《肺炎链球菌肺炎》PPT课件.ppt

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1、肺炎链球菌肺炎坏死性肺炎（necrotizing pneumonia，NP）NPNP是一个病理学名称，与肺脓肿相同。是一个病理学名称，与肺脓肿相同。肺肺脓脓肿肿是是细细菌菌感感染染导导致致的的肺肺实实质质坏坏死死性性病病变变，形形成包含液化坏死物的脓腔成包含液化坏死物的脓腔 有有临临床床学学者者将将直直径径小小于于2 2 cmcm的的肺肺内内多多发发脓脓腔腔病病变变定义为定义为NPNP或肺坏疽（或肺坏疽（pulmonary gangrenepulmonary gangrene，PGPG）NPNP和和肺肺脓脓肿肿的的界界定定是是人人为为的的，大大的的空空洞洞命命名名为为肺肺脓脓肿肿，小小的的多多

2、发发空空洞洞则则称称为为NP NP NP NP 具有影像学表现，可据此诊断。具有影像学表现，可据此诊断。影像学表现 X X线片线片 肺部实变阴影内出现单发或肺部实变阴影内出现单发或多发多发小透亮区或肺大泡小透亮区或肺大泡 CT CT 表现表现 肺肺部部实实变变阴阴影影内内出出现现单单个个或或多多个个低低密密度度区区域域或或空空腔腔或或肺大泡，无气液平面，增强肺大泡，无气液平面，增强CTCT显示没有边缘强化显示没有边缘强化 病 例 1 男，1岁6月，因发热、咳嗽8天，呼吸困难2天入院。患儿体温波动于38.5-39.5，咳嗽逐渐加重，喉中有痰声，当地给予先锋霉素治疗1周，症状无好转，并出现呼吸困难

3、。胸部X线片和胸部CT提示左上下肺大片致密阴影，其内多发透亮区，左侧大量胸腔积液，有粘连包裹。入院诊断左侧坏死性肺炎、胸腔积液。白细胞:白细胞 22109/L,N:85%CRP:180mg/L D-dimer 9.0/L(0.05-0.5)病 例 1 胸水检查提示为化脓性表现。胸水和痰液均培养出肺炎链球菌，确定肺炎、胸腔积液的病原菌为肺炎链球菌。药敏实验（纸片法）提示对万古霉素敏感，青霉素不敏感。给予头孢曲松治疗，转入外科经胸腔镜行胸腔积液引流、清创、胸膜剥脱术。术后体温正常，继续治疗治疗3周出院。出院后随访左侧肺炎部分吸收，多发透亮区逐渐消失，左侧肺部病变区域出现马赛克灌注，提示可能遗留感染

4、后细支气管炎，目前仍在随访中。病例 2 男，7岁，主因发热6天、咳嗽3天入院 2周前因发热、皮疹当地诊断麻疹，治疗后体温正常7天，6天前出现耳痛，诊断为中耳炎，次日再次出现发热，3天前耳痛消失，出现咳嗽，不重，痰少。查体：体温正常，肺左下肺呼吸音降低，双肺无湿性罗音，外耳未见分泌物。血常规：白细胞 27109/L,N:89%CRP:120mg/L,尿常规:白细胞20-30/高倍病例 2胸部CT：双侧肺炎，伴少量胸腔积液痰液培养:肺炎链球菌，青霉素不敏感（纸片）血、尿培养阴性诊断：肺炎链球菌肺炎 中耳炎 泌尿系感染 败血症 治疗：头孢曲松，体温正常，1周咳嗽消失欧洲多中心研究(Mark Wood

5、head,Chest 1998;113:183s-187s)051015202530肺炎链球菌肺炎衣原体肺炎衣原体病毒肺炎支原体肺炎支原体肺炎支原体肺炎支原体嗜肺军团菌嗜肺军团菌嗜肺军团菌嗜肺军团菌流感嗜血杆菌革兰阴性肠肝菌等鹦鹉热衣原体鹦鹉热衣原体鹦鹉热衣原体鹦鹉热衣原体伯氏考克斯体金黄色葡萄球菌卡他莫拉菌其它发病率发病率(%)10个欧洲国家个欧洲国家26个前瞻性研究个前瞻性研究5961位位CAP住院患者住院患者 临床所见 痰痰液液培培养养阳阳性性(菌菌落落100%),100%),1-41-4月月份份占占痰痰液液标标本本的的45%45%左左右右,目前阳性率下降目前阳性率下降,约占约占20-3

