Chapter 47: Infections and Infestations

Buttaro: Primary Care: A Collaborative Practice, 6th Edition

Multiple Choice

1. A previously healthy patient has an area of inflammation on one leg which has well-demarcated borders and the presence of lymphangitic streaking. Based on these symptoms, what is the initial treatment for this infection?

a. Amoxicillin-clavulanate b. Clindamycin c. Doxycycline d. Sulfamethoxazole-trimethoprim

ANS: A a. Mupirocin, 2% ointment b. Culture and sensitivity of the lesions c. Sulfamethoxazole-trimethoprim

This patient has symptoms consistent with erysipelas, which is commonly caused by staphylococcal or streptococcal bacteria. These may be treated empirically with penicillinase-resistant penicillin if not allergic. Clindamycin, doxycycline, and sulfamethoxazole-trimethoprim are used for methicillin-resistant staphylococcus aureus infections.

2. A patient has vesiculopustular lesions around the nose and mouth with areas of honey-colored crusts. The provider notes a few similar lesions on the patient’s hands and legs. Which treatment is appropriate for this patient?

NURSINGTB.COM d. Surgical referral

ANS: A a. Apply moist heat until symptoms resolve. b. Begin treatment with amoxicillin-clavulanate. c. Prescribe trimethoprim-sulfamethoxazole. d. Wait for culture results before ordering an antibiotic.

This patient has symptoms of impetigo which has spread to the hands and legs. Mupirocin, 2% ointment, should be applied three times a day for 10 days. It is not necessary to obtain a culture since this can be treated empirically in most cases. MRSA is unlikely, so sulfamethoxazole-trimethoprim is not indicated. Surgical referrals are generally not indicated.

3. A patient with a purulent skin and soft tissue infection (SSTI). A history reveals a previous MRSA infection in a family member. The clinician performs an incision and drainage of the lesion and sends a sample to the lab for culture. What is the next step in treating this patient?

ANS: C a. Antiviral medications are curative for oral herpes. b. The initial episode is usually the most severe. c. There are no specific triggers for this type of herpesvirus. d. Transmission to others occurs only when lesions are present.

Because of a history of exposure to MRSA, the patient is likely to be colonized and should be treated accordingly. Small lesions may be treated with moist heat, but the likelihood of MRSA requires treatment. Amoxicillin-clavulanate is not effective for MRSA. Treatment should be started empirically.

4. A patient who has never had an outbreak of oral lesions reports a burning sensation on the oral mucosa and then develops multiple painful round vesicles at the site. A Tzanck culture confirms HSV-1 infection. What will the provider tell the patient about this condition?

ANS: B a. Oral antivirals are necessary to treat this type of herpes. b. Preparations containing salicylic acid are most helpful. c. Topical medications can have an impact on pain and discomfort. d. Topical medications will significantly shorten the healing time.

In herpesvirus outbreaks, the initial episode is generally the most severe. Antiviral medications may prevent outbreaks, but do not cure the disease. HSV-1 has several specific triggers. Transmission to others may occur even when lesions are not present.

5. A patient who has had lesions for several days is diagnosed with primary herpes labialis and asks about using a topical medication. What will the provider tell this patient?

ANS: C a. Acyclovir b. Famciclovir c. Topical medications d. Valacyclovir

Topical medications may alleviate discomfort, but do not shorten healing time. Oral antivirals may help shorten healing, but are not necessary as treatment, since the disease is usually self-limiting. Salicylic acid should not be used because it can erode the skin.

6. A patient who has recurrent, frequent genital herpes outbreaks asks about therapy to minimize the episodes. What will the provider recommend as first-line treatment?

ANS: A

NURSINGTB.COM a. The patient does not have tinea capitis. b. The patient is less likely to have tinea capitis. c. The patient is positive for tinea capitis. d. The patient may have tinea capitis.

All three oral antiviral medications help reduce the number of occurrences and the frequency of asymptomatic shedding. Famciclovir and valacyclovir are more costly and no more effective, so should not be first-line therapy. Topical medications are not useful with recurrent, frequent genital herpes.

7. When evaluating scalp lesions in a patient suspected of having tinea capitis, the provider uses a Wood’s lamp and is unable to elicit fluorescence. What is the significance of this finding?

ANS: D a. Oral griseofulvin b. Oral ketoconazole c. Topical clotrimazole d. Topical tolnaftate

8. Although some fungal species causing tinea capitis are fluorescent with a Wood’s lamp, Trichophyton tonsurans, the most common cause or tinea capitis, does not, so lack of fluorescence does not rule out the infection, make it less likely, or diagnose it. Which medication will the provider prescribe as first-line therapy to treat tinea capitis?

