社区获得性重症肺炎病原菌分布与耐药性分析

目的了解社区获得性重症肺炎(SCAP)常见病原菌分布及其耐药性,为临床合理使用抗菌药物提供依据。方法 2006年7月-2013年7月134例SCAP住院患者于入院第1天采集痰液标本,对其分离的病原菌进行鉴定和药物敏感性试验,将结果进行分析。结果 7年调查1 610例患者,发生SCAP134例,发生率8.3%;共分离出病原菌34株,排前3位的病原菌依次为肺炎链球菌、流感嗜血菌、金黄色葡萄球菌,分别占35.5%、20.6%、17.6%;肺炎链球菌对莫西沙星较为敏感,对万古霉素敏感性为100.0%。结论 SCAP感染病原菌以肺炎链球菌为主,对多种抗菌药物耐药现象严重,临床应合理使用抗菌药物。     

儿童社区获得性肺炎病原菌耐药性分析

目的 调查分析宝鸡地区儿童社区获得性肺炎病原菌的分布及耐药性,指导临床合理使用抗菌药物.方法 对2008年1月-2010年12月儿科住院符合社区获得性肺炎1240例患儿,送痰液标本进行分离培养,做菌株鉴定和药敏试验.结果 共分离出病原菌612株,其中革兰阴性菌占63.6％;革兰阳性菌占26.1％;真菌占10.3％,革兰阴性菌以大肠埃希菌、肺炎克雷伯菌为主,对氨苄西林耐药率最高,敏感的抗菌药物为亚胺培南、环丙沙星、哌拉西林/他唑巴坦;革兰阳性菌中以肺炎链球菌和金黄色葡萄球菌为主,肺炎链球菌对大环内酯类耐药率为96.4％,对青霉素的耐药率为74.5％.结论 由于临床多选用β-内酰胺类和大环内酯类抗菌药物治疗,病原菌ESBLs与AmpC酶的产生儿童较成人高,应采取综合措施,科学、合理使用抗菌药物.     

儿童社区获得性肺炎病原菌与耐药性分析

目的了解医院儿科住院社区获得性肺炎(CAP)患儿病原菌分布及药敏率,以指导临床更有效治疗CAP。方法选取2009年8月-2011年12月医院CAP 5岁以下住院患儿512例,采集鼻咽分泌物标本进行细菌培养及药敏检测,并对结果进行统计分析。结果共送检512份痰标本,阳性标本为188份,阳性率为36.7%,检出病原菌207株,男性检出131株,女性76株;其中革兰阳性菌株75株占36.2%,最常见的是金黄色葡萄球菌,革兰阴性菌132株占63.8%,最常见的是大肠埃希菌;革兰阴性菌对氨苄西林/舒巴坦、氨苄西林及第二、三代头孢菌素的耐药率较高,>56.7%,而对亚胺培南、阿米卡星敏感性较高,耐药率<8.3%;革兰阳性菌对红霉素、氨苄西林的耐药率极高,>60.0%,而对万古霉素及利奈唑胺100.0%敏感。结论医院儿童CAP分离菌株中,革兰阴性菌明显多于革兰阳性菌,分离菌株对常用抗菌药物的耐药率较高。     

Pneumococcal conjugate vaccination response in patients after community-acquired pneumonia,differences in patients with S. pneumoniae versus other pathogens

ObjectivesThe goal of this study is to investigate the immune response to the 13-valent pneumococcal conjugate vaccine (PCV13) in former pneumococcal CAP patients. We hypothesize that an impaired or suboptimal humoral immune response against (specific) pneumococcal serotypes might explain the vulnerability for pneumococcal disease.MethodsHospitalised adult CAP patients who participated in two trials (2004–2006 (n = 201) and, 2007–2009 (n = 304)) were screened. Patients eligible for inclusion had CAP caused by either S. pneumoniae (pneuCAP) or due to another well-defined pathogen (otherCAP). Serotype-specific pneumococcal antibody concentrations (total IgG and IgG2/IgG1) before and 3–4 weeks after PCV13 administration were measured (Luminex) and compared between pneuCAP and otherCAP patients.ResultsWe vaccinated 60 patients:i.e. 34 pneuCAP and 26 otherCAP patients. In the pneuCAP group, 74% of patients were categorized as good responders (≥9/13 serotypes with concentration ≥ 1300 ng/ml), versus 77% in the otherCAP group. Significantly fewer full responders (i.e. 13/13 serotypes with a concentration ≥ 1300 ng/mL) were identified in the pneuCAP group (15% vs 42% respectively, p = 0.02). For serotype 1, total IgG and IgG2/IgG1 subset post-vaccination concentrations were significantly lower among pneuCAP patients. Our additional case-series showed that of 16 pneuCAP patients who were infected by a serotype included in PCV13 three patients did not respond against the serotype originally responsible for their CAP episode, including one former bacteraemic pneumococcal CAP patient who also failed to show a response against the serotype responsible for CAP during infection. Thirteen patients did respond to the previously infecting serotype following PCV13 including three patients who had bacteraemic pneumococcal pneumonia and did not show a response during infection against the serotype responsible for CAP.ConclusionsOur results confirm the immunogenic properties of PCV13 in former pneumococcal CAP patients including patients previously regarded as potential hyporesponders. A slightly diminished overall humoral response to polysaccharides characterizes the former pneumococcal CAP patients.ClinicalTrials.gov Identifier: NCT02141009.     

