167.3 🩺 內科專科考前版

167.3.0.1 1️⃣ ESBL Risk Factors

• Recent abx (3rd ceph, FQ)
• Recent hospitalization, ICU
• Recent travel (S Asia, M East)
• LTC / nursing home
• Recurrent UTI
• Foley / catheter

167.3.0.2 2️⃣ MERINO Trial 2018

• ESBL bacteremia: pip-tazo vs meropenem
• Pip-tazo INFERIOR (mortality 12% vs 4%)
• Carbapenem 是 standard for severe ESBL
• Mild UTI 仍 PO options OK

167.3.0.3 3️⃣ AmpC Inducible Organisms (“SPACE-M” / “ESCAPPM”)

• Serratia, Proteus vulgaris, Acinetobacter, Citrobacter, Enterobacter, Morganella
• Or memory: Enterobacter, Serratia, Citrobacter, Acinetobacter, Proteus, Providencia, Morganella
• Caveat: actually 主要 Enterobacter cloacae, Citrobacter freundii, Klebsiella aerogenes, Serratia marcescens
• Avoid 3rd-gen ceph monotherapy — high risk emergence on therapy

167.3.0.4 4️⃣ Hypervirulent Klebsiella (Taiwan / Asia)

• K1, K2 capsular type
• Pyogenic liver abscess (Asia, 糖尿病人 strong association)
• Metastatic complications: endophthalmitis (失明), meningitis, lung abscess
• String test + (hypermucoviscous colony on agar)
• Treatment: 3rd-ceph / ertapenem; drainage essential
• 病例 increase 中

167.3.0.5 5️⃣ Newer Antibiotics for CRE

藥	Activity	Notes
Ceftazidime-avibactam (CAZ-AVI)	KPC, OXA-48, AmpC, ESBL	Mostly used; some R emerging
Meropenem-vaborbactam	KPC
Imipenem-relebactam	KPC, MDR Pseudomonas
Cefiderocol	All carbapenemases (metallo too)	Last-resort; siderophore Trojan horse
Plazomicin	Aminoglycoside, KPC	UTI mostly
Sulbactam-durlobactam	Acinetobacter	FDA 2023
Eravacycline	MDR GN intra-abd

167.3.0.6 6️⃣ 健保 / Taiwan

• ESBL E. coli/Klebsiella ~ 15-30% community (rising)
• CRE — KPC + IMP + NDM混 (Taiwan endemic IMP)
• 健保 CAZ-AVI / cefiderocol — ID consult restricted
• Hypervirulent K. pneumoniae liver abscess — Taiwan endemic; 糖尿病人 必 imaging if liver enzyme 升 + 燒

167.3.0.7 7️⃣ Stewardship

• Empirical narrow → broaden only if escalation
• De-escalate post-culture
• Avoid 3rd-gen ceph in AmpC + ESBL risk
• Short course UTI (3-5d)
• IV → PO step-down

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