152.3 🩺 內科專科考前版

152.3.0.1 1️⃣ MRSA 流行病學 (Taiwan)

• HA-MRSA 高 (40-60% all S. aureus hospital isolates)
• CA-MRSA USA300 < 美國 (~ 5-15%) 但增加中
• ST59-IV CA-MRSA Taiwan/Asia clone

152.3.0.2 2️⃣ Daptomycin 限制

• NOT for pneumonia (pulmonary surfactant 滅活)
• 適: bacteremia, IE (right-sided), SSTI
• CK monitor (myopathy)
• 高 dose (8-10 mg/kg/d) for IE

152.3.0.3 3️⃣ Vancomycin AUC vs Trough

• 2020 ASHP/IDSA: AUC-guided dosing 取代 trough
• Target AUC 400-600 (vs old trough 15-20)
• 降 nephrotoxicity, 等效 efficacy
• Many institutions still use trough (logistic)

152.3.0.4 4️⃣ Ceftaroline + Newer Anti-MRSA

• Ceftaroline (Teflaro): 5th gen ceph, anti-MRSA, anti-PRSP
  • SSTI, CAP, sometimes bacteremia
• Tedizolid: PO/IV, once daily (vs linezolid BID), less myelosuppression
• Dalbavancin/oritavancin: long t1/2 → 1-2 dose SSTI; emerging IE/OM data
• Omadacycline: oral, similar to tigecycline

152.3.0.5 5️⃣ Endocarditis IDSA Update (2024)

• TEE 必須 for SAB (一律, 不只當 high-risk)
• ID consult mandatory (降 mortality)
• Surgery indications: HF, abscess, large vegetation (> 10 mm), persistent bacteremia
• POET 2019: switch IV → PO after stabilization (specific criteria)
• OVIVA 2018: oral as good as IV for OM

152.3.0.6 6️⃣ ASP — Empirical De-escalation

• 培養 + MSSA → switch to cefazolin/nafcillin (NOT vanco)
• Vanco for MSSA is WORSE (multiple cohorts)
• Coag-neg in blood: contamination vs true → 看臨床、prosthetic、persistent

152.3.0.7 7️⃣ Decolonization Pre-op

• Cardiac, ortho: mupirocin + chlorhexidine 降 SSI
• 不用 routinely for medical patients (selection pressure)

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