Community-Acquired Pneumonia in Adults...2016/10/26 · Hospital-acquired pneumonia (HAP) ：--住院48 小時後，或上次住院結束後14 天之內發生之肺實質的急性感染。

Community-Acquired Pneumonia in Adults日期；2016/10/26

報告人：李怡萱

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Outline�Introduction

�Site-of-Care Decisions

�Diagnostic Testing

�Antibiotic Treatment

�Prevention

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Introduction

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Pneumonia Pneumonia is an infection of the lungs. It is a serious illness that can affect people of any age, but it is most common and most dangerous in very young children, people older than 65, and in those with underlying medical problems such as heart disease, diabetes, and chronic lung disease. There is seasonal variation with more cases occurring in the winter months.

4圖片來源：uptodate

Pneumonia �Community-acquired pneumonia (CAP)：：：：--肺實質的急性感染，發生在未住院或住院未滿 48 小時之病人。--病患胸部 X 光片上有新出現之浸潤，同時表現出急性感染的症狀，如發熱、體溫過低、發抖、出汗、（新出現的）咳嗽（有痰或沒痰）、痰色改變、胸部不適、氣促，其他非特定性症狀（疲倦、肌痛、腹痛、食慾差、頭痛），或聽診之異常（支氣管音，加上/或是局部囉音）

�Hospital-acquired pneumonia (HAP)：：：：--住院 48 小時後，或上次住院結束後 14 天之內發生之肺實質的急性感染。--胸部 X 光片上有新出現或持續進展（>24 小時）之浸潤，同時以下條件至少有兩項存在: (1)發熱：體溫之上昇≥1℃，或體溫≥38.3℃，或＜35℃(2)白血球上升：白血球之增加＞原來值之 25%，或白血球＞10,000/μl 或< 3000 / μl (3)膿性氣管抽吸液或痰：革蘭氏染色呈現＞25 嗜中性白血球/低倍視野（100×）3-6。

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Pneumonia�Ventilator-associated pneumonia (VAP)：：：：--為使用呼吸器 48 小時以後產生的院內肺炎。

�Healthcare-associated pneumonia(HCAP)：：：：--肺炎病患有下列情況者稱之。

-在 90 天內曾在急性病醫院住院大於二天以上者-住在安養院或長期照護機構的患者-30 天內接受針劑抗生素、化療、傷口照護的病患，洗腎的病人。

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PathogenesisTypical Atypical

Etiologic agent Incidence (%) Etiologic agent Incidence (%)

Streptococcus pneumoniae

Haemophilus influenzae

Staphylococcus aureus

Klebsiella pneumonia

E.coli

23.8 ~ 26.0

4.8 ~ 9.0

1.0 ~ 1.8

4.8 ~ 5.0

1.0 ~ 1.8

Legionella spp.

Mycoplasma pneumoniae

Chlamydia pneumoniae

Viruses

Mycobacterium

tuberculosis

12.2 ~ 20.0

4.7 ~ 13.0

1.2 ~ 6.6

1.0 ~ 10.0

1.2 ~ 2.0

7表格來源：臨床肺炎指引

Common pathogens 在台灣的社區肺炎常見菌種與其他國家的文獻報告相近，如附表 (一)，Streptococcus pneumoniae 是最常見引起肺炎菌種，尤其是大於 65 歲的病患。年輕病患的肺炎應先排除Mycoplasma pneumoniae。中壯年的重度肺炎應考慮 Klebsiella pneumoniae 的可能性 13-15。兩種病菌或兩種以上的混合感染比率約佔社區肺炎病人的 13~16%14,15。如果嚴重到呼吸衰竭的重度肺炎病例，則應考慮的菌種如 S. pneumoniae, K. pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus 等 15-17。在台灣 Burkholderia pseudomallei, Acinetobacter baumannii 也是重度的社區肺炎的可能病因 17。

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Site-of-Care DecisionsHOSPITAL ADMISSION DECISION

ICU ADMISSION DECISION

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Hospital admission decision�Assessment of severity

- CURB-65

- Pneumonia Severity Index (PSI)

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CURB-65�Confusion (based upon a specific mental test or disorientation to person, place, or time)

�Urea (blood urea nitrogen in the United States) >7 mmol/L (20 mg/dL)

�Respiratory rate >30 breaths/minute

�Blood pressure (systolic

CURB-65C Confusion

U Urea >7 mmol/L (20 mg/dL)

R Respiratory rate >30 breaths/minute

B Blood pressure (systolic

CURB-65points meaning recommendation

0 to 1 Points Low severity (risk of death

Pneumonia Severity Index (PSI)Sex

Male

female

(0)

(-10)

