犐犆犛犆 50 犠犛 / 犜 !"#$%&' 犘犲狉犳狅狉犿犪狀犮犲犵狌犻犱犲犾犻狀犲犳狅狉犫犪犮狋犲狉犻犪犾犮狌犾狋狌狉犲狅犳犾狅狑犲狉狉犲狊狆犻狉犪狋狅狉狔狋狉犪犮狋犻狀犳犲犮狋犻狅狀狊 ()*+,-.

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1 犐犆犛犆 50!"#$%&' 犘犲狉犳狅狉犿犪狀犮犲犵狌犻犱犲犾犻狀犲犳狅狉犫犪犮狋犲狉犻犪犾犮狌犾狋狌狉犲狅犳犾狅狑犲狉狉犲狊狆犻狉犪狋狅狉狔狋狉犪犮狋犻狀犳犲犮狋犻狅狀狊 ()*+,-.

2 Ⅲ Ⅳ !"# 4.2!$% &'! ()*+,-!./ )*0!./ :; 4( C) <=> 7 6?@ABC F GH IJKLM NBC O 12 A( ) 78+9 ; ( ; PQ 13 B( ) RST)*0"#!UVWX PQ Y 14 C( ) 4Z[\( ]^6 _` 15 abc 17 Ⅰ

3 ! GB/T ,! : 2 2 Y! ; : Ⅲ

4 0.1 < F 2 -, CFU/ ml~10 12 CFU/mL M4, 4 ; DE 4 Q 4 < 3 4,./,DE0%4 1 &'!4 " #$%4 < &'; > (4)-*+,- 0.2!"#$ > ?5 L 67, M4 89: ;7R ;+2./ 4 M4, )M4,!4,DE0%4 +2 4<= >? +24 ( 8+9BCD< E,+2 F2- ) F G78+9,HI J8+ K LM $:NO 78+9 PE, %&' ( )* +, HP PI< Q, R P4S _` 5,T _` U V,WL`XX54 Y 78+9 P WX Z U DE [\! <, ] ^ _ 4 `a P4WX Z b c G I<23 M / RST)*0 > T)* :!UV M4 <, < 4 4Z, WX78+9 Z 82%~91%,WX! F2- ' _`IT P423 (4)-`a!%Y 3 4 _ K 0BC, ; _ 4G!Y BC `a ( M4 BC Ⅳ

5 6 :+; 1! M4 b! U + F2-2 9, 7 G! I,!U! I,!( )U! WS/T503 F2- $ b 3 <=>5 7 U! 3.1?@ABC-. 犆狌狉狊犮犺犿犪狀狀狊狊狆犻狉犪犾犳犻犫犲狉狊 RS 7,@ 6 T)* 9:,E8+ &, )" DE?, F07 7,, 3.2 DE 犆犺犪狉犮狅狋犔犲狔犱犲狀犆狉狔狊狋犪犾 T)*, [, 7 [L B, 3, I,, # M?# V, # M G 4 \./, 2./ : FGH6I 犮犻犾犻犪狋犲犱犮狅犾狌犿狀犪狉犲狆犻狋犺犲犾犻狌犿犮犲犾 ; 78+9, ;7M 5 < R, < 9: 7M, 9:< M4 Z-, R,! M4 9:" #$ 3.4 JK6I 狆狌犾犿狅狀犪狉狔犿犪犮狉狅狆犺犪犵犲狊 %M Y, &, 8+MT)* 7 *9', 2 M,( M M ) b *+,, :;BCD< +2-) M4 Z-.2, 8 M ), / 8+99:" R $ 80, 1

