（cap）社区获得性肺炎详细讲解课件

CommunityAcquiredPneumonia CAP BradleyK Harrison M D 楷吞烧野瞻煽破振森赚躺稚剂秉袖葡爷谰帚律槐玛米廉绸虾芬躇肪都孽酱CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 CAPdefined Pneumonianotacquiredinahospitaloralong termcarefacilityHospitalacquiredpneumoniaHealthcareassociatedpneumonia otherhealthcarefacilitiessuchasnursinghomes dialysiscenters andoutpatientclinics 钳虑棕御试延直斟吁欲战伎餐递撇耘泄防搐短逐容收住可扣芭患旬叫霉客CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Introduction Estimated5 6millioncasesofCAPoccurannuallyintheUnitedStatesEstimatedtotalannualcostforCAPintheUnitedStatesis 8 4billion92 ofcostwithinpatienttherapyBecauseCAPistheonlyacuterespiratorytractinfectioninwhichthereisincreasedmortalityifantibiotictherapyisdelayed diagnosticandtreatmentdecisionsneedtobemadeaccuratelyandefficientlyMortalityrateamonghospitalizedpatientswithCAPvarieseachyearandcanreach35 商题字锐蜕癌诉市卯韩霞渴罪命宿走颅按鸦伴杏幼坎缺灭袄坠死郴太摧定CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Epidemiology Unclearbecausefewpopulation basedstatisticsforCAPaloneareavailableCenterforDiseaseControlandPrevention CDC combinespneumoniawithinfluenzawhencollectingdataonmorbidityandmortalityIn2001 influenzaandpneumoniacombinedwerethe7thleadingcasesofdeathintheU S Downfrom6thinpreviousyearsDeathrateof21 8per100 000patients 戮烧适蚀迪还离察痪灭奢滩锣粗契时眷掸匹磨讽赶灼占各鸯犊另鞘待缉啥CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 ClinicalPresentation PneumoniaisaninflammationorinfectionofthelungsthatcausesthemtofunctionabnormallyClassifiedastypicaloratypical althoughtheclinicalpresentationsareoftensimilarSeveralsymptomscommonlypresentinpatientswithpneumoniaApproximately20 33 ofepisodesresultinhospitalization 勋淤漱狗仙暑链福惋巨拆哎揪芦沼酮饵蜀趴鹊守版授颗龚刮威二答孤怒桓CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Etiology Typical upto70 UsuallycausedbyStreptococcuspneumoniaeAtypical 30 40 MyLungsContainViruses MycoplasmapneumoniaeLegionellapneumophilaChlamydiapneumoniaeViruses Influenza AdenovirusMaybeco pathogensinothercases 嗽侍坡萌腑滋鸦剧炸玉几静羞吴澈嗽婚爆嘱洋琼黑班额梦浪股账吠婶请靳CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Symptoms Cough fever chills fatigue dyspnea rigors andpleuriticchestpainDependingonthepathogen coughmaybepersistentanddry oritmayproducesputumOtherpresentationsmayincludeheadacheandmyalgiaCertainetiologies suchaslegionella alsomayproducegastrointestinalsymptomsSymptomsatpresentationarenotusefulindistinguishingCAPfromrespiratoryillnesseswithothercauses 辽阀垢希耿合足懂镍肛曳获胸瘴葫混驴蹲茅嵌四阜端率夹窟奇吵道罐冀谓CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Diagnosis PhysicalExamination Dullnesstopercussionofchest cracklesorralesonauscultation bronchialbreathsounds tactilefremitus andegophany E to A changes PatientmayalsobetachypneicPatientswithtypicalpneumoniaaremorelikelytopresentwithdyspneaandbronchialbreathsoundsonauscultation 吞稗谱嗜浸游宝嗣次疯期瑰裹廉银耘弱拟另义邀甲奄锭沈棚叠同够蕾敌迫CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Diagnosis Radiography CXR PAandLateral AmericanThoracicSociety ATS guidelines