DOI: 10.4046/trd.2011.70.1.1 ISSN: 1738-3536(Print)/2005-6184(Online) Tuberc Respir Dis 2011;70:1-9 CopyrightC2011. The Korean Academy of Tuberculosis and Respiratory Diseases. All rights reserved. 지역사회획득폐렴 Riview 부산대학교의학전문대학원내과학교실 이민기 Community Acquired Pneumonia Min Ki Lee, M.D. Department of Internal Medicine, Pusan National University School of Medicine, Busan, Korea Community-acquired pneumonia (CAP) is a major cause of morbidity, of mortality, and of expenditure of medical resources. The etiology and antimicrobial susceptibility of CAP pathogens can differ by country. Treatment guidelines need to reflect the needs of individual countries based on pathogen susceptibility studies. Recent treatment guidelines for CAP in Korea were published by the Joint Committee of the Korean Academy of Tuberculosis and Respiratory Diseases, the Korean Society for Chemotherapy, and the Korean Society of Infectious Diseases. In this article, the etiologies, diagnoses, treatments for CAP will be reviewed and compared to the recent published Korean guidelines for CAP treatment. Key Words: Pneumonia, Community-Acquired 서론지역사회획득폐렴은감염성질환중가장흔한사망원인중의하나이다. 국내 10대사망원인중감염으로인한사망중 1위에해당되며, 항생제치료에도불구하고사망률이 12 14% 에이른다. 향후노인인구의증가로인해폐렴유병률과이로인한사망률은증가추세를보일것으로예상된다. 2007년에미국 Infectious Disease Society of America/ American Thoracic Society (IDSA/ATS) 에서지침이발표된바있으며 1, 국내에서는호흡기학회에서 2005년에폐렴지침이출간되었고, 최근 2009년에지역사회획득폐렴의치료지침권고안이발표되었다 2. 폐렴의원인균분포는나라에따라차이가있으며특히 항생제내성실태도다르기때문에국내연구자료를토대로한국형치료지침이절대적으로필요한상황이나근거자료가될국내연구성과가미흡한실정이다. 향후연구가활성화되면우리나라실정에맞는좋은치료지침이완성될것으로생각된다. 본원고는최근국내치료지침권고안을바탕으로하여지역사회획득폐렴의진단과치료등에대해전반적으로살펴보고자하며, 권고안에사용된등급은 3가지로나누되외국연구논문인경우는 level I III, 국내연구논문인경우는 1 3등급으로표시하였다 (Table 1). 지역사회획득폐렴은 18세이상의한국인에게서발생한폐렴으로면역저하환자는대상에서제외하였다. 국내지역사회획득폐렴의원인균 Address for correspondence: Min Ki Lee, M.D. Department of Internal Medicine, Pusan National University School of Medicine, 1-10, Ami-dong 1-ga, Seo-gu, Busan 602-739, Korea Phone: 82-51-240-7216, Fax: 82-51-254-3127 E-mail: leemk@pusan.ac.kr Received: Dec. 26, 2010 Accepted: Dec. 26, 2010 국내지역사회획득폐렴의원인균은다양한데대체로다른나라와비슷한분포를보인다 1. 세균성폐렴중 S. pneumoniae가가장중요한원인균으로보고에따라 27 44% 를차지한다. 중요한호흡기병원균인 Hemophilus 나 Moraxella 는기저폐질환이있는환자에서흔히폐렴을일으키는데, 국내자료에서는보고에따라크게차이가난 1
