Board review course

Samar assem Badreddine, MDDr Soliman Fakeeh hopsital

June 2015

• A 29-year-old male bank employee is referred to youbecause of a reactive tuberculin skin test. The test was obtained as part of new-employee screening He is indian. He received bacille Calmette-Guerin vaccine but had no previous tuberculin skin test, and he denied any contact precautions with tuberculosis patients. He is asymptomatic. Examination is unremarkable. Chest radiography shows thickening of the left apical pleura with upper lobe scarring. You repeat the tuberculin skin test and observe a reaction with 12 mm of induration. You do which of the following?

a. Initiate therapy with isoniazid 300 mg daily for 9 monthsb. Initiate therapy with isoniazid 300 mg daily, rifampin 600 mg

daily, pyrazinamide 1500 mg and ethambutol 1,200 mg daily for 6 months

c. Arrange for annual repeat tuberculin skin testing and Advise screening all household contact precautionss of the patient for possible tuberculosis

d. Do not do anything since the positive tuberculin test is due to prior BCG vaccintion

e. Advise no intervention because the diameter of induration is less than 15 mm

• A 35-year-old Somali woman with diabetes presents with 4-weeks history of cough and fatigue. Her chest radiograph shows a fibronodular infiltrate in the right upper lobe with a small cavitary lesion. Sputum samples show the presence of acid-fast bacilli on smear. The patient is given a clinical diagnosis of pulmonary tuberculosis and while culture results are pending, therapy with isoniazid rifampin, pyrazinamide, and ethambutol is started.

• 2 weeks after starting the 4 anti TB medications , she started developing nausea and RUQ pain. You did liver function tests for her and found that she had elevated ALT and AST (3.5 times of upper normal) , and alkaline Phosphatase ( 4 times of upper normal)

• What the most likely offender drug?a. Rifampicinb. INHc. Pyrazinamided. Ethambutole. A,b,c,f. A,bg. A,c

• What would be the best next action?a. Keep all medications since enzymes elevation is less than

5 times upper normalb. Stop all medications except ethambutol, and replace the

discontinued ones with second line drugsc. Stop all medications except ethambutol , add Moxifloxacin

and streptomycin, re-introduce isoniazid and monitor ALT. if ALT does not rise again after introduction of INH, then continue on it.

d. Stop all medications except ethambutol , add Moxifloxacin and streptomycin and continue therapy on these

Introduction of isoniazid did not make ALT rise again, so you continued your patient on INH, ethambutol, quinolone and streptomycin. The duration of therapy is:

a. 6 monthsb. 9 monthsc. 12 monthsd. 18 months

• After 1.5 months of therapy, numbness and tingling involving both feet and lower legs develop, and these conditionslater become painful. What is the most likely cause of this patient's symptoms?

a. Isoniazidb. Rifampinc. Pyrazinamided. Ethambutol

• After the second month of therapy, the patient missed her menstrual period. She is married and is sexually active with her husband of 6 years. You order a pregnancy test, which is positive. A pregnancy test taken at the onset of her antituberculosis treatment was negative. She has been taking all her tuberculosis medications on a daily basis and the oral contraceptive ethinyl estradiol and norethindrone (Ortho-Novum 1/35). She reports no dietary changes and has not started taking any additional medications during the past month. Whichone of the following is the most likely cause of the failure of her oral contraceptive?

a. Isoniazidb. Rifampinc. Pyrazinamided. Ethambutole. Noncompliance with taking the birth control pills

• Answer b.

Rifampin induces hepatic microsomal cytochrome P 450-mediated enzyme activity, which can profoundly decrease the serum levels of other drugs metabolized by this pathway Rifampin interaction with more than 100 drugs, including oral contraceptive agents, has been described. Additionally, rifampin may alter intestinal flora that, in turn, alter the enterohepatic circulation of oral contraceptives. In the treatment of HTV and tuberculosis coinfection, rifampin will induce the metabolism of protease inhibitors, reducing their antiviral activity. Other side effects of rifampin include hepatotoxicity. Cytopenia (decreased leukocyte and platelet counts), orange discoloratio of body fluids, and hypersensitivity reactions.

27 year old Patient has 5 weeks history of cough, hemoptysis, night sweats and weight loss. Chest X-ray shows that patient has cavitary lesions in right upper lung. What tests are best to make a timely diagnosis: a. GenXpertbb. Sputum AFBc. Sputum for TB Cultured. Sputum for TB PCRe. a,b,cf. All of the above

