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儿童社区获得性肺炎管理指南(2013修订)(下)

发布时间:2013-12-11 09:01:04  

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.标准.方案.指南.儿童社区获得性肺炎管理指南(2013修订)(下)中华医学会儿科学分会呼吸学组

《中华儿科杂志》编辑委员会

(2013年8月)

(接第10期752页)

概要

本指南在循证基础上,较广泛参阅当今儿童社区获得性

肺炎(communityacquiredpneumonia,CAP)相关文献,尽可

能结合我国国情,以贴近临床、贴近基层。概要是本指南各

部分的要点并列上推荐等级。推荐等级分为3级,等级A的

证据来自随机对照研究(randomizedcontrolledtrials,RCTs)

及高质量的系统综述;等级B的证据来自一项或多项研究;

等级C则是专家观点及其他资料13“,但可供儿科临床

参考。

一、定义

CAP是指原本健康的儿童在医院外获得的感染性肺炎,

包括感染了具有明确潜伏期的病原体而在入院后潜伏期内

发病的肺炎。

二、病原学(表1)

CAP病原包括细菌、病毒、支原体、衣原体、真菌、原虫

等,本指南未涉及结核分枝杆菌、真菌和原虫。必须注意儿

童CAP往往有混合病原感染。

1.根据年龄能很好地预示儿童CAP的可能病原[B]。

2.年幼儿CAP50%由病毒病原引起,年长儿常由细

菌、肺炎支原体(MP)感染所致[B]。

3.呼吸道合胞病毒(RSV)是引起CAP的首位病毒病

原,其次是副流感病毒I型、Ⅱ型、Ⅲ型和流感病毒A型、

B型[B]。

4.肺炎链球菌(SP)是儿童CAP最常见细菌病原,流感

嗜血杆菌(HI)、卡他莫拉菌(MC)仍是儿童CAP常见病原,

社区相关性耐甲氧西林金黄色葡萄球菌(CA—MRSA)是CAP

的重要病原菌之一,多发生在年幼儿[B]。

5.MP不仅是学龄期和学龄前期儿童CAP常见病原,在

1~5岁儿童中亦不少见[B]。

6.婴幼儿常见病毒一细菌、病毒一病毒混合感染,年长儿

多为细菌和非典型病原混合感染[c]。

三、临床特征

1.呼吸增快:<2月龄RR/>60次/min,2月龄~RR≥

DOI:10.3760/cma.j.issn.0578-1310.2013.11.012

通信作者:陆权,200040上海交通大学附属儿童医院呼吸科

(Email:luquan—sh@vip.sina.oom)

万方数据表1不同年龄儿童社区获得性肺炎的病原情况…”

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50次/rain,1~5岁RR1>40次/min,>5岁RR≥30次/min提示肺炎;RR>70次/min常提示低氧血症[B]。

2.呼吸困难对肺炎的提示意义比呼吸增快更大[B]。3.病毒性肺炎和MP肺炎可出现喘鸣,喘鸣对判定婴幼)LN炎的严重度没有帮助[B]。

4.MP肺炎经大环内酯类抗菌药物正规治疗7d及以上,临床征象加重、仍持续发热、肺部影像学表现加重者,可考虑为难治性MP肺炎[B]。

四、严重度评估(表2)

1.2月龄~5岁CAP儿童出现胸壁吸气性凹陷或鼻翼扇动或呻吟之一表现者,提示有低氧血症,为重度肺炎;如果出现中心性紫绀、严重呼吸窘迫、拒食或脱水征、意识障碍(嗜睡、昏迷、惊厥)之一表现者为极重度肺炎[c]。

2.CAP住院指征,有下列1项者[c]:

(1)呼吸空气条件下,SaO!≤0.92(海平面)或≤0.90(高原)或有中心性紫绀;

(2)呼吸空气条件下,RR>70次/min(婴儿),RR>507次./min(年长儿),除外发热、哭吵等因素的影响;

(3)呼吸困难:胸壁吸气性凹陷、鼻翼扇动;(4)间歇性呼吸暂停,呼吸呻吟;

(5)持续高热3—5d不退者或有先天性心脏病、先天性支气管肺发育不良、先天性呼吸道畸形、重度贫血、重度营养不良等基础疾病者;

(6)胸片等影像学资料证实双侧或多肺叶受累或肺叶实变并肺不张、胸腔积液或短期内病变进展者;

(7)拒食或有脱水征者;

(8)家庭不能提供恰当充分的观察和监护,或2月龄以下CAP患儿。

3.收住或转至ICU的指征,具备下列1项者[c]:(1)吸人氧浓度(FiO:)≥0.6,Sa02≥0.92(海平面)或0.90(高原);

