Тяжелые бактериальные пневмонии в сезон гриппа

»
:
,
,
.,
15.09.2015
.
.
post mortem
1918 .
1957 . > 2/3
H.influenzae;
S.pneumoniae, S.aureus
2009-2010 .
S.pyogenes
van der Sluijs et al. Critical Care 2010, 14:219
/H1N1/pdm09 –
?
29%
/H1N1
2009 .
(
)
:>
:>
van der Sluijs et al. Critical Care 2010, 14:219;
Metersky et al. Int J Infect Dis 2012; 16:e321
/H1N1/pdm09
585
/
Viasus D. et al. Enferm Infecc Microbiol Clin 2012; 30(Supl 4):43
?
, 2005-2008
• 4.765
,
• 1392 (29%) –
:
> 75
(
1,27)
(
(
1,45)
1,37)
.
:
(27%
(18%
7
(9%
10%)
5%)
(30%
12%)
2%)
Garg S. et al. BMC Infectious Diseases 2015; 15:369
,
,
van der Sluijs et al. Critical Care 2010, 14:219
:
;
,
,
:
,
,
(
4
14
)
(
,
–
,
–
)
van der Sluijs et al. Critical Care 2010, 14:219
,
•
•
•
•
•
•
/
(
)
»
-
.
Metersky et al. Int J Infect Dis 2012; 16:e321
,
:
,
Streptococcus pneumoniae
Haemophilus influenzae
Staphylococcus aureus
Streptococcus pyogenes
Enterobacteriaceae
(E.coli,
K.pneumoniae) 3%
5%
+
(S.aureus, S.viridans)
5%
H.influenzae 4%
S.pneumoniae 82%
Streptococcus group
B 6%
Streptococcus group
A 5%
Falguera et al. Clin Infect Dis 2009; 49:409
H.influenzae 7%
S.pneumoniae 82%
Burton et al. Am J Public Health 2010; 100:1904
¼
2
50%
–
65
),
,
,
,
:
: 78% vs 28% (
)
: 9,3-26,0%
Tilghman et al. Arch Intern Med 1937; 59:602
Ortqvist et al. Chest 1993; 103:710
Moroney et al. Clin Infect Dis 2001; 33: 797
Gentile et al. MEDICINA (Buenos Aires) 2003; 63: 9
Spindler et al. Eur Respir J 2006; 28: 816
Berjohn et al. Medicine 2008;87:160–166
Marrie et al. Medicine (Baltimore) 2011; 90:171
Christensen et al. Eur J Clin Microbiol Infect Dis 2012; 31:2719
Naucler et al. Thorax 2013; 68:571
:
7
45
40
35,0
Cases
30
25
5
Deaths
21,0
4
18,7
16,9
20
100,000
100,000
35
6
3
15
2
10
1
5
0
0
<1
1
2-4
5-17
18-34
(
35-49
)
50-64
65
http://www.cdc.gov/abcs/reports-findings/survreports/spneu11.pdf
(
2004 . –
2009 . –
2009 .)
2010 .)
(
5
Fleming-Dutra K. et al. The Journal of Infectious Diseases 2013; 207: 1135
:
)
Musher, et al. Medicine (Baltimore) 2000;79:210
Jover, et al. Eur J Intern Med 2008;19:15
Jover, et al. Eur J Intern Med 2008;19:15
Jacups & Cheng. Vaccine 2011; 29:5386
Palma, et al. J Bras Pneumol 2012; 38:422
Kang, et al. Journal of Infection 2013; 66: 34
S.pneumoniae
1, 4, 5, 7F, 8, 12F, 14, 18C 19A
Song, et al. J Korean Med Sci 2013; 28:4
S.pneumoniae
(1999-2010 .)
Cobo et al. Inf Dis Rep 2012; 4:e29
<2
65
, 2007-2009
.
1580
30-
(AOR 1,55, 95%
:
1,09-2,22)
(AOR 3,82, 95%
(AOR 1,79, 95%
1,85-7,85)
1,02-3,14)
(AOR 5,15, 95%
(AOR 1,84, 95%
(AOR 2,63, 95%
1,74-15,26)
1,02-3,33)
1,53-4,50)
–
30-
,
:
9,3% 1,3% 26,1% -
45
85
• S.aureus –
(2-3%,
–
½ - MRSA)
,
,
,
,
.)
