Review article Infect Chemother 2011;43(5): pissn eissn Infection & Chemotherapy

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Review article http://dx.doi.org/10.3947/ic.2011.43.5.

1 Review article Infect Chemother 2011;43(5): pissn eissn Infection & Chemotherapy 세균성상부호흡기감염 김신우경북대학교의학전문대학원내과학교실 Bacterial Upper Respiratory Infections Acute bacterial upper respiratory infections include acute rhinosinusitis, acute pharyngotonsillitis, acute laryngitis, and acute epiglottitis. These are common reasons for primary care visits. Acute bacterial sinusitis usually occurs as a secondary complication of acute viral sinusitis. Acute viral sinusitis will recover over the course of 7-10 days without antibiotics. Amoxicillin is a drug of choice for acute bacterial sinusitis in the practice guidelines. Patients with acute pharyngotonsillitis should be treated with antibiotics (amoxicillin) for 10 days with the purpose of prevention of rheumatic fever. Use of rapid antigen detection should be encouraged for the appropriate use of antibiotics, especially in Korea. Etiologies of acute laryngitis in adults are mainly viruses. However, M. pneumoniae, M. catarrhalis, H. influenzae are major bacterial pathogens of laryngtitis. Acute epiglottitis, cellulitis of the epiglottis, is a life-threatening infection. Airway keeping and antibacterial therapy against H. influenzae and other bacterial pathogens are main stays of management. Evidence-based approach is greatly in need for appropriate care for patients with bacterial upper respiratory infections. Shin-Woo Kim Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea Key Words: Upper respiratory infections, Bacterial Infections, Evidence-based practice 서론 상기도감염은이견이있을수는있지만상기도인코, 부비동, 인후, 후두및후두개에생기는감염을이르는것이다. 급성상기도감염중바이러스성감염으로는급성바이러스성비인두염 ( 감기 ) 이가장흔하지만이경우항생제의사용이필요없으며, 세균성감염합병증을줄이기위해항생제를사용하는것도도움이된다는근거를보여주지못한다 [1]. 반면급성세균성상기도감염 ( 일부인두염, 후두개염, 부비동염등 ) 은항생제사용을필요로하는경우가많은감염으로바이러스성급성상기도감염과의감별이임상에서요구된다 [2]. 저자는항생제의처방이필요한세균성상기도감염과항생제처방이필요없고합병증이거의없는바이러스성상기도감염의구별을위한임상적으로구분되는부분들에대해나누고, 현재의세균성상기도감염의치료에대해근거의학적접근 ( 가이드라인, 메타분석등 ) 과최근연구결과를살펴보고자한다. Copyright 2011 by The Korean Society of Infectious Diseases Korean Society for Chemotherapy Submitted: October 10, 2011 Accepted: October 10, 2011 Correspondence to Shin-Woo Kim, M.D. Department of Internal Medicine, Kyungpook National University Hospital, 50, Samduk 2-Ga, Chung-Gu, Daegu , Korea Tel: , Fax: ksw2kms@knu.ac.kr