Demographic factors

Age

Nursing home resident

(1 point for each year)

(+10)

Comorbid illnesses

Neoplastic disease

Chronic liver disease

Heart failure

Cerebrovascular disease

Chronic renal disease

(+30)

(+20)

(+10)

(+10)

(+10)

14表格來源：uptodate

Pneumonia Severity Index (PSI)Physical examination findings

Altered mental status

Respiratory rate ≥30/minute

Systolic blood pressure

Pneumonia Severity Index (PSI)points meaning recommendation

0 to 50 Points Class I 0.1% mortality outpatients

51 to 70 Points Class II 0.6% mortality

71 to 90 Points Class III 0.9% mortality treated in an observation unit or with a

short hospitalization

91 to 130 Points Class IV 9.3% mortality require hospitalization

131 to 395 Points Class V 27.0% mortality

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ICU admission decision�Direct admission to an ICU is required for patient

with septic shock requiring vasopressors with acute respiratory failure requiring intubation and mechanical ventilation.

� Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP.

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ICU admission decisionMajor criteria

Septic shock requiring vasopressors

Acute respiratory failure requiring intubation and mechanical ventilation

Minor criteria

Respiratory rate ≧ 30 breaths/minPaO2/FiO2 ratio≦ 250 Multilobar infiltrates

Confusion/disorientation

Uremia (BUN level, ≧ 20 mg/dL)Leukopenia (WBC count,

Diagnostic Testing

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Diagnosis�Clinical evaluation

�Radiologic evaluation

�Diagnostic testing for microbial-Outpatients-Hospitalized patients

Blood culturesSputumUrinary antigenPolymerase chain reaction

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-cough, fever, pleuritic chest pain, dyspnea,

and sputum production

-gastrointestinal symptoms (nausea,

vomiting, diarrhea

-mental status changes.-

Radiologic evaluation The presence of an infiltrate on plain chest radiograph is considered the gold standard for diagnosing pneumonia when clinical and microbiologic features are supportive

22圖片來源：uptodate

Diagnostic testing for microbial�Outpatients

-Routine diagnostic tests are optional

�Hospitalized patients- Pretreatment blood samples for culture and an expectorated sputum sample for stain and

culture should be obtained from hospitalized patients with the clinical indications

- Patients with severe CAP, as defined above, should at least have blood samples drawn for culture, urinary antigen tests for Legionella pneumophila and Streptococcus pneumoniae performed, and expectorated sputum samples collected for culture

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24表格來源：IDSA Guidelines on the Management of Community-Acquired Pneumonia in Adults

Testing for microbial�Blood cultures

- Easy to obtain blood samples, simple, cheap, high specificity- The blood culture positivity rate is relatively low.

�Sputum Gram stain- If a good quality sputum can be obtained- The sensitivity of Gram stain microscopy in S. pneumoniae pneumonia can be as high as 85% - not for diagnosis of atypical pneumonia (Legionella spp, M. pneumoniae, C. pneumoniae)

�Urinary antigen- detect S. pneumoniae and Legionella- Only useful for the diagnosis of L. pneumophila group 1 infection

�Polymerase chain reaction- For some difficult to cultivate or slow growth of pathogens

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Antibiotic TreatmentEMPIRICAL ANTIMICROBIAL THERAPY

PATHOGEN-DIRECTED THERAPY

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Empirical antimicrobial therapy�Outpatient treatment

�Inpatients, non-ICU treatment

�Inpatients, ICU treatment

�Special concerns

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Empirical antimicrobial therapyOutpatient treatmentS. pneumoniae/ M. pneumoniae/ C. pneumoniae /H. influenzae /S. aureus

� Previously healthy and no use of antimicrobials within the previous three months

1.Macrolide (azithromycin, clarithromycin, erythromycin)

2.Doxycyline

� Presence of comorbidities such as chronic heart, lung, liver, or renal disease; diabetes mellitus;

alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing

drugs; or use of antimicrobials within the previous three months

1.respiratory fluoroquinolone (moxifloxacin, gemifloxacin, levofloxacin)

2. beta-lactam (high-dose amoxicillin, amoxicillin-clavulanate//ceftriaxone, cefuroxime)

+ macrolide (azithromycin, clarithromycin, erythromycin)

� In regions with a high rate (>25 percent) of infection with high-level (MIC ≥16 mcg/mL) macrolide-

resistant Streptococcus pneumoniae, consider use of alternative agents listed in (2) above.


Empirical antimicrobial therapy

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Outpatient treatment

� Previously healthy and no use of antimicrobials within the previous three months

1.Macrolide

- azithromycin →500 mg on day 1 followed by four days of 250 mg a dayor 500 mg QD for 3 days

- clarithromycin →500 mg twice daily for 5 days

2.Doxycyline* →100 mg twice daily

*：：：： Doxycycline may be used as an alternative to a macrolide, but there is stronger evidence to support the use of a macrolide than doxycycline for CAP.

