* In the gram stain, most gram negative bacteria are bacilli, & most gram positive bacteria are cocci. *you have to know the ones bordered

# Many of 6th year questions in OSCE were from this lecture, & "what you don't learn in 4th year, you won't learn in 6th year" a wise man said :3

It is challenging ease so do your best.

MSSA (methicillin Sensitive S.aureus) & MRSA (methicillin Resistant S.aureus). Diseases:

o Skin/Soft tissue/bone infections: Cellulitis, Abscess, Osteomyelitis, Septic Arthritis.

o infections associated with foreign bodies (central line, VP shunt, Foley’s catheter): S.epedermidis (causes gradual indolent not life threatening infections) S.aureus (rapid acute and life threatening and it is the 2nd most common cause of central line infections after S.agalactiae)

o Hospital acquired infections: mostly MRSA. Also pseudomonas, actinobacter. o Staph saprophyticus: cause of UTI infection in sexually active female adolescents.

* Lactose +: Lactose fermenters.

*SCEEK: Serratia, Citrobacter, E.

Coli, Enterobacter, Klebseilla are

the commonest causes of UTI.

o S. Pneumonia: Pneumonia, meningitis, otitis media, sinusitis [The most common cause

of all these], Moraxella and H.influenza are the 2nd and 3rd most common. o S.Pyogenes (Group A strep): Tonsillitis, Skin/soft tissue infections (abscess, cellulitis)

impetigo and scarlet fever. o S.Agalactiae (Group B strep): Neonatal infection(neonatal sepsis, neonatal meningitis) o Enterococcus: UTI & Infective endocarditis; it’s most of the time just a contamination of

blood, except in two cases: 1-if the patient has heart disease that predispose him for infective endocarditis (S.viridans is the most common cause/ viridans means green). 2- Immunocomprimised causes sepsis.

o UTI and Intra-abdominal infections

Intra-abdominal infections are caused by gram negative bacteria & anaerobes The most common cause of UTI infection is E.coli, but the most common gram +ve

infection of UTI is enterococcus.

o Fever in neutropenia, immunocompromised patients (Opportunistic infections) o Hospital acquired infections

o Intra-abdominal infections, Aspiration pneumonia, brain abscess. o Aspiration pneumonia is common, especially in CP patients. Brain abscesses are not common

o Mycoplasma, Chlamydia, Legionella

o Pneumonia in school age children(>5 yrs old) and it is called walking pneumonia (as it is mild so the pt doesn't stay in bed and comes walking).

o treated with macrolides and if the pt is old enough we use tetracycline or fluroquinolone. ( we don't give cell wall inhibitors Antibiotics such as penicillin because atypical bacteria doesn't have a cell wall)

It is not a mess the next is a real mess

Actinobacter it's only treated by colistin and sometimes it's pan-drug resistant; no drug in the world can treat it!

For an antibiotic to be clinically useful, it must exhibit selective toxicity Bacteriostatic: Capable of inhibiting the growth or reproduction of bacteria. Bactericidal: Capable of killing bacteria. are used for immunocompromised patients & for serious infections meningitis & infective endocarditis.

Penicillins Cephalosporins Carbapenems Glycopeptides

Lincosamide Macrolides Metronidazole Aminoglycosides

Trimethoprim-sulfamethoxazole Fluroqinolones Tetracyclines

o Allergy to one βlactam is associated with cross reaction to most (but not always all) other βlatams. o Monobactams are not used in Jordan.

o Inhibit cell-wall synthesis: Bactericidal

o Classification Memorize the drugs in purple.

o Natural PCN: PCN G (IV) and PCN V (Oral, Gi). PCN G (IV) is not available in Jordan. o Synthetic PCN: Antistaphylococcal penicillins (penicillinase resistant):

(nafcillin, oxacillin, cloxacillin and dicloxacillin): effective ONLY Against MSSA. o Broad spectrum penicillins:

