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Curtailing the Use of Antibiotics In the discussion of counteracting or at least slowing down resistance development by curbing the use of antibiotics , it becomes relevant to ask if the resistance properties of bacte- ria are reversible . If this is the case , it invites a solution that would include a cyclic use of antibiotics . That is , when high and widely spread resistance strikes one antibiotic , its distribution is stopped and it is exchanged for another until sus- ceptibility possibly returns through evolutionary development . It is logical to surmise that resistance involves a biological cost to the bacterium , because it includes a molecular deviation from the normal physiology of the bacterial cell , which has adapted to its environment for a long period during evolution . Spontaneous test tube mutants resistant against sul- fonamides, for example, show that they have had to pay a price for their resistance. The mutation hits the sulfonamide target enzyme, dihydropteroate synthase, which then shows a lower susceptibility to sulfonamides but also makes the enzyme require a higher concentration of its normal substrate (p-aminobenzoic acid) for optimal function. The resistant bacterium has traded off part of its general survival value for the acutely necessary resistance in the presence of sulfonamide. It has also been shown experimentally that in a mixture of susceptible and resistant bac- teria that are resistant either by mutation or by plasmid-borne resistance genes, resistance is a strain on bacterial growth, in that susceptible bacteria will soon dominate in a culture grown in the absence of antibiotic. The purpose was to discover if the increasing trimetho- prim resistance that had been observed in the area would stabilize or possibly diminish. The results were negative, however, prob- ably because plasmids carrying trimethoprim resistance also carry other resistance genes, and trimethoprim resistance is then co-selected with them. This was illustrated in Chapter 3, where we discussed sulfonamide resistance in Neisseria meningitidis. This bacterium seems to have the ability to neutralize the growth strain of resistance by the introduction of compensating mutations. This could be compared to the argument in an earlier section, where experimental results showed sulfonamide resistance mutations to have a price in the form of an increased Km value for the normal substrate of the target enzyme mutated. Normal Km values are, however, seen in sulfonamide-resistant clinical isolates of N. This must mean that other mutations in the gene for the target enzyme dihydropteroate synthase have changed the conformation of the enzyme to normalize substrate binding. This is an evolutionary phenomenon leading to the complete bacterial adaptation to the presence of sulfonamides. One area of obvious restriction in the distribution of antibi- otics is their use for growth promotion in animal husbandry. It took almost 40 years, however, for these ideas to be translated into legislation in Europe. Introduction of Truly New Antibacterial Agents A solution to the present clinical situation with increasing antibi- otic resistance would be to find new antibacterial agents with truly new properties of action. Literally thousands of antibiotics have been isolated since the 1940s, but only a small fraction of these have proved suitable for medical and veterinary use. Also, the pace of discovering new antibacterial agents has slowed through the years. Trimethoprim was introduced in 1970 and oxa- zolidinones in 2000, both representing new antibacterial agents in the true sense at their introduction, that is, no truly new antibacterials were introduced for 30 years. This could be taken to mean that the screening of natural products and of presumed antimetabolites will be able to contribute less and less to finding new antibiotics. New principles for antibacterial treatment that are conceptually different from the antibiotics used presently are needed urgently. Antibacterial Peptides Humans and animals have an inborn mechanism of protection against bacterial infections which acts instantly; that is, it works differently from the immune system, the response of which has to await the growth of antibody-producing cells. Host defense peptides or antibacterial peptides of this type seem to be produced by all multicellular organisms, including plants, and also by many unicellular organisms. Compared to antibiotics, which are target-specific molecules acting in a single well-defined manner, these peptides have more complex inhibitory patterns and multiple activities. They are amphi- phile, cationic molecules, which with their positive charge bind to the negatively charged membrane of microbes. The crucial physicochemical feature for the antibiotic activity of host defense peptides is their amphiphilic character, which enables them to adopt conformations in which polar and charged amino acid side chains orient to one side and apolar residues to the other (Fig. These peptides can then bind to negatively charged bacterial surfaces and integrate into and disrupt underlying cytoplasmic membranes. There is substantial evidence that the charge-mediated binding of host defense peptides is critical for their antibacterial activity. This knowledge regarding the lipid bilayer disturbing effect is, however, based on studies of model membranes, which leaves many questions regarding the precise mechanism of the bacteria-killing activity. Several hundred peptides of this kind have now been described and classified according to structural characteristics; they include alpha- and beta-defensins, cathelicidines, cecropins, magainins, bactenecins, and protegrins. Those that are called cathelicidines and defensins dominate within the group of ver- tebrates. Cathelicidines in an active form vary in size between 12 and about 80 amino acid residues and appear in various ter- tiary structures. Amino acid sequences are given for the two peptides and for the human betade- fensin, also the intramolecular cystine disulfide bridges mentioned in the text. Defensins and other antimicrobial peptides are possible candidates to be pharmaceutical preparations for use in the clinical treatment of bacterial infections. A rather recently published example of such a candidate peptide is plectasin, an antimicrobial defensin isolated from the mold Pseudoplectania nigrella. It was reported that the plectasin- producing gene could be transferred to another fungus, which could produce and excrete plectasin in large amounts. This could be a solution to a serious problem with antibacterial peptides, which is to produce them in sufficient amounts and in a way that is economically defendable. The mice test is a parallel to the historically famous experiment with penicillin by Howard Florey in May 1940. In a recent report it was found, astonishingly, that the plectasin peptide