Pozalikarnyana pneumonia of the clinical. Posal carnial pneumonia

ROSISKE Respiratory Association

MIZHREGIONALNA ASOCIATSIYA ON KLINICHNO MIKROBIOLOGIS I antimicrobial chemotherapy (MACMAC)

Pozalikarnyana pneumonia in older adults: practical recommendations for diagnostics, treatment and prevention

(Posibnik for likariv)

A.G. Chuchalin1, A.I. Sinopalnikov2, R.S. Kozlov3, I.Є. Tyurin2, S.A. Rachina3

1 NDI Pulmonology of the Federal Medical and Biological Agency of Russia, Moscow

2 State Budgetary Educational Institution of Higher Professional Education "Russian Medical Academy of Education" of the Ministry of Health Protection of Russia, Moscow

3 NDI antimicrobial chemotherapy GBOU HPE "Smolenska State Medical Academy" Ministry of Health of Russia

Book of ABBREVIATIONS

AMP - antimicrobial drug ABT - antibacterial drug VP - postcarnial pneumonia ІХС - ischemic ailment of the heart SHVL - piece ventilation lungs КІ - clinical dosage LZ - lykarskiy zasib LF - likarska form

Refinery - non-steroidal prototypes

ВІТ - introduction of intensive therapy

PRP - penicilin-resistant B. rpeitotae

PPP - penicilin-sensitive B. rpeitotae

SHOE - the speed of the collection of erythrocytes

COPD - chronic obstructive disease

LIST OF SHORT MICROORGANISMS

B. cepacia - Burkholderia cepacia Candida spp. - рід Candida

C. pneumoniae - Chlamydophila pneumoniae Chlamydophila spp. - genus Chlamydophila Enterobacteriaceae - family Enterobacteriaceae Enterococcus spp. - рід Enterococcus

H. influenzae - Haemophilus influenzae

K. pneumoniae - Klebsiella pneumoniae

Klebsiella spp. - рід Klebsiella

L. pneumophila - Legionella pneumophila

Legionella spp. - рід Legionella

M. catarrhalis - Moraxella catarrhalis

M. pneumoniae - Mycoplasma pneumoniae

MSSA - methicilin-sensitive Staphylococcus aureus

MRSA - methicilin-resistant Staphylococcus aureus

Mycoplasma spp. - рід Mycoplasma

Neisseria spp. - рід Neisseria

P. aeruginosa - Pseudomonas aeruginosa

S. aureus - Staphylococcus aureus

Staphylococcus spp. - рід Staphylococcus

S. pneumoniae - Streptococcus pneumoniae

S. pyogenes - Streptococcus pyogenes

In non-carnial pneumonia (VP) is carried to the most frequent ailments in humans and one of the leading causes of death from infectious ailments. Enough tribute has been accumulated until now national recommendations on the prevention of ailments from the VP. The main meta of clinical recommendations is the provision of diagnostics and diagnostics of ailments from VP in outpatient practice and hospitals.

The development of recommendations is addressed to physicians-therapists and pulmonologists of polyclinics and inpatients, resuscitators, clinical pharmacologists, clinics of medical universities, as well as to present interests for specialty patients. Clinical recommendations can serve as the basis for the development of standards medical aid on federal and regional level.

In practical recommendations, the main respect is attached to the nutritional diagnosis and antibacterial therapy of EP in older adults. At the same hour, beyond the scope of the recommendations, such important problems as VP in patients with serious defects in immunity (VIL-infection, oncology, oncology, , are guilty but subject to an agreement.

The authors of the recommendations were asked to critically assess the determination of the early approaches to diagnostics and the diagnosis of EP from the position of evidence-based medicine. At the same time, all of the recommendations presented by the bullet have been classified as prior to the level of evidence. Daniy pidhid viglyadaє is strictly primed for the development of the algorithm for diagnostics and provision of patients from the joint venture. At the same time, there were no problems with the validity of evidence of recommendations for antibacterial therapy. Even more efficiently and correctly stashed on the level of proof of antibiotics vibration. It’s tied together, so more randomized clinical dosages of antibiotics are carried out until the ear

rokogo zasosuvannya, if the level of resistance to them is minimal. In addition, there is a trail of regional specificity of resistance. It is not necessary for this to be able to broaden the donations to Russia, which were held in the countries of the world. The authors see that recommendations on the choice of antibiotics are guilty of being grounded at the Duma experts (category of evidence D), as well as local data about the level of antibiotic resistance.

Spravzhnі rekomendatsії Je result uzgodzhenogo pillows ekspertіv, viroblenogo on pіdstavі retelnogo analіzu vsіh opublіkovanih for ostannі 15 rokіv doslіdzhen in tsіy oblastі in vіtchiznyanіy i zarubіzhnіy lіteraturі, vklyuchayuchi chislennі zarubіzhnі rekomendatsії on conducting grown patsієntіv of VP: rekomendatsії Britanskogo Thoracic suspіlstva (BTS, 2004 2009 pp .), European Respiratory Society (ERS, 2005), American Society of Infectious Diseases Association and American Thoracic Suspension (IDSA / ATS, 2007).

Pershe Vidanov pogodzhuvalnih natsіonalnih rekomendatsіy schodo Keeping grown patsієntіv іz JV pіdgotovlene EXPERT Rosіyskogo respіratornogo tovaristva, Mіzhregіonalnoї asotsіatsії of klіnіchnoї mіkrobіologії that antimіkrobnoї hіmіoterapії (IACMAC) i Alliance klіnіchnih hіmіoterapevtіv i mіkrobіologіv, viyshlo in Svit in 2003. p However, the authors rekomendatsіy chіtko usvіdomlyuvali scho in the force of a very small statement about VP (loss and expansion happy news about the epidemiology of respiratory infections, new methods of diagnostics and іn.), it is necessary to regularly review this updated document.

Other reports, published in 2006, included more reports on Russian antibiotics on antibiotics, new data on the resistance of key respiratory illnesses (Streptococcus pneumoniae and Haemophilus influenzae) in Russia, new razdіli, assigned to the analysis of the real practice of VP treatment in the Russian Federation.

prove

A randomized control of the number of patients necessary for the designation of reliable results. Can be primed and recommended for wide storage.

In the randomized control of the previous test. Proof based on the randomized control of the previous test, the number of included patients is insufficient for a reliable statistical analysis. Recommendations can be extended to the population.

FROM A NON-RANDOMIZED CLINIC PRESLIDENIA Prove it was based on nonrandomized clinical pre-sledges, or pre-siblings, carried out on a contiguous number of patients.

D Dumka of Experts Prove based on the consensus on singing problems, rooted in a group of experts.

It seems to be a third view of the recommendations of the traditional update in the development of medical diagnostics in the Russian Federation, the antibiotic resistance of the most relevant educational practices and the practice of conducting patients in hospitals for medical examinations, including the results of the RF diagnostic There was a new distribution, assignments of X-ray diagnostics of VP.

I. Epidemiology

Pozalikarnyana pneumonia is reported up to the number of the most widespread hospitals and infectious diseases. There are official statistics (the Central Science and Preceding Institute for Organizational and Informatization of Health Protection of the Federal Health Service), in 2006, 591,493 cases were registered in the Russian Federation, which was 4.14%; for individuals> 18 years, the incidence rate was 3.44%. The most severe disease for pneumonia in the middle of older adults is indicated in the Siberian and Pivnichno-Zakhidny federal districts (4.18 and 3.69% according to the case), the naymensh - in the Central federal region (3.07%).

Obviously, however, these figures do not represent the true incapacity of the VP in Russia, as there are 14-15% of the population, and the number of ailing people in the country is 1.5 million people. At the okremikh categories, the indicator of sickness of the VP appears quite simply as a tribute from the Zagalnorossiysk. So, the withers, the incapacitation of the VP of the middle of the military service, who served for the prize, in 2008, in the middle, dropped to 29.6%.

According to the data of foreign epidemiological preoccupations, the incidence of VP in older adults (> 18 years) grows in a wide range: in the young and middle age it becomes 1-11.6%; in senior groups - 25-44%. With a hand to fate, a number of grown-up ailments (> 18 years) VP in 5 European countries(Great Britain, France, Italy, Nimechchina, Spain) change 3 million people.

The United States routinely diagnoses more than 5 million HIV infections, of which more than 1.2 million ailments require hospitalization. From the number of the remaining, without the middle from the airspace, more than 60 yew die. Cholovik. According to the data of the Ministry of Health of Russia, in 2006, in our country, in the middle of the population, 38,970 individuals died from pneumonia, which dropped 27.3 per 100 thousand. Population.

Mortality in case of CAP is the lowest (1-3%) in the young and middle age without fellow illnesses. Navpaki, in patients older than 60 years of age with the presence of serious concomitant pathology (COPD, malignancy, alcoholism, diabet, Injury of nirok and liver, heart-vascular system and in.), And also in cases of severe interruptions of VP (multilobar infections, secondary bacteria, frequency> 30 / min, hypotension, hospitality nirkova lack), Tsei indicator of reach 15-30%.

An analysis of Russian tributes in the surrounding regions indicates that the greatest mortality rate from the VP can be rebuilt among the people of the first time.

Risk factors for the lethal outcome in CAP, including data on anamnesis, physical and laboratory dosage presented in table. 1. One of the typical for our country officials in the risk of a lethal result is also the death of patients for medical assistance.

Table 1. Immovability of the lethal result of ailments of CAP in the prevalence according to the anamnesis, physical condition and laboratory indicators

Preslidzhuvaniy criterion Stated chances

Demography - cholovicha become 1.3 (1.2-1.4)

The history of the disease - hypothermia - a change to the mental status - bad luck 0.4 (0.2-0.7) 2.0 (1.7-2.3) 2.9 (1.9-3.8)

Sufferer disability - chronic heart failure - immunodeficiency disease - suicidal diabetes - loss of coronary artery disease - oncological disability - neurological disability - sickness of nirok 2.4 (2.2-2.5) 1.2 (1.3-1.8) , 1-1.4) 1.5 (1.3-1.6) 2.7 (2.5-2.9) 4.4 (3.8-4.9) 2.7 (2.5-2.9 )

Physical dosage - tachypnoe (NPV> 28 / hv) - hypothermia (1 tila<37 С) - гипотензия (СД <100 мм Н$ 2.5 (2,2-2,8) 2.6 (2,1-3,2) 5,4 (5,0-5,9)

Laboratory dosage - blood nitrogen (> 7.14 mmol / l) - leukopenia (<4х109/л) - лейкоцитоз (>10x109 / l) - hypoxemia (Pa02<50 мм Нй) - наличие инфильтрации на рентгенограмме ОГК более чем в 1 доле 2,7 (2,3-3,0) 5,1 (3,8-6,4) 4.1 (3,5-4,8) 2.2 (1,8-2,7) 3,1 (1,9-5,1)

II. VALUE I KLASIFIKATSIYA

Pneumonia is a group of ages in etiology, pathogenesis, morphological characteristics of infectious diseases (overwhelmingly bacterial) illnesses, which are characterized by a high degree of respiratory failure due to

Oskilki VP - state of the art of infection, then the value of "gostra" before the diagnosis of "pneumonia" є we are more likely to diagnose "chronic pneumonia" є pathogenetically not priming, and term

In the International Classification of Ailments, Injuries and Causes of Death in X glance (ICD-X, 1992 r), VPs are clearly seen from among those in the igneous ignorant illnesses, the legend of non-infectious walking. So, from the heading "Pneumonia" for the disease, diseases for the physical (promenovy pneumonitis) or for the chemical ("gasoline" pneumonia) factors,

Table 2. Classification of pneumonia according to the International Classification of ailments, injuries and causes of death X glance (1992)

J13 Pneumonia, wiclican Streptococcus pneumoniae

J14 Pneumonia, Wiclican Haemophilus influenzae

J15 Bacterial pneumonia, not classified in the other headings (excluded: pneumonia, Chlamydia spp. - J16.0 і "legionary ailment" - A48.1)

J15.0 Pneumonia, wiclicana Klebsiella pneumoniae

J5.1 Pneumonia, viclicana Pseudomonas spp.

J15.2 Pneumonia, wiclican Staphylococcus spp.

J15.3 Pneumonia, viclican streptococcus group B

J15.4 Pneumonia caused by streptococcus

J15.5 Pneumonia, Wiclican Escherichia coli

J15.6 Pneumonia caused by some aerobic gram-negative bacteria

J15.7 Pneumonia, Wiclican Mycoplasma pneumoniae

J15.8 Bacterial pneumonia

J15.9 Bacterial pneumonia, unspecified etiology

J16 Pneumonia, wiklikana with pupils, which are not classified in the other headings (exclusions: ornitosis - A70, pneumocystic pneumonia - B59)

J16.0 Pneumonia, wiclicana Chlamydia spp.

J16.8 Pneumonia caused by other emergencies

J17 * Pneumonia in cases of illness, classified in the same headings

J17.0 * Pneumonia in case of bacterial infections, classified in the other headings (pneumonia in case of: actinomycosis - A42.0, Siberian - A22.1, gonorrhea - A54.8, nokardiasis - A43.0, salmonellosis - A022.2 A721.2, typhoid fever - A031.0, cough - A37.0)

J17.1 * Pneumonia in case of viral ailments, classified in the other headings (pneumonia in case of cytomegalovirus ailment - B25.0, cortex - B05.2, rubella - B06.8, vitriol - B01.2)

J17.2 * Pneumonia in mycoses

J17.8 * Pneumonia in case of illnesses, classified in the other headings (pneumonia in case of ornitosis - A70, Ku-lichomancy -A78, severe rheumatic fever - A100, spirochitosis - A69.8)

J18 Pneumonia without specification

* Indicated pneumonia in case of illness, classified in the same headings, and not included in the heading "Pneumonia".

Embolism of the Legendary Arteries) Firing processes in legends with a number of highly contagious ailments, which are affected by regional pathogens of bacterial or viral nature, are seen within the framework of common nosological forms (Fever-fever, plague, typhoid fever, rubella) ".

Not victorious summaries, but the classification, the most predominantly imagining the particularity of overcoming pneumonia and allowing the priming of etiotropic therapy, is guilty but prompted by the ethiological principle. The whole principle is laid in the basis of the classification of pneumonia, presented in the ICD-X (Table 2).

However nedostatnya іnformativnіst i-valued trivalіst traditsіynih mіkrobіologіchnih doslіdzhen (vіdsutnіst 20-30% patsієntіv productive cough, nemozhlivіst vidіlennya vnutrіshnoklіtinnih zbudnikіv at vikoristannі STANDARD dіagnostichnih pіdhodіv, іdentifіkatsіya zbudnika lishe 48-72 year s time otrimannya materіalu, trudnoschі in rozmezhuvannі "mіkroba-svіdka "І" microbe-zabudnik ", the practice of taking antibacterial drugs has been expanded to the brutality for medical assistance)

In the Danish hour of the most widening of the nabula of the classification, which you woke up, in which there was a problem; at the same time, it is also possible to proclaim the peculiarities of the information on the legacy tissue and the immunological reactivity of the patient's organism (Table 3). A little bit permits, with a significant part of the problem, to transfer the ethology of the disease.

From a practical point of view, the most significant is the development of pneumonia in the post-carnial and nosocomial. Slid of adolescence, but such a fatigue is not tied to the harsh interruption of ailment, the main criterion for the separation is those in which pneumonia has developed.

One hour in the vicinity of the group began to see pneumonia, associated with healthcare-associated pneumonia. Until the whole category, for example, pneumonia is reported in individuals who are in booths for people who have been kidnapped or in those settings that are tricky to look at. Behind the minds of the winners, you can see how many people are standing, protesting, as a rule, are seen as the last structure of the culture and the profile of their anti-bioresistance.

On the way to the state of mind of the state of mind, when it was in the late state of minds, so it’s the position of the stationary, if it’s 4 times when the whiskey was sent out, because it was diagnosed in the first 48th year at the time of the state’s awakening medical care> 14 dib, if you are susceptible to symptoms of infection of the lower

Table 3. Classification of pneumonia (R.G. Wunderink, G.M. Mutlu, 2006; from zinami)

Pozalikarnya pneumonia Nosocomial Pneumonia, tied for reasons

pneumonia of medical aid

I. Typova (in patients with a turn of the day I. Vlasne nosocomial - I. Pneumonia in sack buds

impairment of immunity): naya pneumonia of older

a. bacterial; II. Ventilatoroassociro- II. Інші categories of patients:

b. virusna; bath pneumonia a. antibacterial therapy

v. fungus; III. Nosocomial in the front 3 m / s;

m mycobacterium; pneumonia in patients b. hospitalization (from be-like drive) in those

II. In patients with rotational impairments to immunity: c. reboot in other installations

niteta: a. recipients have a tricky look;

a. syndrome of full immune deficiency of donor organs; m chron_chny dіalіz stretching> 30 dіb;

(SNID); b. at patients, d. treatment of the surface of the wound

b. іnshі disease / pathological conditions are recognized in home minds;

III. Aspiracy pneumonia / abscesses of the lungs cytostatic therapy for immunodeficiency diseases /

getting sick.

them shlyakhiv (feverish woman, cough, seeming phlegm, moaning, bile in breast cancer, Zadishka) and radiological signs of "fresh" in the cognitive-infiltrative changes in the legends when there is an obvious diagnostic alternative.

III. PATHOGENESIS

Anti-infectious diseases dikhalnyh nobles good mechanical factors (aerodynamic filtration, bronchial discharge, epiglottis, cough and chhannya, colonic ruffles of the blinking epithelium), as well as the mechanisms of nonspecific and specific. The reasons for the development of an ignition reaction can be both a decrease in the efficiency of microorganism mechanisms in macroorganism, as well as a large dose of microorganisms and / or a decrease in the effectiveness of microorganisms.

It is possible to see 4 pathogenetic mechanisms, zooming in on the development of VP at a different frequency:

■ aspirating the secretion of the oropharynx;

■ inhaling aerosol to take revenge on microorganisms;

■ hematogenous enlargement of microorganisms from the posterior region of infection (endocarditis from lesions of the tricuspid valve, septic thrombophlebitis);

■ without an increase in infection from susceptible organs (for example, in case of liver abscess) or as a result of infection in case of penetrating wounds of the thoracic cell.

It is necessary to note that the main ones are the first two pererakhovannyh vische mechanisms.

Aspirations in the place of the oropharynx are the main pathways for the development of respiratory infections and the basic pathogenetic mechanism of development of VP. In normal minds, a number of microorganisms, for example, Streptococcus pneumoniae, can colonize the oropharynx, and even the lower parts of the dichny paths become sterile. Microaspiracy to the secret of the oropharynx is a physiological phenomenon, which is practically spontaneous in half of healthy individuals, regardless of sleep. However, the cough reflex, mucocyl-

arnium clence, antibacterial activity of alveolar macrophages and secretory immunoglobulins, without the elimination of an inferred secret from the lower indications of mental health and sterility.

In case of multiple mechanisms of "self-cleaning" of the tracheobronchial tree, for example, in case of viral respiratory infections, if the function of viral diseases of the bronchial tubes is impaired and the phagocytic activity of the macrophage decreases. In the surroundings of the self-styled pathogenetic factor There can be an array of doses of microorganisms, or penetration into respiratory organs, or the ease of finding single viscous microorganisms.

Inhalation of microbial aerosol - mensh often discourage development of VP. Vіn vіdіgraє the main role in the infarction of lower wіddіlіv іddіlіv іddіlіv іddіlіv іddіlіv іddіlіv іddіlіv іddіlіv іddіlіv іddіlіv іddіlіv іddіlіv іnіdіlіvnyh szlіchіvnyh izbudnikov, for example Legionella spp. Even less significant (for the frequency of populations) is hematogenous (for example, Staphylococcus spp.) І direct expansion of the origin of infection.

With regard to the descriptions of the peculiarities of the pathogenesis of VP, it is obvious that the ethology in the transition to a large number of types is linked to the microflora of the upper ones of the dickheads, the storehouse for the middle stage of this healthy state.

IV. Ethiology

Ethiology of the VP without a priori tied with normal microflora, Colonized upper branches or dichny nobles. Out of the number of microorganisms, no deyakis, but the volodynuyuyu virulentnistyu, when they hit in the lower parts of the wicked way, will ignite the reaction. Up to the number of such diseases, the number of pneumococcus (Streptococcus pneumoniae) is 30-50% of cases of infection.

Suttuve meaning in the ethology of VP may be so called atypical microorganisms, on a part of which in the sum of seizures from 8 to 30% of cases of malaise:

Chlamydophila pneumoniae;

Mycoplasma pneumoniae;

Legionella pneumophila.

Prior to childbearing (3-5%) students of the VP should be introduced:

Haemophilus influenzae;

Staphylococcus aureus;

Klebsiella pneumoniae, even earlier - іnshі enterobacte-rії.

In even more rare cases of CAP, Pseudomonas aeruginosa may be vicious (in ailments for cystic fibrosis, with bronchiectasis).

It is important to admit it, but it is not easy for older patients to endure CAP, to see a change or infection. So, for example, it’s not in the skin of another ailment with pneumococcal etiologic disease that serologic signs of active mycoplasma abnormal infections are immediately introduced.

Respiratory viruses are not easy to guess among those of the VP (virus type A and B, parainfluenza, adenovirus and respiratory syncytial virus), but in the event of stinks, the lungs rarely respond to middling. Viral respiratory infections, and persh for all the epidemic flu, crazy, looking like a provincial bureaucrat Rizik fired legends, being a kind "guide" bacterial infections... However, it is viral pathological changes in the legacy fabric, pneumonia does not follow and, moreover, it is necessary to clearly see it from mezhovuvati, about the way to the liking of two stanovy principles. From the point of view, there is no longer any extension of the term "viral-bacterial pneumonia", although bacterial pneumonia is clearly seen in the most frequent cases of interstitial viral lesion.

