• A 65-year-old man came to the emergency department via ambulance

after a generalized seizure.

•Relatives accompanied the patient and described a 1-day history of fever
and intermittent confusion.The patient had a 10-year history of chronic
lymphocytic leukemia; 2 months ago, he had a trial of oral chlorambucil
because of progressive fatigue, anemia, thrombocytopenia, and
splenomegaly.Then, 3 weeks ago, the patient attended a family reunion at
a cousin’s dairy farm. He enjoyed eating homemade soft cheese, sausage,
and fresh vegetables from the garden. Several family members who
attended the reunion reported transient febrile gastroenteritis.
•The patient’s physical examination in the emergency department
revealed a stuporous man with temperature 103.3°F (39.6°C), blood
pressure 122/68 mm Hg, pulse 112 beats per minute, and respirations 26
per minute. He had nuchal rigidity, diffuse adenopathy, and
hepatosplenomegaly. Passive flexion of the neck caused flexion at hips
and knees (Brudzinski’s sign). The patient resisted passive extension of
the flexed knee and hip (Kernig’s sign). Papilledema was absent. There
were no focal neurological deficits. Skin examination revealed no
eruption.
1
• Peripheral blood tests showed 36,000 leukocytes (66% ymphocytes),
hemoglobin 9.0 g/dL, platelet count 99,000. A lumbar puncture was
performed. The opening pressure of cerebrospinal fluid was 220 mm
of water. Cerebrospinal fluid tests revealed no organisms on Gram
stain, glucose 60 mg/dL, protein 200 mg/dL, lactate 50 mg/dL,
leukocytes 2000 per mm3 (10% neutrophils, 60% lymphocytes, 30%
monocytes). Bacterial antigen tests on cerebrospinal fluid were
negative for H. influenzae type B, S. pneumoniae, Neisseria
meningitidis, E. coli K1, and group B streptococci. What is the best
empirical antibiotic therapy for this patient?

1
• The emergency department physician suspected acute bacterial
meningitis in a patient with impaired immunity secondary to
hematologic malignancy. The physician also noted the exposure to
a food-borne pathogen associated with dairy products. The
epidemiological risk assessment suggested the need for empirical
antibiotic therapy to cover potential gram-negative enteric
pathogens and L. monocytogenes.
• Immediately after obtaining blood and spinal fluid specimens, the
emergency department personnel initiated therapy with ampicillin 2
g intravenously every 4 hours and ceftazidime 2 g intravenously
every 8 hours.
• On the next day, the clinical microbiology laboratory reported
diphtheroids growing in the patient’s blood culture bottles. On the
second hospital day, the laboratory identified L. monocytogenes
growing in blood and spinal fluid specimens. Ceftazidime was
discontinued. The patient completed a 21-day course of ampicillin
and gentamicin 1.7 mg/kg intravenously every 8 hours.

1
•A 28-year-old white man was on vacation for 2 weeks in
northern Minnesota in July. He was fishing and hiking in the
forest for a number of days. He was healthy, with no known
underlying disease or illness. Approximately 3 weeks after
returning from his vacation, a red macule–papule developed
on his right anterior thigh. Increasing redness developed
around the initial site. The central area of this lesion showed
some clearing. Several other similar lesions developed on his
right leg and trunk. The patient did not note any arthropod
bites. Which of the following antimicrobials would be the
drug of choice for this patient?

(A) Chloramphenicol
(B) Cephalexin
(C) Doxycycline
(D)Gentamicin
(E) Ampicillin

2
C. The primary stage of Lyme disease is readily
treatable with oral antibiotics. Doxycycline is considered
to have the best activity against Lyme disease, so it the
drug of choice for treatment in adults unless there is a
history of allergy or intolerance to doxycycline.

2
•A urine culture in an asymptomatic female patient with an
indwelling Foley catheter comes back with more than 50,000
colonies of enterococci. The urinalysis is unremarkable. The
best course of action would be to

(A) Start IV vancomycin to cover enterococci

(B) Seek linezolid for possibility of vancomycin-resistant
enterococci (VRE)
(C) Initiate a quinolone like levofloxacin with broad-spectrum
coverage for UTIs
(D) Discontinue use of the Foley catheter if possible and obtain
follow-up cultures if she develops symptoms
(E) Watchful waiting

3
D. It is not unusual to get colonized by hospital flora,
especially with an indwelling Foley catheter. If the patient
does not have any clinical evidence of infection, it is not
necessary to start therapy with vancomycin or for that matter,
any antibiotic. Enterococcal UTI can still be treated with
penicillins, but they are increasingly resistant to penicillins
and even vancomycin. Since susceptibility data are still
pending, neither vancomycin nor linezolid is yet indicated.
Levofloxacin, although a good drug for UTIs, does not have
enterococcal coverage. Discontinuation of the Foley catheter
if possible and follow-up appear to be the best option.
Watchful waiting may not be effective because these patients
may go on to develop complicated UTIs.

