感染科醫生在臨床抗感染工作中的角色 台大醫院小兒部 李秉穎 G.Q.

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1 感染科醫生在臨床抗感染工作中的角色 台大醫院小兒部 李秉穎 G.Q.

2 The role of infectious disease specialist A correct diagnosis A correct diagnosis beyond the field of infectious diseases A correct treatment A correct and creative treatment Avoid overuse of antibiotics Infection control Control of emerging infectious diseases

3 A case with fulminant hepatitis Fever,, jaundice for 1 week Check hepatitis A, hepatitis B, hepatitis C, hepatitis D virus serology Elevated blood urea nitrogen, creatinine level Leptospirosis

4 A case with juvenile rheumatoid arthritis 8 yrs old, girl Problem #1: juvenile rheumatoid arthritis for 1+ year Poorly controlled bilateral knee arthritis Using immunosuppressant Problem #2: febrile neutropenia Problem #3: tinea versicolor Treated for 4 months without apparent effect Tinea versicolor

5 JRA Lyme disease Lyme disease: Caused by the bacterium Caused by the bacterium Borrelia burgdorferi and is transmitted to humans by the bite of infected blacklegged ticks. Typical symptoms include fever, headache, fatigue, and a characteristic skin rash called erythema migrans.. If left untreated, infection can spread to joints, the heart, and the nervous system. G.Q. Erythema migrans

6 The role of infectious disease specialist A correct diagnosis A correct diagnosis beyond the field of infectious diseases A correct treatment A correct and creative treatment Avoid overuse of antibiotics Infection control Control of emerging infectious diseases

7 5 m/o,, male, /02/2005 A baby with P. aeruginosa sepsis No free air, no operation.

8 5 m/o,, male, /02/2005 A baby with P. aeruginosa sepsis Cross-table, lateral decubitus view

9 The role of infectious disease specialist A correct diagnosis A correct diagnosis beyond the field of infectious diseases A correct treatment A correct and creative treatment Avoid overuse of antibiotics Infection control Control of emerging infectious diseases

10 8 y/o,, female, /29/2005 A case of AML with febrile neutropenia Ear temperature ( O C) Days post-onsect of fever ANC < 500/mm 3 piperacillin/tazobactam + gentamicin Cefepime + amikin Amphotericin B

11 8 y/o,, female, /29/2005 A case of AML with febrile neutropenia Ear temperature ( O C) Days post-onsect of fever ANC < 500/mm 3 Meropenem Vancomycin Amphotericin B

12 Ecthyma gangrenosa

13 Otitis media unresponsive to amoxicillin-clavulanate clavulanate therapy 2.5 year, boy [Sep 1, 2006] Bilateral AOM with pneumonia 2 weeks ago Rx: Augmentin 43 mg/kg/day tid X 1 week Left ear pain with fever for 1 day Change to Augmentin 90 mg/kg/day tid Fever and left ear pain subsided immediately

14 The role of infectious disease specialist A correct diagnosis A correct diagnosis beyond the field of infectious diseases A correct treatment A correct and creative treatment Avoid overuse of antibiotics Infection control Control of emerging infectious diseases

15 A 13-year year-old girl with recurrent CVC infections June, June, 2006: CVC infection by C. parapsilosis Antimicrobial-lock lock therapy by amphotericin B 33 days after completion of ALT: Fever and inflammatory changes at the catheter insertion site Blood from Hickman catheter and peripheral vein: methicillin-susceptible Staphylococcus aureus. Vancomycin 3 days, oxacillin and rifampin 2 days persisted tenderness Add erythromycin 40 mg/kg/day local erythema and tenderness improved on the next day G.Q. Wu CY, Lee PI. J Antimicrob Chemother 2007;doi: /jac/dkm262

16 The role of infectious disease specialist A correct diagnosis A correct diagnosis beyond the field of infectious diseases A correct treatment A correct and creative treatment Avoid overuse of antibiotics Infection control Control of emerging infectious diseases

17 鼻病毒感冒症狀的變化 80% 60% 發燒流鼻水咳嗽聲音沙啞 40% 20% G.Q. 0% 發病天數

18 Judicious use of antimicrobial agents common cold Antimicrobial agents should not be given for the common cold Mucopurulent rhinitis (thick, opaque, or discolored nasal discharge) frequently accompanies the common cold and is not an indication for antimicrobial treatment unless it persists for days, suggesting possible sinusitis. AAP, AAFP, CDC, 1998

19 Antibiotics for colds in children Who are the high prescibers? 34,624 episodes of URI in children: Kentucky Medicaid progrm,, High prescribers: More More years away from medical school graduation (27 vs. 19 yrs) Compared with pediatricians,, odds ratio 409 for family practitioners,, 318 for other primary care physicians G.Q. Arch G. Arch Pediatr Adolesc Med 1998;152:349.

