Korean Journal of Medicine : Vol. 58, No. 2, 2000,,,,,,,,,,.,,...,,,,,. 3,, M ycoplasma pneumonia, Legionnaire., Legionnaire., Mycopl

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1 : , , 1, /5. 1 5%, 25% 1).,,,,. Chlamydia pneumoniae, hantavirus. macolides, beta- lactams, fluoroquinolones, carbapenems (meropenem, imipenem), streptogramins ,. (),.,, 1-4)... (virulence),,,,., H emophilus influenzae, M oraxella catarrhalis. Legionella,, K lebsiella,. (T able 1)4). Table 1. (, )/ Streptoccus pneumoniae, H emophilus influenzae, M oraxella catarrhalis, Legionella species Streptoccus pneumoniae, H emophilus influenzae, Anaerobes Influenza, Streptoccus pneumoniae, Hemophilus influenzae, Staphylococcus aureus, Streptococcus pyogenes Streptoccus pneumoniae, Anaerobes, H emophilus influenzae, Legionella pneumophila, Gram negative bacilli, M ycobacterium tuberculosis

2 Korean Journal of Medicine : Vol. 58, No. 2, 2000,,,,,,,,,,.,,...,,,,,. 3,, M ycoplasma pneumonia, Legionnaire., Legionnaire., Mycoplasma. Q fever, tularemia,, Legionnaire. Mycoplasma, pigmented cast creatine phosphokinase influenza virus, Legionnaire,. 5lobar or segmental consolidation, patch bronchopneumonia, nodules(,, ), interstitial pattern... Pneumocystis Nocardia,,. 6,, buffy coat...., Q, adenovirus ,. protected specimen brushing, plugged telescoping catheter sampling, standard bronchoalveolar lavage, protected bronchoalveolar lavage, transtracheal aspiration( ),,,.,,, 5).,,,

3 Joon Chang : Community acquired pneumonia. 80% (single rigor),. H. influenzae, S. aureus, gram- negative enteric bacilli 1). M ycoplasma. Legionella influenza 1)... M ycoplasma, Legionella, Chlamydia. Legionella,,,, AIDS. M ycoplasma pneumoniae 4)., H. influenzae, influenza C. pneumoniae. Legionella. M ycoplasma pneumoniae. 3-6 M ycoplasma pneumoniae 4).. 80% 80%, 60 80%, 30%, 40 50%, (rigor) 15%.,,,,,,. 1,6) %, %, % , () virus, mycoplasma, chlamydia, tularemia, legionella 6). 40%.., (fine crackles) 80%...,., bronchial breath sounds, egophony( ' ' ' ' ) (consolidation) 30%.., 24, P. carinii 10 30%, 7).,,.,. 3%, 28%. 37.8, 100, 8)

4 : subsegmental, segmental, lobar pneumonia. (patch peribronchial multifocal) (bronchopneumonia).,, (, ), (, ) 5).,.,,,,.. K lebsiella pneumoniae. Klebsiella (current jelly) minor (horizontal) fissure (buldging fissure),. Klebsiella,. buldging fissure. serotype III,,. H. influenzae, M. pneumoniae, virus. 25 < 5 (10 ). 85%. (Legionella, influenza virus,, P. carinii).,,,,.,, % 80%. 85% 90%. 41%.. 1-2, EnterobacteriaceaeS. aureus. Enterobacteriaceae, S. aureus )

5 : 45 50%, H. influenzae 34 47% 6),. 60%, 90%. 10% 2 H. influenzae.,,. 25% 20%, 2..,... peroxidase verdobilin. 10%,.,. Quellung. Counterimmunoelectrophoresis(CIE) %. Coagglutination latex agglutination,. 50%, Quellung. H emophilus influenzae coccobacilli 40 80%. 108 colony forming unit (CFU)/ml.,., group 1 3. Staphylococcus aureus 7).,,,.., 10 30% transtracheal aspiration,, protected catheter specimen brush,,. Legionella 5% 40,, beta- lactam, Legionella,. direct immunofluorescent antibody staining 25 75%, 99.9%, L. pneumophila. Legionella70%L. pneumophila subgroup