A trace of memory about those who VP can be tied with new, previously unheard-of zabudniks, who wicked sleepers become ill. Prior to the emergence of diseases in the outbreak of VP, it is possible to introduce SARS-associations of coronavirus, avian influenza virus, metapneumovirus.

For microorganisms, development of broncho-legionic inflammation is uncharacteristic. Х vision of phlegm, better for everything, to indicate the contamination of the material with the flora of the upper forms of the dichally nobles, and not about the ethological significance of the microbes. Such microorganisms are referred to:

Streptococcus viridans;

Staphylococcus epidermidis and other coagulase-negative staphylococci;

Enterococcus spp .;

Neisseria spp .;

The ethiological structure of the EP can be seen in the presence of ailments, the severity of the illness, the manifestation of the concomitant pathology. In patients who are hospitalized for therapeutic purposes, in the ethology of VP, pneumococci are transplanted, in the area of ​​M. pneumoniae and C. pneumoniae, the total seizure is close to 25%. Nawpaki, the rest do not miss the hundredth value in this

logics of important EP, which helps to improve the outcome of the intensive therapy (BIT); at the same hour, the role of Legionella spp., as well as S. aureus and gram enterobacterium, is growing in the category of ailments (Table 4).

Table 4. Ethiology of VP in the number of cases of severity of disease (in%)

Microorganisms Outpatient Patients Hospitalized Patients

in therapeutic advice at ВІТ

S. pneumoniae 5 17.3 21

H. influenzae 2.3 6.6 -

S. aureus - 2.9 7.4

M. pneumoniae 24 13.7 -

C. pneumoniae 10.1 -

L. pneumophila - 1.3 5.8

Graduator-ni aerobic bacteria 4.1 8.8

Ethiology not established 48 Nemag Danikh 35.6

Key pupils of VP at patients young vik without supportive illnesses (vіyskovosluzhbovtsі) with a slight interruption of illnesses, for the data of one of the Russian illnesses, є pneumococci, "atypical" microorganisms and їkh later (Fig. 1).

S. pneumoniae C. pneumoniae M. pneumoniae

C. pneumoniae + M. pneumoniae

S. pneumoniae + C. pneumoniae + M. pneumoniae

Small. 1. Ethiology of EP in patients of a young age

Інші K. pneumoniae

H. influenzae + S. aureus

C. pneumoniae + H. influenzae + M. pneumoniae

L. pneumophila C. pneumoniae M. pneumoniae + H. influenzae S. pneumoniae + H. influenzae S. pneumoniae H. influenzae M. pneumoniae

Enterococcus spp. + K. pneumoniae

E.coli + P. pneumoniae

H. influenzae + S. pneumoniae + K. pneumoniae

5 10 15 20 25 30 35

Small. 2. The structure of low-value VP in old-age hospitalized patients (%, n = 109)

Small. 3. The structure of important EPs in older hospitalized patients (%, n = 17)

In the small Russian preschool diagnostics, the structure of bacterial diseases of the VP was found in adult patients, hospitalized in the hospitalized hospital for standard pneumonia pneumonia, M. pneumonia, M. pneumonia. Respiratory specimens (sputum, BAL) were used as material for the preschool age, in patients with the importance of EP, they received shelter, and fatal - autopsy material.

Ethiological diagnosis of the number of cases in 42.7% of cases, most often M. pneumoniae, H. influenzae and S. pneumoniae were found, in this part (in monocultures and associations) 77.9% of cases of pneumonia were accounted for. The structure of EPs with gravity level grades is shown in Fig. 2 and 3.

The lethality in case of CAP in the fallowness of the plant is presented in table. 5. Most temporal lethality is susceptible to CAP, S. pneumoniae, Legionella spp., S. aureus, K. pneumoniae.

In the course of a dense Russian pre-diagnosis of the etiology of fatal CAP (material for pre-detection as autopsy material), it has been shown that most often appear as diseases in this category of pneumonia, K. pneumonia, 31, S. pneumonia, S. buli. , 6; 12.9 and 11.4% of the most common strains, for example).

Table 5. Mortality in CAP

Zbudnik Lethality,%

S. pneumoniae 12.3

H. influenzae 7.4

M. pneumoniae 1.4

Legionella spp. 14.7

K. pneumoniae 35.7

C. pneumoniae 9.8

Practical positions for the diagnosis of a group of patients with VP with chronic diseases of the disease (COPD, diabetic diabetes, congestive heart failure, cerebrovascular disease, therapies for chronic liver disease, chronic liver disease) antibiotics for> 2 last days for the last 3 months) In different groups, there can be more evidence of not only the ethological structures, the broadening of the drug-resistant strains of the different species of plants, but in the prognosis (Table 6).

Table 6. Groups of ailments VP and imovirni zhvoryuvannya

Characteristics of the patients Misce likuvannya Ymovirni zbudniki

EP of lung was transferred in individuals without supportive ailments, when they were not taken in the last 3 m / s AMP Potency of treatment in outpatient drains (from medical positions) S. pneumoniae M. pneumoniae C. pneumoniae

EP of lung was interrupted in individuals from patients with disabilities, or if they took in the last 3 m / s AMP Potential for treatment in outpatient minds (from medical positions) S. pneumoniae H. influenzae C. pneumoniae S. aureus Enterobacteriaceae

EP of lung interruption of life in the minds of the hospital: ascertaining the profile of S. pneumoniae H. influenzae C. pneumoniae M. pneumoniae S. aureus Enterobacteriaceae

VP of an important transition to the hospital in the minds of the hospital: the introduction of intensive therapy for S. pneumoniae Legionella spp. S. aureus Enterobacteriaceae

Table 7. Dynamics of resistance of S. pneumoniae to AMP in the Russian Federation

V. RESISTANCE OF MAIN STUDENTS Before AMP

An important problem in Denmark is the widening of the middle of pneumococci strains from a decrease in sensitivity to penicillin. In some regions, the resistance of pneumococci to penicillin is 60%, and moreover, there are many of them with resistance up to 3 classes of antibiotics and more. Such pneumocock plugs are called polyresistant.

The resistance of pneumococci to penicillin will develop to cephalosporins I-II generations, tetracyclines, co-trimoxazole. At the same hour, the activity of cephalosporin III-IV generations (except for ceftazidime), respiratory fluorochinoloni, vancomicin and linesolide is observed.

The data on the monitoring of the resistance of the clinical strains of S. pneumoniae in the Russian Federation within the framework of the multi-center monitoring of PEGAS-III are presented in table. 7. As shown, the level of pneumocock stiffness to penicillin in our country is stable and does not overtake 10%, with a large number of cases appearing along with resistant stems. All penicilin-resistant pneumococci (PRP) are sensitive to amoxicilin and amoxicilin / clavulanate, resistance to ceftriaxone becomes 2.8%.

Strength of S. pneumoniae to macrolides does not overtake 10%, protein in dynamics is determined by the increase of a part of insensitive strains to macrolides

Antibiotic 1999- 2004- 2006-

2003 pp. 2005 pp. 2009 rr.

(N = 791) (n = 913) (n = 715)

R / R,% R,% R / R,% R,% R / R,% R,%

Penicilin 7.8 1.9 6.9 1.2 9.1 2.1

Amoxicilin 0 0.1 0 0.3 0.4 0

Amoxicilin / clavulanate 0 0 0 0.3 0.4 0

Ceftriaxone / cefotaxime 1.4 0.4 0.9 1.1 0.4 0.6

Cefixime - - - - 2.2 4.6

Ceftibuten - - - - 6.2 6.7

Ertapenem - - - - 0 0

Erythromicin 0.1 8.1 0.2 6.4 1.0 3.6

Azithromicine 0.5 7.6 0.2 6.2 0.9 6.4

Clarithromicin 0.5 7.5 0.3 6.1 1.6 5.7

Josamicine - - - - 1.1 4.1

Midekamitsina acetate 0.5 3.3 0.4 3.9 0.6 6.0

Spiramicin 1.0 1.0 0.9 3.6 1.0 5.3

Clindamicine 0.1 2.8 0 3.6 0.2 4.3

Levofloxacin 0 0 0 0.1 0 0

Moxifloxacin 0.3 0 0.1 0 0 0

Hemifloxacin - - - - 0 0

Ciprofloxacin - - - - 6.4 1.4

Tetracycline 2.4 24.9 4.8 24.8 3.1 21.5

Co-trimoxazole 26.3 5.4 29.1 11.8 22.4 16.6

Chloramphenicol 0 7.7 0 5.9 0 7.1

Vankomitsin 0 0 0 0 0 0

Note. U / R - with respect to resistant strands; P - resistant strands.

pneumococci, as well as the growth of their stiffness to clindamycin, which may be indicative of a change in the Russian Federation, which is more susceptible to the phenotype of resistance to cinnamon;

The high activity of S. pneumoniae is known to be responsible for respiratory fluorochinoloni (levofloxacin, moc-sifloxacin, hemifloxacin), vancomicin, ertapenem.

Slide means a high rate of pneumococci stiffness to tetracycline and co-trimoxazole, which is unimportant at respiratory infections in outpatient practice.

The main mechanism of resistance of H. influenzae dressings with the production of ß-lactamases hydrolyzing aminopenicillin. However, to show the last PEGAS II, the level of stiffness to aminopenicilin in the middle of the clinical strains of H. influenzae in the Russian Federation in 2003-2005 pp. h-

Table 8. Resistance of H. influenzae to AMP in the Russian Federation (n = 258)

Antibiotic U / R,% P,%

Ampicilin 4.6 0.8

Amoxicilin / clavulanate 0 0

Cefotaxime 0 0

Imipenem 0 0

Ciprofloxacin 0 0

Levofloxacin 0 0

Tetracycline 2.7 2.3

Co-trimoxazole 17.4 12.4

Chloramphenicol 4.3 0.4

Note. U / R - approximately resistant; P - resistant.

representing 5.4%. There were no strains resistant to amoxicillin / clavulanate, cephalosporins III generation(Ceftriaxone), carbapenems, fluoroquinolones (Table 8). Resistance to tetracycline was 5.0%. The most high level of strength of H. influenzae is associated with co-trimoxazole (29.8% of insensitive strains).

Vi. CLINICAL AND X-RAYGENOLOGICAL SYMPTOMS AND SIGNS

clinical diagnostics

The key signs and symptoms of CAP can be formed by the next rank in the outward view of the keys:

■ In most cases, they are primed for analysis classic paintings being ill, do not give in to the hope of seeing about the etiology of the VP. The link from the cym of the VP to the "type" (for example, pneumococcal) and "atyp" (mycoplasma abo chlamidine) is added to the special key meaning.

■ Such signs of VP, like a cob with a feverish guest, bile in the breast, etc. They can be out of the way, especially in weakened patients and children. Approximately 25% of patients over 65 years of age are feverish, leukocytosis is determined to be less than 50-70%, and clinical symptoms can be presented by stomatomy, weakness, nudota, anorexia, abdominal pain. It is not often the EP "debut" with symptoms of decompensation of the suppressive illness.

■ Diagnostics and treatment of the ear of antibacterial therapy (over 4 years old) in hospitalized patients will summarize the highest prognosis for ill health.

■ Pleuralvipit (as a rule, encirclement) accelerated the surplus of VP in 10-25% of cases and is not particularly significant in the prognosis of the etiology of incapacitation.

0 10 20 30 40 50 60 70 80 90 100 Immovability,%

Small. 4. Immovability of EP diagnostics according to the data of the clinical situation

A dose for pneumonia is guilty of being diagnosed with an ailing fever in the presence of scargia for a cough, a bad stomach, or a sputum and / or more in the breast. Ailments, such as carrying pneumonia, are often susceptible to unmotivated weakness, stomachache, more perspiring at night.

Information, how to be discarded in case of a physical condition of the patient, to accumulate some of the factors, including the degree of severity of illness, the widening of pneumonic infiltration, in general, the manifestation of suppression.

Classical ob'ktivnymi signs of VP є shortening (dullness) of percussion sound over the level of dilean legends, locally lingering bronchial dichotomy, focus of sonorous dull-sounding wheezing or strengthening of bronchial vocalization, lightening However, in some patients, the signs of VP can be seen as typical ones, but they do not appear (in about 20% of the sick). The diagnostic value of anamnesis and physical condition is shown in Fig. 4.

X-ray diagnostics

X-ray diagnostics of ailments from home or due to pneumonia is aimed at detecting signs ignition process in the lungs and the young ones are quicker, as well as the assessment of the dynamics of the flow in the opposite direction. The great value of the differential diagnosis of changes in the lungs with other pathological processes, which may be similar to pneumonia cleverly show.

If a person is ill for pneumonia, he should be guilty of taking a look-at X-ray of the organs of the thoracic emptying in the anterior straight line and in the bichny projections. In case of an unacceptable localization of the ignition process, it is worthwhile to determine the knowledge in the right bichniy projection. V practical robot Single-format fluorography is often replaced by large-frame fluorography or digital fluorography, yak

in all kinds of vipadkas to be seen in analogous projections. Fluoroscopy in Danish hour is not an obligatory ligament and it is more than the original method of X-ray diagnostics of ailments of pneumonia.

X-ray examination should be carried out on the cob of an infection and not earlier than in 14 days for an ear of antibacterial drug. X-ray advancements can be made by a viconano and in a larger early period at an early date, for example, a short period of time for a clinical picture.

The appearance of fiery changes in the fabric of the legacy lies in the form of a victorious method of X-ray dosage and the correctness of the vikonannya. Naybilsh informative methodology є Computer tomography(CT). Shown before її zasosuvannya є:

1. A patient with obvious clinical symptomatology of pneumonia in the legends on the x-ray signs (fluorogram) in the daytime or may have an indirect character (for example, the snake of a Legendary baby).

2. When an X-ray patient is diagnosed with pneumonia, it is not typical for a sick person.

3. a) Recurrent pneumonia, when there is a lack of lung tissue, 1 changes in the same part (segment), but also in the middle of the disease, or b) prolonged pneumonia, when there is a triviality of the lungs In both cases, the reason for the repeated incidence of a trivial saving of changes in the legacy tissue can be stenosis of the great bronchus, obumenation, including malignant new ideas, or less disease of the lung.

The main x-ray signs of pneumonia are local impairment (occlusion, infiltration) of the lung tissue on the most critical symptoms of the zakvoryuvannya lungs. When there is a symptom of impairment of the lung tissue and radiological symptoms, the manifestation of pneumonia is inappropriate. The symptoms of a legacy baby without infiltrating a legacy tissue are diagnosed in cases of other illnesses, often as a result of a deterioration in the lung blood circulation, as a result of intoxication and a deterioration in the balance of pulmonary disease, as a result

The main types of pneumonic changes in X-ray diagnostics are: pleuropneumonia, bronchopneumonia, interstitial pneumonia. The X-ray picture of pneumonia is not correlated with the ethiological pneumonia, the degree of severity of the clinical interruption and does not allow the prognosis of the disease to be significant. The private features of the X-ray picture of pneumonia are not traced to the definition of the etiology of pneumonia.

Naybіlsh frequent accelerated pneumonia, which appears with X-ray dosage, є

exudative pleurisy and abscess. In the development of pleural vipot, the main significance is polypositional fluoroscopy and ultrasound. For the detection of signs of suppuration, a complete CT scan or radiography in the dynamics.

The triviality of the developmental development of pneumonia can occur in wide fringes, or it can become 3-6 times. X-ray show allow pneumonia to take longer than a trivial hour, lower clinical symptoms, І not є for the continuation of or for the love affair. The control roentgenologic dosage in case of a friendly clinical interruption of the disease should be carried out not earlier than after 2 years from the ear of the ear. Methods of radiography in cich vipads є the detection of central cancer and tuberculosis of the lungs, which protects against the mask of pneumonia.

Vii. LABORATORY DIAGNOSTICS І DODATKOVI DOSLIJENNY METHODS

The data from the clinical analysis of blood does not allow one to see about the potential for the cause of the VP. However, leukocytosis is greater than 10-12x109 / l, depending on the high degree of bacterial infection; leukopenia lower 3x109 / l or leukocytosis in the stomach 25x109 / l є unpleasant prognostic signs.

Biochemical analysis of blood (functional tests of the liver, nirok, glucose, etc.) regimes їх stasosuvannya.

In patients with symptoms of mental deficiency, accumulated with widened pneumonic inflammation, massive pleural vipot, development of VP on aphids of COPD and with saturation of blood sour<90% необходимо определение газов артериальной крови. Гипоксемия со снижением уровня РаО2 ниже 60 мм рт.ст. (при дыхании комнатным воздухом) является прогностически неблагоприятным признаком, указывает на необходимость помещения больного в ОИТ и является показанием к кислородотерапии. Распространенная в нашей стране практика исследования газов в капиллярной крови имеет относительную диагностическую ценность, плохую воспроизводимость и зачастую не соответствует результатам исследования артериальной крови.

The effectiveness of microbiological diagnostics is abundant in what lies in the freedom and correctness of the collection of clinical material. Naybilsh is often a material for sputum, which can be discarded when dislodging. The rules for eliminating, securing and transporting vidokremlyuvannoy sputum are presented in Dodatka 1.

The first stage of microbiological dosage is the preparation of sputum smear after Gram. when there is

no less than 25 polymorphonuclear leukocytes and 10 epithelial cells (at least 10 polymorphic leukocytes at least 10 polymorphic leukocytes when looking at at least 10 polymorphic leukocytes with an increase of x100) the cultural awareness of the development is not adequate, so as in the whole context of the early warning

The appearance in the smear of a great number of gramopoly-positive aboriginal microorganisms with a typical morphology (lanceolate gram-pooled diplococci - S. pneumoniae; mildly inferior gram-negative organisms for therapeutics) - H. influenzae antibodies.

Interpretation of the results of bacterioscopy and culture-natural dosage of sputum is guilty of being carried out with the help of clinical donations.

For patients with severe CAP, it is necessary to trim the shelter for cultural follow-up to the ear of antibacterial therapy (taking 2 samples of venous blood from 2 small veins). The general rules for the rejection of blood for bacteriological pre-admission are presented in Dodatka 1.

However, not being sensitive to the importance of rejecting laboratory material (phlegm, shelter) to the sign of antibiotics, microbiological until recently it is not guilty to serve as the reason for taking antibacterial therapy. In the first place, we will be introduced to the children with an important interruption of ill health.

Serological diagnostics of infections, infections M. pneumoniae, C. pneumoniae and Legionella spp. pochvoryuvannya cob), not a key, but an epidemiological level of diagnostics. In addition, the abundant commercial test systems available for diagnostics of significant infections are characterized by low incidence of results.

Viznachennya antigens. In the last hour, an expanded immunochromatographic test was made for the results in S. pneumoniae and L. pneumophila antigens (serogroup I). According to epidemiological dosages, 80-95% of cases of community-acquired legionellosis are accounted for on a portion of L. pneumophila serogroup I. The sensitivity of the test varies from 70 to 90%, the specificity of detection of L. pneumophila serogroup I reaches 99%. It is susceptible to the visibility of large-scale illnesses of L. pneumophila spreading as an origin of VP in the Russian Federation; For the first time, it may be important to avoid getting sick, because of the factor of the disease of hyonellosis pneumonia (for example, the recent rise), the ineffectiveness of the starting ABT by ß-lactamimiantibiotics for thinking of an adequate vibration. Slid mother on uvaz, but a negative test does not lead to the diagnosis of legionella pneumonia, so yak

not hardened for the detection of L. pneumophila from other serogroups and legional species.

Pneumococcal express test, demonstrating a reasonable sensitivity (50-80%) and reaching a high specificity (> 90%) in case of CAP in older adults. Yogo vikorstannya is most promising in case of ill-health of rejecting sputum sputum in patients, as well as receiving a systemic ABT, which is a little ahead of the reception of antibiotics, but rather a decrease in the amount of cultural information.

Legionellosis and pneumococcal expressiveness are lost in positive stretching of decile symptoms of the transferred epizode of VP, because the stench may seem to be a diagnostic value only in case of obvious clinical manifestations of entrapment.

Polymerase lantsyugov reaction (PLR). The whole method is promising for the diagnosis of such bacterial pathogens of CAP, such as C. pneumoniae, M. pneumoniae and L. pneumophila. However, the place of PLR in the ethiological diagnosis of EP is not residual, so the availability of test systems will require validation, and the data on the injection of routine testing of PLR in the ethological diagnosis of EP on the basis of the measurement results.

When nayavnostі vipotu i pleural drain Bezpieczne Venue of plevralnoї punktsії (vіzualіzatsіya on laterogramme vіlno zmіschuєtsya rіdini tovschinoyu ball of> 1.0 cm) doslіdzhennya plevralnoї rіdini Got peredbachati pіdrahunok leykotsitіv of wbc, viznachennya pH aktivnostі LDH vmіstu bіlka, bakterіoskopіyu smear pofarbovanogo according to Gram and with the help of other methods using the method of detecting mycobacteria, sowing on aerobi, anaerobes and microbacteria.

Invasive diagnostic methods. Fіbrobronho-scopy of kіlkіsnoyu otsіnkoyu mіkrobnoї obseme-nennya otrimanogo materіalu ( "zahischena" brush-bіopsіya, bronchoalveolar lavage) abo INSHI Metodi іnvazivnoї dіagnostiki (transtracheal aspіratsіya, transthoracic bіopsіya i іn.) Rekomenduyutsya tіlki at pіdozrі on tuberkuloz legen at vіdsutnostі productive cough, "Obstructive pneumonia" on the ground of bronchogenic carcinoma, aspirated outside body bronchus, etc.

In the last few years, hospitalized patients with the method of differential diagnostics of VPs from other infections of the lower dysfunctional paths and due to the seriousness of the disease - all the greater respect for the improvement of the level of reactivity It has been shown that the highest concentration of the C-reactive cell in the eye is indicated in patients with severe pneumococcal or legionella pneumonia. Rivne procalcitonin, due to the winter data, is also the main reason for the difficult status of patients with VP and can be a predictor of the development of an accelerated and unpleasant result. However, nutrition about the adolescence of vicarious tests in routine practice in case of CAP is still not viral.

