1、肺 炎 簡 介,高雄醫學大學 感染內科 陳彥旭,World Infection associated mortality 1997/2002,(21,000),(282,000),(285,000),(81,000),(745,000),(1,124,000),(2,866,000),(2,001,000),(1,644,000),(3,871,000),WHO The world health report 2002 data,(140,000),(275,000),(410,000),(605,000),(960,000),(2,100,000),(2,300,000),(2,455,00
2、0),(2,910,000),(3,745,000),2002,1997,Community Acquired Pneumonia,Epidemiology: 4-5 million cases annually 500,000 hospitalizations 45,000 deaths Mortality 2-30% 65 yrs mortality disproportionately high in 65 yrs,Bartlett. CID 1998;26:811-38.,Community Acquired Pneumonia,Adeel A. Butt, MD,# in 1000s
3、,Incidence,Community Acquired Pneumonia,Adeel A. Butt, MD,# in 1000s,Mortality,Risk Factors for pneumonia age alcoholism smoking asthma immunosuppression institutionalization COPD PVD dementia,Community Acquired Pneumonia,ID Clinics 1998;12:723. Am J Med 1994;96:313,何謂肺炎？,肺炎的診斷依據？,肺炎的定義為何？,肺炎是否一定會發燒
4、？,不發燒是否就一定不會是肺炎？,肺炎的治療？,呼吸疾病病程與症狀變化,Craig C. Freudenrich, Ph.D.,病毒感染呼吸道細胞,被感染的細胞死亡,杯狀細胞分泌黏液,干擾素與細胞酵素 引起發炎,死亡的上皮細胞(病毒) 發炎細胞 分泌的黏液 鼻咽喉移生的細菌增殖,A. Nasal cavity B. Pharynx C. Larynx D. Trachea E. Alveoli F. Bronchial tree G. Diaphragm,吸引發炎細胞聚集,發燒、喉痛、 噴涕,發燒、流鼻水,傳染期,痰,中 耳 炎,鼻 竇 炎,支 氣 管 炎,菌 血 症,病 毒 血 症,肺 炎,
5、膿 胸,社區性肺炎的病原,微生物,典型肺炎(細菌)S. pneumoniaeH. influenzaeS. aureusGNBOthers 非典型肺炎Legionella spp.M. pneumoniaeC. pneumoniae 病毒性 吸入性肺炎 無病原診斷,北美1967-95,英國胸腔學會1987,1966-95,20 30% 20 60%3 10%3 5%3 10%3 5% 10 20%2 8%1 6%4 6%2 15%6 10% 30 60%,60 75%4 5%1 5% Rare ND NA2 5%5 18% NA8 16%NDNA,65% 12%2%1%3% 12%4%7%1%
6、3%NDND,常見呼吸道病原之感染季節,7,8,9,10,11,12,1,2,3,4,5,6,副流感病毒,流行性感冒病毒 A & B,Q fever,鏈球菌 GAS,肺炎球菌 Sp,退伍軍人肺炎桿菌 Lp,嗜血桿菌 Hi,月份,黴漿菌 Mp / 披衣菌 Cp,腺病毒,冠狀病毒,原 發 性 肺 炎,次 發 性 肺 炎,伺機性肺炎,CMV, PCP, Fungus,肺炎的診斷,臨床診斷肺炎的依據 臨床症狀 理學檢查 CXR 檢查 一般檢驗:ABGCBC/DCCRP,肺炎的病因診斷？ 培養 細菌染色: 快速抗原: 血清抗體: 分子生物:PCR,典型肺炎與非典型肺炎比較表,黴漿菌肺炎(Mp) 流行病學
7、(Seattle, 1963-75),Seattle US 1963-75,Incidence/1,000/year,Definition: 1. Mp titer 1:32 2. Mp titer 4x rise 3. Mp isolated,高雄地區披衣菌肺炎(Cp)血清流行病學,年齡,%,N=,97,26,21,312,171,73,84,223,78,1085,Wang 1993,MIF IgG1:16,73.4%,臨床診斷,病因診斷,培養 染色: Gram, AFS 快速抗原: 血清抗體: 分子生物:PCR,肺炎的診斷,流行病學資訊,臨床症狀 理學檢查,CXR 一般檢驗,季節性 地域
8、性 接觸史 傳染源與傳播力 潛伏期,痰(採集方式) 咽喉拭子 肋膜液 血液 尿液,肺炎治療,經驗治療,專一性治療,檢驗方法,適當的檢體與採集,輔助治療,肺炎的病因診斷方式？,顯微鏡抗原偵測抗體-免疫螢光-血清 微生物培養分子生物學,檢體種類,適合微生物,痰 氣管鏡抽取液 胃液 痰、氣管抽取液 尿液 鼻腔液、痰液 血液痰 氣管鏡抽取液 胃液 痰、氣管抽取液,Sp, Hi, GNB, GPC, Tb, Fungus Sp, Hi, GNB, GPC, Tb, fungus Tb Virus (Adv, Flu, PIF, RSV, SARS Legionella Legionella, virus
9、-specific Mp, Cp, Ct, Legionella, Cb, Flu, Adv, CXB1-6, Mp, Bacteria, Legionella, Tb Mp, Bacteria, Legionella, Tb Tb Any extrinsic pathogens,臨床診斷與抗生素的使用,OPD antibiotics prescription, data of CDC,肺炎的治療,單一抗生素治療,支持性治療,強化性抗生素治療,散彈槍抗生素治療,預防性抗生素治療?,臨床診斷,病因診斷,肺炎治療,經驗治療,專一性治療,輔助治療,單一抗生素治療,化痰劑 蒸氣 物理治療,肺炎治療,臨
10、床診斷,Resistance Burden in Taiwan,SMART 2000,臺灣地區主要的呼吸道致病菌抗藥性,Hsueh PR. Antimicro Agents Chemother 2000,肺炎治療觀念與方法,社區性支氣管肺炎或肺炎,病毒性肺炎,外因性肺炎,病毒感染併發 細菌性性肺炎,院內感染性肺炎 低抵抗力肺炎,症狀治療 體液補充 預防性抗生素?,症狀治療 體液補充 處理併發症 選擇治療性抗生素,典型肺炎: S. pneumoniae H. influenzae Others,非典型肺炎: M. pneumoniae C. pneumoniae Legionella spp.