ANS: A a. Bullous lesions on the soles of the feet and palms of the hands b. Intraepidermal burrows on the interdigital spaces of the hands c. Nits and small bugs along the scalp line at the back of the neck d. Pustular lesions in clusters on the trunk and extremities

Systemic antifungal medications are used for widespread tinea and always with infections that involve the nails or scalp. Oral ketoconazole should be avoided due to risks of hepatotoxicity and serious drug interactions.

9. A patient has a pruritic eczematous dermatitis which has been present for 1 week and reports similar symptoms in other family members. What will the practitioner look for to help determine a diagnosis of scabies?

ANS: B a. All household contacts will be treated only if symptomatic.

The scabies mite typically burrows no deeper than the stratus corneum and burrows may be found in the interdigital spaces of the hands, among other places. Bullous lesions may occur with impetigo. Nits and small bugs are characteristic findings with pediculosis. Pustular lesions represent superficial skin infections.

10. The provider is prescribing 5% permethrin cream for an adolescent patient who has scabies. What will the provider include in education for this patient?

NURSINGTB.COM b. Itching 2 weeks after treatment indicates treatment failure. c. Stuffed animals and pillows should be placed in plastic bags for 1 week. d. The adolescent’s school friends should be treated.

ANS: C a. Culture the lesions to determine the cause. b. Evaluate the patient for HIV infection. c. Order topical nystatin cream. d. Prescribe a cephalosporin antibiotic.

Bedding and clothing of persons with scabies should be washed in hot water and dried on hot dryer settings. Items that cannot be washed should be put in plastic bags for 1 week. All household contacts should be treated. Itching may persist because of the secondary dermatitis for up to 2 weeks and does not represent treatment failure. Casual contacts do not require treatment.

11. A patient with intertrigo shows no improvement and persistent redness after treatment with drying agents and antifungal medications. The patient reports an onset of odor associated with a low-grade fever. What will the provider do next to manage this condition?

ANS: A a. An antiviral medication will prevent transmission to others. b. As long as her lesions are covered, there is no risk of transmission. c. Contagion is possible until all her lesions are crusted. d. Varicella-zoster and herpes zoster are different infections.

This patient has symptoms of a secondary bacterial infection. The lesions should be cultured and the results used to determine the appropriate antibiotic. Patients with recurrent candida infections should be evaluated for underlying HIV infection, diabetes, and other immunocompromised states. Topical nystatin cream is used for candida infection and these symptoms are consistent with bacterial infection. Antibiotics should be chosen based on culture results.

12. An older patient experiences a herpes zoster outbreak and asks the provider if she is contagious because she is going to be around her grandchild who is too young to be immunized for varicella. What will the provider tell her?

ANS: C a. Polymerase chain reaction analysis b. Serum immunoglobulins c. Tzanck test d. Viral culture

Herpes zoster lesions contain high concentrations of virus that can be spread by contact and by air; although they are less contagious than primary infections, contagion is possible until all lesions are crusted. Antiviral medications shorten the course, but do not reduce transmission. Covering the lesions does not prevent transmission. Herpes zoster and varicella-zoster are the same.

13. A patient has a unilateral vesicular eruption which is described as burning and stabbing in intensity. To differentiate between herpes simplex and herpes zoster, which test will the provider order?

ANS: A

NURSINGTB.COM

The PCR is a rapid and sensitive test that can differentiate between the two. Serum Ig levels are not diagnostic. The Tzanck test identifies the presence of a herpes virus but does not differentiate between the two types. Viral culture will differentiate, but it is not rapid.

Multiple Response

1. What instructions will the primary care provider give to parents of a child who has scabies who is ordered to use 5% permethrin cream? (Select all that apply.)

a. Apply the cream at bedtime and rinse it off in the morning.

b. It is not necessary to wash bedding or clothing when using this cream.

c. Massage the cream into the skin from head to toe.

d. The rash should disappear within a day or two after using the cream.

e. Use once now and repeat the treatment in 1 to 2 weeks.

ANS: A, E a. Aluminum sulfate solution b. Burrow’s solution compresses c. Cornstarch application d. Nystatin cream e. Topical steroid cream

Permethrin cream should be applied from the neck down in children and rinsed off in 8 to 12 hours. The treatment should be done once and then repeated in 1 to 2 weeks. Bedding and clothing should be washed thoroughly. Adults should apply from head to toe, since the scabies can infest the hairline of adults. The rash may still be present for several weeks after treatment.

2. When recommending ongoing treatment for a patient who has recurrent intertrigo, what will the provider suggest? (Select all that apply.)

ANS: A, B

Aluminum sulfate solution and other drying agents are recommended, and Burrow’s solution compresses may be soothing. Cornstarch is ineffective and may result in fungal growth. Nystatin cream is used only for candida intertrigo. Topical steroids may promote infection.