內(nèi)科學教學課件：13 Pneumonia （肺炎）

RespiratoryDiseases

Pneumonia（肺炎）Pneumonia-Isitleadingcauseofdeathinantibioticera?2023/12/10Dr.BijieHU32023/12/10Dr.BijieHU4SevereAcuteRespiratorySyndrome(SARS)2023/12/10Dr.HUBijie5廣東省中醫(yī)院二沙分院急診科護士長

葉欣武警北京總隊醫(yī)院內(nèi)二科主治醫(yī)師李曉紅

HAPVAP2023/12/10Dr.HUBijie6Pneumoniaisnot the“captainofdeath” anymore?MortalityTrendswithPneumoniafrom1900to2000inUSA2012年全球前十位死亡原因2023/12/10Dr.BijieHU8Definition&Classificationsof

Pneumonia2023/12/10Dr.HUBijie10Whatispneumonia?Tothepathologistaninfectionofthealveoli,distalairways,andinterstitiumofthelungincreasedweightofthelungs,consolidationalveolifilledwithWBC,RBC,andfibrinTotheclinicianfever,chills,cough,pleuriticchestpain,sputumproduction,hyper-orhypothermia,increasedrespiratoryrate,dullnesstopercussion,bronchialbreathing,egophony,crackles,wheezes,pleuralfrictionrubopacityonchestradiography2023/12/10Dr.HUBijie11DefinitionPneumoniaistheinflammationoflowerrespiratorytractsincludingalveoli,interstitialtissues,andbronchiolebythemicroorganisms,chemicalirritationsorbyanimmunologicalprocess

2023/12/10Dr.HUBijie12Classifications?LobarPneumonia

Congestion,redhepatization,grayhepatization,resolutionBronchopneumonia

apatchyconsolidationinvolvingoneorseverallobesInterstitialPneumonia

inflammatoryprocesspredominantlyinvolvingtheinterstitium,includingthealveolarwallsandtheconnectivetissuearoundthebronchovasculartreeMiliaryPneumonia

Original:diffuselydistributed2-to3-mmlesionsofhematogenoustuberculosistomilletseedscurrent:numerousdiscretelesionsresultingfromthespreadofthepathogentothelungsviathebloodstreamCAPvsHAPCommunity-acquiredpneumoniatreatedinanambulatoryadmissiontothehospitalHospital-acquiredpneumonia(Healthcare-associatedpneumonia)(nosocomialpneumonia)non-ventilator-associatedventilator-associatedVentilatorAssociatedPneumonia(VAP)

NursingHomeAcquiredPneumonia(NHAP)

Long-term-carefacilities(LTCFs)

Health-careAssociatedPneumonia(HCAP)

2023/12/10Dr.HUBijie13Classifications&TerminologyAcute,subacute,chronicMild,moderate,severeInfectionsvs.noninfectionsTypicalvs.Atypical(Mycoplasma,Chlamydia,Legionella)Bacterial,viral,fungal,parasitic(tuberculosis)Immune-compromisedvs.immune-competent

Immune-compromisedHostPneumonia(ICHP)ClinicalandEtiologicalDiagnosisof

Pneumonia2023/12/10Dr.HUBijie16Diagnosis－ClinicalFever>380CNewcough,±sputum,hemoptysis+PleuriticchestpainWBC>10×109or<4×109Rales(crackles),rhonchi,wheezingNeworevolvinginfiltrateonchestradiographHigh-resolutioncomputedtomography(CT)2023/12/10Dr.HUBijie17MedicalImagingChestPlainX-rayfilm(CXR)ComputedTomography(CT)scan infiltrate,consolidation,bronchograms……UltrasoundImagingMagneticresonanceimaging(MRI)

胸部CT是肺部感染病原診斷的“眼睛”2023/12/10Dr.BijieHU182023/12/10Dr.HUBijie19Diagnosis－

MicrobiologicalPleuralfluid&bloodSputumstainsandculture: (washing,quantitation,cytologicalscreening)collectedbyexpectorationSimilar:bynasotracheal,orotrachealaspirate

Lowerrespiratorysecrets(LRTsterilebutURT,mouthandnose,colonisedbylargenumbersofdifferentbacteria)Transtrachealaspiration,TTAEndotrachealaspiration,ETAProtectedspecimenbrush,PSBBronchialalveolarlavage,BALLungaspiration,LA2023/12/10Dr.HUBijie20Gram'sstainofexpectoratedsputumSensitivityandspecificityvarywidelyCytologicalscreening>25neutrophilsand<10squamousepithelialcellsperlowpowerfieldnotevaluatedforLegionella,mycobacteriaorviralinfectionsDirectstainingdiagnosticforMycobacteriumsp.EndemicfungiLegionellasp.(DFAstain)P.carinii2023/12/10Dr.BijieHU212023/12/10Dr.HUBijie222023/12/10Dr.HUBijie23DETECTIONOFANTIGENSOFPULMONARYPATHOGENSINURINEL.pneumophilaserogroup1antigen