S.aureus,
,
(PVL)
)
:
Tong S. et al. Clinical Microbiology Reviews 2015; 28: 603
S.aureus
:
• 1953 . –
S.aureus
,
4%
20%
Stuart-Harris C. Practitioner 1953; 171:595
• 1968 . -
S.aureus
6%
, 19,4%
H3N2
Schwarzmann S. et al. Arch Intern Med 1971;127:1037
• 2009 . – S.aureus
1/3
/H1N1/pdm09
Rice T. et al. Crit Care Med 2012; 40:1487
• 2009 . – S.aureus –
/H1N1/pdm09
Blyth C. et al. Influenza Other Respir Viruses 2013;7:168
PVL+
S.aureus
,
–
,
),
–
56%
Tong S. et al. Clinical Microbiology Reviews 2015; 28: 603
Rouzic N. et al. J Clin Microbiol 2010; 48: 1952
59
,
,
MRSA)
20%
,
S.aureus (59,3% -
–
39,1% vs 8,3%
,
:
(
6,69, 95%
1,05, 95%
1,01-1,09)
1,45-30,96)
(
5,96, 95%
1,08-33,10)
Schreiber, et al. Journal of Critical Care 2011; 26:395
S.pyogenes
•
•
•
•
•
,
,3
– 26
,
8075 (0,12%) c
7/10
7/10
(70%)
5/10
(
2009 .
S.pyogenes,
10
/H1N1/pdm09
, 8/10
4
)
Jean C. et al. Clinical Infectious Diseases 2010; 50: e59
+
+
R/
(2
)
,
+
)
(
,
)
,
,
,
)
(PSI, CURB-65)
:
2
)
–
25
100
–
10
10
(
!)
S.aureus
S.pneumoniae
– 57-82%,
– 93-98%
Anevlavis, et al. Journal of Infection 2009; 59:83
McCarter, et al. Clinical Microbiology Newsletter 2013; 35:5
H.influenzae
:
• Streptococcus viridans
• Staphylococcus epidermidis
.
• Enterococcus spp.
• Neisseria spp.
• Candida spp.
.
!!!
BacT/Alert, Bactec)
2
2
(
)
2
(
)
,
;
(Moderate recommendation; level
I evidence)
,
,
,1
S.pneumoniae
,
recommendation; level II evidence)
L.pneumophila
(Moderate
1.
2.
3.
4.
5.
6.
7.
8.
Binax NOW Urinary Antigen Test
FDA 1999 .
S.pneumoniae)
15
74,0%
(95%
66,6-82,3%),
97,2% (95%
92,7-99,8%)
–
70-100%
Selickman, et al. Diagnostic Microbiology and Infectious Disease 2010; 67:129
Sinclair, et al. Journal of Clinical Microbiology 2013; 51:2303
,
Binax UAT
PSI
Binax UAT
(95%
11,4%
9,6-13,6)
Said, et al. PLoS ONE 2013; 8: e60273
Binax NOW UAT vs PCR
Binax NOW UAT
88% (95%
77-95%),
– 53,5% (95%
40-67%)
•
Binax NOW UAT
Binax NOW UAT
,
Smith, et al. J Clin Microbiol 2009; 47: 1046
Streptococcus pneumoniae
)
,
,
CRB-65
0,
,
: «S» (SaO2<90%
:
,
,
)
CRB-65 (DS-CRB-65)
4
«D»
,
Kolditz M. et al. doi: 10.1111/joim.12349
116
(CALC-I)
,
–
,
(
- PCT)
,
CALC-I
,
,
,
,
,
,
–
PCT:
(
-1 ,
6)
PCT:
)
(
-
,
PCT
,
,
• PCT
,
-
PCT
PCT
2-4
,
8-
24 ,
:
1000
:
PCT
• PCT
in vivo
in vitro (
)
24
< 0,05
24
H1N1)
6,2
0,9-20
H1N1
(95%
,
)
(
73,3-93,5%)
0,56
0,18-3,33
)
(cut-off)
0,5
80,5%
Schuetz P. et al. BMC Medicine 2011; 9: 107
–
– 19/1063 (1,8%)
,
,
9/1350
,
,
(0,7%) ( <0,02)
Kaiser L. et al. Arch Intern Med 2003;163:1667
:
,
(1)
:
,
http://www.cdc.gov/flu/pdf/professionals/antivirals/antiviral-summary-clinicians.pdf
:
(2)
:
2
65
:
(
)
(
)
(
(
,
,
,
)
,
.)
(
)
http://www.cdc.gov/flu/pdf/professionals/antivirals/antiviral-summary-clinicians.pdf
:
(3)
:
(
,
.
)
(
)
19
2
,
(
40)
http://www.cdc.gov/flu/pdf/professionals/antivirals/antiviral-summary-clinicians.pdf
,
)
)
(5
(10
)
)
75
2
75
1
30
45
60
75
3
3
2
2
2
2
30
45
60
75
3
1
1
1
1
12
15
15-23
23-40
> 40
3-12
<3
2
2
1
Aoki, et al. J Infect Dis Med Microbiol 2012; 23:e79
-
–
-
,
36-48
,
Labella, et al. Med Clin N Am 2013; 97:621
• 920
541
,
H1N1pdm09,
:
–
–
–
–
18,2% 2,9% 4,6% 4,9% -
48
2
5
5
92,1%, 88,0%
, 14
PaO2/FiO2<200,
83,5%
.
