NSG 554/ NSG554 Exam 3 V2 – Nurse Practitioners in Primary Care I Guide| Wilkes (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A

NSG 554/ NSG554 Exam 3 V2 – Nurse Practitioners in Primary Care I Guide| Wilkes (Latest 2026/ 2027 Update) 100% Verified Questions & Answers | Grade A Systematic Approach for Selection of Antimicrobials Confirm the presence of infection Identify the pathogen Select empiric therapy considering every infected site Monitor therapeutic response Hallmark for ID? FEVER Controlled elevation of body temperature above normal range Temp for fever 37°C, 98.6°F Consider APAP/NSAID mask and drugs causing fever How do differential WBC change with infection Total WBC over 10,000 Increased NEUtrophils DECREAsed lymphocytes At least of the 4 following signs and symptoms must be present for a patient to meet "SIRS" criteria TWO Temperature 38°C or 36°C Heart rate 90 beats per minute WBC 12,000 or 4,000 or 10% bands Respiratory rate 20 breaths per minute Confirming Sepsis Sepsis: life-threatening **organ dysfunction** caused by a dysregulated host response to infection Empiric therapy Best guess at causative organism and susceptibility No culture and susceptibility results available Directed at organisms that are known to cause the infection Definitive therapy Choosing agent after culture and susceptibility reports available Choose antimicrobial of choice for infection if it is susceptible and there are no contraindications Selection of empiric therapy HOST factors Site of infection *Drug allergies* *Age* - ADR, organ f(x), etiology Renal and hepatic function Concomitant drug therapy Concomitant disease states- CF (Pseudomonas, diabetics, infection) Pregnancy Selection of empiric therapy DRUG factors Tissue penetration Pharmacokinetic and pharmacodynamics [PK-PD] considerations T MIC Peak: MIC AUC:MIC Drug toxicity Cost Sanford Guide: Find ABX, antivirals, meds that do NOT require renal adjustment Table 17B azithromycin ceftriaaxone chloramphenicol ciprofloaxicin clindamycin doxycycline linezolid minocycline moxifloaxcin nafcillin ortiavancin polymyxin B Pyrimethamine Rifaximi Tedizolid Tigecycline T/F Selecting correct ABX therapy can improve patient outcomes Yes!!!! True Pharmacodynamics ideal, concerntration dep. Cmax MIC want high peak compared to MIC LARGE DOSES less frequently concentration dep. abx has good post antibiotic effect pharmacodynamic- time dependent abx shorten interval-increase frequency Selecting empiric therapy tool Antibiogram- lists local resistance rates 90% or greater is good Although a single agent is generally preferred, combination of two or more antimicrobials is recommended in the following scenarios: Broaden the spectrum of coverage Synergy Prevent resistance non-therapeutic consderations of infection SOURCE control (if vent, can we stop vent?) hydration Primary goal of ABX stewardship Optimize outcomes Minimize unintended consequences (toxicity, resistance) Secondary goal of ABX stewardship Reduce healthcare costs Consequences of ABX use toxicity resistance collateral damage- 2ndary infection *C.Diff* ID pharmacist role Limit inappropriate antibiotic use Optimize antimicrobial selection, dosing, route, and duration of therapy Strategies: Prospective audit and feedback Formulary restriction Education Clinical pathways Stream-lining or de-escalating empiric therapy Dose optimization IV to PO conversion Allergy assessment Failure of Antimicrobial Therapy why? resistant organism susceptible organism - inappropriate drug selection - Inappropriate drug dosage or route of administration - Drug interaction - Poor host defenses - Poor source control - Use of a "bacteriostatic" instead of "bactericidal" drug for neutropenic patient Can you use daptomycin for MRSA pneumonia? NONONONO will be deactivated by the lungs Clinical situations in which bactericidal action considered necessary Endocarditis Meningitis Osteomyelitis Neutropenia Common misuses of ABX Treat too LONG Prolonged empiric treatment without clear evidence of infection Treatment of a positive clinical culture in the absence of disease Failure to narrow therapy when a causative organism is identified Bacteremia how to det. effectiveness check repeat blood cultures document clearance [day 1 tx = day of first negative culture blood] Distinguish between contaminatino vs.. *bactermia* clinical scenario- leukocytosis number + culutres- more + more likely final