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Self-Assessment Questions

Critical Care Medicine

Sepsis: Review Questions

Joseph Varon, MD, FACP, FCCP, FCCM

Dr. Varon is Associate Professor of Medicine, Pulmonary and Critical Care Section, Baylor College of Medicine, Houston, TX, and Research Director, Department of Emergency Services, The Methodist Hospital, Houston.

Paul E. Marik, MD, FCCM

Dr. Marik is Director, Medical Intensive Care Unit, Washington Hospital Center, Washington, DC.

Choose the single best answer for each question.

1. A 70-year-old woman who weighs 55 kg is admitted to the intensive care unit (ICU) with Escherichia coli urosepsis. On admission her blood urea nitrogen (BUN) is 25 mg/dL, and her serum creatinine is 1.4 mg/dL. She is treated with gentamicin 120  mg every 12 hours. A trough gentamicin level taken before the third dose is 1.8 µg/mL, and the dosage of gentamicin is not changed. By the eighth ICU day, her BUN and serum creatinine increase to 78 mg/dL and 4.3 mg/dL, respectively, and her urine output decreases. The gentamicin is stopped. Her serum creatinine peaks on the 12th hospital day and then declines to 2.3 mg/dL by the end of the third week. Which one of the following dosing/drug regimens is most likely to have reduced the risk of renal toxicity in this patient?
  1. Concomitant low-dose dopamine (2 µg/kg/min)
  2. Gentamicin 200 mg once daily
  3. Gentamicin 100 mg once daily
  4. Tobramycin 100 mg every 12 hours
  5. Netilmicin 100 mg every 12 hours
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2. A 67-year-old man with a history of chronic obstructive pulmonary disease (COPD), hypertension, and chronic renal failure is admitted to the ICU with community-acquired pneumonia. His treatment includes broad-spectrum antibiotics, corticosteroids, and inhaled ß2 stimulants. Due to a severe ileus and gastric intolerance, total parenteral nutrition is commenced. The patient’s temperature normalizes after the third day in ICU, and his oxygenation improves. However, on the ninth hospital day he develops a fever with an increase in the peripheral leukocyte count. Antibiotics are stopped; and blood, urine, and sputum cultures are performed. Candida krusei is isolated from a single blood culture, and 60,000 CFU/mL of C. krusei is isolated from the urine. Which of the following is the most appropriate next step in the management of this patient?
  1. Remove, culture, and replace all vascular catheters.
  2. Remove, culture, and replace all vascular catheters and begin intravenous (IV) fluconazole.
  3. Remove, culture, and replace all vascular catheters and begin IV amphotericin.
  4. Remove, culture, and replace all vascular catheters; replace urinary catheter; and begin amphotericin bladder irrigations.
  5. Repeat the blood and urine cultures and observe the patient.
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3. A 55-year-old man with a history of COPD is admitted to the ICU with severe community-acquired pneumonia and respiratory failure. A chest radiograph shows bilateral lower lobe consolidation. Gram’s stain of the patient’s sputum reveals numerous inflammatory cells as well as gram-negative and gram-positive organisms with no predominant organism. Which one of the following is the most appropriate empiric antibiotic regimen?

  1. Ceftazidime
  2. Ceftriaxone and erythromycin
  3. Erythromycin
  4. Ampicillin with sulbactam and doxycycline
  5. Cefuroxime
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