HIV Vaccination
- 建議每年施打一劑流行性感冒疫苗
Info
Ditched Notion for Obsidian for some time, as Notion takes forever to open a big, fat note. However, Obsidian isn’t very sharable without the paid Publish feature. Finally set up this blog so that I can access (some of) my notes while I’m seeing patients in the out-patient department or in jail!
My Notion site is still functioning, although a bit out-dated:
Treatment of MDR Gram-negative bacilli
Green, susceptibility anticipated to be >80%; yellow, susceptibility anticipated to be 30% to 80%; red, intrinsic resistance or susceptibility anticipated to be <30%. 1, US Food and Drug Administration–approved agent; 2, synthetic tetracycline derivative; 3, imipenem-cilastatin–relebactam; 4, synthetic aminoglycoside; 5, polymyxin class. Abbreviations: KPC, Klebsiella pneumoniae carbapenemase; NDM, New Delhi metallo-β-lactamase. (Tamma et al., 2024)
反重力
作者：黃崇凱 原文出版年：2024
五十年前夢見的未來是什麼？ 以小說測量歷史的距離 重訪七○年代內在景觀之作 一九六九年七月二十一日，太空人阿姆斯壯在月球的第一步，終結了太空競賽，改變歷史的重力，為一九七○年代拉開騷動序幕。 彼時飄流異國的中輟留學生、暗殺失敗的槍手、脫逃的教授、等待判決的囚徒、化名的異議分子、爆炸倖存者、博覽會接待員與追查案件謎團的調查員，時代人物在格差的世界中偶遇或錯過，卻隱隱在命運暗面彼此相連。 小說主角各自燃燒理想，對抗戒嚴年代的高重力，嘗試著哪怕只有短短一瞬的反重力行動。儘管反重力是妄想，是虛構，是不可能的事，他們仍然奮力一搏，渴求一個超越此時此地的世界，一個改變重力的世界，一個反重力的世界。他們持續燃燒，直到化為灰燼，直到飄升空中，直到成為遙遠而閃爍的塵埃，微弱地改變來自宇宙的光。 《反重力》圍繞半個世紀前臺灣幾個重要政治事件：刺殺蔣經國、彭明敏逃亡、泰源事件、臺南美新處爆炸案……，但小說的時間與空間又超過了這些，指向整個一九七○年前後的地球，詢問著來不及發生的失去：在那個時代，島嶼上的人們曾經創造出哪些如今回看無比閃耀的可能性？
DM
American Diabetes Association Professional Practice Committee, ElSayed, N.A., Aleppo, G., Bannuru, R.R., Beverly, E.A., et al. (2024) Summary of Revisions: Standards of Care in Diabetes—2024. Diabetes Care. 47 (Supplement_1), S5–S10. doi:10.2337/dc24-SREV.
Diagnosis
Criteria for the diagnosis of diabetes in nonpregnant individuals 1
- A1C ≥6.5% (≥48 mmol/mol). The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay.2 OR
- Fasting plasma glucose (FPG) ≥126 mg/dL (≥7.0 mmol/L). Fasting is defined as no caloric intake for at least 8 h.2 OR
- 2-h plasma glucose ≥200 mg/dL (≥11.1 mmol/L) during oral glucose tolerance test. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.2 OR
- In an individual with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma glucose ≥200 mg/dL (≥11.1 mmol/L). Random is any time of the day without regard to time since previous meal.
劇本閱讀與一點點（真的一點點）寫作練習
提到劇本與劇作，大家可能會想起那些經典的名字：莎士比亞、契訶夫、易卜生。
本期的劇本閱讀課會從經典劇作入門，延伸至近代的台灣作品，每堂課會選讀作品的片段，分析並且討論，也會有一點點（真的一點點）的寫作練習。
除了劇場劇本之外，也會選摘影視劇本的片段，分析不同載體之下寫作策略的差異。
Recommendations for the Treatment of Methicillin-Resistant Staphylococcus aureus (MRSA)
Source [@Liu2011ClinicalPractice]
Treatment of CRAB
- The use of high-dose ampicillin-sulbactam (total daily dose of 6–9 g of the sulbactam component) in combination with at least 1 other agent is suggested for the treatment of CRAB infections.
