On post‐operative day six, he developed a fever to 102°F and a leukocytosis. A new right lobe infiltrate is seen on chest x‐ray, and he is diagnosed with ventilator‐associated pneumonia. Culture results are positive for Acinetobacter. What is the appropriate treatment?Piperacillin‐tazobactam and gentamicinVancomycinColistinMeropenemCiprofloxacinAcinetobacter is a gram‐negative bacilli that is a common cause of late‐onset VAP. Acinetobacter species are sensitive to carbapenems, ampicillin‐sulbactam, and colistin. Carbapenems and ampicillin‐sulbactam are preferred to colistin due to the risk of nephrotoxicity with colistin. Vancomycin is ineffective. Historically, ciprofloxacin has been effective in treating Acinetobacter, but the rate of ciprofloxacin‐resistant Acinetobacter infections has been reported as high as 67% in recent years and is thus no longer considered an effective empiric treatment. Gentamicin is a viable treatment option for an Acinetobacter infection; however, the addition of piperacillin‐tazobactam in choice A is unnecessary to treat this infection.Answer: DKalil AC, Metersky ML, Klompas M, et al. Management of adults with hospital‐acquired and ventilator‐associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016; 63(5):e61–e111. doi:10.1093/cid/ciw353Wood GC, Hanes SO, Croce MA, et al. Comparison of ampicillin‐sulbactam and imipenem‐cilastatin for the treatment of Acinetobacter ventilator‐associated pneumonia. Clin Infect Dis. 2002; 34(11):1425–1430. doi:10.1086/34005513 A 35‐year‐old man suffers a 50% total body surface area third‐degree burns after a house fire and has been in the burn ICU for the past 28 days. He has undergone multiple surgeries for his wounds and has been treated for a ventilator‐associated pneumonia and a central line infection. Overnight, he develops a fever to 103°F and increased tachycardia and hypotension. On the changing of his dressings in the morning, the wound care nurse notes a sweet smell and areas of his torso wound appear to have a blue‐green color. What is the appropriate treatment?Cefepime and ciprofloxacinPiperacillin‐tazobactamColistinVancomycinTobramycin and amikacinThis patient has an infected burn wound. Pseudomonas aeruginosa; the blue‐green color and sweet, grape smell are characteristic. This patient with his prolonged hospital stay and previously treated infections is at risk for multidrug‐resistant strains. Wound culture is important to obtain to determine susceptibility. For initial empiric therapy, while there is controversy in monotherapy versus combination therapy, combination therapy is used due to the high risk of drug resistance in Pseudomonas. In combination therapy, the goal is to use antibiotics with two different mechanisms of action (tobramycin and amikacin are both aminoglycosides and share the same mechanism of action, making this an inappropriate choice). Colistin, a polymyxin, should be preserved for serious infection with proven multidrug isolates. Vancomycin is not an appropriate choice since it does not cover Pseudomonas. While piperacillin‐tazobactam covers Pseudomonas, it is a single agent.Answer: ATraugott KA, Echevarria K, Maxwell P, et al. Monotherapy or combination therapy? The Pseudomonas aeruginosa conundrum. Pharmacotherapy. 2011; 31(6):598–608. doi:10.1592/phco.31.6.598Micek ST, Lloyd AE, Ritchie DJ, et al. Pseudomonas aeruginosa bloodstream infection: importance of appropriate initial antimicrobial treatment. Antimicrob Agents Chemother. 2005; 49(4):1306–1311. doi:10.1128/AAC.49.4.1306‐1311.2005Kang CI, Kim SH, Kim H Bin, et al. Pseudomonas aeruginosa bacteremia: risk factors for mortality and influence of delayed receipt of effective antimicrobial therapy on clinical outcome. Clin Infect Dis. 2003; 37(6):745–751. doi:10.1086/377200