of 40 amino acid residues with its amphipathic nature does not compromise bacterial membrane integrity as do similar defensins with the characteristic intramolecular cystine disulfide bridges stabiliz- ing their tertiary structures. Instead, it was actually found to interfere with bacterial cell wall synthesis, which was originally observed as severe cell-shaped deformations occurring in its presence. In more detail, the action of plectasin was more like the glycopeptide antibiotics (such as vancomycin, Chapter 5) found to form a stoichiometric complex with an intermediate in the biosynthetic pathway of cell wall formation. This intermediate is the glycopeptide–lipid complex, which translocates across the cytoplasmic membrane to the outside, where the glycopeptide is incorporated into the peptidoglycan polymer through the activity of transglycosylases and transpeptidases (see Chapter 4). It can be concluded that plectasin is a promising substance for further drug development. The results obtained seem to show that in the future, antibacterial peptides could play an important role in the treatment of infectious disease. One obstacle is that they are peptides susceptible to degradation in the gastrointestinal tract. This could, for example, be to inhibit the adhesion of bacteria to the epithelial cells of the ureters in the urinary tract in severe infections in the upper parts of this tract. This complexity and the fact that trans- port through the syringe needle requires energy makes it likely that the proper secretion mechanism could be inhibited without interfering with the growth of the bacterium. Small molecular inhibitors with this effect have been identified and ought to be developed into anti-infectious remedies. The new and important aspect of this approach is that only the pathogenicity is inter- fered with; bacterial growth and survival are unaffected. This is different from other antibacterial agents and eliminates the immediate risk of resistance development. Bacterial growth is normal, which means that mutations affecting the pathogenic- ity inhibition are not selected. Inhibition of Bacterial Fatty Acid Synthesis Pharmaceutical companies have to a large extent retreated from the field of antibacterial drugs, concentrating instead on chronic diseases, which has market advantages. Earlier, there was a cooperation between the health care and pharmaceuti- cal industries, which has now ceased, particularly regarding antibacterial agents. It was therefore very encouraging that the Merck pharmaceutical company took on the work of character- izing and developing a new approach to antibacterial action. As it turned out, it also became a good illustration of the great risks involved with developing a new antibacterial agent. This particular approach began with a report about a new antibiotic produced by the soil bacterium Streptomyces platensis isolated from a soil sample from South Africa. The finding was the result of a large screening program involving 250,000 extracts from drug-producing microorganisms. Itturnedouttobe a small molecule (molecular mass: 441 Da), consisting of two distinct structural elements: 3-amino-2,4-dihydroxybenzoic acid and lipophilic pentacyclic ketolide, linked together by an amide bond. Platensimycin showed a new mechanism of action, inter- fering selectively with the enzymatic elongation mechanism at the bacterial synthesis of fatty acids, which in sizes of 8 to 18 carbon atoms build bacterial membranes and cell surfaces. It ought to be pointed out here that inhibition of bacterial fatty acid synthesis for antibacterial action was used before in the action of the tuberculostatic agent of isoniazid, discussed in Chapter 9. So far, platensimycin has only been tested in vitro and in preliminary animal experiments with mice, where it showed inhibiting effects against staphylococci and pneumococci similar to those of penicillin against susceptible strains of these bacteria. There is still a long way to a clinically useful agent, and there would be a risk of resistance by mutational enzyme changes. Again it is interesting that the extensive research work regarding platensimycin was performed and the cost defrayed by a large pharmaceutical company, which by economic con- siderations seems to continue research regarding antibacterial agents. To explain the scarcity of new antibacterial agents and the risks involved in their development, the future potential of platensimycin is important to assess. The future use of platen- simycin as an antibiotic was hit by a great disappointment. The biosynthetic machinery of fatty acid formation is encoded by sev- eral bacterial genes involving the fab loci of the bacterial genome. Fab proteins come together to construct fatty acids two carbon atoms at a time in a cyclic process. This biosynthetic pathway is essential for the formation of cellular membranes in many bacte- rial pathogens. The process is distinct from fatty acid biosynthesis in mammalian cells, which suggests that its inhibition in bacteria could be selective. Yet older studies, from the 1970s, showed that bacteria could acquire fatty acids from their surroundings and incorporate them into their cell membranes. In a recent report, evidence was presented to question antibiotic therapies that target fatty acid biosynthesis. Inhibitors of fatty acid syn- thesis were quite effective at inhibiting the growth of pathogenic strains resistant to other antibiotics in standard laboratory media (which lack fatty acids), but this effect was abolished when fatty acids were added or when human serum, which is rich in fatty acids, was added. These observations would raise the bar for target validation not only for platensimycin but for future drug discovery in general. The authors of this report define what they call the resistome, comprising a gigan- tic collection of antibiotic resistance genes among soil-living microorganisms. This concept of the resistome will dramatically reshape our approach to finding new antibacterial drugs. There is abundant information regarding soil bacteria producing and encountering large amounts of antibiotics, which has meant that these organisms have evolved corresponding sensing and evad- ing strategies. It is a fact that most clinically relevant antibiotics originate from soil-dwelling actinomycetes. Antibiotic produc- ers harbor resistance elements for self-protection, which are often found together with antibiotic biosynthetic operons. Genes ortol- ogous to these have been observed on mobile genetic elements in resistant pathogenic bacteria isolated from patients. For example, and as mentioned earlier, aminoglycoside- modifying enzymes (Chapter 6) and the lactate-substituting machinery making the peptidoglycan synthesis insensitive to vancomycin probably originated in soil-dwelling antibiotic pro- ducers (Chapter 5). The presence of antibiotics in the environment has been shown to promote the acquisition or