Key Opportunities to Improve Antibiotic Use
| 狀況 | 診斷考量 | 經驗治療 | 根據培養結果調整最終療法並確定治療時長，包括出院處方 |
|---|---|---|---|
| 社區性肺炎 | 治療開始後複查病例以確認肺炎診斷或排除非感染性病因。 | 除非有臨床指徵，避免經驗性使用抗綠膿桿菌β-lactam類藥物和/或抗MRSA藥物。 | 大多數無併發症的成年肺炎病例可在患者迅速臨床反應的情況下進行5天治療。數據也顯示，MRSA鼻腔移生檢測結果為陰性可幫助指導停用MRSA肺炎的經驗性治療 |
| 泌尿道感染 | 實施尿液培養開立標準，以確保陽性培養更可能代表感染而非膀胱移生。例如： 僅在患者出現符合UTI的徵兆和症狀時訂開立培養，如尿急、頻尿、排尿困難、耻骨上疼痛、側腹疼痛、骨盆不適或急性血尿。 對於使用導尿管的患者，若無UTI的徵兆和症狀，避免僅因尿液外觀混濁或氣味難聞而進行尿液培養。 譫妄、噁心和嘔吐等非特異性徵兆和症狀應謹慎解讀，因為單獨這些徵兆對UTI的特異性較低。 |
建立標準以區分無症狀和有症狀的菌尿症。除非在某些臨床情況下需要治療（如妊娠婦女和進行侵入性泌尿生殖手術的患者），否則應避免對無症狀菌尿症進行抗生素治療。 | 使用臨床適宜的最短抗生素治療時長。 |
| 皮膚和軟組織感染 | 制定診斷標準以區分化膿性和非化膿性感染，以及疾病的嚴重程度（即輕度、中度和重度），以便根據指南適當管理皮膚和軟組織感染。 | 除非有臨床指徵，避免經驗性使用抗綠膿桿菌β-lactam類藥物和/或抗厭氧菌藥物。對於無併發症的非化膿性蜂窩織炎，可能不需要使用特別針對MRSA的治療。 | 大多數無併發症的細菌性蜂窩織炎病例可在患者迅速臨床反應的情況下進行5天治療。 |
BACTEREMIA
Definitions
- Primary bacteremia: bloodstream infection due to direct inoculation of the blood
- Central line associated bloodstream infection (CLABSI): bacteremia in which the same organism is growing from peripheral and catheter cultures (CID 2009;49:1)
- Secondary bacteremia: infection of another site (eg, UTI, pneumonia, colitis, etc.) spreading to blood
- Contaminant: bacteria growing in a blood culture that does not represent a true infection
Risk factors for bloodstream infections (JAMA 2012;308:502; CID;2020;71)
- Syndromes with high likelihood of bacteremia:
- Sepsis
- Endovascular infections: endocarditis, infection of pacemaker, vascular graft or IV catheter
- Vertebral osteomyelitis, epidural abscess, septic arthritis
- Risk factors: indwelling lines, IVDU, immunosupp. (neutropenic, transplant)
- Organisms
- More likely pathogenic: S. aureus, β-hemolytic strep, enterococci, GNR, S. pneumo, Neisseria, Candida
- Less likely pathogenic: coag-neg staph, diphtheroids, Cutibacterium
- Time to growth: <24 h → higher risk, >72 h → lower risk (except slow-growing, eg, HACEK)
- Factors increasing likelihood of endocarditis: high-grade bacteremia w/o source, persisting after line removal or drainage of focal source, in hosts at risk for endocarditis or w/ organisms known to cause IE; emboli
Diagnosis
- ≥2 sets blood culture prior to antibiotics (set = aerobic + aneaerobic culture) at separate puncture sites
- If proven bacteremia, daily surveillance cultures until 48 hrs of ⊖ cultures. May not need for GNRs (ClD 2017;65:1776)
- Transthoracic echocardiography (TTE)/transesophageal echocardiography (TEE) if concern for endocarditis (see IE section)
- TTE and urgent ophthalmology evaluation if yeast is growing in blood culture
Treatment (CID 2009;49:1; JAMA 2020;323:2160)
- Empiric antibiotics based on Gram stain, culture, & clinical syndrome, then tailor based on sensitivity
Short-Term Central Venous Catheter-Related Bloodstream Infections
| Pathogen | Management |
|---|---|
| S. aureus | Risk of endocarditis in bacteremia: ˜25% (JACC 1997;30:1072) ID consult a/w ↓ mortality (ClD 2015;60:1451) Remove CVC, evaluate for endocarditis, osteo, hardware infections Preferred antibiotics: MSSA → nafcillin, oxacillin, or cefazolin. MRSA → vancomycin. Duration: 2 wks if normal host, no implants, no evidence of endocarditis or metastatic complications. Otherwise 4-6 wks. |
| Coag-neg staphylococci | CVC retention does not ↓ rate of resolution, but a/w ↑ rate of recurrence (CID 2009;49:1187). If CVC left, treat 10-14 days; if removed 5-7 days. |
