今日の臨床サポート

肺炎球菌性肺炎

著者: 福地貴彦 自治医科大学附属さいたま医療センター 総合診療科

監修: 具芳明 東京医科歯科大学大学院医歯学総合研究科 統合臨床感染症学分野

著者校正/監修レビュー済:2021/02/10
参考ガイドライン:
  1. American Thoracic Society(ATS)/Infectious Diseases Society of America(IDSA):Diagnosis and Treatment of Adults with Community-acquired Pneumonia.
  1. 日本呼吸器学会:成人肺炎診療ガイドライン2017
患者向け説明資料

概要・推奨   

  1. 市中肺炎と診断したら、種々のガイドラインに則って重症度を算出し、外来/一般病棟/ICUのいずれでどのように治療するかを検討することは、おそらく推奨される(推奨度1)
  1. 肺炎球菌性肺炎と診断した場合、治療の基本は高用量のペニシリン系薬剤とすることがおそらく推奨される(推奨度2)
  1. 髄膜炎を合併した肺炎球菌性肺炎患者では、β-ラクタム系薬とバンコマイシンの併用療法がおそらく推奨される(細菌性髄膜炎参照)(推奨度2)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
福地貴彦 : 特に申告事項無し[2021年]
監修:具芳明 : 特に申告事項無し[2021年]

のポイント:
  1. ATS/IDSAガイドラインは実用的で非常に参考になる。基本的にはこの推奨に従うが、コストを抑えるために推奨されなくなった内容も多い。臨床医としての基本を維持するために、敢えて旧版の内容を残してある箇所も複数ある。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 肺炎球菌性肺炎は、市中肺炎の外来患者で12~22%、入院患者で24~38%を占め、原因微生物として第1位である。
  1. 菌血症を伴う肺炎球菌性肺炎は、人口10万人成人当たり9~18人の発症率である。
  1. 市中肺炎と診断し、良質な喀痰ないし血液培養より肺炎球菌が分離されれば診断する。
  1. 喀痰が採取できない場合、尿中肺炎球菌抗原を代用しても可である。
  1. 肺炎球菌は、インフルエンザ後の続発性肺炎の原因菌としても、28~48%と最多である。
  1. 鼻咽腔に保菌している状態から、エアロゾルとなり肺胞に到達すると考えられている。
  1. 古典的には大葉性肺炎になることが多いとされており、壊死性肺炎や膿胸の合併はまれである。
  1. 重症化し得る疾患である。
  1. 侵襲性肺炎球菌感染症(侵襲性感染症のうち肺炎球菌が髄液または血液から検出された場合)は、感染症法の5類感染症に分類され、診断した医師は、7日以内に最寄りの保健所に届け出る必要がある。
問診・診察のポイント  
  1. バイタルサイン(特に呼吸数、血圧、SpO2)の状態を評価し、必要に応じ早期にO2投与、気管挿管、輸液を考慮する。
  1. 聴診をし、肺炎を来している部位に応じて、coarse crackleを聴取する。

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文献 

著者: Joshua P Metlay, Grant W Waterer, Ann C Long, Antonio Anzueto, Jan Brozek, Kristina Crothers, Laura A Cooley, Nathan C Dean, Michael J Fine, Scott A Flanders, Marie R Griffin, Mark L Metersky, Daniel M Musher, Marcos I Restrepo, Cynthia G Whitney
雑誌名: Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. doi: 10.1164/rccm.201908-1581ST.
Abstract/Text Background: This document provides evidence-based clinical practice guidelines on the management of adult patients with community-acquired pneumonia.Methods: A multidisciplinary panel conducted pragmatic systematic reviews of the relevant research and applied Grading of Recommendations, Assessment, Development, and Evaluation methodology for clinical recommendations.Results: The panel addressed 16 specific areas for recommendations spanning questions of diagnostic testing, determination of site of care, selection of initial empiric antibiotic therapy, and subsequent management decisions. Although some recommendations remain unchanged from the 2007 guideline, the availability of results from new therapeutic trials and epidemiological investigations led to revised recommendations for empiric treatment strategies and additional management decisions.Conclusions: The panel formulated and provided the rationale for recommendations on selected diagnostic and treatment strategies for adult patients with community-acquired pneumonia.

PMID 31573350  Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-e67. d・・・
著者: M J Fine, T E Auble, D M Yealy, B H Hanusa, L A Weissfeld, D E Singer, C M Coley, T J Marrie, W N Kapoor
雑誌名: N Engl J Med. 1997 Jan 23;336(4):243-50. doi: 10.1056/NEJM199701233360402.
Abstract/Text BACKGROUND: There is considerable variability in rates of hospitalization of patients with community-acquired pneumonia, in part because of physicians' uncertainty in assessing the severity of illness at presentation.
METHODS: From our analysis of data on 14,199 adult inpatients with community-acquired pneumonia, we derived a prediction rule that stratifies patients into five classes with respect to the risk of death within 30 days. The rule was validated with 1991 data on 38,039 inpatients and with data on 2287 inpatients and outpatients in the Pneumonia Patient Outcomes Research Team (PORT) cohort study. The prediction rule assigns points based on age and the presence of coexisting disease, abnormal physical findings (such as a respiratory rate of > or = 30 or a temperature of > or = 40 degrees C), and abnormal laboratory findings (such as a pH <7.35, a blood urea nitrogen concentration > or = 30 mg per deciliter [11 mmol per liter] or a sodium concentration <130 mmol per liter) at presentation.
RESULTS: There were no significant differences in mortality in each of the five risk classes among the three cohorts. Mortality ranged from 0.1 to 0.4 percent for class I patients (P=0.22), from 0.6 to 0.7 percent for class II (P=0.67), and from 0.9 to 2.8 percent for class III (P=0.12). Among the 1575 patients in the three lowest risk classes in the Pneumonia PORT cohort, there were only seven deaths, of which only four were pneumonia-related. The risk class was significantly associated with the risk of subsequent hospitalization among those treated as outpatients and with the use of intensive care and the number of days in the hospital among inpatients.
CONCLUSIONS: The prediction rule we describe accurately identifies the patients with community-acquired pneumonia who are at low risk for death and other adverse outcomes. This prediction rule may help physicians make more rational decisions about hospitalization for patients with pneumonia.

