Download Pneumonia

Pneumonia
Definition
• Pneumonia is an acute
infection of the
parenchyma of the
lung(肺实质), caused by
bacteria, fungi(真菌）,
virus, parasite（寄生虫） etc.
• Pneumonia may also be
caused by other factors
including X-ray,
chemical, allergen
Epidemiology

The morbidity and mortality of pneumonia
are high especially in old people.
Etiology

There are two factors
involved in the
formation of
pneumonia , including
pathogens and host
defenses.
Classification



Classification of anatomy
Classification of pathogen
Classification of acquired environment
Ⅰ.Classification by pathogen
Pathogen classification is the most useful
to treat the patients by choosing effective
antimicrobial agents
Bacterial pneumonia
(1) Aerobic Gram-positive bacteria,such
as streptococcus pneumoniae, staphylococcus aureus, Group A hemolytic
streptococci
(2) Aerobic Gram-negative bacteria, such
as klebsiella pneumoniae, Hemophilus
influenzae, Escherichia coli
(3) Anaerobic bacteria
Atypical pneumonia
Including Legionnaies pneumonia ,
Mycoplasmal pneumonia ,chlamydia pneumonia.
Fungal pneumonia
Fungal pneumonia is commonly caused by
candida(念珠菌) and aspergilosis(曲菌).
pneumocystis jiroveci（肺孢子虫）
Viral pneumonia
Viral pneumonia may be caused by
adenoviruses, respiratory syncytial
virus, influenza, cytomegalovirus,
herpes simplex
Pneumonia caused by
other pathogen
Rickettsias (a fever rickettsia),
(立克次体）
parasites(寄生虫)
protozoa（原虫）
Ⅱ.Classification by anatomy
1. Lobar（大叶性）: Involvement of an entire
lobe
2. Lobular（小叶性）: Involvement of parts of
the lobe only, segmental or of alveoli contiguous
to bronchi (bronchopneumonia).
3. Interstitial（间质性）
Lobar pneumonia
Lobular pneumonia
Interstitial pneumonia
Classification by acquired
environment
 Community
acquired pneumonia，CAP
 （社区获得性肺炎）
 Hospital acquired pneumonia，HAP ，NP
 （医院获得性肺炎）
 Nursing home acquired pneumonia,NHAP
 (护理院获得性肺炎）
 Immunocompromised host pneumonia,(ICAP)
 (免疫宿主低下肺炎）
Diagnosis（诊断步骤）



Give a definite diagnosis of pneumonia
To evaluate the degree of the pneumonia
To definite the pathogen of the pneumonia
Diagnosis
 History
and physical
examination(5W)
 X-ray examination
 Pathogen identification
Differentiation





Pulmonary tuberculosis
Lung cancer
Acute lung abecess
Pulmonary embolism
Noninfectious pulmonary infiltration
Pathogen identification






Sputum: More than 25 white blood cells
(WBCs) and less than 10 epithelial cells.
Nasotracheal suctioning
BAL, ETA, PSB, LA
Blood culture or pleural effusion culture
Serologic testing (immunological testing)
Molecular Techniques
The principal of therapy


Select antibiotics
According to guideline
Therapy



The therapy should always follow
confirmation of the diagnosis of pneumonia
and should always be accompanied by a
diligent effort to identify an etiologic agent.
Empiric therapy,(4-8h)
Combined empiric therapy to target therapy
It is important to evaluate the
severity degree of pneumonia

The critical management decision is
whether the patient will require hospital
admission. It is based on patient
characteristics, comorbid illness, physical
examinations, and basic laboratory findings.
The diagnostic standard of sever
pneumonia






Altered mental status
Pa02<60mmHg. PaO2/FiO2<300, needing MV
Respiratory rate>30/min
Blood pressure<90/60mmHg
Chest X-ray shows that bilateral infiltration,
multilobar infiltration and the infiltrations enlarge
more than 50% within 48h.
Renal function: U<20ml/h, and <80ml/4h
CAP (社区获得性肺炎）

