Heffelfinger J D, Dowell S F, Jorgensen J H, Klugman K P, Mabry L R, Musher D M, Plouffe J F, Rakowsky A, Schuchat A, Whitney C G
Respiratory Diseases Branch, Centers for Disease Control and Prevention, Atlanta, GA, USA.
Arch Intern Med. 2000 May 22;160(10):1399-408. doi: 10.1001/archinte.160.10.1399.
To provide recommendations for the management of community-acquired pneumonia and the surveillance of drug-resistant Streptococcus pneumoniae (DRSP).
We addressed the following questions: (1) Should pneumococcal resistance to beta-lactam antimicrobial agents influence pneumonia treatment? (2) What are suitable empirical antimicrobial regimens for outpatient treatment of community-acquired pneumonia in the DRSP era? (3) What are suitable empirical antimicrobial regimens for treatment of hospitalized patients with community-acquired pneumonia in the DRSP era? and (4) How should clinical laboratories report antibiotic susceptibility patterns for S pneumoniae, and what drugs should be included in surveillance if community-acquired pneumonia is the syndrome of interest? Experts in the management of pneumonia and the DRSP Therapeutic Working Group, which includes clinicians, academicians, and public health practitioners, met at the Centers for Disease Control and Prevention in March 1998 to discuss the management of pneumonia in the era of DRSP. Published and unpublished data were summarized from the scientific literature and experience of participants. After group presentations and review of background materials, subgroup chairs prepared draft responses, which were discussed as a group.
When implicated in cases of pneumonia, S pneumoniae should be considered susceptible if penicillin minimum inhibitory concentration (MIC) is no greater than 1 microg/mL, of intermediate susceptibility if MIC is 2 microg/ mL, and resistant if MIC is no less than 4 microg/mL. For outpatient treatment of community-acquired pneumonia, suitable empirical oral antimicrobial agents include a macrolide (eg, erythromycin, clarithromycin, azithromycin), doxycycline (or tetracycline) for children aged 8 years or older, or an oral beta-lactam with good activity against pneumococci (eg, cefuroxime axetil, amoxicillin, or a combination of amoxicillin and clavulanate potassium). Suitable empirical antimicrobial regimens for inpatient pneumonia include an intravenous beta-lactam, such as cefuroxime, ceftriaxone sodium, cefotaxime sodium, or a combination of ampicillin sodium and sulbactam sodium plus a macrolide. New fluoroquinolones with improved activity against S pneumoniae can also be used to treat adults with community-acquired pneumonia. To limit the emergence of fluoroquinolone-resistant strains, the new fluoroquinolones should be limited to adults (1) for whom one of the above regimens has already failed, (2) who are allergic to alternative agents, or (3) who have a documented infection with highly drug-resistant pneumococci (eg, penicillin MIC > or =4 microg/mL). Vancomycin hydrochloride is not routinely indicated for the treatment of community-acquired pneumonia or pneumonia caused by DRSP.
为社区获得性肺炎的管理及耐青霉素肺炎链球菌（DRSP）的监测提供建议。
我们探讨了以下问题：（1）肺炎链球菌对β-内酰胺类抗菌药物的耐药性是否应影响肺炎治疗？（2）在DRSP时代，门诊治疗社区获得性肺炎合适的经验性抗菌治疗方案有哪些？（3）在DRSP时代，治疗住院社区获得性肺炎患者合适的经验性抗菌治疗方案有哪些？以及（4）临床实验室应如何报告肺炎链球菌的抗生素敏感性模式，若关注的综合征为社区获得性肺炎，监测中应包括哪些药物？肺炎管理专家及DRSP治疗工作组（包括临床医生、院士和公共卫生从业者）于1998年3月在美国疾病控制与预防中心开会，讨论DRSP时代肺炎的管理。从科学文献及参与者的经验中总结已发表和未发表的数据。在小组报告及背景资料审查后，各小组主席起草了回应草案，并进行了小组讨论。
若肺炎病例中分离出肺炎链球菌，当青霉素最低抑菌浓度（MIC）不大于1μg/mL时应视为敏感，MIC为2μg/mL时视为中度敏感，MIC不低于4μg/mL时视为耐药。对于门诊治疗社区获得性肺炎，合适的经验性口服抗菌药物包括大环内酯类（如红霉素、克拉霉素、阿奇霉素）、8岁及以上儿童用的多西环素（或四环素），或对肺炎链球菌有良好活性的口服β-内酰胺类药物（如头孢呋辛酯、阿莫西林，或阿莫西林与克拉维酸钾的组合）。住院肺炎合适的经验性抗菌治疗方案包括静脉用β-内酰胺类药物，如头孢呋辛、头孢曲松钠、头孢噻肟钠，或氨苄西林钠与舒巴坦钠的组合加用大环内酯类。对肺炎链球菌活性增强的新型氟喹诺酮类药物也可用于治疗成人社区获得性肺炎。为限制氟喹诺酮耐药菌株的出现，新型氟喹诺酮类药物应限于以下成人使用：（1）上述方案之一已治疗失败的患者；（2）对替代药物过敏的患者；或（3）有记录感染高度耐药肺炎链球菌（如青霉素MIC≥4μg/mL）的患者。盐酸万古霉素通常不用于治疗社区获得性肺炎或DRSP所致肺炎。
