Sepsis

Question 1

What bacteria is most often related to infected intravascular devices, artificial heart valves and stents, and the use of intravenous (IV) and intra-arterial catheters?

Answer 1

Staphylococcus epidermidis (G+)

Question 2

What is the most common fungal cause of bloodstream infections?

Answer 2

Candida albicans (Candidemia)

Question 3

List 2 drugs that can induce shock

Answer 3

1) Cyanide (nitroprusside)
2) Carbon monoxide (long acting opioids)

Question 4

Gram (+) organisms create __________ that will activate T-cells causing an inflammatory response; activation of cytokines

Answer 4

exotoxins

Question 5

The presence of ______________ triggers an immunologic response when released by the bacterium

Answer 5

endotoxin

Question 6

Disseminated intravascular coagulation (DIC) leads to widespread microvascular _________ and profuse _________ from various sites

Answer 6

thrombosis; bleeding

Question 7

Acute phase interaction of the pro-inflammatory and hypercoagulative state is believed to do what?

Answer 7

Sequester bacteria as part of compartmentalization

Question 8

DIC leads to what 3 pro-inflammatory cytokines?

Answer 8

TNF, IL-1, and IL-6

Question 9

List and describe 4 more complications of sepsis

Answer 9

1) AKI: Hypoperfusion > to renal ischemia
2) ARDS: Activated neutrophils and platelets adhering to the pulmonary capillary endothelium; pulmonary edema
3) Hemodynamics: Microvascular impairment
4) Septic shock: type of vasodilatory/distributive shock

Question 10

What is one way to predict sepsis mortality?

Answer 10

Elevated serum lactate concentration (↓O2 = ↑lactate)

Question 11

How many blood cultures do you need to get for sepsis?

Answer 11

At least 2 (both aerobic and anaerobic bottles)

Question 12

Fluid therapy: Dynamic assessment was defined as increase in stroke volume of more than ____% to ___% after a fluid challenge of 250 to 500 mL of crystalloids or from endogenous source by using the passive leg raise

Answer 12

10% to 15%

Question 13

What is the number of isotonicity?

Answer 13

Isotonicity ≈ 280 mOsmol / L (kidneys are an exception)

Question 14

List potential side effects of:
1) Normal saline
2) Dextrose 5%

Answer 14

1) Hyperchloridemia metabolic acidosis
2) May increase lactate and CO2

Question 15

What are the Four phases of septic shock?

Answer 15

1) Resuscitation: onset
-Positive fluid balance
2) Optimization: hours within onset
-Neutral fluid balance
3) Stabilization: days within onset
-Neutral fluid balance
4) Evacuation: days to weeks within onset
-Negative fluid balance

Question 16

List the empiric antimicrobial Txs for the following community acquired sources of sepsis:
1) Urinary tract
2) Resp. tract
3) Intra-abdominal
4) Skin/ soft tissue
5) Unknown

Answer 16

1) Ceftriaxone or cipro/ levo
2) Levo/ moxifloxacin or ceftriaxone + clarithro/ azithro
3) Ertapenem, or cipro/ levo + metro, or ceftriaxone + metro
4) Vancomycin or linezolid or daptomycin
5) Piperacillin/ tazobactam or carbapenem

Question 17

List the empiric antimicrobial Txs for the following hospital acquired sources of sepsis:
1) Urinary tract
2) Resp. tract
3) Intra-abdominal

Answer 17

1) Ceftriaxone/ ceftazidime or cipro/ levo
2) Piperacillin/ tazobactam or ceftazidime or cefepime or carbapenem + levo/ cipro or aminoglycoside +/ vanc or linezolid
3) Piperacillin/ tazobactam, or carbapenem, or ceftazidime/ cefepime + metronidazole

Question 18

List the empiric antimicrobial Txs for the following hospital acquired sources of sepsis:
1) Skin/ soft tissue
2) Catheter-related
3) Unknown

Answer 18

1) Vancomycin + piperacillin/ tazobactam
2) Vancomycin
3) Carbapenem

Question 19

How should you Tx Healthcare-associated infections?

Answer 19

Multidrug resistance: Meropenem, imipenem/cilastatin or doripenem
OR
Piperacillin/tazobactam

Question 20

How should you Tx the following Nosocomial infections?:
1) MRSA
2) VRE

Answer 20

1) Vancomycin or linezolid or daptomycin
2) Daptomycin

Question 21

How should you Tx Extended-spectrum beta-lactamases (ESBL)-producing Enterobacteriaceae?

Answer 21

Meropenem, imipenem/cilastatin or doripenem

Question 22

When should you consider combination therapy?

Answer 22

1) Pseudomonas
2) Multidrug-resistant gram-negative bacteremia such as Acinetobacter
3) Neutropenic patients

Question 23

What is the empiric therapy for suspected invasive candidiasis in nonneutropenic patients in the ICU?

Answer 23

Echinocandins: Anidulafungin, micafungin, or caspofungin

Question 24

Antifungal therapy:
Hemodynamically stable patients who have not had previous triazole exposure and not known to be colonized with azole-resistant Candida species should be treated with what?

Answer 24

Fluconazole or voriconazole

Question 25

Echinocandins: caspofungin, micafungin & anidulafungin: 1) What is the ROA? 2) What is a potential complication? 3) What are 2 Adverse effects to monitor?