independent evo- lution of specific resistance elements in soil organisms in the absence of innate antibiotic production. The soil could thus be looked at as a large reservoir for resistance, the largest part of which might not yet have emerged in clinically important bac- teria. The report mentioned is a systematic study of 480 morpholog- ically different soil microbes regarding their resistance to 21 different antibacterial agents, including natural products such as vancomycin and erythromycin, and also completely synthetic molecules such as quinolones, sulfonamides, trimethoprim, and linezolid. Many of the agents tested were well established, but importantly, antibacterial drugs that have only recently been approved for clinical use were also tested. Astonishingly, every isolate was found to be multidrug resistant to seven or eight antibiotics on average, with two strains being resistant to 15 of the 21 antibacterial agents tested. Interestingly, five of the vancomycin-resistant soil microbe isolates were, by the use of polymerase chain reaction, shown to carry the cluster of three genes that in clinical isolates of vancomycin-resistant pathogenic bacteria has been shown to mediate resistance to this drug. Despite the lack of known prior exposure to fluoroquinolones, some 10% of the soil microbes in the study demonstrated intrinsic resistance to ciprofloxacin. All the soil microbe strains were resistant to the synthetic agent trimethoprim, which as mentioned earlier, works by inhibiting the bacterial dihydrofolate reductase. Further studies along these lines could assist in the elucidation of new resistance mechanisms that may emerge clinically, as well as serve as a foundation for the development of new antibiotics. These results, combined with earlier experiences of the spread of antibiotics resistance by efficient gene transport mechanisms, indicate that resistance development is probably going to accelerate. The observations described could lead to the view that the wonderful asset of antibiotics has been available on loan from nature, and that this loan is now expiring slowly, with devalued assets. A dissertation submitted to the faculty of the University of North Carolina at Chapel Hill in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Pharmaceutical Sciences in the Eshelman School of Pharmacy (Division of Pharmacotherapy and Experimental Therapeutics). These infants are at high risk of systemic infections, and most are treated with antimicrobial agents. Extrapolation of dosing information from older children and adults to preterm infants often results in therapeutic failures or unwanted toxicities. Unique challenges posed by preterm infants, however, limit the ability to evaluate drug disposition in this population. Novel, minimal-risk methods can provide the platform to overcome these challenges and optimize antimicrobial dosing. In this proposal, several of these methods were employed to deliver antimicrobial dosing recommendations specifically designed for preterm infants. Two commonly used antimicrobials, piperacillin and metronidazole, were used to evaluate the utility of these methods. A multiplex liquid chromatography-tandem mass spectrometry assay for the simultaneous quantification of ampicillin, piperacillin, tazobactam, meropenem, acyclovir, and metronidazole in ultra-low (<50 uL) human plasma was developed and validated.

D Low magnesium can be caused by gastrointestinal Chemistry/Apply knowledge to recognize sources of loss , as occurs in diarrhea and pancreatitis (loss of error/Specimen collection and handling/3 Mg and Ca as soaps) . Which of the following conditions is associated increased release of both calcium and magnesium with a low serum magnesium? Interference in calcium complexometric dye o-cresolphthalein assays is prevented by addition of 8-hydroxyquinoline , complexone , magnesium is kept from which chelates magnesium . It is more specific for Ca+2 than the others , and does not require Chemistry/Apply principles of basic laboratory addition of a Mg+2 chelator . Which electrolyte measurement is least affected by Answers to Questions 56–60 hemolysis? Chemistry/Apply knowledge to recognize sources of error/Specimen collection and handling/2 57 . D Addison’s disease (adrenocortical insufficiency) results in low levels of adrenal corticosteroid 57 . Which of the following conditions is associated hormones , including aldosterone and cortisol. Alkalosis and digoxin intoxication cause release of intracellular Chemistry/Correlate clinical and laboratory data/ potassium. Alkalosis causes potassium to move from Electrolytes/2 the extracellular fluid into the cells as hydrogen ions 58. Which of the following conditions is most likely move from the cells into the extracellular fluid to to produce an elevated plasma potassium? Digitalis overdose and Addison’s disease are other frequent causes of Chemistry/Correlate clinical and laboratory hyperkalemia. Hypoparathyroidism indirectly causes data/Electrolytes/2 hypokalemia by inducing alkalosis via increased renal retention of phosphate and bicarbonate. Which of the following values is the threshold syndrome (adrenal cortical hyperfunction) results in critical value (alert or action level) for low plasma low potassium and elevated sodium. Poor tubular reabsorption of sodium offsets reduced Chemistry/Correlate clinical and laboratory data/ glomerular filtration. Unfiltered sodium draws both Electrolytes/2 chloride and water, causing osmotic equilibration between filtrate, serum, and the tissues. In renal disease, serum sodium is often normal, although total body sodium is increased owing to fluid and salt retention. Diarrhea hypothyroidism, central nervous system injury, Chemistry/Correlate clinical and laboratory data/ drugs, and malignancy. B The adult reference range for plasma sodium is characteristics/Electrolytes/1 approximately 135–145 mmol/L. Which of the following conditions is associated hypovolemia, and circulatory and heart failure. When a Electrolytes/2 sample result is below or above the low or high alert level, respectively, the physician must be notified immediately. A Total body sodium excess often occurs in persons with renal failure, congestive heart failure, and cirrhosis of the liver. When water is retained along with sodium, total body sodium excess results rather than hypernatremia. Heart failure causes sodium and water retention by reducing blood flow to the kidneys. Cirrhosis causes obstruction of hepatic lymphatics and portal veins, leading to local hypertension and accumulation of ascites fluid. Renal failure results in poor glomerular filtration and isosmotic equilibration of salt and water. Which of the following conditions is associated Answers to Questions 65–67 with hyponatremia? Which of the following conditions involving hypernatremia by promoting sodium reabsorption electrolytes is described correctly? Pseudohyponatremia occurs only when Diabetes