摘要
近二三十年来新发和再发感(传)染病频现、病原学分子检测技术进步、抗生素耐药、人群生活方式和免疫状态变化(包括疫苗接种)等原因,致CAP病原学发生新的演变。(1)肺炎链球菌虽然仍是CAP的常见病原体,但在中国和美国已不居首位。(2)病毒的挑战与困扰增加。(3)肺炎支原体在成人CAP的地位和经验性抗菌治疗常规覆盖的观点存在争议。(4)CAP多耐药菌特别多重耐药GNB感染受到关注。(5)共感染常见而报道混乱。由于CAP病原学演变呈现出多样化、地方化的趋势,给大国制订统一指南带来困难,本文对制订地方性CAP诊治指导意见提出建议。
Over the past two to three decades,the emergence and re-emergence of new infectious diseases,advances in molecular detection techniques of pathogens,antibiotic resistance,changes in population lifestyle and immune status(including vaccination),and other factors have led to new evolutions in the etiology of community-acquired pneumonia(CAP).(1)Although Streptococcus pneumoniae remains a common pathogen of CAP,it is no longer the leading cause in China and the United States.According to the results of 2 multicenter studies in China in the early 21st century,Streptococcus pneumoniae accounted for 10.3%and 12.0%of adult CAP pathogens,respectively,ranking second.A study on key pathogens of adult CAP in nine cities in China's Mainland from 2014 to 2019 using real-time quantitative PCR and conventional culture on respiratory and blood specimens showed an overall prevalence of Streptococcus pneumoniae of 7.43%,ranking sixth.However,its ranking varied from third to seventh among the nine cities.(2)Challenges and concerns about viruses have increased.National surveillance of acute respiratory tract infections and epidemiology in China from 2009 to 2019 indicated that the positivity rates for viral infections in adult pneumonia was 20.5%.These rates were similar to the results of the CDC′s CAP pathogen study in the United States,although the rankings were different(viruses ranked second in China and first in the United States).Over the past 20 years,the emergence of new viral respiratory infections caused by mutant strains or zoonotic strains has significantly increased the challenges and threats posed by viral respiratory infections.(3)The role of Mycoplasma pneumoniae(M pneumoniae)in adult CAP and the need for routine empirical antibiotic coverage are controversial.In addition to the influence of epidemic cycles,the prevalence of M pneumoniae is influenced by factors such as age,season,study design,and detection methods,and geographical distribution is also an important influencing factor.Although M.pneumoniae ranks first among CAP pathogens in China's Mainland(11.05%),there are significant regional differences.In Beijing,Xi′an,and Changchun M.pneumoniae ranks first,while in Harbin,Nanjing,and Fuzhou it ranks second to sixth.In Wuhan,Shenzhen,and Chengdu M.pneumoniae ranks after the tenth position.Available evidence supports the notion that routine coverage of M.pneumoniae is not necessary for empirical treatment of CAP,except in severe cases.In regions with a high prevalence of M.pneumoniae,the decision to cover atypical pathogens in patients with mild to moderate CAP should be based on local data and individualized.(4)CAP caused by multidrug-resistant bacteria,especially multidrug-resistant Gram-negative bacilli(GNB),has become a concern.According to a systematic review of Chinese literature,Klebsiella pneumoniae accounted for 8.12%of adult CAP patients,ranking fifth,and Pseudomonas aeruginosa accounted for 4.7%(ninth).The China Antimicrobial Resistance Surveillance System(CARSS)reported an average resistance rate of 27.7%for Klebsiella pneumoniae to third-generation cephalosporins and a resistance rate of 10.0%to carbapenems in 2021.The average resistance rate of Pseudomonas aeruginosa to carbapenems was 16.6%.Early empirical treatment should consider predicting the resistance profile using a"locally validated risk factor"scoring system.(5)Co-infections are common but under-reported.The development of non-culture detection techniques over the past 40 years has significantly increased the detection rate of respiratory pathogens,especially viruses,leading to an increasing number of reports of bacterial-viral co-infections in CAP.It has been reported that co-infections account for 39%of severe CAP cases on ventilators in the ICU.Currently,there is inconsistency and confusion regarding the definition and concept of co-infection,the choice of detection techniques,and the differentiation between co-detection and co-infection.Many reports of co-infections in COVID-19 lacked pathogenic evidence,and some even listed"effective antibiotic treatment"as one of the diagnostic criteria for viral-bacterial co-infections,suggesting to some extent an overuse of antibiotics in COVID-19.Due to the diverse etiological spectrum of CAP between regions in the recent years,it is challenging to develop unified guidelines for the management of CAP in large countries.This article provides recommendations for the development of local guidelines for the diagnosis and treatment of CAP.
作者
何礼贤
He Lixian(Department of Respiratory and Critical Care Medicine of Zhongshan Hospital,Fudan University,Shanghai 200032,China)
出处
《中华结核和呼吸杂志》
CAS
CSCD
北大核心
2024年第6期576-581,共6页
Chinese Journal of Tuberculosis and Respiratory Diseases