3
A 43-year-old man presents to the emergency department with
fever, cough, and shortness of breath. He has no chronic
medical illnesses. He was in his usual state of health until 2
days ago, when he developed fatigue and anorexia. During the
previous night, he developed fever of 103° F (39.4° C), a
shaking chill, and copious, thick sputum production. He
denies having nausea, emesis, diarrhea, or rash or having come
into contact with anyone who was sick. He has smoked one
pack of cigarettes a day for the past 25 years. On physical
examination, the patient’s temperature is found to be 102.4° F
(39.1° C). Rales are heard in the left posterior midlung field,
with associated egophony and increased palpable fremitus.
Chest x-ray reveals consolidation of the left lower lobe. Sputum
Gram stain reveals gram-positive diplococci. The patient’s
white blood cell count is 25,000/mm3, with a marked left shift.

4
Which of the following statements regarding pneumococcal
pneumonia is true?
❑ A. Pneumococcal pneumonia accounts for up to 90% of community
acquired pneumonias
❑ B. Pneumococcal pneumonia typically causes significant tissue
necrosis, resulting in prominent fibrosis
❑ C. In patients with pneumococcal pneumonia, a bronchopneumonic
pattern is radiographically more common than lobar consolidation
❑ D. This patient’s fever and marked leukocytosis reflect an
unfavorable host response to his infection

4
The classic physical and radiographic findings of lobar consolidation may be
absent in patients with pneumococcal pneumonia. In fact, a
bronchopneumonic pattern is radiographically more common than lobar
consolidation. Dehydration may minimize pulmonary findings, and
underlying chronic lung disease may predispose to patchy areas of
pulmonary infiltration. The pneumococcus accounts for up to 40% of
community acquired pneumonias, causing or contributing to 40,000 deaths
annually. Because pneumococci only rarely produce significant tissue
necrosis, healing is usually complete and residual fibrosis is minimal.
Interestingly, a lack of febrile response and a normal or low white blood cell
count are readily measurable factors that are associated with worse outcome.
Thus, although white blood cell counts of 25,000 to 30,000/mm3 with a left
shift may be alarming, they indicate a favorable host response to infection.
(Answer: C—In patients with pneumococcal pneumonia, a
bronchopneumonic pattern is radiographically more common than lobar
consolidation)

4
A 47-year-old woman is in the hospital waiting to undergo a gastric bypass
procedure. A central venous line is placed in the subclavian position for
vascular access. Her procedure is completed without complication. On the
fifth day after her procedure, she develops a fever of 103.5° F (39.7° C). On
physical examination, the patient’s postoperative wounds are normal. Her
lung fields are clear to auscultation, and she denies having any abdominal
pain, dysuria, or cough. Urinalysis is negative for pyuria. Sputum Gram stain
reveals normal flora. Blood cultures grow gram-positive cocci in clusters.

5
Which of the following statements regarding Staphylococcus aureus
bacteremia is true?
❑ A. In recent years, community-acquired methicillin-resistant S.
aureus (MRSA) infections have decreased in prevalence throughout the
United States.
❑ B. Patients with community-acquired S. aureus bacteremias are
more likely to have endocarditis and secondary metastatic infections
than patients with nosocomial infections
❑ C. All patients with S. aureus bacteremia should be treated for a
minimum of 7 days with parenteral intravenous antibiotic therapy
❑ D. When compared with monotherapy, combination antibiotic
therapy reduces long-term mortality in patients with S. aureus
bacteremia and endocarditis

5
Patients with community-acquired bacteremias are more likely to have
endocarditis and secondary metastatic infections than patients with
nosocomial infections, who are more likely to have an evident portal of
entry and severe underlying diseases. In recent years, community-
acquired MRSA infections have increased in prevalence in many
regions of the United States, Japan, and Southeast Asia. Controlled
trials are necessary to determine the safety and efficacy of short-term
therapy for staphylococcal bacteremia.
It may therefore be prudent to treat patients with staphylococcal
bacteremia as though they have endocarditis. I.V. antibiotic therapy
should, in any case, be continued for at least 10 to 15 days. Because of
the high mortality associated with staphylococcal bacteremia and
endocarditis, combination therapies utilizing nafcillin or vancomicin
with gentamycin or rifampin are being studied. Thus far, combination
therapy appears to reduce the duration of bacteremia but not to change
the long-term mortality.
(Answer: B—Patients with community-acquired S. aureus bacteremias
are more likely to have endocarditis and secondary metastatic infections
than patients with nosocomial infections)
5
A 64-year-old man with long-standing diabetes mellitus presents to the
emergency department for evaluation of shortness of breath. He was in his
usual state of health until 2 days ago, when he developed cough with green
sputum, dyspnea on exertion, and a fever of 102 F (38.9 C). He denies having
been in contact with persons who were sick. He has no history of cigarette
smoking or cardiac or pulmonary illnesses. The patient has never been
vaccinated for pneumonia. On physical examination, the patient is
tachycardic, is tachypneic, and has rales in the left midlung zone with
associated egophony and increased fremitus. Laboratory studies reveal
leukocytosis with a left shift. A chest x-ray reveals left lower lobe pneumonia.
For this patient, which of the following statements regarding penicillin and
cephalosporin therapy is false?
A. Like the penicillins, the cephalosporins are bactericidal antibiotics
B. Third-generation cephalosporins are active against most penicillin
nonsusceptible pneumococci
C. In treating an infection with penicillin-resistant Streptococcus
pneumoniae, adding a β-lactamase inhibitor to a regimen of penicillin will
augment antibiotic killing
D. Cefepime has activity against aerobic gram-positive bacteria, methicillin-
susceptible Staphylococcus aureus, and gram-negative bacteria,
including Pseudomonas 6
Like the penicillins, the cephalosporins are bactericidal antibiotics that
inhibit bacterial cell wall synthesis and have a low intrinsic toxicity.
Although third-generation agents are less active against many gram-
positive cocci than the older cephalosporins, they are active against
most penicillin-nonsusceptible pneumococci. Penicillin-resistant strains
of S. pneumoniae have altered penicillin-binding proteins and are not
affected by the addition of a β-lactamase inhibitor. Cefepime is a
fourth-generation cephalosporin with broad antimicrobial activity
against both aerobic gram-positive bacteria (e.g., penicillin-
nonsusceptible S. pneumoniae) and methicillin-susceptible S. aureus; it
is also effective against gram-negative bacteria, including Haemophilus
influenzae, Neisseria, and Enterobacteriaceae. Its activity against
Pseudomonas is similar to that of ceftazidime.