- Amino-PCN (ampicillin IV, amoxicillin PO): extend to cover gram negative bacteria like E. coli (ampicillin IV is not available in KAUH). - Ureidopenicillins (piperacillin IV, carbenicillin and ticarcillin): against pseudomonads.

o Coverage & Use

1- [Natural PCN]; Gram-positive cocci: Group A strep, Group B strep, some* strep pneumonia and some enterococcus.

o The resistance rate of group A and group B β-hemolytic strep to penicillin (penicillin, amoxicillin, and ampicillin) is zero! So NO need for 2nd or 3rd line treatment, the DOC is always penicillin! As in tonsillitis caused by group A strep. Or in neonatal sepsis caused by strep agalctiae(group B strep) where the DOC is IV ampicillin or penicillin G (benzyl penicillin) (IV route).

o S.Pneumonia infections have 2nd and 3rd line treatments, it has resistance to penicillin. 2- Most anaerobes (except Bacteroides, the intestinal anaerobes). *Amoxicillin provides a very good coverage for mouth flora; therefore it can be used alone as a prophylaxis before dental surgeries. 3- Some gram negative bacteria. 4- Resistance is through Alteration in penicillin-binding protein (PBPs) (MRSA). 5- When you add beta-lactamase inhibitor: (ampicillin and sulbactam, amoxicillin and clavulonic acid, piperacillin and tazobactam), will extend to more gram negative Moraxella & Haemophilus which cause URTI, Anaerobes including Bacteriodes and MSSA.

It acts by Inhibiting transpeptidase, the enzyme that catalyzes the final cross-linking step in the synthesis of peptidoglycan , it bactericidal, but cells only when they are growing

Augmentin or Amoclan®: Amoxicillin & Clavulanic Acid Unasyn: Ampicillin and Sulbactam Tazosyn®: Piperacillin and Tazobactam

You don’t have to add Flagyl to Tazosyn to cover anaerobes of intra-abdominal infections.

Inhibit cell-wall synthesis: Bactericidal

Classification o 1st generation (cefazolin IV and cefalexin PO). o 2nd gen: (cefuroxime IV and PO), include cephamycin subgroup against

Bacteroides (anaerobes) (cefoxitin and cefotetan). o 3rd gen: (cefotaxime IV, ceftriaxone IV, and cefixime PO) against Pseudomonas

aeruginosa (ceftazidime IV). *Cefixime PO: Suprax® *Ceftriaxone: Rocephin® *Ceftazidime is Not available in Jordan

o 4th gen: (cefepime IV) Not available in Jordan. o 5th gen: (ceftaroline IV) Not used yet in children.

o Coverage & Usage 1-First generation: Coverage: Most gram-positive cocci (Except MRSA, enterococcus). Some gram negatives like E. coli. Anaerobic pathogens except Bacteroides. Are very similar to amoxicillin, but unlike cephalosporin, amoxicillin cannot cover MSSA. Usage: Skin/soft tissue infections, some UTI, Group A strep infections,preoperative prophylaxis. 2-Second generation: Coverage: less active against gram-positive cocci than the first generation but more active against gram-negative bacilli, Haemophilus influenzae and Moraxella catarrhalis. Usage: Pneumonia& URTI Pelvic inflammatory diseases (cefoxitin: more anaerobic coverage). 3-Third generation: Coverage: less active against gram-positive organisms than the first generation. Usage: Meningitis, Sepsis, Pneumonia, UTI and many others.

• Ceftazidime has poor activity against gram-positive organisms and should be reserved for use in proven or highly suspected P. aeruginosa.

• Ceftriaxone causes the formation of "sludge“in the biliary tract and displacement of bilirubin from albumin causing hyperbilirubinemia (not used < 1 mo of age); Use cefotaxime IV instead.

