不同类型老年吸入性肺炎的病原学、抗生素应用及临床转归

目的 比较老年社区获得性吸入性肺炎(CAP)、医疗相关性吸入性肺炎(HCAP)及医院获得性吸入性肺炎(HAP,包括呼吸机相关性吸入性肺炎)三者病原学、抗生素应用及治疗转归的关系.方法 收集2005年1月一2010年12月北京二炮总医院呼吸科住院的216例老年吸人性肺炎患者病例,分析其病原学结果、抗生素应用的及治疗转归.结果 三种吸入性肺炎的病原学有显著差异,与CAP和HCAP相比,HAP患者G-杆菌的感染比例明显增多(P<0.001);抗生素应用方案有明显差异,CAP组病人未调整抗生素应用比率明显高于HCAP组与HAP组(P<0.001);抗生素应用策略不同,所致死亡率有明显差异,以升阶梯方案为最高,以降阶梯治疗为最低(P=0.03).结论 三种吸入性肺炎在感染病原菌种类、抗生素应用策略及治疗转归上有明显差异,应根据不同类型的老年吸入性肺炎特点合理经验性使用抗菌药物.     

老年卫生保健性肺炎多重耐药菌感染相关因素

目的分析老年卫生保健性肺炎(HCAP)患者多重耐药菌(MDRO)感染的相关因素。方法回顾性分析516例老年HCAP患者的临床资料,比较其中93例MDRO感染患者与423例非MDRO感染患者的差异,并进行多因素Logistic回归分析。结果 516例老年HCAP患者检出MDRO感染93例,MDRO感染率为21. 99%。单因素分析显示,年龄≥70岁、肺炎严重指数(PSI)分级高、90 d内住院天数≥15 d、入住ICU、30 d内抗菌药物使用时间7 d、30 d内联用抗菌药物≥3种、30 d内累计使用抗菌药物≥3种7个因素是HCAP患者MDRO感染的危险因素(P0. 05);多因素分析显示,30 d内联用抗菌药物(≥3种)、90 d内住院天数(≥15 d)、入住ICU、30 d内抗菌药物使用时间(7 d)、年龄≥70岁5个因素是老年HCAP患者MDRO感染的独立危险因素(P0. 05)。结论老年HCAP患者MDRO感染主要与环境MDRO定植交叉感染和抗菌药物的不合理应用有关。防控应首先减少不必要住院时间与入住ICU时间,减少MDRO的感染与定植;减少抗菌药物不合理的长期、反复及联合使用,根据微生物检测采取有针对性的抗感染方案。     

医院获得性肺炎、呼吸机相关性肺炎、卫生保健相关性肺炎的最新治疗进展

尽管目前有很好的抗生素治疗,对症支持治疗和预防,但是医院获得性肺炎(HAP)、呼吸机相关性肺炎(VAP)和卫生保健相关性肺炎(HCAP)仍是导致患者发病和死亡的重要原因,本文对 HAP,VAP 和 HCAP 的最新治疗进展将在此作一综述。     

多重耐药菌所致呼吸机相关性肺炎的临床疗效分析

目的分析本院重症监护病房(ICU)呼吸机相关性肺炎(VAP)的病原菌构成及其对抗菌药物的耐药性,以及患者使用抗菌药物后的治疗效果,为临床治疗方案的制定提供参考。方法选取我院84例VAP患者进行呼吸道分泌物的细菌培养及其对常用抗菌药物的敏感性、耐药性分析,并检测患者接受治疗方案后的参数变化。结果 84例呼吸机相关性肺炎患者呼吸道分泌物培养的病原菌均为多重耐药的条件致病菌,其中革兰氏阴性杆菌占83.5%,革兰氏阳性菌占9.2%,真菌占7.3%,大多呈多重耐药。最初采用经验性治疗,然后参考细菌培养报告缩小抗菌谱,同时观察患者的感染参数调整用药。结论呼吸机相关性肺炎是感染了革兰氏阴性杆菌为主的多重耐药病原菌引起的,宜尽早采用合理有效的抗菌药物治疗,减少耐药菌株引起的二重感染。     

