HAART failure definition

Washington maunual, 35/e, chap. 16

HAART failure definition:

1. less than a log (10-fold) reduction of the viral load 4-6 weeks after starting a new ART
2. failure to reach an undetectable viral load after 6 months of Tx
3. detection of the virus after initial complete suppression of viral load => possible resistant
4. persistent decline of CD4 cell count or clinical deterioration

4-6 weeks after initiation of ART => viral load and CD4 count

Q3-6M regular follow under stable medication control

PI and cobicistat both inhibit andinduce the P450 system => macrolides, antifungals, rifamycins, anticonvulsants; antihistamines, antiarrhthmic (flecainide, encainide, quinidine), fentanyl, meperidine, midazolam, warfarin, statin (pravastatin is the safest), oral contraceptives

2009 NDT--Systematic review of antimicrobials for the prevention of haemodialysis catheter-related infections

2009 NDT--Systematic review of antimicrobials for the prevention of haemodialysis catheter-related infections

Conclusion. The use of AMLs and exit-site antimicrobials are useful measures in the reduction of CRIs, whereas antimicrobial impregnated catheters and peri-operative systemic antimicrobial administration have not been found to be beneficial. Further head-to-head trials of various AMLs and exit-site antimicrobials are needed to know about their comparative clinical efficacy. 

因此，abx lock therapy or exit site abx 是有效預防CRBSI；

但是術前後中後術prophylatic abx或是把catheter浸泡在abx中，似乎沒有benefit for prevention CRBSI

2011 IDSA guideline有提到，如果是dialysis catheter可以考慮使用topical abx，
不過倒是沒有說要用哪種topical abx

2004 AJKD--Dialysis catheter-related bacteremia: treatment and prophylaxis. vs. 2004 AJMS--Hemodialysis vascular catheter-related bacteremia.

Dialysis catheter-related bacteremia: treatment and prophylaxis.

More recent studies suggested that instillation of an antibiotic-anticoagulant lock into the catheter lumen, as an adjunct to systemic antibiotic therapy, can cure approximately two thirds of catheter-related bacteremias without requiring catheter replacement. 

用lock therapy for perm cath (suspected Perm cath related CRBSI) 只有三分之二的成功率，而不用換掉。其實成功率還是不夠高。

Hemodialysis vascular catheter-related bacteremia.

Bacteremia in patients with catheters results from luminal or extraluminal contamination and may be perpetuated by infected fibrin sheaths associated with the catheter. Bacteremic patients require antibiotic therapy and catheter removal. Guide wire catheter exchange is appropriate in stable patients, but catheter removal and later reinsertion of a new catheter is indicated for tunnel infection or frank sepsis.

看來，要in-line change，並不建議在tunnelled catheter，而比較適合用在non-tunnelled catheter（？）。

當然，在IDSA 2011年的guideline也沒有絕對禁止in-line change這件事。

2012 QJM--Vascular access type and risk of mortality in a national prospective cohort of haemodialysis patients.

2012 QJM--Vascular access type and risk of mortality in a national prospective cohort of haemodialysis patients.



Conclusions: Compared with an arteriovenous fistula or graft, sustained use of tunnelled CVCs for vascular access is associated with higher risks of all-cause, cardiovascular and infection-related mortality.

因此，能用AVF or AVG就用；不行再考慮裝Tunnelled catheter

Short term antibiotic strategy (episode control strategy) for infection control

Short term antibiotic strategy (episode control strategy) for infection control

2011 CID--Strategies for Reduction in Duration of Antibiotic Use in Hospitalized Patients

On the basis of published RCTs, shorter treatment durations seem just as likely as more prolonged, traditional regimens to cure most common bacterial infections.

2011 Critical Care--Duration of antibiotic therapy for bacteremia: a systematic review and meta-analysis

No significant differences in clinical cure, microbiologic cure and survival were detected among bacteremic patients receiving shorter versus longer duration antibiotic therapy. An adequately powered randomized trial of bacteremic patients is needed to confirm these findings.

• The optimal duration of treatment for bloodstream infections is understudied.

• Available data from bacteremic subgroups of prior randomized controlled trials suggest that shorter duration therapy (not more than 7 days) may be as effective as longer-duration therapy in achieving clinical cure, microbiologic cure, and survival among most patients with bloodstream infections.

