BCPS QUESTIONS WITH COMPLETE SOLUTIONS

Patient Case RL is a 68 year old man Chief complaint: cough and shortness of breath HPI: Symptoms began 4 days ago and have worsened over the last 24 hours. He is coughing up yellowish-green sputum and complains of chills with a fever to 102.4°F PMH: CAD with an MI 5 years ago, CHF, hypertension and osteoarthritis. SH: rarely drinks alcohol; quit smoking; lives at home with wife Meds on admission: lisinopril 10mg daily, hydrochlorothiazide 25mg daily and acetaminophen 650mg QID. PE: alert and oriented - VS: Temp 101.8°F, HR 100, RR 32, BP 142/94. Labs: nl except BUN=32 mg/dl (Scr=1.23mg/dl). Chest x-ray: infiltrates in the right lower lobe. Sputum specimen is not available. Which is the best empiric therapy for RL? Ampicillin/sulbactam 1.5g IV q6h Piperacillin/tazobactam 4.5g IV q6h plus gentamicin 180mg IV q12h Ceftriaxone 1g IV q24h plus azithromycin 500mg IV daily Doxycycline 100mg IV q12h correct answer: Ceftriaxone 1g IV q24h plus azithromycin 500mg IV daily (CAP pt case) Patient factors NOT seen in CAP correct answer: -Hospitalization 2 or more days in past 90 days -Residence in long-term care facility -Received IV abx, chemotherapy, or wound care in last 30 days -Attendance at hospital or HD clinic CAP most common organisms correct answer: S. pneumoniae M. pneumoniae H. influenzae Community-acquired PNA - Outpatient Therapy Previously healthy / No antibiotics in 3 months correct answer: Macrolide (clarithromycin or azithromycin, especially if H. influenzae suspected) Doxycycline Community-acquired PNA - Outpatient Therapy Comorbidities / Antibiotics in 3 months correct answer: "Respiratory" Fluoroquinolone (levo- 750mg, moxi-, gemi-) Macrolide (or doxycycline) with high-dose amoxicillin (1g TID) or amoxicillin/clavulanate (2g BID) or cephalosporin (ceftriaxone, cefotaxime, cefpodoxime) Community-acquired PNA (Moderately severe) - Inpatient Therapy correct answer: Fluoroquinolone (levo- 750mg, moxi-, gemi-) Macrolide (or doxycycline) plus 3rd generation cephalosporin, ampicillin or [ertapenem] Corticosteroids (typically prednisone 20-50mg for 7 days) Benefit of corticosteroids in CAP inpatient therapy correct answer: Decreases need for mechanical ventilation, ARDS and hospital stay (by 1 day)