12 A 71‐year‐old man with a history of poorly controlled diabetes presents to the ED for a foul‐smelling left lower extremity. He is found to be hypotensive and tachycardic with altered mental status. He is admitted to the ICU in septic shock and is awaiting the OR for amputation. CMS has core measures for septic shock and requires that the patient's volume status be reassessed within 6 hours of admission.Which of the following assessments qualifies for full reassessment?Straight leg raisePoint of care ultrasoundWedge pressureCentral venous pressureComprehensive physical examThe Centers for Medicare and Medicaid Services core measures require either a comprehensive physical examination or two other measures of volume status. The comprehensive physical examination must include either: focused examination documented by provider that includes vital signs (including blood pressure, pulse, respiratory rate, and temperature), cardiopulmonary examination (heart and lung), capillary refill evaluation, peripheral pulse evaluation, and skin examination; or two of the following: central venous pressure measurement, central venous oxygen measurement, bedside cardiovascular ultrasound, passive leg raise, or fluid challenge.Answer: EFord, H. Severe Sepsis and Septic Shock: Management Bundle. Centers for Medicare and Medicaid Services, 2020.ProCESS Investigators, Yealy DM, Kellum JA, et al. A randomized trial of protocol based care for early septic shock. N Engl J Med. 2014; 370(18):1683–1693.ARISE Investigators, ANZICS Clinical Trials Group, Peake SL, et al. Goal‐directed resuscitation for patients with early septic shock. N Engl J Med. 2014; 371(16):1496–1506.
13 A 63‐year‐old man with a past medical history of depression for which he takes citalopram is admitted to the ICU following a motor vehicle collision. He also has a history of anaphylaxis to cephalosporins and vancomycin. After 10 days in the ICU, he remains intubated and develops a fever to 39.9 °C. Laboratory analysis shows hemoglobin level of 7.3 g/dL, white blood cell count 1500/μL, and platelet count 40 000/μL. Blood cultures from peripheral blood and central venous catheters rapidly grow gram‐positive cocci in clusters. Rapid molecular assay identifies the organism in the blood as methicillin‐resistant Staphylococcus aureus. Sensitives are pending.After removal of the central venous catheter, the best antibiotic for this patient is?LinezolidPiperacillin/tazobactamMeropenemDaptomycinVancomycinDaptomycin and vancomycin are good options for MRSA bacteremia. However, with the patient's history of anaphylaxis to vancomycin (choice E), daptomycin is preferred. Linezolid is not FDA‐approved for Staphylococcus aureus bacteremia as no significant data exist. Adverse effects of Linezolid include worsening pancytopenia/thrombocytopenia (choice A). Linezolid can also interact with selective serotonin reuptake inhibitors (SSRIs) and other drugs that may increase serotonin levels. This patient is taking SSRIs (citalopram) and linezolid can predispose the patient to a higher risk of serotonin syndrome. If a strain of Staphylococcus is resistant to oxacillin or methicillin, it is resistant to all ß‐lactam antibiotics, including penicillins, cephalosporins, and carbapenems (choice B/C). Piperacillin/tazobactam, ampicillin/sulbactam, and meropenem do not have activity against MRSA. Also, with the patient's history of anaphylaxis secondary to cephalosporins, caution must be taken when administering penicillins or carbapenems.Answer: DThwaites GE, Edgeworth JD, Gkrania‐Klotsas E, et al. Clinical management of Staphylococcus aureus bacteraemia. Lancet Infect Dis. 2011; 11(3):208–222.Woytowish MR, Maynor LM . Clinical relevance of linezolid‐associated serotonin toxicity. Ann Pharmacother. 2013; 47(3):388–397.Kelkar PS, Li JT . Cephalosporin allergy. N Engl J Med. 2001; 345(11):804–809.