VIII. DIAGNOSIS CRITERIA

Diagnosis of VP by perennial (category of proofs A) in case of presence of a patient with radiological evidence of an onset of diagnostics of the disease key signs from the number of offensives: a) gostra fever on the cob zhvoryuvannya (> 38.0 ° C); b) cough with phlegm; c) physical signs (focus of crepitations and / abo wheezing, acute bronchial dyhannya, short percussion sound); d) leukocytosis> 10x109 / l і / abo stab ssv (> 10%). The connection from the cym has passed according to the possibility of pragmatism to the clinical and radiological confirmation of the diagnosis of EP. However, it is necessary to determine the quality of the various types of sickness / pathological conditions.

Visibility or the inaccessibility of radiological confirmation of the detection of information in the legends (X-ray or large-frame fluorography of the chest organs) rob the diagnosis of EP inaccurate / irrelevant (category). At the same time, the diagnosis of an illness is primed on the basis of an epidemiological history, scarg and other local symptoms.

Yakscho at obstezhennі patsієnta of lihomankoyu, Skarga cough, zadishku, vidіlennya mokrotinnya that / abo bіl in grudnіy klіttsі rentgenologіchne doslіdzhennya viyavlyaєtsya unavailable, i vіdsutnya vіdpovіdna is local symptoms (vkorochennya / tupіst percussion sound over urazhenoyu dіlyankoyu legenі locally visluhovuvati bronhіalne dihannya, focus sonorous dry throat wheezing or inspiratory crepitus, improving bronchophonia and vocal tremor), then the hypothesis of VP will become maloimovirny (category of evidence A).

Diagnostics of VP, yak primed on the results of physical and radiological conditions, can be used for lichen to syndromic diagnosis; nosological wines of the age were sent to the name of the zhvoryuvannya.

I will help you to predict the etiology of EP, you can get a more detailed history of the epidemiological history (category of evidence B and C) (Table 9).

It is also necessary to provide for the peculiarities of the clinical surplus of VP in the fallowness of the ethology (category of evidence B and C). So, for pneumococcal VP, the cob is characteristic, temporal fever, Pain in the breast; for legionella - diarrhea, neurological symptomatology, important disruption of the disease, deterioration of the functions of the liver; for mycoplasma - malignant and headache, symptoms of infection of the upper respiratory path.

It is unimportant for those who are in the vicinity of the disease to be stricken with the sound of the VP and the clinical and radiological manifestations, especially the clinical and radiological interruption of the VP cannot be considered adequate predictors of the etiology of the disease.

Table 9. Epidemiology and factors in the development of VP in ethology

Umovi viniknennya Ymovirni zbudniki

Alcoholism S. pneumoniae, anaerobic, aerobic gram (-) bacteria (often K. pneumoniae)

COPD / cure S. pneumoniae, H. influenzae, M. catarrhalis, Legionella spp.

Decompensation of diabetics S. pneumoniae, S. aureus

Moving in old booths S. pneumoniae, representatives of the family Enterobacteriaceae, H. influenzae, S. aureus, C. pneumoniae, anaerobi

Unanimated empty ships of Anaerobi company

Epidemic influenza S. pneumoniae, S. aureus, S. pyogenes, H. Influenzae

Transferred to Massive Faculty of Anaerobi

VP growth on aphids of bronchiectasis, cystic fibrosis P. aeruginosa, B. cepacia, S. aureus

Internal drug addiction S. aureus, anaerobic

Local bronchial obstruction (for example, bronchogenic carcinoma) anaerobi

Contact with air conditioners, dry food, water cooling systems and L. pneumophila

Sleeping in a closed, organized collective (for example, schoolchildren, servicemen) S. pneumoniae, M. pneumoniae, C. pneumoniae

nya (category of proofs B). At the same time, it is more common to show that it is more often associated with the biology of the student, and with such factors, the macroorganism, such as, the manifestation of the presence of other diseases (category of evidence B). The linkage of the cysts of VP to the "type" (to wick, to the front of S. pneumoniae) and "atypical" (to the magnification of M. pneumoniae, C. pneumoniae, L. pneumophila) was added to the special key sense.

To establish the etiology of EP, bacterioscopy of a sputum smear prepared according to Gram and a culture-natural sputum smear is carried out. Also, it is necessary to be obligatory in the hospital and not obligatory in the outpatient mind. However, being sensitive to the sensitivity of the methods of bacteriological pre-development, the ethology of the EP does not fit into 25-60% of the types of tests (categories of evidence B and C).

A trace of memory, that no diagnostics before it was not guilty of being the reason for picking up the ear of antibacterial therapy (category of evidence B).

IX. CHARACTERISTIC OF BASIC CLASSES AMP

The natural activity of AMPs from the worms of the VP is presented in table. ten.

ß-lactam antibiotics

ß-lactam antibiotics have an important role to play in the detection of patients from VP, which is explained by their efforts to bactericidal activity in a number of key diseases of VP (including S. Pneumonia), low, pre-toxic Uninvolved in the development of resistance of S. pneumoniae to penicillin, ß-lactates, they are highly clinically effective in case of CAP, viclican PRP. In a large number of patients without important immunity disorders, the link between resistance to penicillin and gross inheritance of VP was not established.

The greatest significance in the therapy of EP in outpatients may be amoxicillin and a combination of ß-lactamase inhibitors - amoxicilin / clavulanate, amoxicilin / sulbactam.

Amoxicilin appears to be highly active against S. pneumoniae, for H. influenzae strains, does not produce ß-lactamases, in cases of ampicilin volodyne is significantly more readily available when taking all the way in the middle intestinal tract.

Perevagoyu іngіbіtorozahischenih amіno-penіtsilіnіv Je aktivnіst schodo ß-lactamase shtamіv i H. influenzae M. catarrhalis, a number of Gram enterobakterіy (K. pneumoniae that іn.) Metіtsіllіnochuvstvіtelnih shtamіv S. aureus i nesporoutvoryuyuchih anaerobіv, SSMSC produkuyut chutlivі to іngіbіtorіv ß-lactamase.

Amoxicilin and amoxicilin / clavulanate at a dose of 80-90 mg / kg / day according to amoxicillin, the activity of the PRP is obtained. In 2010 in the Russian Federation, a new form of amoxicilin / clavulanate was registered in the Russian Federation; , which will prevent the activity from being adjusted according to the PRP, I will allow the drug to be taken 2 times for good and characterized by a reduction in tolerance.

The key drugs for the treatment of hospitalized patients from VP є cephalosporin of the third generation are cefotaxime and ceftriaxone, which may be very active in S. pneumoniae, including PRP, H. influenzae, and M. catarrhizae. We emphasize the pharmacokinetic test of ceftriaxone є a trivial period of time, which allows you to inject it once per dob.

Benzylpenicillin has a high activity of S. pneumoniae (including PRP) and is recommended in the first place in case of pneumococcal disease.

Amoxicillin / clavulanate and amoxicilin / sulbac-there may be vicarious in the case of a stage of EP therapy in hospitalized patients.

The main shortcoming of all ß-lactam antibiotics is the activity rate of "atypical" microorganisms (M. pneumoniae, C. Pneumoniae, L. pneumophila).

macrolidi

The activity of “atypical” microorganisms (M. pneumoniae, C. pneumoniae, L. pneumophila) is affected by macrolides in the order of ёkh diєyu on S. pneumoniae є temporal. Such macroliths kindly penetrate into the bronchial secretions and Legenev tissue, developing concentrations in them, which is important to transplant such in blood, are characterized by an agreeable profile of safety and anti-allergic diseases.

Macrolide (erithromycin, clarithromycin, azithromycin, etc.) Є Vibor preparations for the therapy of VP, viciklikan atypical microorganisms (mycoplasma, chlamydia), legionella pneumonia. Erythromicin, clarithromicin, spiramicin and azithromicin are available in both parenteral and oral lykarsky forms(LF), to help motivate people to spend in the framework of frequent EP therapy.

A new LF for azithromycin is available in the Russian Federation today, which is a microcrystalline substance in the form of azithromycin digidrate, which, when renewed in water, will form a suspension. Tse of pumovlyuє more vivilnennya diyuchoy speech in the slunker and twelve-fingered intestines. A one-time intake of new LF azithromycin in a dose of 2.0 g, which will preserve 100% compliance, allows for a higher and stable concentration of the drug in plasma and is characterized by an effective therapy with standard courses of 3-5 days. According to the results of KI, a one-time administration of new LF azithromycin for poor VP was not applied for the effectiveness of 7-day therapy with clarithromycin and levoflok-satin.

Having shown a number of retrospective and prospective dosages, the stagnation of macrolides in combination with ß-lactams, in the case of monotherapy with ß-lactams, in the case of hospitalized patients with the help of hospitalization

Є Some information about the ineffectiveness of macrolides in the presence of S. pneumoniae before them in vitro, which in most cases was spontaneous in case of an important interruption of EP, which was supervised by bacteremia. In addition, due to the low natural activity of macrolides, it is obvious that H. influenzae.

Table 10. Natural in vitro activity of AMPs in the main AMPs

Antibiotic S. pneumoniae (PPP) S. pneumoniae (PPP) H. influenzae M. pneumoniae, C. pneumoniae Legionella spp. S. aureus (MSSA) S. aureus (MRSA) Klebsiella pneumoniae Pseudomonas aerugi-nosa

Benzylpenicillin1 +++ 0 + 0 0 0 0 0 0

Ampicilin ++ + ++ 0 0 0 0 0 0

Amoxicilin +++ +++ ++ 0 0 0 0 0 0

Amoxicilin / clavulanate, amoxicilin / sulbactam +++ +++ +++ 0 0 +++ 0 ++ 0

Cefazolin + 0 + 0 0 +++ 0 0 0

Cefuroxime ++ + ++ 0 0 ++ 0 ++ 0

Cefotaxime, ceftriaxone +++ ++ +++ 0 0 ++ 0 +++ 0

Ceftazidime 0 0 +++ 0 0 0 0 +++ +++

Cefepim +++ ++ +++ 0 0 +++ 0 +++ +++

Imipenem, meropenem 2 +++ ++ +++ 0 0 +++ 0 +++ +++

Ertapenem ++ + +++ 0 0 ++ 0 +++ 0

Macrolidi +++ ++ 0 / + 3 +++ +++ ++ 0 0 0

Doxycycline ++ ++ ++ +++ ++ ++ 0 0 0

Clindamicin, lincomicin4 +++ ++ 0 0 0 +++ + 0 0

Co-trimoxazole ++ + ++ 0 + ++ ++ + 0

Ciprofloxacin + + +++ ++ +++ + + +++ +++

Levofloxacin, moxifloxacin, gemifloxacin5 +++ +++ +++ +++ +++ ++ ++ +++ ++

Vancomicin +++ +++ 0 0 0 +++ +++ 0 0

Linesolid +++ +++ + 0 0 +++ +++ 0 0

Note. PPP - penicillin-sensitive strains of S. pneumonia; PRP - penicillin-resistant strains of S. pneumoniae; MSSA - methicillin-sensitive strains of S. aureus; MRSA - Meticillin-resistant strains of S. aureus; +++ - visoka activity, supported by key data (AMP can be a Vibor drug); ++ - good activity, confirmed by key data (AMP can be an alternative drug); + - low AMP activity; 0 - the rate of clinically significant activity (in some cases during in vitro activity; 1 the rate of insensitivity to benzylpenicylin pneumococci in the Russian Federation becomes 11.2% (of which 2.1% - with the highest level of resistance 2 mg / - L; 2 imipenem kіlka bіlsh gram-positive activity schodo kokіv 3 klіnіchno znachuschoyu aktivnіstyu schodo H. influenzae volodіyut azitromіtsin i klaritromіtsin; 4 lincomycin aktivnіstyu for in vitro postupaєtsya clindamycin vіdnosno bіlshostі zbudnikіv; 5 aktivnіst moxifloxacin schodo nizhche P. aeruginosa, nіzh y i levofloxacin not Got values ​​klіnіchnogo ; Levofloxacin, according to its activity against S. pneumoniae, is supplied to moxifloxacin and Hemifloxacin.

fluorohinoloni

Among the drugs in the whole group of greatest importance in case of CAP may be so called respiratory fluorochinoloni - levofloxacin, moxiflox-cin and hemifloxacin, which are used practically on all iimovirus diseases of pneumonia, including H. S.aureus is an integral part of the production of fluoro-nolone from the front generation (ciprofloxacin, ofloxacin, etc.).

Good microbiological characteristics of the preparations are compatible with the friendly pharmacokinetic

high parameters (a trivial period of time, which will prevent the possibility of storing one time for additional, high concentration in bronchial secretions and legacy tissue).

The presence of oral and parenteral LF in levofloxacin and moxifloxacin allows vikoristovuvati for stage of frequent EP therapy in hospitalized patients.

In the course of numerical tests, levofloxacin and moxif-loxacin have been demonstrated that it is possible to improve the clinical efficiency of patients with macrolides, p-lactams and their combination in outpatients and hospitals.

Fluorochinoloni II generation (ciprofloxacin, ofloxacin, etc.) Due to the low activity of S.pneumoniae and "atypical" diseases (with the blame of Legionella spp.) In monotherapy for CAP, it is not sufficiently stagnant.

tetracycline

Between tetracycline it is most acceptable, from a look at the pharmacokinetic features, tolerance and efficiency of the intake of doxycycline. Wine is characterized by good activity of atypical microorganisms (M. pneumoniae, C. pneumoniae, L. pneumophila) and a low level of secondary resistance of H. influenzae in the Russian Federation. Another challenge is the low cost and availability of the drug. However, the temporal frequency of seeing tetracyclineresistant strains of S. pneumoniae in Russia does not allow the viewing of this drug Vibor for empiric therapy of EP.

Preparations of the other groups

We are available in Danish hour in CLINIC PRACTICE oxazolidinones, having demonstrated efficacy in case of CAP caused by abnormally transmitted pneumococcal etiology, є linezolide. The main test drug is the temporal activity of polyresistant gram-positive microorganisms, including PRP, methicilin-resistant S. aureus. Oral and parenteral DF with high bioavailability, which allows the drug to be taken in hospitalized patients for frequent therapy.

Sered carbapenem is the most promising drug for the treatment of VP with the drug є ertapenem. Due to the activity of a relatively large number of gram-positive and gram-thrilling microorganisms, the wines are similar to the microorganisms and meropenems, the protein is of the classically significant activity of P. aeruginosa and acineto. The clinical and microbiological efficiency of Erta-penem was brought to the attention of hospitalized patients from the joint venture. For an excellent drug є the power of one-time consuming for doba.

Linesolide and ertapenem are not active as "atypical" plants (M. pneumoniae, C. pneumoniae, Legionella spp.).

X. ethiotropic therapy of EP

In the given section of representations of AMP vibir for ethiotropic therapy of the main diseases of VP with the urahuvannya of natural activity of drugs. However, in a specific skin situation, it is necessary to increase the breadth and nature of the secondary resistance of the pupils.

Vibor preparations for the treatment of pneumococcal VP є ß-lactates - benzylpenicilin, amino-penicilin (amoxicilin - vseredin, ampicilin -

parenteral), including ingibitoroprotection (amoxicilin / clavulanate and in.) and III generation cephalosporin (cefotaxime, ceftriaxone). Macrolide antibiotics є alternative drugs for allergies to ß-lactates. High efficiency (including for CAP, viclican PRP) may be respiratory fluorochinoloni (levofloxacin, moxifloxacin, hemifloxacin), vancomicin and linesolide.

Aminoglykozidi (gentamicin and in.) Do not seem to be of clinically significant activity in relation to S. pneumoniae.

Vibor preparations for the treatment of VP, viclican H. influenzae, є aminopenicilin (amoxicilin - vseredin, ampicilin - parenteral), amoxicilin / clavulanate, amoxicilin / sulbactam (active) ciprofloxacin, ofloxacin, levofloxacin, moxifloxacin, gemifloxacin).

M. pneumoniae, C. pneumoniae

The most natural activity of the "atypical" pupils is volodyut macrolide, tetracycline (doxycycline), respiratory fluorochinoloni, as well as with preparations of vibor in case of VP mycoplasma and chla-mediated. Nowadays about the manifestation of the peculiarity of microorganisms to macrolides, tetracyclines and fluorochinolones become lonely and do not conceal the central meaning of the word.

Vibor preparations for the treatment of legionella VP є macrolide (erithromicin, clarithromicin, azithromicin). Fluorochinoloni (levofloxacin) has also been shown to be highly effective in preschool children. Doxycycline can be used as an alternative to the drug.

The overvoltage of combined therapy in case of suspected legionellosis VP, zokrem, the degree to which it is given to macrolides in rifampicin, is not obvious on the current day.

Vibor is used for staphylococcus pneumoniae, MSSA є oxacilin, or buty amoxicilin / clavulanate, amoxicilin / sulbactam, cephalosporin I generation, linkosamid. In the case of the development of MRSA, it is recommended to test vancomycin or linesolide, and moreover, the rest of the way from the past to a greater extent of the addictive legacy pharmacokinetics.

Enterobacteriaceae

High natural activity of amoxicillin / clavulanate, amoxicilin / sulbactam, cephalosporin III-IV generation, carbapenemi, fluorochinoloni.

XI. VIBIR MISTSIA LIKUVANNYA

Vibir miscibility is the key to nutrition for the patient to diagnose VP, so that he is responsible for diagnostic procedures and, in such a rank, vitrati for lykuvannya. According to the current principles of the management of older patients from joint ventures, the number of people can be found at home. At the connection with a special meaning, the criteria are given or indicated before the hospitalization. There are a number of clinical and laboratory scales, which, on the basis of the assessment of the prognosis, give recommendations on how to choose the best choice. The PORT scale (Pneumonia Outcomes Research Team) was the most widespread in the light, but the allowance for 20 key and laboratory parameters, on the basis of which the names of the Pneumonia Severity Index (PSI -Pneumonia Severity Index) are to be predicted treatment and priority in empirical antibacterial therapy (Dodatok 2). However, for PSI to be determined, it is necessary to monitor a whole range of biochemical parameters, including blood sugar, sodium, glucose, hematocrit, arterial blood pH, which is not available in outpatient and polyclinic settings at the Russian Federation hospital.

More simple and accessible for routine testing є prognostic scales CURB-65 and CRB-65. The scale of British thoracic suspension has been modified, for the allowance for the assessment of 5 and 4 parameters, as follows: In case of a lethal result, the patients should be divided into 3 groups, for those with skin it is recommended to take a treatment (on an outpatient basis, in the case of an outpatient profile, or at BIT). The minimum number of points for this scale is 0, the maximum is 4 or 5 points. A detailed description of the CURB-65 and CRB-65 scales is presented in Dodatku 2.

From a practical point of view, the greatest interest is the CRB-65 scale, which can be found in outpatient wards, since it is not necessary for anyone to change the nitrogen of the blood.

To show that the predictive potential of the CURB-65 / CRB-65 scales in terms of performance up to patients with a low risk of an uncomfortable prognosis is not compromised by the PORT scale. At the same hour, mensh vivcheni stink, lower PORT scale. In addition, on the current day, on a day-to-day prospective monitoring until the end of the day, to confirm the fast frequency and unprinted hospitalization at victorious scales CURB-65 and CRB-65 in routine

Another scale that has been broken up recently by the Australian Working Group on EP, is based on the assessment of the severity of EP, sprout, emerging patients, who require intensive respiratory symptoms and

vasopressors with an adequate level of arterial vise. The SMART-COP scale transmits to the ballnumerary assessment of clinical, laboratory, physical and radiological signs of the values ​​of imovinous consumption in terms of intensive methods of treatment. This is described in Dodatka 2. Modifications of the SMRT-C0 scale options can be used in outpatient practice and in the most appropriate hospital settings, as it is not possible to determine the significance of such parameters, such as blood pH, blood oxygen levels. Doslidzhennya P.G.P. Charles and spivavt. demonstrated more high sensitivity SMART-COP in diagnosed patients with important VP in the case of the described PORT and CURB-65 scales.

Doslidzhenna V.A. Rudnova і spіvavt., Yakiy, including the analysis of the warning for 300 VP drops in ВІТ, showed a consistent informativeness of the PORT, CURB-65, CRB-65 and SMRT-CO scales when predicting the result in patients with an important interruption.

In addition, the description of prognostic scales for CAP is insanely corny, which allows the speed of the frequency of non-primed hospitalization among patients with a low risk of an uncomfortable prognosis, as well as the type of therapy that is used intensively. However, there are a number of difficulties associated with a number of difficulties: the stench of assessing the severity of the patient's camp and / for the forecast in a specific period of the hour, at which the variability of the VP's classic picture is not possible and the possibility of even more successful progress. The prognostic scales do not look at such factors as decompensation of other chronic ailments, as the main reason for hospitalization of patients, and also immediately shown before hospitalization. That is, whether from the prognostic scales, it can only be organized in the vibration of the mice, in the specific skin type of nutrition that can be used individually.

Hospitalization in case of a confirmed diagnosis of VP is indicated in the presence of a minimum of one of these signs:

1. Data of physical conditioning: frequency of response> 30 / min; diastolic arterial vise <60 мм рт.ст.; систолическое артериальное давление <90 мм рт.ст.; частота сердечных сокращений >125 / hv; temperature<35,5 °С или >39.9 ° C; destruction of svidomostі.