PMID 8995086  N Engl J Med. 1997 Jan 23;336(4):243-50. doi: 10.1056/N・・・
著者: W S Lim, S V Baudouin, R C George, A T Hill, C Jamieson, I Le Jeune, J T Macfarlane, R C Read, H J Roberts, M L Levy, M Wani, M A Woodhead, Pneumonia Guidelines Committee of the BTS Standards of Care Committee
雑誌名: Thorax. 2009 Oct;64 Suppl 3:iii1-55. doi: 10.1136/thx.2009.121434.
Abstract/Text
PMID 19783532  Thorax. 2009 Oct;64 Suppl 3:iii1-55. doi: 10.1136/thx.2・・・
著者: J A Ramirez, J Bordon
雑誌名: Arch Intern Med. 2001 Mar 26;161(6):848-50.
Abstract/Text BACKGROUND: The identification of Streptococcus pneumoniae bacteremia in hospitalized patients with community-acquired pneumonia is considered by some investigators to be an exclusion criterion for early switch from intravenous to oral therapy.
OBJECTIVE: To determine whether the switch from intravenous to oral therapy in such patients, once the bx;1patient reaches clinical stability, is associated with poor clinical outcome.
METHODS: The medical records of 400 patients with community-acquired pneumonia hospitalized at the Veterans Affairs Medical Center of Louisville (Louisville, Ky) were reviewed to identify patients with bacteremic S pneumoniae. Four criteria were used to define when a patient reached clinical stability and should be considered a candidate for switch therapy: (1) cough and shortness of breath are improving, (2) patient is afebrile for at least 8 hours, (3) white blood cell count is normalizing, and (4) oral intake and gastrointestinal tract absorption are adequate.
RESULTS: A total of 36 bacteremic patients were identified. No clinical failures occurred in 18 patients who reached clinical stability and were switched to oral therapy or in 7 patients who reached clinical stability and continued intravenous therapy. Clinical failures (5 deaths) occurred in the group of 11 patients who did not reach clinical stability.
CONCLUSION: Once a hospitalized patient with community-acquired pneumonia reaches clinical stability, it is safe to switch from intravenous to oral antibiotics even if bacteremia caused by S pneumoniae was initially documented.

PMID 11268227  Arch Intern Med. 2001 Mar 26;161(6):848-50.
著者: Yoshihito Niki, Hideaki Hanaki, Tetsuya Matsumoto, Morimasa Yagisawa, Shigeru Kohno, Nobuki Aoki, Akira Watanabe, Junko Sato, Rikizo Hattori, Naoto Koashi, Michinori Terada, Tsuneo Kozuki, Akinori Maruo, Kohei Morita, Kazuhiko Ogasawara, Yoshisaburo Takahashi, Kenji Matsuda, Kunio Nakanishi, Keisuke Sunakawa, Kenichi Takeuchi, Seiichi Fujimura, Hiroaki Takeda, Hideki Ikeda, Naohito Sato, Katsunao Niitsuma, Miwako Saito, Shizuko Koshiba, Michiyo Kaneko, Makoto Miki, Susumu Nakanowatari, Hiroshi Takahashi, Mutsuko Utagawa, Hajime Nishiya, Sayoko Kawakami, Yasuko Aoki, Naohiko Chonabayashi, Hideko Sugiura, Masahiko Ichioka, Hajime Goto, Daisuke Kurai, Takeshi Saraya, Mitsuhiro Okazaki, Koichiro Yoshida, Takashi Yoshida, Hiroki Tsukada, Yumiko Imai, Yasuo Honma, Toshinobu Yamamoto, Atsuro Kawai, Hiroshige Mikamo, Yoshio Takesue, Yasunao Wada, Takeyuki Miyara, Hirofumi Toda, Noriko Mitsuno, Yasunori Fujikawa, Hirokazu Nakajima, Shuichi Kubo, Yoshio Ohta, Keiichi Mikasa, Kei Kasahara, Akira Koizumi, Reiko Sano, Shinichi Yagi, Mariko Takaya, Yukinori Kurokawa, Nobuchika Kusano, Eiichiro Mihara, Motoko Nose, Masao Kuwabara, Yoshihiro Fujiue, Toshiyuki Ishimaru, Nobuo Matsubara, Yuji Kawasaki, Hirokazu Tokuyasu, Kayoko Masui, Masamitsu Kido, Toshiyuki Ota, Junichi Honda, Junichi Kadota, Kazufumi Hiramatsu, Yosuke Aoki, Zenzo Nagasawa, Katsunori Yanagihara, Jiro Fujita, Masao Tateyama, Kyoichi Totsuka
雑誌名: J Infect Chemother. 2011 Aug;17(4):510-23. doi: 10.1007/s10156-011-0214-5. Epub 2011 Mar 17.
Abstract/Text For the purpose of nationwide surveillance of the antimicrobial susceptibility of bacterial respiratory pathogens collected from patients in Japan, the Japanese Society of Chemotherapy conducted a third year of nationwide surveillance during the period from January to April 2008. A total of 1,097 strains were collected from clinical specimens obtained from well-diagnosed adult patients with respiratory tract infections. Susceptibility testing was evaluable with 987 strains (189 Staphylococcus aureus, 211 Streptococcus pneumoniae, 6 Streptococcus pyogenes, 187 Haemophilus influenzae, 106 Moraxella catarrhalis, 126 Klebsiella pneumoniae, and 162 Pseudomonas aeruginosa). A total of 44 antibacterial agents, including 26 β-lactams (four penicillins, three penicillins in combination with β-lactamase inhibitors, four oral cephems, eight parenteral cephems, one monobactam, five carbapenems, and one penem), three aminoglycosides, four macrolides (including a ketolide), one lincosamide, one tetracycline, two glycopeptides, six fluoroquinolones, and one oxazolidinone were used for the study. Analysis was conducted at the central reference laboratory according to the method recommended by the Clinical and Laboratory Standard Institute (CLSI). The incidence of methicillin-resistant S. aureus (MRSA) was as high as 59.8%, and those of penicillin-intermediate and penicillin-resistant S. pneumoniae (PISP and PRSP) were 35.5 and 11.8%, respectively. Among H. influenzae, 13.9% of them were found to be β-lactamase-non-producing ampicillin (ABPC)-intermediately resistant (BLNAI), 26.7% to be β-lactamase-non-producing ABPC-resistant (BLNAR), and 5.3% to be β-lactamase-producing ABPC-resistant (BLPAR) strains. A high frequency (76.5%) of β-lactamase-producing strains was suspected in Moraxella catarrhalis isolates. Four (3.2%) extended-spectrum β-lactamase-producing K. pneumoniae were found among 126 strains. Four isolates (2.5%) of P. aeruginosa were found to be metallo β-lactamase-producing strains, including three (1.9%) suspected multidrug-resistant strains showing resistance to imipenem, amikacin, and ciprofloxacin. Continual national surveillance of the antimicrobial susceptibility of respiratory pathogens is crucial in order to monitor changing patterns of susceptibility and to be able to update treatment recommendations on a regular basis.