2 384 SW Kim Bacterial Upper Respiratory Infections 급성부비동염 (acute sinusitis), 급성비부비동염 (acute rhinosinusitis) 부비동염이란감염, 알레르기, 자가면역등으로부비동의점막에발생하는염증으로, 대부분이주변비강의염증과동반되므로비부비동염 (rhinosinusitis) 으로도흔히쓰인다 [3]. 급성부비동염은 4주미만의병기를가진경우이다 [3, 4]. 아급성은 4-8 주, 만성은 8주이상의병기를가진것으로분류된다. 반복성비부비동염은 1년에 4회이상의급성부비동염을가질때를이른다 [5]. 또한부비동염은주된감염장소에따라서상악동 (maxillary), 전두동 (frontal), 사골동 (ethmoid), 접형동 (sphenoid) 부비동염으로부를수있다. 부비동염은세균에의한감염증으로생각하기쉬운데감기에동반되는바이러스성부비동염 (acute viral rhinosinusitis) 인경우가대부분이며 [3], 검출되는바이러스는 rhinovirus, influenza virus 및 parainfluenza virus 등이많다 [6]. 급성세균성부비동염 (acute bacterial rhinosinusitis) 은바이러스성비부비동염에의해부비동의배출구가막히거나점액배출의장애로인한이차적인세균감염에의하며약 0.5-2% 정도의바이러스성비부비동염환자에서합병증으로발생한다 [3]. 세균의 2차적침입이어떻게발생하는지는잘알려져있지않으나부은점막이부비동의점액의배설을방해하고, 코를푸는행위가비루 (nasal discharge) 를부비동안으로넣는데기여할것으로추정한다. 세균성부비동염의경우콧물, 코막힘, 안면통증등이주증상이며후각저하, 압박감, 상악골치통, 두통, 후비루등의증상이동반될수있다 [4]. 급성세균성부비동염의흔한원인균은 Table 1에요약되어있다 [4, 6-8]. 분비물에서악취가나는경우혐기성세균이관계되며치아의감염과연관된다 [9]. 세균성부비동염의진단을위해부비동의흡입천자배양을시도할수있으나침습적인방법으로실제시행하기는어려우므로임상적으로진단을하게되는경우가많다 [4]. 임상적진단은 7일이상의경과를가지며다음중하나이상을가질때의심한다 ; 1) 농성비루, 2) 상악부위치통이나안면통, 특히편측, 3) 편측상악동의압통, 4) 초기호전후악화 [1, 10]. 비경, 굴곡성비인두경, 철조법 (transillumination), 부비동방사선사진, 부비동전산화단층촬영등이임상적진단에도움을주지만 [4], 모든환자에서적용하기는어렵다. 그러나급성부비동염이아니고만성부비동염이나반복성급성부비동염으로의심되는경우부비동전산화단층촬영등의촬영이반드시필요하다 [4]. 임상의는세균성부비동염과바이러스성부비동염의구분을하도록 Table 1. Pathogens of Bacterial Rhinosinusitis in Adult and Child [4] Organisms Adults (N = 339) Children(N = 30) N % N % Streptococcus pneumoniae Haemophilus influenzae Anaerobes 16 7 Streptococcal species Moraxella catarrhalis Staphylococcus aureus 7 3 Other 노력하여야된다 [4]. 바이러스감염에의한경우증상은대개 7-10 일경에호전되고 [4], 세균성부비동염은 7일이내호전되는경우가적으므로, 증상이 7일이상인경우세균성감염을의심해볼수있으나진단의특이도가낮다 [11]. 그외세균성감염을시사하는증상으로는상악에안면통증이나압통, 상악골치통, 화농성콧물, 처음에는증상이호전되다다시악화되는경우 ( double sickening, double worsening ) 등이있다. 한메타분석에서는대부분의급성부비동염의경우도대증요법만으로도호전되므로 ( 위약군 80% vs. 