Competency questions

Antimicrobial Stewardship Training
Post-Test - Part 1: Review of Basic Principles and Selected Antimicrobials
1. Select the groupings of antibiotics which ALL have activity against Pseudomonas aeruginosa : A. aztreonam, ertapenem, ampicillin/sulbactam, ticarcillin/clavulanic acid B. meropenem, ceftazidime, ampicillin/sulbactam, cefepime C. imipenem, cefepime, tobramycin, amikacin D. ceftriaxone, piperacillin/tazobactam, meropenem, imipenem E. amoxicillin/clavulanic acid, ciprofloxacin, levofloxacin, cefixime
Given the following susceptibility data, answer questions 2 and 5:
Organism: Staphylococcus aureus, Source: skin abscess Drug MIC Penicillin >8 R Ampicilin/sulbactam <=4/2
2. Select which of the following antibiotics cannot be used for this infection:
A. dicloxacillin B. augmentin C. ampicillin D. cephalexin 3. Select which of the following antibiotics cannot be used for this infection:
A. nitrofurantoin B. bactrim C. unasyn D. nafcillin 4. Select which of the following antibiotics cannot be used for this infection:
A. doxycycline B. cefadroxil C. amoxicillin D. Septra 5. Which antibiotic will have activity against this isolate? A. azithromycin B. ertapenem C. metronidazole D. aztreonam 6. Which of the following statements about ertapenem is FALSE? A. it is dosed once daily B. it covers MSSA, Bacteriodes fragilis, E. coli and Streptococcus viridans C. it covers Acinetobacter baumannii, Pseudomonas aeruginosa and MSSA D. it is indicated for CAP and diabetic foot infections Antimicrobial Stewardship Training
For questions 7 and 8: Jane Doe is a 79 y.o. woman who presented to clinic with some mild dysuria
and increased frequency of voiding. She was sent home without antibiotics but her urine culture
showed an E. coli infection (see below). The MD would like help selecting an antibiotic for the
patient’s UTI. She is otherwise doing well at home. Other info: Height: 5’3” Weight: 72kg Scr: 2.4
Allergies: penicillin: rash (has tolerated cefazolin in the past), sulfonamides: hives
Urinalysis: Leukocyte esterase: Large Urine WBC: >182, Epithelial cells: 0-2 Organism: >100K cfu of Escherichia coli Source: urine (clean catch) 7. Which of the following is the single best antibiotic that would be safe and effective to use for this A. Nitrofurantoin B. Cephalexin C. Ceftriaxone D. Septra E. Augmentin On her way to pick up the prescription, the patient falls and fractures her ankle. She is admitted to the
hospital and the admitting MD wants to change to an IV antibiotic for treatment of the UTI.
8. Which one antibiotic would be the most ‘streamlined’ choice to treat this patient’s infection?
A. Ampicillin B. Cefotetan C. Cefazolin D. Cefixime E. Cefuroxime 9. All of the beta-lactam based antibiotics need to be adjusted in renal insufficiency except for: A. ampicillin and amoxicillin B. cefepime and ceftriaxone C. nafcillin and ertapenem D. ceftriaxone, dicloxacillin and nafcillin E. piperacillin/tazobactam and cefoxitin
10. Which one of the following statements is true about the beta-lactam/beta-lactamase inhibitor
A. Ampicillin/sulbactam is the only one that does not cover B. fragilis B. All are clinically active against Pseudomonas aeruginosa C. There are no oral agents in this class D. The addition of the beta-lactamase inhibitor confers activity against beta-lactamase producing E. Even if an Enterococcus isolate is ampicillin sensitive, it will not be covered by any of the Antimicrobial Stewardship Training

Use the following list for questions 11 through 13
1. cefazolin 2. ertapenem 3. penicillin 4. amoxicillin 5. ceftriaxone 6. meropenem 7. aztreonam
Tissue Culture, Collected: 7/13/2009 01:15, Source: Tissue
Final Report
----CULTURE POSITIVE----
GRAM STAIN : GRAM POSITIVE COCCI IN CLUSTERS
CRITICAL VALUE CALLED TO AND READ BACK BY:
DR.DOE @ 0430 07/15/09.