MK Lee: Community-acquired pneumonia Table 1. Grading levels of evidence Studies performed outside Korea Levels of evidence Studies performed in Korea Definition Level I 1 Well-performed, randomized, controlled trials Level II 2 Well-designed, non-randomized, controlled trials Cohort study, case-control study Large-scale case series study with systematic analysis for etiology Level III 3 Case series study or experts opinion Antimicrobial susceptibility data Table 2. Etiologies according to severity Place for treatment Outpatient Hospitalization Intensive care unit Etiology* S. pneumoniae, M. pneumoniae, H. influenzae, C. pneumoniae, respiratory viruses S. pneumoniae, M. pneumoniae, C. pneumoniae, H. influenzae, Legionella spp., respiratory viruses E. coli, P. aeruginosa, Enterobacter, H. influenzae, Legionella spp. *Others: M. tuberculosis, Orientia tsutsugamushi, Leptospira. Table 3. Etiologies according to the risk factors Risk factors Common etiology Heavy alcohol drinking S. pneumoniae, oral anaerobes, Gram-negatives including K. pneumoniae, M. tuberculosis COPD±smoking H. influenzae, P. aeruginosa, Leionella spp. S. pneumoniae, M.catarrhalis, C. pneumoniae Structural lung diseases such as bronchiectasis P. aeruginosa, B. cepacia, S. aureus Aspiration Enterobacteriaceae, Anaerobes Bronchial obstruction Anaerobes, S. pneumoniae, H. influenzae, S. aureus Influenza season S. pneumoniae, S. aureus, H. influenzae Occurring in autumn, rash with eschar Orientia tsutsugamushi Intravenous drug abuser S. aureus, Anaerobes, M. tuberculosis, S. pneumoniae Exposure to air conditioning of building for last 2 weeks Legionella spp. Exposure to birds C. pneumoniae 다. S. aureus 도비교적흔한원인균으로서인플루엔자유행뒤에흔히발생한다. 국내자료에서 K. pneumoniae 와 Pseudomonas 등그람음성균의비율이비교적높은데이는대부분국내연구가 3차대학병원에서수행되어서만성호흡기질환으로병원에자주입원하는환자가연구에많이포함되었기때문으로생각된다. 두가지이상의미생물에의한혼합감염도드물지않다는것이국내외연구를통해보고된바있으며, 여기에는비정형폐렴원인균과의혼합감염도포함된다. 환자의중증도나위험인자에따른원인균분포에관한연구는국내연구자료가거의없어미국의가이드라인을참조하였다 (Tables 2, 3) 1. 비정형폐렴의원인미생물국내보고는매우적은편이며, Mycoplasma 폐렴은 6.3 9.2% 를차지하고있으며, C. pneumoniae는 7.3 13.2%, Legionella는 0 5.3% 로보고되었다. 특히 Legionella 는중환자실입원이필요한중등도이상의폐렴에서다른비정형폐렴균에비해더흔한원인균이었다 3. 바이러스에대한원인을살펴보면지역사회획득폐렴의 10.1% 에서바이러스가분리되었으며 A형인플루엔자 (5%), 파라인플루엔자, 아데노바이러스, respiratory syncytial virus 의빈도로분리되었다. 드문원인으로서 SARS 바이러스나 H5N1 형조류인플루엔자바이러스도원인으 2
