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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

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

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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

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  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: “Mycobacteriumspp.”) 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(27911162-219)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：27892137

  5. 加護病房病人發燒處理流程 Fever in ICU

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

  7. 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) • 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 • 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 Initiate appropriate antimicrobial therapy Consider antimicrobial therapy Blood cultures (-) & CVC not cultured Blood cultures (-) & CVC cultures (．) Blood cultures (-) & CVC≧15 CFU Blood cultures (+) & CVC ≧15 CFU If continued fever & no other source found, remove & culture CVC 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

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

  9. 放置導管病人出現菌血症 • Fever or chills • Likely pathogen (Figure 4) • >1blood culture (+) (peripheral & CVC/ID) • No other source of fever • Verification of infection: • Luminal colonization? • Contamination? • Infection? • 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 Catheter-related Infection? • Complications: • Persistent bacteremia? • Septic thrombosis? • Retinitis? • Endocarditis? • Blood culture (+) on therapy • Doppler venogram (+) • Fundoscopic exam (+) • TEE or TTE (+)

  10. Tunneled central venous catheter (CVC)- or implantable device (ID)- related bacteremia 放置導管病人出現菌血症 Complicated Uncomplicated Tunnel infection, port abscess Septic thrombosis, endocarditis, osteomye litis Coagulase-negative staphylococcus Gram-negative bacilli Candida spp. S. aureus • 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 antibiotics for 10-14 days Remove CVC/ID & treat with antibiotics for 4-6 weeks; 6-8 weeks for osteomye litis • May retain CVC/ID & use systemic antibiotic for 7 days plus antibiotic lock therapy for 10-14 days • Remove CVC/ID if there is clinical deterioration, persisting or relapsing bacteremia • Remove CVC/ID & treat 10-14 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 10-14 days • Remove CVC/ID & treat with antifungal therapy for 14 days after last positive blood culture

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

  12. 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) Afebrile within first 3-5 days of treatment Etiology identified No etiology identified Adjust to most appropriate treatment Low risk High risk Change to: Ciprofloxacin + Amoxicillin-clavulanate (adults) or cefixime (child) Continue same antibiotics Discharge

  13. 經過3-5日治療後病人持續發燒處理流程 Guide to treatment ofpatients who have persistentfever after 3-5 daysof treatment and forwhom the cause ofthe fever is notfound. (IDSA guideline CID 2002;34:730-51) Persistent fever during first 3-5 days of treatment: no etiology Reassess patient on days 3-5 Antifungal drug, with or without antibiotic change Continue initial antibiotics Change antibiotics 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

  14. 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 3 3 3 3 • Initial high risk • ANC＜100 cells/mm • Mucositis • Unstable signs Initial low risk Clinically well Stop 4-5 days after ANC＞500 cells/mm Stop antibiotics 48 h after afebrile + ANC ≧500 cell/mm 3 Continue for 2 weeks 3 3 Stop when afebrile for 5-7 days Continue antibiotics Reassess Reassess Stop if no disease and condition is stable

  15. 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 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 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) If HIV pos., add: Microsporidia (Gram-chromotrope) M. avium complex +panel A Consider quinolone for suspected shigellosis in adults(fever, inflammation); macrolide for suspected resistant Discontinue antimicrobials if possible; consider metronidazole if illness worsens or persists Treat per results of tests

  16. 醫護及臨床工作者接觸HIV後處理流程

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