Discussion 考察
In this study, we found that S. pneumoniae was the most frequent causative pathogen in all HCAP groups as well as in the CAP group.
本研究では、CAP群と同様に全HCAP群で
肺炎連鎖球菌が最も頻度の高い起因菌だった
Importantly, we documented a low incidence of multidrug-resistant organisms.
重要なことは、多剤耐性微生物の低い発症率を証明したことだ
On the other hand, aspiration pneumonia was frequent, especially among patients who resided in a nursing home or long-term-care facility.
一方、誤嚥性肺炎は、とりわけ老人ホームまたは
介護施設に住む患者の間で頻度が高かった
This finding may be explained by the fact that these patients were older and more often had cerebrovascular diseases and
impaired consciousness at presentation.
この結果はこれらの患者が、より高齢で、
心血管疾患と診察時の意識障害の頻度がより多いことによって説明できる可能性がある
Difficulty in swallowing is relatively frequent among patients with these conditions, and they are more prone to aspiration [16].
飲み込み困難はこれらの状態の患者の間で
比較的頻度が多く、彼らはより誤嚥しやすい
The rate of atypical pathogens in patients with HCAP was low, reinforcing the concept that coverage of atypical pathogens in HCAP is not routinely needed.
HCAP患者における非定型病原体の割合は低くく、
HCAPにおいて非定型病原体の填補が必ずしも必要ないというコンセプトを補強する
Finally, L. pneumophila was more common in patients with CAP, probably reflecting the fact that this population is more frequently exposed to exogenous sources [17].
最後にCAP患者ではレジオネラニューモフィラがより多かった、おそらく
この集団が外因性の原因に曝露する頻度がより多いことを反映する
Our finding of a low incidence of multidrug-resistant organisms markedly differs from those of previous studies, mostly from the USA and Japan [3–5,18].
我々の多剤耐性菌の低い発生率の結果は、ほとんど米国と日本からの、以前の研究とは、著しく異なる
In these studies, the number of pneumonias caused by methicillin-resistant Staphylococcus aureus, P. aeruginosa and Enterobacteriaceae with varying levels of resistance was unexpectedly high, even in patients with CAP.
それらの研究では、メチシリン耐性黄色ブドウ球菌、緑膿菌、
さまざまなレベルの耐性をもつ腸内細菌科が原因の肺炎の数が、CAP患者でさえ予想外に高かった
In contrast, in a recent interesting study of 150 consecutive cases of
nursing home-acquired pneumonia documented over a 10-year period, Polverino et al. [19] found that S. pneumoniae was the most frequent causative agent (58% of cases), whereas methicillin-resistant Staphylococcus aureus and P. aeruginosa were less common (three cases and two cases, respectively).
対照的に、最近のPolverino らの10年間にわたって
老人ホーム施設内発症肺炎の150の継続症例の興味深い研究では、
肺炎連鎖球菌が原因菌で最も多く(症例の58%)
一方メチシリン耐性黄色ブドウ球菌と緑膿菌はより少なかった(各々3症例と2症例)
It is important to note that current data on the causative organisms of HCAP in the USA is mainly reported by retrospective studies that have retrieved the information from a database without the use of uniform criteria for
distinguishing colonization bacteria from pathogens [3–5,18].
米国でのHCAPの原因微生物の最近のデータは主に
病原体と定着菌を区別する統一基準の使用がないデーターベースからの情報を
検索する、後ろ向き研究によって
報告されていることに注意することは重要だ
Moreover, the definition of HCAP included immunocompromised patients in some studies [4,18].
さらにその上、HCAPの定義は複数の研究では免疫不全患者を含んでいた
On the other hand, the relevance of aspiration pneumonia could have been underestimated, because of the difficulties inherent in diagnosis.
一方、誤嚥性肺炎の関連性は診断に内在する困難のために、過小評価されてかた
可能性がある
Recognition of aspiration pneumonia requires a careful clinical evaluation when macroscopic aspiration is not observed.
マクロな誤嚥が観察されない時は、誤嚥性肺炎発症の認識には注意深い臨床的評価が
必要だ
Moreover, the results of microbiological studies are often negative, because the invasive procedures necessary to obtain a reliable diagnosis are not usually performed.
さらにその上、確定診断を得るために必要
な侵襲的手技を通常は実施しないため
微生物学的検査の結果は陰性が多い
Consequently, retrospective studies based on positive cultures are not able to detect this entity.
その結果、培養陽性に基づいた後ろ向き研究は
この実体を検出することができない
Patients with HCAP commonly present a worse clinical course than those with CAP, and a prolonged length of hospital stay [2–5].