6、0%20-30%重症肺炎链球菌肺炎近重症肺炎链球菌肺炎近2 2年加重年加重,出现坏死性肺炎或肺脓肿、脓胸出现坏死性肺炎或肺脓肿、脓胸肺炎链球菌坏死性肺炎近近年年来来，几几个个不不同同地地区区的的研研究究均均显显示示儿儿童童肺肺炎炎链链球菌球菌NPNP有增多现象。有增多现象。美美国国TanTan等等比比较较了了单单纯纯和和复复杂杂性性肺肺炎炎链链球球菌菌肺肺炎炎（合合并并坏坏死死、脓脓胸胸、肺肺炎炎旁旁胸胸腔腔积积液液或或肺肺脓脓肿肿）病病例例分分布布，发发现现复复杂杂性性病病例例进进行行性性增增加加，从从19941994年的增加到年的增加到19991999年的年的5353。英英国国Ramphu

7、l Ramphul 等等分分析析了了19971997年年2 2月月到到20032003年年7 7月月收收治治的的7575例例儿儿童童脓脓胸胸，1515例例伴伴有有肺肺空空洞洞性性疾疾病病，其其中中2000-20032000-2003占占1313例。例。肺炎链球菌坏死性肺炎台台湾湾HsiehHsieh等等回回顾顾分分析析表表明明国国立立台台湾湾大大学学医医院院（NTUHNTUH）收收治治的的7171例例儿儿童童肺肺炎炎链链球球菌菌肺肺炎炎中中4040例例（）表表现现为为复复杂杂性性肺炎肺炎.复复杂杂性性肺肺炎炎占占肺肺炎炎链链球球菌菌肺肺炎炎的的比比率率从从19951995年年到到2003200

8、3年年明明显升高（显升高（19951995年年2525，20032003年年7070）.复杂性肺炎的发生机制肺炎链球菌不产生坏死毒素，它导致NP的机制不清。研究表明肺炎链球菌3型在成人经常引起肺组织化脓坏死，Hammond等认为这与其具有大量的荚膜多糖抗原，抵抗吞噬有关。复杂性肺炎与血清型有关？TanTan等等报报道道引引起起肺肺炎炎的的肺肺炎炎链链球球菌菌血血清清型型以以6B6B、1414和和19F19F为主，为主，1 1型容易引起复杂性肺炎型容易引起复杂性肺炎 Ramphul Ramphul 等等检检测测了了1111例例儿儿童童脓脓胸胸合合并并空空洞洞性性疾疾病病病病例例肺肺炎炎链链球球菌

9、菌的的细细菌菌血血清清型型，4 4例例1 1型型，3 3例例3 3型，型，2 2例例1414型，型，2 2例为例为9V9V型。型。HeishHeish等等检检测测3838个个菌菌株株进进行行了了血血清清型型分分型型，1414型型最为常见，但血清型的分布在两组间并没有差异最为常见，但血清型的分布在两组间并没有差异 复杂性肺炎与血清型有关？五家医院常见的4种型19F、19A、23F和6B 19F明显较往年增加.复杂性肺炎与耐药有关?肺炎链球菌青霉素耐药和敏感性降低也是引起复杂性肺炎的原因？Heish等检测了50株分离于肺炎病例的肺炎链球菌的MIC，青霉素不敏感或头孢曲松不敏感菌株在大叶性和复杂性肺

10、炎病例的分布没有差异。复杂性肺炎与毒力有关还有学者认为肺炎链球菌导致坏死病例增多与细菌毒力增强有关肺炎链球菌毒力因子的变异有可能导致肺清除细菌的能力下降，从而进展为肺组织坏死。坏死性肺炎与其他机制?Hsieh等对3例NP死亡病例进行了尸体解剖，大体观右肺中叶存在气肿、坏死和坏疽；坏疽区显示大面积的梗塞和坏死，右肺中叶肺动脉内有血栓。认为肺炎链球菌引起儿童NP，可能与儿童很少发生的血管栓塞和PG有关。抗生素治疗 279279株肺炎链球菌对株肺炎链球菌对8 8种抗菌药物的敏感性检测结果显示种抗菌药物的敏感性检测结果显示:肺肺炎炎链链球球菌菌对对青青霉霉素素的的不不敏敏感感率率为为，处处于于中中介介

