Tuberculosis and Respiratory Diseases

  • 제59권5호
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  • Pages.522-529
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  • 2005
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  • 1738-3536(pISSN)
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  • 2005-6184(eISSN)
대한결핵및호흡기학회 (The Korean Academy of Tuberculosis and Respiratory Diseases)
권호 표지

국내 한 3차 병원 중환자실에 입원한 중증지역획득폐렴 환자의 원인 미생물과 경험적 항균제 치료 성적의 고찰

The Etiologies and Initial Antimicrobial Therapy Outcomes in One Tertiary Hospital ICU-admitted Patient with Severe Community-acquired Pneumonia

  • 이재승 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 정주원 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 고윤석 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 임채만 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 정영주 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 오연목 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 심태선 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 이상도 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 김우성 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 김동순 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 김원동 (울산대학교 의과대학 서울아산병원 호흡기내과) ;
  • 홍상범 (울산대학교 의과대학 서울아산병원 호흡기내과)
  • Lee, Jae Seung (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Chung, Joo Won (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Koh, Yunsuck (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Lim, Chae-Man (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Jung, Young Joo (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Oh, Youn Mok (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Shim, Tae Sun (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Lee, Sang Do (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Kim, Woo Sung (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Kim, Dong-Soon (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Kim, Won Dong (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center) ;
  • Hong, Sang-Bum (Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center)
  • 투고 : 2005.06.28
  • 심사 : 2005.09.23
  • 발행 : 2005.11.30
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초록

배 경 : 국내에서는 중증지역획득폐렴 원인균의 빈도에 대한 자료가 부족하여, 외국의 항균제 투여 지침을 따르고 있는 실정이다. 이에 본 저자들은 중증지역획득폐렴을 일으키는 원인균과 초기 경험적 항균제 투여 종류에 따른 치료 성적을 분석하여 향후 경험적 항균제 선택에 도움을 주고자 본 연구를 수행하였다. 대상 및 방법 : 2002년 3월부터 2004년 3월 사이에 울산대학교 의과대학 서울아산병원 내과계 중환자실에 입원했던 18세 이상의 성인 환자들 중 지역획득폐렴의 정의를 만족하는 환자를 대상으로 후향적 의무기록 분석을 시행하였다. 세균학적 검사 결과로 원인균의 빈도를 조사하였고, 항균제 투여 종류에 따른 중환자실 재원기간, 중환자실 사망률과 30일 사망률을 비교 분석하였다. 결 과 : 대상 기간 동안 총 116명의 환자가 본 연구 대상에 포함되었다. 대상 환자의 평균 연령은 66.5 (19-89)세 였고, 남자가 95 (81.5%)명으로 다수를 차지하였다. 원인균은 116명의 환자 가운데 54명 (46.5%)에서 동정되었는데, S. pneumoniae 14례, P. aeruginosae 9례, K. pneumoniae 9례, S. aureus 8례, H. influenza 7례 이었다. 비정형 폐렴균은 Legionella 3례, M. pneumoniae 2례 이었다. 총 116명의 환자의 중환자실 평균 재원 일수는 $15.0{\pm}13.7$일 이었으며, 중환자실 사망자 수는 27명 (23.2%), 30일 사망자 수는 33명 (28.4%) 이었다. 전체적으로 항균제 투여 군간의 중환자실 재원일수와 중환자실 사망률 및 30일 사망률은 통계적으로 유의한 차이를 보이지 않았다 (p=0.482, 0.719,0.682). 사망 예후 인자의 다변량 분석에서는 급성호흡곤란증후군, 급성 신부전, K. pneumoniae가 통계적으로 유의한 예후 인자이었다. 결 론 : 본 연구에서 중증지역획득폐렴의 원인균은 S. pneumoniae, P. aeruginosae, K. pneumoniae, S. aureus가 가장 많았고, K. pneumoniae는 높은 사망률을 보여 주었다. 초기 경험적 항균제 종류에 따른 중환자실 재원일수 및 30일 사망률은 차이가 없었다.

