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WorksheetsModule 5: Antibiotic Stewardship (Stanford University)
Total questions: 100
Worksheet time: 50mins
What is a major cause of morbidity and mortality in cancer patients, particularly those receiving intensive chemotherapy or undergoing hematopoietic cell transplantation?
Infections
Hypertension
Diabetes
Arthritis
Antimicrobial agents are commonly prescribed to cancer and hematopoietic cell transplant patients for which of the following purposes?
Pain management
Treatment and prevention of infectious complications
Nutritional support
Psychological support
True or False: Cancer patients are a homogenous group in terms of infectious risk.
True
False
List two factors that dictate an individual's infectious risk in cancer and hematopoietic cell transplant patients.
Net state of immunosuppression, level of organ dysfunction, pathogen exposure (any two)
Age and gender of the patient
Type of chemotherapy only
Nutritional status and exercise routine
What are the two types of pathogen exposure mentioned in the passage?
Endogenous and exogenous
Aerobic and anaerobic
Bacterial and viral
Direct and indirect
Which of the following is NOT listed as a risk factor for infection shared by solid tumor patients?
Obstruction of bronchi by tumor
Local tissue injury from chemo or radiation therapy
High blood pressure
Postoperative infections
Autologous transplant recipients have _______ infectious complications than their allogeneic counterparts and their infections occur when they are neutropenic.
fewer
more
the same number of
no
For allogeneic transplant patients, the types of infections to which they are most vulnerable can be roughly divided based upon the _______ elapsed from transplantation.
time
location
donor type
immunosuppressant
Routine antibiotic prophylaxis was not practice before 2006 at a Tertiary Cancer Center in New York City, but the prevention of pre-engraftment viridans streptococcal sepsis and allogeneic hematopoietic cell transplant patients was a high priority due to an incidence of 7.4% and an attributable mortality of _______.
21%
5%
35%
12%
Which of the following was associated with complete elimination of viridans streptococci bacteremia in a joint antimicrobial stewardship, infectious disease and transplant service analysis?
Penicillin prophylaxis
Vancomycin base prophylaxis
Ciprofloxacin prophylaxis
No prophylaxis
According to the passage, what is a common problem that occurs during receipt of cytotoxic therapy for the underlying malignant disease?
Fever and neutropenia
Hypertension and bradycardia
Hyperglycemia and weight gain
Rash and joint pain
The 2010 Infectious Diseases Society of America guideline provides a blueprint for the antimicrobial management of which type of patients?
Febrile neutropenic patients
Patients with chronic kidney disease
Patients with diabetes mellitus
Patients with autoimmune disorders
High-risk neutropenic patients are anticipated to have an absolute neutrophil count less than ____ for more than seven days after cytotoxic chemotherapy and/or have significant co-morbidities.
100
500
1000
1500
Low-risk neutropenic patients can receive initial oral or intravenous doses in a clinic or hospital and then be transitioned to outpatient oral or intravenous treatment, provided they meet specific criteria.
True
False
Which of the following is a well-studied regimen for outpatient therapy in neutropenic patients?
Oral quinolone and Amoxicillin clavulanate
Oral penicillin and cephalosporin
Intravenous vancomycin and ceftriaxone
Oral tetracycline and erythromycin
What should patients whose clinical condition worsens or who have recurrent fever or new signs of infection do, according to the passage?
They should be able to reach their local medical facility within an hour and warrant admission and management as for high-risk patients.
They should continue their current treatment at home without any changes.
They should only seek medical help if symptoms persist for more than a week.
They should increase their fluid intake and rest at home.
Antimicrobial stewardship teams can assist prescribers in making modifications to initial empiric therapy for patients who are known to be colonized and/or have prior infection due to multi-drug resistant organisms.
True
False
According to the passage, at any one time, what percent of residents are on antimicrobial therapy in long-term care settings?
Eight percent
Twenty percent
Thirty-five percent
Fifteen percent
What is the estimated percentage of systemic antimicrobial use in the long-term care setting that is considered inappropriate and suboptimal?
25-75 percent
5-15 percent
80-95 percent
0-5 percent
Residents who had received Levofloxacin in the hospital were how many times more likely to develop MRSA in the long-term care facility?
1.6 times
2.5 times
0.8 times
3.2 times
Which of the following is NOT an objective of an antibiotic stewardship program?
Minimize acquired resistance
Increase patient toxicities
Improve patient outcomes
Reduce treatment costs
The Joint Commission has now established criteria for a hospital antibiotic stewardship program.
True
False
What is the take-home message from the passage regarding antibiotic exposures and infection control measures?
Antibiotic exposures and infection control measures in the hospital influence a long-term care facility residents' health and vice versa. Every attempt must be made to improve antibiotic use in both acute and long-term care settings.