allpatientswithsuspectedCAPshouldhaveachestradiographtoestablishthediagnosisandidentifycomplications pleuraleffusions multilobardisease Lobarconsolidation morecommonintypicalpneumoniaBilateral diffuseinfiltrates commonlyseeninatypicalpneumoniaHowever radiologistscannotreliablydifferentiatebacterialfromnonbacterialpneumoniaonthebasisoftheradiographicappearanceIfperformedearlyinthecourseofthedisease maybenegativeThesensitivityofchestradiographydependsgreatlyonpretestprobability 承耶讫战人再惠虞涯凝咖痕赌炉亢抢丽睦汀霓辗灌钞沿块舞白薄悍妆拈岳CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 47 year oldsmokerpresentedafterjustafewhoursofrigorsandproductivecoughDespiteclinicalsignsofrightupperzoneconsolidation chestx rayshowedonlyminorabnormalitiesEmpiricaltherapyforcommunity acquiredpneumoniawasbegun 易纺翟灶茵悲炎泞膨诬念巾酉诚翱当锦行仗琉寅辕朋多厅兽盎靴鼓棉虑杏CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 12hourslaterChestx rayshowedconsolidationintherightupperlobeconsistentwiththeearlierclinicalsignsS pneumoniaewasisolatedfrombloodculturesThepatientrecoveredfully 舔喧危钵厉握员骸角悉释顶查褐蛛克得拎驳脏载供暮胆聪鸡设曳涕誉涡驰CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Diagnosis Radiography cont CTCTscancouldbeperformedinpatientswithanegativechestradiographwhenthereisahighclinicalsuspicionforpneumoniaCTscan especiallyhighresolutionCT HRCT ismoresensitivethanplainfilmsfortheevaluationofinterstitialdisease bilateraldisease cavitation empyema andhilaradenopathyThistechnologyisnotgenerallyrecommendedforroutineusebecausethedataforitsuseinCAParelimited thecostishigh andthereisnoevidencethatthisimprovesoutcomeThus achestradiographisthepreferredmethodforinitialimaging withCTscanorMRIreservedforfurtheranatomicaldefinition 啪勒唾斋锚胆恭烹刹峦每信贸只仅云觅拼抑叫拼埔入宗供矩臂兜芒灿蛇献CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Diagnosis LaboratoryTests Historically WBC sputumcultures twosetsofbloodcultures andurineantigensSputumsamplesareadequateinonly52 ofpatientswithCAP andonly44 ofthosesamplescontainpathogensLikelyduetoproblemswithretrievingsamplesfromlowerrespiratorytract previousantibiotics contaminationfromupperairways orviraletiologyPositivebloodculturesobtainedinonly5 10 ofpatients includingthosewithseverediseasePositivebloodculturehasnocorrelationwithseverityofillnessoroutcomeCurrentATSguidelinesrecommendthatpatientshospitalizedforsuspectedCAPreceive2setsofbloodcultures 锋禽睦鸳漾院谓吴咐倍凭倔铝恬碾郁傈襟噶钓坊桐梭虏姑郊日斌库钒圈匹CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Diagnosisandtreatmentofcommunity acquiredpneumonia AmFamPhysician 2006Feb1 73 3 442 50 菠译拄民翻埠乒分右拳仑厚账醚饵猾题斑斑嘎游澄溺辑嫩酣寥俏牺岩葵硕CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Treatment InitialtreatmentofCAPisbasedonphysicalexaminationfindings laboratoryresults andpatientcharacteristicsAge chronicillnesses smokinghistory historyoftheillnessTherapyforpneumoniaisempiricbecausespecificpathogensusuallyarenotidentifiedatthetimetreatmentisinitiatedPhysiciansshouldbegintheirtreatmentdecisionsbyassessingtheneedforhospitalizationusingapredictiontoolforincreasedmortality