2. Laboratory and X-ray data: number of leukocytes in peripheral blood<4,0х109/л или >20.0x109 / l; SaO2<92% (по данным пульсоксиметрии), РаО2 <60 мм рт.ст. и/или РаСО2 >50 mm Hg with dichannes of the rooms; blood creatinine> 176.7 μmol / l, or sechovine nitrogen> 7.0 mmol / l (sechovine nitrogen = sechovina, mmol / l / 2.14); pneumonic infiltration, which can be localized more low in one particle; the presence of empty (empty) rospad; pleural infection; the advancement of prognostic-infiltrative changes in the legends (increase in infiltration> 50% in the range of 2 dB); hematocrit<30% или

hemoglobin<90 г/л; внелегочные очаги инфекции (менингит, септический артрит и др.); сепсис или полиорганная недостаточность, проявляющаяся метаболическим ацидозом (рН <7,35), коагулопатией.

3. The impossibility of seeing all the licars' attributions in the home minds adequate to a glance.

The food about the change of the stationary VP can be seen in the offensive vipads:

1. Вік older than 60 years.

2. Evidence of supportive illness (chronic bronchitis / COPD, bronchiectasis, malignant disease, chronic diabetes, chronic deficiency, heart failure, chronic alcoholism, drug addiction

3. Ineffectiveness of starting antibacterial therapy.

4. Viability.

5. Bazhannya of the patient and / or members of the yogi family.

In quiet patients, if the patient may have signs of a serious interruption of VP (tachypnoe> 30 / min; systolic arterial vise<90 мм рт.ст.; двусторонняя или многодолевая пневмоническая инфильтрация; быстрое прогрессирование очагово-инфильтративных изменений в легких, септический шок или необходимость введения вазопрессоров >4 hours; state institution nirkova lack), an unavailable hospitalization in VRIT is required.

In addition to taking an anamnesis and physical condition, the diagnostic minimum is to be blamed for the diagnosis, so that you can establish a diagnosis of VP and nutritional status about the severity of the interruption and the need for hospitalization. To them are admitted:

X-ray of the organs of the breast tissue in 2 projections;

Zagalny blood analysis.

Diagnosis of VP can be made only on the basis of the clinical picture of the incapacitation and the data of the physical situation without carrying out X-ray dosage. However, the X-ray of the breast cancer is docile in the plan for the assessment of the severity of the illness, in the obviousness of the acceleration and release of the food about the hospitalization.

Routine microbiological diagnostics of EP in outpatient practice is insufficiently informative and does not spoil the fuel injection on the vibration antibacterial drug(Category of proofs B).

The characteristics of the activity of different AMP classes, which become stagnant for the treatment of VP in key plants, are presented in Table. ten.

fight for ethological structures and tactics of antibacterial therapy. The dosage regimen of antibacterial drugs is presented in the table. twenty.

In group 1, patients without a fellow patient were included and did not take for the last 3 ms of systemic AMP> 2 days. In cich ailments, an adequate clinical effect can be withdrawn from the intake of oral medications (category of evidence C). Augmentin cillin (category of evidence D) or macrolide antibiotics is recommended in the choice of preparations in the choice. They do not care for those who in vitro aminopenicyl-Lines do not overshadow the whole spectrum of potential diagnostics, in the course of clinical reports there is no evidence of any evidence of antibiotic response

Macrolide after the turnover at adolescence for "atypical" etiology of illness (M. pneumoniae, C. pneumoniae).

Nutrition of the individual efficacy of antibacterial drugs in case of CAP inoculation by metal analysis of 13 randomized clinical patients, including 4314 outpatients in patients> 18 years. In metaanalysis, the results of oral medications in children were varied, including volodiut (macrolide, fluorocholine) and not volodym (cephalosporin, aminopenicylin) active in the winter. Until recently, there were no statistically significant changes in macrolides and fluoro-chinolones before ß-lactams, as well as any other indications according to the inheritance between certain classes of drugs, zorem macrolides and fluorides.

Table 11. Antibacterial therapy of pneumonia in outpatients

Easy VP in patients without supportive ailments, who did not take for the remainder of 3 m / s AMP> 2 days

Nybіlsh parts of the teachers

S. pneumoniae M. pneumoniae C. pneumoniae H. influenzae

Mild VP S. pneumoniae Amoxicilin /

in H. influenzae patients, clavulanate,

with C. pneumoniae amoxicilin supporters /

with S. aureus sulbactam in the middle

i / or Entero- ± macrolide in the middle

took bacteriaceae or respiratory

for the rest of the fluorochinolone

3 m / s AMP (levofloxacin,

> 2 days moxifloxacin,

hemifloxatsin) in the middle

Note. 1 Macrolide є with Vibor preparations in case of adolescence for "atypical" etiology of VP (C. pneumoniae, M. pneumoniae). Slid from a perevagu is most vivified with EP macrolides with reduced pharmaco-kinetic powers (azithromycin, clarithromycin), for example, with a favorable profile of safety and minimal frequency likarskikh vzaєmodiy(Josamicin, spiramicin).

Vibor preparations

Amoxicilin vseredin or macrolide inside1

Up to the 2nd group included ailments of VP with concomitant ailments (COPD, congestive diabetes, congestive heart deficiency, chronic nirchosis, cirrhosis of the liver, chronic alcoholism, drug addiction, dysfunctions) 3 Well, it’s good to fit into the ethology and educate the unpleasant result of the disease.

In the patients of the whole group, an adequate clinical effect can also be rejected in the presence of oral antibiotics. Oscillations of the etiological role of gram-negative microorganisms (including those with some mechanisms of resistance) in cich ailments of growth, as the drug Vibor is recommended amoxicillin / clavulanate and / amoxicyl. Patients of this category may have a combination of p-lactates and macrolide in conjunction with a youthful atypical ethiology VP, however, on the current day, this strategy is not reported, but such a strategy will reduce the results and find the result. An alternative to the combined therapy with p-lactams and macrolides can be the intake of respiratory fluorochinolone (levof-loxacin, moxifloxacin, hemifloxacin).

I have expanded in some regions the practice of widespread treatment of aminoglycosides (gen-tamitsin and in.), Cefazolin and ciprofloxacin in case of VP treatment, which is considered pardon, since the stench is not active in key diseases.

Parenteral administration of antibiotics in outpatient minds

Parenteral antibiotics for CAP elimination in outpatient minds does not seem to be overwhelming before oral administration. The stench can be stagnant in single cases (for example, when there is low compliance with oral medications, because of the unhappiness of free state hospitalization). In patients who are younger than 60 years of age, with the presence of significant family members illnesses, ceftriaxone or benzylpenicylin procaine can be consumed internally. For patients 60 years of age and older, it is recommended to use ceftriaxone internally. It is possible to add high-grade preparations with macrolides or doxy-wedge (category of evidence D).

The first assessment of the effectiveness of the therapy is carried out in 48-72 years after the ear of the disease (repeated look). Assistant telephone contact with the patient on the coming day for a cob of therapy. The main criteria of efficiency in terms of the term are lowering the temperature, reducing symptoms of intoxication, weakness and other manifestations of mental deficiency. If the patient has a fever in the temporal area and intoxication, or the symptomatology is progressing, then the treatment becomes ineffective. In general, it is necessary to re-evaluate the tactics of antibacterial therapy and re-evaluate the

the absence of the patient's hospitalization. Recommendations for changing the regimen of antibacterial therapy guidance in the table. 12. At the time of daytime adequate to the effect during therapy with amoxicillin, it will be replaced (or given) macrolide antibiotics(Category of proofs C).

Table 12. Vibir of antibacterial drug in case of ineffectiveness of the initial EP therapy regimen in outpatient minds

Preparations for I Preparations for II Comments

stage of treatment stage of treatment

Amoxicilin macrolide Moles "atypov" microorganisms (C. pneumoniae, M. pneumoniae)

Amoxicilin / clavulanate Amoxicilin / sulbactam Respiratory fluorochinolone macrolide Can "atypov" microorganisms (C. pneumoniae, M. pneumoniae)

Macrolide Amoxicilin Amoxicilin / clavulanate Amoxicilin / sulbactam Respiratory fluorochinoloni Can there be a reason non-efficacy of macrolides -resistant pneumococci abo Gram (-) bacteria

Note. Macrolide can be recognized as a substitute, as well as in addition to p-lactam.

Until the present hour, the optimal triviality of the treatment of patients from the VP to become a subject of discussion. The key criterion for ABT in case of poor VP is the normalization of the temperature of the fire for 48-72 years with positive dynamics of the other symptoms and the appearance of signs of clinical instability:

temperature<37,8 °С;

Heart rate is very fast< 100/мин;

dichanna frequency< 24 мин;

Systolic AT> 90 mm Hg;

Saturation 02> 90% abo Pa02> 60 mm Hg at the dichanna of the roommates.

With such an approach, the triviality of the problem will not change for 7 days (category of proofs C). Viconies in the last few rocky years have been reported about those that, in case of persistent airway pressure, the clinical effectiveness can be reached with victorious and more short courses of antibacterial therapy. Zokrema, in the meta-analysis ¿.1. 1_1 і spіvavt. the efficiency of the short (<7 дней) и стандартного (>7 days) courses of antibiotic therapy in older adults with poor VP in randomized clinical pre-sluggish patients (in the group of short-course boules, preparations of the older classes - r-lactams, fluoroquinoloni, macrolide). For such parameters, such as the frequency of clinical failures, mortality and microbiological efficiency of groups

and have not been reliably developed. Similar results were taken into account in the general metaanalysis of G. Dimopoulus and spivavt., Which included outpatient and hospitalized patients with unimportant VP. Short courses of therapy (3-7 days) were not developed in terms of clinical efficiency and safety as standard (7-10 days).

At the same hour, it will mean that a short course of antibacterial therapy can only be used in patients with non-eased VP. The short course may be poorly effective in patients with kidnapped patients, with chronic suppressive patients, in general patients with illnesses, as well as in patients with VP, viclikana, and P. aeruginosa such pupils.

Criteria for the adequacy of antibacterial therapy for EP:

temperature<37,5 °С;

Intoxication rate;

The visibility of the sputum swelling;

<10х109/л, нейтрофи-лов <80%, юных форм <6%;

The appearance of negative dynamics on the roentgenogram. Saving the environment for clinical, laboratory and

roentgenologic signs of EP are not absolute indications until the continuation of antibacterial therapy or modification (Table 13). In the middle of the

Table 13. Clinical signs and I will become, which are not indicated for the continuation of antibacterial therapy, for replacing AMP

Клінічні Signs Explanation

Stiff subfebrile condition (temperature in the interins 37.0-37.5 ° C) When there are signs of bacterial infection, it can be a manifestation of non-infectious inflammation, postinfectious asthenia (vegetative), medical dysfunction

Saving surplus changes on the X-ray (infiltration, strengthening of the Legendary baby)

Dry cough can be prevented by a stretch of 1-2 m / s after the transferred VP, especially in quiet, scorching, patients with COPD

Preservation of wheezing during auscultation Dry wheezing can be prevented by a stretch of 3-4 months or more after the transferred VP and to visualize the natural plin of sickness (local pneumosclerosis at the point of focus)

Збільшення ШОЕ Non-specific indicator, not familiar with bacterial infections

Preserve weakness, preference Manifest post-infectious asthenia

As a result, it was possible to see it on its own, for example, in response to symptomatic therapy. It is trivial to get a subfebrile condition not familiar with bacterial infections (category of evidence B).

Radiological manifestations of EPs appear more often than clinical symptoms, so the control radiography of the breast cancer cannot serve as a criterion for determining the triviality of antibacterial therapy (category of evidence B).

At the same time, in case of pre-clinical, laboratory and radiological symptomatology of VP, it is necessary to carry out differential diagnostics for such illnesses, such as cancer of the legacy, tuberculosis, congestive heart failure, and others. (Div. Rozdil XII).

hospitalized

PATSIUNTIV

Diagnostic minimum of maintenance

In addition to taking an anamnesis and a physical condition, the diagnostic minimum is to blame for the diagnosis, so that it is possible to establish a diagnosis of VP and nutrition about the severity of interruption and the diagnosis of a patient To them are mentioned (categories of proofs B and C):

■ X-ray of the breast cell in 2 projections;

■ zagalny blood analysis;

■ biochemical analysis of blood - sechovina, creatі-

nin, elektrolіti, pechіnkovі ferments;

■ microbiological diagnostics:

Microscopic smear of sputum, prepared according to Gram;

Bacteriological dosage of phlegm for the vision of the originator and the value of his sensitivity to antibiotics;

Bacteriological blood count (optimally, there are two samples of venous blood from the veins) *.

In the capacity of preadopted methods of pre-admission in patients with poor VP, it is possible to recommend culture-soximetry (BaO2<90% является критерием тяжелой ВП и показанием для проведения кислородотерапии) и электрокардиографическое исследование. При тяжелой ВП целесообразно исследовать газы артериальной крови (Р02, РС02) для уточнения потребности в проведении ИВЛ (категория доказательств А). В качестве дополнительного метода исследования могут быть рекомендованы экспресс-тесты на наличие пневмококковой и легионел-лезной антигенурии.

If there is evidence of pleural vomiting, the puncture and the cytological, biochemical and microbiological prediction of pleural birth (category of evidence C and B) are displayed.

* Pre-treatment obov'yazkovo with important VP.

Criteria for an important interruption of a VP and the need for a patient at a VIT

In case of a proper patient with a VP in the hospital, it is necessary, first for everything, to assess the severity of your camp and nutritional status about the moment of love (seeing a foreign profile to a BIT).

Important VP is a special form of a disease of developmental etiology, which manifests itself as a twisted dysfunctional deficiency and / or signs of severe sepsis, which is characterized by a bad prognosis and intensive therapy (Table 14). The detection of cutaneous due to the values ​​of the criteria reliably increases the risk of an unpleasant result of illness (category of evidence A).

Table 14. Criteria for important interruption VP1

Clinical and instrumental laboratory criteria

criteria

Gostra dikhalna Leukopenia (<4*109/л)

deficiency: Hypoxemia:

Dikhannya frequency - Pa02<60 мм рт.ст. Гемоглобин <100 г/л

EA02<90% Гематокрит <30%

Hypotense Gostra nirkov

Systolic AT deficiency (creatine

<90 мм рт.ст. крови >176.7 μmol / l,

Diastolic AT nitrogen of the sečovina> 7.0 mmol / l)

<60 мм рт.ст.

Double- or multi-part

training leg

loss of property

posalegenevium in the fire

інфекції (menіngіt,

pericarditis and in.)

Note. 1 If there is a desire for one VP criterion, it is important to be recognized.

In case of EP, it is extremely important є conducting a quick assessment of the severity of the patient will be a sign of important EP, which is not necessary for non-advanced therapy (category of evidence D), as it should be carried out in VRIT.

As a promising method of detecting a group of patients, as it requires intensive respiratory training and / or the introduction of vasopressors, the prognostic scale SMART-COP (Dodatok 2) can be seen.

Vibration starting antibacterial therapy

The hospitalized patients rely on the respect for a more important breakdown of the EP, for that they will do a good job of treating the therapy with parenteral antibiotics. After 2-4 days of treatment with normal temperature, changes in toxicity and other symptoms of illness, a possible transition from parenteral to oral administration of antibiotics until the completion of the second course of therapy (category). In case of a slight overrun of VP in hospitalized ailments, especially in times of hospitalization for immediate indications, it is allowed to immediately indicate antibiotics in the middle (category of evidence B).

In hospitalized patients with poor VP, it is recommended to internally consume benzylpenicilin, ampicilin, ingibitorosis-entrapped aminopenicillins (amoxicilin / cl-vulanate), amoxicillin

Table 15. Antibacterial therapy of pneumonia in hospitalized patients

Pneumonia of the lung 1 S. pneumoniae H. influenzae C. pneumoniae S. aureus Enterobacteriaceae Benzylpenicillin IV, i / m ± macrolide inside2 Ampicilin i / v, i / m ± macrolide inside i / v, i / m ± macrolide 2 Cefotaxime i / v, i / m ± macrolide inside2 Ceftriaxone i / v, i / m ± macrolide inside2 Ertapenem i / v, i / m ± macrolide inside2 abo Respiratory fluorochinolone (levofloxacin), moxifloxacin i / v

Major pneumonia3 S. pneumoniae Legionella spp. S. aureus Enterobacteriaceae Amoxicilin / clavulanate i / v + macrolide i / v Cefotaxime i / v + macrolide i / v Ceftriaxone i / v + macrolide i / v Ertapenem i / v + macrolide i / v abo Respiratory fluorochloxinolone (levoxifloxinolone) i / v + cefotaxime, ceftriaxone i / v

Note. 1 Shrinking the foot of the therapy. When the patient is stable, it is allowed to immediately take the drug into the middle.

2 As a result of the disease, we are most likely to vivify in case of EP macrolides with reduced pharmacokinetic powers (azithromicine, clarithromycin) and / or with an agreeable profile of safety and minimal frequency of drug-induced diseases.

3 In the presence of factors in the risk of infection of P. aeruginosa (bronchioctasis, administration of systemic glucocorticoids, therapy with broad spectrum antibiotics for more than 7 days with the rest of the disease, hanging) with drugs Viborum ceftamacidime, meropenem, imipenem), ciprofloxacin. All high-grade drugs can be used in monotherapy or in combination with aminoglycosides of II-III generations. In case of adolescence for aspirations, docitolally vikoristovuvati amoxicilin / clavulanate, cefoperazone / sulbactam, ticarcilin / clavulanate, pperacylin / tazobactam, carbapenemi (meropenem, imipenem).

III generation (cefotaxime, ceftriaxone) or ertapenem. According to the results of a number of prospective and retrospective reports, the presence of antibiotics in the initial mode of therapy, active, apparently atypical microorganisms, will shorten the prognosis and speed up the rate of recovery of the sick person in the hospital. Qia obedienta rob the use of r-lactates in combination with macrolide.

An alternative to combined therapy (P-lacto ± macrolide) can be monotherapy with respiratory fluorochinolone (moxifloxacin, levofloxacin).

If there is an important EP, the antibiotics are guilty of being inaccessible (category of evidence B); an extra line in їх assigned for 4 years and more іtototno poorly forecast. Vibor preparations for internal cephalosporin of the third generation, antibiotic protection of penicillin (amoxicillin / clavulanate), but carbo-penemia without antipseudomonal activity (ertapenem) in combination for macrolysis The assignments of the combination practically overlap the entire spectrum of potential problems (both typical and "atypical") of important EP.

Early fluorochinoloni (ciprofloxacin and in.)

Three preparations of a group of fluoroquinolones in the transfusion are followed by respiratory fluorochinolones (moxif-loxacin, levofloxacin), which are administered intravenously. Є The data of the control of KI against the standard regime of therapy (combination of r-lactates and macrolide) of the efficacy of monotherapy with respiratory fluorochinolones in case of important EP. However, the combination of fluorochinolones with cephalo-SPORINA III generation (cefotaxime, ceftriaxone) is also more important.

Criteria for the effectiveness of antibacterial therapy

The first assessment of efficiency should be carried out in 48-72 years after the ear of a drink. The main criteria of efficiency in terms of the term are lowering the temperature of the child, intoxication and mental disabilities. Yaksho at the patient's eye

fever and intoxication or symptoms of becoming ill, then treatment becomes ineffective. In general, it is necessary to change the tactics of antibacterial therapy. Recommendations for changes in antibiotics guidance in the table. 16. In case of ineffectiveness of the therapy of p-lactam and macrolide, the respiratory fluorochinolones are partially assigned - levofloxacin, moxifloxacin (category of evidence C).

In case of ineffectiveness of antibacterial therapy at stage II, it is necessary to carry out a thoroughness of the patient in order to clarify the diagnosis of any possible acceleration of VP (div. Rozdili XI-XII).

To assess the patient's status and the effectiveness of the therapy, docily, in addition to microbiological diagnostics, this is how it is advised:

■ Regional blood analysis: if appropriate, on the 2-3rd day after the end of antibacterial therapy;

■ Biochemical analysis of blood (ALT, AST, creatine, sechovine, glucose, electrolyte): if appropriate, after 1 day for the appearance of changes in the first advanced or clinical failure;

■ Pre-treatment of arterial blood (in case of an important interruption): before normalization of indicators;

■ X-ray of the organs of the breast: when it is appropriate and after 2-3 months, when an ear of milk is taken; when I die, I will - in more early terms.

The triviality of antibacterial therapy

If VP is not important, antibacterial therapy can be completed after reaching a stable normalization of temperature for 48-72 hours. In case of important EP of unspecified ethology of recommendations, a 10-day course of antibacterial therapy (category of evidence D). Longer trivial therapy (not less than 14 days) is indicated for CAP of staphylococcal etiology and VP, vicious enterobacteria and P. aeruginosa (category of evidence C), and with the appearance of lateral symptoms, the appearance of triple disease begins. In case of legionellosis pneumonia, make sure to complete the 7-14-day course of therapy, protest with an accelerated interruption, post-mortem infections and the most common reason for the triviality of the treatment to start individually (category).

Table 16. Vibir of antibacterial drug in case of ineffectiveness of the initial therapy regimen in hospitalized patients

Preparations for stage I treatment preparations for stage II treatment Comments

Ampicilin Substitute for (or additionally) macrolide In case of death, substitute for cephalosporin of the third generation, ingibitoroprotective aminopenicilin + macrolide Possible "atypov" microorganisms, S. pneumoniae, C. pneumonia.

Ingibitor-resistant aminopenicilin Dosage macrolide Moles "atypical" microorganisms (C. pneumoniae, M. pneumoniae, Legionella spp.)

Cephalosporin III generation Dodati macrolide Can "atyp" microorganisms (C. pneumoniae, M. pneumoniae, Legionella spp.)

