欧洲重症CAP指南202304
文摘
科学
2023-04-24 00:00
上海
近日，四大学会联合发布的基于证据的重症CAP指南，针对8个临床问题给出了解答，简介如下，推荐看全文。ERS/ESICM/ESCMID/ALAT guidelines for the management of severe community-acquired pneumoniaIgnacio Martin-Loeches, Antoni Torres, Blin Nagavci, Stefano Aliberti, Massimo Antonelli, Matteo Bassetti, Lieuwe Bos, James D. Chalmers, Lennie Derde, Jan de Waele, Jose Garnacho-Montero, Marin Kollef, Carlos Luna, Rosario Menendez, Michael Niederman, Dmitry Ponomarev, Marcos Restrepo, David Rigau, Marcus J. Schultz, Emmanuel Weiss, Tobias Welte, Richard WunderinkEuropean Respiratory Journal 2023 61: 2200735; DOI: 10.1183/13993003.00735-2022适用范围：不包括免疫抑制人群，例如接受糖皮质激素治疗或化疗、移植、血液系统恶性肿瘤或HIV、CD4 T淋巴细胞低于200的患者。In patients with sCAP, should rapid microbiological techniques be added to current testing of blood and respiratory tract samples?If the technology is available, we suggest sending a lower respiratory tract sample (either sputum or endotracheal aspirates) for multiplex PCR testing (virus and/or bacterial detection) whenever non-standard sCAP antibiotics are prescribed or considered (conditional recommendation, very low quality of evidence).如技术可及，凡是使用或考虑使用非标准重症CAP抗菌药物治疗时，建议采集痰或气管内吸引物做多重PCR检测病毒和/或细菌。
In hypoxaemic patients with sCAP, can either non-invasive mechanical ventilation or high-flow nasal oxygen be used initially – rather than supplemental standard oxygen administration – to avoid intubation and reduce mortality?如有低氧血症，起始的呼吸支持是用NIV或HFNO还是标准氧疗？
In patients with sCAP and acute hypoxaemic respiratory failure not needing immediate intubation, we suggest using high-flow nasal oxygen (HFNO) instead of standard oxygen (conditional recommendation, very low quality of evidence).对于不需要紧急插管的患者，建议使用HFNO而不是标准氧疗。
Non-invasive mechanical ventilation (NIV) might be an option in certain patients with persistent hypoxaemic respiratory failure not needing immediate intubation, irrespective of HFNO (conditional recommendation, low quality of evidence).When using initial empirical therapy for sCAP, should a macrolide or fluoroquinolone be used as part of combination therapy, to reduce mortality and adverse clinical outcomes?初始经验性治疗应该使用大环内酯类或氟喹诺酮类药物作为联合治疗的一部分吗？
We suggest the addition of macrolides, not fluoroquinolones, to beta-lactams as empirical antibiotic therapy in hospitalised patients with sCAP (conditional recommendation, very low quality of evidence).建议beta-内酰胺类药物联合大环内酯类而不是氟喹诺酮类药物。
The task force also considered the duration of treatment of macrolides being between 3 and 5 days. This would be a reasonable timing especially in the context of de-escalation therapy.In patients with sCAP, can serum PCT be used to reduce the duration of antibiotic therapy and improve other outcomes in comparison to standard of care not guided by serial biomarker measurements?We suggest the use of PCT to reduce the duration of antibiotic treatment in patients with sCAP (conditional recommendation, low quality of evidence).The recommendation of using PCT must be considered together with clinical assessment with the aim of reducing antibiotic treatment duration.PCT might not be useful when clinical stability is achieved, and duration of antibiotic therapy is between 5–7 days.临床稳定是决定疗程的最关键因素，如果在指南推荐的5-7天疗程时达到了临床稳定，这种情况下加做PCT可能意义不大。Should oseltamivir be added to standard therapy in patients with sCAP and confirmed influenza?We suggest the use of oseltamivir for patients with sCAP due to influenza confirmed by PCR (conditional recommendation, very low quality of evidence).When PCR is not available to confirm influenza, we suggest the use of empirical oseltamivir during the influenza season (conditional recommendation, very low quality of evidence).PCR不可及但在流感季节，建议经验性使用奥司他韦。Does the addition of steroids to antibiotic therapy in specific sCAP populations lead to better outcomes in comparison to when steroid therapy is not used?In patients with sCAP, we suggest the use of corticosteroids if shock is present (conditional recommendation, low quality of evidence).Based on common exclusion criteria from clinical trials, this recommendation does not apply to patients with viral sCAP (influenza, SARS and MERS), uncontrolled diabetes and corticosteroid treatment for other reasons.由于临床研究数据不足，该推荐意见不适用于病毒性肺炎、未控制的糖尿病以及存在需要使用糖皮质激素的其他疾病时。
When corticosteroid therapy is considered, methylprednisolone (0.5 mg·kg−1 every 12 h for 5 days) is a reasonable option.选择甲泼尼龙，0.5mg/kg体重 q12h，5天。
Does the use of a prediction score for drug-resistant pathogens lead to more appropriate therapy and improved outcomes (mortality, treatment failure, duration of antibiotic therapy, prolonged ICU stay)?We suggest integrating specific risk factors (eventually computed into clinical scores) based on local epidemiology and previous colonisation to guide decisions regarding drug-resistant pathogens (excluding those immunocompromised) and empirical antibiotic prescription in sCAP patients (conditional recommendation, moderate quality of evidence).建议在当地流行病学和患者定植史的基础上整合特定危险因素形成临床评分，用于指导经验性抗菌治疗的药物选择。
Do patients with sCAP and aspiration risk factors have better outcomes (mortality, length of stay, treatment failure) if treated with a risk-based therapy regimen instead of standard sCAP antibiotics?对于有吸入风险的患者，基于风险进行抗菌治疗是否优于标准治疗？
In patients with sCAP and aspiration risk factors we suggest standard CAP therapy regimen and not specific therapy targeting anaerobic bacteria (ungraded, good practice statement).建议标准抗菌治疗，不需要特别针对厌氧菌。
最后，封面图片来自文心一格生成的“临床指南”，图片本身还行，只是不知道为什么标的文字既不是中文也不是英文，输入clinical guideline提示要输入中文才能生成图片，不明白是什么机制![]()
