1.

Following the treatment of an oral abscess with clindamycin, a patient develops a greenish, foul-smelling watery diarrhea with left lower quadrant pain. Other signs and symptoms include fever, leukocytosis, and lethargy. If the toxin produced by Clostridium difficile is detected in the stool, the patient would most appropriately be treated with A. cisapride B. gentamicin C. loperamide D. metronidazole E. sulfasalazine The correct answer is D. Antibiotic-induced colitis (pseudomembranous colitis) is characterized by severe persistent greenish, foul-smelling diarrhea and severe abdominal cramps, as well as fever, leukocytosis, and lethargy. This condition is caused by the toxin produced by Clostridium difficile. This disorder is generally seen toward the end of clindamycin therapy; however, it may begin up to several weeks after discontinuation of therapy. The treatment of this form of colitis is to discontinue medication, provide fluid and electrolyte replacement, and give corticosteroids (systemic and/or via enema), as well as metronidazole or vancomycin. Metronidazole is the treatment of choice for treatment of antibiotic-induced colitis since it is less expensive than vancomycin and does not encourage the emergence of vancomycin-resistant bacteria. 2. A patient treated for months with large doses of broad spectrum antibiotics would be most likely to develop which of the following? A. Bleeding in joints B. Bony abnormalities C. Decreased night vision D. Neurologic deficits E. Scurvy Explanation: The correct answer is A. To answer this question you have to identify two pieces of information. First, you have to recognize that it is about vitamin deficiency acquired by antibiotic therapy (vitamin K is made by bacteria in the gut) and then recognize the deficiency syndrome that would be produced (bleeding tendency secondary to the inability to make clotting factors II, VII, IX, X, and proteins C and S). The other vitamin/syndrome associations are as follows: Vitamin D deficiency can lead to bony abnormalities (choice B). Vitamin A deficiency can result in decreased night vision (choice C). Vitamin B12 and thiamine deficiency can lead to neurological defects (choice D). Vitamin C deficiency can lead to scurvy (choice E). 3. An 86-year-old male complains of cough and blood in his sputum for the past two days. On admission, his temperature is 103 Degree F. Physical examination reveals rales in his right lung, and x-ray examination shows increased density in the right middle lobe. A sputum smear shows many Gram-positive cocci, confirmed by sputum culture as penicillinase-producing Staphylococcus aureus. Which of the following agents should be given? Or Rx for IV user w/vegetations on tricuspid valve (staph. Aureus) a. Ampicillin b. Oxacillin c. Carbenicillin d. Ticarcillin e. Vancomycin The answer is b. Unlike the other listed drugs, oxacillin is resistant to penicillinase. The other four agents are broadspectrum penicillins, while oxacillin is generally specific for Gram-positive microorganisms. Use of penicillinase-resistant penicillins should be reserved for infections caused by penicillinase-producing staphylococci. 4. A 30-year-old type I diabetic with renal complications develops acute pyelonephritis. P. aeruginosa is found in urine cultures and blood cultures. Combined therapy is instituted with an aminoglycoside and which of the following? a. Clavulanic acid b. Vancomycin c. A second-generation cephalosporin d. Azithromycin e. Piperacillin The answer is e. Piperacillin is effective against P. aeruginosa. The ease with which these organisms develop resistance with single-drug therapy has necessitated that combination with aminoglycosides be used in pseudomonal infections. 4. Clavulanic acid is important because it a. Easily penetrates Gram-negative microorganisms b. Is specific for Gram-positive microorganisms

