Peds ID Antibiotics Question of the Week

Bug Bytes are weekly antibiotic tidbits created by Melodie Miranda and reviewed with the Harbor-UCLA Pediatric Infectious Diseases Division

Information presented as part of the case vignettes / questions is for general education only, and is not meant to be used in clinical decision-making for an individual patient’s care.

Week 1         Week 2          Week 3         Week 4          Week 5         Week 6          Week 7

Week 8         Week 9          Week 10       Week 11       Week 12       Week 13       Week 14

Week 15      Week 16        Week 17       Week 18       Week 19       Week 20       Week 21

Peds ID Antibiotics Question of the Week ran from April – September 2017 and was provided by the Harbor-UCLA Pediatric Infectious Diseases Division as part of their Antibiotic Stewardship program. Answer choices are centered around infectious causes and will not address non-infectious causes in the differential diagnosis.

9/23/17 question of the week

3 year old female who is fully immunized with history of asthma and AOM ~1 year ago presents with right ear pain, cough and rhinorrhea x1 day.  Denies sore throat, fever, chills, N/V/D or dysuria.  PE: Right TM – erythematous, dull, mild effusion, no bulging. Left TM- clear. Lungs: + bilateral expiratory wheezing

For the AOM you should (choose all that apply):

a) Treat symptoms with analgesia

b) Give delayed RX to fill in 2 days if symptoms do not improve

c) Treat for AOM with amoxicillin 90mg/kg/day BID x7 days

d) Treat for AOM with augmentin 90mg/kg/day BID x7 days

e) Treat with single dose of ceftriaxone

For answer and discussion, click here

9/12/17 question of the week

13 y/o female comes in with nausea and vomiting with abdominal pain for 24hrs.  On exam she has suprapubic tenderness and right flank pain.  She is febrile to 38.5 and had mild tachycardia.  After a fluid bolus she improves.  She is given Zofran and a PO challenge and tolerates well.  Her UA comes back with WBC >182, RBC 10, + Nitrites, and mild ketones.  Gram stain was not done.   Patient appears well enough to go home with close follow up.

Appropriate initial antibiotic choices for this patient include (choose all that apply):

a) Ciprofloxacin 500mg PO BID x 7 days

b) Ceftriaxone 1gm IV/IM x 1 dose

c) Bactrim DS 1 tab PO BID x 7-14 days

d) Cephalexin 500mg PO TID x 7 days

e) Macrobid 100mg PO BID x 14 days

f) Fosfomycin 3gm qday x 7 days

For answer and discussion, click here

9/5/17 question of the week

20yo female with 3 day history of vaginal discharge and dysuria.  PMH significant for multiple episodes of pyelonephritis and UTIs (last treated 2 months ago at an urgent care), BV and chlamydia in 3/2017- she did not abstain from sex for one week after treatment as was recommended.  She denies fever, chills, n/v/d, abdominal pain, CVA tenderness or hematuria.

UA:  trace blood, 3+ leuks, (-) nitrites, 41 WBCs, 1 RBC, 1+ bacteria, 1 Sq cell

You should (select all that apply):

a) Treat with nitrofurantoin for 5 days for simple cystitis

b) Treat with Bactrim for 3 days for simple cystits

c) Screen for STIs

d) Treat empirically for gonorrhea/chlamydia

e) Give Rx to patient for partner treatment

f) Give a single dose of Ceftriaxone given her recent treatment

g) Give Ciprofloxacin for 3 days

h) Give cephalexin (Keflex) for 3 days

i) Give levofloxacin for 7 days for STI and complicated UTI

For answer and discussion, click here

8/29/17 question of the week

17 year old with hx of asthma presenting with 3 days of sore throat and fever.  She was seen in an urgent care yesterday, told she has strep throat and was given a “shot” (unknown name of medication), plus a prescription for cefdinir.  She did not fill the prescription.  Today she comes to the ED for persistent throat pain and fever and she noticed blisters on her gums.

PE:  3+ tonsils, bilateral exudates, no uvula deviation, no tripod positioning or drooling.  +swelling and 2 vesicular lesions to the left upper gum area.  + bilateral anterior cervical node swelling

You should:

a) Centor score 4/5 – reassure patient she has strep throat and recommend she complete the course of cefdinir

b) Centor score 4/5 – high likelihood of strep throat, give Rx for amoxicillin for 10 days

c) Test for strep, treat if positive only

d) Do not test for strep as she has been partially treated and the test will be difficult to interpret

e) This is likely coxsackie virus, recommend supportive care

f) Check for EBV

g) Give a shot of Bicillin (needs ID approval) as she is non-compliant and needs to be treated

