剛收到一個外勞的體檢報告. 有人芽囊原蟲感染. 查詢了一下相關規定. 在"受聘僱外國人健康檢查管理辦法"中, 關於健康檢查不合格. 腸道寄生蟲糞便檢查僅列出 痢疾阿米巴原蟲陽性需再次採檢. 沒有規定人芽囊原蟲感染的處置. 閱讀了疾管署提供的資料和相關文獻後. 發現人芽囊原蟲是否有致病性仍有爭議. 無症狀帶原者是否該治療也有爭議. 確實不適合列入法規管控.
疾管署-傳染病介紹-其他傳染病--人芽囊原蟲感染--疾病介紹
人芽囊原蟲感染
症狀: 通常無症狀, 一部分感染人芽囊原蟲的人，曾出現的症狀，包括：腹瀉、腹痛、肛門癢、體重減輕、便秘、脹氣等, 但這些症狀不一定就是人芽囊原蟲引起.
潛伏期: 數年
傳染方式:不明
人芽囊原蟲感染途徑仍不是很清楚，似乎與環境衛生或個人衛生不佳有關。研究發現可能的感染風險，包括：食用受污染的食物或飲水、暴露於安養院環境或與動物接觸。
治療方法與就醫資訊：
1. 處方藥物可以治療人芽囊原蟲感染。然而，有些治療效果不佳，仍需尋找其他可能導致症狀的原因。
2. 若人芽囊原蟲感染者保持良好個人衛生習慣，傳染給他人的風險低。良好的個人衛生習慣，包括：如廁後及調理食物前，徹底地使用肥皂及清水洗手。
疾管署介紹文最後還附上美國疾管局的建議, 僅擷取治療的段落貼上
布氏囊蟲感染的治療仍是一個複雜的問題。由於布氏囊蟲的真正致病性仍存在諸多爭議，因此關於是否需要治療也存在許多爭議。目前仍在尋求更多關於布氏囊蟲基因分型和亞型以及不同亞型對致病性和抗菌療效的影響方面的知識[22]。
對於有症狀的患者，如果在糞便檢體中分離出囊腫，則應進行全面評估，以排除其他導致患者胃腸道不適的原因，因為可能存在與其他病原體合併感染的情況。
糞便中分離出布氏囊蟲的患者可能同時感染其他病原體，例如藍氏賈第鞭毛蟲、溶組織內阿米巴和脆弱雙核阿米巴[52]。
or
接受甲硝唑(metronidazole )或複方磺胺甲噁唑(trimethoprim-sulfamethoxazole , TMP-SMX) 治療後出現臨床症狀改善的患者，其臨床症狀的改善很可能是由於繼發性病原體的治療所致。
(人芽囊蟲感染同時有症狀的患者, 就算經過治療而改善症狀, 有可能是其他病原被殺死. 不代表就是人芽囊蟲感染)
迄今為止，已有多種抗菌藥物用於治療人類芽囊原蟲感染（表1）；然而，隨機對照試驗數量有限。
metronidazole
甲硝唑被認為是第一線治療藥物，但據報導，該藥物根除人類芽囊原蟲的成功率在0%至100%之間[53]。目前已發表的兩項安慰劑對照研究均得出結論：症狀的緩解與病原體的根除有關。
Nigro等人[54]進行了一項安慰劑對照試驗，評估了76例人類芽囊原蟲感染患者，結果顯示，甲硝唑治療組88%的患者在治療1個月後臨床症狀緩解，而安慰劑組僅為14%。甲硝唑治療組80%的患者微生物學檢測結果為陰性，安慰劑組僅3%。此外，在治療開始6個月後對患者進行評估時，甲硝唑治療組40例患者中有30例（75%）仍無症狀，而安慰劑組36例患者中僅有12例（33%）無症狀。目前尚不清楚這些患者中是否有人攜帶抗藥性亞型或發生再次感染[54]。
Mogaddham等人[55]的研究顯示，104例布氏囊蟲感染患者中有28例被歸類為重症感染。其中12例患者接受了甲硝唑治療，但僅有4例感染被根除。甲硝唑可能對某些患者有效，但無法完全根除感染，尤其是在重症感染患者中；或者，未對甲硝唑產生反應的患者可能感染了抗藥性亞型。對於可能無法耐受或對甲硝唑治療無反應的患者，TMP-SMX 已被用作二線藥物。
Ok 等人 [56] 研究了 38 名兒童和 15 名成人，他們均有症狀地感染了人類芽囊原蟲（糞便標本未檢出其他寄生蟲或細菌感染），並接受了為期 7 天的 TMP-SMX 治療。在38名兒童中，36名（94.7%）糞便中的布氏囊蟲被清除；在15名成人中，14名（93.3%）糞便中的布氏囊蟲被清除。在接受評估的53名患者中，39名（73.6%）臨床症狀消失，10名（18.9%）症狀有所改善。一項使用硝唑尼特的研究也觀察到了類似的結果，但研究未對患者進行長期隨訪，因此療效可能短暫。
儘管這些研究提供了迄今為止關於該寄生蟲致病潛力的最佳證據，但這兩項研究均使用了廣譜抗寄生蟲藥物，因此治療反應可能歸因於其他潛在腸道病原體的清除[2]。
其他藥物，如碘喹啉、替硝唑、硝唑尼特、依米丁、噴他脒、碘氯羥喹和呋喃唑酮，也已被用於治療布氏囊蟲感染，但其療效不一[55, 57]。
評估治療效果的困難之一在於接受布氏囊蟲感染治療的患者在治療後追蹤方面存在巨大的個體差異[22]。
治療後微生物分析顯示糞便中存在布氏囊蟲，但這可能並非治療失敗或抗藥性，而是代表再次感染。
患者也可能有繼發性疾病，該疾病最初對治療有效，但隨後治療失敗。已有數項研究探討了使用替代藥物治療布氏囊蟲感染。
例如，Yakoob等人[58]研究了大蒜和其他草藥與甲硝唑在體外治療布氏囊蟲感染方面的療效，研究對象包括健康對照組和腸躁症（IBS）患者。作者評估了濃度為0.01和0.1 mg/mL的大蒜和甲硝唑抑制布氏囊蟲生長的療效。他們發現，大蒜和甲硝唑在兩種濃度下療效相當。分離出的布氏囊蟲對其他受試草藥（包括生薑、黑胡椒和白孜然）的敏感度較低。
益生菌效果居然高於抗生素
布拉氏酵母菌（一種益生菌）也曾被用於布氏囊蟲的治療研究[59]。在Dinleyici等人[59]的研究中，有兩週胃腸道症狀史且糞便中分離出布氏囊蟲的兒童被隨機分配接受布拉氏酵母菌、甲硝唑或安慰劑治療，療程為10天。在治療開始後的第15天和第30天，對患者進行臨床和微生物學治癒情況的評估。結果顯示，治療15天后，布拉氏酵母菌組的臨床治癒率為77.7%，甲硝唑組為66.6%，安慰劑組為40%。甲硝唑組和酵母菌組的糞便中囊腫持續存在率分別為20%和27.8%，而安慰劑組為73.4%。治療開始30天后，酵母菌組的臨床治癒率為94.4%，甲硝唑組為73.3%。酵母菌組和甲硝唑組的糞便中囊腫消退率分別為94.4%和93.3%。甲硝唑組的感染率為3%，但差異無統計學意義（P=0.43）[59]。
無症狀不一定需治療
鑑於目前對人類芽囊原蟲致病性的認識尚不一致，因此對於哪些患者應接受人類芽囊原蟲感染治療尚無共識。對於無症狀患者，不一定需要治療。若在有症狀患者的糞便中分離出人類芽囊原蟲，則應進行全面檢查，以排除其他引起胃腸道不適的原因。
有持續腹瀉症狀且找不到其他原因可考慮治療
對於持續腹瀉或經過全面檢查仍未發現其他病原體或胃腸道感染源的患者，可以考慮嘗試抗菌治療。甲硝唑或複方磺胺甲噁唑（TMP-SMX）是合理的首選藥物。需要進行更多隨機對照試驗，以更好地評估其他抗寄生蟲藥物的療效及其在該感染中的應用。
布氏囊蟲與人類疾病的關係尚不明確，許多用於治療布氏囊蟲感染的藥物都存在顯著的副作用。至少需要間隔一段時間，在可靠的寄生蟲學實驗室進行三次糞便檢查才能構成充分的檢查。
如果患者無症狀，我們不建議特定的抗寄生蟲治療。