6 Korean Journal of Medicine : Vol. 58, No. 2, %- 60%, 95%. L. pneumophila subgroup 1 Legionella. 4). cold agglutinin 1:64 M. pneumoniae 30%- 60% 4). M. pneumoniae IgM Mycoplasma mycoplasma mycoplasma. Chlamydia Legionella. C. pneumoniae 1 IgM 3, IgG 8 C. pneumoniae. IgG IgM. Legionella. 1:256, 15%. IgM IgG 4). polymerase chain reaction (PCR), PPD PCR. FDA AFB PCR 4). (CBC),,,,,., ,000 30,000 /mm3.. Gram M. pneumoniae, Chlamydia pneumoniae, respiratory viruses, 1)....,. H. influenzae Quellung, capsular polysaccaharide , (31%) 20, 18 (7.3%), 3, 13 (Klebsiella 7 ), H emophilus 11, S. aureus 5, M ycoplasma 4, mucormycosis 1. 12).,. 1),,,

7 Joon Chang : Community acquired pneumonia 11).,,,, 1)...,,, 4,, 1)., 11).. 13)... penicillin Streptococcus pneumoniae 25% 80% cefaclor, cefotaxime cephalosporins 14), cephalosporinss. pneumoniae 15). S. pneumoniae 16). S. pneumoniae penicillin 80%, 17, 18). Penicillin 3 11). 65,,,. penicillin S. pneumoniaecephalosporin betalactams, sulfamethoxazole/trimethoprim, macrolide cefotaxime 81%, imipenem 43%17, 18). 1 ug oxacillin disk 99%, 80% 20% 4). MIC. penicillin (MIC ug/ml) penicillin amoxicillincephalosporins, macolides. ceftriaxone, cefotaxime MIC 2.0 ug/ml, vancomycin, imipenem/ cilastin 4). penicillin MIC 4.0 ug/ml vancomycin ceftriaxone, cefotaxime MIC 2.0 ug/ml, imipenem/ cilastin4). fluoroquinolones 4). fluoroquinolone levofloxacin, sparfloxacin, grepafloxacin, trovafloxacin 4). penicillin 89% 4).,,,,,,, dependent part 4). 60% coliform bacteria. 1). transtracheal aspirate,

8 : % 7). clindamycin penicillin G. metronidazole microaerophilic streptococci. metronidazole penicillin, amoxicillin/clavulinic acid. imipenem, meropenem, chloramphenicol, beta lactam/ beta lactam inhibitor. clindamycin metronidazole penicillin amoxicillin/clavulinic acid 4) % %, 40-45%. Prevotella melaninogenica, Bacteroides, Por - phyromonas, Fusobacterium, peptostreptococci, peptococci, microaerophilic streptococci. Legionella sp., (40 ),,,, ( ),,, (20-40%),,, phosphorus,, CPK, lactic dehydrogenase > 700 U/ml, 4). Legionella. 2-6%.,,,,,,,. erythromycin 2-4 g rifampicin(300 mg mg 1 ), fluoroquinolone(ciprofloxacin 400 mg mg 12, levofloxacin 500 mg 1 ) 19). erythromycin. Azithromycin 500 mg 1, clarithromycin 500 mg , 19). 21. Azithromycin ).,,, Streptococcus pneumoniae, M ycoplasma pneumoniae, Respiratory viruses, Chlamydia pneumoniae, Hemophilus influenzae 5%, 1% Legionella sp., T able (1 5%)* : S treptococcus pneum oniae, M ycoplasm a pneum oniae, Respiratory viruses, Chlam idia pneum oniae, H em ophilus influenzae : Legionella sp., Staphyococcus aureus, Mycobaterium tuberculosis, aerobic gram negative bacilli : MacrolideT etracycline Macrolide, Fluoroquinolone, or Doxycycline (17-40Doxycycline) * 1/3 1/2 Erythromcin, H. influenzae roxithromycin, clarithromycin, azithromycin, dirithromycin macrolide S. pneumoniae tetracyclines macrolides