,
3
, 5-8
Dodds et al. CMAJ 2007; 176: 463
CDC
2009 .
H1N1pdm09
– 3,8% (30/788)
:
– I
– II
– III
– 7,1%
– 26,8%
– 64,3%
Siston et al. JAMA 2010; 303: 1517
,
,
,
,
Pierce et al. BMJ 2011; 342: d3214
–
,
Aoki et al. J Infect Dis Med Microbiol 2012; 23:e79
Louie et al. N Engl J Med 2010; 362:27
?
(
)
?
?
?
?
?
?
(
)
?
?
?
?
?
, 2003-2007
.
• 125
aHR
1
4
95% CI
p
5,06
1,63-15,71
0,005
2,62
1,06-6,45
0,037
1,17
1,02-1,34
0,023
3,03
1,22-7,51
0,016
2,21
1,01-4,86
0,048
90-
1
4
Garnacho-Montero, et al. Scand J Infect Dis 2010; 42:185
4
4
Garnacho-Montero, et al. Scand J Infect Dis 2010; 42:185
/
8%
Kumar A. et al. Crit Care Med 2006; 34: 1589
?
(
)
?
?
?
?
?
(%)
S. pneumoniae (2007-2009 .)
– 715 (
-III)
16,6
22,4
-
21,5
3,1
2,1
9,1
0,5 / 0,5 /
0,1 0,1
1,6 /
2,8
6,4
0,9
5,7
1,6
5,3
1,0
0,3 /
7,8
0/
0
7,1
0
,
, 2010
(%)
H.influenzae
.
2006; 8:33
:
III
IV
,
P.aeruginosa, A.baumannii)
+
/
+
/
,
»/«
»/
»
?
,
+,
–
–
–
–
•
:
Staphylococcus spp.,
MRSA
Enterococcus spp.,
VRE
K.pneumoniae, E.coli, Enterobacter spp.,
Acinetobacter baumannii (
-R)
(
. Bacteroides fragilis)
Pseudomonas aeruginosa!
:
,
)
+
•
215
,
,
•
,
(150
12
0,5
0,25
1
200
/100
–
–
/75
12 )
: 100 /50
: 200
/ 100
12
12
Ramirez, et al. Antimicrobial Agents and Chemotherapy 2013; 57:1756
•
54
vs 46
)
–
(50
(100
–
–
-R A.baumannii
12 )
12
K.pneumoniae
in vivo
/H1N1,
MRSA
,
MRSA;
7-
–
6
24
:
(KC, MIP-2, IFN- , TNF-a, IL-1b)
?
(
)
?
?
?
?
?
vs
:
:
+
,
?
–
–
–
Caballero & Rello. Annals of Intensive Care 2011; 1:48
?
(
)
?
?
?
?
?
• 3024,5%
20,3%, 90
,
30(
0,3, 95%
0,2-0,7)
90 .
.
0,3, 95%
0,2-0,6)
,
,
-R
.
.
-R
Restrepo, et al. Respir J 2009; 33: 153
, 27
9
, 218
75,7% – 37,6%
:
(
0,23-0,97)
0,48, 95%
,
Martin-Loeches, et al. Intensive Care Med 2010; 36:612
?
(
)
?
?
?
?
?
13
254.950
,
.
,
,
,
(
0,62, 95%
0,54-0,71),
Corrales-Medina, et al. Journal of Infection 2012; 63: 187
Sibila, et al. Infect Dis Clin N Am 2013; 27:133
• 34
: 19 –
20
, 15 –
,
(
4
,
,
-6,
-10,
)
,4
0,39, 95%
, 264
0,17-0,90)
,
,
Cheng, et al. Respir Care. 2013 Sep 17 [Epub ahead of print]
,
.
,9
0,62, 95%
0,26, 95%
, 1001
0,37-1,04),
0,11-0,64).
5
(
0,51, 95%
0,26-
0,97)
,
Nie, et al. PLoS 2012; 7:e47926
Nie, et al. PLoS 2012; 7:e47926
• 6925
983
–
,
,±
:
0,5-2,5
• 785
18
50
)
per os 7
vs
(4,4
(3,0
) ( <0,0001)
30-
• 3
, 151
:
–
–
–
–
3,8
3,9
4,4
3,28
Zhang, et al. Cochrane Database Syst Rev 2012; 3:CD006607
?
(
)
?
?
?
?
?
IDSA/ATS
(2007)
5
,
48-72 ,
.
,
(
ERS/ESCMID
(2011)
)
8
,
.
,
,
.
BTS (2009)
7
,
7-10
.
.
10
14-21
,
Enterobacteriaceae, S.aureus, P.aeruginosa,
Legionella pneumophila
(
.
)
,
(5-7
)
(7-21
)
3-5
,
4,
)
65
(
,
,
,
,
.)
((L.pneumophila,
L.pneumophila,
S.aureus,
)
)
,
=
www.infectology.bsmu.by –
!