S.pneumoniaeurinaryantigen

SEROLOGY

M.pneumoniaeC.pneumoniaeChlamydiapsittaciLegionellaspp.C.burnetiiadenovirus,parainfluenzaviruses,influenzavirusA.

POLYMERASECHAINREACTIONDNAofLegionellaspp.,M.pneumoniae,andC.pneumoniae2023/12/10Dr.BijieHU242023/12/10Dr.BijieHU2517種社區(qū)肺炎常見病原體，我國多數(shù)醫(yī)院微生物實驗室，只具有檢出2-4種病原體的能力！2014年Davidson內(nèi)科教科書，羅列17種社區(qū)肺炎的常見病原體。按照目前的相關政策，先進的微生物檢驗技術，不能有效引入臨床使用，中國對感染病的病原學診斷，與國際先進技術差距越來越大，今后相當長的時間內(nèi)，經(jīng)驗性用藥仍“大行其道”，抗生素選擇壓力和誘導耐藥問題，不能根本扭轉和解決，耐藥菌問題，必定會越演越烈！ 2023/12/10Dr.BijieHU26/thread-145724-1-1.html【案例7】男47，咳嗽、黃痰、氣促、發(fā)熱2012.8.17胸部CT痰培養(yǎng)8.17痰培養(yǎng)：煙曲霉1+8.20痰培養(yǎng)：煙曲霉1+8.28痰培養(yǎng)：煙曲霉1+9.3痰培養(yǎng)：曲霉菌屬1+9.6痰培養(yǎng)：煙曲霉1+痰抗酸染色及結核培養(yǎng)8.17痰抗酸染色、結核培養(yǎng)：-8.20痰抗酸染色：-8.28痰抗酸染色、結核培養(yǎng)：-9.6痰抗酸染色：-血清學檢測8.17九聯(lián)檢：-8.21G試驗：<108.21GM試驗：-8.21乳膠凝集試驗：-8.21T-spot：-8.21肺炎支原體：-9.18G試驗：15.232023/12/10Dr.BijieHU29【案例4】咳嗽、高熱12天，伴氣急、痰血雙肺片狀模糊影，邊界不清，內(nèi)密度不均，可見支氣管充氣征，左側少量胸腔積液入院診治過程2002.1.16血清軍團菌抗體：1:16(可疑陽性)2002.1.16更改抗感染方案：紅霉素靜滴0.5g靜滴，q8h×20d。次日體溫降至38，第3日后基本降至正常。2002.1.17胸部CT：雙肺片狀模糊影，邊界不清，內(nèi)密度不均，可見支氣管充氣征，左側少量胸腔積液。2002.1.20軍團菌培養(yǎng)：米克戴德軍團菌。2002.1.25胸片隨訪：片狀模糊影，較前吸收2002.1.31血清軍團菌抗體：1:64（升高四倍）紅霉素治療2周，1月后復查，兩肺炎癥基本吸收。2023/12/10Dr.HUBijie302013.10.15我院胸部CT顯示：兩肺支氣管擴張伴少許炎癥【案例13】男，24歲，反復咳嗽伴痰中帶血1年2013.11.7廣東省廣州市中山醫(yī)學院病原學診斷中心寄生蟲全套+旋毛蟲+廣圓線蟲+絲蟲檢查：肺吸蟲（+），裂頭蚴（+）Howtotreat

Pneumoniawisely?我會想到….如何選擇抗菌藥物？給藥途徑？療程？是否住院？費用？2023/12/10Dr.HUBijie34肺炎的臨床正確處置，您覺得應包括哪些方面？2023/12/10Dr.HUBijie352023/12/10Dr.HUBijie36MeehanTP,etal.JAMA1997;278:2080-2084.PneumoniaMQISProjectDatesofdiscoveryofdistinctclassesofantibacterialdrugsANTIMICROBIALRESISTANCEGlobalReportonsurveillance2014Community-acquiredPneumonia(CAP)CAP是全美第六位的致死原因是感染性疾病主要的致死原因200萬-300萬/年CAP患者500,000CAP患者/年需入院治療45,000人/年因CAP死亡用于治療的費用：210億美元BartlettJGetal.ClinInfectDis.2000;31:347-382;MarstonBJetal.ArchInternMed.1997;157:1709-1718.美國CAP流行病學，中國呢？2023/12/10Dr.HUBijie40EpidemiologyIncidence