| Enterococcus | Remove CVC & treat for 7-14 days |
| GNR** | Remove CVC esp if Pseudomonas. Therapy for 14 days (7 if uncomplicated). |
| Yeast | Remove CVC & treat for 14 from first ⊖ BCx. ID consult a/w ↓ mortality. |
| - Persistently ⊕ BCx: remove CVCs, look for metastatic infection (endocarditis, septic arthritis, osteo), infected thrombosis, or prosthetic material (vascular graft, PPM) |
BACTERIAL ENDOCARDITIS
Definition
- Infection of endothelium of heart (including but not limited to the valves) including both prosthetic valve endocarditis (PVE) and native valve endocarditis (NVE)
Risk Factors
- Abnormal valve (JAMA 1997;277:1794; JACC 2018;72:2443)
- High risk: prior endocarditis, prosthetic valve or ring, some congenital heart disease (unrepaired cyanotic; shunt/conduit; prosthesis in past 6 mos), transplant heart, valvulopathy, ventricular assist device
- Medium risk: previous rheumatic fever, non-rheumatic valve disease (including MVP w/ MR or thickened leaflet), HCM, bicuspid AoV
- Risk of bacteremia: IVDU, indwelling venous catheters, hemodialysis, prosthetic material in heart (eg, pacemaker, ICD, graft), poor dentition
Microbiology of Endocarditis
| Native Valve (NVE) | Prosthetic Valve (PVE) | |||
|---|---|---|---|---|
| Etiology | Non-IVDA | IVDU | Early (≤60 days) | Late (>60 d) |
| S. viridans et al. | 36% | 13% | <5% | 20% |
| Enterococcus | 11% | 5% | 8% | 13% |
| S. aureus | 28% | 68% | 36% | 20% |
| S. epidermidis | 9% | <5% | 17% | 20% |
| GNR | <5% | <5% | 6% | <5% |
| Other | <5% | <5% | 10% | 10% |
| Fungal^ | 1% | 1% | 9% | 3% |
| Culture ⊖^^ | 11% | <5% | 17% | 12% |
| ^ ↑ risk w/DM, indwelling lines, immunosupp. | ||||
| ^^ Cx ⊖ = abiotrophic strep, HACEK (Haemophilus para-influenzae & aphrophilus, Actinobacillus, Cardiobacterium, Eikenella, and Kingella), T. whipplei, Bartonella, Coxiella, Chlamydia, Legionella, Brucella (JAMA 2007;297:1354; Annals 2007;147:829; J Clin Microbiol 2012;50:216) |
Clinical manifestation (Lancet 2016;387:882)
- Persistent bacteremia → fever (80-90%), rigors, night sweats, anorexia, myalgias
- Valvular or perivalvular infection → HF, conduction abnormalities (eg, AVB)
- Septic emboli: stroke, embolic MI, renal/splenic/pulmonary infarcts, septic arthritis, osteo
- Immune complex phenomena: arthritis, glomerulonephritis
- Subacute endocarditis can present with subacute progressive “B” sx (fatigue, wt loss)
Physical exam
- Cardiac murmur (85%), s/s of new HF (pulmonary edema, JVP elevation, edema)
- Skin/ocular changes (uncommon but highly specific)
- Janeway lesions (painless hemorrhagic macules on palms/ soles due to septic emboli)
- Osler's nodes (painful nodules on pads of digits due to immune complex deposition)
- Splinter hemorrhages in fingernails or toenails
- Roth spots (retinal hemorrhages)
- MSK: point tenderness along spine, red/hot joints
- Neurologic deficits c/f embolic stroke; vertebral tenderness c/f osteo or epidural abscess
- Devices: evaluate CVCs, PM/ICD pocket, and sites of other hardware/ prosthetics
Diagnosis (CID 2010;51:131; EHJ 2015;36:3075; Circ 2015;132:1435)
- Blood cultures (before abx): 3 sets (aerobic & anaerobic bottles) from different sites, ideally spaced ≥1 h apart. ✓ BCx (at least 2 sets) after appropriate abx have been initiated to document clearance; repeat q24-48h until ⊖.
