: 58 2 2000 6, 1. 400, 1,000112 1/5. 1 5%, 25% 1).,,,,. Chlamydia pneumoniae, hantavirus. macolides, beta- lactams, fluoroquinolones, carbapenems (meropenem, imipenem), streptogramins.. 90. 10.,. (),.,, 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 - 129 -
Korean Journal of Medicine : Vol. 58, No. 2, 2000,,,,,,,,,,.,,...,,,,,. 3,,.. 4.. 110 M ycoplasma pneumonia, 24 1-2 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. 7. 8.,. protected specimen brushing, plugged telescoping catheter sampling, standard bronchoalveolar lavage, protected bronchoalveolar lavage, transtracheal aspiration( ),,,.,,, 5).,,, - 130 -
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). 68 78%, 24 45 69%, 100 45%... 1 10, () 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). 3-131 -
: 58 2 474 2000 3. 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).,,,,.,,.. 50-60% 80%. 85% 90%. 41%.. 1-2, 2-5.. EnterobacteriaceaeS. aureus. Enterobacteriaceae, S. aureus.. 8 30 9). - 132 -
: 45 50%, H. influenzae 34 47% 6),. 60%, 90%. 10% 2 H. influenzae.,,. 25% 20%, 2..,... peroxidase verdobilin. 10%,.,. Quellung. Counterimmunoelectrophoresis(CIE) 75 100%. 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 1. - 133 -
Korean Journal of Medicine : Vol. 58, No. 2, 2000 50%- 60%, 95%. L. pneumophila subgroup 1 Legionella. 4). cold agglutinin 1:64 M. pneumoniae 30%- 60% 4). M. pneumoniae IgM 1 2-12. 7-10 3. 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),,,,,., 60. 15,000 30,000 /mm3.. Gram M. pneumoniae, Chlamydia pneumoniae, respiratory viruses, 1)....,. H. influenzae Quellung, capsular polysaccaharide.. 1995 1996 61, 24776 (31%) 20, 18 (7.3%), 3, 13 (Klebsiella 7 ), H emophilus 11, S. aureus 5, M ycoplasma 4, mucormycosis 1. 12).,. 1),,,. - 134 -
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 0.12 1.0 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, - 135 -
: 58 2 474 2000 30% 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).... 90%. 40-65%, 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 2 600 mg 1 ), fluoroquinolone(ciprofloxacin 400 mg 8 750 mg 12, levofloxacin 500 mg 1 ) 19). erythromycin. Azithromycin 500 mg 1, clarithromycin 500 mg 2.. 3 10-144, 19). 21. Azithromycin 5-1019).,,,. 1. 60 Streptococcus pneumoniae, M ycoplasma pneumoniae, Respiratory viruses, Chlamydia pneumoniae, Hemophilus influenzae 5%, 1% Legionella sp., T able 2. 60 (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. - 136 -
: 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).,,,. 2. 60 S. pneumoniae, Respiratory viruses, H. influenzae, Aerobic gram- negative bacilli, S. aureus 1% M oraxella catarrhalis, Legionella sp., M. tuberculosis Table 3. 60 : 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 - 137 -
Korean Journal of Medicine : Vol. 58, No. 2, 2000 Table 4. ( ) 1. 65 2. :,,,,,, 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, 17-40 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.. 60. 5 25% 7.. 2/3cephalosporin betalactam/beta- lactamase inhibitor, Legionella sp. macrolide Legionella sp.rifampin 1 600 1,200 mg 1 2. 1). cefotaximeceftriaxone 3 cephalosporin macrolide, fluoroquinolone, cefuroxime macrolide, azithromycin 4). - 138 -
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 1 900 1,200 mg 2 : 5 25%, 7 cefotaxime, ceftriaxone macrolide Fluoroquinolone Table 6. ( 1 ) 1. > 30 2. PaO2/FiO2 ratio < 250 mmhg(fio2: ) 3. 4., 48 50% 5. (90 mmhg 60 mmhg ). 6. 4 7. 20 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, - 139 -
: 58 2 474 2000 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)., - 140 -
:.,, 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). 14-21, azithromycin 5. Azithromycin half- life 11-14 erythromycin 1.5-3, clarithromycin 3.8. azithromycin 1). 42-56 4-5 21).,. 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). 48 72. 72. 2 4, S. pneumoniae 2.5 6-7. 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) - 141 -
Korean Journal of Medicine : Vol. 58, No. 2, 2000..,,,.,. 7),. 1)., 1). 24-48. 24-48, Pseudomonas aeruginosa M. pneumoniae 4). 4).,,., P. carinii,,.,,, bronchiolitis obliterans organizing pneumonia, Wegener,... 72 6.5%, 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 3 5 1 3 1 3 3 5 1 5 3 5 1 3 1 3 3 5 2 5 3 0 % 2 5 % * 1 0 % 2 0% * Unde rly ing cance r, COPD, - 142 -
Joon Chang : Community acquired pneumonia M ycoplasma, virus,.,.,,. 10 14.,, penicillin (T able 8).. 55. 55,,,,. 65, 80% 70%....,,,,.,,,,,,,,, 6)..., (increased vocal or tactile fremitus), egophony,.,,..,... 20% 70 80%, 30 40%. 90%.. 5 1 5-6. 1. 1. 65,,, asplenia,,,,, Hodgkin,,,, HIV. influenza 4). 2. - 143 -
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