Criteria for the adequacy of antibacterial therapy for EP:

temperature<37,5 °С;

Intoxication rate;

The visibility of dyshalal deficiencies (the frequency of dyshnoyas is less than 20 / min);

The visibility of the sputum swelling;

Number of leukocytes in the blood<10х109/л, нейтрофи-лов <80%, юных форм <6%;

The appearance of negative dynamics on the roentgenogram. Preservation of the environment for clinical, laboratory

and radiological signs of EP are not absolute indications until further antibiotic therapy or modification (Table 13). The overwhelming majority of the problems allowed them to appear independently. It is trivial to get a subfebrile condition as well as not familiar with bacterial infections.

X-ray signs of pneumonia appear more often than clinical symptoms, so the control X-ray cannot serve as a criterion for the detection of antibiotics, but it should be shown that antibiotics should be indicated before further antibiotic therapy. However, in case of pre-clinical, laboratory and radiological symptomatology of CAP, it is necessary to carry out a differential diagnosis of those with illnesses, for all diseases of the disease and tuberculosis (Div. Rozdil XII).

Stage of antibacterial therapy of EP

Stage 2 of antibiotic therapy for the transmission of antibiotics 2-stage non-intake of antibiotics: an ear of treatment with parenteral drugs with a further transition to oral administration as a result of stabilization of the patient's standard patient. The main idea of ​​the step therapy of the field in the change of the triviality of the parenteral antibacterial therapy, as well as the reduction of the rate of treatment and the quicker term of the patient in hospital in the case of a child

The optimal option for frequent therapy is the last day of treatment of 2 drug forms (for parenteral administration and intravenous administration) of one and the same antibiotic, which will prevent a decrease in the rate of drug use. It can be the last time that the drugs are consumed that are close to their antimicrobial authorities and with the same kind of dumb stiffness. The transition from parenteral to oral antibiotic after the stabilization of the patient's body, normalization of temperature and improvement of the clinical picture of EP (category of evidence B). With a lot of adorably victorious criteria, such criteria are:

The temperature is normal (<37,5 °С) при двух измерениях с интервалом 8 ч;

Zadishki change;

The visibility of the deterioration of the property;

Positive dynamics of other symptoms of illness;

The visibility of the debris from moisture in the intestinal tract;

Zgoda (mood) of patients on oral administration.

In practice, it is possible to switch to the oral route of administration of an antibiotic to appear in the middle after 2-3 days after the ear is taken.

For frequent therapy, antibiotics are used: amoxicilin / clavulanate, levofloxacin, moxifloxacin, clarithromicin, azithromicin, spiramycin, erithromicin. For antibiotics, which do not have LF for oral administration, you can substitute a drug that is close in terms of antimicrobial spectrum (for example, ampicilin ^ amoxicilin; cefotac-sym, ceftriaxone ^ amoxicilanin) / clavulan.

In the last hour of the day, there is evidence of the admissibility of biogenic stimulants, antigenic drugs, vitamins, immunomodulators (including granulocytic colon stimulants) The efficiency and safety of the named LZ are not confirmed by the results of randomized control of CI, but it is not allowed to recommend them for the treatment of VP.

At the same hour, with an important EP, antibacterial therapy is guilty of supra-urinary symptoms;

XIV. Folding VP

Up to the number of acceleration of VP, the following are introduced: b) pace of pleurisy; c) destruction / abscess formation of the leg tissue; d) Hostry Respiratory Distress Syndrome; e) stately dyshally lack of; f) septic shock; g) secondary bacterimia, sepsis, hematogenous disease in the brain; h) pericarditis, myocarditis; i) jade and in. With a special significance (including from the point of view of planned antibacterial therapy), there may be a gnarly-destructive accelerated illness.

The abscess of the legacy is characterized by the formation of interleaved empty spaces in the legacy fabric as a result of necrosis and molten melting. The development of an abscess of the lung will ring, in front, with anaerobic stumps - x Bacteroides spp., F. nucleatum, Peptostreptococcus spp. that in. - rarely in the case of enterobacteria or S. aureus. Vibor antibiotics are amoxicilin / clavulanate, ampicilin / sulbactam, cefoperazone / sulbactam, ticarcilin / clavulanate iv. Prior to alternative drugs should be: cephalosporin III-IV generation, ciprofloxacin or levofloxacin + metronidazole or carbapenemi. The triviality of therapy begins individually, but, as a rule, it should not be less than 3-4 times.

Empіma pleurisy (gnіyny pleurisy1) is characterized by purchased pus in the pleural emptying. The main prototypes of pleurisy are anaerobic (in the second place with gram-negative aerobic bacteria). In most cases, ethiotropic antibacterial therapy is administered with the help of microbiological dosages instead of pleural emptying.

If the gnarly vipit appears to be sterile, if antibiotics are indicated (aka the combination), as well as the activity of young children - in the diseases of the so-called pneumonia, S. pneumonia, S. pneumonia, S. influenzae. In the present of the clinical situation, the perevag went on to form cephalosporins of the III-IV generation.

Ridsche - in case of pidgostroma / chronic interruption of the rate - the ethiological significance of anaerobic streptococci, bacterioids and gram-negative enterobacteria. In conjunction with cym drugs Vibor є amoxicilin / clavulanate, ampicilin / sulbactam, cefoperazone / sulbactam, ticarcilin / clavulanate, and before alternative cephalosporin III-IV generation, carbapenemi. As a rule, the order of antibacterial therapy is brought to thoracotomy drainage, and in rare cases - to thoracoscopy and decortication.

XV. UNAUTHORIZED (ACCEPTABLY allowed) PNEUMONIA

In a large number of VPs, for 3-5 days after the ear of potentially effective antibacterial therapy, the temperature of the body will normalize and some of the most important manifestations of illness will regress. With a whole roentgenologic study, as a rule, it appears as a clinical one. In quiet cases, if on the last few days of the clinical picture at the end of the 4th season, from the ear of the ear, it is not possible to reach the full radiological permission of the focal-infiltrative serpents in the legends.

In some of the most important situations, it’s for everything, you can establish the risk factor for a protracted transition from getting sick: a) people older than 55 years; b) alcoholism; c) the manifestation of the supportive incapacitating internal organs (COPD, congestive heart failure, nirkova deficiency, malignant new development, diabetic diabetic and inn.); d) an important transition of the VP; e) multi-barnyh іnfіltratsіya; f) visokovirulent zhvoryuvannya (L. pneumophila, S. aureus, gram-negative enterobacteria); g) kurnnya; h) clinical ineffectiveness of the initial therapy (leukocytosis and fever); i) secondary bacteria.

1 Vipot with a number of leukocytes> 25,000 / ml (with samples of polymorphonuclear forms) and / or for detections during bacterioscopy or due to microorganisms / or pH<7,1.

In a number of possible reasons for the permissiveness of VP, there may be secondary resistance to antibiotics. systemic glucocorticoids), multiple suppression of internal organs.

Especially respect is guilty but attributed to the correctness of the choice of empirical antibacterial therapy, the regimen of dosage and treatment of the patient's recommendations. It is necessary to keep in mind that, with the prescribed regime of therapy, it is necessary to concentrate in the midst of infection, and it means that we are guilty of being able to “sequester” the focus of infection (for example, the application of abscesses)

Viklyuchne meaning is a great differential diagnosis of CAP of prolonged interruption from focal-inflammatory tuberculosis of the lung.

I, nareshty, next to mothers in the country a wide number of non-infectious ailments, an hour later they can get pneumonia and start in conjunction with a variety of differential diagnostics difficulties (Table 17).

Table 17. Non-infectious causes of non-infectious diseases in the legends

newfound

Primary cancer of the lung (especially the so-called pneumonic

a form of bronchioalveolar cancer)

endobronchial metastases

bronchial adenoma

lymphoma

Thromboembolism of the lung artery and pulmonary infarction

immunopathological illnesses

Systemic vasculature

Vovchakovy pneumonitis

Allergic broncholegenic aspergilosis

Obliterative bronchitis with pneumonia

Idiopathic legenevius fibrosis

eosinophilic pneumonia

bronchocentric granulomatosis

Іnshі disease / pathological conditions

Lack of heart

Lykarska (toxic) pneumopathy

Aspirations of the side

sarcoidosis

Legenevian alveolar proteinosis

lipoid pneumonia

rounded atelectasis

As a factor in the risk of the presence of the patient permissively, and immediately in the absence of a disease, it is necessary to prevent clinical treatment, then in 4 days it is worthwhile to carry out an X-ray control of the organs of the breast cancer. Although the clinical training does not mean (abo) the method of the patient's examination of the patient according to the permission of the VP, then it is insanely shown that the pre-examination is carried out in a non-secret order (computer tomography of the chest organs, the chest examination,

Pneumonia is generally allowed ^

The emergence of risiks of a protracted interruption of ailments

Control roentgenographic coverage after 4 hours

Dose of pneumonic infiltration

Dodatkovo obsozhennya (CT, fiberoptic bronchoscopy and

The appearance of the risk of a protracted interruption of the disease ^

Small. 5. Scheme of the provision of a patient with a syndrome (protracted) EP

XVI. ANALYSIS OF REAL PRACTICE І Types of pardons FOR LIKUVANNIA VP

U 2005-2006 rr. In 29 highly specialized medical institutions in the Russian regions, the practice of treating hospitalized patients from joint ventures from the point of view of the advancement of indicators of quality (IK) was analyzed:

1.radiologic dosage of organs in the breast cancer with the presence of clinical signs of EP for 24 years from the moment of hospitalization (as it did not go to the outpatient stage);

2. bacteriologic dosage of phlegm before antibiotics;

3. the bacteriological level of blood until the sign of antibiotics (in patients with an important CAP);

4. the introduction of the first dose of a systemic antibiotic in the first 8 years from the moment of hospitalization;

5. the relevance of the starting antibacterial therapy regimen to national recommendations;

6. testing of frequent antibacterial therapy (for patients who required parenteral antibiotics);

The analysis included 3798 VPVs in patients from 16 to 99 years old (middle age - 49.5 ± 19.9 years), of which 58% of people. The size of VP is small in 29.5% of cases; the acceleration of the increase in the number of patients was 69.4% of patients.

The average level and the range of indicators of longevity in the winter ІК are shown in Fig. 6. Naybіlsh high standard of tameness, characteristic for the radiological dosage of organs of the chest

100 90 80 70 60 50 40 30 20 10 0

Small. 6. Habilitation of ІК among hospitalized patients with VPs in high-profile medical institutions of the Russian Federation, 2005-2006 rr. * The hour of the introduction of the first dose of AMP is estimated at 61% of the doses.

% 40 35 30 25 20 15 10 5

Small. 7. Factors significant for patients with AMP vibration in outpatient CAP patients (%)

30 + 27D 25 20 15 10 5 0

Small. 8. The structure of the AMP, scho vikorisovvali for the starting monotherapy of EP in outpatient minds in 2007

clitini (92%) and hourly (<8 ч с момента госпитализации) начала антибактериальной терапии (77%).

Prior to the indicators with the lowest level of addiction, the rate of bacteriological pretreatment of blood (1%) and phlegm (6%), the availability of recommendations for vaccination against pneumococcal (14%) and influenza (16%); The stage of antibacterial therapy of vicorisovas was in the middle in 18% of cases.

The prevalence of initial antibacterial therapy recommendations was high in case of low pneumonia (72%) and low in case of an important interruption of illness (15%); the main problems of antibacterial therapy of important pneumonia bully are not primed for monotherapy, inadequate introduction of antibiotics and stagnation of non-rational combinations.

At the large-center prospective pharmacological study of myology, which was carried out in 2007 in the outpatient-polyclinic establishments of 5 regions of Russia, there were factories that started vibrating drugs for antibacterial drugs, such as 104 doctors took part in the pre-adolescents, of whom 87% were medical therapists.

The practice of treatment of 953 outpatients from the joint venture was analyzed.

The most significant factors in antibiotics vibration in patients with VP in outpatient minds from the point of view of the doctor are presented in Fig. 7.

The structure of the AMP in the developmental centers is shown in Fig. 8. The order of amoxicilin, amoxicilin / clavulanate and macrolides is a significant part in the structure of cefazolin and cy-profloxacin; the temporal frequency of the third generation parenteral cephalosporins - Cefo-Taximo and ceftriaxone was indicated.

Altogether 57% of the drugs in the case of CAP treatment were given an oral dose of AMP, 6% - parenteral; They didn’t wander around, so as you will be prickly to act as orally, as well as parenteral lykarski forms of antibiotics.

In the list of the most significant information about AMP, 85% of the users reported to conferences / round tables and materials from representatives of pharmaceutical companies;

XVII. RECEPTIONS of antibacterial therapy of VP in grown-ups

Table 18. Naybіlsh broadenings of antibacterial therapy of EPs in adults _Appointment _ \ _ Comments_

For vibor drug (easy VP)

Gentamicin Activity rate of pneumococcus and atypical diseases

Ampicilin in the middle Low bioavailability of the drug (40%) in patients with amoxicilin (75-93%)

Cefazolin Low antipneumococcal activity, the rate of clinically significant activity in relation to H. influenzae

Ciprofloxacin Low activity of S. pneumoniae and M. pneumoniae

Doxycycline Visoka resistance of S. pneumoniae in the Russian Federation

Respiratory chinoloni Insufficiently victorious in the quality of drugs in the vibor when there are factors in the risk of therapeutic failure

For the vibration of the drug (important VP)

ß-lactams (including cefotaxime, ceftriaxone) in the capacity of monotherapy Chi does not overshadow the spectrum of potential plants, L. pneumophila zocrem

Carbapenemi (іmіpenem, meropenem) Stagnation in the capacity of starting therapy is not economically viable; may vikoristovuvatis only at aspiration and adolescence for infection, P. aeruginosa viclican (crim ertapenem)

Antisinuclear cephalosporin of the third generation (ceftazidime, cefoperazone) is used for the activity of S. pneumoniae cefotaxime and ceftriaxone; vikristannya vypravdan only in case of adolescence for infection, viclican P. aeruginosa

Ampicilin Chi does not overshadow the spectrum of potential diseases of important VP, sprouts, S. aureus and large enterobacteria

Introduced by Vibor

The form of step therapy Step therapy allows for the rapidity of vitrati to the disease without deteriorating the prognosis. In most patients, the transfer to oral intake of antibiotics on the 2-3rd day of therapy

Intra-intravenous administration of antibiotics in case of important CAP

By the terms of cob therapy

An increase in the ear of antibacterial therapy The line with the signs of antibiotics at the time of hospitalization for 4 years and more and more often the prognosis

For the triviality of therapy

Frequent change of AMP in the process of treatment, "how to explain" the development of the resistance of AMP in the process of treatment, with the blame for the problem of clinical inefficiency, and / or intolerance and insufficient. Shown for replacing antibiotics: clinical ineffectiveness, you can judge about it in 48-72 years of therapy; development of serious non-biased manifestations, which can be used to generate antibiotics; visoka potential toxicity of antibiotics, which will intertwine the triviality of its antibiotics

Continuing AB therapy to the full knowledge of all clinical and laboratory indicators The main criteria for the antibiotics are the rapid development of the clinical symptoms of CAP: normalization of the temperature of the body; malignant cough; change in the amount of money i / or to improve the nature of the sputum and in. Preservation of laboratory and / or radiological changes is not an absolute criterion until further antibiotic therapy

XVII. PROFILACTIC

In the past, pneumococcal and influenza vaccines are used to protect against pneumococcal flu vaccine.

The completeness of the pneumococcal vaccine intake is explained by the reason for all that, and in the current S. pneumoniae, to become a provincial CAP in older adults, who are unimpressed on the available effective antibacterial therapy, and have acquired the summer. With the method of specific prophylaxis of invasive pneumococcal infections, including pneumococcal VP with secondary bacteremia,

It is a 23-valent unconjugated vaccine to avenge purified capsular polysaccharide antigens of 23 serotypes of S. pneumoniae (proof category A).

Oskilki patients who require a pneumococcal vaccine from the introduced pneumococcal vaccine, which are not required for an influenza vaccine, then a memory, which offending vaccines can be administered one hour (in the hands of the patient) without the need for additional proof

Patients in a patient> 65 years old3 without immunodeficiency A Another dose is recommended, if the vaccine was taken out> 5 years old and at the time the patient was given a bullet<65 лет

Individuals at віці> 2 і<65 лет с хроническими заболеваниями: сердечно-сосудистой системы (например, застойная сердечная недостаточность, кардиомиопатии) легких (например, ХОБЛ) сахарным диабетом алкоголизмом печени (цирроз) ликвореей А А А В В В Не рекомендуется

Individuals at віці> 2 і<65 лет с функциональной или органической аспленией (например, с серповидно-клеточной анемией, после спленэктомии) А Если в возрасте >10 rounds, revaccination is recommended after 5 rounds after the front dose

Individuals at віці> 2 і<65 лет, живущие в определенных условиях окружающей среды или из особой социальной среды (например, аборигены Аляски и др.) С Не рекомендуется

Individuals with immunodeficient camps in> 2 years, including patients from: VIL-infectious; leukemia; Hodzhkin's ailment; a lot of myloma; generalized malignant new solutions; on immunosuppressive therapy (including chemotherapy); chronic nirk deficiency; nephrotic syndrome; organ deficiency, for example, a cystic marrow transplant.

Note. 1 А - reliable epidemiological data and values ​​of clinical trials for vaccination; B - on the basis of proof of the effectiveness of the vaccine; C - the effectiveness of vaccination has not been brought to light, however, a high risk of development of ill health, potential changes and safety of vaccination create the basis for carrying out immunization;

3 as immunization status of nevidomas, vaccination is recommended for patients of cich groups.

The effectiveness of influenza vaccine in the development of influenza and its acceleration (including VP) in healthy individuals younger than 50 years of age will be estimated to reach high (category of proofs A). In individuals 65 years of age and older, vaccination appears to be equally effective, but at the same time there is a high reduction in the frequency of epizodes of diseases of upper mental health, VP, hospitalization of cases and deaths (category).

See the advance target groups for vaccination:

Individuals older than 50 years;

Individuals who live in booths with a tricky look for people who have been kidnapped;

Patients with chronic broncholegenic (including bronchial asthma) and heart-and-heart disease;

Doroslі, which look for permanent medical gaze and were on a stationary lіkuvannі in front of the drive of the metabolic

rozladiv (including diabetics), malady of nirok, hemoglobinopathies, immunodeficiency stans (including VIL-infection);

Women in the II and III trimesters of vaginosti.

Oscillations of vaccination of medical practitioners reduce the risk of a lethal result in the middle of patients as seen by the nurses, then it is shown before the date of the expansion to include such contingents as:

Physicians, nurses and staff of medical and outpatient facilities;

Athletes see a trivial look;

Family members (including and children) of individuals, which enter the group;

Medical practitioners, as they go to the house to look after the persons, to enter before the group. The optimal hour for vaccination

zhovten - persha half of leaf fall. Vaccination is carried out scrupulously, since the level of antibodies is reduced by a stretch of fate (category of proofs A).

XIX. MODE OF ADDING AMP FOR EMERGENCY THERAPY OF EP IN ADULT

Table 20. The dosage regimen of AMP in grown-up ailments VP Preparations Vseredin

Cefoperazone / sulbactam

amikacin

parenterally

Notes

natural penicillin

Benzylpenicillin - 2 million OD 4-6 times per dob

Benzylpenicillin procaine - 1.2 million OD 2 times for doba

aminopenicyliniv

Amoxicilin 0.5-1 g 3 times for doba - Independently from the reception

Ingibitor-proof peniciline

Amoxicilin / clavulanate 0.625 g 3 times for dobu or 1-2 g 2 times for dobu 1.2 g 3-4 times for dobu Pid hour

Ampicilin / sulbactam 1.5 g 3-4 times for dobu

Amoxicilin / sulbactam 1 g 3 times for dobu or 2 g 2 times for dobu 1.5 g 3 times for dobu

Ti carcillin / clavulanate - 3.2 g 3 times for dobu

Peperacylin / tazobactam - 4.5 g 3 times for dobu

Cephalosporin III generation

Cefotaxime - 1-2 g 2-3 times for doba

Ceftriaxone - 1-2 g 1 time per doba

Cephalosporin IV generation

1-2 g 2 times for doba

Ingibitoroprotection of cephalosporin

2-4 g 2 times for doba

carbapenemi

Imipenem - 0.5 g 3-4 times for doba

Meropenem - 0.5 g 3-4 times for doba

Ertapenem - 1 g 1 time for doba

macrolidi

Azithromicin 0.251 - 0.5 g 1 time for additional or 2 g once 2 0.5 g 1 time for additional 1 year before їzhі

Clarithromicin 0.5 g 2 times for dobou 0.5 g 2 times for dobu

Clarithromicin SR 1 g 1 time per additional hour

Dzhozamitsin 1 g 2 times for doba or 0.5 g 3 times for doba

Spiramitsin 3 million MO 2 times for additional 1.5 million MO 3 times for additional

linkozamidi

Clindamicin 0.3-0.45 g 4 times for dobu 0.3-0.9 g 3 times for dobu Do uzhi

early fluorochinoloni

Ciprofloxacin 0.5-0.75 g 2 times for doba 0.4 g 2 times for dobu Do uzhi. One-hour intake of antacids, drugs M ^, Ca, A1

Respiratory fluorochloroni

Levofloxacin 0.5 g 1 time per add 0.5 g 1 time per dob Nezalezhnaya vіd vіzhі. One-hour intake of antacids, drugs M ^, Ca, A1

Moxifloxacin 0.4 g once for dobu 0.4 g once for dobu

Hemifloxacin 320 mg 1 time per dose -

aminoglycosidi

15-20 mg / kg 1 time per doba

іnshі drugs

Rifampicin 0.3-0.45 g 2 times for doba 1 year before їzhі

Metronidazole 0.5 g 3 times for dobu 0.5 g 3 times for dobu Pislya uzhi

Linezolide 0.6 g 2 times for dob 0.6 g 2 times for dob

Note. 1 In the first place, a subdivision dose is indicated - 0.5 g; 2 lykarska form of azithromycin prolonged production.

