成人社区及医院获得性肺炎病原菌及耐药性差异

 目的 比较非呼吸机相关医院获得性肺炎（NV-HAP）、呼吸机相关肺炎（VAP）与社区获得性肺炎（CAP）感染病原菌分布及耐药性。方法 回顾性调查2017年10月-2019年9月某院肺炎患者病历资料,按NV-HAP、VAP、CAP定义将患者分别列为NV-HAP组、VAP组、CAP组。收集三组患者痰、支气管肺泡灌洗液、血标本培养病原菌及药敏试验结果,分析三组患者感染病原菌构成和耐药性差异。结果 共纳入肺炎患者4 391例,NV-HAP组1 080例,VAP组126例,CAP组3 185例,各组分别检出病原菌841、191、1 440株,均以革兰阴性（G^-）菌为主,依次占72.77%、84.82%和61.18%,三组患者检出病原菌分布比较,差异有统计学意义（χ²=64.037,P<0.001）。鲍曼不动杆菌对头孢吡肟、头孢哌酮/舒巴坦、亚胺培南、庆大霉素、妥布霉素、左氧氟沙星、环丙沙星和复方磺胺甲口恶唑耐药率,铜绿假单胞菌对头孢哌酮/舒巴坦和亚胺培南耐药率,肺炎克雷伯菌对常用抗菌药物耐药率,三组比较差异均有统计学意义（均P<0.05）;金黄色葡萄球菌对红霉素、克林霉素和环丙沙星的耐药率比较,CAP组高于NV-HAP组（P<0.05）。结论 NV-HAP、VAP和CAP在病原菌分布及细菌耐药性方面均存在差异,在制定临床治疗方案时,要区别对待不同感染类型的肺炎。     

高剂量左氧氟沙星片治疗社区获得性肺炎临床分析

目的 评价口服高剂量左氧氟沙星片治疗社区获得性肺炎(CAP)的临床疗效及安全性.方法 对53例社区获得性肺炎患者,口服左氧氟沙星片0.5 g,1次/d,疗程7～14 d.结果 高剂量左氧氟沙星片治疗社区获得性肺炎临床有效率为86.8%,细菌清除率为86.9%,药物不良反应发生率为9.4%,主要为轻度胃肠道反应.结论 高剂量左氧氟沙星片口服治疗社区获得性肺炎疗效好、安全性高,并能降低医疗费用和不良反应,值得临床推广.     

单用左氧氟沙星与头孢呋辛联用阿奇霉素治疗社区获得性肺炎的对照研究

目的 比较左氧氟沙星与头孢呋辛联用阿奇霉素治疗社区获得性肺炎的临床疗效、细菌清除率和安全性。方法 将55例社区获得性肺炎患者,随机分为左氧氟沙星治疗组和头孢呋辛联用阿奇霉素治疗组,观察两组患者的临床疗效、细菌清除率和不良反应。结果 左氧氟沙星组30例患者,痊愈25例（83.3%）,显效3例（10.0%）,总有效率93.3%,细菌清除率85.7%,不良反应发生率3.3%;头孢呋辛联用阿奇霉素组25例患者,痊愈20例（80.0%）,显效3例（12.0%）,总有效率92.0%,细菌清除率88.9%,不良反应发生率4.0%。结论 左氧氟沙星与头孢呋辛联用阿奇霉素治疗社区获得性肺炎的临床疗效、细菌清除率和安全性差异无统计学意义。     

左氧氟沙星治疗老年社区获得性肺炎临床研究

目的评价左氧氟沙星治疗老年社区获得性肺炎的有效性和安全性. 方法以左氧氟沙星静脉滴注为治疗组,头孢曲松静脉滴注为对照组,对两组治疗老年社区获得性肺炎的疗效和安全性进行随机对照观察. 结果入选 318例病例,可评价病例 301例,治疗组可评价病例 148例,对照组 153例;治疗组和对照组的总有效率分别为95.3%和92.2%,治愈率分别为81.8%和77.8%;两组共分离细菌 162株,细菌清除率分别为88.8%和85.4%,不良反应发生率分别为7.5%和3.8%;实验室异常发生率分别为8.8%和10.0%;上述结果经统计学处理差异无显著性(P＞0.05). 结论左氧氟沙星静脉滴注治疗老年社区获得性肺炎疗效良好,不良反应发生较少且安全.     

