Geriatrics:

學習重點可以包含：Geriatric syndrome, Multidisipline discussion, 以及CGA(comprehensive geriatric assessment), 多重用藥問題…

簡單review一下 Geriatric syndrome中（dementia, falling down, delirium…)的delirium.

1.     Geriatric syndrome跟內科分析方法不同的是：往往內科可能有很多differential diagnosis，但是可以從臨床線索中找出一個較相關的論述導出病人最可能的診斷並給予治療。不過老人科的症狀卻往往是多個因素彼此累積的結果。

2.     Delirium 按老人textbook Hazzard 6/e表格中predisposing以及precipitating factor可指出如下：

兩者間的關係大概可以下圖表示。Ex: 如果病人本身有嚴重的dementia, 可能一個劑量的安眠藥就可能讓病人產生delirium.

3.     在approach病人方面主要確定三個重點：

a.     confirmed diagnosis, 可借助CAM。Delirium 因為underlying disease關係，mortality 近似於MI及sepsis.

b.     排除一些可能致命的potential contributor

c.     management s/s

4.     treatment: 
           a.  以non-pharmacological management為主。包含輔助病人的視力聽力、幫助睡眠、溝通運動、講話。
           b.  反應不良考慮藥物。如果沒有parkinsonism可以用Haldo: starting dose 0.5-1.0 mg orally or parenterally. may repeated every 30 mins after the vital signs have been rechecked and until the sedation has been reached. total loading dose should < 3-5 mg in 24 hrs. 持續性的maintain dose則在下一個24 hrs內用半量loading dose分次給予之後tapper. 
      ＠ 絕對不能使用BZD以及psychoactive的藥物

How to Treat MRSA? (EBM) IDSA Issues First Guidelines for Treatment of MRSA

[cited from medscape/ CME]

Study Highlights

• SSTIs (skin soft tissue infections)
• The primary treatment of cutaneous abscess is incision and drainage.
• Antibiotic treatment is recommended for abscess associated with severe disease, rapid progression with cellulitis, systemic illness, comorbidities or immunosuppression, extremes of age, areas difficult to drain, septic phlebitis, and poor response to incision and drainage.
• Purulent cellulitis should be treated empirically for MRSA.
• Nonpurulent cellulitis should be treated empirically for β-hemolytic streptococci.
• Oral antibiotic options for community-acquired MRSA are clindamycin, trimethoprim-sulfamethoxazole, a tetracycline, or linezolid for 5 to 10 days.
• Hospitalized patients should receive surgical debridement, broad-spectrum antibiotics, and empiric MRSA treatment (intravenous vancomycin, oral or intravenous linezolid, daptomycin, telavancin, or clindamycin) for 7 to 14 days.
• In children, minor infections can be treated with topical mupirocin and complicated infections with vancomycin.
• Recurrent MRSA SSTIs
• Preventive measures include personal and environmental hygiene, decolonization, and treatment of symptomatic contacts or asymptomatic household contacts.
• Bacteremia and infective endocarditis
• Vancomycin or daptomycin is recommended to treat uncomplicated bacteremia for at least 2 weeks, complicated bacteremia for 4 to 6 weeks, and infective endocarditis for 6 weeks.
• Echocardiogram is recommended for adults with bacteremia and children at risk for endocarditis.
• In children with bacteremia and infective endocarditis, vancomycin is recommended for 2 to 6 weeks.
• Pneumonia
• Empiric community-acquired MRSA treatment with intravenous vancomycin, oral or intravenous linezolid, or oral or intravenous clindamycin is recommended for 7 to 21 days in those in intensive care, those with necrotizing or cavitary infiltrates, or those with empyema.
• Bone and joint infection
• The primary treatment of osteomyelitis and septic arthritis is surgical debridement and drainage.
• Antibiotic options are vancomycin, daptomycin, trimethoprim-sulfamethoxazole plus rifampin, linezolid, and clindamycin.
• Treatment duration is at least 8 weeks for osteomyelitis in adults and 4 to 6 weeks in children and 3 to 4 weeks for septic arthritis in adults or children.
• Central nervous system
• Recommended treatment includes at least 2 weeks of intravenous vancomycin for meningitis and removal of infected shunts.
• For brain abscess, subdural empyema, spinal epidural abscess, and septic thrombosis of cavernous or dural venous sinus, the treatment is evaluation for incision and drainage and intravenous vancomycin for 4 to 6 weeks, possibly with rifampin.
• Adjunctive therapy
• Protein synthesis inhibitors and intravenous immunoglobulin might be used in certain cases.
• Vancomycin dosing
• The dose for intravenous vancomycin is 15 to 20 mg/kg/dose up to 2 g/dose every 8 to 12 hours in adults and 15 mg/kg/dose every 6 hours in children.
• The recommended serum trough level before the fourth or fifth dose is 15 to 20 μg/mL.
• For most SSTIs, the vancomycin dose is 1 g every 12 hours, and trough levels are not needed.
• Vancomycin susceptibility
• If the vancomycin minimum inhibitory concentration is more than 2 μg/mL or clinical response is poor, then an alternative is recommended.
• Persistent bacteremia and vancomycin treatment failures
• Recommended treatment is removal of other infection foci, drainage or surgical debridement, high-dose daptomycin plus another agent, or quinupristin-dalfopristin, trimethoprim-sulfamethoxazole, linezolid, or telavancin.
• Neonates
• Full-term neonates with mild localized disease can be treated with topical mupirocin.
• Premature or very-low-birth-weight infants with localized disease or full-term infants with extensive disease can be treated with intravenous vancomycin or clindamycin.

Clinical Implications

• The recommended treatment of MRSA SSTIs includes incision and drainage, oral antibiotics for 5 to 10 days, or intravenous antibiotics for 7 to 14 days, depending on the severity of infection.
• The recommended intravenous vancomycin dose for MRSA infection is 15 to 20 mg/kg/dose up to 2 g/dose every 8 to 12 hours for adults and 15 mg/kg/dose every 6 hours in children. Trough vancomycin levels before the fourth or fifth dose are the most accurate method to determine dosing.

January 11, 2011 — The Infectious Diseases Society of America (IDSA) has issued its first clinical practice guidelines for the treatment of methicillin-resistant Staphylococcus aureus (MRSA) infections in children and adults.

The guidelines, released on January 5, will be published in the February 1 issue of Clinical Infectious Diseases

The guidelines have been endorsed by the Pediatric Infectious Diseases Society, the American College of Emergency Physicians, and the American Academy of Pediatrics.