• GenXpert TB result comes as follows:” MTB detected, Rifampicin resistance detected”. What would be the best treatment regimen:a. INH, Rif, pyrazinamide and ethambutolb. INH, pyrazinamide and ethambutolc. INH, pyrazinamide , Moxifloxacin and

ethambutold. Pyrazinamide, moxifloxacin, streptomycin and

ethambutol

• What transmission based precautions you must apply when dealing with this patient?a. Airborne precautionsb. standard and Airborne precautionsc. standard and droplet precautionsd. No need for precautions since the patient is

already started on therapy

• When to stop precautions?a. After 48 hours of starting therapyb. After 2weeks of starting therapyc. After 2 weeks of starting therapy AND patient

showing clinical improvement AND 3 samples of sputum are negative for AFB

d. After 2 months of starting therapy

47 year old patient, admitted to ICU because of acute anterior wall MI. 4 days after being in ICU, the patient started developing fever and chills. Physical exam is negative including exam of the insertion site of right Internal jugular vein that was inserted for him upon admission to ICU.Physician suspects Central line associated blood stream infection (CLABSI). What is the best way to make the diagnosis?

a. Since physical exam of insertion site is negative, then the possibility of CLABSI shall not be considered.

b. Draw Blood cultures both from central line and from peripheral veinsc. Remove central line and send tip for culture

• Blood culture came positive for MRSA. What is the best management approach?a. Start patient on Vancomycin, remove central line and

place the patient on contact precautions precautions.b. Start patient on Vancomycin, remove central line and

no need to place the patient on any precautions since line is removed.

c. Start patient on Vancomycin, Do NOT remove the central line and place the patient on contact precautions precautions.

CALBSI diagnosis is confirmed. What measures could have prevented this hospital acquired infection?

a. Use of Chlorhexidine for skin prep during insertion of central line

b. Apply Maximum barrier precautions during the insertion of the central line

c. The nurse shall “Scrub the hub” when accessing the IV port/ hub

d. All of the above

When do you stop the contact precautions precautions?

a. After obtaining 3 nasal swabs that are negative for MRSA

b. After the repeat blood culture becomes negativec. After removal of the line and completion of 14 days

of IV antibioticsd. Continue precautions as long as the patient is

hospitalized, and precautions shall be stopped upon discharge from the hospital

CAUTI

Patient is 79 years old, admitted for acute stroke. Developed fever on day 5 after admission. Had a foley catheter on 1st day of admission. No dysuria. Urine culture grew ESBL positive E.Coli. What precautions you will place the patient on?a. contact precautionsb. contact precautionsc. Droplet precautionsd. Airborne precautions

Duration of precautions

You will continue the patient in transmission based precautions until:

a. Patient received the full course of antibioticsb. Repeat urine culture shows no growthc. Continue on precautions as long as the patient is

admitted even if this is more than 1 month

This was confirmed as catheter associated UTI (CAUTI). What measures could have prevented this hospital acquired infection?

a. Not inserting a foley catheter unless clinically indicatedb. Removing the foley catheter as soon as clinically

indicatedc. Full aseptic techniques during insertion of foley catheterd. Keep foley catheter as closed system with dependent

drainagee. All of the above

A 20 years old women presents with 1 day history of fever, cough and shortness of breath. She lives in Jeddah. No contact precautions with camels. She has SLE and is on chronic steroids. Chest X-ray showed bilateral interstitial lung infiltrates. She received influenza vaccine at the beginning of the fall season. Wbc was 6.2, 78% segmented. The differential diagnosis includes which of the following:

a. Mers CoVb. Legionellac. Influenza virusd. Mycoplasma pneumoniae. PCPf. All of the above

What transmission based precautions you shall apply awaiting the final diagnostic results?

a. contact precautionsb. Droplet and standard precautionsc. contact precautions, droplet and standard

precautionsd. Airborne , and contact precautionse. No need for precautions before the result is back

Nasopharyngeal swab PCR comes positive for Mers CoV . What transmission based precautions you keep your patient on and for how long?

a. contact precautions, droplet and standard precautions until patient is asymptomatic

b. contact precautions, droplet ad standard precautions until repeat PCR is negative

c. a and b

Patient clinical condition deteriorated and he got intubated. 3days after being on the mechanical ventilation, he started spiking fever and developed right middle lung consolidation. Sputum culture grew MDR acinetobacter. Ventilator associated pneumonia was diagnosed. What measures could have prevented this hospital acquired infection ?

a. Keeping head of patient elevated to 45 degrees while on the ventilatorb. Giving peptic ulcer disease prophylaxisc. Giving DVT prophylaxisd. Giving patient some time of sedation vacation every daye. Doing daily mouthwash with chlorhexidinef. All of the above

Patient is 35 year old female, started 5 days ago on ciprofloxacin 500 mg Bid for UTI. Today presented to ER with bloody diarrhea and abdominal cramps. No fever. You suspect that this could be clostridium difficile colitis. What is the best way to confirm the diagnosis?

a. Stool for Toxin antigen detectionb. Stool for B toxin PCRc. a,and b

What precautions you have to put your patient on?a. contact precautions, and use alcohol based

antiseptics after finishing interaction with the patientb. contact precautions, and wash your hands with soap

and water after finishing interaction with the patientc. Contact and droplet precautions, and wash your

hands with soap and water after finishing interaction with the patient

Which of the following diagnoses does not mandate putting your patient on transmission based precautions.

a. Pneumococcal meningitisb. Tuberculous arthritisc. HIVd. Brucellosise. Dengue feverf. All of the above