(Answer: C—In treating an infection with penicillin-resistant

Streptococcus pneumoniae, adding a β-lactamase inhibitor to a regimen
of penicillin will augment antibiotic killing)

6
A 41-year-old woman is admitted to the hospital for evaluation of fever
and abdominal pain. She was well until 2 days ago, when she developed
dysuria and right flank pain. She denies having cough, dyspnea, nausea,
emesis, or diarrhea. She has not traveled recently, and she is
monogamous with her husband of 15 years. On physical examination,
moderate tenderness to palpation is noted over the bladder, and
costovertebral angle tenderness is noted on the right. The rest of the
examination is unremarkable. Laboratory studies reveal leukocytosis
and pyuria. A CT scan of her abdomen and pelvis is consistent with
pyelonephritis without evidence of nephrolithiasis or obstructive
uropathy. The patient is started on intravenous hydration and a
fluoroquinolone antibiotic.
Which of the following statements regarding fluoroquinolones is false?
A. The fluoroquinolones are bactericidal compounds that inhibit DNA
synthesis and introduce double-strand DNA breaks by targeting DNA
gyrase and topoisomerase IV
B. Ciprofloxacin is the drug of choice for Bacillus anthracis
C. The newer fluoroquinolones are preferred for the treatment of
community-acquired pneumonia
D. The bioavailability of the fluoroquinolones is greatly augmented
when given intravenously 7
The fluoroquinolones are bactericidal compounds that inhibit
DNA synthesis and introduce double-strand DNA breaks by
targeting DNA gyrase and topoisomerase IV. Ciprofloxacin is the
drug of choice for B. anthracis, though other fluoroquinolones
are also active in vitro. Because the newer quinolones bind
equally to DNA gyrase and topoisomerase IV and because they
have enhanced pharmacokinetic and pharmacodynamic
parameters for S. pneumoniae, it has been argued that they are
the preferred quinolones for community-acquired pneumonia.
The fluoroquinolones are rapidly absorbed from the
gastrointestinal tract and have nearly 100% bioavailability.
D. The bioavailability of the fluoroquinolones is greatly
augmented when given intravenously

7
The fluoroquinolones are among the most important of the newer antibiotics,
largely because of their spectrum of activity, ease of administration, and
favorable safety profile. With their increasing popularity and widespread use
have come growing concerns about the emergence of bacterial resistance, and
it is recommended that clinicians use such broad-spectrum antimicrobials
judiciously.

Which of the following statements regarding fluoroquinolones is false?

