Z.K. Zeinulina

GKP at RVC City Clinic No. 4, pediatrician

The widespread occurrence of acute pneumonia poses a great danger to children. Timely correct diagnosis of acute pneumonia in children, assessment of the severity of the disease, taking into account concomitant diseases, the correct choice of antibacterial therapy allows full recovery children from pneumonia, reducing complications and mortality from pneumonia.

Bibliography: 5.

Keywords: children, pneumonia, etiology, antibiotics.

Pneumonia is a group of acute infectious diseases different in etiology, pathogenesis and morphology ( infectious processes), characterized by damage to the respiratory parts of the lungs with the obligatory presence of intra-alveolar exudation.

Every year in Russia, 1.5 million people fall ill with pneumonia, and the correct diagnosis is made in 1/3 of patients (3).

Acute pneumonia (AP) is an acute respiratory disease with local manifestations in the lungs, confirmed by x-ray.

Current trends in acute pneumonia (5):

Increased frequency of intracellular microorganisms;

Over- (56%) and under-diagnosis (33%);

Preference for admission antibacterial drugs inside;

Shorter courses of antibacterial therapy;

Refusal intravenous infusions fluid and gamma globulin;

Inappropriateness of physiotherapy.

Classification of pneumonia today (2):

According to the form - focal, focal-confluent, lobar, segmental, interstitial;

According to the place of occurrence and etiology - community-acquired, hospital-acquired, perinatal, with immunodeficiency, atypical, against the background of influenza, aspiration;

According to the course - acute up to 6 weeks, protracted in the absence of resolution for a period of 6 weeks to 8 months;

According to the presence of complications - uncomplicated, complicated.

Criteria for the diagnosis of pneumonia: impaired general condition, increased body temperature, cough, shortness of breath of varying severity, characteristic physical changes in the lungs. X-ray confirmation is based on identifying infiltrative changes on a radiograph. In the pathogenesis of the development of pneumonia have great importance the following factors:

microaspiration of nasopharyngeal secretions occurs in 70% of healthy individuals (impaired self-cleaning);

inhalation of aerosol with microorganisms: 60% of children under school age and 30% of school-age children and adults are carriers of pneumococcus;

20-40% of children in preschool institutions are carriers of Haemophilus influenzae;

there may be hematogenous spread of infection and direct spread of infection from neighboring organs.

Gold standard for clinical diagnosis (4):

Increased body temperature;

Shortness of breath (up to 2 months - 60; 2 - 12 months - 50; 1 - 5 years - 40);

Local auscultatory and percussion symptoms;

Leukocytosis in peripheral blood analysis;

X-ray changes;

Toxicosis.

Once diagnosis is made, the choice of initial antibiotic is important (1).

The choice of the initial antibiotic depends on the clinical situation, the antimicrobial spectrum of action of the selected antibiotic, the results of sputum smear bacterioscopy, the pharmacokinetics of the antimicrobial drug, the severity of pneumonia, the safety and cost of the drug, the spectrum of antibacterial action, including potential pathogens, proven clinical and microbiological effectiveness, ease of use, accumulation at the site of inflammation, good tolerability and safety, affordable price.

Age 1-6 months. Hospitalization is a must!

“Typical” pneumonia: amoxicillin, amoxicillin/clavulanate, ampicillin/sulbactam, 3rd generation cephalosporins.
“Atypical” pneumonia – macrolides.

Non-severe pneumonia in children 6 months – 6 years old

drugs of choice: amoxicillin, macrolides, alternative drugs amoxicillin/clavulanate, cefuroximaxetil. Over 7 years amoxicillin, macrolides.

It is possible to switch to oral antibiotics if

stable normalization of temperature, reduction of shortness of breath and cough, reduction of leukocytosis and blood neutrophilia (5-10 days of therapy).

If there are clear clinical positive dynamics, a control radiograph at discharge is not necessary, but it is necessary to X-ray control outpatient at 4-5 weeks.

The following are not indications for continuing antibacterial therapy: low-grade fever, dry cough, persistence of wheezing in the lungs,

acceleration of ESR, persistent weakness, sweating, persistence of residual changes on the radiograph (infiltration, enhancement of the pattern)

Therapy is considered ineffective if there is no improvement within 24 to 48 hours: signs of respiratory failure increase; a drop in systolic pressure, which indicates the development of infectious shock; an increase in the size of pneumonic infiltration by more than 50% compared to the initial data; the appearance of other manifestations of organ failure. In these cases, it is necessary to switch to alternative ABs and strengthen the functional support of organs and systems.

Errors in antibacterial therapy: prescribing gentamicin, co-trimoxazole, oral ampicillin and antibiotics in combination with nystatin, frequent changes of antibiotics during treatment,

continuation of antibacterial therapy until all clinical and laboratory parameters disappear completely (2,3).

Hospitalization requirements (3):

The child is less than 2 months old. regardless of the severity and extent of the process

Age up to 3 years with lobar lung damage

Age up to 5 years with damage to more than one lobe of the lung

Leukopenia< 6 тыс., лейкоцитоз >20 thousand

Atelectasis

Unfavorable localization (C4-5)

Children with severe encephalopathy of any origin

Children of the first year of life with intrauterine infections

Children with congenital malformations, especially heart defects

Children with concomitant bronchial asthma, diabetes mellitus, diseases of the cardiovascular system, kidneys, and oncohematology

Children from poor social conditions

No guaranteed execution therapeutic measures at home

A direct indication for hospitalization is toxic course pneumonia: shortness of breath over 60 per minute for children of the first year of life and more than 50 per minute for children over one year of age; retraction of the intercostal spaces and especially the jugular fossa during breathing; groaning breathing, irregular breathing rhythm; signs of acute heart failure; intractable hyperthermia; disturbance of consciousness, convulsions.

Complicated course of pneumonia: pneumonic toxicosis of varying severity; pleurisy; pulmonary destruction, lung abscess; pneumothorax; pyopneumothorax.

Conclusions: Over the past 3 years, pediatricians have been conducting early detection of acute pneumonia and timely hospitalization in pediatric areas. After discharge from the hospital, rehabilitation measures and medical examination are carried out. There wasn't one fatal outcome because They were diagnosed early and adequate therapy was prescribed.

For quotation: Community-acquired pneumonia. Interview with prof. L.I. Butler // RMJ. 2014. No. 25. S. 1816

Interview with the head of the Department of Internal Diseases of the State Budgetary Educational Institution of Higher Professional Education “First Moscow State Medical University named after I.M. Sechenov”, Doctor of Medical Sciences, Professor L.I. Butler

Pneumonia, having been a severe, often fatal disease for centuries, continues to be a serious clinical problem, many aspects of which require careful analysis today. What determines the relevance of the problem of pneumonia today?
- The incidence of community-acquired pneumonia (CAP) in our country reaches 14-15%, and the total number of patients annually exceeds 1.5 million people. In the United States, more than 5 million cases of CAP are diagnosed annually, of which more than 1.2 million people require hospitalization, and more than 60 thousand of them die. If the mortality rate for CAP among young and middle-aged people without concomitant diseases does not exceed 1-3%, then in patients over 60 years of age with serious concomitant pathology, as well as in cases of severe disease, this figure reaches 15-30%.

Are there risk factors for severe pneumonia that should be taken into account by practitioners, especially outpatients?
- Factors that, unfortunately, are not always taken into account by doctors include male gender, the presence of serious concomitant diseases, the high prevalence of pneumonic infiltration, according to X-ray examination, tachycardia (>125/min), hypotension (<90/60 мм рт. ст.), одышка (>30/min), some laboratory data.

