Relevance of pneumonia in children. Pneumonia actuality of the disease

Introduction

The relevance of this work is due to the fact that pneumonia is an infectious inflammatory process in the lungs, in young children, accompanied by dysfunctions of various organs and body systems. The inflammatory process is localized in the alveoli, bronchioles with a reaction of the vascular system of the interstitial tissue, with disturbances in the microvasculature. Pneumonia can be primary or secondary as a complication of any disease.
The object of study of this work is pneumonia in young children.
The subject of the study is the features of the course of pneumonia in young children.
According to the accepted classification (1995), morphological forms in children distinguish between focal, segmental, focal-confluent, croupous and interstitial pneumonia. Interstitial pneumonia is a rare form in pneumocystosis, sepsis, and some other diseases. Identification of morphological forms has a certain prognostic value and may influence the choice of initial therapy.
The course of pneumonia can be acute or prolonged. Protracted pneumonia is diagnosed in the absence of resolution of the pneumonic process within a period of 6 weeks to 8 months from the onset of the disease; this should be an occasion to search for possible causes of such a flow.
When pneumonia recurs (with the exclusion of re- and superinfection), it is necessary to examine the child for the presence of cystic fibrosis, immunodeficiency, chronic food aspiration, etc.
The purpose of this work is to study the features of the course of pneumonia in young children.
The achievement of this goal contributes to the solution of the following tasks:
- to study the classification of pneumonia;
- consider the diagnosis of pneumonia;
- conduct a study of young children with this disease.
The following research methods were used in this work:
- study of special literature on this issue;
- conducting a study within the framework of a given topic in the Kazan Regional Children's Clinical Hospital for the detection and treatment of pneumonia in young children.
The theoretical significance of this work lies in studying the course of the disease, identifying the features of pneumonia in young children.
The practical significance of this work: the materials of this work can be used as a lecture by a teacher of medical affairs, and the materials of this work can also be used as notes by students of a medical college.
The history of this issue is studied and covered in the works of a number of scientists. These studies are used in the practice of treating patients with pneumonia.
The degree of study of the topic is quite high, since pneumonia in young children is a common disease.
When writing the work, special literature, research data, materials from periodicals were used, describing the latest developments in the field of research, detection and treatment of the disease.
The structure of the work is determined by the goals and objectives set. The work consists of an introduction, three chapters with paragraphs, a conclusion, a list of references, an appendix.
Chapter 1. Pneumonia as a disease of the respiratory tract
1.1. Disease classification

For citation: community-acquired pneumonia. Interview with prof. L.I. Dvoretsky // RMJ. 2014. No. 25. S. 1816

Interview with the head of the Department of Internal Medicine, SBEI HPE “First Moscow State Medical University named after I.M. Sechenov”, Doctor of Medical Sciences, Professor L.I. Butler

Pneumonia, being a serious, often fatal disease for centuries, continues to be a serious clinical problem, many aspects of which still require careful analysis today. What is the relevance of the problem of pneumonia in our days?
- The incidence of community-acquired pneumonia (CAP) in our country reaches 14-15%, and the total number of patients annually exceeds 1.5 million people. In the United States, more than 5 million cases of CAP are diagnosed each year, of which more than 1.2 million people require hospitalization, with more than 60,000 of them dying. If mortality in CAP among young and middle-aged people without concomitant diseases does not exceed 1-3%, then in patients older than 60 years with serious concomitant pathology, as well as in cases of severe disease, this figure reaches 15-30%.

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

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

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

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

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

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

The sensitivity to ABP of key respiratory pathogens is of no small importance when choosing a starting ABP. To what extent can the presence of antibiotic resistance correct the choice of antibiotics?
- There are such concepts as microbiological and clinical resistance of pathogens to antibiotics. And they do not always coincide in relation to some groups of antibiotics. So, with a low level of pneumococcal resistance to penicillin, amoxicillin and third-generation cephalosporins retain clinical efficacy, however, at higher doses: amoxicillin 2-3 g/day, ceftriaxone 2 g/day, cefotaxime 6 g/day. At the same time, the microbiological resistance of pneumococcus to macrolides, second-generation cephalosporins, or fluoroquinolones is accompanied by clinical treatment failure.

