spent above the MIC leads to maximal effectiveness of ampicillin.

T>MIC: beta-lactams (penicillins, cephalosporins)

Cmax:MIC: aminoglycosides, fluoroquinolones, daptomycin, colistin

AUC:MIC: vancomycin, macrolides, tetracyclines

61

Helen is a 68 year-old female who comes to the clinic for an urgent appointment. She has been feeling awful due to her "flu-like" symptoms and she cannot get any rest because of her coughing. Her past medical history is significant for heart failure, status-post breast cancer, peptic ulcer disease and gout. Helen is diagnosed with community acquired pneumonia. Which is the best treatment regimen for her community acquired pneumonia?

A. Clarithromycin 500 mg PO Q12H
B. Cefpodoxime 500 mg PO Q12H
C. Doxycycline 100 mg PO Q12H
D. Moxifloxacin 400 mg PO daily
E. Patient should be admitted to the hospital for intravenous therapy
 

D. A respiratory fluoroquinolone is a treatment of choice for patients at risk for drug resistant S. pneumonia community acquired pneumonia. Helen is at risk due to her age and co-morbidities. A beta-lactam plus a macrolide is another treatment option.

62

Julie comes to the emergency department with a large wound that is oozing pus on her lower right leg. She has diabetes and did not want to see a doctor earlier because she does not have medical insurance. It is presumed that the infection is due to community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA). Which of the following oral medications can be used to treat CA-MRSA? (Select ALL that apply.)

A. Clindamycin
B. Sulfamethoxazole/trimethoprim
C. Ciprofloxacin
D. Linezolid
E. Quinupristin/dalfopristin
 

A, B, D. Ciprofloxacin does not have activity against CA-MRSA and quinupristin-dalfopristin is not available as an oral agent.

CA-MRSA coverage: Bactrim DS, doxycycline, minocycline, clindamycin, linezolid, daptomycin, tigecycline, caftaroline, vancomycin, telavancin, dalbavancin, tedizolid

Nosocomial MRSA coverage: vancomycin, linezolid, Synercid, daptomycin, ceftaroline, telavancin, tigecycline, dalbavancin, tedizolid, rifampin (in combination), SMX/TMP

63

Chief Complaint:  “I need something for pain”

History of Present Illness: KA is a 62 y/o Hispanic male who was admitted to the hospital on 10/16/14 complaining of severe pain that has worsened over 2 days.  The pain is in the center of his abdomen.  He vomited once today, but it did nothing to help the pain.  The pain is a 9 out of 10.  KA has never experienced anything like this before.  He reports no trauma and has no fever.  He admits to social alcohol and tobacco use.  KA’s past medical history is significant for hypertension, osteoarthritis, type 2 diabetes, and hypothyroidism.           

Allergies:  NKDA

Medications: Benicar 40 mg daily, Byetta 10 mcg SC BID, Synthroid 75 mcg daily, Tylenol 650 every 6 hours and Glucosmine & Chondroitin capsules

Physical Exam / Vitals: 

Height: 5’11”  Weight: 226 pounds   

BP: 146/89 mmHg  HR: 88 BPM  RR: 16 BPM Temp: 98.9°F  Pain: 9/10

Labs on 10/16/14:

Na (mEq/L) = 137 (135 – 145)              

WBC (cells/mm3) = 7.3 (4 – 11 x 10^3)       

K (mEq/L) = 3.7 (3.5 – 5)                      

Hgb (g/dL) = 16.5 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 100 (95 – 103)                

Hct (%) = 48.4 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 28 (24 – 30)              

Plt (cells/mm3) = 302 (150 – 450 x 10^3)

BUN (mg/dL) = 16 (7 – 20)                  

AST (IU/L) = 35 (10 – 40) 

SCr (mg/dL) = 1.1 (0.6 – 1.3)              

ALT (IU/L) = 32 (10 – 40)   

Glucose (mg/dL) = 120 (100 – 125)    

Albumin (g/dL) = 4.1 (3.5 – 5)   

Ca (mg/dL) = 9.2 (8.5 – 10.5)              

A1C (%) = 8.7 

Mg (mEq/L) = 1.9 (1.3 – 2.1)               

PO4 (mg/dL) = 3.2 (2.3 – 4.7)                

Tests on 10/16/14: 

CT Abdomen: acute pancreatitis   

Plan:  Discontinue Byetta and manage with insulin.  Control pain with IV opioids.   

10/18/14 

Vitals: BP: 142/85 mmHg  HR: 80 BPM  RR: 15 BPM Temp: 102.4°F  Pain: 3/10

Labs on 10/18/14:

Na (mEq/L) = 137 (135 – 145)              

WBC (cells/mm3) = 13.1 (4 – 11 x 10^3)       

K (mEq/L) = 3.8 (3.5 – 5)                      

Hgb (g/dL) = 14.6 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 99 (95 – 103)                  

Hct (%) = 43.5 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 28 (24 – 30)              

Plt (cells/mm3) = 300 (150 – 450 x 10^3)

BUN (mg/dL) = 15 (7 – 20)                  

AST (IU/L) = 33 (10 – 40) 

SCr (mg/dL) = 1.1 (0.6 – 1.3)              

ALT (IU/L) = 22 (10 – 40)   

Glucose (mg/dL) = 108 (100 – 125)    

Albumin (g/dL) = 4.1 (3.5 – 5)   

Ca (mg/dL) = 9.2 (8.5 – 10.5)              

A1C (%) = 8.5 

Mg (mEq/L) = 1.9 (1.3 – 2.1)               

PO4 (mg/dL) = 3.1 (2.3 – 4.7)                

Tests on 10/18/14: 

CT abdomen: resolving pancreatic inflammation 

Chest xray: right lower lobe infiltrate   


Question: 
Which of the following antimicrobial regimens is best to initiate for KA on 10/18/14 based on the suspected pathogens?

A. Azithromycin monotherapy
B. Linezolid monotherapy
C. Ampicillin/sulbactam monotherapy
D. Vancomycin + meropenem
E. Piperacillin/tazobactam + ciprofloxacin
 

C. KA is 48 hours into his hospital stay. Common pathogens for early HAP are similar to CAP with increased prevalence of enteric Gram-negatives and decreased prevalence of atypical pathogens.

64

Many hospitalized patients with MRSA skin and soft tissue infections are typically treated with IV therapy and transitioned to an oral agent to allow ease of use and discharge from the hospital. Prior to sending patients home on clindamycin, what test should be performed to ensure clindamycin's effectiveness?

A. Hodge test
B. D-test
C. E-test
D. Synergy test
E. MBC test
 

B. The "D-test" is used to determine the presence of constitutive (already present) resistance in MRSA. The Hodge test detects carbapenemase production. E-tests are drug strips that determine minimal inhibitory concentrations of an antibiotic and bacteria. Synergy tests determine if the effects of combining two antibiotics is greater than the sum of the individual agent. MBC test is minimal bactericidal concentration needed to kill bacteria.

65

A patient has an MRSA wound infection. She has heart failure and impaired renal function with an estimated creatinine clearance of 40 mL/min. Her current medications include Toprol XL, Zestril and Lasix. She is going to receive intravenous vancomycin while in the hospital. Choose the correct statement:

A. Vancomycin should not be used in patients with heart failure.
B. She should receive the vancomycin orally due to the risk of further renal insufficiency.
C. She is at an elevated risk of ototoxicity due to the concurrent use of furosemide.
D. The trough is not important; only vancomycin peaks should be monitored.
E. She should receive ceftazidime instead of vancomycin.
 

C. Oral vancomycin is not absorbed and could not treat a systemic infection. Nephrotoxicity and ototoxicity are the primary toxicities that can occur with vancomycin therapy, and the risk is increased with concomitant medications that have these same side effects such as loop diuretics and aminoglycosides.

66

Which of the following statements concerning bronchitis are correct? (Select ALL that apply.)

A. Most cases of acute bronchitis are viral; antibiotics will not help
B. In mild-moderate cases of acute bronchitis, treatment is generally supportive.
C. It is best to suppress a cough that brings up mucus.
D. Antibiotics may be considered for patients who meet the definition of acute exacerbation of chronic bronchitis.
E. Antibiotics are utilized when fever is present.
 

A, B, D. It is best not to suppress a cough that brings up mucus. Breathing in warm, moist air can be helpful and a humidifier will be useful in cold weather if the heating unit is drying out the air in the home. This can be particularly beneficial during sleep. Drinking adequate fluids and getting enough rest are important. Antibiotic use is not indicated in uncomplicated bronchitis.

67

A patient is starting quadruple therapy for treatment of active tuberculosis. Rifampin is part of the regimen. Which of the following is correct regarding rifampin therapy?

A. This medication should be taken with meals.
B. This medication is a potent inhibitor of many hepatic enzymes leading to many drug interactions.
C. This medication can cause orange-red discoloration of body secretions and stain contact lenses.
D. This medication can cause optic neuritis.
E. This medication is taken three times daily.
 

C. Rifampin is a potent inducer of many hepatic enzymes and will lead to many drug interactions. It is important to take on an empty stomach; food decreases absorption.

Isoniazid is a potent inhibitor of hepatic enzymes.

Ethambutol causes optic neuritis.

Rifampin and isoniazid are taken once daily on an empty stomach.  

All tuberculosis drugs are taken once daily.

68

The clinical pharmacist is preparing for rounds. He calls the laboratory to see if the cultures are ready on Mr. Jones. The laboratory states that the Gram stain is purple in color. What class of organisms appears purple on a Gram stain?

A. Gram-positive organisms
B. Gram-negative organisms
C. Fungal organisms
D. Atypical organisms
E. Viral organisms
 

A. Gram staining is an empirical method of differentiating bacterial species into two large groups, Gram-positive and Gram-negative. Gram-positive organisms stain purple (bluish-purple) while gram-negative organisms stain pink (reddish-pink). The pharmacist can recommend "empiric" therapy. Once the specific organisms have been identified, the empiric therapy should be changed to directed therapy that targets only the identified organism/s.

69

Chief Complaint:  “I need something for pain”

History of Present Illness: KA is a 62 y/o Hispanic male who was admitted to the hospital on 10/16/14 complaining of severe pain that has worsened over 2 days.  The pain is in the center of his abdomen.  He vomited once today, but it did nothing to help the pain.  The pain is a 9 out of 10.  KA has never experienced anything like this before.  He reports no trauma and has no fever.  He admits to social alcohol and tobacco use.  KA’s past medical history is significant for hypertension, osteoarthritis, type 2 diabetes, and hypothyroidism.           

Allergies:  NKDA

Medications: Benicar 40 mg daily, Byetta 10 mcg SC BID, Synthroid 75 mcg daily, Tylenol 650 every 6 hours and Glucosmine & Chondroitin capsules

Physical Exam / Vitals: 

Height: 5’11”  Weight: 226 pounds   

BP: 146/89 mmHg  HR: 88 BPM  RR: 16 BPM Temp: 98.9°F  Pain: 9/10

Labs on 10/16/14:

Na (mEq/L) = 137 (135 – 145)              

WBC (cells/mm3) = 7.3 (4 – 11 x 10^3)       

K (mEq/L) = 3.7 (3.5 – 5)                      

Hgb (g/dL) = 16.5 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 100 (95 – 103)                

Hct (%) = 48.4 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 28 (24 – 30)              

Plt (cells/mm3) = 302 (150 – 450 x 10^3)

BUN (mg/dL) = 16 (7 – 20)                  

AST (IU/L) = 35 (10 – 40) 

SCr (mg/dL) = 1.1 (0.6 – 1.3)              

ALT (IU/L) = 32 (10 – 40)   

Glucose (mg/dL) = 120 (100 – 125)    

Albumin (g/dL) = 4.1 (3.5 – 5)   

Ca (mg/dL) = 9.2 (8.5 – 10.5)              

A1C (%) = 8.7 

Mg (mEq/L) = 1.9 (1.3 – 2.1)               

PO4 (mg/dL) = 3.2 (2.3 – 4.7)                

Tests on 10/16/14: 

CT Abdomen: acute pancreatitis   

Plan:  Discontinue Byetta and manage with insulin.  Control pain with IV opioids.   

10/18/14 

Vitals: BP: 142/85 mmHg  HR: 80 BPM  RR: 15 BPM Temp: 102.4°F  Pain: 3/10

Labs on 10/18/14:

Na (mEq/L) = 137 (135 – 145)              

WBC (cells/mm3) = 13.1 (4 – 11 x 10^3)       

K (mEq/L) = 3.8 (3.5 – 5)                      

Hgb (g/dL) = 14.6 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 99 (95 – 103)                  

Hct (%) = 43.5 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 28 (24 – 30)              

Plt (cells/mm3) = 300 (150 – 450 x 10^3)

BUN (mg/dL) = 15 (7 – 20)                  

AST (IU/L) = 33 (10 – 40) 

SCr (mg/dL) = 1.1 (0.6 – 1.3)              

ALT (IU/L) = 22 (10 – 40)   

Glucose (mg/dL) = 108 (100 – 125)    

Albumin (g/dL) = 4.1 (3.5 – 5)   

Ca (mg/dL) = 9.2 (8.5 – 10.5)              

A1C (%) = 8.5 

Mg (mEq/L) = 1.9 (1.3 – 2.1)               

PO4 (mg/dL) = 3.1 (2.3 – 4.7)                

Tests on 10/18/14: 

CT abdomen: resolving pancreatic inflammation 

Chest xray: right lower lobe infiltrate

 
Question: 
Which of the following infections does KA most likely have based on his labs and tests on 10/18/14?

A. Cellulitis
B. Peritonitis
C. Bronchitis
D. Meningitis
E. Pneumonia

E. Pneumonia is diagnosed with a chest xray. KA’s increased white blood cell count and temperature also support the clinical picture of an infection.

70

Itraconazole is used for a variety of fungal infections including blastomycosis, histoplasmosis, aspergillosis and onychomycosis. Itraconazole cannot be used with certain drugs. Which of the following drugs is contraindicated with the use of itraconazole?

A. Cetirizine
B. Quinidine
C. Zafirlukast
D. Azithromycin
E. Amphotericin B
 

B. Itraconazole is a strong 3A4 inhibitor. Use with certain drugs has been associated QT prolongation and ventricular arrhythmias.

Cetirizine (Zyrtec)

Quinidine (Quinidex)

Zafirlukast (Accolate)

Amphotericin B (Fungizone)

Liposomal amphotericin B (AmBisome)

71

In patients with infective endocarditis who are receiving traditional dosing of gentamicin in combination with vancomycin, what is the peak goal for gentamicin?

A. 1 mcg/mL
B. 2 mcg/mL
C. 4 mcg/mL
D. 5 mcg/mL
E. 10 mcg/mL
 

C. Gentamicin peak goal for synergy in infective endocarditis is 3-4 mcg/mL. Traditional dosing of gentamicin is recommended for this condition.

72

A patient is taking Moxatag for treatment of strep throat. Which of the following statements is correct regarding Moxatag?

A. Moxatag can be used in patients with a creatinine clearance less than 30 mL/min.
B. Moxatag should be administered within 1 hour of finishing a meal.
C. Moxatag should be stored in the refrigerator.
D. Moxatag is an extended release product delivered by the osmotic-controlled release oral delivery system (OROS).
E. Moxatag is safe to use in a patient who has a penicillin allergy.
 

B. Moxatag is extended-release amoxicillin indicated for pharyngitis caused by Streptococcus pyogenes. It is taken once daily within 1 hour of finishing a meal. Moxatag should not be used in patients with a creatinine clearance less than 30 mL/min.

73

Many patients test positive for tuberculosis (TB). Which of the following patients should be given treatment for latent tuberculosis if the Mantoux tuberculin skin test has an induration of 8 mm? (Select ALL that apply.)

A. Persons with a close contact of a known TB case.
B. HIV-infected persons.
C. Healthcare worker.
D. Patients without any known risk factors who are over 35 years of age.
E. Persons who are immunocompromised.
 

A, B, E. The Mantoux tuberculin skin test is the standard method of determining whether a person is infected with TB. It is performed by injecting 0.1 mL of tuberculin purified protein derivative (PPD) into the inner surface of the forearm. An induration of 5 mm or more is positive in immunocompromised patents or those with close contacts of a known TB patient. If there are no known risk factors, an induration greater than 15 mm is positive.