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Rules for eliminating phlegm for cultural dosage

1. Slyzi get into yakomog more early terms from the moment of hospitalization and until the ear of ABT.

2. Before collecting sputum, it is necessary to clean the teeth, the inner surface of the shchik, and rinse the mouth with water.

3. Patients need to be instructed about the viscosity of a large slurry for rejecting instead of the lower ones, rather than the mouth or nasopharynx.

4. The sputum must be rotated in sterile containers, since they were delivered to the microbiological laboratory not even after 2 years or less from the moment the material was removed.

Dodatok 1

Rules for the rejection of blood for cultural education

1. For otrimannya hemoculture dotsіlno vikoristovuvati komertsіynі bottles with a life-giving middle.

2. A small amount of venipuncture is covered with a sprinkle of 70% ethyl alcohol, less than 1-2% iodine.

3. When the antiseptic from the skin veins is removed, not less than 10.0 ml of blood should be collected (optimal shelter / Seredovische is not guilty of 1: 5-1: 10). Miscellaneous venipuncture can be palpated by cleaning with an antiseptic.

4. Transporting facilities to laboratory health at room temperatures is inherently disregarded.

I. PORT Scale

ALGORITHM OF EVALUATION OF RISKS OF UNAFFICIENT RESULTS IN CAP

Dodatok 2

Вік> 50 rockіv?

Seryoznі sutnі ailing?

Visiting physical signs? (Div. Table 1)

balna assessment

demographic

supporter

get sick,

results

physical,

roentgenologic,

laboratory

rigidity

(<70 баллов)

(71-90 points)

(91-130 points)

(> 130 points)

INFEKTSIJNI HVOROBI: news, thoughts, news # 2 2013

Table 1. Balna assessment of factors in the risk of CAP

Bali parameter

demographic characteristics

Cholovik vik (rockiv)

Zhinka vik (rokiv) -10

Moving to a booth for young people / setting a tricky one + 10

Ailment

Malicious new solution + 30

Zagvoryuvannya stove + 20

Heart failure + 10

Cerebrovascular disease + 10

Zagvoryuvannya nirok + 10

physical signs

Damaged property + 20

Dikhannya frequency> 30 / hv + 20

systolic vise<90 мм рт.ст. + 20

temperature<35 °С или >40 ° C + 15

Pulse> 125 / hv + 10

Laboratory and X-ray data

arterial blood pH<7,35 + 30

Blood section> 10.7 mmol / l + 20

sodium blood<130 ммоль/л + 20

Blood glucose> 14 mmol / l + 10

hematocrit<30% + 10

PaO2<60 мм рт.ст. или Эа02 <90% + 10

Pleuralvipit + 10

Note. In the rubric "Malicious new affirmations" there are drops of plump ailments, screaming "active" plin or diagnosed with a stretch of the rest of the rock, including basal-clitinous or squamous cancer of the shkiri. In the rubric "Poisoning of the liver" there are signs of clinical and / or histological diagnosis of liver cirrhosis and chronic active hepatitis. In the rubric "congestive heart failure - CHF", there are cases of congestive heart failure in cases of systolic or diastolic dysfunction of the little one, documentation of anamnesis, physical condition, results of chest X-ray

In the heading "Cerebrovascular congestion", there are symptoms of actual insult, transient ischemic attacks, or CT documents, or MRI of the brain, excessive symptoms of the transferred hostile damage to the cerebral blood circulation. In the rubric "Inferiority nirok" there are indications of anamnestically susceptible chronic illnesses or an increase in the concentration of creatine / residual nitrogen in the blood. Just have a victorian calculator for a full scale of points available in Danish hours on the Internet (http://ursa.kcom.edu/CAPcalc/default.htm, http: // ncemi. Org, www.emedhomom.com/dbase.cfm) ...

Table 2. Classification and clinical profile of ailments with VP

Clas riziku I II III IV V

Number of points -<70 71-90 91-130 >130

Mortality,% 0.1-0.4 0.6-0.7 0.9-2.8 8.5-9.3 27-31.1

Mice lіkuvannya Outpatient Outpatient Short-hour hospital Hospital

II. Scale CURB / CRB-65

ALGORITHM OF ASSESSMENT for the risk of an unpleasant result I VIBORA MISTSYA LIKUVANNYA FOR EP (CURB-65 SCALE)

SSimptoms and signs:

Blood nitrogen> 7 mmol / l (Urea)

Respiratory rate> 30 / hv (Respiratory rate)

systolic AT< 90 или диастолическое АД < 60 мм рт.ст. (В1оос1 pressure)

У ^ »Вік> 65 rockіv (65) __ у

Group I (lethality 1.5%)

Group II (mortality rate 9.2%)

> 3 points \

Group III (mortality rate 22%)

Outpatient clinic

Hospitalization (shortly) or outpatient treatment by visual

Unavailable hospitalization

ALGORITHM OF ASSESSMENT for the risk of an unpleasant result I VIBORA MISTSYA LIKUVANNYA FOR EP (SCALA CRB-65)

f Symptoms and signs:

Confusion

Respiratory rate> 30 / hv (Respiratory rate)

systolic AT< 90 или диастолическое АД < 60 мм рт.ст. ^lood pressure)

Вік> 65 rockіv (65)

Group I (mortality 1.2%)

Outpatient clinic

Group II (mortality rate 8.15%)

Precautions and assessments in the hospital

> 3 points \

Group III (mortality rate 31%)

Unavailable hospitalization

III. Scale SMART-COP A. Parameters for assessment

Bali Indicator Value

S Systolic AT<90 мм рт.ст. 2

M multilobar information on radiographs of OGK 1

R Frequency of reaction> 25 / min at vіtsі<50 лет и >30 / хв у віці> 50 rockіv 1

T heart rate> 125 / min 1

C Loss of property 1

O Oxygenation: PaE02 *< 70 мм рт.ст. или Эр02 < 94% или Ра02/РЮ2 <333 в возрасте <50 лет Ра02* < 60 мм рт. ст. или Эр02 <90% или Ра02/РЮ2 <250 в возрасте >50 rock 2

P pH * arterial blood<7,35 2

B. Interpretation of SMART-COP

Bali Demanding in respiratory care and vasopressors

0-2 Low risik

3-4 Middle risik (1 of 8)

5-6 Visokiy Rizik (1 of 3)

> 7 V. Interpen Bal Duzhe visoky risik (2 of 3) SMRT-CO retation Respiratory requirements and vasopressors

0 Douzhe low rizik

1 Low Rizik (1 in 20)

2 Middle risik (1 in 10)

3 Visokiy Rizik (1 of 6)

> 4 Visoky Rizik (1 of 3)

Number of balls

Note. * - not evaluated in the SMRT-CO scale.

Supplement 3 Indicators of the quality of medical aid for CAP in hospitalized patients *

Indicator of quality

X-ray dosage of organs in the breast cancer with the presence of clinical signs of EP for 24 years from the moment of hospitalization (even if not on an outpatient basis) 100

Bacteriological dosage of phlegm before antibiotics 50

Bacteriologic blood loss to antibiotics for important VP 100

The introduction of the first dose of systemic AMP in the term< 4 ч (при септическом шоке <60 мин) с момента госпитализации 100

The relevance of the initial antibiotic therapy regimen to the national or based on local recommendations / therapy standards 90

Victory of frequent antibacterial therapy 80

Note. * - traditionally stagnant parameters for assessing the health of people who are ill (lethality, frequency of hospitalization in VRIT, triviality in hospitalization) are characterized by low sensitivity in case of VP, it is recommended that

supplement 4

List of international (non-patented) and patented (trade) names of the main antibacterial agents, which can be used for the treatment of VP (the preparations of the main virobnik are seen in bold)

Generic name (international non-patented name) Trade (patented) name

azithromicine Sumamed

Hemomycin

Zetamax ™ retard

Amoxicilin Flemoxin solutab

Khikontsil

Amoxicilin / clavulanate Augmentin

Amoxiclav

Flemoklav solutab

Amoxicilin / sulbactam Trifamox IBL

ampicilin Pentrexil

Ampicilin / sulbactam Unazin

Hemifloxacin fact

Josamitsin Vilprafen Solutab

doxycycline Vibramicin

Unidox solutab

Imipenem / Cilastatin Tienam

clarithromicin klacid

Klacid SR

Fromilid

Fromilid Uno

Clindamicin Dalatsin C

Klimitsin

levofloxacin Tavanik

linezolide Zyvox

Meropenem Meronem

metronidazole Prapori

Metrogyl

trichopolum

moxifloxacin avelox

Peperacylin / tazobactam tazocin

rifampicin rifadin

Benemitsin

Rimactan

spiramicin Rovamicin

Ticarcilin / clavulanate Tymentin

Cefepim Maxipim

Cefoperazone / Sulbactam Sulperazone

cefotaxime Claforan

Cefantral

ceftriaxone Rocefin

lendatsin

longacef

cefuroxime Zinacef

ciprofloxacin Tsiprobay

Cyprinol

erithromicin Grunamitsin

Erigeksal

Ertapenem Inwanz

Pneumonia, or igniting legends, is referred to as important ailments. Frequently there is a hospitalization in the hospital. Without adequate treatment, with such a diagnosis of ailments, you can be bothered.

Fired up legends can capture new people, and people who have been kidnapped. Some pathologies develop on aphids of GDVI, influenza, bronchitis - yak accelerated. Ale is often the case for a disease.

Pneumonia can be affected by bacteria, viruses and fungi. Frequently, it is protested violently, with swirling symptomatology and intoxication, however, the erasure of the disease also occurs.

Opportunities for an adequate diagnosis to lay down the prognosis for the health and life of the patient, the Russian Respiratory Association of the Russian Federation of National and Federal Clinical Recommendations for the diagnosis and therapy of ailments.

Russian respirator suspension

Russian respirator suspension is a professional medical organization, which includes pulmonologists. There are a number of suspensions in the largest countries - American Thoracic in the USA, British Thoracic and European Respiratory - in Europe.

One of the most significant establishments is the distribution of clinical recommendations from the same person who is ill. For the first time, such recommendations were published in 1995 - for the therapy of bronchial asthma, and sometimes for chronic obstructive ailments of the lungs.

They took the fate of many people in the pulmonology profile of the Russian Federation, and the editor-in-chief was Professor, Doctor of Medical Sciences, Academician of the RAMS Chuchalin A.G.

value

Pneumonia is the center of health care for the legacy of tissue, as it supervises the signs of infection in the lower spirits and is confirmed radiologically.

Prior to the characteristic symptoms, the legends are recorded:

• Likhomanku.
• Show intoxication (headball, blues, self-respect).
• Cough with phlegm, sometimes dry.
• Zadishku.
• Pain in the breasts.

When X-ray is taken, the sign will start in the display of information.

Існ кілька clasifikatsіy pneumonia. Oscillations of the pupil in a large number of cases do not appear in any way, it is accepted that the pathology is resolved by the person and in the way of verifying.

Pneumonia buvaє:

• Pozalikarnyanoyi, or home (create the most frequent).
• Hospital (internal, nosocomial). Protect yourself more importantly, give it a nasty taste.
• Aspirations. The qia form is often called the association of microbes.
• In people with important immunodeficiency (VIL, immunosuppressive therapy). Maє unfriendly prognosis.

Likar, whether it is a specialty of goiters, to suspect a diagnosis for the sukupnisty of characteristic symptoms and data of an objective condition. Prior to them, it should be mentioned:

• Shortening the percussion sound in the middle of the Infiltration.
• The appearance of vologic wheezing or crepitations.
• Bronchial dichannya in an atypical scene.

However, such a diagnosis can be deprived of a radiological diagnosis.

Sometimes it is possible to carry out an X-ray during the day. As soon as I look around, I’ll see the blight of the legends, we can talk about inaccurate, or unverified diagnosis.

As well, there are no active and radiological signs of pneumonia, the diagnosis is low. In addition, there are laboratory and laboratory methods of conditioning.

laboratory methods

If pneumonia is mild or moderately severe, and the patient is treated on an outpatient basis, then it is necessary to use the following analyzes:

• Zagalny blood analysis.
• Biochemistry of blood (type of transaminases, serum and creatine, electrolytes). Daniy analiz vikonuua on opportunity.

Laboratory diagnostics as a routine method is not carried out through lack of appreciation.

• At the hospitalization of a sick person in a hospital, if the patient is overwhelmed by the disease, he / she will receive the following:
• Microscopic examination of sputum smear, gram-sized.
• Seed phlegm for sensitivity to antibacterial drugs.
• Pre-treatment of hemocultures (venous blood).
• Viznachennya gas storage of blood. It is shown in case of important forms for nutritional supplementation about the need for SHVL.

Yaksho є vipit, a person who is sick should undergo a pleural puncture to clarify the diagnosis.

A slid of nobility, but in the use of pneumonia, non-drug methods (physiotherapy) are not effective, and they are underestimated. The winyat is only dyshalful gymnastics, but when singing, you see phlegm.

The basis of lіkuvannya zapannya legends - tse antibiotics. The drug is used to treat diseases of the clinical form of ailments.

So, outpatients with post-carnial pneumonia - according to the federal recommendations - are treated with oral antibiotics (tablets and capsules).

The drugs of the first row are the group penicilin (amoxicilin) ​​and macrolide (clarithromicin, azithromicin). Others are recognized in case of adolescence to the chlamydian etiology of illness, as well as in case of allergy to penicillin.

An alternative to cysts (in case of intolerance or ineffectiveness) is fluoroquinoloni (levofloxacin).

In young patients (over 60 years of age), as well as in the presence of concomitant pathology, therapy is repaired with aminopenicillins (amoxiclav) or cephalosporins (cefuroxime). An alternative for such ailments is also fluorohіnoloni.

Zahvoryuvannya, scho to make up for overbig pneumonia and lose the forecast, - tse:

• Sertseva's lack.
• Diabetes mellitus.
• Oncopathology.
• Physical viscosity, dystrophy.
• Alcoholism and drug addiction.
• Chronic liver and nirkov deficiency, liver cirrhosis.

Unimportant to pathology, pneumonia in such patients can also be carried out in tablet form.

Likuvannya of severe form of pneumonia

Important forms of pneumonia in the hospitalization of patients in the hospital for open and permanent likarsky look.

Antibacterial therapy in such a situation is carried out parenterally - it is administered intravenously. Name the combination "amoxiclav + macrolide" or "ceftriaxone + macrolide". Hiring antibiotics can change - it is a bad sign of a drug, but in accordance with the national recommendations, it is worthwhile to immediately introduce drugs to a group of penicillin and cephalosporins and macrolides.

If the clinical effect is reached, positive dynamics in 3-5 days, the patient can be transferred to the tablet form of the preparation.

efficiency criteria

The effectiveness of the treatment carried out when the legends are ignited, assess the third one for another. In the first place, I respect the following indicators:

• fever;
• intoxication;
• dikhannya.

The patient is guilty of lowering hyperthermia to subfebrile condition or to bring about new normalization. Symptoms of intoxication, with the correct treatment, change significantly, and the dysfunctional lack of day or night is weak.

In case of important forms of dynamism, do not expect such a fast, the protest is guilty of being positive until the end of the third dobi.

Even after 72 years, the polyphenia cannot be tested, the antibiotic therapy regimen is reduced. With adequate antibacterial treatment, the storage capacity is 7-10 days.

atypical pneumonia

Unimportant to those who have atypical pneumonia on the basis of є pozalikarnya, I won’t especially name the creators of my classy picture. For the general form of ailments, the following features are characteristic:

• Most often it is important for young children.
• The ear is similar to a chill or GDVI (undead, weakness, pain in the meat).
• Likhomanka is gone.
• The cough is dry.
• Dani percussion and auscultation of little information.
• At day-long leukocytosis in lateral blood analysis.

The change of pathology is great. However, most often there are microorganisms:

• Hlamіdії.
• Mycoplasmi.
• Legionella.

Therapy for atypical pneumonia

• Macrolide (erithromicin, clarithromicin, azithromicin).
• Tetracycline (doxycycline).
• Respiratory fluorochinoloni (levofloxacin).

With an easy form, it is permissible to repair the use of tablets or capsules, the protection of pneumonia in the form of antibiotics is permissible.

The criteria for the effectiveness of treatment are also the same as in case of acute pneumonia. The triviality of the drink will grow more and more in between 12-14 days.

Pozalikarnyana pneumonia in children

Filling up the legends of a childish child often tries to finish. The Russian Respiratory Association for Children with the Interregional Pediatric Respiratory Partnership and the Federation of Pediatricians of the Territory of the National Social Security and Social Development of the Russian Federation will have a lot of problems with some of the most important recommendations for young patients.

Diagnostics of the cycle of pathology in the history of the group of their own specialties. Foreign students do not care about the additional examination of X-rays to all children with advanced pneumonia, as only because of the health of the country the stench does not require hospitalization.

Solidarity with them і "The standard of primary medical and sanitary assistance", which is a buf of fragmentation and hardening in 2012.

However, on the thought of a large number of Russian experts, on the basis of a dose of legends - the price of writing for a radiography review, some unfortunate therapy is needed for more people, the dose of optimization is lower.

If the X-ray sign of the child is not informative, a computer tomography of the breast organs is recommended.

Vibir antibiotics for post-carnial pneumonia in children is caused by many factors. They are aware of the sensitiveness of a young child, a child, a sick person, in front of an antibacterial treatment.

In case of mild and moderate forms, the therapy is repaired with amoxicilin tablets. Dispersion of tablets is rendered overwhelming, in conjunction with greater and higher bioavailability.

Children with background pathologies, as well as those who have recently taken antibiotics, indications of amoxiclav or cephalosporin of another generation.

In case of important pneumonia, the leaks are introduced internally or internally.

As for the patients, there are signs of chlamydian or microplasmic pneumonia, therapy to do a good job of repairing macrolides.

The triviality of ailments in children can vary from 7 to 14 days in fallowness from the forest.

General information

Professional organization, which is the respiratory support of Russia, common doctors involved in the pulmonary profile. Reports from the diagnosis and treatment of pneumonia, which counter in the lower forms and from the gravity of the degree of severity of illness, formed the basis of the recommendations, which allow differentiated steps to go to:

• signs of diagnostics minimum;
• selection of the most effective antibacterial drugs;
• Accept the decision about the professionalism of treatment in stationary minds or on an outpatient basis.

Classification of pathology

Pneumonia is not uncommonly ill, with whom it is often necessary to take care of an important patient in the hospital, to be supervised by signs of intoxication, high temperature, intense weak cough, darkening. However, do not expect the ignition process to appear in the legends of the opposite in such a different form.

I’ll look at the form, I’ll show you becoming ill, breaking down criteria, and seeing the onset of the types of pathology:

1. Pozalikarnyana pneumonia. Vona f - non-hospital, home or outpatient. Price of most options extensions. Infected worms - spilkuvannya with noses of animals (pneumococci, staphylococci, trash and blue sticks). The form is given to ignite the legends of the enemy to the lower body.
2. Hospital (nosocomial or internal). Clinical signs of great variety, the likeness of the general hospitalization.
3. Aspiracyna. Zbudnik zvoryuvannya vistupaє kіlka vidіv bacterіy.

The classification also transmits the vision of the onset of the species, which is responsible for the localization of the pathological process:

• right-handed pneumonia;
• l_vostoronnya;
• bilateral.

For the growth of the ignition process, the onset of the type of pathology is seen:

• vognischeva pneumonia - to prevent a small amount of lung disease;
• segmental - є kіlka vognisch;
• totalitarian - zapalennya ohoplyuє everything is easier, or just two.

Behind the degree of the gravity of the classical picture, the legends of the light, medium and important form are inflamed.

As a matter of fact, the patient will be looking for individual tactics of treatment, such as allowance for outpatient treatment under continuous control of the doctor.

atypical pneumonia

Tsey przvodyvannya zhvoryuvannya be admitted to the postal category. The peculiarities of the clerical perebigu formed the basis of the name. Among the characteristic manifestations of ailments on the cob, symptoms are more likely to occur, the power of GDVI or extreme cold, - nezduzhannya, aches in the slopes, nasal congestion. Then there are some symptoms:

• chills;
• undead;
• unproductive cough;
• wheezing in legends is practically not audible;
• leukocytes appear in small forms;
• the main plants are mycoplasma, legionella, chlamydia.

• clarithromicin;
• erithromicine;
• azithromicine;
• doxycycline;
• Levofloxacin.

Give medicinal preparations effective in prototype ailing agents. The positive dynamism of the economy is encouraged to last for 24-48 years. However, the additional course of therapy should be 10 - 12 days.

Pozalikarnyana pneumonia in children

In general, the disease of a certain species is more often discouraged. Clinical signs of pathology are often seen as manifestations characteristic of patients with a kidney disease. Increased gratitude and wakefulness are characteristic of young children, as well as in vіkovychіtіvіtіvіtіvіstіt svіdomosti.

On top of that, all of the other symptoms (the stench of pretending food) in children appear to be more intensive and varied, which served as a guide for the development of classroom recommendations, so that there is a lack of problems.

The Russian expert will base its point of view on the grounding of the development of the rapid development from the unsettled treatment, the increased pressure on the child's body is more negative, the dose of optimization is not insignificant.

Especially respect comes to nourishing antibacterial therapy... It is recommended to use the following factors:

• the sensitiveness of the emerging animals to the singing number of antibiotics;
• vіk little patient;
• a presence in the anamnesis of a concomitant ailment;
• antibiotics taken earlier.

A high degree of fitness is subject to criteria for the effectiveness of pneumonia in children. The stench will transfer the onset of positive dynamics in the child's camp for 2-3 days of therapy and the residual weariness after 6-12 dB.

Federal retail outlets will transfer the picture to the eye and listen to the patient about the information about the next diagnostic procedures:

• X-ray for diagnostics confirmation;
• clinical blood supply;
• biochemical tests for the detection of transaminase, creatine, sechovine, electrolytes.