血清降钙素原在社区获得性肺炎诊断与病情判断中的价值

目的 评价血清降钙素原(PCT)在社区获得性肺炎(CAP)诊断与病情判断中的价值.方法 2005年11月至2006年8月CAP患者96例(CAP组).对照组30例.检测入院次日及第8天的血清PCT、CRP和血WBC.结果 (1)在CAP组及对照组中,分别取PCT、CRP、WBC的临界值为1.5μg/L、10 mg/L、10×109/L做受试者工作特征(ROC)曲线,其曲线下面积分别为0.979、0.831、0.736.(2)PCT在细菌性肺炎、非典型病原体肺炎、病毒性肺炎中分别为(9.74±6.20)、(7.81±5.70)、(12.20±6.50)μg/L,三者之间差异无统计学意义.(3)PCT与CURB-65评分之间存在相关性(r=0.258,P=0.011).PCT在轻、中、重症肺炎中存在差异.结论 血清PCT在CAP诊断中的敏感度和特异度均高于CRP、WBC,PCT与CAP病情严重程度有一定的相关性,提示PCT在CAP病情判断中具有实用价值.     

社区获得性肺炎治疗失败的原因和危险因素分析

目的 探讨社区获得性肺炎(CAP)治疗失败的原因和危险因素.方法 回顾性分析2006年1-12月拟诊CAP入院病例378例,以无反应性肺炎及进展性肺炎定义治疗失败,以此分析治疗失败CAP患者的临床特征,探讨治疗失败的原因,并进行高危因素分析.结果 378例CAP患者中,治疗失败50例,其中无反应性肺炎32例,进展性肺炎18例.分析失败原因:感染性原因35例,占70%;非感染性原因11例,占22%;无法明确原因4例,占8%.50例患者中共有9例死亡(18%),8例为感染性原因,1例为无法明确原因.C反应蛋白、多叶受累、白蛋白<30g/L、肾功能损害、肝功能损害均与CAP治疗失败有关,其中多叶受累、白蛋白<30 g/L、肾功能损害是CAP治疗失败独立的危险因素.结论 CAP治疗失败及死亡的主要原因是感染性原因,多为耐药菌株感染.     

社区获得性肺炎治疗失败的原因和危险因素分析

目的 探讨社区获得性肺炎(CAP)治疗失败的原因和危险因素.方法 回顾性分析2006年1-12月拟诊CAP入院病例378例,以无反应性肺炎及进展性肺炎定义治疗失败,以此分析治疗失败CAP患者的临床特征,探讨治疗失败的原因,并进行高危因素分析.结果 378例CAP患者中,治疗失败50例,其中无反应性肺炎32例,进展性肺炎18例.分析失败原因:感染性原因35例,占70%;非感染性原因11例,占22%;无法明确原因4例,占8%.50例患者中共有9例死亡(18%),8例为感染性原因,1例为无法明确原因.C反应蛋白、多叶受累、白蛋白<30g/L、肾功能损害、肝功能损害均与CAP治疗失败有关,其中多叶受累、白蛋白<30 g/L、肾功能损害是CAP治疗失败独立的危险因素.结论 CAP治疗失败及死亡的主要原因是感染性原因,多为耐药菌株感染.     

社区获得性肺炎治疗失败的原因和危险因素分析

目的 探讨社区获得性肺炎(CAP)治疗失败的原因和危险因素.方法 回顾性分析2006年1-12月拟诊CAP入院病例378例,以无反应性肺炎及进展性肺炎定义治疗失败,以此分析治疗失败CAP患者的临床特征,探讨治疗失败的原因,并进行高危因素分析.结果 378例CAP患者中,治疗失败50例,其中无反应性肺炎32例,进展性肺炎18例.分析失败原因:感染性原因35例,占70%;非感染性原因11例,占22%;无法明确原因4例,占8%.50例患者中共有9例死亡(18%),8例为感染性原因,1例为无法明确原因.C反应蛋白、多叶受累、白蛋白<30g/L、肾功能损害、肝功能损害均与CAP治疗失败有关,其中多叶受累、白蛋白<30 g/L、肾功能损害是CAP治疗失败独立的危险因素.结论 CAP治疗失败及死亡的主要原因是感染性原因,多为耐药菌株感染.     