Antibiotic exposures are only important in hospitals and do not affect long-term care facilities.
Infection control measures are not necessary in long-term care settings.
Antibiotic use in acute care settings has no impact on residents of long-term care facilities.
According to the passage, what is one reason why infectious diseases trained personnel are usually not present at long term care facilities?
Lack of necessary personnel, lack of funding, and paucity of well-validated strategies specific to long term care facilities.
High turnover rates among residents and staff.
Strict government regulations prevent hiring such personnel.
Long term care facilities have no need for infection control measures.
What is the main challenge in the clinical diagnosis of infection in long term care facility residents?
Symptoms are often not expressed or misinterpreted due to hearing and cognition issues and comorbidities.
Infections are always accompanied by high fever in these residents.
Laboratory tests are always conclusive in diagnosing infections in these residents.
Residents in long term care facilities rarely develop infections.
Which organization has developed the core elements for antibiotic stewardship in long term care facilities?
The Centers for Disease Control and Prevention (CDC)
World Health Organization (WHO)
American Medical Association (AMA)
Food and Drug Administration (FDA)
Which of the following is NOT mentioned as a strategy for antimicrobial stewardship in long term care facilities?
Passive monitoring
Education
Increasing funding for new drugs
Pre-authorization of antibiotics
Passive monitoring in antimicrobial stewardship includes measuring types and quantities of antibiotics used.
True
False
What is the most intrusive strategy for antimicrobial stewardship mentioned in the passage?
Post prescriptive review and feedback by expert antimicrobial prescribers.
Routine hand hygiene audits.
Annual staff training on infection control.
Distribution of educational pamphlets.
According to the passage, how is asymptomatic bacteriuria defined?
Positive urine cultures with clinical signs and symptoms
Positive urine cultures in the absence of clinical signs and symptoms
Negative urine cultures with symptoms
Negative urine cultures without symptoms
Treatment for asymptomatic bacteriuria is indicated in which of the following situations?
In all elderly patients
In pregnancy and after the general urinary tract is manipulated only
In patients with pyuria
In patients with chronic symptoms
Multiple treatments are often given for asymptomatic bacteriuria in the elderly, but trial after trial have shown that there is no real benefit from ______ patients with asymptomatic bacteriuria.
treating
diagnosing
isolating
hospitalizing
What is a major consequence of treating patients with antibiotics for asymptomatic bacteriuria?
Improved patient outcomes
Unnecessary adverse drug effects and colonization with multi-drug resistant organisms
Decreased mortality
Increased pyuria
Over 90 percent of elderly with bacteriuria have pyuria.
True
False
What intervention was found to be effective in decreasing total urine culture sent and inappropriate cultures in long-term care facilities?
Increasing empiric therapy
Educational intervention targeting diagnosis and treatment of asymptomatic bacteriuria
Treating all positive urine cultures
Using more antibiotics
Antibiotic use in the study was most often inappropriate and only indicated in ______ percent of the cases evaluated.
18
45
32
60
What is the main goal of antimicrobial stewardship programs in long-term care facilities?
To increase the use of antimicrobials
To standardize infection control and reduce unnecessary antimicrobial use
To focus only on acute care settings
To avoid involving families in care
The syndromic approach in long-term care facilities may be used as low-hanging fruit to target syndromes such as ______ or UTI.
pneumonia
arthritis
diabetes
hypertension
What is the stated goal of palliative care at the end of life?
Palliation (symptom management, especially pain management) is the stated goal.
To cure the underlying disease completely.
To prolong life at any cost.
To focus solely on spiritual counseling.
Which of the following is NOT typically a focus of end of life care?
Symptom management
Diagnostics
Preventing and treating suffering
Anticipating patient needs
Select the three physical symptoms that might occur at the end of life.
Pain, difficulty breathing, fatigue
Increased appetite, improved vision, rapid healing
Frequent exercise, weight gain, improved memory
Heightened energy, faster reflexes, increased strength
According to the passage, what is a common reason for increased risk of infection in patients at the end of life?
Poor hygiene
Underlying disease and disease therapies
Overuse of antibiotics
Lack of medical care
How many patients were reviewed by the University of Michigan palliative care service during a five month period in 2008?
70
131
145
88
Piperacillin-tazobactam accounted for ___ percent of antibiotics administered in the University of Michigan palliative care study.
37
15
52
24
What percentage of patients hospitalized at the University of Michigan Health System from 2004 to 2007 received antibiotics?
64 percent
87 percent
70 percent
45 percent
Of the 126 patients who got antibiotics, ___ percent had clinical findings suggestive of infection.
70
40
85
55
Which antibiotic was given to 72 percent of patients, but only 15 percent had a clear microbiological indication?
Cefepime
Vancomycin
Piperacillin-tazobactam
Aminoglycosides
Administration of broad-spectrum antibiotics is frequent, even less than one day prior to death, according to the passage.