CAP refers to pneumonia acquired outside of
hospitals or extended-care facilities .
 Streptococcus pneumoniae remains the most
commonly identified pathogen.
 Other pathogens include Haemophilus influenzae,
mycoplasma pneumoniae, Chlamydophilia
pneumoniae, Moraxella catarrhalis and ects.
 Drug resistance streptococcus pneumoniae(DRSP)
Clinical manifestation



The onset is accute
Respiratory symptoms
Extrapulmonary symptoms
signs



Consolidation signs
Moist rales
Respiratory rate or heart rate
Laboratory examination


WBC
X-ray features
Diagnosis



Clinical diagnosis
Pathogen diagnosis
Evaluate the severity degree of pneumonia
Therapy


Antiinfectious therapy(Combined empiric
therapy to target therapy)
Supportive therapy
Empiric therapy (1)

Outpatient<60 years
old and no comorbid
diseases
 Common pathogens:
S pneumoniaes,
M pneumoniae,
C pneumoniae,
H influenzae and
viruses

A new generation
macrolide
 A beta-lactam: the first
generation
cephlosporin
 A fluoroquinolone
Empiric therapy (2)

Outpatient>65 years old or
having comorbid diseases
or antibiotic therapy
within last 3 months
 Common pathogens: S
pneumoniae(drugresistant), M pneumoniae,
C pneumoniae, H
pneumoniae, H influenzae,
Viruses, Gram-negative
bacilli and S aureus



A fluoroquinolone
A beta-lactam / betalactamase inhibitor
The second generation
cephalosporin
or combination of a
macrolide
Empiric therapy (3)

Inpatient : Not
severely ill.
 Common pathogen:S
pneumoniae, H
influenzae,
polymicrobial,
Anaerobes, S aureus,
C pneumoniae, Gramnegative bacilli.

The second or third
generation
cephalosporin plus A
macrolide
 A betalactam/betalactamase
inhibitor.
 A newer
fluoroquinolone
Empiric therapy (4)


Inpatient severely ill
Common pathogens:S
pneumoniae, Gramnegative bacilli, M
pneumoniae, S aureus and
viruses




The second or third
generation cephalosporin
plus A macrolide
A betalactam/betalactamase
inhibitor.
A newer fluoroquinolone
Vancomycin
Empiric therapy (5)

Patients in ICU without
Pneudomonas aeruginosa
infection




The second or third
generation cephalosporin
plus A macrolide
A betalactam/betalactamase
inhibitor.
A newer fluoroquinolone
Vancomycin
Empiric therapy (6)

Patients in ICU with
Pneudomonas
aeruginosa infection

A antipneudomonas
aeruginosa betalactam/betalactamase
inhibitor plus
fluoroquinolone
prognosis
preventive
HAP（医院获得性肺炎）


HAP refers to pneumonia acquired in the
hospital setting.
Enteric Gram-negative organisms, S. aureus,
Pneudomonas aeruginosa, ects.
The pathogen of HAP
 Gram-negative
bacteria (GNB) account for
55% to 85% of HAP infections
 gram-positive cocci account for 20% to
30% and some other pathogens.
EPIDEMIOLOGY

General risk factors for developing
HAP include age more than 70 years,
serious comorbidities, malnutrition,
impaired consciousness, prolonged
hospitalization, and chronic
obstructive pulmonary diseases.
EPIDEMIOLOGY

HAP is the most common infection occurring in
patients requiring care in an intensive care unit
(ICU), with incidence rates ranging from 6% up to
52%, much higher than the 0.5% to 2% incidence
reported for hospitalized patients as a whole.
This increased incidence is due to the fact that
patients located in an ICU often require
mechanical ventilation, and mechanically
ventilated patients are 6 to 21 times more likely to
develop HAP than are nonventilated patients.
Mechanical ventilation is associated
PATHOGENESIS