Comparative Analysis of Length of Stay, Total Costs, and Treatment Success between Intravenous Moxifloxacin 400 mg and Levofloxacin 750 mg among Hospitalized Patients with Community-Acquired Pneumonia

Objective:  This study aimed to evaluate the length of stay (LOS), costs, and treatment consistency among patients hospitalized with community-acquired pneumonia (CAP) initially treated with intravenous (IV) moxifloxacin 400 mg or IV levofloxacin 750 mg.
Methods:  Adults with CAP receiving IV moxifloxacin or IV levofloxacin for ≥3 days were identified in the Premier Perspective comparative database. Primary outcomes were LOS and costs. Secondary outcomes included treatment consistency, which was defined as 1) no additional IV moxifloxacin or levofloxacin after ≥1 day off study drug; 2) no switch to another IV antibiotic; and 3) no addition of another IV antibiotic.
Results:  A total of 7720 patients met inclusion criteria (6040 receiving moxifloxacin; 1680 receiving levofloxacin). Propensity matching created two cohorts (1300 patients each) well matched for demographic, clinical, hospital, and payor characteristics. Before the patients were matched, mean LOS (5.87 vs. 5.46 days; P  = 0.0004) and total costs per patient ($7302 vs. $6362; P  < 0.0001) were significantly greater with moxifloxacin. After the patients were matched, mean LOS (5.63 vs. 5.51 days; P  = 0.462) and total costs ($6624 vs. $6473; P  = 0.476) were comparable in both cohorts. Treatment consistency was higher for moxifloxacin before (81.0% vs. 78.9%; P  = 0.048) and after matching (82.8% vs. 78.0%; P  = 0.002).
Conclusions:  In-hospital treatment of CAP with IV moxifloxacin 400 mg or IV levofloxacin 750 mg was associated with similar hospital LOS and costs in propensity-matched cohorts.     

Community-acquired Staphylococcus aureus pneumonia following influenza and the choice of empirical antibiotic treatment

A 30-year-old man presented with community-acquired pneumonia (CAP), directly following influenza. Sputum Gram stain confirmed Staphylococcus aureus pneumonia. Initial empirical antimicrobial therapy did not cover S. aureus. The isolated S. aureus strain contained genes encoding exotoxins, such as Panton-Valentine leukocidin (PVL). This exotoxin is associated with high mortality and methicillin resistance, but in this patient the strain was susceptible to methicillin. The patient died. In the Netherlands the risk of methicillin resistance in PVL-positive S. aureus CAP is low but real. This should be taken into account when selecting empirical treatment, which can include the combination of flucloxacillin and rifampicin. This case report illustrates the difficulty in predicting the causative agent in CAP and highlights the usefulness of the sputum Gram stain. Moreover, clinical awareness and recognition of S. aureus CAP remains essential to the early initiation of directed therapy.     

左氧氟沙星治疗老年社区获得性肺炎临床观察

目的 了解左氧氟沙星治疗老年社区获得性肺炎(CAP)的临床有效性和不良反应的发生情况.方法 老年CAP患者36例,均应用左氧氟沙星治疗,每日1次0.5 g静脉滴注,疗程5～14 d.结果 22例痰培养检出多药耐药的肺炎链球菌,8例检出铜绿假单胞菌,6例检出流感嗜血杆菌,临床有效率为75.0%;细菌清除率为82.1%;相关腹泻、皮疹、肾损害各2例,占16.7%.结论 左氧氟沙星治疗老年CAP疗效好,不良反应发生率相对较低.     