One of the important aspects of the problem of pneumonia is timely and correct diagnosis. What is the current situation regarding the diagnosis of pneumonia?
- The level of diagnosis of pneumonia, unfortunately, turns out to be low. Thus, out of 1.5 million cases of pneumonia, the disease is diagnosed in less than 500 thousand, i.e., only in 30% of patients.

Agree that the current situation should be considered clearly unsatisfactory, if not simply alarming. After all, this is the 21st century, and we should have made progress in improving the diagnosis of a disease such as pneumonia. What is the reason for such unsatisfactory diagnosis?
- Along with subjective factors that determine, to a certain extent, unsatisfactory diagnosis of CAP, it is necessary to take into account objective reasons. Establishing a diagnosis of pneumonia is complicated by the fact that there is no specific clinical sign or set of such signs that can be relied upon reliably to suspect pneumonia. On the other hand, the absence of any nonspecific symptom, as well as local changes in the lungs (confirmed by the results of clinical and/or radiological examination) makes the diagnosis of pneumonia unlikely. When diagnosing pneumonia, the doctor should be based on the main signs, among which the following should be highlighted:
1. Sudden onset, febrile fever, shaking chills, chest pain are characteristic of the pneumococcal etiology of CAP (it is often possible to isolate Streptococcus pneumoniae from the blood), partly for Legionella pneumophila, less often for other pathogens. On the contrary, this picture of the disease is completely atypical for Mycoplasma pneumoniae and Chlamydophila pneumoniae infections.
2. “Classical” signs of pneumonia (feverish onset, chest pain, etc.) may be absent, especially in weakened patients and elderly/senile people.
3. Approximately 25% of patients over the age of 65 years who experience CAP do not have fever, and leukocytosis is recorded only in half of the cases. In this case, clinical symptoms can often be represented by nonspecific manifestations (fatigue, weakness, nausea, anorexia, impaired consciousness, etc.).
4. Classic objective signs of pneumonia are shortening (dullness) of the percussion tone over the affected area of ​​the lung, locally auscultated bronchial breathing, a focus of sonorous fine rales or crepitus, increased bronchophony and voice tremors. However, in a significant proportion of patients, objective signs of pneumonia may differ from typical ones, and in approximately 20% of patients they may be completely absent.
5. Taking into account the significant clinical variability in the picture of CAP and the ambiguity of the results of physical examination, almost always, diagnosing CAP requires an x-ray examination confirming the presence of focal infiltrative changes in the lungs.

What is the diagnostic value radiation methods studies, including high-resolution ones, in patients with CAP? We can again ask a trivial question that often arises: is the diagnosis of pneumonia clinical or radiological?
- One of the diagnostic criteria for pneumonia is the presence of pulmonary infiltration, detected using methods radiology diagnostics, in particular during X-ray examination of the patient. Meanwhile, an analysis of the quality of management of patients with CAP indicates insufficient use this method studies before prescribing ABP. According to S.A. Rachina, an X-ray examination of the patient before starting therapy was carried out in only 20% of patients.
X-ray negative pneumonia apparently exists, although from the point of view of modern pulmonological concepts, the diagnosis of inflammation of the lung tissue without radiation examination, primarily x-ray, cannot be considered sufficiently substantiated and accurate.

The key problems of antibacterial therapy (ABT) in patients with CAP are the choice of the optimal antibacterial therapy, timing of administration, monitoring of effectiveness and tolerability, decision-making on changing the antibacterial therapy, and duration of administration of the antibacterial therapy. S.A. Rachina, who analyzed the quality of care for patients with CAP in various regions of Russia, showed that when choosing an ABP, doctors are guided by different criteria. This includes the penetration of ABP into the lung tissue, availability in oral form, the cost of the drug, and more. Is there any general, unified principle for choosing ABP in patients with CAP?
- When choosing an ABP in this category of patients, one should first of all focus, on the one hand, on the clinical situation, and on the other, on the pharmacological properties of the prescribed ABP. It is necessary to be aware that ABT for a patient with CAP begins (at least should begin) immediately after the clinical and radiological diagnosis of the disease, in the absence of data from bacteriological examination of sputum. The maximum that can be done is bacterioscopy of Gram-stained sputum samples. Therefore, we are talking about tentative etiological diagnosis, that is, the probability of the presence of a particular pathogen, depending on the specific clinical situation. It has been shown that a certain pathogen is usually “tied” to the corresponding clinical situation (age, nature of concomitant and background pathology, epidemiological history, risk of antibiotic resistance, etc.). On the other hand, it is important for the doctor to have comprehensive information about the ABP that is supposed to be prescribed. It is especially important to be able to correctly interpret this information in relation to a specific patient with CAP.
Today there is the possibility of “antigenic” rapid diagnosis of pneumonia using immunochromatographic determination of soluble antigens Streptococcus pneumoniae and Legionella pneumophila in urine. However, this diagnostic approach is justified, as a rule, in severe cases of the disease. In practice, antimicrobial therapy for CAP in the vast majority of cases is empirical. Agreeing that even a thorough analysis of the clinical picture of the disease hardly allows one to reliably determine the etiology of pneumonia, it should be recalled that in 50-60% of cases the causative agent of CAP is Streptococcus pneumoniae. In other words, CAP is primarily a pneumococcal infection of the lower respiratory tract. And hence the obvious practical conclusion - the prescribed ABP must have acceptable antipneumococcal activity.

Is it right to talk about the “most effective” or “ideal” drug among the available arsenal of ABPs for the treatment of CAP, taking into account the results of clinical trials conducted to date?
- The desire of doctors to have an “ideal” antibiotic for all occasions is understandable, but practically difficult to achieve. In a young or middle-aged patient with CAP without comorbidity, the optimal antibiotic is amoxicillin, based on the presumed pneumococcal etiology of the disease. In older patients age groups or with chronic obstructive pulmonary disease, the optimal antibiotic would be amoxicillin/clavulanic acid or a parenteral cephalosporin of the third generation - taking into account the likely role in the etiology of CAP, along with pneumococcus, Haemophilus influenzae and other gram-negative bacteria. In patients with risk factors for infections caused by antibiotic-resistant pathogens, comorbidity and/or severe CAP, the optimal antibiotic will be a “respiratory” fluoroquinolone - moxifloxacin or levofloxacin.

The sensitivity of key respiratory pathogens to ABP becomes important when choosing a starting ABP. To what extent can the presence of antibiotic resistance influence the choice of antibiotics?
- There are such concepts as microbiological and clinical resistance of pathogens to antibiotics. And they do not always coincide for some groups of antibiotics. Thus, with a low level of resistance of pneumococcus to penicillin, amoxicillin and third-generation cephalosporins retain clinical effectiveness, although in higher doses: amoxicillin 2-3 g/day, ceftriaxone 2 g/day, cefotaxime 6 g/day. At the same time, microbiological resistance of pneumococcus to macrolides, second generation cephalosporins or fluoroquinolones is accompanied by clinical ineffectiveness of treatment.