QT prolong

Pregnancy X

表格來源：IDSA Guidelines on the Management of Community-Acquired Pneumonia in Adults

Empirical antimicrobial therapy

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Outpatient treatment

� Presence of comorbidities such as chronic heart, lung, liver, or renal disease; diabetes mellitus;

alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing

drugs; or use of antimicrobials within the previous three months

1.respiratory fluoroquinolone

- moxifloxacin →400 mg QD - gemifloxacin →320 mg QD - levofloxacin →750 mg QD

2.beta-lactam

- high-dose amoxicillin →1 g TID- amoxicillin-clavulanate →2g BID-cefuroxime →500mg BID

- + macrolide (azithromycin, clarithromycin, erythromycin)

For 5 day

QT prolong


Empirical antimicrobial therapy-Inpatients, non-ICU treatmentS. pneumoniae /H. influenzae /Other GNB/ Legionella spp./ C. pneumoniae

1.respiratory fluoroquinolone

- moxifloxacin →400mg QD IV or PO- levofloxacin →750mg QD IV or PO

2.antipneumococcal beta-lactam

- cefotaxime →1~2g IV Q8H - ceftriaxone →1~2g IV QD - ampicillin-sulbactam →1.5~3g IV Q6H- ertapenem →1g IV QD+macrolide (azithromycin, clarithromycin, or erythromycin)

3.tigecycline

IInitial: 100 mg IV as a single dose; then 50 mg Q12h for 7 to 14 days

*An increase in all-cause mortality has been observed, Tigecycline should be reserved for use in

situations when alternative treatments are not suitable.


Empirical antimicrobial therapy-Inpatients, ICU treatmentK. pneumoniae/ S. pneuomniae /Legionella spp./ Other GNB /P. aeruginosa/ Acinetobacter spp

1.antipneumococcal beta-lactam (cefotaxime, ceftriaxone, or ampicillin-sulbactam)

azithromycin

respiratory fluoroquinolone (moxifloxacin,levofloxacin)

2. penicillin-allergic patients

respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin)

+ aztreonam

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+


Empirical antimicrobial therapy-

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Special concerns

� Pseudomonas aeruginosa

1.antipneumococcal, antipseudomonal beta-lactam

- piperacillin-tazobactam → 4.5g Q6H- cefepime →2 g Q8H

- ceftazidime →2g Q8H- imipenem →500mg IV Q6H- meropenem →1g Q8H

either ciprofloxacin or levofloxacin

aminoglycoside PLUS azithromycin

aminoglycoside PLUS a respiratory fluoroquinolone

for penicillin-allergic patients, substitute aztreonam for above beta-lactam

� CA-MRSA

Add vancomycin or linezolid

+


Drug-resistant S. pneumoniae(DRSP)Risk factors for drug-resistant S. pneumoniae in adults include:

�Age >65 years

�Beta-lactam, macrolide, or fluoroquinolone therapy within the past three to six months

�Alcoholism

�Medical comorbidities

�Immunosuppressive illness or therapy

�Exposure to a child in a daycare center

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Pathogen-directed therapy.


Duration of antibiotic therapy�Patients with CAP should be treated for a minimum of 5 days

�Should be afebrile for 48–72 h, and should have no more than 1 CAP-associated sign of clinical instability


Prevention

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VaccineFactor Pneumococcal polysaccharide vaccine Inactivated influenza vaccine

Administration Intramuscular injection Intramuscular injection

Type of vaccine Bacterial component (polysaccharide capsule) Killed virus

Recommended groups 1. All persons ≥65 years of age

2. High-risk persons 2–64 years of age

3. Current smokers

1.All persons ≥50 years of age

2.High-risk persons 6 months–49 years of age

3. Household contacts of high-risk persons

4. Health care providers

5. Children 6–23 months of age

Revaccination schedule One-time revaccination after 5 years for

(1) adults ≥65 years of age, if the first dose is

received before age 65 years

(2) persons with asplenia

(3) immunocompromised persons

Annual revaccinatio


Pneumococcal vaccination�Pneumococcal polysaccharide vaccine (PPSV)—PPSV23

- All persons ≥65 years of age

- High-risk persons 2–64 years of age(Chronic heart disease. Chronic lung disease. Diabetes mellitus. Alcoholism. Chronic liver disease, cirrhosis. Cigarette smoking)