치료군 90%)[12], 임상적으로급성세균성부비동염이의심되면서증상이심한경우와대증치료에호전이없는경우에한하여항생제를사용하는것이필요하다고한다 [12]. 그러나세균성부비동염과바이러스성부비동염을구분하여시행된연구는없으며이메타분석도이한계위에서분석되므로해석에주의가요한다. 세균성부비동염이의심되는경우에항생제를사용하지않을필요는없으며흔한균주에대한좁은스펙트럼의약을사용하는것이요구된다. 세균성감염의흔한균은 Streptococcus pneumoniae, Haemophilus influenzae 순으로이두가지가약 75% 를차지한다 [4]. 이외의균들로는 Moraxella catarrhalis, Staphylococcus aureus, Streptococcus 종, 혐기균등이있다 [4]. 2008년 1월새로이개정된미국 Clinical and Laboratory Standards Institute (CLSI) 의 S. pneumoniae 의 penicillin 감수성판정기준이크게변경되었는데 ( 즉, 기존에는수막염외의질환에서 S. pneumoniae 의 penicillin MIC 기준점이 감수성 : 0.06 (μg/ml); 중등도내성 : ; 내성 : 2.0 이었으나개정판에서는 감수성 : 2 (μg/ml); 중등도내성 : 4.0; 내성 : 8.0 임 ), 이런기준의변화는내성을우려하여무조건적으로 cephalosporin 계나다른계열약제의사용이필요하지않음을뒷받침한다고생각된다. 메타분석과가이드라인에서는 amoxicillin 이나 amoxicillin/clavulanate 를가지고치료한군과 cephalosporin 계나 macrolide 계약물의치료결과의차이는없다고한다 [4, 11, 12]. 가이드라인에서는 amoxicillin 을 1차선택약으로추천하고있다 [4]. 10 일간의치료가균의박멸을위해필요하다. Cephalosporin 계약물중에서는 cefpodoxime, cefdinir, cefuroxime 등이사용될수있다. Quinolone 계열항생제중 gatifloxacin, levofloxacin, moxifloxacin 등도효과적이지만결핵균과 S. pneumoniae 등에서의내성발생측면에서사용을주의하여야한다. H. influenzae 은베타락탐분해효소를생산하는균주를고려하여 amoxicillin/clavulanate, cefuroxime, cefdinir 등을사용할수있다. 항생제치료기간은 일간이다. 혐기성세균감염이의심되는경우는혐기균에도항균스펙트럼이좋은 amoxicillin/clavulanate 또는 ampicillin/sulbactam 의선택이 cephalosporin 제제보다우선적으로고려되어야하며 cephalosporin 을선택한경우혐기균에대한스펙트럼보완을위해또는 metronidazole 이나 clindamycin 을추가로사용하기도한다. 적절한항생제를 시간사용하면증상이호전되는데만일악화되는경우, 특히눈이나중추신경계로의합병증이의심되는경우외과적처치가필요하므로이비인후과진료가필요하다 [9].

3 Infect Chemother 2011;43(5): 항생제외에비강충혈제거제 ( 국소및전신 ), 해열제및진통제, 항히 스타민등도흔히사용된다. 비강내국소스테로이드의사용에대한체계적분석에서제한된근거이지만비강내국소스테로이드의사용은항생제를병용하던지하지않던지증상의호전에도움이되며 ( 국소스테로이드군 vs. 위약 : 73% vs. 66.4%) 부작용은큰문제가되지않는것으로보고하였다 [13]. 그러나이분석은국소스테로이드사용의기대이익위약에비해크지않을뿐아니라바이러스성부비동염과세균성부비동염을구분하지않은것으로세균성부비동염의가능성이뚜렷한경우사용하지않는것이더안전할것으로생각된다. 급성인두염 (acute pharyngitis) 및급성인두편도염 (acute pharyngotonsillitis) 급성인두염은급성편도선염과급성인후편도선염을포함하며인후통을특징으로하고경우에따라연하곤란을일으키기도한다. 인후통외열감, 두통, 복통, 기침등이동반될수있다. 대부분 adenovirus, influenza virus, parainfluenza virus, rhinovirus, respiratory syncytial virus (RSV) 등의바이러스감염에의한다. S. pyogenes 가가장임상적으로중요한세균이며, 이세균이환자의감염원인인지를구분하는것이필요하다고대부분의가이드라인이동의한다 [14]. 