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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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.
October 8, 2024
MKSAP 18 Endocrinology & Metabolism Question 67
Stem:
A 65-year-old woman comes to the office to establish care. Her medical history is notable for hypothyroidism due to Hashimoto thyroiditis treated with levothyroxine. She does not have any symptoms at this time. There is no history of head or neck radiation exposure.
On physical examination, vital signs are normal. The patient's thyroid gland is enlarged. The right lobe is larger than the left, and a mobile 2-cm nodule is palpable in the lower pole. There is no palpable cervical adenopathy.
Laboratory studies show a serum thyroid-stimulating hormone level of 2.0 µU/mL (2.0 mU/L).
Which of the following is the most appropriate diagnostic test to perform next?
Responses Received from Members (830 Responses):
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The Correct Answer is: D. Ultrasound of the neck
Educational Objective
Evaluate a thyroid nodule with neck ultrasonography.
Critique
The most appropriate diagnostic test to perform next is ultrasound of the neck. Ultrasound can confirm the presence of thyroid nodules palpated on examination and those detected on other imaging studies.
Ultrasound must be performed prior to fine-needle aspiration biopsy (FNAB) to confirm the presence of a nodule, determine that biopsy is indicated, ensure that there are no additional nonpalpable nodules that warrant FNAB, and assess the cervical lymph nodes. In patients with solitary palpable nodules, 15% will have no corresponding nodule on ultrasound, and a similar proportion will have an additional nodule measuring 1 cm or larger.
Performing a CT scan of the neck is a more costly test, exposes the patient to unnecessary radiation, and is inferior to ultrasound at assessing the thyroid gland.
FNAB should not be performed prior to thyroid/neck ultrasound. Whether or not FNAB is indicated depends on the size and sonographic appearance of the nodule, clinical risk factors for malignancy, and presence of pathologic lymph nodes. Nodules that are predominantly cystic or posteriorly located within the thyroid gland are prone to sampling error.
Measurement of serum thyroid-stimulating hormone (TSH) is also part of the initial evaluation of a thyroid nodule. The purpose of measuring TSH is to evaluate for the presence of autonomously functioning or “hot” nodules, which account for 5% to 10% of palpable thyroid nodules. Autonomous nodules may cause hyperthyroidism and are associated with a very low risk of malignancy. Autonomous nodules can be confirmed by performing a thyroid uptake and scan. They concentrate radioactive iodine to a greater extent than normal thyroid tissue, which shows absent or diminished uptake. The TSH in this patient is normal, which does not support a diagnosis of an autonomously functioning thyroid nodule; therefore performing a thyroid uptake and 131I scan is not indicated.
Key Points
Ultrasound can confirm the presence of thyroid nodules palpated on examination and based on findings can help to determine if fine-needle aspiration is needed to assess for malignancy.
Haugen BR, Alexander EK, Bible KC, Doherty GM, Mandel SJ, Nikiforov YE, et al. 2015 American Thyroid Association Management Guidelines for Adult Patients with Thyroid Nodules and Differentiated Thyroid Cancer: The American Thyroid Association Guidelines Task Force on Thyroid Nodules and Differentiated Thyroid Cancer. Thyroid. 2016;26:1-133. PMID: 26462967 doi:10.1089/thy.2015.0020
Copyright 2018, American College of Physicians.