引用本文：周飞, 刘正平, 曹彬. 社区获得性肺炎年度进展2025[J]. 中华结核和呼吸杂志, 2026, 49(3): 339-344. DOI: 10.3760/cma.j.cn112147-20251124-00741.
摘要：近1年，美国和法国相继更新CAP指南，同时国内外学者聚焦CAP流行病学、病原分子诊断技术应用、抗感染方案和免疫调节治疗等，取得系列进展。本文就2024年10月1日至2025年9月30日CAP领域进展进行了简要总结。
社区获得性肺炎（community acquired pneumonia，CAP）是全球重大健康挑战。随着对CAP认识的加深及诊疗新方法的出现，其治疗更强调个性化综合管理、急性期后康复干预及预防措施。本文总结2024年10月1日至2025年9月30日国内外发表的CAP领域重要研究及指南、共识更新重点，阐述病原学、病情严重程度评价、病原分子诊断应用、抗感染及激素免疫调节治疗的新成果，以期帮助读者了解CAP相关进展。
一、CAP病原学
肺炎链球菌是CAP主要的细菌性病因，欧美国家广泛接种肺炎链球菌疫苗后，成人CAP患者肺炎链球菌检出率自1996—2000年的17.4%降至2016—2020年的13.5%，且以血清型3型为主［1］。国内肺炎链球菌疫苗的接种程度普遍较低，仍以19F血清型感染为主［2］。我国肺炎支原体对大环内酯类药物耐药率持续攀升，增速加快，平均耐药率达90%以上，北京、江苏和甘肃等地甚至超95%，A2063G突变为耐药肺炎支原体（macrolide-resistant mycoplasma pneumonia，MRMP）最常见的突变［3］。因此，国家儿童健康与疾病临床研究中心牵头制定专家共识，推荐儿童患者使用核酸方法检测MRMP，并建议将新型四环素类药物作为其一线治疗［4］。
据中国疾病预防控制中心统计，2025年流感季我国以A（H3N2）亚型流感病毒为主。2025年3月以来，国内收验的所有A（H3N2）亚型和B型流感毒株均对神经氨酸酶抑制剂敏感，仅A（H1N1）pdm09亚型中4.2%敏感性降低［5］，所有毒株均对聚合酶抑制剂敏感。对比流感，呼吸道合胞病毒（respiratory syncytial virus，RSV）感染住院的患者病情更重，28 d病死率达5.4%，为住院流感患者的6倍［6］，提示高危人群积极预防RSV感染的重要性。2024年12月，我国人偏肺病毒感染人数上升引发世界卫生组织关注［7］，北方地区流行水平明显超既往，B2亚基因型取代A2c 111nt-dup基因型成为优势株，免疫逃逸能力增加［8］，但肺炎和重症肺炎发生率有所降低。
二、病情严重程度评价
传统肺炎严重程度评分仍是预测CAP患者短期预后的重要工具，按病情严重程度分级指导治疗地点选择不仅具有更好卫生经济学效益，也能保障患者疗效［9］。需注意，病情严重程度评分本质是死亡风险预测，有助于判断患者是否需住院，但对患者是否需要入住重症监护室接受生命支持治疗的判断效能不及针对性更强的“重症社区获得性肺炎标准”或SMART-COP评分［10］。近年有学者建议使用序贯器官衰竭评分（sequential organ failure assessment，SOFA）优化重症监护室收治患者识别，其核心是筛选就诊时就已出现器官衰竭的患者。随着SOFA-2评分的提出［11］，其在CAP患者中的应用前景与临床价值亦值得挖掘。
三、病原检测方法