6 4 LM 4.1 NO % U./, 1 : (ICU)(- (CAP) ':(AECOPD) 23(0 H U!) M 4 P Q. /( A) 0,./L42/456 ; K./0,7,89>:: ; )* *./, 67 (G, ), "#)*+,-! /)* +, L4 9>%Y :)* *24h?< 4,=>? %Y)*+,-, K BCN I@ /A G ( 38 ),VQ ( 36 ) BM &, M ^ $ %Y?,%Y$ (]Qab WS/T503!"# %Y;C) (" P 犅 ) NO01 4QR "#)*0! D 7: a) )*0 "# <!, T ) * :(bronchoalceolarlavage, BAL) T ) * :!(bronchialwashings,bw)!(protectedspecimen brush,psb)(t)*e +Y!,S 8+, "#; b) B _, "+2 F,8/Gb +> :!; c)!"#hi :BW BAL PSB +Y!, J $ 犅犃犔 KRST)*0 T)* 2L42/45, 40mL~80mL L : M1mL T)*NO -; <_, #? <%Y 犘犛犅!RST)*0 2 T)*, T)*0 Y P, QR* ( S TU V), >2 -,"W?! L 2 QR* X,RST)*0,L4Y YX, 1mL 2/45 L4 ( ),]^%Y 4.2 ST L4B #!,! ( Z)?, 2h ( )%#F2- = [ %Y,!K H\ 4 23, P4 < G^ B 4 23,!! 2 ~8 ]^(2h~24h),T 5!4 \ 4 < ^ _=! `, <G BC `a 2

7 4.3 UVWXY 5 &'!7: a) 24h :a"# M4!; b) ::; c) ;b : - ; c ; d)!; e) > R* # T)*!; f) 4!; g) K 1: T)*E +,- PSB"# - QR* ( ) + Y > _! Q, R!SIUV 4 2: K! U Y 4 B% %4,G R P4Y, C! 5, R 5 LM 5.1 % Z!./!;C7: a)!( b Ⅱ 2-. ; b) ]./!, 1 Y W 2./ ICU./ _`"#!(: BAL +Y!), 4 +,J :a"#!; c) H./@A./! [\ L4c >U<( IJ )2,L$,)*+,-,1 $IJ IJ, IJ(, R P, 4 ),? < 5.1.3! $IJ IJ (CO2:5%~10%),, IJ 5,35 ~ h~48h,$IJ IJ #72h &' ]^ _ IJ?, IJ c, WS ( 7 ), K?, V (,, ), ]^ 3,DE,? DE E'I F Z,]Q: a) 95%UV 30s; b) UV(Q 3 7,, 1 ) 1s~5s( S ); c) ( F ),# FL (! <4 M C ) :HDE b., 1,H BC C 3

8 5.1.5 `a bc]^ _ V -07Y 20 ~40,)*+,- 1 V 0 (LPF) 0 (OIF)7 M M I S <, 1 7 K M (SECs) [ % B M (WBCs) M4 <, 1 1 `a bc]^ _ 1+( ) 2+( <) 3+( <) 4+( <) M (V 0) 1 /LPF 1 ~9 /LPF 10 ~25 /LPF 25 /LPF M4 ( 0) 1 /OIF 1 ~5 /OIF 6 ~30 /OIF 30 /OIF 犅犃犔 BAL!30s~60s ! IJ1: 'W (, 10μL ])>10μLBAL!,1 a# $IJ IJ, 4L IJ?4Z [\4Z (10 2 ) - 4Z 100,<V (10 4 CFU/mL) IJ2:1μL < ]( )>1]BAL!,1 $IJ IJ,L4L I J? 4 Z [ \ 4 Z (10 3 ) - 4 Z 10,< (10 4 CFU/mL) := ] IJ,2 3 4 Z < V < P L I J, < B C :> mL b:(pbs) *,'250μLBAL P:!, ; / >100μL 1 $IJ IJ, 4L IJ?4Z [\4Z (10 3 ) - 4Z 10,< (10 4 CFU/mL) 2:> mLPBS *,'250μL !, ;/ >100μL 1 $IJ IJ, 4L IJ?4Z [\4Z (10 5 ) : b: >:0.067mol/LNa2HPO370mL N0.067mol/LKH2PO330mL V(pH7.2), 4? H 犘犛犅 !1mL!* 30s~60s 4

