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1、感染內科簡介,By R4 林尚儀,Introduction,成員 大家長：陳田柏教授、陳瑩霖教授 主任：陳彥旭醫師 主治醫師：蔡季君醫師、盧柏樑醫師、林蔚如醫師、陳惇杰醫師、張科醫師、謝効烝醫師、林俊祐醫師、郭政諭醫師、陳立遠醫師 總住院醫師：陳季玉醫師、黃崇豪醫師、 張雅婷醫師、林尚儀醫師,、,、,本科常見疾病,Skin and soft tissue infection Bone and joint infection Fever of unknown origin Tuberculosis Other infection associated with vectors Infective
2、 endocarditis HIV / AIDS,Pneumonia,Community-acquired pneumonia 肺實質的急性感染，發生在未住院或住院未滿48 小時之病人。病患胸部X 光片上有新出現之浸潤，同時表現出急性感染的症，如發熱、體溫過低、發抖、出汗、（新出現的）咳嗽（有痰或沒痰）、痰色改變、胸部適、氣促，其他非特定性症（疲倦、肌痛、腹痛、食慾差、頭痛），或聽診之常（支氣管音，加上/或是局部囉音）。Hospital-acquired pneumonia 住院48 小時後，或上次住院結束後14 天之內發生之肺實質的急性感染。胸部X 光片上有新出現或持續進展（24 小時）之浸
3、潤，同時以下條件至少有項存在: (1).發熱：體溫之上昇1，或體溫38.3，或35 (2).白血球上升：白血球之增加原值之25%，或白血球10,000/l 或20mg/dl，RR 30 /分，血壓下（收縮壓小於90 mmHg 或舒張壓小於60mmHg）10；以上每項代表一分，最高五分。 pneumonia severity index,Adapt from 台灣肺炎診治指引 2007,社區肺炎常致病菌,Adapt from 台灣肺炎診治指引 2007,院內肺炎常致病菌及相關床病徵,Adapt from 台灣肺炎診治指引 2007,Soft tissue infection,Cellulitis
4、 and erysipelas,Similar symptoms/ signs Lymphangitis, inflammation of regional lymph nodes Vesicles, bullae, and ecchymoses or petechiae Different symptoms/ signs cellulitis: deeper dermis and subcutaneous fat Erysipelas: the upper dermis and superficial lymphatics a clear line of demarcation betwee
5、n involved and uninvolved tissue,MICROBIOLOGY,The most common pathogens beta-hemolytic streptococci Staphylococcus aureus, including MRSA gram-negative aerobic bacilli Other pathogens Animal bites: Pasteurella multocida and Capnocytophaga canimorsus Water exposure: Aeromonas hydrophila and Vibrio vu
6、lnificus Clostridium species Pelvic LND: Streptococcus agalactiae Penetrating wound: Pseudomonas aeruginosa Others,Treatment,Elevation the affected area facilitates gravity drainage of edema and inflammatory substances Manage the underlying condition tinea pedis, lymphedema, and chronic venous insuf
7、ficiency Antibiotics treatment,NECROTIZING FASCIITIS,a deep seated infection of the subcutaneous tissue that results in progressive destruction of fascia and fat Type I mixed infection occurs after surgical procedures, diabetes, peripheral vascular disease Type II a monomicrobial infection caused by
8、 group A streptococcus (GAS, Streptococcus pyogenes) or MRSA,Clinical manifestations,Unexplained pain, which increases rapidly over time, may be the first manifestation soft tissue involvement with pain out of proportion to skin findings, and elevated CPK. Within 24 to 48 hours, erythema may develop
9、 or darken to a reddish-purple color, frequently with associated blisters and bullae,Scoring system,A total score 6 should raise the suspicion for necrotizing fasciitis a score 8 was highly predictive (75 percent). CRP 150 mg/L (4 points) WBC 15,000 to 25,000/microL (1 point) or 25,000/microL (2 poi
10、nts) Hb 11.0 to 13.5 g/dL (1 point) or 11 g/dL (2 points) Na 1.6 mg/dL (2 points) Serum glucose 180 mg/dL (10 mmol/L) (1 point),Crit Care Med. 2004 Jul;32(7):1535-41,Management,While suspicion, considering image study if necrotizing fasciitis is confirmed, to perform aggressive surgical debridement
11、of the involved fascia Antibiotics treatment Intravenous immune globulin Hyperbaric oxygen,Fever of Unknown origin,New classification of FUO(1991),Classical FUO 38 3wk,2visits or 3 days in hospital Nosocomial FUO Neutropenic FUO HIV-associated FUO,Etiology of FUO,Infections Autoimmune or rheumatolog
12、ic diseases Neoplasm Drug fever and other miscellaneous causesUndiagnosed,Management of FUO,Detailed repeated history taking Travel history, contact history, sexual exposure, medication, social habit, food history, localization Detailed physical examination Skin, mucosa, lymph node, cardiac murmur,
13、DRE, Sinus Laboratory tests BUS routine, WBC classification, biochemistry, CXR ESR & CRP Smear & culture Serology, antigen detection, PCR etc. Therapeutic trial,Associated symptoms/ signs,Animal exposure Systemic disease Sick family Occupation Chronology Illicit drug/ alcohol/ smoking Allergy Travel
14、 Event: procedure, operation Drug,Harrisions principles of internal medicine, 16th,Tuberculosis Infection,Tuberculosis,結核菌是長110 m，寬0.20.7 m 而為彎曲的細長桿菌無鞭毛、無芽胞、無莢膜，有時呈現多形性，如近乎球形或長鏈。其細胞壁富於脂質而會妨礙色素的通過，因而染色。染色時要以添加媒染劑之色素溶液，加溫染色。結核菌的染色一般推薦Ziehl-Neelsen 法, 故又稱耐酸菌(acid-fast bacilli) 結核菌屬於偏性好氣菌(strict aerobes
15、)，發育最宜溫為37C，最宜酸鹼pH 為6.47.0。自床檢體培養結核菌，一般常使用以全為基礎的固態培養基，如：Lwenstein-Jensen (LJ) 培養基結核菌的分速很慢，大約每20 小時分一次。痰中結核菌在此培養基中孵養發育，經38 週形成R 型菌。,傳染途徑,飛沫核(droplet nuclei)傳染 帶菌的結核病患者常在 吐痰或藉在公共場所講話、咳嗽、唱歌或大笑時產生的飛沫排出結核菌。這些飛沫在塵埃中，乾燥後飛沫殘核飛揚飄浮在空中，直徑小於5 的飛沫殘核可經由呼吸道到達正常的肺胞，造成感染。 結核菌傳染最常發生在較親密的接觸者，常常發生在親近的人，或居住在同房屋者。,何時開始治療
16、新病人,臨床診治不曾接受過結核藥物治療或曾接受少於4週結核藥物治療的新病人，如符合以下條件之一，應考慮開立結核藥物： 兩套痰耐酸菌塗片檢查陽性，且臨床懷疑肺結核的病人。 痰結核菌培養陽性，且臨床懷疑肺結核的病人 組織病理學或組織培養證實之肺外結核病人。 不具以上條件的病人，安排各項檢查、給予廣效性抗生素治療，經蒐集完整臨床資料後，如認為仍須接受結核藥物治療，方可開藥治療。診療醫師應盡可能避免在缺乏臨床證據下，以嘗試性治療（therapeutic trial）為由給予結核藥物。 (所使用的廣效性抗生素應避免 fluoroquinolone 及 aminoglycoside) 極度重症的疑似結核病人，診療醫師可於驗痰結果未明時，先行給予結核藥物治療。,
