病毒性肺炎

2019年12月,新型冠状病毒肺炎在湖北省武汉市暴发。目前,疫情仍在持续,且有全球蔓延趋势。冬、春季节为病毒性肺炎的高发时期,而呼吸道病毒是成人获得性肺炎的重要病原体,近年来,高致病性病毒性肺炎的数次暴发使人们意识到其诊治的难度及重要性。本文就病毒性肺炎病原学、致病机制、临床特征、诊断及治疗进展和预防与控制作一综述。     

Association between sarcopenia and pneumonia in older people

Pneumonia is a major cause of death in older people, and the number of such deaths is increasing. Present guidelines for pneumonia management are based on a pathogen‐oriented strategy that relies on the optimal application of antibiotics. Older pneumonia inpatients show the high incidence of aspiration pneumonia. The main cause of aspiration pneumonia is an impairment in the swallowing and cough reflexes. These facts suggest a limitation of present management strategies and a requirement for new strategies for aspiration pneumonia. Sarcopenia is the loss of muscle strength and mass, and declining physical function with aging. Recently, a decrease in the mass or strength of the swallowing muscles was suggested to be associated with reduced swallowing function. Accordingly, dysphagia caused by sarcopenia of the systemic and swallowing‐related muscles was named sarcopenic dysphagia. Presently, few studies have shown associations between aspiration pneumonia and sarcopenic dysphagia. As for the cough reflex, strong cough prevents aspiration pneumonia, and its strength is regulated by respiratory muscles. A few studies have reported a relationship between muscles and pneumonia in older people. Sarcopenia is a risk factor for pneumonia in older people, and aspiration pneumonia inpatients with low muscle mass show high mortality rates. Aspiration pneumonia induced muscle atrophy in respiratory, swallowing, and skeletal muscles in an animal model and humans. Associations between respiratory muscle strength and pneumonia are currently under investigation. Evaluation and management of sarcopenia could potentially become a new strategy to prevent and treat pneumonia in older patients, and research has only recently been launched. Geriatr Gerontol Int 2020; 20: 7–13 .     

Community‐acquired pneumonia management and outcomes in the era of health information technology

Pneumonia continues to be a leading cause of hospitalization and mortality. Implementation of health information technology (HIT) can lead to cost savings and improved care. In this review, we examine the literature on the use of HIT in the management of community‐acquired pneumonia. We also discuss barriers to adoption of technology in managing pneumonia, the reliability and quality of electronic health data in pneumonia research, how technology has assisted pneumonia diagnosis and outcomes research. The goal of using HIT is to develop and deploy generalizable, real‐time, computerized clinical decision support integrated into usual pneumonia care. A friendly user interface that does not disrupt efficiency and demonstrates improved clinical outcomes should result in widespread adoption.     

Treatment with mesenchymal stromal cells is a risk factor for pneumonia-related death after allogeneic hematopoietic stem cell transplantation

We performed a retrospective cohort study to find out whether the use of reduced‐intensity conditioning (RIC) might reduce the risk of early death from pneumonia. Pneumonia‐associated deaths were evaluated in 691 hematopoietic stem cell transplantation (HSCT) patients. The majority had a hematological malignancy (n = 504) and an HLA‐matched donor (n = 584). RIC was given to 336 patients and myeloablative conditioning (MAC) to 355. Data concerning radiology, culture and autopsy results were evaluated together with risk factors for death related to pneumonia within or after 100 d after HSCT (early and overall pneumonia). In 60 patients, pneumonia contributed to death (early n = 17). The cumulative incidence of early pneumonia‐related death was 2.8% and 2.1% in MAC and RIC patients, respectively. The cumulative incidence of overall pneumonia‐related death was 8.2% and 10.5%, respectively. In 40 patients, (67%) an etiology could be established, with 19 patients having proven or probable mold infection. In the multivariate analyses, acute graft‐versus‐host disease (GVHD) grades II–IV, cytomegalovirus (CMV) infection and having received mesenchymal stromal cells (MSCs) were factors associated with overall pneumonia‐related death. Bacteremia and a previous HSCT were associated with early pneumonia‐related death. RIC did not reduce the incidence of early death associated with pneumonia. Acute GVHD II–IV, CMV infection and MSC treatment were factors associated with pneumonia‐related death. Mold infection was the most common contributor to pneumonia‐related death in HSCT patients.     