�Pneumococcal conjugate vaccine (PCV) —PCV7、PCV10、PCV13

- For infants and children

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肺炎鏈球菌感染高危險群：

(1)脾臟功能缺損或脾臟切除者。

(2)先天或後天免疫功能不全者(包括愛滋病毒感染者) 。

(3)人工耳植入者。

(4)慢性疾病：慢性腎病變、慢性心臟疾病、慢性肺臟病、糖尿病、慢性肝病與肝硬化患者、酒癮者、菸癮者等。

(5)腦脊髓液滲漏者。

(6)接受免疫抑制劑或放射治療的惡性腫瘤者或器官移植者。

高危險群之接種方式：

(1) 未曾接種 PCV13 或 PPV23 者：接種 1 劑 PCV13，間隔至少 8 週再接種 1 劑 PPV23。

(2) 曾接種 PPV23 者：接種 1 劑 PCV13，與前劑 PPV23 應間隔至少 8 週。※完成上述接種之高危險群， 5 年後可經醫師評估再追加 1 劑 PPV23。

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公費疫苗�兒童(PCV13)

-實施對象：出生滿 2 個月以上至未滿 60 個月，未曾接種或尚未完成 PCV13 之幼童。-常規接種採3劑時程(出生滿2個月、4個月分別接種1劑，滿12~15個月追加1劑)

�老人(PPCV23)一、75 歲以上從未接種肺炎鏈球菌疫苗者，公費提供 1 劑 PPV。二、75 歲以上曾經接種肺炎鏈球菌疫苗者，依下列原則接種：

(1) 65 歲以後曾接種 PPV 者，無需再接種 PPV。(2) 65 歲以前曾接種 PPV 者，經醫師評估可再接種 1 劑 PPV。(3) 曾接種 13 價結合型肺炎鏈球菌疫苗 (PCV13) 者且 65 歲以後從未接種 PPV 者，間隔 1 年以上，可經醫師評估再接種 1 劑 PPV。

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Reference�1. Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community-Acquired Pneumonia in Adults

�2.Uptodate

�3.肺炎臨床診療指引

�4.衛生福利部疾病管制署

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Vaccine�Pneumococcal polysaccharide vaccine (PPSV)

-PPSV23 不適合兩歲以下兒童

�Pneumococcal conjugate vaccine (PCV)

-PCV7

-PCV10

-PCV13

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No comorbidities, no recent antibiotic use, and low rate of resistance

For uncomplicated pneumonia in patients who do not require hospitalization, have no significant comorbidities and/or use of antibiotics within the last three months, and where there is not a high prevalence of macrolide-resistant S. pneumoniae strains, we recommend any one of the following oral regimens:

Azithromycin – 500 mg on day 1 followed by four days of 250 mg a day or 500 mg daily for three days

●Clarithromycin – 500 mg twice daily for five days

●Clarithromycin XL – Two 500 mg tablets (1000 mg per dose) once daily for five days

●Doxycycline – 100 mg twice daily

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Comorbidities, recent antibiotic use, or high rate of resistance

chronic obstructive pulmonary disease [COPD], liver or renal disease, cancer, diabetes, congestive heart failure, alcoholism, asplenia, or immunosuppression

A respiratory fluoroquinolone (levofloxacin 750 mg daily or moxifloxacin 400 mg daily or gemifloxacin 320 mg daily) for five days.

Combination therapy with a beta-lactam effective against S. pneumoniae (high-dose amoxicillin 1 g three times daily or amoxicillin-clavulanate XR 2 g twice daily or cefpodoxime 200 mg twice daily or cefuroxime500 mg twice daily) PLUS either a macrolide (azithromycin 500 mg on day 1 followed by four days of 250 mg a day or clarithromycin 500 mg twice daily or clarithromycin XL 1000 mg once daily) or doxycycline(100 mg twice daily). Treatment should generally be continued for five days

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Empiric therapy Antibiotics should be started as soon as possible once the diagnosis of CAP is established

�The most likely pathogen(s

�Clinical trials proving efficacy

�Risk factors for antimicrobial resistance. The choice of empiric therapy must take into account the emergence of antibiotic resistance among S. pneumoniae, one of the most common bacteria responsible for CAP.

�Medical comorbidities that may influence the likelihood of a specific pathogen and that may be a risk factor for treatment failure

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Risk factors for drug resistance Age >65 years

Beta-lactam, macrolide, or fluoroquinolone therapy within the past three to six months

Alcoholism

Medical comorbidities

Immunosuppressive illness or therapy

Exposure to a child in a daycare center

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Documents

Community-Acquired Pneumonia in Adults...2016/10/26 · Hospital-acquired pneumonia (HAP) ：--住院48 小時後，或上次住院結束後14 天之內發生之肺實質的急性感染。