196.3 🩺 內科專科考前版

196.3.0.1 1⃣ HSV Encephalitis Treatment

  • Acyclovir 10 mg/kg IV q8h × 14-21d ASAP
  • Slow infusion, hydration (crystal nephropathy)
  • Foscarnet if resistant
  • Steroid adjunct under study (not standard yet)

196.3.0.2 2⃣ CMV in Transplant Prophylaxis

  • HSCT: letermovir (no marrow toxicity)
  • SOT: valganciclovir 900 mg qd × 100-200d
  • Pre-emptive vs prophylactic strategy varies by center
  • Letermovir investigating for SOT prophylaxis

196.3.0.3 3⃣ Paxlovid Drug Interactions

  • Major: amiodarone, immunosuppressants (tacrolimus, cyclosporine, sirolimus), simvastatin/lovastatin, eletriptan, alfuzosin, rivaroxaban, midazolam, sildenafil for PAH, lurasidone, oral OC
  • Review with pharmacist / Liverpool COVID interaction tool
  • Some require dose adjustment, hold, or alternative

196.3.0.4 4⃣ Oseltamivir in Pregnancy

  • Recommended per CDC + WHO + ACOG
  • Influenza in pregnancy = severe disease risk + fetal harm
  • Treat all pregnant with suspected/confirmed flu
  • PEP for high-risk exposure

196.3.0.5 5⃣ Nirsevimab + Universal Infant RSV

  • 2024 ACIP universal recommendation
  • 5-fold reduction in RSV hospitalization (MELODY trial)
  • Cost-effectiveness analyses positive
  • Shortage issues 2023-2024 — manufacturer scale-up ongoing
  • Maternal vaccine (Abrysvo) alternative

196.3.0.6 6⃣ Tecovirimat 2024 Update

  • STOMP trial NEGATIVE for Mpox treatment
  • Likely still useful in severe / immunocompromised but routine use questioned
  • CDC expanded access protocol continues
  • Vaccines (JYNNEOS) primary prevention

196.3.0.7 7⃣ CMV Resistance — Maribavir Role

  • Ganciclovir resistance: UL97 mutations (M460, A594, L595, C603)
  • Maribavir works against ganciclovir-R (different mechanism)
  • Replacing foscarnet/cidofovir in many cases
  • 12-yr+, post-transplant

196.3.0.8 8⃣ Antiviral Stewardship

  • Empirical oseltamivir for suspected flu hospitalized — start within hours
  • Empirical acyclovir for suspected HSV encephalitis — start immediately, even before LP results
  • Don’t withhold during pregnancy if indicated
  • Drug interaction review (especially Paxlovid)
  • Renal dose adjustment

196.3.0.9 9⃣ Future Antivirals

  • Pan-coronavirus inhibitors in development
  • CRISPR-Cas13 antivirals experimental
  • Maribavir extensions to other indications
  • Direct-acting antivirals for HSV in development
  • Mpox-specific drugs post-STOMP