不同类型老年吸入性肺炎的临床特点、治疗及转归

目的 比较老年吸入性肺炎中社区获得性肺炎(CAP)、医疗相关性肺炎(HCAP)及医院获得性肺炎(HAP)(包括呼吸机相关性吸入性肺炎)的临床特点、治疗及转归.方法 收集2005年1月至2010年12月北京第二炮兵总医院呼吸科住院的216例老年吸入性肺炎患者病例,分析其临床特点、治疗及转归.结果 三组患者皆以男性居多,且HAP组患者男性比例较其他两组为多(P=0.032),HAP组患者年龄较其他两组为大(P=0.024)；三组患者均有3～4种合并症,合并症的种类和数量并无显著差异；三组间外周血白细胞计数、中性粒细胞比例及X线检查无显著差异；和CAP、HCAP患者相比,HAP患者革兰阴性杆菌感染率尤为高,需联合应用广谱的抗生素药物,特别是针对革兰阴性杆菌药物；HAP组留置胃管、行灌洗吸痰例数要高于CAP组与HCAP组(P＜0.001)；HAP组的治愈率较CAP组与HCAP组低(P＜0.05),死亡率较CAP组高(P=0.004).结论 三种类型老年吸入性肺炎在人口学资料、临床表现上差异不明显,但在治疗及转归等方面有明显差异,应加强对不同类型老年吸入性肺炎的理解和认识,以利于区别化的治疗.     

高龄医疗保健相关性肺炎患者的临床特征、病原学特点及预后

目的研究高龄医疗保健相关性肺炎(HCAP)患者的临床特征、病原学特点与预后。方法对该院2012年4月至2015年4月收治的40例高龄HCAP患者的临床资料进行回顾性分析。结果 HCAP组患者的年龄、肺炎严重指数(PSI)评分、心血管疾病、慢性肺部疾病、慢性肾脏疾病、肿瘤、至少2种并发症发生率均显著高于社区获得性肺炎(CAP)组,铜绿假单胞菌、金黄色葡萄球菌、多耐药菌比例均显著高于CAP组,肺炎链球菌比例显著低于CAP组,单一抗生素比例显著低于CAP组,更换抗生素、初始治疗失败、需要机械通气、转入重症监护室、1个月内院内死亡比例均显著高于CAP组,住院时间显著长于CAP组(均P0.05)。结论高龄HCAP患者具有较大的年龄、较多的基础疾病、较为严重的病情、较高的死亡率,革兰阴性菌是主要病原菌,预后较差。     

医疗保健相关性肺炎

医疗保健相关性肺炎是新近提出的独立的肺炎类型,其不同于社区获得性肺炎、医院获得性肺炎和呼吸机相关性肺炎.医疗保健相关性肺炎患者来源于院外,某些病例特征在一定程度上与社区获得性肺炎存在交叉,但其临床表现、危险因素、病因学、预后及初始经验性抗生素治疗又与社区获得性肺炎有所差异,反而与医院获得性肺炎有诸多重叠.因此当务之急,医务工作者应全面且正确识别医疗保健相关性肺炎,这对我们指导治疗、改善预后意义极其重大.     

优化社区获得性肺炎抗菌药物应用策略:避免过度治疗

正社区获得性肺炎(community acquired pneumonia,CAP)是全球范围内最常见的感染性疾病之一,具有高发病率和病死率~([1])。随着病原体耐药性的不断增加,使得抗菌药物治疗方案的选择处于"成功治疗"与"减少耐药"的两难境地。我国CAP初始经验性治疗临床实践中存在一些不容忽视的问题,如对CAP的诊断的准确性不够和缺乏严重程度的评估、过度使用广谱抗菌药物等,特别是在选择抗     

老年社区获得性肺炎怎样分类

2005年美国胸科学会／美国感染学会ATS／IDSA在成人医院获得性肺炎（hospitalacguired pneumonia，HAP）指南中引入“健康护理相关性肺炎”（healthcare associated-pneumonia，HCAP）的概念，将生活在护理院老年人罹患的肺炎归入HCAP。因为他们频繁或长期接受治疗和护理，处于感染多耐药（multiple resistance drug，MDR）病原菌的危险之中，需要象HAP一样给予广谱抗生素经验性治疗。     