病原多重PCR（multiplex polymerase chain reaction，mPCR）检测、靶向高通量测序（targeted next generation sequencing，tNGS）和宏基因组二代测序（metagenomics next-generation sequencing，mNGS）技术在我国已广泛应用。尽管病原检出率因此提升，但以上技术对指导抗菌药物使用、改善患者预后的价值争议较大。对比多项研究，儿童CAP患者的mPCR、tNGS检测结果似乎更易被采纳，从而减少抗菌药物使用［12, 13］，这与临床医生对儿童CAP患者主要病原类型的认知相关。但这一问题在住院成人患者中则相对复杂，如果对所有住院患者常规使用mPCR检测，未能减少抗菌药物暴露［14］。2025年法国CAP指南对于非重症患者仅推荐结合流行病学史情况下进行流感或新冠单病原核酸检测，除非检出其他病毒对处置（抗菌药物降级、隔离）有指导作用，否则不扩展检测谱。mPCR检测仅建议用于重症患者采用非常规的经验性抗菌方案时［15］，用于对治疗方案进行“矫正”。实际上，若初始经验性抗菌方案规范且“窄谱”，检出病原以细菌为主，或者临床医生因顾虑不良预后而回避降级策略时，mPCR检测难以带来更多获益。mNGS临床价值多基于回顾性证据［16, 17］，仅我国学者发布RCT研究结果［18］，显示其可缩短重症监护室患者抗菌药物使用时间，但能否改善预后尚不确定。
四、抗感染治疗
1. 经验性抗感染治疗的合理用药：住院CAP患者，对于在β-内酰胺类治疗基础上是否联合大环内酯类药物的问题，首要考量的是患者非典型病原体感染的可能性，以及不覆盖所带来的后果。Meta分析表明，对所有住院患者不加区分地常规联用大环内酯无更多获益［19］。另外，大环内酯类药在免疫调节方面也可能发挥一定作用。在Odeyemi等的回顾性研究中，联合阿奇霉素似乎较联合多西环素患者的预后更优［20］。ACCESS研究及其亚组分析也显示，联用大环内酯类药物，能使患者症状和炎症指标（降钙素原）得到更快缓解［21］。然而，这种抗炎作用目前尚未能切实降低患者病死率。在我国，选择联合用药时还需充分考虑大环内酯类药物的耐药问题。
减少不必要的广谱抗菌药物使用，以及缩短抗感染疗程，是避免抗菌药物过度暴露的重要手段。即使面对免疫抑制或老年患者，在没有耐药菌感染或误吸危险因素时，无需常规覆盖耐甲氧西林金黄色葡萄球菌（MRSA）和厌氧菌［22, 23］。病毒检测阳性的肺炎患者，是否需要经验性使用抗菌药物仍是临床面临的重要难题。观察性研究显示，对于住院的非重症新冠患者，常规应用抗菌药物无获益［24］。然而，依靠现有检验方法区分是否合并细菌感染仍不可靠［25］。2025年美国CAP指南对此提出分层指导原则［26］，其本质是基于患者病情严重程度，从流行病学层面考虑合并细菌感染的概率；从个体层面出发，综合实验室检查结果、基础疾病等因素评估患者合并感染的倾向性，同时权衡漏用或延迟抗菌治疗的后果。
目前，对于短疗程抗菌方案的定义、用药种类以及停药附加条件，在各项研究中尚无统一标准［27, 28］，根据Kuijpers等［29］对相关研究系统评价的再评价，我们认为对于非重症患者，基于“达临床稳定标准”的5 d短疗程方案，相关证据较为充分。但是，也有研究观察到，在早期达临床稳定的高龄（≥75岁）患者中，约20%可能出现病情反复，30 d病死率达5.7%，尤其合并基础疾病较多的患者风险更高［30］。因此，针对老年、免疫抑制等特殊人群，如何制定更为合理的抗感染疗程，以及更短疗程方案是否安全尚需进一步探索。
2. 新型抗菌药物：头孢吡罗和来法莫林是近年国内获批治疗CAP的新型抗菌药物。需注意，头孢吡罗对于危重症患者的最佳剂量尚需探索，尤其当头孢吡罗对检出病原的最小抑菌浓度≥2 mg/L时，可能3 g/d剂量才能达到有效肺泡衬液浓度［31, 32］。我国CHINET数据显示，来法莫林作为新机制药物，对耐药肺炎支原体、肺炎链球菌、流感嗜血杆菌及卡他莫拉菌保持高度敏感性［33］。但其对于部分肠杆菌及非发酵革兰阴性菌疗效偏弱，因此我国学者合并多项Ⅲ期临床研究数据，针对老年人群进行分析，显示来法莫林总体疗效与莫西沙星相当［34］。以上两种药物在国内应用经验较少，对某些特殊人群的应用价值和最佳剂量尚需更多上市后评价。