9 ! I1:'W >10μL!(,10μL ])1 $IJ IJ,L4L IJ,?4Z [\4Z (10 2 ) - 4Z 10,< (10 3 CFU/mL) I2:1μL < ]( )>1μL IJ,?4Z [\4Z (10 3 CFU/mL) !1 $IJ IJ,L4L > mL b : *,' 250μLPSB P :!,,/ > 100μL 1 $IJ IJ,L4L IJ?4Z [\4Z (10 3 ) [\ W $IJ IJ?, >100μLBAL!,PSB!, 5.1.3; _"#! 'U<,L42/45,! : $IJ IJ, 3 #4d ]^ _! <?,>U<BAL!. M 5 ;! V, ]^ 3,DE 犅犃犔, ( G BAL!5?, ;. %4 4 4( 4 O P Y 5.3 Wbc 18h~24h? IJ, Y, < \ DE0%4! " 4 ( 犅狅狉犱犲狋犲犾犪 spp.),ij Y?1 #72h, <G L W (" P 犆 ) β β $!4 8+9:; 4, : $IJK β $ 4 Z,$ I J # ' 5%$%$ <H O&,= 4Z $ ' ]Q 7: a) Y β $4Z 6 0W 7, G"!4; b) 6 = 2!4:? %4 (0.04U/ ),35,= A 2!4, 2!4 () *+ (PYR) ; c).!y =, $], 61B!4(L-!4),=CAMP (./ 01!4), d) 6 R < 1 23 β $!4 4Z β $!4,F!4S K

10 !4!4,Y[\N!4 α $4Z, 7 : a) 4 : 4ZK 10% :1, 35 15min~30min?,=4Z,@A!4 ;=4ZI, 2 3(optochin,OP)U 4; b) OPU :!4Z $IJ, OP (5μg/ ), 35 5%( CO2)] ^,=, 45( 6 14mm X U ),@A!4 ; c) )U :]^ 4Z, )U ; OP 4, Y)UBC = R!4(_ 4) : G,G2 3 )!47,!8 9VY ^ :;@A ]^ " #$%4 23 IJK!%4, $IJKI23,T 01!4' 7 23 " #$%46 `:$IJ (4ZI $)W MH IJ 0;,X V E 23`: Y4 MH IJK XE V E (X+V)E,X V ' I2 3,T (X+V) ' 2 3; K _ ` S X X " # $ % 4, ALA (aminolevulinicacid) 4, β :;!" 4 $IJK23, S, 48h, 4Z ]^ 9 H 1 23, <<,5 L 6 R\ DE0%4,=>4,E8S K 8+9 4,< 8+@A ]^ 9 DE0!4, ; R?@4 ABCD4,E 7]^ &: a) Y < ] P 4Z,WDNA, 4 R?@4(90% K R?@47 β +, XX) b) Y IJK 4Z, $IJKI23,23I,01 (+) (+) - (-), 46 ABCD4,L )U ]^ 9, IJK23 DE0%4,E 7]^ &: a) = 233 M4 3 <, L R 4,5 F &,G4 = H%4 M4 1 IJ4, 6 )U ; b) G -./,I* = R P4,Y < K 4 L I %4 MN J O"4 #, 4,E84 P : )4, " ; c) =23 K R < DE0%4, I JK ) [\ 4Z BC) 6

11 5.4.5 G 23 01!4./_`7: a) =DE 1!4NBM O, L R < 4, G <./ 01!4. 6 ; b) = -./,E =>P,<H <4 P QY RS T = ); c) 001!4 IJKUV,W 6 5I /, )U, R01!4S G 23 H!4./_`7: a) XY 7, <23 23UV,F 2 6 4; b) < DE! ,PYR # (LAP) ]^ 9 G 7 23 DE %4./,E RDE %45 I,]Q7: a) & " < Y >./ Z 4!4(9:W4Z ); b) DE %4, " [\ %4 ]W %4; c) ^_6 7%4 7` Y WM4 <1 23,H6 DE % 4 a Fb. 6, : 1) 47]^ ( B$ %4 B% %4 ); 2)!Y ICU c *./ G23 7 4, W 4./_`7: a) G ( Q,]^_ 4, 4); b) / 48h IK5 4( B 4! 4), W 4 4Z; c) Y - " 2!4,L G R W 4. 6 ; d) 4 4, XY 7,G,<H/78+9! 5 4, H /,= L. 6 ;TG 3./(:B$ )./, 2,;. 6 Y 78+9! W 4( &' " 6 M4,T?> G[\ M423, <EH3(4)- _;TI<" < 4 0!" 4 %4 ( N 9@, PY 5.5 $ ]^ _ DE = (BC7: a) G, a DE F =, = '1 ; b) DE =47:./ 01!4ATCC25923,7!4 V ; c) DE 0 =47: H 4ATCC25922, %4 V 7

