2014 Peds Q&as Questions Book Cardio

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MedStudy’s 2014 Pediatrics Board-Style Questions & Answers

Editor in Chief

Robert A. Hannaman, MD

MedStudy

Colorado Springs, CO

Author

Paul Catalana, MD, MPH, FAAPAssistant Dean of Admissions

Clinical Associate Professor of Pediatrics

University of South Carolina School of Medicine Greenville

Greenville, SC

Note: Paul Catalana, MD, MPH, FAAP has documented that he has no relationships with entities producing, marketing,

re-selling, or distributing health care goods or services consumed by, or used on, patients.

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It is the policy of MedStudy to ensure balance, independence, objectivity, and scientific rigor in all of its educational

activities. In keeping with all policies of MedStudy and the Accreditation Council for Continuing Medical Education

(ACCME), specifically ACCME’s Standards for Commercial Support, any contributor to a MedStudy CME activity

is required to disclose all relevant relationships with any entity producing, marketing, re-selling, or distributing healthcare goods or services consumed by, or used on, patients. Failure to do so precludes acceptance by MedStudy of any

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MedStudy Corporation, including all of its employees, has no financial interest, arrangement or affiliation with any

commercial entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on,

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address the ethical obligations that underpin physician participation in CME: 8.061, “Gifts to physicians from industry,”and 9.011, “Ethical issues in CME,” and 9.0115, “Financial Relationships with Industry in CME.”

For Further Study

MedStudy Pediatrics Board Review Core Curriculum, 6th Edition. MedStudy Corporation, Colorado Springs, CO, 2014.

MedStudy Pediatrics Flash Cards, 2014–2015 Edition, MedStudy Corporation, Colorado Springs, CO, 2014.

Nelson Textbook of Pediatrics, 19th Edition. Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Gerne, Nina Schor, and

Richard E. Behrman. W.B. Saunders. Elsevier Science Health Science Division, New York, NY, 2011.

Rudolph’s Pediatrics, 22nd Edition. Colin D. Rudolph, Abraham M. Rudolph, George Lister, Lewis R. First, and

Anne A. Gerson (eds). McGraw Hill Medical, New York, NY, 2011.

Oski’s Pediatrics: Principles and Practice, 4th Edition. Julia McMillan, Ralph D. Feigin, Catherine D. DeAngelis, and

M. Douglas Jones (eds). Lippincott Williams & Wilkins, Philadelphia, PA, 2006.

Smith’s Recognizable Patterns of Human Malformation, 7th Edition. Kenneth Jones. W.B. Saunders.

Elsevier Science Health Science Division, New York, NY, 2013.

Atlas of Pediatric Physical Diagnosis, 6th Edition. Basil J. Zitelli and Holly W. Davis. Mosby/Elsevier Science

Health Science Division, New York, NY, 2012.

Bright Futures: Guidelines for Health Supervision of Infants, Children, and Adolescents, 3rd Edition. Joseph F. Hagan, Jr.,

Judith S. Shaw, and Paula M. Duncan (eds). American Academy of Pediatrics, Philadelphia, PA, 2008.



Web-based:

National Guideline Clearinghouse: http://www.guideline.gov/

AAP Clinical Practice Guidelines: http://www.aap.org/en-us/professional-resources/practice-support/

quality-improvement/Pages/Clinical-Practice-Guidelines.aspx

AAP-Endorsed Clinical Practice Guidelines:

http://pediatrics.aappublications.org/search?flag=endorsed_practice_guidelines&submit=yes&x=18&y=8&format=standard&hit

s=30&sortspec=date&submit=Go

AAP Clinical Reports: http://pediatrics.aappublications.org/search?fulltext=clinical+reports&submit=yes&x=44&y=10