Aspiration :Microaspiration of
contaminated oropharyngeal secretions
seems to be the most important of these
factors, as it is the most common cause of
HAP.
Inhalation
Contamination
Clinical manifestations



The onset is acute or insidious
Respiratory symptoms
Physical signs
Laboratory examinations

Chest X-ray
diagnosis



Clinical diagnosis
Pathogen diagnosis
Evaluate the severity degree of pneumonia
Treatment (1)

Antibiotic therapy: antimicrobial therapy begin
promptly because delays in administration of
antibiotics have been associated with worse
outcomes.
 The initial selection of an antimicrobial agent is
almost always made on an empiric basis and is
based on factors such as severity of infection,
patient-specific risk factors, and total number of
days in hospital before onset.
Treatment (2)

All empiric treatment regimens should
include coverage for a group of core
organisms that includes aerobic gram
negative bacilli (Enterobacter spp,
Escherichia coli, Klebsiella spp, Proteus spp,
Serratia marcescens, and Hemophilus
influenzae) and gram-positive organisms
such as Streptococcus pneumoniae and
Staphylococcus aureus.
Treatment (3)

In patients with mild or moderate infections and
no specific risk factors for resistant or unusual
pathogens, monotherapy with a second-generation
cephalosporin such as cefuroxime; a
nonpseudomonal third-generation cephalosporin
such as ceftriaxone; or a beta-lactam/betalactamase inhibitor such as ampicillin/sulbactam,
ticarcillin/clavulanate, or piperacillin/tazobactam
may be appropriate.
 For patients in this low-risk category who have an
allergy to penicillin, it is appropriate to initially
use a fluoroquinolone
Treatment (4)




Patients with severe infections with specific risk factors
should have broadened empiric coverage.
Combination therapy should be employed in these cases
because of the high rate of acquired resistance among these
organisms.
Appropriate combinations for this group of patients
include an aminoglycoside or ciprofloxacin in addition to a
beta-lactam with antipseudomonal coverage.
Additionally, vancomycin should be considered if the
patient has risk factors that suggest methicillin-resistant
Staphylococcus aureus could be a pathogen.
Prevention



Release aspiration
Washing hands
vaccination
ICHP (免疫低下宿主肺炎)

Pneumonia in an immunocompromised host
describes a lung infection that occurs in
a person whose ability to fight infection is
greatly impaired.
(Non-HIV-ICH)
Causes, incidence, and risk factors

Immunosuppression can be caused by HIV
infection, leukemia, organ transplantation, bone
marrow transplant, and medications to treat cancer.
 Microorganisms include all kinds of bacteria and
virus(CMV), candida(念珠菌) and
aspergilosis(曲菌).
pneumocystis carinii（PCP,卡氏肺孢子虫）
Symptoms





The onset is incidous , but clinical
Symptoms are severe.
Fever
Nonproductive (dry) cough or cough with
mucus-like, greenish, or pus-like sputum
PCP
Fungal infection
Diagnosis


Earlier finding and diagnosis
Pathogen diagnosis
Chest x-ray
Sputum gram stain, other special stains, and
culture
Arterial blood gases
Bronchoscopy
Chest CT scan,
 Tissue diagnosis
Treatment

Antimicroorganism therapy
 The goal of treatment is to get rid of the infection
with antibiotics or antifungal agents. The specific
drug used will depend on what kind of organism
is causing the problem. One drug may kill one
type of organism, but not another.
 Respiratory treatments (to remove fluid and mucus)
and oxygen therapy are often needed.
Pneumococcal pneumonia
Abstraction
• Pneumococcal
pneumonia is produced
by
streptococcal
pneumoniae
• It is the most commonly
occurring bacterial
pneumonia
Etiology
•
Streptococcus pneumonia
are encapsulated,
gram-positive cocci that
occur in chains or
pairs
•
The capsule which is a
complex polysaccharide
has specific antigenicity
• Type 3 is the most virulent,
usually causing
severe pneumonia in adults,
but type 6,14,19
and 23 are virulents is
children
Bacteria are introduced into the
lungs by the four routes