insipidus and nephrotic syndrome promote undiluted samples are measured hypernatremia by causing water loss. C When serum albumin is low, the equilibrium between heparinized plasma than in serum bound and Cai is shifted, producing increased Ca. Hypercalcemia may be induced by low serum from platelets and leukocytes during coagulation, magnesium causing serum levels to be higher than plasma. Chemistry/Correlate clinical and laboratory data/ Pseudohyponatremia is a measurement error caused Electrolytes/2 by diluting samples containing excessive fat or 67. The colloids displace plasma water, resulting usually associated with cystic fibrosis? Sweat chloride greater than 60 mmol/L Only ion-selective electrodes that measure whole B. Therefore, hypocalcemia can be associated with either Chemistry/Evaluate laboratory data to recognize health magnesium deficiency or magnesium excess. A Cystic fibrosis causes obstruction of the exocrine glands including the sweat glands, mucus glands, and pancreas. Newborns with pancreatic involvement demonstrate fecal trypsin deficiency, which may be detected by a low fecal chymotrypsin or immunoreactive trypsin result. More than 98% of affected infants have elevated sweat sodium and chloride and low serum levels. When performing a sweat chloride collection, Answers to Questions 68–70 which of the following steps will result in analytical error? Using unweighed gauze soaked in pilocarpine of pilocarpine to stimulate sweating, and the use nitrate on the inner surface of the forearm to of iontophoresis (application of 0. Collecting more than 75 mg of sweat in iontophoresis, the skin on the inner surface of the 30 minutes forearm is washed with deionized water and dried, C. Rinsing the collected sweat from the gauze pad gauze must be completely covered to prevent using chloride titrating solution contamination and loss of sweat by evaporation. Chemistry/Apply knowledge of fundamental biological A minimum mass of 75 mg sweat is required for characteristics/Electrolytes/2 collection in gauze and 15 μL sweat for collection in macroduct tubing. Chemistry/Calculate/Osmolality/2 Because sodium associates with a counter ion, two times the sodium estimates the millimoles per liter of electrolytes. Dividing glucose by 18 converts from milligrams per deciliter to millimoles per liter. Which of the following biochemical processes is Answers to Questions 1–3 promoted by insulin? Uptake of glucose by cells enzymes, and inhibits formation of glucose from Chemistry/Apply knowledge of fundamental biological pyruvate and Krebs cycle intermediates. Which of the following hormones promotes gluconeogenesis and epinephrine stimulates hyperglycemia? Chemistry/Apply knowledge of fundamental biological Aldosterone is the primary mineralocorticoid hormone characteristics/Carbohydrates/1 and stimulates sodium reabsorption and potassium 3. Requires an oral glucose tolerance test for promotes activation of angiotensinogen and diagnosis aldosterone secretion. Type 1 accounts for only Chemistry/Correlate clinical and laboratory data/ about 10%–20% of cases of diabetes mellitus, Biological manifestation of disease/2 and is usually diagnosed by a fasting plasma glucose. Approximately 95% of patients produce autoantibodies against the beta cells of the pancreatic islets. Which of the following is characteristic of Answers to Questions 4–7 type 2 diabetes mellitus? Hyperglycemia is often controlled without obese and over 40 years of age, although the insulin replacement incidence is increasing in both children and young D. Which of the following results falls within the prevent ketosis and hyperglycemia can be controlled diagnostic criteria for diabetes mellitus? Two-hour plasma glucose of 180 mg/dL following criteria for diagnosing diabetes mellitus: following a 75 g oral glucose challenge fasting glucose ≥ 126 mg/dL, casual (random) D. Random plasma glucose of 250 mg/dL and glucose ≥ 200 mg/dL in the presence of symptoms presence of symptoms (polyuria, increased thirst, weight loss), glucose Chemistry/Evaluate laboratory data to recognize health ≥ 200 mg/dL at 2 hours after an oral dose of 75 g of and disease states/Carbohydrates/2 glucose, and hemoglobin A1c ≥ 6. Select the most appropriate adult reference range of diabetes mellitus is indicated if any one or for fasting blood glucose. Te patient remains ambulatory for 3 days prior for impaired fasting plasma glucose (prediabetes) to the test recommended by the American Diabetes Association. No food, coffee, tea, or smoking is allowed associated clinical hypoglycemia, and neonates have a 8 hours before and during the test lower limit of approximately 40 mg/dL owing to D. Such and disease states/Glucose tolerance/2 persons are classified as having prediabetes and 9. Is diagnosed using the same oral glucose such as respiratory distress syndrome, high birth tolerance criteria as in nonpregnancy weight, and neonatal jaundice. Converts to diabetes mellitus after pregnancy usually screened between 24 and 28 weeks’ in 60%–75% of cases gestation. Presents no increased health risk to the fetus nonfasting and consists of an oral 50-g glucose D. Is defined as glucose intolerance originating challenge followed by serum or plasma glucose during pregnancy measurement at 1 hour. A result ≥ 140 mg/dL is Chemistry/Evaluate laboratory data to recognize health followed by a 2-hour or 3-hour oral glucose and disease states/Glucose tolerance test/2 tolerance test to confirm gestational diabetes. Which of the following findings is characteristic the 3-hour test, a 100-g dose of glucose is used of all forms of clinical hypoglycemia? A fasting blood glucose value below 55 mg/dL exceeded: fasting, ≥ 95 mg/dL or higher; 1 hour, B. Neuroglycopenic symptoms at the time of low higher; 3 hour, ≥ 140 mg/dL or higher. C Clinical hypoglycemia can be caused by insulinoma, drugs, alcoholism, and reactive hypoglycemia. Reactive hypoglycemia is characterized by delayed or excessive insulin output after eating and is very rare. High fasting insulin levels (usually > 6 μg/L) are seen in insulinoma, and patients with insulinoma almost always display fasting hypoglycemia, especially when the fast is extended to 48–72 hours. In hypoglycemia, low levels indicate an exogenous insulin source, whereas high levels indicate overproduction of insulin. Which statement regarding glycated (glycosylated) Answers to Questions 11–14 Hgb (G-Hgb) is true? C G-Hgb results from the nonenzymatic attachment of the β chain a sugar such as glucose to the N-terminal valine of B. Will be abnormal within 4 days following an are three G-Hgb fractions designated A1a, A1b, and episode of hyperglycemia Alc. Hemoglobin A1c makes up about 80% of glycated hemoglobin, and is used to determine Chemistry/Correlate laboratory data with physiological the adequacy of insulin therapy. The time-averaged processes/Glycated hemoglobin/2 blood glucose is approximated by the formula 12. A glycated