A. In addition to having activity against enteric gram-negative organisms and
intracellular organisms such as Chlamydia, ciprofloxacin and levofloxacin
provide reasonable coverage against anaerobes
B. The fluoroquinolones have been noted to cause arthropathy in young
animals and are therefore generally not used in patients who are younger than
18 years or are pregnant
C. Ciprofloxacin is the agent of choice for treating Bacillus anthracis (anthrax)
D. The fluoroquinolones are absorbed rapidly through the GI tract; The
bioavailability achieved through oral administration generally approaches that
of parenteral administration
E. The fluoroquinolones are bactericidal agents that work by inhibiting DNA
gyrase
8
The fluoroquinolones are among the most widely prescribed antimicrobials.
These drugs have a broad spectrum of activity and rapidly kill bacteria by
impairing DNA synthesis. High serum and tissue levels are achieved by
intravenous and oral administration, and relatively long serum half-lives allow
for once- and twice-daily dosing regimens. Given their good activity against
both gram-positive organisms such as S. Pneumoniae and aerobic gram-
negative organisms, fluoroquinolones are among the firstline drugs used to
treat community-acquired pneumonia and UTIs. The recent outbreaks of B.
anthracis have demonstrated the efficacy of ciprofloxacin in the treatment
and prevention of disease, and this agent is considered first-line therapy.
Fluoroquinolones are generally not given to children or pregnant women
because of studies in animals that suggest that these drugs induce
arthropathy. In adults, the development of tendinitis (and even Achilles
tendon rupture) is a well-described (but relatively rare) complication. Other
than trovafloxacin, the use of which has been severely limited after reports of
hepatotoxicity, the fluoroquinolones generally do not have sufficient activity
against anaerobic organisms (e.g., Bacteroides species) to warrant their use
when an anaerobic infection is suspected.
(Answer: A—In addition to having activity against enteric gram-negative
organisms and intracellular organisms such as Chlamydia, ciprofloxacin and
levofloxacin provide reasonable coverage against anaerobes)
8
A 50-year-old man with type 2 diabetes, hypertension, and peripheral vascular
disease is admitted to the hospital 2 days after injuring his right leg. While
mowing the grass, he was struck in the calf by a rock,
which resulted in a deep puncture wound. On the day of admission, he noted
the rather abrupt onset of pain in the area of the wound, followed by the
development of localized edema and the discharge of a thin, bloody fluid.
On examination, he appears ill. His vital signs are as follows: temperature,
100.4° F (38° C); heart rate, 112 beats/min; blood pressure, 102/44 mm Hg;
respiratory rate, 18 breaths/min. The right leg appears markedly swollen in
the area around the wound; the skin of the lower leg is pale and cool, and
there is slight crepitus over the calf muscle. Radiographs of the leg reveal
gas formation in the surrounding soft tissue.
Which of the following statements is false regarding this patient's condition?
A. Gram stain of wound exudate is likely to demonstrate large gram positive
rods and a paucity of inflammatory cells
B. The most appropriate initial antibiotic therapy consists of intravenous
clindamycin and high-dose penicillin G
C. Urgent surgical debridement is indicated, and amputation may be
necessary
D. Initial treatment should be guided by the results of anaerobic culture
E. With adequate treatment, the mortality is 10% to 25%
9
Clostridial myonecrosis (gas gangrene, clostridial myositis) is a rapidly progressive but
relatively rare infection that occurs in deep necrotic wounds. Infection is usually
caused by C. perfringens. It often occurs after trauma. It can also occur in the setting
of necrotic bowel; after surgery involving the biliary tract; and in association with
vascular insufficiency, as in this patient. The incubation period is short, usually
ranging from 1 to 3 days. After inoculation of a wound with spores (which are
ubiquitous in the environment), replicative organisms are generated. These organisms
elaborate several toxins, including α-toxin. α-Toxin lyses myofibrils and allows for rapid
invasion and destruction of surrounding healthy tissue. Typical features of severe
infection include pain and swelling at the wound site, pallor, tachycardia, and
diaphoresis. Progression to hypotension, acute renal failure, shock, and death occur in
the absence of definitive treatment. Radiographs often reveal gas formation, for which
the infection receives its common name. Gram stain may demonstrate the pathogenic
Clostridia species and mixed anaerobic flora; a typical finding is the absence of a
prominent inflammatory response. If meticulously collected, anaerobic cultures will
often grow C. perfringens, but given the rapid clinical course, these cultures serve no
useful purpose in guiding initial therapy. Prompt surgical debridement of necrotic
tissue is the mainstay of therapy. Adjuvant antibiotic therapy with high-dose penicillin
G has been routinely recommended; studies have demonstrated that combination
therapy with clindamycin appears superior to penicillin alone. Despite adequate
medical and surgical management, there remains significant morbidity and mortality
associated with clostridial myonecrosis. (Answer: D—Initial treatment should be
guided by the results of anaerobic culture)
9
You are treating a 75-year-old woman for severe community-acquired
pneumonia with ceftriaxone and azithromycin. By hospital day 6, she
has improved markedly with respect to her pulmonary status but
has developed frequent watery diarrhea with cramping abdominal
pain. You suspect C. difficile colitis, and stool toxin tests confirm
this.

Which of the following is the most cost-effective initial treatment for

this patient's condition?
A. I.V. vancomycin
B. Oral vancomycin
C. I.V. metronidazole
D. Oral metronidazole
E. Oral bacitracin

10
Metronidazole and vancomycin are equally effective as initial
therapy for C. difficile colitis. Metronidazole is considerably less
expensive, however, and the oral route is preferable over the I.V.
route when the patient can tolerate oral therapy. Bacitracin is as
effective as vancomycin and metronidazole in treating the
symptoms of C. difficile colitis but is not as effective as these two
agents in eradicating the organism. (Answer: D—Oral
metronidazole)

10
Escherichia coli is a facultative anaerobe that colonizes the human
intestine. At least six pathotypes have been identified that can cause
diarrhea, urinary tract infections (UTIs), and nosocomial illness.