What approaches exist to choosing an adequate antibacterial drug for the treatment of patients with CAP? What are they based on and how are they implemented in clinical practice?
- In order to optimize the choice of ABP for the treatment of a patient with CAP, several groups of patients should be distinguished based on the severity of the disease. This determines the prognosis and decision-making about the place of treatment for the patient (outpatient or inpatient), allows us to tentatively suggest the most likely pathogen and, taking this into account, develop ABT tactics. If in patients with mild pneumonia there are no differences in the effectiveness of aminopenicillins, as well as individual representatives of the class of macrolides or “respiratory” fluoroquinolones, which can be prescribed orally, and treatment can be carried out on an outpatient basis, then in more severe cases of the disease hospitalization is indicated, and it is advisable to start therapy with parenteral antibiotics. After 2-4 days of treatment, when body temperature normalizes, intoxication and other symptoms decrease, it is recommended to switch to oral antibiotics until the full course of therapy is completed (stepped therapy). Patients with severe pneumonia are prescribed drugs that are active against “atypical” microorganisms, which improves the prognosis of the disease.
- How often is pneumonia treated using stepwise therapy?
- Clinical practice indicates that the stepwise therapy regimen in the treatment of hospitalized patients with CAP is used infrequently. According to S.A. Rachina, stepwise therapy is carried out in no more than 20% of cases. This can be explained by the lack of awareness and inertia of doctors, as well as their underlying belief that parenteral drugs are obviously more effective than oral ones. This is not always and not entirely true. Of course, in a patient with multiple organ failure, the method of administering the antibiotic can only be parenteral. However, in a clinically stable patient without gastrointestinal dysfunction, there are no significant differences in the pharmacokinetics of different dosage forms of antibiotics. Therefore, the presence of an antibiotic in an oral dosage form with good bioavailability is a sufficient basis for transferring the patient from parenteral treatment to oral treatment, which can also be significantly cheaper and more convenient for him. Many parenteral antibiotics have oral dosage forms with high bioavailability (more than 90%): amoxicillin/clavulanic acid, levofloxacin, moxifloxacin, clarithromycin, azithromycin. It is also possible to carry out step therapy in the case of using a parenteral antibiotic that does not have a similar oral form with high bioavailability. In this case, an oral antibiotic with identical microbiological characteristics and optimized pharmacokinetics is prescribed, for example, cefuroxime IV - cefuroxime axetil orally, ampicillin IV - amoxicillin orally.

How important is the timing of initiation of antimicrobial therapy once CAP is diagnosed?
- Special attention began to be paid to the time before the first administration of an antibiotic to patients with CAP relatively recently. Two retrospective studies demonstrated a statistically significant reduction in mortality among hospitalized patients with CAP with early initiation of antimicrobial therapy. The authors of the first study proposed a threshold time of 8 hours, but subsequent analysis showed that lower mortality was observed at a threshold time not exceeding 4 hours. It is important to emphasize that in the studies mentioned, patients who received antibiotics in the first 2 hours after medical examination were clinically more severe than patients who began antimicrobial therapy 2-4 hours after admission to the hospital emergency department. Currently, experts, not considering it possible to determine a specific time interval from the beginning of the examination of the patient to the administration of the first dose of antibiotic, call for the earliest possible start of treatment after establishing preliminary diagnosis diseases.

Prescribing an ABP, even as early as possible, of course, does not exhaust the mission of the supervising physician and does not finally resolve all issues. How to evaluate the effect of a prescribed ABP? What are the performance criteria? What time frames should be considered critical for making a decision about the lack of effect, and, consequently, about changing the antibiotic?
- There is a “third day” rule, according to which the effectiveness of antimicrobial therapy should be assessed 48-72 hours after its start. If the patient’s body temperature has normalized or does not exceed 37.5 o C, signs of intoxication have decreased, there is no respiratory failure or hemodynamic disturbances, then the effect of the treatment should be regarded as positive and the antibiotic should be continued. In the absence of the expected effect, it is recommended to add oral macrolides (preferably azithromycin or clarithromycin) to the first-line drug, for example, amoxicillin or “protected” aminopenicillins. If this combination is ineffective, an alternative group of drugs should be used - “respiratory” fluoroquinolones. In the case of an initially irrational antibiotic prescription, as a rule, first-line drugs are no longer used, but are switched to “respiratory” fluoroquinolones.

No less important issue The tactics of ABT in patients with CAP is the duration of treatment. Doctors often worry about under-treating the disease. Is there the same danger in both “under-treating” and “over-treating” a patient?
- Many patients with CAP who have achieved a clinical effect against the background of ABT are sent to the hospital to continue treatment. From the doctor’s point of view, the reasons for this are low-grade fever, persistent, although decreased in volume, pulmonary infiltration, according to X-ray examination, an increase in ESR. In this case, either ABT is carried out as before, or a new ABT is prescribed.
In most cases, antimicrobial therapy for patients with CAP continues for 7-10 days or more. Comparative studies of the effectiveness of short and habitual (in terms of duration) courses of antibiotics did not reveal significant differences in both outpatient and hospitalized patients if the treatment was adequate. According to modern concepts, antimicrobial therapy for CAP can be completed provided that the patient has received treatment for at least 5 days, his body temperature has normalized over the last 48-72 hours and there are no criteria for clinical instability (tachypnea, tachycardia, hypotension, etc.). Longer treatment is necessary in cases where the prescribed ABT did not have an effect on the isolated pathogen or when complications develop (abscess formation, pleural empyema). The persistence of individual clinical, laboratory or radiological signs of CAP is not an absolute indication for continuation of antimicrobial therapy or its modification.
According to some data, up to 20% of patients with non-severe CAP do not respond properly to treatment. This is a serious figure, which makes it advisable to conduct more careful and, possibly, more frequent radiation monitoring of the condition of the lungs. Found at X-ray examination prolonged resolution of focal infiltrative changes in the lungs even against the background of a clear reverse development clinical symptoms illness often serves as a reason to continue or modify ABT.
The main criterion for the effectiveness of ABT is the reverse development of clinical manifestations of CAP, primarily the normalization of body temperature. The timing of radiological recovery, as a rule, lags behind the timing of clinical recovery. Here, in particular, it is appropriate to recall that the completeness and timing of radiological resolution of pneumonic infiltration also depend on the type of causative agent of CAP. So, if with mycoplasma pneumonia or pneumococcal pneumonia without bacteremia, the period of radiological recovery is on average 2 weeks. - 2 months and 1-3 months. accordingly, in cases of disease caused by gram-negative enterobacteria, this time interval reaches 3-5 months.

What can you say about pneumonia with a delayed clinical response and delayed radiological resolution in immunocompetent patients?
- In such situations, doctors often panic. Consultants, primarily TB specialists and oncologists, are called in to help, new antibiotics are prescribed, etc.
In most patients with CAP, by the end of 3-5 days from the start of ABT, body temperature normalizes and other manifestations of intoxication regress. In those cases when, against the background of improvement of the condition by the end of the 4th week. from the onset of the disease it is not possible to achieve complete radiological resolution, one should speak of non-resolving/slowly resolving or protracted VP. In such a situation, one should first of all establish possible risk factors for the protracted course of CAP, which include advanced age, comorbidity, severe course of CAP, multilobar infiltration, and secondary bacteremia. In the presence of the above risk factors for slow resolution of CAP and simultaneous clinical improvement, it is advisable after 4 weeks. conduct a control x-ray examination of organs chest. If clinical improvement is not observed and/or the patient does not have risk factors for slow resolution of VP, then in these cases computed tomography and fiber-optic bronchoscopy are indicated.

