作者:刘庆华 单位:同济大学附属东方医院呼吸与危重症医学科 一、概述 军团菌类型分为:①嗜肺军团菌:尤其1型是最常见的军团菌肺炎菌种;②非嗜肺军团菌:可引起严重免疫抑制患者的肺部感染。采用常规检测方法可能会导致漏诊,因此需要辅以一些新的检测手段。 二、危险因素 1995—2016年14个国家52个中心对80例(主要来自法国、意大利和西班牙)患者的研究发现,19例(23.8%)患者早期出现军团病(移植后1~30天);从造血干细胞移植(HSCT)到军团病的中位时间为203天(范围0~4099天),异体移植后患者以男性为主(70%),中位年龄为46.6岁(范围7.2~68.2)。27例(33.8%)患者死于军团病(44%);异体HSCT(OR 2.27,95%CI 1.08~4.80,P=0.03)和既往其他感染(OR 2.96,95CI 1.34~6.52,P=0.007)是死亡的独立预测因子。该研究得出结论:军团病是移植后罕见的并发症,主要发生在移植后30天内,并伴有高病死率。HSCT后,在早期(0~15天)可能会有感染的爆发,但随着时间的延长,军团病的发生率会越来越低。 三、临床表现 四、影像学 五、诊断 2017年,Cunha教授又对上述6项评分进行了更新:①体温>38.9℃(伴相对缓脉);②ESR>90 mm/h或CRP>180 mg/L;③铁蛋白高于正常值2倍;④低磷血症;⑤磷酸激酶升高>2倍;⑥入院时镜下血尿。【注:如有大于其中3项,则高度怀疑军团菌肺炎】 六、治疗相关问题 免疫功能低下宿主更容易发生重症军团菌肺炎,此类患者的病死率会显著增加。一项研究纳入了43例重症患者,其中14例(33%)死于重症军团菌肺炎,29例存活。38例(88%)接受氟喹诺酮类药物联合大环内酯类药物治疗,2例单独使用红霉素,3例单独使用氧氟沙星。SAPSⅡ评分>46分[OR 8.69;95%CI 1.15~66.7;P=0.036],入院前症状持续时间超过5天(OR 7.46;95%CI 1.17~47.6)是死亡的独立危险因素。到达ICU后8小时内给予氟喹诺酮类药物(OR 0.16;95%CI 0.03~0.96;P=0.035)与死亡率降低有关,也提示我们此类患者应尽可能早覆盖。 七、小结 参考文献(向下滑动查看全部文献) [1] Fields BS, Benson RF, Besser RE. Legionella and Legionnaires' disease: 25 years of investigation[J]. Clin Microbiol Rev, 2002, 15(3):506-526. [2] Mikulska M, Tridello G, Hoek J, et al. Legionellosis after hematopoietic stem cell transplantation[J]. Bone Marrow Transplant, 2021, 56(10):2555-2566. [3] Aga M, Shiba A, Hamakawa Y, et al. Legionella pneumophila pneumonia with rapid clinical course in a lung cancer patient[J]. Respirol Case Rep, 2021, 9(11):e0850 [4] del Castillo M, Lucca A, Plodkowski A, et al. Atypical presentation of Legionella pneumonia among patients with underlying cancer: a fifteen-year review[J]. J Infect, 2016, 72(1):45-51. [5] Chow JW, Yu VL. Legionella: a major opportunistic pathogen in transplant recipients[J]. Semin Respir Infect, 1998,13(2):132-139. [6] Viasus D, Gaia V, Manzur-Barbur C, et al. Legionnaires' Disease: Update on Diagnosis and Treatment. Infect Dis Ther, 2022, 11(3):973-986. [7] Jasper AS, Musuuza JS, Tischendorf JS, et al. Are fluoroquinolones or macrolides better for treating Legionella Pneumonia? A systematic review and meta-analysis[J]. Clin Infect Dis, 2021, 72:1979-1989. [8] Kato H, Hagihara M, Asai N, et al. Meta-analysis of fluoroquinolones versus macrolides for treatment of Legionella pneumonia[J]. J Infect Chemother, 2021, 27:424-433. [9] Baltch AL, Smith RP, Ritz W. Inhibitory and bactericidal activities of levofloxacin, ofloxacin, erythromycin, and rifampin used singly and in combination against Legionella pneumophila[J]. Antimicrob Agents Chemother, 1995, 39:1661-1666. [10] Descours G, Ginevra C, Ader F, et al. Rifampicin-macrolide synergy against Legionella pneumophila serogroup 1 in human macrophages using a quantitative real-time PCR assay[J]. Int J Antimicrob Agents, 2011, 38:188-189. [11] Varner TR, Bookstaver PB, Rudisill CN, et al. Role of rifampin-based combination therapy for severe community-acquired Legionella pneumophila pneumonia[J]. Ann Pharmacother, 2011, 45:967-976. [12] Amsden GW. Treatment of Legionnaires' disease[J]. Drugs, 2005, 65:605-614. [13] Chahin A, Opal SM. Severe pneumonia caused by Legionella pneumophila: differential diagnosis and therapeutic considerations[J]. Infect Dis Clin N Am, 2017, 31:111-121. [14] Lanternier F, Ader F, Pilmis B, et al. Legionnaires' disease in compromised hosts[J]. Infect Dis Clin N Am, 2017, 31:123-135. [15] Blázquez-Garrido RM, Espinosa-Parra FJ, Alemany-Francés L, et al. Antimicrobial chemotherapy for Legionnaires disease: levofloxacin versus macrolides[J]. Clin Infect Dis, 2005, 40:800-806. [16] Heath CH, Grove DI, Looke DF. Delay in appropriate therapy of Legionella pneumonia associated with increased mortality[J]. Eur J Clin Microbiol Infect Dis, 1996, 15(4):286-290. [17] Gacouin A, Le Tulzo Y, Lavoue S, et al. Severe pneumonia due to Legionella pneumophila: prognostic factors, impact of delayed appropriate antimicrobial therapy[J]. Intensive Care Med, 2002, 28(6):686-691. 作者简介
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