급성인두염에대한가이드라인은현재국가단위의지침이 12개정도가있을만큼각나라와학회에서는 1차진료에서그중요성을고려해임상의사 Table 2. Pathogens of Acute Pharyngotonsilitis Pathogen Associated Disorder(s) Bacterial Streptococcus, group A Pharyngitis, tonsillitis, scarlet fever Streptococcus, groups C, G Pharyngitis, tonsillitis Mixed anaerobes Vincent's angina Fusobacterium necrophorum Pharyngitis, tonsillitis, Lemierre's syndrome Neisseria gonorrhoeae Pharyngitis, tonsillitis Corynebacterium diphtheriae Diphtheria Arcanobacterium haemolyticus Pharyngitis, scarlatiniform rash Yersinia enterocolitica Pharyngitis, enterocolitis Yersinia pestis Plague Francisella tularensis Tularemia, oropharyngeal form Treponema pallidum Secondary syphilis Viral Rhinovirus Common cold Coronavirus Common cold Adenovirus Pharyngoconjunctival fever Herpes simplex type 1 & 2 Pharyngitis, gingivostomatitis Parainfluenza Cold, croup Coxsackie A Herpangina, hand-foot-mouth disease Epstein-Barr virus Infectious mononucleosis Cytomegalovirus Cytomegalovirus mononucleosis HIV Primary HIV infection Influenza A, B Influenza Mycoplasmal Mycoplasma pneumoniae Pneumonia, bronchitis, pharyngitis Chlamydophilial Chlamydophila psittaci Acute respiratory disease, pneumonia Chlamydophila pneumoniae Pneumonia, pharyngitis 들을위한지침을제공하고있으나 [5], 이들이다일치하지는않고있다 [14, 15]. 보고자에따라차이가있지만성인에서는약 5-10% 에서, 소아에서는 15-36% 가 S. pyogenes 에의한다 (Table 2)[5, 16, 17]. S. pyogenes 에의한세균성인두염과가장감별이필요하면서도임상적으로중요한바이러스감염은 Epstein-Barr virus (EBV) 에의한전염성단핵구증에동반된인두염과급성 HIV 감염에동반된인두염이다. 이들은항생제의사용이불필요하며특히급성 HIV 감염은향후추적, 치료및전파방지가중요한질환이다. 대부분의인두염환자가항생제치료를받고있는것으로추정되며인두염에대한항생제치료가항생제의과도한사용의매우중요한이유가되고있다 [18, 19]. 또한사용되는항생제는교과서나가이드라인에서권장하는것보다광범위한항균력을가진약제들이처방되고있다고보고된다 [5]. 급성인두염의항생제치료목적은세균성감염후에발생하는후기합병증인류마티스열과급성합병증인편도농양이나인두주위및뒤농양 (peritonsillar/retropharyngeal abscess), 연조직염, 화농성임파선염, 뇌수막염, 균혈증, 중이염등을예방하고병의전파를방지하며증상을완화하고유병기간을줄이고자함이다 [5, 20]. 그중류마티스열의예방이항생제사용의가장큰이유이다 [14, 15, 21]. 항생제치료가사구체신염을줄인다는결과는충분하지는않으며메다분석에서줄이는경향성을가진정도로분석된다 [21]. 성인에서는이런후기합병증들의발생빈도는매우낮다 [5]. S. pyogenes 에의한인두염이의심되는경우성인에서도항생제를사용하는것이바람직하다 [5]. 증상이매우심하고지속되며목이붇고침을삼키기힘들어하고목소리가변하는 ( hot potato voice) 경우급성합병증을고려하여야하며컴퓨터단층촬영등의검사와함께이비인후과적처치가필요한지반드시협진을하는것이필요하다. S. pyogenes 에의한경우와바이러스에의한경우의임상상을 Table 3으로비교하여정리할수있다 [5]. 