BCPS EXAM QUESTIONS AND ANSWERS
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 - Answers :Ceftriaxone 1g IV q24h plus azithromycin
500mg IV daily
(CAP pt case)
Patient factors NOT seen in CAP - Answers :-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 - Answers :S. pneumoniae
M. pneumoniae
H. influenzae
Community-acquired PNA - Outpatient Therapy
Previously healthy / No antibiotics in 3 months - Answers :Macrolide (clarithromycin or
azithromycin, especially if H. influenzae suspected)
Doxycycline
Community-acquired PNA - Outpatient Therapy
Comorbidities / Antibiotics in 3 months - Answers :"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 - Answers
: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 - Answers :Decreases need for
mechanical ventilation, ARDS and
hospital stay (by 1 day)
Greater incidence of hyperglycemia requiring treatment
Community-acquired PNA (Severe) - Requiring ICU Therapy - Answers
:Ampicillin/sulbactam plus a respiratory fluoroquinolone or azithromycin
3rd generation cephalosporin plus a respiratory fluoroquinolone or azithromycin
May also need broader antibacterial activity
When to add on MRSA coverage for severe CAP - Answers :ICU admission
Necrotizing or cavitary infiltrates
Empyema
Predictors of more complicated CAP infection - Answers :-Age >65
-Co-morbidities (COPD, DM, CHF, ESRD)
-Temp >101F
-Bacteremia
-AMS
-Immunosuppression/CA
-High-risk etiology (Legionella, S. aureus, GNB, anaerobic aspiration)
-Multi-lobe involvement or pleural effusions
CAP duration - Answers :5-7 days
(Need to be afeb 48-72 hours with no more than 1 sign of clinical instability before
therapy d/c)
Patient Case
BP is a 66 year old woman
HPI: CABG x2 8 days ago; now on ventilator in ICU. She has a new infiltrate and is
spiking temperatures.
PMH: CAD with an MI 2 years ago, COPD, and hypertension.
All anti-pseudomonal antibiotics are active against at least 90% of strains
Which is the best empiric therapy for BP?
Ceftriaxone 1 g daily plus gentamicin 7mg/kg daily plus linezolid 600mg q12h
Piperacillin/tazobactam 4.5g IV every 6 hours
Levofloxacin 750 mg IV daily plus linezolid 600mg IV q12h
, Cefepime 2 g IV q8h plus tobramycin 7mg/kg IV daily plus vancomycin 15 mg/kg IV
q12h - Answers :Cefepime 2 g IV q8h plus tobramycin 7mg/kg IV daily plus vancomycin
15 mg/kg IV q12h
(HAP/VAP pt case)
HAP - Answers :PNA >48 hrs after hospitalization that was NOT incubating at time of
admission
VAP - Answers :PNA >48-72 hrs after intubation
HAP and VAP common pathogens - Answers :GNR + S. aureus
Risk factors for MDR organisms in HAP/VAP - Answers :IV antibiotic therapy within the
last 90 days (HAP or VAP)
Hospitalization > 5 days (VAP only)
Septic shock at time of VAP (VAP only)
ARDS preceding VAP (VAP only)
Acute renal replacement therapy prior to VAP (VAP only)
VAP treatment - Answers :Anti-Pseudomonal first agent
Beta-lactam ([ceftazidime], cefepime, imipenem, meropenem, piperacillin/tazobactam
or [aztreonam])
Anti-Pseudomonal second agent
If MDR risk factor or monotherapy resistance > 10%
Aminoglycoside or fluoroquinolone (cipro-, levo-),
colistin or aztreonam
MRSA active agent
If MDR risk factor or >10-20% of S. aureus is MRSA
Vancomycin or linezolid
HAP treatment - Answers :Anti-Pseudomonal first agent
Beta-lactam ([ceftazidime], cefepime, imipenem, meropenem, piperacillin/tazobactam
or [aztreonam])
Anti-Pseudomonal second agent
IV abx in 90 days, high mortality risk or culture risk
Aminoglycoside or fluoroquinolone (cipro-, levo-),
colistin or aztreonam
MRSA active agent
IV abx in 90 days or >10-20% of S. aureus is MRSA
