No, but I'm an evil bastard! Here, I'll just post it here:
For the next three questions, please refer to the following patient information. Choose the best answer to the question, and make sure to read the questions and information carefully before choosing your answer.
Mitsuru Kirijo is an eighteen year old female with a past medical history of schizophrenia and asthma. Her current medications are haloperidol 50 mg by mouth at bedtime, albuterol inhaler PRN, montelukast 10 mg at bedtime, and trazodone 50 mg at bedtime. She has an allergy to levofloxacin (which presents as shortness of breath and hives). She presents to the hospital secondary to a suicide attempt via haloperidol overdose. She developed neuroleptic malignant syndrome, was intubated, and now resides in the MICU (medical intensive care unit), where she has been for the past three weeks. She is maintained on normal saline (0.9% sodium chloride) and norepinephrine for blood pressure support, as well as propofol and fentanyl for sedation and pain control. She was catheterized one week ago secondary to incomplete voiding, and decreased urine output secondary to kidney injury. Recently, her urine has become cloudy, and when taken off her sedation, has complained of pain upon urination. Labs and other values drawn at this time are shown below:
Vitals: Temp 39.7 C, BP 70/56, P 102, Wt 50 kg, Ht 69"
Labs: Chem 7 is WNL except for an elevated SrCr (2.6)
Hematology: WNL except for WBC (23.9)
CBC with Diff: Neutrophils 78, Bands 20, otherwise WNL
UA: Cloudy, yellow, pH 6.0, SpGr 1.03, - bili, 2+ blood, + ketones, 3+ LE, + nitrite, 222 protein, + glucose, > 300 WBC, many bacteria, many WBC clumps
Diagnostic Tests: US shows an abscess with fluid collection in right kidney, blood and urine cultures show < 100,000 cfu of Gm- rods (identification pending), ECG shows an elongated QRS interval of 480 ms
1) The doctors diagnose Mitsuru with a complicated urinary tract infection compounded with urosepsis. They decide to treat her aggressively. Which of the following treatment algorithms would be inappropriate for this patient, based on the information you know?
a) Ciprofloxacin 400 mg IV Q12H
b) Nitrofurantoin 100 mg PO Q6H
c) Cefuroxime 750 mg IV Q8H
d) a & b above
e) b & c above
2) Three days into therapy, Mitsuru is still sick and showing no improvements clinically. The culture returns to show Pseudomonas aeruginosa. No sensitivity pattern is available - the micro lab was out having a party at Dave & Buster's instead. Based on the antibiogram for the hospital below, which of the following treatment options would provide adequate empiric coverage before the sensitivity profile is available?
Pseudomonas aeruginosa (2159 isolates)
Drug % susceptible
Piperacillin 65
Piperacillin/Tazobactam 76
Ceftazidime 44
Cefepime 79
Meropenem 86
Doripenem 90
Aztreonam 12
Tobramycin 88
Amikacin 90
a) Piperacillin/Tazobactam + Amikacin
b) Doripenem
c) Tobramycin + Cefepime
d) All of the above
e) None of the above
3) Mitsuru is successfully treated for fourteen days with a combination of meropenem and amikacin. She is extubated, her catheter is pulled, and the micro lab team brings her a pizza from Dave & Buster's to celebrate. She is eventually discharged a month later from a psychiatric hospital on 80 mg of fluoxetine to treat her depression and suicidality. However, two weeks after this, she is hit by a car and rehospitalized in the STICU (surgical/trauma intensive care unit). She is re-catheterized, and once again develops symptoms of a UTI similar to her previous admission one week after catheterization. She is being medically managed by a surgeon with little background in infectious diseases. What organisms would you suggest covering for in her for this admission?
I. Pseudomonas aeruginosa
II. E. coli
III. P. mirabilis
a) I only
b) I and III only
c) II and III only
d) II only
e) I, II, and III