4-Fourth generation: greater activity against the gram-negative Cefepime is as active against Pseudomonas aeruginosa (febrile neutropenia & Hospital acquired infections). 5-Fifth generation: Ceftaroline has a spectrum of activity similar to ceftriaxone but with improved gram-positive activity (MRSA). *Some organisms, including all enterococci, Listeria, Atypical bacteria (Legionella, Mycoplasma, and Chlamydia) are ALWAYS resistant to cephalosporin.

o Side effects They're generally well tolerated. Oral cephalosporin may cause nausea, vomiting, & diarrhea.

Take a deep breath

Inhibit cell-wall synthesis: Bactericidal. Imipenem, meropenem, ertapenem, doripenem: Very broad spectrum of activity.

o Coverage & Usage

Activity against many gram +ve ,-ve, anaerobic bacteria and stable to beta-lactamases including extended-spectrum beta-lactamases (ESBL).

o Intra-abdominal infections (gram negatives & anaerobs). o Nosocomial pneumonia (not first line). o Febrile neutropenia (not first line, use Tazosyn instead).

imipenem is prescribed in combination with cilastatin, not like Ertapenem and meropenem.

o Imipenem must be administered with Cilastatin to avoid hydrolysis and to reduce

nephrotoxicity. In general, tolerability to carbapenems is good.

o Carbapenems lack the activity against Enterococcus faecium, MRSA. o Ertapenem lacks the activity against Pseudomonas aeruginosa.

o Side effects Seizures are a well-known side effect of imipenem/cilastatin, especially in patients who have meningitis; the incidence of seizures can be as high as 33%. But approximately 3% of patients who do not have CNS infections.

It’s the only drug available against ESBL, carbapenemase producing enterobacteriaceae started to appear in some countries where carbapemens are abused.

Free ½ Page

Inhibit cell-wall synthesis: Bactericidal (not βlactam drugs therefore isn’t degrades by βlactamase). against certain gram +ve bacteria ( MRSA ) ( PRSP ) ( VRE ).

Vancomycin IV and PO, Teicoplanin IV (is used in adults).

o Coverage & Usage o Gram positive including MRSA and enterococcus. o Meningitis (S. pneumonia). o Hospital-acquired infections (Staph aureus). o Foreign body associated infection (VPS prosthetic materials)(S.aureus & S.epidermidis). o C. difficile (PO only) - Vancomycin is used mainly IV, given PO in only one case: C.

difficile colitis (Pseudomembranous colitis). Because it can't be absorbed from the intestine.

o Side effects

o Red man syndrome: Slow the infusion rate to over 2 hours and increase the dilution volume Antihistamine & Steroids are given in severe cases. It’s not an allergic reaction caused direct effect on mast cells and basophils characterized by redness and itchiness of the whole body.

o Extravasation will cause serious injury with possible necrosis and tissue sloughing. o It’s might cause nephrotoxicity.

o Aztreonam Have excellent activity against many gram-ve rodes entrobacteriaceae and pseudomona but are inactive against gram+ and anaerobic.

2nd line drug in the treatment of TB. And superficial skin infections but too toxic for systemic use.

Binds to the 50s ribosomal subunit of bacteria

disrupting protein synthesis: Bacteriostatic.

Clindamycin.

o Coverage & Usage o Anaerobic; Aspiration pneumonia. o streptococcal & staphylococcal infections; Bone/Joint and skin/soft tissue infection

including MRSA.

o Toxic shock syndrome; To stop toxin production Antitoxin effect against toxin-elaborating streptococci and staphylococci.

Vancomycin doesn’t stop the toxin production of Staph & Strep, therefore you should give Clindamycin with it in case of very ill patients.

o Side effects The most common side effect is diarrhea. It’s the most common cause of C-difficile colitis.

Binds to the 50s ribosomal subunit of bacteria disrupting protein synthesis: Bacteriostatic.

