🧠🌀🦠💉🔬💊 NEUROSYPHILIS

A 46‑year‑old man with untreated HIV infection (CD4 = 180 cells/µL, HIV RNA = 75 000 copies/mL) is brought to the emergency department because of progressive memory loss, gait unsteadiness, and bilateral lower‑limb weakness over two months. He reports intermittent headaches and blurred vision.

• Vitals: T 37.4 °C, BP 126/72 mm Hg, HR 88 bpm.

• Neuro exam: wide‑based gait, positive Romberg, brisk patellar reflexes; pupils accommodate but are sluggish to light.

• Serum RPR: reactive 1 : 128 (prior documentation six months ago: non‑reactive).

• CSF: WBC 95 cells/µL (90 % lymphs), protein 110 mg/dL, VDRL reactive 1 : 16.

Question
Which antibiotic regimen is most appropriate to treat this patient’s infection?

A) Aqueous crystalline penicillin G 3 million units IV every 4 h for 14 days
B) Meropenem 2 g IV every 8 h for 14 days
C) Doxycycline 200 mg orally twice daily for 28 days
D) Ceftriaxone 2 g IV once daily for 14 days
E) Levofloxacin 750 mg IV once daily for 14 days

🫀🦠 MSSA Endocarditis

A 48‑year‑old man with poorly controlled type 2 diabetes and a history of intravenous heroin use presents with three days of fever, rigors, and pleuritic chest pain.

• Vitals: T 39.2 °C, HR 110 bpm, BP 118/66 mm Hg
• Exam: new holosystolic murmur at the left lower sternal border; several Janeway lesions on the palms; no focal neurological deficits.
• Investigations: Three blood‑culture sets grow methicillin‑susceptible Staphylococcus aureus (MSSA) within ten hours (oxacillin MIC ≤ 2 µg/mL). Transthoracic echo shows a 1.2 cm vegetation on the tricuspid valve with mild regurgitation. Renal and liver function are normal.
He has no β‑lactam allergy.

QUESTION
Which intravenous antibiotic regimen is most appropriate to start—and continue—for this infection?

A) Cefazolin 2 g IV every 8 h for at least six weeks
B) Vancomycin dosed to trough 15–20 mg/L for at least six weeks
C) Daptomycin 10 mg/kg IV once daily for at least six weeks
D) Linezolid 600 mg IV every 12 h for at least six weeks
E) Gentamicin 3 mg/kg IV once daily plus rifampicin 300 mg orally every 8 h

🦶🦠Diabetic foot infection

A 62‑year‑old man with poorly‑controlled type 2 diabetes (HbA1c 9.4 %) is admitted with a worsening plantar ulcer under the right first metatarsal head.

Two weeks ago his podiatrist prescribed trimethoprim–sulfamethoxazole (TMP‑SMX) for presumed mild cellulitis. The ulcer has enlarged, now draining malodorous pus.

Vitals: T 38.3 °C, HR 96 bpm, BP 132/78 mm Hg.
Exam: 3 × 2 cm ulcer, erythema extending 4 cm, no bone palpated. Peripheral pulses intact.
Labs: WBC 13 000/µL (85 % neutrophils), CRP 110 mg/L, Cr 1.0 mg/dL.
X‑ray: soft‑tissue swelling; no osteitis.

You plan empiric IV therapy while awaiting deep‑tissue culture.

Which regimen is most appropriate now?

A. Continue TMP‑SMX and add oral clindamycin
B. Vancomycin plus cefepime
C. Piperacillin–tazobactam (Zosyn)
D. Linezolid monotherapy
E. Ciprofloxacin plus metronidazole

⛰️ Fever after traveling to TN - "magical" antibiotic

A previously healthy 27-year-old male presents to the emergency department in mid-July with a 5-day history of fever, chills, severe frontal headache, diffuse muscle aches, and nausea. He returned from a camping trip in Tennessee approximately one week ago. Vital signs upon presentation show temperature 39.3°C (102.7°F), heart rate 112 bpm, blood pressure 98/64 mmHg, and respiratory rate 20/min. On physical examination, the patient appears acutely ill and has a diffuse maculopapular rash involving his palms and soles. There is no neck rigidity, and cardiopulmonary examination is normal. Laboratory studies reveal:

Laboratory Test	Result	Normal Range
WBC	3,400/mm³	(4,500–11,000/mm³)
Platelets	62,000/mm³	(150,000–400,000/mm³)
Hemoglobin	13.8 g/dL	(13.5–17.5 g/dL)
Sodium	130 mEq/L	(135–145 mEq/L)
AST	112 U/L	(10–40 U/L)
ALT	95 U/L	(10–40 U/L)
Creatinine	1.2 mg/dL	(0.6–1.2 mg/dL)

Given the clinical findings and lab abnormalities, immediate empiric antibiotic therapy is initiated pending confirmatory testing.

Which of the following antibiotics is the most appropriate initial therapy?

