318.4 📋 章末速記 Summary

318.4.1 🔑 一句話總結

HAP = ≥ 48 h post-admission；VAP = ≥ 48 h post-intubation；HCAP category RETIRED (2016 IDSA/ATS) — 改用個別 MDR risk factors；MDR risk factors：recent IV antibiotics 90d + septic shock + ARDS + hospitalization ≥ 5d + MRSA/Pseudo colonization；最常見病原：Pseudomonas (top in VAP) + MRSA + Acinetobacter + ESBL/CRE Enterobacteriaceae + Stenotrophomonas；empiric therapy：anti-Pseudomonas β-lactam (pip-tazo / cefepime / meropenem) + MRSA cover (vanc or linezolid)；high MDR risk + double anti-Pseudomonas (AG or FQ)；de-escalate within 48-72h per cultures；duration：7 days for most (PneumA trial)，14 days for MDR/complicated；modern MDR antibiotics：ceftaz-avibactam (ESBL/CRE/Pseudo)、meropenem-vaborbactam + imipenem-relebactam (CRE)、ceftolozane-tazo (MDR Pseudo)、cefiderocol (broadest but mortality signal in APEKS-NP)；VAP prevention bundle：HOB 30-45°、SAT/SBT daily、oral care、subglottic suction、early mobilization。

318.4.2 💊 治療精要

• anti-Pseudomonas β-lactam：pip-tazo 4.5 g q6h、cefepime 2 g q8h、meropenem 1 g q8h、ceftazidime；ESBL → meropenem；CRE → ceftaz-avibactam、meropenem-vaborbactam、imipenem-relebactam
• MRSA cover：vancomycin (trough 15-20) or linezolid 600 BID；NOT daptomycin (surfactant inactivates)
• 2nd anti-Pseudomonas (high MDR risk)：tobramycin / gentamicin / amikacin OR ciprofloxacin / levofloxacin
• Acinetobacter：sulbactam (high-dose), colistin, tigecycline, cefiderocol — limited options
• Stenotrophomonas：TMP-SMX first-line；levofloxacin alternative
• anaerobic cover (aspiration)：β-lactam-β-lactamase inhibitor or add metronidazole
• de-escalate per cultures within 48-72 h
• duration：7 days for most；14 for MDR Pseudo + complicated
• VAP prevention bundle：HOB elevation + SAT/SBT + oral care + subglottic suction + early mobilization

318.4.3 🎯 盧醫師的考前提醒

1. HCAP category 已 retired (2016)：改用 individual MDR risk factors，不再 routine vancomycin + anti-Pseudomonas for all HCAP
2. MDR risk factors triggering double cover：recent IV abx 90 days、septic shock、ARDS、prolonged hospitalization ≥ 5d、MRSA/Pseudomonas colonization、local MDR > 25%
3. Pseudomonas 在 VAP 是 #1 pathogen；MRSA 是 #1 Gram-positive
4. daptomycin 不能用於 pneumonia：pulmonary surfactant inactivates；vanc 或 linezolid 替代
5. PneumA trial (2003)：8-day vs 15-day course equivalent → 7 days for most HAP/VAP is current standard；shorter reduces resistance
6. modern MDR antibiotics (2020s)：ceftazidime-avibactam (ESBL + CRE-KPC + Pseudo)、meropenem-vaborbactam + imipenem-relebactam (CRE-KPC)、ceftolozane-tazobactam (MDR Pseudo)、cefiderocol (broad including Acinetobacter and Stenotrophomonas，但 APEKS-NP/CREDIBLE-CR mortality signal in critically ill — reserved)
7. VAP prevention bundle Class I：HOB elevation 30-45°、SAT/SBT daily paired、oral care、subglottic suction endotracheal tubes、cuff pressure 20-30 cm H2O、hand hygiene、early ambulation；reduces VAP rates
8. oral chlorhexidine controversial 2024：原 routine 推薦，現 some evidence ↑ pneumonia and mortality；個別評估
9. CRE specific antibiotics：ceftaz-avibactam + meropenem-vaborbactam + imipenem-relebactam for KPC；cefiderocol for NDM/OXA-48 + Acinetobacter
10. procalcitonin in HAP/VAP stewardship：< 0.5 + downward trend → consider stopping；helps shorten duration without compromising outcomes