11、水水平平，耐药。耐药。在在检检测测的的内内酰酰胺胺类类抗抗菌菌药药物物中中，肺肺炎炎链链球球菌菌对对阿阿莫莫西西林还保持着很高的敏感性，敏感率为。林还保持着很高的敏感性，敏感率为。的的菌菌株株对对头头孢孢曲曲松松敏敏感感，仅仅有有的的菌菌株株对对头头孢孢呋呋辛辛敏敏感。感。几乎全部菌株（）对红霉素耐药。几乎全部菌株（）对红霉素耐药。抗 生 素 对对万万古古霉霉素素和和氧氧氟氟沙沙星星有有很很高高的的敏敏感感率率。值值得得注注意意的的是是在在上上海海分分离离到到1 1株株万万古古霉霉素素不不敏敏感感菌菌株株 对亚胺培南的不敏感率为，以中介株为主。对亚胺培南的不敏感率为，以中介株为主。其他治疗引流

12、治疗 胸穿、闭氏引流、胸腔镜 闭氏引流的条件：白细胞、LDH、糖含量抗凝治疗等细菌性气道感染背景背景 临临床床上上,看看到到一一些些病病例例,持持续续咳咳嗽嗽(3(3周周以以上上),),有有痰痰,可可伴伴有有喘喘息息,无无发发热热、不不伴伴有有中中毒毒症症状状，胸胸片片和和CTCT未未见见肺肺炎炎征征象象或或存存在在纹纹理理粗粗乱乱,小小叶叶中中性性性性结结节节、细细支支气气管管壁壁增增厚厚、轻轻微微或或局局限限的的支支气气管管扩扩张张等等，肺肺部部可可有有干干性性罗罗音音、喘喘鸣音鸣音 小小年年龄龄组组多多见见于于气气管管、支支气气管管不不通通畅畅（软软化化、狭狭窄窄、异异物物后后）、病病毒

13、毒感感染染后后、BOBO、哮哮喘喘、脑脑瘫瘫等等基基础础疾疾病病；大大年龄组无明显诱因。年龄组无明显诱因。细菌性气道感染 文献称细菌化脓性气道疾病（中心气道有脓性分泌物）文献称细菌化脓性气道疾病（中心气道有脓性分泌物）细细菌菌性性细细支支气气管管炎炎（CTCT提提示示有有细细支支气气管管炎炎表表现现，小小叶叶中性性结节、细支气管壁增厚）中性性结节、细支气管壁增厚）持续细菌性支气管炎：超过持续细菌性支气管炎：超过1 1个月个月 多误诊为哮喘、多误诊为哮喘、BOBO、病毒感染、免疫功能低下、病毒感染、免疫功能低下 常见细菌为肺炎链球菌，常见细菌为肺炎链球菌，需要抗生素治疗需要抗生素治疗2-62-6

14、周周Outcomes in children treated for persistent bacterial bronchitis BACKGROUND:BACKGROUND:Persistent Persistent bacterial bacterial bronchitis bronchitis(PBB)(PBB)seems seems to to be be under-recognised under-recognised and and often often misdiagnosed as asthma.misdiagnosed as asthma.METHODS:METHOD

15、S:A A retrospective retrospective chart chart review review was was undertaken undertaken of of 81 81 patients patients in in whom whom a a diagnosis diagnosis of of PBB had been made.PBB had been made.Diagnosis Diagnosis was was based based on on the the standard standard criterion criterion of of

16、a a persistent,persistent,wet wet cough cough for for 1 1 month month that that resolves resolves with appropriate antibiotic treatment.with appropriate antibiotic treatment.Thorax.2007 Jan;62(1):80-4.Thorax.2007 Jan;62(1):80-4.Outcomes in children treated for persistent bacterial bronchitisRESULTS:

17、RESULTS:The The most most common common reason reason for for referral referral was was a a persistent persistent cough cough or or difficult asthma.difficult asthma.In In most most of of the the patients,patients,symptoms symptoms started started before before the the age age of of 2 2 years,years,

18、and and had had been been present present for for 1 1 year year in in 59%59%of of patients.patients.At At referral,referral,59%59%of of patients patients were were receiving receiving asthma asthma treatment treatment and 11%antibiotics.and 11%antibiotics.Haemophilus Haemophilus influenzae influenza

19、e and and Streptococcus Streptococcus pneumoniae pneumoniae were were the the most commonly isolated organisms.most commonly isolated organisms.Over Over half half of of the the patients patients were were completely completely symptom symptom free free after after two courses of antibiotics.two cou

20、rses of antibiotics.Only 13%of patients required or=6 courses of antibiotics.Only 13%of patients required or=6 courses of antibiotics.Chronic wet cough:Protracted bronchitis,chronic suppurative lung disease and bronchiectasisPediatr Pulmonol.2008,43(6):519-31.Pediatr Pulmonol.2008,43(6):519-31.The r

21、ole of persistent and recurrent bacterial infection The role of persistent and recurrent bacterial infection of the conducting airways(endobronchial infection)in the of the conducting airways(endobronchial infection)in the causation of chronic respiratory symptoms,particularly causation of chronic r

22、espiratory symptoms,particularly chronic wet cough,has received very little attention over chronic wet cough,has received very little attention over recent decades other than in the context of cystic recent decades other than in the context of cystic fibrosis(CF).fibrosis(CF).This is probably relate

23、d(at least in part)to the(a)This is probably related(at least in part)to the(a)reduction in non-CF bronchiectasis in affluent countries reduction in non-CF bronchiectasis in affluent countries and,(b)intense focus on asthma.In addition failure to and,(b)intense focus on asthma.In addition failure to

24、 characterize endobronchial infections has led to under-characterize endobronchial infections has led to under-recognition and lack of research.recognition and lack of research.Chronic wet cough:Protracted bronchitis,chronic suppurative lung disease and bronchiectasis The article describes our curre

25、nt perspective of inter-related The article describes our current perspective of inter-related endobronchial infections causing chronic wet cough;endobronchial infections causing chronic wet cough;persistent bacterial bronchitis(PBB),chronic suppurative lung persistent bacterial bronchitis(PBB),chro

26、nic suppurative lung disease(CSLD)and bronchiectasis.disease(CSLD)and bronchiectasis.In all three conditions,impaired muco-ciliary clearance seems to In all three conditions,impaired muco-ciliary clearance seems to be the common risk factor that provides organisms the be the common risk factor that

27、provides organisms the opportunity to colonize the lower airway.opportunity to colonize the lower airway.Respiratory infections in early childhood would appear to be the Respiratory infections in early childhood would appear to be the most common initiating event but other conditions(e.g.,most commo

28、n initiating event but other conditions(e.g.,tracheobronchomalacia,neuromuscular disease)increases the risk tracheobronchomalacia,neuromuscular disease)increases the risk of bacterial colonization.of bacterial colonization.Also misdiagnosis of asthma is common and the diagnostic process Also misdiag

29、nosis of asthma is common and the diagnostic process is further complicated by the fact that the co-existence of is further complicated by the fact that the co-existence of asthma is not uncommon.asthma is not uncommon.The principles of managing PBB,CSLD and bronchiectasis are the The principles of

30、managing PBB,CSLD and bronchiectasis are the same.Further work is required to improve recognition,diagnosis same.Further work is required to improve recognition,diagnosis and management of these causes of chronic wet cough in children.and management of these causes of chronic wet cough in children.O

31、utcomes in children treated for persistent bacterial bronchitisCONCLUSION:CONCLUSION:PBB PBB is is often often misdiagnosed misdiagnosed as as asthma,asthma,although although the two conditions may coexist.the two conditions may coexist.In In addition addition to to eliminating eliminating a a persi

32、stent persistent cough,cough,treatment treatment may may also also prevent prevent progression progression to to bronchiectasis.bronchiectasis.Further Further research research relating relating to to both both diagnosis diagnosis and and treatment is urgently required.treatment is urgently required.