Source
Route

colonization
aspiration

Air
Non-pulmonary
infection
Contiguous
infection
inhalation
blood
stream
direct
extention




Response
lung
defenses
Outcome
pneu.
pathogenesis

Pneumococci usually
reach the lungs by
inhalation or
aspiration. They lodge
in the bronchioles,
proliferation and
initiate an
inflammatory process.
Pathology
Congestion
red hepatization
grey hepatization
resolution)
Pathology
Red hepatilization
◆
All of the four main stages of the inflammatory
reaction described above may be present at the
same time
◆
In most cases, recovery is complete with
restoration of normal pulmonary anatomy
Clinical manifestations
Clinical manifestations (1)
• Many patients have had an upper respiratory
infection for several days before the onset of
pneumonia
• Onset usually is sudden, half cases with a
shaking chill
• The temperature rises during the first few
hours to 39-40℃
Clinical manifestations (2)
Typically, patients have the symptoms of
high fever , shaking chill, sharp chest
pain, cough, dyspnea and blood-flecked
sputum.
But in some cases, especially those at age
extremes symptoms may be more
insidious.
Clinical manifestations (3)
• The pulse accelerates
• Sharp pain in the involved hemi thorax
• The cough is initially dry with pinkish or
blood-flecked sputum
• Gastrointestinal symptoms such as,
anorexia, nausea, vomiting abdominal
pain, diarrhea may be mistaken as acute
abdominal inflammation
Signs 1
• The acutely ill patient is tachypneic, and
may be observed to use accessory muscles
for respiration, and even to exhibit nasal
flaring
• Fever and tachycardia are present, frank
shock is unusual, except in the later stages
of infection or DIC
Signs 2
• Auscultation of the chest reveals
bronchovesicular or tubular breath
sounds and wet rales over the
involved lung
• A consolidation occurs, vocal and
tactile fremitus are increased
Laboratory examinations
Laboratory examinations (1)
• The peripheral white blood cell (WBC) count
• Before using antibiotic, the culture of blood and
of expectorated purulent sputum between 24-48
hours can be used to identify pneumococci
• Colony counts of bacteria from bronchoalveolar
lavage washings obtained during endoscopy are
seldom available early in the course of illness
• Use of the PCR may amplify pneumococcal
DNA and improve potential for detection
X-ray examination
• Chest radiographs is more sensitive than
physical examination
• PA and lateral chest radiographs are
invaluable to detect pneumonia
X-ray examination
• Usually lobar or
segmental
consolidation
suggests a bacterial
cause for pneumonia
• If blunting of the
costophrenic angle is
noted, pleural
effusion may be exist.
The features of CT
Air-bronchogram sign
Complications
In 5% to 10% of patients, infection may extend into the pleural
space and result in an empyema
（脓胸）
In 15% to 20% of patients, bacteria may enter
the blood stream (bacteremia) via the lymphatics
and thoracic dust.
Invasion of the blood stream by pneumococci
may lead to serious metastatic disease at a
number of extra pulmonary sites (meningitis,
arthritis, pericarditis, endocarditis, peritonitis,
ostitis media etc).
Complications
sepsis （脓毒性休克）
lung abscess（肺脓疡） or
empyema
pleural effusion（胸腔积液）
pleuritis
ARDS（急性呼吸窘迫综合征）
ARF（急性呼吸衰竭）
pneumothorax（气胸）
Extrapulmonary infections
Diagnosis
According to history, the clinical signs ,
physical
examinations,
laboratory
examinations and radiographic features
it is not difficult to make the diagnosis
Differential diagnosis
• pulmonary tuberculosis
• Other microbial pneumonias:
klebsiella pneumonia,
staphylococal pneumonia,
pneumonias due to G (-) bacilli,
viral and mycoplasmal
• Acute lung abscess
• Bronchogenic carcinoma
• Pulmomary infarction
Treatments



