社區肺炎元兇－非典型肺炎 - tma.org.tw

1 (community-acquired pneumonia, CAP) 48 60 CAP 13-15% 1,2 CAP 6 C A P C A P (Streptococcus pneumoniae) (Haemophilus influenzae) (Staphylococcus aureus) (atypical pneumonia) (Mycoplasma pneumoniae) (Chlamydophila pneumoniae) (Legionella pneumophila) 3,4 CAP CAP 5,6 3-48% 7 Arnold 8 2007 CAP CAP 22% 28% 21% 20% CAP 2-30% 6-19% 2-15 ( 1) C A P 2 - 3 0 % - 1 2012 56 4 37 p e n i c i l l i n vancomycin cephalosporin ( )

2 9 14-21 ( 2-3 ) 6 25-50% 10,11 X X (ESR) 7 (cold agglutinin)( 4 ) ( 3-4 ) 4 12 ( o b l i g a t e i n t r a c e l l u l a r p a r a s i t e s ) ( C h l a m y d i a t r a c h o m a t i s ) (Chlamydia psittaci) 6-19% 15-23 3 13 X E S R (direct fluorescent antibody test, Direct FA test) ( e n z y m e - l i n k e d immunosorbent assay, ELISA) (polymerase chain reaction , PCR)

3 - 2012 56 4 38 - 14 (Pontiac fever) CAP 2-15 15,16 (opportunistic infection) 40 15 90% I (LP1) 6 (LP6) 17 2 - 1 0 ( 40 ) ( ) 60% ( ) 10% (ARDS) (disseminated intravascular coagulation, DIC) X 50-70% ( 130 mmol/L) 2010 ( 40 ) 2012 56 4 39 - ( ) ( 130 mmol/L) -lactamase aminoglycoside (Indirect FA test, IFA)

4 (nucleic a c i d p r o b e ) ( u r i n a r y antigen immunoassays) PCR ELISA Legionella Urinary Antigen Test (immunochromatographic membrane a s s a y, I C T ) 3 0 L P 1 ( 1 ) 3 18 : 4 ( ) C F 1:6 4 M I F 1 : 3 2 I FA 1:128 I ( ) ( 1) PCR D N A CAP CAP Arnold8 21 4 3 3 7 C A P (meta-analysis) 1996 9 2004 4 CAP 1 BALF PSBIFA EIA MIF CF EIAPCR( ) PA EIA CFPCR( )19 BALF (bronchoalveolar lavage fluid) PSB (protected specimen brush) IFA ( ) EIA (enzyme-linked immunosorbent assay) CF (complement fixation test) MIF (microimmunofluoresence)

5 PA (particle agglutination) urinary antigen test I (LP1) 2012 56 4 40 ( ) ( , P ) 2 0 0 7 / (Infectious Diseases Society of America/American Thoracic Society, IDSA/ATS)(20) C A P - ( - l a c t a m a s e ) (macrolide) (fluoroquinolones) ma c r o l i d e azithromycin clarithromycin roxithromycin fluoroquinolones moxifloxacin levofloxacin m a c r o l i d e fluoroquinolones (post-antibiotic effect) 1 9 9 8 2 0 0 0 I D S A l e v o f l o x a c i n 2 0 0 7 levofloxacin fluoroquinolones 1998 2000 IDSA 2003 macrolide 2007 macrolide macrolide ( 25%, MIC 16 mg/L) macrolide IDSA/ATS fluoroquinolones - l a c t a m a s e m a c r o l i d e 2 0 0 5 fluoroquinolones l e v o f l o x a c i n levofloxacin MIC 8 mg/L( 60 CAP )

6 Moxifloxacin I D S A -lactamase 2007 -lactamase I C U C A P f l u o r o q u i n o l o n e s - 2012 56 4 41 (pseudomonas aeruginosa) ciprofloxacin aminoglycoside C A P C A P (respiratory quinolone) levofloxacin, moxifloxacin macrolide -Lactamase(20) (Klebsiella pneumoniae) (Acinetobacter baumannii) 17 CAP 4,15 5,6 CAP (Human immunodeficiency virus, HIV) 2 0 1 0 ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( ) ( )

7 ( ) ( ) - 2012 56 4 42 Gram stain 1. A l m i r a l l J , B o l i b a r I , U i d a l J , e t a l : E p i d e m i o l o g y o f c o m m u n i t y a c q u i r e d p n e u m o n i a i n a d u l t s : a p o p u l a t i o n - b a s e d study. Eur Respir J 2000; 15: Bartlett JG, Mundy LM: Community-acquired pneumonia. N Engl J Med 1995; 333: 1618 Gupta SK, Sarosi GA: The role of atypical pathogens in community acquired pneumonia.

8 Med Clin North Am 2001; 85: 1349 Ewig S, Birkner N, Strauss R, et al: New p e r s p e c t i v e s o n c o m m u n i t y - a c q u i r e d p n e u m o n i a i n 3 8 8 4 0 6 p a t i e n t s . R e s u l t s from a nationwide mandatory performance m e a s u r e m e n t p r o g r a m m e i n h ea l t h c a r e quality. Thorax 2009; 64: d e R o u x A , E w i g S , G a r c a E , e t a l : M i x e d c o m m u n i t y - a c q u i r e d p n e u m o n i a i n h o s p i t a l i z e d p a t i e n t s . E u r R e s p i r J 2006;27 Lieberman D,Schlaeffer F,Boldur I, et al: Multiple pathogens in adult patients admitted with community acquired pneumonia: a one year prospective study of 346 consecutive patients.

9 Thorax 1996;51 Sopena N, Sabria M, Pedro-Botet ML, et al: Prospective study of community-acquired pneumonia of bacterial etiology in adults. Eur J Clin Microbiol Infect Dis 1999; 18: 852 A r n o l d F W, S u m m e r s g i l l J T, L a j o i e A S , et al: A worldwide perspective of atypical pathogens in community-acquired pneumonia Am J Respir Crit Care Med 2007; 175: Lieberman D, Schlaeffer F, Lieberman D, et al: Mycoplasma pneumoniae community-a c q u i r e d p n e u m o n i a : a r e v i e w o f 1 0 1 hospitalized adult patients. Respiration 1996; 63: 261 Va rma -Ba s il M, D w ive di SK , K uma r K , e t a l : R o l e o f M y c o p l a s m a p n e u m o n i a e infection in acute exacerbations of chronic o b s t r u c t i v e p u l m o n a r y d i s e a s e.

10 J M e d Microbiol 2009; 58: 322 Wa l t e r N D , G r a n t G B , B a n d y U , e t a l : - 2012 56 4 43C o m m u n i t y o u t b r e a k o f My c o p l a s m a p n e u m o n i a e i n f e c t i o n : s c h o o l - b a s e d c l u s t e r o f n e u r o l o g i c d i s e a s e a s s o c i a t e d with household transmission of respiratory illness. J Infect Dis 2008; 198: 1365 Uldum SA, Jensen JS, S nderg rd-Andersen J, et al: Enzyme immunoassay for detection o f i m m u n o g l o b u l i n M ( I g M) a n d I g G antibodies to Mycoplasma pneumoniae. J Clin Microbiol 1992; 30: 1198 B t n Y, K s e S , B a b a y ii t A , e t a l : Chlamydia and Mycoplasma serology in r e s p i r a t o r y t r a c t i n f e c t i o n s o f c h i l d r e n.