🧠🌀🦠💉🔬💊 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

🤮🫁Aspiration Pneumonia in a Healthy Young Adult

Scenario:
A 28‑year‑old man with no significant past medical history presents with a 36‑hour history of high fevers (39 °C), productive cough, and pleuritic right lower‑lobe chest pain. He reports binge drinking and one episode of vomiting the night before. On exam he is tachypnoeic (26 breaths/min), tachycardic (115 bpm), and has dullness to percussion with crackles at the right base. A chest X‑ray shows a right lower‑lobe consolidation. He appears ill and hypoxic on room air (SpO₂ 90%).

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Question:
Which empiric IV antibiotic regimen is most appropriate for this patient?

A) Clindamycin
B) Ampicillin–sulbactam (Unasyn)
C) Piperacillin–tazobactam
D) Levofloxacin
E) Ceftriaxone plus metronidazole

Acute Pyelonephritis with possible Bacteraemia

Scenario:
A 35‑year‑old woman with a history of recurrent urinary tract infections presents to the ED with a 2‑day history of high fever (39.5 °C), chills, nausea, and severe left flank pain. On exam she is tachycardic (120 bpm), hypotensive (BP 90/55 mmHg), and appears unwell. Costovertebral angle tenderness is present on the left. Urine dipstick is positive for nitrites and leukocyte esterase. You draw blood and urine cultures; initial Gram stain of the blood cultures shows gram‑negative rods.

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Question:
Which of the following is the best empiric IV antibiotic for this patient?

A) Ceftriaxone
B) Cefepime
C) Aztreonam
D) Piperacillin–tazobactam (Zosyn)
E) Meropenem

🦵🔥 Obesity with Cellulitis and Possible Bacteremia

Morbid Obesity with Cellulitis and Possible Bacteraemia

Scenario:
A 52‑year‑old man with a body mass index of 45 kg/m² presents with a 24‑hour history of rapidly spreading erythema and tenderness over his right lower leg. He is mildly febrile (39 °C) and tachycardic (110 bpm). There are no underlying chronic illnesses. Blood cultures are drawn given concern for early bacteraemia, and you plan admission for IV therapy covering Streptococcus spp. and MRSA.

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Question:
Which empiric IV antibiotic is most appropriate for this patient?

A) Vancomycin
B) Daptomycin
C) Linezolid
D) Ceftaroline
E) Clindamycin

Vignette #2: Diabetic Boil Management – Optimising Empiric Therap

A 59-year-old man with poorly controlled type 2 diabetes (A1c 9.3%) presents with a painful 5 cm boil on his left thigh that has been progressively enlarging over 4 days. The lesion is fluctuant and surrounded by mild cellulitis. He is afebrile, and systemic symptoms are absent. You perform an I&D in the ED, and because no culture results are immediately available, you must decide on empiric oral antibiotic therapy to cover both MRSA and Streptococcus (especially Group B Streptococcus, frequently seen in diabetics).

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Question:
Given the patient’s risk factors and the polymicrobial nature of diabetic skin infections, which of the following empiric oral antibiotic strategies is preferred?

A) Bactrim alone
B) Amoxicillin (or Augmentin) alone
C) Doxycycline alone
D) Amoxicillin + Bactrim
E) Oral Linezolid

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✅ Preferred Answer: E) Oral Linezolid

Alternative Option: D) Amoxicillin + Bactrim

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📘 Mini-Lesson & Explanation

1. The Case for Oral Linezolid (Preferred Option)

• Excellent Gram-Positive Coverage:
  Linezolid provides robust coverage against both MRSA and Streptococcus species, including Group B Streptococcus. This dual coverage is key in diabetic patients who are at risk for polymicrobial infections.

• High Oral Bioavailability:
  With nearly 100% bioavailability, oral linezolid ensures effective serum and tissue concentrations, making it ideal as a step-down or primary oral agent.

• Generic Availability:
  Although Linezolid once carried a high cost, it is now available as a generic, making it a cost-effective option under many circumstances.

• Safety and Efficacy:
  Despite its potential side effects (e.g. bone marrow suppression, peripheral neuropathy, serotonin syndrome), these risks are generally acceptable in short-course therapy for uncomplicated soft tissue infections, particularly when weighed against the risk of treatment failure.

2. The Case for Combination Therapy with Amoxicillin + Bactrim (Alternative Option)

• Rationale for Combination:

  • Bactrim Alone: Excellent MRSA coverage; however, its Streptococcus coverage is inadequate.

  • Amoxicillin Alone: Provides reliable coverage against Streptococcus, including Group B Streptococcus, but lacks activity against MRSA.

  • Together: The combination mitigates the gaps when either is used as monotherapy, covering both MRSA and Streptococcus.

• Considerations:

  • Safety & Adherence: While the combination offers broad-spectrum coverage, it involves administering two medications, which can increase pill burden and potential for drug interactions.

  • Local Resistance Patterns: In settings with high MRSA prevalence and documented clindamycin resistance, the combination might be second-best compared to the single-agent efficacy of Linezolid.

3. Why Other Options Are Less Suitable

• A) Bactrim Alone:
  Inadequate coverage for Streptococcus, a significant risk in diabetics.

• B) Amoxicillin (or Augmentin) Alone:
  Lacks any significant anti-MRSA activity; it fails to address the dual infection potential.

• C) Doxycycline Alone:
  Variable and unreliable activity against Streptococcus, which may lead to suboptimal outcomes in complicated diabetic skin infections.

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🧠 Teaching Pearls

• Empiric Coverage in Diabetics:
  Diabetic patients frequently have infections caused by both MRSA and Streptococcus. Empiric therapy should cover both, taking into account local antibiotic resistance patterns.