PMID 21409533  J Infect Chemother. 2011 Aug;17(4):510-23. doi: 10.1007・・・
著者: Lionel A Mandell, Richard G Wunderink, Antonio Anzueto, John G Bartlett, G Douglas Campbell, Nathan C Dean, Scott F Dowell, Thomas M File, Daniel M Musher, Michael S Niederman, Antonio Torres, Cynthia G Whitney, Infectious Diseases Society of America, American Thoracic Society
雑誌名: Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72. doi: 10.1086/511159.
Abstract/Text
PMID 17278083  Clin Infect Dis. 2007 Mar 1;44 Suppl 2:S27-72. doi: 10.・・・
著者: Larry M Baddour, Victor L Yu, Keith P Klugman, Charles Feldman, Ake Ortqvist, Jordi Rello, Arthur J Morris, Carlos M Luna, David R Snydman, Wen Chien Ko, M Bernadete F Chedid, David S Hui, Antoine Andremont, Christine C C Chiou, International Pneumococcal Study Group
雑誌名: Am J Respir Crit Care Med. 2004 Aug 15;170(4):440-4. doi: 10.1164/rccm.200311-1578OC. Epub 2004 Jun 7.
Abstract/Text Retrospective studies have suggested that combination antibiotic therapy for severe bacteremic pneumococcal pneumonia may reduce mortality. We assessed this issue in a prospective, multicenter, international observational study of 844 adult patients with bacteremia due to Streptococcus pneumoniae. The effect of combination antibiotic therapy versus monotherapy on mortality was examined by univariate analyses and by logistic regression models. The 14-day mortality was not significantly different for the two groups. However, among critically ill patients, combination antibiotic therapy was associated with lower 14-day mortality (23.4 versus 55.3%, p = 0.0015). This improvement in survival was independent of country of origin, intensive care unit support, class of antibiotics, or in vitro activity of the antibiotics prescribed. Combination antibiotic therapy improved survival among critically ill patients with bacteremic pneumococcal illness.

PMID 15184200  Am J Respir Crit Care Med. 2004 Aug 15;170(4):440-4. do・・・
著者: Asa Karlström, Kelli L Boyd, B Keith English, Jonathan A McCullers
雑誌名: J Infect Dis. 2009 Feb 1;199(3):311-9. doi: 10.1086/596051.
Abstract/Text Pneumonia occurring as a secondary infection after influenza is a major cause of excess morbidity and mortality, despite the availability and use of antibiotics active against Streptococcus pneumoniae. We hypothesized that the use of a bacteriostatic protein synthesis inhibitor would improve outcomes by reducing the inflammatory response. BALB/cJ mice infected with influenza virus and superinfected with S. pneumoniae were treated with either the cell-wall-active antibiotic ampicillin or the protein synthesis inhibitor clindamycin or azithromycin. In the model, ampicillin therapy performed significantly worse (survival rate, 56%) than (1) clindamycin therapy used either alone (82%) or in combination with ampicillin (80%) and (2) azithromycin (92%). Improved survival appeared to be mediated by decreased inflammation manifested as lower levels of inflammatory cells and proinflammatory cytokines in the lungs and by observation of less-severe histopathologic findings. These data suggest that beta-lactam therapy may not be optimal as a first-line treatment for community-acquired pneumonia when it follows influenza.

PMID 19113989  J Infect Dis. 2009 Feb 1;199(3):311-9. doi: 10.1086/596・・・
著者: Yuanjing Chen, Ka Li, Hongshan Pu, Taixiang Wu
雑誌名: Cochrane Database Syst Rev. 2011 Mar 16;(3):CD007720. doi: 10.1002/14651858.CD007720.pub2. Epub 2011 Mar 16.
Abstract/Text BACKGROUND: Pneumonia is an acute inflammation of the lungs and treatments differ depending on the type and severity. Corticosteroids can influence immune regulation, carbohydrate metabolism, protein catabolism, electrolyte balance and stress response. However, the benefits of corticosteroids for patients with pneumonia remains unclear.
OBJECTIVES: To assess the efficacy and safety of corticosteroids in the treatment of pneumonia.
SEARCH STRATEGY: We searched Cochrane Central Register of Controlled Clinical Trials (CENTRAL) (The Cochrane Library 2010, Issue 11) which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1966 to December week 4, 2010), EMBASE (1974 to December 2010), the China National Knowledge Infrastructure (CNKI) (1978 to December 2010) and VIP (1986 to December 2010).
SELECTION CRITERIA: Randomised controlled trials (RCTs) assessing the effectiveness of corticosteroids for pneumonia.
DATA COLLECTION AND ANALYSIS: Three review authors selected studies. We telephoned the trial authors to confirm the randomisation method used. We extracted and analysed the methodological details and data from the included studies.
MAIN RESULTS: We included six studies including 437 participants in the review. Two studies were of high methodological quality and three were of poor quality. All studies involved small numbers of participants. Two small studies provided weak evidence that corticosteroids did not significantly reduce mortality (Peto odds ratio (OR) 0.26; 95% CI 0.05 to 1.37), but accelerated the resolution of symptoms or time to clinical stability, and decreased the rate of relapse of the disease. Steroids can improve the oxygenation and reduce the need for mechanical ventilation in severe pneumonia. There was no significant difference between treatment groups with regards to the time to discharge from the intensive care unit (ICU). There were insufficient data to report the time to pneumonia resolution and admission to ICU. Typical adverse events associated with corticosteroid therapy were infrequent.
AUTHORS' CONCLUSIONS: In most patients with pneumonia, corticosteroids are generally beneficial for accelerating the time to resolution of symptoms. However, evidence from the included studies was not strong enough to make any recommendations.

PMID 21412908  Cochrane Database Syst Rev. 2011 Mar 16;(3):CD007720. d・・・
著者: Jorge I F Salluh, Pedro Póvoa, Márcio Soares, Hugo C Castro-Faria-Neto, Fernando A Bozza, Patrícia T Bozza
雑誌名: Crit Care. 2008;12(3):R76. doi: 10.1186/cc6922. Epub 2008 Jun 11.
Abstract/Text INTRODUCTION: The purpose of this review was to evaluate the impact of corticosteroids on the outcomes of patients with severe community-acquired pneumonia (CAP).
METHODS: We performed a systematic MEDLINE, Cochrane database, and CINAHL search (1966 to November 2007) to identify full-text publications that evaluated the use of corticosteroids in CAP.
RESULTS: An initial literature search yielded 109 articles, and 105 studies were excluded after the first analysis. We found four studies eligible for analysis. On the basis of their results, the use of corticosteroids as adjunctive therapy in severe CAP should be categorized as a weak recommendation (two studies) and a strong recommendation (two studies) with either low- or moderate-quality evidence. However, no evidence of adverse outcomes or harm is present in the evaluated studies.
CONCLUSION: According to the GRADE system, available studies do not support the recommendation of corticosteroids as a standard of care for patients with severe CAP. Further randomized controlled trials with this aim should enroll a larger number of severely ill patients. However, in patients needing corticosteroids, it may be reasonable to conclude that corticosteroid administration is safe in patients with severe infections receiving antimicrobial therapy.

