What is the difference between community-acquired pneumonia and pneumonia? Community-acquired pneumonia - what is it? Causes, symptoms, diagnosis and treatment of pneumonia. Community-acquired pneumonia in children

The term “community-acquired pneumonia” refers to a whole group of diseases characterized by a common localization and similar signs of manifestation. However, the causes of the disease, its course and further prognosis in each specific case may differ significantly. The success of treatment depends on an accurate determination of the origins of the disease, the correct selection of drugs from the group of antibiotics and the elimination of all factors that aggravate the condition.

This name refers to pneumonia, the causes of which are not related to hospital stay. In other words, all diseases of this kind are divided into two large categories: community-acquired and hospital-acquired (those that arose during treatment in the hospital or no more than three days after discharge).

Pneumonia is considered one of the most common infectious diseases.

According to medical estimates, every year in Russia we have about one and a half million sick people, among whom the most vulnerable group of people are the elderly. In this category of citizens, from 25 to 44% fall ill.

Pneumonia is also one of the most common causes of death due to infection. Among mild cases, no more than 5% die. At the same time, in the most severe forms, mortality can reach 50%.

Pneumonia is a disease that is usually infectious in nature. In the presence of a pathogen, a pathological process develops in the smallest structures of the lungs - the alveoli.

• This process is characterized by all the signs of inflammation.
• Swelling appears in the tissues that form the alveoli.
• In the cavity of the bubbles, which are normally filled with air, exudate is detected, released from the surrounding capillaries.

Damage to the respiratory organs is accompanied by a weakening of their main function - oxygen saturation of the blood. Lack of treatment contributes to the growth of the inflammatory process involving an increasing amount of tissue.

Causes and risk factors

It is extremely rare that inflammation begins for a reason unrelated to infection. Such diseases occur against the background of injuries affecting the lung tissue, as a result of which the free outflow of secretions is disrupted.

The most common reason is the penetration of an infectious agent from non-sterile parts of the respiratory tract (nose, oropharynx) into the deep parts of the lungs.

The upper sections are colonized by a huge number of microbes, but only some of them are highly pathogenic and can cause inflammation of the alveoli, being found inside the lungs even in the smallest quantities. These pathogens are either constantly present in the upper respiratory tract or enter there along with contaminated air.

The causative agents of the disease can be bacteria, viruses and fungi:

• From one to two thirds of cases are due to pneumococcal infection. Pneumococcus is the most common cause of the disease.
• Less commonly, the source of the disease is mycoplasma or chlamydia (12.5% ​​each). In such cases we are talking about “atypical” inflammation.
• In less than 5% of patients, it is possible to isolate Legionella or Haemophilus influenzae from pathological fluids. These pathogens of community-acquired pneumonia are most common in the warm and humid climate of the Mediterranean.
• Viruses and fungi account for up to 6% of cases. Seasonality plays an important role in their activity. They are more viable in autumn and winter. Among this category of pathogens, the most common pathogen is the influenza virus.
• In a significant number of cases (about 40%), it is not possible to identify the infectious agent at all.

Factors contributing to the development of the disease include:

• smoking;
• alcohol abuse;
• decreased motor activity;
• lack of vitamins;
• immunodeficiency states;
• genetic diseases, such as cystic fibrosis, in which the condition of the mucous membranes worsens;
• untreated inflammatory diseases of the bronchi and larynx;
• the presence of a constant inflammatory process in the oral cavity.

As evidence for the last point, we can cite the results of tests conducted over three years from 2013 to 2016. Scientists have identified a direct relationship between the incidence and condition of the teeth. In the population that did not visit the dentist regularly twice a year, the probability of infection increased by 86%.

Symptoms and signs of the disease

Typical pneumonia, provoked by microbes common to this disease, such as streptococcus, Haemophilus influenzae and Escherichia coli, as well as Klebsiella, is characterized by a vivid clinical picture:

• The first sign of the disease is a jump in temperature to 39 – 40 ºС. Pneumonia fever usually cannot be controlled with conventional remedies such as paracetamol.
• From the very first days, the patient develops a profuse and wet cough. There is separation of greenish sputum.
• Sweating increases at night.
• When a large area of ​​the lungs is affected, the patient experiences chest pain.
• The skin becomes pale.
• Shortness of breath may be present.

When infected with microbes atypical for this disease (mycoplasma, chlamydia, legionella), the severity of symptoms increases gradually. At the onset of the disease there is a low temperature. The patient's condition is similar to that of ARVI. He is dominated by muscle and headaches, lethargy and general malaise. The cough does not start immediately. First, a sore throat appears, then a dry cough, after a few days it turns into a wet one.

Diagnosis and consultation with a doctor

Lack of improvement for more than five days is a reason to consult a doctor and get examined.

A specialist should suspect pneumonia already at the stage of questioning and examination. In a patient with a typical picture, when tapping the chest, short ringing sounds are clearly audible. When examining with a phonendoscope, the doctor pays attention to voice trembling and wheezing.

At the appointment, the patient is given a preliminary diagnosis indicating the location. Due to the physiological structure, right-sided pneumonia is more common, in which the pathological process develops on the right. In elderly patients, due to lack of physical activity, lower lobe pneumonia (inflammation involving the lower lobes of the lung) is most severe.

After a preliminary diagnosis has been established, the patient is sent for x-rays and blood tests. Using a blood test, you can determine the nature of the disease and understand whether the inflammation is caused by a virus or bacteria. With the typical development of inflammation, darkened areas are clearly visible on x-rays.

Using X-rays, localization is established down to the lobe and segment. Enter the final diagnosis. SARS does not provide such a clear picture. Its foci are more difficult to detect using this method.

To clarify the diagnosis, the patient may be given a referral for sputum analysis. The discharge from the lungs is examined by microscopy and culture on nutrient media. With the help of a detailed study, it is possible to identify the pathogen and prescribe the most adequate treatment.