METHICILLIN RESISTANT STAPH AUREUS ISOLATED
---------SUSCEPTIBILITY RESULTS----------
ORGANISM: 01 MRSA
MIC
Ampicillin >8 R
Ciprofloxacin <=1 S
Gentamicin <=1 S
Oxacillin >2 R
Penicillin >8 R
Rifampin <=1 S
Tetracycline <=4 S
Trimeth/Sulfa <=2/38 S
Vancomycin <=2 S
11. Given the microbiology above, which antibiotic(s) from the list can be used to treat this infection? 12. If the isolate above were MSSA instead of MRSA, which antibiotic(s) from the list can be used to 13. Which of the following regimens would be the most appropriate therapy to treat the isolate above? A. Meropenem IV B. Vancomycin IV C. Ciprofloxacin IV D. Rifampin IV E. Doxycycline IV Antimicrobial Stewardship Training
14. Which statement about the carbapenems class is false:
A. Carbapenems seem to have a low rate of cross-allergenicity in patients with Type I reactions B. Meropenem can be used for meningitis and covers Acinetobacter baumannii C. Carbapenems have activity against ESBL producing Enterobacteriaciae D. Ertapenem is dosed once daily and has activity against Pseudomonas aeruginosa E. Doripenem and Meropenem cover Pseudomonas aeruginosa 15. Which combination of words correctly completes the following sentence: _____________ and ___________ are __________ generation cephalosporins and are the only ones with appreciable activity against anaerobic bacteria. A. cefotaxime, ceftriaxone, third B. cefixime, cefpodoxime, second C. cefotetan, cefoxitin, second D. cefotetan, cefotaxime, second E. ceftazidime, ceftizoxime, first 16. The only cephalosporins with activity against Pseudomonas are: A. ceftazidime, ceftriaxone B. ceftriaxone, cefazolin C. cefepime, ceftazidime D. cefixime, ceftazidime E. cefpodoxime, ceftriaxone
Use the following data to answer questions 17 & 18.
Urine Culture, Collected: 7/28/2009 10:03, Source: URINE Final Report GREATER THAN 100,00 COL/ML ENTEROCOCCUS FAECALIS --------------SUSCEPTIBILITY RESULTS---------------- ORGANISM: 01 ECOC MIC BLOOD URINE Ampicillin <=2 S Ciprofloxacin 1.0 S Nitrofurantoin <=16 S Tetracycline <=1 S Vancomycin <=1 S 17. Which of the following antibiotics will have activity against this isolate? A. amoxicillin B. clindamycin C. cefotetan D. nafcillin Given the following information about the patient: Allergies: penicillin (rash, “my throat became itchy”) No other information regarding what antibiotics the patient has tolerated in the past Antimicrobial Stewardship Training
18. Which of the following antibiotics could you recommend to safely and effectively treat this infection? A. Aztreonam B. Cefepime C. Unasyn D. Doxycycline 19. In comparison to piperacillin by itself, the addition of tazobactam to piperacillin A. increases activity against Pseudomonas aeruginosa B. increases activity against certain Enterobacteriaciae (E. coli, Klebsiella spp.) and anaerobes C. increases piperacillin’s ability to cross the blood brain barrier D. increases activity against methicillin resistant Staphylococcus aureus E. does not increase activity against beta-lactamase producing gram positive organisms
Use the following data to answer questions 20 & 21

Blood Culture, Collected: 7/18/2009 14:38, Source: BLOOD
Final Report STAPHYLOCOCCUS AUREUS ISOLATED
--------------SUSCEPTIBILITY RESULTS---------------
ORGANISM: 01 S aureus
MIC BLOOD URINE
Ampicillin 4.0 R
Ampicillin/Sulb <=4/2 S
Augmentin <=2/1 S
Cefazolin <=2 S
Ceftriaxone <=4 S
Ciprofloxacin <=0.25 S
Clindamycin <=0.25 S
Erythromycin <=0.5 S
Gentamicin <=1 S
Oxacillin <=0.25 S
Penicillin 8.0 R
Rifampin <=1 S
Tetracycline <=1 S
Trimeth/Sulfa <=.5/9.5 S
Age: 52 Sex: M HT: 6’3” WT: 72.5kg
Allergies: penicillin (hives), sulfonamides (hives), tetracycline (rash)
WBC: 13.2 Scr: 0.99
Current antibiotics: vancomycin 1.25g iv q12h & cefuroxime 1.5g iv q8h
Other information: Patient is afebrile, clinically stable.