12 5.5.2 _ ( = (BC7: a) G, a ( F =, = '1 ; b) ( =47:B% %4 ATCC25177( 7),,]23 %4b =47, 7%4 V ; c) ( 0 =47: H 4ATCC25922, %4 V , > 5%%$IJ = 47 BC : a) 2!4ATCC19615,β $,23 V ; b)!4atcc49619,α $( $),4Z P 4Z? V , > IJ, = 47 BC : " #$%4ATCC49247,23 P 4Z V ' = F : a) 2 (OP) (5mg/ ): = 4 7! 4 ATCC49619, 4 5>14mm V b) %4 (0.04U/ ): =47 2!4ATCC19615,[ 45 V c) PYR : =47 2!4ATCC19615, V = F : a) 3% ( ): G 47./ 01!4 ATCC25923, ) ;0G 47 H!4ATCC29212,I ), 2 <) b) $,- # F( #E ` ): G 47./ 01!4 ATCC25923, I 7 #,0G 47 01!4ATCC12228,I # c) $,- # F( *` ): =47 b), 4h, G 4 7;0G 4 :\ ( HEDTA ( $, ` 0BC, *` 4,E 10%~15%./ 01!47 ` 0 ) d) 1%4 GR +( ): G 47 K 4ATCC27853,10s ;0G 47 H 4ATCC25922,I e) P (nitrocefin)(β + ) : G 47./ 01!4 ATCC29213, ;0G 47./ 01!4ATCC25923,I 8

13 6 LM 6.1 ]^ _ % ( T)*+,-! DE BC 2 2 % 01 &']^ _ : 10 SECs/LPF? T)*+,-./: 10 SECs/LPF,> M4. :> M4! :: K ,@ A 10 7 K M /V,!8::_,I I,@A!_,> M4, :%! ; > M4,T WBCs < 4+, R S M, :, F0 4 R SK = M4; 4 #$%4 M4EN RSI, < Y;c 4,G [%BM I 10 SECs/LPF, < [ % B M ( 25 WBCs/LPF), M ;7K M 25 WBCs/LPF, 25 SECs/LPF;, WBCs:SECs 10 1, [\ M4< 3+~4+ V 7!!, < [%BM M4 B, PRS RS BM W Q(corporaamylacea) 7- I B ;G >./, M./<H> BM,TL 7K M,, 3 8+9, (COPD) 8+9 * < U 4,2 < [% B M,B M,Q ; : DE!4 G, "!4 DE!4 "./ 01!4 DE0!4 R?@4 ^ DE0!%4 " #$%4 DE0 %4 IJ4, RH%4 M4 < [%BM, < D E 0 % 4! % 4,D E!4( RI [\ M4, W 4 RZ B, 4 DE 7 % 4, Z [ 7M4( < (4)-*+ 1 :+ 2,E B C ,K , H, 4, <,:( 9

14 T)*+,-! DE BC 7Y : a) BM 1 4(I 7K M K) b) 0 10, 10 [\M4 NBM O( BM ', 1 BM M4), 1 4/20 0 c) 4 I,T [\ M4SNBM d) <H > M4 [./7, < 4, 4 4 B% %4, R HP 4; e) <V!, 4 ( M4(5 BM -,: ), 犅犃犔 6I &' = M 5 >b BAL! DE,Y U 10 5 M /ml,10 4 M /ml, = 0 1, M4,@ A D E [ \ ( B M B C, G M 4 N + O 犘犛犅 DE [\(BM BC, GM4N+ O a ( P47: a) 2!4; b) B β $!4( ); c)!" 4, 1 T)*!" 4; d) Z 4 ; e) 2!4; 4); g) 4( 4); h) [\ %4( 4); i) 7 4(" 24_ ) >&' (./ - ab BC, DE 6M M4 [\N -. G, N : 23 M4 F 6M O,@A 7 P4: b) " β * 2345 L 7Y XX54 <] : a) 23 P4 < 7Y,XX : 10

