Instruction: The following continuous assessment sheets contain two categories.

Category I: Simple short answer contain 10 questions

Category II: Case study contain 2 case scenarios

 Category I questions are designed for all students as individual assignment. But one
student expected to work only selected 5 question (you can select only 5 question)
 Category II questions are selected cases as your group assignment. Group member for
each assigned group doesn’t exceed 10. Each group must have mandatory to work all
case scenarios
NB: Try your best... Do your best... The best is right in you!
If u have any question u can forward. Thanks!

Category I. Short answer

1. Describe how antimicrobials differ from other drug classes in terms of their effects on
individual patients as well as on society as a whole.
2. Explain the cause of antimicrobial resistance in antimicrobial therapy.
3. Identify two guiding principles to consider when treating patients with antimicrobials,
and apply these principles in patient care.
4. Differentiate between microbial colonization and infection based on patient history,
physical examination, and laboratory and culture results.
5. Evaluate and apply at least six major drug-specific considerations when selecting
antimicrobial therapy.
6. Evaluate and apply at least seven major patient-specific considerations when selecting
antimicrobial therapy.
7. Identify two common causes of patients failing to improve while on antimicrobials, and
recognize other less common but potential reasons for antimicrobial failure.
8. Explain the difference between the following terms Normal flora and endogenous
infection
9. List out what organisms reside in the following respective anatomical site (skin, CNS,
Upper and lower respiratory tract, small and large intestine and urinary tract). In addition,
what anatomic sites are normally sterile?
10. What are the Considerations for Selecting Antimicrobial Regimens for treating infection
Category II: Case study

Case1.

HPI
A 72-year-old man with a history of congestive heart failure, diabetes, hypertension, and
hyperlipidemia presents to the local emergency room with complaints of increasing shortness of
breath, cough productive of yellow-green sputum, chest pain, fever, and malaise. He was
hospitalized 12 days ago for urosepsis, for which he received 10 days of levofloxacin.
PMH
• Congestive heart failure, diabetes mellitus × 22 years, hypertension, hyperlipidemia
• Chronic renal insufficiency: baseline SCr 1.8 mg/dL (137.3 µmol/L)
FH
• Father died of a myocardial infarction at age 75.
• Mother died of complications after cerebrovascular accident (CVA) at age 87.
SH
• Retired accountant
• Alcohol: 2 to 3 drinks per day
Meds
• Enalapril 10 mg bid
• Metoprolol XL 25 mg daily
• Furosemide 40 mg daily
• Insulin glargine (Lantus) 30 units SC qhs
• Glipizide 10 mg daily
• Atorvastatin 20 mg daily
• Aspirin 81 mg daily
• Home oxygen at 2 L/minute

1. What information in the history supports an infectious etiology?

2. Is this patient at risk for resistant pathogens? Why?

Patient History
• History of present illness
• Comorbidities
• Current medications
• Allergies
• Previous antibiotic exposure (May provide clues as to colonization or infection with new
specific pathogens or pathogens that may be resistant to certain antimicrobials)
• Previous hospitalization or health care utilization (Also a key determinant in selecting therapy
because the patient may be at risk for specific pathogens and/or resistant pathogens)
• Travel history
• Social history
• Pets/animal exposure
• Occupational exposure
• Environmental exposure
Physical Findings
• Findings consistent with an infectious etiology?
• Vital signs
• Body system abnormalities (e.g., rales, altered mental status, localized inflammation, erythema,
warmth, edema, pain, and pus)
Diagnostic Imaging
• Radiographs (x-rays)
• Computed tomographic (CT) scans
• Magnetic resonance imaging (MRI)
• Labeled leukocyte scans
Non-Microbiologic Laboratory Studies
• White blood cell count with differential
• Erythrocyte sedimentation rate
• C-reactive protein
Microbiologic Studies
• Gram stain
• Culture and susceptibility testing
ROS
Patient with malaise, wheezing, dyspnea, cough, chest pain, and chills. No reports of emesis or
diarrhea but with decreased appetite.
PE
• VS: BP 160/88, P 84, RR 28, T 39.1°C, O2sat 86%, Ht 6 ft, 0 in, Wt 80 kg
• HEENT: Dry mucous membranes
• Chest: Rales and rhonchi R greater than L; diminished breath sounds RML and RLL
• CV: Tachycardic with regular rhythm; normal heart sounds
Laboratory Data
• WBC 18,800/mm3, segs 80%, bands 10%, lymphs 10%
• SCr 2.5 mg/dL (190.8 µmol/L)
• Glucose 322 mg/dL (17.9 mmol/L)
• Sputum Gram stain: less than 10 epithelial cells, greater than 25 WBCs, predominance of gram-
negative bacilli
Chest X-Ray
Pulmonary infiltrate right middle and lower lobes of right lung
3. What findings on physical examination are suggestive of an infectious process?
4. What laboratory findings and/or diagnostic studies have been performed to help establish
the presence of an infection?
5. Are these laboratory and diagnostic studies suggestive of an infection?
6. What is your working diagnosis based on this patient encounter
Update
The patient was admitted to the hospital with a presumptive diagnosis of health care–associated
pneumonia (based on the recent hospitalization). He received intravenous hydration with normal
saline, 5 L oxygen via face mask, an insulin infusion to control his glucose, and empirical
antimicrobial therapy with piperacillin-tazobactam 2.25 g intravenously every 6 hours and
vancomycin 1 g intravenously every 24 hours. All other medications are continued with the
exception of the diabetes medications.
After 48 hours of therapy, the following parameters are obtained:
PE
• VS: BP 145/82, P 77, RR 22, T 37.9°C, O2sat 92% on 4 L
• Repeat chest x-ray: Increased fluid density in bases, infiltrate unchanged, rales and rhonchi
unchanged
Laboratory Data
• WBC 13,200 cells/mm3
• SCr 1.9 mg/dL (145 µmol/L)
• Glucose 181 mg/dL (10.0 mmol/L)
• Urine and blood cultures × 2: Negative
• Sputum culture: 3+ P. aeruginosa
Sensitivity Report
Cefepime Sensitive
Piperacillin/taz. Sensitive
Imipenem Resistant
Gentamicin Sensitive
Amikacin Sensitive
Ciprofloxacin Resistant