74

How long should peri-operative antibiotic prophylaxis be continued for most surgeries?

A. 5 days
B. 7 days
C. 10 days
D. 1 day or less
E. 2 days
 

D. Most surgeries require only 1 day (or less, sometimes just 1 dose) of antibiotic use for prevention of infections. Cardiac bypass surgery requires 2 days of prophylactic antibiotic therapy.

75

Roger is a 58 year-old male who is in the medical intensive care unit with a severe Pseudomonas aeruginosa infection. He is on ciprofloxacin and cefepime and his infection does not seem to be clearing. Which of the following medications should be used to replace the current therapy?

A. Doribax
B. Invanz
C. Zyvox
D. Minocycline
E. Tygacil
 

A. All the carbapenems, except Invanz, cover Pseudomonas aeruginosa. Ciprofloxacin and cefepime often cover Pseudomonas aeruginosa, but perhaps this infection is resistant.


Doribax (doripenem)
Invanz (ertapenem)
Zyvox (linezolid)
Minocycline (Solodyn)
Tygacil (tigecycline), does not cover Pseudomonas, Proteus, Providencia (Remember Four T's of Tygacil)
 

76

Which of the following are common components of Antimicrobial Stewardship Programs? (Select ALL that apply.)

A. Antimicrobial pre-authorization policy
B. Open formulary policy
C. Intravenous to oral switching protocol
D. De-escalation of therapy
E. Disease care pathways or protocols
 

A, C, D, E. Allowing for an open formulary means that drugs are not restricted in any way and are available for prescribing. All other options encourage judicious prescribing.

77

Linezolid will most likely have a drug-drug interaction with which of the following medications?

A. Venlafaxine
B. Metoprolol
C. Enalapril
D. Calcium carbonate
E. Ampicillin
 

A. Linezolid is a reversible monoamine oxidase inhibitor and it interacts with anti-depressants such as SSRIs, SNRIs (venlafaxine), TCAs, and other drugs potentially causing serotonin syndrome.

78

A nine year-old girl has an acute otitis media infection. Her mother has received a prescription for antibiotics and was told to watch the girl first to see if she improves, prior to filling the prescription. The mother is fine with this plan, but wants something now to treat the child's ear pain. Which of the following are acceptable options for her daughter's ear pain? (Select ALL that apply.)

A. Acetaminophen
B. Aspirin
C. Ibuprofen
D. Topical benzocaine otic drops
E. Debrox
 

A, C, D. Systemic acetaminophen or ibuprofen can be used. Acetaminophen or ibuprofen is preferred, however, topical benzocaine otic drops can be used. The concern with the use of the otic medications is that they can mask worsening illness. If topical drops are used, the patient should be re-evaluated after 2 days to check for improvement. Aspirin should not be used in children.

79

YS is an 8 year old male who was found to be colonized with methicillin-resistant Staphylococcus aureus. He was seen at an outpatient clinic for his first ever skin infection, a pustule and probable cellulitis. What is the most appropriate oral antibiotic therapy for YS?

A. Cetriaxone
B. Ciprofloxacin
C. Clindamycin
D. Vancomycin
E. Minocycline
 

C. Tetracyclines like minocycline should not be used in children younger than 8 years old. Ciprofloxacin is not effective in treating MRSA. Ceftriaxone does not come in an oral formulation. Oral vancomycin will not achieve appreciable systemic levels to treat skin infections. Clindamycin is a viable oral option due to efficacy and the lack of contraindications.

80

When should peri-operative antibiotic prophylaxis with cefazolin be initiated in patients undergoing elective surgeries such as hip arthroplasty?

A. Within 1 hour of incision
B. Within 2 hours of incision
C. Within 3 hours of incision
D. Within 2 hours after the surgery is over
E. Immediately after the surgery is over
 

A. Cefazolin is typically infused over 30 minutes and distributes throughout the body within 30 minutes to prevent surgery related infections. Infusing antibiotics after surgery does not effectively prevent infections.

81

A 42 year-old female patient is choosing an OTC product for a vaginal fungal infection. She has had three vaginal fungal infections in three months. She is overweight and is eating a candy bar. She should be recommended to have the following conditions tested:

A. Diabetes and HIV
B. Cancer and neoplasm
C. Hypothyroidism and hepatitis
D. Sinusitis and otitis media
E. Bipolar and schizophrenia
 

A. Frequent fungal infections can indicate more serious conditions. She should be tested for both diabetes and HIV.

82

PM is a 70 year old man who was recently diagnosed as having a severe case of Clostridium difficile infection (CDI). He has a serum white blood cell count of 24,000 cells/mm3 and a SCr of 2.2 mg/dL with 6-7 loose bowel movements per day. What is the most appropriate therapy for PM?

A. Metronidazole 500 mg IV QID
B. Vancomycin 125 mg PO QID and metronidazole 500 mg IV Q8H
C. Metronidazole 500 mg PO TID
D. Vancomycin 500 mg IV QID
E. Vancomycin 125 mg PO QID
 

E. Severe, uncomplicated CDI episodes should be treated with oral vancomycin monotherapy.

Mild-mod: metronidazole 500mg PO TID x 10-14 days

Severe uncomplicated: vancomycin 125mg PO QID x 10-14 days

Severe complicated: vancomycin 500mg PO QID + metronidazole 500mg IV Q8H

83

Chief Complaint:  “I need something for pain”

History of Present Illness: KA is a 62 y/o Hispanic male who was admitted to the hospital on 10/16/14 complaining of severe pain that has worsened over 2 days.  The pain is in the center of his abdomen.  He vomited once today, but it did nothing to help the pain.  The pain is a 9 out of 10.  KA has never experienced anything like this before.  He reports no trauma and has no fever.  He admits to social alcohol and tobacco use.  KA’s past medical history is significant for hypertension, osteoarthritis, type 2 diabetes, and hypothyroidism.           

Allergies:  NKDA

Medications: Benicar 40 mg daily, Byetta 10 mcg SC BID, Synthroid 75 mcg daily, Tylenol 650 every 6 hours and Glucosmine & Chondroitin capsules

Physical Exam / Vitals: 

Height: 5’11”  Weight: 226 pounds   

BP: 146/89 mmHg  HR: 88 BPM  RR: 16 BPM Temp: 98.9°F  Pain: 9/10

Labs on 10/16/14:

Na (mEq/L) = 137 (135 – 145)              

WBC (cells/mm3) = 7.3 (4 – 11 x 10^3)       

K (mEq/L) = 3.7 (3.5 – 5)                      

Hgb (g/dL) = 16.5 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 100 (95 – 103)                

Hct (%) = 48.4 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 28 (24 – 30)              

Plt (cells/mm3) = 302 (150 – 450 x 10^3)

BUN (mg/dL) = 16 (7 – 20)                  

AST (IU/L) = 35 (10 – 40) 

SCr (mg/dL) = 1.1 (0.6 – 1.3)              

ALT (IU/L) = 32 (10 – 40)   

Glucose (mg/dL) = 120 (100 – 125)    

Albumin (g/dL) = 4.1 (3.5 – 5)   

Ca (mg/dL) = 9.2 (8.5 – 10.5)              

A1C (%) = 8.7 

Mg (mEq/L) = 1.9 (1.3 – 2.1)               

PO4 (mg/dL) = 3.2 (2.3 – 4.7)                

Tests on 10/16/14: 

CT Abdomen: acute pancreatitis   

Plan:  Discontinue Byetta and manage with insulin.  Control pain with IV opioids.   

10/18/14 

Vitals: BP: 142/85 mmHg  HR: 80 BPM  RR: 15 BPM Temp: 102.4°F  Pain: 3/10

Labs on 10/18/14:

Na (mEq/L) = 137 (135 – 145)              

WBC (cells/mm3) = 13.1 (4 – 11 x 10^3)       

K (mEq/L) = 3.8 (3.5 – 5)                      

Hgb (g/dL) = 14.6 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 99 (95 – 103)                  

Hct (%) = 43.5 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 28 (24 – 30)              

Plt (cells/mm3) = 300 (150 – 450 x 10^3)

BUN (mg/dL) = 15 (7 – 20)                  

AST (IU/L) = 33 (10 – 40) 

SCr (mg/dL) = 1.1 (0.6 – 1.3)              

ALT (IU/L) = 22 (10 – 40)   

Glucose (mg/dL) = 108 (100 – 125)    

Albumin (g/dL) = 4.1 (3.5 – 5)   

Ca (mg/dL) = 9.2 (8.5 – 10.5)              

A1C (%) = 8.5 

Mg (mEq/L) = 1.9 (1.3 – 2.1)               

PO4 (mg/dL) = 3.1 (2.3 – 4.7)                

Tests on 10/18/14: 

CT abdomen: resolving pancreatic inflammation 

Chest xray: right lower lobe infiltrate   


Question: 
Several days later on 10/20/14, KA is improving on IV antibiotics.  One of the medical students on the team caring for KA suggests a “respiratory fluoroquinolone” for outpatient management of KA’s infection.  Which of the following correctly lists the three respiratory fluoroquinonlones and explains why they are called “respiratory fluoroquinolones”? 

A. Gatifloxacin, gemifloxacin, and moxifloxacin; because they have enhanced Gram-negative and anaerobic activity.
B. Ciprofloxacin, levofloxacin, and norfloxacin; because they have enhanced Gram-positive and anaerobic coverage.
C. Gemifloxacin, levofloxacin, and moxifloxacin; because they have enhanced Gram-positive and atypical coverage.
D. Ciprofloxacin, levofloxacin, and ofloxacin; because they have enhanced Gram-positive and anaerobic activity.
E. Levofloxacin, gatifloxacin, and moxifloxacin; because they have enhanced Gram-negative and atypical coverage.

C.

They are referred to as respiratory fluoroquinolones due to enhanced coverage of Streptococcus pneumoniae and atypical coverage.

84

Ryan is a 70-year-old male who lives in a skilled nursing facility. He has been complaining about urinary urgency and painful urination. His laboratory tests are negative for all sexually transmitted diseases, but positive for an Extended Spectrum Beta-Lactamase (ESBL) producing Klebsiella pneumoniae. What empiric antimicrobial regimen would you recommend for Ryan?

A. Zosyn
B. Invanz
C. Timentin
D. Maxipime
E. Teflaro
 

B. Carbapenems are the drugs of choice for Extended Spectrum Beta-Lacatamsase (ESBL) producing bacteria.

Zosyn (piperacillin/tazobactam)
Invanz (ertapenem)
Timentin (ticarcillin/clavulanate)
Maxipime (cefepime) - 4th generation
Teflaro (ceftaroline) - 5th generation

85

A man with chills and a fever sneezes and coughs inside a crowded bus. The other passengers in the bus may have been put at risk of contracting the following conditions which are transmitted by aerosolized droplets, via sneezing or coughing: (Select ALL that apply.)

A. Tuberculosis
B. Varicella
C. Clostridium difficile
D. Trichomoniasis
E. Influenza
 

A, B, E. Influenza and tuberculosis are both airborne diseases; they are spread by sneezing, coughing or talking. Varicella can be transmitted person to person or via droplet particles (airborne).

86

Jeannie is being transitioned from ciprofloxacin intravenous to ciprofloxacin oral suspension. Which of the following statements regarding ciprofloxacin oral suspension are true? (Select ALL that apply.)

A. This agent may prolong the QT interval.
B. The patient's blood sugar may be affected.
C. This medication should not be given through feeding tubes.
D. This agent can cause peripheral neuropathies.
E. This medication should be shaken prior to use.
 

A, B, C, D, E. Ciprofloxacin oral suspension should not administered through feeding tubes since the suspension is oil-based and adheres to the tubing. Hypo (especially if on hypoglycemics) or hyperglycemia may occur; monitor BG levels in at-risk patients. FQs have a warning regarding peripheral neuropathies.

87

Which cephalosporin can be dosed once daily in patients with normal renal function?

A. Ceftaroline
B. Cefuroxime
C. Ceftazidime
D. Cefepime
E. Ceftriaxone
 

E. The only IV cephalosporin than can be given once daily is ceftriaxone.

88

Zosyn is a commonly used medication in hospitals since it has broad spectrum coverage. Zosyn contains:

A. Imipenem and cilastatin
B. Ticarcillin and tazobactam
C. Ticarcillin and clavulanic acid
D. Piperacillin and tazobactam
E. Piperacillin and clavulanic acid
 

D. Zosyn contains pipericillin and tazobactam.

89

HM is a 45 year old female who was recently diagnosed with mild-moderate Clostridium difficile and was treated with metronidazole 2 weeks ago. HM now has his first recurrence of the same severity. What treatment should HM receive now?

A. Metronidazole 500 mg IV Q6H
B. Metronidazole 500 mg PO TID
C. Vancomycin 125 mg PO QID
D. Vancomycin 500 mg PO QID
E. Fidaxomicin 200 mg PO BID
 

B. The first recurrence of CDI of the same severity is treated with the same therapy that was previously used.

Mild-mod: metronidazole 500mg PO TID x 10-14 days

Severe uncomplicated: vancomycin 125mg PO QID x 10-14 days

Severe complicated: vancomycin 500mg PO QID + metronidazole 500mg IV Q8H

90

Which of the following antibiotics require dose adjustment for severe renal dysfunction (CrCl < 30 mL/min)? (Select ALL that apply.)

A. Doxycycline
B. Piperacillin/Tazobactam
C. Daptomycin
D. Nafcillin
E. Ciprofloxacin
 

B, C, E. Nafcillin and doxycycline do not require dose adjustment in CrCl < 30 mL/min.

91

When a patient is diagnosed with community acquired Clostridium difficile infection (CDI) for the first time, what measures should be taken to minimize therapeutic failure?

A. Discontinue the offending antimicrobial agent(s) as soon as possible
B. Initiate antiperistaltic drugs such as loperamide immediately
C. Initiate monotherapy treatment and continue for 30 days to ensure eradication of CDI
D. Initiate combination therapy immediately
E. Start on probiotics immediately
 

A. Whenever possible, discontinuing the antimicrobial that caused Clostridium difficile will help prevent it from being prolonged. Probiotics are not effective for treatment of CDI. Taking anti motility agents may increase the risk for toxic megacolon and should be avoided. Standard therapy for CDI is 10-14 days. Combination therapy is for severe, complicated CDI cases.

92

Tessa is a 22 year-old female who has a serious intra-abdominal Gram-negative infection. She has been in the hospital for 12 days and is suffering from moderate renal impairment. The medical team wants to treat her infection but not put her kidneys at risk for further toxicity. Which of the following antibiotics do not require dose adjustment in moderate renal impairment?

A. Zosyn
B. Cipro
C. Vancocin
D. Maxipime
E. Tygacil
 

E. Tygacil does not require dose adjustment in renal impairment.

Zosyn (piperacillin/tazobactam)
Cipro (ciprofloxacin)
Vancocin (vancomycin)
Maxipime (cefepime)
Tygacil (tigecycline)

93

What are acceptable treatment options for latent tuberculosis? (Select ALL that apply.)

A. Isoniazid
B. Azithromycin
C. Rifampin + pyrazinamide
D. Pyrazinamide
E. Rifampin
 

A, E. Isoniazid and rifampin can be used for latent TB. Rifampin plus pyrazinamide is no longer recommended due to increased risk of hepatotoxicity.

94

Which of the following classes of antibiotics work by concentration-dependent killing?

A. Tetracyclines
B. Carbapenems
C. Fluoroquinolones
D. Macrolides
E. Streptogramins
 

C. Concentration-dependent antibiotics include aminoglycosides, fluoroquinolones, daptomycin and others.

Cmax:MIC: aminoglycosides, fluoroquinolones, daptomycin, colistin

AUC:MIC: vancomycin, macrolides, tetracyclines

T>MIC: beta-lactams (penicillins, cephalosporins)

95

A patient presents with a mild-moderate Clostridium difficile infection. What is the best treatment option for this patient?

A. Vancomycin 125 mg PO QID 10-14 days.
B. Vancomycin 250 mg PO QID x 7-10 days.
C. Metronidazole 500 mg PO three times daily x 10-14 days.
D. Metronidazole 500 mg PO three times daily x 7-10 days.
E. Metronidazole 250 mg PO BID x 14 days.
 

C.