Which of the following does NOT contribute to the pathogenicity of

the various E. coli strains?
A. Production of Shiga toxin
B. Direct binding of enterocytes and destruction of microvilli
C. Production of catalase
D. Production of coagulase
E. Production of heat-labile enterotoxins

11
Several distinct pathotypes of E. coli are known to induce a wide range
of disease. Among the common virulence factors shared by all
pathotypes of E. coli is the catalase enzyme, which helps protect the
organism from host respiratory burst defenses by reducing hydrogen
peroxide to water and oxygen. The enterotoxigenic pathotypes of E. coli
also produce heat-labile and heat-stable enterotoxins that bind to
intestinal cells and cause the efflux of chloride, sodium, and water into
the intestinal lumen, resulting in diarrhea. The enterohemorrhagic
pathotypes (among which serotype O157:H7 is the most important)
cause diarrhea by binding to the apical surface of enterocytes, which
results in destruction of microvilli (described histologically as the
attaching and effacing effect). In addition, these enterohemorrhagic
strains share with Shigella the ability to release Shiga toxin, which
induces cell death and is responsible for the serious systemic
complications of infection with these strains, including hemolytic-
uremic syndrome (HUS). Coagulase production is not a significant
means of pathogenesis for E. coli. (Answer: D—Production of
coagulase)
11
A 68-year-old man presents to the emergency department with productive
cough, shortness of breath, dizziness, and fever. His symptoms began 2
days ago and have been worsening. On presentation, the patient is febrile,
hypoxic, tachycardic, and mildly confused. Chest x-ray shows an infiltrate
in the left lower lobe. Gram stain of sputum is performed.

Which of the following statements is true regarding the cause of this

patient's pneumonia?
A. Pseudomonas aeruginosa, Legionella pneumophila, Haemophilus
influenzae, and Moraxella (Branhamella) catarrhalis generally are readily
apparent on sputum Gram stain as gram-negative rods
B. The apparent severity of the patient's illness suggests that M.
catarrhalis is not the etiologic agent
C. A third-generation cephalosporin would cover all important potential
gram-negative pathogens
D. H. influenzae pneumonia in adults is now rare because an effective
vaccine is available
E. The development of an empyema would be uncharacteristic of a
gram-negative pathogen
12
P. aeruginosa is generally well visualized on Gram stain of sputum as a gram-negative
rod. Legionella organisms are poorly seen on routine Gram stain, but visualization of
these small, pleomorphic gram-negative bacilli is improved if basic fuchsin is used as
the counterstain in place of safranin O. H. influenzae is often visible on Gram stain,
but the morphology of the organism is often misleading: plump gram-negative rods,
filamentous organisms, gram-negative diplococci, and under-decolorized gram-
positive cocci have been described. M. catarrhalis is a gram-negative diplococcus that
is morphologically indistinguishable from Neisseria species. This patient's signs and
symptoms are not consistent with the usual presentation of pneumonia caused by M.
catarrhalis. Pneumonia caused by M. catarrhalis occurs most often in the elderly,
particularly those with underlying chronic obstructive pulmonary disease. The clinical
features are those of a mild, acute pneumonia. A third-generation cephalosporin would
cover M. catarrhalis and H. influenzae but would not cover Legionella. H. influenzae is
the second or third most common cause of community-acquired pneumonia in adults.
Most of the isolates in these cases are nontypeable strains not affected by the vaccine
active against the type b capsular polysaccharide. Suppurative complications such as
empyema can certainly be seen in pneumonia caused by H. influenzae, but empyema
is rare in pneumonia caused by L. pneumophila and M. catarrhalis. (Answer: B—The
apparent severity of the patient's illness suggests that M. catarrhalis is not the etiologic
agent)

12
A patient who is currently neutropenic after induction of chemotherapy for
acute myeloid leukemia becomes hypotensive and is transferred to the
intensive care unit. He is given broad-spectrum antibiotics and shows initial
improvement, but 36 hours later he becomes tachypneic and hypoxic and
requires intubation and mechanical ventilation. By this time, blood cultures
have grown Pseudomonas aeruginosa, and a chest x-ray shows multifocal
infiltrates.
Which of the following statements correctly characterizes the complications
of nosocomial P. Aeruginosa infection?
A. Ecthyma gangrenosum, the characteristic skin lesion of Pseudomonas
bacteremia, initially manifests as painful nodules and then undergoes central
ulceration
B. Sputum obtained from the endotracheal tube that grows Pseudomonas
confirms the diagnosis of a ventilator-associated pneumonia
C. Right lower quadrant abdominal pain in this patient would be characteristic
of typhlitis
D. Initial therapy of suspected pseudomonal bacteremia or pneumonia
should be monotherapy with high doses of an antipseudomonal β-lactam
E. Pseudomonal bacteremia commonly results in infective endocarditis