Antibiotics
Support therapy
Therapy of complications
Antibiotic therapy (1)
• All patients with suspected pneumococcal
pneumonia should be treated as promptly as
possible with penicillin G
• The dose and route of delivery may have to
be on the basis of patients status adverse reaction or complication that occur
Antibiotic therapy (2)
• For patients who are believed to be allergic to
penicillin, one may select the first or second
generation cephalosporin or advanced
macrolide+ β -lactam or respiratory
fluoroquinolone alone.
For patients with PRSP, one may select the
second and third generation cephalosporin or
advanced macrolide+ β -lactam or respiratory
fluoroquinolone alone.
In some cases, vancomycin may be used.
Antibiotic therapy
• Treatment with any effective agent
should be given for at least 5 to 7 day or
after the patients have been afebrile for
2-3 days
Supportive measure

Supportive measure are generally used in
 the initial management of acute pneumo coccal pneumonia, such measures include
 • Bed rest
• Monitoring vital signs and urine output
• Administering an occasional analgesic to
relieve pleuritic pain
• Replacing fluids, if the patient is dehydrated
• Correcting electrolytes
• Oxygen therapy
Treatment of complications
• Empyema develops in appoximately 5% of patients
with pneumococcal pneumonia, although pleural
effusion commonly develop in 10%- 20% patients
• Chest X-ray with lateral decubitus films are often
useful in the early recognition of pleural effusion,
pleural fluid that is removed should be subjected to
routing examination
• If pneumococcal bacteremia occurs, extra pulmonary
complications such as arthritis, endocarditis must be
excluded, because the therapy requires higher dosages
• Treatment of infections shock
Prognosis
Prognosis is much better
Any of the following factors makes the prognosis
less favorable and convalescence more prolonged
elderly:
• involvement of 2 or more lobes
• underlying chronic diseases (heart lung
kidney) normal temperature and WBC
count <5000
• immunodeficiency with severe complication
Prevention
The most important
preventive tool available
is using a poly valent
pneumococcal vaccine
in those with chronic
lung diseases, chronic
liver diseases,
splenectomy, diabetes
mellitus
and aged
Staphylococcus pneumonia
• Staphylococcal
pneumonia is usually caused
by
staphylococcus aureus
• It is often a complication
of influenza, but may be
primary, particularly in
infants and the aged
•
It occurs in immunocompromissed patients such as
diabetes mellitus
hematologic disease ( leukemia, lymphoma,
leukopenia )
AIDS, liver disease, malnutrition, alcoholism
• Staphylococcal bacteremia complicating infections
at
other sites (furuncles, carbuncles) may cause
hematogenous pulmonary involvement (due to
blood
spread)
• Some or all of the symptoms of pneumococcal
pneumonia (high fever, shaking chill, pleural pain,
productive cough) may be present, sputum may be
copious and salmon-colored
• Prostration is often marked
• According the symptoms, signs of pneumonia,
leukocytosis and a positive sputum or blood
culture, the diagnosis can be made
• Gram stain of the
sputum provides earliest
diagnostic clue
• Chest X-ray early in
the disease shows
many small round
areas of densities that
enlarge and coalesce
to from abscess, and
leave evidence of
multiple cavities
• Until the sensitivity results are know, a
penicillinase–resistant penicillin or a
cephalosporin should be given
• Therapy is continued for 2 weeks after
the patient has become afebrile and the
lungs have shown signs of clearing
• Vancomycin is the drug of choice for
patients allergic to penicillin and cephalosporin and for those not responding to
other antistaphylococcal drugs, mainly used
