University of Western Australia, Perth, Australia.
Am J Respir Crit Care Med. 2011 Jan 15;183(2):157-64. doi: 10.1164/rccm.201002-0272CI. Epub 2010 Aug 6.
Despite many advances in medical science, the mortality rate from community-acquired pneumonia (CAP) has changed little in the past four decades. Death and adverse outcomes from CAP result from a complex interplay between the pathogen and the host. Newer information about the effect of pneumonia on comorbidity and underlying diseases, especially long term, suggests this is an important additional axis that differs from the traditional triangular concept of pathogen, host defense, and antibiotic treatment. A number of clinical scoring systems have been developed to help physicians identify patients with CAP at risk of adverse outcomes. None of the criteria have been prospectively demonstrated to avoid late intensive care unit transfers or lower mortality, raising interest in the use of biomarkers such as procalcitonin. Quantitative bacterial genomic load represents a potentially important risk stratification. Optimal antibiotic management appears to include use of a macrolide, although the mechanism of benefit remains unclear. Attempts to improve CAP outcomes through setting measurable process of care standards are to be applauded, but making sure that these standards do not become the end in themselves, but rather that the entire process of care is improved, remains critical.
尽管医学科学取得了许多进展，但在过去的四十年中，社区获得性肺炎（CAP）的死亡率变化不大。CAP 导致的死亡和不良结局是病原体和宿主之间复杂相互作用的结果。关于肺炎对合并症和基础疾病的影响的新信息，尤其是长期影响，表明这是一个重要的附加轴，与传统的病原体、宿主防御和抗生素治疗的三角概念不同。已经开发了许多临床评分系统来帮助医生识别有不良结局风险的 CAP 患者。这些标准都没有前瞻性地证明可以避免重症监护病房的延迟转移或降低死亡率，这引起了人们对降钙素原等生物标志物的使用的兴趣。定量细菌基因组负荷代表了一种潜在的重要风险分层。抗生素管理的最佳方法似乎包括使用大环内酯类药物，尽管其获益机制仍不清楚。通过设定可衡量的护理标准来提高 CAP 结局值得称赞，但重要的是要确保这些标准本身不是目的，而是整个护理过程得到改善。
