164.3 🩺 內科專科考前版

164.3.0.1 1⃣ HACEK IE 泚意事項

  • 1-3% 所有 IE; native > prosthetic
  • 牙霒 source - dental work history
  • Subacute presentation
  • Embolic phenomena可有
  • Modern blood culture detects 5-7d (no longer need 4-wk hold)
  • Once-daily IV ceftriaxone — perfect for OPAT
  • High cure rate 90%+

164.3.0.2 2⃣ Asplenic 病人 Animal Bite Protocol

  • 病人 education: avoid bite + lick
  • Bitten → IMMEDIATE seek care
  • Prophylactic amox-clav 5 days
  • Family physician + ID consult
  • Vaccine update (pneumococcal, Hib, meningococcal — splenic 預防)

164.3.0.3 3⃣ 為什麌 1st-gen ceph + dicloxacillin 沒芆 Pasteurella?

  • Pasteurella + Eikenella + Capnocytophaga 對 cephalexin / dicloxacillin / clindamycin alone 䞍 sensitive
  • Cat / dog / human bite empirical → amox-clav (Augmentin) 是 标准

164.3.0.4 4⃣ Cat Scratch 鑑別 — Atypical Mycobacterial LAP

  • 兒童 unilateral persistent LAP → 鑑別
  • M. avium complex, M. scrofulaceum 也 cause
  • LAP > 4 wk + no response to abx → biopsy / culture
  • Biopsy histology: granuloma; Bartonella IHC stain
  • M. avium → excision (medical not great)

164.3.0.5 5⃣ Brucellosis IE / Spondylitis

  • Spinal involvement: L lumbar > T thoracic; pedicle / disc / paravertebral abscess
  • IE: aortic valve > mitral; high mortality, often need surgery
  • Doxy + rifampin + IV ceftriaxone / aminoglycoside 6-12 mo
  • Surgical drainage abscess / valve replacement

164.3.0.6 6⃣ Bioterror Awareness

  • Tularemia, plague, anthrax (Bacillus anthracis), botulinum, smallpox = Cat A
  • 通報 Public Health 立即
  • Empirical broad-spectrum until ID
  • PEP for exposed contacts

164.3.0.7 7⃣ 健保 / Taiwan

  • HACEK IE 健保 admit, ceftriaxone OPAT 仍 inpatient (Taiwan OPAT 還䞍癌達)
  • Bartonella / Brucellosis 眕芋, 通報
  • 街友 health 蚈畫 — Bartonella quintana surveillance
  • 動物咬傷: amox-clav 健保, tetanus + rabies (depending exposure)

164.3.0.8 8⃣ Rabies Post-Exposure (Animal Bite)

  • 䞍是 bacterial 䜆 always co-consider
  • Bite / scratch from suspect animal:
    • 觀察 animal 10 days
    • Wound wash + tetanus + amox-clav
    • Rabies HRIG + vaccine if rabies risk
  • Wild animal (bat, raccoon, fox, skunk) - 立即 PEP
  • Taiwan: bat + civet 監枬 rabies; cat/dog 郜 rabies vaccine domestic