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1 대한내과학회지 : 제 79 권제 4 호 2010 특집 (Special Review) - 노인감염성질환 노인성폐렴 경북대학교의학전문대학원내과학교실 장현하 Community-acquired pneumonia in elderly patients Hyun-Ha Chang, M.D. Department of Internal Medicine, Kyungpook National University School of Medicine, Daegu, Korea Pneumonia is the one of the 10 leading causes of overall mortality and the most common cause of infection-related death in Korea, especially in elderly patients. Streptococcus pneumoniae is the most common pathogen causing community-acquired pneumonia (CAP) in elderly patients, and gram-negative bacilli have also been reported as an important pathogen in Korea. Treatment guidelines for community-acquired pneumonia, which were published by the Joint Committee of the Korean Society for Chemotherapy, the Korean Society of Infectious Diseases, and the Korean Academy of Tuberculosis and Respiratory Diseases, are briefly presented in this article. A special consideration should be given to active preventive measures for CAP in elderly patients, especially vaccination using a seasonal influenza and pneumococcal 23-valent polysaccharide vaccine. (Korean J Med 79: , 2010) Key Words: Pneumonia; Community-acquired infections; Elderly 서론노인성폐렴은일반적으로 65세이상의환자에게서발생하는폐렴을말한다. 통계청자료에의하면우리나라는인구의고령화가다른선진국에비교하여상당히빠르게진행하는나라로 2026년에는전체인구의 20% 이상을 65세이상노인이차지하는초고령사회에진입할것으로예상되고있다 1). 이러한노인인구의증가와함께고령층에서더높은발생빈도와사망률을보이는노인성폐렴도증가할것으로예상되며, 노인인구에게서폐렴은중요한사망원인중하나이며우리나라의노인의감염성질환중가장흔한사망원인이다 2). 노인성폐렴은만성호흡기질환과같은기저질환이나뇌혈관질환과연관된연하장애가동반된경우흡인폐렴이발생하며, 그원인균분포가보고마다다양하다. 특히지역사회거주자가아닌요양원과같은장기요양시설에서발생된 폐렴도많아일반적인인구집단에서나타나는지역사회획득폐렴과는양상이다를것으로예상되나이에대한연구는아직까지많지않다. 본논문에서는노인에서발생한지역사회획득폐렴에대하여지금까지보고된노인성폐렴의위험인자등임상특징, 예방등에대하여살펴보고, 대한화학요법학회, 대한감염학회와대한결핵및호흡기학회공동으로발표된 2009년지역사회획득폐렴의치료지침권고안의치료에대해간략히다루고자한다. 역학지난한세기동안의학의눈부신발전으로수명이연장되고노인인구가증가하면서노인에게서더흔히발생하는폐렴도같이증가하는추세를보이게되었다. 핀란드에서 46,979명을대상으로나이에따라지역사회폐렴의인구

2 - Hyun-Ha Chang. Community-acquired pneumonia in elderly patients - 1,000명당발생수를조사하였는데 5세미만에서는 36.1명, 5~14세는 16.2명, 15~59세사이는 6.0명으로 15~59세에서발생수가가장낮고, 60~74세사이는 15.4명으로다시증가하며, 75세이상은 34.2명의발생수를보여나이가증가함에따라폐렴의발생수도증가하였다 3). 미국에서도일반인구집단에서의폐렴발생은 2.66명 /1,000명 / 년인데비하여 65세이상노인에서는 10.12명 /1,000명 / 년으로 4배이상높은것으로알려져있으며 4), 매년 900,000예이상의지역사회획득폐렴이발생하여의료비지출의상당한부분을차지하며, 85세이상의노인의경우매년 20명중한명은폐렴이발생하는것으로알려져있다 5). 