In clinical practice, diagnostic and therapeutic errors are inevitable. We discussed the reasons for late or erroneous diagnosis of pneumonia. What are the most typical mistakes made by ABT in patients with CAP?
- Most common mistake the starting antibiotic should be considered to be inconsistent with accepted clinical recommendations. This may be due to doctors' insufficient familiarity with existing clinical guidelines, or their ignorance, or even simply ignorance of their existence. Another mistake is the lack of timely change of the ABP in case of its obvious ineffectiveness. We have to deal with situations where ABT is continued for 1 week, despite the lack of clinical effect. Errors in the dosing of antibiotics and the duration of antibiotic therapy are less common. If there is a risk of the emergence of antibiotic-resistant pneumococci, penicillins and cephalosporins should be used in an increased dose (amoxicillin 2-3 g/day, amoxicillin/clavulanic acid 3-4 g/day, ceftriaxone 2 g/day), and some antibiotics should not be prescribed (cefuroxime, macrolides). In addition, the practice of prescribing antibiotics for CAP in subtherapeutic doses against pneumococci, for example, azithromycin in daily dose 250 mg, clarithromycin in a daily dose of 500 mg, amoxicillin/clavulanic acid in dosage form 625 mg (and even more so 375 mg). At this time, increasing the dose of levofloxacin to 750 mg may be warranted.

We often witness unnecessary hospitalization of patients with CAP, which, according to some data, occurs in almost half of cases of CAP. It seems that when making a decision about hospitalization of a patient with CAP, most doctors are guided by subjective assessments, although there are specific, primarily clinical, indications for this.
- The main indication for hospitalization is the severity of the patient’s condition, which can be caused by both pulmonary inflammation itself, leading to the development of respiratory failure, and decompensation of the patient’s concomitant pathology (worsening heart failure, renal failure, decompensation diabetes mellitus, increased cognitive impairment and a number of other signs). When deciding on hospitalization, it is important to assess the patient’s condition and determine the indications for hospitalization in the intensive care unit. There are different scales for assessing the severity of pneumonia. The most suitable scale for this purpose is the CURB-65 scale, which assesses the level of consciousness, respiratory rate, systolic blood pressure, urea content in the blood and the patient’s age (65 years or more). A high correlation has been shown between CAP severity scores on the CURB-65 scale and mortality. Ideally, a standardized approach to the management of a patient with CAP should be introduced based on the CURB-65 score: the number of points is 0-1 - the patient can be treated on an outpatient basis, higher - should be hospitalized, and in the hospital if there are 0-2 points the patient is in therapeutic (pulmonology) department, if there are 3 or more points - must be transferred to the intensive care unit.

Exist practical recommendations for the management of patients with CAP. How important is it to follow these recommendations and is there evidence of better treatment outcomes in such cases?
- The recommendations lay down the principles of examining the patient and present a unified approach to the management of this category of patients. It has been shown that following certain provisions of the recommendations reduces the likelihood of early therapeutic failure (in the first 48-72 hours) by 35% and the risk of death by 45%! Therefore, in order to improve the diagnosis of CAP and treatment of this category of patients, doctors can be encouraged to follow clinical recommendations.

It is one of the most relevant in modern therapeutic practice. Over the past 5 years alone, the incidence rate in Belarus has increased by 61%. The mortality rate from pneumonia, according to various authors, ranges from 1 to 50%. In our republic, the mortality rate has increased by 52% over 5 years. Despite the impressive successes of pharmacotherapy and the development of new generations of antibacterial drugs, the share of pneumonia in the morbidity structure is quite large. Thus, in Russia every year more than 1.5 million people are observed by doctors for this disease, of which 20% are hospitalized due to the severity of the condition. Among all hospitalized patients with bronchopulmonary inflammation, not counting ARVI, the number of patients with pneumonia exceeds 60%.

IN modern conditions The “economical” approach to financing healthcare prioritizes the most appropriate expenditure of allocated budget funds, which predetermines the development of clear criteria and indications for hospitalization of patients with pneumonia, optimization of therapy in order to obtain a good final result at lower costs. Based on principles evidence-based medicine, we think it is important to discuss this problem in connection with the urgent need to introduce clear criteria for hospitalization of patients with pneumonia into everyday practice, which would facilitate the work of the local therapist, save budgetary funds, and timely predict possible outcomes of the disease.

Mortality from pneumonia today is one of the main indicators of the activity of medical institutions. Health care organizers and doctors are required to constantly reduce this indicator, unfortunately, without taking into account the objective factors leading to death in various categories of patients. Each case of death from pneumonia is discussed at clinical and anatomical conferences.

Meanwhile, world statistics indicate an increase in mortality from pneumonia, despite advances in its diagnosis and treatment. IN THE USA this pathology ranks sixth in the structure of mortality and is the most common cause deaths from infectious diseases. More than 60,000 fatal outcomes from pneumonia and its complications are recorded annually.

It should be assumed that in most cases pneumonia is a serious and serious illness. Tuberculosis and lung cancer are often hidden under its mask. A study of autopsy reports of people who died from pneumonia over 5 years in Moscow and St. Petersburg showed that the correct diagnosis was made within the first day after admission to the hospital in less than a third of patients, and within the first week - in 40%. 27% of patients died on the first day of hospital stay. The coincidence of clinical and pathoanatomical diagnoses was observed in 63% of cases, with underdiagnosis of pneumonia being 37%, and overdiagnosis - 55% (!). It can be assumed that the detection rate of pneumonia in Belarus is comparable to that in the largest Russian cities.

Perhaps the reason for such depressing figures is the change in modern stage the “gold standard” for the diagnosis of pneumonia, including the acute onset of the disease with fever, cough with sputum, chest pain, leukocytosis, less often leukopenia with a neutrophilic shift in the blood, and an x-ray detectable infiltrate in the lung tissue, which was not previously determined. Many researchers also note the formal, superficial attitude of doctors towards the issues of diagnosis and treatment of such a “long-known and well-studied” disease as pneumonia.

In the winter season, with the onset of cold weather, the risk of diseases of the upper and lower respiratory tract increases: pneumonia, sore throat, tracheitis.

Pneumonia is now one of the most common diseases. Despite the successes of drug therapy, pneumonia is still considered dangerous, and sometimes even fatal disease. Patients with pneumonia make up a significant percentage of those seeking medical care in clinics, therapeutic and pulmonology departments of hospitals, which is associated with high morbidity, especially during influenza epidemics and outbreaks of acute respiratory diseases.

This is an acute infectious disease, predominantly of bacterial (viral) etiology, characterized by focal damage to the respiratory parts of the lungs, the presence of intra-alveolar exudation, detected during physical and instrumental examination, expressed in varying degrees by a febrile reaction and intoxication.

Suspect inflammatory disease lungs is possible if the following symptoms are present:

• Fever (temperature above 38 degrees);
• Intoxication, general malaise, loss of appetite;
• Pain when breathing on the side of the affected lung, aggravated by coughing (when the pleura is involved in the process of inflammation);
• Cough is dry or with phlegm;
• Dyspnea.

The diagnosis is made by a doctor. It is important to seek medical help on the first day of illness. A chest x-ray helps a doctor make a diagnosis. computed tomogram, auscultatory data. The selection of drug therapy is strictly individual, depending on the suspected causative agent of the disease. Treatment of pneumonia is carried out on an outpatient or inpatient basis, depending on the severity of the disease. Indications for hospitalization are determined by the doctor.

Relevance of the problem of pneumonia

The problem of diagnosis and treatment of pneumonia is one of the most pressing in modern therapeutic practice. Over the past 5 years alone, the incidence rate in Belarus has increased by 61%. The mortality rate from pneumonia, according to various authors, ranges from 1 to 50%. In our republic, the mortality rate has increased by 52% over 5 years. Despite the impressive successes of pharmacotherapy and the development of new generations of antibacterial drugs, the share of pneumonia in the morbidity structure is quite large. Thus, in Russia every year more than 1.5 million people are observed by doctors for this disease, of which 20% are hospitalized due to the severity of the condition. Among all hospitalized patients with bronchopulmonary inflammation, not counting ARVI, the number of patients with pneumonia exceeds 60%.