Azithromycin, Erythromycin, Clarithromycin.

o Coverage & Usage o gram-positive bacteria (streptococci, staphylococci). o Atypical bacteria Atypical pneumonia. o Bordetella pertussis. o Common substitute for patients with a penicillin allergy.

o Side effects Common side effect in neonates is hypertrophic pyloric stenosis.

Chloramphenicol wide anaerobic static(- h.inf. s.pneu n.men)BM toxicity aplastic anemia

gray baby syndrome

Double coverage means the use of more

than one type of antibiotics in serious

infections so if one type doesn't work the

other may work.

There is only one indication where we have to use doxycycline even in one year old child. It is spotted Rocky Mountain fever (tick-borne) and rickettsia diseases.

o Binds the 30S ribosomal subunit inhibiting protein synthesis. Depending on their concentration, they act as bacteriostatic or bactericidal agents.

Gentamicin, tobramycin, amikacin, neomycin(preoperative bowel preparation).

Not available orally Must be given intrathecally in the treatment of meningitis.

o Coverage & Usage

Gram-negative aerobic bacteria, including pseudomonas. They are ineffective against anaerobes. Gram positive usually as synergistic effect.

The synergistic effect between aminoglycosides and β-lactam antibiotics is well established against gram positives; (b lactams destroy the cell wall then aminoglycoside enters and inhibit synthesis of proteins).

Usually used for synergy or double coverage, or for UTI.

o Side effects Ototoxicity and nephrotoxicity are the most notable adverse effects.

However, studies have failed to demonstrate a consistent correlation between aminoglycosides and hearing loss in pediatric patients; the risk for nephrotoxicity in pediatric patients also has rarely been demonstrated.

o Binds the 30S ribosomal subunit inhibiting

protein synthesis, bacteriostatic. Bacteriostatic agent has wide spectrum.

o Side effects o They suppression of lactobacillus in vaginal normal flora results in a rise in pH which

allows C.Albican to grow and cause vaginitis. o Brown staining of the teeth of fetuses and young children. o Avid calcium and iron chelators. o Photosensitive.

o Tetracycline isn't given for children under 8 yrs because it causes permanent

staining of teeth and joints.******* There are

2 pages

It inhibits nucleic acid synthesis by disrupting

the DNA Synthesis; bactericidal.

o Coverage & Usage: Anaerobic bacteria: Aspiration pneumonia, Intra-abdominal infections, lung abscess. Clostridium difficile infection. Protozoa: Amoebiasis, Griadia,Trichomonas.

Inhibit folate biosynthesis and metabolism: Bactericidal

o Coverage & Usage o Gram-ve and most gram+ve (MRSA), no coverage for group A strep. o Urinary tract infections o Skin/soft tissue and bone/joint infections o Treatment and prophylaxis of Pneumocystis jirovecii pneumonia (PCP); o Shigella o Stenotrophomonas maltophilia

is an aerobic gram-ve bacillus. It is an uncommon pathogen in humans. It is usually incapable of causing disease in healthy hosts without the assistance of invasive medical devices that bypass normal host defenses. It's associated with pulmonary infections in Cystic Fibrosis patients.

o Side effects o Not used in G6PD (causes hemolysis). o Not used in neonates (displaces Bilirubin).

o bactericidal agents block DNA gryase. For complicated UTI Ciprofloxacin, Clevofloxacin, Norfloxacin, Oflofloxacin.

o Achilles tendonitis and rupture of tendone o Isn't given for children under 18 yrs and pregnants because they damage the bone and

cartilage

• Anti-pseudomonas

Aminoglycosides,quinolones , cephalosporins (ceftazidime, cefepime), antipseudomonal penicillins, carbapenems.

• Anti-Anaerobic

metronidazole, clindamycin, penicillin (i.e. ticarcillin, ampicillin, piperacillin) and a beta- lactamase inhibitor (i.e. clavulanic acid, sulbactam, tazobactam), carbapenem.

• Anti-Atypical

Macrolides and Tetracyclines.

