177.3 🩺 內科專科考前版

177.3.0.1 1⃣ Stenotrophomonas Treatment Algorithm

  • AST always
  • Bacteremia / pneumonia: TMP-SMX first
  • TMP-SMX intolerance / allergy: minocycline, levofloxacin
  • Severe / refractory: combination (TMP-SMX + minocycline + levo)
  • Cefiderocol alternative for difficult cases
  • Caveat: line removal critical (biofilm)

177.3.0.2 2⃣ TMP-SMX Renal Dose Adjustment

  • CrCl 15-30: 50% dose reduction
  • CrCl < 15: avoid or major reduction + monitor
  • Hyperkalemia + acute kidney injury common
  • Folate + folinic acid supplementation in long courses

177.3.0.3 3⃣ Melioidosis in Returned Traveler

  • Returning from Thailand / SE Asia / N Australia + sepsis / abscess / chronic pneumonia → 考慮
  • DM patient especially — Thailand has high melioidosis rate
  • Blood + abscess culture (mention to lab — Burkholderia pseudomallei BSL-3 careful)
  • 通報 (notifiable in endemic regions; bioterror potential in non-endemic)

177.3.0.4 4⃣ Climate Change + Melioidosis

  • Tropical / sub-tropical expansion
  • 2021 US outbreak (aromatherapy spray imported)
  • 2022-2024 Mississippi / Texas / Caribbean sporadic cases
  • WHO + CDC monitoring
  • Practitioner awareness + ID consult

177.3.0.5 5⃣ Cepacia Syndrome in CF

  • Acute fulminant pneumonia + sepsis + 高 mortality
  • Treat: meropenem + TMP-SMX + tobramycin (often combination, even of R drugs synergistic)
  • Difficult to eradicate
  • Lung transplant — debate; B. multivorans accepted some centers, B. cenocepacia historically contraindicated
  • CF community guidelines for B. cepacia colonization

177.3.0.6 6⃣ ASP in Nonfermenter Era

  • Empirical broad cover (pip-tazo + vanco) for severe HAP / sepsis
  • Once culture: de-escalate
  • For Stenotroph + Burkholderia + Acinetobacter — narrow to TMP-SMX / specific drugs
  • Avoid carbapenem 過床 use → selecting Stenotroph

177.3.0.7 7⃣ 健保 / Taiwan

  • Stenotrophomonas + Burkholderia — 醫院 isolates 偶芋
  • 健保 TMP-SMX, minocycline, ceftazidime / mero / cefiderocol 倧倚 covered ID indication
  • Melioidosis 眕芋 Taiwan but tropical south occasional
  • 旅遊 returnees + DM + sepsis → consider

177.3.0.8 8⃣ Vaccine + Future

  • Melioidosis vaccine (subunit + live attenuated) Phase 2
  • Stenotroph + Burkholderia — no vaccine candidate developed
  • New antibiotics: cefiderocol, plazomicin coverage of these organisms 確 evaluated