id bactera= not normal flora. Usually yeast, MRSA (coagulase-negative staff is normal and pathogenic hmm) management of bacteremia SOURCE CONTROL MRSA: complicated or uncomplicated MRSA: *uncomplicated* or complicated MEET ALL- *2 weeks** MRSA only 1) Follow-up blood cultures obtained 2 - 4 days after the initial set that do not grow MRSA 2) Defervescence within 72 hours of initiating effective therapy 3) No evidence of metastatic sites of infection 4) No implanted prostheses 5) Exclusion of endocarditis complicted Duration = 4 weeks Risks for bacteremia Hematologic malignancies Immunosuppressing medications Neutropenia IV drug use Chronic renal failure [especially if on hemodialysis] IV catheters Parenteral nutrition Risk factors for infective endocarditis Prosthetic valve Previous endocarditis IV drug use duke criteria: definite vs. possible What is definite infective endocarditis? 2 major criteria OR 1 major criteria and 3 minor criteria OR 5 minor criteria (1, 3, 5) What is possible infective endocarditis? 1 major criterion and 1 minor criterion OR 3 minor criteria IE cause for IV drug use S. Aureaus (MRSA, MSSA) IE cause for poor dental health, dental health Streptococci (viridans) HACEK IE cause for DM S. aureus Beta hemolytic streptococci S. pneumoniae IE cause for GI Strep bovis Enterrococcus Clostridium speticum empiric viridans strep IE therapy ceftriaxone empiric, then get MIC penicillin results IE viridans group duration 4weeks native 6 weeks prosthetic IE staphycocci Native valve MRSA dosing Vanco 15 mg/kg/dose IV x 6 weeks OR daptomycin = 8 mg/kg/dose q 24 hrs (concentration dependent, high dose compared to 4 mg/kg/dose normal) x 6 weeks Native valve staph endocarditis avoid which therapy NO GENTAMICIN or Aminoglycosides IVDU with UNCOMPLICATED RIGHT SiDED S. aureus IE only TWO WEEKS with nafcillin is ok uncomplicated = lack of Renal failure Extrapulmonary metastatic infections Aortic or mitral valve involvement Meningitis Infection with MRSA Double beta-lactam regimens are reasonable for Patients with creatinine clearance 50 mL/min Patients with IE caused by aminoglycoside-resistant enterococcal strains Double dosing regimen for enterococcus 2g IV every *12 hours* 12 g IV over 24 hours x6 weeks when picking IE therapy Types of valve Site organism Animal bite -cats and human tx ALWAYS augmentin (dog bites if s/s infection) Diabetic foot empiric tx by severity Sanford Guide PAGE 16 polymicrobial conditions sepsis diabetic neuorpathy DNA gyrase vs. DNA topoisomerase Gyrase = supercoling to fit, CRAMMING (cont. slowly) Topoisomerase = replication unraveling (fails if inhibted) Why are quinolones selective? humans lack dna gyrase we have topoisomerase II Most major SE of fluoroquinolones Athropathy- joint pain, swelling, and rupture, cartilage and collagen damage, can occur as quickly as 2-3 hours after 1st dose to 6 months after last dose. Do not use in 18 years old - FQ inhibit MMP9 Otitis media (little kids symptoms) *Otalgia* *Ear tugging* sudden fever- for smaller kids irritability When should you treat AOM? children 2 years old (utilize Sanford guide) High dose amoxcillion 80-90mg/kg/day divided Q8h to Q12h (no on Sanford guide) key take aaway sinusiti same bugs as otitis media AUGMENTIN same duration as otitis media Childresn = DOUBLE DAYS 14 days Adults = 7 days Treat everybody with... STREPT THROAT maybe watch and wait for sinusitis (not severe complications) What are drugs of choice for pharyngitis? FOR STREPT THROAT PEN VK ICU CAP Cetriaxone + fluoroquinolone (hospital = ceftriaxone + aithrmoaxin) which disease does NOT affect alveoli Acute Bronchitis URI when do you want to use ABX for Acute brioncitis more than a week elderly immunosuppressed febrile (else symptomatically) DOC for Actue brhonicitis macrolides doxycyline NOT fluroqunolines What drug classes are indicated to treat CB? SEE SANFORD GUIDE Beta-lactam 2nd or 3rd gen ceph tetracyclines- doxycyline (fluroquinolones) CAP positive culture for strep pneumo NOT EVER CAP CURB -65 is on what page Sanford guide PAGE 39!! CAP-Outpatient (walking pneumonia tx) Macrolides- Azithromycin HI DOSE 500 MG ***(not Z-pak like stanford guide)*** or doxycycline HCAP- ICU patient GUIDELINS sanford beta-lactam + fluroquinolone (ceftaroline + levofloxacin) Persons at higher risk for complications of flu - Children 2 years old - Persons aged 65 and older - Persons with chronic pulmonary or cardiovascular, renal, hepatic, neurologic, hematologic, or metabolic disorders - Persons who are immunocompromised - Women who are or will be pregnant during the influenza season - Residents of nursing homes and other long-term care facilities - Persons who are morbidly obese [BMI ≥ 40] - American Indians/Alaska Natives how long are healthy you infectious with the flu 48 to 72 hrs Which flu vaccine is no longer recommended Flumist. not good for h1n1 What age is indicated for flublok? 