A. Ceftriaxone
B. Ciprofloxacin
C. Vancomycin
D. Doxycycline
E. Chloramphenicol

🫁🤒Community‑Acquired Pneumonia in a Young Adult

Scenario
A 45‑year‑old man with no significant past medical history presents with a 3‑day history of fever (38.5 °C), productive cough, pleuritic chest pain, and mild dyspnea. He is haemodynamically stable (BP 125/80, HR 95, RR 20, SpO₂ 94% on room air). Laboratory tests show WBC 12 × 10⁹/L. Chest X‑ray demonstrates a right lower‑lobe consolidation. His CURB‑65 score is 1 (age < 65 but BUN normal), indicating inpatient—or close outpatient—management.

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Question:

Which empiric antibiotic regimen is most appropriate for this patient?

A) IV ceftriaxone + IV azithromycin
B) IV ampicillin–sulbactam + IV azithromycin
C) IV levofloxacin monotherapy
D) IV ceftaroline + IV azithromycin

👊Human Bite (“Fight Bite”) to the Hand

Scenario
A 28‑year‑old man presents to the ED 12 hours after punching another person in the face and sustaining a 1 cm laceration over the dorsal aspect of his right third metacarpophalangeal joint. He cleaned it at home but now has:

• Increasing pain, swelling, and erythema over the joint

• Temperature 38.2 °C, pulse 100 bpm

• Mild crepitus when extending the finger

• No obvious abscess, but the wound is tender with a small serosanguineous discharge

He is otherwise healthy, with no penicillin allergy.

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Question

Which empiric oral antibiotic regimen is most appropriate for this patient?

A) Amoxicillin–clavulanate
B) Clindamycin monotherapy
C) Doxycycline + metronidazole
D) Cephalexin
E) Dicloxacillin

🧠‑🤒 Meningitis in a Young Adult (Weekend)

A 24‑year‑old woman with no significant medical history presents on a Saturday evening with a 12‑hour history of fever (39 °C), worsening headache, photophobia, and neck stiffness. She is alert but irritable, with a heart rate of 110 bpm and blood pressure 120/70 mmHg. A head CT is not immediately available, and lumbar puncture (LP) cannot be done until Monday. You draw blood cultures and decide to start empiric antibiotics without delay.

Which empiric IV regimen is most appropriate while awaiting LP and cultures?

A) Ceftriaxone + Vancomycin
B) Ampicillin + Gentamicin
C) Vancomycin + Acyclovir
D) Meropenem alone
E) Vancomycin + Cefepime

🦠 HAP in a Haemodialysis Patient - in shock

Scenario:
A 68‑year‑old man on thrice‑weekly haemodialysis, recently transferred from a nursing home, develops a new fever (38.8 °C), worsening dyspnoea on BiPAP, hypotension (BP 85/50 mmHg) and tachycardia (115 bpm) five days into his admission for heart failure. A chest X‑ray shows a new right lower‑lobe infiltrate. His WBC is 18 × 10⁹/L and procalcitonin is elevated. Blood and sputum cultures are pending.

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Question:
Which empiric IV regimen is most appropriate for this critically ill patient at high risk for ESBL‑producing organisms?

A) Vancomycin + Cefepime
B) Vancomycin + Piperacillin–Tazobactam
C) Vancomycin + Meropenem
D) Levofloxacin monotherapy

🤰Perforated Diverticulitis with Septic shock

Scenario:
A 63‑year‑old woman with recurrent diverticulitis presents with 24 hours of severe abdominal pain, fever (39 °C), rigors and hypotension (BP 85/50 mmHg). She appears "peritonitic" and is tachycardic at 120 bpm. CT scan shows free intraperitoneal air and colonic perforation. She has had three courses of broad‑spectrum antibiotics over the past year and now requires urgent laparotomy.

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Question:
Which empiric IV regimen is most appropriate in this critically unwell patient to cover broad Gram‑negatives, anaerobes and Candida?

A) Piperacillin–tazobactam + fluconazole
B) Meropenem + micafungin
C) Cefepime + metronidazole + fluconazole
D) Piperacillin–tazobactam + micafungin
E) Meropenem alone

🦠 Severe Diverticulitis Requiring Admission

Scenario:

A 55‑year‑old woman presents with 48 hours of severe left lower‑quadrant pain, fever (38.5 °C), and inability to tolerate oral intake. She reports nausea and has been unable to pass flatus. On examination she is tender in the left lower quadrant with guarding but no peritonism. Her white cell count is 16 × 10^9/L, and CRP is elevated. A CT scan confirms uncomplicated diverticulitis (no abscess or perforation) with marked pericolic fat stranding. Given her pain, systemic features and inability to eat, you admit her for IV antibiotic therapy.

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Question:
Which empiric IV regimen is most appropriate on admission?

A) Piperacillin–tazobactam
B) Ceftriaxone + metronidazole
C) Ertapenem
D) Meropenem
E) Ampicillin–sulbactam

🩸🦠🤒 Febrile Neutropenia—Empiric Anti‐Pseudomonal Coverage

Scenario:
A 57‑year‑old woman with acute myeloid leukaemia is 7 days post‑induction chemotherapy. Her absolute neutrophil count is 80 cells/µL. She presents with a single episode of fever (38.6 °C) and mild malaise. There are no focal signs of infection on exam, and chest X‑ray is clear.

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Question:
Which empiric IV antibiotic is most appropriate to cover her risk of Gram‑negative bacteraemia, including Pseudomonas?

A) Cefepime
B) Piperacillin–Tazobactam
C) Meropenem
D) Ceftazidime
E) Aztreonam