Mild-mod: metronidazole 500mg PO TID x 10-14 days

Severe uncomplicated: vancomycin 125mg PO QID x 10-14 days

Severe complicated: vancomycin 500mg PO QID + metronidazole 500mg IV Q8H

96

Which of the following statements regarding fidaxomicin in the treatment of C. difficile-associated diarrhea is correct?

A. Clinical evidence supports that fidaxomicin is more efficacious than metronidazole
B. Clinical evidence supports that fidaxomicin is less efficacious than metronidazole
C. Clinical evidence supports that fidaxomicin is more efficacious than vancomycin
D. Clinical evidence supports that fidaxomicin is equally as efficacious as vancomycin
E. Clinical evidence supports that fidaxomicin is less efficacious than vancomycin
 

D. Fidaxomicin was approved after the development of the IDSA Clostridium difficile guidelines. The clinical trials indicate that fidaxomicin is as efficacious as oral vancomycin for this indication. Fidaxomicin has been associated with lower recurrence rates compared to vancomycin.

97

Which of the following patients is a good candidate for antimicrobial prophylaxis prior to a dental procedure?

A. A patient with heart failure
B. A patient with atrial fibrillation
C. A patient with GERD
D. A patient with a prosthetic heart valve
E. A patient with a history of bacteremia
 

D. Prophylactic therapy is required for patients with a strong risk for endocarditis, which includes prosthetic heart valves. Having heart disease (a heart condition due to atherosclerosis) does not increase the risk of endocarditis.

Dental procedures and IE prophylaxis:

An artificial (prosthetic) heart valve or heart valve repaired with artificial material.

A history of endocarditis.

A heart transplant with abnormal heart valve function.

Certain congenital heart defects.

98

A patient is picking up a prescription for erythromycin ethylsuccinate (E.E.S.) oral suspension. Choose the correct statement:

A. This medication cannot be used if the patient has a penicillin allergy.
B. This medication should not be administered with food.
C. This medication is a major inhibitor of cytochrome P450 2C9.
D. This medication is effective for treating the flu.
E. This medication should be refrigerated.
 

E. Erythromycin ethylsuccinate is a macrolide antibiotic and is not effective for treating viral infections like influenza. The drug should be taken with food to minimize stomach upset and should be stored under refrigeration. Erythromycin is a major inhibitor of 3A4. As a macrolide antibiotic and not a penicillin, this may be an option if a penicillin allergy is present.

Refrigeration required: amoxicillin/clavulanate (Augmentin), ceprozil (Cefzil), cefuroxime (Ceftin), cephalexin (Keflex), erythromycin ethylsuccinate/sulfisoxazole (E.S.P.), penicillin VK (Veetids)

Do Not Refrigerate: azithromycin (Zmax), cefdinir, clarithromycin (Biaxin-bitter taste, thickening/gels), clindamycin (Cleocin-thickening, crystallize), ciprofloxacin (Cipro), doxycycline (Vibramycin), fluconazole (Diflucan), levofloxacin (Levaquin), linezolid (Zyvox), sulfamethoxazole/trimethoprim (Septra, Sulfatrim), voriconazole (VFEND)

99

Don comes to the hospital from a skilled nursing facility with signs and symptoms of a severe osteomyelitis infection. His cultures are positive for MRSA. Upon further work up, the MRSA is found to have a vancomycin minimum inhibitory concentration (MIC) of 4 mcg/mL. The medical team asks whether vancomycin should be used in this patient. Which of the following statements regarding vancomycin use in this patient is correct?

A. Vancomycin should be diluted in normal saline only.
B. Vancomycin should be stored at room temperature. Refrigeration causes crystallization.
C. Vancomycin should not be used in this patient due to the high MIC.
D. Vancomycin can be used in this patient as long as the trough level is maintained between 15-20 mcg/mL.
E. Vancomycin should be used in this patient as long as higher doses are used.
 

C. It is recommended to use an alternative agent when the vancomycin MIC of an organism is 2 mcg/mL or greater. If vancomycin is chosen, clinical failure of the drug may result.

100

A 43 year-old woman went to the doctor complaining of urinary frequency and urgency. She has a history of hypertension and migraine headaches. Her medications include atenolol 50 mg daily and sumatriptan 50 mg as-needed. Her listed allergies are trimethoprim-sulfamethoxazole (rash) and ciprofloxacin (headache, joint pain). She has been diagnosed with a urinary tract infection (UTI). Choose the correct statement:

A. The patient should be treated with Bactrim, the drug of choice for community-acquired UTIs.
B. Most cases of community-acquired UTI are caused by S. pneumonia.
C. The patient should be treated with nitrofurantoin for an uncomplicated UTI.
D. The patient should be treated with clindamycin.
E. The patient should be treated with moxifloxacin for 3 days.
 

C. Most cases of community-acquired UTIs are caused by E. coli. Other probable organisms include S. saprophyticus, P. mirabilis, K. pneumoniae and enterococcus. A sulfa allergy is present, therefore, we cannot recommend Bactrim. Nitrofurantoin 100 mg BID x 5 days can be used.

101

Regimens for treating TB have an initial phase of 2 months, followed by a choice of several options for the continuation phase of either 4 or 7 months (or longer). Which medications are included in the preferred treatment regimen for the initial phase of TB treatment?

A. Isoniazid, rifampin, ethambutol, pyridoxine
B. Isoniazid, rifampin, streptomycin, pyrazinamide
C. Isoniazid, rifampin, ethambutol, pyrazinamide
D. Isoniazid, ethambutol, pyrazinamide, pyridoxine
E. Isoniazid, rifampin, ethambutol, kanamycin
 

C. This is the four-drug treatment regimen.

102

Charles comes to the clinic and is diagnosed with syphilis. Choose the correct statement:

A. Syphilis is due to an infection caused by the organism Syphilis pallidum.
B. The treatment for early syphilis is Bicillin C-R.
C. Primary syphilis presents as a painful, oozing lesion several days after infection.
D. The treatment for neurosyphilis is doxycycline.
E. Doxycycline is an alternative for primary syphilis if the patient was allergic to penicillin.
 

E. Syphilis is a sexually transmitted disease caused by the spirochete Treponema pallidum.

103

Gerri is receiving amphotericin B deoxycholate for treatment of aspergillosis. Which of the following side effects are most likely to occur with treatment?

A. Hyponatremia, hypocalcemia, hypokalemia
B. Hyponatremia, hypokalemia, chest tightness
C. Hypocalcemia, hyperkalemia, leucopenia
D. Hypomagnesemia, hypokalemia, rigors
E. Hyperkalemia, hypermagnesemia, hypotension
 

D. Common side effects associated with amphotericin B deoxycholate include hypomagnesemia, hypokalemia, chills, rigors, hypotension, tachycardia, and nephrotoxicity.

Conventional dosing is lower than liposomal formulation.

104

Tommy is picking up a prescription for Keflex. Tommy should be counseled on the following points: (Select ALL that apply.)

A. It is important to finish the entire course of therapy even if you start feeling better.
B. This medication can increase your risk of sunburn.
C. The medication can cause a rash, GI upset, and diarrhea.
D. This medication may darken your urine.
E. If your symptoms worsen, contact your doctor.
 

A, C, E. Take until the medication is all gone. Photosensitivity is not associated with the cephalosporins.

105

A physician calls and asks the pharmacist to provide information on the drug telithromycin. Choose the correct statement:

A. This drug can cause acute hepatic failure.
B. This drug covers Gram-negative organisms only.
C. The brand name is Vibativ.
D. This drug is not associated with visual disturbances.
E. The brand name is Tygacil.
 

A. Telithromycin is a broad spectrum antibiotic that can cause acute hepatic failure (sometimes fatal) and visual problems, along with QT prolongation. Monitor liver function and visual acuity.

106

JM is a 50 year old man recently diagnosed with a mild case of Clostridium difficile infection. He has a serum white blood cell count of 14,000 cells/mm3 and a SCr of 1.0 mg/dL with 6-8 loose bowel movements per day. What is the most appropriate therapy for JM?

A. Metronidazole 500 mg IV Q6H
B. Metronidazole 500 mg PO TID
C. Vancomycin 125 mg PO QID
D. Vancomycin 500 mg PO QID
E. Vancomycin 125 mg PO QID and metronidazole 500 mg IV Q8H
 

B. Oral metronidazole is recommended for mild cases of Clostridium difficile infection (CDI).

Mild-mod: metronidazole 500mg PO TID x 10-14 days

Severe uncomplicated: vancomycin 125mg PO QID x 10-14 days

Severe complicated: vancomycin 500mg PO QID + metronidazole 500mg IV Q8H

107

Eleanor, a 62 year-old female, is receiving metronidazole intravenously for a Bacteroides fragilis infection. Choose the correct statement for metronidazole when given intravenously:

A. This medication should be stored at room temperature.
B. This medication should be infused no faster than 2.5 mg/min.
C. Use a slow infusion rate or severe hypotension could result.
D. Do not use this medication if gout is present.
E. There is no interaction with warfarin or other anticoagulants.
 

A. Metronidazole, when prepared for intravenous administration, should be kept at room temperature. If refrigerated, crystals may form. Crystals may dissolve upon re-warming to room temperature.

108

Which of the following is a common goal associated with Antimicrobial Stewardship Programs?

A. Promoting carbapenem utilization
B. Reducing the emergence of resistance and toxicity associated with antimicrobial agents.
C. Minimizing the bulk of the pharmacy budget being spent on antimicrobials
D. Reducing physician autonomy
E. Minimizing inter-disciplinary relationships
 

B. Antimicrobial stewardship programs are intended to improve patient care at the moment and in the future by minimizing resistance rates. Encouraging carbapenem use would increase resistance rates. Spending more on antimicrobials is the end result of over-utilizing antimicrobials. Stewardships are meant to better patient care through interdisciplinary ventures without limiting prescribers' autonomy.

109

Choose the correct statement concerning vancomycin pharmacodynamics/pharmacokinetics and therapeutic drug monitoring. (Select ALL that apply).

A. Vancomycin exhibits concentration-dependent kill.
B. Treating pneumonia requires higher troughs (15-20 mcg/mL) as vancomycin has relatively poor lung penetration.
C. Alternative agents should be considered if the MIC of an organism is ≥ 2 mcg/mL.
D. Treating meningitis requires a higher trough (15-20 mcg/mL) as vancomycin has poor CNS penetration.
E. Vancomycin troughs should be drawn at steady state (generally before the fourth dose).
 

B, C, D, E. Vancomycin exhibits time-dependent killing. Peaks are generally not monitored, but trough levels are and should be drawn at steady state (generally before the fourth dose). Despite time-dependent killing, the parameter that is best correlated with vancomycin efficacy is AUC:MIC ratio.

110

A patient presents to the physician with the following symptoms: productive cough with blood, fatigue, night sweats and poor appetite. He has lost 16 pounds unintentionally over the past few months. He is likely to be tested positive for the following infection:

A. Lung cancer
B. Crohn's disease
C. HIV disease
D. Tuberculosis
E. Influenza
 

D. These symptoms, taken together, are a classic presentation of a tuberculosis (TB) infection. Other markers of TB infection include bibasilar infiltrates and pleuritic chest pain.

111

Which antimicrobial is not considered to be part of the standard therapeutic regimens for treating Helicobacter pyloriinfections?

A. Amoxicillin
B. Clarithromycin
C. Telithromycin
D. Tetracycline
E. Metronidazole
 

C. Telithromycin is a ketolide antibiotic used to treat respiratory tract pathogens. The remaining 4 antibiotics are used to treatH. pylori.

112

Mr. Smith comes to the pharmacy with a prescription for azithromycin for treatment of his community-acquired pneumonia. Choose the common etiologies of community-acquired pneumonia: (Select ALL that apply.)

A. Pseudomonas
B. Enterococcus
C. Streptococcus pneumoniae
D. Mycoplasma pneumoniae
E. Haemophilus influenza
 

C, D, E. Streptococci and Haemophilus, along with atypicals are common pathogens in community-acquired pneumonia.

113

Which of the following statements is correct regarding intravenous ampicillin?

A. Ampicillin is compatible with D5W for 24 hours under refrigeration.
B. Ampicillin is compatible with D5W for 8 hours at room temperature
C. Ampicillin is compatible with NS for 8 hours at room temperature.
D. Ampicillin is compatible with NS for 4 days under refrigeration
E. Ampicillin does not come in an intravenous formulation.
 

C. Ampicillin IV is compatible with NS and is stable for 8 hours at room temperature or for 2 days under refrigeration.

114

Choose an acceptable treatment option for daily suppressive therapy for a herpes simplex genital infection:

A. Acyclovir 400 mg PO BID
B. Ganciclovir 250 mg PO BID
C. Valganciclovir 500 mg PO daily
D. Famciclovir 2,000 mg PO daily
E. Foscarnet 50 mg IV daily
 

A. 

Daily suppressive therapy:

For genital HSV: acyclovir 400mg PO BID, valacyclovir 500mg PO daily or 1 gm PO daily, famciclovir 250mg PO BID

For Oral HSV: acyclovir 400mg PO BID

115

Based on national resistance rates, which of the following antibiotics is considered to be least effective in treating MRSA skin and soft tissue infections empirically?

A. Clindamycin
B. Vancomycin
C. Linezolid
D. Daptomycin
E. Telavancin
 

A. Vancomycin is the gold standard for MRSA therapy. Linezolid, daptomycin, and telavancin have minimal resistance rates (~5% nationally). Resistance is commonly associated with clindamycin and susceptibility tests are performed prior to using clindamycin. 

The test performed is called the D-Test.

116

Patricia works as a home health nurse. She visits patients with tuberculosis (TB) and watches them take their medication. Choose the correct statements: (Select ALL that apply.)

A. The primary purpose is to increase adherence and reduce the risk to the public health.
B. The TB medications, if used in this type of program, can be dosed twice or three times weekly instead of daily.
C. Rifampin cannot be used in a DOT program.
D. DOT is not necessary for TB as this infection is not fatal.
E. This is called directly observed therapy (DOT).
 

A, B, E. In directly observed therapy, a trained health care worker monitors the patient taking each dose of anti-tuberculosis medication. When TB patients receive all medications as prescribed under a program of DOT, both the patient and the public health benefit. It is not necessary to use DOT for all patients but is preferred in some patient types.

117

Which of the following statements concerning Nizoral A-D is correct?

A. It contains clotrimazole 1%.
B. It contains clotrimazole 2%.
C. It contains ketoconazole 2%.
D. It contains itraconazole 1.5%.
E. It contains ketoconazole 1%.
 

E. Nizoral A-D contains ketoconazole 1%.

118

Becky is a 34 year old female who was recently diagnosed with an uncomplicated urinary tract infection (UTI). She has a history of VRE in the past. She has an allergy history of hives to several antibiotic drug classes including penicillin, sulfa, nitrofurantoin and fluoroquinolones. Which of the following medications would be the best choice to treat Becky's UTI?

A. Norfloxacin
B. Ampicillin-sulbactam
C. Fosfomycin
D. Septra DS
E. Fidaxomicin
 

C. Penicillin, sulfa, and a fluoroquinolone allergy disqualifies norfloxacin, ampicillin-sulbactam, and Septra DS. Fidaxomicin is not absorbed systemically and is used to treat Clostridium difficileonly. Fosfomycin is an urinary antiseptic that is a non-beta-lactam, sulfa, and fluoroquinolone agent. It has activity against the likely pathogens.

119

DT is a 29-year-old, 45 kg female who was hospitalized for 7 days for after a motor vehicle accident (MVA). She is now ready to be discharged home, but describes burning on urination and increased frequency of urination for the past 24 hours.  Her renal function is normal, but her urinalysis confirms a lower urinary tract infection.  DT has no known drug allergies.  The culture and sensitivity reports are below:
 
Culture and Sensitivity Report for Pseudomonas aeruginosa:
Amikacin - S 
Ciprofloxacin - S 
Gentamicin - R 
Tobramycin - S 
Levofloxacin - S 
Piperacillin/tazobactam - S 
Cefepime - S 
Imipenem - S 
SMX/TMP  - R 
Culture and Sensitivity Report for Klebsiella pneumoniae 
Amikacin - S 
Ciprofloxacin - S 
Gentamicin - S 
Tobramycin - S 
Levofloxacin - S 
Piperacillin/tazobactam - S 
Cefepime - S 
Imipenem - S 
SMX/TMP - S 
DT's physicians would still like to send her home today even if home health must administer IV antibiotics to treat the infection.  Based on the culture and sensitivity reports, select the most appropriate outpatient treatment regimen for DT's urinary tract infection.