True
False
According to the passage, what is the main reason clinicians feel compelled to offer antimicrobial therapy at the end of life?
Possible infection
Patient request for antibiotics
Legal requirements
To prolong life unnecessarily
How many nursing home residents with advanced dementia were examined in the study by Erica D'Agata and Susan Mitchell published in 2008?
214
120
350
98
What was the mean number of antibiotic courses per resident in the study of advanced dementia patients?
Four courses
Two courses
Six courses
Eight courses
Which antimicrobial agents were most commonly used among the residents?
Quinolones and Cephalosporins
Penicillins and Macrolides
Tetracyclines and Sulfonamides
Aminoglycosides and Carbapenems
The number of antimicrobials prescribed and days of therapy per 1,000 days increased significantly as subjects approached death, especially during the final two weeks.
True
False
What percentage of patients received antibiotics by mouth?
55 percent
25 percent
70 percent
40 percent
What was the survival rate at 90 days among those not given an antibiotic?
33 percent
50 percent
75 percent
10 percent
According to the passage, what was the average adjusted increase in survival time associated with antibiotic administration compared to untreated episodes?
90 days
180 days
270 days
365 days
The unadjusted comfort scores were highest for episodes that were not treated with ________ agents, and patients had progressively lower scores with more aggressive care.
antibiotic
analgesic
antiviral
antifungal
Which of the following statements is TRUE based on the passage?
Oral antibiotics were less effective than IV antibiotics in terms of survival.
Patients who received treatment had higher comfort levels than those who received no treatment.
Discomfort appeared to increase with more aggressive treatment modalities.
Antimicrobial agents were rarely prescribed among patients with advanced dementia.
According to the passage, if the primary goal is comfort, what should be done regarding antimicrobial use at the end of life?
Antimicrobials should always be given
Antimicrobials should be withheld and palliation provided
Only IV antimicrobials should be used
Antimicrobials should be given only for pneumonia
Prescribing regimens in congruent with a short life expectancy and goals of care can increase the reservoir of ________ pathogens and place unreasonable costs on a hospice system.
resistance
beneficial
nutritional
commensal
Current evidence supports the notion that antibiotics uniformly provide comfort at the end of life.
True
False
According to the passage, for pneumonia at the end of life, what is suggested as a better approach to symptom management than antibiotics?
Opioids
Antidepressants
Antihistamines
Corticosteroids
What should be carefully assessed in each individual when considering treatment with antimicrobials, especially when palliation is a stated goal?
The potential burdens and benefits of treatment with antimicrobials.
The patient's dietary preferences.
The availability of hospital beds.
The cost of non-antimicrobial medications.
Antibiotics at the end of life, especially empiric use with IV agents, may distract from the focus of care and delay transition to hospice or discharge from the acute care setting.
True
False
According to the passage, what is a good place to begin when implementing changes in antimicrobial use practice?
Start by reaching out to patients only
Start by reaching out to colleagues and starting a discussion
Ignore educational sessions
Only consider oral antibiotics
In the context of expanding stewardship into the small community hospital setting, what do the data from Intermountain Healthcare show about antibiotic use rates in small versus large community hospitals?
A number of the small community hospitals have very similar antibiotic use rates to the large community hospitals.
Small community hospitals have significantly higher antibiotic use rates than large community hospitals.
Antibiotic use rates are consistently lower in small community hospitals compared to large ones.
There is no available data comparing antibiotic use rates between small and large community hospitals.
According to the passage, what percentage of hospitals with 0 to 50 beds had antibiotic stewardship programs that met all of the CDC core elements?
31%
50%
66%
100%
According to the passage, what percentage of hospitals with more than 200 beds met all of the CDC core elements?
31%
50%
66%
100%
Small community hospitals have less than ____ beds, and small hospitals are, many times, located in very rural settings.
200
50
500
1000
Most small hospitals have access to specialty care, including infectious disease providers.
True
False
What is the typical number of patients on antibiotics in a 50 bed hospital, according to the passage?
25
10
40
5
The time required for stewardship interventions is likely to be less in small hospitals compared to large hospitals because:
small hospitals have fewer patients and simpler organizational structures
small hospitals have more complex cases
large hospitals have fewer staff members
large hospitals have less need for stewardship interventions
According to the passage, why is it recommended to combine antibiotic stewardship meetings and committees into other standing committees in small hospitals?
Because clinicians in small hospitals often have multiple commitments and combining meetings helps manage their workload.
Because it increases the number of meetings clinicians need to attend.
Because it allows for more specialized focus on antibiotic stewardship.
Because it reduces the importance of antibiotic stewardship in small hospitals.
What is one way small hospitals are involving ID clinicians, as mentioned in the passage?