13
Pseudomonas infection is associated with significant morbidity and high
mortality in patients requiring intensive care. Ecthyma gangrenosum is a
distinctive skin infection that occurs in the setting of bacteremia. The lesions
may be discrete or multiple; They begin as painless macules or nodules and
may become bullous. Lesions undergo central necrosis over a period of 12 to 24
hours; surrounding the lesion is a rim of tender erythema. Pseudomonas and
other pathogens commonly colonize the trachea in intubated patients without
causing pneumonia. The diagnosis of P. aeruginosa pneumonia is most
accurately made from quantitative cultures of bronchoscopic specimens.
Whether bronchoscopy actually affects outcome is unclear. Typhlitis refers to
localized gangrenous necrosis of the cecum that causes pain in the right lower
quadrant. It is associated with neutropenia as well as Pseudomonas infection.
Treatment of suspected P. aeruginosa infection should begin with high doses of
an antipseudomonal β-lactam in combination with an aminoglycoside or
fluoroquinolone. The use of two agents increases the likelihood of effective
initial therapy. P. aeruginosa is a rare cause of infective endocarditis. Most
reported cases have occurred in injection drug users; Episodes have been
known to complicate cardiac surgery. Hemodynamic decompensation in a
bacteremic patient should always provoke consideration of infective
endocarditis as the underlying cause.
(Answer: C—Right lower quadrant abdominal pain in this patient would be
characteristic of typhlitis 13
A 21-year-old woman presents with a complaint of sore throat. She was in
her usual state of health until 3 days ago, when she developed a
nonproductive cough, nasal drainage, ear pain, and a sore throat. She
denies having shortness of breath, sputum production, fever, rash, joint
pains, or astrointestinal symptoms. She also denies having been in contact
with sick persons. For the past 2 years, she has been in a sexual relationship
with a single sexual partner. On physical examination, the patient is found
to have erythema of the posterior pharynx and nasal turbinates. Small,
bilateral, serous, middle-ear fluid collections are noted. Lung examination
is normal. The patient is afebrile. She requests antibiotics, stating that she
always improves much more quickly with this therapy.
Which of the following statements regarding pharyngitis is true?
A. Group A streptococci are the most common cause of pharyngitis
B. Four clinical criteria have been proposed as suggestive of group A
streptococcal pharyngitis: tonsillar exudates, tender anterior
adenopathy, absence of cough, and history of fever
C. Office-based rapid diagnostic tests for group A streptococcal pharyngitis
have a sensitivity of nearly 100%
D. Pneumococci and staphylococci are emerging causes of pharyngitis

14
The following four clinical criteria have been proposed as suggestive of
group A streptococcal pharyngitis: tonsillar exudates, tender anterior
adenopathy, absence of cough, and history of fever. Group A streptococci are
the most therapeutically important cause of pharyngitis, although in terms
of frequency, they cause as few as 5% of the cases of pharyngitis. Throat
cultures remain the standard method for identifying group A streptococci in
the pharynx. In addition, rapid diagnostic tests suitable for office use are
available. These procedures entail the extraction of streptococcal antigens
from throat swabs and the rapid identification of the antigens through
immunologic tests such as latex agglutination or enzyme-linked
immunosorbent assay. The sensitivity of these tests ranges from 77% to 95%;
specificity ranges from 86% to 100%. Many other bacterial species can be
cultured from the pharynges of both symptomatic and asymptomatic
patients, but they almost never cause pharyngitis.
(Answer: B—Four clinical criteria have been proposed as suggestive of group
A streptococcal pharyngitis: tonsillar exudates, tender anterior adenopathy,
absence of cough, and history of fever)

14
A 45-year-old woman comes to your clinic complaining of fever,
purulent nasal discharge, and left facial and upper molar pain of 3 days'
duration. On physical examination, the patient appears well. Her
temperature is 100.4ｰ F (38.0ｰ C), and she has tenderness to palpation
and percussion over her left maxilla.

Which of the following statements is true regarding the treatment of

this patient's sinusitis?
A. Antihistamines are helpful in promoting sinus drainage
B. Antibiotics that are resistant to β-lactamases have greater efficacy
than other antibiotics
C. All cases of acute sinusitis require antibiotic therapy
D. Nasal decongestants, such as pseudoephedrine, are a mainstay of
therapy
E. Surgical intervention is now indicated

15
The treatment of acute sinusitis is aimed at promoting drainage
of the sinuses. Nasal decongestants are of paramount
importance, and physical measures such as sleeping at a 45 angle,
sleeping with the unaffected side dependent, and inhalation of
steam can also be helpful. Antihistamines may thicken nasal
secretions and would not be helpful. Although it is traditional to
prescribe antibiotics for 7 to 10 days for sinusitis, data suggest that
in uncomplicated cases, antibiotics do not affect the clinical
course of sinusitis, and antibiotics that are β-lactamase resistant
have not been shown to have any greater efficacy than those that
are not. Surgical intervention is reserved for patients who fail to
respond to medical therapy or who have complications.
(Answer: D—Nasal decongestants, such as pseudoephedrine, are
a mainstay of therapy)