A. Zosyn 4.5 gm IV Q6H
B. Amikacin 5 mg/kg IV Q8H
C. Bactrim DS PO BID
D. Cipro 500 mg PO BID
E. Monurol 3 gm PO daily
 

D. If an oral option will treat both organisms, it would be an ideal choice in this case. Per the culture and sensitivity (C&S) report, both organisms are sensitive to ciprofloxacin and it achieves excellent levels in the urine.

120

Stephanie, a 49 year-old female, is picking up a prescription for moxifloxacin. Her medical history is significant for dyslipidemia, diabetes, atrial fibrillation and osteoporosis. She is currently taking atorvastatin, amiodarone, Januvia, Byetta, metformin, calcium citrate, and vitamin D.  Which of the following can be caused by potential drug interactions in this medication regimen? (Select ALL that apply.)

A. QT prolongation
B. Impaired absorption of moxifloxacin
C. Hypoglycemia or hyperglycemia
D. Peripheral edema, fluid retention due to quinolone addition
E. Additive nephrotoxicity
 

A, B, C. She is at risk for QT prolongation due to the history of atrial fibrillation and concomitant use of amiodarone and moxifloxacin. She is also at risk for blood sugar alterations due to diabetes and the use of moxifloxacin. Calcium citrate can chelate moxifloxacin if taken together, preventing the absorption of moxifloxacin.

121

Which of the following antimicrobials require dose adjustment in patients with renal impairment? 

A. Avelox and Rocephin
B. Cubicin and Doribax
C. Zyvox and Cleocin
D. Flagyl and Zithromax
E. Synercid and Dificid
 

B. Cubicin and Doribax require renal dose adjustments in the setting of renal impairment. The other agents do not.

Avelox (moxifloxacin)

Rocephin (ceftriaxone)

Cubicin (daptomycin)

Doribax (doripenem)

Zyvox (linezolid)

Cleocin (clindamycin)

Flagyl (metronidazole)

Zithromax (azithromycin)

Synercid (quinupristin/dalfopristin)

Dificid (fidaxomicin)

122

Cedric has been getting gentamicin for the last 10 days. Which of the following are side effects associated with gentamicin? 

A. Cardiotoxicity, pulmonary toxicity, nephrotoxicity
B. Neurotoxicity, cardiotoxicity, ototoxicity
C. Pulmonary toxicity, ototoxicity, cardiotoxicity
D. Pulmonary toxicity, nephrotoxicity, cardiotoxicity
E. Neurotoxicity, nephrotoxicity, ototoxicity
 

E. Aminoglycosides have a boxed warning regarding the risk of neurotoxicity and nephrotoxicity. They can also cause ototoxicity which is proportional to the amount of drug given and the duration of treatment.

123

MR is a 27 year-old female patient who received emergency treatment for a ruptured appendix. She has received IV cefazolin since surgery. On day four, she complains of diffuse pain over the incision site. The patient's temperature is recorded at 103.5°F. A CT scan of her abdomen revealed a peritoneal abscess. The abscess was drained and fluid was sent to the laboratory. The physician wishes to use a single drug that provides both aerobic and anaerobic coverage. What are two single drug options that cover both aerobic and anaerobic Gram-negative pathogens implicated in intra-abdominal infections that could be recommended to the physician? 

A. Zosyn and Cipro
B. Maxipime and Avelox
C. Rocephin and Cipro
D. Timentin and Cefoxitin
E. Cefoxitin and Nafcillin
 

D. Timentin and cefoxitin both have the desired coverage as single drug choices. Cipro and Maxipime do not have anaerobic coverage.

Timentin (ticarcillin/clavulanate) - covers Gram negative pathogens

Cefoxitin (Mefoxin) - 2nd generation, covers anaerobic pathogens

124

Of the following oral suspension antibiotics, which one should not be refrigerated?

A. Augmentin
B. Pen VK
C. Ceftin
D. Keflex
E. Biaxin
 

E. Biaxin should not be refrigerated. Refrigeration can cause thickening and the product may crystallize.

Refrigeration required: amoxicillin/clavulanate (Augmentin), ceprozil (Cefzil), cefuroxime (Ceftin), cephalexin (Keflex), erythromycin ethylsuccinate/sulfisoxazole (E.S.P.), penicillin VK (Veetids)

Do Not Refrigerate: azithromycin (Zmax), cefdinir, clarithromycin (Biaxin-bitter taste, thickening/gels), clindamycin (Cleocin-thickening, crystallize), ciprofloxacin (Cipro), doxycycline (Vibramycin), fluconazole (Diflucan), levofloxacin (Levaquin), linezolid (Zyvox), sulfamethoxazole/trimethoprim (Septra, Sulfatrim), voriconazole (VFEND)

125

Which group of agents cover atypical pathogens?

A. Levaquin, Doryx, Augmentin
B. Flagyl, Erythromycin, Ceftin
C. Bactrim, Keflex, Amoxil
D. Cefdinir, Cipro, Biaxin
E. Doxycycline, Zithromax, Avelox
 

E. Doxycycline, Zithromax and Avelox cover atypicals. Flagyl and cefdinir, along with other beta-lactams, do not cover atypicals.

Doryx (doxycycline)

Ceftin (cefuroxime) - 2nd generation

Cefdinir (Omnicef) - 3rd generation

Biaxin (clarithromycin)

126

Which of the following medications require patient counseling for risk of photosensitivity? 

A. Vfend
B. Vigamox
C. Keflex
D. Augmentin XR
E. Unasyn
 

A. Vfend can cause photosensitivity. The others do not.

127

David is a 61 year-old male who experienced a painful, blistery rash on his neck and upper chest. He was diagnosed with shingles and prescribed valacyclovir 1 gram TID for 7 days. Which of the following counseling points on valacyclovir is correct?

A. It must be taken with food.
B. This medicine often causes a rash; if the rash appears severe contact your doctor immediately.
C. If you feel better, you do not need to continue the medication for the full 7 days.
D. Since you have had a shingles attack, you are not a candidate for the shingles vaccine.
E. You may experience headache, and possible nausea, from using this medicine, but it is usually mild.
 

E. Valacyclovir is taken without regard to meals. In addition to headache, some patients get nausea. Otherwise, drugs in this class are generally well-tolerated.

128

A patient is purchasing miconazole 200 mg vaginal suppositories for a fungal infection. The instructions state to insert one vaginal suppository once daily for three days. Which of the following counseling statements are correct? 

A. You can use tampons or douches while using this medication; separate from the timing of the dose by 4 hours.
B. This product is safe to use with condoms or diaphragms, but it is preferable to avoid sex until treatment is complete.
C. It is best to use prior to bed; unwrap and insert medication right before lying down so that the medicine stays at the site of infection.
D. This medication can be used to treat other viral infections.
E. You can use 4 courses of over the counter therapy before consulting a physician.
 

C. Patients should be instructed to refrain from vaginal intercourse during therapy. Only sanitary napkins (not tampons) should be used during the course of therapy. Condoms and diaphragms may be damaged by the medication. Instruct patient to use a protective covering on the bed as some of the medication is likely to leak out. If symptoms do not improve contact a physician as systemic therapy (fluconazole) may be needed. Miconazole is an antifungal, not an antiviral agent.

129

Which of the following agents have excellent bioavailability suitable for a 1:1 intravenous:oral conversion? 

A. Zosyn, Zyvox
B. Cubicin, Flagyl
C. Flagyl, Zyvox
D. Sulfatrim, Vancocin
E. Sivextro, Zithromax
 

C. Many of the agents above do not have an oral formulation available (mainly due to low oral bioavailability).

130

Metronidazole is likely to be useful in which group of infections? 

A. Urinary tract infection, community-acquired pneumonia, trichomoniasis
B. Community-acquired pneumonia, bacterial vaginosis, urinary tract infection
C. Trichomoniasis, bacterial vaginosis, peritonitis due to fecal contamination
D. Peritonitis due to fecal contamination, community-acquired pneumonia, urinary tract infection
E. Bacterial vaginosis, trichomoniasis, community-acquired pneumonia
 

C. Metronidazole is an agent with only anaerobic activity. All of the infections listed above are anaerobic infections except community-acquired pneumonia and urinary tract infection.

131

Which of the following antimicrobials is not associated with additive QT prolongation when combined with amiodarone?

A. Zithromax
B. Pen VK
C. Ketek
D. Levaquin
E. Avelox
 

B. All of the agents are associated with QT prolongation with the exception of Pen VK (beta-lactams are not associated with QT prolongation).

132

Which one of the following agents does not cover Pseudomonas aeruginosa? 

A. Primaxin
B. Coly-Mycin M
C. Zyvox
D. Timentin
E. Meropenem
 

C. 

Primaxin (imipenem/cilastatin)

Coly-Mycin M (colistin)

Zyvox (linezolid)

Timentin (ticarcillin/clavulanate)

meropenem (Merrem)

133

A patient comes into the clinic with classic signs and symptoms of an infection. The patient has an extensive history of alcohol abuse. Which of the following antibiotics would be the least safe option for this patient?

A. Cefuroxime
B. Cefotaxime
C. Cefotetan
D. Cefprozil
E. Cefaclor
 

C. Cefotetan has a chemical structure (a N-MTT side chain) that puts patients at risk for a disulfiram-like reaction if alcohol is consumed.

134

Choose the statement that best describes the activity of cefazolin:

A. 1st generation cephalosporin: Better gram positive than gram negative activity.
B. 2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity.
C. 3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity.
D. 4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation.
E. 5th generation cephalosporin: Best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.
 

A. Cefazolin is a first generation cephalosporin.

 1st generation cephalosporin: Better gram positive than gram negative activity. PEK (Proteus mirabilis, E. coli, Klebsiella sp.)

2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity. HN PEK (Haemophilus, Neisseria)

3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity. HN PEKS (Serratia)

4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation. HN PEK CAPES (Citrobacter, Acinetobacter, Pseudomonas, Enterobacter)

5th generation cephalosporin: Best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.

135

Chief Complaint:  “I need antibiotics for my foot"

History of Present Illness: DR is a 58 y/o male with type 2 diabetes.  He is concerned about an infection on his left foot that has not healed over 3-4 months.  It started when he picked a scab on the bottom of his foot.  The infection covers about 6 inches with mostly open areas on the lateral side of the left foot and there is superficial cellulitis on the dorsal surface of the foot.  Due to his obesity, DR has avoided coming to the hospital or to his doctor to have this addressed. 

Allergies:  NKDA

Past Medical History: Type 2 diabetes x 10 years (poorly controlled) and hypertension

Medications: Glucophage XR 1,000 mg daily, lisinopril 20 mg daily

Physical Exam / Vitals: 

Height: 5’8”  Weight: 265 pounds   

BP: 165/98 mmHg  HR: 98 BPM  RR: 16 BPM Temp: 100.2°F  Pain: 5/10 

General: Obese male, unable to walk in current state 

Lungs: clear

CV:  RRR 

GI: Normal bowel sounds, some tenderness to palpation in RUQ

Ext: As noted in HPI.  Very faint/absent peripheral pulses.

Labs:

Na (mEq/L) = 142 (135 – 145)              

WBC (cells/mm3) = 12.6 (4 – 11 x 10^3)       

K (mEq/L) = 4.3 (3.5 – 5)                      

Hgb (g/dL) = 14.1 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 102 (95 – 103)                

Hct (%) = 41.2 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 28 (24 – 30)              

Plt (cells/mm3) = 341 (150 – 450 x 10^3)

BUN (mg/dL) = 17 (7 – 20)                  

PMNs (%) = 87 (45 – 73)

SCr (mg/dL) = 1.2 (0.6 – 1.3)                

Bands (%) = 5 (3 – 5) 

Glucose (mg/dL) = 258 (100 – 125)      

Eosinophils (%) = 1 (0 – 5)

Ca (mg/dL) = 10.1 (8.5 – 10.5)              

Basophils (%) = 0 (0 – 1)

Mg (mEq/L) = 2.0 (1.3 – 2.1)                

Lymphocytes (%) = 22% (20 – 40)

PO4 (mg/dL) = 4.1 (2.3 – 4.7)                

Monocytes (%) = 1 (2 – 8)

AST (IU/L) = 29 (10 – 40)

ALT (IU/L) = 32 (10 – 40) 

Albumin (g/dL) = 4.1 (3.5 – 5)

A1C (%) = 9.8

Tests: 

Xray left foot: soft tissue swelling, unable to rule out osteomyelitis. Recommend bone scan.   

Plan:

Wound management for I&D.  Surgery consult for viability of lateral toes and schedule for amputation as needed.


Question: 
An I&D is performed and osteomyelitis is ruled out.  The culture reveals mixed E. coli, Klebsiella, and Streptococci.  The order for antibiotic sensitivities was overlooked and the sensitivities were not performed. DR has received 4 days of IVZosyn monotherapy and the foot looks much better.  DR is afebrile and lab indicators of infection have normalized.  What is the best recommendation?     

A. Change to Keflex PO
B. Change to Clindamycin PO
C. Change to Augmentin/ PO
D. Change to Zyvox PO
E. Change to Rocephin IV

C. Antibiotic streamlining should occur in this case despite not having antibiotic sensitivities. Clinicians should use the information available and knowledge of suspected pathogens to streamline therapy. Since Pseudomonas did not grow from the culture, this therapy should be streamlined to avoid collateral damage. Anaerobic cultures must be specifically ordered - anaerobes will not grow on standard aerobic cultures. Anaerobes are treated if they are suspected based on site of infection. IV to PO switch would facilitate discharge in this case.

136

Which of the following oral antibiotic suspensions require refrigeration? (Select ALL that apply.)

A. Septra
B. Keflex
C. Ceftin
D. Cubicin
E. Levaquin
 

B, C. Keflex and Ceftin require refrigeration. Levaquin and Septra should not be refrigerated. Cubicin is not available in an oral suspension.

Refrigeration required: amoxicillin/clavulanate (Augmentin), ceprozil (Cefzil), cefuroxime (Ceftin), cephalexin (Keflex), erythromycin ethylsuccinate/sulfisoxazole (E.S.P.), penicillin VK (Veetids)

Do Not Refrigerate: azithromycin (Zmax), cefdinir, clarithromycin (Biaxin-bitter taste, thickening/gels), clindamycin (Cleocin-thickening, crystallize), ciprofloxacin (Cipro), doxycycline (Vibramycin), fluconazole (Diflucan), levofloxacin (Levaquin), linezolid (Zyvox), sulfamethoxazole/trimethoprim (Septra, Sulfatrim), voriconazole (VFEND)

137

The pharmacist is on rounds with the internal medicine team. They are discussing a patient who has oral candidiasis due to a recent chemotherapy treatment. The infection is very painful for the patient and is considered moderate to severe. Which of the following is the best regimen to recommend for this patient?

A. Clotrimazole troches 10 mg PO 5 times per day x 7-14 days
B. Fluconazole 200 mg IV daily x 7-14 days
C. Posaconazole 400 mg PO BID x 14-21 days
D. Amphotericin B 15 mg/kg IV BID x 14-21 days
E. Itraconazole 200 mg PO daily for 14-21 days
 

B. Patients with severe and painful oral candidiasis will not tolerate taking medications orally without analgesics. The most appropriate therapy would be an antifungal given intravenously. The amphotericin dosing is too high. The duration of therapy is 7-14 days.

Fluconazole is the drug of choice for oropharyngeal candidiasis in HIV and in moderate-severe candidiasis in non-HIV.

138

Which of the following agents are associated with ototoxicity? 

A. Ethambutol and rifampin
B. Voriconazole and vancomycin
C. Gentamicin and vancomycin
D. Penicillin and ciprofloxacin
E. Daptomycin and gentamicin
 

C. Vancomycin and aminoglycosides are ototoxic, especially when given in high doses for prolonged periods.

139

Each of the following drugs can be used to treat nosocomial-acquired MRSA skin-soft tissue infections except?

A. Daptomycin
B. Tigecycline
C. Telithromycin
D. Vancomycin
E. Quinupristin-dalfopristin
 

C. Telithromycin does not cover MRSA.

Daptomycin (Cubicin)
Tigecycline (Tygacil)
Telithromycin (Ketek)
Vancomycin (Vancocin)
Quinupristin-dalfopristin (Synercid)

140

Which of the following statements is correct with regards to Rocephin? 