In modern conditions of a “economical” approach to healthcare financing, the priority is the most appropriate expenditure of allocated budget funds, which predetermines the development of clear criteria and indications for hospitalization of patients with pneumonia, optimization of therapy in order to obtain a good final result at lower costs. Based on the principles of evidence-based medicine, it seems important to us to discuss this problem in connection with the urgent need to introduce clear criteria for hospitalization of patients with pneumonia into everyday practice, which would facilitate the work of the local therapist, save budget funds, and timely predict possible outcomes of the disease.

Mortality from pneumonia today is one of the main indicators of the activity of medical institutions. Health care organizers and doctors are required to constantly reduce this indicator, unfortunately, without taking into account the objective factors leading to death in various categories of patients. Each case of death from pneumonia is discussed at clinical and anatomical conferences.

Meanwhile, world statistics indicate an increase in mortality from pneumonia, despite advances in its diagnosis and treatment. In the United States, this pathology ranks sixth in the structure of mortality and is the most common cause of death from infectious diseases. More than 60,000 fatalities from pneumonia and its complications are recorded annually.

It should be assumed that in most cases pneumonia is a serious and severe illness. Tuberculosis and lung cancer. A study of autopsy reports of people who died from pneumonia over 5 years in Moscow and St. Petersburg showed that the correct diagnosis was made within the first day after admission to the hospital in less than a third of patients, and within the first week - in 40%. 27% of patients died on the first day of hospital stay. The coincidence of clinical and pathoanatomical diagnoses was observed in 63% of cases, with underdiagnosis of pneumonia being 37%, and overdiagnosis - 55% (!). It can be assumed that the detection rate of pneumonia in Belarus is comparable to that in the largest Russian cities.

Perhaps the reason for such depressing figures is the change at the present stage in the “gold standard” for diagnosing pneumonia, which includes acute onset of the disease with fever, cough with sputum, chest pain, leukocytosis, and less often leukopenia with a neutrophilic shift in the blood, radiologically detectable infiltrate in the lung tissue , which was not previously defined. Many researchers also note the formal, superficial attitude of doctors towards the issues of diagnosis and treatment of such a “long-known and well-studied” disease as pneumonia.

You are reading the topic:

On the problem of diagnosis and treatment of pneumonia

Community-acquired pneumonia in children: clinical, laboratory and etiological features

Orenburg State Medical Academy

Relevance. Respiratory diseases occupy one of the leading places in the structure of morbidity and mortality in children. Pneumonia plays an important role among them. This is due both to the high incidence of respiratory tract lesions in children and to the serious prognosis of many late-diagnosed and untreated pneumonias. In the Russian Federation, the incidence of pneumonia in children is in the range of 6.3-11.9%. One of the main reasons for the increase in the number of pneumonia is high level diagnostic errors and late diagnosis. The proportion of pneumonia in which the clinical picture does not correspond to radiological data has increased significantly, and the number of asymptomatic forms of the disease has increased. There are also difficulties in the etiological diagnosis of pneumonia, since over time the list of pathogens expands and modifies. Until relatively recently, community-acquired pneumonia was associated mainly with Streptococcus pneumoniae. Currently, the etiology of the disease has expanded significantly, and in addition to bacteria it can also be represented by atypical pathogens (Mycoplasma pneumoniae, Chlamydophila pneumoniae), fungi, as well as viruses (influenza, parainfluenza, metapneumoviruses, etc.), the role of the latter is especially great in children under 5 4 years old. All this leads to untimely correction of treatment, worsening of the patient’s condition, and the prescription of additional medications, which ultimately affects the prognosis of the disease. Thus, despite a fairly detailed study of the problem of childhood pneumonia, there is a need to clarify modern clinical features pneumonia, studying the significance of various pathogens, including pneumotropic viruses, in this disease.

Purpose of the study: identification of modern clinical, laboratory and etiological features of the course of pneumonia in children. Materials and methods. A comprehensive examination was conducted of 166 children with community-acquired pneumonia aged from 1 to 15 years, who were treated in the pulmonology department of the children's hospital of the State Autonomous Institution "Children's City clinical Hospital» Orenburg. Among the examined children there were 85 boys (51.2%) and 81 girls (48.8%). All patients were divided into 2 groups according to the morphological forms of pneumonia (patients with focal pneumonia and segmental pneumonia) and into 4 groups according to age - children early age(1 - 2 years old), preschoolers (3 - 6 years old), junior schoolchildren (7 - 10 years old) and senior schoolchildren (11 - 15 years old). All patients underwent the following examination: clinical analysis blood, general urine test, biochemical blood test with determination of the level C-reactive protein(CRP), chest radiography, microscopic and bacteriological examination sputum flora and sensitivity to antibiotics. To identify respiratory viruses and S. pneumoniae, 40 patients underwent a study of tracheobronchial aspirates using real-time polymerase chain reaction (PCR) to detect ribonucleic acid (RNA) of respiratory syncytial virus, rhinovirus, metapneumovirus, parainfluenza virus 1, 2, 3, 4 types, deoxyribonucleic acid (DNA) adenovirus and pneumococcus. The data obtained during the study was processed using the STATISTICA 6.1 software product. During the analysis, the calculation of elementary statistics, construction and visual analysis of correlation fields of connection between the analyzed parameters were carried out, comparison of frequency characteristics was carried out using non-parametric methods chi-square, chi-square with Yates' correction, and Fisher's exact method. Comparison of quantitative indicators in the study groups was performed using Student's t-test at normal distribution sample and Wilcoxon-Mann-Whitney U test if not normal. The relationship between individual quantitative characteristics was determined by the Spearman rank correlation method. Differences in average values ​​and correlation coefficients were considered statistically significant at the significance level of p 9 /l, segmental - 10.4±8.2 x10 9 /l.

In the group of segmental pneumonia, the ESR value was higher than in focal pneumonia - 19.11±17.36 mm/h versus 12.67±13.1 mm/h, respectively (p 9/l to 7.65±2.1x 10 9 /l (p

List of sources used:

1. Community-acquired pneumonia in children: prevalence, diagnosis, treatment and prevention. – M.: Original layout, 2012. – 64 p.

2. Sinopalnikov A.I., Kozlov R.S. Community-acquired respiratory tract infections. Guide for doctors - M.: Premier MT, Our City, 2007. - 352 p.

Hospital pneumonia

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INTRODUCTION

Pneumonia is currently a very pressing problem, since despite the constantly growing number of new antibacterial drugs, the mortality rate from this disease remains high. Currently, for practical purposes, pneumonia is divided into community-acquired and nosocomial. In these two large groups, there are also aspiration and atypical pneumonias (caused by intracellular agents - mycoplasma, chlamydia, legionella), as well as pneumonia in patients with neutropenia and/or against the background of various immunodeficiencies.