14 A 73‐year‐old man is admitted to the surgical ICU after ground level fall leading to a subdural hematoma. The patient's Glasgow coma score is 15. On admission, he required placement of a urinary catheter. Three days into hospitalization, although asymptomatic, he developed a fever which prompted a urinalysis and urine culture to be sent during his workup. The urinalysis demonstrates budding yeast and the culture grows 103 CFU Candida albicans.What is the next best step?Start fluconazoleStart micafunginObtain ophthalmology consultationRemove the urinary catheterFlush the foley Funguria is commonly seen in patients in the ICU. The most common pathogen is Candida species. Risk factors include an indwelling urinary catheter, immunosuppression, diabetes, TPN, and recent urologic procedures. In an asymptomatic patient, most candiduria is colonization and observation without antifungals is appropriate. This is confirmed by the urine culture demonstrating < 105 CFU. If a risk factor such as indwelling urinary catheter is present, the catheter should be removed or exchanged if still needed (Choice D). Persistent candiduria should prompt renal ultrasound or CT evaluation. Patients with candidemia should have an ophthalmologic evaluation to evaluate for endophthalmitis (choice C). Candida albicans is usually responsive to fluconazole (choice A), while other candida organisms such as glabrata should be treated with micafungin (choice B). Flushing the foley would not help with candiduria (choice E).Answer: DKauffman CA, Fisher JF, Sobel JD, Newman CA. Candida urinary tract infections‐‐diagnosis. Clin Infect Dis. 2011; 52 Suppl 6:S452–S456.Pappas PG, Kauffman CA, Andes D, et al. Clinical practice guidelines for the management of candidiasis: 2009 update by the Infectious Diseases Society of America Clin Infect Dis. 2009; 48:503–535.
15 A 59‐year‐old woman is admitted to the ICU after a sigmoid colectomy for perforated diverticulitis with end colostomy. On postoperative day 4, she is now having fever and chills. Two blood cultures are positive for vancomycin‐resistant Enterococcus faecium. She is started on IV daptomycin.Which of the following laboratory parameters should be monitored for daptomycin toxicity?Creatinine kinaseUric acidActivated partial thromboplastin timePlateletsAmylaseClinical trials for daptomycin showed decreased skeletal muscle activity and increases in creatinine kinase levels. Daptomycin is approved in dose range 4–6 mg/kg every 24 hours, in patients with a creatinine clearance greater than 30 mL/min. The Infectious Diseases Society of America (IDSA) has endorsed higher doses for bacteremia and endocarditis. It is recommended to monitor creatinine kinase levels once weekly while on therapy (choice A). Uric acid (choice B), Ptt (choice C), Platelets (choice D), and Amylase (choice E) are not affected by daptomycin.Answer: ABhavnani SM, Rubino CM, Ambrose PG, Drusano GL. Daptomycin exposure and the probability of elevations in the creatine phosphokinase level: data from a randomized trial of patients with bacteremia and endocarditis. Clin Infect Dis. 2010; 50(12):1568–1574.Arbeit RD, Maki D, Tally FP, et al. The safety and efficacy of daptomycin for the treatment of complicated skin and skin‐structure infections. Clin Infect Dis. 2004; 38(12):1673–1681.Liu C, Bayer A, Cosgrove SE, et al. Clinical practice guidelines by the infectious diseases society of america for the treatment of methicillin‐resistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011; 52(3):e18–e55.
16 Which of the following therapeutics has been found to help prevent Clostridium difficile‐associated diarrhea?Prophylactic metronidazoleVancomycin enemaEnteral nutritionProbioticsProton pump inhibitorsA recent Cochrane meta‐analysis and systematic review and meta‐analysis of 31 randomized controlled trials including 8672 patients, moderate certainty evidence suggests that probiotics are effective for preventing C. diff associated diarrhea. There is no evidence to suggest use of prophylactic oral, systemic or rectal antibiotic administration helps to prevent C. diff associated diarrhea. PPIs have been shown to be a risk factor for the development of C. diff.Answer: DGoldenberg JZ, Yap C, Lytvyn L, et al. Probiotics for the prevention of Clostridium difficile‐associated diarrhea in adults and children. Cochrane Database Syst Rev. 2017; 12:CD006095.
17 A 24‐year‐old woman was involved in an ATV accident in which she collided with a tractor on her farm. She was found to have an extensive right lower extremity open fracture with large soft tissue defect and degloving injury. She was taken to the OR with orthopedics for washout and placement of external fixation. On hospital day 7, her wound was found to be black and necrotic appearing. Culture was found to be growing Mucormycosis. In addition to emergent surgical debridements, which of the following therapeutics should be initiated?FluconazoleAmphotericin BCaspofunginVoriconazoleLiposomal amphotericin BInvasive fungal infections such as mucormycosis are a rare but serious complication of traumatic injury characterized by fungal angioinvasion and resultant vessel thrombosis and tissue necrosis. Risk factors for development in invasive fungal infections include large contaminated wounds from soil, gravel, and plant matter. Prompt recognition of the invasive infection is key although may be difficult to diagnose at first. Early treatment with aggressive surgical debridement and antifungals are key. The treatment of choice is Amphotericin B. Liposomal Amphotericin B has