2014

MedStudy®

2 0 0 9

P e d i a t r i c s B o a r d - S t y l e Q u e s t i o n s & A n s w e r s

QUESTIONS

Edited by Robert A. Hannaman, MD



MedStudy

TABLE OF CONTENTS

ADOLESCENCE .............................................................. 5

ALLERGY / IMMUNOLOGY / RHEUMATOLOGY .... 21

CARDIOLOGY ................................................................ 33

DERMATOLOGY ............................................................ 41

EMERGENCY MEDICINE ............................................. 59

ENDOCRINOLOGY ........................................................ 71

ENT / OPHTHALMOLOGY / ORTHOPEDICS ............. 79

GASTROENTEROLOGY ................................................ 85

GENETICS / METABOLIC DISEASES ......................... 95

GROWTH and DEVELOPMENT. ................................... 111

HEALTH SUPERVISION ................................................ 119

HEMATOLOGY / ONCOLOGY ..................................... 131

INFECTIOUS DISEASES ................................................ 143

NEPHROLOGY ............................................................... 165

NERVOUS SYSTEM / NEUROLOGY ........................... 171

NEWBORN / PRENATAL CARE ................................... 179

NUTRITION / TEETH ..................................................... 195

RESPIRATORY ............................................................... 203

APPENDIX A – Reference color photos

APPENDIX B – Antibiotics Tab

Important: These Q&A books are meant to be used as an adjunct to the MedStudy Pediatrics Review Core Curriculum. The Pediatric

Boards cover a vast realm of diagnostic and treatment knowledge. Board-simulation exercises such as these self-testing Q&As arevaluable tools, but these alone are not adequate preparation for a Board exam. Be sure you use a comprehensive Pediatrics review resource

in addition to these Q&As for adequate exam preparation.

© 2014 by MedStudy Corporation.

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Or e-mail to: [email protected]

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A note on editorial style: MedStudy follows a standardized approach to the naming of diseases, using the non-possessive form when the

proper name of a disease is followed by a common noun. So you will see phrasing such as “This patient would warrant workup for Crohndisease” (as opposed to “Crohn’s disease”). Possessive form will be used, however, when an entity is referred to solely by its proper name

without a following common noun. An example of this would be “The symptoms are classic for Crohn’s.” Styles used in today’s literature

can be highly arbitrary, some using possessive and some not, but we believe consistency is important. It has become nearly obsolete to use

the possessive form in terminology such as Lou Gehrig’s disease, Klinefelter’s syndrome, and others. The AMA Manual of Style, JAMA,

Scientific Style and Format , and Pediatrics magazine are among the publications that are now promoting and using the non-possessive

form. We concur with this reference.

Content: The primary purpose of this activity is educational. Medicine and accepted standards of care are constantly changing. We atMedStudy do our best to review and include in this activity accurate discussions of the standards of care, methods of diagnosis, and

selection of treatments. However, the author, editors, advisers, and publisher—and all other parties involved with the preparation of this

work—disclaim any guarantee that the information contained in this activity and its associated materials is in every respect accurate orcomplete. MedStudy further disclaims any and all liability for damages and claims that may result from the use of information or

viewpoints presented. We recommend you confirm the information contained in this activity and in any other educational material withcurrent sources of medical knowledge whenever considering actual clinical presentations or treating patients.



2014 Pediatrics Board-Style Questions

About the questions and answers in this learning activity

The questions, answers, and explanations in this learning activity are developed by the author,Paul V. Catalana, MD, MPH, FAAP. Dr. Catalana has a background of more than 20 years in professionalmedical education. He is also a reviewer/section editor for the MedStudy Pediatrics Review Core Curriculum and

a teacher at the MedStudy live Pediatrics Intensive Board Review Course. Dr. Catalana is a Clinical AssociateProfessor of Pediatrics at the University of South Carolina School of Medicine in Greenville, South Carolina. Heis Board Certified in both pediatrics and adolescent medicine and is a member of the American Academy ofPediatrics.

Knowing the importance that the Peds Boards place on established standards of care, having researched recentand pertinent practice guidelines, and having reviewed the ABP Board exam blueprints, Dr. Catalana is wellaware of the areas of knowledge most likely to be tested on today’s Board exams. The questions emphasize testareas that are difficult to learn as well as provide classic vignettes to help you remember more common diseases.You will find questions of varying length here. The very short ones are designed to nail home an important point

you need to know and remember for your Boards. The lengthier questions help you integrate content on a subjectwith additional clinical information to better simulate a real-life patient scenario.

This helps you recognize disease states and associated treatment, which is a skill heavily tested on Board exams.Some selected patient case scenarios may appear more than once, or with only slight variations, with the

associated questions addressing different diagnosis and treatment aspects of the case. This is in keeping with theapproach Board questions take in limiting patient case assessments to one key testing point.

In short, this Q&A material is designed to impart not only relevant knowledge for Peds Board exams but alsochallenge your skills in interpretation and intervention, which is what Board exams attempt to assess. Which is

why we call these, appropriately, “Board-style” questions and answers.