Tuberculosis and Respiratory Diseases Vol. 70. No. 1, Jan. 2011 로고려할필요가있다 (3등급). 기타미생물로는 M. tuberculosis, nontuberculous mycobacteria, Orientia tsutsugamushi, Leptospira, Coxiella burnetti 등을생각할수있다. 특히국내결핵의유병률은 2006년보고자료에따르면인구 10만명당 92명으로아직높은편이며 4, 지역사회획득폐렴의원인중하나로결핵의가능성을항상고려해야할것이다. 항생제치료에대한반응이느리거나, 당뇨병, 만성폐쇄성폐질환, 만성신질환, 스테로이드장기복용과같은기저질환동반시폐렴의원인으로결핵가능성을고려하여야한다. 그리고결핵에의한폐렴은전형적인세균성폐렴비정형폐렴형태로의발생이모두가능하다는점을유념하여야한다. 최근사용이늘고있는 fluoroquinolone 의사용은결핵의진단을지연시킬가능성이있어결핵을배제할수없는경우라면경험적치료에서 1차치료제로그선택을피하는것이바람직하다. 원인균의진단 1. 외래환자에서원인균진단을위한방법외래환자의경우원인균진단을위한검사가필수적인것은아니다 (level III-3 등급 ). 항생제내성이의심되거나일반적경험적항생제투여로치료가어려운세균이의심되면객담그람염색과배양검사를시행할수있으며, 폐결핵이의심될경우객담항산성염색과결핵균배양검사를시행한다 (level III-3 등급 ). 레지오넬라증이나인플루엔자등이의심되는경우에도진단을위한검사시행이권장된다. 2. 입원환자에서원인균진단을위한적절한방법항생제투여전에혈액배양검사와객담그람염색및배양검사를임상적적응이되는모든폐렴환자에서시행하는것이좋다 (level I-3 등급 ). 항생제투여전에배출된객담으로검사하여야하며, 객담이적절히배출되고, 수집, 이동, 처리할수있는경우에실시한다 (level II-3 등급 ). 중증지역사회획득폐렴환자의경우혈액배양검사와 legionella, S. pneumoniae에대한소변항원검사, 객담배양검사가시행되어야한다 (level II-2 등급 ). 3. 혈액배양검사혈액배양검사는반드시항생제투여전에시행되어야하며균검출률은 5 14% 정도이다. 중증지역사회획득 폐렴에서는반드시시행되어야한다. 4. 호흡기검체의도말및배양검사입원하는모든지역사회획득폐렴환자에서객담도말및배양검사를시행한다. 적절한검사를위한기준을만족해야하며, 유도객담검사는결핵균과폐포자충검출에유용하다 (level II-3 등급 ). 후향적연구에의하면중증폐렴환자에서정확한원인균을밝혀도생존율의차이가없다고보고하고있지만, 중증폐렴환자의일부에서는정확한조기진단이바람직하다 (level III-3 등급 ). 5. 배양검사의해석호흡기검체배양의결과는상재균이나오염된균의가능성때문에해석에주의를요한다. 6. 기타배양검사흉수와관절액, 뇌척수액등다른부위의감염이의심되면해당부위의그람염색과배양을시행한다. 7. 항원검사 S. pneumoniae 와 legionella 폐렴진단을위한소변항원검사는결과를신속히알수있고, 항생제를사용한후에검사해도진단율이높은장점이있다. 단점은고비용과항생제감수성검사를할수없다는점이다 (level II-2 등급 ). 8. 혈청검사 Chlamydia, Mycoplasma, Legionella pneumophila가아닌기타 Legionella 등의비정형폐렴균의진단은급성기및회복기의혈청검사를통해서가능하다 (level II-2 등급 ). 초기진단에는대개유용하지않기때문에임상적으로의심되는경우에시행하며후향적확진과역학적연구에이용될수있다. 9. 기타검사 PCR, 단클론항체, DNA 탐색자등을이용한진단적검사가개발되고있지만통상적사용은고려되고있지않다. 바이러스배양은통상적으로사용되지는않으나인플루엔자가유행하는계절에항원을신속히진단하는검사는약제사용여부결정에도움이된다. 3
MK Lee: Community-acquired pneumonia 주요원인균의항생제내성실태 1. 국내 S. pneumoniae의항생제내성국내에서분리되는 S. pneumoniae 의 penicillin 내성률은매우높은것으로잘알려져왔으며이전의감수성판정기준에따른내성률조사에서는중등도내성내성을보이는경우가 64.5 91.3% 였다. 하지만이런경우에도폐렴의임상성적이 penicillin 내성과연관성이별로없다는전문가의의견에따라서미국 CLSI 의감수성판정기준이 2008 년 1월개정되었다. 개정된기준에따르면 MIC 2.0 μg/ml일때감수성, MIC 4.0 μg/ml 일때중등도내성, MIC 8.0 μg/ml 일때내성으로보고된다. 