HCAP患者は通常CAP患者よりも悪い臨床経過
と入院期間の延長を示す
In our study, patients who attended a
hospital or haemodialysis clinic or received intravenous chemotherapy in the 30 days before pneumonia (group 2) and those who resided in a nursing home or long-term-care facility (group 4) had significantly higher overall case-fatality rates than the remaining patients (9.1% and 19.8%, respectively).
我々の研究では、肺炎発症前の30日内に
病院または透析クリニックに通う、または点滴の化学療法を受けた患者(グループ2)と
老人ホームまたは介護施設に住む患者(グループ4)は、そうでない残りの患者よりも、
全致死率が有意に高かった 各々9.1% と 19.8%)
These two groups have the highest ages and the highest prevalence of comorbid conditions: cancer, chronic cardiac disease, chronic renal disease, and, especially,
cerebrovascular disease and dementia.
これら2つのグループは年齢がより高く、
並存疾患の有病率がより高かった:癌、慢性心臓病、慢性腎臓病、とりわけ脳血管疾患と認知症
These patients have a higher risk of aspiration pneumonia, which has been associated with poor clinical outcomes in a number of previous studies [19–22].
これらの患者は、多くの過去の研究において予後不良と関係があった
誤嚥性肺炎リスクがより高い
Some studies have found that patients with HCAP are more likely to receive inappropriate antimicrobial treatment than patients with CAP [3–5].
HCAP患者はCAP患者よりも不適切な抗菌剤治療を
受ける可能性がより多いことを示した複数の研究が
ある
In the present study, we did not find significant differences regarding inappropriate initial empirical therapy between the pneumonia groups.
本研究では、肺炎群の間で
不適切な初期エンピリック治療(診断確定の前に治療を開始する)に関する、
有意な差はみられなかった
This fact is probably related to the low frequency of multidrug-resistant pathogens isolated in our study.
この事実はおそらく、我々の研究における
多剤耐性病原体の低い頻度と関係がある
Interestingly, we found that the commonest type of pneumonia among patients with HCAP receiving inappropriate initial empirical antibiotic therapy was aspiration pneumonia.
興味深いことに、不適切な初期エンピリック抗菌剤治療を受けるHCAP患者の間で最も多いタイプの肺炎は誤嚥性肺炎だった
(難しいが、誤嚥性肺炎は、抗菌剤治療が
必要ないタイプがある。化学的肺炎。
他にも抗菌剤治療が必要でないケース)
This finding concurs with that of Polverino et al. [19], demonstrating that the lack of aspiration assessment was a frequent cause of treatment inadequacy.
この結果は、誤嚥評価の欠如が、不十分な治療の多い原因だったことを示した、
Polverinoらと一致する
Despite a number of strengths, our prospective observational study has certain limitations that should be acknowledged.
多くの強みにもかかわらず、我々の観察研究(横断研究)は、認識すべき特定の限界がある
The research was performed at a single Spanish institution, and the numbers of patients in some HCAP groups were relatively small.
この調査は単一のスペインの施設で実施され、複数のHCAP群の患者の数は小規模だった
Therefore, our results should be interpreted with caution, as different causative organisms and rates of antibiotic resistance may be encountered in other countries.
それゆえ他の国では、異なる起因微生物と耐性菌割合になる可能性があるため
我々の結果は注意深く解釈されるべきだろう
Finally, the rate of admission to the intensivecare unit and the requirement for mechanical ventilation was low.
最後に、集中治療施設への入院の割合と、人工換気治療の必要は低くかった
This might limit the applicability of our results.
このことが我々の結果の適応性を制限する可能性がある
It should be noted, however, that HCAP patients are significantly older than CAP patients.
しかしながらHCAP患者はCAP患者よりも
有意に高齢であることは明記されるべきだろう
In this regard, it has been shown that elderly patients are less frequently admitted to the intensive-care unit and less frequently undergo mechanical ventilation, probably because of the disappointing prognosis (16).
この点に関して、高齢患者は
おそらく予後不良の理由で
集中治療室への入院の頻度が少なく人工換気補助治療の
施行が少ない
In conclusion, our results highlight the heterogeneity of patients included in the current concept of HCAP.
結論として我々の結果は現在のHCAPの概念に含まれる患者の異質性を強調した
Significantly, we documented a low frequency of multidrug-resistant pathogens causing HCAP pneumonia in our area.
意義深いことに我々の地域でのHCAP肺炎の間で多剤耐性病原体の頻度が少ないことも文書化した
Our results argue in favour of individual evaluation of each patient's characteristics, and a targeted approach when selecting initial empirical antibiotic therapy. Most patients with HCAP may be treated in the same way as patients with CAP, after carefully ruling out the presence of aspiration pneumonia
In this study, we found that S. pneumoniae was the most frequent causative pathogen in all HCAP groups as well as in the CAP group.