hemoglobin test should Chemistry/Evaluate laboratory data to recognize health be performed at the time of diagnosis and every and disease states/Glucose/2 6 months thereafter if the result is < 6. Levels do not need to be done fasting performed every 3 months until control is B. Samples should be measured within 2 hours of 2–3 months prior to blood collection, the dietary collection status of the patient on the day of the test has no D. Refrigerated whole-blood Chemistry/Apply knowledge to recognize sources of samples are stable for up to 1 week. Hgb A is 1C error/Glycated hemoglobin/2 assayed by cation exchange high-performance liquid chromatography or immunoassay 14. Which stationary phase is used for the (immunoturbidimetric inhibition) because both measurement of hemoglobin A1c by high methods are specific for stable Hgb A1C, and do performance liquid chromatography? Normal hemoglobin A has a weak positive charge at an acidic pH and binds weakly to the resin. Glycated hemoglobin has an even weaker positive charge and is eluted before hemoglobin A. Abnormal hemoglobin molecules S, D, E, and C have a higher positive charge than hemoglobin A and are retained longer on the column. According to American Diabetes Association whole-blood hemolysate, and identify the cause criteria, which result is consistent with a diagnosis and best course of action. Te result is not reportable because labile Chemistry/Evaluate laboratory data to recognize health hemoglobin A1c is present and disease states/Glucose/2 D. Te result is reportable; neither hemoglobin F or C interfere Answers to Questions 15–17 Chemistry/Evaluate laboratory data to recognize problems/Glycated hemoglobin/3 15. Which statement best describes the use of the completely separated from Hgb A and does not 1c Hgb A1C test? Labile hemoglobin is formed initially when the aldehyde of glucose reacts with the N-terminal valine of the β globin chain. This Shiff base is reversible but is converted to Hgb A1c by rearrangement to a ketoamine. A fasting glucose of 126 or higher on two consecutive occasions indicates diabetes. A fasting glucose of 99 mg/dL is considered Peak Calibrated Retention Peak normal. May be used only to monitor persons with type 2 diabetes Chemistry/Correlate clinical and laboratory data/ Glycated hemoglobin/2 210 Chapter 5 | Clinical Chemistry 18. What is the recommended cutoff for the early Answers to Questions 18–21 detection of chronic kidney disease in diabetics using the test for microalbuminuria? The term microalbuminuria is defined as albumin excretion ≥ 30 mg/g creatinine Chemistry/Evaluate laboratory data to recognize health but ≤ 300 mg/g creatinine. The use of the albumin and disease states/Glucose/2 to creatinine ratio is preferred to measures of 19. In addition to measuring blood glucose, Hgb A1c, albumin excretory rate (μg/min) because the latter and microalbumin, which test should be done on is subject to error associated with timed specimen diabetic persons once per year? Estimated glomerular filtration rate have diabetes, it is not sensitive enough to manage Chemistry/Select method/Carbohydrates/2 glucose control on a daily basis, and has been 20. Which testing situation is appropriate for the use replaced by whole-blood glucose monitoring or of point-of-care whole-blood glucose methods?

Urine cultured from the catheter of an 18-year-old female patient produced more than 100 ,000 col/mL 16 . Colonies were catalase positive , possibilities because they are both catalase positive , coagulase negative by the latex agglutination slide coagulase negative , urease positive , and ferment method as well as the tube coagulase test . Novobiocin susceptibility is the test of choice single test for identification is: for differentiating these two species . The tube (cellulitis) was negative for the slide coagulase test test should be performed because the slide test was (clumping factor) and negative for novobiocin negative . A Staphylococci are susceptible to furazolidone , identification is (are): giving zones of inhibition that are 15 mm or greater. Furazolidone (Furoxone) susceptibility is a test greater is considered susceptible. The Staphylococcus used to differentiate: species are resistant and grow up to the disk, while A. Microbiology/Select methods/Reagents/Media/Bacteria/ Filter paper disks that are saturated with oxidase Identification/2 reagent (tetramethyl-p-phenylenediamine in 19. Microbiology/Select methods/Reagents/Media/Bacteria/ Identification/2 420 Chapter 7 | Microbiology 21. Streptococcus species exhibit which of the following Answers to Questions 21–25 properties? Facultative anaerobe, oxidase negative, catalase grow aerobically as well, and are oxidase and catalase negative negative. Facultative anaerobe, β-hemolytic, catalase blood agar, it is best to stab the agar to create positive anaerobiosis because streptolysin O is oxygen labile. A Group A β-hemolytic streptococci are the cause of Microbiology/Apply knowledge of fundamental scarlet fever, and some strains produce toxins biological characteristics/Streptococci/1 (pyrogenic exotoxins A, B, and C) that cause a scarlatiniform rash. A The bacitracin disk test is used in conjunction Microbiology/Apply knowledge of fundamental with other confirmatory tests for the β-hemolytic biological characteristics/Bacteria/1 streptococci. A fourfold rise in titer of which antibody is the and G are also β-hemolytic and give a positive test best indicator of a recent infection with group A for bacitracin (a zone of inhibition of any size). Anti-B α-hemolytic, is susceptible to small concentrations Microbiology/Select methods/Reagents/Media/Bacteria/ of bacitracin, as are other α-hemolytic streptococci. Susceptible or resistant Susceptible Group B Resistant Resistant Microbiology/Correlate clinical and laboratory data/ Non-A, Susceptible Susceptible Bacteria/Streptococci/2 non-B or Resistant 27. Identification/2 Group D streptococci (enterococci and nonenterococci) are positive, causing blackening 29. Te bile solubility test causes the lysis of: of half or more of the slant within 48 hours. Streptococcus bovis colonies on a blood agar plate Viridans streptococci are negative (do not grow B. Group B streptococci in broth culture by dropping 2% sodium deoxycholate onto a few Microbiology/Apply knowledge to identify sources of well-isolated colonies of S. The bile error/Identification/Streptococci/1 salts speed up the autolysis observed in pneumococcal cultures. Optochin disk test, 5 μg/mL or less The same phenomenon can be seen using a broth B. Bile esculin test of the suspension after incubation at 35°C for Microbiology/Select methods/Reagents/Media/Bacteria/ 3 hours. However, Optochin at a concentration in excess of 5 μg/mL inhibits viridans streptococci as well. A zone of inhibition of 14 mm or more around the 6-mm disk is considered a presumptive identification of S. Group D streptococci (nonenterococci) streptococci