然而，我們理解可能會有人反對這項建議，因為大多數專家建議對排出囊腫的無症狀個體進行治療，例如感染溶組織內阿米巴和藍氏賈第鞭毛蟲的患者。如果患者確實出現胃腸道症狀，且糞便中存在大量囊腫（例如，每個高倍視野下有0.5個囊腫），則該患者可能適合接受治療。在這種情況下，需要排除其他潛在病因。因此，這些患者可能需要額外的糞便樣本進行寄生蟲分析以及細菌病原體培養。我們觀察到一些糞便中檢出人類芽囊原蟲的患者，在後續檢查中又檢出賈第鞭毛蟲或溶組織內阿米巴。部分此類患者可能需要進行內視鏡檢查和影像學檢查，以排除發炎性腸道疾病和腸躁症等疾病。對於糞便中檢出人類芽囊原蟲且伴隨皮疹的患者，在排除其他病因後應考慮治療，但此建議是基於有限的數據。根據現有的臨床試驗數據，我們通常將甲硝唑作為第一線治療藥物。如果甲硝唑無效，我們通常會使用複方磺胺甲噁唑或硝唑尼特作為第二線治療藥物。
TREATMENT
Treatment of Blastocystis infection remains a complicated issue. Because there is still a great deal of debate about the true pathogenicity of Blastocystis, there is still much debate about the need for treatment. Further knowledge about the genotyping and subtyping of Blastocystis and the impact that various subtypes may have on pathogenicity and antimicrobial efficacy is still being sought [22]. In a symptomatic patient, isolation of cysts in stool specimens should trigger a thorough evaluation for other causes of the patient’s gastrointestinal tract complaints, given the possibility for coinfection with other pathogens. Patients with Blastocystis isolated in the stool can be coinfected with other pathogens, such as G. lamblia, Entamoeba histolytica, and D. fragilis [52]. It is quite possible that patients who respond to treatment for Blastocystis with metronidazole or trimethoprimsulfamethoxazole (TMP-SMX) may actually have clinical improvement owing to treatment of a secondary pathogen. To date, a number of antimicrobial agents have been used for treatment ofBlastocystis infection (Table 1); however, randomized, controlled trials are limited. Metronidazole is considered firstline treatment, but the success of eradicating Blastocystis with this drug has been reported to be anywhere from 0% to 100% [53]. There have been 2 published placebo-controlled studies, and both concluded that resolution of symptoms was associated with eradication of the organism. Nigro et al [54] conducted a placebo-controlled trial evaluating 76 patients with Blastocystis infection, of whom 88% treated with metronidazole had resolution of clinical symptoms, compared with only 14% in the placebo group, 1 month after treatment. Microbiologic resolution was found in 80% of metronidazole-treated patients, compared with only 3% of the placebo group. In addition, when patients were evaluated 6 months after initiation of treatment, 30 (75%) of 40 in the metronidazole-treated group were still asymptomatic, compared with 12 (33%) of 36 in the placebo group. It is not clear whether any of these patients harbored resistant subtypes or were reinfected [54]. In a study by Mogaddham et al [55], 28 of 104 Blastocystis-infected patients were classified as having severe infection. Twelve of these patients were treated with metronidazole, with infection eradicated in only 4. It is possible that metronidazole is effective for certain patients but does not provide complete eradication, particularly in those with severe infection, or that patients who did not respond may have been infected with resistant subtypes. TMP-SMX has been