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

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

Appointment of antibiotics, even at the earliest possible date, of course, does not exhaust the mission of the supervising physician and does not finally solve all issues. How to evaluate the effect of the prescribed ABP? What are the performance criteria? What terms should be considered critical for making a decision about the lack of effect, and, consequently, about changing the BPA?
- There is a “third day” rule, according to which the effectiveness of antimicrobial therapy should be assessed 48-72 hours after its initiation. If the patient had a normalization of body temperature or it does not exceed 37.5 ° C, signs of intoxication have decreased, there is no respiratory failure or hemodynamic disorders, then the effect of the treatment should be regarded as positive and the antibiotic should be continued. In the absence of the expected effect, it is recommended to add oral macrolides (preferably azithromycin or clarithromycin) to the first-line drug, for example, amoxicillin or "protected" aminopenicillins. If such a combination is ineffective, an alternative group of drugs should be used - "respiratory" fluoroquinolones. In the case of an initially irrational prescription of an antibiotic, as a rule, they no longer turn to first-line drugs, but switch to taking "respiratory" fluoroquinolones.

An equally important issue in the tactics of ABT in patients with CAP is the duration of treatment. Doctors often have a fear that the disease will not be cured. Is the danger of both “under-treatment” and “over-treatment” of the patient the same?
- Many patients with CAP who have achieved a clinical effect on the background of ABT are sent to the hospital to continue treatment. From the point of view of the doctor, the reasons for this are subfebrile temperature, which persists, although the pulmonary infiltration has decreased in volume, according to the X-ray examination, an increase in ESR. In this case, either ABT is carried out in the same mode, or a new ABP is appointed.
In most cases, antimicrobial therapy in patients with CAP continues for 7-10 days or more. Comparative studies of the effectiveness of short and habitual (in duration) courses of antibiotics did not reveal significant differences in both outpatients and hospitalized patients if the treatment was adequate. According to modern concepts, antimicrobial therapy for CAP can be completed if the patient has received treatment for at least 5 days, his body temperature has normalized over the past 48-72 hours and there are no criteria for clinical instability (tachypnea, tachycardia, hypotension, etc.). Longer treatment is necessary in cases where the prescribed ABT had no effect on the isolated pathogen or in the development of complications (abscess formation, pleural empyema). The persistence of individual clinical, laboratory or radiological signs of CAP is not an absolute indication for the continuation of antimicrobial therapy or its modification.
According to some reports, up to 20% of patients with non-severe CAP do not respond properly to ongoing treatment. This is a serious figure, which determines the expediency of more thorough and, possibly, more frequent radiation monitoring of the lungs. The protracted resolution of focal infiltrative changes in the lungs, detected during radiological examination, even against the background of a clear regression of the clinical symptoms of the disease, often serves as a reason for continuing or modifying ABT.
The main criterion for the effectiveness of ABT is the regression of the clinical manifestations of CAP, primarily the normalization of body temperature. The terms of radiographic recovery, as a rule, lag behind the terms of clinical recovery. Here, in particular, it is appropriate to recall that the completeness and timing of radiological resolution of pneumonic infiltration also depend on the type of causative agent of EP. So, if with mycoplasmal pneumonia or pneumococcal pneumonia without bacteremia, the terms of radiographic recovery average 2 weeks. - 2 months and 1-3 months. accordingly, in cases of a disease caused by gram-negative enterobacteria, this time interval reaches 3-5 months.

What can you say about pneumonias with delayed clinical response and prolonged radiographic resolution in immunocompetent patients?
- In such situations, doctors often panic. Consultants are called for help, primarily phthisiatricians, oncologists, new antibiotics are prescribed, etc.
In most patients with CAP, by the end of 3-5 days from the start of ABT, body temperature normalizes and other manifestations of intoxication regress. In the same cases, when, against the background of an improvement in the condition by the end of the 4th week. from the onset of the disease, it is not possible to achieve full radiological resolution, we should talk about non-resolving / slowly resolving or protracted EP. In such a situation, one should first of all establish possible risk factors for a protracted course of CAP, which include advanced age, comorbidity, severe CAP, multilobar infiltration, and secondary bacteremia. In the presence of the above risk factors for slow resolution of EAP and simultaneous clinical improvement, it is advisable after 4 weeks. Conduct a chest X-ray. If there is no clinical improvement and / or the patient does not have risk factors for slow resolution of EAP, then in these cases, computed tomography and fiberoptic bronchoscopy are indicated.

