317.2 🩺 國考版

317.2.1 高頻考點

317.2.1.1 Pathogens

  • S. pneumoniae (most common bacterial)
  • M. pneumoniae, C. pneumoniae (atypicals, young)
  • Legionella (severe, water, atypical features + hyponatremia)
  • H. influenzae (COPD)
  • S. aureus (post-flu, IVDU, MRSA)
  • Klebsiella (alcoholic, currant jelly sputum)
  • Viral (influenza, RSV, COVID, rhinovirus) — increasingly recognized

317.2.1.2 CURB-65 (MEMORIZE)

  • Confusion + Urea > 7 + RR ≥ 30 + BP < 90/60 + age ≥ 65
  • 0-1: outpatient
  • 2: hospitalize short
  • ≥ 3: full admit, consider ICU at ≥ 4

317.2.1.3 IDSA/ATS Severe CAP (≥ 1 major OR ≥ 3 minor)

  • Major: mechanical ventilation, septic shock
  • Minor: RR ≥ 30, PaO2/FiO2 ≀ 250, multilobar, confusion, uremia, leukopenia, thrombocytopenia, hypothermia, hypotension

317.2.1.4 Treatment Algorithm

  • Outpatient healthy: amoxicillin / doxy / macrolide
  • Outpatient comorbid: amox-clav / cephalosporin + macrolide OR fluoroquinolone
  • Inpatient non-ICU: β-lactam + macrolide OR fluoroquinolone
  • ICU: β-lactam + macrolide OR β-lactam + fluoroquinolone
  • Pseudomonas: pip-tazo, cefepime, meropenem + AG/FQ
  • MRSA: vanc or linezolid

317.2.1.5 Special Pathogens

  • Legionella: hyponatremia, transaminitis, GI; urinary antigen serogroup 1
  • Mycoplasma: cold agglutinins, bullous myringitis (rare)
  • Klebsiella: alcoholic + currant jelly sputum
  • Post-influenza S. aureus: post-viral pneumonia

317.2.1.6 CAPE COD (2023) — Hydrocortisone for Severe CAP

  • 200 mg/d × 4-8 days
  • ↓ Mortality
  • Class IIa

317.2.1.7 Procalcitonin

  • High in bacterial, low in viral
  • Stewardship (duration, initiation)

317.2.1.8 Vaccines (2024)

  • PCV20 single dose adults ≥ 19 high-risk or ≥ 65
  • PCV15 + PPSV23 alternative
  • RSV ≥ 60 + risk factors
  • Annual influenza + COVID-19

317.2.1.9 Key Trials

  • CAPE COD (2023): hydrocortisone for severe CAP ↓ mortality
  • PROCAP, PROHOSP, PROADAPT: procalcitonin reduces antibiotic exposure
  • RECOVERY: dexamethasone for COVID
  • REMAP-CAP: tocilizumab/baricitinib for severe COVID

317.2.2 易混淆比范

Type Onset Sputum X-ray Treatment
Typical (Strep) Acute Productive Lobar consolidation β-lactam + macrolide
Atypical (Mycoplasma) Gradual Dry Patchy bilateral Macrolide or doxy
Legionella Severe Purulent Variable Levo or azithro
Aspiration Insidious Foul Dependent lobes Amox-clav or pip-tazo
Post-flu S. aureus After flu Bloody Cavitating Vanc + standard
Klebsiella Severe Currant jelly Upper lobe + cavity Cefepime + AG
PCP Subacute Dry Diffuse TMP-SMX + steroids

317.2.3 Special Topics

317.2.3.1 “Walking Pneumonia”

  • Mycoplasma + Chlamydia + Legionella + viral
  • Younger, healthy
  • Milder symptoms
  • Atypical features

317.2.3.2 Switch IV to PO

  • Clinically stable (improving signs)
  • Tolerating PO
  • Saves cost + hospital stay
  • Discharge often within 24-48 hours after switch