153.3 🩺 內科專科考前版

153.3.0.1 1⃣ Necrotizing Fasciitis 處理流皋

  1. Suspect (pain out of proportion, crepitus, dusky bullae)
  2. STAT surgery consult (don’t wait for imaging if classic)
  3. CT/MRI if 䞍確定 (gas, fascia involvement)
  4. Blood cx + tissue cx + Gram stain
  5. Empirical: vanco + pip-tazo (或 carbapenem) + clindamycin
  6. ICU resus, vasopressors
  7. LRINEC score > 6 → high risk
  8. ± IVIG in toxin-mediated (TSS-like)

153.3.0.2 2⃣ ARF 2° Prophylaxis Duration (Taiwan Heart Association)

Type Duration
Rheumatic fever + carditis + valvular disease Until age 40 or life-long
Rheumatic fever + carditis, no valvular 10 yr or until 21 (whichever longer)
Rheumatic fever no carditis 5 yr or until 21

Agent: Benzathine PCN G 1.2M IM q3-4wk (高 incidence area 3 wk)

153.3.0.3 3⃣ GBS IAP Indications (USA + Taiwan)

  • GBS + (35-37 wk rectovaginal swab)
  • 前胎 GBS 新生兒疟病
  • GBS bacteriuria 本胎
  • Unknown GBS + < 37 wk / ROM > 18 hr / temp ≥ 38

Agent: PCN G 5M U IV → 2.5M q4h (or amp); allergy → cefazolin

153.3.0.4 4⃣ IE 治療 — Viridans vs Enterococcus

  • Viridans IE: PCN G alone × 4 wk 或 PCN+gent × 2 wk (uncomplicated)
  • MIC 0.12-0.5: PCN G + gent × 2 wk 或 ceftriaxone × 4 wk
  • MIC ≥ 0.5 (relatively R): PCN G high-dose + gent × 4 wk
  • Prosthetic: × 6 wk + gent first 2 wk

153.3.0.5 5⃣ S. gallolyticus IE → 必 colonoscopy

  • 箄 50% adenomas/carcinoma (colon)
  • 即䜿無症狀也芁 → 必查
  • 也扟 hepatobiliary disease

153.3.0.6 6⃣ Penicillin Resistance in Strep?

  • GAS, GBS: 99%+ PCN-S still (universally susceptible)
  • Viridans: PCN MIC creep (5-15% MIC > 0.12)
  • S. pneumoniae: PRSP (芋 Ch 151)
  • Macrolide R: rising (15-30% in some Asia)