In clinical practice, diagnostic and therapeutic errors are inevitable. We discussed the causes of delayed or misdiagnosis of pneumonia. What are the most typical mistakes in ABT in patients with CAP?
- The most common mistake should be considered the non-compliance of the starting antibiotic with accepted clinical guidelines. This may be due to insufficient familiarity of doctors with the available clinical guidelines, or their ignorance, or even simply ignorance of their existence. Another mistake is the lack of a timely change of the BPA in case of its obvious inefficiency. We have to deal with such situations when ABT continues for 1 week, despite the absence of a clinical effect. Less common are errors in the dosing of ABP, the duration of ABT. If there is a risk of developing antibiotic-resistant pneumococci, penicillins and cephalosporins should be used at an increased dose (amoxicillin 2-3 g / day, amoxicillin / clavulanic acid 3-4 g / day, ceftriaxone 2 g / day), and some antibiotics should not be prescribed (cefuroxime, macrolides). In addition, it should be recognized as erroneous the practiced prescription of antibiotics in CAP in subtherapeutic doses against pneumococci, for example, azithromycin at a daily dose of 250 mg, clarithromycin at a daily dose of 500 mg, amoxicillin / clavulanic acid in a dosage form of 625 mg (and even more so 375 mg) . At present, it may be justified to increase the dose of levofloxacin to 750 mg.

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

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

The problem of diagnosis and treatment of pneumonia is one of the most urgent in modern therapeutic practice. Only in the last 5 years in Belarus, the increase in the incidence amounted to 61%. Mortality from pneumonia, according to different authors, ranges from 1 to 50%. In our republic, mortality increased by 52% over 5 years. Despite the impressive success of pharmacotherapy, the development of new generations of antibacterial drugs, the proportion of pneumonia in the incidence structure is quite large. Thus, in Russia every year more than 1.5 million people are observed by doctors for this disease, of which 20% are hospitalized due to the severity of the condition. Among all hospitalized patients with bronchopulmonary inflammation, not counting SARS, the number of patients with pneumonia exceeds 60%.

In modern conditions of the "economical" approach to financing health care, the most appropriate spending of the allocated budget funds is a priority, which predetermines the development of clear criteria and indications for the hospitalization of patients with pneumonia, optimization of therapy in order to obtain a good end result at a lower cost. Based on the principles of evidence-based medicine, it seems important to us to discuss this problem in connection with the urgent need to introduce clear criteria for the hospitalization of patients with pneumonia into everyday practice, which would make it possible to facilitate the work of the district physician, save budgetary funds, and predict possible outcomes of the disease in a timely manner.

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

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

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

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

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On the problem of diagnosis and treatment of pneumonia

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

Orenburg State Medical Academy

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

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

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

List of sources used:

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

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

hospital pneumonia

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INTRODUCTION

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

The international statistical classification of diseases provides for the definition of pneumonia solely on an etiological basis. More than 90% of HP cases are of bacterial origin. Viruses, fungi and protozoa are characterized by a minimal "contribution" to the etiology of the disease. Over the past two decades, there have been significant changes in the epidemiology of HP. This is characterized by the increased etiological significance of pathogens such as mycoplasma, legionella, chlamydia, mycobacteria, pneumocystis and a significant increase in the resistance of staphylococci, pneumococci, streptococci and Haemophilus influenzae to the most widely used antibiotics. The acquired resistance of microorganisms is largely due to the ability of bacteria to produce beta-lactamases that destroy the structure of beta-lactam antibiotics. Nosocomial bacterial strains are usually distinguished by high resistance. In part, these changes are due to the selective pressure on microorganisms of the ubiquitous new broad-spectrum antibiotics. Other factors are the growth in the number of multidrug-resistant strains and the increase in the number of invasive diagnostic and therapeutic manipulations in a modern hospital. In the early antibiotic era, when only penicillin was available to the doctor, about 65% of all nosocomial infections, including HP, were due to staphylococci. The introduction of penicillinase-resistant beta-lactams into clinical practice reduced the relevance of staphylococcal nosocomial infection, but at the same time the importance of aerobic gram-negative bacteria (60%) increased, which replaced gram-positive pathogens (30%) and anaerobes (3%). Since that time, multiresistant gram-negative microorganisms (intestinal aerobes and Pseudomonas aeruginosa) have been put forward among the most relevant nosocomial pathogens. Currently, there is a resurgence of gram-positive microorganisms as topical nosocomial infections with an increase in the number of resistant strains of staphylococci and enterococci.