Background : Several national societies have published guidelines for empirical antimicrobial therapy in patients with severe community-acquired pneumonia (SCAP). This study investigated the etiologies of SCAP in the Asan Medical Center and assessed the relationship between the initial empirical antimicrobial regimen and 30 day mortality rate. Method : retrospective analysis was performed on patients with SCAP admitted to the ICU between March 2002 and February 2004 in the Asan Medical Center. The basic demographic data, bacteriologic study results and initial antimicrobial regimen were examined for all patients. The clinical outcomes including the ICU length of stay, the ICU mortality rate, and 30 days mortality rates were assessed by the initial antimicrobial regimen. Results : One hundred sixteen consecutive patients were admitted to the ICU (mean age 66.5 years, 81.9 % male, 30 days mortality 28.4 %). The microbiologic diagnosis was established in 58 patients (50 %). The most common pathogens were S. pneumoniae (n=12), P. aeruginosae (n=9), K. pneumonia (n=9) and S. aureus (n=8). The initial empirical antimicrobial regimens were classified as: ${\beta}$-lactam plus macrolide; ${\beta}$-lactam plus fluoroquinolone; anti-Pseudomonal ${\beta}$-lactam plus fluoroquinolone; Aminoglycoside combination regimen; ${\beta}$-lactam plus clindamycin; and ${\beta}$-lactam alone. There were no statistical significant differences in the 30-day mortality rate according to the initial antimicrobial regimen (p = 0.682). Multivariate analysis revealed that acute renal failure, acute respiratory distress syndrome and K. pneumonae were independent risk factors related to the 30 day mortality rate. Conclusion : S. pneumoniae, P. aeruginosae, K. pneumonia and S. aureus were the most common causative pathogens in patients with SCAP and K. pneumoniae was an independent risk factor for 30 day mortality. The initial antimicrobial regimen was not associated with the 30-day mortality.