또한일반인구집단에서의지역사회획득폐렴의사망률은 1~5% 이나, 노인에서는 23~40%, 특히장기요양원입원환자의경우 57% 까지높게나타나는것으로보고되고있어노인에서의폐렴은심각한사회의학적문제가되고있다 6-8). 원인균노인의경우환자의인지기능장애나협조불능으로인하여제대로된객담검체를받아배양검사를하기쉽지않다. Kaplan 등 9) 의연구에서는노인지역사회획득폐렴환자들의 2/3 이상에서원인균이증명되지않았으며, Zalacain 등 10) 의연구에서도 40% 에서만원인균이증명되었다고보고하였다. 국내의연구보고들에서도노인의지역사회획득폐렴원인균이검출되는빈도는외국의보고들과비슷하며 39.4% 부터 51.4% 정도의빈도를보인다 11-13). 폐렴의원인균을증명하는것은치료항생제선택에도많은영향을미치므로올바른객담채취방법을환자와보호자 에게교육하여배양검사를실시하여원인균분리동정율을높이는것이필요하다. 환자의객담검체는반드시항생제투여전에확보하여야하며, 객담을받아내기전물로입안을가글링하는것이좋다. 그러나객담을받아내기전양치질을하거나약품을이용한가글링은추천되지않으며, 객담을받아내기 1시간전부터는충분한양의물을마시도록하나음식은먹지않도록한다. 환자가똑바로앉은상태에서 3회정도크게숨을쉰후, 최대한깊게기침을하여바로객담검체운반용기에객담을받아내도록한다. 특히타액이나코뒤분비물 (postnasal discharge) 을받지않도록주의하여야한다. 확보한검체는냉장보관하지않고바로검사실로가능한빨리접수하여배양검사가시행되도록해야폐렴의원인균규명을위한객담배양검사양성률을높일수있다. 지역사회획득폐렴의원인균에대한연구마다지역에따라분포에차이가많으나, 아시아지역과국내에도가장흔한것은폐렴사슬알균 (Streptococcus pneumoniae) 이다 14). 노인성폐렴의원인균과분리율에대한보고는많지않으나, 다른지역사회획득폐렴과마찬가지로폐렴사슬알균이가장흔한것으로보고되고있다 8,10). 국내에서노인성폐렴의원인균을조사한연구보고는 3건 11-13) 이있으며, 그결과는외국의보고들과크게다르지않다. 객담배양검사음성률은외국의보고와비슷하거나약간높은 49~61% 이며, 원인균이규명된경우모두공통적으로폐렴사슬알균이가장흔한원인균으로동정되었고, 연구에따라약간의차이는있으나 K. pneumoniae나그람음성막대균이그다음주요원인균으로보고되었다 ( 표 1). 국내의연구보고들은모두단일기관을대상으로한것으로각각의대상환자수가 100명내외로많지않아향후국내전국규모의다기관참여전향적연구를통한 Table 1. Major community-acquired pneumonia pathogens in elderly patients in Korea Moon et al. 11) (N = 99) Yu et al. 12) (N = 119) Jeong et al. 13) (N = 107) Not identified (60.6%) Not identified (53%) Not identified (48.6%) Streptococcus pneumoniae (39.4%) Streptococcus pneumoniae (25%) Streptococcus pneumoniae (17.8%) Gram-negative bacilli (12.1%) Klebsiella pneumoniae (20%) Staphylococcus aureus (8.4%) Staphylococcus (7.1%) Staphylococcus aureus (16%) Klebsiella pneumoniae (7.5%) Hemophilus influenzae (4.0%) Other Gram-negative bacilli (13%) Pseudomonas aeruginosa (5.6%) Pseudomonas spp. (2.0%) Hemophilus influenzae (11%) Other Gram-negative bacilli (2.8%) Pseudomonas aeruginosa (5%) Hemophilus influenzae (0.9%) Mycoplasma pneumoniae (4%) Others (8.4%) Mycobacterium tuberculosis (2%) Others (7%)

3 - 대한내과학회지 : 제 79 권제 4 호통권제 602 호 노인성폐렴의원인균조사가필요할것으로사료된다. 위험인자잘알려진노인성폐렴의위험인자로는알코올중독, 천식, 만성폐질환, 심장질환, 요양원입원, 70세이상등이있다. Koivula 등 15) 에의하면각위험인자에따른비교위험도는알코올중독은 9.0배 (95% 신뢰구간, 5.1~16.2), 천식 4.2배 (95% 신뢰구간, 3.3~5.4), 폐질환 3.0배 (95% 신뢰구간, 2.3~3.9), 심장질환 1.9배 (95% 신뢰구간, 1.7~2.3), 요양원입원 1.8배 (95% 신뢰구간, 1.4~2.4), 그리고 70세이상의고령이 60~69 세에비하여 1.5배 (95% 신뢰구간, 1.3~1.7) 더높은것으로보고하였다. 