CHAPTER 1. PNEUMONIA.

Pneumonia - a group of different etiology, pathogenesis,

morphological characteristics of acute infections (mostly bacterial) diseases
characterized by focal lesions of the lungs with respiratory obligatory presence
of intraalveolar exudation, identified by physical and radiological examination.
Classification of pneumonia.
I. Community-acquired (acquired outside the hospital) pneumonia
(synonyms: home, outpatient).
II. Nosocomial (hospital, nosocomial) pneumonia.
III. Inhalation pneumonia
IV. Pneumonia in patients with severe immune defects (congenital
immunodeficiency, HIV infection, iatrogenic immunosuppression).
The practical significance is the unit and community-acquired
pneumonia in the nozokominalnye. It must be emphasized that the main and
sole criterion of distinction is that the environment in which developed
pneumonia.
Community-acquired pneumonia (CAP) - an acute disease that
emerged in the community (outside the hospital or diagnosed in the first 48
hours after admission), accompanied by symptoms of lower respiratory tract
infection (fever, cough, sputum production, possibly pus, pain in the chest,
dyspnea) and radiological signs of "fresh" focal-infiltrative changes in the
lungs in the absence of an alternative
diagnosis (Figure 1).

Fig.1. Community-acquired pneumonia with localization in the middle

and lower lobes of the right legkogogo.
Etiology.
Common pathogens EP are:
Streptococcus pneumoniae (30-50% of cases );
Haemophilus influenzae ( up 10%).

Some importance in the etiology of the EP have atypical organisms,

accounting together account for 8 to 30% of the cases:
- Chlamydophila pneumoniae,
- Mycoplasma pneumoniae,
- Legionella pneumophila.
The rare (3-5%) are the agents of the EP:
- Staphylococcus aureus ,
- Klebsiella pneumoniae , at least - other enterobacteria.
In very rare cases:
- Pseudomonas aeruginosa ,
- Pneumocystis jiroveci .
Sometimes adults revealed mixed or co-infection. For some
microorganisms characterized by the development of bronchopulmonary
inflammation, so their selection of sputum suggests material contamination
flora of the upper respiratory tract, and not about the etiological significance of
these microbes.
In patients hospitalized in medical department, Pneumocokk (the share
of mycoplasma and chlamydia is 25%).
In
severe
VP
release
following
pathogens: Legionella spp ., S . aureus and gram-negative enterobacteria.
Table 1 shows the group of patients with CAP for age, comorbidity and
severity of disease.
Table 1
Group of patients with CP and the likely pathogens
Group
1.

Characteristics of patients

Likely pathogens

Outpatients

Streptococcus pneumoniae

VP non-severe flow

Mycoplasma pneumoniae

In patients younger than 60 years Haemophilus influenzae

with no comorbidity

2.

Outpatients

Streptococcus pneumoniae

In persons older than 60 years and /

or with concomitant diseases

Haemophilus influenzae
S. and ureus

E nterobacteriacae

3.

Hospitalized patients

Streptococcus pneumoniae

(Department of general)

Haemophilus influenzae

VP non-severe flow

Streptococcus pneumoniae
S. and ureus
E nterobacteriacae

4.

Hospitalized patients

Streptococcus pneumoniae

(ICU)

Legionella spp .

VP severe

S. and ureus
E nterobacteriacae

Note. Pulmonology. National leadership ed. AG Chuchalina, 2009.

Pathogenesis.
There are four major pathogenetic mechanism, which at different times
cause the development of the EP:
- Aspiration of oropharyngeal secretions;
- Inhalation aerosol containing bacteria;
- Hematogenous spread of microorganisms from the extracellular site
of infection (endocarditis tricuspid valve, septic thrombophlebitis of the veins
of the pelvis);
- Direct spread of infection from adjacent affected organs (eg, liver
abscess) or by infection with penetrating injuries of the chest.
Diagnostics.
Suspected pneumonia should occur if the patient fever combined with
complaints of cough, dyspnea, sputum production, and / or chest pain.
Classical objective evidence of the EP are:
- Strengthening the voice trembling;
- Shortening (dullness) percussion over the affected areas of the lung;
- Locally listens bronchial breathing;
- Crepitus or finely wheezing;
- Strengthening brohofonii.

The presence of focal and infiltrative changes in the lungs on chest

radiography in conjunction with the appropriate symptoms in the lower
respiratory tract can verify the diagnosis of pneumonia.
Radiographic signs of pneumonia - infiltrative, usually unilateral lung
tissue shadowing, which can be focal, confluent, segmental (Fig. 2), equity
(usually homogeneous) and total. X-ray examination should be performed in
two projections - posterior-anterior and lateral. In carrying out the study should
assess the prevalence of infiltration, the presence or absence of pleural effusion
and oral destruction.
Pleural effusion complicates the course of the EP in 10-25% of cases and
is not important in predicting the etiology of the disease (3).

Fig. 2. Community-acquired pneumonia segmental localized in the right

upper lobe.