Changes in pathogens and pneumococcal serotypes causing community-acquired pneumonia in The Netherlands

BackgroundIn 2006 a 7-valent pneumococcal conjugate vaccine (PCV7) was introduced in the immunisation programme for infants in The Netherlands and replaced by PCV10 in 2011. Limited data exist about the impact of PCV on the aetiology of CAP as a whole. The aim of the present study is to describe the overall changes in microbial aetiology, pneumococcal burden (including non-bacteraemic pneumococcal pneumonia) and its serotypes in adult community-acquired pneumonia (CAP) after the introduction of these PCVs.MethodsHospitalised adult CAP patients who participated in three consecutive trials were studied (2004–2006 (n = 201), 2007–2009 (n = 304) and 2012–2016 (n = 300) and considered as pre-PCV7, PCV7 and PCV10 period). Extensive conventional microbiological testing was applied for all patients. In addition, patients with a serotype-specific pneumococcal antibody response were diagnosed with pneumococcal CAP. Changes in proportions of causative pathogens and distributions of pneumococcal serotypes were calculated.ResultsThe proportion of pneumococcal CAP decreased from 37% (n = 74/201) to 26% (n = 77/300) comparing the pre-PCV7 period with the PCV10 period (p = 0.01). For other pathogens, including Legionella spp., Mycoplasma pneumoniae, S. aureus, H. influenzae, and respiratory viruses, no sustained shifts were observed in their relative contribution to the aetiology of CAP. Within the pneumococcal CAP patients, we observed a decrease in PCV7 and an increase in non-PCV10 serotype disease. PCV10-extra type disease did not decrease significantly comparing the PCV10 period with the pre-PCV7 and PCV7 period, respectively. Notably, PCV7 type disease decreased both in bacteraemic and non-bacteraemic patients.ConclusionsOur findings confirm that PCV introduction in infants impact the microbial aetiology of adult CAP and suggest herd effects in adults with CAP after introduction of PCVs in children.     

Can radiologic features of community-acquired pneumonia presume etiologic agents?

During a one-year and nine months (from June 1987 to February 1989) survey of community-acquired pneumonia, we investigated in 130 patients if radiologic features presume etiologic agents. Incidences of etiologic agents are 21 (16%) pneumococcus, 18 (14%) mycoplasma, 14 (11%) tuberculosis, 12 (9%) hemophilus, and 54 (42%) unknown agents, respectively. In correlates of radiologic features and etiologic agents, alveolar shadows spreading bilateral lungs presume tuberculosis and pneumococcal pneumonia. Lobar distributing alveolar shadows presume pneumococcal, mycoplasmal tuberculous diseases and other agents, equally. Segmentally distributing shadows presume pneumococcal and mycoplasma pneumonia. Radiologic subgrouping features of alveolar shadows composed of acinar, lobular, and lobar shadows did not presume specific agents. Centrilobular (peribronchiolar) shadows suspect hemophilus infections. Pleural fluid accumulations suspect tuberculosis and anaerobic infections and cavitary shadows, tuberculosis, respectively. Radiologic features can presume etiologic agents.     

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。     

儿童社区获得性肺炎的流行特征和临床表现及病原菌调查

目的调查儿童社区获得性肺炎的流行特征、临床表现与病原菌检出情况。方法选择连云港市第一人民医院2017年2月-2019年2月诊断为儿童社区获得性肺炎的586例患儿,根据小儿年龄将其分为婴儿组200例,幼儿组203例,学龄前组131例,学龄期组30例。设计一般情况调查表,询问并记录患儿一般资料、其他检查情况、听诊结果等,记录病原菌鉴定结果。结果 586例儿童社区获得性肺炎患儿主要涉及年龄范围为1个月～14岁,主要集中于1个月～3岁。儿童社区获得性肺炎的危险因素调查显示:诱因不明确者占比高,为55.29%。586例儿童社区获得性肺炎患儿中有食物过敏/湿疹史者243例,占41.47%。患儿多伴咳嗽、气促症状,婴儿组发热症状相对少见,伴或不伴喘息、腹泻等症状,各年龄段患儿皮疹均少见。肺部听诊湿啰音是疾病主要体征,多伴喘鸣。心肌损害是常见合并症,轮状病毒肠炎主要发生于婴幼儿时期。586例患儿病原体阳性检出率为62.29%,共检出病原体479株,主要为病毒感染,后依次为细菌感染、非典型性病原体感染。婴儿组、幼儿组、学龄前组、学龄期组病原体检出率分别为70.00%、69.46%、38.93%、63.46%,其中学龄前组病原体检出率最低,均低于其他3组(P<0.05)。结论儿童社区获得性肺炎主要集中于≤3岁婴幼儿,发病诱因多不明确,过敏体质占比较高,咳嗽、发热、气促是其主要临床表现,肺部听诊湿罗音、喘鸣音是其主要体征;病原体以病毒感染为主,各年龄段病原体分布类型不同,临床应重视各年龄段病原体检测与合理抗生素的应用。     