키워드

참고문헌

  1. Niederman MS, Mandell LA, Anzueto A, Bass JB, Broughton WA, Campbell GD, et al. Guidelines for the management of adults with community-acquired pneumonia: diagnosis, assessment of severity, antimicrobial therapy and prevention. Am J Respir Crit Care Med 2001;163:1730-54 https://doi.org/10.1164/ajrccm.163.7.at1010
  2. Bartlett JG, Dowell SF, Mandell LA, File TM Jr, Musher DM, Fine MJ. Practice guidelines for the management of adults with community-acquired pneumonia in adults. Clin Infect Dis 2000;31:347-82 https://doi.org/10.1086/313954
  3. Mandell LA, Bartlett JG, Dowell SF, File TM Jr, Musher DM, Whitney C. Update of practice guidelines for the management of community-acquired pneumonia in immunocompetent adults. Clin Infect Dis 2003;37:1405-33 https://doi.org/10.1086/380488
  4. British Thoracic Society. Guidelines for the management of community-acquired pneumonia in adults. Thorax 2001;56:IV1-64 https://doi.org/10.1136/thorax.56.1.1
  5. Marrie TJ, Durant H, Yates L. Community-acquired pneumonia requiring hospitalization: 5-year prospective study. Rev Infect Dis 1989;11:586-99 https://doi.org/10.1093/clinids/11.4.586
  6. Torres A, Serra-Batlles J, Ferrer A, Jimenez P, Celis R, Cobo E, et al. Severe community-acquired pneumonia: epidermiology and prognostic factors. Am Rev Respir Dis 1991;144:312-8 https://doi.org/10.1164/ajrccm/144.2.312
  7. Rello J, Quintana E, AussinaV, Net A, Prats G. A three year study of severe community-acquired pneumonia with emphasis on outcome. Chest 1993;103: 232-5 https://doi.org/10.1378/chest.103.1.232
  8. Almirall J, Mesalles E, Klamburg J, Parra O, Agudo A. Prognostic factors of pneumonia requiring admission to the intensive care unit. Chest 1995;107:511-6 https://doi.org/10.1378/chest.107.2.511
  9. Rello J, Rodriguez R, Jubert P, Albarez B. Severe community-acquired pneumonia in the elderly: epidermiology and prognosis. Clin Infect Dis 1996;23: 723-8 https://doi.org/10.1093/clinids/23.4.723
  10. Pachon J, Prados MD, Capote F, Cuello JA, Garnacho J, Verano A. Severe community-acquired pneumonia: etiology, prognosis, and treatment. Am Rev Respir Dis 1990;142:369-73 https://doi.org/10.1164/ajrccm/142.2.369
  11. Ruiz M, Ewing S, Torres A, Arancibia F, Marco F, Mensa J, et al. Severe community-acquired pneumonia: risk factors and follow up epidermiology. Am J Respir Crit Care Med 1999;160:923-9 https://doi.org/10.1164/ajrccm.160.3.9901107
  12. Leroy O, Santre C, Beuscart C, Georges H, Guery B, Jacquier JM, et al. A 5-year study of severe communityacquired pneumonia with emphasis on prognosis in patients admitted to an ICU. Intensive Care Med 1995;21:24-31 https://doi.org/10.1007/BF02425150
  13. Dahmash NS, Chowdhury MN. Re-evaluation of pneumonia requiring admission to an intensive care unit: a prospective study. Thorax 1994;49:71-6 https://doi.org/10.1136/thx.49.1.71
  14. Woo JH, Kang JM, Kim YS, Shin WS, Ryu JH, Choi JH, et al. A prospective multicenter study of communityacquired pneumonia in adults with emphasis on bacterial etiology. Korean J Infect Dis 2001;33:1-7
  15. Battleman DS, Callahan M, Thaler HT. Rapid antibiotic delivery and appropriate antibiotic selection reduce hospital length of stay of patients with communityacquired pneumonia. Arch Intern Med 2002;162:682-8 https://doi.org/10.1001/archinte.162.6.682
  16. Houck PM, Bratzler DW, Nsa W, Ma A, Bartlett JG. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with communityacquired pneumonia. Arch Intern Med 2004;164:637-44 https://doi.org/10.1001/archinte.164.6.637
  17. Oh SY, Park SJ, Koh YM, Suh GY, Chung MP, Kim H, et al. Efficacy of the antibiotics chosen by ATS guideline in the treatment of Korean patients with community-acquired pneumonia admitted to a tertiary hospital. Tuberc Respir Dis 1999;47:460-70 https://doi.org/10.4046/trd.1999.47.4.460
  18. Rello J, Bodi M, Mariscal D, Navarro M, Diaz E, Gallego M, et al. Microbiological testing and outcome of patients with severe community-acquired pneumonia. Chest 2003;123:174-80 https://doi.org/10.1378/chest.123.1.174
  19. Luna CM, Famiglietti A, Absi R, Videla AJ, Noguerira FJ. Fuenzalida AD, et al. Community-acquired pneumonia: etiology, epidemiologist, and outcome at a teaching hospital in Argentina. Chest 2000;118:1344-54 https://doi.org/10.1378/chest.118.5.1344
  20. Feldman C, VilJoen E, Morar R, Richards G, Sawyer L, Goolam Mahomed A. Prognostic factors in severe community acquired pneumonia in those without comorbid illness. Respirology 2001;6:323-30 https://doi.org/10.1046/j.1440-1843.2001.00352.x
  21. Paganin F, Lilienthal F, Bourdin A, Lugagne N, Tixier F, Genin R, et al. Severe community-acquired pneumonia: assessment of microbial aetiology as mortality factor. Eur Respir J 2004;24:779-85 https://doi.org/10.1183/09031936.04.00119503
  22. Oh HK, Seo JY, Kim DK, Choi JE, Mo EK, Park MJ, et al. Clinical characteristics and prognostic factors of severe community-acquired pneumonia. Tuberc Respir Dis 1997;4:44:1072-82
  23. Houck PM, Maclehose RF, Niederman MS, Lowery JK. Empiric antibiotic therapy and mortality among medicare pneumonia in patients in 10 Western States: 1993, 1995 and 1997. Chest 2001;119:1420-6 https://doi.org/10.1378/chest.119.5.1420
  24. Sthal JE, Barza M, DesJardin J, Martin R, Eckman MH. Effect of macrolides as part of initial empiric therapy on length of stay in patients hospitalized with community-acquired pneumonia. Arch Intern Med 1999; 159:2576-80 https://doi.org/10.1001/archinte.159.21.2576
  25. Waterer GW, Somes GW, Wunderink RG. Monotherapy may be suboptimal for severe bacteremic pneumococcal pneumonia. Arch Intern Med 2001;161:1837-42 https://doi.org/10.1001/archinte.161.15.1837
  26. Gleason PP, Meehan TP, Fine JM, Galusha DH, Fine MJ. Associations between initial antimicrobial therapy and medical outcomes for hospitalized elderly patients with pneumonia. Arch Intern Med 1999;159:2562-72 https://doi.org/10.1001/archinte.159.21.2562
  27. Rello J, Catalan M, Diaz E, Bodi M, Alvarez B. Associations between empirical antimicrobial therapy at the hospital and mortality in patients with severe community acquired pneumonia. Intensive Care Med 2002;28:1030-5 https://doi.org/10.1007/s00134-002-1325-3
  28. Feldman C, Smith C, Levy H, Ginsburg P, Miller SD, Koornhop HJ. Klebsiella pneumoniae bacteraemia at an urban general hospital. J Infect 1990;20:21-31 https://doi.org/10.1016/S0163-4453(90)92258-M