Answers

1. C. In an outbreak setting, involved hospital staff may undergo culture investigation of their skin flora and orifices to determine the source of infection. Oral vancomycin is not usually absorbed from the GI tract to be effective, and IV vancomycin is not indicated to eradicate colonization. Bacitracin ointment has been used with limited success and may be an option, along with strict handwashing and isolation precautions. Polymyxins are effective topical agents for gram-negative infections. A furlough from patient care responsibilities is unlikely to eradicate her nasal colony.

2. E. Trimethoprim, which exhibits broad-spectrum activity, with sulfamethoxazole is active against most aerobic and facultative gram-positive and gram-negative organisms. It is very effective in UTIs caused by gram-negative bacteria. Teico-planin, bacitracin, and vancomycin are antibiotics with limited spectra of gram-positive coverage. Although polymyxins are active against gramnegative organisms, their only use is topical because of severe nephrotoxicity associated with IV therapy. Alternative therapy would be to use quinolone.

3. C. Minor suture irritation and superficial infection can be treated topically. Effective agents in the absence of culture results would be an ointment such as triple antibiotic, which has gram-positive and gram-negative spectra. Generally, polymyxins are active only against gram-negative organisms, and bacitracin works only against gram-positive organisms. Intravenous antibiotics are not indicated unless this evolves into a deeper soft tissue infection. Observation without any active management is unlikely to be successful.

4. D. It is not unusual to get colonized by hospital flora, especially with an indwelling Foley catheter. If the patient does not have any clinical evidence of infection, it is not necessary to start therapy with van-comycin or for that matter, any antibiotic. Entero-coccal UTI can still be treated with penicillins, but they are increasingly resistant to penicillins and even vancomycin. Since susceptibility data are still pending, neither vancomycin nor the new drug linezolid is yet indicated. Levofloxacin, although a good drug for UTIs, does not have enterococcal coverage. Discontinuation of the Foley catheter if possible and follow-up appear to be the best option. Watchful waiting may not be effective because these patients may go on to develop complicated UTIs.

5. C. Teicoplanin, although used in Europe, is not approved for use in the United States. It can be used to treat a variety of gram-positive infections and should be considered in resistant gram-positive infections as well. Bacitracin and polymyxins are topical agents with potential for serious nephrotoxicity when used parenterally. Linezolid is recently approved for resistant gram-positive infections (VRE and MRSA) and is available in the United States.

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