Garcia-Vidal Carolina, Carratalà Jordi
Infectious Disease Service, Hospital Universitari de Bellvitge. Institut d'investigació Biomèdica de Bellvitge, University of Barcelona, L'Hospitalet de Llobregat, Barcelona, Spain.
Semin Respir Crit Care Med. 2009 Apr;30(2):154-60. doi: 10.1055/s-0029-1202934. Epub 2009 Mar 18.
Treatment failure is a matter of great concern in the management of community-acquired pneumonia (CAP). Defined generally as lack of response or clinical deterioration, failure is considered early when it occurs within the first 72 hours and late when it occurs after 72 hours. The reported incidence of treatment failure among hospitalized patients with CAP ranges from 2.4 to 31% for early failure and from 3.9 to 11% for late failure. Most cases of early failure occur because of inadequate host-pathogen responses. Factors associated with treatment failure include high-risk pneumonia, liver disease, multilobar infiltrates, Legionella pneumonia, gram-negative pneumonia, pleural effusion, cavitation, leucopenia, and discordant antimicrobial therapy. Conversely, influenza vaccination, initial treatment with fluoroquinolones, and chronic obstructive pulmonary disease have been linked with a lower risk of failure. Treatment failure is associated with high morbidity and mortality rates. Its detection and management require careful clinical assessment. Certain serum biological markers may be helpful to identify patients with a higher risk of deterioration and poor prognosis. Because inadequate host-pathogen responses are responsible for a significant number of failures, strategies aimed at modulating the inflammatory response should be investigated. Discordant therapy can be prevented by rational application of the current antibiotic guidelines.
治疗失败是社区获得性肺炎（CAP）管理中备受关注的问题。治疗失败一般定义为缺乏反应或临床病情恶化，若在最初72小时内发生则视为早期失败，若在72小时后发生则视为晚期失败。据报道，住院CAP患者中早期治疗失败的发生率为2.4%至31%，晚期治疗失败的发生率为3.9%至11%。大多数早期治疗失败病例是由于宿主 - 病原体反应不足所致。与治疗失败相关的因素包括高危肺炎、肝病、多叶浸润、军团菌肺炎、革兰氏阴性菌肺炎、胸腔积液、空洞形成、白细胞减少以及抗菌治疗不恰当。相反，流感疫苗接种、初始使用氟喹诺酮类药物治疗以及慢性阻塞性肺疾病与较低的治疗失败风险相关。治疗失败与高发病率和死亡率相关。其检测和管理需要仔细的临床评估。某些血清生物学标志物可能有助于识别病情恶化风险较高和预后较差的患者。由于大量治疗失败是由宿主 - 病原体反应不足所致，应研究旨在调节炎症反应的策略。合理应用当前的抗生素指南可预防抗菌治疗不恰当的情况。
