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AntibioticAntifungalAntiviralSmall Group Activity

Objectives1. Recall antimicrobial therapy spectrums of activity, mechanisms of action, adverse effects, and nuances2. Collaborate with colleagues to discuss patient cases3. Apply antimicrobial concepts to patient cases

Break up into your assigned group and take 15-20 minutes to discuss the clinical vignette given to you. The assigned question number can be found on the last slide. Utilize any resources that you would like. Once the discussion time is up, have a designated speaker, present what answers you have, and provide an explanation for the answer to your vignette. The vignettes and answers will be posted after this session. Lastly, have fun with it! And please ask us any questions that you may have in the meantime. Looking forward to an exciting discussion!

1

A 23 year old female presents to the clinic with complaints of fever, cough, sputum production, and tachypnea. The patient has an anaphylactic reaction to penicillins from a couple years ago, a rash to fluoroquinolones, and shortness of breath to tetracyclines. What antibiotic should be used to treat her community-acquired pneumonia?

2

A 46 year old male develops a fever, cough, and leukocytosis five days into his hospitalization for an asthma exacerbation. He has a penicillin allergy which he further elaborates that he had a rash with amoxicillin five years ago. Procalcitonin is elevated, and a nasal MRSA PCR is ordered along with sputum cultures. His QTc is prolonged and he has sustained an acute kidney injury. He has received no other antibiotics in the recent months. He has no history of infections with multidrug resistant organisms. In addition to an antibiotic to treat MRSA, what would be the most appropriate antibiotic to add?

3

A 75 year old female is receiving ampicillin-sulbactam for treatment of aspiration pneumonia. She states that her grandson is a medical student and wants to know how the antibiotic works. How do you describe the mechanism of action to her?

4

During rounds, a patient is initiated on levofloxacin for treatment of community-acquired pneumonia requiring hospitalization. What is the mechanism of action and what are some serious side effects that could occur? What should be monitored while receiving a fluoroquinolone?

5

A 98 year old male is diagnosed with ventilator-associated pneumonia. He is started on vancomycin and meropenem for treatment. What is the mechanism of action of vancomycin and what should be monitored while he is on this antibiotic?

6

A patient experienced a vancomycin infusion reaction and refused to receive that antibiotic again. Given that this patient requires coverage for MRSA pneumonia, linezolid is suggested. How does linezolid work and what other classes of drugs should be used with caution with linezolid?

7

A 67 year old female with a past medical history significant for breast cancer, currently receiving chemotherapy with her last cycle approximately two weeks ago, diabetes, COPD, osteoporosis, and psoriasis comes in with complaints of sore throat, fever, muscle aches, cough, shortness of breath, and hypoxia with an O2 saturation of 89% on room air. The chest X-ray shows a pattern consistent with COVID-19, and the nasal PCR comes back positive for SARS-Cov-2. She is started on dexamethasone, but she requires additional therapy with a medication that inhibits the SARS-CoV-2 RNA-dependent RNA polymerase by acting as an adenosine triphosphate analog and competes for incorporation into RNA. Which medication needs to be added and what are the associated side effects?

8

A 56 year old male presents for a follow-up visit after initiating treatment for Pneumocystis jirovecii pneumonia. After a couple weeks of therapy, the patient states that he broke out into a rash and hives. He eventually reveals that he has a sulfa allergy. Which drug was he most likely started on and what is its mechanism of action?

9

A 35 year old male presents with a cystic fibrosis exacerbation. He is initiated on meropenem and linezolid for treatment. You are informed that the patient requires an additional anti-Pseudomonal antibiotic. The patient has QTc prolonged on EKG. What other antibiotic cannot be used? Instead what can be added? What is its mechanism of action? What are side effects of the drug and what needs to be monitored?

10

A 69 year old female presents with interstitial pneumonitis and will require a long steroid taper starting from prednisone 60 mg daily that will be slowly decreased by 5 mg per week. This patient also has a past medical history significant for Crohn’s disease, currently receiving infliximab. She has a sulfa allergy. She will require therapy for preventing Pneumocystis jirovecii infection until the prednisone dose is less than 20 mg per day, so she is started on dapsone. What is the mechanism of action and what should be screened for prior to initiation of therapy? What other side effects are there?

11

A 55 year old female presents with complaints of shortness or breath. She has a history of leukemia and is currently receiving chemotherapy. Hematology recommends that she is started on Pneumocystis jirovecii prophylaxis but has a sulfa allergy and G6PD deficiency. What alternative therapy can be used, how does it work, and what are some of its most common side effects?

16

A patient presented for management of pneumonia, but all the bacterial tests came back negative. However, the fungal tests come back positive for blastomycosis. She requires treatment with amphotericin B. What class of drug does this belong to? How does it work? And what are some possible issues to consider when a patient is receiving amphotericin B?

12

A 43 year old male patient presents with cough, sputum production, fever and complaints of erythema and purulent drainage from a laceration he sustained a couple days ago. He otherwise is stable. An antibiotic is to be initiated for community acquired pneumonia as well as purulent cellulitis. What antibiotic will have activity against both methicillin-resistant Staphylococcus aureus, Streptococcus pneumoniae, and atypical organisms? How does that antibiotic work and what are some adverse reactions associated with it?

17

A 59 year old presents for chemotherapy and requires a few prophylactic medications such as fluconazole. Typically fluconazole would be utilized to treat candidiasis but due to risk of prolonged neutropenia following chemotherapy, he will require prophylaxis with it. What is the mechanism of action of fluconazole? What are some of the major side effects? What special considerations are there?

13

A 58 year old female presents with complaints of chest pain on inspiration, fever, fatigue, cough, and shortness of breath. It is highly suspected that this patient has pneumonia, and a CT of the chest reveals a likely empyema. This patient has a history of throat closure to penicillins a few months ago and refuses to take metronidazole. What is an alternative therapy that will provide anaerobic coverage? How does it work and what are some of its side effects?

18

An 87 year old male with a past medical history of prostate cancer, hypertension, and chronic kidney disease presents following chemotherapy with fever, chills, rigors, cough, and neutropenia. He is initiated on broad spectrum antibiotics for 48 hours. Despite this, the patient remains febrile and neutropenic and blood cultures are growing fungus. It is recommended to start an echinocandin. What are some examples of echinocandins? How do they work and what are some adverse reactions?

14

A 67 year old male with a past medical history significant for diabetes, hypertension, renal transplant, and seizures comes to the clinic with complaints of runny nose, headache, cough, general aches and pains, and sore throat. A respiratory pathogen panel is completed since he had exposure to sick contacts recently, which comes back positive for SARS-CoV-2. He is otherwise on room air. What medication does he qualify for to manage his COVID-19? What is the mechanism of action and what is the biggest concern with this drug?

19

A 27 year old female presents with headache, confusion, stiff neck, nausea, photophobia, fever, cough, shortness of breath. Due to the history that the patient provides, a test for HIV is sent and comes back positive. Chest imaging reveals diffuse pulmonary infiltrates. Cultures are negative for bacteria, and serum cryptococcal antigen comes back positive. With concerns for possible neurological involvement, the patient is initiated on amphotericin and flucytosine. How does flucytosine work? What should you monitor while this patient is on flucytosine?

15

A 74 year old male with a past medical history significant for asthma, chronic kidney disease, hypertension, and cirrhosis is inquiring about receiving something for influenza prophylaxis since his wife has the flu. It has been approximately 24 hours since he was exposed, and he has not had the chance to get vaccinated yet this season. He is inquiring about oseltamivir. How does it work and what are some dosing considerations? What side effects can the patient expect with taking Tamiflu?