There is a popular misconception that members of organizations perceived to be associated with medical boardswrite Board exam questions, such as AAP/PREP with the American Board of Pediatrics. Not only is this not true,it is actually forbidden for anyone to write formal Board exam questions if they work for a company or

organization in the business of producing Board preparation materials. This would compromise the integrity ofthe examining process.

MedStudy is proud to be able to bring you Board-style questions and answers of the highest quality—to offer you

education that is relevant in a format that reinforces your knowledge to prepare you well for whatever challengethe ABP Board exam presents you. One final note: Even the best question-and-answer exercise by itself is not anadequate preparation for a Board exam. These Q&As should be used as an adjunct to a comprehensive Board

review course (such as the MedStudy Pediatrics Review Core Curriculum). The Boards cover a vast realm ofinformation that Board-simulation Q&As alone cannot encompass.

Robert A. Hannaman

Editor in ChiefMedStudy




© 2014 MedStudy Cardiology Questions 33

CARDIOLOGY

72.

While working as a landscaper during summer vacation, a 16-year-old male, according to his boss, suddenly

“fainted just after complaining of being nauseated and dizzy.” He reportedly “came around quickly” after hislegs were elevated and a cold rag was applied to his forehead. No associated tonic-clonic activity was observed.On physical examination, his blood pressure is 110/75; pulse is 64 beats/minute and regular. No murmurs are

noted on cardiac auscultation. The patient reports that he “fell out” on 3 previous occasions within the lastseveral months. Following additional evaluation, the patient is prescribed fludrocortisone.

Which of the following was most likely abnormal during the further assessment of this patient?

A. EchocardiogramB. Tilt table testC. Adrenal ultrasoundD.

Cranial MRI

E.

Nuclear stress test ___________________________________________________________________________________________

73.

A 15-year-old girl presents for a pre-participation sports physical. She has no complaints, is on no chronicmedications, and runs an average of 50 miles/week. On physical exam, her blood pressure is 100/65 with a resting

pulse of 56 beats/minute. An echocardiogram is performed after a murmur is heard on cardiac auscultation, whichreveals an ostium secundum defect in the area of the fossa ovalis.

Which of the following best describes expected cardiac findings during physical examination of this

patient?

A.

A systolic ejection murmur, best heard at the mid-to-upper left sternal border associated with

a loud first and widely fixed, split-second heart soundB. A systolic ejection murmur, best heard at the mid-to-upper left sternal border associated with

a diminished single-second heart soundC.

A continuous murmur throughout systole and diastole associated with bounding peripheral pulsesD. A rumbling mid-diastolic murmur, best heard at the upper left sternal border, associated with

a loud first and widely fixed, split-second heart soundE. A harsh holosystolic murmur associated with a loud first heart sound and a paradoxically split-second

heart sound ___________________________________________________________________________________________



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34 © 2014 MedStudy—Please Report Copyright Infringements to [email protected]

74.

During review of an electrocardiogram obtained on a 17-year-old patient, a PR interval of 0.1 seconds is noted

in association with a slow upstroke of the QRS complex. The QRS complex is also widened.

Which of the following best describes the most likely clinical presentation of this patient?

A. Intermittent episodes of supraventricular tachycardia

B. Bradycardia associated with complete heart blockC. Cardiomegaly associated with congestive heart failureD.

Frequent episodes of syncope or near syncope following changes in position

E. Chest pain associated with a pericardial friction rub ___________________________________________________________________________________________

75.

A 4-year-old girl presents to the emergency room with a 24-hour history of cough, chest pain, and decreased

exercise tolerance. On physical examination, she is alert but lethargic. Temperature is 100.2° F; blood pressure90/65; heart rate 115 beats/minute; respiratory rate 32 breaths/minute associated with accessory muscle use andgrunting. Her heart is enlarged on chest x-ray. Of note, she was recently discharged from the hospital afterundergoing open atrial septal defect repair 3 weeks earlier.

Which of the following is most likely to be identified during additional evaluation of this patient?

A.

Muffled heart sounds on auscultationB. Painful violaceous nodules in the pulp of the fingers and toes

C. Absence of breath sounds over one lung field associated with a shift in the point of maximal impulse(PMI) over the cardiac apex

D.

A continuous murmur heard best over the left upper sternal border

E.

Excessive drooling and inspiratory stridor ___________________________________________________________________________________________

76.

A 6-week-old girl with a rash is noted to have a heart rate of 52 beats/minute. On 12-lead ECG, the P–P andR–R intervals are regular, the PR interval is variable, and there is no apparent relationship between the P waves

and the QRS complexes.