• Oral Bioavailability:
  When considering oral therapy, ensure that chosen agents provide reliable systemic absorption. Linezolid excels in this aspect, with nearly equivalent bioavailability to its IV formulation.

• Drug Toxicity & Stewardship:
  Always weigh potential side effects and toxicity—Linezolid has noteworthy risks, so its use should be monitored closely, particularly for treatment durations beyond the typical 10-14 days in uncomplicated infections.

Streptococcal Pharyngitis

A 22-year-old university student presents with a 2-day history of sore throat, fever, and tender anterior cervical lymphadenopathy. On examination, there is marked tonsillar erythema with exudates, but the patient denies any cough. 

A rapid antigen detection test for group A Streptococcus is positive.

Question:
What is the most appropriate first-line treatment for this patient?

A) Amoxicillin
B) Bactrim (trimethoprim-sulfamethoxazole)
C) Ciprofloxacin
D) Cephalexin

Clinical Vignette: Outpatient Cystitis in an Elderly Patient

A 78-year-old woman with a history of chronic kidney disease (CKD stage 3b, baseline creatinine 2.1 mg/dL, eGFR ~35 mL/min), atrial fibrillation (on amiodarone), and type 2 diabetes mellitus presents to her primary care physician with a three-day history of dysuria, increased urinary frequency, and mild suprapubic discomfort. She denies fever, flank pain, nausea, or vomiting.

Initial Workup:

• Urinalysis: Positive for leukocyte esterase, nitrites, pyuria, and bacteriuria
• Urine culture: Grows Escherichia coli (pan-sensitive)
• Serum creatinine: 2.1 mg/dL (baseline), eGFR ~35 mL/min

Given her clinical presentation, she is diagnosed with an uncomplicated cystitis and requires an appropriate oral antibiotic 

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Question:

Which of the following antibiotics is the best choice for treating this patient’s cystitis?

A) Oral nitrofurantoin (Macrobid)
B) Oral trimethoprim-sulfamethoxazole (Bactrim)
C) Oral fosfomycin
D) Oral cefdinir
E) Oral ciprofloxacin

Clinical Vignette: When Nitrofurantoin (Macrobid) is Inappropriate

Clinical Vignette: When Nitrofurantoin (Macrobid) is Inappropriate Due to Renal Failure, Advanced Age, and Sepsis

A 79-year-old woman with a history of chronic kidney disease (CKD stage 4, baseline creatinine 2.8 mg/dL), hypertension, and osteoarthritis is brought to the emergency department from her nursing home with fever (38.9°C), confusion, and dysuria for the past two days.

On arrival, she is lethargic with a blood pressure of 85/55 mmHg, heart rate 110 bpm, and oxygen saturation 94% on room air. She is confused and unable to provide a clear history.

Initial Workup:

• Leukocytosis (WBC 17,500/mm³) with left shift
• Serum creatinine 3.1 mg/dL (baseline 2.8 mg/dL, eGFR ~18 mL/min)
• Lactate 3.2 mmol/L
• Urinalysis: Positive for leukocyte esterase, nitrites, pyuria, and bacteriuria
• Blood cultures and urine cultures pending

She is diagnosed with  sepsis secondary to a complicated urinary tract infection (UTI) and started on IV fluid resuscitation and empiric Meropenem.

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Question:

The patient’s urine culture later grows Escherichia coli, which is sensitive to multiple antibiotics, including:
✅ Nitrofurantoin (Macrobid)
✅ Ceftriaxone , Cefepime and Meropenem 
✅ Piperacillin-tazobactam
✅ Ciprofloxacin

✅ Bactrim

Which of the following is the most appropriate antibiotic choice for this patient?

A) Oral nitrofurantoin (Macrobid)
B) IV ceftriaxone
C) Oral fosfomycin
D) Oral trimethoprim-sulfamethoxazole (Bactrim)
E) Continue broad-spectrum IV piperacillin-tazobactam

Clinical Vignette -Acute Prostatitis with Bacteremia

Clinical Vignette: Acute Prostatitis with Bacteremia in a Patient with CKD – Avoiding Nephrotoxic Agents

A 64-year-old man with a history of chronic kidney disease (CKD stage 3, baseline creatinine 1.8 mg/dL), type 2 diabetes mellitus, and benign prostatic hyperplasia (BPH) presents with a 3-day history of fever (39.2°C), dysuria, perineal pain, and urinary hesitancy. He also reports chills and malaise.

On examination, he appears ill, with a blood pressure of 100/65 mmHg, heart rate 112 bpm, and mild suprapubic tenderness. Digital rectal examination reveals an enlarged, exquisitely tender prostate, raising suspicion for acute bacterial prostatitis.

Initial Workup:

• Leukocytosis (WBC 15,000/mm³)
• Serum creatinine 2.2 mg/dL (baseline 1.8 mg/dL)
• Blood cultures: Positive for Escherichia coli
• Urine cultures: Pending

After IV hydration and empiric ceftriaxone, the E. coli isolate is found to be sensitive to all tested antibiotics, including:

• Fluoroquinolones (Ciprofloxacin, Levofloxacin, Moxifloxacin)
• Trimethoprim-Sulfamethoxazole (Bactrim)
• Amoxicillin-Clavulanate (Augmentin)
• Ceftriaxone

The patient is clinically stable for discharge  

Question:

Which of the following is the most appropriate oral antibiotic regimen for treating acute bacterial prostatitis in this patient while minimizing nephrotoxicity?

1. Oral ciprofloxacin  
2. Oral levofloxacin 
3. Oral moxifloxacin  
4. Oral trimethoprim-sulfamethoxazole (Bactrim)  
5. Oral amoxicillin-clavulanate (Augmentin)  
6. Continue IV ceftriaxone for 14 days