9 : Staphyococcus aureus, M ycobaterium tuberculosis, aerobic gram negative bacilli (T able 2). 1 5%, 1/3 1/2 1). penicillin beta- lactam S. pneumoniae beta- lactam, penicillin cephalosporin beta- lactam M ycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila. erythromycin macrolide erythromycin in vitroh. influenzae, S. pneumoniae tetracyclines. macrolide clarithromycin, azithromycin, roxithromycin, dirithromycin in vitro M. pneumoniae, C. pneumoniae, L. pneumophila S. pneumoniae, H. influenzae, 60 H. influenzae 1).,,,,..,. H. influenzae 50% 20), 30%beta- lactamase 1), 2/3cephalosporin, amoxicillin/ clavulinic acid, ampicillin/sulbactam, doxycycline, fluoroquinolone., 3 cephalosporin. sulfamethoxazole/trimethoprim, azithromycin ampicillin 4, 21).,,, S. pneumoniae, Respiratory viruses, H. influenzae, Aerobic gram- negative bacilli, S. aureus 1% M oraxella catarrhalis, Legionella sp., M. tuberculosis Table : S. pneum oniae, Respiratory viruses, H. influenz ae, Aerobic gram- negative bacilli, S. aureus : Moraxella catarrhalis, Legionella sp., M. tuberculosis : 2cephalosporin Sulfamethoxazolem/trimethoprim Beta- lactam/ beta- lactamase inhibitor Erythromycin macrolide Macrolide, Fluoroquinolone, or Doxycycline ( ) Fluoroquinolone Amoxicillin/clavulinic acid. HIV. 1/3 1/2 Legionella sp. fluoroquinolone: levofloxacin, sparfloxacin, grepafloxacin, trovafloxacin

10 Korean Journal of Medicine : Vol. 58, No. 2, 2000 Table 4. ( ) :,,,,,, 1,,,, 3. : 30, 60 mmhg, 90 mmhg, 38.3,, 4. : 4,000/mm3, 30,000/mm3, 1,000/mm3, PaO2 60 mmhg PaCO2 50 mmhg,, creatinine > 1.2 mg/dl BUN 20 > mg/dl, 2,,,, 30%, 9 g/dl, (, prothrombin time, partial thromboplastin time,, fibrin split products > 1:40) (T able 3). Gram negative bacilli, M. catarrhalis, M. tuberculosis. Legionella sp. 7). 5%, 20% 1). 2cephalosporin, sulfamethoxazole/ trimethoprim, Beta- lactam/beta- lactamase inhibitor, Legionella sp. erythromycin macrolide1). macrolide, fluoroquinolone, doxycycline ( ) amoxicillin/clavulinic acid, 2cephalosporin(cefuroxime, cefpodoxime, cefprozil). fluoroquinolone, amoxicillin/clavulinic acid, doxycycline 4). Sulfamethoxazole- trimethoprim S. pneumoniae 10% 1). cepahalosporin in vitro cefpodoxime > cefuroxime > cefprozil > cefixime > cefaclor= loracarbef > cefadroxil = cephalexin 4). 3., T able 4 1). 4. S. pneumoniae, H. influenzae, (), gram- negative bacilli, Legionella sp., S. aureus, C. pneumoniae, Respiratory viruses, M. pneumoniae, M oraxella catarrhalis, M. tuberculosis (T able 5)., Leg ionella sp % 7.. 2/3cephalosporin betalactam/beta- lactamase inhibitor, Legionella sp. macrolide Legionella sp.rifampin ,200 mg ). cefotaximeceftriaxone 3 cephalosporin macrolide, fluoroquinolone, cefuroxime macrolide, azithromycin 4)

11 Joon Chang : Community acquired pneumonia Table 5. ( ) : S. pneumoniae, H. influenzae, Polymicrobial (including anaerobic bacteria), Aerobic gram- negative bacilli, Legionella sp., S. aureus, C. pneumoniae, Respiratory viruses : M. pneumoniae, M oraxella catarrhalis, M. tuberculosis : 2/3cephalosporin Beta- lactam/beta- lactamase inhibitor Macrolide Fluoroquinolone. HIV. 1/3 1/2 Legionella sp. macrolide ; Legionella sp.rifampin ,200 mg 2 : 5 25%, 7 cefotaxime, ceftriaxone macrolide Fluoroquinolone Table 6. ( 1 ) 1. > PaO2/FiO2 ratio < 250 mmhg(fio2: ) 3. 4., 48 50% 5. (90 mmhg 60 mmhg ) ml, 4 80ml, 5. T able 6,. 65% 4). 30, BUN 19.6 mg/dl, 60 mmhg 22). Streptococcus pneumoniae, Legionella pneumophila,,,. P seudomonas aeruginosa,. M. pneumoniae, Respiratory viruses, H. influenzae, M. tuberculosis. 50%. Legionella sp. macrolide Pseudomonas 3 cephalosporin imipenem/cilastatin, fluoroquinolones. Legionella sp. rifampin. P. aeruginosa, 3cephalosporin, imipenem, ciprofloxacin aminoglycoside (T able 7)1). P. aeruginosa 1),. P. aeruginosa. Legionella sp., M ycoplasma,

