Aleva R M, Boersma W G
Máxima Medisch Centrum, afd. Longziekten, Eindhoven.
Ned Tijdschr Geneeskd. 2005 Nov 5;149(45):2501-7.
Community-acquired pneumonia (CAP) is associated with considerable morbidity and mortality. The incidence of CAP in the Netherlands is estimated to be 5-10 per 1000 per year. This guideline can be used for the scientifically-based diagnosis and antibiotic treatment of adults with CAP. Streptococcus pneumoniae is the most frequent causative agent In 30-50% of patients, the aetiological pathogen cannot be identified. In the Netherlands, the resistance of S. pneumoniae to penicillin is less than 1%. In addition to patient history and physical examination, chest radiography is indispensable to the diagnosis of CAP. Cultures of sputum, blood, and, if present, pleural effusion are needed to detect the causative agent. Bronchoscopy can be considered if the patient's condition deteriorates during antibiotic therapy. Urinary antigen detection is important if signs of legionellosis are present; only Legionella pneumophila serotype can be identified with this technique. The severity of CAP and the risk factors can be measured by the pneumonia severity index, which may be helpful in deciding whether to hospitalise a patient. The choice of antibiotic therapy is based on the intention of providing optimal therapy, the epidemiological features ofvarious microorganisms in the Netherlands, and an inference of the most likely pathogen, based on comorbidity. Empirical antibiotic therapy should target primarily S. pneumoniae because of its high incidence. In both seriously ill patients and those suspected of having legionellosis, antibiotic therapy should also target L. pneumophila. Antibiotic therapy should be adjusted if the pathogen is subsequently identified. Parapneumonic effusion frequently occurs in cases of CAP. Drainage is indicated if the pleural fluid contains bacteria or yields a pH < 7.0. Influenza vaccination is recommended in the elderly to prevent CAP.
社区获得性肺炎（CAP）与相当高的发病率和死亡率相关。荷兰CAP的发病率估计为每年每1000人中有5 - 10例。本指南可用于成人CAP的科学诊断和抗生素治疗。肺炎链球菌是最常见的病原体，30% - 50%的患者无法确定病因病原体。在荷兰，肺炎链球菌对青霉素的耐药率低于1%。除患者病史和体格检查外，胸部X线摄影对CAP的诊断不可或缺。需要进行痰、血以及如有胸腔积液则对胸腔积液进行培养以检测病原体。如果患者在抗生素治疗期间病情恶化，可考虑进行支气管镜检查。如果存在军团菌病迹象，尿抗原检测很重要；该技术仅能识别嗜肺军团菌血清型。CAP的严重程度和危险因素可通过肺炎严重指数来衡量，这可能有助于决定是否将患者住院。抗生素治疗的选择基于提供最佳治疗的目的、荷兰各种微生物的流行病学特征以及根据合并症推断最可能的病原体。由于肺炎链球菌发病率高，经验性抗生素治疗应主要针对该菌。对于重症患者和疑似患有军团菌病的患者，抗生素治疗也应针对嗜肺军团菌。如果随后确定了病原体，应调整抗生素治疗。肺炎旁胸腔积液在CAP病例中经常发生。如果胸腔积液中含有细菌或pH值<7.0，则需要引流。建议老年人接种流感疫苗以预防CAP。
