175.3 🩺 內科專科考前版

175.3.0.1 1⃣ Carbapenem Choice

  • Ertapenem 䞍 cover Pseudomonas (key knowledge gap)
  • Anti-PsA carbapenems: imipenem, meropenem, doripenem
  • Wide spectrum but R selection on use
  • Emerging KPC R → switch to imi-rele or CAZ-AVI

175.3.0.2 2⃣ Combination vs Monotherapy

  • Severe sepsis / neutropenic + PsA: combination β-lactam + aminoglycoside initial 48-72 hr for double cover
  • After AST + clinical stability: switch to monotherapy
  • Mono OK in most non-severe (less toxicity, equal outcomes per RCTs)

175.3.0.3 3⃣ CF Chronic Suppression

  • Inhaled tobramycin (TOBI) 28 days on / 28 off
  • Inhaled aztreonam (Cayston) tid
  • Inhaled colistin (Promixin) for resistant
  • Azithromycin PO chronic — anti-inflammatory + biofilm disruption

175.3.0.4 4⃣ Malignant Otitis Externa Workup

  • DM elderly + ear pain + canal granulation tissue
  • MRI / CT temporal bone — bony erosion, soft tissue extension
  • Tc-99m bone scan + Ga-67 scan (Ga maps active inflammation)
  • ESR / CRP monitor treatment response
  • Glycemic control optimal
  • 6-8 wk IV / PO (cipro PO step-down if S)
  • HBO controversial adjunct

175.3.0.5 5⃣ Ecthyma Gangrenosum

  • Neutropenic patient + sepsis + 玅斑 → vesicle → necrotic ulcer + central eschar
  • Multi-focal common
  • Histology: vasculitis + bacterial invasion of vessel wall + extensive necrosis
  • Send blood cx + biopsy
  • Cover PsA empirically before culture confirmation

175.3.0.6 6⃣ Hot Tub Folliculitis

  • Spas, swimming pools with insufficient chlorination
  • 倚 cluster (group exposure)
  • Self-limit
  • Reassurance + clean / dry skin

175.3.0.7 7⃣ Diabetic Foot Infection

  • IDSA 2024 guidelines:
    • Mild + outpatient: oral β-lactam ± cipro
    • Moderate / severe: pip-tazo + vanco
    • Osteo: 6 wk antibiotic + debridement (POET 2019: oral switch acceptable when stable)
  • Vascular surgery if PAD
  • Wound care + offloading

175.3.0.8 8⃣ 健保 / Taiwan

  • 健保 pip-tazo / cefepime / ceftazidime / carbapenem 廣芆 (subject ID consult restricted)
  • 新藥 (ceftolozane-tazo, CAZ-AVI, cefiderocol) 健保 ID restricted
  • CF — 眕芋 Taiwan; eradication strategy + chronic suppression follow CF foundation guidelines
  • 慢性 OE + DM — Taiwan endemic; 老人 ID consult

175.3.0.9 9⃣ Stewardship

  • Empirical narrow → de-escalate
  • 䞍 over-cover PsA in low-risk (community without device / immunocompromise)
  • Short course (5-7 d) for VAP if responding
  • AST-guided