15
An 18-year-old woman presents at your clinic complaining of fevers, chills,
tenderness along the left side of her neck, and pain when she turns her head
to the right. Two weeks ago, she had a sore throat, cough, mild nausea, and
vomiting, for which she did not seek care. On physical examination, the
patient’s temperature is 102.4ｰ F (39.1ｰ C). She is able to open her mouth
easily. HEENT examination is remarkable for swelling of the face. The
oropharynx is erythematous, and the side of the neck is tender but not
swollen. On pulmonary examination, there are crackles and decreased
fremitus at the left base.
Which of the following is appropriate for managing this patient's condition?
A. Contrast-enhanced CT scan of the neck and chest, two sets of blood
cultures, and intravenous antibiotics effective against anaerobic bacteria
B. Contrast-enhanced CT scan of the neck and chest, two sets of blood
cultures, intravenous antibiotics effective against anaerobic bacteria, and
heparin infusion
C. Two sets of blood cultures, intravenous antibiotics effective against
anaerobic bacteria, and heparin infusion
D. Contrast-enhanced CT scan of the neck and chest, two sets of blood
cultures, intravenous antibiotics effective against anaerobic bacteria, heparin
infusion, and drainage/resection of the involved structure
16
Lemierre syndrome occurs most commonly in children and young adults
and is characterized by septic thrombophlebitis of the internal jugular vein,
septic pulmonary emboli, and anaerobic bacteremia. It is typically caused
by Fusobacterium necrophorum. Lemierre syndrome starts as pharyngitis
with invasion into the deep pharyngeal tissue; this allows drainage into the
lateral pharyngeal space and subsequent thrombosis of the internal jugular
vein. CT scanning of the neck can lead to a diagnosis of thrombosis
(ultrasound can also be used); blood cultures are important in identifying
the pathogen. Penicillin G, metronidazole, and clindamycin have been the
mainstays of therapy, although since the 1970s, Fusobacterium species
have been found to be positive for β- lactamase, and some authors
recommend using antibiotics that are β-lactamase-stable or antibiotic
combinations that include β-lactamase inhibitors. Heparin therapy has not
been conclusively shown to improve outcomes, and ligation and surgical
resection of the internal jugular vein are rarely necessary with adequate
antibiotic therapy.
(Answer: A—Contrast-enhanced CT scan of the neck and chest, two sets
of blood cultures, and intravenous antibiotics effective against anaerobic
bacteria)
16
A 26-year-old woman presents to your office for the evaluation of fever. She
was in her usual state of health until 24 hours ago, when she developed
fatigue, myalgias, and severe headache. Her temperature rose to 102 F (38.9
C), and she developed a nonproductive cough and chest tightness. She
reports worsening nausea and diarrhea over the same period. She denies
having any sick contacts, and she was previously healthy. On physical
examination, her temperature is 101.5 F (38.6 C). Bilateral rales with
tachycardia are noted. She has no meningismus. Chest x-ray reveals
bilateral, patchy air-space and interstitial infiltrates. She is admitted to the
hospital for further evaluation and monitoring.
Which of the following statements regarding Legionnaires disease is true?
A. Legionella pneumophila is typically acquired by person-to-person
contact
B. There are currently no available methods of rapidly diagnosing
infection with L. pneumophila
C. Current evidence indicates that azithromycin or levofloxacin is the
treatment of choice
D. In patients in whom monotherapy with azithromycin or levofloxacin
fails, there are no other medical alternatives
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On in vitro susceptibility testing, L. pneumophila has been shown to be
susceptible to a variety of antimicrobial agents, including erythromycin,
clarithromycin, azithromycin, tetracycline, rifampin, and the
fluoroquinolones. According to current evidence, azithromycin or
levofloxacin is the treatment of choice. Human disease is acquired
primarily by inhalation of aerosols contaminated with organisms; person-
to-person transmission has not been documented. A method of rapid
diagnosis involves detection of L. pneumophila antigen in the urine; this
radioimmunoassay test is highly specific and has a sensitivity of about 80%
to 90%. However, the test is available only for L. Pneumophila serogroup 1,
which is the most common cause of Legionnaires disease. A combination
of rifampin and either azithromycin or levofloxacin may be considered in
patients who fail to respond to monotherapy and in immunologically
impaired patients with overwhelming disease.
(Answer: C—Current evidence indicates that azithromycin or levofloxacin
is the treatment of choice)