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

ETIOLOGY AND PATHOGENESIS of nosocomial pneumonia

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

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

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

Lecture plan

• Definition, relevance of pneumonia

• The pathogenesis of pneumonia

• Classification of pneumonia

• Criteria for diagnosing pneumonia

• Principles of treatment: organization of the regimen, aerotherapy, antibiotic therapy, immunotherapy and physiotherapy methods of treatment, prevention

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

Relevance:

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

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

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

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

Etiology

• Intrahospital (nosocomial) pneumoniae in most cases are caused by Ps. aeruginosa, less often - Cl. pneumoniae, St. aureus, Proteus spp. and others. These pathogens are resistant to antibiotics, which leads to a severe course of the disease and mortality.

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

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

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

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

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

From 6 months to 5 years in the first place are Str. Pneumoniae (70-88% of all pneumonias) and H. influenzae type b (Hib infection) - up to 10%. In these children, respiratory syncytial virus, influenza, parainfluenza, rhino and adenoviruses are also often isolated, but most authors consider them to be factors that contribute to infection of the lower respiratory tract by bacterial flora.

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

• With insufficiency of the humoral link of immunity, pneumococcal, staphylococcal, cytomegalovirus pneumonias are observed.

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

Pathogenesis

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

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

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

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

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

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

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

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

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

• airborne;

• hematogenous spread of the pathogen from the extrapulmonary focus of infection;

• Spread of infection from adjacent tissues of neighboring organs.

Classification

• Pneumonia

• primary (uncomplicated)

• secondary (complicated)

• Forms:

• focal

• segmental

• croupous

• interstitial

Localization

• unilateral

• bilateral

• lung segment

• lung lobe

• lung

Flow

• acute (up to 6 weeks)

• protracted (from 6 weeks to 6 months)

• recurrent

Respiratory failure

• 0 st.

• I st.

• II Art.

• III Art.

Pneumonia complicated:

• General violations

• toxic-septic condition

• infectious-toxic shock

• cardiovascular syndrome

• DVZ syndrome

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

• Pulmonary-purulent process

• destruction

• abscess

• pleurisy

• pneumothorax

• Inflammation of various organs

• sinusitis

• pyelonephritis

• meningitis

• osteomyelitis

Pneumonia code according to MKH-10:

• J11-J18 - pneumonia

• P23 - congenital pneumonia

Clinical criteria for pneumonia in a newborn child

• aggravated ante- and intranatal history;

• pallor, perioral and acrocyanosis;

• groaning breath;

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

• respiratory arrhythmia;

• rapid increase in pulmonary heart failure and toxicosis;

• muscle hypotension, inhibition of reflexes of the newborn;

• hepatolienal syndrome;

• weight loss;

• coughing; less cough;

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

• radiograph: lung tissue infiltrates, often on both sides; strengthening of the pulmonary pattern in the perifocal areas.

Clinical criteria for the diagnosis of pneumonia in young children:

• wet or unproductive cough;

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

• remote wheezing in broncho-obstructive syndrome;

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

• pale skin, perioral cyanosis, aggravated by exercise;

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

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

• shortening of percussion sound in the projection of the infiltrate;

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

• radiograph: lung tissue infiltrates, increased lung pattern in the perifocal areas.

Criteria for the degree of DN

Treatment of pneumonia

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

• 1) vital indications - intensive therapy, resuscitation measures are necessary;

• 2) a decrease in the reactivity of the child's body, the threat of complications;

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

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

• Wet cleaning, quartzing, airing (4-6 times a day) should be carried out in the ward.

• The head of the bed should be raised.

Nutrition

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

Treatment of respiratory failure

• Ensure free airway patency.

• The microclimate of the ward: fresh enough humid air, tº in the ward should be 18-19ºС.

• With respiratory failure of the II degree, oxygen therapy is added: through a nasal probe - 20-30% of oxygen utilization; through a mask - 20-50%, in an incubator - 20-50%, in an oxygen tent - 30-70%.

• With DN III degree - artificial ventilation of the lungs.

Antibacterial therapy

• Basic principles of rational antibiotic therapy in children.

• Start of treatment - after diagnosis. It is desirable to carry out crops on the flora with the determination of sensitivity to antibiotics. The results will be in 3-5 days. We select the starting therapy empirically, taking into account the age of the patient, home or hospital pneumonia, and regional characteristics.

• First grade - prescribe broad-spectrum antibiotics (mainly β-lactams).

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

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

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

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

• Choosing a rational combination: synergism is required, only bactericidal or only bacteriostatic. Drugs should not enhance the toxic effect of each other.

• Conditions for stopping treatment: not earlier than 3 days of normal temperature, the general condition of the child.

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