Such a minimum of samples is carried out with a slight interruption of the disease, admitting an outpatient course of therapy.

The development of the middle and important step of the lighting of the legends of the transfer to the hospitalization of the patient and the carrying out of more destructive diagnostics. Among them:

• sowing sputum for detecting the type of infection with sensitivity to antibiotics;
• microscopic smear (by gram);
• biochemistry of blood;
• CT scan of the breast;
• test for gas storage of blood.

The remainder of the test is carried out with an important form of the pathological camp.

The presence of pleural vipotus, which is supervised by ailing symptoms in the area of ​​the chest wall and backwardness, is shown before the puncture is carried out.

The results of the thoroughness become essential for the diagnosis, the possibility of an outpatient treatment or the need to conduct an emergency course in the minds of the stationary.

The fundamental principle of therapeutic action in the field of firing є storing antibacterial drugs for the treatment of a differentiated approach to infusion for different types of pathology, as well as special features and the patient's age:

1. Outpatient treatment for pneumonia transmission of antibiotics in the penicillin series in tablets or capsules. It is recommended to sign amoxicillin. When chlamydial fever is detected, or intolerance to penicilin, macrolide is indicated - Azithromycin or clarithromycin. The rate of effectiveness of therapy is allowed to be substituted for fluorochinoloni. A new drug from the group Levofloxacin.
2. An important change in the pathology of the old is shown to the obovascovogo treatment in stationary minds. The main recommendation is a combination of antibiotics of the penicilin series and macrolithics or cephalosporins. The drug should be injected internally. Vikoristovuyatsya offensive combinations: macrolide drug in a single drug with Amoxiclav or macrolide with Ceftriaxone.
3. Detection in patients over 60 years of age (diabetes, dystrophy, alcoholism, liver cirrhosis or lack of liver) As an alternative to the sign of fluoroquinolone preparation. Most of the severity of pathology, therapy is carried out with a pill course or injections of lykarsky zasobiv.
4. Clinical recommendations for pneumonia in children can also be used to administer antibiotics in tablets and capsules with a slight breakdown of ailments. Pneumonia of the middle and important form is shown before the administration of the internal or internal method of drug administration. Even in the anamnesis of the presence of antibiotics in advance, it is recommended to sign Amoxiclav or cephalosporin. Diagnostics of mycoplasma and clamid etiology of impairment of transmission of macrolide drugs.

Criteria for the effectiveness of therapy are based on declining clinical signs - laxity, fever, and signs of intoxication, stabilization of temperature indicators. With an adequate response, the positive dynamics are spontaneous in the first three days... The duration of the course is shown for a period of time until the scheme of the therapeutic course is changed.

Victimization of the vaccine in the meaning of the world of the effectiveness of therapy in outpatient and inpatient treatment of pneumonia.

In sprobі Know balance mіzh vіdpovіdalnim pіdhodom to antibakterіalnoї terapії that Bezpieczne i efektivnosti lіkuvannyam Pevnyi nozokomіalnih іnfektsіy, Nove kerіvnitstvo rekomenduє trivalіst rate lіkuvannya antibiotics is shown 7 dnіv i less then i for vnutrіshnolіkarnyanoї pnevmonії (CAP), i for fan-asotsіyovanoї pnevmonії (VAP), tobto, for both categories, such as poklikanі substitute for yourself a larger early zbіrny term "pneumonia, associated with medical aid." A new document issued by the American Society of Infectious Diseases (IDSA) and the American Thoracic Suspension (ATS), published online April 14, 2016. in Clinical Infectious Diseases. Win replaces the previous version of the certificate from 2005r. Another important aspect of the new recommendations is that I am glad to develop my antibiokogram for skin lesions. The price of local analysis of bacterial pneumonia is guilty, as it is seen on a small place of quiet illnesses, which are hanging in the form of intensive therapy, as well as antibiotics, diseases They explained the author of the document in the press release, as well as on a regular basis they read information about the VP and VAP in their installations, as well as about their sensitivity up to antibiotics, you can smell more. Antibiotics can also help you to indivisibly help you get sick and want the patient to get the right antibiotic at the earliest possible date.

A new document was developed by a multidisciplinary group of experts, who set before themselves the method of developing antibiotic resistance without risk for safety of patients and laid down at the same time on the data of new and new systematic problems. On the other hand, the results of recent publications did not become the basis for any specific recommendations from the new policy;

Taken at once, VP and VAP become 20-25% of internal carnial infections, and, according to estimates, 10-15% of such infections should be produced before the patient's death. As soon as it is seen in the category of okremos, VAP develops approximately in the tenth skin patient on the IVL, and 13% of these infections are fatal.

Uninvolved at the call of the zerosum, the progression to more aggressive treatment of these stanovies, the scientific data did not show that the more trivial courses of antibacterial therapy can be performed over the shorter courses. With a large triviality of antibiotic treatment, it is associated with a greater frequency of side effects, sprouting, diarrhea, more high risk of infection with Clostridium difficile, and the reduction of taints for the treatment of infection.

During the trip from the world, experts recommend 7-day antibiotic treatment for antibiotics, for VP, and for VAP, if you want to stink of hesitation, but there are situations, if therapy is shown to be more short or more antibiotic and laboratory parameters. Smell also recommend reducing the intensity of antimicrobial therapy for antibiotics with a wider spectrum to replace drugs with a wide range of drugs, as well as being a combination of monotherapy, and not a combination.

If you accept the decision about the possibility of using antibiotics in patients from the VP and VAP IDSA and ATS, I recommend to add to the main criteria, if you want to use the evidence, if you want to use the author's base, but not to show the testimonials on the clients

Our recommendations are to focus on non-invasive methods for diagnosing VAP, which provide clinical criteria for antibacterial therapy, as well as the empirical vibration of options for singing in singing. On the other hand, the evidence base in the base of the large number of these recommendations is also not overconfused.

In the case of antibiotics development, authorize the skin settings and also take decisions, as often antibiograms will be updated. At the same time, there is such a world as the speed of the microbiological situation, the resources are established and the amount of data available for analysis is established.

Nareshty, the specific recommendations for starting empirical antibacterial therapy have been updated. In the middle of the world, the risk of infection with methicillin-resistant strains of Staphylococcus aureus, the risk of mortality and evidence of antibiotics, and also In patients with pre-treated VAP in all schemes of empirical antibiotic therapy, it is recommended to hunt such animals, such as S. aureus, Pseudomonas aeruginosa and the lowest gram-negative microorganisms. In patients who have already been treated empirically from the drive of the VP, it is recommended to use drugs that are active S. aureus.

Uzgodzheni and consolidated by the Russian partnership of neonatologists on the submission of the results of collective discussion of the draft of the clinical recommendations.

Working group

Antonov Albert Grigorovich - Doctor of Medical Sciences, Professor, Chief Scientist of the Federal State Budgetary Institution "National Medical Pre-Old Center for Obstetrics, Gynecology and Perinatology. acad. V.I. Kulakov "Ministry of Health of Ukraine, Professor of the Department of Neonatology, Federal State Autonomous Educational Institution of Higher Education" First Moscow State Medical University IM. I.M. Sechenov "Ministry of Health of Russia

Baibarina Olena Mykolaivna - Doctor of Medical Sciences, Professor, Chief Scientist of the Federal State Budgetary Institution "National Medical Center for Obstetrics, Gynecology and Perinatology. acad. V.I. Kulakov "Ministry of Health of Russia, Moscow

Balashova Katerina Mykolaivna - Candidate of Medical Sciences, assistant in clinical robots in the field of reanimation and intensive therapy of the Federal State Budgetary Institution National Medical Prelude Center of Obstetrics, Gynecology and Perinatology. acad. V.I. Kulakov "Ministry of Health of Russia, Moscow

Degtyarov Dmitro Mikolayovich - Doctor of Medical Sciences, Professor, Patron of the Director of Science Robotics of the Federal State Budgetary Institution "National Medical Pre-Old Center for Obstetrics, Gynecology and Perinatology. acad. V.I. Kulakov "Ministry of Health of Ukraine, Head of the Department of Neonatology of the Federal State Autonomous Educational Institution of Higher Education" First Moscow State Medical University IM. I.M. Sechenov "Ministry of Health of Russia, head for the sake of the Russian Association of Neonatologists

Zubkov Viktor Vasilovich - Doctor of Medical Sciences, Head of the Department of Neonatology and Pediatrics of the Federal State Budgetary Institution "National Medical Center for Obstetrics, Gynecology and Perinatology. acad. V.I. Kulakov "Ministry of Health of Ukraine, Professor of the Department of Neonatology, Federal State Autonomous Educational Institution of Higher Education" First Moscow State Medical University IM. I.M. Sechenov "Ministry of Health of Russia, Moscow

Ivanov Dmitro Olegovich - Doctor of Medical Sciences, Professor, Head post-graduate Specialist of the Ministry of Health of Ukraine in Neonatology, Chief Executive Officer Rector of the Federal State Budgetary Educational Institution of Higher Education "St. Petersburg State Pediatric Medical University" of the Ministry of Health of Russia, member of the Russian Association of Fakhivts of Perinatal Medicine, St. Petersburg

Ioniv Oleg Vadimovich - PhD acad. V.I. Kulakov "Ministry of Health of Russia, Associate Professor of the Department of Neonatology, Federal State Autonomous Educational Institution of Higher Education" First Moscow State Medical University IM. I.M. Sechenov "Ministry of Health of Russia

Karpova Hanna Lvivna - Candidate of Medical Sciences, patron of the head physician in the family of the State Budgetary Healthcare Institution of the Kaluzka Region "Kaluzka Oblast Clinical Hospital - Perinatal Center", head neonatologist of the Kaluzka Oblast, Kaluga

Kirtbaya Anna Revazievna - Candidate of Medical Sciences, supervisor for clinical robots in the field of reanimation and intensive therapy of the Federal State Budgetary Institution National Medical Prelude Center of Obstetrics, Gynecology and Periodology. acad. V.I. Kulakov "Ministry of Health of Russia, Associate Professor of the Department of Neonatology, Federal State Autonomous Educational Institution of Higher Education" First Moscow State Medical University IM. I.M. Sechenov "Ministry of Health of Russia

Krokhina Ksenia Mykolaivna - Candidate of Medical Sciences, Senior Scientist in the Department of Reanimation and Intensive Therapy of the Federal State Budgetary Institution "National Medical Pre-Old Center of Obstetrics, Gynecology and Perinatology. acad. V.I. Kulakov "Ministry of Health of Russia, Moscow

Kryuchko Dar'ya Sergiyivna - Doctor of Medical Sciences, head of the Department of Medical Analysis and Coordination of Robotics, Associate Professor of the Department of Obstetrics, Gynecology, Neonatology, Anesthesiology and Reanimatology acad. V.I. Kulakov "Ministry of Health of Russia, Moscow

Lenyushkina Anna Oleksiyivna - Candidate of Medical Sciences, supervisor for clinical robots in reanimation and intensive therapy of the Federal State Budgetary Institution "National Medical Prelude Center of Obstetrics, Gynecology and Periodology. acad. V.I. Kulakov "Ministry of Health of Russia, Moscow

Chi Oleksandr Georgiyovich - physician-reanimatologist, head of the department of reanimation and intensive therapy of newborns in the perinatal center of the St. Petersburg State Pediatric Russian Medical University

Malyutina Lyudmila V'yacheslavivna - PhD

Mebelova Inesa Isakivna - candidate of medical sciences, head of the neonatal center of the State Budgetary Healthcare Institution "Child of the Republic of Karelia", head post-graduate neonatologist of the Republic of Karelia, Petrozavodsk

Nikitina Iryna Volodymyrivna - Candidate of Medical Sciences, Senior Scientist in the Department of Reanimation and Intensive Therapy of the Federal State Budgetary Institution "National Medical Prelude Center of Obstetrics, Logic and Perinatology. acad. V.I. Kulakov »Russia, Moscow

Petrenko Yuriy V. - Head neonatologist Pіvnіchno-Zahіdnogo Federal District Russie, Vice-Rector of lіkuvalnoї robot FGBOU IN "St. Peterburzky Reigning pedіatrichny medichny unіversitet" Ministry of Health Russie Rindіn Andriy Yuevіch - Candidate medichnih Sciences, Senior NAUKOVO spіvrobіtnik vіddіlennya reanіmatsії that іntensivnoї terapії FGBU "Natsіonalny medichny old center for obstetrics, gynecology and perinatology im. acad. V.I. Kulakov "Ministry of Health of Russia, Associate Professor of the Department of Neonatology, Federal State Autonomous Educational Institution of Higher Education" First Moscow State Medical University IM. I.M. Sechenov "Ministry of Health of Russia

Ryumina Iryna Ivanivna - Doctor of Medical Sciences, a doctor of pathology for newborns and premature babies of the Federal State Budgetary Institution National Medical Center for Obstetrics, Gynecology and Perinatology. acad. V.I. Kulakov "Ministry of Health of Ukraine, Professor of the Department of Neonatology, Federal State Autonomous Educational Institution of Higher Education" First Moscow State Medical University IM. I.M. Sechenov "Ministry of Health of Russia

Romanenko Vladislav Oleksandrovich - Doctor of Medical Sciences, Professor of the Department of Pediatrics and the Institute of Advanced Professional Education of the Federal State Budgetary Educational Institution of Higher Education "Pivdenno-Ural State Medical University" of the Ministry of Health of Russia, Chelyabinsk

fast

ABT - antibacterial therapy

BPD - bronchogenic dysplasia

BP - waterless prom_zhok

VAP - ventilator-associated pneumonia

VSHK - internal slugs of blood

VCHOV - high-frequency oscillatory ventilation of the legends

SHVL - piece ventilation of legends

ІМП - infection of the secular nobles

KOS - acid-tin mill

CTG - fetal cardiotocogram

НІ - neutrophilic index

NSG - neurosonography

UAC - blood analysis

OAM - the out-of-the-box analysis of the sech

ONMT - duzhe low masa tila

ORITN - introduction of reanimation, intensive therapy

new marijuana

ORS - display reanimation system

PIT - intensive therapy ward

PCT - procalcitonin test

ignited)

RDS - Respiratory Distress Syndrome

РСІ - randomized controls not available

SRB - S-reactive block

GBS - streptococcus group B

PLR - polymerase lantsyugov reaction

EKG - electrocardiography

ЕНМТ - extremely low masa tila

EchoKG - echocardiography

INSURE (INtubate-SURfactant - Extubate) - intubation-

the introduction of a surfactant - extubation and transfer to

non-invasive respiratory therapy

Fi02 - fraction of sourness at inhaling gas sum

Peep - a peak vise in kintsi vidihu

Pip - Pikovy vise on the inhale

SpO2 - saturation, blood saturation,

use the pulse oximeter method

CO2 - partial spill in carbon dioxide

CPAP (continuous positive airway pressure) - continuously

positive grip in the bizarre way

1. Short information

1.1. value

Progeny pneumonia is a condition of infectious disease due to significant respiratory diseases in cases of accumulation of ignition exudates in the middle of the alveoli, which appear when there is an active and permanent radiological condition.

1.2. Ethiology and pathogenesis

The cause of congenital pneumonia є intrauterine or intrapartum fetal infection by microorganisms of the developmental etiology transplacental,

do not walk with a contact path. Infections of congenital pneumonia:

bacteria Escherichia coli, Enterobacter aerogenes, Klebsiella spp., Pseudomonas aeruginosa, Group B Streptococcus, Staphylococcus epidermidis, Staphylococcus aureus, Haemophilus influenza, Klebsiella pneumoniae, Pneumococcus;

atypical pathogens: Chlamydia trachomatis, Urea-plasm aurealyticum, Mycoplasma hominis, Mycoplasma pneumoniae, Listeria monocytogenes, Treponema pallidum, Mycobacterium tuberculosis;

viruses: Herpes simplex virus, Cytommegalovirus (CMV), Respiratory syncytial virus, Rubella; fungi: Candida spp.

Pathogenesis and pathological anatomy

A great role is played in the development of congenital pneumonia, infection and ignition of organs of the slaughter and state of the mother's systems (polyonephritis, Chorio-nionitis, endometritis, etc.); gestational maturity of the fetus, the body of the surfactant system and the broncho-lung apparatus, malformations of the bronchial tree, intrauterine hypoxia was transferred, asphyxia in the canopy, aspiration of meconium and accumulation of water. Prematurity, respiratory distress syndrome (RDS), impaired heart-lung adaptation, fetal hypoxia develop the development of the infectious process in the way of functional, morphological and immunological tissue of the lungs.

Possibility to develop in cases of hematogenous infestation of the pediatrician in the last few days, because of poor vaginosity, or as a result of the diagnosis of lesions, within an hour I will enter before them in the presence of flooded waters (infections with endometritis, etc.) In all vypadki there is a double lesion (like alveoli, as well as interstitium). These changes will increase the amount of evidence for folk hypercapenia, hypoxemia, low acidosis and hypoxia, degrading the synthesis of sur-factant, and the appearance of atelectases, parenchymal obstruction As a result of progressive hypoxia, acidosis and deterioration of microcirculation, polyorganic deficiencies develop even more quickly (a handful of heart-legeneva, sometimes - of other organs).

The X-ray picture of pneumonia is caused by the type of infiltration of tissue and stage of inflammation.

Type of information:

■ the alveolar type of infiltration is suppressed when the air-supply-services of the alveoli are filled with an ignition exudate (deflation, consolidation of space);

■ Interstitial type of infiltration - to be spared in case of interstitial spaces filled with exudate, in case of a large alveoli, to avenge it (a symptom of "dull slope").

stage fired

I. Stage of infiltration (1st stage of ailment). Darkening of the leg tissue without clear contours and between, as a rule, is localized in the peripheral segments of the segments and often. In singing dilyankas, the darkening can be surrounded by intersegmental or interlobar partitions; in the summery segments, reactions to the interstitium appear.

II. Stage of rosmoktuvannya (2nd stage of ailment). The triviality and intensity of the inflammation can change, there is a possibility of the reduction of the partial reduction and the development of the disease in the period of small size in the case of the diseases of the lung tissue of the acute pneumonia.

III. The stage of interstitial changes (end of the 2nd ear of the 3rd generation). Infiltrative changes are absent

everyday and interstitial changes occur at the stage of infiltration in the eyes of peribronchial changes, frequent deformity of the lung baby, severity.

1.3. Epidemiology

The incidence of pneumonia in the middle of full-term newborns, with literary dzherel, becomes close to 1%, premature babies - close to 10%. Mortality with congenital pneumonia becomes 5-10%.

According to the official statistics, in the Russian Federation in 2015, pneumonia was diagnosed in 0.98% of preterm newborns with males of weight in the case of 1000 g and more or 20.77% of new newborns from 500 to 9 years of age. , 66%, premature babies born with a body weight of 1000 g or more, - 2.3%, children born with an extremely low body weight, - 11.8% (form No. 32).

1.4. Cody for MCX 10 Vrodzhena pneumonia (P23): P23.0 Virusna vrodzhena pneumonia

P23.1 Progenitus pneumonia, wiclikana with trash P23.2 Progenitus pneumonia, wiklicana with staphylococci

P23.3 Vrodzhena pneumonia, viclican streptococcus group B

P23.4 Congenital pneumonia, intestinal viclikana (Escherichia coli)

P23.5 Progenit pneumonia, Pseudomonas viclican P23.6 Pseudomonas pathogen, viclican other bacterial agents: Haemophilus influenzae, Klebsiella, Mycoplasma, streptococcus, behind a vignette of group B

P23.8 Congenital pneumonia, viclikana and other diseases

P23.9 Congenital pneumonia, unspecified For congenital pneumonia, infections with rubella virus, herpes simplex type II, cytomegalovirus (CMV), and may also be a manifestation of congenital bacterial sepsis, congenital tuberculitis, congenital tuberculosis Infectious diseases (P35 - div. "Infections"). Pneumonia is a symptom of early congenital syphilis and is restructuring under the code A50.

The term “neonatal pneumonia” is more ominous and common (P23), aspirating (P24) and addictions, including nosocomial pneumonia. Remaining, according to the ICD-10, be classified according to the ethological principle; for the їх statistical domain, the code must be assigned to the letters "J" (class X "Ailments of organisms dichannya").

1.5. CLINIC CLASSIFICATION

Neonatal pneumonia are classified (Table 1) by the offensive rank:

■ for an hour the examination: intrauterine (vrodzhena, yaka manifested itself in the first 72 years of life) and neonatal (early and early);

Table 1. Classification of neonatal pneumonia (Sotnikova K.A., 1985)

Period of examination Ethiology Type Severity Excess

Intrauterine Viruses. Bronchopneumonia: Easy. Gostre.

(Vrodzheni). Microbial. - dibnovognischevі; Medium-Subacute.

(Pridbani): Mycoplasma. - zlivni; Vazhka - without interruption;

Early, Fungi. - mono- - і from sharpened і relapses.

Piznі Zmіshanі and polysegmental; - Interstitial Without acceleration. With accelerated disease (otitis media, pneumothorax, pleurisy, etc.)

■ for a wider process: vognischeva, segmental, chastkovo, one-sided, two-sided;

■ by the severity of the process: light, medium-heavy, heavy;

■ over the course of: gostra, pidgostra, protracted.