- Serial ECGs to assess for conduction disease and ↑ PR interval (c/f perivalvular abscess)
- Echocardiogram: TTE in all Pts. TEE if (i) TTE abnl but nondx, (ii) TTE ⊖ but high suspicion, (iii) complications suspected or present (eg, AVB), (iv) high-risk (prosthetic valve, CIED, prior IE, congenital heart dis.), (v) S. aureus, enterococcus, or fungus, (vi) Δ in signs or sx (eg, new conduction abnl, regurgitation, etc.) (vii) if considering a shortened course (10-14 d) of abx (vide infra)
| Sensitivity | |||
|---|---|---|---|
| NVE | PVE | Abscess | |
| Transthoracic (TTE) | 39-58% | 33% | 18-63% |
| Transesophageal (TEE) | >90% | 86% | 76-100% |
- Gated cardiac CT useful if TTE/TEE equivocal or suspected paravalvular abscess
- PET/CT using FDG useful for suspected PVE or CIED infxn if TTE/TEE equivocal
- Brain/spine imaging if concern for CNS spread (mycotic aneurysms, embolic stroke) or spinal involvement (vertebral osteo, epidural abscess)
- Cx ⊖ endocarditis: may be due to abx prior to BCx. PCR, bacterial 16S ribosomal RNA, serol. may be helpful. Detailed hx: animal exposure, travel, unpast. dairy, etc. ID eval. Consider organisms listed in Cx ⊖ footnote in microbiology table (vide supra).
Modified Duke Criteria
- Definitive: 2 major or 1 major+3 minor or 5 minor; Possible: 1 major+1 minor or 3 minor
| Major | Minor |
|---|---|
| - Blood cultures with common endocarditis pathogen (grown in 2 separate culture) - Coxiella serology ≥1:800 - Endocardial involvement: vegetation, abscess, prosthetic dehiscence or new valvular regurgitation |
- Predisposing condition (see risk factors) - Fever - Vascular phenomena: septic arterial or pulmonary emboli, mycotic aneurysms, ICH, Janeway lesions - Immune phenomena: ⊕ RF, GN, Osler's nodes, Roth spots - ⊕ blood culture not meeting major criteria |
| Se ˜90%, Sp >95%, NPV ≥92% (CID 2000;30:633). |
Features Guiding the Need for Echocardiographic Assessment in Patients with Selected Monomicrobial Bacteremia
| S. AUREUS | E. FAECALIS | NON-β-HEMOLYTIC STREPTOCOCCI |
|---|---|---|
| Intracardiac device | Symptoms ≥7 days | Symptoms ≥7 days |
| Prior endocarditis | Emboli | Greater than two positive cultures |
| Injection drug use | Greater than two positive cultures | One species: S. gallolyticus, S. sanguinis, S. mutans (not S. anginosus) |
| Cerebral/peripheral emboli | Unknown origin (no focus) | |
| Meningitis | Heart murmur | Heart murmur or valve disease |
| Preexisting valve disease | Valve disease (including prior endocarditis) | Community acquired |
| Persistent bacteremia (≥72 hours) | ||
| Vertebral osteomyelitis | ||
| Community acquisition | ||
| Non-nosocomial health care associated | ||
| Indeterminate or positive TTE |
Treatment (ID consult is strongly recommended)
| Pathogen | Treatment (Circ 2015;132:1435) |
|---|---|
| Empiric | NVE or PVE >12 mos post-op: vancomycin + ceftriaxone PVE <12 mos post op: vancomycin + ceftriaxone ± gentamicin (if OK renal function) |
| Strep | Penicillin, ampicillin, ceftriaxone; if PVE consider gentamicin in discussion w/ ID |
| Staph (S. aureus and lugdunensis) | MRSA: vancomycin or daptomycin MSSA: nafcillin, oxacillin, or cefazolin (avoid if CNS involvement due to poor penetration); vanc inferior to β-lactam for MSSA For PCN allergy w/ MSSA consider desensitization Consider rifampin / gentamicin in PVE in discussion w/ ID |
