感染癥暨熱帶醫(yī)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癥候群通報流程(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(fā)燒細菌性腦膜炎放置導管病人出現(xiàn)急性發(fā)燒放置導管病人出現(xiàn)相關血流感染放置導管病人出現(xiàn)菌血癥中性球低下病人發(fā)燒處理流程感染性腹瀉醫(yī)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(xiàn)發(fā)燒HIV病人有發(fā)燒咳嗽癥狀HIV病人腹瀉HIV病人口腔念珠菌感染HIV病人發(fā)生頭痛神智改變HIV接觸後處理流程1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(yī)師感染科總醫(yī)師填寫通報單填寫通報單醫(yī)勤組(例假日時至醫(yī)勤組急診掛號櫃檯)

國防部臺北市感管會軍醫(yī)局

衛(wèi)生局

2新感染癥候群通報流程(I)病患臨床軍醫(yī)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(yī)師通知內湖衛(wèi)生所(27911162-219)收取檢體通報單第一聯(lián)及臨床資料表送至醫(yī)勤組姜小姐(17354)3新感染癥候群通報流程(II)注意事項急性出血熱癥候群需送全血急性腹瀉癥候群通報定義，過去為健康之正常人，出現(xiàn)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(yī)院實驗室可做的檢查：Adenovirus,Aeromonasspp.,Chloera,Campylobacterjejuni,Listeriamonocytogenes,Rotavirus,typhoidfever

檢體有問題請電：27892137456FeverinICU加護病房病人發(fā)燒處理流程7SuspicionforbacterialmeningitisPapilledemaand/orfocalneurologicdeficits(excludingophthalmoplegia)AbsentPresentObtainbloodculturesEmpiricalantimicrobialtherapyObtainbloodculturesandperformlumbarpunctureSTATCTscanofheadNomasslesionMasslesionCSFconsistentwithbacterialmeningitisPositiveGramstainorbacterialantigentestresultEmpiricalantimicrobialtherapySpecificantimicrobialtherapyConsideralternativediagnosis細菌性腦膜炎處理流程NoYesLancet1995;346:16758Ifcontinuedfever&noothersourcefound,remove&cultureCVCBloodcultures,2sets(1peripheral)Ifnosourceoffeveridentified,removeCVC,culturetip&insertatnewsite,orexchangeoveraguidewireConsiderantimicrobialtherapyBloodcultures,2sets(1peripheral)Ifnosourceoffeveridentified,removeCVC,culturetip&insertatnewsiteorexchangeoveraguidewirePatientwitharemovableCVC&anacutefebrileepisode放置導管病人出現(xiàn)急性發(fā)燒Mildormoderatelyill;(nohypotensionororganfailure)Seriouslyill;(hypotension,hypoperfusion,signs&symptomsoforganfailure)InitiateappropriateantimicrobialtherapyBloodcultures(-)&CVCnotculturedBloodcultures(-)&CVCcultures(．)Bloodcultures(-)&CVC≧15CFUBloodcultures(+)&CVC≧15CFULookforanothersourceofinfectionInpatientswithvalvularheartdiseaseorneutropenia,&S.aureusorCandidacolonizationofCVC,monitorcloselyforsignsofinfection&repeatbloodculturesaccordinglySeemanagementstrategiesoutlinedinFigure29RemoveCVC&treatwithsystemicantibioticfor4-6weeks;6-8weeksforosteomyelitisRemovablecentralvenouscatheter(CVC).Relatedbloodstreaminfection放置導管病人出現(xiàn)相關血流感染ComplicatedUncomplicatedSepticthrombosis,endocarditis,osteomyelitis,etcCoagulase-negativestaphylococcusS.aureusGram-negativebacillCandidaspp.RemoveCVC&treatwithasystemicantibiotic5-7daysIfcatheterisretained,treatwithsystemicantibiotic+/-antibioticlocktherapyfor10-14daysRemoveCVC&treatwithasystemicantibioticfor14daysIfTEE(+),extendsystemicantibiotictreatmentto4-6weeksRemoveCVC&treatwithsystemicantibiotictherapyfor10-14daysRemoveCVC&treatwithantifungaltherapyfor14daysafterlastpositivebloodculture10放置導管病人出現(xiàn)菌血癥Verificationofinfection:Luminalcolonization?Contamination?Infection?Catheter-relatedInfection?Complications:Persistentbacteremia?Septicthrombosis?Retinitis?Endocarditis?FeverorchillsLikelypathogen(Figure4)>1bloodculture(+)(peripheral&CVC/ID)NoothersourceoffeverSiteortunnelinfectionLikelypathogenQuantitativeCVC/PBC>5:1DifferentialCVC/PBCtimetopositivity,>2h(seetext)Noothersourcefor(+)bloodcultureBloodculture(+)ontherapyDopplervenogram(+)Fundoscopicexam(+)TEEorTTE(+)11RemoveCVC/ID&usesystemicantibioticfor14daysifTEE(-)ForCVC/IDsalvagetherapy.IfTEE(-),usesystemic&antibioticlocktherapyfor14daysRemoveCVC/ID&ifthereisclinicaldeterioration,persistingorrelapsingbacteremiaRemoveCVC/ID&treatwithantifungaltherapyfor14daysafterlastpositivebloodculture放置導管病人出現(xiàn)菌血癥Tunneledcentralvenouscatheter(CVC)-orimplantabledevice(ID)-relatedbacteremiaComplicatedUncomplicatedTunnelinfection,portabscessSepticthrombosis,endocarditis,osteomyelitisCoagulase-negativestaphylococcusS.aureusCandidaspp.Gram-negativebacilliRemoveCVC/ID&treat10-14daysForCVC/IDsalvage,usesystemic&antibioticlocktherapyfor14daysIfnoresponse,removeCVC/ID&treatwithsystemicantibiotictherapyfor10-14daysMayretainCVC/ID&usesystemicantibioticfor7daysplusantibioticlocktherapyfor10-14daysRemoveCVC/IDifthereisclinicaldeterioration,persistingorrelapsingbacteremiaRemoveCVC/ID&treatwithantibioticsfor4-6weeks;6-8weeksforosteomyelitisRemoveCVC/ID&treatwithantibioticsfor10-14days12中性球低下病人發(fā)燒處理流程(IDSAguidelineHughesWTetalCID2002;34:730-51)Fever(temperature≧38.3℃)+Neutropenia(＜500neutrophils/mm