노인성폐렴의상당수를차지하는것이흡인폐렴 (aspiration pneumonia) 이다. 노인성폐렴의 5~15% 는흡인폐렴으로알려져있으며 16), 실제둘의구분이모호한경우도많다. 비인두나위장관내용물의흡인은노인에서상당히빈번하게발생하는것으로잘알려져있으며, 노인에게서는뇌혈관질환이나퇴행뇌신경계질환과연관되어나타나는연하곤란과기침반사의저하가주요원인이다 17). 노인에서가장흔한연하장애의원인은급성뇌중풍으로, 급성뇌중풍환자의약 80% 에서연하장애가발생하고 40~50% 는흡인폐렴이발생한다 17). 그외에다른흔한원인으로는치매, Alzheimer 병이나 Parkinson 병, 그리고식도질환등이있다. 노인에서는이러한신경학적질환이없더라도자는동안무증상의흡인이빈번하게일어나는환자에게서더흔하게지역사회획득폐렴이관찰된다는보고 18) 가있으며, 나쁜구강위생, 일상생활을못할정도의기능장애, 경구식사장애등도흡인으로인한노인에서의폐렴발생을증가시키는주요위험인자로보고되었다 19). 임상특징노인에서의폐렴의가장큰특징은젊은폐렴환자들에게서나타나는전형적인급성호흡기증상이잘나타나지않는다는것이다 20,21). Metlay 등 21) 은총 1,812명 (65세이상은 32%) 의환자들을대상으로 5개의호흡기증상, 13개의비호흡기증상으로총 18개증상의빈도를조사하였는데, 65세이상과 65세미만환자군을비교하여 65세이상의환자군에서증상들의빈도가현저히감소하였다. 따라서노인성폐렴의증상은대개객담, 기침, 고열, 흉통그리고호흡곤란같은전형적인호흡기증상이미미하여환자가병원에도착하 여폐렴이진단되는데걸리는시간이길어지게되며 20), 이러한폐렴진단의지연은노인에서폐렴의사망률을높이는요인이된다. 고열, 기침, 그리고객담같은전형적인폐렴의증상보다는오히려섬망등의의식변화로오는경우가많아 45% 까지흔하다고보고하였다 20). 국내보고에서도유등 12) 이총 214명의지역사회획득폐렴환자를대상으로 65세이상의환자와 65세미만의지역사회폐렴환자의임상양상을비교하였는데흉통과같은전형적인증상은 65세미만의대조군에서더흔하였으나, 전신의쇠약감, 식욕부진, 근육통, 관절통등의비특이적인증상들이 65세이상의폐렴환자들의주요증상이었고, 의식변화도 65세미만의환자에서는한건도나타나지않았으나 65세이상에서는 13% 로높게나타났다. 국내의보고들 11-13) 은외국보고들에비하여의식저하의빈도가높지않은데, 이는지금까지의국내연구보고들이주로의무기록을검토하여정보를얻는후향적연구로서자료누락에따른바이어스가있을것으로사료되어앞으로국내에서도전향적대규모연구를통한노인성폐렴의임상양상조사가필요할것으로사료된다. 노인성폐렴은이와같이전형적인폐렴증상이잘나타나지않아의료진이초기에임상적으로의심하기가힘들뿐만아니라, 초기단순흉부방사선촬영소견에서도불분명한폐침윤을보이거나거의정상소견을보이는경우가많아 22) 더욱빠른초기진단이어려워임상에서주의를요한다. 폐렴의중증도평가현재지역사회획득폐렴의중증도평가에가장많이쓰이는것은 Fine 등 23) 이보고한점수체계와 Lim 등 24) 이주장한 CURB-65가가장흔히사용된다. 방법에는차이가있지만두가지점수체계모두공통적으로나이가 65세이상노인이거나연령이증가할수록예후가나쁨을반영하고있다. Fine 등은지역사회획득폐렴환자의나이, 성별, 요양원거주여부, 기저질환 ( 종양, 간질환, 폐질환, 신장질환과뇌혈관질환 ) 의여부와신체검사소견 ( 의식변화, 호흡수, 혈압, 체온, 맥박수 ) 을기초로하여폐렴의중증도를 5단계로평가하였으며이는환자의사망률과높은상관관계를보일뿐아니라환자의입원기간을정확히예측하는데도유용하여지금도임상연구에서흔히 PSI (pneumonia severity index) 점수로사용되고있다 23). 그러나 Fine 등의방법은동맥혈가스검사등필요한혈액

4 - 장현하. 노인성폐렴 - Table 2. Severe community-acquired pneumonia (SCAP) score 26) Major criteria Arterial ph <7.30 Systolic blood pressure <90 mmhg Minor criteria Respiratory rate >30 breaths/min PaO 2/FiO 2 <250 mmhg BUN >30 mg/dl Altered mental status Age 80 years Multilobar/bilateral infiltrates on chest X-ray PaO 2/FiO 2, partial pressure of arterial O 2 to the fraction of inspired O 2; BUN, blood urea nitrogen. 검사항목이많고계산이다소복잡하여시간이촉박한외래환자에게는다소사용하기불편한점이많아정신혼동 (confusion), 혈액 urea (BUN) 수치, 분당호흡수, 혈압과나이를이용한 CURB 또는 CURB-65를간편하게사용할수있다 24). 