社区获得性肺炎治疗中的几个重要问题

1初始治疗中的抗菌药物选择问题社区获得性肺炎(community-acquired pneu-monia,CAP)的初始抗菌药物治疗均为经验性治疗,最初选择的抗菌药物恰当与否对患者(尤其是重症患者)的预后和总体诊疗费用均会产生很大影响,如何在保证疗效的同时避免广谱抗生素的滥用一直是备受关注的问题。国外已有大量的流行病学研究结果证实,CAP的致病原构成和细菌耐药情况在不同人群中是存在明显差异的,因此,国外的CAP诊治指南大多倾向于针对不同患者人群推荐不同的初始抗菌药物治疗方案[1~5,12]。我国最近完成的两项全国性CAP致病原流行病学调查的结果显示,…     

Clinical features of healthcare-associated pneumonia (HCAP) in a Japanese community hospital: comparisons among nursing home-acquired pneumonia (NHAP), HCAP other than NHAP, and community-acquired pneumonia

Background and objective: More than 100 000 Japanese die of pneumonia every year. The number of people residing in nursing homes is increasing with the ageing of the population. In 2005, the American Thoracic Society/Infectious Diseases Society of America (ATS/IDSA) published important guidelines for the management of healthcare‐associated pneumonia (HCAP). In Japan, however, the optimum strategy for management of HCAP is still unclear. The purpose of this study was to clarify the clinical features of patients with HCAP. Methods: Patients (n = 202) who were consecutively admitted with a diagnosis of acute pneumonia between October 2007 and September 2009 were retrospectively evaluated. Using the ATS/IDSA guidelines, patients were divided into three groups: a community‐acquired pneumonia (CAP) group (n = 123), a nursing home‐acquired pneumonia (NHAP) group (n = 46) and a HCAP other than NHAP (O‐HCAP) group (n = 33). These groups were then compared with respect to laboratory data, microbiological findings and mortality. Results: Thirty‐day mortality in the NHAP group (10.9%) tended to be higher than that in the CAP group (3.3%) or the O‐HCAP group (0%). The pathogens most frequently identified were Streptococcus pneumoniae and Haemophilus influenzae in the CAP group, methicillin‐resistant Staphylococcus aureus and Klebsiella pneumoniae in the NHAP group, and S. pneumoniae and K. pneumoniae in the O‐HCAP group. Conclusions: The NHAP group was clinically different from the O‐HCAP group, based on bacteriological examination and mortality rates. In order to accurately diagnose, and formulate optimum treatment strategies for Japanese patients, the categories of HCAP, as specified in the ATS/IDSA guidelines, should not be applied directly either to patients with NHAP or those with O‐HCAP.     

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.     

Healthcare‐associated pneumonia: A US disease or relevant to the Asia Pacific,too?

The term ‘health care‐associated pneumonia’ (HCAP) was introduced by the American Thoracic Society and the Infectious Diseases Society of America in 2005 to describe a distinct entity of pneumonia that resembles hospital‐acquired pneumonia rather than community‐acquired pneumonia (CAP) in terms of occurrence of drug‐resistant pathogens and mortality in patients that—while not hospitalized in the traditional sense—have been in recent contact with the health‐care system. It was proposed that HCAP should be treated empirically with therapy for drug‐resistant pathogens. Over the last few years, there has been increasing controversy over whether HCAP is a helpful definition, or leads to unnecessary and potentially problematic overtreatment. The term HCAP has been extensively criticized in Europe. While most studies have shown that HCAP is associated with more frequent drug‐resistant pathogens and higher mortality than CAP, there is no clear evidence that this is due to inappropriate antibiotic therapy. Therapy consistent with HCAP treatment guidelines has also not been found to improve mortality. Based on current evidence, we suggest broad‐spectrum antibiotic therapy to treat possible pathogens not usually covered in CAP be based on assessment of individual risk factors rather than applying a HCAP classification system in the Asia‐Pacific Region.     

健康护理相关性肺炎的研究进展

健康护理相关性肺炎代表一种新的肺炎种类,有别于社区获得性肺炎和医院获得性肺炎.尽管健康护理相关性肺炎患者描述为来自于社区,但其流行病学、细菌学特征和l临床表现与社区获得性肺炎有明显差异.本文综述近年来健康护理相关性肺炎的研究进展,旨在提高临床医师对健康护理相关性肺炎的认识和深入了解.     