A. It is considered a broad-spectrum antimicrobial agent with activity against Pseudomonas.
B. It is cleared unchanged by the kidney and requires dose adjustments in renal impairment.
C. It is the drug of choice for primary peritonitis infections.
D. It should be avoided in patients who are pregnant.
E. It can be used with calcium containing IV products in neonates.
 

C.

Contraindications for ceftriaxone: hyperbilirubinemic neonates (causes biliary sludging), concurrent use with calcium-containing IV products in neonates <28 days old.

141

What is the brand name for ceftaroline?

A. Cubicin
B. Teflaro
C. Vibativ
D. Invanz
E. Sivextro
 

B. Teflaro is the brand name for ceftaroline.

Cubicin (daptomycin)
Vibativ (telavancin)
Invanz (ertapenem)
Sivextro (tedizolid)

142

A pharmacy intern is giving a presentation on antibiotic therapy for Gram-positive infections. She is preparing a slide on penicillins.  Which of the following points would be incorrect information to include?

A. Penicillins can raise the seizure threshold.
B. A possible side effect of penicillins is rash.
C. Most penicillins require dose reductions in patients with renal insufficiency.
D. Penicillins are safe to use in pregnancy.
E. Penicillins do not have atypical coverage.
 

A. Penicillins can lower the seizure threshold when they accumulate, particularly in renal impairment if not dosed appropriately. Rash and urticaria are two of the more common side effects of penicillins. Most, but not all of the penicillins require dose adjustment in renal impairment.

143

Which of the following clinical scenarios would be considered appropriate use of vancomycin? (Select ALL that apply.)

A. 62 year-old male with no known allergies presenting with a life-threatening MRSA pneumonia.
B. 18 year-old female presenting with Streptococcus pneumoniae meningitis who has a severe beta-lactam allergy (e.g., anaphylaxis).
C. 24 year-old female with no known allergies presenting with a urinary tract infection (cultures pending).
D. 42 year-old male presenting with a severe C. difficile colitis refractory to metronidazole.
E. 62 year-old female with cirrhosis presenting with primary peritonitis (spontaneous bacterial peritonitis).
 

A, B, D. Vancomycin is indicated for MRSA infections. Vancomycin should be considered to cover streptococci when beta-lactams are contraindicated in the setting of anaphylaxis. Vancomycin is first-line when given orally for C. difficile colitis when severe or refractory to metronidazole. Vancomycin does not have clinical coverage for enteric Gram-negatives, thus it is not useful for UTIs or primary peritonitis.

144

An infectious disease pharmacist is designing an empiric antibiotic regimen for a patient. The pharmacist suspectsLegionella may be a causative organism. Select the following antibiotics that would provide coverage for Legionella. (SelectALL that apply.)

A. Augmentin
B. Biaxin
C. Levofloxacin
D. Clindamycin
E. Cefdinir
 

B, C. Legionella is a Gram-negative bacterium that can cause CAP or HAP. Levofloxacin and Biaxin are the only options listed above with Legionella coverage.

145

A physician is examining a patient in a clinic who is found to have tularemia. Which medication is the best treatment option to treat tularemia?

A. Azithromycin
B. Metronidazole
C. Doxycycline
D. Meropenem
E. Gentamicin
 

E. The drugs of choice for the treatment of tularemia are gentamicin and tobramycin, given 5 mg/kg/day divided Q8H for 7-14 days.

146

Linda was initiated on gentamicin 200 mg IV Q8H for treatment of Gram-negative urosepsis. The peak level comes back at 3.8 mcg/mL and her trough level was undetectable. What is the best recommendation to make regarding the gentamicin regimen?

A. Increase the gentamicin dose
B. Decrease the gentamicin dose
C.Increase the dosing interval to Q12H
D. Decrease the dosing interval to Q6H
E. Increase the dose and the dosing interval
 

A. The target peak range for gentamicin is 5-10 mcg/mL when used as monotherapy to treat a Gram-negative infection. The dose of the medication correlates with the peak level. The patient's trough is fine, but the peak is low.

Traditional Dosing Target Drug Concentration

Gentamicin: Gram-positive infection (Peak 3-4 mcg/mL, Trough <1 mcg/mL), Gram-negative infection (Peak 5-10 mcg/mL, Trough <2 mcg/mL)

Tobramycin (Peak 5-10 mcg/mL, Trough <2 mcg/mL)

Amikacin (Peak 20-30 mcg/mL, Trough <5 mcg/mL)

147

A pharmacist is filling an order for Maxipime 2 grams IV Q8H. Which of the following is an appropriate generic substitution for Maxipime?

A. Cefuroxime
B. Aztreonam
C. Doripenem
D. Cefepime
E. Imipenem/cilastatin
 

D. The generic name for Maxipime is cefepime.

Cefuroxime (Ceftin)
Aztreonam (Azactam)
Doripenem (Doribax)
Imipenem/cilastatin (Primaxin)

148

Which of the following organisms are considered to be anaerobes? 

A. Enterobacter, Clostridium, Peptostreptococcus
B. Enterococcus, Bacteroides, Staphylococcus
C. Bacteroides, Peptostreptococcus, Clostridium
D. Staphylococcus, Bacteroides, Clostridium
E. Staphylococcus, Enterobacter, Enterococcus
 

C. Enterobacter is a Gram-negative rod and Staphylococci and Enterococcus are Gram-positive cocci; the rest are anaerobes.

149

Nafcillin is considered the drug of first choice for which of the following pathogens?

A. Methicillin susceptible Staphylococcus aureus (MSSA)
B. Streptococcus pneumoniae
C. Enterococcus faecalis
D. Escherichia coli
E. Bacteroides fragilis
 

A. Nafcillin is generally reserved for MSSA infections and is considered the drug of choice. While it does have some activity against streptococci species it's activity against Streptococcus pneumoniae is weak.

150

Each of the following drugs can be used to treat Pseudomonas aeruginosa except:

A. Aztreonam
B. Doripenem
C. Levofloxacin
D. Cefuroxime
E. Amikacin
 

D. Depending on the site of infection, this organism may require therapy with two anti-pseudomonal agents given concurrently, preferably with synergy.

151

Choose the statement that best describes the activity of ceftaroline:

A. 1st generation cephalosporin: Better gram positive than gram negative activity.
B. 2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity.
C. 3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity.
D. 4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation.
E. 5th generation cephalosporin: best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.
 

E. Ceftaroline is a 5th generation cephalosporin.

1st generation cephalosporin: Better gram positive than gram negative activity. PEK (Proteus mirabilis, E. coli, Klebsiella sp.)

2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity. HN PEK (Haemophilus, Neisseria)

3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity. HN PEKS (Serratia)

4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation. HN PEK CAPES (Citrobacter, Acinetobacter, Pseudomonas, Enterobacter)

5th generation cephalosporin: Best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.

152

A physician calls the pharmacy and wants to know what to prescribe for his patient with primary Lyme disease. The patient is a 27 year-old female who is 29 weeks pregnant. Which of the following agents would you recommend?

A. Amoxicillin 500 mg PO TID x 14 days
B. Itraconazole 400 mg PO BID x 14 days
C. Fluconazole 400 mg PO daily x 14 days
D. Ciprofloxacin 500 mg PO BID x 14 days
E. Doxycycline 100 mg PO BID x 14 days
 

A. Lyme disease is a tick-borne disease usually treated with doxycycline in adults. Doxycycline is Pregnancy Category D. Amoxicillin is a safe and effective alternative to use in pregnancy.

153

Choose the statement that best describes the activity of cefuroxime:

A. 1st generation cephalosporin: Better gram positive than gram negative activity.
B. 2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity.
C. 3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity.
D. 4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation.
E. 5th generation cephalosporin: best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.
 

B. Cefuroxime is a second generation cephalosporin.

1st generation cephalosporin: Better gram positive than gram negative activity. PEK (Proteus mirabilis, E. coli, Klebsiella sp.)

2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity. HN PEK (Haemophilus, Neisseria)

3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity. HN PEKS (Serratia)

4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation. HN PEK CAPES (Citrobacter, Acinetobacter, Pseudomonas, Enterobacter)

5th generation cephalosporin: Best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.

154

A 71 year-old female patient status post renal transplant on tacrolimus and prednisone immunosuppressive therapy has been prescribed ciprofloxacin 500 mg daily for 10 days to treat her infection. Her other medical conditions include heart failure, COPD and GERD. She presents to the grocery-store pharmacy with an extremely painful Achilles' tendon. She cannot put weight on her foot and is being supported by her daughter. Which of the following risk factors does this patient have for fluoroquinolone-associated tendonitis? 

A. Age, transplant history, steroid use
B. Heart failure, gender, tacrolimus use
C. Age, gender, steroid use
D. Transplant history, heart failure, tacrolimus use
E. Tacrolimus use, age, gender
 

A. Fluoroquinolones increase the risk of tendonitis and tendon rupture and this frequently involves the Achilles' tendon. The medication should be stopped immediately. Risk factors include age greater than 60 years, concurrent corticosteroid use, and organ transplant patients.

155

Which of the following statements is correct regarding piperacillin/tazobactam? 

A. Tazobactam is added to inhibit beta-lactamase activity.
B. The brand name is Zofran.
C. It exhibits concentration-dependent kill.
D. The dosing is 0.375 grams/3 grams of piperacillin/tazobactam respectively.
E. It is available as an oral suspension and intravenous formulation.
 

A. Piperacillin/tazobactam (Zosyn) is bactericidal and exhibits time-dependent killing. Tazobactam is a beta-lactamase inhibitor which expands it's spectrum of activity. The correct dosing formulation is 3 g/0.375 g of piperacillin/tazobactam, respectively.

156

Which of the following antimicrobials are associated with seizures and/or decreasing the seizure threshold? (Select ALL that apply.)

A. Imipenem/Cilastatin
B. Ciprofloxacin
C. Cefuroxime
D. Penicillin G
E. Ganciclovir
 

A, B, C, D, E. All of the following have been associated with seizures, in particular beta-lactams.

157

A pharmacist is traveling in Mexico with a group of health care professionals to perform medical work in the area. One of the nurses on the trip develops traveler's diarrhea. She is afebrile, slightly dehydrated, and states that there is no blood in her stool. She asks the pharmacist about taking loperamide. Which of the following statements regarding loperamide therapy for this patient is correct?

A. She is not a candidate for loperamide therapy if she is taking an antibiotic concurrently.
B. She is a candidate for loperamide. Start with 2 mg and repeat every 2 hours for a maximum daily dose of 16 mg.
C. She is a candidate for loperamide. Start with 4 mg and take 2 mg after each loose stool for a maximum daily dose of 8 mg.
D. She is a candidate for loperamide. Start with 6 mg and take 2 mg after each loose stool for a maximum daily dose of 24 mg.
E. She is not a candidate for loperamide therapy due to her symptoms.
 

C. Loperamide should not be used longer than 2 days. The maximum dose differs for traveler's diarrhea and acute diarrhea in general.

Loperamide is not recommended if patient has signs of dysentery, high fever or blood in stool.

158

Choose the statement that best describes the activity of cefepime:

A. 1st generation cephalosporin: Better gram positive than gram negative activity.
B. 2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity.
C. 3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity.
D. 4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation.
E. 5th generation cephalosporin: best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.
 

D. Cefepime is a 4th generation cephalosporin.

1st generation cephalosporin: Better gram positive than gram negative activity. PEK (Proteus mirabilis, E. coli, Klebsiella sp.)

2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity. HN PEK (Haemophilus, Neisseria)

3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity. HN PEKS (Serratia)

4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation. HN PEK CAPES (Citrobacter, Acinetobacter, Pseudomonas, Enterobacter)

5th generation cephalosporin: Best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.

159

Choose the statement that best describes the activity of ceftriaxone:

A. 1st generation cephalosporin: Better gram positive than gram negative activity.
B. 2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity.
C. 3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity.
D. 4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation.
E. 5th generation cephalosporin: best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.
 

C. Ceftriaxone is a third generation cephalosporin.

1st generation cephalosporin: Better gram positive than gram negative activity. PEK (Proteus mirabilis, E. coli, Klebsiella sp.)

2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity. HN PEK (Haemophilus, Neisseria)

3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity. HN PEKS (Serratia)

4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation. HN PEK CAPES (Citrobacter, Acinetobacter, Pseudomonas, Enterobacter)

5th generation cephalosporin: Best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.

160

Which of the following cephalosporins are considered to be third generation cephalosporins? 

A. Cefprozil, Cephalexin, Fortaz
B. Kefzol, Zinacef, Suprax
C. Cefdinir, Cefditoren, Cefepime
D. Cefpodoxime, Claforan, Cefdinir
E. Cefadroxil, Rocephin, Cedax
 

D. 

Cefpozil (Cefzil) - 2nd, Cephalexin (Keflex) - 1st, Fortaz (ceftazidime) - 3rd

Kefzol (cefazolin) - 1st, Zinacef (cefuroxime) - 2nd, Suprax (cefixime) - 3rd

Cefdinir (Omnicef) - 3rd, Cefditoren (Spectracef) - 3rd, Cefepime (Maxipeme) - 4th

Cefopodoxime (Vantin) - 3rd, Claforan (Cefotaxime) - 3rd, Cefdinir (Omnicef) - 3rd

Cefadroxil (Duricef) - 1st, Rocephin (ceftriaxone) - 3rd, Cedax (Ceftibuten) - 3rd

161

Adrian is in the intensive care unit for a severe intra-abdominal infection. It was stated he had symptoms for a couple of days, but initially refused to see a doctor. Looking at his chart, the pharmacist notices that he has an allergy to penicillin (hives). The team wants to start broad spectrum antibiotics immediately. Which drug regimen would be best to recommend?

A. Cefepime and metronidazole
B. Imipenem/cilastatin
C. Zosyn and metronidazole
D. Doribax
E. Levaquin and metronidazole
 

E. Levaquin is a fluoroquinolone and does not cross react with a penicillin allergy. The combination of the fluoroquinolone and metronidazole provides broad spectrum coverage.

Cefepime (Maxipeme)

Metronidazole (Flagyl)

Imipenem/cilistatin (Primaxin)

Doribax (doripenem)

Levaquin (levofloxacin)

162

Chief Complaint:  “I need antibiotics for my foot"

History of Present Illness: DR is a 58 y/o male with type 2 diabetes.  He is concerned about an infection on his left foot that has not healed over 3-4 months.  It started when he picked a scab on the bottom of his foot.  The infection covers about 6 inches with mostly open areas on the lateral side of the left foot and there is superficial cellulitis on the dorsal surface of the foot.  Due to his obesity, DR has avoided coming to the hospital or to his doctor to have this addressed. 

Allergies:  NKDA

Past Medical History: Type 2 diabetes x 10 years (poorly controlled) and hypertension

Medications: Glucophage XR 1,000 mg daily, lisinopril 20 mg daily

Physical Exam / Vitals: 

Height: 5’8”  Weight: 265 pounds   

BP: 165/98 mmHg  HR: 98 BPM  RR: 16 BPM Temp: 100.2°F  Pain: 5/10 

General: Obese male, unable to walk in current state 

Lungs: clear

CV:  RRR 

GI: Normal bowel sounds, some tenderness to palpation in RUQ

Ext: As noted in HPI.  Very faint/absent peripheral pulses.

Labs:

Na (mEq/L) = 142 (135 – 145)              

WBC (cells/mm3) = 12.6 (4 – 11 x 10^3)       

K (mEq/L) = 4.3 (3.5 – 5)                      

Hgb (g/dL) = 14.1 (13.5 – 18 male, 12 – 16 female)

Cl (mEq/L) = 102 (95 – 103)                

Hct (%) = 41.2 (38 – 50 male, 36 – 46 female)

HCO3 (mEq/L) = 28 (24 – 30)              

Plt (cells/mm3) = 341 (150 – 450 x 10^3)

BUN (mg/dL) = 17 (7 – 20)                  

PMNs (%) = 87 (45 – 73)

SCr (mg/dL) = 1.2 (0.6 – 1.3)                

Bands (%) = 5 (3 – 5) 

Glucose (mg/dL) = 258 (100 – 125)      

Eosinophils (%) = 1 (0 – 5)

Ca (mg/dL) = 10.1 (8.5 – 10.5)              

Basophils (%) = 0 (0 – 1)

Mg (mEq/L) = 2.0 (1.3 – 2.1)                

Lymphocytes (%) = 22% (20 – 40)

PO4 (mg/dL) = 4.1 (2.3 – 4.7)                

Monocytes (%) = 1 (2 – 8)

AST (IU/L) = 29 (10 – 40)

ALT (IU/L) = 32 (10 – 40) 

Albumin (g/dL) = 4.1 (3.5 – 5)

A1C (%) = 9.8

Tests: 

Xray left foot: soft tissue swelling, unable to rule out osteomyelitis. Recommend bone scan.   