그러나실제완벽히구분하기는어 Table 3. Clinical and Epidemiological findings and Diagnosis of Pharyngitis due to Streptococcus pyogenes [5] Features suggestive of S. pyogenes as etiologic agent Sudden onset Sore throat Fever Headache Nausea, vomiting, and abdominal pain Inflammation of pharynx and tonsils Patchy discrete exudate Tender, enlarged anterior cervical nodes Patient aged 5 15 years Presentation in winter or early spring History of exposure Features suggestive of viral etiology Conjunctivitis Coryza Cough Diarrhea

4 386 SW Kim Bacterial Upper Respiratory Infections 렵다. 환자가내원하였을때임상소견을이용하여사슬알균성인두염을감별하고자하는시도는여러가지가있다. 이중 Centor 등이제시한기준이가장흔히이용되고있고몇가이드라인들도 Centor 점수 (Centor score) 을사용할것을권한다 [15]. Centor 점수는 1) 편도삼출, 2) 전경부림프절염, 3) 발열, 4) 기침이동반되지않는임상소견중 3-4 가지의소견을보일때 ( 양성예측치 40-60%) S. pyogenes 에의한인두염을의심하고항생제치료를권장하고있다 [22]. 가이드라인마다이견이아직있지만 Centor 점수가 2-3 점일때신속항원검사 (rapid antigen detection test) 를시행하여항생제치료를결정하도록하는것이바람직하다고생각된다 년 Centor 점수체계를수정한것 (Modified Centor criteria)(table 4) 이제시된바있으며여기서는점수 3-4 에서도불필요한항생제의사용이많다고보고하였다 [23]. 신속항원검사는항원- 항체복합체를응집반응으로보는것으로감수성과특이도가각각 70-90%, % 로외국문헌에서보고된다 [21, 24, 25]. 국내는신속항원검사 (rapid antigen detection test) 가활성화되어있지않은데, 여러가지사회적인식, 의사들의인식, 최근에서야보험이되는상황, 항생제를그냥주는것이환자들의요구를들어주는것등과관련되는것같다. 신속항원검사와 Centor 기준은상관관계가좋은것으로보고된다 (Table 5)[26, 27]. 이를 spectrum bias 라고흔히이르며 [26, 27], 임상의에게는임상적질환의정도를고려하여검사결과를해석하는것이필요함을시사한다. 최근국내에서사용 Table 4. Modified Centor Score and Culture Management Approach for Pharyngitis [23] Criteria Points Temperature >38 1 Absence of cough 1 Swollen, tender anterior cervical nodes 1 Tonsillar swelling or exudate 1 Age 3-14 yr yr 0 45 yr or older 1 Score Risk of Streptococcal Infection Suggested Management 0 1%-2.5% No further testing or antibiotics 1 5%-10% 2 11%-17% Culture all: Antibiotics only for positive 3 28%-35% culture results 4 51%-53% Treat empirically with antibiotics and/or perform culture Table 5. Correlation between Rapid Antigen Detection Test (RADT) and Centor Score Centor Score Sensitivity of RADT Pediatrics Adults a a * * 97 a groups combined in study [26, 27] 할수있는 SD Bioline Strep A RAT (SD, Yongin, Korea) 을이질환에적용하여민감도 95.9%, 특이도 91.8% 양성예측치 95.9%, 음성예측치 91.8% 를보고한바있다 [28]. 