akinohanayuki ブログ

学位を持っても、センスのない、感染制御専門薬剤師のブログ.  I have Ph.D. but less sense ID pharmacist.

レジオネラ肺炎

内科医と実習生共に「レジオネラ肺炎」を考えました。

薬学実習生も聴診器の扱いに慣れてきました。

 

80代 男性

尿中レジオネラ抗原 + 

感度74%、特異度99.1% 

すなわち2-3割は偽陰性

 

既往からのリスク因子 : 高齢、慢性肝障害、喫煙、喘息

 

Ccr >100mL/min

CHADS2-VASc : 5点

 

PSI : 120点

CURB65 : 3点

A-DROP : 3点

 

血液ガス分析  pO2 :64

肺雑 +

呼吸数 > 30

Poutiac熱による疼痛 なし

 

提案 : LVFX or AZM inj

期間 : 10-14日、反応が悪ければ21日

治療経過の想定 : レジオネラ肺炎の臨床反応はゆっくり

 

反省、今回はLVFXを推してしまった。結核マスクの問題などがあり、AZMを選択した方がよかったかもしれない。海外はLVFX 750mgであり日本より高用量である。

また、LVFXを選択した場合、ポンティアック熱に対する痛みカバーにNSAIDsも使用しずらい。ワーファリン服用しているため、キノロン影響が考えられる。

 

Up To Date より引用し復習

 

  抗菌薬

The newer macrolides (especially azithromycin) and the respiratory tract quinolones (especially levofloxacin) are effective for Legionella infection. In four studies that included a total of nearly 600 patients with Legionnaires' disease, outcomes were similar in patients who received quinolones (levofloxacin, ofloxacin,ciprofloxacin) compared with those who received macrolides (erythromycin, clarithromycin). However, more rapid defervescence, fewer complications, and/orshorter hospital stay were seen with the quinolones. 

     

   アプローチ

Suspected or proven Legionella pneumonia should be treated in most patients with levofloxacin (750 mg once daily) or azithromycin (1 gram on day one, followed by 500 mg once daily). Patients from long-term care facilities, those with nosocomial infection, and those who have received transplants should be treated with a fluoroquinolone to provide better coverage of other gram-negative bacilli and, in the case of transplant recipients and HIV patients, to avoid interactions between macrolides and immunosuppressive drugs. 

 

   スウィッチ

We recommend parenteral treatment initially for all patients with suspected Legionella pneumonia, given gastrointestinal dysfunction in some patients. A switch to oral therapy can be made after the patient defervesces. 

 

   投与期間

The total duration of therapy for Legionella pneumonia is 7 to 10 days. A longer course of antibiotics of 21 days might be considered for immunosuppressed patients who are severely ill upon presentation. 

 

   コンビネーション

Combination antibiotic therapy of a quinolone plus azithromycin might be considered for severely ill patients with extrapulmonary legionellosis. We also userifampin as part of combination therapy with quinolones in selected patients, but drug interactions can be problematic.

 

   予防

Legionnaires' disease is not transmitted from person-to-person; thus, isolation for hospitalized patients is unnecessary. Since the source of the organism is the hospital drinking water, prevention of nosocomial legionellosis is possible by routine culturing of the hospital drinking water. Monochloramine disinfection of municipal water supplies is associated with decreased risk of Legionella infection in the community. 

 

クラリスロマイシンより、レボフロキサシン

 

クラリス、エリスロより、レボフロ

 

クラリス、エリスロとレボフロは同等

 

エリスロとシプロフロキサシンは同等