18 + Which inactivated vaccine is only for adults Afluria (Fluvirin is 4 yrs, Fluzone 6 months) New recommendation For children aged 6 months - 8 years old: Receive 2 doses of influenza vaccine administered at least 4 weeks apart during their first season of vaccination when should PEP for influenza be started within *48* hrs of infection/symptoms Who can get zanamivir? 5 years and older Influenza prophylaxis vs treatment dose treatment: BID and only 5 days (vs. 7 days) Hospital influenza tx differences increase dose to 150 mg can start within 4-5 days can extend to 10 days pregnant flu tx imunocompromised oral oseltamivir (C) Primary infection duration of shedding oral: 10-14 days genital: 2-4 weeks Recurrent infection duration of shedding Oral: 4 days Genital: 7-12 days 10 more recurrent genital herpes Valcyclovir 1 g for 1 year or longer 1 day herpes therapy Recurrent Valacyclovir 2g PO BID FOR 1 DAY Famciclovir 1500mg PO x1 dose FOR 1 DAY AE of IV acyclovir CRYSTALS IN renal tutubles - nephrotoxicity **PREHYDRATION** Topical antivirals for genital herpes?? NONONONONONONONONON Topical for Oral only Afraid of needles for influenza Afluria - needless injector Fluzone Intradermal Similarities between Giadiasis and amebiasis protozoa cysts and water transfer tinidazole or metronidazole diarrhea Amebiaasis is more severe Steps in the malaira life cycle 1. Plasmodium sprozite in mosquito saliva 2. Blood meal - inject sporozites 3. Sportozites treavel to LIVER - infect hepatocytes 4. Multiply - RUTURE THE HEPATOCYTE - encase in hepatocyte membrane (avoids immune system (merozoites) 5. Merozites then infects the RBC and eat the Hbg 6. Hbg is metabolized by psmalodium lyssome - toxin hemozin 7. Hemozin- ruture of RBC - plasodium detefcted by immune esystem (SYMPTOMS, fever, reaction!!!) Risk factors for Hep C Intravenous drug use (IVDU) Sexual transmission Baby boomer - Unsterile tattoos or piercings Intranasal illicit drug use Clotting factors before 1987 Needle sticks Vertical transmission Blood transfusions before 1992 Chronic hemodialysis Acute disease manifestations Hep C 0-24 weeks 30% clear naturally nondescript feverlike stuff Chronic disease Hep C 24 weeks - 50 years LFTs Coagulopathy Jaundice ascities Liver cirrohosis Hep C 10-40 years Viral replication Fibroscan Lab abnormalities LFTs Coagulation Albumin Bilirubin Compensated vs. decompensated Sustained virologic response (SVR**) definition No virus === cure Correlates with clearance of virus and cure Defined as *undetectable* viral load Checked *12 weeks following completion of therapy* (SVR12) Benefits of new HepC therapies High cure rate (90%) (vs 70% old) Tablet only formulations (vs. injections old) Low pill burden (vs. Ribavirin 6 tabs qd) Well tolerated NS3-4A Protease inhibitors -PRE-VIR Simeprevir (SMV) Paritaprevir Grazoprevir NS5B Polymerase Inhibitors -(B)U-VIR Sofosbuvir (SOF) Dasabuvir NS5A Inhibitors -(A)U-VIR Ledipasvir (LDV) Daclatasvir Ombitasvir Elbasvir Velpatasvir Harvoni (ledipasvir-sofosbuvir) 1 tablet once daily May be taken with or without food May cause headache, fatigue, insomnia, nausea (benign) Contact pharmacist or physician if need to use any form of *gastric acid suppressive therapy NO ** Zepatier (elbasvir-grazoprevir) 1 tablet once daily *Can be used in patients with chronic kidney disease (CKD) and End stage renal disease (ESRD)* only safe one May cause headache, fatigue, nausea, elevation of *liver enzyme (ALT)* already have it at baseline (3x) Epclusa (sofosbuvir-velpatasvir) *Pan-genotypic* 1QD Contact pharmacist or physician if need to use any form of *gastric acid suppressive therapy NO ** Viekira XR (Paritaprevir-Ritonavir-Ombitasvir-Dasabuvir) 3 tablets once daily *Potential for many drug-drug interactions due to ritonavir component* PROD Sovaldi (sofosbuvir) Used with simeprevir or daclatasvir 1QD Daklinza (daclatasvir) Dose adjustment: 30 mg daily if used with strong CYP-3A4 