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.

難治性肺炎

難しい…肺炎治療
肺炎重症度とは既往歴
既往歴から難しい戦いが予測される

難治性肺炎を復習

UpToDate より

まとめ

Slow or incomplete resolution of pneumonia despite treatment is a common clinical problem, estimated to be responsible for approximately 15 percent of inpatient pulmonary consultations and 8 percent of bronchoscopies. 

Normal resolution of pneumonia is not easily defined and may vary depending upon the underlying cause. Patients typically note subjective improvement within three to five days of treatment; more specific clinical criteria for resolution include improvement in fever, cough, crackles, leukocytosis, arterial oxygenation (PaO2), and level of C-reactive protein. Determining whether a patient has nonresolving or progressive pneumonia must also take into account several factors that affect the expected rate of resolution, including comorbidities, age, severity, and etiology.

Data are available regarding resolution of pneumonia caused by different etiologic agents, including factors that affect the course of particular types of pneumonia.

Alternative pathogens, in addition to the usual bacterial causes of pneumonia, need to be considered in the patient who fails to respond to treatment.Particularly important pathogens in this category include mycobacteria (either Mycobacterium tuberculosis or atypical mycobacteria), fungi, Nocardia, and Actinomyces. 

The presence of a resistant pathogen is an important consideration for any pneumonia that is not responding appropriately to antibiotic therapy.

A variety of host factors may be associated with delayed resolution of pneumonia, including alcoholism, older age, and the presence of comorbid diseases such as diabetes and chronic obstructive lung disease. In addition, disorders of immune function, particularly AIDS and syndromes associated with deficient humoral immunity, can be associated with delayed resolution of pneumonia.

Sequestered foci of infection may prevent adequate concentrations of antibiotic agents from reaching the site of infection. The two main forms of sequestered focus preventing adequate resolution of pneumonia are empyema and lung abscess.

A variety of noninfectious etiologies of pulmonary infiltrates can mimic pneumonia and therefore represent causes of presumed nonresolving pneumonia. These fall into the categories of neoplastic, inflammatory, drug-induced, and vascular disease.

Further evaluation of patients with an apparent nonresolving pneumonia generally centers around more detailed imaging studies or obtaining material for microbiologic and pathologic analysis.


Abnormality Duration (days)
Tachycardia and hypotension 2
Fever, tachypnea, and hypoxia 3
Cough 14
Fatigue 14
Infiltrates on chest radiograph 30


Noninfectious etiologies of nonresolving pneumonia

Neoplastic disorders
Bronchogenic carcinoma
Bronchoalveolar cell carcinoma
Lymphoma
Immunologic disorders
Vasculitis:
Granulomatosis with polyangiitis (Wegener's)
Diffuse alveolar hemorrhage
Bronchiolitis obliterans-organizing pneumonia (BOOP)
Eosinophilic pneumonia syndromes
Acute eosinophilic pneumonia
Chronic eosinophilic pneumonia
Acute interstitial pneumonia
Pulmonary alveolar proteinosis
Sarcoidosis
Systemic lupus erythematosus
Drug toxicity
Pulmonary vascular abnormalities
Heart failure
Pulmonary embolism

少し詳しく

INFLUENCE OF SPECIFIC BACTERIAL PATHOGENS — Data are available regarding resolution of pneumonia caused by different etiologic agents, including factors that affect the course of particular types of pneumonia. It should be noted that the empiric approach to treatment of community-acquired pneumonia (CAP) and hospital-acquired pneumonia (HAP) suggested by most guidelines can result in failure to treat appropriately when pneumonia is the result of less common pathogens, like anaerobes and fungi.
  1. Streptococcus pneumoniae
  2. Legionella infection
  3. Mycoplasma pneumoniae
  4. Chlamydia pneumoniae
  5. Haemophilus influenzae

MISDIAGNOSIS OF PATHOGENSAlternative pathogens in addition to the usual bacterial causes of pneumonia need to be considered in the patient who fails to respond to treatment. Particularly important pathogens in this category include mycobacteria (either Mycobacterium tuberculosis or atypical mycobacteria), fungi, Nocardia, and Actinomyces.

  1. Tuberculosis
  2. Fungi
  3. Nocardia and Actinomyces

RESISTANT BACTERIAL PATHOGENS — 
The presence of a resistant pathogen is an important consideration for any pneumonia that is not responding appropriately to antibiotic therapy. Although penicillin-resistant Streptococcus pneumoniae (pneumococcus) is the organism of most concern, multidrug-resistant Haemophilus influenzae and Pseudomonas aeruginosa, as well as methicillin-resistant Staphylococcus aureus, are increasingly recognized in the community setting as possible causes of a nonresolving or recurrent pneumonia.

HOST FACTORS — 
A variety of host factors may be associated with delayed resolution of pneumonia, including alcoholism, older age, and the presence of comorbid diseases, such as diabetes and chronic obstructive lung disease. In addition, disorders of immune function, particularly AIDS and syndromes associated with deficient humoral immunity, can be associated with delayed resolution of pneumonia.

  1. AIDS
  2. Primary humoral immune deficiencies

DEVELOPMENT OF COMPLICATIONS FROM THE INITIAL PNEUMONIA — 
Sequestered foci of infection may prevent adequate concentrations of antibiotic agents from reaching the site of infection. The two main forms of sequestered focus preventing adequate resolution of pneumonia are empyema and lung abscess

  1. Empyema
  2. Lung abscess

NONINFECTIOUS ETIOLOGIES
 A variety of noninfectious etiologies of pulmonary infiltrates can mimic pneumonia and therefore represent causes of presumed nonresolving pneumonia. These fall into the categories of neoplastic, inflammatory, drug-induced, and vascular disease. Some of these noninfectious etiologies may also be associated with nonresolving pneumonia through other pathophysiologic mechanisms, such as endobronchial obstruction by bronchogenic carcinoma.

  1. Neoplastic disorders 
  2. Inflammatory disorders 
  3. Drug-induced lung disease
  4. Pulmonary embolism
  5. Hydrostatic pulmonary edema

FURTHER EVALUATION OF NONRESOLVING PNEUMONIA — 
Further evaluation of patients with an apparent nonresolving pneumonia generally centers around more detailed imaging studies or obtaining material for microbiologic and pathologic analysis 

  1. Imaging studies 
  2. Bronchoscopy
  3. Thoracoscopic or open lung biops
  4. Approach to diagnosis