Healthcare-associated pneumonia among hospitalized patients in a Korean tertiary hospital

Background  

Healthcare-associated pneumonia (HCAP) has more similarities to nosocomial pneumonia than to community-acquired pneumonia (CAP). However, there have only been a few epidemiological studies of HCAP in South Korea. We aimed to determine the differences between HCAP and CAP in terms of clinical features, pathogens, and outcomes, and to clarify approaches for initial antibiotic management.     

Health care-associated pneumonia requiring hospital admission: epidemiology, antibiotic therapy, and clinical outcomes

BACKGROUND: Health care-associated pneumonia (HCAP) has been proposed as a new category of respiratory infection. However, limited data exist to validate this entity. We aimed to ascertain the epidemiology, causative organisms, antibiotic susceptibilities, and outcomes of and empirical antibiotic therapy for HCAP requiring hospitalization. METHODS: Observational analysis of a prospective cohort of nonseverely immunosuppressed hospitalized adults with pneumonia. Patients who had recent contact with the health care system through nursing homes, home health care programs, hemodialysis clinics, or prior hospitalization were considered to have HCAP. RESULTS: Of 727 cases of pneumonia, 126 (17.3%) were HCAP and 601 (82.7%) were community acquired. Compared with patients with community-acquired pneumonia, patients with HCAP were older (mean age, 69.5 vs 63.7 years; P < .001), had greater comorbidity (95.2% vs 74.7%; P < .001), and were more commonly classified into high-risk pneumonia severity index classes (67.5% vs 48.8%; P < .001). The most common causative organism was Streptococcus pneumoniae in both groups (27.8% vs 33.9%). Drug-resistant pneumococci were more frequently encountered in cases of HCAP. Legionella pneumophila was less common in patients with HCAP (2.4% vs 8.8%; P = .01). Aspiration pneumonia (20.6% vs 3.0%; P < .001), Haemophilus influenzae (11.9% vs 6.0%; P = .02), Staphylococcus aureus (2.4% vs 0%; P = .005), and gram-negative bacilli (4.0% vs 1.0%; P = .03) were more frequent in HCAP. Patients with HCAP more frequently received an initial inappropriate empirical antibiotic therapy (5.6% vs 2.0%; P = .03). The overall case-fatality rate (< 30 days) was higher in patients with HCAP (10.3% vs 4.3%; P = .007). CONCLUSIONS: At present, a substantial number of patients initially seen with pneumonia in the emergency department have HCAP. These patients require a targeted approach when selecting empirical antibiotic therapy.     

Clinical impact of broad-spectrum empirical antibiotic therapy in patients with healthcare-associated pneumonia: a multicenter interventional study

Healthcare-associated pneumonia (HCAP) has been proposed as a new category of pneumonia distinct from community-acquired pneumonia (CAP). A multicenter observational study in 2008 finds that patients with HCAP have a mortality rate significantly higher than patients with CAP, and a worse outcome is associated at logistic regression analysis with a low adherence to empirical antibiotic therapy recommended by ATS/IDSA guidelines. We designed a prospective interventional study to establish whether administration of a broad-spectrum antibiotic therapy consistent with the 2005 ATS/IDSA guidelines has an effect on the clinical outcome of hospitalized patients with HCAP. All patients with HCAP prospectively admitted in 25 medical wards of 20 Italian hospitals during a 1-month period were included in the study. All patients were assigned to receive an empirical therapy including a fluoroquinolone plus an anti-MRSA agent plus either piperacillin?Ctazobactam or a carbapenem. Main measures for improvement were duration of antibiotic therapy, length of hospital stay, and in-hospital mortality rate. Patients were compared with a historical control group of 90 patients, and followed up to discharge or death. HCAP patients receiving a guideline-concordant therapy had a shorter duration of antibiotic therapy (median 15 vs. 12?days, p?=?0.0002), a shorter duration of hospitalization (median 18 vs. 14?days, p?=?0.02), and a lower mortality rate (17.8 vs. 7.1?%, p?=?0.03). Our results suggest that an empirical broad-spectrum therapy is associated with improved outcome in patients with HCAP.     