in MRSA.
Pneumonia caused by klebsiella
Klebsiella pneumonia ( also named Friedlander
pneumonia) is an acute lung infection, caused by
Klebsiella pneumoniae 1, it occurs much more in
aged, malnutrition, chronic alcoholism, and in
whom with bronchial pulmonary disease
• This pneumonia is most likely to be found in
man with middle age, onset usually is sudden,
with high fever, cough, pleuritic pain, abundant
sputum, cyanosis, tachycardia my be present,
half cases with a shaking chill
• Shock appears in early stage
• Clinical manifestations are similar to sever
pneumococcal pneumonia
• The sputum is viscid and “ropy”, and may be
“brick red” in color
• Chest X-ray shows a downward curve of the
horizontal interlobar fissure, if the right
upper lobe is involved
• Areas of increased radiance whithin dense
consolidation suggest cavitation
• It constitutes 2% of bacterial pneumonia,
but mortality may be as high as 30%
• When an elderly patient suffered from acute
pneumonia with sever toxic symptom, viscid
and “brick red”, sputum must consider this
disease
• The diagnosis is determined by bacterial
examination of sputum
• Early using antimicrobial therapy is important for patients with survivable illillnesses, aminoglycoside (Kanamycin, Amikacin,
Gentamycin ) and the third generation
cephalosporin are often used.
Mycoplasmal pneumonia
•
Mycoplasmal pneumonia is
caused by Mycoplasmal
pneumoniae
• Mycoplasmal pneumoniae is
one of the smallest
organisms
125-150 μm
capable of replication in
cell-free media
•
Infection is spread form
person to person by
respiratory
secretions
expelled during bouts of
coughing, causing epidemic
• It commonly occurs in children, adolescent, mainly
in fall and winter
• It constitutes more than 1/3 of non bacterial
pneumonias, or 10% of pneumonias from all cause
• Cellular infiltrate around bronchioles, and in
alveolar interstitium, consists mostly of mononuclear elements
Clinical findings
• The illness begins insidiously with
constitutional
symptomatology:
malaise, sore throat, cough, fever,
myalgia
• Half of cases have no symptom
•
Chest X-ray
Chest X-ray findings are
manifold
• Most patients have
unilateral lower lobe
segmental abnormalities
• The earliest signs are an
interstitial accentuation
of marking with
subsequent patch air space
consolidation and thickened
bronchial shadows
• The pneumonia may persist for 3-4 weeks
a slight leukocytosis is seen, with a normal
differential count
• The diagnosis is generally proved by a single
antibody titer of 1:32 or greater, a titer of
cold agglutinins of 1:32 or greater a single
Ig M determination
• The most promising in terms of speed,
sensitivity and specificity is PCR although
cost and lack of general availability limit its
routine use
Therapy
A definite clinical response
is seen to erythromycin and some
other newer macrolide
Legionnaies Pneumonia
Legionella can be an opportunistic
pathogen.
Patients with immunosuppression are at
increased risk for infection. But
sometimes outbreaks do occur in
previously healthy individuals.
Legionellae are small,
gram-negative,
obligately aerobic baclli.
.
Legionnaires’ disease is acquried
by inhaling aerosolized water
containing Legionella
organisms or possibly by
pulmonary aspiration of
contaminated water.
The contaminated water are
derived from humidifiers,
shower heads, respiratory
therapy equipment, industrail
cooling water.
Because of the frequently use of
air conditioner, Legionnaies
pneumonia is also seen in
CAP
Clinical manifestations



The onset of L.pneumonia is sometimes
severe.
High fever, rigors, and significant
hypoxemia are usually seen in patients
with L.pneumonia.
Failure to rapidly appropriate therapy in
these cases is likely to result in a poor
outcome.