Additional diagnostic methods include computed tomography and bronchoscopy. They are rarely resorted to and only in cases where the basic methods do not provide a clear understanding of the situation.

Treatment of pneumonia

Antibiotics play a vital role in the treatment of pneumonia.

The choice of drugs is based on the diagnostic results. Antibiotic agents are selected taking into account the type of pathogen and its specific type.

The sensitivity of microorganisms is not always determined in the laboratory. Sometimes the same microbes can behave differently and react accordingly to drugs inside the body and in a test tube. Therefore, the selection of antibiotics is often done experimentally.

The effectiveness of treatment is assessed, among other things, by external signs. If the patient's condition does not improve within three days, the previous drug is discontinued and a different one is prescribed.

To help with the main treatment, agents are added that dilate the bronchi and make breathing easier. Along with antibiotics, drugs that stimulate the outflow of mucus, as well as drugs that reduce swelling, may be prescribed.

Drugs and antibiotics

For typical pneumonia and in cases where the type of pathogen cannot be determined, clavulanic acid-protected antibiotics of a number of penicillins and cephalosporins (Flemoxin, Ceftriaxone) are prescribed, which are administered intramuscularly or intravenously. In case of allergies, these drugs can be replaced with macrolides (Erythromycin, Clarithromycin), carbapenems and fluoroquinolones (Levofloxacin).

For all patients, medications are selected individually depending on the presence of concomitant chronic diseases and characteristics of the reaction. The duration of therapy is determined by the severity of the condition. In any case, treatment continues for at least three days after the temperature normalizes and visible improvements appear on radiography.

Antibiotics are prescribed to help:

• bronchodilators (“Salbutamol”);
• mucolytics (“Fluimucil”, “ACC”);
• corticosteroids (Singulair).

Medicines are used in the form of pills, syrups, injections and inhalations. Their role is to improve the general condition of the patient. These kinds of drugs are used to suppress the main symptoms: relieving congestion, facilitating breathing, reducing pain in the lungs. They remove swelling, improve bronchial aspiration, and create conditions for freeing the alveoli from contaminated secretions.

Folk remedies for community-acquired pneumonia

In case of pneumonia, hospitalization is necessary. Community-acquired pneumonia in children and the elderly is treated only in a hospital setting.

A doctor can take an adult patient under outpatient observation only if there is no threat to life and health.

Treatment of community-acquired pneumonia exclusively with folk remedies is unacceptable. But if the doctor allows the use of such methods, they can be included as an addition to the main therapy.

Herbs such as:

• marshmallow;
• licorice;
• violet;
• sage;
• eucalyptus.

They can be used separately and together as a ready-made pharmacy chest collection. A tablespoon of herbal powder is brewed in half a glass of boiling water. After fifteen minutes, the infusion is filtered and drunk.

Cough herbs are taken after meals. The medicine is brewed three to four times a day. Relief can be felt on the third or fourth day. In general, herbal medicine lasts about two weeks.

Is pneumonia contagious to other people?

Pneumonia, of course, can be transmitted from person to person, but this does not mean that infection will follow after any contact with the patient. An important criterion when assessing the situation is the strength of individual immunity.

The air exhaled by a sick person will contain pathogens that cause inflammation. They can also penetrate into the lungs of others. However, among those who encounter the infection, not everyone will get sick. If one's immunity is strong enough, one can easily defeat the enemy.

The concentration of the pathogen in the air is no less important. Not just any amount of a microbe can provoke a disease. If very few pathogenic particles enter the lungs, then most likely they will be destroyed by immune cells.

Possible complications

Inflammation of the lungs can give impetus to the development of purulent-necrotic or destructive processes with rejection of the affected tissue, resulting in an abscess or gangrene.

The accumulation of purulent discharge has a detrimental effect on lung function, causing the development of obstruction or obstruction. Sometimes pneumonia results in acute respiratory failure.

If left untreated, the inflammatory process can spread to neighboring and distant tissues, causing endocarditis and meningitis.

The most severe consequences are pulmonary edema and sepsis, which increase the likelihood of death of the patient.

Prevention measures

Since the main factors in the development of the disease are weakened immunity, low mobility, in which the lungs are poorly ventilated, and a high bacterial load of the surrounding air, prevention should include the following measures:

• taking vitamin and mineral complexes in the off-season;
• regular walks in the fresh air;
• maintaining a daily routine, avoiding stressful situations;
• proper nutrition and getting rid of bad habits;
• daily exercise;
• timely treatment of diseases caused by respiratory infections;
• maintaining the oral cavity in good condition;
• regular wet cleaning of the premises;
• mandatory ventilation even in the cold season;
• refusal to attend public events.

Pneumonia is caused by a huge number of microorganisms. In each individual case, the disease may progress differently. Staying at home and being treated only with folk remedies is very presumptuous. To avoid more serious consequences, you need to contact a specialist in a timely manner.

Today, community-acquired pneumonia remains a widespread and potentially life-threatening disease.

The disease is common not only among adults, but also among children. There are from 3 to 15 cases of pneumonia per 1000 healthy individuals. This range of figures is due to the different prevalence of the disease in the regions of the Russian Federation. 90% of deaths after 64 years are due to community-acquired pneumonia.

If a patient is diagnosed with pneumonia, in 50% of cases doctors will decide to hospitalize him, because the risk of complications and deaths from this disease is too great.

So, what is community-acquired pneumonia?

Community-acquired pneumonia is an acute infectious process in the lungs that occurred outside a medical institution or within 48 hours of hospitalization, or developed in people who were not in long-term medical observation units for 14 days or more. The disease is accompanied by symptoms of lower respiratory tract infection (fever, cough, shortness of breath, sputum production, chest pain. Radiologically, it is characterized by “fresh” foci of changes in the lungs, subject to the exclusion of other possible diagnoses.

