124.1 ๐ ้ซๅญธ็็
ๅฐ่ฑก๏ผM3-M6 ้ซๅญธ็ใๆฏไฝๆๆ็ ไบบ้ฝ่ฆๅ: ๆฏ่ชฐ? ๅจๅช? ็บไป้บผ? (Who, Where, Why)
124.1.0.1 ๐ ไธ้ ้้ป
- ไธๅๆ ธๅฟๅ้ก:
- Who is the host? (ๅนด้ฝกใๅ ็ซ็ๆ ใๅ ฑ็ )
- Where is the infection? (่งฃๅ้จไฝ)
- What is the pathogen? (็ดฐ่ใ็ ๆฏใ็่ใๅฏ็่ฒ)
- Empirical therapy = ๆถต่ๆๅฏ่ฝ + ๆๅฑ้ช็็ ๅ (ๅพ ๅน้ค็ตๆ)
- Antimicrobial stewardship ไธๅคง: right drug, right dose, right duration
- Sepsis bundle (1 hr): lactate + cultures + broad-spectrum antibiotics + IV fluid + vasopressor
124.1.0.2 1๏ธโฃ ็ ๅฒๆก้่ฆ้ป
๐ ไธญๆๆฆๅฟต่ชชๆ๏ผ็ ๅฒ็้ๅฅๅๅคงๆผๆชข้ฉใไธไปฝๅๅพไป็ดฐ็็ ๅฒ็ถๅธธๅฏไปฅๆ้ๅฅ่จบๆทๆถๆๅฐ 2-3 ๅ็ ๅๅ้ธ๏ผๅ็จๆชข้ฉๅป้ฉ่ญ๏ผๅไนๆชข้ฉไธ่ผชๆไธๅปๅปๅไธๅฐ้้ต exposure (ไพๅฆ cat-scratchใๆชๆฎบ่่ตทๅธใๆฑๅไบๆ ้)๏ผ็ งๆจฃๆๆผ่จบใไธ่กจๅๅบ้ซ yield ็ๅ่จบ้ขๅ๏ผ่จๅบไธ่ฆ้คๆใๆฏๅๆๆ็ ไบบ้ฝ่ทไธ้ใ็็ฟๆ ฃ โ ็นๅฅๆฏไธๆๅๅ ็ผ็ (FUO)ใๅ ็ซไฝไธๅฎฟไธปใๅๅ travelerใ
| ไธป้ก | ้้ตๅ้ก |
|---|---|
| ๆด้ฒๅฒ | ๆ ้ใ่ทๆฅญใๅฏต็ฉใๆง่ก็บใๆฏๅใๅบ้ |
| ็ซ่ | COVID, flu, pneumococcal, HBV, HPV, MMR |
| ๅ ็ซ็ๆ | HIV, chemo, transplant, biologic, splenectomy |
| ๆ็็ด ๅฒ | ่ฟ 3 ๆ (้ ๆธฌ resistance)ใไฝ้ขๅฒ (HAI ้ขจ้ช) |
| ้ฃ็ฉๆฐดๆบ | ็้ฃใๆชๆดๆฐดใๆชๆฎบ่ไนณ่ฃฝๅ |
| ๅ็ฉๆฅ่งธ | ้ณฅ (psittacosis), ่ฒ (toxoplasma, bartonella), ่ฑ (Lyme, RMSF) |
| ๆๅบ | ๆฅๆง (< 1 ้ฑ) vs ไบๆฅๆง (1-4 ้ฑ) vs ๆ ขๆง (> 4 ้ฑ) |
124.1.0.3 2๏ธโฃ ็ๅญธๆชขๆฅ้้ป
