176.3 🩺 內科專科考前版

176.3.0.1 1⃣ Sulbactam-Durlobactam (Xacduro, FDA 2023)

  • First drug specifically approved for CRAB
  • Combine with imipenem-cilastatin routinely (synergy)
  • 1 g / 1 g IV q6h × 7-14 days
  • 預臚床 + ATTACK Phase 3 — non-inferior to colistin + imipenem with less nephrotoxicity
  • 健保 Taiwan — likely ID-restricted indication
  • 重點: first-line CRAB serious infection per 2023 IDSA AMR Guidance

176.3.0.2 2⃣ Cefiderocol Pharmacology

  • “Trojan horse” siderophore — uses iron transporters to enter bacterial cell
  • Stable to all β-lactamases incl. OXA, MBL, KPC
  • Q8h infusion (3 hr each) — patient flexibility issue
  • Dose: 2 g q8h IV
  • Active against CRE, CRAB, MDR-PsA, Stenotrophomonas
  • High cost; ID-restricted

176.3.0.3 3⃣ Combat / Military Acinetobacter

  • US military Iraq/Afghanistan (2003-2014) — MDR-AB epidemic among casualties
  • Believed transferred via medical evacuation chain
  • Lessons: rapid debridement + early ID + AST + isolation
  • Ukraine war (2022+) — similar concerns; reports of MDR colonization in transferred patients
  • Civilian + military hospital infrastructure share

176.3.0.4 4⃣ Inhaled / Intrathecal Antibiotics

  • Inhaled tobramycin / amikacin / colistin — improve lung concentration in VAP
  • Intrathecal / intraventricular colistin / amikacin — meningitis / shunt infection
  • Caution: chemical meningitis, seizures (intrathecal aminoglycoside)
  • Adjunct to IV not replacement

176.3.0.5 5⃣ Polymyxin Toxicity

  • Nephrotoxicity (ATN) 30-60% — often dose-limiting
  • Neurotoxicity (paresthesia, dizziness, neuromuscular blockade)
  • Polymyxin B preferred over colistin (less variable PK, less nephrotoxic in some studies)
  • AKI risk → cefiderocol or sulbactam-durlobactam preferred

176.3.0.6 6⃣ Stewardship + Isolation

  • Contact precautions mandatory (gloves + gown)
  • Environment cleaning chlorhexidine or bleach (Acinetobacter survives long)
  • Cohort positive patients
  • Hand hygiene critical
  • Antibiotic stewardship reduces selection pressure

176.3.0.7 7⃣ 健保 / Taiwan

  • Acinetobacter highly endemic in Taiwan ICUs
  • 健保 sulbactam-durlobactam + cefiderocol — ID restricted (2024-)
  • 通報 outbreak / cluster
  • ICU infection prevention key program
  • Combat / trauma — military / police hospitals

176.3.0.8 8⃣ ASP — Empirical

  • HAP / VAP empirical: pip-tazo + vanco; add Acinetobacter cover (cefepime, mero) if MDR risk
  • Bacteremia: cover Pseudomonas + Acinetobacter empirically in ICU
  • De-escalate post-culture