Department of Science and Technology/National Research Foundation: Vaccine Preventable Diseases, University of the Witwatersrand, Johannesburg, South Africa.
Pediatr Infect Dis J. 2011 Oct;30(10):e192-202. doi: 10.1097/INF.0b013e31822d989c.
Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality in human immunodeficiency virus (HIV)-infected children.
A systematic review of studies that were published between January 1990 and February 2009 on the etiology and antimicrobial or adjunctive systemic management of CAP in HIV-infected children.
Pneumocystis jirovecii had the strongest association with HIV infection, with a summary odds ratio of 10.1 (95% confidence interval [CI], 17.7-62.1) and 9.1 (95% CI, 2.5-33.1) in antemortem and postmortem studies, respectively. Cytomegalovirus was strongly associated with HIV positivity among fatal cases of pneumonia (summary odds ratio = 14.4 [95% CI, 6.7-30.8]). There was a trend toward a greater prevalence of Staphylococcus aureus (odds ratio, 2.5; 95% CI, 0.95-6.4) in HIV-infected children. Major limitations identified included substantial methodological heterogeneity across studies, limited sensitivity of assays for diagnosing bacterial pneumonia, and studies primarily being undertaken in the absence of antiretroviral treatment or cotrimoxazole prophylaxis. No a priori-planned randomized controlled trials on antimicrobial management of CAP in HIV-infected children were identified.
A World Health Organization panel used this review as well as analysis of risks and benefits to revise recommendations for antimicrobial treatment of CAP. Ampicillin plus gentamicin or ceftriaxone is now recommended as first-line empiric regimens for treating severe and very severe CAP in HIV-infected children. In addition, treatment with cloxacillin or vancomycin is recommended in settings with a high incidence of methicillin-resistant S. aureus, and particularly if clinical or microbiological evidence of S. aureus pneumonia exist. Further studies in HIV-infected children on CAP etiology and antibiotic treatment are required in the era of antiretroviral treatment.
社区获得性肺炎（CAP）是导致人类免疫缺陷病毒（HIV）感染儿童发病和死亡的主要原因。
对 1990 年 1 月至 2009 年 2 月间发表的关于 HIV 感染儿童 CAP 的病因学和全身抗菌或辅助治疗的研究进行系统评价。
肺孢子菌与 HIV 感染的相关性最强，在生前和死后研究中，其合并优势比（OR）分别为 10.1（95%可信区间[CI]，17.7-62.1）和 9.1（95%CI，2.5-33.1）。在致命性肺炎病例中，巨细胞病毒与 HIV 阳性高度相关（合并 OR = 14.4[95%CI，6.7-30.8]）。在 HIV 感染儿童中，金黄色葡萄球菌的流行率呈上升趋势（OR = 2.5；95%CI，0.95-6.4）。研究中存在的主要局限性包括：研究间方法学存在较大异质性、用于诊断细菌性肺炎的检测方法敏感性有限、以及主要在未进行抗逆转录病毒治疗或复方新诺明预防的情况下开展的研究。未发现针对 HIV 感染儿童 CAP 抗菌治疗的预先计划的随机对照试验。
世界卫生组织（WHO）小组使用本综述以及对风险和获益的分析对 CAP 的抗菌治疗推荐进行了修订。在 HIV 感染儿童中，氨苄西林加庆大霉素或头孢曲松现被推荐作为治疗严重和极严重 CAP 的一线经验性治疗方案。此外，在甲氧西林耐药金黄色葡萄球菌发病率高的地区，以及存在金黄色葡萄球菌肺炎的临床或微生物学证据时，推荐使用氯唑西林或万古霉素治疗。在抗逆转录病毒治疗时代，需要在 HIV 感染儿童中开展 CAP 病因学和抗生素治疗的进一步研究。