PMID 18547407  Crit Care. 2008;12(3):R76. doi: 10.1186/cc6922. Epub 20・・・
著者: Sabine C A Meijvis, Hans Hardeman, Hilde H F Remmelts, Rik Heijligenberg, Ger T Rijkers, Heleen van Velzen-Blad, G Paul Voorn, Ewoudt M W van de Garde, Henrik Endeman, Jan C Grutters, Willem Jan W Bos, Douwe H Biesma
雑誌名: Lancet. 2011 Jun 11;377(9782):2023-30. doi: 10.1016/S0140-6736(11)60607-7. Epub 2011 Jun 1.
Abstract/Text BACKGROUND: Whether addition of corticosteroids to antibiotic treatment benefits patients with community-acquired pneumonia who are not in intensive care units is unclear. We aimed to assess effect of addition of dexamethasone on length of stay in this group, which might result in earlier resolution of pneumonia through dampening of systemic inflammation.
METHODS: In our double-blind, placebo-controlled trial, we randomly assigned adults aged 18 years or older with confirmed community-acquired pneumonia who presented to emergency departments of two teaching hospitals in the Netherlands to receive intravenous dexamethasone (5 mg once a day) or placebo for 4 days from admission. Patients were ineligible if they were immunocompromised, needed immediate transfer to an intensive-care unit, or were already receiving corticosteroids or immunosuppressive drugs. We randomly allocated patients on a one-to-one basis to treatment groups with a computerised randomisation allocation sequence in blocks of 20. The primary outcome was length of hospital stay in all enrolled patients. This study is registered with ClinicalTrials.gov, number NCT00471640.
FINDINGS: Between November, 2007, and September, 2010, we enrolled 304 patients and randomly allocated 153 to the placebo group and 151 to the dexamethasone group. 143 (47%) of 304 enrolled patients had pneumonia of pneumonia severity index class 4-5 (79 [52%] patients in the dexamethasone group and 64 [42%] controls). Median length of stay was 6·5 days (IQR 5·0-9·0) in the dexamethasone group compared with 7·5 days (5·3-11·5) in the placebo group (95% CI of difference in medians 0-2 days; p=0·0480). In-hospital mortality and severe adverse events were infrequent and rates did not differ between groups, although 67 (44%) of 151 patients in the dexamethasone group had hyperglycaemia compared with 35 (23%) of 153 controls (p<0·0001).
INTERPRETATION: Dexamethasone can reduce length of hospital stay when added to antibiotic treatment in non-immunocompromised patients with community-acquired pneumonia.
FUNDING: None.

Copyright © 2011 Elsevier Ltd. All rights reserved.
PMID 21636122  Lancet. 2011 Jun 11;377(9782):2023-30. doi: 10.1016/S01・・・
著者: Andrew Rhodes, Laura E Evans, Waleed Alhazzani, Mitchell M Levy, Massimo Antonelli, Ricard Ferrer, Anand Kumar, Jonathan E Sevransky, Charles L Sprung, Mark E Nunnally, Bram Rochwerg, Gordon D Rubenfeld, Derek C Angus, Djillali Annane, Richard J Beale, Geoffrey J Bellinghan, Gordon R Bernard, Jean-Daniel Chiche, Craig Coopersmith, Daniel P De Backer, Craig J French, Seitaro Fujishima, Herwig Gerlach, Jorge Luis Hidalgo, Steven M Hollenberg, Alan E Jones, Dilip R Karnad, Ruth M Kleinpell, Younsuk Koh, Thiago Costa Lisboa, Flavia R Machado, John J Marini, John C Marshall, John E Mazuski, Lauralyn A McIntyre, Anthony S McLean, Sangeeta Mehta, Rui P Moreno, John Myburgh, Paolo Navalesi, Osamu Nishida, Tiffany M Osborn, Anders Perner, Colleen M Plunkett, Marco Ranieri, Christa A Schorr, Maureen A Seckel, Christopher W Seymour, Lisa Shieh, Khalid A Shukri, Steven Q Simpson, Mervyn Singer, B Taylor Thompson, Sean R Townsend, Thomas Van der Poll, Jean-Louis Vincent, W Joost Wiersinga, Janice L Zimmerman, R Phillip Dellinger
雑誌名: Intensive Care Med. 2017 Mar;43(3):304-377. doi: 10.1007/s00134-017-4683-6. Epub 2017 Jan 18.
Abstract/Text OBJECTIVE: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012".
DESIGN: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.
METHODS: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.
RESULTS: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.
CONCLUSIONS: Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.

PMID 28101605  Intensive Care Med. 2017 Mar;43(3):304-377. doi: 10.100・・・
著者: Jan Jelrik Oosterheert, Marc J M Bonten, Margriet M E Schneider, Erik Buskens, Jan-Willem J Lammers, Willem M N Hustinx, Mark H H Kramer, Jan M Prins, Peter H Th J Slee, Karin Kaasjager, Andy I M Hoepelman
雑誌名: BMJ. 2006 Dec 9;333(7580):1193. doi: 10.1136/bmj.38993.560984.BE. Epub 2006 Nov 7.
Abstract/Text OBJECTIVES: To compare the effectiveness of an early switch to oral antibiotics with the standard 7 day course of intravenous antibiotics in severe community acquired pneumonia.
DESIGN: Multicentre randomised controlled trial.
SETTING: Five teaching hospitals and 2 university medical centres in the Netherlands.
PARTICIPANTS: 302 patients in non-intensive care wards with severe community acquired pneumonia. 265 patients fulfilled the study requirements.
INTERVENTION: Three days of treatment with intravenous antibiotics followed, when clinically stable, by oral antibiotics or by 7 days of intravenous antibiotics.
MAIN OUTCOME MEASURES: Clinical cure and length of hospital stay.
RESULTS: 302 patients were randomised (mean age 69.5 (standard deviation 14.0), mean pneumonia severity score 112.7 (26.0)). 37 patients were excluded from analysis because of early dropout before day 3, leaving 265 patients for intention to treat analysis. Mortality at day 28 was 4% in the intervention group and 6% in the control group (mean difference 2%, 95% confidence interval -3% to 8%). Clinical cure was 83% in the intervention group and 85% in the control group (2%, -7% to 10%). Duration of intravenous treatment and length of hospital stay were reduced in the intervention group, with mean differences of 3.4 days (3.6 (1.5) v 7.0 (2.0) days; 2.8 to 3.9) and 1.9 days (9.6 (5.0) v 11.5 (4.9) days; 0.6 to 3.2), respectively.
CONCLUSIONS: Early switch from intravenous to oral antibiotics in patients with severe community acquired pneumonia is safe and decreases length of hospital stay by 2 days.
TRIAL REGISTRATION: Clinical Trials NCT00273676 [ClinicalTrials.gov].