Symptoms

Diagnosing pneumonia is difficult because there is no specific symptom or combination of symptoms unique to this disease. Community-acquired pneumonia is diagnosed based on a combination of nonspecific symptoms and an objective examination.

Symptoms of community-acquired pneumonia:

• fever;
• cough with or without phlegm;
• difficulty breathing;
• chest pain;
• headache;
• general weakness, malaise;
• hemoptysis;
• heavy sweating at night.

Less common:

• pain in muscles and joints;
• nausea, vomiting;
• diarrhea;
• loss of consciousness.

In older people, symptoms from the bronchopulmonary system are not expressed; general symptoms come first: drowsiness, sleep disturbance, confusion, exacerbation of chronic diseases.

In young children with pneumonia, the following signs are present:

• temperature increase;
• cyanosis;
• dyspnea;
• general signs of intoxication (lethargy, tearfulness, sleep disturbance, appetite, breast refusal);
• cough (may or may not be present).

In older children, symptoms are similar to those in adults: malaise, weakness, fever, chills, cough, chest pain, abdominal pain, increased respiratory rate. If a child over 6 months of age does not have a fever, community-acquired pneumonia can be ruled out according to the latest clinical guidelines.

The absence of fever in children under 6 months in the presence of pneumonia is possible if the causative agent is C. trachomatis.

Treatment in adults and children

The main treatment method is antibacterial therapy. At the first stages of outpatient and inpatient treatment, it is carried out empirically, that is, the doctor prescribes the drug based only on his assumptions regarding the causative agent of the disease. This takes into account the patient’s age, concomitant pathology, severity of the disease, and the patient’s self-use of antibiotics.

Mild community-acquired pneumonia is treated with tablets.

When treating mild pneumonia with a typical course on an outpatient basis in people under 60 years of age without concomitant diseases, therapy can be started with amoxicillin and macrolides (azithromycin, clarithromycin). If there is a history of an allergy to penicillin or an atypical course of pneumonia is observed, or the effect of penicillins is not observed, then preference should be given to macrolide antibiotics.

For patients over 60 years of age with concomitant diseases, treatment begins with protected penicillins (amoxicillin/clavulanate, amoxicillin/sulbactam). As an alternative, antibiotics from the group of respiratory fluoroquinolones (levofloxatsuin, moxifloxacin, gemifloxacin) are used.

Severe community-acquired pneumonia requires the prescription of several antibiotics at once. Moreover, at least 1 of them must be administered parenterally. Treatment begins with 3rd generation cephalosporins in combination with macrolides. Amoxicillin/clavulanate is sometimes prescribed. As an alternative, respiratory fluoroquinolones are used in combination with 3rd generation cephalosporins.

Every patient with pneumonia must undergo a bacteriological examination of sputum. Based on its results, an antibiotic is selected that is sensitive specifically to the detected pathogen.

If pneumonia caused by Legionella is suspected, parenteral rifampicin must be added.

If pneumonia is caused by Pseudomonas aeruginosa, then combinations of cefipime, or ceftazidime, or carbopenems with ciprofloxacin or aminoglycosides are used.

For pneumonia caused by Mycoplasma pneumoniae, it is best to prescribe macrolides, or respiratory fluoroquinolones or doxycycline.

For Chlamydia pneumoniae, the disease is also treated with fluoroquinolones, macrolides and doxycycline.

The principles of antibacterial therapy in children differ between groups of antibiotics. Many drugs are contraindicated for them.

The selection of an antibiotic is also carried out presumably until the microorganism that caused the disease is determined.

For mild and moderate pneumonia in children from 3 months to 5 years, protected penicillins (amoxicillin/clavulanate, amoxicillin/sulbactam, ampicillin/sulbactam) are prescribed orally. In case of severe cases in the same age category - they are the same, but parenterally for 2-3 days, followed by switching to tablet forms. Antibiotics with the prefix “Solutab” are more effective.

If hemophilus influenzae infection is suspected, amoxicillin/clavulanate with a high amoxicillin content is selected (14:1 from 3 months to 12 years and 16:1 from 12 years).

In children over 5 years of age, if there is no effect from amoxiclav therapy, macrolides (josamycin, midecamycin, spiramycin) can be added to the treatment.

The use of fluoroquinolones in children is contraindicated up to 18 years of age. The possibility of their use should be approved only by a council of doctors in a life-threatening situation.

What other antibiotics can be used in children under 3 months? If pneumonia is caused by enterobacteriaceae, then aminoglycosides are added to protected penicillins. In addition to amoxicillin, ampicillin and benzylpenicillin can be used parenterally in children of this age. In severe cases where resistant bacteria are present, carbapenems, doxycycline, cefotaxime or ceftriaxone can be used.

Rules of antibacterial therapy

• the sooner antibacterial treatment is started, the better the patient’s prognosis;
• the duration of antibiotic use in both adults and children should not be less than 5 days;
• in case of mild pneumonia and prolonged normalization of temperature, treatment can be stopped ahead of schedule for 3-4 days;
• the average duration of antibiotic treatment is 7-10 days;
• if pneumonia is caused by chlamydia or mycoplasma, treatment is extended to 14 days;
• intramuscular administration of antibiotics is impractical, because their availability is less than with intravenous administration;
• assessment of the effectiveness of treatment can be carried out only after 48-72 hours;
• effectiveness criteria: reduction in temperature, reduction in intoxication;
• The x-ray picture is not a criterion by which the duration of treatment is determined.

Among the pediatric population, community-acquired pneumonia may be caused not by bacteria, but by a virus. In such cases, the use of antibiotics will not give any result, but will only worsen the prognosis. If pneumonia develops 1-2 days after the initial manifestations of a viral disease (especially influenza), then treatment can be started with antiviral drugs: oseltamivir, zanamivir, umifenovir, inosine pranobex, rimantadine.

