內(nèi)科學(xué)教學(xué)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(hù)士長(zhǎng)

葉欣武警北京總隊(duì)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(shí)驗(yàn)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(guān)政策，先進(jìn)的微生物檢驗(yàn)技術(shù)，不能有效引入臨床使用，中國對(duì)感染病的病原學(xué)診斷，與國際先進(jìn)技術(shù)差距越來越大，今后相當(dāng)長(zhǎng)的時(shí)間內(nèi)，經(jīng)驗(yàn)性用藥仍“大行其道”，抗生素選擇壓力和誘導(dǎo)耐藥問題，不能根本扭轉(zhuǎn)和解決，耐藥菌問題，必定會(huì)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(jié)核培養(yǎng)8.17痰抗酸染色、結(jié)核培養(yǎng)：-8.20痰抗酸染色：-8.28痰抗酸染色、結(jié)核培養(yǎng)：-9.6痰抗酸染色：-血清學(xué)檢測(cè)8.17九聯(lián)檢：-8.21G試驗(yàn)：<108.21GM試驗(yàn)：-8.21乳膠凝集試驗(yàn)：-8.21T-spot：-8.21肺炎支原體：-9.18G試驗(yàn)：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(cè)少量胸腔積液入院診治過程2002.1.16血清軍團(tuán)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(cè)少量胸腔積液。2002.1.20軍團(tuán)菌培養(yǎng)：米克戴德軍團(tuán)菌。2002.1.25胸片隨訪：片狀模糊影，較前吸收2002.1.31血清軍團(tuán)菌抗體：1:64（升高四倍）紅霉素治療2周，1月后復(fù)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(kuò)張伴少許炎癥【案例13】男，24歲，反復(fù)咳嗽伴痰中帶血1年2013.11.7廣東省廣州市中山醫(yī)學(xué)院病原學(xué)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(huì)想到….如何選擇抗菌藥物？給藥途徑？療程？是否住院？費(fèi)用？2023/12/10Dr.HUBijie34肺炎的臨床正確處置，您覺得應(yīng)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(fèi)用：210億美元BartlettJGetal.ClinInfectDis.2000;31:347-382;MarstonBJetal.ArchInternMed.1997;157:1709-1718.美國CAP流行病學(xué)，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(xué)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(chǔ)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(xiǎn)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(xì)菌CRE■■耐藥淋球菌嚴(yán)重的威脅■■多重耐藥不動(dòng)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(xì)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(jié)核病關(guān)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(yán)重與關(guān)注

2005-2010年上海XX醫(yī)院

鮑曼不動(dòng)桿菌對(duì)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(jí)細(xì)菌“多重耐藥鮑曼不動(dòng)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(xì)胞>50%PaO2/FiO2(氧合指數(shù))>240或ARDS

240，且ARDS氣管吸出物細(xì)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(xì)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