Early onset pneumonia in patients with cholinesterase inhibitor poisoning

Background and objective: Organophosphates and carbamates are potent cholinesterase inhibitors that are widely used as insecticides in agriculture. Pneumonia is a frequent complication of cholinesterase inhibitor poisoning (CIP) and a risk factor for death. The aim of this retrospective study was to assess the risk factors for pneumonia in patients with CIP. Methods: The medical records of 155 patients, who were treated for CIP in a 1300‐bed medical centre in central Taiwan, from January 2002 to December 2004, were retrospectively analysed. Pneumonia was diagnosed by a new or persistent infiltrate on CXR, as well as clinical symptoms. Demographic data, comorbidities, acute respiratory failure and in‐hospital mortality were also recorded. Results: Of the 155 patients, 31 (20%) died and 92 (59.4%) developed acute respiratory failure. Thirty‐four patients (21.9%) were diagnosed with early onset pneumonia during hospitalization. Acute respiratory failure (OR 12.10, 95% CI: 2.55–57.45), underlying cardiovascular disease (OR 3.02, 95% CI: 1.02–8.91), undergoing gastric lavage at peripheral hospitals (OR 6.23, 95% CI: 1.52–25.98) and development of respiratory failure at the study centre after gastric lavage (OR 3.43, 95% CI: 1.17–10.0) were predictive factors for early onset pneumonia. Cardiopulmonary resuscitation (OR 23.58, 95% CI: 6.03–92.29), early onset pneumonia (OR 7.45, 95% CI: 2.02–27.5) and lower Glasgow coma score (OR 1.26, 95% CI: 1.08–1.48) were predictive factors for mortality. Conclusions: Pneumonia was a significant risk factor for death in patients with CIP. In addition to aggressive management of patients with CIP who develop respiratory failure, careful respiratory evaluation before and after gastric lavage would help to decrease the incidence of early onset pneumonia in patients with CIP.     

Consensus statement on the management of methicillin‐resistant Staphylococcus aureus nosocomial pneumonia in Asia

Nosocomial pneumonia (NP; encompassing hospital‐acquired, health care‐associated and ventilator‐associated pneumonia) is one of the most common nosocomial infections and is associated with a mortality rate of 18.7%–40.8% in Asian countries. The burden of methicillin‐resistant Staphylococcus aureus (MRSA) infections in Asia is high, and approximately 13% of NP cases in Asia are caused by this pathogen. Evidence regarding optimal management of MRSA NP continues to evolve and is complicated by the fact that a significant proportion of cases are likely to be caused by isolates with reduced susceptibility to the main therapeutic agent, vancomycin. The Asian Consensus Taskforce on MRSA Nosocomial Pneumonia has developed this statement to provide consensus points on diagnosis, antimicrobial treatment and prevention strategies for MRSA NP in the Asian context, based on our review of Asian data, previous international guidelines and recent scientific evidence.     

儿童肺炎支原体肺炎治疗进展

肺炎支原体肺炎是学龄儿童常见的一种肺炎,婴幼儿也可发生.虽然肺炎支原体感染有一定的自限性,但近年来难治性肺炎支原体肺炎的出现,使肺炎支原体肺炎治疗面临巨大挑战,如何合理治疗肺炎支原体肺炎,对儿童健康的恢复具有重要意义.肺炎支原体肺炎的治疗包括有效抗菌药物、免疫调节及支气管镜等,应根据患儿不同的病情进展情况采取相应的治疗方案.     

Pneumonia in severely malnourished children in developing countries – mortality risk, aetiology and validity of WHO clinical signs: a systematic review

Objectives To quantify the degree by which moderate and severe degrees of malnutrition increase the mortality risk in pneumonia, to identify potential differences in the aetiology of pneumonia between children with and without severe malnutrition, and to evaluate the validity of WHO‐recommended clinical signs (age‐specific fast breathing and chest wall indrawing) for the diagnosis of pneumonia in severely malnourished children. Methods Systematic search of the existing literature using a variety of databases (Medline, EMBASE, the Web of Science, Scopus and CINAHL). Results Mortality risk: Sixteen relevant studies were identified, which universally showed that children with pneumonia and moderate or severe malnutrition are at higher risk of death. For severe malnutrition, reported relative risks ranged from 2.9 to 121.2; odds ratios ranged from 2.5 to 15.1. For moderate malnutrition, relative risks ranged from 1.2 to 36.5. Aetiology: Eleven studies evaluated the aetiology of pneumonia in severely malnourished children. Commonly isolated bacterial pathogens were Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pneumoniae, Escherichia coli, and Haemophilus influenzae. The spectrum and frequency of organisms differed from those reported in children without severe malnutrition. There are very few data on the role of respiratory viruses and tuberculosis. Clinical signs: Four studies investigating the validity of clinical signs showed that WHO‐recommended clinical signs were less sensitive as predictors of radiographic pneumonia in severely malnourished children. Conclusions Pneumonia and malnutrition are two of the biggest killers in childhood. Guidelines for the care of children with pneumonia and malnutrition need to take into account this strong and often lethal association if they are to contribute to the UN Millennium Development Goal 4, aiming for substantial reductions in childhood mortality. Additional data regarding the optimal diagnostic approach to and management of pneumonia and malnutrition are required from regions where death from these two diseases is common.     

