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感染症暨熱帶醫學科疾病 診斷及治療流程 目錄 法定傳染病處理流程 新感染症候群通報流程 (I)(II) 抗生素使用原則 疑似肺結核 不同病況的肺結核病人治療藥物建議 加護病房病人發燒 細菌性腦膜炎 放置導管病人出現急性發燒 放置導管病人出現相關血流感染 放置導管病人出現菌血症 中性球低下病人發燒處理流程.

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Presentation on theme: "感染症暨熱帶醫學科疾病 診斷及治療流程 目錄 法定傳染病處理流程 新感染症候群通報流程 (I)(II) 抗生素使用原則 疑似肺結核 不同病況的肺結核病人治療藥物建議 加護病房病人發燒 細菌性腦膜炎 放置導管病人出現急性發燒 放置導管病人出現相關血流感染 放置導管病人出現菌血症 中性球低下病人發燒處理流程."— Presentation transcript:

1 感染症暨熱帶醫學科疾病 診斷及治療流程 目錄 法定傳染病處理流程 新感染症候群通報流程 (I)(II) 抗生素使用原則 疑似肺結核 不同病況的肺結核病人治療藥物建議 加護病房病人發燒 細菌性腦膜炎 放置導管病人出現急性發燒 放置導管病人出現相關血流感染 放置導管病人出現菌血症 中性球低下病人發燒處理流程 感染性腹瀉 醫護及臨床工作者接觸 HIV 後處理流程 HIV 接觸後預防性給藥方式 HIV 病人出現發燒 HIV 病人有發燒咳嗽症狀 HIV 病人腹瀉 HIV 病人口腔念珠菌感染 HIV 病人發生頭痛神智改變 HIV 接觸後處理流程

2 檢驗室證實法定 傳染病處理流程 臨床病理科 ( 細菌組、病毒室 ) TB 陽性檢驗報告單 HIV 陽性檢驗 ( 含 AFB”+” 及 TB 報告單 ( 病毒室 ) culture: “Mycobacterium spp.”) 和其他陽性之法定 傳染病檢驗報告單 感管會 感管會 各科總醫師 感染科總醫師 填寫通報單 填寫通報單 醫勤組 ( 例假日時至醫勤組急診掛號櫃檯 ) 國防部 台北市 感管會 軍醫局 衛生局

3 新感染症候群通報流程 (I) 病患 臨床軍醫 護理站 感染管制委員會拿通報單及臨床資料表 ( 病 歷審查用 ) 檢體送至單一窗口並請醫師通知內湖衛生 所 ( ) 收取檢體 通報單第一聯及臨床資料表送至醫勤組姜 小姐 (17354)

4 新感染症候群通報流程 (II) 注意事項 急性出血熱症候群需送全血 急性腹瀉症候群通報定義,過 去為健康之正常人,出現急性 腹瀉,伴有嚴重病情,年齡大 於五歲 檢體收集管請貼上疾管局的黃 色專用標籤,並用拉鍊袋裝好 醫院實驗室可做的檢查: Adenovirus, Aeromonas spp.,Chloera, Campylobacter jejuni, Listeria monocytogenes, Rotavirus, typhoid fever 檢體有問題請電:

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7 Fever in ICU 加護病房病人發燒處理流程

8 Suspicion for bacterial meningitis Papilledema and/or focal neurologic deficits (excluding ophthalmoplegia) Absent Present Obtain blood cultures Empirical antimicrobial therapy Obtain blood cultures and perform lumbar puncture STAT CT scan of head No mass lesion Mass lesion CSF consistent with bacterial meningitis Positive Gram stain or bacterial antigen test result Empirical antimicrobial therapy Specific antimicrobial therapy Consider alternative diagnosis 細菌性腦膜炎處理流程 No Yes Lancet 1995;346:1675

9 If continued fever & no other source found, remove & culture CVC Blood cultures, 2 sets (1 peripheral) If no source of fever identified, remove CVC, culture tip & insert at new site, or exchange over a guidewire Consider antimicrobi al therapy Blood cultures, 2 sets (1 peripheral) If no source of fever identified, remove CVC, culture tip & insert at new site or exchange over a guidewire Patient with a removable CVC & an acute febrile episode 放置導管病人出現急性發燒 Mild or moderately ill ; (no hypotension or organ failure) Seriously ill ; (hypotension, hypoperfusion, signs & symptoms of organ failure) Initiate appropriate antimicrobial therapy Blood cultures (-) & CVC not cultured Blood cultures (-) & CVC cultures ( . ) Blood cultures (-) & CVC ≧ 15 CFU Blood cultures (+) & CVC ≧ 15 CFU Look for another source of infection In patients with valvular heart disease or neutropenia, & S. aureus or Candida colonization of CVC, monitor closely for signs of infection & repeat blood cultures accordingly See management strategies outlined in Figure 2

10 Remove CVC & treat with systemic antibiotic for 4-6 weeks; 6- 8 weeks for osteomyelitis Removable central venous catheter (CVC). Related bloodstream infection 放置導管病人出現相關血流感染 ComplicatedUncomplicated Septic thrombosis, endocarditis, osteomyelitis, etc Coagulase- negative staphy lococcus S. aureus Gram-negative bacill Candida spp. Remove CVC & treat with a systemic antibiotic 5-7 days If catheter is retained, treat with systemic antibiotic +/- antibiotic lock therapy for days Remove CVC & treat with a systemic antibiotic for 14 days If TEE (+), extend systemic antibiotic treatment to 4-6 weeks Remove CVC & treat with systemic antibiotic therapy for days Remove CVC & treat with antifungal therapy for 14 days after last positive blood culture