7. What information suggests improvement in the patient’s condition?

8. Do any of the antimicrobial doses need to be adjusted for changes in organ function?
9. Should antimicrobial therapy be modified based on the culture results?
10. Can the antimicrobial therapy be converted from intravenous to oral therapy?
Case2.
R.G., a 63-year-old, 70-kg man in the intensive care unit, underwent emergency resection of
his large bowel. He has been mechanically ventilated throughout his postoperative course. On
day 20 of his hospital stay, R.G. suddenly becomes confused; his blood pressure (BP) drops to
70/30 mm Hg, with a heart rate of 130 beats/minute. His extremities are cold to the touch, and he
presents with circumoral pallor. His temperature increases to 40°C (axillary), and his respiratory
rate is 24 breaths/minute. Copious amounts of yellow–green secretions are suctioned from his
endotracheal tube.
Physical examination reveals sinus tachycardia with no rubs or murmurs. Rhonchi with
decreased breath sounds are observed on auscultation. The abdomen is distended, and R.G.
complains of new abdominal pain. No bowel sounds can be heard, and the stool is guaiac
positive. Urine output from the Foley catheter has been 10 mL/hour for the past 2 hours.
Erythema is noted around the central venous catheter.
A chest radiograph demonstrates bilateral lower lobe infiltrates, and urinalysis reveals >50 white
blood cells/high-power field (WBC/HPF), few casts, and a specific gravity of 1.015. Blood,
endotracheal aspirate, and urine cultures are pending. Other laboratory values include the
following:
Sodium (Na), 131 mEq/L (normal, 135–147)
Potassium (K), 4.1 mEq/L (normal, 3.5–5)
Chloride (Cl), 110 mEq/L (normal, 95–105)
CO2, 16 mEq/L (normal, 20–29 mEq/L)
Blood urea nitrogen (BUN), 58 mg/dL (normal, 8–18)
Serum creatinine (SCr), 3.8 mg/dL (increased from 0.9 mg/dL at admission; normal, 0.6–1.2)
Glucose, 320 mg/dL (normal, 70–110)
Serum albumin, 2.1 g/dL (normal, 4–6)
Hemoglobin (Hgb), 10.3 g/dL (13.5–17.5 g/dL male patients)
Hematocrit (Hct), 33% (normal, 39%–49% [male patients])
WBC count, 15,600/μL (normal, 4,500–10,000/μL) with bands present
Platelets, 40,000/μL (normal, 130,000–400,000)
Prothrombin time (PT), 18 seconds (normal, 10–12)
Erythrocyte sedimentation rate (ESR), 65 mm/hour (normal, 0–20)
Procalcitonin, 1 mcg/L (normal <0.25mcg/L)

11. Which of R.G.’s signs and symptoms are consistent with infection?
R.G.’s medical history includes temporal arteritis and seizures chronically treated with corticosteroids and
phenytoin. Perioperative “stress doses” of hydrocortisone recently were administered because of his
surgical procedure.
12. What medications or disease states confuse the diagnosis of infection?
13. What are the most likely sources of R.G.’s infection?
14. What are the most likely pathogens associated with R.G.’s infection(s)?
In light of the positive culture for Serratia, his increased respiratory secretions, and a worsening chest
radiograph, ventilator-associated pneumonia is likely present. Pending susceptibility results, R.G. is
empirically started on imipenem and gentamicin. In review of his patient records, R.G. has no known
allergies.
15. Are there equally effective, less toxic options for this patient?
The Serratia was determined to be susceptible to ciprofloxacin. Oral ciprofloxacin was considered for the
treatment of R.G.’s presumed Serratia pneumonia, but the IV route was prescribed.
16. Why is the oral administration of ciprofloxacin reasonable (or unreasonable) in R.G.?
17. What dose of IV ciprofloxacin should be given to R.G.?
18. What factors must be taken into account in determining a proper antimicrobial dose?