流行病学
非典型细菌性病原体是下呼吸道疾病(包括社区获得性肺炎)相对常见的病因。[1]Marchello C, Dale AP, Thai TN, et al. Prevalence of atypical pathogens in patients with cough and community-acquired pneumonia: a meta-analysis. Ann Fam Med. 2016 Nov;14(6):552-66. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389400/ http://www.ncbi.nlm.nih.gov/pubmed/28376442?tool=bestpractice.com 社区获得性肺炎中,非典型病原体的全球发病率约为 22%,但此病的发病率因地区而异。[2]Arnold FW, Summersgill JT, Ramirez JA. Role of atypical pathogens in the etiology of community-acquired pneumonia. Semin Respir Crit Care Med. 2016 Dec;37(6):819-28. http://www.ncbi.nlm.nih.gov/pubmed/27960206?tool=bestpractice.com
高达 20% 的社区获得性肺炎病例由肺炎支原体感染引发,并且肺炎支原体可导致基于医院的流行。肺炎支原体感染常见于儿童和年轻成人,并且往往见于关系密切的社会机构,如寄宿学校、大学和军事基地。[3]Jain S, Williams DJ, Arnold SR, et al; CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among US children. N Engl J Med. 2015 Feb 26;372(9):835-45. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4697461/ http://www.ncbi.nlm.nih.gov/pubmed/25714161?tool=bestpractice.com 这是在 ≥5 岁、因社区获得性肺炎住院的儿童中最常检出的细菌。[4]Kutty PK, Jain S, Taylor TH, et al. Mycoplasma pneumoniae among children hospitalized with community-acquired pneumonia. Clin Infect Dis. 2019 Jan 1;68(1):5-12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6552676/ http://www.ncbi.nlm.nih.gov/pubmed/29788037?tool=bestpractice.com 在夏末或秋季,发病率相对增加。每隔 3-6 年出现流行。[1]Marchello C, Dale AP, Thai TN, et al. Prevalence of atypical pathogens in patients with cough and community-acquired pneumonia: a meta-analysis. Ann Fam Med. 2016 Nov;14(6):552-66. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389400/ http://www.ncbi.nlm.nih.gov/pubmed/28376442?tool=bestpractice.com 先前暴露于病原体具有保护性作用,而吸烟会增加感染风险。[5]Waites KB, Talkington DF. Mycoplasma pneumoniae and its role as a human pathogen. Clin Microbiol Rev. 2004;17:697-728. http://www.ncbi.nlm.nih.gov/pubmed/15489344?tool=bestpractice.com [6]File TM. Community-acquired pneumonia. Lancet. 2003 Dec 13;362(9400):1991-2001. http://www.ncbi.nlm.nih.gov/pubmed/14683661?tool=bestpractice.com [7]Klement E, Talkington DF, Wasserzug O, et al. Identification of risk factors for infection in an outbreak of Mycoplasma pneumoniae respiratory tract disease. Clin Infect Dis. 2006;43:1239-45. http://www.ncbi.nlm.nih.gov/pubmed/17051486?tool=bestpractice.com [8]Feikin DR, Moroney JF, Talkington DF, et al. An outbreak of acute respiratory disease caused by Mycoplasma pneumoniae and adenovirus at a federal service training academy: new implications from an old scenario. Clin Infect Dis. 1999;29:1545-50. http://www.ncbi.nlm.nih.gov/pubmed/10585810?tool=bestpractice.com
3.5%-10% 的社区获得性肺炎病例由肺炎衣原体感染所致。和肺炎支原体一样,感染主要发生于儿童和年轻成人,并且与关系密切的社会机构有关。[1]Marchello C, Dale AP, Thai TN, et al. Prevalence of atypical pathogens in patients with cough and community-acquired pneumonia: a meta-analysis. Ann Fam Med. 2016 Nov;14(6):552-66. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389400/ http://www.ncbi.nlm.nih.gov/pubmed/28376442?tool=bestpractice.com [3]Jain S, Williams DJ, Arnold SR, et al; CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among US children. N Engl J Med. 2015 Feb 26;372(9):835-45. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4697461/ http://www.ncbi.nlm.nih.gov/pubmed/25714161?tool=bestpractice.com [6]File TM. Community-acquired pneumonia. Lancet. 2003 Dec 13;362(9400):1991-2001. http://www.ncbi.nlm.nih.gov/pubmed/14683661?tool=bestpractice.com [9]File TM Jr, Tan JS. Chlamydia pneumoniae pneumonia. Semin Respir Critical Care Med. 2000;21(4):285-94. http://www.ncbi.nlm.nih.gov/pubmed/16088739?tool=bestpractice.com [10]Conklin L, Adjemian J, Loo J, et al. Investigation of a Chlamydia pneumoniae outbreak in a Federal correctional facility in Texas. Clin Infect Dis. 2013 Sep;57(5):639-47. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4678872/ http://www.ncbi.nlm.nih.gov/pubmed/23723194?tool=bestpractice.com 荷兰的一项研究通过痰液聚合酶链反应 (PCR)(在可操作时)发现鹦鹉热衣原体造成了 4.8% 的社区获得性肺炎,高于先前报道的数据 (2.1%)。[11]Spoorenberg SM, Bos WJ, van Hannen EJ, et al. Chlamydia psittaci: a relevant cause of community-acquired pneumonia in two Dutch hospitals. Neth J Med. 2016 Feb;74(2):75-81. http://www.njmonline.nl/getpdf.php?id=1676 http://www.ncbi.nlm.nih.gov/pubmed/26951352?tool=bestpractice.com
