【医学课件】成人社区获得性肺炎处理指南.ppt

* * * * Chlamydia pneumoniae has emerged as an important cause of pneumonia in both adults and children as young as 2 years old.[24,27,30,31] Over 50% of adults worldwide have antibodies against the pathogen, indicating prior infection. Unfortunately, immunity is not long lived. Chlamydia pneumoniae has an incubation period of 2-4 weeks. The disease is usually mild but may be prolonged. Fever and cough are common symptoms, and chest examination usually reveals crackles.[12] Among patients who develop C. pneumoniae pneumonia, the illness is often biphasic, with patients presenting with pharyngitis, then recovering, and then developing pneumonia 1-3 weeks later. Mortality associated with C. pneumoniae pneumonia is surprisingly high, at 9.8% of hospitalized patients.[32] Unfortunately, microbial diagnosis of C. pneumoniae infection is complicated by the lack of commercially available systems for rapid microimmunofluorescence antibody detection and by the fact that most laboratories are not equipped to culture the organism. Therefore, the method most often used for documentation of infection is chlamydial complement fixation antibody testing, which requires IgM or IgG elevations that take a minimum of 2-3 weeks to rise after acute infection. As with other atypicals, confirmation of C. pneumoniae is generally not sought and treatment is empiric.  HAP的流行病学 HAP在中国医院内感染中占第1位 HAP在美国医院内感染中占第2位 教学医院；ICU；胸腹部手术；机械通气 早期的HAP：住院4 d内发生的肺炎,通常由敏感菌引起,预后好 晚期的HAP是指住院≥5 d发生的肺炎,致病菌常是多药耐药菌(MDR) ,病死率高 HAP的病原学 非免疫缺陷者 通常由细菌感染引起, 可能为多种细菌的混合感染 常见的致病菌有需氧革兰阴性杆菌 铜绿假单胞菌、大肠杆菌、肺炎克雷伯菌、 不动杆菌 由真菌和病毒引起的感染少见 HAP的病原学 免疫缺陷者和部分免疫正常者 口咽部定植菌 化脓链球菌、凝固酶阴性葡萄球菌 奈瑟菌属、棒状杆菌属 HAP的危险因素与病原学分布的相关性 金黄色葡萄球菌：昏迷、头部创伤、近期流感病毒感染．糖尿病、肾衰竭 铜绿假单胞菌：长期住ICU、长期应用糖皮质激素、先期抗生素应用、支气管扩张症、粒细胞缺乏、晚期AIDS 军团菌：应用糖皮质激素、地方性或流行性因素 厌氧菌：腹部手术、可见的吸入 HAP的病原学 主要的MDR包括: MRSA 、铜绿假单胞菌 不动杆菌属、肺炎克雷伯菌 HAP： MRSA和肺炎克雷伯菌更多见 VAP：铜绿假单胞菌、嗜麦芽窄食单胞菌、不动杆菌、嗜肺军团菌更多见 　 MDR病原菌引起HAP的危险因素 90 d内用过抗生素治疗 本次住院时间≥5 d 所在社区或病区的抗生素耐