Coccidioidomycosis as a common cause of community-acquired pneumonia

The early manifestations of coccidioidomycosis (valley fever) are similar to those of other causes of community-acquired pneumonia (CAP). Without specific etiologic testing, the true frequency of valley fever may be underestimated by public health statistics. Therefore, we conducted a prospective observational study of adults with recent onset of a lower respiratory tract syndrome. Valley fever was serologically confirmed in 16 (29%) of 55 persons (95% confidence interval 16%-44%). Antimicrobial medications were used in 81% of persons with valley fever. Symptomatic differences at the time of enrollment had insufficient predictive value for valley fever to guide clinicians without specific laboratory tests. Thus, valley fever is a common cause of CAP after exposure in a disease-endemic region. If CAP develops in persons who travel or reside in Coccidioides-endemic regions, diagnostic evaluation should routinely include laboratory evaluation for this organism.     

儿童常见病原体所致社区获得性肺炎胸部X射线摄片影像学表现

社区获得性肺炎(CAP)是导致<5岁儿童死亡的主要原因之一,对家庭及社会均造成较大疾病负担。儿童CAP病原体构成多样,流行病学、易感人群、临床及影像学表现各异。胸部X射线摄片(CR)对辅助诊断儿童CAP,具有经济、快速、利于动态监测等优势。笔者拟就病毒性[呼吸道合胞病毒(RSV)、腺病毒、流行性感冒(Flu)病毒、副流行性感冒病毒(PIV)],细菌性[肺炎链球菌(SP)、金黄色葡萄球菌(SA)、流行性感冒嗜血杆菌(HI)、大肠埃希菌(EC)、肺炎克雷伯菌(KP)、铜绿假单胞菌(PA)]及非典型性[肺炎支原体(MP)、肺炎衣原体(CP)、嗜肺军团菌(LP)]3类儿童CAP的临床特点及其CR特点的最新研究进展进行阐述,旨在为临床辅助诊断不同病原体感染所致CAP及其早期治疗提供参考,并且对CR诊治常见病原体感染所致CAP患儿的临床前景进行展望。     

Antibiotic resistance in community-acquired pneumonia.

Antibiotic resistance in bacteria is but one of many factors to consider when treating patients with community-acquired pneumonia. Many bacterial resistance patterns are stable, but wide geographical variation, increasing penicillin resistance in pneumococci and ampicillin resistance in Haemophilus influenzae are now being found. The importance of these features and their impact on therapy are reviewed.     

Adult community-acquired pneumonia in central London.

Strep. pneumoniae was diagnosed as the cause of pneumonia in 40 (50%) of 80 consecutive adults admitted to St Stephen's Hospital with community-acquired pneumonia. None of the patients had evidence of Mycoplasma pneumoniae infection, and Legionella pneumophila serology was positive on only one occasion. In 29 patients (36%) no causative organism was demonstrated. The diagnosis of pneumococcal infection was obtained in 15 cases by isolating Strep. pneumoniae from the sputum, in 13 further cases by demonstrating pneumococcal capsular antigen in sputum, and in 12 other cases by detecting pneumococcal antigen in serum only. Only 2 cases with pneumococcal pneumonia were bacteraemic and 3 patients (7%), all aged more than 75 years, died. The relatively low bacteraemic and mortality rates suggest that community-acquired pneumococcal pneumonia currently seen in patients admitted to hospital in central London may not be so severe as in some other areas.     

