检验室证实法定 传染病处理流程

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 andperform lumbar puncture STATCT scan of headNo mass lesion Mass lesionCSF consistent with bacterial meningitisPositive Gram stain orbacterial antigen test resultEmpirical antimicrobial therapy Specific antimicrobial therapyConsider alternative diagnosis細菌性腦膜炎處理流程NoYesLancet 1995;346:1675If continued fever&no other source found,remove&culture CVCBlood cultures,2 sets(1 peripheral)If no source of fever identified,remove CVC,culture tip&insert at new site,or exchange over a guidewireConsider antimicrobial therapyBlood cultures,2 sets(1 peripheral)If no source of fever identified,remove CVC,culture tip&insert at new site or exchange over a guidewirePatient with a removable CVC&an acute febrile episode放置導管病人出現急性發燒Mild or moderately ill;(no hypotension or organ failure)Seriously ill;(hypotension,hypoperfusion,signs&symptoms of organ failure)Initiate appropriate antimicrobial therapyBlood cultures(-)&CVC not culturedBlood cultures(-)&CVC cultures()Blood cultures(-)&CVC15 CFUBlood cultures(+)&CVC 15 CFULook for another source of infectionIn patients with valvular heart disease or neutropenia,&S.aureus or Candida colonization of CVC,monitor closely for signs of infection&repeat blood cultures accordinglySee management strategies outlined in Figure 2Remove CVC&treat with systemic antibiotic for 4-6 weeks;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&treat with a systemic antibiotic 5-7 daysIf catheter is retained,treat with systemic antibiotic+/-antibiotic lock therapy for 10-14 daysRemove CVC&treat with a systemic antibiotic for 14 daysIf TEE(+),extend systemic antibiotic treatment to 4-6 weeksRemove CVC&treat with systemic antibiotic therapy for 10-14 daysRemove CVC&treat with antifungal therapy for 14 days after last positive blood culture放置導管病人出現菌血症Verification of infection:Luminal colonization?Contamination?Infection?Catheter-relatedInfection?Complications:Persistent bacteremia?Septic thrombosis?Retinitis?Endocarditis?Fever or chillsLikely pathogen(Figure 4)1blood culture(+)(peripheral&CVC/ID)No other source of feverSite or tunnel infectionLikely pathogenQuantitative CVC/PBC 5:1Differential CVC/PBC time to positivity,2 h(see text)No other source for(+)blood cultureBlood culture(+)on therapyDoppler venogram(+)Fundoscopic exam(+)TEE or TTE(+)Remove CVC/ID&use systemic antibiotic for 14 days if TEE(-)For CVC/ID salvage therapy.If TEE(-),use systemic&antibiotic lock therapy for 14 daysRemove CVC/ID&if there is clinical deterioration,persisting or relapsing bacteremiaRemove CVC/ID&treat with antifungal therapy for 14 days after last positive blood culture放置導管病人出現菌血症Tunneled central venous catheter(CVC)-or implantable device(ID)-related bacteremiaComplicatedUncomplicatedTunnel infection,port abscessSeptic thrombosis,endocarditis,osteomye litisCoagulase-negative staphylococcusS.aureusCandida spp.Gram-negative bacilliRemove CVC/ID&treat 10-14 daysFor CVC/ID salvage,use systemic&antibiotic lock therapy for 14 daysIf no response,remove CVC/ID&treat with systemic antibiotic therapy for 10-14 daysMay retain CVC/ID&use systemic antibiotic for 7 days plus antibiotic lock therapy for 10-14 daysRemove CVC/ID if there is clinical deterioration,persisting or relapsing bacteremiaRemove CVC/ID&treat with antibiotics for 4-6 weeks;6-8 weeks for osteomye litisRemove CVC/ID&treat with antibiotics for 10-14 days中性球低下病人發燒處理流程中性球低下病人發燒處理流程中性球低下病人發燒處理流程中性球低下病人發燒處理流程(IDSA guideline Hughes WT et al CID 2002;34:730-51)(IDSA guideline Hughes WT et al CID 2002;34:730-51)Fever(temperature 38.3)+Neutropenia(500 neutrophils/mm )Low riskHigh riskOralivVancomycin not neededVancomycin neededCiprofloxacin+Amoxicillin-clavulanate(adults only)MonotherapyCefepime,Ceftazidime,orCarbapenemVancomycin+Aminoglycoside+Antipseudomonal penicillin,Cefepime,Ceftazidime,orCarbapenemTwo DrugsVancomycin+Cefepime,ceftazidime,orCarbapenemaminoglycosideReassess 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 of patients who have persistentpatients who have persistent fever after 3fever after 3-5 days5 days of treatment of treatment and forand for whom the cause ofwhom the cause of the fever is notthe fever is not found.(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 riskANC100 cells/mmMucositisUnstable signsInitial low risk Clinically wellStop antibiotics 48 h after afebrile+ANC 500 cell/mmStop 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 outbreaksCheck all that applyConsider quinolone for suspected shigellosis in adults(fever,inflammation);macrolide for suspected resistantCulture or test for:SalmonellaShigellaCampylobacterE.Coli O157:H7(if blood in stool also test for Shiga toxin and refer isolates if toxin pos.)C.Difficile toxins AB(if antibiotics or chemotherapy taken in recent weeks)Test for C.Difficile toxins AB(In suspect nosocomial outbreaks,in patients with bloody stools,and in infants,also add tests in panel A)A.Community acquired or travelers diarrhea(esp.if accompanied by significant fever or blood in stool)B.Nosocomial diarrhea(onset after 3 d in hospital)C.Persistentdiarrhea7d(esp.if immunocomp romised)Consider parasites Giardia CryptosporidiumCyclosporaIsospora belli+Inflammatory screen Discontinue antimicrobials if possible;consider metronidazole if illness worsens or persistsIf HIV pos.,add:Microsporidia(Gram-chromotrope)M.avium complex+panel ATreat per results of tests醫護及臨床工作者接觸HIV後處理流程104