Common signs include cough, dyspnea,
pleuritic chest pain, gastrointestinal
symptoms, especially diarrhea or
localized abdominal pain, nausea,
vomitting are a prominent finding in
20% to 40% of patients with
L.pneumonia.
Physical examination



Physical finding are often similar to other
pneumonias.
Rales are usually present over involved
areas
Pulse rate is not coincide to the body
temperate.
Chest X-ray

No diagnostic
features on the chest
X-ray distinguish it
from other
pneumonia
 Infiltrates can be
unilateral, bilateral,
patchy, or dense, and
can spread very
quickly to involve the
entire lung, pleural
effusion, usually
Laboratory examination


Serologic testing is the most often used
for establishing a diagnosis.
A fourfold or greater rise in antibody is
considered definitively exist for
Legionella.
Diagnosis

According to history, clinical signs, X-ray
features and serologic testing, we can
diagnose it.
Therapy

Erythromycin is considered the drug of
choice.It should be given until clinical
improvement is seen.It usually lasts 2-3
weeks.
Candidiasis
Candidiasis is an opportunistic disease, it is
caused by candida.
Clinical signs


Respiratory signs: fever,cough, sputum
production, dyspnea.
X-ray shows no specific.It is similar to
acute pneumonia.
diagnosis

Mainly according to sputum culture or
biopsy of lung.
Therapy

Nystatin or various azole drugs
Aspergillosis

Aspergillosis refers to infection with any of
species of the genus Aspergillus
Clinical signs


The disease generally occurs in
immunosuppressed and anticancer
therapy patients.
There are four types of pulmonary
aspergillosis.
Clinical signs of Pulmonary
aspergillosis

Presents as chronic productive cough,
hemoptysis, dyspnea, weight loss, fatigue, chest
pain, or fever
 Sometimes patients with pulmonary
aspergillosis accompany with prior chronic
lung disease.
 Typical picture of an aspergilloma is a fungus
ball in a cavity in an upper lobe
 The sputum culture is positive in most patients.
Diagnosis

The repeated isolation of Aspergillus
from sputum or the demonstration of
hyphae in sputum or BALF suggests
endobronchial infection.
Treatment


With intravenous amphotericin B (1.0 to
1.5 mg/kg daily)
Patients with severe hemoptysis due to
fungus ball of lung may benefit from
lobectomy
Therapy to Infectious Shock

Treatment in intensive care units
cardiac rhythm, blood pressure, cardiac performance, oxygen
delivery, and metabolic derangements can be monitored

Adequate oxygenation and ventilatory support
(sometimes mechanical ventilation)
 Effective antibiotic therapy
 Maintain blood pressure, including maintain
circulation blood volume, use of dopamine
Summary






1.肺炎的定义
2.肺炎的分类
3.CAP和HAP的定义和常见的病原体
4.肺炎球菌肺炎的典型的临床表现和影象
特点及其治疗原则
5.各种病原体肺炎的治疗原则
6.感染性休克的治疗原则
Questions



1.What is the differences between CAP and
HAP?
2.What is the standard of sever pneumonia?
3.what are the principals of antibiotic
therapy of various of pneumonias?
Case report
患者,男性,32岁
 主诉:发热伴咳嗽6天
 现病史:患者于6天前劳累后出现发热,体温最高
达39℃,稍有畏寒,自服退热药后热退,之后体温
又上升,达38℃,伴有咳嗽,痰为白色黏液样,偶呈
黄脓性,遂于我院就诊,胸部X线显示:左下肺片
状高密度影,外周血白细胞6.0*109 /L,N66.2%,在
门诊予与亚星和左克抗感染3天,体温不退,行胸
部CT检查示:左下肺片状密度增高影。故收入
院进一步诊治。

入院体检

神清，一般可，T：38℃，P90次/分，
R18次/分，BP110/70mmHg，口唇无紫绀，
全身浅表淋巴结未及肿大，颈软，两肺
呼吸音粗，未及干湿罗音，腹软，无压
痛，双下肢无浮肿，NS(-)
辅助检查



血支原体抗体IgM１：160
胸片
胸部CT
胸片
胸部CT
case2
患者，男性，50岁
 主诉:咳嗽伴咳黄痰二十余天
 现病史:患者于入院前二十余天开始无明显诱因下出现
咳嗽,咳黄脓痰,量中,无咯血,胸痛和呼吸困难等其他呼
吸系统症状。四天后出现发热一次，体温未测，自服
安乃近后热平，但一直有夜间出汗较多伴乏力，遂于
当地医院就诊，胸片示两肺多发阴影，拟肺炎后于次
日来我院行CT（见CT结果），为进一步诊治入院。
 追问病史患者于入院约半年前确诊天疱仓，遂开始服
用强地松片30mg/d,后因病情反复增加用量，并于入院
前２月加用硫唑嘌呤２片／d

