195.3 🩺 內科專科考前版

195.3.0.1 1⃣ MAC Pulmonary Treatment Decisions

  • Treat all immunocompromise + symptomatic + radiographic progression
  • Asymptomatic with stable imaging: surveillance OK
  • Pretreatment AST (especially macrolide)
  • Consider toxicity vs benefit (long course)
  • Lady Windermere: 2-3×/wk dosing acceptable (less GI toxicity)

195.3.0.2 2⃣ Inhaled Amikacin Liposomal (Arikayce)

  • FDA 2018 for refractory MAC lung
  • Direct delivery to lung
  • Hopes for better pulmonary penetration with less systemic toxicity
  • Caveat: ototoxicity, persistent culture, bronchospasm
  • ID consult

195.3.0.3 3⃣ Hot Tub Lung

  • HP-like (hypersensitivity pneumonitis from M. avium inhalation)
  • CT: ground-glass + small nodules
  • BAL: lymphocytic
  • Avoidance of hot tub usually resolves
  • Steroid for severe
  • Not antibiotic primarily

195.3.0.4 4⃣ M. abscessus + CF

  • Increasing recognition
  • Lung transplant evaluation: M. abscessus complex — relative contraindication (varies by center)
  • Aggressive treatment pre-transplant
  • Genome sequencing for cluster identification
  • Strict cohort segregation in CF clinics

195.3.0.5 5⃣ Cardiac Surgery + M. chimaera

  • 2014-2017 global outbreak (LivaNova heater-cooler units)
  • 50,000+ patients exposed
  • Late presentation (median 17 months post-op)
  • Symptoms: fever, fatigue, sweat, hepatitis, prosthetic valve endocarditis, cytopenia, vision loss
  • 治療: rifabutin + clarithromycin + ethambutol + amikacin 6-12+ mo; sometimes prosthetic explant
  • Hospital surveillance + manufacturer device alerts

195.3.0.6 6⃣ Cosmetic Procedure Outbreaks

  • M. fortuitum, M. chelonae, M. abscessus
  • Inadequately sterilized equipment, contaminated solutions
  • 2024: ongoing global awareness
  • Reporting + investigation
  • Surgical clinic infection control

195.3.0.7 7⃣ NTM Lymphadenitis in Children

  • Surgical excision = preferred (cure with single procedure)
  • Antibiotic alone slower + variable outcome
  • 倧倚 painless cervical mass < 5 yr
  • Histology + culture
  • Confirm species (M. avium most, also M. scrofulaceum, M. haemophilum)
  • Postoperative course: monitor for sinus tract / recurrence

195.3.0.8 8⃣ NTM AST

  • Specialty labs (CDC, university)
  • Broth microdilution standard
  • MAC: clarithromycin most important
  • M. abscessus: macrolide (erm gene check), amikacin, cefoxitin, imipenem
  • M. kansasii: rifampin
  • Resistance patterns species-specific

195.3.0.9 9⃣ 健保 / Taiwan

  • 健保 covers TB drugs (rifampin, INH, EMB, PZA, clarithromycin, etc.)
  • NTM-specific: amikacin, clofazimine, imipenem etc. typically restricted indication
  • 通報: pulmonary NTM not 通報 like TB but case-by-case
  • 盧醫垫 hint: 老幎 + bronchiectasis + chronic cough + CXR ç•°åžž + 痰 AFB+ → 確認 species (TB vs NTM); 治療 plan differs

195.3.0.10 10. Future + Vaccines

  • No NTM vaccine
  • Surveillance + early treatment
  • Improved diagnostics (PCR, MALDI-TOF)
  • New drugs in development (bedaquiline activity vs MAC under study)
  • Combination + duration optimization ongoing