Which of the following best describes the likely rash in this patient?

A. Sharply demarcated annular scaling plaques on the cheeks and periocular areas

B.

Reticulate bluish mottling of the lower extremitiesC. Indurated, well-circumscribed nodular erythematous plaques on the shoulders and backD.

Blotchy erythematous macules and edematous, yellowish papules and pustules on the face,

trunk, and extremitiesE. Papules and papulopustules associated with fine, white scales and hyperpigmented macules in areas

where previous lesions have ruptured; located primarily on the inferior chin, neck, and forehead ___________________________________________________________________________________________





77.

During a pre-participation sports physical, a 15-year-old girl is noted to have a mid-systolic click associated witha 1/6 mid-systolic murmur. Her peripheral pulses are normal, and her examination is otherwise unremarkable.

Which of the following best describes an additional feature of the disorder described in this patient?

A. The murmur and click are best heard over the right second intercostal space.B. Standing moves the click closer to the second heart sound.C. Maneuvers that increase left ventricular volume enhance ausculatory findings.

D. These auscultatory findings occur with greater frequency among individuals with a 45,XO karyotype.E.

These auscultatory findings represent the most common cardiac complication among patients with acute

rheumatic fever. ___________________________________________________________________________________________

78.

A 7-year-old boy with a history of recurrent otitis media and sinusitis is found to have normal serumimmunoglobulin levels with the exception of a serum IgA concentration of < 7 mg/dL.

This patient is at increased risk of adverse side effects associated with the routinely recommended

treatment of which of the following disorders?

A. Type I diabetesB. Kawasaki diseaseC. Absence (petit mal) seizure disorderD. Atopic dermatitis

E. Cystic fibrosis ___________________________________________________________________________________________

79.

A febrile 8-year-old boy with a 3-day history of warm tender swelling of both knees and the right ankle is noted

to be tachycardic. The measured PR interval on ECG is 0.26 seconds. On cardiac auscultation, a new murmur,characterized by a high-pitched apical holosystolic murmur radiating to the axilla, is noted. Just prior

to an echocardiogram, a rash is observed.

Which of the following best describes the most likely appearance of this patient’s rash?

A. Erythematous, serpiginous macular lesions with pale centers on the trunk and extremities

B. Diffusely distributed, round erythematous swollen plaques, target lesions, and marginated

wheals with central vesiclesC. Diffuse erythema with small punctate papules accentuated in the flexural areasD.

Erythematous macules and petechiae prominent around the ankles, wrists, palms, and solesE. Deep-seated and more superficial vesicles with peripheral erythema on the palms and plantar surfaces

___________________________________________________________________________________________



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80.

A 4-year-old girl, hospitalized 6 weeks earlier with Kawasaki disease, continues recommended treatment

to reduce the risk of coronary artery aneurysm.

This patient should be considered at increased risk for which of the following complications if she wereto become infected with an influenzae virus?

A. Toxic epidermal necrolysisB. Autoimmune hepatitisC. Reye syndromeD. Drug reaction with eosinophilia and systemic symptoms (DRESS) syndromeE. Pseudotumor cerebri

___________________________________________________________________________________________

81.

A 3-year-old boy is hospitalized and treated for Kawasaki disease after presenting with a history of increasedtemperature, extreme irritability, morbilliform rash, and mucous membrane changes.

Which of the following complications is associated with the greatest risk of morbidity in patients

with this disorder?

A. Coronary artery dilation of ≥ 8 mm B.

Administration of intravenous immune globulin ≥ 5 days after onset of symptoms C. Administration of corticosteroids ≥ 7 days after onset of symptoms

D. Heart rate ≥ 120 beats/minute on presentation E. Mitral regurgitation on echocardiogram

___________________________________________________________________________________________

82.

A 4-month-old girl returns for follow-up several days after being diagnosed with “bronchiolitis” at a localemergency department. Stridor is noted on physical examination. An AP chest x-ray reveals a wide heart base

and, on lateral film, a narrowed trachea displaced forward at C3–C4.

Which of the following is the most likely cause of this patient’s clinical and radiographic findings?

A.

A double aortic arch

B. Pulmonary slingC. Aberrant right subclavian artery

D.

Anomalous origin of the left coronary arteryE. Pulmonary arteriovenous fistula

___________________________________________________________________________________________

83.

An ECG in a 17-year-old male with multisystem failure following a near drowning is noted to have a QTc intervalof 0.36 seconds and an abrupt upslope of the T wave.





Which of the following is the most likely cause of this patient’s ECG findings?

A. HypokalemiaB.

Hypercalcemia

C. HyperkalemiaD. Hypocalcemia

E.

Hypothermia ___________________________________________________________________________________________

84.

When reviewing an electrocardiogram, which of the following components represents the time it takes

for the cardiac impulse to travel through the atrioventricular (AV) node?

A. The P waveB. The ST segmentC. The PR intervalD. The QT segmentE.

The T wave

___________________________________________________________________________________________

85.

During review of a chest radiograph, a “snowmansign,” formed by a large supracardiac shadow lying

just above the cardiac shadow, is identified.(see image)

Which of the following best describes the anatomicanomaly typically associated with this

radiographic sign?

A. Abnormal development of the pulmonaryveins

B. Discordant atrioventricular relationshipsC. Downward displacement of an abnormal

tricuspid valve into the right atriumD. Anterior deviation of the infundibular septumE.

A single arterial trunk arising from the heart

___________________________________________________________________________________________



MedStudy


86.

A 17-year-old girl with no known drug allergies and a prosthetic aortic valve is scheduled for a tonsillectomy

and adenoidectomy.

Which of the following best describes recommended antimicrobial prophylaxis in this patient?

A. Cefixime 400 mg orally, 48 and 24 hours prior to, the day of, and 24 hours after the procedure

B. Amoxicillin-clavulanate 875 mg orally, twice daily one day prior to, the day of, and one dayafter the procedure

C.

Amoxicillin-clavulanate 1 gm orally, one hour before and one hour after the procedure

D. Amoxicillin 2 gm orally, one hour before the procedureE. Amoxicillin 1 gm orally, one hour before and one hour after the procedure

___________________________________________________________________________________________

87.

A 20-day-old, severally ill male born at 25 weeks gestation, and undergoing treatment for respiratory distresssyndrome, is noted to have a prominent apical impulse, bounding peripheral pulses, and a continuous murmur

best heard at the second left intercostal space.

The most likely cause of his cardiac findings is best treated with which of the following medications?

A. DigoxinB.

IndomethacinC. Dexamethasone

D. Inhaled nitric oxideE. Prostaglandin E1

___________________________________________________________________________________________

88.

A 6-year-old girl with a history of supraventricular dysrhythmias due to Wolff-Parkinson-White syndromeis also noted on ECG to have a right bundle-branch block and tall peaked P waves in leads II and VI.

Which of the following best describes likely findings on echocardiogram in this patient?

A. Displacement of the tricuspid valves and a dilated right atriumB.

Ventricular septal defect and dextroposition of the aorta with override of the ventricular septum

C. Juxtaductal aortic coarctation and a bicuspid aortic valveD. Deformity of the pulmonary valve and right ventricular hypertrophy

E.

Increased right ventricular end-diastolic dimensions, flattening and abnormal motion of the ventricularseptum, and an atrial septal defect

___________________________________________________________________________________________

89.

An obese 14-year-old boy with Type 2 diabetes mellitus returns for follow-up 6 weeks after beginning treatmentfor primary hypertension. His blood pressure has improved, but he complains of a persistent cough since

the onset of treatment.





Which of the following classes of hypertensive medications is most likely to cause a chronic cough?

A. DiureticsB.

Beta-blockers

C. Calcium channel blockersD. Angiotensin-converting enzyme inhibitors

E.

Central alpha antagonists ___________________________________________________________________________________________

90.

An 18-year-old male is transported to the emergency room after a syncopal episode. He reports a historyof increased fatigue, shortness of breath soon after beginning to exercise, and several recent episodesof hemoptysis. Clubbing is present on physical examination; a right ventricular heave is noted in association

with a loud pulmonic component of the second heart sound, and a holosystolic murmur along the left sternal border. Moderate cardiac enlargement, enlargement of the pulmonary vessels in the hilar areas, and relative pulmonary under-vascularity in the outer two-thirds of the lung fields are noted on chest x-ray.

Which of the following best describes the likely pathophysiology of this patient’s clinical and radiographic

findings?

A. High pulmonary vascular resistanceB.

Anomalous drainage of the pulmonary veinsC. Downward displacement of an abnormal tricuspid valve into the right ventricle

D. Juxtaductal obstruction and hypoplasia of the transverse aortaE. Left-to-right shunting of blood through an ostium secundum defect and mitral valve insufficiency

___________________________________________________________________________________________

91.

An 18-month-old boy is transported to the emergency department following removal from his home dueto medical neglect. On physical examination, he appears cyanotic and severely malnourished. His respiratory rate

is 38 breaths/minute; heart rate is 140 beats/minute. A gallop rhythm is noted on cardiac auscultation. Chest x-rayreveals cardiomegaly, especially of the right side of the heart.

Which of the following vitamin deficiencies is the most likely cause of his symptoms?

A. Vitamin AB. Vitamin B1 (thiamine)C. Vitamin B2 (riboflavin)

D. Vitamin B6 (pyridoxine)

E.

Vitamin C ___________________________________________________________________________________________



MedStudy




Appendix A — Reference Color Photos

Adolescence, Question 35

Allergy&Immunology/Rheumatology,

Question 61

Adolescence, Question 36

Cardiology, Question 85



Appendix B — Antibiotic Review

Pediatrics Antibiotic Review Short and to-the-point information you need to know ...

BETA-LACTAM DRUGS

I. PENICILLINS

A. Pen G

• Group A Strep (Streptococcus pyogenes) responsible for “strep throat,”toxic shock syndrome, impetigo, and also known as the “flesh-eatingbacteria”

• Group B Strep (S. agalactiae) in babies and pregnant women

• Groups C–G Streptococci (sore throat and occasional blood streaminfections)

• Human bite or fist wounds (animal bites = amoxicillin-clavulanate)

• Gram (+) rods – Listeria causing neonatal and elderly meningitis

• S. pneumoniae (30% resistant to penicillin, 10% resistant to 3 rd generation cephalosporin) (If worried about meningitis, use vancomycin +3rd generation cephalosporin)

B. Ampicillin

• Drug of choice for Enterococcus (+ aminoglycoside, if serious infection orendocarditis) and Listeria

• Groups A&B Strep, mouth anaerobes

• Always include in an empiric regimen for kids less than 2 months of agewith meningitis because of Listeria and Enterococcus

• Do not use: No Klebsiella are sensitive

C. Piperacillin, Ticarcillin• Called extended spectrum penicillins because they expand gram-negative

spectrum to non-beta-lactamase producing GNR—E. coli , Pseudomonas,and anaerobes. Does not cover MRSA. To cover beta-lactamaseproducers: add a beta-lactam inhibitor (see below) to parent compound.

If the organism produces beta-lactamase:

• Amoxicillin + clavulanate (Augmentin®) (only oral formulation)

• Ampicillin + sulbactam (Unasyn®) (will NOT get Pseudomonas)

• Anti-pseudomonal extended-spectra penicillins:o Piperacillin + tazobactam (Zosyn®)

(if treating Pseudomonas—higher dose is required)

o Ticarcillin + clavulanate (Timentin

®

)

NOTE: NO ORAL PENICILLIN EFFECTIVE FOR PSEUDOMONAS

D. Oxacillin & Nafcillin

• Methicillin-sensitive Staph (MSSA) and Strep, but not as good for Strepas penicillin (if organism penicillin-susceptible)

• NO Enterococcus

• NO gram-negatives




II. CEPHALOSPORINS

A. 1st Generation: Cefazolin (Ancef ®, Kefzol®)

• Good for Gram (+) bugs

• Osteomyelitis

• Strep– Group A• Staph– MSSA & MSSE

• Poorer choices: E. coli (50% resistant), Klebsiella

B. 2nd Generations:Cefuroxime (Zinacef ®)

• Much better gram-negative coverage (except Pseudomonas)

• Good: Gram (+) (esp. Strep pneumoniae), Groups A&B, MSSAo H. influenzae—but not meningitis!o E. coli and Klebsiella

• 2nd Generations do not enter CSF well, so not for meningitis!Cefoxitin and Cefotetan are only cephalosporins that cover anaerobes (esp.gut)!!

• ***Side effect of most 2nd generations is prolonged prothrombin time inpatients with underlying liver disease or vitamin K deficiency (they inhibitrecycling of vitamin K) EXCEPT for cefuroxime.o Board question—patient with underlying liver disease placed on

2nd generation cephalosporin for anaerobic coverage and PT returnsout of range

C. 3rd Generations: Ceftriaxone (Rocephin®), Cefotaxime (Claforan®), andCeftazidime (Fortaz®)

• Expands spectra for gram-negatives (Ceftazidime includes

Pseudomonas, but no longer recommended for empiric coverage forfebrile neutropenics.)