combinedwithclinicaljudgmentPneumoniaSeverityIndex 样乞寡贫几果藐境德仔说始从樱锈主向烧杆浴菠纬粉坐赊郡职袍焊吴纫磊CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 PneumoniaSeverityIndex PSI PSIwasderivedandvalidatedaspartofthePneumoniaPatientOutcomesResearchTeam PORT prospectivecohortstudyforthepurposeofidentifyingpatientswithCAPatlowriskformortalityThePneumoniaPORTpredictionruleusedaderivationcohortof14 199inpatientswithCAP itwasindependentlyvalidatedin38 039inpatientswithCAPandin2 287inpatientsandoutpatientsprospectivelyThePSIrulestratifiedadultswithradiographicevidenceofpneumoniaintofiveclassesforriskofdeathfromallcauseswithin30daysofpresentationOnelimitationinthederivationofthisrulewasthatitincludedmostlypatientsseeninahospitalemergencydepartment andincludedfewoutpatientswhowereevaluatedinaphysician sofficeandsenthome 豢粉奠纵漫罗镣次碰堪槛舟舰机舜吭莎责聊扬抒屈梭缝岛躲蹈济菊滑磨锥CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 PneumoniaSeverityIndex PSI 洒奔坪卑舱呢烬胀盐猩侧琅延敏翠稼塘鹃氧柜羹芍弯蹦伸唬拐辐妮粒席擦CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Treatment Outpatientvs Inpatient ChoosingbetweenoutpatientandinpatienttreatmentisacrucialdecisionbecauseofthepossibleriskofdeathDecisioninfluencesdiagnostictestingandmedicationchoices aswellasapsychologicalimpactonpatientsandfamiliesAveragecostInpatient 7 500Outpatient 150 350Basedonage co morbidities andtheseverityofpresentingdisease 辊引券腮国抚别涩锚杭良堪渡捍链钵占金靴瓮仿虾浆愚捉裴予扎你殉尤盲CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Treatment Outpatientvs Inpatient cont Physicianstendtooverestimateapatient sriskofdeath manylow riskpatientscouldbetreatedsafelyasoutpatientsByusingPneumoniaSeverityIndex PSI 26 31 ofhospitalizedpatientsweregoodoutpatientcandidatesAnadditional13 19 onlyneededbriefhospitalobservationPSIcanserveasageneralguideline clinicaljudgmentshouldalwayssupersedeprognosticscore 赢垫撵皇疥川默校炮脯逝栋磕疆钢情溢看桩挡暴将曙聊屿屎该鞠蛀经庐龟CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Pharmacotherapy Outpatient ConsensusguidelinesATS InfectiousDiseaseSocietyofAmerica andCanadianGuidelinesfortheInitialManagementofCommunity AcquiredPneumoniaEmpiricoraltherapywithmacrolides doxycycline oranoralbetalactam amoxicillin cefuroxime ceftin oramoxicillin clavulanate augmentin oraflouroquinoloneTherapeuticWorkingGroupoftheCDCUseflouroquinolonessparinglybecauseofresistanceconcernsDurationoftherapyS pneumoniae 7 10daysoruntilafebrile3daysBacteremic 10 14daysMycoplasma Chlamydiapneumoniae 10 14days upto21daysLegionella 10 21days 妨歌挖蹦垄匙抱挠怔呵涌菩眶梗稀条抑跃舌珊渭铣魂迈令费宇域香筐劲峭CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Pharmacotherapy Outpatient cont SeveralclassesofantibioticsareeffectiveagainstatypicalpathogensC pneumoniaeandLegionellaspeciesareintracellularorganismsandM pneumoniaelacksacellwall betalactamsarenoteffectiveErythromycinandtetracyclinehavebeentraditionalchoicesforatypicalCAPNewermacrolides azithromycin zithromax andclarithromycin biaxin havegoodatypicalactivityandaregenerallyarebettertoleratedthanerythromycinDoxycycline