(2)休克和(或)意识障碍;

(3)呼吸频率加快、脉速伴严重呼吸窘迫和耗竭征象,伴或不伴PaCO:升高;

(4)反复呼吸暂停或出现慢而不规则的呼吸。五、放射学诊断评估

1.对于一般状况良好且可以在门诊治疗的疑似CAP患儿,无需常规行胸片检查[A]。

2.对于初始抗菌药物治疗失败,需要验证是否存在肺炎并发症或病情加重的患儿应及时做胸片检查[B]。

3.胸部CT扫描和胸部侧位片不宜列为常规[B]。4.在除外肺不张、肺梗死、肺出血等之后,胸片实变征象可诊断肺炎[B]。

5.胸片征象对CAP病原学的提示性差[B]。

6.对于临床上肺炎已康复,一般状况良好的患儿,无需反复胸片复查[B]。

六、实验室检查

1.红细胞沉降率(ESR)、C反应蛋白(CRP)浓度或血清

万方数据

降钙素原(PCT)浓度,不能单独或联合用来区分细菌性或病毒性CAP[A]。

2.CAP死亡的危险性和低氧血症程度关系密切,因此所有住院肺炎和疑似低氧血症的患儿,有条件者都应监测血氧饱和度[A]。

3.拟诊细菌性CAP、病情严重,或有并发症的住院患儿应常规进行血培养,阳性者经治疗后应复查,但sP菌血症患儿经治疗临床改善明显者可不复查[B]。

4.拟诊病毒性CAP应常规检测流感病毒与其他常见呼吸道病毒[B]。

5.临床怀疑MP感染者应进行MP检测,急性期和恢复期双份血清特异性IgG抗体比较有4倍以上的升高或下降到原来的1/4是MP感染的确诊依据[A]。

6.有胸腔积液者应尽可能进行胸腔积液涂片染色与细菌培养[B]。

七、治疗1.原则

(1)轻度CAP可以在门诊/家中治疗,由社区/乡镇医疗中心管理,如治疗48h无效、高热不退,或病情恶化出现呼吸急促、呼吸困难、紫绀等,必须及时转诊治疗[C]。

(2)重度CAP应收住院治疗,选择区/县级及以上医院

[c]。

2.对症支持治疗

(1)海平面、呼吸空气条件下,Sa02≤0.92或PaO:≤

60mmHg(1

111111

Hg=0.133

kPa)应予吸氧[A];氧疗患儿

应每4小时监测体温、脉率、RR和脉搏血氧饱和度[c]。

(2)鼻胃管可能影响小婴儿的呼吸,尽可能选择小号胃管[c],少量多次喂食可减轻对呼吸的影响[B]。

(3)如必须静脉补液,总液量按基础代谢正常需要量的80%计算,补液种类应为5%~10%葡萄糖溶液与生理盐水比例为4~5:I,应监测血清电解质[C]。

(4)胸部物理治疗无确切益处,不必常规采用[B]。3.CAP患儿无常规使用糖皮质激素的指征[c]4.抗病原微生物治疗(表3)

表2社区获得性肺炎患儿病情严重度评估

注:“呼吸明显增快:婴儿RR>70次/min,年长儿RR>50次/

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表3儿童社区获得性肺炎常用抗微生物药物的剂量和用法

抗微生物药物剂量及给药间隔

[ms/(kg?次)]母夯犁}(g/次)给药途径”““‘

青霉素类

青霉素G(penicillinG)2.5万~5.0万U/(kg?次),q6h肌肉注射或静脉滴注

大剂量5.0万~1Q0万u/(kg?次),q6h肌肉注射或静脉滴注

青霉素V(penicillinV)8—12.q6~8h口服

氨苄西林(ampicillin)常用剂量:15~25,q6~8h大剂量:50~75,q6~8h20口服或肌肉注射或静脉滴注阿莫西林(amoxicillin)常用剂量:lO~15,q6~8h大剂量:25~30,q6~8h20口服

羧苄西林(carbenicillin)25~50.q6-8h2.0肌肉注射或静脉滴注美洛西林(mezloeillin)75,q6-8h3.0肌肉注射或静脉滴注哌拉西林(piperacillin)25~50.q6-8h20肌肉注射或静脉滴注苯唑西林(oxacillin)25~50.q6~8h20静脉滴注

