医院与社区获得性耐甲氧西林金黄色葡萄球菌 RAPD-DNA指纹图谱分型比较

目的比较社区获得性与院内获得性耐甲氧西林金黄色葡萄球菌(MRSA)RAPD-DNA指纹图谱,推断两者在遗传基础上是否存在差异.方法收集临床MRSA标本,将其分为社区获得性MRSA与医院获得性MRSA两组,用Chelex 100裂解法制备DNA模板,PCR扩增mecA基因,选择mecA基因(+)的DNA模板,用RAPD技术扩增出各菌株的RAPD-DNA指纹图谱.随机取两组标本的RAPD-DDNA指纹图各20份,运用SPSS11.5软件聚类分析.结果医院获得性MRSA较社区获得性MRSA耐药性高;将RAPD-DNA指纹图行聚类分析,分成两种基因型,社区获得性MRSA与医院获得性MRSA均以第一种基因型为主,两者分组无显著差异.结论社区获得性MRSA与医院获得性MRSA在遗传基础上无差异.     

质子泵抑制剂和重症患者的医院获得性肺炎之间的关系

目的研究质子泵抑制剂（PPI）是否为危重患者发生医院获得性肺炎的危险因素。方法收集2002年6月-2009年6月收治的198例重症患者资料,分为使用PPI组（96例）和未使用PPI组（102例）。采用logistic回归分析PPI使用情况和医院获得性肺炎的关系。结果使用PPI组肺炎的发生率较高（26.9%）,尤其是PPI使用时间超过7d者（37.5%）。在不同的多变量logistic回归模型中,分别用APACHEⅡ评分和入住重症监护室原因校正后,使用PPI以及使用天数均是医院获得性肺炎发生的危险因素（P=0.031,OR=2.230,95%CI：1.957～2.947;P=0.002,OR=1.824,95%CI：1.457～2.242）。结论长时间应用PPI可能是增加ICU患者发生医院获得性肺炎的一种风险因素。     

老年社区获得性肺炎的临床特征分析

目的探讨老年社区获得性肺炎的临床特征、病原学特点及抗生素的合理选择。方法选择2010年1月1日-12月31日呼吸内科和干部病房住院治疗并确诊为社区获得性肺炎,年龄≥60岁的126例患者,从病原学、临床表现、辅助检查结果及治疗转归方面入手,回顾性分析老年社区获得性肺炎的临床特征。结果 77.7%(98/126)的老年社区获得性肺炎患者合并有其他基础疾病,其中84.7%(83/98)合并慢性阻塞性肺病,81.6%(80/98)合并高血压,39.2%(40/98)合并冠心病,25.5%(25/98)合并有糖尿病。126例患者中,68.3%(86/126)有气促等呼吸道症状,75.6%(95/126)有食欲减退等消化道症状,61.1%(77/126)有反应迟钝等精神状态的改变;72.2%(91/126)的患者肺部体征明显,而27.8%(35/126)的患者无明显肺部体征;88.9%(112/126)的老年患者胸部CT提示有斑点状、小片状阴影。有89例患者进行了痰培养,其中58例出现阳性结果,46例对头孢菌素敏感、36例对喹诺酮类药物敏感、39例对氨基糖甙类敏感及青霉素敏感。给予抗感染、支持对症治疗后,56.3%(71/126)的患者治愈、33.3%(42/126)的患者病情好转、10.3%(13/126)的患者死亡,死亡原因均为呼吸衰竭。结论老年社区获得性肺炎患者临床特征复杂,应重视其社区获得性肺炎的早期诊断,并进行及时有效的治疗。     

隐源性机化性肺炎反复误诊为社区获得性肺炎

目的：探讨隐源性机化性肺炎(cryptogenic organizing pneumonia, COP)的诊治要点,以减少误诊。方法回顾分析我科收治的1例误诊为社区获得性肺炎(community acquired pneumonia, CAP)的 COP 临床资料,并复习相关文献。结果本例因发现双肺反复渗出性病灶5个月就诊。病程中多次就诊当地医院行胸部 CT 扫描诊断为CAP,反复予抗感染治疗无效。入我院后查血常规未见明显异常,胸部 CT 检查示两肺上叶、右肺下叶多发炎性病灶;纤维支气管镜未见异常;B 超检查未见全身浅表淋巴结增大;肿瘤标志物检测、痰病原学及感染生物标志物检查均(-)。后行 CT 引导下经皮肺穿刺活检病理检查,并结合影像学表现,确诊为 COP,予大剂量甲泼尼龙琥珀酸钠冲击后序贯口服治疗,病情好转出院。随访1年病情稳定。结论临床遇及肺部多发渗出性实变患者,病程较长,常规抗感染治疗无效,尤其对糖皮质激素治疗敏感时应高度警惕 COP,及时行纤维支气管镜或 CT 引导下经皮肺活检病理检查,以减少误诊误治。     

Clinical features of Escherichia coli pneumonia

Escherichia coli pneumonia was clinically reviewed. Twenty-two patients with E. coli pneumonia were admitted for treatment to Kawasaki Medical School Kawasaki Hospital, between January 2006 and December 2008. Clinical features were retrospectively reviewed. Results showed that: (1) hospital-acquired pneumonia occurred in elderly patients with underlying diseases, such as cerebrovascular disease, diabetes mellitus, or chronic obstructive pulmonary disease; (2) more patients had complications of urinary-tract infection or alimentary infection due to E. coli; (3) previous administration of antibacterial agents did not become a risk factor; (4) resistance to ampicillin (ABPC) and levofloxacin (LVFX) was observed; and (5) mortality was 22.7%.     

Community-acquired bacterial pneumonia in adult HIV-infected patients

Introduction: Despite active antiretroviral therapy (ART), community-acquired pneumonia (CAP) remains a major cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected patients and incurs high health costs.

Areas covered: This article reviews the most recent publications on bacterial CAP in the HIV-infected population, focusing on epidemiology, prognostic factors, microbial etiology, therapy, and prevention. The data discussed here were mainly obtained from a non-systematic review using Medline, and references from relevant articles.

Expert commentary: HIV-infected patients are more susceptible to bacterial CAP. Although ART improves their immune response and has reduced CAP incidence, these patients continue to present increased risk of pneumonia in part because they show altered immunity and because immune activation persists. The risk of CAP in HIV-infected patients and the probability of polymicrobial or atypical infections are inversely associated with the CD4 cell count. Mortality in HIV-infected patients with CAP ranges from 6% to 15% but in well-controlled HIV-infected patients on ART the mortality is low and similar to that seen in HIV-negative individuals. Vaccination and smoking cessation are the two most important preventive strategies for bacterial CAP in well-controlled HIV-infected patients on ART.     

Community-acquired pneumonia: an unfinished battle

Community-acquired pneumonia remains a common illness with substantial morbidity and mortality. Current management challenges focus on identifying the likely etiologic pathogens based on an assessment of host risk factors, while attempting to make a specific etiologic diagnosis, which is often not possible. Therapy is necessarily empiric and focuses on pneumococcus and atypical pathogens for all patients, with consideration of other pathogens based on specific patient risk factors. It is important to understand the expected response to effective therapy, and to identify and manage clinical failure at the earliest possible time point. Prevention is focused on smoking cessation and vaccination against pneumococcus and influenza.     

Outpatient Antimicrobial Stewardship: Targets for Community-acquired Pneumonia

Purpose

Community-acquired pneumonia (CAP) is one of the leading causes of death in the United States. The primary objective of this study was to determine the prevalence of appropriate diagnosis and treatment of outpatients treated for CAP. Knowledge of problems with CAP treatment can be helpful in developing stewardship initiatives to improve care of outpatients with CAP.

Hospital-acquired pneumonia in Japan may have a better mortality profile than HAP in the United States: a retrospective study

The characteristics of hospital-acquired pneumonia (HAP) are not well documented. In the present study we investigated the severity and mortality, microbiological profile, and the value of Gram staining in culture-confirmed HAP in a Japanese hospital by retrospective review conducted at a Japanese university hospital. Only culture-confirmed cases with good specimen quality were included in the analysis. The clinical characteristics of HAP, as well as the causative organisms, were investigated. Furthermore, the prognostic ability of existing prediction rules were evaluated for prediction of overall mortality. Forty-two cases were enrolled in this analysis. The majority of patients were admitted to the ICU (61.9 %), and 40.5 % had ventilator-associated pneumonia (VAP). The 30-day mortality was 23.8 %, which is less than that reported in the United States. Factors commonly known to be associated with worse outcome in the USA did not appear to influence the mortality from HAP in Japan. The most frequent causative organisms were methicillin-resistant Staphylococcus aureus (MRSA), followed by Pseudomonas spp. Sensitivity and negative predictive value of Gram staining were 89.4 and 85.7 %, respectively. SMART-COP predicted 30-day mortality with an area under the ROC curve (AUC) >0.7. The characteristics of HAP in Japan differ from HAP reported in the USA. In addition to lower mortality, we found both fewer ICU cases and VAP. Gram staining of good-quality specimens demonstrated promising sensitivity to predict the causative organisms. SMART-COP predicted mortality with appropriate ROC curve (AUC).     

Serial quantification of procalcitonin (PCT) predicts clinical outcome and prognosis in patients with community-acquired pneumonia (CAP)

Procalcitonin (PCT), a calcitonin precursor, is commonly measured in the setting of community-acquired pneumonia (CAP). However, the clinical significance of serial PCT changes has not been established. We conducted a prospective observational study of 122 patients with CAP. Thirty-day mortality was the primary endpoint. Secondary endpoints included: (1) initial treatment failure, (2) 30-day mortality and/or initial treatment failure, and (3) intensive care unit (ICU) admission. In subgroup analysis, we classified patients into pneumococcal pneumonia and non-pneumococcal pneumonia groups. The baseline frequency of 30-day mortality was 10.7%. Increases in serum PCT levels from admission to Day 3 were observed with statistically higher frequency in patients with 30-day mortality (P = 0.002). For secondary endpoints, only the 30-day mortality and/or initial treatment failure group was statistically significant (P = 0.007). Subgroup analysis revealed statistically significant changes in the non-pneumococcal pneumonia group (N = 85) across several endpoints, including 30-day mortality (P = 0.001), initial treatment failure (P = 0.013), and 30-day mortality and/or initial treatment failure (P < 0.001). No significant changes in endpoint measurements were found in the pneumococcal pneumonia group (N = 28). Interestingly, serum PCT levels at the time of diagnosis were higher in patients with pneumococcal pneumonia than those with non-pneumococcal pneumonia (P = 0.006), and this positively correlated with disease severity scores for all patients (PCT vs. PSI: R = 0.380, P < 0.001; PCT vs. A-DROP: R = 0.422, P < 0.001) and for non-pneumococcal pneumonia (PCT vs. PSI: R = 0.468, P < 0.001; PCT vs. A-DROP: R = 0.448, P < 0.001), but not for pneumococcal pneumonia. In conclusion, serial quantification of PCT can predict clinical outcomes for patients with CAP.     

Community-acquired pneumonia: An overview

Community-acquired pneumonia is still a significant cause of morbidity and mortality and is often misdiagnosed and inappropriately treated. Although it can be caused by a wide variety of micro-organisms, the pneumococcus, atypicals, such as Mycoplasma pneumoniae and Chlamydophila pneumoniae, Staphylococcus aureus and certain Gram-negative rods are the usual pathogens encountered. The site-of-care decision is critical in determining the site and type of care as well as the extent of diagnostic workup. Antimicrobial therapy should be started as soon as possible particularly in those requiring admission to hospital, but typically the physician does not know with any degree of certainty the identity of the etiologic pathogen. A number of national guidelines have been published to help the physician with this choice. The initial drug(s) can be modified if necessary if the pathogen and its antimicrobial susceptibility pattern becomes known. Adjunctive therapy such as pressors and fluid replacement are of value and macrolides appear to help as well, likely secondary to their immunomodulatory effects. Recent data also suggest a role for steroids.     

A retrospective study of health care-associated pneumonia patients at Aichi Medical University hospital

Health care-associated pneumonia (HCAP) was defined in the American Thoracic Society/Infectious Disease Society of America guidelines on hospital-acquired pneumonia in 2005. However, little is known about the occurrence of HCAP in Japan. A retrospective review of background characteristics, pathological conditions, causative organisms, initial treatments, and risk factors for HCAP was conducted to determine the relationship of HCAP to community-acquired pneumonia and hospital-acquired pneumonia. Thirty-five patients who were admitted to our hospital for pneumonia acquired outside our hospital were included and were stratified by disease severity according to the Japanese Respiratory Society risk stratification guidelines (A-DROP [age, dehydration, respiratory failure, orientation disturbance, and shock blood pressure] criteria). All patients had an underlying disease. A total of 70 microbial strains (25 gram-positive, 37 gram-negative, 6 anaerobic, and 2 causative of atypical pneumonia) were isolated from sputum cultures, showing high isolation frequencies of Pseudomonas aeruginosa and Staphylococcus aureus and extremely low isolation frequencies of Streptococcus pneumoniae and Haemophilus influenzae. “History of hospitalization within 90 days before the onset of pneumonia” was the most common risk factor, and most of the patients had two or three risk factors. Initially, monotherapy [mainly tazobactam/piperacillin (TAZ/PIPC), sulbactam/ampicillin (SBT/ABPC), ceftriaxone (CTRX), cefepime (CPFM), carbapenems, or fluoroquinolones] or combination therapy (beta-lactam and fluoroquinolone) were administered and gave clinical effects in 63% (22/35) of cases. Bacteriological effects were seen in most strains (57%; 40/70). Since the causative organisms of HCAP were closely related to those of hospital-acquired pneumonia and not to community-acquired pneumonia, we believe that aggressive chemotherapy using broad-spectrum antimicrobials is needed in the initial treatment.     

C反应蛋白在社区获得性肺炎严重度及预后评估中的作用

目的 探讨C反应蛋白(CRP)及肺炎严重指数(PSI)在社区获得性肺炎(CAP)中的变化,以进一步了解CRP在CAP严重度及预后评估中的作用.方法 我院2009年1月至2011年5月住院CAP患者106例,按PSI评分、是否重症CAP、是否≥65岁患者分别分组,测定血清CRP.结果 CRP与PSI评分呈显著正相关(r=0.453 P=0.000); CAP老年组CRP与PSI评分无相关性,非老年组CRP[(81.70 ±75.63)mg/L]与PSI评分[(78.30±42.63)分]呈显著正相关(r=0.489,P＜0.001);CAP重症组PSI评分[(89.24±36.44)分]及CRP[(106.93±74.76)mg/L]与非重症组PSI评分[(53.59±35.41)分]及CRP[(31.34±33.68)mg/L]比较差异均有统计学意义(t值分别为-4.289、-5.934,P均＜0.001).结论 CRP及PSI可作为是否重症CAP分级,且CRP可作为PSI评分系统的一个补充,尤其在非老年患者的预后评估中.     

Outcomes of Macrolide Deescalation in Severe Community-acquired Pneumonia

PurposeCurrent data suggest potential benefits with β-lactam plus macrolide combination therapy for empiric treatment of intensive care unit (ICU) patients with severe community-acquired pneumonia (CAP). However, it is unclear whether deescalation to β-lactam monotherapy in the absence of positive results on diagnostic tests, such as the BioFire FilmArray Respiratory Panel 2 (BioFire polymerase chain reaction [PCR]), affects clinical outcomes. The purpose of this study was to compare outcomes between patients with negative BioFire PCR results deescalated to β-lactam monotherapy with those not deescalated.MethodsThis single-center, retrospective cohort study assessed the in-hospital mortality rates of critically ill adults with CAP treated for ≥48 h with combination β-lactam and azithromycin therapy. Additional end points included hospital length of stay (LOS), ICU LOS, duration of mechanical ventilatory support, 30-day readmission, and incidence of azithromycin-related adverse effects.FindingsA total of 94 patients were included: 53 in the deescalation group and 41 in the nondeescalation group. No difference was observed with respect to in-hospital mortality (2.4% vs 11.3%, P = 0.312), although patients in the deescalated group experienced shorter ICU (1.9 vs 3.4 days, P = 0.029) and hospital LOS (6 vs 7 days, P = 0.025). No differences were found between groups with respect to additional secondary end points. Simple logistic regression confirmed that deescalation was not associated with hospital mortality (odds ratio = 0.17, 95% CI, 0.02–1.70).ImplicationsIn this study of ICU patients with severe CAP and a negative BioFire PCR result, deescalation from combination β-lactam and macrolide therapy to β-lactam monotherapy was not associated with increased in-hospital mortality but was associated with decreased hospital and ICU LOS. Larger prospective studies are warranted to verify these findings.     

Clinical efficacy of carbapenems on hospital-acquired pneumonia in accordance with the Japanese Respiratory Society Guidelines for management of HAP

Hospital-acquired pneumonia (HAP) is the second most common cause of hospital-acquired infection and is the leading cause of death. In 2002, the Japanese Respiratory Society (JRS) published guidelines for the diagnosis and treatment of HAP (JRS GL 2002). In these guidelines, treatment with carbapenems is recommended for all disease types of HAP, excluding cases of mild or moderate pneumonia with no risk factors, and cases with early-onset ventilation-acquired pneumonia. To evaluate the efficacy of carbapenems on HAP in accordance with JRS GL 2002, we conducted a prospective study of HAP patients treated with carbapenems based on JRS GL 2002. The results of this study were also analyzed based on the revised guidelines published in June 2008 (JRS GL 2008), and the validity of the new guidelines was examined. Of the 33 subjects, 19 were judged as responders to the treatment, corresponding to a response rate of 57.6%. There were 3 deaths, corresponding to a mortality rate of 9.1%. The efficacy of carbapenems for the treatment of HAP based on JRS GL 2002 was confirmed. The severity rating system in JRS GL 2002 has a tendency to overestimate the severity of the cases and may lead to overtreatment in some cases. On the other hand, the severity rating system by JRS GL 2008 seemed to be more accurate and closely correlated with the efficacy of the treatment. It is suggested that JRS GL 2008 is more useful in clinical practice for accurately judging the severity of the disease and initiating appropriate subsequent antibiotic therapy.     

Risk stratification and prediction value of procalcitonin and clinical severity scores for community-acquired pneumonia in ED

Objective

Community-acquired pneumonia (CAP) is a common presentation to the emergency department (ED) and has high mortality rates. The aim of our study is to investigate the risk stratification and prognostic prediction value of precalcitonin (PCT) and clinical severity scores on patients with CAP in ED.

76例医院获得性肺炎临床特点分析

目的：探讨医院获得性肺炎（HAP）的临床特点、病原学分布和药敏情况,以指导临床诊疗。方法：回顾性分析2008年1月-2012年12月收治的76例HAP患者的临床资料。结果：HAP的发生率为1．69％,所有患者均有相关基础疾病和易患高危因素,合并两种以上基础疾病者死亡率高。分离的病原菌中,革兰氏阴性菌占60．17％,革兰氏阳性菌占32．20％,真菌占6．78％,不动杆菌、铜绿假单胞菌、肺炎克雷白杆菌、金黄色葡萄球菌为主要致病菌。不动杆菌、产ESBLs的肺炎克雷白杆菌耐药率较高,但碳青霉烯类和β-内酰胺类抗生素／酶抑制剂治疗效果仍较好,所有革兰氏阳性菌对万古霉素和利奈唑胺敏感。结论：减少各种高危因素,严格进行病原学检测和药敏试验,针对病原菌情况合理应用抗生素是提高HAP疗效的关键。