内科学教学课件：13 Pneumonia （肺炎）

RespiratoryDiseases

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

葉欣武警北京总队医院内二科主治医师李晓红

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是肺部感染病原诊断的“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种社区肺炎常见病原体，我国多数医院微生物实验室，只具有检出2-4种病原体的能力！2014年Davidson内科教科书，罗列17种社区肺炎的常见病原体。按照目前的相关政策，先进的微生物检验技术，不能有效引入临床使用，中国对感染病的病原学诊断，与国际先进技术差距越来越大，今后相当长的时间内，经验性用药仍“大行其道”，抗生素选择压力和诱导耐药问题，不能根本扭转和解决，耐药菌问题，必定会越演越烈！ 2023/12/10Dr.BijieHU26/thread-145724-1-1.html【案例7】男47，咳嗽、黄痰、气促、发热2012.8.17胸部CT痰培养8.17痰培养：烟曲霉1+8.20痰培养：烟曲霉1+8.28痰培养：烟曲霉1+9.3痰培养：曲霉菌属1+9.6痰培养：烟曲霉1+痰抗酸染色及结核培养8.17痰抗酸染色、结核培养：-8.20痰抗酸染色：-8.28痰抗酸染色、结核培养：-9.6痰抗酸染色：-血清学检测8.17九联检：-8.21G试验：<108.21GM试验：-8.21乳胶凝集试验：-8.21T-spot：-8.21肺炎支原体：-9.18G试验：15.232023/12/10Dr.BijieHU29【案例4】咳嗽、高热12天，伴气急、痰血双肺片状模糊影，边界不清，内密度不均，可见支气管充气征，左侧少量胸腔积液入院诊治过程2002.1.16血清军团菌抗体：1:16(可疑阳性)2002.1.16更改抗感染方案：红霉素静滴0.5g静滴，q8h×20d。次日体温降至38，第3日后基本降至正常。2002.1.17胸部CT：双肺片状模糊影，边界不清，内密度不均，可见支气管充气征，左侧少量胸腔积液。2002.1.20军团菌培养：米克戴德军团菌。2002.1.25胸片随访：片状模糊影，较前吸收2002.1.31血清军团菌抗体：1:64（升高四倍）红霉素治疗2周，1月后复查，两肺炎症基本吸收。2023/12/10Dr.HUBijie302013.10.15我院胸部CT显示：两肺支气管扩张伴少许炎症【案例13】男，24岁，反复咳嗽伴痰中带血1年2013.11.7广东省广州市中山医学院病原学诊断中心寄生虫全套+旋毛虫+广圆线虫+丝虫检查：肺吸虫（+），裂头蚴（+）Howtotreat

Pneumoniawisely?我会想到….如何选择抗菌药物？给药途径？疗程？是否住院？费用？2023/12/10Dr.HUBijie34肺炎的临床正确处置，您觉得应包括哪些方面？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200万-300万/年CAP患者500,000CAP患者/年需入院治疗45,000人/年因CAP死亡用于治疗的费用：210亿美元BartlettJGetal.ClinInfectDis.2000;31:347-382;MarstonBJetal.ArchInternMed.1997;157:1709-1718.美国CAP流行病学，中国呢？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影像学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单用呼吸喹诺酮或大环内酯＋ß-内酰胺类大环内酯＋ß-内酰胺类或单用呼吸喹诺酮门诊既往体健且最近未使用抗生素有基础疾病或最近使用过抗生素大环内酯耐药肺链感染率较高地区大环内酯类多西环素单用呼吸喹诺酮或大环内酯＋ß-内酰胺类*呼吸喹诺酮：莫西沙星,左氧氟沙星750mg，吉米沙星大环内酯：阿奇霉素,克拉霉素，红霉素病房ICUß-内酰胺类＋大环内酯或呼吸喹诺酮抗铜绿ß-内酰胺类联合环丙或左氧或联合氨基糖苷＋大环内酯或联合氨基糖苷＋抗铜绿氟喹诺酮有铜绿危险因素所有患者均考虑覆盖非典型病原体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紧迫的威胁■■艰难梭菌■■耐碳青霉烯类肠杆菌科细菌CRE■■耐药淋球菌严重的威胁■■多重耐药不动杆菌■■耐药弯曲杆菌■■氟康唑耐药念珠菌（一种真菌）■■产超广谱β内酰胺酶肠杆菌科细菌

（ESBLs）■■耐万古霉素肠球菌VRE■■多重耐药绿脓杆菌■■耐药的非伤寒沙门氏菌■■耐药伤寒沙门氏菌■■耐药志贺氏菌■■耐甲氧西林金黄色葡萄球菌MRSA■■耐药肺炎链球菌■■耐药结核病关注的威胁■■万古霉素耐药的金黄色葡萄球菌

（VRSA）■■红霉素耐药A群链球菌■■克林霉素耐药B群链球菌2023/12/10Dr.BijieHU62ANTIBIOTICRESISTANCETHREATS

intheUnitedStates,2013

2013年美国首次发布的抗生素耐药威胁分3类：紧迫、严重与关注

2005-2010年上海XX医院

鲍曼不动杆菌对亚胺培南耐药率变化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，日本某医院46人感染超级细菌“多重耐药鲍曼不动杆菌”，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气管分泌物少多多且脓性胸部X线浸润无浸润弥漫(散在)区域发热（℃）36.5～38.438.5～38.9

39或

36周围血WBC

4×109/L,

11×109/L<4×109/L或>11×109/L<4×109/L或>11×109/L，且杆状核细胞>50%PaO2/FiO2(氧合指数)>240或ARDS

240，且ARDS气管吸出物细菌培养

1种或无>1种>1种且革兰染色也能发现相同细菌1种以上CPIS6，则高度怀疑存在HAP2023/12/10Dr.HUBijie71DiagnosisClinicalfever;coughwithpurulentsputum……RadiographicneworprogressiveinfiltratesonCXR,LaboratorialleukocytosisorleukopeniaMicrobiologicSuggestivegramstainandpositiveculturesofsputum,trachealaspirate,BAL,PSB,pleuralfluidorbloodQuantitativecultures2023/12/10Dr.HUBijie72DifferentialdiagnosisARDSPulmonaryedemaPulmonaryembolismAtelectasisAlveolarhemorrhageLungcontusion2023/12/10Dr.HUBijie73InitialempiricantibiotictherapyforHAPorVAPinpatientswithnoknownriskfactorsforMDRpathogens,earlyonset,andanydiseaseseverity2023/12/10Dr.HUBijie74InitialempirictherapyforHAP,VAP,andHCAPinpatientswit