重症市中肺炎 - JSEPTIC

1 2014/3/11 ICU Shinji Kawano contents NPPV/high flow Community acquired pneumonia jikei ICU jikei ICU for the iniJal management of adults with Community- Acquired Pneumonia: diagnosis, assessment of severity, and iniJal anJmicrobial therapy (ATS) Am Rev Resp Dis 1993;148:1418- 26 Acquired Pneumonia in adults: Guidelines for management(IDSA) CID 1998.

2 26:811- 38 guidelines for the management of .community- Acquired Pneumonia in adults(IDSA) CID 2000;31:347- 82 4. Guidelines for the management of adults with Community- Acquired Pneumonia: diagnosis, assessment of severity, anJmicrobial therapy, and prevenJon(ATS) Crit Care Med 2001.

3 163:1730- 54 of PracJce Guidelines for the Management of Community- Acquired Pneumonia in Immunocompetent Adults(IDSA) CID 2003;37:1405- 33 6. 2007 Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management of Community- Acquired Pneumonia in Adults(ATS IDSA) CID 2007.

4 44:S27- 72 Community- Acquired Pneumonia Guidelines Community acquired pneumonia jikei ICU jikei ICU CAP Community-acquired pneumonia 48 HCAP HCAP Health care-associated pneumonia 90 2 HAP Hospital-acquired pneumonia 48 CAP HCAP HAP PSI (=PORT study) the pneumonia severity index CURB65 the modified BriJsh Thoracic Society severity score A- DROP Japan Respiratory Society community associated pneumonia severity index I- ROAD Japan Respiratory Society hospital community associated pneumonia severity index rATS the revised American Thoracic Society score CURB- 65 A DROP CURB- 65 ICU CURB- 65 4 IDSA/ATS Clinical InfecJous Diseases 2008; 47:375 84 Clinical InfecJous Diseases 2007.

5 44:S27 72 v severe sepsis sepJc shock v v Intern Med 50: 1917- 1922, 2011 IDSA/ATS Crit Care 2012 16 Rl41 Journal of Medical Microbiology (2005), 54, 395 400 J Infect Chemother (2006) 12:63 69 J Infect Chemother (2004) 10:359 363 CHEST 2007; 132:515 522 Intern Med 52: 317- 324, 2013 Clinical InfecJous Diseases 2007; 44:S27 72 v v v v Severe sepsis, sepJc shock Pathogen- associated molecular pagern(PAMP) damage- associated molecular pager(DAMP) J Ciin Invest 1992 122 2731 40 NEngl J Med 2013 369 840 51 sepsis v v v v immunomodula7on Immunomodulatory agents in the treatment of community- acquired pneumonia: A systemaJc review Journal of InfecJon 2011.

6 63, 187- e199 Journal of InfecJon 2011: 63, 187- e199 Journal of InfecJon 2011: 63, 187- e199 Journal of InfecJon 2011: 63, 187- e199 v v ATS/IDSA - v quorum- sensing An7microb Agents Chemother 45 6 1930 1933 2001 v An7microb Agents Chemother 48 6 2251 2259 2004 An7- microb Agents Chemother 52 1 137 145 2008 v AmlPhysiol Lung Cell Mol Physiol 289 4 L565 573.

7 2005 v v IL 8 Am Rev ResPir Dis 148 1061 1065 1993 ResPira7on 63 1 42 48 1996 v J an7biot Tokyo 46 9 1406 1413 1993 J an7biot Tokyo 47 1 80 89 1994 v Am J ResPir Crit Care Med 168 5 581 587 2003 Chest 122 1 213 218 2002 LPS 150 pg/mL ICR 1 5 5 AZM CAM RXM JM 100 1 1 2 4 LPS ELISA 100 50 0 JJA 57 Supul. A : 79, 2004 LPS IL- 1 LPS RXM CAM AZM JM 4 pg/mL 3 1 0 LPS RXM CAM AZM JM 600 pg/mL 400 200 0 LPS RXM CAM AZM JM IL- 1 IL- 6 TNF- 2 500 300 100 500mg 1 1 2 500mL /mL 15 N 9 10 2011 12 Clinical InfecJous Diseases 2007.

8 44:S27 72 - ATS/IDSA 2007 Inadequate anJmicrobial treatment of infecJons a risk factor for hospital mortality among criJcally ill paJents Chest 115 462- 474 1999 A worldwide perspecJve of atypical pathogens in community- acquired pneumonia AJRCCM175 1086- 1093 2007 lntensive Care Med 36 4 612- 620 2010 CAP Intensive Care Med 36 4 :612 620 2010 75 30/40 28/52 ATS/IDSA 2007 ProspecJve, observaJonal cohort, mulJcenter study 9 27 ICU 218 CAP CombinaJon anJbioJc therapy with macrolides improves survival in intubated paJents with community- acquired pneumonia lntensive Care Med 36 4 612- 620 2010 Macrolide- Based Regimens and Mortality in Hospitalized PaJents With Community- Acquired Pneumonia: A SystemaJc Review and Meta- analysis Clinical InfecJous Diseases 2012;55(3):371 80 RCT RCT Macrolides and Mortality in CriJcally Ill PaJents With Community- Acquired Pneumonia: A SystemaJc Review and Meta- Analysis* Crit Care Med 2014.

9 42:420 432 ICU 347795 1391180 1348672 264626 193906 Azithromycin and the risk of cardiovascular death. N Engl J Med 2012; 366: 1881- 90 95%CI , p< 95%CI , p= 5 Use of Azithromycin and Death from Cardiovascular Causes N Engl J Med 2013;368:1704- 12. 18 64 1997 2010 110 2050 1 1 220 4100 110 2419 V 736 4292 18 64 5 95% 17 V 146 V 95% RCT SIRS

10 / CAP MulJcenter trial CAP ICU 46 200mg bolus 10mg/hr 7 RCT HydrocorJsone Infusion for Severe Community- acquired Pneumonia A Preliminary Randomized Study PaO2 FIO2 CRP MulJple organ dysfuncJon MODS Am J Respir Crit Care Med Vol 171. pp 242 248, 2005 48 50 4 2m dL 1 30 PaO2 FIO2 250 X 2 90mmH 60mmH 2 Dexamethasone and length of hospital stay in paJents with community- acquired pneumonia: a randomised, double- blind, placebo- controlled trial Lancet 2011; 377: 2023 30 double- blind, placebo- controlled trial, we randomly assigned adults aged 18 years or older with confirmed community- acquired pneumonia who presented to emergency departments of two teaching hospitals in the Netherlands receive intravenous dexamethasone (5 mg once a day) or placebo for 4 days from admission The primary outcome was length of hospital stay Lancet 2011; 377: 2023 30 CorJcosteroids in the Treatment of Community- Acquired Pneumonia in Adults: A Meta- Analysis PLoS ONE 7(10) 2012,Vol 7 9 1001 Severe CAP (95% ) PLoS