12 : Table 7. : S. pneumoniae, Legionella sp., Aerobic gram- negative bacilli, M. pneumoniae, Respiratory viruses : H. influenzae, M. tuberculosis : Macrolide PLUS 3cephalosporin with anti- Pseudomonas activity# antipseudomonal agents such as imipenem/cilastatin, fluoroquinolones. HIV. 1/3-1/2 Legionella sp.rifampin # P. aeruginosa, 3cephalosporin, imipenem, ciprofloxacin aminoglycoside - 50% - Legionella sp. Chlamydia, virus 6). erythromycin, azithromycin, fluoroquinolone cefotaxime, cefotriaxone, beta lactam/beta lactam inhibitor 4). Pseudomonas penicillin, carbapenem, cefepime macrolide fluoroquinolone aminoglycoside. fluoroquinolone clindamycin. fluoroquinolone clindamycinmetronidazole, beta lactam/beta lactam inhibitor 4). Beta lactam/beta lactam inhibitorampicillin/ sulbactam, ticarcillin/clavulinic acid, piperacillin/tazobactam, ticarcillin/clavulinic acid, piperacillin/tazobactam 4). 3cephalosporins 2cephalosporin. cefotaxime ceftriaxone T able 5. P seudomonas aeruginosaceftazidime cefoperazone 3cephalosporin, imipenem/cilastatin, ciprofloxacin fluoroquinolones 1). aminoglycosides,. P seudomonas aeruginosa.,... rifampin, legionella menigococcus mycoplasma, chlamydia, methicilline. cycloserine,, chlamydia, amynoglycosides kanamycin, amikacin. Mycoplasma,,,. quinolones, beta- lactam penicillins/lactamase inhibitor ( : amoxicillin/clavulinic acid), macrolide, amikacin, cephalosporin(, ceforanide).,

13 :.,, 1-4). S. pneumoniae 7-10 ( 72, 5 ) 1,4). M. pneumonia, C. pneumoniae 14 (21 ). Legionnaires 14, 21 4). E nterobactericeae, P seudomonas 21, 42, Staphylococcus 21 21) , azithromycin 5. Azithromycin half- life erythromycin 1.5-3, clarithromycin 3.8. azithromycin 1) ).,. doxycycline, minocycline, chloramphenicol, sulfamethoxazole/trimethoprime, fluoroquinolones 1)... metronidazole, amoxicillin/clavulinic acid, amoxicillin, clindamycin 23). Cefuroxime, ampicillin, erythromycin, flucloxacillin. ceftriaxone cefixime, cefotaxime cefpodoxime 23). Ceftazidime ciprofloxacin. 24, 3. S. aureus,. 95% 1,7) , S. pneumoniae M. pneumoniae 1-2.,, Legionella. Legionella 5. 4, 20 40%7 1, 6). S. pneumoniae 50 X- ray 460%,,,, X- ray 25%4X- ray. M. pneumoniae X- ray, Legionella sp.. ( Pore of Kohn, channel of Lambert ). (red hepatization) (gray hepatization) (consolidation)

14 Korean Journal of Medicine : Vol. 58, No. 2, ,,,.,. 7),. 1)., 1) , Pseudomonas aeruginosa M. pneumoniae 4). 4).,,., P. carinii,,.,,, bronchiolitis obliterans organizing pneumonia, Wegener, %, 72 7%, 41%. Legionella sp.,,,, P. carinii,. protected specimen brush.,,., Legionella sp., Table 8. ( ) S. pne um oniae Group B s tr e ptococci S. aure us H. influe nzae Le gione lla T WAR( chlam ydia) B. catharrhalis Gram ne gative Viral % 2 5 % * 1 0 % 2 0% * Unde rly ing cance r, COPD,