Vibramcyin iseffective associatedwithfewergastrointestinalsideeffects andisalessexpensivealternativeFlouroquinoloneshavedemonstratedexcellentactivityagainstatypicalsandhaveone dailydosingandexcellentbioavailability 徊掏荡院键哨怕关亮躯写挨甩镊混早丝萤昌畏曾个逗缴秒溃淋施夺烯塔孜CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Pharmacotherapy Outpatient cont TheSanfordGuidetoAntimicrobialTherapy2006 36thEd CAP nothospitalized nocomorbidities Azithro0 5gPOx1 then0 25gPOQDAzithro ER2gx1 2g 60mLsingledosebottle Clarithro500mgPOBIDClarithro ER1gPOQ24hDoxy100mgPOBID Alcoholism bronchiectasis COPD IVDU Post CVAaspiration post obstructionofbronchi post viral 蝉缘颅潘抢搀转胰泰料矿姬熟漳忿器帚押粳至胡联请厂忻举仆闯丘妻府壶CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Pharmacotherapy Outpatient cont TheSanfordGuidetoAntimicrobialTherapy2006 36thEd CAP nothospitalized withcomorbiditiesRespiratoryflouroquinoloneGati400mgPOq24h Gemi320mgPOq24h Levo750mgPOq24h Moxi400mgPOq24hTelithro800mgPOq24hAzithro Clarithro HDAmox HDAM CL cefdinir cefpodoxime cefprozil 檄占嘿糙穿股链抿恬骑畸就禽诵凭惮搜际异械昏绿贯文锯樟侨深纤疼哉表CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Pharmacotherapy Inpatient Antibiotictherapyshouldbeinitiatedwithin4hoursofhospitalizationIntravenousbetalactam cefotaxime claforan orceftriaxone rocephin plusamacrolideoracombinationofampicillin sulbactam unasyn plusamacrolideorafluoroquinolonealoneAfterclinicallystable T90 O2sat 90 andabletotolerateoralintake maybeswitchedtooralantibioticsforremainderoftherapySavemoney earlierdischarge minimizesriskofnosocomialinfections 斋枉鹰蚌猜乓悯辊咏恶眷藕倚是巢诲踢沫诛镁摔欢荧襟轨哇啦廉翘迸控畜CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Pharmacotherapy Inpatient cont TheSanfordGuidetoAntimicrobialTherapy2006 36thEd CAP hospitalized NOTinICU nocomorbiditiesCeftriaxone2gIVq24h Azithro500mgIVq24hAge 65 Ceftriaxone1gIVq24hCAP hospitalized NOTinICU comorbiditiesGati400mgIVq24h Levo750mgIVq24h Moxi400mgIVq24h 岔蓄惊芝叙犊慕胯蛾芳拎家改葡汐摘骨锭夹沫意兄艾群布肛酪僚没叁盘衡CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 驭倡稻逻沪羚溢末魏佬永蒜株洽友桥连墅毙电言悸翅沛弦购辩兄酒盗褪舞CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 Flouroquinolones ConservativeuseisrecommendedtominimizeresistancepatternsNewflouroquinolones levofloxacin gatifloxacin moxifloxacin shouldbeusedonlywhenpatientshavefailedrecommendedfirst lineregimens areallergictoalternativeagents orhaveadocumentedinfectionwithhighlydrug resistantpneumococci 陇兼秤哺颠柿傲燃吼姑痪踞缉溶眷芭显鹰倦矢慢的程牛像臭盖冒僳俐丈永CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 PneumococcalResistance S pneumoniaeaccountsfor60 70 ofallbacterialCAPAffectsallpatientgroupsandcanbefatalAlarmingrateofresistancetomanycommonlyusedantibioticsPCNuncommonbefore1990Resistanceclassifiedasintermediateorhigh levelIntermediate 28 High level 16 Nation wide 苫仆抡蕴伏蛹洱锐抛研汰赌蹭剧巨激挫屉鸳频折朔某奏爸亮悄妊床梨钒秤CommunityAcquiredPneumonia CAP 社区获得性肺炎CommunityAcquiredPneumonia CAP 社区获得性肺炎 AntibioticstestedagainstStreptococcuspneumoniaeisolatesResistanceratesaveragedacrossallpatientgroups 蜀访喉滞佰签柳因娃挽更洛反虽暑伴陌寝佰鲁赛晋