20 The role of infectious disease specialist A correct diagnosis A correct diagnosis beyond the field of infectious diseases A correct treatment A correct and creative treatment Avoid overuse of antibiotics Infection control Control of emerging infectious diseases

21 Infection control Hand hygiene: the single most important practice. Antiseptic activity of alcohols Bacteria: OK Enveloped virus: OK SARS, influenza, respiratory syncytial virus, human immunodeficiency virus, hepatitis B, herpes simplex Unenveloped virus: NOT OK Enterovirus, rotavirus, norovirus, adenovirus, rhinovirus, hepatitis A

22 Virucidal activity of antiseptic agents Enveloped viruses Virus HIV HIV HIV HBV HSV Agent Log reduction 70% ethanol 7.0 in 1 min chloroxylenol povidone-iodine iodine inactivated in 1 min inactivated 80% ethanol 7.0 in 2 min 75% ethanol > 5.0 in 1 min RSV 35% isopropanol Influenza > 4.3 in 1 min 95% ethanol undetectable in 30 sec G.Q. CDC. MMWR 2002;51(RR-16):1. 16):1.

23 Virucidal activity of antiseptic agents Nonenveloped viruses Virus Agent Log reduction Rotavirus 10% povidone-iodine iodine > 3.0 in 1 min Rotavirus Adenovirus Coxsackievirus Echo virus Hepatitis A Rhinovirus 60% ethanol > 3.0 in 10 sec 95% ethanol >1.4 95% ethanol % ethanol % ethanol 87.4% reduction 60% ethanol > 3.0 G.Q. CDC. MMWR 2002;51(RR-16):1. 16):1.

24 Probable SARS cases Taiwan, (N=698)

25 SARS 是如何傳染的? 世界衛生組織一開始強調只有親密接觸者會得到感染, 這是過分樂觀的想法 飛沫傳染固然以親密接觸比較容易發生, 但在公共場所還是有些許機率發生傳染 香港疫情擴散的源頭, 是一位大陸罹病教授在旅館傳染給同一樓層的很多房客. 筆者認為這類接觸傳染的可能性無法排除

26 The role of infectious disease specialist A correct diagnosis A correct diagnosis beyond the field of infectious diseases A correct treatment A correct and creative treatment Avoid overuse of antibiotics Infection control Control of emerging infectious diseases

27 Enterovirus 71 epidemic in 1998 No. cases Others: 162 Death: 57 Mar 15- -Sep 5 Mar Apr May Jun Jul Aug Sep

28 Enterovirus 71 infection Hand-foot-mouth disease G.Q.

29 Enterovirus 71 infection Pulmonary edema/hemorrhage

30 Enterovirus 71 infection Brain stem encephalitis G.Q.

31 Treatment of severe EV71 infection, 1998 Fatal Near-fatal P N=57 N=18 value Inotropic agents 57(100%) 16(89%) NS Furosemide 19(33%) 7(39%) NS Mannitol/glycerol 21(37%) 9 (50%) NS IVIG 29(51%) 13(72%) NS Steroid 9(16) 8(44%) NaHCO 3 40(70%) 2(11%) <0.001 Ca agents 17(30%) Fluid challenge 36(63%) 3(17%) Fluid restriction 9(16%) 10(56%) 0.002

32 Treatment guideline for severe enterovirus 71 infection Principle: cardiogenic shock Avoid fluid challenge Inotropic agent Intracranial pressure lowering agents Fluid therapy: guided by central venous pressure G.Q.

33 SARS in NTUH G.Q year year-old girl May 3, 2003

34 SARS: steroid treatment? 別怕 SARS: 對於 SARS 的治療方法尚無定論, 一開始出現的病例接受過 ribavirin 抗病毒治療 類固醇治療及免疫球蛋白治療, 這些治療都是在缺乏實證基礎 2003 春之煞 : 筆者認為細胞激素風暴的理論可能有誤 類固醇的治療可能有害, 理由包括 : SARS 病人的淋巴球大幅減少, 類固醇會讓這種情形更加惡化 在肺部看到很多巨噬細胞 肺部出現急性呼吸窘迫症候群時, 不代表致病機轉一定是細胞激素風暴 SARS 死亡病例身上到處都是病毒

35 SARS 地區別死亡率 世界衛生組織資料 (7/11/2003) % 死亡率 G.Q. 0 中國大陸越南台灣加拿大新加坡香港 世界衛生組織網站資料 年齡

36 SARS: Systematic Review of Treatment Effects CDC, USA Delayed viral clearance Psychosis Diabetic onset Avascular necrosis G.Q. Stockman LJ. PLoS Med 2006;3(9):e343.

37 Affected areas with confirmed cases of H5N1 avian influenza WHO, G.Q. WHO web site ( gamapserver.who.int/maplibrary/app/searchresults.aspx)

38 H5N1 禽流感人類病例死亡率 1997 香港 (N=18) 2004 泰國 (N=17) 越南 (N=20) 2005 柬埔塞 (N=4) 100% 死亡率 80% 類固醇使用率 比率 60% 40% 20% G.Q. 0% 香港 1997 泰國 2004 越南 2004 胡志明市 2005 Writing committee WHO. N Engl J Med 2005;353:1374.

39 Guideline for clinical management of human infection with avian influenza A(H5N1) virus WHO, updated advice 15 Aug In summary, there is no clear benefit in treating A(H5N1) virus-associated pneumonia or ARDS with high-dose corticosteroids while there is the potential for significant harm, particularly in terms of immunosuppression leading to enhanced A(H5N1) viral replication or secondary infections, and musculoskeletal side effects. It is recommended that high dose steroids should not be given for treatment of A(H5N1) disease. G.Q. WHO web site:

40 Thanks