Postoperative nosocomial endophthalmitis: is perioperative antibiotic prophylaxis advisable? A single centre's experience

Healthcare-associated pneumonia (HCAP) is considered to represent a category of disease distinct from community-acquired pneumonia (CAP). We describe the incidence and characteristics of HCAP compared with CAP in patients hospitalised through the emergency department (ED). Pneumonia diagnosed at the ED of Ghent University Hospital from 1 November 2006 to 31 October 2007 was retrospectively categorised as CAP or HCAP according to the definition of the American Thoracic Society/Infectious Diseases Society of America. We categorised 287 episodes of pneumonia, diagnosed in 269 patients, as CAP [159 (55%)] or HCAP [128 (45%)]. Patients with HCAP were older [75 years (range: 64-83) vs 68 (41-78); P < 0.001], had more comorbidity, and had more severe pneumonia [CURB-65: 2 (1-3) vs 1 (0-2); P < 0.001] in comparison to patients with CAP. Patients with HCAP had more frequently an unfavourable clinical course (27% vs 15%; P < 0.01) and a longer hospital stay (12 days vs 9 days; P<0.001) compared with patients with CAP. In multivariate regression analysis, nursing home residence (odds ratio: 2.96; 95% confidence interval: 1.12-7.84; P = 0.03) but not HCAP was an independent predictor for in-hospital mortality. In conclusion, a high percentage (45%) of patients hospitalised with pneumonia through the ED was classified as HCAP. Classification as HCAP was associated with an unfavourable clinical course. Nursing home residence was an independent predictor for increased mortality.     

吉米沙星治疗老年社区获得性肺炎疗效评价

目的评价吉米沙星在社区获得性肺炎(CAP)老年人群中的疗效和安全性。方法采用前瞻性设计,将80例老年患者随机分为治疗组(42例)和对照组(38例),治疗组予吉米沙星片0.32 g,po,qd,疗程14 d。对照组予左氧氟沙星0.2 g,po,bid,疗程14 d。统计分析治愈率、症状缓解时间、不良反应等。结果疗程结束后,治疗组和对照组治愈率分别为91%和89%,差异无统计学意义(P0.05)。但在疗程早期治疗组治愈率高于对照组,差异有统计学意义(P0.05)。治疗组多种症状(发热、咳嗽、痰液性状改善、胸痛等)缓解时间更短,有统计学意义(P0.01,P0.05)。吉米沙星不良反应少,均可耐受。结论吉米沙星治疗老年CAP患者临床疗效肯定,安全,给药方便。     

社区获得性肺炎的病原体调查与药物敏感性分析

目的研究社区获得性肺炎CAP病原体种类、药物敏感性等,为临床有效诊断、治疗提供依据。方法对154名社区获得性肺炎患者的标本进行细菌培养和血清学检测,并进行药物敏感性试验。用PCR检测社区获得性肺炎非典型病原体。结果在社区获得性肺炎患者中多重感染十分常见;在典型病原体感染中,以肺炎链球菌最为常见;在非典型病原体感染中,以肺炎支原体最为常见,非典型病原体感染在8～14岁阶段检出率最高;明确了各种病原体对常用抗菌药物的敏感性。结论明确了该地区社区获得性肺炎的病原谱,及其对药物敏感性的差异,为临床有效治疗提供了依据。     

发热门诊病人中社区获得性肺炎的发病状况研究

[目的]研究分析发热病人中社区获得性肺炎(CAP)的发病状况以及临床特征,为CAP的及时诊断和治疗提供参考依据。[方法]对我院发热门诊2007年度诊治的发热病人全部进行胸部X线摄片,采用统一的诊断标准进行CAP诊断,记录患者年龄、性别、发热天数、呼吸道症状(咳嗽、咳痰等)、外周末梢血常规检查等资料,并进行统计分析。[结果]6539例发热门诊就诊病人中10~39岁者占61.0,60岁以上仅为15.6;共诊断CAP病人402例,总体患病比例为6.1,其中60岁以上的CAP病人占38.1,患病比例随年龄增大而逐渐升高,CAP病人确诊时体温一般在38.0℃以上,20~40岁CAP病人中外周末梢血白细胞计数不升高比例为62.4,而50岁以上白细胞升高比例则为58.5,无呼吸道症状的CAP病人占CAP病人的36.8,86.1的CAP病人可在3d内确诊,4d内确诊则达92.3。[结论]在发热病人中有较高的CAP患病比例,患病比例随年龄增加而升高,老年人更易患CAP,CAP患者中36.8无呼吸道症状,应引起重视。     

Should Nursing Home-Acquired Pneumonia Be Treated as Nosocomial Pneumonia?