• Ceftriaxone and Cefotaxime very good against S. pneumoniae (use withvancomycin if treating meningitis) and H. influenzae; ceftazidime poorchoice for pneumococcus

• Donʼt use for Staph aureus

• Drugs of choice for most CNS infections

D. 4th Generation:Cefepime (Maxipime®)

• Very broad spectrum ICU drug but does not cover most gut anaerobes!

• Good for Pseudomonas treatment

Ceftaroline (Teflaro®

) (Not approved in < 18 years of age)• First cephalosporin that covers MRSA

• Approved in adults for pneumonia and skin and soft tissue infections

III. OTHER BETA-LACTAM DRUGS

A. Monobactams-Aztreonam

• Aerobic, gram-negatives only




• Doesn’t cover Pseudomonas as well as aminoglycosides and veryexpensive

• ***Common Board question: Only beta-lactam that can be given if patienthas a history of anaphylaxis to penicillins.

B. Carbapenems: Imipenem (Primaxin®) and Meropenem

• Very broad spectrum: MSSA, gram (+), gram (-), Pseudomonas,anaerobes

• One of few antibiotics still effective in settings of “extended spectrumbeta-lactamase production”

• ***Will cross Blood Brain Barrier but may induce seizures (mainlyimipenem, in 10% of renal failure pts)

AMINOGLYCOSIDES

Gentamicin, Tobramycin, Amikacin

• Aerobic, gram-negatives only

• Good choice for Pseudomonas infections!

• **Use for Synergy with Beta-Lactams for Enterococcus, and Group BStrep

• Streptomycin for use in multi-drug resistant TB and Tularemia

• Toxic to otovestibular system and kidneys

QUINOLONES

Divided into “generations,” like the cephalosporinsDon’t use in pregnancy or those under 18 years of age, except approved as 2 nd linetherapy for urinary tract infections in children.Bioavailability of oral and IV formulations are same, so use PO if gut OK.

All quinolones lower seizure threshold and may cause CNS disturbances (dizziness).

A. 1st and 2nd generations: Ofloxacin and Ciprofloxacin

• Gram-negatives

• NO anaerobes

• NO PNEUMOCOCCUS

• Ciprofloxacin gets chelated by Aluminum, Mg hydroxide and Iron(i.e., antacids and vitamins) and bioavailability is reduced treatmentfailure

• Donʼt use with theophylline

• Ofloxacin–can give for Chlamydia (no longer effective for gonorrhea)

B. 3rd

Generation: Levofloxacin• Much broader spectrum with enhanced pneumococcal activity

• Better Gram (+) coverage than ciprofloxacin/ofloxacin

• Atypicals like Mycoplasma

• Gram-negatives

• No Anaerobes

• Single mutation in topoisomerase has led to resistant pneumococci.Watch out for this!




C. 4th Generations: Gemifloxacin (Factive®) and Moxifloxacin (Avelox®)

• Enhanced pneumococcal activity

• Some add anti-staphylococcal activity

• Some add anaerobic activity

• Known side-effects: Prolongs the QT interval and should be avoided inanybody with long QT, uncorrected hypokalemia, patients receiving anti-arrhythmics (procainamide, amiodarone, sotalol). Use with caution witherythromycin, antipsychotics, and tricyclics.

• Approved uses:o Gemifloxacin– Good for pneumonia and covers pneumococcus,

Haemophilus, Moraxella, Mycoplasma, Chlamydia o Moxifloxacin– Adds anaerobic & anti-Staph activity! Approved for

pneumonia, sinusitis, diabetic foot infections, intraabdominalabscesses, complicated skin and soft tissue infections

o Gatifloxacin– Adds anaerobic and anti-Staph activity but drugapproved for following infections: pneumonia, sinusitis, urinary tractinfections, and pyelonephritis, uncomplicated skin and soft tissueinfections, and rectal infections. (Gatifloxacin can cause severederangements in blood glucose and is contraindicated in diabetics!)

OTHER ANTIBIOTICS

A. Vancomycin

• MRSA, MRSE, and ampicillin-resistant Enterococcus

• All Gram (+) aerobic cocci and rods, except for lactobacillus

• S. pneumoniae meningitis—especially if resistant to beta-lactamantibiotics

• NOT for gram-negatives

•

“Red Man Syndrome” is a side-effect if given too quickly; not an allergybut due to histamine release (treatment: decrease rate of infusion anddiphenhydramine).