c. Is a potent inhibitor of cell-wall transpeptidase d. Inactivates bacterial beta-lactamases e. Has a spectrum of activity similar to that of penicillin G The answer is d. The antibiotic clavulanic acid is a potent inhibitor of b-lactamases. The mode of inhibition is irreversible. Although clavulanic acid does not effectively inhibit the transpeptidase, it may be used in conjunction with a b-lactamasesensitive penicillin to potentiate its activity. 5.A 60-year-old male with a temperature of 104?F and a productive cough is diagnosed as having staphylococcal pneumonia. After several days on nafcillin, he develops truncal urticaria and pruritis. Which of the following agents is best avoided in this patient? a. Cefazolin b. Clarithromycin c. Sparfloxacin d. Clindamycin e. Tetracycline The answer is a. Cephalosporins and penicillins have similar structures (they have a b-lactam ring), penicillins having a penicillic acid and the cephalosporins a cephalosporinic acid moiety. Both groups of antimicrobials inhibit the transpeptidase enzyme necessary for cross-linking of the peptidylglycan layer necessary for cell-wall stabilization. It appears that the mechanism is not totally identical for every drug for every bacterial species. Cephalosporins have a greater overall activity against Gram-negative organisms than do the penicillin Gtype compounds. The hypersensitivity reactions associated with the penicillins and the cephalosporins appear to be identical in signs and symptoms. There is a crossover sensitivity between the penicillins and cephalosporins that must be considered when a patient is sensitive to either of these antibiotics. It occurs in about 5% to 10% of cases. 6. Which of the following cephalosporins would have increased activity against anaerobic bacteria such as Bacteroides fragilis? a. Cefaclor b. Cephalothin c. Cephalexin d. Cefuroxime e. Cefoxitin The answer is e. Cefoxitin and cefotetan are suitable for treating intraabdominal infections. Such infections are caused by mixtures of aerobic and anaerobic Gram-negative bacteria like B. fragilis. Cefoxitin alone has been shown to be as effective as the traditional therapy of clindamycin plus gentamicin. 7/ Cefoperazone being lipid soluble, has high plasma protein binding capacity thus the conc. inside brain is not clinically optimum but metabolizes in the liver. 1.A 57-year-old alcoholic is hospitalized in the intensive care unit after a multivehicle accident. Twenty hours after the accident, the patient develops a fever and a cough productive of purulent sputum. If a chest radiograph shows lobar consolidation and the sputum reveals the presence of gram-negative encapsulated rods, the most appropriate initial therapy would be A. cefotaxime (IV) B. erythromycin (IV) C. gentamicin (IV) + vancomycin (IV) D. ticarcillin-clavulanic acid (IV) + vancomycin (IV) E. trimethoprim-sulfamethoxazole (PO) Explanation: The correct answer is A. The patient is presenting with signs and symptoms of pneumonia. Since the patients signs and symptoms are appearing 20 hours after admission, his pneumonia is most likely a "community-acquired" pneumonia; one of the criteria for diagnosing a nosocomial infection is that the infection must not occur before 48 hours after admission. The appearance of plump gram-negative encapsulated rods in an alcoholic is highly suggestive of Klebsiella pneumonia. The most appropriate treatment of Klebsiella pneumonia in this patient is the administration of a third-generation cephalosporin, such as cefotaxime, ceftriaxone, or ceftazidime. Erythromycin (choice B) is a macrolide antibiotic used in the treatment of a variety of gram-negative and gram-positive infections. Although it is not the treatment of choice in this patient, it is the treatment of choice of Legionella pneumonia. Gentamicin (choice C) is an aminoglycoside antibiotic that is generally added to improve the efficacy of broad spectrum antibiotics, such as penicillin and cephalosporins, in the treatment of Pseudomonas and Enterococcus infections. Vancomycin (choices C and D) is an antibiotic used in the treatment of life-threatening infections caused by grampositive infections; the use of this agent in a gram-negative infection is inappropriate. Because of the severe nature of this infection, the use of an oral agent, such as trimethoprim-sulfamethoxazole (choice E), would be inappropriate. 8. A 20-year-old male has a urethral discharge. Culture of the discharge shows Neisseria gonorrhoeae. Which of the following agents is the best choice for treating this patient? a. Ceftriaxone b. Benzathine penicillin G c. Imipenen d. Amikacin