13--Antibiotic therapy of community-acquired pneumonia (CAP) caused by atypical agents

Macrolides, fluoroquinolones, doxycycline, and ketolides show a good intrinsic activity against intracellular pathogens which are responsible for a variable percentage of community-acquired pneumonia (CAP). These therapeutic agents all seem effective in treating most cases of CAP caused by Mycoplasma pneumoniae, Chlamydia pneumoniae, or Legionella spp. Among quinolones, the more recent fluoroquinolones, such as gemifloxacin or moxifloxacin, generally show a better intrinsic activity than the older ones. Among macrolides, azithromycin, and clarithromycin show a better pharmacokinetic profile. Both of them are available in intravenous form. It is quite common for M. pneumoniae and C. pneumoniae to continue to be shed in respiratory secretions, weeks after an effective therapy. The clinical relevance of this finding is not clear since most of these patients have a good outcome. Azithromycin, due to its advantageous pharmacokinetic profile, seems the best option when antibiotic prophylaxis is considered in some epidemiological settings. It has been proved effective in closed M. pneumoniae outbreaks.     

The burden of community-acquired pneumonia in Spain.

BACKGROUND: Community-acquired pneumonia accounts for a large number of hospitalizations and deaths in developed countries. METHODS: Data for Spain were obtained from the national surveillance system for hospital data and comprises all hospital discharges for pneumonia reported during a two-year period. RESULTS: The annual incidence of hospitalization for pneumonia was 160 per 100,000 population. Incidence of hospitalization, mortality, average length of stay and case-mortality rate were higher in persons > or = 65 years of age. The annual cost of these hospitalizations was 115 million ECUs (1 ECU = 1.19 US Dollars). CONCLUSION: Community-acquired pneumonia accounts for 53,000 hospitalizations per year in Spain, and this imposes a large economic cost on the National Health-care System.     

An outbreak of community-acquired Legionnaires' disease pneumonia.

In October 1981, an outbreak of 29 cases of community-acquired pneumonia occurred among adult residents of Johnson County, Iowa. Retrospective study revealed 12 cases (41 per cent) had laboratory evidence of Legionnaires' disease (LD). No significant differences in clinical or epidemiological features were found between LD cases and the other pneumonias in the outbreak. All LD cases received erythromycin; one case died for a case-fatality rate of 8 per cent. The outbreak's focus could not be identified.     

Initial management of community-acquired pneumonia

There continue to be major controversies in the management of community-acquires pneumonia, concerning either investigations, decision to hospitalize and antibiotic therapy. All authors agree that a chest radiography must be obtained in all cases, and two sets of blood cultures for hopitalized patients but there is there controversies about other microbiological tests. Decision to hospitalize must be based on clinical judgement but can be helped by Fine's predictive rule. Initial therapy is almost always empiric, antibiotic selection being primarily based on disease severity.     

Acute community-acquired pneumonia. A review of clinical trials

Optimal antibiotic treatment of community-acquired pneumonia (CAP) remains controversial. The clinical impact of S. pneumoniae resistance to macrolides is well documented. By contrast high dosage amoxicillin (1 g tid) remains active against such strains and no failure has been reported. The aim of this paper was to review clinical trials in community-acquired pneumonia, published from January 1, 1999, to December 31, 2005. One hundred seventy-three articles were collected, using Medline, 35 of which were analyzed, and 16 finally used. Telithromycin and pristinamycin may be used in mild to moderate CAP. Anti-pneumococcal fluoroquinolones such as levofloxacin and moxifloxacin may be used in at risk patients, but levofloxacin has only been investigated in patients with severe CAP and patients with Legionnaire's disease. Amoxicillin 1 g tid remains the drug of choice for pneumococcal CAP.     

Prediction of community-acquired pneumonia using artificial neural networks.

BACKGROUND: Artificial neural networks (ANN) have been used in the prediction of several medical conditions but have not been previously used to predict pneumonia. The authors used ANN to predict the presence or absence of pneumonia among patients presenting to the emergency department with acute respiratory complaints and compared the results with those obtained using logistic regression modeling. METHODS: Feed-forward back-propagation ANN were trained on sociodemographic, symptom, sign, comorbidity, and radiographic outcome data among 1,044 patients from the University of Illinois (the training cohort) and were applied to 116 patients from the University of Nebraska (the testing cohort). ANN trained using different strategies were compared to each other and to main-effects logistic regression. Calibration accuracy was measured as mean square error and discrimination accuracy as the area under a receiver operating characteristic (ROC) curve. RESULTS: A 1 hidden-layer ANN trained using oversampling of pneumonia cases had an ROC area in the training cohort of 0.895, which was greater than the area of 0.840 for logistic regression (P = 0.026). This ANN had an ROC area in the testing cohort of 0.872, not significantly different from its area in the training cohort (P = 0.597). Operating at a threshold of 0.25, the ANN would have detected 94% to 95% of patients with pneumonia in the 2 cohorts while correctly excluding 39% to 50% of patients with other conditions. ANN trained using other strategies discriminated equally in the 2 cohorts but no better than did logistic regression. CONCLUSIONS: Among adults presenting with acute respiratory illness, ANN accurately discriminated patients with and without pneumonia and, under some circumstances, improved on the accuracy of logistic regression.