PMID 17090560  BMJ. 2006 Dec 9;333(7580):1193. doi: 10.1136/bmj.38993.・・・
著者: Jonathan Z Li, Lisa G Winston, Dan H Moore, Stephen Bent
雑誌名: Am J Med. 2007 Sep;120(9):783-90. doi: 10.1016/j.amjmed.2007.04.023.
Abstract/Text PURPOSE: There is little consensus on the most appropriate duration of antibiotic treatment for community-acquired pneumonia. The goal of this study is to systematically review randomized controlled trials comparing short-course and extended-course antibiotic regimens for community-acquired pneumonia.
METHODS: We searched MEDLINE, Embase, and CENTRAL, and reviewed reference lists from 1980 through June 2006. Studies were included if they were randomized controlled trials that compared short-course (7 days or less) versus extended-course (>7 days) antibiotic monotherapy for community-acquired pneumonia in adults. The primary outcome measure was failure to achieve clinical improvement.
RESULTS: We found 15 randomized controlled trials matching our inclusion and exclusion criteria comprising 2796 total subjects. Short-course regimens primarily studied the use of azithromycin (n=10), but trials examining beta-lactams (n=2), fluoroquinolones (n=2), and ketolides (n=1) were found as well. Of the extended-course regimens, 3 studies utilized the same antibiotic, whereas 9 involved an antibiotic of the same class. Overall, there was no difference in the risk of clinical failure between the short-course and extended-course regimens (0.89, 95% confidence interval [CI], 0.78-1.02). In addition, there were no differences in the risk of mortality (0.81, 95% CI, 0.46-1.43) or bacteriologic eradication (1.11, 95% CI, 0.76-1.62). In subgroup analyses, there was a trend toward favorable clinical efficacy for the short-course regimens in all antibiotic classes (range of relative risk, 0.88-0.94).
CONCLUSIONS: The available studies suggest that adults with mild to moderate community-acquired pneumonia can be safely and effectively treated with an antibiotic regimen of 7 days or less. Reduction in patient exposure to antibiotics may limit the increasing rates of antimicrobial drug resistance, decrease cost, and improve patient adherence and tolerability.

PMID 17765048  Am J Med. 2007 Sep;120(9):783-90. doi: 10.1016/j.amjmed・・・
著者: George Dimopoulos, Dimitrios K Matthaiou, Drosos E Karageorgopoulos, Alexandros P Grammatikos, Zoe Athanassa, Matthew E Falagas
雑誌名: Drugs. 2008;68(13):1841-54.
Abstract/Text BACKGROUND: The evidence for traditionally recommended 7- to 14-day duration of antibacterial therapy for community-acquired pneumonia (CAP) is not well established.
OBJECTIVES: We endeavoured to assess the effectiveness and safety of shorter than traditionally recommended antibacterial therapy for CAP.
METHODS: We performed a meta-analysis of randomized controlled trials (RCTs) comparing short- (< or = 7 days) versus long- (> or = 2 days difference) course therapy for CAP with the same antibacterial regimens, in the same daily dosages.
RESULTS: Five RCTs involving adults (including outpatients and inpatients who did not require intensive care) and two RCTs involving children (aged 2-59 months, residing in developing countries) were included. All RCTs were double-blind and assessed patients with CAP of mild to moderate severity. No differences were found between short- (adults 3-7 days; children 3 days) and long- (adults 7-10 days; children 5 days) course regimens (adults - amoxicillin, cefuroxime, ceftriaxone, telithromycin and gemifloxacin; children - amoxicillin) regarding clinical success at end-of-therapy (six RCTs; 5107 patients [1095 adults, 4012 children]; fixed-effect model [FEM]; odds ratio [OR] = 0.89; 95% CI 0.74, 1.07), clinical success at late follow-up, microbiological success, relapses, mortality (seven RCTs; 5438 patients; FEM; OR = 0.57; 95% CI 0.23, 1.43), adverse events (five RCTs; 3214 patients; FEM; OR = 0. 90; 95% CI 0.72, 1.13) or withdrawals as a result of adverse events. No differences were found in subset analyses of adults or children, and of patients treated with no more than 5-day short-course regimens versus at least 7-day long-course regimens.
CONCLUSION: No difference was found in the effectiveness and safety of short- versus long-course antimicrobial treatment of adult and paediatric patients with CAP of mild to moderate severity.

PMID 18729535  Drugs. 2008;68(13):1841-54.
著者: Liu Catherine C, Bayer Arnold A, Cosgrove Sara E SE, Daum Robert S RS, Fridkin Scott K SK, Gorwitz Rachel J RJ, Kaplan Sheldon L SL, Karchmer Adolf W AW, Levine Donald P DP, Murray Barbara E BE, J Rybak Michael M, Talan David A DA, Chambers Henry F HF, Infectious Diseases Society of America
雑誌名: Clin Infect Dis. 2011 Feb 1;52(3):e18-55. doi: 10.1093/cid/ciq146. Epub 2011 Jan 4.
Abstract/Text Evidence-based guidelines for the management of patients with methicillin-resistant Staphylococcus aureus (MRSA) infections were prepared by an Expert Panel of the Infectious Diseases Society of America (IDSA). The guidelines are intended for use by health care providers who care for adult and pediatric patients with MRSA infections. The guidelines discuss the management of a variety of clinical syndromes associated with MRSA disease, including skin and soft tissue infections (SSTI), bacteremia and endocarditis, pneumonia, bone and joint infections, and central nervous system (CNS) infections. Recommendations are provided regarding vancomycin dosing and monitoring, management of infections due to MRSA strains with reduced susceptibility to vancomycin, and vancomycin treatment failures.