5~10/1,000/year6thleadingcauseofdeathinU.S.Numberoneamongtheinfectiousdiseases5.6millionpatientsannuallyinUSMortalityOPD1-5%Inpatients25%ICU50-60%2023/12/10Dr.HUBijie41Etiologyandantimicrobialresistanceofcommunity-acquired

pneumonia（CAP）inadultpatientsinChinaTAOLi-li,HUBi-jie,HELi-xian,et

al.

ChineseMedicalJournal2012;125(17):2967-29722023/12/10Dr.HUBijie42ManifestationSystematicoftenprecededbyaURIsuddenonset,shakingchill,Feverother:nausea,vomiting,malaise,andmyalgiasLocalpainwithbreathingontheaffectedside(pleurisy)Cough：(dryinitiallybutusuallybecomesproductive,dyspnea,andsputumproduction）SignT:38°~40.5°;pulseisusually100to140beats/min;respirationsaccelerateto20to45breaths/min.lobarconsolidation;crackles;pleuraleffusion2023/12/10Dr.HUBijie43Independentriskfactorsalcoholism(RR9)asthma(RR4.2)immunosuppression(RR1.9)ageof>70years(RR1.5vs.anageof60to69years)pneumococcalpneumonia:dementia,seizures,congestiveheartfailure,cerebrovasculardisease,tobaccosmoking,alcoholism,COPD,HIVLegionnaires'disease:malegender,currenttobaccosmoking,diabetes,hematologicmalignancy,cancer,end-stagerenaldisease,andHIVinfectionGNB:probableaspiration,previoushospitaladmission,previousantimicrobialRx,bronchiectasis,heavydrinkers2023/12/10Dr.HUBijie44Modifyingfactorsthatincreasetheriskof

infectionwithspecificpathogens2023/12/10Dr.HUBijie45SeasonaldistributionofLDcasesinEU2023/12/10Dr.HUBijie46GeneralLabExaminationsBloodtests：leukocytosiswithashifttothelefthypoxemia＋respiratoryalkalosisCRPPCT影像學2023/12/10Dr.HUBijie47TREATMENT

SITEOFCAREANTIBIOTICTHERAPYSWITCHFROMINTRAVENOUSTOORALANTIBIOTICTHERAPY

DURATIONOFANTIBIOTICTHERAPY

2023/12/10Dr.HUBijie48AssociatedMortalitybyAgeandTreatmentAge Mortality18-64yr 10%-15%65-74yr 20%75-84yr 30%>85yr 40%Untreated 50%-90%CURB-65criteria

(Severity-of-illnessscores)Confusion(toperson,place,ortime)Uremia(BUN>20mg/dL)Respiratoryrate>30/minlowBloodpressure(SBP<90mmHgorDBP<60mmHg)Age>

65years2023/12/10Dr.HUBijie490-1outpatient=2admission>=3ICU2007年IDSA/ATS成人CAP指南CAP患者病房非ICU最近有使用抗菌素最近未使用抗菌素單用呼吸喹諾酮或大環(huán)內(nèi)酯＋?-內(nèi)酰胺類大環(huán)內(nèi)酯＋?-內(nèi)酰胺類或單用呼吸喹諾酮門診既往體健且最近未使用抗生素有基礎疾病或最近使用過抗生素大環(huán)內(nèi)酯耐藥肺鏈感染率較高地區(qū)大環(huán)內(nèi)酯類多西環(huán)素單用呼吸喹諾酮或大環(huán)內(nèi)酯＋?-內(nèi)酰胺類*呼吸喹諾酮：莫西沙星,左氧氟沙星750mg，吉米沙星大環(huán)內(nèi)酯：阿奇霉素,克拉霉素，紅霉素病房ICU?-內(nèi)酰胺類＋大環(huán)內(nèi)酯或呼吸喹諾酮抗銅綠?-內(nèi)酰胺類聯(lián)合環(huán)丙或左氧或聯(lián)合氨基糖苷＋大環(huán)內(nèi)酯或聯(lián)合氨基糖苷＋抗銅綠氟喹諾酮有銅綠危險因素所有患者均考慮覆蓋非典型病原體16.ClinicalInfectiousDiseases.2007;44:S27–72YeX,MaJ,HuB,et

al.

