住院醫師的移植後發燒處理無腦流程圖，依時間和抗生素使用狀況分階段處理
NCCN Guidelines® References (v1.2026):
- FEV-5: Initial Inpatient Empiric Therapy for Fever and Neutropenia (p. 33)
- FEV-A-2: Antibacterial Agents - Anti-Pseudomonal (p. 42)
- INF-1: Antimicrobial Prophylaxis Based on Overall Infection Risk (p. 7)
- FEV-8: Evaluation and Treatment Modifications for Specific Clinical Presentations — Day 0 (p. 36)
- 發燒定義：單次體溫 ≥38.3°C 或持續1小時 ≥38.0°C
- 1小時內給予第一劑抗生素[2][3]
- 抽血培養（周邊+中心導管各一套）、尿液培養、胸部X光
單一抗生素即可[1][4][3]：
| 藥物 | 劑量 | 證據等級 |
|---|---|---|
| Cefepime | 2g IV q8h | Category 1 |
| Piperacillin-tazobactam | 4.5g IV q6h | Category 1 |
| Meropenem | 1-2g IV q8h | Category 1 |
| Imipenem-cilastatin | 500mg IV q6h | Category 1 |
- Carbapenem ± aminoglycoside[4][2]
- 或 β-lactam + aminoglycoside[4]
- 或 新型β-lactam/BLI組合（如ceftazidime-avibactam）[4]
- 加Vancomycin：導管感染、皮膚軟組織感染、肺炎、血流動力學不穩、已知MRSA定植[2][1]
- 加Acyclovir：水泡性病灶、疑似HSV/VZV[1]
- 加抗黴菌藥：高風險黴菌感染（如肺部浸潤且高風險患者）[1]
評估是否需要加藥：
- 複查培養結果：依藥敏調整抗生素（de-escalation）[4][7][5]
- 若培養陰性但仍發燒：
- 加Vancomycin（若尚未使用）：考慮革蘭氏陽性菌[5]
- 重新評估感染源（重複影像學、考慮CT）[1]
- 檢查Galactomannan、β-D-glucan（黴菌標記）[8]
- 考慮升級抗生素至更廣效（如carbapenem）[7][5]
- 或加第二支抗革蘭氏陰性菌藥物[4]
開始經驗性抗黴菌藥（Empiric antifungal therapy）[6][8][10]
適應症：
- 廣效抗生素治療4-7天後仍發燒[6][8]
- 中性球低下持續 >7-10天[9][8]
- 或有黴菌感染高風險因素[10][11]
| 藥物 | 證據等級 | 備註 |
|---|---|---|
| Liposomal amphotericin B | Category A-I | |
| Caspofungin | Category A-I | |
| Voriconazole | — | 若疑似麴菌 |
- 換不同類別的抗黴菌藥[6]
- 例如：Fluconazole預防 → 換成Caspofungin或Liposomal amphotericin B[6]
- De-escalation：依藥敏結果降階至窄效抗生素[4][7][5]
- 76.7%中心會在培養陽性、藥敏感且臨床穩定時降階[5]
- 考慮停藥：即使中性球未恢復[4][7]
- 54.1%中心會在發燒原因不明但臨床穩定時降階[5]
- 49.5%中心會在中性球恢復前停藥[5]
- 繼續廣效抗生素+抗黴菌藥
- 考慮非感染原因（藥物熱、移植物抗宿主疾病GVHD、腫瘤復發）[9]
- 考慮少見病原體（Nocardia、分枝桿菌、地方性黴菌）[12][13]
| # | 原則 | 說明 |
|---|---|---|
| 1 | 時間就是生命 | 發燒後1小時內給第一劑抗生素[2][3] |
| 2 | 依風險分層 | 穩定患者用單一抗生素，不穩定或高風險用組合療法[1][4][2] |
| 3 | 不要常規加Vancomycin | 除非有特定適應症[2] |
| 4 | 4-7天仍發燒 | 考慮加抗黴菌藥[6][8] |
| 5 | 積極降階 | 培養結果出來後依藥敏調整，避免過度使用廣效抗生素[4][7][5] |
| 6 | 考慮停藥 | 臨床穩定且培養陰性，即使中性球未恢復也可考慮停藥[4][7] |
這個流程圖強調時間導向和風險導向的抗生素使用策略，避免過度使用廣效抗生素，同時確保高風險患者得到足夠覆蓋。
- Prevention and Treatment of Cancer-Related Infections. National Comprehensive Cancer Network. Updated 2026-03-11.