Microbiology/Correlate clinical and laboratory data/ Microbiology/Evaluate laboratory data to make Bacteria/Streptococci/2 identifications/Bacteria/3 33. Te quellung test is used to identify which Answers to Questions 31–36 Streptococcus species? Both groups Microbiology/Apply knowledge of fundamental grow on bile esculin agar. Group A and B β-hemolytic streptococci methylene blue stain (microprecipitin reaction) C. Nongroup A or B β-hemolytic streptococci occurs between the carbohydrate of the capsule D. Binding Microbiology/Apply knowledge of fundamental of antibodies to the bacteria causes the capsule to biological characteristics/Streptococci/1 swell, identifying the organisms as S. The nongroup A, B, identifications/Bacteria/3 or D streptococci will not grow in 6. Staphylococcal cross-streak test Microbiology/Select methods/Reagents/Media/Bacteria/ Microbiology/Apply knowledge of fundamental Identification/1 biological characteristics/Streptococci/1 Answers to Questions 37–41 38. Many α-hemolytic streptococci recovered from a wound were found to be penicillin resistant. Two blood cultures on a newborn grew β-hemolytic streptococci with the following reactions: 41. Nystatin and amphotericin B are used to prevent growth of yeasts Which is the most likely identification? Nongroup A, nongroup B, nongroup D streptococci Microbiology/Evaluate laboratory data to make identifications/Bacteria/3 424 Chapter 7 | Microbiology 42. Variation in colony types seen with fresh isolates Answers to Questions 42–47 of Neisseria gonorrhoeae and sometimes with Neisseria meningitidis are the result of: 42. Multiple nutritional requirements sizes and appearances of gonococci are the result B. Colony size and coloration (or light reflection) are the basis of Kellogg’s scheme Microbiology/Apply knowledge of fundamental (types T1 through T5). Types T1 and T2 have pili biological characteristics/Neisseria/2 on the surface and T3, T4, and T5 do not. A Gram stain of a urethral discharge from a species form long filaments or long spindle-shaped man showing extracellular and intracellular cells when grown near a 10-unit penicillin disk. Neisseria lactamica flora contain gram-negative cocci and diplococci resembling gonococci and, therefore, no presumptive Microbiology/Evaluate laboratory data to make identification should be reported for N. A Oxacillin is the drug used to screen staphylococci Fructose = Neg for resistance to antibiotics having the β-lactam ring. Microbiology/Apply knowledge of fundamental biological characteristics/Gram-negative cocci/1 52. D The standard Kirby–Bauer method used for disk diffusion susceptibility testing recommended by 51. Tetracycline Microbiology/Apply knowledge of fundamental biological characteristics/Antibiotic susceptibility/1 426 Chapter 7 | Microbiology 53. Which one of the following organisms is a known Answers to Questions 53–54 producer of β-lactamase–producing strains, and should be tested (screened) by a commercial 53. C A test for β-lactamase production should be β-lactamase assay prior to susceptibility testing? An example is biological characteristics/Antibiotic susceptibility/2 heteroresistant mecA-positive S. This is referred to as being D-zone Microbiology/Apply knowledge of fundamental positive. Large gram-positive spore-forming rods growing Answers to Questions 1–2 on blood agar as large, raised, β-hemolytic colonies that spread and appear as frosted green-gray glass 1. Bacillus anthracis and Bacillus cereus can best be positive and produce acid from glucose. Lecithinase and catalase Microbiology/Select methods/Reagents/Media/Bacteria/ Identification/2 β Hemolysis Motility Oxidase Catalase Lecithinase Glucose B. Which is the specimen of choice for proof of food Answers to Questions 3–6 poisoning by Bacillus cereus? Penicillin (10-unit) susceptibility test performed in a biological safety hood, and personnel B. Which of the following tests should be performed appears on the Gram stain smear as gram-positive for initial differentiation of Listeria monocytogenes short, thin, diphtheroidal shapes, whereas from group B streptococci? Culture of a finger wound specimen from a meat streptococci packer produced short gram-positive bacilli on a blood agar plate with no hemolysis. Colonies Motility (wet prep) = Neg growing on blood agar are small and transparent, Motility (media) = Neg (bottle-brush growth in stab may be either smooth or rough, and are often culture) surrounded by a green tinge. Bacillus subtilis Microbiology/Evaluate laboratory data to make identifications/Bacteria/3 7. A non–spore-forming, slender gram-positive rod Answers to Questions 7–11 forming palisades and chains was recovered from a vaginal culture and grew well on tomato juice agar. D Corynebacterium species recovered from a throat Microbiology/Evaluate laboratory data to make culture are usually considered part of the normal identifications/Bacteria/2 throat flora. In this event, direct inoculation on Loeffler culture is considered a pathogen when it produces: serum medium or tellurite medium and the following A. A pseudomembrane of the oropharynx biochemical tests should be performed to confirm B. Gray-black colonies with a brown halo on Tinsdale’s agar Gelatin hydrolysis = Neg Catalase = + D. D A Gram stain smear from a vaginal secretion showing can be made using which of the following many squamous epithelial cells loaded with findings? A gram-positive branching filamentous organism Kinyoun stain and 1% sulfuric acid as the decolorizing recovered from a sputum specimen was found to agent. The other organisms listed are negative for be positive with a modified acid-fast stain method. Darkfield microscopy for direct identifications/Bacteria/2 visualization or indirect immunofluorescence using 11. Routine laboratory testing for Treponema fluorescein-conjugated antihuman globulin (the pallidum involves: fluorescent treponemal antibody-absorption test, A. Gram staining including chemiluminescence and point-of-care Microbiology/Select methods/Reagents/Media/ immunochromatography. Spirochetes often detected in the hematology Answers to Questions 12–17 laboratory, even before the physician suspects the infection, are: 12. D Lyme disease may result in acute arthritis and Microbiology/Apply knowledge of fundamental meningitis and is caused by B. This biological characteristics/Spirochetes/1 spirochete is carried by the deer tick belonging to the Ixodes genus (I. Which of the following organisms is the cause of North-central United States and I. A Serological analysis using immunofluorescence or Microbiology/Apply knowledge of fundamental an enzyme immunoassay is the method of choice biological characteristics/Spirochetes/1 for diagnosis of Lyme disease. Te diagnostic method most commonly used for be cultured directly from lesions, and darkfield the identification of Lyme disease is: microscopy can be used for detection of spirochetes A. Primary atypical pneumonia is caused by: from the upper and lower respiratory tracts onto A. Which organism typically produces “fried-egg” is grown on “M” agar containing arginine and colonies on agar within 1–5 days of culture from a phenol red. Treponema pallidum Colonies of Ureaplasma are small and golden brown on A7/A8 agar. Te manganous chloride–urea test is used for the utilizes manganous chloride (MnCl2) in the presence identification of which organism? Borrelia burgdorferi is observed under a dissecting microscope and is a Microbiology/Select methods/Reagents/Media/ rapid test for the identification of U. A gram-positive (gram-variable), beaded organism Answers to Questions 18–22 with delicate branching was recovered from the sputum of a 20-year-old patient with leukemia. D All of the listed organisms produce mycelium (aerial Te specimen produced orange, glabrous, waxy or substrate), causing them to appear branched colonies on Middlebrook’s agar that showed when Gram stained, but only the Nocardia spp. What is the most likely opportunistic pathogen, and cultures typically have a identification? A The “whiff” test is used for a presumptive diagnosis stained with Loeffler methylene blue stain showed of an infection with G. Culture using McCoy and Hela cells produce antibodies especially in extra respiratory D. Which test is the most reliable for the detection of to produce an IgM response especially in recurrent Mycoplasma pneumonia in serum and for the infections, so the best confirmatory approach is a confirmation of diagnosis? Complement fixation Microbiology/Select test/Identification/Mycoplasma/2 432 Chapter 7 | Microbiology 23. Identify the following bacterium and specimen Answers to Questions 23–25 pairing that is mismatched (specimen not appropriate for isolation). Chlamydia (Chlamydophila) psittaci: fecal swab classification for Chlamydia psittaci. Chlamydia trachomatis: first voided urine found naturally in psittacine birds and other avian C. Chlamydia pneumonia: throat swab or sputum contact with pet birds, or from occupational contact in poultry farming or processing. Inhalation of the Microbiology/Apply knowledge of standard operating organisms from aerosols, fecal material, or feather procedure/Specimen collection/Chlamydia/1 dust causes a respiratory infection and the specimen 24. Which of the following organisms are transmitted of choice is a throat swab or sputum. He removed the tick, diagnosis can be made by direct observation of the but 2 weeks later noticed a circular, bull’s eye rash basophilic inclusions (morulae) in leukocytes of at the site of the bite. Which specimen(s) should Giemsa’s or Wright’s stained blood or buffy coat be obtained to establish a diagnosis of Lyme smears.

Controlled study on the use of hand-held insulin dosage computers enabling conversion to and optimizing of meal-related insulin therapy regimens . Health Telematics - Current Developments and Consequences for Hospitals and Care-providers . Diabetes self-adjustment by a computerized program-­ first experiences in inpatient and outpatient treatment . Evaluation of documentation of patient height , weight , and allergy information at a university medical center . Design and acceptability of patient-oriented computerized diabetes care reminders for use at the point of care . Medication safety teams’ guided implementation of electronic medication administration records in five nursing homes . An empirical and policy analysis of the impact of Divisions within the Australian health care system . Achieving better in-hospital and after-hospital care of patients with acute cardiac disease . Early implementation experiences with an orders interface from a clinical information system to a pharmacy system: Challenges of blending two workflows. Impact of robotic technology on the accuracy and quality of a centralized cart fill process. Toward development of a computer-based methodology for evaluating and reducing medication administration errors. Antiretroviral drug interactions: often unrecognized, frequently unavoidable, sometimes unmanageable. Financial/workload evaluation for an automated controlled substance dispensing system. Implementation of a commercially available clinical decision support system to decrease adverse drug events: an exploratory descriptive analysis. Advances in Patient Safety: From Research to Implementation 2005;2: Concepts and Methodology: Grey Lit. Adverse drug event detection in a community hospital utilising computerised medication and laboratory data. Computer networking to enhance pharmacist-physician communication: A pilot demonstration project in community settings. Steps in multidisciplinary implementation of `smart pump” technology to optimize patient safety. Imputation of consumption to patient in three different clinical units with automated dispensing systems. Modeling patient-specific therapeutic strategy in the guideline-based management of a chronic disease. Reminder-based or on-demand decision support systems: a preliminary study in primary care with the management of hypertension. Computerized ambulatory care pharmacy information system for direct order entry by prescribers. Development of an electronic pharmacy patient profiling system in the era of computerized physician order entry. Wireless clinical alerts for critical medication, laboratory and physiologic data. Primary care physicians’ use of an electronic medical record system: a cognitive task analysis. Review of the evidence of the impact of computerized physician order entry system on medication errors. The development of a computerised equipment and drug calculator for use in resuscitation. HandiStroke: A handheld tool for the emergent evaluation of acute stroke patients. Understanding the impact on intensive care staff workflow due to the introduction of a critical care information system: a mixed methods research methodology. A Meta-analysis of 16 randomized controlled trials to evaluate computer-based clinical reminder systems for preventive care in the ambulatory setting. Past, present, and future of insulin pump therapy: A better shot at diabetes control. Comparison of the applicability of rule-based and self- organizing fuzzy logic controllers for sedation control of intracranial pressure pattern in a neurosurgical intensive care unit. Towards effective implementation of a pediatric asthma guideline: integration of decision support and clinical workflow support. Proceedings - the Annual Symposium on Computer Applications in Medical Care 1994;797-801. Computer-based guideline implementation systems: A systematic review of functionality and effectiveness. Analysis of medication administration time and the effects of an automated distribution system. Exclude - Not a Primary Study Shklovskiy-Kordi N, Zingerman B, Rivkind N and others. The effects of on-screen, point of care computer reminders on processes and outcomes of care. Effect of point-of-care computer reminders on physician behaviour: A