感染症暨熱帶醫學科疾病 診斷及治療流程 目錄 法定傳染病處理流程 新感染症候群通報流程(I)(II) 抗生素使用原則 疑似肺結核 不同病況的肺結核病人治療藥物建議 加護病房病人發燒 細菌性腦膜炎 放置導管病人出現急性發燒 放置導管病人出現相關血流感染 放置導管病人出現菌血症 中性球低下病人發燒處理流程 感染性腹瀉 醫護及臨床工作者接觸HIV後處理流程 HIV接觸後預防性給藥方式 HIV 病人出現發燒 HIV 病人有發燒咳嗽症狀 HIV 病人腹瀉 HIV 病人口腔念珠菌感染 HIV 病人發生頭痛神智改變 HIV接觸後處理流程檢驗室證實法定 傳染病處理流程臨床病理科(細菌組、病毒室)TB陽性檢驗報告單 HIV陽性 檢驗 (含AFB”+”及 TB 報告單(病毒室)culture: “Mycobacterium spp.”) 和其他陽性之法定 傳染病檢驗報告單感管會 感管會各科總醫師 感染科總 醫師 填寫通報單 填寫通報 單醫勤組(例假日時至醫勤組急診掛號櫃檯)國防部 台北市 感管會軍醫局 衛生局新感染症候群通報流程(I)病患臨床軍醫護理站感染管制委員會拿通報單及臨床資料 表(病歷審查用)檢體送至單一窗口並請醫師通知內湖 衛生所(27911162-219)收取檢體通報單第一聯及臨床資料表送至醫勤 組姜小姐(17354)新感染症候群通報流程(II) 注意事項 急性出血熱症候群需送全血 急性腹瀉症候群通報定義， 過去為健康之正常人，出現 急性腹瀉，伴有嚴重病情， 年齡大於五歲 檢體收集管請貼上疾管局的 黃色專用標籤，並用拉鍊袋 裝好 醫院實驗室可做的檢查： Adenovirus, Aeromonas spp.,Chloera, Campylobacter jejuni, Listeria monocytogenes, Rotavirus, typhoid fever 檢體有問題請電：27892137Fever in ICU加護病房病人發燒處理流程Suspicion for bacterial meningitisPapilledema and/or focal neurologic deficits (excluding ophthalmoplegia)Absent PresentObtain blood culturesEmpirical antimicrobial therapyObtain blood cultures and perform lumbar puncture STATCT scan of headNo mass lesion Mass lesionCSF consistent with bacterial meningitisPositive Gram stain or bacterial antigen test resultEmpirical antimicrobial therapy Specific antimicrobial therapyConsider alternativediagnosis細菌性腦膜炎處理流程NoYesLancet 1995;346:1675If continued fever (no hypotension or organ failure)Seriously ill ; (hypotension, hypoperfusion, signs 6-8 weeks for osteomyelitisRemovable central venous catheter (CVC). Related bloodstream infection放置導管病人出現相關血流感染ComplicatedUncomplicatedSeptic thrombosis, endocarditis, osteomyelitis, etcCoagulase- negative staphy lococcusS. aureusGram-negative bacillCandida spp.Remove CVC 6-8 weeks for osteomye litisRemove CVC/ID 34:730-51)(IDSA guideline Hughes WT et al CID 2002;34:730-51)Fever (temperature 38.3) + Neutropenia (500 neutrophils/mm )Low riskHigh riskOralivVancomycin not neededVancomycin neededCiprofloxacin + Amoxicillin-clavulanate (adults only)MonotherapyCefepime, Ceftazidime, or CarbapenemVancomycin+Aminoglycoside + Antipseudomonal penicillin, Cefepime, Ceftazidime, or CarbapenemTwo DrugsVancomycin + Cefepime, ceftazidime, or Carbapenem aminoglycosideReassess after 3-5 days3經過經過3-53-5日治療後病人退燒處理流程日治療後病人退燒處理流程( (IDSA guideline Hughes WT et al CID 2002;34:730-51)IDSA guideline Hughes WT et al CID 2002;34:730-51)Afebrile within first 3-5 days of treatmentNo etiology identifiedEtiology identifiedLow riskAdjust to most appropriate treatmentChange to: Ciprofloxacin + Amoxicillin- clavulanate (adults) or cefixime (child)High riskContinue same antibioticsDischarge經過經過3-53-5日治療後病人持續發燒處理流程日治療後病人持續發燒處理流程 Guide to treatment ofGuide to treatment ofpatients who have persistentpatients who have persistentfever after 3fever after 3- -5 days5 daysof treatment of treatment and forand forwhom the cause ofwhom the cause ofthe fever is notthe fever is notfound. (IDSA guideline CID 2002;34:730-found. (IDSA guideline CID 2002;34:730- 51)51)Persistent fever during first 3-5 days of treatment: no etiologyReassess patient on days 3-5Continue initial antibioticsChange antibioticsAntifungal drug, with or without antibiotic changeIf no change in patients condition (consider stopping vancomycin)If progressive disease, If criteria for vancomycin are metIf febrile through days 5- 7 and resolution of neutropenia is not imminent抗生素治療期程之建議抗生素治療期程之建議 ( (IDSA guideline Hughes WT et al CID 2002;34:730-51)IDSA guideline Hughes WT et al CID 2002;34:730-51)Duration of antibiotic therapyAfebrile by days 3-5Persistent feverANC500 cells/mm for 2 consecutive daysANC500 cells/mm by day 7ANC500 cells/mmANC500 cells/mmContinue for 2 weeksStop 4-5 days after ANC500 cells/mm Initial high risk ANC100 cells/mm Mucositis Unstable signsInitial low risk Clinically wellStop antibiotics 48 h after afebrile + ANC 500 cell/mm Stop when afebrile for 5-7 daysContinue antibioticsReassessReassessStop if no disease and condition is stable3333333感染性腹瀉處理流程Evaluate severity and duration Obtain history and physical examination Treat dehydration Report suspected outbreaks Check all that applyConsider quinolone for suspected shigellosis in adults(fever, inflammation); macrolide for suspected resistantCulture or test for: Salmonella Shigella Campylobacte