국내에서도신속항원검사가보험급여가되고있는상태로불필한항생제의사용을줄이고적절한치료를위해지금보다더적극적인사용이임상의들에게필요하다. 인두세균배양검사는확진을위해서중요하나환자가처음내원하였을때바로결과를얻을수없어초기항생제사용의판단에도움이되지않는다. 배양을하는경우직접보면서면봉으로분비물을체취하여서가능한빨리배지에바르는것이좋은결과를위해중요하다. Antistreptolysin O는급성인두염의진단에는도움이되지않고후기합병증의심시시행이필요하다 [5]. 혈액내백혈구수는바이러스성에서도백혈구수의증가가동반될수있어바이러스성과세균성의감별에큰도움이되지않는다. 급성삼출성인두염의경우세균성의가능성에대한치료를하게되며항생제치료는원인균을인두에서없애는것이목적이므로, 감수성인항생제를적절한기간 (10 일 ) 동안유지하는것이중요하다 [5]. 외국가이드라인의경우선택약으로경구 penicillin V의사용을권하고있으나 [5, 14, 15], 국내의경우 penicillin V가사용하기어려우므로 amoxicillin 을선택하는것이대안이다. Penicillin 계를사용하지못하는경우 1세대세파로스포린등을사용할수있다. 경구치료의순응도가좋지않을것같은환자에게는 benazathine penicillin G 120 만단위를일회근주하는것이바람직하다 [5]. 최근인두염가이드라인의일부와미국심장학회에서는하루한번경구 amoxicillin 1,500 mg (30 kg 이하 750 mg) 의투여가 4개의임상연구 (amoxicillin 2회, penicillin V 의 2회또는 3-4 회요법과비교 ) 에서비열등함을보인것을근거로이를권장한다 [29, 30]. 이방법은비용효과적이며순응도가좋은장점이있다. 또한가지고려하여야할사항은고령이나장기간의스테로이드사용과같은면역억제환자의경우이다. 이러한환자에서는 herpes simplex virus 감염을고려하며이경우발병 2일이내인경우항바이러스제가도움이된다. 특히스테로이드흡입제를사용하는환자에서는진균인 Candida albicans 에의한감염도흔히일어나므로, 구강내부와편도의진찰에주의를기울여야한다. 감염외에 Stevens-Johnson 증후군의시작도인후통증을증상으로흔히시작하므로피부병변, 피부점막경계부병변등을통해감별하는것이필요하다. 급성후두염 (acute laryngitis) 급성으로발생하는쉰소리를특징으로하며, 목아픔, 마르고가려운목안의감각, 기침등이흔히동반된다. 급성후두개염 (epiglottitis) 이동반하는경우에는소아의크룹 (croup) 과같이호흡곤란및사망의원인이된다. 소아에서는 H. influenzae type B가가장흔한원인이었으나서구에서는예방접종의증가로감소추세이며, 성인에서는대부분이 rhinovirus, influenza virus, parainfluenza virus, adenovirus, coronavirus 등의바이러스가원인이며, 일부에서 Mycoplasma

5 Infect Chemother 2011;43(5): Table 6. Frequency of Laryngitis Associated with Common Respiratory Pathogens Agent % Rhinovirus Influenza Parainfluenza Adenovirus Coronavirus 0.25 Mycoplasma pneumoniae 3-37 Chlamydophila pneumoniae 0.3 Group A β-hemolytic Streptococcus Human metapneumovirus 4-91 오며배양이양성인경우가 3-14% 정도로보고되며이중에서는 H. influenzae 가가장흔하다. 미국에서 H. influenzae type B 백신의사용으로소아에서의급성후두개염의큰감소가보고되어있다 [36]. 항생제치료에있어서는 H. influenzae, S. pneumoniae, S. aureus 등을고려한선택을해야한다. 어른에서는초기에 ceftriaxone 또는 cefotaxime 을사용하여야하며베타락탐을사용할수없는경우 H. influenzae, S. pneumoniae 에효과를가지는퀴놀론을선택할수있겠다. 치료기간은명확하게정해져있지는않지만 7-10 일정도를임상적상황에맞게고려한다. pneumoniae, M. catarrhalis, H. influenzae 등의세균이분리된다 (Table 6)[31, 32]. 