개정된기준에따라분석한경우내성률은 0%, 중등도내성 25.8% 였고, MIC90은 4 μg/ml였다 5. Amoxicillin/clavuanic acid의경우내성률 9.7%, 중등도내성 6.5% 였으며, cefuroxime 은내성률 61.3%, 중등도내성 3.2% 였다 5. Macrolide 에대한내성은 62.0 87.6% 로보고되었다. Fluoroquinolone 의경우아직내성률이높지않지만점차상승추세에있는데, ciprofloxacin 12.6%, levofloxacin 2.2 3.0%, moxifloxacin 0 1.7% 정도를보이고있다 6,7. 2. 국내 Hemophilus nfluenzae의항생제내성중등도내성내성률이 ampicillin 58.1%, amoxicillin/clavulanic acid 13.5%, cefuroxime 9.2%, cefaclor 41%, levofloxacin 1.3% 등으로보고되었다 8. 3. 기타국내에서 Mycoplasma pneumoniae의항생제감수성연구보고는많은편이며, 최근일본에서는 macrolide 내성률이 14.4% 로내성이증가하고있음을보고한바있다 9. 국내에서도지역사회획득 S. aureus 감염에서 MRSA 의비중이증가하고있기는하나지역사회획득폐렴에서 MRSA의역할에대해서는아직연구된바가없으며향후이에대한연구가필요할것으로생각된다. 입원치료여부의결정 1. 배경지역사회획득폐렴이진단된후의진료에서중요한것은입원여부의결정이다. 처음에외래치료하다가입원하 는폐렴의경우사망률이더높고, 중증환자가처음에중환자실로입원하지않는경우에사망률이더높다고보고되었다. 따라서환자의중증도나사망위험도에따라적절하게외래치료혹은입원치료를결정하여야한다. 따라서객관적인지표에의한입원여부의결정이필요하며현재까지가장널리알려진지표는 Pneumonia Severity Index (PSI) 와 CURB-65이다. 2. 폐렴중증지표 : PSI 와 CURB-65 PSI는 Pneumonia Patient Outcome Research Team (PORT) 연구에서나온자료를분석하여만든점수체계이 Table 4. Criteria for admission: pneumonia severity index (PSI) score Factor Patient age, age in yr Male Female Nursing home resident Coexisting illness* Neoplastic disease Liver disease Congestive cardiac failure Cerebrovascular disease Chronic renal disease Signs on examination Acutely altered mental state Respiratory rate 30/min Systolic blood pressure <90 mm Hg Temperature <35 o C or 40 o C Pulse rate 125/min Results of investigations Arterial ph <7.35 BUN 30 mg/dl Serum sodium <130 meq/l Serum glucose >250 mg/dl Hb <9 g/dl (Hematocrit <30%) PaO 2 <60 mm Hg (SaO 2 <90%) at room air Pleural effusion on chest X-ray Score Age Age-10 +30 +15 +15 +30 *Coexisting illness (Neoplastic disease: within one year, excluding cutaneous basal cell carcinoma or cutaneous squamous cell carcinoma; Liver disease: clinical or histological liver cirrhosis or chronic active hepatitis; Congestive cardiac failure: diagnosed by history, physical examination or laboratory findings; Cerebrovascular disease: clinical stroke or confirmed cases by CT or MRI). Atlered mental state: disorientation to person, place and time; or recently decreased level of consciousness. 4
