154.3 🩺 內科專科考前版

154.3.0.1 1⃣ IE Treatment Algorithm

E. faecalis IE:

  1. PCN/Amp + gent (low-level R): 4-6 wk
  2. HLAR + PCN-S: Amp + Ceftriaxone × 6 wk (Fernandez-Hidalgo 2013, IDSA 2015)
  3. HLAR + PCN-R or amp-R: VRE workup → vanco / dapto / linezolid

E. faecium IE (often amp-R):

  1. Vanco + gent (if not HLAR) × 4-6 wk
  2. VRE: dapto 10-12 mg/kg + ampicillin (synergy) or linezolid

154.3.0.2 2⃣ Daptomycin High-Dose for VRE

  • 10-12 mg/kg/d (vs S. aureus 6-10)
  • Monitor CK weekly
    • cell wall agent (amp, ceftaroline) — beta-lactam priming
  • Lung not effective (surfactant)

154.3.0.3 3⃣ Linezolid Pitfalls

  • Bacteriostatic — concerns in deep / IE (still works clinically)
  • Myelosuppression (> 2 wk; thrombocytopenia first)
  • Serotonin syndrome with SSRI/MAOI
  • Optic neuropathy > 4 wk
  • Lactic acidosis (long use)

154.3.0.4 4⃣ VRE Bacteremia 處理

  • Source: line, GI, urinary, abdominal
  • IDSA: dapto or linezolid (no superiority shown consistently)
  • Recent VANCE + RCT favored dapto (linezolid was bacteriostatic)
  • Dose: dapto 10-12 mg/kg + monitor + β-lactam priming

154.3.0.5 5⃣ Stewardship

  • VRE risk: 前 vanco/3rd-gen ceph 䜿甚
  • Contact precaution + cohort + chlorhexidine bath
  • Decolonization (oral vanco) NOT routine — selects more R

154.3.0.6 6⃣ 健保 / 台灣

  • Linezolid 健保 VRE / MRSA pneumonia covered
  • Dapto 健保限定
  • E. faecium ratio rising in Taiwan tertiary centers
  • Tigecycline 健保有條件