- Outpatient Management of Fever and Neutropenia in Adults Treated for Malignancy: American Society of Clinical Oncology and Infectious Diseases Society of America Clinical Practice Guideline Update. Taplitz RA, Kennedy EB, Bow EJ, et al. Journal of Clinical Oncology. 2018;36(14):1443-1453. doi:10.1200/JCO.2017.77.6211.
- Guideline for the Management of Fever and Neutropenia in Pediatric Patients With Cancer and Hematopoietic Cell Transplantation Recipients: 2023 Update. Lehrnbecher T, Robinson PD, Ammann RA, et al. Journal of Clinical Oncology. 2023;41(9):1774-1785. doi:10.1200/JCO.22.02224.
- Empirical and Targeted Antimicrobial Therapy in Patients With Febrile Neutropenia and Haematological Malignancy or After Haematopoietic Cell Transplantation: Recommendations From the 10th European Conference on Infections in Leukaemia. Averbuch D, Vanbiervliet Y, Baccelli F, et al. The Lancet. Infectious Diseases. 2025;:S1473-3099(25)00619-X. doi:10.1016/S1473-3099(25)00619-X.
- Current Antimicrobial Practice in Febrile Neutropenia Across Europe and Asia: The EBMT Infectious Disease Working Party Survey. Verlinden A, Mikulska M, Knelange NS, Averbuch D, Styczynski J. Bone Marrow Transplantation. 2020;55(8):1588-1594. doi:10.1038/s41409-020-0811-y.
- Fourth European Conference on Infections in Leukaemia (ECIL-4): Guidelines for Diagnosis, Prevention, and Treatment of Invasive Fungal Diseases in Paediatric Patients With Cancer or Allogeneic Haemopoietic Stem-Cell Transplantation. Groll AH, Castagnola E, Cesaro S, et al. The Lancet. Oncology. 2014;15(8):e327-40. doi:10.1016/S1470-2045(14)70017-8.
- Infection Control Issues in Patients With Haematological Malignancies in the Era of Multidrug-Resistant Bacteria. Ruhnke M, Arnold R, Gastmeier P. The Lancet. Oncology. 2014;15(13):e606-e619. doi:10.1016/S1470-2045(14)70344-4.
- Practice Guidelines for the Diagnosis and Management of Aspergillosis: 2016 Update by the Infectious Diseases Society of America. Patterson TF, Thompson GR, Denning DW, et al. Clinical Infectious Diseases. 2016;63(4):e1-e60. doi:10.1093/cid/ciw326.
- Fever of Unknown Origin. Haidar G, Singh N. The New England Journal of Medicine. 2022;386(5):463-477. doi:10.1056/NEJMra2111003.
- Italian Guidelines for Diagnosis, Prevention, and Treatment of Invasive Fungal Infections in Solid Organ Transplant Recipients. Grossi PA, Gasperina DD, Barchiesi F, et al. Transplantation Proceedings. 2011 Jul-Aug;43(6):2463-71. doi:10.1016/j.transproceed.2011.06.020.
- Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021. Evans L, Rhodes A, Alhazzani W, et al. Critical Care Medicine. 2021;49(11):e1063-e1143. doi:10.1097/CCM.0000000000005337.
- Pneumonia in Solid Organ Transplantation: Guidelines From the American Society of Transplantation Infectious Diseases Community of Practice. Dulek DE, Mueller NJ. Clinical Transplantation. 2019;33(9):e13545. doi:10.1111/ctr.13545.
- Diagnostic and Therapeutic Approach to Infectious Diseases in Solid Organ Transplant Recipients. Timsit JF, Sonneville R, Kalil AC, et al. Intensive Care Medicine. 2019;45(5):573-591. doi:10.1007/s00134-019-05597-y.