inhibitors 90 mg daily if used with CYP3A4 inducers Olysio (simeprevir) *must take with food* Advise patient to use sunscreen to protect against photosensitivity Genotypes 1A and 1B A is awful PROD 1A vs. 1B 1a = need ribavirin 1B = no ribavirin Avoid ribavirin at all costs due to Anemia (hbg drops) Shortness of breath Rash and pruritus Teratogenic Harvoni with which statin? NOT WITH CRESTOR PPI avoid which hepC drug? NOOTTT EPCLUSA PPI which drug ok Zepatir! HepC and amiodarone, which drugs Harvoni Epclusa anything with sobosofir Zepatir is safe to give with what HIV drugs? TDF/TAF NOTHING ELSE HIV PI HIV Stribild and NO HCV Harvoni (cobistat-harvoni) Zepatir Zepatir NO to which HIV drugs EFV (inducer of CYP) ETR Stribild Velpatasvir-sobovir NO to which HIV drugs EFV NS- ETF NS- NVP Hep B Manifestatiions take aways Acute = mailse, rash, anoexerica Kids for Chronic (asympomtamic) More likely to progress Facotrs to Treat or not treat Hep B, all need to be treated NOT ALL NEED TO BE TREATED When to treat Hep B basically Hi HBV DNA levels AND LFT levels High barrier vs. low barrier to resistance virus will mutate quickly for lamivudine (Lo-lamivuidine) everything else is high Hep B drug flares Withdrawal of tx can result in flare of hep B Entacavir Hep C tx points 1 daily Renally adjusted double dose if lamivudine experienced Adefovir experienced avoid which drug? Tenofavir TAF vs. TDF TAF TAKKE WITH FOOD Go to in lamivudine resistance for Hep B Adefovir clamidya is the---- most common STI in the US *CO-ifnected with gonnerrhea** greatest risk facor for STI # of sexual partners clamidya presentation ASYMPTOMATIC (just some discharge) men vs. women for gonnerhea Men- 90% symptomatic women- not really SG use for which STI's p. 24 (Clamidya Gonnhrea tx Rocephin IM or IV- generally well ++++ Azithromycin 1 g once Behavioral counseling clamidya/gonorrhea No sex for 7 days or until asymptomatic TELL YOUR PARTNERS in 60 days NeuoSyphillis happens WHENEVER, ANYTIME Bicillin inj SE Jarisch-hexheimer first 24 hrs (fever, headache, hurts) - give tylenol The mainstay of this therapy is penicillin. Syphillis For this STI, a pregnant women would be treated with Azithromycin 1 gm PO x1 clamidya Neurosyphyllis with allergy. Desensitivzation IV Penicillin G (18-24 million units) x14 days Stage that syphillis untreated 30%. tertiary altnerative regimen for pregnant patient with late latent syphillis densensitization. no alternative. single painless canker on the penis what stage of syphillis primary drug dose frequency for pregnant patient with secondary syphillis Benzathine penicillin G 2.4 million units IM x 1 dose may repeat one week later non-pregnant teritiary syphillis severe PEN allergy •Doxycycline 100 mg PO BID for 28 days + syphills, asymptomatic, last negative was 5 months ago early latent syphillis (1 yr ago) pregnant, late latent, penicillin (anaphlaxis) •Desensitization to penicillin Benzathine penicillin G 2.4 million units IM once weekly x 3 doses non-pregnant patient with primary syphillis Benzathine penicillin G 2.4 million units IM x 1 dose 1 week symptoms, maculopapular rash, flu, 6 weeks ago had sex secondary syphillis suspected gonorrhea itching to penicillin Ceftriaxone 250 IM x1 + Azithromycin 1g PO x1 Trich first line therapy flagyl 2 g po x1 tinadzole 2 g po x1 Why are mycobacterium hard to treat? grow so so SLOW and have HIGH FAT cell walls How to stain mycobacterium Ziehl-neelsen stain AFB = acid fast bacili Mycobacterium Defenses Cell wall impermeable to many agents due to high concentration of mycolic acid Bacteria located intracellularly in macrophages with acidic pH-anaerobic conditions slow replication High number of efflux pumps in cell membrane IGRA test in TB good for - Patients with difficulty following up (homeless) - * History of BCG vaccine* - Immunosuppression with impaired cellular - - immunity where is the mycolic aicd in mycobacterium cell membrane? NOPE the cell wall PZA: INH: EMB: cell cell cell cell membrane- PZA cell wall synthesis inhibitor- INH, glycolic acid EMB-- cell wall, arabinoglycan Which Hep C genotype is the most common Genotype 1 #1 risk factor for Hep C IV drug use When is majority of damage to the liver by Hep C occur 10-40 years out Liver cirrohsis stage 3% go to cancer T/F Most Hep C are symptomatic in the acute phase FALSE only 10% MOSTLY asymptomiatc Like HIV, HCV is chornic with no cure FALSE!!!! Goal is cure