Hiring more full-time ID physicians
Utilizing tele-infectious disease and stewardship programs
Sending all patients to large hospitals
Reducing the use of antibiotics
In small community hospitals, the patients are typically ______ complex and have more standard infections such as pneumonia, urine infections, and skin infections.
less
more
equally
extremely
Small hospitals often have increased antimicrobial resistance compared to large hospitals.
True
False
What is a common limitation for small hospitals regarding microbiology labs, as described in the passage?
They have more on-site labs than large hospitals
They rely more on offsite microbiology labs
They do not use microbiology labs
They have faster lab results than large hospitals
Given the decreased antibiotic resistance in small hospitals, what should the stewardship program match?
The policies of large hospitals
The antibiotic restriction policies to the microbiology of the facility
The number of patients admitted
The number of ID clinicians available
What is often delayed in small community hospitals due to long turnaround times obtained at these facilities?
Antibiotic de-escalation
Patient admission
Surgical procedures
Discharge planning
Why do small hospitals often lack access to data for antibiotic stewardship programs?
Due to the lack of sophisticated IT departments to pull electronic data.
Because they have too many patients to manage data.
Because they do not use antibiotics.
Because they have more advanced technology than large hospitals.
In small hospitals, what metric is most often used to measure antibiotic consumption?
Defined daily doses
Average length of stay
Number of admissions
Bed occupancy rate
In small hospitals, it is often required to hire one to three additional trained ID personnel to develop their stewardship program.
True
False
What program was developed to provide infectious disease services for 16 community and rural hospitals in Utah and Southern Idaho?
Infectious Disease TeleHealth Program
Rural Health Outreach Initiative
Community Hospital Support Network
Utah-Idaho Medical Partnership
What is essential for all stewardship programs, according to the passage?
That all stewardship programs measure something, and do it in a consistent and sustainable manner.
That all stewardship programs focus only on financial outcomes.
That all stewardship programs avoid any form of measurement.
That all stewardship programs operate independently without any guidelines.
According to the passage, what service is provided 24 hours a day, 7 days a week via an infectious disease hotline?
Telephone consultation and advice for inpatient, outpatient, emergency department, acute care clinics.
In-person surgery scheduling for all hospital departments.
Home delivery of prescription medications for chronic illnesses.
On-site laboratory testing for all infectious diseases.
How many small community hospitals does the Infectious Disease TeleHealth Program staff support with antibiotic stewardship efforts?
16
5
10
22
What is the main purpose of the antibiotic usage dashboard mentioned in the passage?
To show antibiotic usage rates for all antibiotics and CDC-defined categories on a monthly basis.
To track patient recovery rates after antibiotic treatment.
To display the side effects of various antibiotics.
To compare antibiotic prices across different hospitals.
The dashboards provided by the Infectious Disease TeleHealth Program are fully transparent and allow one hospital to see the antibiotic usage rates of other hospitals.
True
False
What is AMR an abbreviation for, as described in the passage?
Antimicrobial Resistance
Automated Meter Reading
Advanced Medical Research
Active Magnetic Resonance
According to the passage, what are some of the main contributors to the risk of losing the gains made by antimicrobials?
Widespread misuse and overuse of life-saving drugs.
Improved sanitation and hygiene practices.
Increased funding for antimicrobial research.
Strict regulation of prescription drugs.
Antimicrobial resistance is only a problem in high-income countries.
True
False
According to the passage, what is the estimated death toll from antimicrobial resistance (AMR) by 2050 if no action is taken?
1 million lives each year
5 million lives each year
10 million lives each year
20 million lives each year
Every ______ seconds a person will die because of a resistant infection, according to the passage.
three
ten
sixty
twenty
Which organization published a global report on the surveillance of antimicrobial resistance in 2014?
United Nations
World Health Organization (WHO)
Centers for Disease Control and Prevention (CDC)
World Bank
According to the passage, what percentage of the 133 countries that provided information for the report have a comprehensive action plan for AMR in place?
10 percent
25 percent
50 percent
75 percent
Antimicrobials are ______ resources, and their current benefits must be balanced against their use leading to resistance.
non-renewable
renewable
infinite
unlimited
Which of the following is NOT mentioned as a challenge in tackling AMR in the passage?
Lacking standard treatment guidelines
High public awareness
Lacking infection prevention and control programs
Low levels of coordination and leadership
According to the passage, what is one of the main reasons for the burden of diseases caused by resistant pathogens?
High quality of care
Poor infection prevention and control practices
Strict enforcement of prescription laws
Low antibiotic consumption
The achievement of several sustainable development goals will depend upon access to, and availability of ________ that work.
affordable antimicrobials
renewable energy sources
clean water technologies
sustainable fertilizers
True or False: The current antibiotic consumption is highest in low-income countries.
True
False