For answer and discussion, click here

8/22/17 question of the week

You decide to admit a 2yo M with cellulitis of the right lower leg about 1cm below the knee.  Per the patient’s caregiver, the area of redness began this morning and rapidly progressed to near-circumferential involvement.  Patient has a fever and tachycardia.  The patient is in no acute distress and is playful. Prior to admission, which of the following would you order as the first dose of parenteral antimicrobial therapy (choose all that apply):

a) Vancomycin + piperacillin-tazobactam

b) Vancomycin

c) Vancomycin + cefazolin

d) Vancomycin + oxacillin

e) Clindamycin

f) Ceftriaxone + clindamycin

For answer and discussion, click here

8/15/17 question of the week

11 year old male returns to the ED with worsening sore throat, left neck swelling, and development of fever (38.6).  He was seen in the ED two days ago and diagnosed with reactive lymphadenopathy.

On physical exam: Neck:  (+) moderate swelling of left anterior cervical region with palpable mandibular angle, non-tender to palpation, no induration or fluctuance. Ears, nose, mouth and throat:  tympanic membranes clear, (+) bilateral tonsillar and posterior pharyngeal swelling with exudate, no uvular deviation, no drooling, normal phonation on exam.

You should (select all that apply):

a) Reassure parents that this is reactive lymphadenopathy

b) Treat with clindamycin for 10 days

c) Order Bartonella serology

d) Order EBV serology

e) Test for GAS

f) Order CBC, CMP and inflammatory markers

For answer and discussion, click here

8/7/17 question of the week

18 year old male with sickle cell disease presents with a 2 days history of productive cough (white sputum), runny nose and fever.  He states he is short of breath but denies chest pain.  No headache, abdominal pain, vomiting, diarrhea or any other symptoms.  No sick contacts.

VS:   T 38.4     HR 110     RR 20      BP 137/63     O2 sat: 95% on RA

WBC: 14.3       H/H: 7.9/22.8         Retic count: 608 (25.8%)       CXR: negative

You should (choose all that apply):

a) Reassure the patient he has a virus and recommend supportive care

b) Order a respiratory PCR panel (Biofire)

c) Treat for PNA with augmentin

d) Treat for PNA with azithromycin

e) Give a dose of ceftriaxone and dc home with azithromycin x5 days for CAP

f) Admit for further work up given Hgb and fevers

For answer and discussion, click here

7/31/17 question of the week

9 year old male presents with fever, sore throat and rash for 3 days.  He reports the itchy rash first appeared on his chest and spread to his axilla and groin area. Denies cough, rhinorrhea.

PE: maculopapular sandpaper rash to chest, axilla, groin

+ tonsillar swelling and exudate

Rapid strep test: positive

Which of the following is the preferred treatment (choose all that apply)?

a) Amoxicillin qday for 10 days

b) Augmentin BID  for 10 days

c) Penicillin VK BID for 10 days

d) Benzathine penicillin G IM x 1 dose

e) Azithromycin qday for 5 days

For answer and discussion, go here

7/24/17 question of the week

19 year old female presents with 2 day history of dysuria and LLQ abdominal pain that radiates to her left flank.  She also had some nausea, vomiting, chills and subjective fevers this morning.  She is sexually active and uses condoms regularly and has had chlamydia in the past. UA:  trace protein, 1+ blood, trace leukocytes, + nitrites, 16 WBCs, 3 RBCs, 3+ bacteria. She is discharged with Ciprofloxacin.

Patient returns 4 days later because of PO intolerance – reports she cannot keep down any food or drink and has vomited nearly every dose of antibiotics. You review her urine cx from 4 days ago and it grew >100,000 Staphylococcus intermedius.

Which of the following would you do next (choose all that apply):

a) Admit for IV antibiotics as she failed outpatient therapy

b) Prescribe zofran to be taken prior to each dose of antibiotics and discharge home

c) Repeat UA and culture

d) Order STI screening labs

e) Switch her antibiotics to nitrofurantoin

f) Ultrasound of kidneys

For answer and discussion, go here

7/10/17 question of the week

6 yo old previously healthy male presented with 4 days of ear pain and drainage.  One week prior he had fever, vomiting and diarrhea. Physical exam:  dull left tympanic membrane with air fluid levels, decreased hearing, mild protuberance of left ear, crusting and drainage in the ear canal.  He was sent home on Amoxicillin-Clavulanate 900mg BID and ciprofloxacin + dexamethasone otic drops. One day later, he returns to the ED because he cannot tolerate the PO abx.  A CT scan showed mastoid effusion.  You are admitting the child for IV antibiotics.