| Enterococci | Ampicillin + CTX or gent]; if VRE: linezolid, dapto, ampicillin if sensitive |
| Gram negatives | HACEK: CTX, ampicillin or FQ. Pseudomonas: 2 anti-Pseudomonal agents [eg, β-lactam + (aminoglycoside or FQ)] |
| Fungi (candida, aspergillus) | Candida: amphotericin B ± flucytosine or micafungin Aspergillus: amphotericin B or voriconazole Ophtho consult for fungemia to rule out endophthalmitis |
| - De-escalate abx to organism-directed therapy based on speciation and sensitivities | |
| - If on anticoagulation or antiplatelet, typically can continue unless concern for stroke, intracranial hemorrhage, or need for emergent surgery | |
| - Monitor for complications of endocarditis (CHF, conduction block, osteomyelitis, new embolic phenomenon) which can occur even on abx | |
| - Duration is usually 4-6 wks | |
| - After ≥10d IV abx can consider Δ'ing to PO if clinically appropriate and available PO abx in consultation with ID (NEJM 2019;380:415) | |
| - Uncomplicated right-sided NVE or PCN-S Strep spp → 2 wks may be adequate | |
| - IVDU-associated best managed by multidisciplinary teams including Addiction Medicine |
Recommendations for antibiotic regimens for initial empirical treatment of infective endocarditis (before pathogen identification)^a
Recommendations for antibiotic treatment of infective endocarditis due to oral streptococci and Streptococcus gallolyticus group
Recommendations for antibiotic treatment of infective endocarditis due to Staphylococcus spp.
Recommendations for antibiotic treatment of infective endocarditis due to Enterococcus spp.
Antibiotic treatment of blood culture-negative infective endocarditis
| Pathogens | Proposed therapya | Treatment outcome |
|---|---|---|
| Brucella spp. | Doxycycline (200 mg/24 h) plus cotrimoxazole (960 mg/12 h) plus rifampin (300–600 mg/24 h) for ≥3–6 monthsb orally | Treatment success defined as an antibody titre <1:60. Some authors recommend adding gentamicin for the first 3 weeks |
| C. burnetii (Q fever agent) | Doxycycline (200 mg/24 h) plus hydroxychloroquine (200–600 mg/24 h)c orally (>18 months of treatment) | Treatment success defined as anti-phase I IgG titre <1:400, and IgA and IgM titres <1:50 |
| Bartonella spp.d | Doxycycline 100 mg/12 h orally for 4 weeks plus gentamicin (3 mg/24 h) i.v. for 2 weeks | Treatment success expected in ≥90% |
| Legionella spp. | Levofloxacin (500 mg/12 h) i.v. or orally for ≥6 weeks or clarithromycin (500 mg/12 h) i.v. for 2 weeks, then orally for 4 weeks plus rifampin (300–1200 mg/24 h) | Optimal treatment unknown |
| Mycoplasma spp. | Levofloxacin (500 mg/12 h) i.v. or orally for ≥6 monthse | Optimal treatment unknown |
| T. whipplei (Whipple’s disease agent)f | Doxycycline (200 mg/24 h) plus hydroxychloroquine (200–600 mg/24 h)c orally for ≥18 months | Long-term treatment, optimal duration unknown |
| aOwing to the lack of large series, the optimal duration of treatment of IE due to these pathogens is unknown. The presented durations are based on selected case reports. Consultation with an infectious disease specialist is recommended. | ||
| bAddition of streptomycin (15 mg/kg/24 h in 2 doses) for the first few weeks is optional. | ||
| cDoxycycline plus hydroxychloroquine (with monitoring of serum hydroxychloroquine levels) is significantly superior to doxycycline.385 | ||