本研究では、CAP群と同様に全HCAP群で
肺炎連鎖球菌が最も頻度の高い起因菌だった
Importantly, we documented a low incidence of multidrug-resistant organisms.
重要なことは、多剤耐性微生物の低い発症率を証明したことだ
On the other hand, aspiration pneumonia was frequent, especially among patients who resided in a nursing home or long-term-care facility.
一方、誤嚥性肺炎は、とりわけ老人ホームまたは
介護施設に住む患者の間で頻度が高かった
This finding may be explained by the fact that these patients were older and more often had cerebrovascular diseases and
impaired consciousness at presentation.
この結果はこれらの患者が、より高齢で、
心血管疾患と診察時の意識障害の頻度がより多いことによって説明できる可能性がある
Difficulty in swallowing is relatively frequent among patients with these conditions, and they are more prone to aspiration [16].
飲み込み困難はこれらの状態の患者の間で
比較的頻度が多く、彼らはより誤嚥しやすい
The rate of atypical pathogens in patients with HCAP was low, reinforcing the concept that coverage of atypical pathogens in HCAP is not routinely needed.
HCAP患者における非定型病原体の割合は低くく、
HCAPにおいて非定型病原体の填補が必ずしも必要ないというコンセプトを補強する
Finally, L. pneumophila was more common in patients with CAP, probably reflecting the fact that this population is more frequently exposed to exogenous sources [17].
最後にCAP患者ではレジオネラニューモフィラがより多かった、おそらく
この集団が外因性の原因に曝露する頻度がより多いことを反映する
Our finding of a low incidence of multidrug-resistant organisms markedly differs from those of previous studies, mostly from the USA and Japan [3–5,18].
我々の多剤耐性菌の低い発生率の結果は、ほとんど米国と日本からの、以前の研究とは、著しく異なる
In these studies, the number of pneumonias caused by methicillin-resistant Staphylococcus aureus, P. aeruginosa and Enterobacteriaceae with varying levels of resistance was unexpectedly high, even in patients with CAP.
それらの研究では、メチシリン耐性黄色ブドウ球菌、緑膿菌、
さまざまなレベルの耐性をもつ腸内細菌科が原因の肺炎の数が、CAP患者でさえ予想外に高かった
In contrast, in a recent interesting study of 150 consecutive cases of
nursing home-acquired pneumonia documented over a 10-year period, Polverino et al. [19] found that S. pneumoniae was the most frequent causative agent (58% of cases), whereas methicillin-resistant Staphylococcus aureus and P. aeruginosa were less common (three cases and two cases, respectively).
対照的に、最近のPolverino らの10年間にわたって
老人ホーム施設内発症肺炎の150の継続症例の興味深い研究では、
肺炎連鎖球菌が原因菌で最も多く(症例の58%)
一方メチシリン耐性黄色ブドウ球菌と緑膿菌はより少なかった(各々3症例と2症例)
It is important to note that current data on the causative organisms of HCAP in the USA is mainly reported by retrospective studies that have retrieved the information from a database without the use of uniform criteria for
distinguishing colonization bacteria from pathogens [3–5,18].
米国でのHCAPの原因微生物の最近のデータは主に
病原体と定着菌を区別する統一基準の使用がないデーターベースからの情報を
検索する、後ろ向き研究によって
報告されていることに注意することは重要だ
Moreover, the definition of HCAP included immunocompromised patients in some studies [4,18].
さらにその上、HCAPの定義は複数の研究では免疫不全患者を含んでいた
On the other hand, the relevance of aspiration pneumonia could have been underestimated, because of the difficulties inherent in diagnosis.
一方、誤嚥性肺炎の関連性は診断に内在する困難のために、過小評価されてかた
可能性がある
Recognition of aspiration pneumonia requires a careful clinical evaluation when macroscopic aspiration is not observed.
マクロな誤嚥が観察されない時は、誤嚥性肺炎発症の認識には注意深い臨床的評価が
必要だ
Moreover, the results of microbiological studies are often negative, because the invasive procedures necessary to obtain a reliable diagnosis are not usually performed.
さらにその上、確定診断を得るために必要
な侵襲的手技を通常は実施しないため
微生物学的検査の結果は陰性が多い
Consequently, retrospective studies based on positive cultures are not able to detect this entity.
その結果、培養陽性に基づいた後ろ向き研究は
この実体を検出することができない
Patients with HCAP commonly present a worse clinical course than those with CAP, and a prolonged length of hospital stay [2–5].