PMID 21208910  Clin Infect Dis. 2011 Feb 1;52(3):e18-55. doi: 10.1093/・・・
著者: R E Thomas, T Jefferson, V Demicheli, D Rivetti
雑誌名: Cochrane Database Syst Rev. 2006 Jul 19;(3):CD005187. doi: 10.1002/14651858.CD005187.pub2. Epub 2006 Jul 19.
Abstract/Text BACKGROUND: Healthcare workers (HCW) (nurses, doctors, other health professionals, cleaners and porters), have substantial rates of clinical and sub-clinical influenza during influenza seasons and may transmit influenza to those in their care, especially the vulnerable elderly.
OBJECTIVES: To identify and summarise comparative studies assessing the effects of vaccinating healthcare workers (HCW) on the incidence of influenza, influenza-like-illness (ILI) and its complications on elderly residents in long-term facilities.
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews and the NHS Database of Abstracts of Reviews of Effectiveness (DARE) (The Cochrane Library Issue 1, 2006); MEDLINE (January 1966 to Week 1, February 2006); EMBASE (1974 to March 2006); Biological Abstracts (1969 to December 2004); and Science Citation Index-Expanded (1974 to March 2006).
SELECTION CRITERIA: Comparative randomised and non-randomised studies reporting the effects of influenza vaccines on the incidence of viral infections in institutions for the elderly of any type, in any schedule of vaccination given to HCW caring for elderly residents of long-term facilities aged 60 years or older.
DATA COLLECTION AND ANALYSIS: Two authors independently extracted data and assessed the methodological quality using criteria from the Cochrane Reviewers' Handbook and the Newcastle-Ottawa scale (for non-randomised studies).
MAIN RESULTS: We included two cluster randomised controlled trials (C-RCT) and one cohort study. Staff vaccination appears to have significant effect against ILI (absolute vaccine efficacy (VE) 86%, 95% confidence interval (CI) 40% to 97%) only when patients are vaccinated too; if patients are not vaccinated, staff immunisation shows no effect (based on one C-RCT). Based on a small number of observations from two C-RCTs, the vaccines have no efficacy against influenza (odds ratio (OR) 0.86, 95% CI 0.44 to 1.68) or lower respiratory tract infections (OR 0.70, 95% CI 0.41 to 1.20) but were effective against deaths from pneumonia (VE 39%, 95% CI 2% to 62%) and deaths from all causes (VE 40%, 95% CI 27% to 50%). All findings must be interpreted with caution given the presence of selection bias.
AUTHORS' CONCLUSIONS: We concluded that there is no credible evidence that vaccination of healthy people under the age of 60, who are HCWs caring for the elderly, affects influenza complications in those cared for. However, as vaccinating the elderly in institutions reduces the complications of influenza and vaccinating healthy persons under 60 reduces cases of influenza, those with the responsibility of caring for the elderly in institutions may want to increase vaccine coverage and assess its effects in well-designed studies.

PMID 16856082  Cochrane Database Syst Rev. 2006 Jul 19;(3):CD005187. d・・・
著者: D Rivetti, T Jefferson, R Thomas, M Rudin, A Rivetti, C Di Pietrantonj, V Demicheli
雑誌名: Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004876. doi: 10.1002/14651858.CD004876.pub2. Epub 2006 Jul 19.
Abstract/Text BACKGROUND: Influenza vaccination of elderly individuals is recommended worldwide and has been targeted toward the elderly and those at serious risk of complications.
OBJECTIVES: Our aim was to review the evidence of efficacy, effectiveness and safety of influenza vaccines in individuals aged 65 years or older.
SEARCH STRATEGY: We searched the following databases on The Cochrane Library, the Cochrane Central Register of Controlled Trials (CENTRAL), the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effectiveness (Issue 1, 2006); MEDLINE (January 1966 to March Week 3 2006); EMBASE (Dialog 1974 to 1979; SilverPlatter 1980 to December 2005); Biological Abstracts (SilverPlatter 1969 to December 2004); and Science Citation Index (Web of Science 1974 to December 2004).
SELECTION CRITERIA: We considered randomised, quasi-randomised, cohort and case-control studies assessing efficacy against influenza (laboratory-confirmed cases) or effectiveness against influenza-like illness (ILI) or safety. Any influenza vaccine given independently, in any dose, preparation or time schedule, compared with placebo or with no intervention was considered.
DATA COLLECTION AND ANALYSIS: We grouped reports first according to the setting of the study (community or long-term care facilities) and then by level of viral circulation and vaccine matching. We further stratified by co-administration of pneumococcal polysaccharide vaccine (PPV) and by different types of influenza vaccines. We analysed the following outcomes: influenza, influenza-like illness, hospital admissions, complications and deaths.
MAIN RESULTS: Sixty-four studies were included in the efficacy / effectiveness assessment, resulting in 96 data sets. In homes for elderly individuals (with good vaccine match and high viral circulation) the effectiveness of vaccines against ILI was 23% (6% to 36%) and non-significant against influenza (RR 1.04: 95% CI 0.43 to 2.51). We found no correlation between vaccine coverage and ILI attack rate. Well matched vaccines prevented pneumonia (VE 46%; 30% to 58%), hospital admission (VE 45%; 16% to 64%) and deaths from influenza or pneumonia (VE 42%, 17% to 59%). In elderly individuals living in the community, vaccines were not significantly effective against influenza (RR 0.19; 95% CI 0.02 to 2.01), ILI (RR 1.05: 95% CI 0.58 to 1.89), or pneumonia (RR 0.88; 95% CI 0.64 to 1.20). Well matched vaccines prevented hospital admission for influenza and pneumonia (VE 26%; 12% to 38%) and all-cause mortality (VE 42%; 24% to 55%). After adjustment for confounders, vaccine performance was improved for admissions to hospital for influenza or pneumonia (VE* 27%; 21% to 33%), respiratory diseases (VE* 22%; 15% to 28%) and cardiac disease (VE* 24%; 18% to 30%); and for all-cause mortality (VE* 47%; 39% to 54%). The public health safety profiles of the vaccines appear to be acceptable.
AUTHORS' CONCLUSIONS: In long-term care facilities, where vaccination is most effective against complications, the aims of the vaccination campaign are fulfilled, at least in part. However, according to reliable evidence the usefulness of vaccines in the community is modest. The apparent high effectiveness of the vaccines in preventing death from all causes may reflect a baseline imbalance in health status and other systematic differences in the two groups of participants.