11 放置導管病人出現菌血症 Verification of infection: Luminal colonization? Contamination? Infection? Catheter-related Infection? Complications: Persistent bacteremia? Septic thrombosis? Retinitis? Endocarditis? Fever or chills Likely pathogen (Figure 4) >1blood culture (+) (peripheral & CVC/ID) No other source of fever Site or tunnel infection Likely pathogen Quantitative CVC/PBC >5:1 Differential CVC/PBC time to positivity, >2 h (see text) No other source for (+) blood culture Blood culture (+) on therapy Doppler venogram (+) Fundoscopic exam (+) TEE or TTE (+)

12 Remove CVC/ID & use systemic antibiotic for 14 days if TEE(-) For CVC/ID salvage therapy.If TEE (-), use systemic & antibiotic lock therapy for 14 days Remove CVC/ID & if there is clinical deterioration, persisting or relapsing bacteremia Remove CVC/ID & treat with antifungal therapy for 14 days after last positive blood culture 放置導管病人出現菌血症 Tunneled central venous catheter (CVC)- or implantable device (ID)- related bacteremia ComplicatedUncomplicated Tunnel infection, port abscess Septic thrombosis, endocarditis, osteomye litis Coagulase- negative staphylococ cus S. aureus Candid a spp. Gram- negative bacilli Remove CVC/ID & treat days For CVC/ID salvage, use systemic & antibiotic lock therapy for 14 days If no response, remove CVC/ID & treat with systemic antibiotic therapy for days May retain CVC/ID & use systemic antibiotic for 7 days plus antibiotic lock therapy for days Remove CVC/ID if there is clinical deterioration, persisting or relapsing bacteremia Remove CVC/ID & treat with antibiotics for 4-6 weeks; 6-8 weeks for osteomye litis Remove CVC/ID & treat with antibiotics for days

13 中性球低下病人發燒處理流程 (IDSA guideline Hughes WT et al CID 2002;34:730-51) Fever (temperature ≧ 38.3 ℃ ) + Neutropenia ( < 500 neutrophils/mm ) Low riskHigh risk Oraliv Vancomycin not needed Vancomycin needed Ciprofloxacin + Amoxicillin-clavulanate (adults only) Monotherapy Cefepime, Ceftazidime, or Carbapenem Vancomycin+ Aminoglycoside + Antipseudomonal penicillin, Cefepime, Ceftazidime, or Carbapenem Two Drugs Vancomycin + Cefepime, ceftazidime, or Carbapenem ±aminoglycoside Reassess after 3-5 days 3

14 經過 3-5 日治療後病人退燒處理流程 (IDSA guideline Hughes WT et al CID 2002;34:730-51) (IDSA guideline Hughes WT et al CID 2002;34:730-51) Afebrile within first 3-5 days of treatment No etiology identified Etiology identified Low risk Adjust to most appropriate treatment Change to: Ciprofloxacin + Amoxicillin- clavulanate (adults) or cefixime (child) High risk Continue same antibiotics Discharge

15 經過 3-5 日治療後病人持續發燒處理流程 Guide to treatment of patients who have persistent fever after days of treatment and for whom the cause of the fever is not found. (IDSA guideline CID 2002;34: ) Persistent fever during first 3-5 days of treatment: no etiology Reassess patient on days 3-5 Continue initial antibiotics Change antibiotics Antifungal drug, with or without antibiotic change If no change in patient’s condition (consider stopping vancomycin) If progressive disease, If criteria for vancomycin are met If febrile through days 5- 7 and resolution of neutropenia is not imminent

16 抗生素治療期程之建議 (IDSA guideline Hughes WT et al CID 2002;34:730-51) Duration of antibiotic therapy Afebrile by days 3-5 Persistent fever ANC ≧ 500 cells/mm for 2 consecutive days ANC < 500 cells/mm by day 7 ANC ≧ 500 cells/mm ANC < 500 cells/mm Continue for 2 weeks Stop 4-5 days after ANC > 500 cells/mm Initial high risk ANC < 100 cells/mm Mucositis Unstable signs Initial low risk Clinically well Stop antibiotics 48 h after afebrile + ANC ≧ 500 cell/mm Stop when afebrile for 5-7 days Continue antibiotics Reassess Stop if no disease and condition is stable

17 感染性腹瀉處理流程 Evaluate severity and duration Obtain history and physical examination Treat dehydration Report suspected outbreaks Check all that apply Consider quinolone for suspected shigellosis in adults(fever, inflammation); macrolide for suspected resistant Culture or test for: Salmonella Shigella Campylobacter E. Coli O157:H7 (if blood in stool also test for Shiga toxin and refer isolates if toxin pos.) C. Difficile toxins A±B (if antibiotics or chemotherapy taken in recent weeks) Test for C. Difficile toxins A±B (In suspect nosocomial outbreaks, in patients with bloody stools, and in infants, also add tests in panel A) A. Community acquired or traveler’s diarrhea (esp. if accompanied by significant fever or blood in stool) B. Nosocomial diarrhea (onset after > 3 d in hospital) C.Persistent diarrhea > 7d (esp. if immunocomp romised) Consider parasites Giardia Cryptosporidium Cyclospora Isospora belli +Inflammatory screen Discontinue antimicrobials if possible; consider metronidazole if illness worsens or persists If HIV pos., add: Microsporidia (Gram-chromotrope) M. avium complex +panel A Treat per results of tests

18 醫護及臨床工作者接觸 HIV 後處理流程

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