Tuberculosis and Respiratory Diseases Vol. 70. No. 1, Jan. 2011 Table 5. Expected mortality, risk, and recommended place for treatment according to PSI Class PSI score Expected mortality, % Risk Recommendation Class I <50 yr, no underlying disorder, no severe clinical signs 0.1 0.4 Low Home Class II 1 70 0.6 0.7 Class III 71 90 0.9 2.8 Home or admission* Class IV 91 130 8.2 9.3 Moderate Hospitalization Class V >130 27.0 31.1 High Intensive care unit CURB-65 score Mortality (%) Risk Recommendation 0 0.7 Low Home 1 2.1 2 9.2 Moderate Hospitalization 3 14.5 High Intensive care unit 4 40 5 57 *Hospitalization for a short term or treatment at observation unit. PSI: pneumonia severity index. Table 6. CURB-65, mortality, risk, and recommended place for treatment Clinical factor C (Confusion) U (Blood urea): >19 mg/dl R (Respiratory rate): 30/min B (Blood pressure): Systolic pressure 90 mm Hg or diastolic pressure 60 mm Hg 65: 65 yr 다 (Tables 4, 5) 10. PSI기준은사망위험도에따라환자를 5단계로구분하며각군의예측사망률은 Table 3과같다. PSI 1 2군은외래치료가권고되며, 3군은단기간입원혹은외래치료와입원치료의중간단계를취하며, 4 5군은입원치료가권고된다. 나이의영향이너무크다는단점이있으며, 동맥혈산소포화도 <90% 이거나 PaO 2 <60 mm Hg인경우에는 PSI와상관없이입원을권고하는것이유용하다고보고되었다 11. CURB-65 는영국흉부학회에서제시한폐렴중증도지표이다 (Table 6) 12. 이지표는 1,068 명의환자를대상으로한다변량분석으로사망률을증가시키는요인 5가지가제시되었다. CURB-65 에서 U (blood urea) 항목을제외한점수체계가 CRB-65 이다. 현재까지 PSI기준과 CURB-65 를비교한무작위연구가없었으므로어느기준이더우수한지는명확하지않다. PSI 기준은 20개항목을계산해야하므로실제임상적용이불편한반면 CURB-65 는 5항목 (0 5점) 으로이루어져있어서쉽게임상적용이용이하다는장점이있다. 3. 임상적판단객관적점수체계를이용하더라도환자의입원필요성에대해완벽하게올바른결정을내리기는어렵고의료진의 임상적판단 이매우중요하다. 이점수체계는시간경과에따른변화를반영하지못하고단지한시점에서의자료에만의존하므로그정확성이떨어질수있다. 폐렴이기저질환을악화시켜입원이필요하게될수도있는데 CURB-65 점수는기저질환은전혀고려의대상이되지않는다. 점수체계에의해서는저위험군이지만임상적판단에의해서입원이필요하다고판정되는경우는크게다음의 4가지로분류할수있다 : 1) 폐렴의합병증자체 ; 2) 기저질환의악화 ; 3) 경구복용을못하거나외래간호를받기어려운상황 ; 4) 점수체계상으로여러항목이고위험군의기준에약간씩못미쳐서저위험군으로판정된경우이다. 4. 중환자실입원의결정 PSI 5군이나 CURB-65 3 5점에해당되는환자는중환자실입원을고려할수있다. 후향적연구에의하면이점수체계의민감도는높지만특이도는낮았다 ( 중환자실에입원하지않아도되는환자를입원이필요한상태로 5
MK Lee: Community-acquired pneumonia Table 7. Criteria for severe pneumonia Major criteria (2) Invasive mechanical ventilation Requiring vasopressors due to septic shock Minor criteria (9) Respiratory rate 30/min PaO 2/FiO 2 ratio 250 Multilobar pneumonia in chest X-ray Decreased level of consciousness/disorientation BUN 20 mg/dl WBC <4,000/mm 3 Platelet <100,000/mm 3 Core temperature <36 o C Hypotension requiring aggressive fluid therapy Criteria for admission to intensive care unit One major or more Three minor or more 판정하였다 ) 13. 