298.4 📋 章末速記 Summary

298.4.1 🔑 一句話總結

IE 是 endocardium 感染（多為瓣膜）；分 NVE / PVE / CIED-related / IV drug-related / healthcare-associated；最常見病原：S. aureus（acute, 最多 worldwide）、viridans Strep（subacute）、Enterococcus、CoNS（prosthetic）、HACEK、Bartonella、Coxiella、fungi、Strep gallolyticus（colon cancer screen!）；診斷靠 Modified Duke (2023 ESC update) + echo (TTE → TEE) + FDG-PET-CT for prosthetic / CIED；treatment：empiric vancomycin + ceftriaxone → 依 culture 調整 × 4-6 週；POET 2019 證明 stable NVE 10d IV 後改 oral non-inferior；surgery 指徵：HF / persistent bacteremia / abscess / large veg + embolism / fungal；prophylaxis 2024：限於 highest-risk + dental gingival manipulation。

298.4.2 💊 治療精要

• empiric NVE：vancomycin + ceftriaxone OR vanc + gentamicin
• viridans Strep：penicillin G or ceftriaxone × 4 wk + gentamicin × 2 wk
• S. aureus (MSSA)：nafcillin / oxacillin × 4-6 wk；(MRSA)：vancomycin or daptomycin
• Enterococcus：ampicillin + gentamicin × 4-6 wk 或 ampicillin + ceftriaxone (DAILY, less nephrotoxic)
• HACEK：ceftriaxone × 4 wk
• Coxiella：doxycycline + hydroxychloroquine × 18-24 個月
• fungal (Candida)：echinocandin + valve surgery
• POET：stable NVE 10 d IV → 換 PO

298.4.3 🎯 盧醫師的考前提醒

1. Modified Duke Criteria 2023 ESC：major (typical organism blood culture × 2 + imaging — echo/CT/PET-CT)；minor (predisposition + fever + vascular + immunologic + micro)；definite = 2 major OR 1 major + 3 minor OR 5 minor
2. S. aureus 是 IE worldwide #1（acute、aggressive、healthcare-associated、IVDU）
3. viridans Strep 是 subacute NVE 經典原因（oral source）
4. Strep gallolyticus (S. bovis) IE → 一定要做大腸鏡 screen colon cancer
5. culture-negative IE 5-10%：先給過 abx 或 fastidious organisms（HACEK、Bartonella、Coxiella Q fever、Tropheryma、fungi）
6. TEE > TTE for prosthetic valve / 不確定 / complications；FDG-PET-CT 是新工具（特別對 prosthetic > 3 個月、CIED）
7. surgery 必做指徵：HF + 嚴重瓣膜不全 / persistent bacteremia 7d / 心內 abscess / 大 veg (> 10 mm) + recurrent embolism / fungal / MDR organism
8. POET 2019 改變實務：stable NVE 10d IV + 臨床改善後 → 換口服藥 non-inferior（reduces hospital LOS + cost）
9. DAILY trial：Enterococcus IE 用 ampicillin + ceftriaxone（取代 ampicillin + gentamicin）— less nephrotoxicity
10. prophylaxis 2024 ACC/AHA：只限 highest-risk（prosthetic valve / prior IE / unrepaired cyanotic CHD / repair < 6 mo / residual defect adjacent prosthetic / cardiac transplant valvulopathy）+ 牙科 manipulation of gingiva — amoxicillin 2 g 30-60 min pre-procedure