systematic review. Construction and evaluation of new anti-cancer drug prescription support system to promote proper use of anticancer drugs. Gan to Kagaku Ryoho [Japanese Journal of Cancer & Chemotherapy] 2008;35(10):1717-20. Comparison of supplementary prescribers’ and doctors’ compliance with guidelines for drug dosing in haemofiltration on an intensive care unit. Tight glycaemic control: A prospective observational study of a computerised decision-supported intensive insulin therapy protocol. Analysis of physicians’, pharmacists’, and nurses’ attitudes toward the use of computers to access drug information. Computer-generated medication profile review as replacement for automatic stop orders. Automating drug distribution to save cognitive services at an academic medical center. Evaluation of a computerized drug review system: impact, attitudes, and interactions. A usability inspection of medication management in three personal health applications. A usability inspection of medication management in three personal health applications. Symptom management for cancer patients: A trial comparing two multimodal interventions. The process of drug dispensing and distribution at four Brazilian hospitals: A multicenter descriptive study. Personalized neuromuscular blockade through control: clinical and technical evaluation. Assisted drug risk management using computer- controlled infusion pumps and a programmable bedside monitor. Medication prescribing on a university medical service-the incidence of drug combinations with potential adverse interactions. Impact of a pharmacy and nursing service survey after a one month trial with the Pyxis Medstation. Computerized prescribing alerts and group academic detailing to reduce the use of potentially inappropriate medications in older people. Electronic health records: which practices have them, and how are clinicians using them? Physicians’ use of key functions in electronic health records from 2005 to 2007: a statewide survey. Enhancing an ePrescribing system by adding medication histories and formularies: the Regenstrief Medication Hub. Balancing diversion control and medical necessity: the case of prescription drugs with abuse potential. Electronic prescribing systems in pediatrics: The rationale and functionality requirements. Screening, counseling and monitoring drug therapies including those outside the comfort zone. Implementation of standardized concentrations for continuous infusions in a pediatric hospital. Vancomycin control measures at a tertiary-care hospital: impact of interventions on volume and patterns of use. Comparative impact of guidelines, clinical data, and decision support on prescribing decisions: an interactive web experiment with simulated cases. Variables that affect the impact of computerised decision support on patient outcomes: a systematic review. Implementation pearls from a new guidebook on improving medication use and outcomes with clinical decision support. Pharmacy Informatics and risk management: Minimizing negative events and consequences. Recommendations for monitoring and evaluation of in-patient Computer-based Provider Order Entry systems: results of a Delphi survey. Design and implementation of a point-of-care computerized system for drug therapy in Stockholm metropolitan health region--Bridging the gap between knowledge and practice. Evaluation of a computerized pharmacy patient charge system which uses bar code technology. Organizational approach to implementing bar code technology in a university hospital. Development of a miniaturised drug delivery system with wireless power transfer and communication. Chronic care model and shared care in diabetes: randomized trial of an electronic decision support system. Optimizing the use of electronic medication administration records in a rural hospital. Computerized provider order entry system field research: The impact of contextual factors on study implementation. Knowledge modelling and knowledge representation in hospital information systems to improve drug safety. Lost in translation: challenges and opportunities in physician-to-physician communication during patient handoffs. Information technology to support self-management in chronic care: A systematic review. International Journal of Healthcare Technology and Management 2008;9(5-6): Database: Embase Sept 22-09. Management of oral anticoagulation in a population of children with cardiac disease using a computerised system to support decision-making. Enhancement of adherence to tricyclic antidepressants by computerized supervision. Development of a pharmacy-managed medication dictionary in a newly implemented computerized prescriber order-entry system. Development of a pharmacy managed medication dictionary in a newly implemented computerized provider order entry system. The effect of a computerized physician order entry system on managing continuous infusion medications at a pediatric intensive care unit. Securing chemotherapies: fabrication, prescription, administration and complete traceability. Re-engineering of a medication distribution system in the emergency department in a tertiary care institution via implementation of an automated dispensing system. The need for a concept-based medication vocabulary as an enabling infrastructure in health informatics. Spontaneous subarachnoid haemorrhage: expert system for appraisal of the prognosis and computer-supported decision for therapy. Spironolactone: The missing drug in the treatment of patients hospitalized with congestive heart failure. Computerised systematic secondary prevention in ischaemic heart disease: a study in one practice. An effort to improve electronic health record medication list accuracy between visits: patients’ and physicians’ response. Physicians’ attitudes towards eprescribing: A comparative web survey in Austria and Sweden. Curriculum design and program to train older adults to use personal digital assistants. Persuasive pillboxes: Improving medication adherence with personal digital assistants. Too steep to climb: proposed meaningful-use regs ask too much, too soon of providers. Use of web services for computerized medical decision support, including infection control and antibiotic management, in the intensive care unit. Nurses’ experience of using electronic patient records in everyday practice in acute/inpatient ward settings: a literature review. Implementation and evaluation of an automated drug distribution system as a component of the university community clinic pharmacy service models. Hospital admission medication reconciliation in medically complex children: An observational study. Implementation of electronically submit reports of adverse events to the Boards of Health in Germany. One strategy to reduce medication errors: the effect of an online continuing education module on nurses’ use of the Lexi-Comp feature of the Pyxis MedStation 2000.

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