15 1) IJ 2 <23,, -23< 1/4IJ; 2) <23WDE G[\M4N6M O9 P4; 3) IJ 1 23W 90% K, DE G[\M4N 6M O P4 b) < <: 1) BAL:4Z 10 4 CFU/mL; 2) PSB:4Z 10 3 CFU/mL :1 23 M4 IJK I [\4Z <, K < GM4 4Z M <,<HI 1 P4 : a) R?@4 β + BC; b) G-./@A 4 : 1) K 2) #, 3) I %4, 1 L I 4) MNJ < 1 4, 1 54N [%BM P4 : a)./ b) B β $!4( ) C,G β $!4; c) [\DE0%4( 1 d) \ β + BC; e) 7%4,5Y ICU./ 7%4; f) 5 >./! E6 IJK232, DE0%4, 0 - F 6 H%4 M4,@A: 6 H%4 M IJK232, DE0%4, IG 01 F 6,@A: 6 HG M > 9 = 23H!4 /, 0 0 1! 4(, L W 4),@ A D E! 4 V 2 3 ;= -UV, F 6 5I 1, L! =>5 4,G5 :!4 /,H CD4 B$%4 001! 11

16 4 4 ( 犚狅狋犺犻犪 spp.) F!4 4 #$%4 (H" #$%4) =>4 %4 #RS4?@4 H!4 W 4, > <./ 01!4( C =>;C )U ) DE0%4(ABCD4,S@A: 5 4 (, 4 ) 6.4 G 6 IJKLM423,@A LM423, G Y < H(4)- >3 4 PE 6.5 KBC Q,NBC O : #$%4, < 4; b) 23 DE0%4,./ 01!4 1 4,W 8[\ M4N O W@A; c) 0 I<"./ 78+9,E V,W < H( 4)- `a 0BC; d) 0I<"./ < HP CAP P 78+9, WX $ _`Y TPQ PQ 4 (Q W; e) CAP*+ *+,= I PQ, *+ PQ; G -./ > PQ 12

17 P 犃 ( 9 P) ( 78+9 ; ( ; PQ A.1 犃.1 ( / 7\ P4 P4 (P ) a!4 " #$%4 IJ4./ 0 1! 4 4 A BCD4 HP b +2 T P Q " P Q 4 4./ 01!4 DE0%4 DE0%4(H % 4 / I J 4 /I % 4 / 4 )./ 01!4 4 P 4 P Q B % % 4 4 4,!4 $:NO./ 01!4!4 DE0%4 > 4 4 ]^ c )* P 4 Z B% % TPQ PQ, 0! " 4, T P Q PQ ;\ 4 ; \ a!4 " #$%4 4; 4 A B C D 4 G./,? G ;. / 0 1! 4 G 2 3; I J 4 V 2 3, 1, b 5 2- _`]^WX,? $ _ ` Y T P Q P Q 4 (Q W 2- P4, 4,$ Y b WX_` B% %4,]^B%%4:Q,, WX_`Y c ) ]^:N O B% %4 N " - O 4 13

18 P 犅 ( 9 P) -./01 NO )* ( > R RST)*0"#!UVWX PQ Y B.1 犅.1 -./01 NO )* ( > R! UVWX PQ P WX 4, T)* :(BS) a B % % ' 5 % (!(PSB) WXM4 1. <M4 3. (Q`(DFA)Y DE T)* : (BAL) b U Y 4 1. <M4 2. %4 ( (Q`Y 5. (Q`Y 4 abal U WX: 5) O V 7. / ' :(AECOPD) ICU c :6./ (4)-*+> / =./ Y0 B%,T)*B%/ b BSY )9,/Q KL`NBAL 1, K8+9_ 4 14