이는 Fine 등이중심이되어진행한 PORT (pneumonia patient outcome research team) 연구에서나온점수체계인 PSI 점수와상관관계가좋고비교적정확한예후예측이가능하지만 24), BUN 값을알기위해혈액검사를해야하는단점이있어 BUN 값을제외한 CRB-65로더간략하게사용하기도하며일차진료에서간단하고빠르게향후치료를결정하는데도움이된다 25). 심한지역사회획득폐렴의예후를간편하게예측하기위한 SCAP 점수 (severe community-acquired pneumonia score) 26) 는심한지역사회획득폐렴환자의병원내사망률, 인공기계환기의필요, 그리고패혈성쇼크로발전할위험성을임상에서빠르게예측하기위해고안된점수로 ( 표 2) PSI나 CURB-65 보다심한지역사회폐렴에서는임상적으로더유용한것으로보고된바있다 27). SCAP 점수에서도 80세이상의고령환자의폐렴이예후가나쁨을반영하고있다. 예후인자대부분의연구들이환자의나이가많은경우, 동반된기저질환이많을수록, 쇼크를동반할수록예후가나쁘다고보고하고있다. Ewig 등 28) 이병원에입원한 168명의 65세이상노인폐렴환자를대상으로한연구에서는의식혼동, 분당 30회이상의호흡수증가, 이완기혈압 60 mmhg 이하가 65세이상노인의지역사회획득폐렴에서가장중요한사망예측인자라고보고하였다. Zalacain 등 10) 은 503명의노인성폐렴환자를대상으로한연구보고에서침상생활을하는경우, 입원당시혈청 creatinine 1.4 mg/dl 이상인경우, 의식변화, 쇼크, 그리고급성신부전이중요한병원내사망예측인자임을보고하였다. 그외에도연하장애, 37 이하의체온, 분당 30회이상의호흡수증가, 그리고광범위한폐침윤 (3엽이상 ) 이중요사망인자임이보고한바있다 6,7). 또한 Conte 등 29) 은 2,356명의 65세이상노인성폐렴을대상으로한연구에서 85세이상의고령, 동반기저질환, 운동반사의저하, 생체징후이상, 혈청 creatinine 1.5 mg/dl 이상이주요사망예측인자임을보고하였다. 국내의 65세이상의노인지역사회획득폐렴환자를대상으로사망예측인자연구로는두건의연구보고 12,30) 가있다. 유등 12) 은사망과관련된예후인자로높은 APACHE II 점수와기도삽관이필요했던경우를보고하였고, 이등 30) 이 267 명의 65세이상노인을대상으로사망연관요인을조사한연구보고에서는남자, 폐암, 전신쇠약, 걷지못함, BUN 30 mg/dl 이상, 혈청알부민 3 g/dl 미만, 그리고흉수가있는경우로보고하였다. 두연구모두단일기관의소규모환자를대상으로한후향적연구로서국내노인폐렴환자의사망인자및예후예측인자분석을위한대규모전향적인연구가필요하다. 치료현재까지지역사회획득폐렴에대한치료지침으로미국

5 - The Korean Journal of Medicine: Vol. 79, No. 4, Table 3. Korean treatment guidelines for the empirical antimicrobial treatment of community-acquired pneumonia 31) Outpatient treatment beta-lactam ± macrolide (level I-3) amoxicillin or amoxicillin-clavulanate cefpodoxime, cefditoren (level II-3) ± azithromycin, clarithromycin, erythromycin, roxithromycin (level 3) OR Respiratory fluoroquinolone (level I-3) gemifloxacin, levofloxacin, moxifloxacin Inpatients, non-icu treatment If Pseudomonas is not a consideration: beta-lactam+macrolide (level I-3) cefotaxime, ceftriaxone ampicillin/sulbactam, or amoxicillin/calvulanate + azithromycin, clarithromycin, erythromycin, or roxithromycin OR Respiratory fluoroquinolone (level I-3) gemifloxacin, levofloxacin, moxifloxacin Inpatients, ICU treatment If Pseudomonas is not a consideration: beta-lactam+azithromycin (level II-3) cefotaxime, ceftriaxone, ampicillin/sulbactam, amoxicillin/calvulanate + azithromycin OR beta-lactam + fluoroquinolone (level I-3) cefotaxime, ceftriaxone, ampicillin/sulbactam + gemifloxacin, levofloxacin, moxifloxacin * If allergic to penicillin: respiratory fluoroquinolone + aztreonam If Pseudomonas is a consideration: Antipneumococcal, antipseudomonal beta-lactam (cefepime, piperacillin/tazobactam, imipenem, meropenem) + ciprofloxacin or levofloxacin (750 mg/d) OR Antipneumococcal, antipseudomonal beta-lactam + aminoglycoside + azithromycin OR Antipneumococcal, antipseudomonal beta-lactam + aminoglycoside + antipneumococcal fluoroquinolone (gemifloxacin, levofloxacin, moxifloxacin) (level III 3) Macrolide and fluoroquinolone are listed by alphabetical order

6 - Hyun-Ha Chang. Community-acquired pneumonia in elderly patients - Table 4. Recommended antimicrobial therapy according to the microorganism etiology 31) Pathogen Preferred antibiotics Alternative antibiotics Streptococcus pneumoniae penicillin G, high dose amoxicillin 3rd generation cephalosporin (cefotaxime, ceftriaxone), respiratory FQ, glycopeptides Haemophilus influenzae beta-lactamase non-producing amoxicillin respiratory FQ beta-lactamase producing 2nd or 3rd generation cephalosporin, beta-lactam/beta-lactamase inhibitor respiratory FQ Staphylococcus aureus methicillin-susceptible anti-staphylococcal penicillin or 1st generation cephalosporin clindamycin methicillin-resistant glycopeptide linezolid Enterobacteriaceae 3rd generation cephalosporin, carbapenem (except ertapenem), FQ beta-lactam/beta-lactamase inhibitor Pseudomonas aeruginosa antipseudomonal beta-lactam ±aminoglycoside or FQ carbapenem, ciprofloxacin or levofloxacin Mycoplasma pneumoniae macrolides respiratory FQ, doxycycline Chlamydophila spp. macrolides respiratory FQ, doxycycline Legionella spp. respiratory FQ, macrolides doxycycline Coxiella burnetii doxycycline macrolide, FQ Anaerobes beta-lactam/beta-lactamase inhibitor, clindamycin carbapenem Influenza virus oseltamivir FQ, fluoroquinolone 흉부학회치료지침 (American Thoracic Society Guidelines), 미국감염학회치료지침 (Infectious Diseases Society of America Guidelines), 그리고영국흉부학회치료지침 (British Thoracic Society Guidelines) 등이나와있고각국마다치료지침이다수발표되었다. 국내에서도대한화학요법학회, 대한감염학회와대한결핵및호흡기학회공동으로 2009년지역사회획득폐렴의치료지침권고안이발표되어사용되고있으며 31), 그이후현재전국 15개대학병원을중심으로지역사회획득폐렴의치료지침의개정을위한근거자료확충을위한대규모전향적지역사회획득폐렴관찰연구및치료지침개정작업이진행중이다. 지금까지의이들각국의치료지침들중에서 65세이상노인의폐렴에대한항생제치료권고안이따로있는것은없다. 