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A 61-year-old man with a history of alcoholism and seizure disorder arrives at
the emergency department for evaluation. He was found lying on the sidewalk
by passers-by, who notified the emergency medical system. The patient is
partially arousable to pain and voice. His vital signs are stable. Hemoglobin
O2 saturation is 99% on 2 L/min O2 by nasal cannula. Physical examination
is remarkable for poor dentition, fetid breath, rales and egophony in the right
midlung zone, and tachypnea. Chest x-ray reveals a dense infiltrate of the
right lower lobe. He is treated for possible seizure, intubated for airway
protection, and moved to the intensive care unit for further care. Which of the
following statements regarding the diagnosis and treatment of aspiration
pneumonia is true?
A. Aspiration pneumonia always presents as an acute rather than indolent
illness
B. Prevotella melaninogenica, Fusobacterium nucleatum, and
Peptostreptococcus are particularly important causes of aspiration
pneumonia
C. Radiographically, infiltrates are most common in the apices of the
lungs
D. Penicillin monotherapy is no longer considered appropriate therapy
for aspiration pneumonia
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Because anaerobes are the dominant flora of the upper respiratory tract
(outnumbering aerobic or facultative bacteria by 10 to 1), it is not surprising
that anaerobes are the dominant organisms in aspiration pneumonia. Of
particular importance are P. melaninogenica and other Prevotella species, F.
nucleatum, and anaerobic or microaerophilic streptococci and
Peptostreptococcus. As expected, multiple organisms are recovered from
most patients. Patients with mixed aspiration pneumonia may present with
an acute febrile illness, or the illness may follow a more indolent course,
extending over many days or even weeks. Radiographically, infiltrates are
most common in dependent areas of the lung, especially the apical
segments of the lower lobes and the posterior segments of the upper lobes.
With the exception of Bacteroides fragilis, which can be identified along
with other anaerobic species in 17% of patients with classic aspiration
pneumonia, all the anaerobes found are penicillin sensitive. Penicillin is
effective when B. fragilis is present in addition to penicillin-sensitive
organisms, suggesting that aspiration pneumonias are synergistic infections
that can be treated successfully by elimination of most but not necessarily
all of the organisms involved.
(Answer: B—Prevotella melaninogenica, Fusobacterium nucleatum, and
Peptostreptococcus are particularly important causes of aspiration
pneumonia 18
A 68-year-old man with underlying diabetes mellitus and alcoholic
cirrhosis is brought to the emergency department for evaluation of fever
of acute onset and deteriorated mental status. He has no known allergies
and is not taking any medications. On examination, he is febrile and
confused, and meningismus is present. Acute bacterial meningitis is
suspected, and a lumbar puncture shows the following: total protein, 100
mg/dl; glucose, 60 mg/dl (blood, 240 mg/dl); and WBC, 460 cells/mm3
(74% PMN). Results of CSF Gram stain and culture are pending.
Which of the following would be the best choice for empirical antibiotic
therapy for acute bacterial
meningitis in this patient?
A. Ceftriaxone and vancomycin
B. Vancomycin
C. Ampicillin and ceftriaxone
D. Vancomycin, ceftriaxone, and ampicillin
E. Meropenem

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Among adults with acute community-acquired bacterial meningitis,
Streptococcus pneumoniae, Neisseria meningitidis, Haemophilus influenzae,
and Listeria monocytogenes are the most common pathogens. Prompt initiation
of appropriate I.V. antibiotics is critical; antibiotic therapy should be started
before definitive microbiologic results are available. The possibilities of highly
penicillin-resistant S. pneumoniae and L. Monocytogenes should be considered
(especially given this patient's underlying diabetes and liver disease). Although
ceftriaxone is appropriate for susceptible S. pneumoniae, it would not be
adequate for highly penicillin-resistant strains; thus, vancomycin should be
given until definitive microbiologic results are available. The patient's advanced
age and underlying medical conditions (i.e., diabetes, liver disease) predispose
him to L. monocytogenes infection. Ampicillin is the antibiotic of choice for
Listeria infections and should also be given empirically in this patient
(cephalosporins, vancomycin, and meropenem are not sufficiently active against
Listeria). Of the choices listed, only choice D provides coverage against highly
penicillin-resistant S. pneumoniae, L. monocytogenes, H. influenzae, and N.
meningitidis.
(Answer: D—Vancomycin, ceftriaxone, and ampicillin)

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A 34-year-old man seeks evaluation of a cough. His illness began with a sore
throat and nasal congestion 5 days ago. He subsequently developed a cough
productive of green sputum and a burning sensation in the retrosternal chest
that occurs with coughing spells. He has felt cold at times but denies shaking
chills, shortness of breath, and hemoptysis. There is a history of seasonal
allergies, but he takes no medications and has no known drug allergies. He is
a nonsmoker who typically jogs 3 miles, four times weekly. Pulse oximetry
reveals a normal resting oxygen saturation; the patient's temperature is 100.2 F
(37.9 C). The chest is clear to percussion, with audible expiratory wheezes.
After taking a deep breath, the patient coughs, producing green sputum. A
Gram stain of the specimen reveals polymorphonuclear and mononuclear cells
without microorganisms. A chest x-ray is normal.
Which of the following would be the most appropriate choice for antimicrobial
treatment of this patient's condition?
A. No antimicrobial treatment
B. Amoxicillin-clavulanate, 875 mg p.o., b.i.d., for 10 days
C. Trimethoprim-sulfamethoxazole, 1 double-strength tablet p.o., b.i.d.,
for 10 days
D. Azithromycin, 500 mg p.o. once, then 250 mg p.o., q.d., for 4 days❑
E. Levofloxacin, 250 mg p.o., q.d., for 10 days
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This otherwise healthy man who is without underlying lung disease has
acute bronchitis, an illness caused predominantly by respiratory viruses. Up
to 85% of patients diagnosed with acute bronchitis in the United States
receive antimicrobial therapy. This practice has likely contributed to the
rapid emergence of drug-resistant strains of bacteria.
(Answer: A—No antimicrobial treatment)

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