In severe cases, in addition to fighting the pathogen, infusion therapy is carried out to eliminate intoxication, high fever, oxygen therapy, vitamin therapy, and treatment with mucolytics.

The most common mucolytic among adults and children is ambroxol. It not only thins sputum and facilitates its removal, but also promotes better penetration of antibiotics into the lung tissue. It is best used through a nebulizer. Bromhexine can also be used for children from birth. From 2 years of age ACC is allowed, from 1 year of age - Fluimucil. Carbocisteine ​​is allowed for children from 1 month.

Forecast

The prognosis for community-acquired pneumonia is generally good. But severe pneumonia can be fatal in 30-50% of cases. The prognosis worsens if:

• a person over 70 years old;
• the patient is on artificial ventilation;
• there is sepsis;
• bilateral pneumonia;
• there is an arrhythmia with an increase or decrease in heart rate;
• causative agent - Pseudomonas aeruginosa;
• initial treatment with antibiotics is ineffective.

If you develop a high temperature during or after a cold, you should definitely consult a doctor and get an X-ray of your lungs.

Community-acquired pneumonia is a chronic or acute infectious and inflammatory disease of the parenchyma of the lungs and lower respiratory tract, provoked outside of a hospital stay.

That is, any pneumonia that began outside the hospital is defined as community-acquired. It accounts for up to 80% of all clinical cases.

The hospital form of pneumonia is much more complicated and is acquired by patients during their hospital stay. According to the international classification of the ICD, community-acquired pneumonia has the code J18.

Pneumonia is not always infectious-inflammatory. Allergic forms, congestive forms, etc. are possible. What do you need to know about pneumonia? We need to look into this in more detail.

Factors in the development of pneumonia are numerous. However, if you take a closer look, you will find that there are only two groups of significant reasons for the onset of the disease.

The first and main thing is the penetration of the infectious agent into the pulmonary structures. As was said, in the vast majority of cases, pneumonia is of an infectious nature, therefore other forms in the context of the article do not have epidemiological significance.

Main pathogens

What pathogens provoke community-acquired pneumonia? The most common microorganisms found are:

• Pneumococci.
• They account for up to 60-80% of all clinical cases of pneumonia. Inflammation of the lungs develops as a result of damage to parenchymal tissue (alveoli) by this pathogen. Staphylococci are hemolytic and, in particular, aureus.
• They cause severe inflammation of the lungs with damage to the parenchyma and bronchial tree, as well as the pleura. They form stable systems, conglomerates of their own kind, therefore, in therapy, a clear selection of the drug is required. Otherwise, all attempts to defeat staphylococcus will only end with the microorganism developing resistance to the drugs.

Streptococci. They cause relatively weak, sluggish, but protracted pneumonia. However, these are dangerous microorganisms that are quite capable of causing death.

Rare pathogens

• Atypical microorganisms can also cause community-acquired pneumonia. Among them:
• Klebsiella. Causes mild but persistent pneumonia. The microorganism predominantly affects patients of preschool and primary school age.
• Legionellosis lesions. They provoke dangerous pneumonia, which is quite capable of becoming lethal.

Coronavirus. Became the cause of the notorious SARS pandemic back in 2002-2003.

• Herpes virus. Diverse in nature. The following strains of herpetic agent provoke pneumonia:
• Strain of the second type. Causes genital herpes. However, with oral-genital contact, damage to the oral cavity and lower respiratory tract is possible.
• Herpes virus type 3. In adults, it causes severe pneumonia associated with the formation of symptoms of chickenpox.
• Herpes types four and five. Most often provoke the disease.

Causes of decreased immune response

The routes of transmission of these viruses are diverse: oral-genital, sexual, hematogenous, lymphogenous, perinatal, generic (descending), contact-household, airborne.

Considering the high degree of contagiousness (infectiousness) of these pathogens, it can be argued that many are infected, but the immune system fights the virus or bacteria (agent) quite effectively. And here we come to the second factor in the development of pathology. This is a decrease in the efficiency of the immune system.

There are many reasons for this condition. Among them:

A history of human immunodeficiency virus. People suffering from AIDS are more likely to suffer from atypical forms of pneumonia, which is quite natural.

Indirect factors of decreased immunity

Finally, the third group of factors concerns third-party causes that can undermine the body’s strength. These are indirect factors. Among them:

1. Hormonal disorders. First of all, Itsenko-Cushing's disease, diabetes mellitus, excess sex hormones.
2. Diseases of the gastrointestinal tract.

The list of reasons is long. A thorough diagnosis is required.

Symptoms

The symptoms of pneumonia, on the one hand, are very specific, on the other hand, it is impossible to determine which organ is affected by the pathological process based on symptoms alone.

However, in order to react in a timely manner, you need to know the enemy in person and understand what manifestations we are talking about.

Typical signs include:

• Cough. It starts from the very first days, although not always. Variations are possible. A small amount of serous or sputum is produced. Much depends on the type of pneumonia.
• Chest pain. Always developing. The pain is aching, nagging, intensifies when coughing, breathing, or touching the back. It is of medium intensity, or may be so weak that it is not taken into account by the patient.
• Rise in body temperature. Hyperthermia is another frequent visitor to a patient with pneumonia. At the same time, the disease throws dust in the eyes through a period of imaginary well-being, when hyperthermia abruptly goes away along with all the symptoms for a day or two, and then attacks the patient with renewed vigor.
• Manifestations of general intoxication of the body with the development of headache, drowsiness, and severe weakness. Nausea is noted. In some cases, vomiting may begin.
• Whistling, wheezing when breathing. The presence of this symptom depends on the extent of the lesion. Everything is much more complicated.
• Dyspnea (increased breathing), suffocation (difficulty breathing). Typical companions of the patient throughout the entire period of illness. Respiratory failure and, as a result, death are quite possible.

A thorough diagnosis is required; this is the only way to put an end to the question of the origin of the disease.