CORB is the best pneumonia severity score for elderly hospitalised patients with suspected pneumonia

Pneumonia severity scoring systems have been developed to identify patients at highest mortality risk, and are used in guidelines to limit use of broad‐spectrum antibiotics to patients with severe community‐acquired pneumonia. A retrospective audit of hospitalised general internal medicine patients with pneumonia was performed to assess the diagnostic performance of various pneumonia severity scores in an elderly general internal medicine population.     

Stopping tuberculosis in the 21st century: Goals and strategies

The Stop TB Strategy and the Global Plan to Stop TB were launched in 2006 to achieve the tuberculosis (TB)‐related Millennium Development Goals and the Stop TB Partnership targets, and to address new challenges such as that of HIV‐associated TB and multi‐drug‐resistant TB. This paper reviews the historical and recent progress in TB control to show what has changed since the introduction of directly observed therapy (DOTS) in the mid‐1990s, why we needed the new strategy and what the global agenda is today. Major progress was seen in most countries in the last two decades. Globally, the estimated rates of TB prevalence and mortality are declining, but not quickly enough to reach the 2015 Stop TB Partnership targets of halving TB prevalence and death rates compared with 1990. In 2007, it was estimated that more than one‐third of TB patients were not detected or properly treated under proper conditions. Enhancing case detection, while maintaining high treatment success rates, is essential to achieve the 2015 targets. The ultimate goal of TB control is the elimination of the disease as a public health problem. The Stop TB Partnership aims at eliminating TB by 2050 by reaching a global incidence of disease of less than one case per million population. This target will not be achieved unless TB control efforts are further intensified and effective and affordable new technologies to prevent both disease and infection are developed and rapidly introduced in all countries worldwide.     

Health care‐associated pneumonia in haemodialysis patients: Clinical outcomes in patients treated with narrow versus broad spectrum antibiotic therapy

Background and objective: Although the 2005 American Thoracic Society/Infectious Disease Society of America antibiotic guidelines classify pneumonia occurring in patients receiving chronic haemodialysis as health care‐associated pneumonia (HCAP), and thus recommend treatment with broad‐spectrum antibiotics for these patients, little data support this classification. We compared clinical outcomes in haemodialysis patients hospitalized with pneumonia, who were treated with broad‐spectrum antibiotics versus narrow‐spectrum antibiotics. Methods: One hundred twenty‐five haemodialysis patients with pneumonia met eligibility criteria. Categorization into the community‐acquired pneumonia (CAP) group or HCAP group was based on antibiotic therapy patients received. Time to oral therapy, time to clinical stability, length of stay and mortality were compared. Results: CAP and HCAP patients did not differ in Pneumonia Severity Index and Charlson Comorbidity index scores, but HCAP patients were more likely to meet criteria for severe pneumonia. Patients treated with HCAP therapy had a significantly longer time to oral therapy than CAP patients (9.2 vs 3.2 days, P < 0.001) and a significantly longer length of stay (11.9 vs 5.1 days, P < 0.001). Time to clinical stability was marginally longer in the HCAP group (3.1 vs 2.4 days, P = 0.07). Patients treated with HCAP therapy had longer continuation of intravenous antibiotics after reaching clinical stability (5.5 vs 0.78 days, P < 0.001). Conclusions: This study is the first to our knowledge to describe clinical outcomes in patients with haemodialysis as their only HCAP risk factor. Narrow‐spectrum antibiotics may be safe in haemodialysis patients with no other HCAP risk factors. HCAP therapy delayed de‐escalation to oral antibiotics was associated with increased duration of intravenous antibiotics and length of stay.     