The International Statistical Classification of Diseases provides for the definition of pneumonia solely on the basis of etiology. In more than 90% of cases, GP has bacterial origin. Viruses, fungi and protozoa are characterized by a minimal “contribution” to the etiology of the disease. Over the past two decades, significant changes have occurred in the epidemiology of HP. This is characterized by the increased etiological significance of pathogens such as mycoplasma, legionella, chlamydia, mycobacteria, pneumocystis and a significant increase in the resistance of staphylococci, pneumococci, streptococci and Haemophilus influenzae to the most widely used antibiotics. Acquired resistance of microorganisms is largely due to the ability of bacteria to produce beta-lactamases, which destroy the structure of beta-lactam antibiotics. Nosocomial strains of bacteria are usually highly resistant. These changes are partly due to the selective pressure on microorganisms from the widespread use of new antibiotics wide range actions. Other factors are the increase in the number of multi-resistant strains and the increase in the number of invasive diagnostic and therapeutic procedures in a modern hospital. In the early antibiotic era, when only penicillin was available to the doctor, about 65% of all nosocomial infections, including GP, were due to staphylococci. The introduction of penicillinase-resistant betalactams into clinical practice reduced the relevance of staphylococcal nosocomial infection, but at the same time the importance of aerobic gram-negative bacteria (60%) increased, which replaced gram-positive pathogens (30%) and anaerobes (3%). Since this time, multidrug-resistant gram-negative microorganisms (coliform aerobes and Pseudomonas aeruginosa) have become one of the most important nosocomial pathogens. Currently, there is a revival of gram-positive microorganisms as actual nosocomial infections with an increase in the number of resistant strains of staphylococci and enterococci.

On average, the incidence of hospital-acquired pneumonia (HAP) is 5-10 cases per 1000 hospitalized patients, but in patients on mechanical ventilation this figure increases 20 times or more. Mortality in HP, despite objective advances in antimicrobial chemotherapy, today is 33-71%. In general, nosocomial pneumonia (NP) accounts for about 20% of all nosocomial infections and takes third place after wound infections and urinary tract infections. The frequency of NP increases in patients staying in hospital for a long time; when using immunosuppressive drugs; in persons suffering from serious illnesses; in elderly patients.

ETIOLOGY AND PATHOGENESIS of hospital-acquired pneumonia

Hospital (nosocomial, nosocomial) pneumonia (interpreted as the appearance 48 hours or more after hospitalization of a new pulmonary infiltrate in combination with clinical data confirming its infectious nature (a new wave of fever, purulent sputum, leukocytosis, etc.) and with the exclusion of infections, who were in incubation period upon admission of the patient to the hospital) is the second most common and leading cause of death in the structure of nosocomial infections.

Studies conducted in Moscow showed that the most common (up to 60%) bacterial pathogens of community-acquired pneumonia are pneumococci, streptococci and Haemophilus influenzae. Less commonly - staphylococcus, klebsiella, enterobacter, legionella. In persons young Pneumonia is more often caused by a monoculture of the pathogen (usually pneumococcus), and in the elderly - by an association of bacteria. It is important to note that these associations are represented by a combination of gram-positive and gram-negative microorganisms. The frequency of mycoplasma and chlamydial pneumonia varies depending on the epidemiological situation. Young people are more often susceptible to this infection.

Respiratory tract infections occur in the presence of at least one of three conditions: a violation of the body’s defenses, the entry of pathogenic microorganisms into the lower respiratory tract of a patient in quantities exceeding the body’s defenses, and the presence of a highly virulent microorganism.
Penetration of microorganisms into the lungs can occur in various ways, including through microaspiration of oropharyngeal secretions colonized by pathogenic bacteria, aspiration of esophageal/stomach contents, inhalation of an infected aerosol, penetration from a distant infected site by hematogenous route, exogenous penetration from an infected site (for example, the pleural cavity) , direct infection of the respiratory tract in intubated patients from intensive care unit staff or, which remains doubtful, through transfer from the gastrointestinal tract.
Not all of these routes are equally dangerous in terms of pathogen penetration. Of the possible routes of penetration of pathogenic microorganisms into the lower respiratory tract, the most common is microaspiration of small volumes of oropharyngeal secretions previously contaminated with pathogenic bacteria. Since microaspiration occurs quite often (for example, microaspiration during sleep is observed in at least 45% of healthy volunteers), it is the presence of pathogenic bacteria that can overcome the protective mechanisms in the lower respiratory tract that plays a role important role in the development of pneumonia. In one study, oropharyngeal contamination with enteric gram-negative bacteria (EGN) was relatively rare (

Study of factors contributing to the development of community-acquired pneumonia and analysis of effective treatment

Description: In recent years, the number of patients with severe and complicated community-acquired pneumonia has been growing. One of the main reasons for the severe course of pneumonia is underestimation of the severity of the condition upon admission to the hospital due to the poor clinical, laboratory and radiological picture in initial period development of the disease. In Russia medical staff actively participates in conferences on the prevention of pneumonia.

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Chapter 1. What is community-acquired pneumonia?

1.6. Differential diagnosis

1.8. Antibacterial therapy

1.9. Comprehensive treatment of community-acquired pneumonia

1.10. Socio-economic aspects

1.11. Preventive measures

CHAPTER 2. Analysis of statistical data on pneumonia in the city of Salavat

Results of the work performed

Respiratory diseases are one of the leading causes of morbidity and mortality worldwide. At the present stage it is changing clinical course and the severity of these diseases worsens, which leads to an increase in various complications, disability and increasing mortality. Community-acquired pneumonia still remains one of the leading pathologies in the group of respiratory diseases. The incidence of community-acquired pneumonia in most countries is 10-12%, varying depending on age, gender, and socio-economic conditions.

In recent years, the number of patients with severe and complicated community-acquired pneumonia has been growing. One of the main reasons for the severe course of pneumonia is the underestimation of the severity of the condition upon admission to the hospital, due to the poor clinical, laboratory and radiological picture in the initial period of development of the disease. However, a number of works show an underestimation of the data from clinical and laboratory studies, propose complex prognosis methods, and often ignore A complex approach to examining patients. In this regard, the relevance of the problem of comprehensive quantitative assessment of the severity of the condition of a patient with community-acquired pneumonia and predicting the course of the disease in early stages hospitalizations are increasing.

In Russia, medical personnel actively participate in conferences on the prevention of pneumonia. Examinations are carried out annually in medical institutions. But, unfortunately, despite such work, the number of cases of pneumonia remains one of the main problems in our country.

Relevance of the problem. This work focuses on the severity of the disease due to the large number of cases of severe consequences. The situation is being constantly monitored and morbidity statistics, in particular pneumonia, are being studied.

Considering this situation regarding pneumonia, I decided to tackle this problem.

Purpose of the study. Study of factors contributing to the development of community-acquired pneumonia and analysis of effective treatment.

Object of study. Patients with community-acquired pneumonia in a hospital setting.

Subject of study. The role of the paramedic in the timely detection of community-acquired pneumonia and adequate treatment.

1) Identify and study the causes contributing to the disease of community-acquired pneumonia.

2) Determine risk factors for the incidence of community-acquired pneumonia.

3) Assess the comparative clinical, bacteriological effectiveness and safety of various antibacterial therapy regimens in the treatment of hospitalized patients with community-acquired pneumonia.

4) Familiarization with the role of the paramedic in the prevention and treatment of community-acquired pneumonia.

Hypothesis. Community-acquired pneumonia is defined as a medical and social problem.

The practical significance of my work will be to ensure that the population is well versed in the symptoms of pneumonia, understands the risk factors for the disease, prevention, the importance of timely and effective treatment of this disease.

Community-acquired pneumonia is one of the most common infectious diseases of the respiratory tract. Most often, this disease is the cause of death from various infections. This occurs as a result of a decrease in people’s immunity and the rapid adaptation of pathogens to antibiotics.

Community-acquired pneumonia is an infectious disease of the lower respiratory tract. Community-acquired pneumonia in children and adults develops in most cases as a complication of a previous illness. viral infection. The name of pneumonia characterizes the conditions under which it occurs. A person falls ill at home, without any contact with a medical facility.

What is pneumonia like? This disease is divided into three types:

Mild pneumonia is the largest group. She is treated on an outpatient basis, at home.