Diagnostic measures

Diagnosis does not present significant difficulties, unless, of course, we are talking about small segment pneumonia. If you have a problem with pneumonia, you need to consult a pulmonologist. It will help determine further diagnostics.

During the initial examination, the specialist conducts an oral interview with the patient regarding the nature and duration of the complaints. Anamnesis is required. That is, find out what diseases the patient has suffered or is currently suffering from. In the future, additional examinations of the chest organs are required.

• First of all, chest X-ray or fluorography (less preferable) is prescribed. Makes it possible to detect highlights or shadows in the image. These are precisely the foci of pneumonia.
• It is required to undergo MRI or CT diagnostics in the most complex cases.
• In atypical clinical situations, bronchoscopy is prescribed. This is an unpleasant, but not fatal, test that may be required.
• Laboratory research also plays an important role. General blood test, biochemical study of venous blood, etc. Sputum analysis is absolutely necessary.

All of these studies allow us to make a diagnosis of community-acquired pneumonia.

Treatment

Therapy depends largely on the type of pathological process. Treatment of community-acquired pneumonia requires an integrated approach. In most cases, doctors limit themselves to medications.

• Anti-inflammatory non-steroidal origin. Allows you to stop the inflammatory process in the organs and tissues of the lungs.
• Corticosteroids. They solve two problems at once. They make breathing easier, normalize the functioning of the respiratory system, and also relieve inflammation.
• Analgesics. Allows relief of pain in patients.
• . Indicated for severe shortness of breath and suffocation to relieve bronchospasm, which will inevitably manifest itself with pneumonia.
• Antibacterial pharmaceuticals. Required in all cases for the treatment of pneumonia. Before prescribing antibiotic treatment, a general sputum test should be taken and bacteriological cultures should be carried out in order to determine the sensitivity of the flora to the drugs.

In exceptional cases, pulmonary resection or therapeutic bronchoscopy is performed.

Prevention

Doesn't present much difficulty. It is enough to follow the standard recommendations:

• No smoking. This is strictly prohibited.
• Do not abuse alcohol.
• Don't get too cold.
• Treat all acute and chronic diseases in a timely manner so that they cannot become the source of the problem.
• See a doctor in a timely manner and undergo preventive examinations.

Community-acquired pneumonia is a broad concept that includes lobar, and, and even. In all cases, it is recommended to contact a specialist as soon as possible so as not to miss the moment for therapy.

Community-acquired pneumonia in outpatient settings

In contact with

A.I. SINOPALNIKOV, Doctor of Medical Sciences, Professor, Department of Therapy. ANTIBACTERIAL THERAPY

According to modern data, about 75% of all antibiotic prescriptions are for upper (otitis, sinusitis, pharyngitis) and lower (exacerbation of chronic bronchitis, pneumonia) respiratory tract infections. In this regard, it seems extremely relevant to develop approaches to rational antibacterial therapy of respiratory infections, primarily pneumonia, as a pathology of greatest medical and social importance.

Pneumonia is an acute infectious disease of predominantly bacterial etiology, characterized by focal damage to the respiratory parts of the lungs with intra-alveolar exudation, detected by objective and x-ray examination, expressed in varying degrees by a febrile reaction and intoxication.

Classification

Currently, from a clinical point of view, the most preferable classification of pneumonia is one that takes into account the conditions in which the disease developed, the characteristics of infection of the lung tissue, as well as the state of the immunological reactivity of the patient’s body. Correct consideration of the listed factors makes it easier for the doctor to determine the etiological orientation in most cases of the disease.

In accordance with this classification, the following types of pneumonia are distinguished:

• community-acquired (acquired outside a medical institution) pneumonia (synonyms: home, outpatient);
• nosocomial (acquired in a medical institution) pneumonia (Hospital pneumonia is a symptom complex characterized by the appearance 48 hours or more after hospitalization of a new pulmonary infiltrate in combination with clinical data confirming its infectious nature (a new wave of fever, purulent sputum, leukocytosis, etc.) and when excluding infections that were in the incubation period when the patient was admitted to the hospital) (synonyms: nosocomial, hospital);
• aspiration pneumonia;
• pneumonia in persons with severe immune defects (congenital immunodeficiency, HIV infection, iatrogenic immunosuppression).

The main pathogens of community-acquired pneumonia

The etiology of community-acquired pneumonia is associated mainly with the normal microflora of the “non-sterile” parts of the upper respiratory tract (Aspiration (microaspiration) of the contents of the oropharynx is the main route of infection of the respiratory parts of the lungs, and therefore the main pathogenetic mechanism for the development of pneumonia, both community-acquired and hospital-acquired. Other pathogenetic mechanisms development of pneumonia - inhalation of microbial aerosol, hematogenous spread of the pathogen, direct spread of infection from neighboring affected tissues - are less relevant). Of the many types of microorganisms that colonize the upper respiratory tract, only a few with increased virulence are capable of causing an inflammatory reaction upon penetration into the respiratory sections of the lungs, even with minimal disruption of protective mechanisms. The list of typical bacterial pathogens of community-acquired pneumonia is presented in table. 1.

Table 1 Etiological structure of community-acquired pneumonia

Pneumococci (Streptococcus pneumoniae) remain the most common causative agent of community-acquired pneumonia. Two other frequently identified pathogens - M.pneumoniae and C.pneumoniae - are most relevant in young and middle-aged people (up to 20-30%); their etiological “contribution” in older age groups is more modest (1-3%). L.pneumophila is an infrequent causative agent of community-acquired pneumonia, but legionella pneumonia ranks second after pneumococcal pneumonia in terms of the frequency of deaths. H. influenzae is more likely to cause pneumonia in smokers and patients with chronic bronchitis/chronic obstructive pulmonary disease. Escherichia coli, Klebsielia pneumoniae (rarely other representatives of the Enterobacteriaceae family) are irrelevant pathogens of pneumonia, usually in patients with known risk factors (diabetes mellitus, congestive heart failure, renal, liver failure, etc.). S. aureus - the development of community-acquired pneumonia is most likely to be associated with this pathogen in the elderly, drug addicts, patients suffering from influenza, etc.