2003년개정된미국감염학회치료지침만이노인성폐렴에대한원인, 위험인자, 임상양상등을추가하여서술하였으나, 항생제선택및치료는다른일반환자들의지역사회획득폐렴과동일하다고하였다 32). 기본적으로거의모든폐렴치료지침들이주장하는노인성폐렴치료시고려해야하는사항들은 (1) 폐렴사슬알균 (S.pneumoniae) 이가장흔한중요한원인균으로각지역에따른항생제내성, 특히페니실린내성률을고려하여이에효과적인항생제를선택할것 (2) 만성폐쇄폐질환과같은폐질환이나폐의구조적인문제가있는환자, 전에광범위항생제치료를받았거나최근입원한병력이있는환자는 Pseudomonas aeruginosa를고려하여이에효과적인항생제를선택할것 (3) 장기요양원거주환자이거나흡인폐렴이의심되는경우그람음성막대균에효과적인항생제를고려해야한다는점등이다 33). 국내에서는이들을모두고려한 2009년지역사회획득폐렴의치료지침의권고안을적용하여치료하는것이바람직하다고사료된다 ( 표 3, 표 4). 장기요양원에서발생한노인폐렴의경우의료시설폐렴 (healthcare-associated pneumonia, HCAP) 의양상에더근접할것으로예상되므로향후국내의의료시설폐렴이나흡인폐렴에대한연구와이를근거로한치료지침이필요할것으로사료된다. 특히노인에서발생한지역사회획득폐렴의경우항생제병합요법이중요하다. Gleason 등 34) 은 65세이상지역사회획득폐렴환자의치료성적을분석하여 macrolide 와 cephalosporin

7 - 대한내과학회지 : 제 79 권제 4 호통권제 602 호 을병합투여한군이 cephalosporin 단독투여환자군보다 30일사망률이낮음을보고하였고, 스페인에서 1,391명의비교적많은대상을환자로연구한 β-lactam 단독투여와 β-lactam와 macrolide 병용투여비교연구에서도동일한결과를보여 35) 65 세이상의노인환자의지역사회획득폐렴치료에 β-lactam 단독치료보다는 macrolide 를함께병합투여하는것이바람직하다고사료된다. 치료당시경험적항생제의적절한선택뿐만이아니라가급적빨리적절한항생제를투여하는것이일반환자뿐만아니라 65세이상의노인의지역사회획득폐렴환자에서도중요하다. Meehan 등 36) 이 65세이상의노인지역사회획득폐렴환자를대상으로한연구에서 8시간이내에적절한항균제가투여된경우가늦게투여된경우보다사망률이현저히낮음을보고하여, 사망률이높은노인폐렴환자일수록빠른시간내에적절한항균제가투여되도록하여야한다. 65세이상노인의지역사회획득폐렴에서증상과방사선소견이호전되는데소요되는기간에대한연구는많지않다. Marrie 등 37) 은폐렴치료 6주후임상증상이완전히소멸되는것에대한예측인자로젊은나이, 천식이없음, 그리고만성폐쇄폐질환이없는것으로보고하여, 나이가많고동반질환으로만성폐쇄폐질환이있는노인환자의경우임상증상이호전되는데더많은시간이걸릴것으로예상된다. El Solh 등 38) 은 70세이상의 74명의지역사회획득폐렴환자를대상으로폐음영의소실을조사하였는데동반질환이많을수록, 그리고여러폐엽을침범한경우흉부촬영에서음영이소실되는데 12주이상걸린다고보고하여임상에서주의를요한다. 예방노인에서폐렴의예방은일반적인지지요법과예방접종으로나누어볼수있다. 일반적인지지요법으로는상당수의노인에게서문제가되는흡인을감소시키기위한것으로, 특히뇌중풍등중추신경계질환이있어침상생활을해야하는환자들은반누움상태 (semirecumbent position) 로유지하도록하여무증상흡인을막아폐렴의발생을낮출것으로기대된다 39). 특히코위영양관 (nasogastic tube) 은흡인을예방하지는못하며, 오히려더폐렴의위험을높인다는연구결과도있어주의를요한다 40). 위내용물의역류와그로인한흡인을막고자위날문 (gastric pylorus) 을지나위영양관 (gastric tube feeding) 을위치시키기도하는데일반적인위내위영양관위 치와위날문을지나서위영양관을유치시키는것 (postpyloric tube feeding) 을비교한메타분석연구에서폐렴의발생률과사망률에큰차이가없어 41) 일부러흡인을막기위해위날문을지나게위영양관을위치시킬필요는없을것으로사료된다. 이외에불결한구강위생 42) 및낮은알부민수치 6,30) 등도지금까지의연구결과로알려진노인성폐렴의위험인자이므로구강위생을철저히하고영양상태를개선하는것이이환율과사망률을낮출수있을것으로예상된다. 노인에서폐렴을예방하기위한예방접종으로가장중요한것은인플루엔자백신과폐렴사슬알균 (pneumococcus) 백신이다. 현재국내에서대한감염학회의성인예방접종권고안에따르면 65세이상모든노인에서권장되는표준예방접종은파상풍-디프테리아 (Td), 인플루엔자, 폐렴사슬알균백신으로모두여기에속한다 43,44). 65세이상의연령에서인플루엔자백신접종의목적은인플루엔자의발병을예방하는것보다인플루엔자바이러스와연관된폐렴등합병증을막고그로인한입원과사망을낮추는것이다. Nichol 등 45) 에의하여 280,000명이상을대상으로시행한대규모코호트연구에서인플루엔자예방접종은폐렴이나뇌중풍, 그리고심장질환으로인한입원율을감소시키는것으로나타났으며, 다른연구에서도노인에게서균혈증을동반한폐렴발생의위험을낮추고전체이환율과사망률을낮추는것으로보고하고있다 46-48). 