19 P 犆 ( 9 P)!"! 4Z[\( ]^6 _` C.1 犆.1!"! 2!4 (A ) L-!4 (B ) M4 6 ' 6 ;C!4 1.G $!4, G 4.4Z 6>0.5mm, 1.G+!4, G Z $] 1.G+! α $ 4. 40,4ZGB PYR CAMP, 5 $ _` 4 =2_`"#!,4ZI $, 4 5 PYR(0 ) CAMP,$ BC PYR 0!4 1.G+P7! α $ 4, B3 = 4 I 4 T 4 Z P, 4 OP U " #$%4 1.G!%4 2. I J24h 2 3 T $ I J K I 2 3,T $ I J K 0 1!4' 23!" ALA 0 H $ # $ % 4 $ $ %$IJ K β $,ALA 0,E # $ $IJK$ 23 %@4( 4) JK48h 23 4Z,$IJKI23 &=>4 1.G % MAC IJKI23 5.I $ 'B 9 R?@4 1.G! $IJKP4Z Q 4!DE [\!4 N R?@4!%4 1 ABCD4 1.G! $IJK23 G 01,CD4 Fb6 Ⅱ 2-./ AB CD4 - K ) =L 5 C ), XX =L5C),,,

20 犆.1( ) M4 6 ' 6 ;C ,T L ), 42 23, / 01!4 2.G+!4, 3. *`/ `, - # *` 4 1. G ` 0 4 7, 001!4 2.G+!4, 3. *`/ `, - # 4ZI9 *` 4; 90% K 23 W 6 5 I /, 0 )U 1.G+!4, G PYR $ 4 Z < A H!4 2. 0! 4,= $ H =4Z $ H!4 3.I $! 4 % 4 (( O 4 ) 1.G+ % (L Y [\ %4) ]W %4 (H[\ %4) β $( ),4Z 6>1μm 1.G+%4,I 7% I $ 4.L L,, 4 Q ( Fb 6 5I 5.L Z 4 1.G+M3,, 7, 74 2., I % [!7 ( `, 4Q( 16

21 [1],. Y b(.3. :), [2],, *. F2- Y. : 2, [3] +,-,./.0 M4 N O@ ,95(40): [4],. ) U ) U B C. 1 Y.2012,35(8): [5] LynneS.Garcia,editorinchief.ClinicalMicrobiologyProceduresHandbook.ThirdEdition and2007update.asmpress,1752nst.,n.w.,washington,dc. [6] SusanE.Sharp,AnnRobinsonandMichaelSaubole,ect.2004.CumulativeTechniquesand Proceduresin Clinical Microbiology 7B, Lower Respiratory Tract Infections.ASM Press, Washington,D.C. [7] MurrayP.R.,Baron,E.J.,Pfaler,M.,Tenover,F.,andYolken,R.2006.Manualof ClinicalMicrobiology,9thed.ASMPress,Washington,DC. [8] JamesV.,KarenC.C.,JamesH,J.,GuidoF.,MarieL.L.,DavidW.W.2011.Manualof ClinicalMicrobiology,10thed.ASMPress,Washington,DC. [9] GiuseppeCornaglia,ReneCourcol,Jean Louis Herrmann,GunnarKahlmeter,Helene Peigue Lafeuile,JordiVila.EropeanManualMicrobiology.1 st edition.emcm,2012. [10] Nagendra,S.,P.Bourbeau,S.Brecher,M.Dunne,M.LaRocco,and G.Doern Samplingvariabilityinthemicrobiologicalevaluationofexpectoratedsputaandendotrachealaspirates. J.Clin.Microbiol.39: [11] Roson,B.,J.Carratala,R.verdaguer,J.Dorca,F.Manresa,andF.Gudiol.2000.Prospective studyofsputumgramstainintheinitialapproachtocommunity acquiredpneumoniarequiringhospi talization.clin.infec.dis.31: [12] Gleckman,R.,J.DeVita,D.Hibert,C.Peletier,andR.Martin.1988.Sputumgramstainas sessmentincommunity acquiredbacteremicpneumonia.j.clin.microbiol.26:

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