It is extremely important to divide community-acquired pneumonia according to severity - into non-severe and severe (Criteria for severe pneumonia: general serious condition of the patient (cyanosis, confusion, delirium, body temperature > 39°C); acute respiratory failure (shortness of breath - number of breaths > 30/min , with spontaneous breathing - pO2< 60 мм рт.ст, SaO2 < 90%); кордиоваскулярноя недостаточность (тахикардия, не соответствующая степени выраженности лихорадки, систолическое АД < 90 мм рт.ст. и/или диастолическое АД < 60 мм рт.ст.); дополнительные критерии (гиперлейкоцитоз >20*10 9 /l or leukopenia< 4*10 9 /л, двусторонняя или многодолевая инфильтрация легких, кавитация, массивный плевральный выпот, азот мочевины >10.7 mmol/l)). Among the causative agents of non-severe community-acquired pneumonia, S.pneumoniae, M.pneumoniae, C.pneumoniae and H.influenzae dominate, while the actual causative agents of severe pneumonia, along with pneumococcus, are L.pneumophila, Enterobacteriaceae, S.aureus.

Rational antibacterial therapy of community-acquired pneumonia

1. Antibiotic activity against the main pathogens of the disease

The drugs of choice are antibiotics intended for both oral and parenteral administration. Their purpose is determined by the severity of community-acquired pneumonia.

If treatment is possible on an outpatient basis (non-severe community-acquired pneumonia), preference should be given to taking antibacterial drugs orally.

S. pneumoniae. The standard antipneumococcal antibiotic therapy is benzylpenicillin and aminopenicillins. According to its pharmacokinetic characteristics, amoxicillin is preferable to ampicillin (it is 2 times better absorbed from the gastrointestinal tract). Beta-lactam antibiotics of other groups do not exceed the indicated drugs in terms of antipneumococcal activity. The issue of choosing an antibiotic in the treatment of penicillin-resistant pneumococcal infection has not yet been fully resolved. Limited data suggest that benzylpenicillin and aminopenicillins remain clinically effective in infections caused by moderately resistant and penicillin-resistant pneumococci, but third-generation cephalosporins (cefotaxime, ceftriaxone) may be preferable in such cases. As evidenced by the results of individual studies, pneumococcal resistance to penicillin and other beta-lactams is not a significant problem for Russia.

Acute focal lesions of the respiratory parts of the lungs of a non-infectious nature, vascular origin, as well as those included in the symptom complex of certain highly contagious infections (plague, typhoid fever, influenza, glanders, etc.) and tuberculosis are excluded from the list of pneumonia.

Macrolide antibiotics have high antipneumococcal activity. Complete cross-resistance is observed between 14-membered (erythromycin, clarithromycin, roxithromycin) and 15-membered (azithromycin) macrolides, while some S. pneumoniae strains may remain sensitive to 16-membered macrolides (spiramycin, josamycin, midecamycin). The prevalence of erythromycin-resistant pneumococci in our country is low (< 5%).

Fluoroquinolones available in Russia (Currently, fluoroquinolones with antipneumococcal activity - the so-called respiratory fluoroquinolones - (sparfloxacin, levofloxacin, moxifloxacin, gatifloxacin, etc.) are not registered in Russia) (ofloxacin, ciprofloxacin) are characterized by insignificant activity against pneumococci.

The role of tetracyclines and especially co-trimoxazole as antipneumococcal drugs is limited due to the spread of acquired pathogen resistance to them.

H. intiuenzae. Aminopenicillins are highly active against Haemophilus influenzae. However, currently up to 30% of pathogen strains produce broad-spectrum beta-lactamases capable of destroying natural and semi-synthetic penicillins, 1st generation cephalosporins, and partially cefaclor. In this regard, the drugs of choice in the treatment of community-acquired pneumonia caused by H. influenzae strains producing beta-lactamases are “protected” aminopenicillins (amoxicillin/clavulanic acid, ampicillin/sulbactam) and 2nd generation cephalosporins.

Fluoroquinolones are highly active against Haemophilus influenzae; resistance to them is rare.

Macrolides have minor but clinically significant activity.

S. aureus. The drugs of choice for the treatment of lower respiratory tract infections caused by S. aureus (taking into account the production of beta-lactamases by most strains) are oxacillin, “protected” aminopenicillins, and 1-2 generation cephalosporins.

M. pneumoniae, C. pneumoniae. The drugs of choice for the treatment of mycoplasma and chlamydial pneumonia are macrolides and tetracyclines (doxycycline). There is no reliable information about the acquired resistance of microorganisms to these antibiotics. Common fluoroquinolones (ofloxacin, ciprofloxacin) have some activity against these intracellular microorganisms.

Legionella spp. (primarily L. pneumophila). The drug of choice for the treatment of Legionella pneumonia is erythromycin. It is likely that other macrolides may be equally effective (data are limited). There is information justifying the inclusion of rifampicin in the treatment of Legionella pneumonia in combination with macrolides. Common fluoroquinolones (ofloxacin, ciprofloxacin) are highly active and clinically effective.

Enferobacteriaceae spp. The etiological role of representatives of the Enterobacteriaceae family (most often E.coli and Kiebsiella pneumoniae) in the development of community-acquired pneumonia is ambiguous (see above). The mechanisms of resistance development (beta-lactamases) of microorganisms common in community settings do not affect 3rd generation cephalosporins, which makes them the drugs of choice.