Answer 25

1) IV 2) Anaphylaxis 3) ↑ LFTs, hypotension

Question 26

Echinocandins: caspofungin, micafungin & anidulafungin 1) Which should have dose adjustments with hepatic impairment and CYP inducers? 2) Which is pregnancy category B?

Answer 26

1) Caspofungin 2) Anidulafungin

Question 27

All azoles are CYP3A4 inhibitors and have ___________ warnings; monitor ______

Answer 27

QT-prolongation; LFTs

Question 28

1) ____________ and _____________ are the only azoles that penetrate CNS 2) What are these 2 assoc. with?

Answer 28

1) Fluconazole; voriconazole 2) Headache or hallucinations

Question 29

Fluconazole (Diflucan): 1) When is it pregnancy category C? 2) When is it D?

Answer 29

1) 150mg tablet dosed once is pregnancy category C 2) Stronger or more frequent doses are pregnancy category D

Question 30

What is the DOC for aspergillus?

Answer 30

Voriconazole (VFEND)

Question 31

Amphotericin B: 1) What is the MOA? 2) What is the black box warning?

Answer 31

1) Binds to ergosterol and alters cell membrane permeability; fungicidal 2) Verify product name and dose prior to administration

Question 32

Amphotericin B: What are the 3 lipid formulations available to reduce toxicity?

Answer 32

1) Abelcet - lipid complex 2) AmBisome - liposomal 3) Amphotec - cholesteryl sulfate complex  discontinued in 2022/2023

Question 33

Lipid formulations of amphotericin B have _________ doses compared conventional deoxycholate formulation

Answer 33

higher

Question 34

Amphotericin B: _________ formulations do not require renal dose adjustments

Answer 34

Lipid

Question 35

Vasopressors: 1) MAP >= _____mm Hg may be harmful (e.g., increased mortality) 2) What is the preferred vasopressor to correct hypotension in fluid refractory septic shock?

Answer 35

1) 70 2) Norepinephrine

Question 36

Vasopressors: 1) Which is assoc. with lower risk of mortality and lower risk of arrhythmia compared to dopamine? 2) What may be considered as 3rd line agents?

Answer 36

1) Norepinephrine 2) Phenylephrine and dobutamine

Question 37

Vasopressors: What is an alternative for patients with bradycardia with low risk to develop arrhythmias ?

Answer 37

Dopamine

Question 38

1) What is recommended as a second agent added to norepinephrine? 2) When does this drug have a more robust effectiveness?

Answer 38

1) Vasopressin (ADH) 2) In pts with lactate of ≤2 mmol/L

Question 39

IV ____________________ is recommended for adult patients with septic shock who are hemodynamically unstable after initial resuscitation with IV fluids and vasopressors

Answer 39

hydrocortisone

Question 40

Recommend using IV hydrocortisone at a dose of ________mg/day only if hemodynamic stability is not achieved after adequate fluid resuscitation and vasopressor therapy, regardless of _________________________

Answer 40

200; the state of adrenal insufficiency

Question 41

Blood glucose level of less than ______mg/dL (10.0 mmol/L) is recommended along with frequent blood glucose monitoring to avoid hypoglycemia

Answer 41

180

Question 42

What 2 things reduce the risk of GI bleeding?

Answer 42

Stress ulcer prophylaxis with either a proton pump inhibitor (PPI) or histamine 2 receptor antagonist (H2RA)

Question 43

Clostridium difficile infection and pneumonia have been reported with both _________ and _________ use

Answer 43

PPIs and H2RAs

Question 44

IV Vitamin C is ____________________ for adults with sepsis or septic shock

Answer 44

not recommended

Question 45

Oral Candidiasis (Thrush): 1) How should you Tx older adults? 2) What may you Tx epidermis infections with? 3) How do you Tx infants?

Answer 45

1) Nystatin suspension (ie, 100,000 units/mL) 2) Powder formulation 3) 1 ml PO QID; administer half of the dose to each side of the mouth

Question 46

Flucytosine F-5C (Ancobon) 1) What are the indications? 2) What is the warning? 3) What is the boxed warning? 4) What should it not be confused with?

Answer 46

1) Synergistic with Ampho B for Cryptococcus 2) Not for monotherapy 3) Use with extreme caution in patients with renal dysfunction 4) Fluorouracil 5-FU (topically used for keratosis and basal cell carcinoma; can be used for systemically for wide range of other cancers)

Question 47

Griseofulvin (Gris-PEG) 1) Indications? 2) What should you know about administration? 3) Name a contraindication 4) What is an important warning?

Answer 47

1) Infections of hair, skin and nails 2) Give with fatty meal to increase absorption 3) Pregnancy (Cat X) 4) Cross reaction possible with PCN allergy

Question 48

Terbinafine (Lamisil): 1) What are 2 indications? 2) What can it exacerbate? 3) What is an adverse effect?

Answer 48

1) Onychomycosis or dermatomycosis 2) Systemic lupus erythematosus 3) Increase in LFTs (FDA says limit oral dosing to 6 to 12 weeks)

Question 49

Terbinafine (Lamisil): Which form is Rx and which form is OTC?

Answer 49

1) Tablet is prescription only (aka Lamisil 250 mg) 2) Cream available OTC (aka Lamisil AT 1%)

Question 50

List the MOAs of sepsis abx

Answer 50

Question 51

What do amphotericin B, all the azoles, and the echinocandins have in common?

Answer 51

All increase hepatic transaminases