Treatment of community-acquired pneumonia in hospitalised patients

Community-acquired pneumonia (CAP) can be life-threatening. The prognosis is generally poorest in elderly patients and/or those with underlying chronic conditions, but fatalities can occur in all age groups. Current challenges in the clinical management of CAP are discussed, and the criteria for identifying those patients who should be treated in hospital with initial intravenous therapy are considered. Rapid initiation of therapy is important, using an agent that provides coverage against the most likely pathogens--Streptococcus pneumoniae and the atypical organisms. There is an increasing tendency to minimise the duration of intravenous therapy, with an early transition to oral therapy and the rapid return of the patient to the community. The efficacy of oral macrolides in the treatment of CAP is well established. Evidence for the use of intravenous azithromycin to provide effective and well-tolerated, first-line intervention in the hospitalized CAP patient is summarised.     

老年患者肺炎85例临床分析

【摘要】目的研究分析老年患者肺炎的临床表现。方法将85例老年肺炎患者作为调查对象,同时选择85例同期治疗肺炎的青年患者作为对照研究对象。比较两组患者的性别、临床表现、病变位置以及死亡等方面的不同。结果青年组的临床表现中消化道症状为40．0％,意识的变化为15-3％,胸腔积液为8．2％,双肺为8.2％,死亡率为5．9％。远低于老年患者组的70．6％、30．6％、23．5％、21．2％、16．5％（P〈0．05）。结论老年患者由于其身体素质较差,所以其肺炎的发病率较高、且临床症状以及体征不典型,术后恢复较差。医生应该熟悉老年肺炎的临床特点,尽可能做到早发现、早诊断、早治疗。     

Improving outcomes of elderly patients with community-acquired pneumonia

Community-acquired pneumonia (CAP) is a major cause of morbidity and mortality in elderly patients. Therefore, efforts to optimize the healthcare process for patients with CAP are warranted. An organized approach to management is likely to improve clinical results. Assessing the severity of CAP is crucial to predicting outcome, deciding the site of care, and selecting appropriate empirical therapy. Unfortunately, current prognostic scoring systems for CAP such as CURB-65 (confusion, uraemia, respiratory rate, low blood pressure and 65 years of age) or the Pneumonia Severity Index have not been validated specifically in older adults, in whom assessment of mortality risk alone might not be adequate for predicting outcomes. Obtaining a microbial diagnosis remains problematic and may be particularly challenging in frail elderly persons, who may have greater difficulties producing sputum. Effective empirical treatment involves selection of a regimen with a spectrum of activity that includes the causative pathogen. Although most cases of CAP are probably caused by a single pathogen, dual and multiple infections are increasingly being reported. Streptococcus pneumoniae remains the overriding aetiological agent, particularly in very elderly people. However, respiratory viruses and 'atypical' organisms such as Chlamydia pneumoniae are being described with increasing frequency in old patients, and aspiration pneumonia should also be taken into consideration, particularly in very elderly subjects and those with dementia. Age >65 years is a well established risk factor for infection with drug-resistant S. pneumoniae. Clinicians should be aware of additional risk factors for acquiring less common pathogens or antibacterial-resistant organisms that may suggest that additions or modifications to the basic empirical regimen are warranted. In addition to administration of antibacterials, appropriate supportive therapy, covering management of severe sepsis and septic shock, respiratory failure, as well as management of any decompensated underlying disease, may be critical to improving outcomes in elderly patients with CAP. Immunization with pneumococcal and influenza vaccines has also been demonstrated to be beneficial in numerous large studies. There is good evidence that implementation of guidelines leads to improvement in clinical outcomes in elderly patients with CAP, including a reduction in mortality. Protocols should address a comprehensive set of elements in the process of care and should periodically be evaluated to measure their effects on clinically relevant outcomes. Assessment of functional clinical outcome variables, in addition to survival, is strongly recommended for this population.     