11、Environmental,S. pneumoniae H. influenzae Legionella spp. Enterobacteriae,Adenovirus Influenza Parainflu. RSV Chickenpox,%,%,%,常見呼吸道疾病的抗微生物製劑選擇,Penicillin Amoxicillin Amoxi/Clavu- Ampi-/Sulbact- Tetracycline Erythromycin Azithromycin Cefotaxime Cefuroxime Trimeth-/Sulfa- Levofloxacin,肺炎球菌,嗜血桿菌,厭氧菌,G
12、NB,黴漿菌,匹衣菌,Legionella,+ + + + + - +/- + + + +,- + + + + - + + + + +,+ + + + + + + + + - +,- + + + + - +/- + + + +,- - - - + + + - - - +,- - - - + + + - - + +,- - - - + + + - - - +,In vitro,Pneumococcal Disease and Pneumococcal Vaccines,Epidemiology and Prevention of Vaccine-Preventable Diseases,Revi
13、sed December 2004,Streptococcus pneumoniae,Gram-positive bacteria 90 known serotypes Polysaccharide capsule important virulence factor Type-specific antibody is protective,Pneumococcal Pneumonia Clinical Features,Abrupt onset Fever Shaking chills Productive cough Pleuritic chest pain Dyspnea, tachyp
14、nea, hypoxia,Pneumococcal Pneumonia,Estimated 175,000 hospitalized cases per year Up to 36% of adult community-acquired pneumonia and 50% of hospital-acquired pneumonia Common bacterial complication of influenza and measles Case-fatality rate 5%-7%, higher in elderly,Pneumococcal Disease Epidemiolog
15、y,Reservoir Human carriers Transmission RespiratoryAutoinoculationTemporal pattern Winterearly spring Communicability UnknownProbably as long as organism in respiratory secretions,Invasive Pneumococcal Disease Incidence by Age Group1998,*Rate per 100,000 populationSource: Active Bacterial Core Surve
16、illance/EIP Network,Invasive Pneumococcal Disease by Age and YearChildren 5 Years, 1998-2002*,1 yr,2 yrs,3 yrs,4 yrs,1 yr,*2003 data are preliminary. Source: Active Bacterial Core Surveillance/EIP Network,Age group,Pneumococcal Polysaccharide Vaccine,Purified capsular polysaccharide antigen from 23
17、types of pneumococcus Account for 88% of bacteremic pneumococcal disease Cross-react with types causing additional 8% of disease Not effective in children 2 years 60%-70% against invasive disease Less effective in preventing pneumococcal pneumonia,Pneumococcal Conjugate Vaccine,Pneumococcal polysacc
18、haride conjugated to nontoxic diphtheria toxin (7 serotypes) Vaccine serotypes account for 86% of bacteremia and 83% of meningitis among children 90% effective against invasive disease Less effective against pneumonia and acute otitis media,Pneumococcal Polysaccharide Vaccine Recommendations,Adults
19、65 years of age Persons 2 years with chronic illness anatomic or functional asplenia immunocompromised (disease, chemotherapy, steroids) HIV infection environments or settings with increased risk,Pneumococcal Conjugate Vaccine,Routine vaccination of children age 7 months require fewer doses,謝謝收看,病人常在你身邊 正確且適當配戴口罩 正確且勤洗手,