used as a second-line agent in patients who may not be able to tolerate or do not respond to treatment with metronidazole. Ok et al [56] examined 38 children and 15 adults with symptomatic infection with Blastocystis (stool specimens were negative for other parasitic or bacterial infections) treated with TMP-SMX for 7 days. Blastocystis was eradicated from stool in 36 (94.7%) of 38 children and in 14 (93.3%) of 15 adults. Clinical symptoms resolved in 39 (73.6%) and improved in 10 (18.9%) of 53 patients evaluated. Similar outcomes were observed in a study using nitazoxanide, but this study did not follow patients over a long period, so the effect may have been short-lived. Although these studies provide the best evidence to date for the pathogenic potential of this parasite, both studies used broad-spectrum antiparasitic agents, and thus the response to treatment could be attributed to the clearance of another possible enteric pathogen [2]. Additional agents, such as iodoquinol, tinidazole, nitazoxanide, emetine, pentamidine, iodochlorhydroxyquin, and furazolidone, have been used and have shown variable efficacy in eradicating Blastocystis infection [55, 57]. One of the difficulties in assessing therapeutic efficacy is the tremendous variability in posttreatment follow-up of patients treated for Blastocystis infection [22]. Posttreatment microbiologic analysis showing Blastocystis-positive stools may not reflect treatment failure or resistance but could represent reinfection. Patients may also have a secondary process that responded initially to treatment with subsequent treatment failure. There have been several studies examining the use of alternative agents in the treatment of Blastocystis infection. For example, Yakoob et al [58] studied the in vitro efficacy of garlic and other dietary herbs, compared with that of metronidazole, in the treatment of Blastocystis infection in both control subjects and patients with IBS. The authors evaluated the efficacy of garlic and metronidazole at concentrations of 0.01 and 0.1 mg/mL in suppressing the growth of Blastocystis. They found that garlic and metronidazole were equally effective at both concentrations. The isolates of Blastocystis were not as sensitive to the other herbs tested, which included ginger, black pepper, and white cumin. Saccharomyces boulardii (a probiotic) has also been studied for Blastocystis treatment [59]. In a study by Dinleyici et al [59], children with a 2-week history of gastrointestinal symptoms and isolation of Blastocystis from the stool were randomized to treatment with Saccharomyces, metronidazole, or placebo for 10 days. Patients were evaluated for clinical and microbiologic cure at days 15 and 30 after initiation of treatment. Clinical cure was found in 77.7% of the Saccharomyces group and 66.6% of the metronidazole group at 15 days, compared with 40% in the placebo group. Persistence of cysts in stool was noted in 20% of the metronidazole group