Vancomycin or linezolid
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 - Answers :Ceftriaxone 1g IV q24h plus azithromycin
500mg IV daily
(CAP pt case)
Patient factors NOT seen in CAP - Answers :-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 - Answers :S. pneumoniae
M. pneumoniae
H. influenzae
Community-acquired PNA - Outpatient Therapy
Previously healthy / No antibiotics in 3 months - Answers :Macrolide (clarithromycin or
azithromycin, especially if H. influenzae suspected)
Doxycycline
Community-acquired PNA - Outpatient Therapy
Comorbidities / Antibiotics in 3 months - Answers :"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 - Answers
: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 - Answers :Decreases need for
mechanical ventilation, ARDS and
hospital stay (by 1 day)
Greater incidence of hyperglycemia requiring treatment
Community-acquired PNA (Severe) - Requiring ICU Therapy - Answers
:Ampicillin/sulbactam plus a respiratory fluoroquinolone or azithromycin
3rd generation cephalosporin plus a respiratory fluoroquinolone or azithromycin
May also need broader antibacterial activity
When to add on MRSA coverage for severe CAP - Answers :ICU admission
Necrotizing or cavitary infiltrates
Empyema
Predictors of more complicated CAP infection - Answers :-Age >65
-Co-morbidities (COPD, DM, CHF, ESRD)
-Temp >101F
-Bacteremia
-AMS
-Immunosuppression/CA
-High-risk etiology (Legionella, S. aureus, GNB, anaerobic aspiration)
-Multi-lobe involvement or pleural effusions
CAP duration - Answers :5-7 days
(Need to be afeb 48-72 hours with no more than 1 sign of clinical instability before
therapy d/c)
Patient Case
BP is a 66 year old woman
HPI: CABG x2 8 days ago; now on ventilator in ICU. She has a new infiltrate and is
spiking temperatures.
PMH: CAD with an MI 2 years ago, COPD, and hypertension.
All anti-pseudomonal antibiotics are active against at least 90% of strains
Which is the best empiric therapy for BP?
Ceftriaxone 1 g daily plus gentamicin 7mg/kg daily plus linezolid 600mg q12h
Piperacillin/tazobactam 4.5g IV every 6 hours
Levofloxacin 750 mg IV daily plus linezolid 600mg IV q12h
, Cefepime 2 g IV q8h plus tobramycin 7mg/kg IV daily plus vancomycin 15 mg/kg IV
q12h - Answers :Cefepime 2 g IV q8h plus tobramycin 7mg/kg IV daily plus vancomycin
15 mg/kg IV q12h
(HAP/VAP pt case)
HAP - Answers :PNA >48 hrs after hospitalization that was NOT incubating at time of
admission
VAP - Answers :PNA >48-72 hrs after intubation
HAP and VAP common pathogens - Answers :GNR + S. aureus
Risk factors for MDR organisms in HAP/VAP - Answers :IV antibiotic therapy within the
last 90 days (HAP or VAP)
Hospitalization > 5 days (VAP only)
Septic shock at time of VAP (VAP only)
ARDS preceding VAP (VAP only)
Acute renal replacement therapy prior to VAP (VAP only)
VAP treatment - Answers :Anti-Pseudomonal first agent
Beta-lactam ([ceftazidime], cefepime, imipenem, meropenem, piperacillin/tazobactam
or [aztreonam])
Anti-Pseudomonal second agent
If MDR risk factor or monotherapy resistance > 10%
Aminoglycoside or fluoroquinolone (cipro-, levo-),
colistin or aztreonam
MRSA active agent
If MDR risk factor or >10-20% of S. aureus is MRSA
Vancomycin or linezolid
HAP treatment - Answers :Anti-Pseudomonal first agent
Beta-lactam ([ceftazidime], cefepime, imipenem, meropenem, piperacillin/tazobactam
or [aztreonam])
Anti-Pseudomonal second agent
IV abx in 90 days, high mortality risk or culture risk
Aminoglycoside or fluoroquinolone (cipro-, levo-),
colistin or aztreonam
MRSA active agent
IV abx in 90 days or >10-20% of S. aureus is MRSA
Vancomycin or linezolid