The disease is of moderate severity. Such pneumonia is treated in a hospital.

Severe form of pneumonia. She is being treated only in a hospital, in the intensive care unit.

What is community-acquired pneumonia?

Community-acquired pneumonia acute infectious inflammatory disease of predominantly bacterial etiology that arose in a community setting (outside the hospital or later than 4 weeks after discharge from it, or diagnosed in the first 48 hours from hospitalization, or developed in a patient who was not in nursing homes/departments long-term medical observation over 14 days), with damage to the respiratory parts of the lungs (alveoli, small-caliber bronchi and bronchioles), frequent presence characteristic symptoms(acute fever, dry cough followed by sputum production, chest pain, shortness of breath) and previously absent clinical and radiological signs of local damage not associated with other known causes.

Community-acquired pneumonia is one of the most common respiratory diseases. Its incidence is 8-15 per 1000 population. Its frequency increases significantly among elderly and senile people. The list of main risk factors for the development of the disease and death includes:

Smoking habit

Chronic obstructive pulmonary diseases,

Congestive heart failure,

Immunodeficiency conditions, overcrowding, etc.

More than a hundred microorganisms (bacteria, viruses, fungi, protozoa) have been described, which under certain conditions can be the causative agents of community-acquired pneumonia. However, most cases of the disease are associated with a relatively small range of pathogens.

In some categories of patients - recent use of systemic antimicrobial drugs, long-term therapy with systemic glucocorticosteroids in pharmacodynamic doses, cystic fibrosis, secondary bronchiectasis - the relevance of Pseudomonas aeruginosa in the etiology of community-acquired pneumonia increases significantly.

The significance of anaerobes colonizing the oral cavity and upper respiratory tract in the etiology of community-acquired pneumonia has not yet been fully determined, which is primarily due to the limitations of traditional cultural methods for studying respiratory samples. The likelihood of anaerobic infection may be increased in persons with proven or suspected aspiration due to episodes of impaired consciousness during seizures, some neurological diseases(for example, stroke), dysphagia, diseases accompanied by impaired motility of the esophagus.

The frequency of occurrence of other bacterial pathogens - Chlamydophila psittaci, Streptococcus pyogenes, Bordetella pertussis, etc. usually does not exceed 2-3%, and lung lesions caused by endemic micromycetes (Histoplasma capsulatum, Coccidioides immitis, etc.) are extremely rare.

Community-acquired pneumonia can be caused by respiratory viruses, most often influenza viruses, coronaviruses, rhinosyncytial virus, human metapneumovirus, human bocavirus. In most cases, infections caused by a group of respiratory viruses are characterized by a mild course and are self-limiting in nature, however, in elderly and senile people, in the presence of concomitant bronchopulmonary, cardiovascular diseases or secondary immunodeficiency they may be associated with the development of severe, life-threatening complications.

The growing relevance of viral pneumonia in recent years is due to the emergence and spread of the pandemic influenza virus A/H1N1pdm2009 in the population, which can cause primary damage to lung tissue and the development of rapidly progressing respiratory failure.

There are primary viral pneumonia (develops as a result of direct viral damage to the lungs, characterized by a rapidly progressive course with the development of severe respiratory failure) and secondary bacterial pneumonia, which can be combined with primary viral damage to the lungs or be an independent late complication of influenza. The most common causative agents of secondary bacterial pneumonia in patients with influenza are Staphylococcus aureus and Streptococcus pneumoniae. The frequency of detection of respiratory viruses in patients with community-acquired pneumonia is strongly seasonal and increases in the cold season.

In case of community-acquired pneumonia, co-infection with two or more pathogens can be detected; it can be caused either by the association of various bacterial pathogens or by their combination with respiratory viruses. The incidence of community-acquired pneumonia caused by association of pathogens varies from 3 to 40%. According to a number of studies, community-acquired pneumonia caused by an association of pathogens tends to be more severe and have a worse prognosis.

The most common route for microorganisms to enter lung tissue is:

1) Bronchogenic and this is facilitated by:

Inhalation of microbes from the environment,

Relocation pathogenic flora from the upper parts of the respiratory system (nose, pharynx) to the lower ones,

Medical procedures (bronchoscopy, tracheal intubation, artificial ventilation, inhalation of drugs from contaminated inhalers), etc.

2) The hematogenous route of spread of infection (through the bloodstream) is less common with intrauterine infection, septic processes and drug addiction with intravenous drug administration.

3) The lymphogenous route of penetration is very rare.

Further, with pneumonia of any etiology, the infectious agent fixes and multiplies in the epithelium of the respiratory bronchioles; acute bronchitis or bronchiolitis of various types develops, from mild catarrhal to necrotic. The spread of microorganisms beyond the respiratory bronchioles causes inflammation of the lung tissue - pneumonia. Due to disruption of bronchial obstruction, foci of atelectasis and emphysema occur. Reflexively, with the help of coughing and sneezing, the body tries to restore the patency of the bronchi, but as a result, the infection spreads to healthy tissue, and new foci of pneumonia form. Oxygen deficiency, respiratory failure, and in severe cases, heart failure develop. Segments II, VI, X of the right lung and segments VI, VIII, IX, X of the left lung are most affected.

Aspiration pneumonia is common in the mentally ill; in persons with diseases of the central nervous system; in persons suffering from alcoholism.

Pneumonia in immunodeficiency states is typical for cancer patients receiving immunosuppressive therapy, as well as drug addicts and HIV-infected people.

Great importance is attached to the classification of pneumonia in diagnosing the severity of pneumonia, the localization and extent of lung damage, diagnosing complications of pneumonia, which makes it possible to more objectively assess the prognosis of the disease, choose a rational program of complex treatment and identify a group of patients in need of intensive care. There is no doubt that all these headings, along with empirical or objectively confirmed information about the most likely causative agent of the disease, should be presented in modern classification pneumonia.

The most complete diagnosis of pneumonia should include the following categories:

A form of pneumonia (community-acquired, nosocomial, pneumonia due to immunodeficiency conditions, etc.);

The presence of additional clinical and epidemiological conditions for the occurrence of pneumonia;

Etiology of pneumonia (verified or suspected causative agent);

Localization and extent;

Clinical and morphological variant of the course of pneumonia;

The severity of pneumonia;

Degree of respiratory failure;

Presence of complications.

Table 1. Comorbidities/risk factors associated with specific pathogens associated with community-acquired pneumonia.

Lecture outline

• Definition, relevance of pneumonia

• Pathogenesis of pneumonia

• Classification of pneumonia

• Criteria for diagnosing pneumonia

• Principles of treatment: organization of the regimen, aerotherapy, antibacterial therapy, immunotherapy and physiotherapeutic methods of treatment, prevention

• Pneumonia is a nonspecific inflammation of the lung tissue, which is based on infectious toxicosis, respiratory failure, water-electrolyte and other metabolic disorders with pathological changes in all organs and systems of the child’s body.

Relevance:

• The incidence of pneumonia ranges from 4 to 20 cases per 1000 children aged 1 month to 15 years.

• In Ukraine, there has been an increase in the prevalence of pneumonia among children in the last three years (from 8.66 to 10.34).

• Mortality from pneumonia among children in the first year of life is from 1.5 to 6 cases per 10,000 children, which is 3-5% in the overall structure of mortality in children under 1 year of age.

• Every year, about 5 million children die from pneumonia around the world.

Etiology

• In-hospital (nosocomial) Pneumonia in most cases is caused by Ps. aeruginosa, also – Kl. pneumonia, St. aureus, Proteus spp. etc. These pathogens are resistant to antibiotics, which leads to severe disease and mortality.