현재국내에는 12개회사의제품이시판되고있으며모두비활성화백신이며분할백신또는아단위백신이다. 약독화된생백신은현재국내에시판되고있지않다. 비활성화백신의경우건강한성인에서는백신접종후 2주이내에 90% 에서항체생성을하지만접종 6개월후약 50% 정도의항체가가감소한다. 백신항원의변화를고려하여매년인플루엔자백신접종이필요하다 43). 폐렴사슬알균백신은항체형성반응이건강한젊은성인보다노인에서더저하되어나타나는것으로알려져있으며 49), 초기연구에서는성인에서폐렴사슬알균감염에대한예방효과의연구결과가일관되지않게나타나논란의여지가있었으나비교적최근에는대규모관찰연구에서노인을포함한고위험군의침습성폐렴사슬알균감염에대한예방효과가있는것으로나타나 50) 현재 65세이상노인의표준예방접종으로권장되고있다 44). 65세이상의노인에서는폐렴사슬알균예방접종은 1회권장되고있으며 65세이전에접종받은환자의경우최초접종일로부터 5년이지나면다시 1회재접종한다. 현재성인에서사용하는 23가폐렴사슬알

8 - 장현하. 노인성폐렴 - 균다당류백신으로국내에서는뉴모-23 ( 사노피파스퇴르 ( 주 )) 과프로디악스-23 ( 한국 MSD ( 주 )) 이시판되고있다. 특히 Christenson 등 51) 이스웨덴에서실시한대규모코호트연구에서노인에게서백신을하나도맞지않은군보다하나라도맞은군에서더낮은사망률을보였으며, 특히인플루엔자백신과폐렴사슬알균백신, 두백신을다맞은군에서어느하나만맞은군보다폐렴, 인플루엔자와침습적폐렴사슬알균감염으로입원하는빈도가낮게나타나백신접종이매우효과적임을보고하였다. 이와같이노인에게서인플루엔자백신과폐렴사슬알균백신접종은노인인구에게서치명적인폐렴을예방하고, 균혈증등폐렴합병증으로인한사망률을낮출수있는간단하면서도비용대비효과에서도상당히효과적인방법으로, 대한감염학회에서권장하는성인표준예방접종에서도 65세이상노인에서의표준예방접종으로권장되고있다 43,44). 우리나라의경우매년노인들의인플루엔자예방접종율은외국에비교하여높은편이나, 최근한보고에서전체건강한 65세이상노인에게서의폐렴사슬알균예방접종률은 0.8% 로매우저조한것으로보고한연구결과도있어 52) 향후임상현장에서더욱적극적으로노인환자들을대상으로이둘의예방접종을권장, 홍보할필요가있다고사료된다. 중심단어 : 지역사회획득폐렴 ; 노인 REFERENCES 1) 장래인구추계. 통계청, ) 2008 년사망원인통계. 통계청, ) Jokinen C, Heiskanen L, Juvonen H, Kallinen S, Karkola K, Korppi M, Kurki S, Rönnberg PR, Seppä A, Soimakallio S, Sten M, Tanska S, Tarkianien A, Tukiainen H, Pyorala K, Makela PH. Incidence of community-acquired pneumonia in the population of four municipalities in eastern Finland. Am J Epidemiol 137: , ) Marston BJ, Plouffe JF, File TM Jr, Hackman BA, Salstrom SJ, Lipman HB, Kolczak MS, Breiman RF. Incidence of communityacquired pneumonia requiring hospitalization: results of a population-based active surveillance study in Ohio: the Community- Based Pneumonia Incidence Study Group. Arch Intern Med 157: , ) Jackson ML, Neuzil KM, Thompson WW, Shay DK, Yu O, Hanson CA, Jackson LA. The burden of community-acquired pneumonia in seniors: results of a population-based study. Clin Infect Dis 39: , ) Riquelme R, Torres A, El-Ebiary M, de la Bellacasa JP, Estruch R, Mensa J, Fernández-Solá J, Hernández C, Rodriguez-Roisin R. Community-acquired pneumonia in the elderly: a multivariate analysis of risk and prognostic factors. Am J Respir Crit Care Med 154: , ) Rello J, Rodriguez R, Jubert P, Alvarez B. Severe communityacquired