Plan:

Wound management for I&D.  Surgery consult for viability of lateral toes and schedule for amputation as needed.


Question: 
While awaiting further testing, DR will require empiric antibiotics.  Which of the following regimens provides coverage for the common pathogens?

A. Linezolid
B. Clindamycin
C. Ceftriaxone
D. Ampicillin/sulbactam
E. Ciprofloxacin

D. Monotherapy regimens must provide coverage for Gram-positives, Gram-negatives, and anaerobes. This patient does not have obvious MRSA or multi-drug resistant organism (MDRO) risk factors.

Linezolid (Zyvox)

Clindamycin (Cleocin)

Ceftriaxone (Rocephin)

Ampicillim/sulbactam (Unasyn)

Ciprofloxacin (Cipro)

163

JR is a 47 year old obese male with end stage renal disease on hemodialysis presenting with a ruptured appendix and sepsis requiring surgical intervention, antimicrobial therapy and admission to the surgical intensive care unit. JR is allergic to penicillin (rash). Which of the following factor(s) should be considered when selecting empiric antimicrobial therapy and dosing for JR? (Select ALL that apply.)

A. The site of the infection
B. The severity of the infection
C. Organ function (renal and hepatic)
D. Patient size
E. Allergy profile
 

A, B, C, D, E. The site of the infection is the most important factor when determining likely pathogens and deciding on an empiric antimicrobial therapy regimen. In this case, an intra-abdominal infection, is considered to be a mixed infection where aerobic Gram-negatives and Gram-positives, along with anaerobes are possible pathogens. The severity of infection and/or ICU admission may determine the need to cover additional pathogens (e.g., Pseudomonas for intra-abdominal infections). The patient has chronic kidney disease which may require alteration of dosing. The patient's size (obese) may require more aggressive dosing, in particular for lipophilic agents. Last, the patients penicillin allergy will preclude the use of penicillin agents (e.g., piperacillin-tazobactam).

164

George is admitted to the hospital for an acute gastrointestinal bleed. On the third day from admission, he develops a hospital-acquired pneumonia. MRSA is documented from respiratory cultures. Which of the following medications can be used to cover the pneumonia? (Select ALL that apply.)

A. Linezolid
B. Cefazolin
C. Daptomycin
D. Nafcillin
E. Vancomycin
 

A, E. Linezolid, daptomycin and vancomycin cover MRSA; however, daptomycin cannot be used to treat lung infections since it is degraded by surfactant. Nafcillin and cefazolin only cover MSSA.

165

Gwen is a 72 year-old female with atrial fibrillation and degenerative joint disease. She has been well-controlled on warfarin, with an INR in the range of 2.2-2.7 for over a year. She has recently been started on rifampin therapy. What is likely to happen to the level of the INR?

A. No expected drug interaction.
B. The INR will increase to a small extent.
C. The INR will increase to a large extent.
D. The INR will decrease to a small extent.
E. The INR will decrease to a large extent.
 

E. Rifampin is a strong enzyme inducer of many CYP enzymes, including 2C9 and 3A4. The S-isomer of warfarin is largely metabolized by CYP 2C9. When a person who has been stable on warfarin uses rifampin therapy, the warfarin dose will need to be increased between 100-300%.

166

Megan is a 51 year-old female who has been prescribed Ketek for pneumonia. She had a heart attack two years ago. During the hospitalization she was found to have an arrhythmia (atrial fibrillation) and was placed on warfarin. Her other medications include simvastatin, atenolol and one fish oil, taken twice daily. Which of the following statements are correct? (Select ALL that apply.)

A. Ketek causes QT prolongation and is not a safe choice in a patient with an existing arrhythmia.
B. Ketek can cause hepatotoxicity.
C. Ketek will increase the levels of simvastatin and may cause muscle damage.
D. Ketek can increase the levels of atenolol and may cause bradycardia.
E. Ketek can increase the levels of fish oils and increase the bleeding risk.
 

A, B, C. Ketek has many drug interactions including simvastatin. The effect of warfarin may be increased. Ketekhas a boxed warning for hepatotoxicity.

Ketek (telithromycin)

167

Choose the correct statement concerning azithromycin:

A. It has drug interactions similar to clarithromycin.
B. It leaves a metallic taste in the mouth.
C. It binds to the 50S ribosomal subunit.
D. It binds to penicillin-binding proteins.
E. It can be used if an allergy is noted to erythromycin.
 

C. If the "allergy" is actually stomach upset, then azithromycin could be used. The reaction would need to be verified.

50S ribosomal inhibition: macrolides, clindamycin, linezolid, Synercid

30S ribosomal inhibition: aminoglycosides, tetracyclines

168

Which of the following pathogens are covered by Teflaro? 

A. Bacteroides fragilis, E. Coli
B. Methicillin resistant Staphylococcus aureus (MRSA), Pseudomonas
C. Pseudomonas, E. Coli
D. Methicillin resistant Staphylococcus aureus (MRSA), E. Coli
E. Bacteroides fragilis, Streptococci species
 

D. Teflaro has excellent Gram-positive coverage, including streptococci and staphylococci (MRSA). While it covers enteric Gram-negative rods, it does not cover Pseudomonas. It has no activity against gut anaerobes (Bacteroides fragilis).

Teflaro (ceftaroline) - 5th generation

1st generation cephalosporin: Better gram positive than gram negative activity. PEK (Proteus mirabilis, E. coli, Klebsiella sp.)

2nd generation cephalosporin: Better gram negative activity compared to 1st generation, with similar gram positive activity. HN PEK (Haemophilus, Neisseria)

3rd generation cephalosporin: Better gram negative activity than 2nd generation, less staph (gram positive) activity compared to second generation but better strep (gram positive) activity. HN PEKS (Serratia)

4th generation cephalosporin: Best gram negative activity,and gram positive activity that is similar to 1st generation. HN PEK CAPES (Citrobacter, Acinetobacter, Pseudomonas, Enterobacter)

5th generation cephalosporin: Best gram positive activity, covers MRSA, gram negative activity similar to ceftriaxone.

169

A patient is receiving itraconazole for treatment of an aspergillosis infection. Which of the following statements regarding itraconazole therapy is correct?

A. The oral capsule and oral solution can be used interchangeably.
B. The oral capsule is best if administered on an empty stomach.
C. The oral solution should be administered on an empty stomach
D. St. John's wort will have no effect on itraconazole levels.
E. This medication is safe to use in heart failure patients.
 

C. Itraconazole capsules and solution are not bioequivalent and are not interchangeable. The oral solution should be taken on an empty stomach and the oral capsules should be taken after a meal. Use of itraconazole is not recommended for treatment of onychomycosis in patients with heart failure.

Remember "take the capsule with a coke" - need to stimulate stomach acid by eating a meal.

170

Mary comes to the pharmacy to pick up her prescription for Levaquin 500 mg tabs once daily for 10 days. You notice her profile states that she is taking simvastatin, hydrochlorothiazide, amlodipine, rabeprazole, warfarin and aspirin. She is purchasing zinc tablets for her cold. Counseling should include the following: (Select ALL that apply.)

A. Take the medication 2 hours before or 2 hours after the zinc.
B. Take the medication with a full glass of water and drink more water during the day.
C. Take the medication on an empty stomach for best absorption.
D. This medication may interact with her warfarin.
E. This medicine can make your skin more sensitive to the sun.
 

A, B, D, E. Levaquin tablets can be taken without regard to meals. Levaquin oral solution should be administered on an empty stomach. It is associated with photosensitivity.

Levaquin (levofloxacin)

171

A 72 year-old patient has been hospitalized for ten days. She was having difficulty breathing and was just diagnosed with pneumonia. The patient had been on Unasyn for the past 5 days for a UTI infection. The Unasyn was discontinued this morning. The infectious disease specialist suspects MRSA as there is evidence of Gram-positive cocci from the blood cultures. Choose an appropriate option for empiric therapy of the pneumonia:

A. Ampicillin + tigecycline
B. Cefoxitin + vancomycin
C. Piperacillin/tazobactam + metronidazole
D. Piperacillin/tazobactam + vancomycin
E. Piperacillin/tazobactam + tigecycline
 

D. In cases like this, early HAP pathogens must be covered but additional pathogens such as MRSA and Pseudomonas aeruginosa are more prevalent.

172

Which of the following are potential treatment options for vancomycin-resistant enterococci (VRE) skin-soft tissue infection? (Select ALL that apply.)

A. Tygacil
B. Cubicin
C. Merrem
D. Zyvox
E. Levaquin
 

A, B, D. Tygacil, Cubicin and Zyvox are all indicated for VRE skin infections.

Agents used for VRE faecium: daptomycin (DoC), linezolid, Synercid, tigecycline

Agents used for VRE faecalis: Pen G or ampicillin (DoC), linezolid, daptomycin, tigecycline

Dual VRE coverage: daptomycin, linezolid, tigecycline

Tygacil (tigecycline)

Cubicin (daptomycin)

Zyvox (linezolid)

173

Which of the following statements are accurate with regards to aminoglycosides? (Select ALL that apply.)

A. Active against most aerobic Gram-negative pathogens when used alone
B. Active against most Gram-positive pathogens when used alone
C. Significant toxicities include nephrotoxicity and ototoxicity
D. Exhibit concentration-dependent killing
E. Primarily cleared by the kidney
 

A, C, D, E. Aminoglycosides are concentration-dependent killers. They are cleared by the kidney and associated with nephrotoxicity and ototoxicity, especially in high doses for prolonged periods. They are often added to beta-lactams or vancomycin for complicated Staphylococcal and Enterococcal infections.

174

ZC is a 52 year old male with type 2 diabetes who has been started on doxycycline for treatment of acute sinusitis. Which of the following counseling points is not appropriate for a patient starting doxycycline therapy?

A. Common side effects include stomach upset, mild diarrhea, nausea, headache, or vomiting.
B. This medicine should be taken 2 hours before or 4-6 hours after taking antacids, vitamins, magnesium, calcium, iron or zinc supplements, or dairy products.
C. Drink plenty of fluids while using this medicine.
D. This medicine can make your skin more sensitive to the sun, and you can burn more easily. Use sunscreen and protective clothing.
E. If you use blood sugar-lowering medicines, your blood sugar may get unusually low. Be careful to check your sugar level frequently and treat low blood sugar if it occurs.
 

E. Doxycycline does not affect blood sugar. Recall that fluoroquinolones can affect blood sugar and diabetic patients should be counseled on this point.

175

NN is a 42 year old female who was a victim of a house fire. She acquired 3rd degree burns requiring skin grafting. Unfortunately her course has been complicated by post-operative Acinetobacter wound infection and acute kidney injury. NN has no known drug allergies. Which of the following antibacterials would be considered first line in her case as a single agent?

A. Vancomycin
B. Meropenem
C. Ampicillin
D. Fosfomycin
E. Linezolid
 

B. Meropenem is a drug of choice for treating Acinetobacter.

Meropenem (Merrem)

176

Doug has just received a prescription for oseltamivir (Tamiflu) He has been feeling incredibly weak from the flu for the past five days and is hopeful the medicine will offer some relief. Doug has asthma and has been wheezing since he became ill. Choose the correct statements. (Select ALL that apply.)

A. It would be preferable for him to receive zanamivir.
B. He is not a candidate for oseltamivir.
C. A patient who has influenza and is a candidate for a neuraminidase inhibitor will need 10 days of therapy.
D. A patient who has influenza and is a candidate for a neuraminidase inhibitor will need 5 days of therapy.
E. It would be preferable for him to receive amoxicillin.
 

B, D. Oseltamivir should be started within two days of symptoms onset. Patients who are candidates should receive 5 days of therapy.

Must start within 48 hours of symptoms or contact for effective treatment

Oseltamivir (Tamilfu)

Tx: 75mg BID x 5 days

Px: 75mg daily for 10 days

 

Zanamivir (Relenza Diskhaler)

Tx: 10mg (2 inhalations) BID x 5

Px: 10mg (2 inhalations) once daily x 10 days

 

177

Which of the following statements is correct with regards to voriconazole?

A. It is a fungicidal agent that binds to ergosterol in the cell membrane altering cell membrane permeability.
B. Its spectrum of activity includes many Candida and many molds, but excludes Aspergillus.
C. It is a hepatic enzyme inducer reducing the levels of the induced drug.
D. It is associated with hepatotoxicity and ocular toxicity.
E. It must be taken with food, preferably a high fat meal.
 

D. Azoles act by inhibiting the production of ergosterol and are generally considered to be fungistatic. It is a hepatic enzyme inhibitor, not an inducer. Voriconazole is the drug of choice for Aspergillosis. Patients should be counseled to take voriconazole on an empty stomach.

Voriconazole (VFEND)

Do not refrigerate suspension

178

Which of the following statements are true regarding nitrofurantoin? (Select ALL that apply.)

A. Long term toxicities include pulmonary fibrosis.
B. Macrodantin should be dosed 100 mg orally twice daily
C. Educate patients to take with food to enhance absorption.
D. Indicated for uncomplicated UTI due to E. coli, Enterococcus, Klebsiella and/or Enterobacter.
E. Requires dose adjustments for moderate-severe renal impairment.
 

A, C, D. Nitrofurantoin is indicated for uncomplicated UTI due to E. coli, Enterococcus, Klebsiella and/or Enterobacter. It is indicated for cystitis only as it does not achieve adequate concentrations to treat systemic infections. Nitrofurantoin is contraindicated for CrCl < 60 mL/min secondary to reduced efficacy and increased toxicity. Nitrofurantoin is associated with pulmonary toxicities. It is available in two formulations: Macrodantin dosed 100mg PO QID and MacroBID dosed 100mg PO BID. It is important to educate patients to take with food to enhance absorption.

179

Which two antibiotics should be separated from divalent cations (e.g., iron)? 

A. Flagyl and Ceftin
B. Minocin and Levaquin
C. Avelox and Amoxil
D. Bactrim and Zithromax
E. Biaxin and Zyvox
 

B. Tetracyclines and fluoroquinolones should be separated from divalent cations as they may inhibit absorption through chelation.

Flagyl (metronidazole), Ceftin (cefuroxime)

Minocine (minocycline), Levaquin (levofloxacin)

Avelox (moxifloxacin), Amoxil (amoxicillin)

Bactrim (SMX/TMP), Zithromax (azithromycin)

Biaxin (clarithromycin), Zyvox (linezolid)

180

RE, a 23 year old male with poorly controlled asthma, currently is presenting with a flu-like illness for approximately 24 hours. A rapid test reveals influenza B. If indicated, which antiviral agent would be most useful to initiate?

A. Antiviral therapy is not indicated as the patient's symptoms began beyond the point of benefit.
B. Famvir
C. Tamiflu
D. Relenza
E. Flumadine
 

C. Antivirals are indicated as long as the patient presents < 48 hours from symptom onset. Tamiflu is the best option in this case.

Tamiflu (oseltamivir) side effects include vomiting, nausea, abdominal pain, diarrhea.

Relenza (zanamivir) diskhaler side effects include headache, throat pain, cough.

Warning for both agents include rare side effects of neuropsychiatric events.

Relenza warning only: bronchospasm risk (do not use in asthma/COPD or with any breathing problems)

Famvir (famciclovir)

Flumadine (rimantadine) - indicated for Influenza A only

181

RS is a 62 year old male with multiple medical problems including colon cancer status post surgical resection of his colon and chemotherapy who is now presenting with acute kidney injury and a complicated Pseudomonas bloodstream infection. Given the patient's immunocompromised state the team would like to double cover the Pseudomonas with antibiotics that are not strongly associated with nephrotoxicity. Allergies include penicillin (angioedema) and simvastatin (history of rhabdomyolysis). Which of the following regimens represent the best choice? 

A. Cefepime + gentamicin
B. Ertapenem + levofloxacin
C. Aztreonam + ciprofloxacin
D. Meropenem + tobramycin
E. Piperacillin-tazobactam + moxifloxacin
 

C. In this case beta-lactams should be avoided if possible as the patient has a history of a type-1 mediated hypersensitivity reaction to penicillin. Aztreonam, a monobactam is safe to use in this setting. Aminoglycosides should be avoided as the patient has acute kidney injury and there is a safer option. Ertapenem and moxifloxacin do not cover Pseudomonas.

Cefepime (Maxipeme)

Ertapenem (Invanz)

Levofloxacin (Levaquin)

Aztreonam (Azactam)

Ciprofloxacin (Cipro)

Meropenem (Merrem)

Piperacillin/tazobactam (Zosyn)

Moxifloxacin (Avelox)

182

AG is a 22 year female with glomerulonephritis and chronic kidney disease on dialysis who is presenting with a urinary tract infection (acute pyelonephritis). She has the following allergies: sulfa (rash), levofloxacin (rash), nitrofurantoin (nausea). Which of the following agents is most appropriate to treat her UTI without the need for renal dose adjustments?

A. Ciprofloxacin
B. Nitrofurantoin
C. Trimethoprim/sulfamethoxazole
D. Ceftriaxone
E. Ampicillin plus gentamicin
 

D. Ceftriaxone should be utilized in this case.

No renal adjustment required

183

Which of the following oral antibiotic suspensions should not be refrigerated? (Select ALL that apply.)

A. Biaxin
B. Cleocin
C. Diflucan
D. Cipro
E. Ceftin
 

A, B, C, D. Biaxin, Cleocin, Diflucan and Cipro should not be refrigerated.

Refrigeration required: amoxicillin/clavulanate (Augmentin), ceprozil (Cefzil), cefuroxime (Ceftin), cephalexin (Keflex), erythromycin ethylsuccinate/sulfisoxazole (E.S.P.), penicillin VK (Veetids)

Do Not Refrigerate: azithromycin (Zmax), cefdinir, clarithromycin (Biaxin-bitter taste, thickening/gels), clindamycin (Cleocin-thickening, crystallize), ciprofloxacin (Cipro), doxycycline (Vibramycin), fluconazole (Diflucan), levofloxacin (Levaquin), linezolid (Zyvox), sulfamethoxazole/trimethoprim (Septra, Sulfatrim), voriconazole (VFEND)

184

Antiviral agents active against cytomegalovirus (CMV) include which of the following: 

A. Valganciclovir, valacyclovir, acyclovir
B. Atazanavir, valganciclovir, foscarnet
C. Foscarnet, acyclovir, cidofovir
D. Valganciclovir, foscarnet, cidofovir
E. Acyclovir, valacyclovir, ganciclovir
 

D. Ganciclovir, valganciclovir, foscarnet and cidofovir are indicated for CMV. Others listed are indicated for HSV (acyclovir, valacyclovir, famciclovir) or HIV (atazanvir).

HSV, VZV coverage: acyclovir (Zovirax), valacyclovir (Valtrex), famciclovir (Famvir)

CMV coverage: ganciclovir (Cytovene), valganciclovir (Valcyte), cidofovir (Vistide), foscarnet (Foscavir)

185

A 57 year old male presents to his primary care physician with non-pruritic macular lesions covering his palms. A diagnosis of secondary syphilis is made. The patient has no known drug allergies. Choose the most appropriate treatment plan for the problem presented above.

A. Ceftriaxone 1 g IV or IM daily x 7 days.
B. Penicillin G benzathine 2.4 million units IM x 1.
C. Penicillin G 18 million units IV as a continuous infusion x 14 days.
D. Azithromycin 1 g PO daily x 5 days.
E. Doxycycline 100 mg PO twice daily x 7 days.
 

B. The preferred option for treating secondary syphilis is penicillin G benzathine 2.4 million units IM x 1.

Primary, secondary, or early latent (<1 year duration): Penicillin G benzathine 2.4 million units IM x 1

Late latent (>1 year duration), tertiary, or latent syphilis of unknown duration: Penicillin G benzathine 2.4 million units IM weekly x 3 weeks

186

A 48-year-old male with ascites secondary to alcoholic cirrhosis presents with signs and symptoms suggestive of primary peritonitis. In the next room a 32-year old female presents with acute cholecystitis of mild-moderate severity. Both patients have normal renal function and no known drug allergies. Which of the following would be a reasonable empiric antimicrobial regimens for both patients?

A. Ciprofloxacin 750 mg PO weekly - treat for 14 days.
B. Vancomycin 1 gram IV Q12H - treat for 5-7 days.
C. Gentamicin 1 mg/kg IV Q8H - treat for 7-10 days.
D. Ceftriaxone 1 gram IV daily - treat for 5-7 days.
E. Cefepime 1 gram PO Q8H + metronidazole 500 mg IV Q12H - treat for 14 days.
 

D. The preferred option is ceftriaxone 1 gram IV daily for 5-7 days.

Primary peritonitis (aka spontaneous bacterial peritonitis, SBP) common pathogens are Streptococci and enteric Gram-negative organisms (PEK), and rarely anaerobes. Drug of choice is ceftriaxone (Rocephin) for 5-7 days. Alternatives include ampicillin, gentamicin, or a fluoroquinolone. SMX/TMP, ofloxacin, or ciprofloxacin can be used for primary or secondary prophylaxis of SBP.

187

TN is a 42 y/o male patient who has been hospitalized in the ICU of a major trauma center for 25 days.  He had a motor vehicle accident and required several complicated surgeries.  He subsequently developed an intrabdominal infection and pneumonia.  He has received antibiotic therapy over the 25 days with different combinations of Zosyn, Merrem, gentamicin,Maxipime, and ciprofloxacin to treat multi-drug resistant (MDR) gram negatives.  He is currently receiving amikacin and ciprofloxacin.  See below for TN’s culture and sensitivities taken today:   
Culture and Sensitivity Report for Pseudomonas aeruginosa: 
Amikacin - S  
Ciprofloxacin - R  
Gentamicin - R  
Tobramycin - R  
Levofloxacin - R  
Piperacillin/tazobactam - R  
Cefepime - R  
Imipenem - R  
SMX/TMP - R     
Culture and Sensitivity Report for Acinetobacter baumannii  
Amikacin - R  
Ciprofloxacin - R  
Gentamicin - R 
Tobramycin - R  
Levofloxacin - R  
Piperacillin/tazobactam - R  
Cefepime - R 
Imipenem - R  
SMX/TMP - R    
Which of the following strategies is best to manage TN’s MDR infection?

A. Stop all antibiotics, there is nothing that can be done.
B. Change antibiotic regimen to amikacin and Ketek.
C. Change antibiotic regimen to Avelox and INVanz.
D. Change antibiotic regimen to amikacin and Coly-Mycin M.
E. Change antibiotic regimen to Sivextro and Flagyl.
 

D. Not all antibiotics are tested on commercially available panels for sensitivity, but laboratory personnel can test samples for additional antimicrobial susceptibilities if needed. Knowledge of resistance mechanisms is important to interpreting C&S reports. Colistimethate or polymyxin can be used in combination therapy for MDR Gram-negative pathogens.

Ketek (telithromycin)

Avelox (moxifloxacin)

Invanz (ertapenem)

Coly-Mycin M (Colistimethate or Colistin)

Sivextro (tedizolid)

Flagyl (metronidazole)

188

A 36 year old woman with diabetes presents to the emergency department complaining of a red, painful foot. On examination, her entire foot is erythematous and swollen. The affected area extends beyond the ankle, has poorly defined margins, and is hot and painful to touch and is described as "limb threatening." The patient is noted to have a fever of 38.7°C and has chills and rigors, and several small abscesses are noted to be present on the top of the foot. Cultures were drawn in clinic two days prior to presentation to the emergency department which reveal evidence of Streptococcus,Bacteroides fragilis, and enteric Gram-negative pathogens, but not Pseudomonas. The medical team is seeking a single agent dosed once daily to facilitate discharge. The patient has no known drug allergies. Which of the following agents is most appropriate according the the medical team's wishes?

A. Ceftriaxone
B. Ertapenem
C. Piperacillin-tazobactam plus vancomycin
D. Clindamycin
E. Nafcillin
 

B. The only agent that is dosed once daily with coverage of Streptococci, enteric Gram-negative pathogens (e.g., E. coli) and anaerobes is ertapenem. Ceftriaxone has no anaerobic coverage, while nafcillin and clindamycin have no enteric Gram-negative coverage.

Ceftriaxone (Rocephin)

Ertapenem (Invanz)

Piperacillin/tazobactam (Zosyn)

Clindamycin (Cleocin)

Nafcillin (Nafcillin)

189

Which of the following statements are correct with regards to sulfamethoxazole/trimethoprim? (Select ALL that apply.)

A. It is a potent hepatic enzyme inducer resulting in reduced drug concentrations.
B. It has excellent bioavailability, thus can transition from intravenous to oral formulations in a 1:1 fashion.
C. It is active against many Gram-positive pathogens, including Staphylococci, Gram-negative pathogens, and opportunistic pathogens.
D. It is cleared partially by the kidney and requires renal dose adjustments in moderate to severe renal impairment.
E. It is a preferred agent in pregnancy, especially for urinary tract infections.
 

B, C, D. TMP/SMX is a potent CYP 2C9 inhibitor (not inducer). It has 1:1 conversion from IV:PO dosing. It is a broad spectrum agent with excellent Gram-positive, Gram-negative (not Pseudomonas) and opportunistic pathogen coverage. It is partially cleared by the kidney and should be dosed reduced for CrCl < 30 mL/min. Last, it is a Pregnancy Category D and is not a preferred agent in pregnancy, even for treatment of UTIs.

190

CN is a 22 year old female who has been started on Macrobid for a seven day treatment course of a urinary tract infection. Counseling on Macrobid should include the following points? (Select ALL that apply.)

A. Continue to take this medication until the full prescribed amount is finished, even if symptoms disappear after a few days.
B. This medication should be taken four times daily in evenly spaced intervals (every 6 hours).
C. This medication may cause your urine to turn dark yellow or brown in color. This is usually a harmless, temporary effect and will disappear when the medication is stopped.
D. This medicine can make your skin more sensitive to the sun, and you can burn more easily. Use sunscreen and protective clothing.
E. Rarely this medication may rarely cause very serious lung problems. Seek medical attention if you are experiencing severe symptoms of lung problems.
 

A, C, E. Nitrofurantoin (Macrobid) is dosed twice daily, hence the brand name MacroBID. Nitrofurantoin does not cause photosensitivity.

191

Which of the following are appropriate patient counseling points for a patient picking up a prescription for oral rifampin? (Select ALL that apply.)

A. Contact your doctor right away if you are passing brown or dark-colored urine, have pale stools, or if your skin or whites of your eyes become yellow. This may be a sign of liver damage.
B. This medicine can cause the tongue to become black.
C. This medication may cause your urine to turn orange-red in color.
D. This medicine can increase the levels of many other medicines. Please discuss with your pharmacist or physician if any new medications are started.
E. This medicine can affect your vision. Contact your doctor if you have any changes in your vision.
 

A, C. Rifampin is associated with liver toxicity, including hyperbilirubinemia and discoloration (red) of body secretions. Patients should be counseled on these points. Rifampin is a hepatic enzyme inducer and can decrease levels of other medications.

192

TM is a 32 year old male presenting to his primary care physician with two weeks of symptoms of facial/tooth pain, nasal drainage with purulent discharge and a mild fever. His physician has diagnosed him with acute sinusitis. He has an allergy to cephalexin (rash) and silver sulfadiazine (rash). Which of the following options is most appropriate to initiate?

A. Doxycycline 100 mg PO twice daily x 5-7 days.
B. Amoxicillin/clavulanate 500 mg/125 mg PO twice daily x 14 days.
C. No antibiotics are indicated at this time as it is likely a viral etiology.
D. Moxifloxacin 400 mg PO twice daily for 7-14 days.
E. Trimethoprim/sulfamethoxazole 1 DS PO twice daily for 5 days.
 

A. Acute sinusitis of > 7 days duration with severe symptoms of facial/tooth pain and/or nasal discharge should be treated with antibacterial agents for 5-7 days. Doxycycline 100 mg PO twice daily x 5-7 days is an appropriate treatment option.

>7-10 days of symptoms: tooth/face pain, nasal drainage/discharge, congestion or severe/worsening symptoms

1st line: Augmentin, doxycycline

2nd line: oral 2nd or 3rd generation cephalosporins + clindamycin, respiratory fluoroquinolone

Adults: 5-7 days

Children: 10-14 days

Chronic: >21 days + surgical intervention

193

HV is a 37 y/o male in the ICU after sustaining a gunshot wound on 1/10/15.  He has had a complicated hospital course so far and is now being treated for ventilator associated pneumonia and bacteremia with Pseudomonas.  He is 6'2" and weighs 192 pounds.  He is currently on gentamicin 180 mg IV Q8H and Maxipime 1 gm IV Q8H.  The pharmacokinetic service has ordered steady state gentamicin levels today.  Both levels were drawn at the appropriate times with respect to the dose.  The peak level is 9.2 mcg/mL and the trough level is 0.2 mcg/mL. What is the best recommendation to make regarding the gentamicin regimen?

A. Increase the dose and leave the interval the same.
B. Decrease the dose and leave the interval the same.
C. Leave the dose the same and change the interval to Q6H.
D. Increase the dose and change the interval to Q6H.
E. Do nothing, these are target peak and trough gentamicin levels.
 

E. The target peak and trough for gentamicin is 5-10 mcg/mL and < 2 mcg/mL, respectively. There is no need to adjust the dose or the interval in this case.

Traditional Dosing Target Drug Concentration

Gentamicin: Gram-positive infection (Peak 3-4 mcg/mL, Trough <1 mcg/mL), Gram-negative infection (Peak 5-10 mcg/mL, Trough <2 mcg/mL)

Tobramycin (Peak 5-10 mcg/mL, Trough <2 mcg/mL)

Amikacin (Peak 20-30 mcg/mL, Trough <5 mcg/mL)

 

194

JR is a 79 year old male diagnosed with community acquired pneumonia and admitted to the hospital (non-ICU). He has a penicillin allergy (nausea). Which of the following is the most appropriate treatment?

A. Ceftriaxone + azithromycin
B. Gatifloxacin
C. Ampicillin/sulbactam
D. Ertapenem
E. Doxycycline
 

A. Note the "allergy" is not a true allergy, but just a intolerance that does not preclude the use of a beta-lactam.

195

DH is a 42 year old male being treated with Synercid for a complicated VRE and MRSA infection. Which of the following are common toxicities of Synercid? 

A. Infusion reactions, electrolyte abnormalities, nephrotoxicity
B. Arthralgias/myalgias, nephrotoxicity, neurological disturbances
C. Infusion reactions, arthralgias/myalgias, hyperbilirubinemia
D. Hyperbilurbinemia, neurological disturbances, arthralgias/myalgias
E. Electrolyte abnormalities, nephrotoxicity, infusion reactions
 

C. Synercid (quinupristin/dalfopristin) can cause arthralgias/myalgias, hyperbilirubinemia and infusion-related reactions.

Synercid has high incidence of SEs: arthralgia/myalgias (47%), infusion reactions including edema (44%), phlebitis (40%), elevated CPK, hyperbilirubinemia (35%), GI upset, increased LFTs

196

Which of the following statements is incorrect with regard to amphotericin B? 

A. Lipid formulations reduce the risk for infusion reactions and nephrotoxicity.
B. It is a fungicidal agent with broad antifungal spectrum of activity.
C. It is contraindicated in pregnancy - Pregnancy Category X.
D. It is compatible with D5W only.
E. It is commonly associated with nephrotoxicity and electrolyte abnormalities.
 

C. Amphotericin B is a fungicidal agent with broad antifungal activity. It is only compatible with D5W. It is commonly associated with nephrotoxicity and electrolyte abnormalities. Lipid formulations were introduced to reduce the risk for infusion reactions and nephrotoxicity. Amphotericin B is Pregnancy Category B.