Fatal BK virus pneumonia following stem cell transplantation

We report the case of a 39‐year‐old male patient who died of severe BK virus (BKV) pneumonia 168 days after hematopoietic stem cell transplantation (HSCT) for acute lymphoblastic leukemia. After suffering from BKV‐associated late‐onset hemorrhagic cystitis (HC) with long‐term sustained BKV viremia, he died of rapidly progressive pneumonia. On autopsy, numerous viral intranuclear inclusions were seen in his lungs and bladder. An immunohistochemical examination of his lungs was positive for simian virus 40. Based on these pathological results and the high sustained BKV viral load in his blood, we reached a diagnosis of BKV pneumonia. Viral infection can occasionally become life threatening among HSCT recipients. It is widely known that BKV can cause late‐onset HC, but BKV‐associated pneumonia is rare. Because of its rapid progression and poor prognosis, it is difficult to make an antemortem diagnosis of BKV pneumonia. A treatment strategy for BKV pneumonia also needs to be formulated. Similar to other viral pathogens, BKV can cause pneumonia and the clinician should therefore be aware of it in immunocompromised patients.     

Prospective comparison of three validated prediction rules for prognosis in community-acquired pneumonia

PURPOSE: We assessed the performance of 3 validated prognostic rules in predicting 30-day mortality in community-acquired pneumonia: the 20 variable Pneumonia Severity Index and the easier to calculate CURB (confusion, urea nitrogen, respiratory rate, blood pressure) and CURB-65 severity scores. SUBJECTS AND METHODS: We prospectively followed 3181 patients with community-acquired pneumonia from 32 hospital emergency departments (January-December 2001) and assessed mortality 30 days after initial presentation. Patients were stratified into Pneumonia Severity Index risk classes (I-V) and CURB (0-4) and CURB-65 (0-5) risk strata. We compared the discriminatory power (area under the receiver operating characteristic curve) of these rules to predict mortality and their accuracy based on sensitivity, specificity, predictive values, and likelihood ratios. RESULTS: The Pneumonia Severity Index (risk classes I-III) classified a greater proportion of patients as low risk (68% [2152/3181]) than either a CURB score <1 (51% [1635/3181]) or a CURB-65 score <2 (61% [1952/3181]). Low-risk patients identified based on the Pneumonia Severity Index had a slightly lower mortality (1.4% [31/2152]) than patients classified as low-risk based on the CURB (1.7% [28/1635]) or the CURB-65 (1.7% [33/1952]). The area under the receiver operating characteristic curve was higher for the Pneumonia Severity Index (0.81) than for either the CURB (0.73) or CURB-65 (0.76) scores (P <0.001, for each pairwise comparison). At comparable cut-points, the Pneumonia Severity Index had a higher sensitivity and a somewhat higher negative predictive value for mortality than either CURB score. CONCLUSIONS: The more complex Pneumonia Severity Index has a higher discriminatory power for short-term mortality, defines a greater proportion of patients at low risk, and is slightly more accurate in identifying patients at low risk than either CURB score.     

The cost of outpatient pneumonia in children <5 years of age in Fiji

Objectives Pneumonia is the most common reason for visiting an outpatient facility among children <5 years old in Fiji. The objective of this study is to describe for the first time the costs associated with an episode of outpatient pneumonia in Fiji, in terms of cost both to the government health sector and to the household. Methods Costs were estimated for 400 clinically diagnosed pneumonia cases from two outpatient facilities, one in the capital, Suva, and one in a peri‐urban and rural area, Nausori. Household expenses relating to transport costs, treatment costs and indirect costs were determined primarily through structured interview with the caregiver. Unit costs were collected from a variety of sources. Patient‐specific costs were summarised as average costs per facility. Results The overall average societal cost associated with an episode of outpatient pneumonia was $18.98, ranging from $14.33 in Nausori to $23.67 in Suva. Household expenses represent a significant proportion of the societal cost (29% in Nausori and 45% in Suva), with transport costs the most important household cost item. Health sector expenses were dominated by personnel costs at both sites. Both the average total household expenses and the average total health sector expenses were significantly greater in Suva than Nausori. Conclusions A single episode of outpatient pneumonia represents a significant cost both to the government health sector and to affected households. Given the high incidence of this disease in Fiji, this places a considerable burden on society.     

Desquamative interstitial pneumonia may progress to lung fibrosis as characterized radiologically

Background and objective: In some patients, desquamative interstitial pneumonia may progress to lung fibrosis. The aim of this study was to assess the long‐term radiological follow‐up results in patients with desquamative interstitial pneumonia. Methods: Among 75 patients suspected of having desquamative interstitial pneumonia, 31 who fulfilled the criteria were included in this study. Clinical characteristics at presentation, responses to treatment and long‐term follow‐up were evaluated. Results: The 31 patients were predominantly males (94%), and the mean age was 55 years; 93% (28/30) had a history of smoking. The clinical findings included high serum levels of lactate dehydrogenase and immunoglobulin G. Bronchoalveolar lavage (26 patients, 84% of cases) frequently showed an increased percentage of eosinophils (mean 17%). Computed tomography (CT) or high resolution (HR) CT at presentation showed ground glass opacities and/or consolidation in all patients, with one third of patients also showing thin‐walled cysts within the ground glass opacities. There was no honeycombing on CT or HRCT scans at presentation. Corticosteroid therapy was effective early in the course of the disease; long‐term follow‐up (mean 99 months) of 31 patients showed only one death due to progression of the disease, but long‐term follow‐up of 14 patients (mean 125 months) by HRCT showed the development of new thin‐walled cysts and honeycombing in five and lung cancer in four patients, respectively. Conclusions: In a proportion of patients, desquamative interstitial pneumonia may progress to lung fibrosis with honeycombing on HRCT, despite therapy.     