HCAP患者は通常CAP患者よりも悪い臨床経過
と入院期間の延長を示す
In our study, patients who attended a
hospital or haemodialysis clinic or received intravenous chemotherapy in the 30 days before pneumonia (group 2) and those who resided in a nursing home or long-term-care facility (group 4) had significantly higher overall case-fatality rates than the remaining patients (9.1% and 19.8%, respectively).
我々の研究では、肺炎発症前の30日内に
病院または透析クリニックに通う、または点滴の化学療法を受けた患者(グループ2)と
老人ホームまたは介護施設に住む患者(グループ4)は、そうでない残りの患者よりも、
全致死率が有意に高かった 各々9.1% と 19.8%)
These two groups have the highest ages and the highest prevalence of comorbid conditions: cancer, chronic cardiac disease, chronic renal disease, and, especially,
cerebrovascular disease and dementia.
これら2つのグループは年齢がより高く、
並存疾患の有病率がより高かった:癌、慢性心臓病、慢性腎臓病、とりわけ脳血管疾患と認知症
These patients have a higher risk of aspiration pneumonia, which has been associated with poor clinical outcomes in a number of previous studies [19–22].
これらの患者は、多くの過去の研究において予後不良と関係があった
誤嚥性肺炎リスクがより高い
Some studies have found that patients with HCAP are more likely to receive inappropriate antimicrobial treatment than patients with CAP [3–5].
HCAP患者はCAP患者よりも不適切な抗菌剤治療を
受ける可能性がより多いことを示した複数の研究が
ある
In the present study, we did not find significant differences regarding inappropriate initial empirical therapy between the pneumonia groups.
本研究では、肺炎群の間で
不適切な初期エンピリック治療(診断確定の前に治療を開始する)に関する、
有意な差はみられなかった
This fact is probably related to the low frequency of multidrug-resistant pathogens isolated in our study.
この事実はおそらく、我々の研究における
多剤耐性病原体の低い頻度と関係がある
Interestingly, we found that the commonest type of pneumonia among patients with HCAP receiving inappropriate initial empirical antibiotic therapy was aspiration pneumonia.
興味深いことに、不適切な初期エンピリック抗菌剤治療を受けるHCAP患者の間で最も多いタイプの肺炎は誤嚥性肺炎だった
(難しいが、誤嚥性肺炎は、抗菌剤治療が
必要ないタイプがある。化学的肺炎。
他にも抗菌剤治療が必要でないケース)
This finding concurs with that of Polverino et al. [19], demonstrating that the lack of aspiration assessment was a frequent cause of treatment inadequacy.
この結果は、誤嚥評価の欠如が、不十分な治療の多い原因だったことを示した、
Polverinoらと一致する
Despite a number of strengths, our prospective observational study has certain limitations that should be acknowledged.
多くの強みにもかかわらず、我々の観察研究(横断研究)は、認識すべき特定の限界がある
The research was performed at a single Spanish institution, and the numbers of patients in some HCAP groups were relatively small.
この調査は単一のスペインの施設で実施され、複数のHCAP群の患者の数は小規模だった
Therefore, our results should be interpreted with caution, as different causative organisms and rates of antibiotic resistance may be encountered in other countries.
それゆえ他の国では、異なる起因微生物と耐性菌割合になる可能性があるため
我々の結果は注意深く解釈されるべきだろう
Finally, the rate of admission to the intensivecare unit and the requirement for mechanical ventilation was low.
最後に、集中治療施設への入院の割合と、人工換気治療の必要は低くかった
This might limit the applicability of our results.
このことが我々の結果の適応性を制限する可能性がある
It should be noted, however, that HCAP patients are significantly older than CAP patients.
しかしながらHCAP患者はCAP患者よりも
有意に高齢であることは明記されるべきだろう
In this regard, it has been shown that elderly patients are less frequently admitted to the intensive-care unit and less frequently undergo mechanical ventilation, probably because of the disappointing prognosis (16).
この点に関して、高齢患者は
おそらく予後不良の理由で
集中治療室への入院の頻度が少なく人工換気補助治療の
施行が少ない
In conclusion, our results highlight the heterogeneity of patients included in the current concept of HCAP.
結論として我々の結果は現在のHCAPの概念に含まれる患者の異質性を強調した
Significantly, we documented a low frequency of multidrug-resistant pathogens causing HCAP pneumonia in our area.
意義深いことに我々の地域でのHCAP肺炎の間で多剤耐性病原体の頻度が少ないことも文書化した
Our results argue in favour of individual evaluation of each patient's characteristics, and a targeted approach when selecting initial empirical antibiotic therapy. Most patients with HCAP may be treated in the same way as patients with CAP, after carefully ruling out the presence of aspiration pneumonia