• Anti-MRSA Vancomycin, Bactrim, Clindamycin, Doxycycline, Linezolid, ceftaroline.

• Anti-C.diff

Vancomycin & Metronidazole

The last one

OSCE questions

I. Gram stain for CSF for 5 y/o Pt with meningitis. 1- Identify the microorganism? 2- What is the treatment for it ?

Answers:

1- Strep. Pneumonia 2- 1. vancomycin

2. 3rd generation cephalosporin (Both drugs should be wrote)

II. Gram stain test 1- Identify the MO 2- Give one example for the MO

Answers:

1- Gram positive bacilli 2- listeria spp. ,,, clostridium spp.

III. Picture for pt 1- What is your diagnosis? 2- What are the lines of treatment?

Answers:

1- Scarlet fever 2- Penicillin

Note: it is caused by streptococcus pyogenic GABHS

IV. Frequently Q

1- What is your Dx.? 2- Give 2 causative MO.

Answers:

1- Bullous Impetigo. 2- Staph aureus - Group A beta- hemolytic strep. (pyogenes).

V. Hx of a boy who had URTI, then developed bilateral nodular lesions on his lower lembs. 1- What’s your Dx.? 2- Give a non-infectious cause.. 3- Give 2 microorganism causes this condition

Answers:

1- . Erythema 2- Nodosum Sarcoidosis 3- Group A strep - Mycoplasma tuberculosis. - Chlamydia.

Note ; Most gram positives are cocci …… the exceptions are few like: listeria/ bacillus/clostredium .. Most gram negatives are bacilili ….. The only gram negative cocci is niesseria (N gonorrhea and N meningitidis)

Final

4th year questions:

2017

I. Fever and chemotherapy-induced neutropenia all drugs should be given empirically pending blood culture results except

A. Merpenem B. Cefipim C. Ticarcillin/clavulanate D. Piperacillin/tazobactam E. Cefetaxime

Answer:

II. Drug that cause gingival and teeth discoloration? A. Gentamicin B. Tetracycline

Answer: B

2015

III. A patient with ALL presented with fever, all of these drugs can be given except A. Meropenem B. Ceftriaxone C. Gentamicin D. Ceftazidime E. Piperacillin tazobactam

Answer: B

IV. Staph. aureus causes all of the following except A. Endocarditis B. UTI C. Pneumonia D. Septic arthritis E. Cellulitis

Answer: B 2013

V. What drug to give in acute otitis media

Answer : high dose amoxicillin

VI. Most effective third generation cephalosporin against streptococcus infection A. Ceftriaxone B. Ceftazidime.

Answer: A 2009

VII. Concentration-dependent drug: A. Imipenem B. Amikacin

Answer: B

Note: CONCENTRATION dependent drugs: Fluroquinolone, Amiglycosides

2008

VIII. Someone developed streptococcus pyogens and was planning to go for a trip in 2 days, what is the best treatment

A. Penicillin V for 10 days?

Answer: A

Note: “I think because of his trip if there was an option about a shot of penicillin G IM ill choose it”

6th year questions:

2018

I. Child with sore throat, and fever. The child plays & active when afebrile. Yesterday his mother gave him Amoxicillin/clavulanic acid. All are appropriate to tell the mother except:

A. This is mostly viral infection & will resolve spontaneously B. Warm fluids & antipyretic can help to improve his condition C. -Next time she shouldn't give him antibiotic without doctor prescription D. He should continue the course to prevent development of antibiotic resistant

Answer: D

II. Child comes with a picture of bilateral otitis media and purulent eye discharge. The best treatment for this case is:

A. No ttt B. Amoxicillin regular dose C. Amoxicillin high dose D. Amoxicillin + clavulanic acid

Answer D Note: This is something called otitis conjunctivitis syndrome It is probably caused by hib Choice C for otitis media alone, if it is resistant we give choice D If allergic to penicillin we give azithromycin

III. Which drug you do not give to <12 yrs?

Answer : Floroquilines

IV. In which of the following cases you don't give anti-pseudomonals (something like that) A. Community acquired meningitis B. Diabetic with greenish sputum C. Cystic fibrosis exacerbation D. Otitis externa

Answer: A

2017

V. Penicillins are used in treatment of all of the following except A. Treponema Pallidum B. Strep pneumonia C. Staph. Aureus D. H.Influenza

Answer: D

VI. Pertussis tt in neonates?

Answer :Azithromycoin

Note :Treatment: supportive care; hospitalization if <6 months old; erythromycin for 14 days including all household contacts; macrolides can also be given

VII. 4 years old, Brucellosis, what to give?

A. Bactrim for 4 weeks B. Doxycycline + Rifampin for 6 weeks C. Trimethoprim_sulfamethoxazole & rifampin for 6 weeks

Answer:C

Treatment: For patients more than 8 years old give: Oral Doxycyclin & rifampin. · For patients less than 8 years old give: Trimethoprim_sulfamethoxazole & rifampin. · Duration of treatment: at least "6 weeks". · If there is a serious complication (Myocarditis, osteomyelitis, Meningitis) we add streptomycin or Gentamycin over the first 2 weeks & the duration of treatment will be several months. · If there is a skin abscess, surgical drainage is a must 2016

VIII. A term neonate is born to a mother who has chorioamnionitis and fever. He is currently asymptomatic. Which of the following is the best statement regarding administration of antibiotics for this patient?

A. No antibiotics are needed B. Ampicillin and gentamicin C. Vancomycin and gentamicin D. Ceftriaxone and ampicillin

Answer: B *Infants born to mothers with proven or suspected chorioamnionitis should receive empiric antibiotic treatment while awaiting culture results- Uptodate

IX. Apart from the neonatal period, the most common cause of hematogenous osteomyelitis is Answer: Staphylococcus Aureus

X. Which of the following antibiotics doesn’t cover Pseudomonas Aeruginosa? A. Ceftriaxone B. Meropenem C. Ceftazidime D. Cefepime

Answer : A

XI. A young patient presents with soft tissue infection in his lower limbs. Tissue cultures are positive for MRSA. The patient is stable. Which of the following agents can be used in his treatment?

Answer Clindamycin *Other choices included antibiotics with no MRSA coverage

XII. Patients with chronic granulomatous disease are at increased susceptibility of A. Catalase positive organisms B. Coagulase positive organisms C. Gram negative organisms

Answer: A XIII. 7 year old patient presents with sore throat and fever for the last few days. On examination he has

palpable cervical nodes and small amount of exudates on his tonsils. His rapid antigen detection test for Strep is positive. On a previous occasion, his mother reports that her child had a skin rash and swelling of his lips after administration of amoxicillin. Which of the following is true regarding management of this patient?

A. Give the patient amoxicillin B. Give the patient azithromycin C. There is no need for any antibiotics D. Give the patient cefuroxime

Answer:B

2015

XIV. A patient presented with a typical picture of otitis media. He had history of type 1 hypersensitivity to penicillin. What is the drug of choice?

A. Azithromycin B. Cephalexin C. trimethoprim sulfa

Answer A

XV. Mechanism of action for cephalosporins: A. binds to penicillin binding proteins & inhibits cell wall synthesis B. bind to 30s ribosomal subunit c. bind to 50s ribosomal subunit

Answer A

XVI. One of the following cannot be used to treat MRSA: A. meropenem B. linezolid C. vancomycin D. trimethoprim sulfa E. clindamycin

Answer A

2013

XVII. helminth infx, perianal pruritus, +ve scotch tape test, wht rx? Answer Mabendazole 2009

XVIII. Vancomycine is given because Answer : Strep. Resistance to penicillin

XIX. Antipseudomonal effect: Answer : Cefepime

XX. A patient has leukemia , came with fever , decreased WBCs , central line cath. , what to give : A. Cefepime and vancomycin B. Ceftriaxone and vancomycin

Answer A 2008: XXI. Which of the followings is a correct combination?

