NYACP Board Review Question of the Week
Every other Tuesday, NYACP members are sent a Board Review Question from ACP's MKSAP 18 to test professional knowledge and help prepare for the exam. Participant totals and answer percentages are distributed on the first Thursday of the month in IM Connected, the Chapter's eNewsletter, and are also published on this page.
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November 5, 2024
MKSAP 18 General Internal Medicine Question 131
Stem:
A 47-year-old man is evaluated for a 2-day history of cough productive of small amounts of yellow sputum, as well as sinus congestion, frontal headache, rhinorrhea, and malaise. He has had no fevers, chest pain, or shortness of breath. Medical history is otherwise unremarkable.
On physical examination, vital signs are normal. There is tenderness over the maxillary sinuses bilaterally. The nasal mucosa is diffusely edematous with moderate amounts of clear discharge.
Pharyngeal examination reveals erythema without tonsillar exudate. The tympanic membranes appear normal. No cervical lymphadenopathy is noted. The remainder of the examination is normal.
Which of the following is the most appropriate treatment?
A. Amoxicillin
B. Codeine
C. Inhaled albuterol
D. Intranasal fluticasone
Responses Received from Members (Response numbers and distribution posted on Thursday):
The Correct Answer is: D. Intranasal fluticasone
Educational Objective
Treat cough due to acute rhinosinusitis.
Critique
This patient with acute cough due to acute rhinosinusitis should be treated with an intranasal glucocorticoid, such as fluticasone. Most upper respiratory tract infections (URIs) are caused by viral infections and resolve spontaneously within a few days. Patients without clear evidence of bacterial infection should be treated symptomatically. A meta-analysis of patients with acute rhinosinusitis found that use of intranasal glucocorticoids increased the rate of symptom response compared with placebo; there was a dose-response curve, with higher doses offering greater relief. Analgesics, such as NSAIDs and acetaminophen, may relieve pain. Only limited evidence supports saline irrigation in the relief of nasal symptoms; careful attention should be paid to the use of sterile or bottled water. Instructions for nasal saline irrigation are available online (www.fda.gov/ForConsumers/ConsumerUpdates/ucm316375.htm). First-generation antihistamines may help dry nasal secretions; however, evidence supporting their efficacy is lacking, and sedation is a common side effect. Decongestants are of possible benefit in patients with evidence of eustachian tube dysfunction but should be used with caution in elderly patients and those with cardiovascular disease, hypertension, angle- closure glaucoma, or bladder neck obstruction. Antitussive agents are generally ineffective.
Empiric treatment of URI symptoms with antibiotics (such as amoxicillin) is ineffective, increases bacterial antibiotic resistance, and may cause multiple adverse effects, including Clostridium difficile colitis. Antibiotics should be reserved for patients with symptoms lasting more than 10 days, worsening symptoms after initially improving viral illness, or severe symptoms or signs of high fever (>39 °C [102.2 °F]) with purulent nasal discharge or facial pain for at least 3 consecutive days.
A systematic review concluded that centrally acting (codeine, dextromethorphan) or peripherally acting (moguisteine) antitussive therapy results in little improvement in acute cough and is not recommended.
Inhaled albuterol is indicated for patients with evidence of wheezing, which this patient does not have. For patients who develop postinfectious airway hyperreactivity with a subacute or chronic cough, albuterol and other asthma therapies are beneficial.
Key Points
Acute rhinosinusitis may be treated symptomatically with analgesics and intranasal glucocorticoids; antibiotics are not recommended without clearly established bacterial infection.
Harris AM, Hicks LA, Qaseem A; High Value Care Task Force of the American College of Physicians and for the Centers for Disease Control and Prevention. Appropriate antibiotic use for acute respiratory tract infection in adults: advice for high-value care from the American College of Physicians and the Centers for Disease Control and Prevention. Ann Intern Med. 2016;164:425-34. PMID: 26785402
Copyright 2018, American College of Physicians.
October 22, 2024
MKSAP 18 Infectious Disease Question 77
Stem:
A 67-year-old woman is evaluated after a diagnosis of ventilator-associated pneumonia. She was transferred to the ICU 3 days ago for respiratory failure secondary to Guillain-Barré syndrome and was intubated.
Yesterday, the ventilator-associated pneumonia diagnosis was made and empiric antibiotics were started. Today her antibiotic therapy was de-escalated to oxacillin after her sputum culture grew methicillin- sensitive Staphylococcus aureus. Blood cultures were negative. Her medications are oxacillin and low- molecular-weight heparin; she is also undergoing plasmapheresis.
On physical examination, temperature is 37.6 °C (99.6 °F), blood pressure and pulse rate are normal, and respiration rate is 15/min. Oxygen saturation is 97% breathing 40% FIO2. Pulmonary examination reveals scattered rhonchi.
A chest radiograph shows right middle and lower lobe infiltrates without effusions.
Which of the following is the most appropriate antibiotic management?
A. Continue antibiotic therapy for a total of 7 days
B. Continue antibiotic therapy for a total of 14 days
C. Continue antibiotics until extubation
D. Obtain sputum for Gram stain and culture before stopping antibiotics
Responses Received from Members (807 Responses):
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The Correct Answer is: A. Continue antibiotic therapy for a total of 7 days
Educational Objective
Treat ventilator-associated pneumonia for 7 days.
Critique
The recommended treatment duration for ventilator-associated pneumonia (VAP) is 7 days. VAP is defined as pneumonia developing 48 hours after endotracheal intubation. The most significant VAP risk factor is intubation and mechanical ventilation. Early onset (<5 days after hospitalization or intubation) generally results from antimicrobial-sensitive organisms (Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and antibiotic-susceptible gram-negative bacteria); late onset (≥5 days after hospitalization or intubation) is more likely with multidrug-resistant organisms (MDROs), including Pseudomonas aeruginosa, Klebsiella pneumoniae, Acinetobacter species, Stenotrophomonas maltophilia, Burkholderia cepacia, and methicillin-resistant S. aureus. The recommended therapy duration for VAP is 7 days. A longer antibiotic duration does not improve outcomes, leads to the emergence of antibiotic- resistant organisms, and can increase the risk for adverse effects from antibiotic exposure.
Sputum Gram stain and culture are unnecessary for influencing the timing to stop antibiotics; the implicated organism may remain (colonizing) after treatment has been completed and the patient has improved clinically. Persistence of the infecting organism is not an indication to continue antibiotic therapy.
Antibiotics should not be continued until extubation. The antibiotic therapy duration is the same for patients who are successfully extubated during treatment and patients who remain intubated after 7 days of antibiotic therapy as long as clinical improvement occurs. If the patient does not improve clinically (resolution of fever, decrease in oxygenation and suction requirements) or initially improves and then worsens during treatment, the patient should be evaluated to identify development of infectious complications (pleural effusion, empyema, superinfection, antibiotic resistance) or noninfectious complications.
Key Points
Ventilator-associated pneumonia should be treated with a 7-day course of antibiotics; longer courses contribute to the emergence of antibiotic resistance, increase the risk for antibiotic-related adverse effects, and do not improve outcomes.
Kalil AC, Metersky ML, Klompas M, Muscedere J, Sweeney DA, Palmer LB, et al. Management of adults with hospital-acquired and ventilator-associated pneumonia: 2016 clinical practice guidelines by the Infectious Diseases Society of America and the American Thoracic Society. Clin Infect Dis. 2016;63:e61-e111. PMID: 27418577 doi:10.1093/cid/ciw353
Copyright 2018, American College of Physicians.