2007년미국흉부학회 / 감염학회지역사회획득폐렴지침에서는수정된미국흉부학회기준과 CURB 를통합하여새로운기준을제시한바있다 (Table 7) 1. 그러나아직이기준의타당성은검증된바없다. 5. 초기경험적치료시항생제의선택 1) 외래에서의경험적항생제 1 ß-lactam±macrolide ( 경구 ) (level I-3 등급 ) Amoxicillin amoxicillin-clavulanate, cefpodoxime, cefditoren (level II-3등급 )±azithromycin, clarithromycin, erythromycin, roxithromycin (3등급) 2 Respiratory fluoroquinolone ( 경구 ) (level I-3 등급 ) Gemifloxacin, levofloxacin, moxifloxacin 입원을요하지않는환자에서의경험적항생제는 ß- lactam 단독 ß-lactam과 macrolide의병용, respiratory fluoroquinolone 사용이권장된다. 입원을요하지않는환자에서 macrolide 나 tetracycline 단독요법은 S. pneumoniae의높은내성률때문에권장되지않는다. 단, 비정형폐렴균을표적으로병용하는경우에는 macrolide대신 doxycycline을투여할수있다 (level II-3 등급 ). 입원을요하지않는경증의지역사회획득폐렴의치료에있어비정형폐렴의원인균을표적으로하는항생제를사용하여야하는가에대한논란이있다. 국내에서연구가더필요하지만본지침에서는 ß-lactam 단독요법을권고안에포함하였다. Cefuroxime 의경우국내분리 S. pneumoniae의내성률이상당히높아서권고안에서제외되었다. 결핵을배제할수없는경우에는 fluoroquinolone 의경험적사용을피할것을권장한다. Levofloxacin 750 mg 1일 1회 5일요법은우수한효과가보고되면서폐렴치료의표준용법으로자리를잡았다 14. Gemifolxacin의경우에도 5일요법의치료효과가 7일요법과비교하여떨어지지않는다는최근보고가있었다 15. 2) 일반병동으로입원하는경우의경험적항생제 (1) P. aeruginosa 감염이의심되지않는경우 1 ß-lactam+macrolide (level I-3 등급 ) Cefotaxime, ceftriaxone, Ampicillin/sulbactam, or amoxicillin/clavulanate+azithromycin, clarithromycin, erythromycin, or roxithromycin 2 Respiratory fluoroquinolone (level I-3 등급 ) Gemifloxacin ( 경구 ), levofloxacin, moxifloxacin ( 주사경구 ) 3) 중환자실로입원하는경우의경험적항생제 (1) P. aeruginosa 감염이의심되지않는경우 1 ß-lactam+azithromycin (leveli I-3 등급 ) Cefotaxime, ceftriaxone, Ampicillin/sulbactam, or amoxicillin/clavulanate+azithromycin ( 주사혹은경구 ) 2 ß-lactam+fluoroquinolone (level I-3 등급 ) Cefotaxime, ceftriaxone, Ampicillin/sulbactam, or amoxicillin/clavulanate+gemifloxacin ( 경구 ), levofloxacin, moxifloxacin ( 주사경구 ) 페니실린과민반응이있는경우에는호흡기 fluoroquinolone+aztreonam 의사용이권장된다. 중환자실로입원하는중증지역사회획득폐렴의경우에는 fluoroquinolone 단독요법은권고안에포함되지않았고병용요법을권고하였다. (2) P. aeruginosa 감염이의심되는경우의경험적항생제 1 Antipenumococcal, antipseudomonal ß-lactam (cefepime, pipracillin/tazobactam, imipenem, meropenem)+ciprofloxacin 혹은 levofloxacin (750 mg/d) 2 Antipenumococcal, antipseudomonal ß-lactam+ aminoglycoside+azithromycin 6
