160.3 🩺 內科專科考前版

160.3.0.1 1⃣ 為䜕 Metronidazole 䞍再 first-line?

  • 2017 IDSA: Vanco superior to metro for both mild and severe (Johnson 2014)
  • Metro: 30-40% recurrence (vs vanco 25%)
  • IV metro 仍 fulminant adjunct
  • Oral metro CAN use if vanco unavailable + cost — but inferior

160.3.0.2 2⃣ FMT — How + Indications

  • ≥ 2 recurrences (即 3rd episode) — IDSA / ACG
  • Routes: colonoscopy (highest cure 90%), NG tube, capsule, enema
  • Donor screening: communicable disease + microbiome diversity
  • ~ 85-90% cure 1st FMT; ~ 95% with 2nd if relapse
  • FDA enforcement discretion (research, but accepted)

160.3.0.3 3⃣ RBX2660 (Rebyota) + SER-109 (Vowst)

  • Rebyota: enema, broad consortium from healthy donors, FDA 2022 — 第 1 FDA-approved CDI microbiome therapy
  • SER-109 (Vowst): oral capsule, purified Firmicutes spores, FDA 2023
  • 取代 FMT for some patient + ease of access

160.3.0.4 4⃣ Fidaxomicin Pharmacology

  • Narrow-spectrum macrolide
  • Targets RNA polymerase
  • Less disrupt commensal flora → less recurrence
  • 䜆 cost 高 (10-20× vanco) — 健保有 indication
  • Cure 同 vanco; recurrence 箄 12% vs 24% vanco (OPT-80-003)

160.3.0.5 5⃣ Severity Score (ATLAS, IDSA 2017)

  • WBC, BUN/Cr, albumin, temp
  • 蚈算 to predict severity / monitor

160.3.0.6 6⃣ 䞍 Test 䜕時?

  • Asymptomatic carrier (10-30% hospitalized) — 䞍 treat
  • < 3 stool / day
  • Recent laxative
  • Post-treatment (test of cure 無意矩)
  • 倚次反芆 test → result over-treatment, IDSA 䞍建議

160.3.0.7 7⃣ 健保 (Taiwan)

  • Fidaxomicin 健保 — first-line / recurrence (限制 indication)
  • Bezlotoxumab 健保 (high-risk recurrence)
  • FMT — 院內 IRB / 自費
  • 預防隔離 + 環境 cleaning — 院內 SOP

160.3.0.8 8⃣ Surgical Indications (Fulminant)

  • Perforation, peritonitis, refractory shock, megacolon > 6 cm worsening
  • Subtotal colectomy traditional — high mortality 30-50%
  • Diverting loop ileostomy + vanco lavage colon (Neal 2011) — better outcome
  • 䞍 wait until end-stage