ImprovementofClinicalandEconomicOutcomeswithanEmpiricantibiotictherapycoveringAtypicalPathogensforCommunity-acquiredPneumoniapatients:aMulti-centerCohortStudy.InternationalJournalofInfectiousDiseases(2015),/10.1016/j.ijid.2015.03.012

2023/12/10Dr.BijieHU512023/12/10Dr.HUBijie52SevereCommunityAcquiredPneumoniaonemajorcriteriaNeedforMechanicalVentilation;incresinginfiltration>50%within48hoursSepticshock,needforvasopressorsRenalfailuretwominorcriteriaRespiratoryrate>30/minPaO2/FiO2ratio<250mmHgDiffusebilateralinvolvementormultiplelobesB.P.<90mmHgsystolicB.P.<60mmHgdiastolicInadequateResponsetoTherapy

WhattoconsiderConsiderS.aureus,virus,resistantorganism,TB,endemicfungi,PneumocystisMoreunusualpathogens,atypicalmycobacteria,higherbacteria(Nocardia,actinomycetes),fungiNoninfectiousillness:LungneoplasmswithbronchialobstructionLymphomaSystemicautoimmunedisordersPEw/infarct,pulmedema,ARDSConsiderothertesting:Lowertractsampling(bronch)CTchestPEwork-up?SerologictestingOpenlungbiopsy2023/12/10Dr.HUBijie54DurationoftherapySpneumoniae:untilafebrilefor3-5dCpneumoniae:7-14dMpneumoniae:notwellestablished.Legionella:10-21dSaureus,Paeruginosa:10~14d Klebsiella:7~10d anaerobes?ProphylaxisVaccinecontainingthe23specificpolysaccharideantigensofthepneumococcustypes(accountfor85to90%)recommendedforchildren>2yrandadultsatincreasedriskforpneumococcaldiseaseoritscomplications;olderadultsdurationofprotection:5yr(revaccinatedin<5yrstendtohaveamoreintenselocalreaction)2023/12/10Dr.HUBijie55Respiratoryhygiene/coughetiquette

Coveryourcoughandwashyourhands!56CoveryourmouthandnosewithatissuewhenyousneezeORCoughorsneezeintoyouruppersleeve,NOTyourhandsPutyourusedtissueinthewastebasketHospital-acquiredPneumonia(HAP)2023/12/10Dr.HUBijie58Epidemiology：“3high”HighMorbidity：5-10per1000；Incidenceincreasesby6-20foldinVM；HighMortality：leadingcauseofdeathduetoHAI；cruderate30-50%；HighCost：>1billiondollars/yearinUS.Hospitalstayincreasesby7-9days；PathogenesisInvasionofthelowerrespiratorytractby:Aspirationoforopharyngeal/GIorganismsInhalationofaerosolscontainingbacteriaHematogenousspread2023/12/10Dr.HUBijie592023/12/10Dr.HUBijie60Colonization

AspirationHAPMRSA*2023/12/10Dr.HUBijie61EtiologicAgentsS.aureusEnterobacteriaceaeP.aeruginosaAcinetobactersp.PolymicrobialAnaerobicbacteriaLegionellasp.Aspergillussp.ViralUrgentThreats■■Clostridiumdifficile■■Carbapenem-resistantEnterobacteriaceae(CRE)■■Drug-resistantNeisseriagonorrhoeaeSeriousThreats■■Multidrug-resistantAcinetobacter■■Drug-resistantCampylobacter■■Fluconazole-resistantCandida(afungus)■■Extendedspectrumβ-lactamaseproducing

Enterobacteriaceae(ESBLs)■■Vancomycin-resistantEnterococcus(VRE)■■Multidrug-resistantPseudomonasaeruginosa■■Drug-resistantNon-typhoidalSalmonella■■Drug-resistantSalmonellaTyphi■■Drug-resistantShigella■■Methicillin-resistantStaphylococcusaureus(MRSA)■■Drug-resistantStreptococcuspneumoniae■■Drug-resistanttuberculosisConcerningThreats■■Vancomycin-resistantStaphylococcusaureus

(VRSA)■■Erythromycin-resistantGroupAStreptococcus■■Clindamycin-resistantGroupBStreptococcus緊迫的威脅■■艱難梭菌■■耐碳青霉烯類腸桿菌科細菌CRE■■耐藥淋球菌嚴重的威脅■■多重耐藥不動桿菌■■耐藥彎曲桿菌■■氟康唑耐藥念珠菌（一種真菌）■■產(chǎn)超廣譜β內(nèi)酰胺酶腸桿菌科細菌