| dSeveral therapeutic regimens have been reported, including ampicillin or amoxicillin, (12 g/24 h i.v.) or cephalosporins (ceftriaxone 2 g/24 h i.v.) combined with aminoglycosides (gentamicin or netilmicin).381 Dosages are as for streptococcal and enterococcal IE.379,380 | ||
| eNewer fluoroquinolones (levofloxacin, moxifloxacin) are more potent than ciprofloxacin against intracellular pathogens such as Mycoplasma spp., Legionella spp., and Chlamydia spp. | ||
| fTreatment of Whipple’s IE remains highly empirical. In the case of central nervous system involvement, sulfadiazine 1.5 g/6 h orally must be added to doxycycline. An alternative therapy is ceftriaxone (2 g/24 h i.v.) for 2–4 weeks or penicillin G (2 million U/4 h) and streptomycin (1 g/24 h) i.v. for 2–4 weeks followed by cotrimoxazole (800 mg/12 h) orally. Trimethoprim is not active against T. whipplei. Successes have been reported with long-term therapy (1 year). |
Indications for surgery (consult early; JTCS 2017;153:1241; Circ 2021;143:e72)
- Emergent (within 24 h): refractory cardiogenic shock or pulmonary edema
- Urgent (within 3–5 days):
- Sx HF
- Penetrating infection: periannular abscess, heart block, fistula, worsening conduction
- Persistent infection: ⊕ BCx after >5 d of appropriate abx, ↑ or ? large vegetation
- Emboli: recurrent or w/ residual large (>10 mm) vegetation & severe AR/MR. Cerebral emboli not contraindic. unless severe stroke or hemorrhage (Stroke 2006;37:2094).
- MRSA
- PVE (emergent if dysfunction or dehiscence) caused by SA or non-HACEK GNB
- Non-urgent: within same hospital admission
- HF with stable hemodynamics
- Resistant bacteria or fungi other than SA
- PVE not caused SA or non-HACEK GNB
aDespite appropriate antibiotic therapy for >1 week and control of septic embolic foci.
bE.g. patients with significant valvular dysfunction that is, or is not, a direct result of endocarditis process.
cS. aureus (methicillin resistant and non-methicillin resistant), vancomycin-resistant enterococci, non-HACEK Gram-negative bacteria and fungi.
dUrgent for S. aureus, non-urgent for others.
Oral Step-Down Therapy
Endocarditis Prophylaxis (Circ 2007;116:1736)
| Cardiac conditions^ | Prosthetic valve; previous endocarditis; congenital heart disease (CHD) including unrepaired or incompletely repaired cyanotic CHD (palliative shunts or conduits), 1st 6 mo after completely repaired CHD using prosthetic material; cardiac transplant recipients w/ valvulopathy. (Prophylaxis no longer rec. in acquired valvular dysfxn, bicuspid AoV, MVP with leaflet thickening or regurgitation, HCM.) |
|---|---|
| Procedures^ | Dental: manipulation of gingival tissue or periapical region of teeth or perf oral mucosa (eg, extraction, periodontal, implant, root canal, cleaning) |
| Regimens | Oral: amoxicillin 2 g 30-60 min before Unable to take PO: amp 2 g IM/IV or cefazolin or ceftriaxone 1 g IM/IV PCN-allergic: cephalexin or azithro or claritho or doxy |
| ^Pts should meet both indications (high-risk condition & high-risk procedure) to qualify for prophylaxis |
References
- Delgado, V., Ajmone Marsan, N., De Waha, S., Bonaros, N., Brida, M., et al. (2023) 2023 ESC Guidelines for the management of endocarditis. European Heart Journal. 44 (39), 3948–4042. doi:10.1093/eurheartj/ehad193.