入院体检、辅助检查


体检无特殊阳性体征
胸部ＣＴ检查
How do we
diagnose?
选择题






1．男性，58 岁，有慢性咳嗽、咯痰史 15 年，
1 周来高热、咯红砖色胶冻样痰，伴气急紫绀，
谵妄，本 例可能性最大的诊断是：B
A、肺炎球菌肺炎
B、克雷白杆菌肺炎
C、浸润型肺结核
D、病毒性肺炎
E、支原体肺炎






2．男性，35 岁，发热、寒颤 3 天，体温 39 度，
胸片示右上肺大片阴影，痰涂片见较多革兰氏
阳性成对 或短链状球菌，这时治疗首选 ？C
A、头孢唑啉
B、丁胺卡那霉素
C、青霉素
D、氟哌酸
E、红霉素






3．肺炎球菌肺炎在病变消散后肺组织结
构：E
A、纤维组织增生
B、有小空洞残留
C、肺泡壁水肿
D、局部支气管扩张
E、肺泡壁无损坏
4．男，20 岁，低热咽痛，咳嗽半月入院，咳嗽甚剧，
为刺激性干咳，体检：T37.8 度，咽充血，心肺无 阳
性体征，化验：WBC：8＊10^9/L，中性 70％，X 线
胸片示右下肺间质性炎变，间有小片状阴影，以下哪
项检查对明确诊断意义较大？E
 A、痰细菌培养
 B、咽拭子细菌培养
 C、痰查抗酸杆菌
 D、结核菌素试验
 E、冷凝集试验

5．患者，25 岁，女性，咽痛，咳嗽，乏力，四肢肌肉
疼痛，中等发热，双肺呼吸音稍粗，未闻罗音，白 细
胞 9.6＊10^9/L，中性 86％，胸片示：左下肺部斑片状
浸润阴影，血清冷凝集试验：1：64 阳性，最好 应选
择的治疗药物是：E
 A、抗结核药
 B、青霉素
 C、头孢菌素
 D、氨基甙类抗生素
 E、红霉素







6.军团菌肺炎首选的抗生素是:A
A.红霉素
B.青霉素
C.头孢菌素
D.丁胺卡那霉素
E.氯霉素






7．肺炎球菌致病力的主要因素是 E
A．肺炎球菌内毒素
B．肺炎球菌外毒素
C．肺炎球菌菌体蛋白质
D. 肺炎球菌迅速繁殖
E．肺炎球菌含高分子多糖体荚膜对组织
的侵袭力






8．治疗肺炎球菌肺炎首选抗生素是B
A 红霉素
B．青霉素
C．丁胺卡那霉素
D．氯霉素
E．羧苄青霉素







9．男性，25岁，因受凉后突起畏寒、发热
(39.2度)。左
侧胸痛伴咳嗽，咯少量铁锈色痰，胸部X线摄
片见左下肺野大片淡薄阴影。其最可能的诊断
是：C
A.金黄色葡萄球菌肺炎
B．结核性胸膜炎
C．肺炎球菌肺炎
D原发性支气管肺癌合并阻塞性肺炎
E．急性原发性肺脓疡






9．肺炎球菌肺炎患者在抗生素治疗下体
温接近正常后反又升高，白细胞增高，
首先考虑：E
A．细菌产生耐药
B．抗生素用量不足
C．药物热
D．加用退热药
E．出现并发症






10.肺炎球菌肺炎的炎症发展最高峰是：
A
A.灰色肝样变期
B.消散期
C.红色肝样变期
D.病变组织的机化
E.充血期