20. Which other antibiotic would be appropriate to use for this patient’s infection?
A. Unasyn B. aztreonam C. nafcillin D. cefazolin E. doxycycline 21. What would be the one best option in terms of streamlining the patient’s current regimen
A. Stop cefuroxime, start cefazolin and continue vancomycin B. Stop cefuroxime and vancomycin, start nafcillin C. Stop cefuroxime and vancomycin, start cefazolin D. Stop cefuroxime and vancomycin, start ceftriaxone E. No need for intervention, therapy is appropriate F. None of these options are appropriate Antimicrobial Stewardship Training
22. A patient has a culture from an abdominal abscess that is growing Klebsiella oxytoca, Streptococcus viridans and Prevotella spp. (all the isolates are pansensitive meaning sensitive to all antibiotics tested). Patient has NKDA. Which of the following antibiotic(s) would be appropriate to use: A. imipenem & metronidazole B. Unasyn & clindamycin C. ceftriaxone & metronidazole D. ertapenem & moxifloxacin 23. A 21 y.o. man presents to the ED with severe right lower quadrant pain for the past 2 hours while he was at home. He is being admitted with a presumed diagnosis of acute appendicitis. The patient has no drug allergies and no significant past medical history. Which antibiotic provides adequate coverage of bowel flora including anaerobes and would be appropriate to use for this patient? A. meropenem B. moxifloxacin C. cefepime D. ceftriaxone For questions 24-26. A resident calls you to ask for some antibiotic advice in a patient with possible line sepsis. The patient has been mechanically vented in the ICU for the past 7 days due to respiratory failure following a surgical procedure. The patient spiked a fever to 102.5 degrees celsius earlier this morning and had a drop in blood pressure prompting the initiation of vasopressor therapy. At that time, 2 blood cultures were drawn, one from their central line (which upon examination looked inflamed and had pus-like drainage) and a peripheral draw. The microbiology lab called the MD a few minutes ago and said that both cultures showed gram negative rods on gram stain. In addition, the gram stain from the central line culture showed gram positive cocci in clusters. The MD wants to start antibiotics as soon as possible. 24. For the central line culture with gram positive cocci, which of the following bacteria is most A. Staphylococcus hominis B. Staphylococcus aureus C. Micrococcus spp. D. Staphylococcus epidermidis 25. What empiric antibiotic(s) would be appropriate for the MD to start? A. vancomycin & ceftriaxone B. ampicillin, gentamicin and metronidazole C. meropenem D. vancomycin & Zosyn E. vancomycin & ertapenem 26. Which of the following antibiotics would not be an appropriate empiric choice for the treatment of
A. cefepime B. meropenem C. Unasyn D. Zosyn Antimicrobial Stewardship Training
27. Which of the following statements about moxifloxacin is true? A. It has the least activity against S. pneumoniae compared to levofloxacin or ciprofloxacin B. The dosing interval should be increased in severe renal insufficiency and its use is not C. It is indicated for the treatment of ventilator associated pneumonia D. It lacks coverage of MRSA, B. fragilis and Pseudomonas aeruginosa E. It has activity against Legionella pneuomophilia 28. You are conducting antibiotic review for your floor and you find a patient on Unasyn and clindamycin. In what clinical setting would this be appropriate? A. Empiric coverage for anaerobes in head and neck infections B. Adjunctive use of clindamycin for patients with necrotizing fasciitis due to Group A C. Community acquired appendicitis D. Diabetic foot ulcer with vascular disease E. Pelvic inflammatory disease 29. You are conducting antibiotic review for your hospital and you find a patient on meropenem and metronidazole in the ICU. Which of the following scenarios would be an appropriate use of this combination? A. Severe intra-abdominal sepsis with ischemic bowel B. Aspiration pneumonia with aspiration of stomach contents C. Necrotizing pancreatitis with septic shock D. Treatment of ventilator associated pneumonia and suspected C. difficile diarrhea E. Necrotizing fasciitis in an IV drug abuser 30. Vancomycin given orally can be used to treat infections with the following bacteria: A. MRSA B. S. pneumoniae C. C. difficile D. S. epidermidis E. S. hominis Evaluation - Part 1: Review of Basic Principles and Selected Antimicrobials
A) Strongly Agree B) Agree C) Disagree D) Strongly Disagree 2. Content was useful and relevant to my practice needs for the Antimicrobial Stewardship work: A) Strongly Agree B) Agree C) Disagree D) Strongly Disagree Antimicrobial Stewardship Training
3. Module 1 – Microbiology and Laboratory Review was well organized and easy to follow: A) Strongly Agree B) Agree C) Disagree D) Strongly Disagree 4. The information in Module 1 enhanced my knowledge of these topics: A. Strongly Agree B. Agree C. Disagree D. Strongly Disagree 5. Module 2 – Antibiotic Update was well organized and easy to follow A. Strongly Agree B. Agree C. Disagree D. Strongly Disagree 6. The information in Module 2 enhanced my knowledge of antibiotic use: A. Strongly Agree B. Agree C. Disagree D. Strongly Disagree 7. Module 3 – Allergy to Penicilins and B-lactams was well organized and easy to follow A. Strongly Agree B. Agree C. Disagree D. Strongly Disagree 8. The information in Module 3 enhanced my knowledge of antiobiotic allergy: A. Strongly Agree B. Agree C. Disagree D. Strongly Disagree 9. I will be able to apply what I have learned in this program A. Strongly Agree B. Agree C. Disagree D. Strongly Disagree 10. Please rate your overall satisfaction with this program: A) Very satisfied B) Satisfied C) Unsatisfied D) Very unsatisfied

Source: http://www.stollerdesigngroup.com/client/kaiser/playbook/ABX_Stewardship_Competency.pdf