1.6. key picture

Early clinical symptoms of congenital pneumonia, nonspecific:

■ dilemma (tachypnea in 60 and dormancy, retraction of midcostal spaces і / abbreviated sternum, inspiratory retraction of the jugular ridge over the breastbone, swelling of the crill of the nose, pint of vision from the mouth). These clinical signs of nonspecific and can be spontaneous in the case of other pathological camps, in case of critical diseases of the heart (CHD). Using the method of differential diagnostics and the inclusion of CHD, it is necessary to carry out a hyperoxic test, to measure the arterial vise on the lower and upper symptoms, echocardiography (EchoKG), blood pressure pre- and postnatal;

■ foreign signs of ailments and signs of infectious toxicosis: malaise, malignancy, hypotonia / dystonia, “marmoriness” and syrian coloration of a child, a likelihood of a child from perioral hypotension / malaise a decrease in the visibility of a wet reflex, a decrease in the appearance of an abdominal reflex, a deterioration in thermoregulation (like a hyperthermia, as well as an increase in the ability to dissipate heat), the appearance of an early recovery (without a risk of development)

■ physical signs:

with auscultation of legends - weakened abnormalities, localized wheezing and cre-Pitirim wheezing, with illnesses in the head, bronchial dysfunctions may become lingering. With a weakened dichanna, wheezing may not hang;

with percussion of the breast tissue - dulling of the percussion sound over the projection of the infiltration of the legacy tissue.

All descriptions of clinical manifestations of nonspecific

wan dichnoy systems, therefore in diagnostics of great importance may be a factor in the risk of infectious process, radiological and laboratory conditions.

2. Diagnostics

2.1. anamnesis

Evidence of factors in the risk from the side of the mother and child:

■ the manifestation of hospitality of infection at the mother or acute chronic illness;

■ colonization of the birth canal of the mother with streptococcus group B (GBS);

■ front canopy (<37 нед гестации);

■ pre-development of water-free waters (waterless production> 18 years old);

■ adjusting the temperature of the mother before the hour of falling> 38 ° С;

■ bacteriuria in a mother before an hour of given vaginosity;

■ chorioamnionitis;

■ destruction of cardiotocograms (CTG) of the fetus;

■ preterm baby, small in population;

■ Invasive procedures for the hour of vaginosti;

■ inadequate antibacterial therapy (ABT);

■ surgical treatment of the new-born fetus;

■ Insufficient access to infection control in sexual and neonatal monitoring.

2.2. physical condition

When looking around the animals, the temperature is unstable (> 38.5 or<36 °С); снижение насыщения крови кислородом; тахипноэ >60 / xv abo epizodi apnoe; expiratory stohin; retracting of pliable breast plates; the weakening of the dichotomy, the appearance of raspy rattles in the legends, the blasphemy, the whiteness, the “marmoriness” and siruvatie appearance of the barbling of the shkiri, the appearance of the dark; drowsiness for a neurological condition; swelling of the abdomen; undeveloped їzhі; tachycardia> 180 in chilin, deafness of heart tones; a decrease in the effectiveness of the respiratory therapy, and to bring in this number until the improvement of the parameters in the unit ventilation of the lungs (SHVL); Possibly gn_yny vmest in the trachea.

2.3. instrumental provision

Comments. X-ray picture to lie

from the phase and the gravity of the disease. Diffuse decrease in the progression of legeny fields, retinulogranular babies and females educated in the area of ​​the root of the legion (bronchogram) nonspecific and may appear not only with congenital pneumonia in case of severe pneumonia, ale and nonspecific

2.4. Laboratory diagnostics

■ Bacteriological posivi (in the place of sleep, aspirate from the trachea, feces, according to the possibility of shelter and in.)

Comments. The value of the CRP level and the clinical blood analysis should be repeated thoroughly after 48 years, so that in the first place I will add the child's life to the diagnosis of vistavity important. RDS is characterized by negative markers of heating and a negative result of microbiological prescription of blood. Development of CRP * є early acquaintance with bacterial infections in full-term children, so that the regularity of their concentration in the blood of premature children is not apparent and there is no evidence of infection in them.

■ Out-of-pocket clinical analysis of blood.

■ It is recommended to carry out PLR of blood in the mode of real hour per gram +, gramflora, TZhN-infection, viruses, atypical diseases and fungi in the development of trivial treatment of the mother on stationary treatment, anti-inflammatory course of the given vaginal fever in the mother of implanted organs or attachments (piece valves), as well as in the different factors in the development of infection in the mother.

Comments. Conducting the PLR ​​of the blood to lay down from the technical capabilities of the laboratory.

Comments. The value of blood lactate is due to the manifestation and technical capabilities of express laboratory.

Comments. Metaanalysis of 22 randomized dosages showed that PCT is more sensitive in diagnosing nosocomial infections, and not in genitalia. Additions of PCT in syrovattsi blood on the 7th additional ABT indicate the need for further antibiotic therapy. The value of PCT is not a binding test in neonatal women;

2.5. Criteria for diagnostics of congenital pneumonia

There are 2 groups of criteria to be used to confirm the diagnosis: basic and additional. Diagnosis of congenital pneumonia can be confirmed, if the main or 3 (or more) additional diagnostic signs are revealed.

The main criterion for diagnostics of congenital pneumonia

■ The presence of infiltrative shadows on the roentgenograms of the legends (in the first 3 add life).

Comments. Radiologic symptoms of congenital pneumonia do not require the necessary specificity and are variable, so it is practically uncomfortable for them to get rid of the plugging process without taking into account the factors of the ignition process. In a large number of types, there is a twofold increase in the lung tissue, as a rule, in the visual picture of the lungs - Vipit can be seen in the pleural empty spaces. The wrinkles of the legacy tissue in the absence of pleural vomit allow, with a great immorality, to allow the manifestation of bacterial pneumonia, not just any cause of dyshalal damage, especially as a serious factor.

In the hallmarks of the legacy fabric, as a rule, you will pick up the decal of the parcel. Virazhene gorodnennya, surrounded by one, okremo taken in a small part, occasionally grows out of new people.

Additional diagnostic criteria for congenital pneumonia

Table. 2 images of foreign signs for diagnostics of sepsis and pneumonia in newborns

* The upper limit of the normative value of CRP is determined by the vicious method and the type of analyzer. NEONATOLOGIYA: news, thoughts, news # 4 2017

Table 2. Clinical and laboratory signs of overcoming the infectious process in children from the post-conceptual age less than 44 years old

Clinical signs of infection

The temperature is changed

Heat temperature less than 36 ° С or below 38.5 ° С (hyperthermia) I / ABO

Temperature instability

Show heart failure

Bradycardia (heart rate is average less than the 10th percentile for the given period for the duration of therapy with B-blockers or for CHD)

Tachycardia (heart rate is average at 180 per day for the daytime stimuli, trivial lykarsky and large podraznikiv);

Інші broken rhythm;

Arterial hypotension (middle arterial vise less than the 5th percentile for gestational cure);

"Marmurovist" of shkirny curves;

Centralization of blood circulation with impaired perfusion of the shkiri (a symptom of "white blood" for more than 3 seconds)

respiratory failure

epizodi apnea

epizodi tachypnoe

Consume growth in sour;

The need for respiratory care

Show a nirk deficiency

Decrease in dyuresis less than 0.5 ml / kg per year in 1 dobu life, less than 1 ml / kg per year in people older than 1 dobu life

Children of the school and children

Syrian flavor of shkirnykh curves;

sclerem

Show on the side of the intestinal tract

Visibility of food consumption; swelling of the abdomen;

weakening or visibility of peristalsis during auscultation

neurological manifest

blasphemy;

hypotonia;

hypersthesis;

gratitude;

sudominal syndrome

Manifest hemorrhagic syndrome

Petechial visip; shlunkov bleeding; Legeneva bleeding; macrohematuria; bleeding from mice

Інші show the Evidence of birth in the pleural flaps for 1 dib life; early vinikla zhovtyanitsya;

hepatomegaly (in children> 1500 g in populations - more than 2.5 cm in the midclavicular line and more than 2 cm in children<1500 г), спленомегалия (в отсутствие признаков гемолитической болезни новорожденных); наличие других гнойно-воспалительных очагов у ребенка в первые 3 сут жизни

Leukopenia less than 5 * 109 / l ABO

Leukocytosis in 1-2 days of life is more than 30 * 109 / l; in 3-7-th add life more than 20 * 109 / l

The end of the table. 2

Laboratory signs of an infectious process

Absolute number of neutrophils

Neutrophilosis is more than 20 * 109 / l in the 1-2th additional life; more than 7 * 109 / l for 3 dib life;

neutropenia

Vіk, h Neutropenia with mass> 1500 g, cells / μL Vіk, h Neutropenia with mass> 1500 g<1500 г, кл/мкл

0-6 <2000 0-6 <500

>6-12 <4000 >6-12 <1500

>12-24 <6000 >12-30 <1800

>24-48 <4000 >30-48 <1500

>48-72 <2000 >48 <1100

Placement of a part of young forms to a foreign number of neutrophils (neutrophil index)

More than 0.2.

Specific features of the morphology of neutrophils

Toxic graininess;

vacuolization;

The appearance of a small part (basophilic dialects in the cytoplasm)

thrombocytopenia

Mensh 1.5x1011 / l

Adjustment of markers for marking

Adjustments of the level of the C-reactive cell in the blood (the upper limit of the normative value of CRP is determined by the vicorist method and the type of analyzer).

metabolic acidosis

Syrovat lactate ponad 2 mmol / l

placenta preschool

Such changes in the placenta, such as deciduity, function, and infiltration of tissues, can, by and by, lead to the implementation of an infectious process in a newborn and an additional factor when establishing a diagnosis of pneumonia.

Chest x-ray

Strengthening the bronchovascular baby;

Dilution of the little one for the coarse / granular structure, especially on radiographs in times of the previous day with a deficiency of surfactant I / ABO

Local decrease in the progression of the legacy fabric due to the increase in the lightness of the rear in the process of the modification of the legacy fabric

Epizodi of intolerance to glucose, registered as a minimum of two (in case of emergence of rapidity, appropriate glucose)

■ Hypoglycemia less than 2.6 mmol / l;

■ hyperglycemia more than 10 mmol / l

Firing changes in clinical analysis Leukocyturia at 10-15 in the field in the field of bacteriuria and proteinuria (instead of a bottle more than 0.2 mg / l) - at age 48

additional additional diagnostic criteria for congenital pneumonia. About the transfer of the child's infectious process to the presence of at least two clinical and one laboratory signs.

2.6. Differential diagnosis

■ Transient tachypne neonargenic;

■ early neonatal sepsis;

■ syndrome of meconial aspirations;

■ іnshі types of aspіratsії (navkolіdnyh waters, blood, milk);

■ twist syndrome;

■ persistent neonatal hypertension;

■ growth of legends (cystic adenomatosis, aplasia, hypoplasia legen and іn.);

■ incontinence diaphragmatic hernia;

■ defect of the heart;

■ інші reasons for the development of spinal depressions of postgeneous genesis.

3. Likuvannya congenital pneumonia

3.1. conservatively

Lіkuvannya vrodzhenoї pneumonia guilty turn on come, straightened one hour behind a few straight lines.

■ Ethiotropic therapy - injecting without the need for an infectious agent - an anemic disease.

■ Pathogenetic therapy - correction of changes in homeostasis and manifestations of multiple organ deficiencies.

■ Symptomatic therapy.

3.2. Ethiotropic therapy

Antibacterial therapy (ABT) is the main element of congenital pneumonia therapy.

■ ABT for adolescence for the implementation of congenital pneumonia is shown to be in the early years of the population with such categories of children with mental disabilities: from the even low mass of death during the people (ONMT), the people are extremely vimagali conduction of SWL. It is important to repair the ABT for at least 2 years of life, we are new to the ENMT - in the canopy hall. The first time the drug is introduced into the starting scheme, it will work immediately.

■ ABT, if there is evidence of evidence of the results of the primary clinical and laboratory examination. Until this category, patients should be admitted for 1500 g when they were born, but they were not dysfunctional, but they didn’t want to carry out the traditional CPL, as well as to be on noninvasive mental therapy (spontaneous mental illness).

■ ABT, distributing for adolescence in Pershu to add life, skating when there are clinical laboratory and instrumental donations, so that you can endure overcoming pneumonia during 72 years of life.

■ If an accurate diagnosis of pneumonia is evident, the ABT scheme is 3 days (minimum course of ABT in case of congenital pneumonia), at the same time clinical and laboratory testing is carried out with the control of markers.

During normalization of the markers, the blood test (CLA) of ABT is skewed.

Schemes for starting ABT [add-on G].

■ Scheme A: storage of empirical ABT - combination of drugs in ampicilin + gentamicin.

■ Scheme B: transmission of antibacterial therapy to neonatal genes, in mothers of those who are susceptible to flora, resistant to drugs in an empiric ABT regimen. Dozіlno vikoristovuvati stolen penіtsilіni.

■ Comments. Perevaga is considered parenteral administration of antibiotics (internal administration). It is not recommended to prescribe a drug that reveals amoxicilin and clavulanic acid in conjunction with an unpleasant infusion of acid on the intestinal wall, especially in premature newborns. Insufficiently included in the starting scheme of antibacterial therapy is the substitution of cephalosporins, which are synthetically peniciline, through the activity rate of Listeria monocitogene.

ratam. At the time of the sensitivity of the visionary drugs before the preparations in the starting scheme, it is necessary to change the antimicrobial drugs, until the sensitivity is revealed.

The triviality and tactics of antibacterial therapy begin to develop into a skin disorder individually and lie down as a child and normalization of clinical and laboratory data.

3.3. Pathogenetically primed intensive therapy

In connection with this, immaturity and prematurity will develop pneumonia, manifest in the first year, and to add a life of nonspecific, in the context of therapy, it is practically impossible to be aware of the principle of such a birth. Clinical recommendations "Respiratory distress syndrome" 2017].

Comments. Div. Methodical sheet of the Ministry of Health of Russia "First and foremost and reanimation of additional assistance to newborn children" dated 21.04.2010 No. 15-4 / 10 / 2-320.

Comments. Clamping and retching of the umbilical cord after 60 seconds for the population in premature newborns with VLBW and EHMT to significantly reduce the frequency of necrotic enterocolitis, intraventricular bleeding (VZhK0, sepsis, hemorrhage.

Comments. Respiratory therapy is key directly in the treatment of mental disorders in newborns, including children with congenital pneumonia. Vona is guilty of such a zavdannya: reaching and adjusting adequate gas exchange and alveolar ventilation, minimizing the risk of ventilator-associative performance; On the current day, a number of new methods of respiratory therapy for newborns have appeared, including in the canopy hall. When carrying out the SWL, it is seen that the ventilation is under control of the amount of air, some of the strategy is sufficient for an adequate and permanent dichotomy, as well as dysfunctional ventilation with a low grip in the damp way. An early ear of respiratory therapy allows speed and triviality, intermingled with soft ventilation parameters.

In case of ineffectiveness of CPAP and SHVL using a mask.

Comments. ShVL in premature infants is carried out with sparing for CPAP bradycardia or for trivial

(More than 5 min) during the day of self-contained dichotomy. Carrying out an invasive SHL in the canopy before the control of the mental volume in deeply premature patients is a promising technology, which allows minimizing SHL-assisted legends.

In the canopy hall, with the provision of first and foremost and reanimation, help new people.

Comments. Div. Methodical sheet of the Ministry of Health of Russia "First and foremost and reanimation of additional assistance to newborn children" dated 21.04.2010 No. 15-4 / 10 / 2-3204.

Premature babies

are shown directly from the mastilla at the time of the people.

Comments. Div. Methodical sheet of the Ministry of Health of Russia "First and foremost and reanimation of assistance to newborn children" dated April 21, 2010 No. 15-4 / 10 / 2-3204 and Clinical recommendations "Respiratory distress syndrome" 2017.

Surfactant can be found in preterm neonatal infants with RDS, accelerated congenital pneumonia, or the need for additional dose or the multiplicity of its introduction.

Comments. Div. Methodical sheet of the Ministry of Health of Russia "First and foremost and reanimation of assistance to new children" dated April 21, 2010, No. 15-4 / 10 / 2-3204 and Klinichny recommendations. Respiratory Distress Syndrome 2017.

Comments. Shown before SHVL is also important to me: shock, sudominal status, bleeding from the leg. It is necessary to minimize the triviality of invasive medical training. If possible, it is necessary to carry out the SHL with the control of the mental volume, which will speed up the triviality and allow to reduce the frequency of such acceleration, such as bronchogenic dysplasia and IDV. Obov'yazkovuyu mind for a successful vikorstannya given type of mental therapy in newborns є the ability to regularly monitor the gas storage of blood. Routine sedation and analgesia is not recommended for all children on the IVL.

The ineffectiveness of the traditional SHVL is shown for transferring to high-frequency oscillatory ventilation of the legends (VCHOV). When VCHOV for the stabilization of the stabilization of the alveoli, there is a change in atelectasis, an increase in the area of ​​gas exchange and the improvement of the lung blood flow. As a result of correctly carried out therapy of the age,

new adequate ventilation-perfusion control, to produce up to full gas exchange in the legends.

The main principles of infusion therapy:

■ development of the volume of birth and parenteral feeding from physiological needs and pathological inputs;

■ The infusion program is based on the urahuvannya of individual features of the postnatal maturity of the function of nirok;

■ the need for conducting clinical and laboratory control of the water-electrolyte balance for the assessment of its infusion programs;

■ In case of impairment of peripheral and / or central hemodynamics, the sign of cardiotonic drugs is shown.

3.4. symptomatic therapy

Symptomatic therapy is based on respect for the establishment of optimal minds for new people.

■ Regardless of the severity of the state of neonatal diseases due to adolescence for congenital pneumonia, it is the responsibility of the transfers at the clinic of reanimation and intensive therapy of new women, the ward of intensive pathological therapy (PIT).

■ Children are shown to move in the minds of the microclimate of the incubator, to interfere with sensory stimulation (suppression of light, noise, dots), control of the temperature in the presence of thermoregulation, postural prophylactic syndrome, pain

■ In case of hemorrhagic disorders, antihemorrhagic therapy is used.

■ As soon as possible, the earliest ear of enteral feeding, transfer of breast milk.

4. Rehabilitation

In full-term children, who have suffered congenital pneumonia, the prognosis is distant, which, as a rule, is friendly. In deeply premature babies, there is a development of bronchopulmonary dysplasia. The development of hospital infection in the minds of the ORITN has lost the result and the forecast of the main disease.

5. Prevention and dispensary caution

Prophylaxis of congenital pneumonia in polygons in the course of time and illness of infectious diseases in mothers before the hour of vaginosity.

It is necessary to take the sanitary-epidemiological regime into a gentle booth, which is provided for newborns and premature babies.

For a child of an early age, as they suffered pneumonia, there was a lot of caution. It is necessary to maximize the transfer of the child to the fresh, povnotsinne harchuvannya, physical culture (exercise therapy), massage, garment procedures.

Criteria for assessing the quality of medical aid

The name of the group is pneumonia.

Code for MKH-10: P23.

Type of medical aid: specialized, including high-tech.

Vikova group: children.

Take care of the medical assistance: stationary.

Medical aid form: ekstrina.

Criterion of quality

The assessment of the degree of severity of dyshalny damages according to the scales So / Ні

Viconana pulse oximetry with heart rate monitoring very fast at the moment of detection So / Ні

dyshalnye damage (for obviousness in the canopy hall)

There is a donation of nutritious and sour summery, і / or non-invasive piece ventilation So / Ні

lungs, і / abo traditional SHVL, і / abo VCHOV (in the presence of medical indications)

Viconano monitors life and important functions

hemoglobin acidic, frequency of sertsebitty, arterial vise, dyuresis)

Viconano of the level of acid-puddle stagnation and blood gas (pH, PaCO2, Pa02, BE, So / Hi

lactate - with mobility)

Viconano (clinical) blood analysis (OAC), CRP and microbiological pre-diagnosed blood So / Ні

(With technical capability) no more than 24 years from the time of the appearance of mental breakdowns

Viconano repeated preliminaries of UAC, SRB in 48 years, in times of negative results So / Ні

pershu dobu life

Vikonana radiography of the organs of the breast not past 24 years from the time of detection So / Ні

dick

Appointed empirical antibacterial therapy for no more than 1 year at the time of rejection So / Ні

results in UAC, SRB

Dodatok A1. Methodology for developing key recommendations

■ pediatrics;

■ neonatology;

■ obstetrics and gynecology.

Methodology

Methods for sampling / selection of proofs: poshuk in the electronic databases of tributes.

A description of the methods used for the collection / selection of evidence: the evidence base for the recommendations є publication, which were sent to the Cochrane Library, the bases of data EMBASE and MEDLINE, electronic library.ru) (www.eLibrary.ru) Glibina became 5 rocky joke.

Methods for assessing the quality and strength of evidence:

■ consensus of experts;

Methods for the analysis of evidence:

■ systematic look at the tables of evidence.

Description of methods, victorious for the analysis of evidence

Whenever there is a publication of potential proofs of vicoristan in the skin preliminaries, the methodology should be adopted in order to get overwhelmed in the validity. The result of the vivchennya is injected onto the level of evidence, so that it will be attributed to the publication, which will infuse into its own account the power of old recommendations.

The methodological approach is based on a number of key feeds, which are focused on quiet features of the design of the previous generation, which really add to the results and results. The number of nutritional keys can be varied in the availability of various types of reports, as well as stored questionnaires, which can be used to standardize the process of evaluating publications.

At the process of assessment, it is insanely possible to start a sub-active factor. For the minimization of potential pardons for the skin, it was assessed by two independent members of the working group. Whether the opinions in the assessments were discussed by the whole group in the main warehouse. In case of ill-will, reaching consensus, attracted by an independent expert.

The tables of evidence were memorized by the members of the working group.

Methods, vikoristani for the formulation of recommendations: consensus experts.

■ call of expert assessment;

■ internal expert assessment.

References in the previous version of the boule were reviewed by independent experts who were asked to comment on all those, as interpretations of the evidence, which lie in the basis of the recommendations, are available for consideration. Otrimano comments from the side of patients in Primary Lanka and medical therapists for the admissibility of recommendations and assessments of the importance of recommendations as a working tool for every practice.

The front version of the bullet is also directed to the reviewer, who is not enough medical knowledge, to reject comments from the point of view of the prospects of patients.