2. Empirical antibacterial therapy for community-acquired pneumonia

Among patients with community-acquired pneumonia, it is advisable to identify groups with a similar etiology of the disease and, accordingly, requiring similar antibacterial therapy. Where possible, first-choice and alternative antibiotics are identified (see Table 2).

table 2 Empirical antibacterial therapy for community-acquired pneumonia

3. Doses and frequency of administration of antibiotics

The doses of the main antibacterial drugs and the frequency of their administration to adult patients with community-acquired pneumonia are presented in Table. 3.

Table 3. Doses of antibacterial drugs and frequency of their administration for community-acquired pneumonia

4. Routes of administration of antibiotics

In the treatment of non-severe community-acquired pneumonia, preference should be given to oral antibiotics. On the contrary, in severe cases of the disease, antibiotics are administered intravenously. However, in the latter case, stepwise antibacterial therapy may also be highly effective, which involves switching from parenteral to non-parenteral (usually oral) route of administration in the shortest possible time, taking into account the patient’s clinical condition. The main idea of ​​stepwise therapy is to reduce the duration of parenteral administration of an antibacterial drug, which minimizes the cost of treatment and shortens the patient's length of stay in the hospital while maintaining high therapeutic effectiveness. The optimal option for stepwise therapy is the sequential use of two dosage forms (for parenteral administration and oral administration) of the same antibiotic, which ensures continuity of treatment. The transition from parenteral to oral administration of the antibiotic should be carried out when the course of the disease stabilizes or the clinical picture improves:

• reducing the intensity of cough;
• reducing the volume of expectorated sputum;
• decreased shortness of breath;
• normal body temperature with two consecutive measurements with an interval of 8 hours.

5. Duration of antibacterial therapy

For uncomplicated community-acquired pneumonia, antibacterial therapy can be completed once stable normalization of body temperature is achieved (within 3-4 days). With this approach, the duration of treatment is usually 7-10 days.

If there are clinical and/or epidemiological data on mycoplasma/chlamydial or legionella pneumonia, the duration of antibacterial therapy should be longer (risk of relapse of infection) - 2-3 weeks and 3 weeks, respectively.

The duration of administration of antibacterial drugs for complicated community-acquired pneumonia is determined individually.

The persistence of individual clinical, laboratory and/or radiological signs of pneumonia is not an absolute indication for continued antibacterial therapy or its modification. In most cases, their resolution occurs spontaneously or under the influence of symptomatic therapy.

However, if clinical, laboratory and radiological symptoms persist for a long time, it is necessary to conduct a number of additional studies (repeated bacteriological examinations of sputum/bronchial secretions, fibrobronchoscopy, CT of the chest, perfusion scanning of the lungs/occlusive ultrasound venography, etc.), including for exclusion of a number of serious syndrome-related diseases/pathological conditions: local bronchial obstruction (carcinoma), tuberculosis, pulmonary embolism, congestive heart failure, etc.

6. Main mistakes in antibacterial therapy

Widespread use in the Russian Federation of aminoglycosides (gentamicin, etc.) in the treatment of community-acquired pneumonia.

Antibiotics of this group actually do not have antipneumococcal activity.

Widespread use of co-trimoxazole in the treatment of community-acquired pneumonia.

Prevalence of S.pneumoniae strains resistant to the drug in Russia; frequent skin allergic reactions, the presence of safer drugs.

Frequent changes of antibiotics during treatment, “explained” by the danger of developing resistance.

Indications for replacing antibiotics are: a) clinical ineffectiveness, which can be judged after 48-72 hours of therapy; b) development of serious adverse events requiring discontinuation of the antibiotic; c) high potential toxicity of the antibiotic (for example, aminoglycosides), limiting the duration of its use.

Continuation (and modification) of antibacterial therapy while maintaining certain radiological and/or laboratory signs of the disease (focal infiltrative changes in the lungs, acceleration of ESR, etc.) until their complete disappearance.

The main criterion for stopping antibacterial therapy is regression of clinical manifestations of community-acquired pneumonia (primarily persistent apyrexia). The persistence of individual laboratory and/or radiological signs of the disease is not an absolute indication for continued antibacterial therapy (see above).

Frequent prescription of antibiotics with nystatin.

Lack of evidence of the clinical effectiveness of nystatin for candidiasis in patients with community-acquired pneumonia without immunodeficiency, unreasonable economic costs.

Editor

Community-acquired pneumonia (CAP) is a cause of morbidity in adults in developed countries, resulting in high rates of hospitalization.

The 2010 Global Burden of Disease study reported that lower respiratory tract infections, including pneumonia, are the fourth leading cause of death worldwide, exceeded only by coronary heart disease, strokes and chronic obstructive pulmonary disease (COPD).

What it is?

Community-acquired pneumonia (CAP) is an acute infection of the pulmonary parenchyma in a patient who acquired the infection in the community, outside of a health care facility, as opposed to.

ICD-10 code – J18

Causes of occurrence in adults

The causes of pneumonia vary, but for the development of the disease two components are necessary: pathogen And risk factors. Let's start from the second position. In most cases, it is predisposing factors that impair the functioning of the immune system, which gives rise to the introduction and spread of infection.

Risk factors

• smoking;
• weak immune system (drug addiction, HIV (AIDS), tuberculosis, post-radiation conditions, cancer processes, etc.);
• chronic obstructive pulmonary disease (COPD);
• renal and liver failure;
• autoimmune diseases;
• use of certain medications, including proton pump inhibitors (omeprazole);
• chronic alcoholism.

Etiology (pathogens)

Many types of germs can cause pneumonia, but some types are more likely to cause CAP. Worldwide, Streptococcus pneumoniae is the bacterium that most often causes community-acquired pneumonia. in adults. We also list some other common pathogenic bacteria that cause CAP:

• haemophilus influenzae;
• mycoplasma;
• chlamydia;
• legionella;
• gram-negative bacilli;
• staphylococcus aureus.