Antipsychotic use in elderly patients and the risk of pneumonia

Antipsychotics are frequently and increasingly prescribed off-label for the treatment of behavioral and psychological symptoms associated with dementia, despite their modest efficacy. Instead, the safety profile of antipsychotics has been questioned repeatedly in recent years with various concerns, including death. Meta-analyses of randomized controlled trials found that one of the major causes of death associated with atypical antipsychotics use was pneumonia. Only few observational studies, however, have investigated the risk of pneumonia in elderly patients, especially among those receiving conventional antipsychotics. The aim of this editorial is to synthesize the current evidence from observational studies regarding the risk of pneumonia in elderly patients receiving either conventional or atypical antipsychotics. The studies conducted so far document that the risk of pneumonia is two- to threefold increased in a dose-dependent fashion with both classes compared to nonuse, with a possibly higher risk attributable to atypical antipsychotics. The risk seems to peak at the beginning of treatment (e.g., 7 – 30 days), and dissipates over time for both conventional and atypical antipsychotics. The risk–benefit ratio suggests that there will be 1 excess hospitalization for pneumonia for every 2 – 5 patients receiving any clinical improvement in symptoms. Considering the modest improvement in terms of efficacy, the risks associated with antipsychotics in elderly patients may outweigh their benefit.     

纤维支气管镜在老年人坠积性肺炎治疗中的临床价值

目的探讨纤维支气管镜在老年人坠积性肺炎治疗中的临床价值。方法选取2012年5月至2014年5月在佛山市顺德区乐从医院呼吸内科住院的坠积性肺炎患者100例。根据治疗方案的不同将患者分为治疗组（n=50）和对照组（n=50）。治疗组在常规治疗的基础上,行纤维支气管镜吸痰、灌洗及局部注药,经防污染毛刷取样或收集灌洗液行细菌培养;对照组常规治疗,常规取痰行细菌培养;根据细菌培养及药敏结果调整两组患者抗生素的使用。观察指标：治疗效果、死亡率、细菌培养结果、纤维支气管镜治疗的不良反应、住院时间。结果治疗组总有效率为84％,死亡率为8％;对照组总有效率为64％,死亡率为28％;两组比较差异有统计学意义（P〈0．05）。治疗组细菌培养阳性率为88％,对照组为44％,差异有统计学意义（P〈0．05）。治疗组革兰氏阴性致病菌占82．0％,对照组革兰氏阴性致病菌占86．4％;治疗后,治疗组细菌培养阴转率为86．4％,对照组为45．5％;两组对比,差异有统计学意义（P〈0．05）。治疗组平均住院时间为（18．42±4．77）天,对照组为（23．06±6．08）天,差异有统计学意义（P〈0．05）。纤维支气管镜治疗中未发生严重不良反应。结论应用纤维支气管镜治疗老年人坠积性肺炎效果良好,可降低死亡率,提高致病菌检出率,缩短住院时间,降低住院费用,且是安全的,值得临床推广应用。     

厄他培南治疗老年社区获得性肺炎的临床疗效和安全性

目的评价厄他培南治疗老年社区获得性肺炎的疗效和安全性。方法 100例老年(≥65岁)社区获得性肺炎患者随机分为2组,每组50例。实验组给予注射用厄他培南1.0 g,1次/d,对照组给予莫西沙星注射液400 mg,1次/d,两组疗程均为7～14 d。观察治疗前后两组的临床疗效。结果实验组治疗有效率为92%,细菌清除率为88.9%;对照组治疗有效率为76%,细菌清除率为69.8%;两组间比较差异有统计学意义(P<0.05)。结论厄他培南治疗老年社区获得性肺炎临床疗效良好,不良反应较少,安全性高。     

降钙素原对老年社区获得性肺炎的诊断应用分析

目的探讨降钙素原(PCT)在老年社区获得性肺炎(CAP)中的应用价值。方法选择2016年4月~2017年10月我院165例老年CAP患者,根据其病情严重程度分为普通肺炎组(n=104)与重症肺炎组(n=61),另选同期40例老年健康体检者为对照组,均进行PCT检测,比较三组检测结果,并探析社区获得性肺炎严重程度评分(CURB-65)、肺炎严重指数(PSI)与PCT水平的相关性。结果重症肺炎组、普通肺炎组的PCT水平均显著高于对照组(P<0.05),且其中重症肺炎组的PCT(8.15±3.43)μg/L,明显高于普通肺炎组的(1.60±0.79)μg/L。经Spearman相关性分析发现,165例肺炎患者中PCT水平与CURB-65评分呈正相关(r=0.753,P<0.05),与PSI评分也呈正相关(r=0.668,P<0.05)。结论降钙素原具有检测方便迅速、准确率较高等优点,不仅能够辅助诊断CAP,还可有效反映病患的病情严重程度。     

老年吸入性肺炎76例临床分析

目的探讨老年吸入性肺炎的临床特点,为其临床诊治提供依据。方法选择山东大学千佛山医院收治的76例老年吸入性肺炎患者,回顾性分析其合并基础疾病情况、临床表现、病原学检查及治疗、转归情况。结果绝大部分老年吸入性肺炎患者合并有基础疾病,其中合并神经系统疾病居首位,占65.79%(50/76);痰培养病原学检查前三位分别为为肺炎克雷伯菌(25.49%)、大肠埃希菌(12.75%)、铜绿假单胞菌(11.76%);本组最终死亡率为13.76%,死亡的患者均至少合并3种基础疾病。结论老年吸入性肺炎患者临床表现不具有典型性,宜采用降阶梯疗法并根据药敏结果应用抗生素治疗;对于合并3种以上基础疾病的老年患者,应给予积极治疗。     

营养序贯护理干预在老年患者呼吸机相关性肺炎中的应用效果观察

目的 探究营养序贯护理干预在老年患者呼吸机相关性肺炎中的应用效果.方法 抽取2014年10月至2016年3月本院接收的符合研究选取标准的行机械通气治疗的患者86例,根据护理方案不同分为对照组与研究组,各43例.对照组选用传统分次定量鼻饲干预,研究组实施营养序贯护理干预.统计两组呼吸机相关性肺炎及食管反流发生情况,并对比两组预后情况及干预前后两组营养指标(白蛋白、前白蛋白)水平变化情况.结果 研究组呼吸机相关性肺炎发生率(13.95％)及食管反流发生率(16.28％)均明显低于对照组(39.53％、37.21％),机械通气时间[(9.08±2.09)d]及ICU住院时间[(11.65±1.87)d]均明显少于对照组,差异有统计学意义(均P＜ 0.05).干预前,两组白蛋白及前白蛋白水平对比差异无统计学意义(均P＞ 0.05);经护理干预,研究组各指标水平明显优于对照组,差异有统计学意义(均P＜ 0.05).结论 对行机械通气治疗的老年患者应用营养序贯护理干预效果显著,可有效改善患者机体营养状态及预后情况,降低食管反流及呼吸机相关性肺炎发生率,具有推广价值.     

老年血脂异常治疗进展

老年患者较年轻人有更高的血脂异常发生率,更加需要积极治疗。与欧美人群相比,我国老年人血脂水平升高的幅度较低,以轻到中度为主。RCT研究发现,他汀类药物患者的明确获益从治疗后1~2年即开始获得,其不良反应较年轻患者并未明显增加。充分使用他汀类药物后,血脂不能达标或仍出现心血管疾病事件时,可以加用一些新的降脂药物,研究显示LDL-C水平降得越低,患者越能从中获益。     

老年恶性肿瘤患者并发医院获得性肺炎的临床分析

目的:探讨老年肿瘤患者并发医院获得性肺炎的危险因素。方法:选择南通市老年康复医院并发医院获得性肺炎的老年肿瘤患者50例为观察组,随机选择同时段住院治疗未并发医院获得性肺炎的老年肿瘤患者50例为对照组。从住院时间、肿瘤分期、功能状态评分(PS评分)、糖皮质激素的使用、应用广谱抗菌药物、侵入性操作、手术、放疗/化疗、贫血、中性粒细胞缺乏、血清白蛋白水平、是否合并糖尿病、慢性阻塞性肺病(COPD)、长期吸烟等方面比较两组的差异。结果:住院时间≥30d、肿瘤分期(Ⅲ+Ⅳ期)、贫血、中性粒细胞缺乏、PS评分、血清白蛋白水平<30g/L、COPD病史方面两组比较差异有统计学意义(P<0.01),糖皮质激素的使用、应用广谱抗菌药物、侵入性操作、手术、放疗/化疗、是否合并糖尿病、长期吸烟方面两组比较差异有统计学意义(P<0.05)。结论:多种危险因素可以导致老年肿瘤患者并发医院获得性肺炎感染,应该采取积极有效的预防措施,并进行规范治疗。     