- Sabatine, M. (2022) Pocket Medicine. Pocket Notebook Series. 8th ed. Philadelphia, Wolters Kluwer Health.
Invasive Mold Disease
Source: [@Donnell2020RevisionUpdate]
- Proven IFD can apply to any patient, regardless of whether the patient is immunocompromised
- Probable invasive fungal diseases (IFD) requires the presence of at least 1 host factor, a clinical feature and mycologic evidence and is proposed for immunocompromised patients only
- Cases that meet the criteria for a host factor and a clinical feature but for which mycological evidence has not been found are considered possible IFD
- (1,3)-beta-D glucan was not considered to provide mycological evidence of any invasive mold disease
內專考古題感染科試題
- 食媒性疾病，以下哪些配對最不正確？
A. Listeriosis與乳酪
B. Campylobacter jejuni與未煮熟雞肉
C. Salmonella與生雞蛋
D. Norovirus與生蠔或污染的水
E. Q fever與生牛肉
Infections in Immunocompromised Hosts
source: Pocket Medicine, 2022
- Many Pts have ≥1 risk (eg, DM, ESRD, transplant, extremes of age)
- Accurate dx of opportunistic infections and targeted Rx key in this population
- The following is not an exhaustive list, but a delineation of common or classic etiologies
Tuberculosis
source: Pocket Medicine, 2022, 台灣肺結核診治指引第七版
Definitions
- Primary: new Mycobacterium tuberculosis (TB) in a naïve host; symptomatic or asymptomatic; 90% of infected normal hosts will never develop clinically evident disease
- Latent: well-controlled infection without clinical or radiographic evidence of active disease; can persist for years to decades
- Reactivated: activation of latent; more likely in the setting of immunosuppression.
- Milliary: disseminated lympho-hematogenous spread due to primary or reactivated TB
- Multidrug-resistant (MDR): resistant to isoniazid (INH) & rifampin. Can occur as 1° infxn.
- Extensively drug-resistant (XDR): resistant to INH, rifampin (RIF), fluoroquinolones (FQ), and at least one of amikacin, kanamycin, or capreomycin
CNS Infection
source:: Pocket Medicine, 2022
急性細菌性腦膜炎
定義
- 腦/脊髓周圍組織的發炎
- 通常起源於鼻咽部（血行播散）、菌血症或直接接種（手術、鄰近感染、創傷、異物［如腦脊液分流管］）
CORONAVIRUS DISEASE 2019 (COVID-19) / SARS-COV-2 INFECTION
source: Pocket Medicine, 2022; 台灣診治指引
微生物學與流行病學
- 透過呼吸道顆粒在人與人之間傳播；無症狀與症狀前的傳播可能發生
- 潛伏期：最長可達14天，從暴露到症狀出現的中位時間為4-5天
- 確診病人發病==前2天==即可能具傳染力
- 確診病人上呼吸道檢體可持續檢測SARS-CoV-2核酸陽性平均達==兩週==以上，且下呼吸道檢體檢出病毒的時間可能更久
- 輕症個案在發病==10日後==即無法從上呼吸道檢體成功培養出病毒（部分重症個案或免疫不全者可能延長至20日），此時這些個案的病毒量均很低（ Realtime PCR Ct 值高），目前也沒有證據顯示此時這些個案能傳播疾病
Skin and soft tissue infection
source: Pocket Medicine, 2022
定義
