국내 지역사회획득 폐렴과 비교한 요양기관관련 폐렴의 임상적 특징

Abstract

본 연구의 내용을 요약하자면 요양기관관련 폐렴의 경우 지역사회획득 폐렴과 비교하여 서로 다른 임상적 특징을 보여주었다. 하지만 원내사망률의 경우 폐렴의 종류와 상관없이 폐렴의 중증도에 따라 증가하는 것을 확인할 수 있었으며 두 군 모두 streptococcus pneumonia 가 가장 높은 빈도로 동정되었다. 2005년 미국흉부학회/감염학회 진료지침에서 anti-pseudomonal agents를 권고하고 있으나 이는 한국에서의 의료실정에 맞게 검토 되어야 할 것으로 보인다. 본 연구에서 병원성폐렴에 준해 치료해야 할 적응증을 분명하게 제시하지는 못하였기 때문에 요양기관 관련 폐렴과 관련하여 대규모의 코호트 연구가 필요할 것으로 생각된다.

Background: In 2005, the new concept of healthcare-associated pneumonia (HCAP) was introduced. However, HCAP is heterogeneous, clinical features and outcomes are different from region to region. Especially, the optimal strategy for treatment of nursing home acquired pneumonia (NHAP) which is a category of HCAP was controversial among several studies. We aimed to evaluate the clinical features of NHAP patients compared to CAP. Methods: This study was retrospectively conducted in patients with NHAP or CAP that were hospitalized in Jeju national university hospital between January 2012 and December 2012. Results: A total of 283 patients were enrolled and 66(23.3%) had NHAP. Comparing to the CAP group, The median age of the NHAP group was higher than the CAP group (80 vs. 71; p < 0.001). The NHAP group had more frequent CNS disorders, and showed worse clinical parameters such as confusion, respiratory failure and septic shock at onset than the CAP group. The rates of patients with CURB-65 scores of 3 or more (31.8% vs. 17.0%; p = 0.014) and PSI class IV or more (77.2% vs. 57.1%; p = 0.003) were higher in the NHAP group. Although potentially drug resistant pathogens were more frequently detected in the NHAP group (18.1% vs. 7.8%; p < 0.015), Pseudomonas aeruginosa were not significantly different from the rates of isolation in between both group (10.6% vs. 4.1%; p = 0.065). And the pathogen isolated most frequently in both groups was Streptococcus pneumoniae. Multivariable analyses failed to show that the pneumonia type was a prognostic factor for mortality. Only high PSI score was associated with increased mortality (p < 0.001). Conclusions: In patients admitted with NHAP or CAP, the risk of excess mortality seems to be related to underlying patient-related factors rather than the type of pneumonia or the presence of antibiotic-resistant pathogens. We suggested that the empirical treatment of broad-spectrum anti-pseudomonal agents in NHAP should be reserved for patients with severe pneumonia or at high risk of MDR bacterial infection.