盐酸氨溴索治疗老年社区获得性肺炎的疗效

目的 评价盐酸氨溴索注射液对老年社区获得性肺炎患者的临床疗效及安全性.方法 将50例老年社区获得性肺炎患者随机分成治疗组25例和对照组25例.对照组采取常规性治疗方法,治疗组在常规性治疗方法基础上加用盐酸氨溴索注射液,两组疗程10 d.观察两组临床症状改善起效时间、疗效及不良反应情况.结果 治疗组总有效率（92.00%）显著高于对照组（56.00%）,差异有统计学意义（P＜0.05）.治疗组临床症状改善起效时间（41.32±6.79）h短于对照组（55.49±10.03）h,差异有统计学意义（P＜0.05）.两组均未发生药物相关性不良反应.结论 盐酸氨溴索注射液对老年社区获得性肺炎患者效果显著,是一种安全、有效的祛痰药物.     

莫西沙星序贯治疗老年社区获得性肺炎的药物经济学评价

目的对莫西沙星两种不同给药方案治疗老年社区获得性肺炎进行药物经济学评价。方法将80例患者随机分为莫西沙星序贯治疗组(序贯组)和莫西沙星静脉滴注组(对照组),每组各40例。序贯治疗组给予莫西沙星注射液0.4 g,静脉滴注,1次.d-1,5 d后,病情好转,改为莫西沙星片0.4 g,口服,1次.d-1,总疗程11 d;对照组给予莫西沙星注射液0.4 g,静脉滴注,1次.d-1,总疗程11 d。评价临床疗效及药物经济学。结果序贯组和对照组痊愈率分别为57.5%、62.5%(P0.05),有效率分别为90.0%、92.5%(P0.05),不良反应发生率分别为7.5%、10%(P0.05)。序贯治疗组的成本-效果比为2 000.0,低于对照组(3 864.9)。结论莫西沙星序贯治疗老年社区获得性肺炎疗效高、安全、经济。     

莫西沙星治疗社区获得性肺炎老年患者的疗效观察

目的观察莫两沙星治疗社区获得性肺炎（CAP）老年患者的疗效和安全性。方法64例CAP老年患者随机分为治疗组（n=33）和对照组（n=31）。治疗组静脉滴注莫西沙星一日1次400mg,对照组静脉滴注左氧氟沙星一日1次500mg,疗程均为7d．。观察两组的总有效率及细菌清除率。结果治疗组和对照组的总有效率分别为90．9％和71．0％,细菌清除率分别为87．9％和64．5％,两组比较差异有统计学意义（P〈0．05）。两组不良反应发生率差异无统计学意义。结论莫两沙星治疗CAP老年患者安全有效,值得临床推广。     

老年脑血管病患者吸入性肺炎的预防

目的：探讨老年脑血管病患吸入性肺炎的预防方法。方法：对32例严重吞咽障碍并发生过吸入性肺炎和（或）窒息的老年脑血管病患，置鼻胃管加抗反流治疗，观察能否有效预防吸入性肺炎和窒息的发生。结果32例患经置鼻胃管加 治疗后，均未再出现吸入性肺炎和窒息。结论：置处管加抗反流治疗能有效预防老年脑血管病患吸入性肺炎和窒息的发生，而且经济、实用、安全。     

Treatment of chronic hepatitis C in elderly patients

Importance of the field: The issue of age in cases of chronic hepatitis C (HCV) in the West is a major problem; the average age of patients with HCV is increasing and its prevalence increases with advancing age.

Areas covered in this review: This review is devoted to the analysis of the limited number of clinical studies performed to treat HCV in elderly patients.