e. Sulfamethoxazole-trimethoprim Answer is A 3.In the treatment of bacterial meningitis in children, the drug of choice is a. Penicillin G b. Penicillin V c. Erythromycin d. Procaine penicillin e. Ceftriaxone The answer is e. Penicillins were used in the treatment of meningitis because of their ability to pass across an inflamed bloodbrain barrier. The third-generation cephalosporin, ceftriaxone, is preferred because it is effective against ?-lactamase producing strains of H. influenzae that may cause meningitis in children. 9.A 35-year-old male has recently converted to positive on a purified protein derivative of tuberculin (PPD) test for TB. INH is given as prophylaxis. What is the Mechanism of action of this drug? 10 patient being treated with a combination of drugs for pulmonary tuberculosis develops a decrease in visual acuity and red-green color blindness resulting from retrobulbar neuritis. Which of the following agents is responsible for these findings? INH Streptomycin Rifampin Pyrizinamide Ethambutol

10.A 29-year-old medical student developed a positive PPD (purified protein derivative) test. She was started on isoniazid (INH) and rifampin prophylaxis. Three months into her therapy, she began to experience muscle fasciculations and convulsions. Administration of which of the following vitamins might have prevented these symptoms? Niacin Pyridoxine Riboflavin Thiamine Vitamin C The answer is b. Isoniazid inhibits cell-wall synthesis in mycobacteria. Increasing vitamin B6 levels prevents complications associated with this inhibition, including peripheral neuritis, insomnia, restlessness, muscle twitching, urinary retention, convulsions, and psychosis, without affecting the antimycobacterial activity of INH.

11. A patient with tuberculosis develops bright orange-red urine and calls his physician in a panic because he is afraid he is bleeding into the urine. The patient has no other urinary tract symptoms. Which of the following medications is most likely to produce this side effect? Ethambutol Isoniazid Pyridoxine Rifampin Streptomycin The correct answer is D . In addition to discoloring urine, rifampin and its metabolites can discolor feces, saliva, sweat, and tears (and apparently can stain soft contact lenses). 12.A 19-year-old woman is diagnosed with tuberculosis (TB). Before prescribing a drug regimen, you take a careful medication history because one of the drugs commonly used to treat TB induces microsomal cytochrome P450 enzymes in the liver. Which drug is this? Isoniazid Rifampin Pyrazinamide Ethambutol Vitamin B6 The answer is b. Rifampin induces cytochrome P450 enzymes, which causes a significant increase in elimination of drugs, such as oral contraceptives, anticoagulants, ketoconazole, cyclosporine, and chloramphenicol. It also promotes urinary excretion of methadone, which may precipitate withdrawal.

13. Which of the following would be the most appropriate for tuberculosis prophylaxis, in order to minimize the risk of hepatotoxicity and drug-drug interactions, in a 51-year-old man on HIV antiretroviral medications? Clarithromycin Isoniazid Pyrazinamide Rifabutin Rifampin Answer: D Isoniazid should not be used in patients over 50 years 14. A 20-year-old male college student living in the dormitory has a close contact friend who developed a meningococcal infection. Which of the following medications is recommended for meningococcal prophylaxis in this patient? Amoxicillin Cefaclor Ceftriaxone Penicillin G Rifampin Answer: E Rifampin is used prophylactically against possible exposure to meningococci 15 .How cilastatin enhances effect of imipenem ? 16. .50-y-o man has a seizure after taking a drug for a -Lactamase resistant organism causing Sepsis ? 17. .A 39-year-old male with aortic insufficiency and a history of no drug allergies is given an intravenous dose of antibiotic as a prophylaxis preceding the insertion of a valve prosthesis. As the antibiotic is being infused, the patient becomes flushed over most of his body. What antibiotic was given? Or Treatment of S. aureas that is resistant to Methicillin a. Vancomycin b. Gentamicin c. Erythromycin d. Penicillin G e. Tetracycline The answer is a. The red man syndrome is associated with vancomycin, thought to be caused by histamine release. Prevention consists of a slower infusion rate and pretreatment with antihistamines.