[Current status of diagnosis and treatment of community-acquired pneumonia in Shanghai revealed by a questionnaire analysis].

Objective: To understand the current status of diagnosis and treatment of community-acquired pneumonia (CAP) among doctors in various hospitals across Shanghai, for the purpose of promoting the 2016 clinical practice guidelines for adult CAP of China. Methods: A questionnaire was designed to address the common questions in CAP management. The responses were collected via WeChat and the data were analyzed. Results: A total of 1 254 valid questionnaires were received, 46.1% from tertiary , 26.4% from secondary and 27.5% from primary care hospitals. Of these valid respondents, 31.4% were respiratory physicians and 68.6% from non-respiratory physicians. When diagnosing CAP, 78.1% of the doctors would use chest CT in more than 50% of the patients. Regarding the tools for evaluating the severity of CAP, 60.3% of the respondents would prefer CURB-65. "Respiratory failure requiring mechanical ventilation and septic shock" were the most common criteria for admission to ICU. Blood culture was not widely used in severe CAP regardless of the level of hospitals (P>0.05). The results of this survey showed that the top 5 pathogenic microorganisms of CAP were Streptococcus pneumoniae, Mycoplasma pneumoniae, Klebsiella pneumoniae, Haemophilus influenza and Chlamydia pneumoniae. For non-severe CAP patients, all the doctors tended to select monotherapy. The most frequently used antimicrobial regimen for severe CAP was third- or fourth-generation cephalosporin monotherapy. As for combination therapy, the most frequently used regimen in tertiary hospitals was "carbapenem plus vancomycin" , while in primary and secondary hospitals it was "β-lactams plus macrolides" . More doctors from primary hospitals and non-respiratory medicine would consider "complete resolution of pulmonary opacity" as the indication to discontinue antimicrobial therapy or to discharge patients, and "prolonged high fever" , "large area consolidation" , "multiple lobe-segment involvement " as the indication for corticosteroid therapy. A significantly lower proportion of doctors in secondary and tertiary hospitals would recommend patients to receive vaccination than in primary hospitals (P<0.05). Conclusions: This questionnaire study showed that there was a gap between the ideal and the real world practice in CAP management. Efforts should be made to popularize the 2016 CAP guideline in hospitals of any level of care, especially primary hospitals, for the purpose of further standardizing CAP management in China.目的： 了解上海地区各级医院中呼吸与非呼吸专科医师对社区获得性肺炎(CAP)诊断和治疗的认知现况，为中国成人社区获得性肺炎诊断和治疗指南(2016年版)的推广提供方向和依据。 方法： 根据CAP诊治过程中的常见问题设计问卷，在新指南推广培训前告知参会医师通过微信二维码扫描进入电子问卷答题并对结果进行汇总分析。 结果： 共收到有效问卷1 254份，其中三级、二级和一级医院的医师分别占46.1%(578人)、26.4%(331人)和27.5%(345人)；呼吸专科医师占31.4%(394人)，其他相关专业(含急诊科、ICU、感染科、全科、其他内科、外科)占68.6%(860人)。在诊断时78.1%(979人)的医师对超过半数的CAP患者行胸部CT检查，二三级医院的医师及呼吸专科医师进行胸部CT检查的比例更高[三级医院为85.6%(495人)，二级医院为80.0%(265人)，一级医院为63.5%(219人)，呼吸专科医师为88.0%(347人)，其他相关专业为73.5%(632人)]；60.3%(756人)的被调查者采用CURB－65评分评估CAP患者病情的严重程度，"呼吸衰竭、需要机械通气"及"感染性休克"是收入重症监护病房(ICU)最常用的标准。CAP前5位的病原微生物依次为肺炎链球菌、肺炎支原体、肺炎克雷伯菌、流感嗜血杆菌和肺炎衣原体。重症肺炎血培养送检率普遍较低，三级医院为53.6%(310人)，二级医院为51.1%(169人)，一级医院为50.1%(173人)，且各级医院送检率比较差异无统计学意义(P>0.05)。针对非重症CAP的抗菌药物治疗多选择单药，重症CAP中最常用的单药方案是第三四代头孢菌素类。联合用药时三级医院最多选用"碳青霉烯类和万古霉素"，一二级医院为"β－内酰胺类和大环内酯类"，专科医师最多为"β－内酰胺类和喹酮诺类"，非专科医师最多为"β－内酰胺类和大环内酯类"。一级医院及非专科医师更多将"影像学肺部阴影完全吸收"作为停用抗菌药物和出院的指征，将"体温>39 ℃，一般退热药物无效"、"大片实变影"及"多叶段肺炎"等作为糖皮质激素应用的指征。建议患者接种肺炎链球菌或流感疫苗的比例在二三级医院中为59.8%(198人)和58.1%(336人)、61.6%(204人)和58.3%(337人)，均明显低于一级医院的74.8%(258人)和75.1%(259人)，差异有统计学意义(P<0.05)。 结论： 目前在CAP诊治过程中存在胸部CT检查使用过度、重症肺炎血培养送检率低及糖皮质激素应用指征过于宽泛等问题，需要在各级医院尤其是基层医院中加大对中国成人社区获得性肺炎诊断和治疗指南(2016年版)的推广普及力度，进一步规范CAP的诊断和治疗。.