氯唑西林(cloxacillin)125~25.0.q6~8h20静脉滴注

氨苄西林+舒巴坦(规格:2:l注射剂)1.0/,0.5静脉滴注

(ampicillin/sulbactam)(25.0/12.5)~(75.0/37.5),q6~8h

阿莫西林+克拉维酸(规格:7:1口服剂)(20.00/2.85)~(30.130/4.29),q8h1.o/,o.143口服

(amoxicillin/clavulanicacid)(规格:5:1注射剂)(25.00/5.00),q6~8hl_o/,0.2静脉滴注

替卡西林+克拉维酸(规格:15:1注射剂)3.o/,0.2静脉滴注

(ticarcillin/clavulanicacid)(50.00/3.34)~(75.00/5.00),q6~8h3.0/,01

(规格:30:l注射剂)

(30.130/1.oo)~(观00/1.70),q6~8h

哌拉西林+他唑巴坦(规格:8:1注射剂)4.0/0.5静脉滴注

(piperacillin/tazobactam)大于9月龄100.0/12.5q8h2~9月龄80.WIO.0q8h

阿莫西林+舒巴坦(规格:2:1注射剂)按阿莫西林计算30,q6~8h肌肉注射或静脉滴注(amoxiciHin—sulbactam)

头孢菌素类

头孢拉定(cefradine)6.25~1250.q6h1.0口服

1250~25.00,q6~8h1.0肌肉注射或静脉滴注

头孢唑啉(cefazolin)15—25.q6~8h1.0肌肉注射或静脉滴注头孢羟氨苄(cefadroxil)15—25,q12h1.O口服

头孢克洛(cefaclor)10—15.q8ho.5口服

头孢丙烯(cefprozil)7.5~15.0,q12ho.5口服

头孢地尼(cefdinir)3~6,q8h0.2口服

头孢呋辛(cefuroxime)10—15,q12h0.75口服

15~25.q6~8hL0肌肉注射或静脉滴注

头孢噻肟(cefotaxime)50,q8h20静脉滴注

头孢曲松(ceftriaxone)40一80,qd20肌肉注射或静脉滴注头孢哌酮(cefoperazone)15—50.q8h20肌肉注射或静脉滴注头孢他啶(ceftazidime)15—50.q8h20肌肉注射或静脉滴注头孢哌酮+舒巴坦(规格:2:1注射剂)舒巴坦不超过静脉滴注

(cefoperazone/culbactam)常用剂量:(15.0/7.5)~(她0/15.0)q6

大剂量:(m0/20LO)~(80L0/40.0)qh~q12h80.0ms/

6h~q12h(kg?d)

头孢吡肟(cefapime)30—50.q8~12h1.5肌肉注射或静脉滴注大环内酯类

红霉素(erythromycin)10一15.q8ho.5口服

10~15.q12h静脉滴注

罗红霉素(roxithromycin)2.5~5.q12h0.15口服

阿奇霉素(azithromycin)10qd,连用3do.5口服

克拉霉素(clarithromycin)7.5,q12h0.5口服

其他

多西环素(doxycycline)8岁以上,2.2,q12h(第一日),后2.2~4.4,qdo.1口服

万古霉素(vancomycin)10,q6h或20,q12h0.5静脉滴注

利奈唑胺(1inezolid)10,q8h0.6口服或静脉滴注

利福平(rifampin)10~20,qdo.3口服

氨曲南(azla℃onam)30,q6~8h0.5肌肉注射或静脉滴注厄他培南(ertapenem)15,q12h1.0静脉滴注

亚胺培南(imipenem)15—25,q6ho_5静脉滴注

美罗培南(mempenem)10-20,q8h0.5静脉滴注

帕尼培南(panipenem)轻症感染:10—20,q8h重症或难治f生感染:25~30,q6~8h0.5静脉滴注

克林霉素(clindamycin)10,q8~12ho.45口服或静脉滴注

甲硝唑(metronidazole)12.5,q12h0.5口服

首剂15.0,继之7.5,q6—8h1.0静脉滴注

万方数据

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?859?

(1)单纯病毒性肺炎无使用抗菌药物指征[B],但必须注意细菌、病毒、MP、衣原体等混合感染的可能性[c]。

(2)有效和安全是选择抗菌药物的首要原则,轻度CAP可以口服抗菌药物治疗,不强调抗菌药物联合使用[A]。

(3)CAP初始治疗均是经验性的。

轻度CAP:3个月以下儿童有沙眼衣原体肺炎可能,而5岁以上者MP肺炎、CP肺炎比率较高,均可首选大环内酯类,若疑及SP混合感染,可联合阿莫西林口服[B]。对4月

龄~5岁CAP,首选口服阿莫西林,也可以选择阿莫西彬克

拉维酸(7:1剂型)、头孢羟氨苄、头孢克洛、头孢丙烯、头孢地尼等[B]。如怀疑早期sA肺炎,应优先考虑口服头孢地尼[c]。

重度CAP:多选择静脉途径给药。可以首选下列方案之一[B]:

①阿莫西彬克拉维酸(5:1)、氨苄西彬舒巴坦(2:1)

或阿莫西林/舒巴坦(2:1);②头孢呋辛、头孢曲松或头孢噻

肟;③怀疑sA肺炎,选择苯唑西林或氯唑西林,万古霉素不

作首选;④考虑细菌合并有MP或cP肺炎,可以联合使用大环内酯类+头孢曲松/头孢噻肟。

(4)CAP患儿口服抗菌药物是安全有效的[A],仅在重症肺炎或因呕吐等致口服难以吸收时才考虑胃肠道外抗菌药物疗法[B],抗菌药物序贯疗法有良好的推广前景[c]。

(5)使用适当剂量的青霉素或阿莫西林对青霉素不敏感肺炎链球菌(PNSP)依然有效[B]。

(6)一旦明确病原微生物,应即开始针对性强的目标治疗[B]。

(7)初始治疗48h后应作病情和疗效评估,CAP抗菌药物疗程一般用至热退且平稳、全身症状明显改善、呼吸道症状部分改善后3~5d[C]。

(8)病毒性CAP的支持疗法、对症疗法和加强护理等仍居重要地位,而特异性病因治疗尚不多[c]。

5.2%~12%的CAP患儿有胸腔积液,最常见于细菌性肺炎(包括sP、化脓性链球菌以及sA等)[B],积液量的多少和患儿呼吸窘迫的程度是决定治疗方案的重要因素[A]。

6.儿科支气管镜术对于儿童重症或难治性肺炎的诊治有效[B]。

八、特异性预防

1.对高危婴幼儿可给予RSV单克隆抗体(Palivizumab等)预防治疗[c]。

2.已有肺炎链球苗疫苗、b型流感嗜血杆菌疫苗、流感病毒疫苗、百日咳疫苗等,疫苗的预防接种对减少CAP患病率效果肯定[A]。

(李昌崇尚云晓沈叙庄

陈志敏赵顺英执笔)

参与本指南审定人员(以姓氏笔画为序)

王丽

邓力

申昆玲成焕吉向莉刘传合刘兆秋刘恩梅江澜杨永弘张海邻陈爱欢陈强陈慧中赵德育俞蕙

洪建国钱素云董宗祈鲁继荣曾津津

万方数据

参考文献

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M,Clark

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[DB/OL].Centerforevidencebased

medicine,2009[2013-05一

09

1.http://www.cebm.net/?O=1025.

[5]Don

M,CancianiM,KorppiM.Community—acquiredpneumonia

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children:what‘Sold?What’Snew?ActaPaediatr,2010,99:

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吕鹤鸣纪念基金(中国)儿童肝病培训项目招收学员通知

为促进我国儿科肝病临床和科研水平的持续提高,以及在未来建立儿童肝病学术及合作研究网络,吕鹤鸣纪念基金(中国)决定在上海设立儿童肝病培训项目,现面向全国招收学员。经吕鹤鸣纪念基金(中国)评选委员会选定的学员将获得在上海复旦大学附属金山医院儿科和复旦大学附属儿科医院培训的机会。

1.申请人条件:(1)中国大陆儿科医生,获得选送单位儿科主任或院长推荐。(2)至少3年儿科临床经验或已完成儿科住院医生规范化培训。(3)对/bid肝脏病学有浓厚兴趣。(4)同等条件下,优先考虑来自中西部及贫困地区的申请者。

2.培训时间:每位学员培训时间为12个月。分别在每年3月及9月开始学习。

学员将有机会参加儿童肝病病房、门诊或研究工作,参Dll4,JL肝病或儿科讲座,儿童肝病研究小组会议,病理学及影像学讲座。学员培训半年后需撰写中期报告陈述培训情况及研究工作计划,培训结束后需要递交终期报告及科研论著。基金将资助学员在上海期间生活费每月3000元;资助往来上海和学员家庭所在地的来往机票或车票;资助参加全国/],JL肝病有关会议,包括路费、住宿费和注册费。

有兴趣者,请联系复旦大学附属金山医院儿科王建设教授,或Email至jshwang@shmu.edu.all垂询。

万方数据

儿童社区获得性肺炎管理指南(2013修订)(下)作者:

作者单位:

刊名:

英文刊名:

年,卷(期):中华医学会儿科学分会呼吸学组, 《中华儿科杂志》编辑委员会, 中华儿科杂志Chinese Journal of Pediatrics2013,51(11)

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