PMID 16856068  Cochrane Database Syst Rev. 2006 Jul 19;(3):CD004876. d・・・
著者: Anthony E Fiore, Timothy M Uyeki, Karen Broder, Lyn Finelli, Gary L Euler, James A Singleton, John K Iskander, Pascale M Wortley, David K Shay, Joseph S Bresee, Nancy J Cox, Centers for Disease Control and Prevention (CDC)
雑誌名: MMWR Recomm Rep. 2010 Aug 6;59(RR-8):1-62.
Abstract/Text This report updates the 2009 recommendations by CDC's Advisory Committee on Immunization Practices (ACIP) regarding the use of influenza vaccine for the prevention and control of influenza (CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices [ACIP]. MMWR 2009;58[No. RR-8] and CDC. Use of influenza A (H1N1) 2009 monovalent vaccine---recommendations of the Advisory Committee on Immunization Practices [ACIP], 2009. MMWR 2009;58:[No. RR-10]). The 2010 influenza recommendations include new and updated information. Highlights of the 2010 recommendations include 1) a recommendation that annual vaccination be administered to all persons aged >or=6 months for the 2010-11 influenza season; 2) a recommendation that children aged 6 months--8 years whose vaccination status is unknown or who have never received seasonal influenza vaccine before (or who received seasonal vaccine for the first time in 2009-10 but received only 1 dose in their first year of vaccination) as well as children who did not receive at least 1 dose of an influenza A (H1N1) 2009 monovalent vaccine regardless of previous influenza vaccine history should receive 2 doses of a 2010-11 seasonal influenza vaccine (minimum interval: 4 weeks) during the 2010--11 season; 3) a recommendation that vaccines containing the 2010-11 trivalent vaccine virus strains A/California/7/2009 (H1N1)-like (the same strain as was used for 2009 H1N1 monovalent vaccines), A/Perth/16/2009 (H3N2)-like, and B/Brisbane/60/2008-like antigens be used; 4) information about Fluzone High-Dose, a newly approved vaccine for persons aged >or=65 years; and 5) information about other standard-dose newly approved influenza vaccines and previously approved vaccines with expanded age indications. Vaccination efforts should begin as soon as the 2010-11 seasonal influenza vaccine is available and continue through the influenza season. These recommendations also include a summary of safety data for U.S.-licensed influenza vaccines. These recommendations and other information are available at CDC's influenza website (http://www.cdc.gov/flu); any updates or supplements that might be required during the 2010-11 influenza season also will be available at this website. Recommendations for influenza diagnosis and antiviral use will be published before the start of the 2010-11 influenza season. Vaccination and health-care providers should be alert to announcements of recommendation updates and should check the CDC influenza website periodically for additional information.

PMID 20689501  MMWR Recomm Rep. 2010 Aug 6;59(RR-8):1-62.
著者: S A Moberley, J Holden, D P Tatham, R M Andrews
雑誌名: Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000422. doi: 10.1002/14651858.CD000422.pub2. Epub 2008 Jan 23.
Abstract/Text BACKGROUND: Diseases caused by Streptococcus pneumoniae(S. pneumoniae) continue to cause substantial morbidity and mortality throughout the world. Whilst pneumococcal polysaccharide vaccines (PPV) have the potential to prevent disease and death, the degree of protection afforded against various clinical endpoints and within different populations is uncertain.
OBJECTIVES: To assess the effectiveness of PPV in preventing disease or death in adults. Adverse events were not assessed.
SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 2); MEDLINE (January 1966 to June 2007); and EMBASE (1974 to June 2007).
SELECTION CRITERIA: A) Randomised controlled trials (RCTs) comparing PPV with placebo, control vaccines, or no intervention.B) Non-RCTs assessing PPV effectiveness against invasive pneumococcal disease (IPD).
DATA COLLECTION AND ANALYSIS: A) RCTs: trial quality assessment was conducted by two review authors and data extracted by three authors; odds ratios (OR) and 95% confidence intervals (CI) were estimated using a random-effects model.B) Non-RCTs: study quality, including measures to control for confounding, was assessed and data extracted by two review authors; OR and 95% CI were calculated using a random-effects model following the conversion of each study outcome to a log OR and standard error.
MAIN RESULTS: Twenty-two studies met our inclusion criteria (15 RCTs involving 48,656 participants and 7 non-RCTs involving 62,294 participants). Meta-analysis of the RCTs found strong evidence of PPV efficacy against IPD with no statistical heterogeneity (OR 0.26, 95% CI 0.15 to 0.46; random-effects model, I-squared (I(2)) = 0%). Efficacy against all cause pneumonia was inconclusive with substantial statistical heterogeneity (OR 0.71, 95% CI 0.52 to 0.97; random-effects model, I(2) = 87.3%). PPV was not associated with substantial reductions in all-cause mortality (OR 0.87, 95% CI 0.69 to 1.10; random-effects model, I(2) = 75.3%). Vaccine efficacy against primary outcomes appeared poorer in adults with chronic illness but the difference was not statistically significant. Non-RCTs provided evidence for protection against IPD in populations for whom the vaccine is currently utilised (OR 0.48, 95% CI 0.37 to 0.61; random-effects model, I(2) = 31.4%).
AUTHORS' CONCLUSIONS: This meta-analysis provides evidence supporting the recommendation for PPV to prevent IPD in adults. The evidence from RCTs is less clear with respect to adults with chronic illness. This might be because of lack of effect or lack of power in the studies. The meta-analysis does not provide compelling evidence to support the routine use of PPV to prevent all-cause pneumonia or mortality.

PMID 18253977  Cochrane Database Syst Rev. 2008 Jan 23;(1):CD000422. d・・・
著者: Takaya Maruyama, Osamu Taguchi, Michael S Niederman, John Morser, Hiroyasu Kobayashi, Tetsu Kobayashi, Corina D'Alessandro-Gabazza, Sei Nakayama, Kimiaki Nishikubo, Takashi Noguchi, Yoshiyuki Takei, Esteban C Gabazza
雑誌名: BMJ. 2010 Mar 8;340:c1004. Epub 2010 Mar 8.
Abstract/Text OBJECTIVE: To determine the efficacy of a 23-valent pneumococcal polysaccharide vaccine in people at high risk of pneumococcal pneumonia.
DESIGN: Prospective, randomised, placebo controlled double blind study.
SETTING: Nursing homes in Japan.
PARTICIPANTS: 1006 nursing home residents.
INTERVENTIONS: Participants were randomly allocated to either 23-valent pneumococcal polysaccharide vaccine (n=502) or placebo (n=504).
MAIN OUTCOME MEASURES: The primary end points were the incidence of all cause pneumonia and pneumococcal pneumonia. Secondary end points were deaths from pneumococcal pneumonia, all cause pneumonia, and other causes.
RESULTS: Pneumonia occurred in 63 (12.5%) participants in the vaccine group and 104 (20.6%) in the placebo group. Pneumococcal pneumonia was diagnosed in 14 (2.8%) participants in the vaccine group and 37 (7.3%) in the placebo group (P<0.001). All cause pneumonia and pneumococcal pneumonia were significantly more frequent in the placebo group than in the vaccine group: incidence per 1000 person years 55 v 91 (P<0.0006) and 12 v 32 (P<0.001), respectively. Death from pneumococcal pneumonia was significantly higher in the placebo group than in the vaccine group (35.1% (13/37) v 0% (0/14), P<0.01). The death rate from all cause pneumonia (vaccine group 20.6% (13/63) v placebo group 25.0% (26/104), P=0.5) and from other causes (vaccine group 17.7% (89/502) v placebo group (80/504) 15.9%, P=0.4) did not differ between the two study groups.
CONCLUSION: The 23-valent pneumococcal polysaccharide vaccine prevented pneumococcal pneumonia and reduced mortality from pneumococcal pneumonia in nursing home residents. Trial registration Japan Medical Association Center for Clinical Trials JMA-IIA00024.