（ESBLs）■■耐萬古霉素腸球菌VRE■■多重耐藥綠膿桿菌■■耐藥的非傷寒沙門氏菌■■耐藥傷寒沙門氏菌■■耐藥志賀氏菌■■耐甲氧西林金黃色葡萄球菌MRSA■■耐藥肺炎鏈球菌■■耐藥結核病關注的威脅■■萬古霉素耐藥的金黃色葡萄球菌

（VRSA）■■紅霉素耐藥A群鏈球菌■■克林霉素耐藥B群鏈球菌2023/12/10Dr.BijieHU62ANTIBIOTICRESISTANCETHREATS

intheUnitedStates,2013

2013年美國首次發(fā)布的抗生素耐藥威脅分3類：緊迫、嚴重與關注

2005-2010年上海XX醫(yī)院

鮑曼不動桿菌對亞胺培南耐藥率變化18.6%41.9%32.2%44%59.3%2006年2007年2008年2009年2005年68.1%2010年632010年，日本某醫(yī)院46人感染超級細菌“多重耐藥鮑曼不動桿菌”，9人死亡2023/12/10Dr.HUBijie64EtiologicAgentsMildtomoderateHAPorearlysevereHAPStreptococcuspneumoniaeHaemophilusinfluenzaMSSAKlebsiellaPneumoniaeEnterobacter,Ecoli,Proteus,SerratiaSevereHAPPseudomonasAcinetobacterMRSA2023/12/10Dr.HUBijie65AcinetobacteronlyinfectshighlydebilitatedpatientsWithrelativelylowmortality8-12%H.RichetICAAC2004Abstract#403MRSAPaeruginosaAcinetobacterSmaltophiliaPathogenicityHostdebilitationNoantibioticsincaseofcolonization2023/12/10Dr.HUBijie66RiskFactorsHostFactorsExtremesofage,severeillnesses,immunosupression,coma,alcoholism,malnutrition,COPD,DMEnhanceoropharynxandstomachcolonizationICU,antibiotics,endotrachealintubation,etc.FavoringaspirationorrefluxSupineposition,depressedconsciousness,endotrachealintubation,insertionofnasogastrictubeMechanicalventilationImpairedmucociliary,secretionpoolinginsubglotticarea,contaminatedequipmentandhandsofHCWsImpedeadequatepulmonarytoiletHeadandnecksurgery,trauma,sedationetc.2023/12/10Dr.HUBijie67BugsofHosp-acquiredpneumoniaEarlyMiddleLate135101520SPneuHinfluStaphaureusMRSAEnterobacterKlebsiella,EcoliPseudomonasaeruginosaAcinetobacterspStenotrophomonasDaysinHospital2023/12/10Dr.HUBijie68Riskfactorsformultidrug-resistant

pathogenscausingHAP,HCAPandVAPGeneralinvestigatechestradiographfullbloodcounturea,electrolytesandliverfunctiontestsCreactiveprotein(CRP)oxygenationassessmentClinicalPulmonaryInfectionScoreCPIS012氣管分泌物少多多且膿性胸部X線浸潤無浸潤彌漫(散在)區(qū)域發(fā)熱（℃）36.5～38.438.5～38.9

39或

36周圍血WBC

4×109/L,

11×109/L<4×109/L或>11×109/L<4×109/L或>11×109/L，且桿狀核細胞>50%PaO2/FiO2(氧合指數(shù))>240或ARDS

240，且ARDS氣管吸出物細菌培養(yǎng)

1種或無>1種>1種且革蘭染色也能發(fā)現(xiàn)相同細菌1種以上CPIS6，則高度懷疑存在HAP2023/12/10Dr.HUBijie71DiagnosisClinicalfever;coughwithpurulentsputum……RadiographicneworprogressiveinfiltratesonCXR,LaboratorialleukocytosisorleukopeniaMicrobiologicSuggestivegramstainandpositiveculturesofsputum,trachealaspirate,BAL,PSB,pleuralfluidorbloodQuantitativecultures2023/12/10Dr.HUBijie72DifferentialdiagnosisARDSPulmonaryedemaPulmonaryembolismAtelectasisAlveolarhemorrhageLungcontusion2023/12/10Dr.HUBijie73InitialempiricantibiotictherapyforHAPorVAPinpatientswithnoknownriskfactorsforMDRpathogens,earlyonset,andanydiseaseseverity2023/12/10Dr.HUBijie74InitialempirictherapyforHAP,VAP,andHCAPinpatientswit