Which of the following antimicrobials would you start:

a) Unasyn

b) Levofloxaxin

c) Ceftriaxone

d) Zosyn

e) Cefepime

For answer and discussion, go here

7/3/17 question of the week

16 year old male presents to the ED with multiple small abscesses to his inner thighs.  He states “I’ve been getting these big pimples for the past few years.” Patient is afebrile, vital signs are WNL, physical exam is unremarkable except for two 3x2cm erythematous and indurated areas to his right inner thigh.

Which of the following should be done (choose all that apply):

a) Abscesses should be drained and cultured prior to starting antibiotics

b) Treat with keflex for 5-7 days

c) Treat with bactrim for 5-7 days

d) Treat with clindamycin for 5-7 days

e) Consider referral for decolonization regimen with chlorhexidine washes and intranasal mupirocin

f) Decolonization is not worth while as a large percentage will get recolonized

For answer and discussion, click here

6/26/17 question of the week

You are reviewing a urine culture that was done 3 days ago for a 17 y/o otherwise healthy female who came in with complaints of abdominal pain and some nausea.  She reports she is sexually active.  The resident documented some mild diffuse abdominal pain on exam and stated the patient likely has a UTI, but did not prescribe antibiotics. The UA shows 4 WBCs, trace leukocytes, and moderate bacteria and the culture now has grown >100K E.coli (R: amp, cefazolin and Nitrofurantoin, S; Cipro and TMP/SMX).

You should:

a) Call the patient and tell her she has a UTI and needs to pick up a prescription for TMP/SMX for 3 days

b) Call the patient and tell her this is likely a pyelonephritis and tell her she needs admission for IV antibiotics as she might have bacteremia

c) Call the patient and tell her she has pyelonephritis and prescribe ciprofloxacin for 7 days

d) Call the patient to see how she is doing and discuss with her that this is likely asymptomatic bacteriuria and it does not need treatment

e) Call ID for approval of fosfomycin and prescribe this for the patient’s cystitis

For answer and discussion, click here

6/19/17 question of the week

It is the middle of flu season, and a 3 year old female is brought in by mom for 3 days of fever, cough, congestion, decreased PO intake, emesis x 2. Her exam shows fever, mild tachypnea and tachycardia, but she has good urine output. On exam, she also has diminished breath sounds to bilateral bases, mild subcostal retractions. CXR shows bilateral infiltrates, worse in bases.   The child is being admitted, which anti-infective(s) should be initiated in the ED?

a) Ceftriaxone alone

b) Oseltamivir alone

c) Ampicillin alone

d) Ampicillin and azithromycin

e) Ampicillin and oseltamivir

f) Ampicillin, azithromycin and oseltamivir

g) Ceftriaxone and oseltamivir

h) Ceftriaxone, vancomycin, and oseltamivir

For answer and discussion, click here

6/12/17 question of the week

3 year old male with a “spider bite“ x2 days.  Mom states he has been scratching it and noted a small amount of blood yesterday. Today it is more red, swollen and painful.  Denies fever, chills.

Physical exam:  3cm x 4cm erythematous, edematous area to the dorsal aspect of the left arm.  There is a small punctate of dried/crusted blood.  It is mildly indurated, warm and tender to touch, no joint swelling or stiffness.

You should (choose all that apply):

a) Obtain blood cultures

b) Obtain wound cultures from I&D or aspiration

c) Treat with IV dose of clindamycin in ED, followed by oral regimen

d) Admit and start IV antibiotics

e) Send home with Rx for Bactrim or Clindamycin

f) Send home with Rx for Keflex plus Bactrim

g) Send home with Rx for Keflex

For answer and discussion, go here

6/5/17 question of the week

It is early January and you are seeing a previously healthy 3yo F who presents with fever, nasal congestion, cough, and decreased PO intake for 4 days.  The child is febrile.  On exam, there are copious, thick yellow nasal secretions and you note inspiratory crackles bilaterally.  Otherwise, exam is unremarkable.
The caregiver reports that there are multiple sick contacts at home with fever, runny nose, cough, and myalgias.  A chest XR demonstrates hazy bilateral infiltrates.