14 A 47‐year‐old man with obesity and diabetes suffers a deep laceration to his left thigh while working on his farm. He presents one day after the injury with severe pain in his left thigh, spreading erythema, and bullae. Necrotic muscle is visible in the wound, and he has crepitus on exam. The patient is started on broad‐spectrum antibiotics and taken to the OR for debridement. Gram stains reveal a gram‐positive rod. What is the most appropriate antibiotic regimen?Vancomycin, piperacillin‐tazobactam, and clindamycinVancomycin and clindamycinPenicillin and clindamycinGentamycin and piperacillin‐tazobactamPenicillin and metronidazoleNecrotizing soft tissue infections (NSTIs) have high morbidity and mortality. The goal is prompt recognition, antibiotics, and surgical debridement. Initially, it is important to start the patient on broad‐spectrum antibiotics that include coverage for MRSA and anaerobes. Gram stains suggest infection with Clostridium species, which is a gram‐positive rod. For Clostridium myonecrosis, the Infectious Disease Society of America (IDSA) currently recommends starting penicillin and clindamycin. Treatment should continue for 10–14 days after source control. Choices A, B, and D do not include penicillin – the appropriate antibiotic for Clostridium. Choice E does not contain clindamycin, which helps prevent exotoxin release.Answer: CStevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014; 59(2):e10–e52. doi:10.1093/cid/ciu296Stevens DL, Bryant AE . Necrotizing soft‐tissue infections. Longo DL, ed. N Engl J Med. 2017; 377(23):2253–2265. doi:10.1056/NEJMra1600673
15 A 47‐year‐old woman who is eight months status post a deceased‐donor kidney transplant is admitted with nausea, vomiting, and watery diarrhea. She is tachycardic, afebrile, and normotensive with a leukopenia at 3 × 103/microL. Colon biopsies are positive for CMV. In addition to decreasing immunosuppression, which of the following should be started?Oral valganciclovirIV ganciclovirIV foscarnetOral ganciclovirOral oseltamivirCMV is a major cause of infection in solid‐organ transplant patients. The risk is highest in lung and small bowel transplant recipients. Biopsy is occasionally needed to confirm the presence of tissue‐invasive disease if nucleic acid testing is negative. CMV is treated by decreasing immunosuppressive medications and starting appropriate antiviral therapy. IV ganciclovir is the first line therapy for gastrointestinal CMV. Oral valganciclovir, while effective for CMV, will not be effectively absorbed in a patient with GI disease (Choice A). IV foscarnet is a second‐line therapy for treatment and is highly nephrotoxic (choice C). Oral ganciclovir and oseltamivir are not indicated in CMV infection. Oral ganciclovir should not be used for treating CMV disease as there is concern it may lead to emergence of ganciclovir resistance as its poor bioavailability leads to insufficient systemic levels. Oseltamivir is effective in treating influenza viruses, and there is no data to suggest that it would be an effective treatment for CMV infection.Answer: BRazonable RR, Humar A . Cytomegalovirus in solid organ transplantation. Am J Transplant. 2013; 13(SUPPL.4):93–106. doi:10.1111/ajt.12103Eid AJ, Arthurs SK, Deziel PJ, et al. Clinical predictors of relapse after treatment of primary gastrointestinal cytomegalovirus disease in solid organ transplant recipients. Am J Transplant. 2010; 10(1):157–161. doi:10.1111/j.1600‐6143.2009.02861.x
16 Which of the following practices is the least effective in reducing central line‐associated bloodstream infection (CLABSI)?Appropriate hand hygiene and skin preparationFollowing a checklist during line insertionDaily bathing of ICU patients with chlorhexidineRemoval of unnecessary linesChoosing the subclavian vein for a central line insertionCentral line‐associated bloodstream infection (CLABSI) is a frequent cause of hospital‐associated infection. A multimodal approach has been shown to be effective in decreasing CLABSI. Hand hygiene is the most important practice in reducing healthcare‐associated infections. Following a checklist during insertion ensures that steps, such as hand hygiene, skin preparation, and use of maximal sterile barrier precautions, should not be forgotten. The risk of developing a line infection increased with each day of use; reassessing their need daily helps remove a nidus for infection. The femoral site has the highest risk of infection followed by internal jugular and subclavian. Daily bathing of ICU patients with chlorhexidine did not demonstrate a reduction in CLABSIs, catheter‐associated urinary tract infections (CAUTIs), ventilator‐associated pneumonia,