Pathogenesis

First, the microorganism penetrates into the respiratory sections of the lungs (hematogenous, lymphogenous or bronchogenic route). After which, the pathogen fixes on the epithelial cover of the respiratory bronchioles and begins to multiply.

This leads to inflammation (acute bronchitis, bronchiolitis). Then the process moves to the lung tissue, where the formation of pneumonia occurs. As a result of the inflammatory reaction, a lot of viscous sputum is formed, which interferes with normal breathing.

Most often, the focus of inflammation is localized in the lower segments of the lung (2, 6, 10 in the right and 6, 8, 9, 10 in the left lung).

Due to the introduction of a bacterial agent, regional and lymph nodes of the mediastinum may enlarge.

Classification

Pneumonia differs according to various criteria, therefore, for the convenience of studying them, as well as the formation of treatment regimens, a unique classification has been proposed. Let's take a closer look at it.

Community-acquired pneumonia is classified into:

• typical (in patients without immunodeficiency);
• atypical (in patients with immunodeficiency);
• aspiration

By localization:

• one-sided (right and left);
• bilateral.

By severity:

• abortifacient;
• light;
• average;
• heavy;
• extremely heavy.

With the flow:

• acute;
• protracted.

Symptoms

Symptoms of community-acquired pneumonia often develop rapidly. These symptoms may include:

• breathing problems (it becomes shallow, shortness of breath increases);
• cough (first dry, then with a lot of sputum);
• fever and chills;
• chest pain (worsens with deep breaths and coughing);
• nausea and vomiting (less common);
• weakness.

During examination, specialists note other signs: rapid heartbeat (tachycardia), rapid and shallow breathing, wheezing (fine bubbles) or crepitus during auscultation (listening to the lungs).

Diagnostics

First of all, as a result of collecting anamnesis, the doctor finds out the presence of symptoms of the disease. The doctor checks the throat, the condition of the tongue, and measures the body temperature. Be sure to examine the patient’s skin and conduct auscultation of the lungs.

The main diagnostic methods are:

• chest x-ray (in frontal and lateral projection), which often confirms the diagnosis;
• fluoroscopy;
• computed tomogram;
• laser Doppler flowmetry (determination of microcirculation disorders);
• general ;
• culture of sputum.

Differential diagnosis

Some symptoms and signs of pneumonia may be similar to other diseases, so in some cases it is necessary to carry out a differential diagnosis. More details in the table:

Standards of treatment

Treatment may vary depending on the symptoms and type of infection causing community-acquired pneumonia. If you have severe pneumonia, you will have to undergo treatment. After the diagnosis has been formulated, mild forms of the disease can be treated at home.

The hospital uses antibiotics for treatment. In some cases, intravenous administration is required. If necessary, additional methods are used, we list them:

• oxygen therapy;
• breathing exercises;
• administration of solutions of rehydration salts.

Most people begin to respond to treatment within a few days. A small proportion of patients treated in hospital do not respond to antibiotic therapy.

Important! If there are no results of therapy, analogues of other groups of antibiotics are prescribed. Typically, such a replacement is carried out two days from the start of treatment.

Antibacterial therapy

It is the key and main etiological and pathogenetic method of treatment. It begins from the first hours of the disease (immediately after diagnosis) and lasts 7-10 days. In the first days, when the doctor does not yet know the pathogen, he carries out empirical therapy (using broad-spectrum antibiotics), and after the culture results, he adjusts the treatment depending on the sensitivity of the bacterium. However, antibiotics do not help treat viral pneumonia and can often do more harm than good.

The most effective in the treatment of community-acquired pneumonia are:

• penicillins - aminopenicillins (amoxicillin) and protected penicillins (amoxiclav and others);
• cephalosporins 1-3 generations (cefazolin, cefuroxime, cefotaxime and others);
• macrolides (clarithromycin, erythromycin and others);
• fluoroquinolones (ciprofloxacin and others);
• lincosamides (clindamycin and others).

Outpatient conditions

Patients can be treated on an outpatient basis under 60 years of age, without concomitant diseases with mild or moderate severity of pneumonia. These patients are prescribed oral antibiotics. The specialist describes in detail the doses and frequency of taking the antibiotic. In parallel, anti-inflammatory drugs, hepatoprotectors, vitamins, probiotics, etc. are prescribed. How long the disease is treated depends on the severity of the pneumonia.

Complications

Lung abscess and, less commonly, empyema are possible complications of CAP. In empyema, pus accumulates in the pleural cavity (the space between the lungs and the chest). Treatment includes drainage of the pleural cavity. A CT scan can help diagnose this problem.

Attention! Respiratory failure and death are other possible complications. They are more common in older people or people with underlying health conditions.

Prevention

You can reduce your chances of getting community-acquired pneumonia by having a flu shot. There is also a pneumococcal vaccine that protects against S. pneumoniae and helps prevent CAP. Doctors recommend this for all people over 65 years of age. This may be needed if the patient has:

• chronic diseases of the heart, lungs, liver or kidneys;
• diabetes;
• alcoholism;
• weak immune system.

Smokers and people living in long-term care facilities should also get this vaccine before age 65. Revaccination is also performed if you have already been vaccinated before the age of 65, or if the patient has a weakened immune system.

Practicing regular hygiene will also help reduce the risk of developing CAP. This includes frequent hand washing.

Patients with community-acquired pneumonia should be provided with:

• antimicrobial therapy (empirical/etiotropic);
• non-antibacterial therapy (glucocorticosteroids, immunoglobulins, immunostimulants, statins);
• rehabilitation;
• prevention and clinical observation.

The following sanitary and epidemiological rules will help prevent the spread of pneumonia:

1. It is necessary to monitor cases of morbidity in the area and among certain groups of people.
2. Carry out anti-epidemic measures in the source of infection.
3. Engage in hygienic education of the population.

More detailed information about clinical (national) recommendations and SanPin can be downloaded from the following links: