Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, EIRE.
Hospital Clinic, IDIBAPS, Universided de Barcelona.
Curr Opin Infect Dis. 2022 Apr 1;35(2):133-139. doi: 10.1097/QCO.0000000000000819.
Community-acquired pneumonia (CAP) is known as a major worldwide health concern considering it has been shown to account for 78% of infection-related deaths in the USA. It is a common cause for hospitalization with a continued incidence rise in the elderly, high mortality rate and long-term sequelae in critically ill patients. Severe CAP (sCAP) is an accepted terminology used to describe ICU admitted patients with CAP. The aim of this review is to further report on the major advances in treatment for patients with sCAP including new antibiotic treatments despite macrolide resistance as seen in the ICU, and multifaceted antibiotic stewardship interventions that may lead to the reduction broad-spectrum antibiotic use in CAP.
We aim to examine the most recent findings in order to determine appropriate empirical antibiotic choices, timing regimens and evidence for clinical effectiveness. This will be addressed by focusing on the use combination therapies, the usefulness of severity scores and the difficulty to treat multidrug-resistant pathogens, including gram negatives such as Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus. Relevant reports referenced within included randomized controlled trials, meta-analyses, observational studies, systematic reviews and international guidelines where applicable.
New antibiotics have been recently launched with direct agent-specific properties that have been shown to avoid the overuse of previous broad-spectrum antibiotics when treating patients sCAP. Although narrow-spectrum antibiotics are now recommended and imperative in improving a patients' prognosis, there are also some considerations when prescribing antibiotics that are beyond the spectrum. There is a need to implement effective policies of de-escalation to avoid antibiotic resistance and the risk for developing subsequent infections by combining informed clinical judgement and the application of biomarkers. Reaching clinical stability and avoidance of treatment failure are the most important pillars in treatment success.
社区获得性肺炎（CAP）是一个全球性的健康关注点，因为它已被证明占美国感染相关死亡人数的 78%。它是导致住院的常见原因，在老年人中发病率持续上升，死亡率高，重症患者有长期后遗症。重症社区获得性肺炎（sCAP）是一种被广泛接受的术语，用于描述入住重症监护病房（ICU）的 CAP 患者。本文的目的是进一步报告 sCAP 患者治疗的主要进展，包括新的抗生素治疗方法，尽管 ICU 中已出现大环内酯类耐药，但抗生素管理干预措施也可能导致 CAP 中广谱抗生素的使用减少。
我们旨在检查最近的发现，以确定适当的经验性抗生素选择、治疗方案和临床疗效的证据。这将通过关注联合治疗、严重程度评分的有用性以及治疗多种耐药病原体（包括铜绿假单胞菌和耐甲氧西林金黄色葡萄球菌等革兰氏阴性菌）的困难来实现。相关报告包括随机对照试验、荟萃分析、观察性研究、系统评价和国际指南。
最近推出了一些具有直接针对特定病原体特性的新型抗生素，在治疗 sCAP 患者时避免了过度使用以前的广谱抗生素。虽然现在推荐使用窄谱抗生素，并对改善患者预后至关重要，但在开具抗生素时也需要考虑超出抗生素谱的一些因素。需要实施有效的降级策略，以避免抗生素耐药和随后感染的风险，结合知情的临床判断和生物标志物的应用。达到临床稳定和避免治疗失败是治疗成功的最重要支柱。