197

Select the correct dose of oseltamivir for the treatment of influenza in an adult:

A. 75 mg BID for ten days
B. 75 mg BID for five days
C. 75 mg daily for ten days
D. 75 mg daily for five days
E. 75 mg BID for fifteen days
 

B. The treatment dose is 75 mg twice daily for 5 days.

Must start within 48 hours of symptoms or contact for effective treatment

Oseltamivir (Tamilfu)

Tx: 75mg BID x 5 days

Px: 75mg daily for 10 days

 

Zanamivir (Relenza Diskhaler)

Tx: 10mg (2 inhalations) BID x 5

Px: 10mg (2 inhalations) once daily x 10 days

198

A pharmacodynamic strategy being used to yield greater time above the MIC for certain beta lactam antibiotics is:

A. Use of an antibiogram
B. Auditing
C. Synergy
D. Extended infusion
E. Omitting loading doses
 

D. Extended, prolonged or continuous infusions of what were traditionally short infusion drugs (the prototype is piperacillin-tazobactam) are becoming the norm in clinical practice to better treat resistant organisms. Historically Zosyn was infused over 30 minutes. Under a prolonged infusion protocol, the same dose would likely be infused over 4 hours to maximize time above the MIC.

199

Which of the following are potential treatment options for the management vesicular genital lesions caused by a first episode of Herpes Simplex Virus-2 (HSV-2) in a non-HIV positive patient. (Select ALL that apply.)

A. Valcyte 900 mg PO twice daily x 5 days
B. Famvir 250 mg PO three times daily x 7-10 days
C. Valtrex 1 g PO daily x 5 days
D. Foscavir 90 mg/kg IV Q12H x 14 days
E. Zovirax 400 mg PO three times daily x 7-10 days
 

B, E. The preferred options for first episode of HSV-2 genital lesions include acyclovir 400 mg PO three times daily (or 200 mg 5x/day) OR Valtrex 1 g PO twice daily x 7-10 days OR Famvir 250 mg PO TID. The duration of HSV-2, first episode, should be 7-10 days.

HSV, VZV coverage: acyclovir (Zovirax), valacyclovir (Valtrex), famciclovir (Famvir)

CMV coverage: ganciclovir (Cytovene), valganciclovir (Valcyte), cidofovir (Vistide), foscarnet (Foscavir)

200

JR is a 62 year old female with Crohn's Disease who is presenting with recurrent C. difficile (5th episode) that was previously refractory to metronidazole and recently to vancomycin. Which of the following agents is indicated for C. difficileinfections and should be considered in this case of recurrent infection?

A. Clindamycin
B. Fidaxomicin
C. Rifaximin
D. Levofloxacin
E. Metronidazole
 

B. Fidaxomicin would be indicated in this case. Rifaximin is not FDA-approved for C. difficile.

Clindamycin (Cleocin)

Fidaxomicin (Dificid)

Rifaximin (Xifaxan)

Levofloxacin (Levaquin)

Metronidazole (Flagyl)

201

Which of the following groups of pathogens best represents clindamycin's spectrum of activity?

A. Atypicals and anaerobic pathogens
B. Enteric Gram-negative pathogens (E. coli, Pseudomonas) and Enteric Gram-positive pathogens (Streptococci, Staphylococci)
C. Enteric Gram-negative pathogens and anaerobic pathogens
D. Parasitic and fungal pathogens
E. Gram-positive pathogens (Streptococci, Staphylococci) and anaerobic pathogens
 

E. Clindamycin (Cleocin) has excellent coverage for Gram-positive pathogens (Streptococci, Staphylococci, but not Enterococci) and anaerobic pathogens, including Gram-negative anaerobes.

202

A 32 year old critically-ill patient with diabetes is admitted to the intensive care unit with respiratory compromise and acute kidney injury. She is diagnosed with pulmonary Aspergillosis. Which of the following antifungal agents would be most appropriate to initiate?

A. VFEND
B. Flucytosine
C. Zosyn
D. AmBisome
E. Cancidas
 

A. The drug of choice for Aspergillosis is voriconazole. Amphotericin B is an alternative, but should be avoided in the setting of acute kidney injury due to its nephrotoxicity potential.

VFEND (voriconazole)

Flucytosine (Ancobon)

Zosyn (piperacillin/tazobactam)

AmBisome (amphotericin B liposomal)

Cancidas (caspofungin)

203

RS is a 36 year old male who has been started on Bactrim for treatment of an upper extremity cellulitis and abscess. Counseling on Bactrim should include the following points? (Select ALL that apply.)

A. Take this medication with a full glass of water.
B. Do not use if you have an allergy to sulfa medicines.
C. Shake the suspension prior to use. The suspension should be kept at room temperature.
D. This medicine can make your skin more sensitive to the sun, and you can burn more easily. Use sunscreen and protective clothing.
E. Antibiotics work best when the amount of medicine in your body is kept at a constant level. Therefore, take this drug at evenly spaced intervals.
 

A, B, C, D, E. All of the following are appropriate counseling points for Bactrim.

Refrigeration required: amoxicillin/clavulanate (Augmentin), ceprozil (Cefzil), cefuroxime (Ceftin), cephalexin (Keflex), erythromycin ethylsuccinate/sulfisoxazole (E.S.P.), penicillin VK (Veetids)

Do Not Refrigerate: azithromycin (Zmax), cefdinir, clarithromycin (Biaxin-bitter taste, thickening/gels), clindamycin (Cleocin-thickening, crystallize), ciprofloxacin (Cipro), doxycycline (Vibramycin), fluconazole (Diflucan), levofloxacin (Levaquin), linezolid (Zyvox), sulfamethoxazole/trimethoprim (Septra, Sulfatrim), voriconazole (VFEND)

204

Which of the following statement/s is/are true regarding daptomycin? (Select ALL that apply.)

A. Concentration dependent killer with bactericidal activity.
B. Requires dose adjustments for moderate-severe renal impairment.
C. Associated with myopathy / muscle toxicity, thus monitor CPK with prolonged use.
D. Intravenous formulation is compatible with normal saline and lactated ringers only.
E. Oral formulation has excellent bioavailability.
 

A, B, C, D. Daptomycin is concentration dependent with bactericidal activity. It requires dose adjustments for CrCl < 30 mL/min. It is associated with myopathy and rarely rhabdomyolysis, thus CPK should be monitored weekly with prolonged use. Daptomycin is only available in intravenous formulation of which is only compatible only with normal saline and lactated ringers.

205

TM is a 42 year old male who has been started on Biaxin for treatment of pneumonia. Counseling on Biaxin should include the following points? (Select ALL that apply.)

A. Common side effects (2-3%) include diarrhea, abdominal pain, nausea or abnormal (metallic) taste.
B. Biaxin XL tablets should be taken with on an empty stomach.
C. Biaxin liquid suspension should be refrigerated.
D. This medicine can make your skin more sensitive to the sun, and you can burn more easily. Use sunscreen and protective clothing.
E. There are interactions with this drug and other medicines. Please discuss with your pharmacist to make sure this will not pose a problem.
 

A, E. Common side effects of Biaxin are GI side effects and abnormal taste. Biaxin XL should be taken with food. Biaxinsuspension should not be refrigerated. Macrolides are not associated with photosensitivity, but are associated with drug interactions secondary to inhibition of hepatic enzymes (CYP3A4).

206

Which of the following antimicrobial agents have activity against Bacteroides fragilis? (Select ALL that apply.)

A. Tigecycline
B. Metronidazole
C. Ampicillin/sulbactam
D. Cefoxitin
E. Ertapenem
 

A, B, C, D, E. All of the options have activity against Bacteroides fragilis.

Tigecycline (Tygacil)

Metronidazole (Flagyl)

Ampicillin/sulbactam (Unasyn)

Cefoxitin (Mefoxin)

Ertapenem (Invanz)

207

Which of the following are available as chewable tablets?

A. Amoxicillin, Bactrim, and cephalexin
B. Ciprofloxacin, amoxicillin/clavulanate, and fluconazole
C. Ciprofloxacin, amoxicillin/clavulanate, and cefixime
D. Amoxicillin, amoxicillin/clavulanate, and cefixime
E. Ciprofloxacin, Bactrim, and fluconazole
 

D. Chewable products often contain phenylalanine. Verify the contents of products for safety in patients with phenylketonuria (PKU); these patients cannot use phenylalanine as a sweetener.

208

Which of the following intravenous antimicrobial agent(s) have short stability at room temperature once reconstituted (< 24 hours) and are not suitable for continuous infusion delivery? (Select ALL that apply).

A. Ampicillin
B. Zosyn
C. Bactrim
D. Merrem
E. Vancomycin
 

A, C, D. Ampicillin, meropenem and SMX/TMP are stable for < 24 hours at room temperature once reconstituted, thus are not suitable for continuous infusion delivery.

Zosyn (piperacillin/tazobactam)

Bactrim (SMX/TMP)

Merrem (meropenem)

Vancomycin (Vancocin)

209

Which of the following antimicrobials is most likely to be associated with lupus like syndrome?

A. Erythromycin
B. Fluconazole
C. Linezolid
D. Isoniazid
E. Hydralazine
 

D. Isoniazid is the only antibacterial listed that is associated with lupus like syndrome. Rarely, tetracyclines are associated with lupus-like syndrome as well. Note that while hydralazine is associated with lupus it is not an antibacterial.

210

Josie is receiving oseltamivir (Tamiflu). Choose the correct mechanism of action for oseltamivir. 

A. Binds to the ribosomal subunit in viral RNA
B. Stimulates phagocytosis
C. Inhibits neuraminidase
D. Prevents viral shedding
E. Inhibits hemagglutinin
 

C. Hemagglutinin and neuraminidase are proteins on the surface of the influenza virus. Oseltamivir is a neuraminidase inhibitor.

Must start within 48 hours of symptoms or contact for effective treatment

Oseltamivir (Tamilfu)

Tx: 75mg BID x 5 days

Px: 75mg daily for 10 days

 

Zanamivir (Relenza Diskhaler)

Tx: 10mg (2 inhalations) BID x 5

Px: 10mg (2 inhalations) once daily x 10 days

211

A 68 year old woman presents to the clinic with a history of heart failure, alcoholism, COPD, diabetes and gout complaining of shortness of breath, fever, and persistent cough. Tmax: 38.2°C, RR 20, HR: 102. Based on the physician’s interview and assessment, she does not have a recent history of antibiotic use and does not require admission to the hospital and has CAP. The patient has an allergy to penicillin (rash). Which of the following antibiotics are considered first line in this case when used alone?

A. Avelox 400 mg PO daily x 5-7 days.
B. Cefpodoxime 200 mg PO twice daily for 7-10 days.
C. Amoxil 500 mg PO twice daily x 5-7 days.
D. Cipro 500 mg PO daily x 10-14 days.
E. Zithromax 500 mg PO daily x 1 day, then 250 mg PO daily for four days.
 

A.

Patient is not healthy hence the two options are beta-lactam + macrolide or a respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin). Also they want only one drug to be used alone and so a respiratory fluoroquinolone is the best option here.

Avelox (moxifloxacin)

Cefpodoxime (Vantin)

Amoxil (amoxicillin)

Cipro (ciprofloxacin)

Zithromax (azithromycin)

212

GT is a 62 year old male with primary lung cancer in acute respiratory distress requiring ventilation. On hospital day 8 the patient was diagnosed with ventilator associated pneumonia. The team would like to cover for Gram-negative pathogens with meropenem and an additional agent for MRSA coverage. Allergies include vancomycin (angioedema, hypotension) and clindamycin (diarrhea). Which of the following intravenous agents should the pharmacist recommend in this case?

A. Cubicin
B. Tygacil
C. Vancocin
D. Zyvox
E. Rifadin
 

D. Cubicin is not indicated for pneumonia as it is inactivated by lung surfactant. Tygacil has activity against MRSA, however there is limited data supporting it's use for pneumonia and more importantly the FDA has issued a boxed warning noting that it should be reserved for situations when alternate treatments are not suitable (due to increased mortality in studies compared to other agents). Zyvox is the only viable option in this case.

Cubicin (daptomycin)

Tygacil (tigecycline)

Vancocin (vancomycin)

Zyvox (linezolid)

Rifadin (rifampin)

213

Which of the following intravenous antimicrobial agents are compatible in D5W only? 

A. Acyclovir and ampicillin
B. Cubicin and vancomycin
C. Synercid and Bactrim
D. Doxycycline and Cipro
E. Ceftin and Zosyn
 

C. Bactrim and Synercid are compatible in D5W only.

NS only: ampicillin, ampicillin/sulbactam (Unasyn), caspofungin (Cancidas), daptomycin (Cubicin), phenytoin, ertapenem (Invanz), infliximab (Remicade)

D5W only: Amphotericin B (Amphotec), lorazepam (Ativan), quinupristin/dalfopristin (Synercid), and sulfamethoxazole/ trimethoprim (Bactrim)

214

Which of the following statements are true regarding Zyvox? (Select ALL that apply.)

A. It has excellent Gram-positive coverage, including MRSA and VRE.
B. It is cleared primarily by the kidney requiring dose adjustments in the setting of renal impairment.
C. Monitor for serotonin syndrome when used with SSRI antidepressants.
D. Nephrotoxicity is a common toxicity with prolonged use.
E. It has excellent bioavailability, thus can transition from intravenous to oral formulations in a 1:1 fashion.
 

A, C, E. Zyvox has excellent Gram-positive coverage, including MRSA and VRE. It is primarily cleared by the liver, not the kidney. It is a MAO inhibitor and should be used with caution with serotonergic agents such as SSRI antidepressants (monitoring is recommended). Bone marrow suppression is a duration related toxicity, not nephrotoxicity. Zyvox has excellent bioavailability - transition from IV:PO in a 1:1 fashion.

215

A 20 year old male with HIV/AIDS is admitted to the medicine floor for a work-up of sepsis. Blood cultures are performed and reveal germ-tube positive yeast suggesting Candida albicans. The patient has limited intravenous access. The medical team asks if there is an acceptable agent to treat Candida albicans that is available in both intravenous and oral formulations. Which agent could be recommended?

A. Flucytosine
B. Micafungin
C. Nystatin
D. Terbinafine
E. Fluconazole
 

E. Fluconazole is the drug of choice for Candida albicans bloodstream infections (candidemia). The other agents are not appropriate and do not come in both IV and PO forms.

Echinocandins are IV only.

Flucytosine (Ancobon) - PO

Micafungin (Mycamine) - IV

Nystatin (Bio-Statin) - PO suspension

Terbinafine (Lamisil, Terbinex) - PO, topical

Fluconazole (Diflucan) - IV, PO

216

Which of the following statements is incorrect regarding daptomycin? 

A. It exhibits concentration-dependent killing with bactericidal activity.
B. The intravenous formulation is compatible with normal saline only.
C. It is associated with myopathy/muscle toxicity, thus monitor for creatine kinase with prolonged use.
D. It requires dose adjustments for moderate-severe renal impairment.
E. The oral formulation has excellent bioavailability.
 

E. Daptomycin has concentration-dependent killing with bactericidal activity. It requires dose adjustments for CrCl < 30 mL/min. It is associated with myopathy and rarely rhabdomyolysis, thus creatine kinase should be monitored with prolonged use. Daptomycin is only available in intravenous formulation which is compatible with normal saline only.

217

VL is a 67 year old female who has been started on Cipro suspension for treatment of a urinary tract infection because she has trouble swallowing pills. Which of the following counseling points are not appropriate for VL.

A. You may feel dizzy or lightheaded when taking this medication.
B. This medicine should be taken 2 hours before or 6 hours after taking antacids, vitamins, magnesium, calcium, iron or zinc supplements, or dairy products.
C. Cipro liquid suspension should be refrigerated.
D. This medicine can make your skin more sensitive to the sun, and you can burn more easily. Use sunscreen and protective clothing.
E. There are interactions with this drug and other medicines. Please discuss with your pharmacist to make sure this will not pose a problem.
 

C. Fluoroquinolones are centrally acting and have many CNS toxicities and are associated with photosensitivity. They should be separated from divalent cations to avoid chelation and reduced absorption. Cipro suspension should not be refrigerated (contains gel which could thicken). Fluoroquinolones have many drug interactions, including hepatic enzyme inhibition (CYP P450 1A2) and interactions with divalent cations as noted above, along with bismuth subsalicylate.

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