15 Joon Chang : Community acquired pneumonia M ycoplasma, virus,.,.,, ,, penicillin (T able 8) ,,,,. 65, 80% 70%....,,,,.,,,,,,,,, 6)..., (increased vocal or tactile fremitus), egophony,.,,..,... 20% 70 80%, 30 40%. 90% ,,, asplenia,,,,, Hodgkin,,,, HIV. influenza 4)

16 : ,.,. 2,,,,.... R E F E R E N C E S 1) American Thoracic Society. Guidelines for the initial managem ent of adults with comm unity- acquired pneumonia: Diagnosis, assessment of severity, and initial antimicrobial therapy. Am Rev Respir Dis 148: , ) The British T horacic Society. Guidelines for the managem ent of com munity- acquired pneum onia in adults admitted to hospital. Br J H osp M ed 49: , ) Mandell LA, Niederman M. T he Canadian Community Acquired Pneumonia Consensus Conference Group: Antimicrobial treatment of community acquired pneumonia in adults: A conference report. Can J Infect Dis 4:25-28, ) Bartlett JG, Breiman RF, Mandell LA, File TM. Community- acquired pneum onia in adults: Guidelines for management. Guideline from the infectious diseases society of Am erica. Clin Infect Dis 26:811-38, ) Swartz MN. Approach to the patient with pulmonary infections. In: Fishman AP, Elias J A et al. ed. Fishman's Pulmonary diseases and disorders. 3rd ed. N ew York: M cgraw- Hill, 1998: ) Donowitz GR, Mandell GL. Acute pneumonia. In: M andell GL, Bennet J E, Dolin R(eds): Principles and practice of infectious diseases. 4th ed. Churchill Livingstone, N ew York, , ) Bartlett JG, Mundy LM. Community- acquired pneumonia. N Engl J M ed 333: , ) Pomilla PV, Brown RB. Outpatient treatment of community- acquired pneumonia in adults. Arch Intern M ed 154: , ) Brown PD, Lerner SA. Comm unity- acquired pneumonia. Lancet 352: , ) ;28:587() 11) Niederman MS. Guidelines for the management of respiratory infection: why do we need them, how should they be developed, and can they be useful? Curr Opin Pulm M ed 2: , ),,,,,.. 28: , ).. 40: , ) Schreiber JR, Jacobs MR. Antibiotic- resistant pneumococci. Ped Clin North Am 42: , ) Pallares R, Linares J, Vadillo M. Resistance to penicillin and cephalosporin and m ortality from severe pneum ococcal pneumonia in Barcelona, Spain. N Engl J M ed 333: , ) File TM. Overview of resistance in the 1990s. Chest 115:3S- 8S, ) Chong Y, Lee K, Kwon OH, Henrichsen J. Capsular types and antim icrobial resistance of Streptococcus pneumoniae isolated in Korea. Eur J Clin Microbiol Infect Dis 14: , ) Lee H- J, Park J- Y, Jang S- H, Kim E- C, Choi K- W. H igh incidence of resistance to multiple antimicrobials in clinical isolates of Streptococcus pneumoniae from a university hospital in Korea. Clin Infect Dis 20: , ) Stout JE, Yu VL. Legionellosis. N Engl J M ed 337: ), (e ds) ) Sanford JP, Gilbert DN, Sande MA. T he Sanford guide to antim icrobial therapy. 29th ed. Antim icrobial T herapy Inc., Vienna(VA, USA) ) Bernstein JM. T reatment of com munity- acquired pneumonia IDSA guidelines. Chest 115:9S- 13S, ) Nathwani D. Sequential switch therapy for lower respiratory tract infections. Chest 113:211S- 218S,

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$(Microsoft PowerPoint - PUZIRXMUOAQY [\310\243\310\257 \270\360\265\345])$ 경구용 항생제 처방의 실제 분당서울대학교병원 감염내과 송 경 호 1. 감염병의진단과항생제선택 강의순서 2. 경구항생제치료의일반적고려사항 3. 주요감염질환의경구항생제치료 1) 요로계감염 2) 호흡기감염 : 인두염, 부비동염, 폐렴 3) 연부조직감염 4. 항생제치료실패시고려점및부적절한항생제사용의문제점 5. 결론및항생제사용과관련된제언 감염병의 3 요소 미생물 숙주