A. Vancomycin – red man syndrome B. Ampicillin – neuropathy

Answer A

2007: XXII. A drug that is a 3rd generation cephalosporins and has antipseudomonal effect:

A. Ceftazidime B. Ceftaxime C. Cefepime D. Cefdinin

Answer A

XXIII. A drug that is not given below the age of 12 Years: A. Ciprofloxacin B. Tobramycin

Answer A

XXIV. A 3 year old child had an episode of otitis media 2 months ago, then he developed another episode. The best treatment is:

A. Amoxicilin-clavulanic acid B. Amoxicillin C. 3rd generation cephalosporin

Answer B Note: Amoxicillin still use in RECURRANT attack. But in RESISTANT (more than 3 days duration of treatment with Amoxicillin and still persistant) we use Amoxicillin + clavulanic acid. XXV. Regarding OM, one is true:

A. 3rd generation cephalosporins can be used if treatment failed B. Vaccination can prevent strept. Pneumonia that cause OM

Answer A Note: The recommended first-line therapy for most children with acute otitis media is amoxicillin (80 to 90 mg/kg/day in two divided doses). Failure of initial therapy with amoxicillin at 3 days suggests infection with β-lacta-mase-producing H. influenzae or M. catarrhalis or relatively or highly resistant S. pneumoniae. Recommended next-step treatments include high-dose amoxicillin-clavulanate (amoxicillin 80 to 90 mg/kg/day), cefuroxime, cefdiniraxetil, or ceftriaxone (50 mg/kg intramuscularly in one to three daily doses). Note: Pneumococcal vaccine and influenza vaccine may reduce marginally the incidence of otitis media. The conjugate S. pneumoniae vaccine seems to reduce pneumococcal otitis media caused by vaccine serotypes by half, all pneumococcal otitis media by one third, and all otitis media by 6%.

XXVI. Best management of mycoplasma pneumonia :

Answer: Azethromycine

XXVII. 13 year old child with cystic fibrosis presenting with worsening cough, purulent sputum and fever. The culture revealed gram negative bacilli. The most appropriate antibiotic to use:

Answer pipercillin/ tazobactam Note: anti-pseudomonal.

XXVIII. A 4 year old girl with 2 months history of right ear greenish discharge. On examination: painless ear pinna, red and perforated tympanic membrane. The most likely cause is:

A. Staph aureus B. Pseudomonas C. Strept pneumonia D. Moraxilla cataralis E. Hemophillus influenza

Answer B

XXIX. Why do we prescribe high dose of amoxicillin for AOM: A. To overcome moraxilla resistance. B. To overcome resistance of changing penicillin binding proteins C. To overcome resistance caused by B lactamase of strept pneumococcus D. To overcome resistance caused by B lactamase of Hemophillus influenza

Answer B

XXX. What doesn't cause abscess in the lung: A. Chlamydia trachomatis B. Staph aureus C. H. influenza D. Klepsiella

Answer a Note: Causes of Lung Abcess: Aerobe- Staph, Strep, Klebsiella, Hemophilus, Pseudomonas, E.coli Anaerobe- bacteroid Microaerophilic Strep- Strep millary Fungi- Candida, Asparagillus Parasite- E.histolytica Note: chlamydia trachomatis is the most common cause of afebrile pneumonia, commonest at age of 30 days- 3 months

XXXI. A child with impetigo on his face , and now comes with dullness on his right lower lung with decreased TVF and high fever , u give him :

Answer Cefuroxime IV with admission Note: Impetigo due to Staph aureus and dullness on his right lower lung with decrease TVF indicates Pleural effusion. Thus 2nd Generation Cephalosporin is the D.O.C.