317.4 📋 章末速記 Summary

317.4.1 🔑 一句話總結

CAP = 在社區內或入院 < 48h 發生的肺炎；最常見病原 = S. pneumoniae (傳統 bacterial)，現在 viral 比例 ↑（influenza, RSV, COVID）+ atypical (Mycoplasma, Chlamydia, Legionella)；severity scoring：CURB-65 (0-1 outpatient, ≥ 2 hospitalize, ≥ 4 ICU) + PSI + IDSA/ATS severe criteria；treatment：outpatient healthy = amoxicillin/doxy/macrolide；inpatient non-ICU = β-lactam + macrolide OR fluoroquinolone；ICU = β-lactam + macrolide；Pseudomonas + MRSA risk 需 broaden；severe CAP 2023 CAPE COD trial → hydrocortisone 200 mg/d × 4-8 d ↓ mortality；duration 5-7 days；procalcitonin guides stewardship；vaccines 2024：PCV20 single dose + RSV (Arexvy/Abrysvo) ≥ 60 + risk factors。

317.4.2 💊 治療精要

  • outpatient healthy：amoxicillin 1 g TID OR doxycycline 100 BID OR macrolide
  • outpatient comorbid：amox-clav + macrolide OR fluoroquinolone (levo, moxi)
  • inpatient non-ICU：β-lactam (ceftriaxone) + macrolide (azithromycin) OR fluoroquinolone alone
  • ICU：β-lactam + macrolide OR β-lactam + fluoroquinolone
  • Pseudomonas risk：pip-tazo / cefepime / meropenem + aminoglycoside or fluoroquinolone
  • MRSA risk：vancomycin or linezolid
  • severe CAP adjunct：hydrocortisone 200 mg/d × 4-8 d (CAPE COD 2023)
  • influenza coinfection：oseltamivir within 48 hr
  • COVID-19 CAP：dexamethasone (RECOVERY) + tocilizumab/baricitinib (REMAP-CAP) for severe
  • duration：5-7 days typical；procalcitonin-guided shorten if appropriate

317.4.3 🎯 盧醫師的考前提醒

  1. CURB-65 必記：Confusion + Urea > 7 + RR ≥ 30 + BP < 90/60 + age ≥ 65；0-1 outpatient, ≥ 2 admit, ≥ 4 ICU
  2. IDSA/ATS severe CAP：1 major (MV or shock) OR ≥ 3 minor (RR ≥ 30, P/F ≤ 250, multilobar, confusion, uremia, etc.)
  3. CAPE COD 2023：hydrocortisone 200 mg/d × 4-8 d in severe CAP → ↓ 28-day mortality 5.7%；Class IIa for non-COVID severe
  4. Legionella 特徵：hyponatremia + transaminitis + GI symptoms + neurologic + bradycardia 不成比例；urinary antigen serogroup 1 (70% cases)；levofloxacin or azithromycin
  5. post-influenza pneumonia：S. aureus (often MRSA) + S. pneumoniae；severe + cavitary；vancomycin + standard CAP coverage
  6. Klebsiella：“currant jelly” sputum + upper lobe + cavity + alcoholic；severe；anti-pseudomonal β-lactam
  7. PCV20 (Prevnar 20) 單劑成人：≥ 19 high-risk OR ≥ 65；廣譜 covering 更多 serotypes；2024 standard
  8. RSV vaccine 2023 NEW：Arexvy (GSK) + Abrysvo (Pfizer) for adults ≥ 60 + risk factors；reduces hospitalization 70-80%
  9. procalcitonin > 0.25 likely bacterial、< 0.1 bacterial unlikely；trend ↓ → consider stopping abx；stewardship 利器
  10. HCAP category 已 retired：2019 IDSA updated；不再分 HCAP，而是看 individual risk factors for MDR organisms