๐ ไธญๆๆฆๅฟต่ชชๆ๏ผ็ๅญธๆชขๆฅๆๅ ฉๅ็ฎๆจ โ (1) ๅฎไฝๆๆ้จไฝ (locating the focus)๏ผ(2) ่ฉไผฐ sepsis ๅด้ๅบฆ (severity triage)ใ็ๅฝๅพต่ฑกๆฏ first triage (ไฝ่กๅฃ + ้ ปไฟๅผๅธ + ๆ่ญๆน่ฎ้ไธ้ ๆไบๅฐฑ้ qSOFA โฅ 2 ่ญฆ่จ)๏ผ็ฎ่ๅพต่ฑกๆฏ้ฑ่ๆๆ็้่ฆ็ท็ดข (petechiae ่ญฆ็คบ meningococcus / RMSFใJaneway lesions ่ Osler nodes ็ IEใnecrotic eschar ็ Aspergillus ๆ mucor)๏ผไธ่ฆๅฟ่จ็ฟป่ๆพๅฃ็กๆ็กฌ่ๅค่ฟ็ใ็ๆ่ ณๆพ IVDU ๆณจๅฐ็่ endocarditis stigmataใๅนด้ท่ ๆๅ ็ซไฝไธ่ ๅฏ่ฝๆฒๆ็ผ็็่ณไฝ้ซๆบซ๏ผๅ่ไปฅๆ่ญๆน่ฎใ่ทๅใ้ฃๆ พๅทฎไพ่กจ็พ โ ไธๅฏๅ ็บใๆฒ็ใๅฐฑๆ้คๅด้ๆๆใ
- ็ๅฝๅพต่ฑก: ็ผ็ (ๆ ธๅฟๆบซๅบฆ โฅ 38.0ยฐC), HR, BP, RR, SpO2
- ็ฎ่: ็ด ๆใ็ดซๆใpetechia (่ๆ ฎ meningococcus, RMSF)ใๆทๅทด่ ซ
- ้ ญ้ ธ: meningismus, oral lesions, lymphadenopathy
- ่ธ้จ: rales, wheeze, consolidation
- ่ น้จ: tenderness, hepatosplenomegaly
- ๅ่ข: arthritis, cellulitis, IVDU ๆณจๅฐ็
- ็ฅ็ถ: ๆ่ญใ้ ธๅต็กฌใ focal deficit
124.1.0.4 3๏ธโฃ ๅฏฆ้ฉๅฎค่ๅฝฑๅ
๐ ไธญๆๆฆๅฟต่ชชๆ๏ผๆชข้ฉๆ้้ต็่งๅฟตๆฏใๅ ๆฝๅน้คๅ็ตฆๆ็็ด ใ โ ๅน้คๆฏๅพ็บ de-escalation ่ source identification ็ๅฝ่๏ผๆ็็ด ไธ้ฒๅปๅๆฝๆๅคงๅน ้ไฝ yield (ๅฐคๅ ถ IE ็ blood culture yield ๅฏๅพ > 90% ๆๅฐ < 50%)ใCBC + diff ๆฏๅ้ก่ตท้ป (ๅทฆ็งปใๆทๅทดๅข็ใeosinophilia ๅๆๆๅ)๏ผCRP ไธๅ่ผๅปฃ่ญ (็ดฐ่ใ่ช้ซๅ ็ซใ่ ซ็ค็ๆๅ)๏ผPCT ๅฐ็ดฐ่็น็ฐๅบฆ่ผ้ซ๏ผๅฏ่ผๅฉ็ดฐ่ vs ็ ๆฏๅคๆท่่ฟฝ่นคๆฒป็ๅๆ๏ผlactate ๆฏ sepsis ๅด้ๅบฆ็ๅฟซ้ๆๆจ (> 2 ่ญฆ็คบ, > 4 ๅด้)ใๅฝฑๅๅไพๆท็้จไฝๆฑบๅฎ๏ผไธๆฏใๆฏๅ sepsis ้ฝ้ CTใ โ ่ๆฏไพๅ่จบ่็ๅญธๆชขๆฅๆถๆๅพ็้ๅฅ่จบๆท๏ผ้ธๆ informative ็้ฃไธๅผตใ
124.1.0.4.1 ไธ็ทๆชข้ฉ
- CBC + diff: WBC โ left shift (็ดฐ่); lymphocytosis (็ ๆฏ); eosinophilia (ๅฏ็่ฒ, allergy, drug)
- CRP, procalcitonin (PCT): PCT > 0.5 ng/mL โ bacterial; PCT < 0.25 โ ๅค็ ๆฏ
- Lactate: > 2 mmol/L = warning; > 4 = severe sepsis