and 27.8% of the Saccharomyces group, compared with 73.4% of the placebo group. Thirty days after initiation of treatment, clinical cure was found in 94.4% of subjects in the Saccharomyces group, compared with 73.3% of those in the metronidazole group. Resolution of cysts in the stool was found in 94.4% in the Saccharomyces group and 93.3% in the metronidazole group, and the difference was not statistically significant (P 5 .43) [59]. Given the variable agreement regarding the pathogenicity of Blastocystis, there is no consensus as to which patients should undergo treatment for Blastocystis infection. In the asymptomatic individual, treatment is not necessarily indicated. Isolation of Blastocystis in stool from a symptomatic individual should lead to a thorough investigation for other causes of the gastrointestinal complaints. It is reasonable to initiate a trial of antimicrobial therapy in patients who have persistent diarrhea or who have undergone an extensive work-up without any other pathogen or gastrointestinal source identified. Reasonable first-line agents include metronidazole or TMP-SMX. Additional randomized, controlled trials are needed to better assess the therapeutic efficacy of the additional antiparasitic drugs and their use in this infection. The relation of Blastocystis to human disease remains unclear, and many of the drugs used in the treatment of Blastocystis infection have significant side effects. A minimum of 3 stool examinations separated in time and performed in a reliable parasitology laboratory constitute an adequate examination. If the individual is asymptomatic, we do not recommend specific antiparasitic therapy. However, we understand that a counterargument to this recommendation may be made, because most experts recommend treatment of asymptomatic individuals who pass cysts, such as those with E. histolytica and G. lamblia infection. If the individual patient indeed has gastrointestinal signs and symptoms and has a significant number of cysts in the stool (ie, .5 cysts per high-power field), this patient may be a candidate for therapy. In those cases, other potential causes need to be ruled out. Thus, these patients may require additional stool specimens for parasite analysis, as well as cultures for bacterial pathogens. We have observed patients with Blastocystis in the stool who have G. lamblia or E. histolytica detected at subsequent examinations. Some of these patients may require endoscopy and imaging studies to rule out entities such as inflammatory bowel disease and IBS. Those with Blastocystis in the stool who have an associated skin eruption should be considered for treatment in the absence of other causes, but this recommendation is based on scant data. When treatment is given, we usually use metronidazole as first-line treatment, based on the available clinical trial data. If metronidazole is not effective, we usually use either TMP-SMX or nitazoxanide as second-line treatment.