후두경으로후두의발적과부종을관찰할수있다. 세균의경우내시경소견에서후두안의농성분비물이바이러스성보다더흔히관찰된다. 치료는대증적치료로음성을쉬게하고적절한습도를유지해준다. 많은경우경구나주사용항생제가사용된다. 그러나일부연구에서급성후두염환자에서의항생제치료가치료결과에차이를보이지못함을보였다 [33, 34]. 후두염에서세균성과바이러스성을구분한연구는찾아보기어려우며성인에서의급성후두염 ( 바이러스와세균의구분이없음 ) 에대한비교적적은두가지연구를분석한체계적문헌고찰연구에서는항생제치료가도움이된다는증거가부족함을보고하였다 [32]. 호흡곤란등이발생하는경우후두보다는그이하기관및기관지의병변이동반된경우가많다. 이경우기관절개나기관삽관이필요한상황인지를정확히판단하는것이중요하다. 치료에도불구하고만일쉰목소리가오래가는경우, 성대의종양이나유두종 (papilloma) 의진단을위해후두경검사가필요하다. 급성후두개염 (Acute epiglottitis) 후두개 (epiglottis) 의급성연조직염으로빠른경과는생명을위협하는기도폐쇄를야기하는응급상황을만들수있다. 호흡곤란이있는경우기도확보, 산소공급등의처치가우선이다. 성인에서는기도폐쇄가빨리진행하기보다연하통을동반한인후통을주로나타내보인다. 성인에서기도폐색이생기는것을의심하는경우는앉아서있으려는자세, 천명 (stridor), 높은백혈구수치, H. influenzae 의혈액배양양성, 호흡곤란및폐렴의동반소견등이다 [35]. 진단은붓고발적이있는후두개를보는것으로이루어진다. 심한인후통이있는경우후두개염의가능성을고려하고후두개를직접보는것이반드시필요하다 [35]. 후두경을통한시각적관찰이불가능한경우경부측면방사선사진이도움이될수있으나항상특징적인소견 (thumbprint sign) 이보이는것은아니다. 컴퓨터단층촬영이도움이될수있다. 소아는 H. influenzae 가가장흔하며 streptococci, S. pneumoniae 및 S. aureus 등이원인이다 [35]. 성인은배양에서대개음성이나 맺음말 급성부비동염은바이러스성부비동염이대부분이지만일부에서세균성부비동염이합병증으로발생하며이경우 7-10 일안에좋아지지않는부비동염, 특히증상이호전되다다시악화되는경우에더일치한다. 항생제의선택은 amoxicillin 이 1차선택약이며 10 일간의치료가요구된다. 급성인두편도염은 S. pyogenes 에의한감염과다른바이러스성 ( 특히전염성단핵구증및급성 HIV 감염 ) 인두염과감별이중요하며 Centor 점수는임상상을통해세균성감염과바이러스성감별을구분하는지침으로활용될수있다. 세균성감염이임상적으로의심되는경우 S. pyogenes 에대한신속항원검사를통해항생제의사용여부를결정하기를많은가이드라인이권한다. 국내에서는항생제를적게사용하려는노력이적고환자의항생제에대한선호등으로활성화가잘안된상황이다. 내성문제와적절한진료의측면에서접근하여신속항원검사를더적극적으로사용하는것이필요하며현재보험급여를받을수있는상황이다. 급성후두염은성인에서는바이러스가주된원인으로일부에서 Mycoplasma pneumoniae, M. catarrhalis, H. influenzae 등의세균이관계된다. 세균의경우후두안의농성분비물이바이러스성보다더흔히관찰되지만구분이실제적으로어렵다. 많은경우경구나주사용항생제가사용되지만근거중심적측면의분석에서항생제치료가치료결과에차이를보이지못한결과가많아항생제를모두에게사용하기보다선택적으로사용하는것이좋겠다. 급성후두개염은세균성감염인경우가많으며기도확보, 산소공급등이우선적이며흔한세균인 H. influenzae, S. pneumoniae 등에효과적인항생제사용이필요하다. 세균성상기도감염은흔한감염병의하나로바이러스성상기도감염과의구분을위한노력이임상에서필요하다. 항생제내성의문제가심각해지는현시대에근거중심적약물의사용을통해지역사회의내성유도에대한항생제의선택적압력을줄이는것이필요하다. References

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< C3E1B0E8C7D0BCFAB4EBC8B82DB0ADC0C7B7CF2E687770> Essentials of Primary Care: 감염 상기도감염 : 언제항생제를사용할까? 경북대학교의학전문대학원내과학교실 김신우 서론급성상기도감염중급성바이러스성비인두염 ( 감기 ) 이가장흔하고이경우항생제의사용이필요없으며, 세균성감염합병증을줄이기위해항생제를사용하는것도도움이된다는근거를보여주지못한다 [1-3]. 오히려부작용의위험이더있다 [1]. 반면급성세균성상기도감염