• ***Resistance is quickly emerging in Enterococcus (vancomycin-resistantEnterococcus VRE): quinupristin-dalfopristin (Synercid®) and linezolid(Zyvox®) are approved for VRE infections

B. Metronidazole (Flagyl®)

• Anaerobes

• Amebiasis

• Drug of choice for C. difficile colitis–if patient returns with diarrhea, treatagain with Flagyl, but if patient returns again with diarrhea, use PO

vancomycin• Not for aerobes; ***Flagyl is not for aerobic organisms***

C. Clindamycin

• Anaerobes, gram (+) aerobes, good for Staph and Strep

• If osteomyelitis and history of anaphylaxis to penicillin—good choice

• Community-acquired MRSA skin infections often respond to clindamycin.Some MRSA carry a gene for resistance to both erythromycin andclindamycin that gets turned on when exposed to drug. So, don’t use




clindamycin if isolate is resistant to erythromycin on primary susceptibilitytesting.

• NOT for MRSA bacteremia in adults

D. Doxycycline

• All weird organisms–Tularemia, Ehrlichia, RMSF, Q Fever (Coxiella

burnetii )• An inexpensive choice for community-acquired Pneumonia, Strep

pneumoniae, Atypicals (IDSA lists as first drug of choice)

• Ehrlichia –Monocytic form (Arkansas, Missouri, etc.) and Neutrophilic form(Northeast)

E. Macrolides: Erythromycin (EES), Clarithromycin (Biaxin®), and Azithromycin(Zithromax®)

• Mycoplasma; Chlamydia; Legionella

• High incidence of resistance in S. pneumoniae

• Erythromycin is drug of choice for Campylobacter diarrheal illness inchildren who cannot take quinolones.

• Some resistance in Staph and Strep

• Azithromycin adds H. influenzae coverage

• Binds to 50S subunit

• High doses can cause hearing loss.

• EES and clarithromycin inhibit cytochrome p450 system, so lots of druginteractions. Azithromycin doesn’t have same profile.

• Azithromycin drug of choice for Bartonella henselae (cat-scratch fever)

F. Trimethoprim/sulfamethoxazole

• Klebsiella and Pneumocystis jiroveci (PCP)

• Nocardia (if you see pneumonia with brain abscesses)

• Community-acquired MRSA skin infections often respond, if sensitive• NOT for use in MRSA bacteremia

• Hyperkalemia in setting of reduced GFR a common side-effect

G. Chloramphenicol

• RMSF

• Anaerobic brain abscesses

• Aplastic anemia is potential complication

H. Rifampin

• Multi-drug resistant TB

• Synergy with beta-lactams for MRSA and MRSE endocarditis and

prosthetic infections• Prophylaxis for H. influenzae and meningococcus (Neisseria meningitidi s)

NEWER ANTIBIOTICS (rarely used in children)

A. Quinupristin-dalfopristin (Synercid®)

• Approved for vanc-resistant Enterococcus faecium bacteremia andskin/soft tissue infections




• It is ineffective against vancomycin-resistant Enterococcus faecalis!

• Infusion-related myalgia can be severe

• Central line required for delivery

• Not for routine use in MRSA bacteremia

B. Linezolid (Zyvox®)

• Approved for pneumonia caused by MRSA, MSSA, and S. pneumoniae and complicated skin/soft tissue infections for gram-positive coverage

• 100% oral bioavailability, so use PO if gut okay

• Myelosuppression (especially thrombocytopenia with complicating GIbleed) is potential complication and is related to duration of use

• Contraindicated with use of SSRIs due to increased risk of serotoninsyndrome!

C. Tigecycline (Tygacil®)

• Approved for complicated skin/soft-tissue infections and intraabdominalinfections (broad spectrum)

•

Available only in IV formulation• Related to tetracycline; causes fetal harm and should NOT be given

during pregnancy!

• May cause tooth discoloration

D. Daptomycin (Cubicin®)

• Approved for complicated skin/soft-tissue infections caused by gram-positives (including MRSA, streptococci and vancomycin-susceptibleEnterococci ) and MRSA/MSSA bacteremia, including right-sidedendocarditis

• NOT for use in Staph left-sided endocarditis

• NOT for use in pneumonia as drug does not get into lung in high enough

levels• Watch for myositis; measure CPK levels in symptomatic people and

discontinue if > 1,000 U/L

• IV formulation only

Documents

2014 Peds Q&as Questions Book Cardio