What the reader will gain: The importance of the age factor is outlined in nearly all the studies done in the field. Advanced age is associated with a lower sustained virologic response (SVR) rate. Moreover, in elderly patients, these studies also tend to suggest that, before initiating an antiviral treatment, the physician should not only take into account the classical parameters associated with SVR but also the presence of co-morbidities and life expectancy.

Take-home messages: Antiviral therapy should be used in selected elderly HCV patients with advanced fibrosis and more studies are required in this population to better define the parameters associated with SVR. As age is an important factor in the success of antiviral therapy, starting antiviral treatment at a young age should be favored.     

黄芩苷胶囊治疗医院获得性肺炎的临床观察

目的:探讨在常规抗感染基础上联合黄芩苷胶囊对医院获得性肺炎(HAP)的治疗效果。方法:将60例HAP患者按随机数字法分为对照组和治疗组。对照组先给予美洛西林舒巴坦抗感染治疗,再根据临床症状变化及培养结果选用敏感抗生素治疗。治疗组在对照治疗基础上加用黄芩苷胶囊治疗,对比两组患者炎性介质、细菌清除率及疗效。结果:在第2天及第4天,黄芩苷治疗组白介素-6(IL-6)及肿瘤坏死因子-α(TNF-α)水平均明显低于对照组(P<0.05)。治疗组共分离出细菌25株,清除22株,清除率为88.0%;对照组分离出细菌27株,清除21株,清除率为77.8%,治疗组细菌清除率明显高于对照组(P<0.05)。治疗组总有效率为90.0%,对照组为83.3%,虽然治疗组痊愈比例及总有效率有增加趋势,但两组间比较差异无统计学意义(P>0.05)。结论:黄芩苷胶囊联合常规抗感染治疗能够减轻HAP早期炎症反应,促进致病菌清除,对HAP有治疗作用。     

老年吸入性肺炎的临床特点分析

目的探讨老年吸入性肺炎的临床特征及防治对策,提高救治率。方法选择天津市红桥医院脑系科及ICU收治的80例老年吸入性肺炎患者,回顾性分析其合并基础疾病情况、发病机制、临床表现、病原学检查及预防治疗措施、转归情况。结果老年吸入性肺炎患者多合并有慢性基础疾病,其中合并神经系统疾病居首位。临床主要表现为精神萎糜、意识障碍30例(占37.50%),其他包括发热、咳嗽、咳痰、呼吸困难、休克等,双肺可闻及干湿性啰音58例(占72.50%),痰培养阳性54例(占67.50%),多为革兰阴性杆菌(如大肠埃希菌、铜绿假单胞菌、肺炎克雷伯菌)、厌氧菌、金黄色葡萄球菌、肺炎链球菌等,且多为厌氧菌和需氧菌混合感染;80例患者中治愈18例,好转47例,死亡15例,死亡率为18.75%,死亡病例均合并3种及以上基础疾病。结论老年吸入性肺炎临床表现不典型,合并症多,死亡率高,应积极防治,宜采用降阶梯疗法并根据病原学检测及药敏结果合理选择抗菌药物治疗。     

32例老年肺炎患者抗生素合理用药的临床效果研究

目的 探讨老年肺炎患者临床中使用抗生素的特点以及合理用药情况,提出用药建议,以便于指导临床具体实践.方法 选取本院2016年6月至2017年1月期间收治的老年肺炎患者32例,利用回顾性分析方法,针对所研究对象的抗生素使用情况进行统计分析,以判断临床用药的合理性,总结出控制耐药性发生的方法,提高临床老年肺炎治愈率.结果 针对老年肺炎的患者临床抗生素使用种类达到16种,同时还搭配了具有抗菌效应的中药制剂,普遍利用联合用药方案,临床治愈率达37.5％,好转率为62.5％.结论 对于老年肺炎患者的抗生素使用应该选取高效、高敏的药物,主要依据病原学检查以及药敏试验结果,同时严格遵循药物代谢动力学以及药效学,针对不良反应进行合理的用药,切实有效实施药物监护,力争最佳疗效.