320.4 📋 章末速記 Summary

320.4.1 🔑 一句話總結

TB = M. tuberculosis aerosol transmitted；全球 #1 infectious cause of single-pathogen death；分 primary infection + latent TB infection (LTBI) + active TB；台灣 incidence ~ 35-40 / 100,000 (intermediate-high)；diagnosis：AFB smear + culture + Xpert MTB/RIF NAAT (rapid + RIF resistance, WHO/IDSA Class I)；LTBI 用 IGRA (preferred in BCG-vaccinated) or TST；standard DS-TB treatment：RIPE (Rifampin + Isoniazid + Pyrazinamide + Ethambutol) × 2 months → RI × 4 months (total 6 mo)；MDR-TB (INH + RIF resistant) BREAKTHROUGH 2022：BPaL (bedaquiline + pretomanid + linezolid) × 6 months (Nix-TB 2020, ZeNix 2022) or BPaLM (+ moxifloxacin) × 6 months (TB-PRACTECAL 2022) — 取代過去 18-24 month 4-7 drug regimens；LTBI preferred regimens：3HP (rifapentine + isoniazid weekly × 12 weeks) or 4R (rifampin × 4 months)；HIV co-infection：ART + TB simultaneously；risk factors for progression：HIV (100x), TNF-α inhibitor (5-10x), DM, CKD, silicosis；reportable disease + DOT + airborne precautions。

320.4.2 💊 治療精要

  • active DS-TB：RIPE × 2 mo → RI × 4 mo (total 6)；extend to 9 mo if cavitary + culture-positive at 2 mo
  • LTBI：3HP (rifapentine + INH weekly × 12 wk) preferred；4R (rifampin × 4 mo) for INH intolerance；9H older
  • MDR-TB：BPaL or BPaLM × 6 mo (Nix-TB, ZeNix, TB-PRACTECAL 2022) — revolutionary
  • drug doses：rifampin 10 mg/kg、isoniazid 5 mg/kg + pyridoxine 25-50 mg、pyrazinamide 25 mg/kg、ethambutol 15-25 mg/kg
  • HIV + TB：ART within 2 wk if low CD4；rifabutin if drug interactions；watch IRIS
  • TB meningitis：12 mo + corticosteroids；TB pericarditis: 6 mo + steroids (IMPI)；Pott’s: 12 mo
  • pregnancy：INH + RIF + EMB OK；avoid pyrazinamide + streptomycin；pyridoxine

320.4.3 🎯 盧醫師的考前提醒

  1. RIPE 標準 4 藥 + 治療順序：intensive 2 mo (R+I+P+E) → continuation 4 mo (R+I) = 6 月；cavitary + 2-mo culture positive → 9 個月
  2. drug side effects MEMORIZE：R orange fluids + hepatotoxicity + CYP3A4 induction；I hepatotoxicity + peripheral neuropathy (B6) + drug-induced lupus；P hepatic + hyperuricemia (gout)；E optic neuritis (vision baseline + monitoring)；S ototoxicity + nephrotoxicity
  3. Xpert MTB/RIF NAAT 是初診 Class I：rapid (~ 2 hr) + RIF resistance；Xpert MTB/XDR 加 INH + FQ + AG resistance
  4. IGRA preferred 在 BCG-vaccinated populations（Taiwan、亞洲、非洲、拉丁美洲）：不受 BCG 影響、specific for MTB
  5. BPaL/BPaLM 2022 BREAKTHROUGH：MDR/XDR-TB × 6 months (取代 18-24 mo with 4-7 drugs)；Nix-TB、ZeNix、TB-PRACTECAL trials → WHO 2022 endorsement
  6. 3HP (rifapentine + INH weekly × 12 wk) is preferred LTBI regimen — DOT-friendly + shorter + better adherence
  7. HIV + TB co-infection：start ART within 2 weeks if CD4 < 50；within 8 weeks if CD4 ≥ 50；watch IRIS 4-8 wk post-ART start (continue therapy + steroids if severe)
  8. TB meningitis treatment：12 months + adjunctive corticosteroids (dexamethasone) ↓ mortality 31% (BMT 2004)
  9. rifampin drug interactions：CYP3A4 inducer → reduces contraceptives + warfarin + HIV protease inhibitors；rifabutin lesser inducer (alternative for HIV ART)
  10. TNF-α inhibitor + JAK inhibitor：5-10x TB reactivation risk；screen LTBI before starting (IGRA or TST) + treat positive