ObjectivesIt is contentious whether nursing home–acquired pneumonia (NHAP) should be treated as community-acquired pneumonia (CAP) or health care–associated pneumonia. This study aimed to compare NHAP with CAP, and to examine whether multidrug-resistant (MDR) bacteria were significantly more common in NHAP than CAP.DesignA prospective, observational cohort studySettingThe medical unit of a tertiary teaching hospitalParticipantsPatients 65 years and older, hospitalized for CAP and NHAP confirmed by radiographs from October 2009 to September 2010MeasurementsDemographic characteristics, Katz score, Charlson comorbidity index (CCI), pneumonia severity (CURB score), microbiology, and clinical outcomes were measured.ResultsA total of 488 patients were recruited and 116 (23.8%) patients were nursing home residents. Compared with patients with CAP, patients with NHAP were older and had more comorbidities and higher functional dependence level. A larger proportion of patients with NHAP had severe pneumonia (CURB ≥2) than patients with CAP (30.2% vs 20.7%, P = .034). Similar percentages of patients had identified infective causes in the CAP and NHAP groups (27.7% vs 29.3%, P = .734). Viral infection accounted for more than half (55.9%) of NHAP, whereas bacterial infection was the most frequent (69.9%) cause of CAP. MDR bacteria were found in 6 patients of all study subjects. Nursing home residence and history of MDR bacterial infection were risk factors for MDR bacterial pneumonia, which had more severe pneumonia (CURB ≥2). Logistic regression analysis was limited by the small number of patients with MDR bacterial pneumonia.ConclusionIn both CAP and NHAP, MDR bacterial infections were uncommon. Most cases of NHAP were caused by unknown etiology or viral pathogens. We suggest that NHAP should not be treated as nosocomial infection. The empirical treatment of broad-spectrum antibiotics in NHAP should be reserved for patients with severe pneumonia or at high risk of MDR bacterial infection.     

中国“不明原因肺炎”预警病例现状及其临床研究

目的了解我国“不明原因肺炎（PUO）”预警病例的现状和临床特征,为其病例定义等的改进工作提供一定的参考依据。方法在2个项目省选择省级、地市级和县级医院各1所,对其2008年4月1日-2009年3月31日期间“社区获得性肺炎”住院患者的临床资料进行筛选及分析。结果共调查1 506份“社区获得性肺炎”患者病历,其中442例（29.35%）患者符合现有“PUO”的病例定义。此442例患者发病多在冬季(32.35%);男性占60.63%,≤14岁患者占57.24%;临床主要表现为急性起病,发热伴咳嗽、咳痰,预后良好（治愈率>95%）;未引发重大公共卫生事件。结论“社区获得性肺炎”住院患者中符合现有“PUO”定义的预警病例占相当比例,但临床经过良好。建议对临床症状、体征或影像学支持肺炎诊断的患者积极进行流行病学史的询问,以及时且较为特异地发现“PUO”预警病例。     

CURB-65评分对成年人社区获得性肺炎诊治的指导作用

目的 评价CURB-65评分系统在成年人社区获得性肺炎(CAP)诊治中的指导作用.方法 分析2007年1月至2008年1月收治的13例CAP患者的临床资料,列举3例患者的诊治过程,评价CURB-65评分系统对CAP诊治的指导作用.结果 3例CAP患者的CURB-65评分分别为0、2、5分,根据其评分进行分级治疗后,取得很好的疗效.结论 CURB-65评分系统对肺炎严重程度的评价以及诊治过程有很积极的指导意义,但其对重症肺炎鉴别的准确性较差,应结合重症肺炎诊断标准来评价CAP患者病情.     