• A large dedicated randomized trial of treatment duration for bacteremia is urgently needed.

2015 NEJM--Trial of Short-Course Antimicrobial Therapy for Intraabdominal Infection control

In patients with intraabdominal infections who had undergone an adequate source control procedure, the outcomes after fixed-duration antibiotic therapy (approximately 4 days) were similar to those after a longer course of antibiotics  (approximately 8 days) that extended until after the resolution of physiological abnormalities

Measles

Measles

麻疹防治工作手冊

1. 第二類法定傳染病
2. 症狀：高燒、鼻炎、結膜炎、咳嗽 => 內頰側黏膜上有柯氏斑點（Koplik spots）

           => 耳後典型斑丘疹 => 擴散到臉面 => 軀幹和四肢

           => 鱗屑性脫皮＋褐色沈著，有時會有secondary infection to bacteria or virus

           => complications：中耳炎、肺炎、腦炎

3. measles virus ( 麻疹病毒）
4. Reservoir：人為唯一之宿主及傳染窩（reservoir)
5. 傳染方式：空氣、飛沫傳播、病人鼻腔／咽喉分泌物
6. 潛伏期：7~18天，通常14天（自暴露到紅疹出現）；

        可傳染期：發疹前後4天

7. 可以終身免疫
8. 診斷：
1. serum IgM or IgG titer > = 4倍上升；採檢時間為出疹後3~28天，第二次探血要隔2~4週（14天～28天）
2. 尿液／咽喉檢體：real-time PCR and virus isolation ；採檢時間為出疹後7天內
9. 2009年4月開始MMR第一劑改為出生滿12個月接種
10. 通報：24小時內
1. 通報定義：rash + fever (>=38C)，＋以下三者任一：
1. 咳嗽、流鼻水，或結膜炎（三取一）
2. 無麻診相關疫苗接種史
3. 發病前三週內，曾有麻疹流行地區旅遊史
11. 住院病人需呼吸道隔離（respiratory isolation），以避免院內感染

Acute Hepatitis C

acute hepatitis C

急性病毒性C型肝炎工作手冊

1. 發燒、疲倦、厭食、隱約腹部不適、噁心、嘔吐、黃疸
2. RNA virus，6種主要基因型；基因型1個案最多，三分之一在東亞；基因型3個案次之。基因型5最少。 => 台灣：1b最多，其次2a
3. 過去台灣的輸血後肝炎約69%是C肝
1. 81年7月：C型肝炎抗體檢驗納入血液篩檢項目 => 幾乎已無輸血後C肝發生
2. 102年 => 對捐血人全面實施：核酸擴大檢驗法（Nucleic acid amplification testing，NAT）縮短檢驗空窗期
4. 近年發現已感染HIV者，如有MSM且曾感染梅毒者，因性行為造成且門黏膜傷害或性病形成的潰瘍病灶，會增加急性C肝感染之風險
5. Reservoir：可感染黑猩猩
6. 傳染方式：血液透過皮膚或粘膜進入人體內而感染
7. 母子垂直感染方式也可能發生
8. 潛伏期：2週~6個月 （通常6~9週）； 可傳染期 => 發病前1週到整個急性期及慢性帶原期
9. 診斷：anti-HCV or HCV RNA；感染4～10週，C肝抗體呈現陽性反應 ＝》免疫健全者的anti-HCV ab如呈陰性，則可排除C型肝炎感染。
10. 通報：1週內
11. 治療：Interferon + Ribavirin；新藥目前須採自費治療。

新型A流

新型A流

新型A型流感傳染病防治工作手冊

第五類傳染病

1. 症狀：發燒、咳嗽、呼吸短促、嚴重肺炎、ARDS，septic shock，MOF => 死亡
2. 有環境接觸史（染病動物、或其分泌物、排泄物）
3. 感染能力僅限於動物傳人，但H5N1和H7N9曾有極少數家庭內群聚案例
4. Reservoir：野生水禽為自然宿主；雞鴨、豬也可以當宿主。
5. 病毒存在於受感染動物的呼吸道飛沫顆粒、排泄物 => 人類主要透過吸入及接觸病毒顆粒或受汙染的物體環境等途徑而感染
6. 潛伏期：1~10日前 => 尚無足夠證據推論新型A流的可傳染期
7. 通報：24小時內