pneumonia in the elderly: epidemiology and prognosis. Study Group for Severe Community-Acquired Pneumonia. Clin Infect Dis 23: , ) El-Solh AA, Sikka P, Ramadan F, Davies J. Etiology of severe pneumonia in the very elderly. Am J Respir Crit Care Med 163: , ) Kaplan V, Angus DC, Griffin MF, Clermont G, Scott Watson R, Linde-Zwirble WT. Hospitalized community-acquired pneumonia in the elderly: age-and sex-related patterns of care and outcome in the United States. Am J Respir Crit Care Med 165: , ) Zalacain R, Torres A, Celis R, Blanquer J, Aspa J, Esteban L, Menéndez R, Blanquer R, Borderías L. Community-acquired pneumonia in the elderly: Spanish Multicentre Study. Eur Respir J 21: , ) Moon YS, Choi JT, Lee YJ, Yoon BB. Clinical feature of pneumonia in the elderly. J Korean Acad Fam Med 14:17-26, ) Yu CW, Park CW, Hwang BY, Song JY, Park O, Sohn JW, Cheong HJ, Kim WJ, Kim MJ, Park SC. Clinical features and prognosis of community-acquired pneumonia in the elderly patients. Korean J Infect Dis 32: , ) Jeong HW, Park DW, Kee SY, Jung SJ, Sohn JW, Cheong HJ, Kim WJ, Kim MJ, Park SC. Community-acquired pneumonia in elderly: comparison of clinical manifestations and caudetive organisms before and after the separation of prescription and drug-selling. Infect Chemother 36: , ) Song JH, Oh WS, Kang CI, Chung DR, Peck KR, Ko KS, Yeom JS, Kim CK, Kim SW, Chang HH, Kim YS, Jung SI, Tong Z, Wang Q, Huang SG, Liu JW, Lalitha MK, Tan BH, Van PH, Carlos CC, So T. Epidemiology and clinical outcomes of community-acquired pneumonia in adult patients in Asian countries: a prospective study by the Asian network for surveillance of resistant pathogens. Int J Antimicrob Agents 31: , ) Koivula I, Sten M, Mäkelä PH. Risk factors for pneumonia in the elderly. Am J Med 96: , ) Kikawada M, Iwamoto T, Takasaki M. Aspiration and infection in the elderly: epidemiology, diagnosis and management. Drugs Aging 22: , ) Marik PE, Kaplan D. Aspiration pneumonia and dysphagia in the elderly. Chest 124: , ) Kikuchi R, Watabe N, Konno T, Mishina N, Sekizawa K, Sasaki H. High incidence of silent aspiration in elderly patients with community-acquired pneumonia. Am J Respir Crit Care Med 150: , ) Terpenning M. Geriatric oral health and pneumonia risk. Clin

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