受聘僱外國人健康檢查管理辦法
第 5 條
雇主聘僱第一類外國人從事本法第四十六條第一項第四款規定之工作，申請聘僱許可及展延聘僱許可時，應檢具最近三個月內核發之聘僱健康檢查合格證明，送交中央主管機關。
前項聘僱健康檢查合格證明，得為最近三個月內該外國人居住國家合格設立之醫療機構醫師簽章核發，並經我國駐外館處驗證。
第一項聘僱健康檢查合格證明，應包括下列檢查及證明項目：
一、胸部X光肺結核檢查。
二、梅毒血清檢查。但申請展延聘僱許可者，得免辦理。
三、身體檢查。
四、麻疹及德國麻疹之抗體陽性檢驗報告或預防接種證明。但申請展延聘僱許可者，得免檢附。
五、其他經中央衛生主管機關依其曾居住國家疫情或其他特性認定之必要檢查。
第 6 條
第二類外國人應辦理健康檢查之時程如下：
一、申請入國簽證時，應檢具最近三個月內之母國健康檢查合格證明。
二、雇主應安排其接受入國三日內健康檢查及定期健康檢查。
前項健康檢查，應包括下列項目：
一、胸部X光肺結核檢查。
二、漢生病檢查。
三、梅毒血清檢查。但辦理定期健康檢查者，得免辦理。
四、腸內寄生蟲糞便檢查。
五、身體檢查。
六、麻疹及德國麻疹之抗體陽性檢驗報告或預防接種證明。但辦理入國三日內健康檢查及定期健康檢查者，得免檢附。
七、其他經中央衛生主管機關依工作性質及勞動輸出國疫情或其他特性認定之必要檢查。
本條文有附件 第 8 條
受聘僱外國人於指定醫院健康檢查項目不合格者，其認定基準及處理方式，規定如附表。
受聘僱外國人健康檢查結果為不合格或須進一步檢查者，雇主應安排其依下列時程辦理再檢查、治療及預防接種：
一、胸部X光肺結核檢查：疑似肺結核或無法確認診斷者，自收受健康檢查證明之次日起十五日內，至指定機構再檢查。
二、漢生病檢查：疑似漢生病者，自收受健康檢查證明之次日起十五日內，至指定機構再檢查。
三、梅毒血清檢查：於收受健康檢查證明之次日起三十日內，取得完成治療證明。
四、腸內寄生蟲糞便檢查：於收受健康檢查證明之次日起六十五日內，至指定醫院治療後再檢查並取得陰性之證明；經確診為痢疾阿米巴原蟲陽性者，須取得治療後再檢查三次均為陰性之證明。
五、麻疹及德國麻疹抗體檢驗：於收受健康檢查證明之次日起三十日內，取得麻疹及德國麻疹疫苗預防接種證明。
受聘僱外國人健康檢查管理辦法
第 5 條
雇主聘僱第一類外國人從事本法第四十六條第一項第四款規定之工作，申請聘僱許可及展延聘僱許可時，應檢具最近三個月內核發之聘僱健康檢查合格證明，送交中央主管機關。
前項聘僱健康檢查合格證明，得為最近三個月內該外國人居住國家合格設立之醫療機構醫師簽章核發，並經我國駐外館處驗證。
第一項聘僱健康檢查合格證明，應包括下列檢查及證明項目：
一、胸部X光肺結核檢查。
二、梅毒血清檢查。但申請展延聘僱許可者，得免辦理。
三、身體檢查。
四、麻疹及德國麻疹之抗體陽性檢驗報告或預防接種證明。但申請展延聘僱許可者，得免檢附。
五、其他經中央衛生主管機關依其曾居住國家疫情或其他特性認定之必要檢查。
第 6 條
第二類外國人應辦理健康檢查之時程如下：
一、申請入國簽證時，應檢具最近三個月內之母國健康檢查合格證明。
二、雇主應安排其接受入國三日內健康檢查及定期健康檢查。
前項健康檢查，應包括下列項目：
一、胸部X光肺結核檢查。
二、漢生病檢查。
三、梅毒血清檢查。但辦理定期健康檢查者，得免辦理。
四、腸內寄生蟲糞便檢查。
五、身體檢查。
六、麻疹及德國麻疹之抗體陽性檢驗報告或預防接種證明。但辦理入國三日內健康檢查及定期健康檢查者，得免檢附。
七、其他經中央衛生主管機關依工作性質及勞動輸出國疫情或其他特性認定之必要檢查。
本條文有附件 第 8 條
受聘僱外國人於指定醫院健康檢查項目不合格者，其認定基準及處理方式，規定如附表。
受聘僱外國人健康檢查結果為不合格或須進一步檢查者，雇主應安排其依下列時程辦理再檢查、治療及預防接種：
一、胸部X光肺結核檢查：疑似肺結核或無法確認診斷者，自收受健康檢查證明之次日起十五日內，至指定機構再檢查。
二、漢生病檢查：疑似漢生病者，自收受健康檢查證明之次日起十五日內，至指定機構再檢查。
三、梅毒血清檢查：於收受健康檢查證明之次日起三十日內，取得完成治療證明。
四、腸內寄生蟲糞便檢查：於收受健康檢查證明之次日起六十五日內，至指定醫院治療後再檢查並取得陰性之證明；經確診為痢疾阿米巴原蟲陽性者，須取得治療後再檢查三次均為陰性之證明。
五、麻疹及德國麻疹抗體檢驗：於收受健康檢查證明之次日起三十日內，取得麻疹及德國麻疹疫苗預防接種證明。
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