Community-Acquired Pneumonia and its Management

Community-acquired pneumonia (CAP) is a common cause of morbidity and mortality worldwide and places a large burden on medical and economic resources, particularly if hospitalization is required. Indeed, it has been estimated that annual costs of inpatient treatment of patients with CAP currently exceed $US6 billion in the US; a large proportion of this cost is directly related to the duration of hospital stay. Initial antibacterial therapy for CAP is usually empirical, as culture and antibacterial sensitivity test results are rarely available at initial diagnosis. Importantly, treatment must be initiated promptly to achieve the best patient outcome thereby potentially reducing healthcare costs, largely as a result of a decrease in hospitalisation. Any agent selected for empirical therapy should have good activity against pathogens associated with CAP, a favorable tolerability profile and be administered in a simple dosage regimen for good compliance. Streptococcus pneumoniae remains the most common causative pathogen in nonsevere and severe CAP, although the incidence of this organism varies widely. S. pneumoniae strains with decreased susceptibility to penicillin have become increasingly prevalent over the past 30 years and are now a serious problem worldwide. In addition, an increase in the prevalence of pneumococci resistant to macrolides has been observed in Europe over recent years. Mycoplasma pneumoniae and Chlamydia pneumoniae are among the most common atypical pathogens isolated from patients with CAP. Haemophilus influenzae, Staphylococcus aureus and Moraxella catarrhalis are less commonly identified as causative organisms.Because the spectrum of antibacterial activity of levofloxacin includes the pathogens associated with CAP, including penicillin-resistant S. pneumoniae, it is included in US guidelines as an option for the empirical therapy of patients with mild or more severe disease. Levofloxacin is recommended for the initial treatment of outpatients and inpatients with suspected penicillin-resistant S. pneumoniae infection and is particularly useful in geographical areas where there is a high incidence of drug-resistant pneumococci. Nevertheless, β-lactam antibacterial agents, in particular penicillin, remain agents of first choice for the treatment of CAP (caused by penicillin-susceptible pathogens) in many European countries.Levofloxacin monotherapy shows good efficacy in the treatment of patients with CAP and is generally well tolerated. Phototoxicity has been infrequently reported with levofloxacin (incidence 0.03% in 1 study) and occurs less commonly than with sparfloxacin (reported incidence 8%). In addition, the drug has a pharmacokinetic profile that allows a simple administration schedule and offers the potential for intravenous to oral sequential therapy. In randomized comparative trials, intravenous or oral levofloxacin was more effective than intravenous ceftriaxone and/or oral cefuroxime axetil, at least as effective as azithromycin plus ceftriaxone and similar in efficacy to both amoxicillin/clavulanic acid and gatifloxacin. Data comparing the efficacy of levofloxacin with other newer fluoroquinolones, such as moxifloxacin, are as yet unavailable.Levofloxacin was also a beneficial treatment for CAP from a pharmacoeconomic perspective. A critical pathway that used levofloxacin for the treatment of patients with CAP led to a decrease in healthcare resource costs compared with conventional management in a randomized controlled trial conducted in Canada. As a treatment for CAP, levofloxacin was less costly than intravenous ceftriaxone and was more cost effective than cefuroxime plus erythromycin, or ceftriaxone or ciprofloxacin.

Conclusions

Levofloxacin monotherapy is efficacious and shows pharmacoeconomic benefits when used as empirical treatment for adult patients with CAP. The drug has a broad spectrum of antibacterial activity, is administered in a simple dosage regimen and offers the potential for intravenous to oral sequential therapy; it is also well tolerated and is an option for patients allergic to penicillin or macrolides. Levofloxacin has a particularly useful role in the empirical treatment of patients with infections caused by S. pneumoniae in geographical areas where penicillin-resistant strains of pneumococci are prevalent.

     

Optimizing the antibiotics policy in The Netherlands. VIII. Revised SWAB guidelines for antimicrobial therapy in adults with community-acquired pneumonia

The Dutch Working Party on Antibiotic Policy (SWAB) has revised the 1998 guideline for community-acquired pneumonia (CAP) in light of changing resistance patterns for common pathogens and new developments in epidemiology, diagnostic testing and treatment strategies. The current guideline is applicable to both primary and inpatient care, and has been developed by delegates of all professional organisations involved in the treatment of CAP, following recommendations for evidence-based guideline development. Assessment of a patient's 'severity of illness' at presentation is considered important when choosing an optimal empirical antibiotic regimen for CAP. Severely-ill patients should be treated with antibiotics covering the most important expected pathogens, including Legionella. Assessment of the severity of illness may be facilitated by the use of validated scoring systems like the pneumonia severity index and the 'confusion, urea, respiratory-rate, blood-pressure, 65-years-of-age' (CURB-65) score. Patients can also be stratified based on their location during treatment: in the community, a normal ward or an intensive-care unit. Legionella urine antigen testing is considered an important tool in the process of deciding on an optimal antibiotic regimen for CAP. Empirical therapy should be replaced with pathogen-directed therapy if the causative agent is identified.