1

()
( Guidelines for the Management of Adults with Community-acquired Pneumonia)
( introduction )
(community-acquired pneumonia , CAP)


2541 1 5

( definition)
(community acquired pneumonia)
(community organism)
(new pulmonary
infiltration)
2 ( 1 )

3
(immuno-compromised host) HIV
( neutropenia) ( agranulocytosis)

( etiology of community-acquired pneumonia)

1) (outpatient CAP)
Streptococcus pneumoniae , atypical pathogens (Chlamydia pneumoniae, Mycoplasma
pneumoniae , Legionella spp.) viruses S. pneumoniae
9-20 % , M .pneumoniae 13-37 % , C. pneumoniae 10-20 % , Legenella spp. 0.7-13 %
viruses 10-30 % 20-50 %
(
) S. pneumoniae 12-24 % , C. pneumoniae
17-32 % , M .pneumoniae 6-13 % Legenella spp. 6-10 % * H. influenzae
5%
20-34 %
*

( Legionella spp.

2) (inpatient CAP)

S. pneumoniae (20-60%) atypical pathogens C. pneumoniae
M. pneumoniae (10-30%) S . aureus
gram negative enteric bacteria ( 0-5 % 10-20 % )
Pseudomonas aeruginosa
10-15 %
S. pneumoniae (drug resistant streptococcus pneumoniae, DRSP )

DRSP 40-60 % MIC 2 g/ml
(intermediate resistant) DRSP
penicillin

(modifiers)

DRSP , enteric gram negative bacteria P. aeruginosa
( 2 )
( decision for hospitalization)




( 3 )
65
malignancy, chronic renal failure, congestive heart
failure , chronic liver disease, cerebrovascular disease , COPD
> 30 / , systolic blood pressure
< 90 mmHg , pulse > 125 /min , temperature < 35 o C > 40 o C
PaO2 < 60 mmHg ( SpO2< 90% ) , arterial
pH < 7.35 , pleural effusion , Hct < 30 %
(inpatient)

( 4 )
. ( major criteria )

( septic shock)
. (minor criteria )
(systolic blood pressure) 90 .
( multilobar involvement )
(oxygen saturation , SpO2)
90%
1 2

( patient stratification)

4

P. aeruginosa 4 ( 5)
1 (modifiers)

3 ( mild to moderate
illness)
a )
b)
4 (severe illness)

a) P. aeruginosa
b) P. aeruginosa
(diagnostic investigation in
community-acquired pneumonia )

(investigation)


6-7
1 complete blood count (CBC)
2

blood chemistry oxygen saturation

3 4



anti HIV
melioidosis antibody

( S. pneumoniae, atypical pathogens, viruses )

S. pneumoniae




(screen)

1



B. pseudomallei
( serology) (
atypical pneumonia)


serology

(treatment guidelines for community-acquired
pneumonia)
. (principles of antimicrobial therapy)

8

(narrow spectrum antibiotics)

(guidelines )

. (choices of antibiotics)

8-13

atypical pathogens
macrolides ( erythromycin , roxithromycin ,
clarithromycin , azithromycin ) doxycycline
( Gr 1 Gr 4a ) P. aeruginosa
( Gr 4b) doxycycline
1 S. pneumoniae
fluoroquinolones

(Gr 2 - Gr 4b , 9-13) 1
DRSP
fluoroquinolones ( newer
generation fluoroquinolones) atypical pathogens S. pneumoniae (
DRSP) levofloxacin gatifloxacin moxifloxacin

fluoroquinolones ciprofloxacin
P. aeruginosa
( Gr 4b , 13 )
aminoglycoside
enteric gram negative bacteria
aminoglycoside
P. aeruginosa ( Gr 4b , 13 )

( multi-drug resistant strain)

-lactam

- lactam

-lactam
-lactam cefotaxime , ceftriaxone
DRSP DRSP
(high resistance) penicillin
amoxycillin/clavulanate ampicillin/salbactam
ceftriaxone
cefotaxime
. (duration of antibiotics therapy )

7-14 S. pneumoniae
7-10 C. pneumoniae M. pneumoniae 10
14


. (response to therapy)
3

1) (early clinical response)

24-48

2) 72
3) 24-48
2 3
(host
factors)

72



1. (inadequate antibiotics selection)
2. (unusual pathogen) Leptospira spp. , Nocardia spp. ,
Histoplasma spp. Burkholderia pseudomallei ,
Rickettsia tsutsugamushi
3. (complications of pneumonia)

4.
(bronchoscopy ) Pneumocystis carinii

5. (noninfectious illness) ,
pulmonary hemorrhage, hypersensitivity pneumonitis, acute interstitial pneumonia
. (switch to oral therapy)



8

CBC

. ( hospital discharge)

(vaccination recommendations for

the patient at risk for community acquired pneumonia)

influenza vaccine pneumococcal vaccine influenza
vaccine ( > 65 )
pneumococcal vaccine

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1. American Thoracic Society. Guidelines for the management of adults with community acquired pneumonia. Am J Respir Crit Care Med 2001 ; 163 : 1730-1754 .
2. The Infectious Disease Society of America. Practice guidelines for the management of
community-acquired pneumonia in adults. CID 2000 ; 31 : 347-382 .
3. ERS task force report. Guidelines for management of adult community-acquired lower
respiratory tract infection. Eur Respir J 1998 ; 11 : 986-991 .
4. . The 6th Boeringer
Ingelheim annual respiratory workshop on community-acquired pneumonia
12 2544 .
5. Marrie T J. Community-acquired pneumonia : epidemiology, etiology, treatment .
Infect Dis Clinic North America 1998 ; 12 : 723-740 .
6. Liebrman 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. Thorax 1996 ; 51 : 179-184 .
7. , , .

( unpublished data ).
8. , , , .
: 73 (unpublished data ).
9. . : 2001 , 2000 : 39-57 .

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