You decide to (choose all that apply):

a) Start amoxicillin/clavulanate

b) Prescribe oseltamivir

c) Administer a dose of ceftriaxone

d) Send Respiratory PCR Panel (Biofire) testing

e) Obtain a urinalysis and urine culture

f) Supportive care with close follow up

For answer and discussion, go here

5/29/17 question of the week

3 year old female is brought to the Peds ED by mom.  Mom states “she’s been sick for a month, her symptoms improve a little bit but then come back.”  Her PMD diagnosed her with a viral illness 1 week ago.  She has rhinorrhea, cough, subjective fever 2 weeks ago, and is tolerating PO’s. On exam, the patient has upper airway congestion, moderate nasal discharge, with an otherwise normal exam.  Mom is frustrated and insists on going home with antibiotics so “she can get better!” You would do the following (choose all that apply):

a) Order CBC

b) Blood cultures

c) Tell Mom the patient has sinusitis and treat with Augmentin for 10 days

d) Reassure mom that this is just a virus and recommend supportive care

e) Order a respiratory PCR panel (Biofire) and treat if with oseltamivir if positive for influenza

f) Tell Mom this is probably viral, and give her a delayed prescription for 10 days of amoxicillin in case it is sinusitis

For answer and discussion, go here

5/15/17 question of the week

9 year old female with no significant PMH presents with 12 day history of nasal congestion and discharge, cough and intermittent low grade fevers.  Parents feel that her symptoms have not improved.  On exam she has thick, yellow mucus, mild tenderness with palpation over maxillary sinuses.  You should (choose all that apply):

a) Tell mom she has a viral URI

b) Order a Respiratory PCR panel (Biofire), treat if positive for influenza or atypical bacterial pathogens

c) Obtain a CT scan of the sinuses

d) Obtain a plain film of sinuses

e) Treat the with 1gm of ceftriaxone IM

f) Treat with Amox/Clav for 10 days

g) Treat with Amoxicillin for 10 days

For answer and discussion, go here

5/8/17 question of the week

7 y/o boy comes in with mom who reports she has noticed a rash on his knee.  He fell about 2 weeks ago, and the wound did not heal because he picks at the scab.  Prior to his bath mom noticed multiple honey crusted lesions on his legs.

You should (choose all that apply):

a)Prescribe Mupirocin ointment apply to affected area for 5-10 days (or until resolved)

b)Prescribe Keflex as there are multiple lesions

c)Prescribe Clindamycin or Bactrim alone as Staph aureus is more likely the cause

d)No need for treatment as this will likely resolve without problems

e)Culture the wound so that appropriate antibiotics can be selected

For answer and discussion, go here

5/1/17 question of the week

An 18mo M presents with 3 days of URI symptoms, fever, and ear tugging.  On physical exam, you appreciate an erythematous, fluid-filled right tympanic membrane.  The patient has had one prior episode of OM at 9 mos of age, treated by the patient’s pediatrician.

The appropriate first-line antimicrobial therapy is:

a) Azithromycin for 5 days

b) Ceftriaxone single dose IM

c) Amoxicillin low dose for 10 days

d) Amoxicillin high dose for 10 days

e) Amoxicillin/clavulanate high dose for 10 days

f) Amoxicillin/clavulanate low dose for 10 days

For answer and discussion, go here

4/24/17 question of the week

14 y/o presents with sore throat and fevers. Exam with exudative pharyngitis, no lymphadenopathy.  Reports a lot of people sick at school.  Denies any cough, congestion or rhinorrhea.

You should (choose all that apply):

a) Do nothing and treat symptomatically

b) Perform rapid Influenza, if positive treat with Tamiflu

c) This is possibly strep pharyngitis, do a rapid Strep test and treat if positive

d) Centor Criteria suggest high probability, no need to test, treat for strep

e) Send Serology for EBV

f) Send a Monospot

For answer and discussion, go here

4/17/17 question of the week

A 17 year old male comes in with a 5 day history of URI symptoms and reports abdominal pain and fever of 101.4 today.  He was seen by his PMD two days ago and was told he had a virus. He is febrile with crackles in bilateral lower lung fields.  CXR with bilateral infiltrates.

You should (choose all that apply):

a) Order a respiratory PCR panel (Biofire)

b) Treat with Augmentin

c) Treat with Azithromycin

d) Treat with Levofloxacin

e) Treat with Amoxicillin and Azithromycin

f) Order a Pneumococcal urine antigen

For the answer and discussion, go here

4/10/17 question of the week

You are called by lab for a patient with a urine positive for ESBL E. coli, susceptible only to fosfomycin, amikacin and meropenem.  The colony count was 20,000 cfu/mL.  Reviewing the patient’s chart, you discover that the patient is an 22mo F with a history of febrile UTI when she was 12mo and that she presented to the ED 3 days ago with fever and minimal URI symptoms.  A urine dip on a bag specimen at that time demonstrated 2+ leukocyte esterase, positive nitrites.  There was not enough urine for microscopy.

You should:

a) Recommend that the patient return to provide a catheterized specimen for urinalysis

b) Discuss with parent and provide return precautions

c) Call in a prescription for a single dose of fosfomycin to the patient’s pharmacy, and recommend routine follow up with her Pediatrician in 2-3 days

d) Recommend that the patient return for IV antibiotics and admission to preform ultrasound

For the answer and discussion, go here