• Community-acquired pneumonia(home, non-hospital). The spectrum of pathogens depends on the age of the patients.

• Newborns: depends on the spectrum of urogenital infections in women.

• Postnatal pneumonia more often caused by group B streptococci, less often by E. coli, Klebsiella pneumoniae, St. aureus, St. epidermalis.

• Antenatal– streptococci of groups G, D, Ch. frachomatis, ureaplasma urealiticum, Listeria monocytogenes, Treponeta pallidum.

• Children of the first half of the year: staphylococci, gram-negative intestinal flora, rarely - Moraxella catarrhalis, Str. рneumoniae, H. influenzae, Ch. trachomatis.

From 6 months to 5 years Str. comes out on top. Pneumoniae (70-88% of all pneumonias) and H. influenzae type b (Hib infection) - up to 10%. These children also often isolate respiratory syncytial virus, influenza viruses, parainfluenza, rhino- and adenoviruses, but most authors consider them to be factors that contribute to infection of the lower respiratory tract by bacterial flora.

• For children 6-15 years old: bacterial pneumonias account for 35-40% of all pneumonias and are caused by pneumococci Str. pyogenes; M. pneumoniae (23-44%), Ch. Pneumoniae (15-30%). The role of Hib infection is reduced.

• In case of insufficiency of humoral immunity, pneumococcal, staphylococcal, and cytomegalovirus pneumonia are observed.

• In case of primary cellular immunodeficiencies, with long-term glucocorticoid therapy - P. carinii, M. avium, fungi of the genus Candida, Aspergilus. Often viral-bacterial and bacterial-fungal associations (65-80%).

Pathogenesis

• In the pathogenesis of the development of acute pneumonia, V.G. Maidannik distinguishes six phases.

• The first is contamination by microorganisms and edematous-inflammatory destruction of the upper respiratory tract, dysfunction of the ciliated epithelium, and spread of the pathogen along the tracheobronchial tree.

• The second is the primary alteration of lung tissue, activation of lipid peroxidation processes, and development of inflammation.

• Third: damage by prooxidants not only to the structures of the pathogen, but also to the macroorganism (surfactant), destabilization of cell membranes→phase of secondary toxic autoaggression. The area of ​​damage to lung tissue increases.

• Fourth: disruption of tissue respiration, central regulation of respiration, ventilation, gas exchange and perfusion of the lungs.

• Fifth: the development of DN and disruption of the non-respiratory function of the lungs (cleansing, immune, excretory, metabolic, etc.).

• Sixth: metabolic and functional disorders of other organs and systems of the body. The most severe metabolic disorders are observed in newborns and young children.

• There are 4 ways of contamination of the lungs with pathogenic flora:

• aspiration of oropharyngeal contents (microaspiration during sleep) is the main route;

• airborne;

• hematogenous spread of the pathogen from an extrapulmonary source of infection;

• Spread of infection from adjacent tissues of neighboring organs.

Classification

• Pneumonia

• primary (uncomplicated)

• secondary (complicated)

• Shapes:

• focal

• segmental

• lobar

• interstitial

Localization

• one-sided

• bilateral

• lung segment

• lung lobe

• lung

Flow

• acute (up to 6 weeks)

• prolonged (from 6 weeks to 6 months)

• recurrent

Respiratory failure

• 0 tbsp.

• I Art.

• II Art.

• III Art.

Complicated pneumonia:

• General violations

• toxic-septic condition

• infectious-toxic shock

• cardiovascular syndrome

• DVZ syndrome

• changes in the central nervous system - neurotoxicosis, hypoxic encephalopathy

• Pulmonary purulent process

• destruction

• abscess

• pleurisy

• pneumothorax

• Inflammation of various organs

• sinusitis

• pyelonephritis

• meningitis

• osteomyelitis

Pneumonia code according to MKH-10:

• J11-J18 – pneumonia

• P23 – congenital pneumonia

Clinical criteria for pneumonia in a newborn baby

• burdened ante- and intrapartum anamnesis;

• pallor, perioral and acrocyanosis;

• moaning breath;

• tension and swelling of the wings of the nose; retraction of the pliable areas of the chest;

• respiratory arrhythmia;

• rapid increase in pulmonary heart failure and toxicosis;

• muscle hypotonia, inhibition of newborn reflexes;

• hepatolienal syndrome;

• weight loss;

• coughing; less frequent cough;

• increased body temperature; may be normal in immature newborns;

• X-ray: pulmonary tissue infiltrates, usually on both sides; increased pulmonary pattern in perifocal areas.

Clinical criteria for the diagnosis of pneumonia in young children:

• wet or unproductive cough;

• shortness of breath, breathing with the participation of auxiliary muscles;

• distant wheezing in broncho-obstructive syndrome;

• general weakness, refusal to eat, delayed weight gain;

• pale skin, perioral cyanosis, worsens with exercise;

• violation of thermoregulation (hyper- or hypothermia, toxicosis);

• hard bronchial or weakened breathing, after 3-5 days moist rales appear;

• shortening of percussion sound in the projection of infiltrate;

• hemogram: neutrophilic leukocytosis, shift of the formula to the left;

• X-ray: pulmonary tissue infiltrates, increased pulmonary pattern in perifocal areas.

Criteria for the degree of DN

Treatment of pneumonia

• Children with acute pneumonia can be treated at home or in a hospital. Indications for hospitalization are as follows:

• 1) vital indications - intensive care and resuscitation measures are required;

• 2) decreased reactivity of the child’s body, the threat of complications;

• 3) unfavorable living conditions of the family, there is no possibility of organizing a “hospital at home”.

• In a hospital, the child should be in a separate room (box) to prevent cross-infection. Until the age of 6, the mother must be with the child.

• The room should be wet cleaned, quartzed, and ventilated (4-6 times a day).

• The head of the bed should be raised.

Nutrition

• Depends on the age of the child. In a serious condition of a patient in the 1st year of life, the number of feedings can be increased by 1-2, while complementary feeding can be excluded for several days. The main food is breast milk or adapted milk formula. If oral rehydration is necessary, rehydron, gastrolit, ORS 200, herbal tea, in fractions are prescribed.

Treatment of respiratory failure

• Ensure clear airways.

• Microclimate of the room: fresh, fairly humid air, the temperature in the room should be 18-19ºС.

• In case of stage 2 respiratory failure, oxygen therapy is added: through a nasal tube - 20-30% oxygen utilization; through a mask - 20-50%, in an incubator - 20-50%, in an oxygen tent - 30-70%.

• For grade III DN, artificial ventilation is required.

Antibacterial therapy

• Basic principles of rational antibacterial therapy in children.

• Treatment begins after diagnosis. It is advisable to conduct flora cultures to determine sensitivity to antibiotics. Results will be available in 3-5 days. We select initial therapy empirically, taking into account the patient’s age, home or hospital pneumonia, and regional characteristics.

• First course – broad-spectrum antibiotics are prescribed (mainly β-lactams).

• Main course – (replacement of empirically selected antibiotic) depends on culture result or clinical picture.

• Dose selection – depends on the severity, age, body weight.

• Choice of route of administration: in severe cases, it is preferably administered parenterally.

• Choice of frequency of administration: it is necessary to create a constant concentration of antibiotic in the body.

• Choosing a rational combination: synergism is required, only bactericidal or only bacteriostatic. Drugs should not enhance each other's toxic effects.

• Conditions for stopping treatment: no earlier than 3 days of normal temperature and general condition of the child.

• The accuracy of empirical therapy can be 80-90%.