Tuberculosis and Respiratory Diseases Vol. 70. No. 1, Jan. 2011 3 Antipenumococcal, antipseudomonal ß-lactam+ aminoglycoside+antipneumococcal fluoroquinolone (gemifloxacin, levofloxacin, moxifloxacin) (level III-3 등급 ) 음주, 기관지확장증등폐의구조적질환, 반복되는 COPD 악화로인해항생제와스테로이드를자주투여해온병력, 최근 3개월이내항생제투여기왕력등이있는경우에는 Pseudomonas 에의한폐렴가능성을생각해야한다. Pseudomonas의항생제에대한내성이다양할수있기때문에초기경험적치료에서는이세균에대한항균력이우수한항생제를 2개이상병용하되일단원인균동정및감수성보고가되면이를토대로하여항생제를재조정해주어야한다 16. 6. 원인균에따른적절한항생제 1) 항생제에따른적절한용량및용법 : 지역사회획득폐렴의원인미생물이의미있는미생물학적검사방법을통해확인되는경우이를표적으로하는권장항생제로바꾸도록한다 (level III-3 등급 ) 1. 권장되는항생제는 Table 8과같다. 항생제용법은간및신기능에따라조정될수있다. 2) 적절한치료기간 : 통상적으로항생제는 7 10일투여하지만원인미생물, 환자상태, 항생제의종류, 치료에 대한반응, 동반질환및폐렴합병증유무등에따라달라질수있다 (level II-3 등급 ). 일반적으로적어도 5일이상치료하며 (level I-3 등급 ), 치료종료를위해서는 48 72시간동안발열이없어야하고, 치료종료전임상징후중 1개이상이남아있으면안된다 (level II-3 등급 ). 균혈증을동반한 S. aureus 폐렴, 폐외장기의감염이동반된폐렴, 초기치료에효과적이지않았을경우등에서는단기치료로불충분할수가있다. 또한, 공동을형성했거나조직괴사징후가있는경우는장기간치료가필요할수있다. Legionella 폐렴은적어도 14일이상치료한다. 3) 치료에반응하지않는폐렴의원인 : 병원에입원하는지역사회획득폐렴환자의 6 15% 는초기항생제에반응하지않는다. 일반적으로치료에반응하지않는환자의사망률은치료에반응하는환자에비해 7배높다고알려져있다 17. 항생제치료에도불구하고임상적으로호전되지않는경우 Table 9와같은원인을고려한다. 치료에반응하지않는폐렴 이란항생제치료에도불구하고임상적반응이부적절한상황으로정의하지만명확하지않은경우가있을수있다. 7. 경구치료및퇴원시점환자가중환자실에입실한중증폐렴환자가아니라면임상적호전을보이면서, 혈역학적으로안정되고, 정상적 Table 8. Recommended antimicrobial therapy according to etiologic microorganism Pathogen Preferred antibiotics Alternative antibiotics Streptococcus pneumoniae Penicillin G, high dose amoxicillin 3rd generation cephalosporin (cefotaxime, Haemophilus influenzae ceftriaxone), respiratory FQ flycopeptides ß-lactamase non-producing Amoxicillin Respiratory FQ ß-lactamase producing 2nd or 3rd generation cephalosporin, Respiratory FQ ß-lactam/ß-lactamase inhibitor Staphylococcus aureus Methicillin-susceptible Anti-staphylococcal penicillin Clindamycin or 1st generation cephalosporin Methicillin-resistnat Glycopeptide Linezolid Enterobacteriaceae 3rd generation cephalosporin Carbapenem (except ertapenem), FQ ß-lactam/ß-lactamase inhibitor Pseudomonas aeruginosa Antipseudomonal ß-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 ß-lactam/ß-lactamase inhibitor, clindamycin Carbapenem Influenza virus Oseltamivir FQ: fluoroquinolone. 7