3. 抗病毒治疗：我国首款自主研发的流感病毒RNA聚合酶酸性蛋白酶蛋白（PA）抑制剂玛舒拉沙伟上市，具有高效和低耐药率特点［35］。2025年8月，世界卫生组织更新新冠病毒肺炎治疗实时指南，维持奈玛特韦/利托那韦和瑞德西韦推荐意见，因缺乏VV116在重症和危重症患者中的数据，未将其推广［36, 37］。重症新冠联合抗病毒治疗及长疗程方案探索取得一定进展。Choi等［38］对住院新冠患者的目标模拟试验显示，奈玛特韦/利托那韦基础上联合瑞德西韦无额外获益。奈玛特韦/利托那韦10~15 d长疗程抗病毒方案对血液系统肿瘤、嵌合抗原受体T细胞（CAR-T）免疫疗法清除B细胞或骨髓移植等严重免疫抑制患者起到减少“病毒反弹”效果［39］，但对其他免疫抑制患者无更多获益。
五、辅助治疗
糖皮质激素治疗SCAP的价值不明，对无脓毒症休克的SCAP的疗效尤其模糊。2025年REMAP-CAP公布RCT研究数据显示，不论是否伴脓毒症休克，患者均无法从激素治疗中获益［40］，这与2023年《新英格兰医学杂志》发表的CAPE-COD研究结果截然相反。近年我国及全球学者针对激素治疗SCAP的RCT研究开展了多项meta分析［41, 42, 43, 44］，特别是纳入REMAP-CAP等最新研究数据分析后，仍支持激素降低无脓毒症休克SCAP患者病死率的结论［45］，其中氢化可的松在比较不同类型激素疗效的少量研究中略显优势［45, 46, 47］。2024年美国重症医学会指南及2025年美国胸科学会CAP指南将激素的使用指征扩展至所有SCAP（除流感病毒肺炎），不再局限于伴脓毒症休克患者［26，48］。我们对这一改变需格外谨慎，因各项RCT研究的方法学差异以及早期研究质量问题，降低了meta分析结论的可靠性。尽管2025年《新英格兰医学杂志》再发激素相关RCT研究，但入选患者缺乏影像确诊依据和病情严重程度评价［49］，结论难以信服。SCAP的高度异质性同样是激素疗效评价难获一致性结论的重要原因，REMAP-CAP的阴性结论，凸显了相当一部分重症患者激素治疗获益的不确定性。Smit等［50］研究发现，相较于病情严重程度，C反应蛋白>204 mg/L更能准确识别激素治疗获益人群，提示单纯以SCAP标准并不能准确区分获益人群。因此，在临床实践中需辨证看待国外指南推荐意见的变化。除激素外，探索性研究中，间充质干细胞在重症细菌性肺炎辅助治疗中的抗炎作用并不确切，反而可能诱导促凝和固有免疫通路激活，其理论依据需进一步明确［51］。
六、预防
近期我国发布多项呼吸道合胞病毒（respiratory syncytial virus，RSV）感染预防共识与指南，建议≥60岁且具有高危因素或≥75岁老年人群接种RSV疫苗，但疫苗复种价值尚不明确。同时，因缺乏高危险孕妇数据且无法评估RSV抗原亚群在疫苗效力方面的差异，国内对孕妇接种二价RSVpreF重组亚单位疫苗持谨慎态度［52, 53, 54］。共识还推荐 0~1岁婴儿在流行季前应用长效RSV单克隆抗体尼塞韦单抗［52，54］，另一长效RSV单克隆抗体Clesrovimab已纳入国家药监局药品审评中心优先评审。此外，重点面向成人的21价肺炎链球菌疫苗（VV116）于2024年上市，较以往获批疫苗明显增加了成人致病相关肺炎链球菌血清型覆盖［55］。
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