- 蜂窩性組織炎：是真皮和皮下組織的感染，特徵為紅斑、發熱、壓痛和腫脹；通常因皮膚破損引起（JAMA 2016;315:3）。
- 皮膚膿瘍：皮下膿液的聚集。
- 葡萄球菌中毒性休克症候群（Staphylococcal toxic shock syndrome）：快速發作的發燒、皮疹、低血壓和多重器官損傷。診斷不需要葡萄球菌的培養。通常與填充物（如衛生棉條、鼻腔填充物）有關。處理可能需要手術清創加上抗生素治療。
Urinary tract infection
source: Pocket Medicine, 2022
定義
- 無症狀菌尿症：尿液中存在細菌但無感染的徵兆或症狀
- 簡單性：侷限於膀胱，無上尿路或全身感染的跡象
- 複雜性：
- 超越膀胱（如腎盂腎炎、腎/腎周膿腫、前列腺炎），伴隨發燒、寒戰、倦怠、側腹痛、肋脊角壓痛或骨盆/會陰痛等症狀
- 更可能發展為菌血症或敗血症
- 男性、患有腎結石、狹窄、支架、尿路改道、免疫抑制、糖尿病者已不自動歸類為複雜性
- 孕婦和腎移植患者視為複雜性
Non-typhoid Salmonella Vascular Infection
Chen-NTSVI score [@Chen2012simplescoring]
| RIsk factors | Point |
|---|---|
| male sex | +1 |
| hypertension | +1 |
| coronary arterial disease | +1 |
| serogroup C1 | +1 |
| immunosuppressive therapy | -1 |
| malignancy | -1 |
≥ +1 → arrange CT
Se: 95.0%
Sp: 45.3%
AUC: 0.83 (0.78-0.89)
Latent tuberculosis infection
source: Pocket Medicine, 2022; 台灣肺結核診治指引
Whom to screen
- 一個月內新生兒：都要治療
- Open TB：都要檢查
- Smear (-), culture (+)：<13歲、免疫力低下接觸者和同住家人要檢查
- Culture(-)：照CXR即可
- 肺外結核、指標個案<5歲：≥5歲接觸者照CXR
- 1個月至未滿2歲：TST x 2 (一個月內、暴露滿八週後且與前次間隔八週）
- 判讀標準：已打BCG ≥ 10mm，未打BCG, HIV, 接受anti-lymphokines 或其他免疫抑制治療者 ≥ 5mm為陽性
- 治療期滿後TST < 5mm再補打BCG
- 2歲以上：暴露滿八週後IGRA
The Rachel Incident
作者：Caroline O'Donoghue 原文出版年：2023
Americanah
中譯：美國佬 作者：Chimamanda Ngozi Adichie 原文出版年：2013
The Great Believers
中譯：幸運之子 作者：Rebecca Makkai 原文出版年：2018
100 Best Books of the 21st Century
Many of us find joy in looking back and taking stock of our reading lives, which is why we here at The New York Times Book Review decided to mark the first 25 years of this century with an ambitious project: to take a first swing at determining the most important, influential books of the era. In collaboration with the Upshot, we sent a survey to hundreds of literary luminaries, asking them to name the 10 best books published since Jan. 1, 2000.
DAA
Glecaprevir/pibrentasvir (Maviret)
- 3# QD WM，Child-Pugh B/C不可使用，腎功能不佳可使用
- 限使用於 HCV RNA 為陽性及無肝功能代償不全之病毒基因型第 1 型、第 2 型、第 3 型、第 4 型、第 5 型或第 6 型 12 歲（含）以上病患
- 給付療程如下，醫師每次開藥以 4 週為限
- 未曾接受治療之患者，給付 8 週
- 曾接受含 (peg)interferon 及 ribavirin 及合併或不合併 sofosbuvir 治療組合之患者
- 基因型第 1 、 2 、 4 、 5 或 6 型：
- 無肝硬化者，給付 8 週
- 具代償性肝硬化 (Child Pugh score A) 者，給付 12 週
- 基因型第 3 型，且無肝硬化或具代償性肝硬化 (Child Pugh score A) 者，給付16 週
- 基因型第 1 、 2 、 4 、 5 或 6 型：
- 曾接受含 NS5A 抑制劑或 NS3/4A 蛋白酶抑制劑治療之基因型第 1 型患者：
- 若曾接受 NS3/4A 蛋白酶抑制劑治療，但未曾接受 NS5A 抑制劑治療者，給付12 週
- 若曾接受 NS5A 抑制劑治療，但未曾接受 NS3/4A 蛋白酶抑制劑治療者，給付16 週
B肝藥物給付條件
Lamivudine 100mg, entecavir, telbivudine, tenofovir disoproxil, tenofovir alafenamide用於慢性病毒性 B 型肝炎患者之條件如下：