MK Lee: Community-acquired pneumonia Table 9. Causes of pneumonia with no response to antimicrobial therapy Misdiagnosis Correct diagnosis Problem in patients Problem in drugs Problem in microorganisms Metastatic infection Congestive heart failure, pulmonary embolism, myocardial infarction, malignant neoplasm, sarcoidosis, vasculitis (Wegener granulomatosis, etc), renal failure, pulmonary hemorrhage, bronchiolitis obliterans organizing pneumonia, drug-induced lung diseases, eosinophilic pneumonia, hypersensitivity pneumonia Focal site: obstruction, foreign body Immune suppression Complication of pneumonia: pleural empyema, parapneumonic effusion Errors in selection of drugs, dosage, or route of administration Adverse reactions such as drug fever or drug interaction Resistant bacteria, superinfection, uncommon organisms (Mycobacterium, Nocardia, fungus, virus, anaerobes, etc.) Endocarditis, meningitis, arthritis, pericarditis, peritonitis, etc. 인경구섭취및소화기능을보이면경구치료로전환이가능하다. 경구치료로전환하는기준은 1) 기침및호흡곤란의호전 ; 2) 해열 : 8시간동안체온 <37.8 o C 유지 ; 3) 혈액검사에서백혈구수의정상화 ; 4) 충분한경구섭취량및정상적인위장관흡수기능이다 (level II-3 등급 ). 일반적으로경구용항생제는주사로사용된항생제와동일한제제, 만일동일한제제가없다면같은계열의약의사용이권장된다 (level III-3 등급 ). 퇴원은환자가임상적으로안정되어경구치료가가능하고, 기저질환에대한치료가필요없고, 진단적검사가필요없으며, 환자를돌볼수있는사회적환경이된다면고려할수있다 (Table 10) (level II-3 등급 ). 최근발표된전향적연구에서는퇴원시임상적안정상태를만족시키지못하는조건들의수가많을수록환자의 30일사망률이높아짐을보고하였고, 특히발열여부가예후와가장연관성이높다고하였다. 여러동반질환이있는노년층에서퇴원시점을결정할때에는조기재활치료를포함한추가적인조치가필요한지를평가하는것이좋다. 8. 완치판정을위한적절한검사및추적검사기간 1) 완치판정을위한적절한검사방법 : 완치판정을위한적절한검사방법은임상증상과진찰소견이폐렴이전범위로의호전이있으며흉부 X-선음영이소실되거나호전되었을때를완치라고정의할수있다 (level II-3 등급 ). 2) 재방문시점 : 대부분지역사회획득폐렴환자의경우는 7일에서 10일정도의치료기간임을고려할때외래환자의경우는임상적인소견에따라재방문시점을정하고입원후퇴원환자의경우는퇴원후 7일이내에재방문을권유하는것이바람직하다 (level II-3 등급 ). 만성기도질 Table 10. Checklist for decision of discharge Clinically stable state Body temperature 37.8 o C Pulse rate 100 per minute Respiratory rate 24 per minute Systolic pressure 90 mm Hg SaO 2 90% at room air PaO 2 60 mm Hg Possible oral intake Normal level of consciousness Need for treatment of other underlying diseases Need for other diagnostic tests Social circumstances for patient care 환이나고령의환자에서는장기간재방문및추적관찰이필요할것으로판단된다. 호흡기증상은보통 14일정도면폐렴전의상태로호전되고전반적인삶의지표는최대 6개월정도지나야증상전의상태로회복된다는보고가있다 18. 흉부 X-선의이상소견은폐렴의임상소견보다훨씬더서서히호전되며 40 세이상의흡연자에서는폐렴의완치를확인하기위해치료시작후약 7 12주까지도추적검사를해야하는경우도있으며폐렴환자의임상양상과흉부방사선소견이일치하지않은경우흉부전산화단층촬영이나기관지내시경등의검사가필요할수있다. 중증지역사회획득폐렴의경우는한달이상의추적관찰이필요하다 19. 9. 예방접종및금연교육 지역사회획득폐렴의위험성이높은사람에서폐렴구균과인플루엔자예방접종의적응증이되는경우해당백신으로예방접종을시행한다. 모든흡연자는금연하도록 8
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