- Cultures (FIRST!): blood ร 2 sets, urine, sputum, CSF, wound โ antibiotics ็ตฆไนๅ
124.1.0.5 4๏ธโฃ Empirical Therapy ๆ่ทฏ
๐ ไธญๆๆฆๅฟต่ชชๆ๏ผ็ถ้ฉๆงๆฒป็ไธๆฏใๅปฃ่ญ็ไธๅปๅฐฑๅฐใ๏ผ่ๆฏใๆถต่ๆๅฏ่ฝ + ๆๅฑ้ช็ ๅใๅ ฉๆข่ปธ็ท็ไบค้ใ่ฆๅ่ local antibiogram (ๅๆจฃๆฏ CAP๏ผๅฐ็ฃๆไบ้ซ้ข macrolide resistance > 80%๏ผๆ็ดๆฅๅฝฑ้ฟ empirical ้ธๆ)๏ผๅๆ่ฆไพๅฎฟไธปๅฑฌๆง (CAI / HCAI / HAIใๅ ็ซ็ๆ ใๅนด้ฝกใ่ฟๆไฝ้ข่ๆ็็ด ๅฒ) ๆฑบๅฎๅปฃ่ญ็จๅบฆใDe-escalation ๆฏ stewardship ็ๆ ธๅฟ โ ๅน้คๅบไพใ่จๅบ็ฉฉๅฎ๏ผๅฐฑ่ฆไธปๅ narrow spectrum๏ผไธ่ฆใๅๆญฃๆๅฅฝๅฐฑ่ฎไปๆๅฐๅบใ (ๆ็บๅปฃ่ญไธๅชๆตช่ฒปใๅขๅ resistanceใ้ๆ C. difficile colitis ่ fungal superinfection)ใไธ่กจๆฏๅ ง็งๅธธ่ฆๆ ๅข็ empirical ไธ่ฆฝ๏ผไฝๆ็ตๅฟ ้ ไปฅ่ฉฒ้ข antibiogram ็บๆบใ
124.1.0.5.1 ็ฏไพ
| ๆ ๅข | ็ถ้ฉๆฒป็ |
|---|---|
| CAP, mild | Amoxicillin / azithromycin |
| CAP, severe | Ceftriaxone + azithromycin (or levofloxacin) |
| HAI Pneumonia | Pip/tazo or cefepime + vancomycin (cover MRSA) |
| Sepsis ไธๆ | Pip/tazo + vancomycin (or carbapenem if ESBL risk) |
| Meningitis (adult) | Ceftriaxone + vancomycin (+ ampicillin if > 50) ยฑ dexamethasone |
| Cellulitis (non-MRSA) | Cephalexin |
| Cellulitis (MRSA risk) | TMP-SMX or doxycycline |
| UTI uncomplicated | Nitrofurantoin or fosfomycin |
124.1.0.5.2 Stewardship ไบๅคงๅๅ
- Right drug: ๆถต่ๆๅฏ่ฝ็ ๅ + ๅฑ้จ antibiogram
- Right dose: ้ซ้ใ่ ๅ่ฝใPK/PD (time-dependent vs concentration-dependent)
- Right route: IV vs PO (de-escalation when stable)
- Right duration: ๆ็ญๆๆ (e.g., CAP 5 d vs 7-10 d)
- Right de-escalation: culture results โ narrow spectrum