Health care-associated Staphylococcus aureus pneumonia

INTRODUCTION: While Staphylococcus aureus is an uncommon but serious cause of traditional community-acquired pneumonia (CAP), it is a predominant cause of nosocomial pneumonia in addition to the unique clinical entity of health care-associated pneumonia (HCAP). A cohort of bacteremic S aureus pneumonia cases was reviewed to determine the role of HCAP among the cohort, and to assess for differences between CAP and HCAP. PATIENTS AND METHODS: Bacteremic S aureus pneumonia cases were identified from a prospective study of all patients diagnosed with CAP who presented to hospitals in Edmonton, Alberta, between November 2000 and November 2002. These cases were subsequently reviewed retrospectively. Demographic, clinical and microbiological data were obtained, and patients were classified as having CAP or HCAP. Relatedness of isolates was determined by pulsed-field gel electrophoresis analysis in conjunction with epidemiological information. RESULTS: There were 28 cases of bacteremic S aureus pneumonia identified. Fifty-seven per cent were reclassified as having HCAP, and 43% remained classified as having CAP. The CAP cohort was significantly younger than the HCAP cohort (mean age 49.0+/-23.7 years versus 67.8+/-18.6 years; P=0.035) with higher rates of intravenous drug use (50% versus 0%; P=0.002). Long-term care facility residence (44%) was common in the HCAP cohort. The HCAP cohort presented with more severe illness, having a higher mean pneumonia severity index score (143.1+/-41.1 versus 98.2+/-54.6; P=0.028), and despite fewer embolic complications, there was a trend toward a significantly higher mortality rate (31% versus 0%; P=0.052). Two community-acquired isolates cultured in the setting of intravenous drug use were methicillin-resistant, and no isolates were positive for Panton-Valentine leukocidin. There was evidence of relatedness involving 44% of the HCAP isolates by pulsed-field gel electrophoresis analysis. CONCLUSION: HCAP accounts for a significant number of cases that, when using traditional definitions, would be classified as CAP. Severity of illness and mortality was excessive within the HCAP group. There was evidence of relatedness and spread of common strains in the HCAP cohort. The present study supports recommendations for treatment guidelines directed toward the entity of HCAP and the empirical coverage of S aureus among certain high-risk groups.     

Epidemiology and outcomes of health-care-associated pneumonia: results from a large US database of culture-positive pneumonia

CONTEXT: Traditionally, pneumonia developing in patients outside the hospital is categorized as community acquired, even if these patients have been receiving health care in an outpatient facility. Accumulating evidence suggests that health-care-associated infections are distinct from those that are truly community acquired. OBJECTIVE: To characterize the microbiology and outcomes among patients with culture-positive community-acquired pneumonia (CAP), health-care-associated pneumonia (HCAP), hospital-acquired pneumonia (HAP), and ventilator-associated pneumonia (VAP).Design and setting: A retrospective cohort study based on a large US inpatient database. PATIENTS: A total of 4,543 patients with culture-positive pneumonia admitted into 59 US hospitals between January 1, 2002, and December 31, 2003, and recorded in a large, multi-institutional database of US acute-care hospitals (Cardinal Health-Atlas Research Database; Cardinal Health Clinical Knowledge Services; Marlborough, MA).Main measures: Culture data (respiratory and blood), in-hospital mortality, length of hospital stay (LOS), and billed hospital charges. RESULTS: Approximately one half of hospitalized patients with pneumonia had CAP, and > 20% had HCAP. Staphylococcus aureus was a major pathogen in all pneumonia types, with its occurrence markedly higher in the non-CAP groups than in the CAP group. Mortality rates associated with HCAP (19.8%) and HAP (18.8%) were comparable (p > 0.05), and both were significantly higher than that for CAP (10%, all p < 0.0001) and lower than that for VAP (29.3%, all p < 0.0001). Mean LOS varied significantly with pneumonia category (in order of ascending values: CAP, HCAP, HAP, and VAP; all p < 0.0001). Similarly, mean hospital charge varied significantly with pneumonia category (in order of ascending value: CAP, HCAP, HAP, and VAP; all p < 0.0001). CONCLUSIONS: The present analysis justified HCAP as a new category of pneumonia. S aureus was a major pathogen of all pneumonias with higher rates in non-CAP pneumonias. Compared with CAP, non-CAP was associated with more severe disease, higher mortality rate, greater LOS, and increased cost.