Defining severe pneumonia

Pneumonia is an important clinical and public health problem. Identification and prediction of severe pneumonia are significant concerns. Attempts to define severe pneumonia should recognize that different purposes are served by different definitions; no single definition meets all needs. At present, several prediction models have been proposed or validated. Biomarkers are not yet ready for routine use. The authors recommend careful consideration of the implications of any given definition of pneumonia severity. Outcome studies are needed to integrate human and health care system factors with the application of pneumonia severity definitions.     

Australasian respiratory and emergency physicians do not use the pneumonia severity index in community‐acquired pneumonia

Background and objective: The value of community‐acquired pneumonia (CAP) severity scoring tools is almost exclusively reliant upon regular and accurate application in clinical practice. Until recently, the Australasian Therapeutic Guidelines has recommended the use of the Pneumonia Severity Index (PSI) in spite of poor user‐friendliness. Methods: Electronic and postal survey of respiratory and emergency medicine physician and specialist registrar members of the Royal Australasian College was undertaken to assess the use of the PSI and the accuracy of its application to hypothetical clinical CAP scenarios. The confusion, urea, respiratory rate, blood pressure, age 65 or older (CURB‐65) score was also assessed as a simpler alternative. Results: Five hundred thirty‐six (228 respiratory, 308 emergency) responses were received. Only 12% of respiratory and 35% of emergency physicians reported using the PSI always or frequently. The majority were unable to accurately approximate PSI scores, with significantly fewer respiratory than emergency physicians recording accurate severity classes (11.8% vs 21%, OR 0.50, 95% CI: 0.37–0.68, P < 0.0001). In contrast, significantly more respiratory physicians were able to accurately calculate the CURB‐65 score (20.4% vs 15%, OR 1.45, 95% CI: 1.10–1.91, P = 0.006). Conclusions: Australasian specialist physicians primarily responsible for the acute management of CAP report infrequent use of the PSI and are unable to accurately apply its use to hypothetical scenarios. Furthermore, respiratory and emergency physicians contrasted distinctly in their use and application of the two commonest severity scoring systems—the recent recommendation of two further alternative scoring tools by Australian guidelines may add to this confusion. A simple, coordinated approach to pneumonia severity assessment across specialties in Australasia is needed.     

Body mass index and risk of pneumonia: a systematic review and meta‐analysis

The aims of our meta‐analysis were to examine the pattern and gender's influence on body mass index (BMI) – pneumonia relationship. Published studies were searched from PubMed, Web of Science, Cochrane Library databases using keywords of pneumonia, BMI and epidemiologic studies. Random‐effects analysis was applied to estimate pooled effect sizes from individual studies. The Cochrane Q‐test and index of heterogeneity (I²) were used to evaluate heterogeneity, and Egger's test was used to evaluate publication bias. Random‐effects meta‐regression was applied to examine the pattern and gender's influence on BMI–pneumonia relationship. A total of 1,531 studies were initially identified, and 25 studies finally were included. The pooled relative risk (RR) and meta‐regression model revealed a J‐shaped relationship between BMI and risk of community‐acquired pneumonia (underweight, RR 1.8, 95% confidence interval [CI], 1.4–2.2, P < 0.01; overweight, 0.89, 95%CI, 0.8–1.03, P, 0.1; obesity, 1.03, 95% CI, 0.8–1.3, p. 8) and U‐shaped relationship between BMI and risk of influenza‐related pneumonia (underweight, RR 1.9, 95% CI, 1.2–3, P < 0.01; overweight, 0.89, 95% CI, 0.79–0.99, P, 0.03; obesity, 1.3, 95% CI, 1.05–1.63, p. 2; morbidity obesity, 4.6, 95% CI, 2.2–9.8, P < 0.01); whereas, no difference in risk of nosocomial pneumonia was found across the BMI groups. Gender difference did not make significant contribution in modifying BMI–pneumonia risk relationship.