嗜肺军团菌感染导致的社区获得性肺炎比例较低(约 2.7%),[1]Marchello C, Dale AP, Thai TN, et al. Prevalence of atypical pathogens in patients with cough and community-acquired pneumonia: a meta-analysis. Ann Fam Med. 2016 Nov;14(6):552-66. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5389400/ http://www.ncbi.nlm.nih.gov/pubmed/28376442?tool=bestpractice.com 但有高达 16% 需要住院治疗的病例由此引起。通常与暴露于淋浴或冷却系统中的新雾化水来源有关。已知的危险因素包括吸烟、慢性肺疾病、免疫抑制和免疫调节药物。[12]Lanternier F, Tubach F, Ravaud P, et al. Incidence and risk factors of Legionella pneumophila pneumonia during anti-tumor necrosis factor therapy: a prospective French study. Chest. 2013 Sep;144(3):990-8. http://www.ncbi.nlm.nih.gov/pubmed/23744173?tool=bestpractice.com 它可能与最近旅行有关,男性更易感。[6]File TM. Community-acquired pneumonia. Lancet. 2003 Dec 13;362(9400):1991-2001. http://www.ncbi.nlm.nih.gov/pubmed/14683661?tool=bestpractice.com [13]Arcavi L, Benowitz NL. Cigarette smoking and infection. Arch Intern Med. 2004;164:2206-16. http://www.ncbi.nlm.nih.gov/pubmed/15534156?tool=bestpractice.com [14]Den Boer JW, Nijhof J, Friesema I. Risk factors for sporadic community-acquired Legionnaires' disease. A 3-year national case-control study. Public Health. 2006 Jun;120(6):566-71. http://www.ncbi.nlm.nih.gov/pubmed/16707144?tool=bestpractice.com [15]England AC III, Fraser DW, Plikaytis BD, et al. Sporadic legionellosis in the United States: the first thousand cases. Ann Intern Med. 1981 Feb;94(2):164-70. http://www.ncbi.nlm.nih.gov/pubmed/7469207?tool=bestpractice.com
病毒(包括流感、腺病毒、呼吸合胞病毒,以及其他病毒)可能会引起肺炎,符合非典型细菌性肺炎的特点,占社区获得性肺炎患者 25%。[16]von Baum H, Schweiger B, Welte T, et al; the THE CAPNETZ STUDY GROUP. How deadly is seasonal influenza associated pneumonia? The German Competence Network for Community-acquired pneumonia (CAPNETZ). Eur Respir J. 2011 May;37(5):1151-7. https://erj.ersjournals.com/content/37/5/1151.long http://www.ncbi.nlm.nih.gov/pubmed/20817703?tool=bestpractice.com [17]Niederman MS. Viral community-acquired pneumonia: if we do not diagnose it and do not treat it, can it still hurt us? Chest. 2010 Oct;138(4):767-9. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7130252/ http://www.ncbi.nlm.nih.gov/pubmed/20923793?tool=bestpractice.com [18]Metlay JP, Waterer GW, Long AC, et al. Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical practice guideline of the American Thoracic Society and Infectious Diseases Society of America. Am J Respir Crit Care Med. 2019 Oct 1;200(7):e45-67. https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST http://www.ncbi.nlm.nih.gov/pubmed/31573350?tool=bestpractice.com [19]Lieberman D, Shimoni A, Shemer-Avni Y, et al. Respiratory viruses in adults with community-acquired pneumonia. Chest. 2010 Oct;138(4):811-6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7094496/ http://www.ncbi.nlm.nih.gov/pubmed/20363845?tool=bestpractice.com 一项系统评价显示,流行性感冒病毒是社区获得性肺炎成人患者中最常发现的病毒,占病例的 9%。[20]Alimi Y, Lim WS, Lansbury L, et al. Systematic review of respiratory viral pathogens identified in adults with community-acquired pneumonia in Europe. J Clin Virol. 2017 Oct;95:26-35. http://www.ncbi.nlm.nih.gov/pubmed/28837859?tool=bestpractice.com
大约 1%的肺炎病例由贝氏柯克斯体感染所致;然而,在源自牲畜的气溶胶高暴露地区,其发病率更高。它是在欧洲和加拿大某些地区更常见的肺炎病因。[21]Marrie TJ. Coxiella burnetii pneumonia. Eur Respir J. 2003 Apr;21(4):713-9. https://erj.ersjournals.com/content/21/4/713.long http://www.ncbi.nlm.nih.gov/pubmed/12762362?tool=bestpractice.com
社区获得性肺炎的具体病因可因季节、位置和年龄而异。[3]Jain S, Williams DJ, Arnold SR, et al; CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among US children. N Engl J Med. 2015 Feb 26;372(9):835-45. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4697461/ http://www.ncbi.nlm.nih.gov/pubmed/25714161?tool=bestpractice.com [22]Gadsby NJ, Russell CD, McHugh MP, et al. Comprehensive molecular testing for respiratory pathogens in community-acquired pneumonia. Clin Infect Dis. 2016 Apr 1;62(7):817-23. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4787606/ http://www.ncbi.nlm.nih.gov/pubmed/26747825?tool=bestpractice.com [23]Jain S, Self WH, Wunderink RG, et al; CDC EPIC Study Team. Community-acquired pneumonia requiring hospitalization among US adults. N Engl J Med. 2015 Jul 30;373(5):415-27. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4728150/ http://www.ncbi.nlm.nih.gov/pubmed/26172429?tool=bestpractice.com [24]Dumke R, Schnee C, Pletz MW, et al; Capnetz Study Group. Mycoplasma pneumoniae and Chlamydia spp. infection in community-acquired pneumonia, Germany, 2011-2012. Emerg Infect Dis. 2015 Mar;21(3):426-34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4344269/ http://www.ncbi.nlm.nih.gov/pubmed/25693633?tool=bestpractice.com
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