)LowriskHighriskOralivVancomycinnotneededVancomycinneededCiprofloxacin+Amoxicillin-clavulanate(adultsonly)MonotherapyCefepime,Ceftazidime,orCarbapenemVancomycin+Aminoglycoside+Antipseudomonalpenicillin,Cefepime,Ceftazidime,orCarbapenemTwoDrugsVancomycin+Cefepime,ceftazidime,orCarbapenem±aminoglycosideReassessafter3-5days313經過3-5日治療後病人退燒處理流程

(IDSAguidelineHughesWTetalCID2002;34:730-51)Afebrilewithinfirst3-5daysoftreatmentNoetiologyidentifiedEtiologyidentifiedLowriskAdjusttomostappropriatetreatmentChangeto:Ciprofloxacin+Amoxicillin-clavulanate(adults)orcefixime(child)HighriskContinuesameantibioticsDischarge14經過3-5日治療後病人持續(xù)發(fā)燒處理流程Guidetotreatmentof

patientswhohavepersistent

feverafter3-5days

oftreatmentandfor

whomthecauseof

thefeverisnot

found.(IDSAguidelineCID2002;34:730-51)Persistentfeverduringfirst3-5daysoftreatment:noetiologyReassesspatientondays3-5ContinueinitialantibioticsChangeantibioticsAntifungaldrug,withorwithoutantibioticchangeIfnochangeinpatient’scondition(considerstoppingvancomycin)Ifprogressivedisease,IfcriteriaforvancomycinaremetIffebrilethroughdays5-7andresolutionofneutropeniaisnotimminent15抗生素治療期程之建議(IDSAguidelineHughesWTetalCID2002;34:730-51)

DurationofantibiotictherapyAfebrilebydays3-5PersistentfeverANC≧500cells/mm

for2consecutivedaysANC＜500cells/mmbyday7ANC≧500cells/mmANC＜500cells/mmContinuefor2weeksStop4-5daysafterANC＞500cells/mm

InitialhighriskANC＜100cells/mmMucositisUnstablesignsInitiallowriskClinicallywellStopantibiotics48hafterafebrile+ANC≧500cell/mmStopwhenafebrilefor5-7daysContinueantibioticsReassessReassessStopifnodiseaseandconditionisstable333333316感染性腹瀉處理流程EvaluateseverityanddurationObtainhistoryandphysicalexaminationTreatdehydrationReportsuspectedoutbreaksCheckallthatapplyConsiderquinoloneforsuspectedshigellosisinadults(fever,inflammation);macrolideforsuspectedresistantCultureortestfor:SalmonellaShigella