PMID 20211953  BMJ. 2010 Mar 8;340:c1004. Epub 2010 Mar 8.
著者: Miwako Kobayashi, Nancy M Bennett, Ryan Gierke, Olivia Almendares, Matthew R Moore, Cynthia G Whitney, Tamara Pilishvili
雑誌名: MMWR Morb Mortal Wkly Rep. 2015 Sep 4;64(34):944-7. doi: 10.15585/mmwr.mm6434a4. Epub 2015 Sep 4.
Abstract/Text Two pneumococcal vaccines are currently licensed for use in the United States: the 13-valent pneumococcal conjugate vaccine (PCV13 [Prevnar 13, Wyeth Pharmaceuticals, Inc., a subsidiary of Pfizer Inc.]) and the 23-valent pneumococcal polysaccharide vaccine (PPSV23 [Pneumovax 23, Merck and Co., Inc.]). The Advisory Committee on Immunization Practices (ACIP) currently recommends that a dose of PCV13 be followed by a dose of PPSV23 in all adults aged ≥65 years who have not previously received pneumococcal vaccine and in persons aged ≥2 years who are at high risk for pneumococcal disease because of underlying medical conditions (Table) (1-4). The recommended intervals between PCV13 and PPSV23 given in series differ by age and risk group and the order in which the two vaccines are given (1-4).

PMID 26334788  MMWR Morb Mortal Wkly Rep. 2015 Sep 4;64(34):944-7. doi・・・
著者: J P Nuorti, J C Butler, M M Farley, L H Harrison, A McGeer, M S Kolczak, R F Breiman
雑誌名: N Engl J Med. 2000 Mar 9;342(10):681-9. doi: 10.1056/NEJM200003093421002.
Abstract/Text BACKGROUND: Approximately half of otherwise healthy adults with invasive pneumococcal disease are cigarette smokers. We conducted a population-based case-control study to assess the importance of cigarette smoking and other factors as risk factors for pneumococcal infections.
METHODS: We identified immunocompetent patients who were 18 to 64 years old and who had invasive pneumococcal disease (as defined by the isolation of Streptococcus pneumoniae from a normally sterile site) by active surveillance of laboratories in metropolitan Atlanta, Baltimore, and Toronto. Telephone interviews were conducted with 228 patients and 301 control subjects who were reached by random-digit dialing.
RESULTS: Fifty-eight percent of the patients and 24 percent of the control subjects were current smokers. Invasive pneumococcal disease was associated with cigarette smoking (odds ratio, 4.1; 95 percent confidence interval, 2.4 to 7.3) and with passive smoking among nonsmokers (odds ratio, 2.5; 95 percent confidence interval, 1.2 to 5.1) after adjustment by logistic-regression analysis for age, study site, and independent risk factors such as male sex, black race, chronic illness, low level of education, and living with young children who were in day care. There were dose-response relations for the current number of cigarettes smoked per day, pack-years of smoking, and time since quitting. The adjusted population attributable risk was 51 percent for cigarette smoking, 17 percent for passive smoking, and 14 percent for chronic illness.
CONCLUSIONS: Cigarette smoking is the strongest independent risk factor for invasive pneumococcal disease among immunocompetent, nonelderly adults. Because of the high prevalence of smoking and the large population attributable risk, programs to reduce both smoking and exposure to environmental tobacco smoke have the potential to reduce the incidence of pneumococcal disease.

PMID 10706897  N Engl J Med. 2000 Mar 9;342(10):681-9. doi: 10.1056/NE・・・
著者: David Greenberg, Noga Givon-Lavi, Arnon Broides, Irena Blancovich, Nechama Peled, Ron Dagan
雑誌名: Clin Infect Dis. 2006 Apr 1;42(7):897-903. doi: 10.1086/500935. Epub 2006 Feb 16.
Abstract/Text BACKGROUND: Exposure to tobacco smoke is associated with higher risk of Streptococcus pneumoniae and Haemophilus influenzae infection. The aim of this study was to determine the influence of smoking and exposure to tobacco smoke on S. pneumoniae and H. influenzae carriage rates in children and their mothers.
PATIENTS AND METHODS: We performed a cross-sectional surveillance study of nasopharyngeal and oropharyngeal carriage of S. pneumoniae and H. influenzae in 208 children aged <60 months and their mothers. Smoking exposure and medical history were recorded. Carriage rates for children and their mothers in nasopharyngeal and oropharyngeal specimens were analyzed on the basis of smoking exposure.
RESULTS: The S. pneumoniae carriage rate was higher among children exposed to smoking than among nonexposed children (76% vs. 60%; P=.016). Exposed children more frequently carried S. pneumoniae serotypes included in the conjugate 7-valent vaccine, compared with nonexposed children (49% vs. 30% of all S. pneumoniae-positive nasopharyngeal cultures; P=.02). Carriage rates of S. pneumoniae were higher among mothers who smoked than among mothers exposed to smoking and among nonexposed mothers (32%, 15%, and 12%, respectively; P=.03). There were no differences in H. influenzae carriage rates between children and mothers from smoking and nonsmoking families.
CONCLUSIONS: Exposure to tobacco smoke increased S. pneumoniae carriage rates in general and for carriage of serotypes included in the conjugate 7-valent vaccine in particular in children. Smoking mothers had a higher S. pneumoniae carriage rate than did nonsmoking mothers. Smoking or exposure to smoking did not increase H. influenzae carriage rates in children and mothers.

PMID 16511750  Clin Infect Dis. 2006 Apr 1;42(7):897-903. doi: 10.1086・・・
著者: T J Marrie
雑誌名: Clin Infect Dis. 1994 Apr;18(4):501-13; quiz 514-5.
Abstract/Text
PMID 8038304  Clin Infect Dis. 1994 Apr;18(4):501-13; quiz 514-5.

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