Figure 3. Community-acquired pneumonia, complicated by exudative

pleurisy.
Destruction of the lung cavities occur when staph infections, aerobic
Gram-negative enteric pathogens and anaerobes.

According to the X-ray method of investigation can not be said about the
etiology of pneumonia.
Minimum diagnostic examination:
- Chest radiography in two projections;
- CBC: leukocytosis of 10-12 10 9 / l indicates a high likelihood of
bacterial infection, and leukopenia below 3 x 10 9 / L or leukocytosis above
25 x 10 9 / L are adverse prognostic features.
- Blood chemistry - urea, creatinine, electrolytes, liver enzymes;
- Microbiological diagnostics: smear microscopy, Gram stained,
sputum culture to isolate the pathogen and evaluation to determine its
sensitivity to antibiotics, blood culture study (optimally conduct sampling of
two samples of venous blood from different veins at intervals of 30-60 minutes
prior to the appointment of antibiotic therapy).
- Arterial blood gas (PaO 2 , PaCO 2 ) to clarify the need for mechanical
ventilation.
- In the presence of pleural effusion and safety conditions of the pleural
puncture (visualization on laterogramme svobodnosmeschaemoy fluid layer
thickness>1.0 cm) study of the pleural fluid.
Criteria for diagnosis.
Diagnosis VI is certain if the patient radiographic evidence of focal
infiltration of the lung tissue, and at least two clinical signs of the following:
a) acute fever at onset ( t of > 38.0 o C);
b) cough;
c) the objective evidence (short percussion, focus crepitations and / or
finely wheezing, severe bronchial breathing);
d) leukocytosis> 10x10 9 / L and / or stab shift (> 10%) .
The absence or unavailability of radiographic evidence of focal
infiltration in the lung (radiography or fluorography krupnokadrovaya chest)
makes the diagnosis of VP inaccurate / uncertain . This diagnosis of the
disease based on the account data of epidemiological history, complaints and
the corresponding local symptoms.
If the examination of the patient with fever, complaining of cough,
dyspnea, sputum production, and / or pain in the chest X-ray examination of
the thoracic cage is not available and there is no corresponding local
symptoms (shortening / dullness) percussion over the affected areas of the
lung, locally listens bronchial breathing, focus sonorous finely wheezing or
inspiratory crepitations, strengthening bronhofonii and voice jitter), the
assumption that the EP is unlikely .
Diagnostics VI, based on the results of a physical examination and xray, can be equated to a syndromic diagnosis, nosological he becomes after
determining the causative agent.

Criteria for severe CAP.

Severe form of the EP - a special form of the disease of various
etiologies, manifested severe respiratory failure and / or signs of severe sepsis
or septic shock, characterized by a poor prognosis and require intensive care
(Table 2).

Table 2
Criteria for severe CAP.
Clinical

Laboratory

1. Acute respiratory failure:

1. Leukopenia (<4x10 9 / l)

- Respiratory rate> 30 min,

2. Anoxemia

2. Hypotension

- SaO 2 <90%

- Systolic blood pressure < 90 mm.Hg

- PaO 2 <60 mm Hg

- Diastolic
mm.Hg

blood

pressure

< 60 3. Hemoglobin <100 g / L

3. Two or mnogodolevoe defeat

4. Impaired consciousness
5. Extrapulmonary site of infection
(meningitis, pericarditis, etc.)

4. Hematocrit <30%
5. Acute renal failure (anuria, blood
creatinine> 176 mmol / l, urea nitrogen
7,0 mg / dl)

Complications EP.
Among the complications of the EP are:
a) pleural effusion (Figure 4);
b) empyema;
a) Destruction / abstsedirovanie lung tissue (Fig. 5);
d) acute respiratory distress syndrome;
e) acute respiratory failure;
e) of septic shock;
g) secondary bacteremia, sepsis, hematogenous focus dropout rates;
h) pericarditis, myocarditis;
and) nephritis, etc.

Figure 4. Right hand

effusion

pleural

Fig. 5. polysegmentary
necrotizing
pneumonia with the localization of the
middle and lower lobes of the right lung
and the lower left.

Indications for consultation with other specialists:

- TB specialist advice to exclude pulmonary tuberculosis,
- Consulting oncologist for suspected neoplasm
- Consulting cardiologist to avoid cardiovascular disease.
Treatment.
Antimicrobial therapy of CAP in ambulatory patients is presented in
Table 3, in hospitalized in Table 4.
Table 3
Antimicrobial therapy of community-acquired pneumonia in
outpatients .
Group

The most
The drug of choice
Alternative
common
medications
pathogens
Non-severe CAPS . pneumoniae Amoxicillin
in
or**
Respiratory
in patients underM. pneumoniae macrolides * inside
fluoroquinolones
60 years of ageS. pneumoniae
(levofloxacin,
without
N. Influenwe
moxifloxacin,
concomitant
gemifloxacin)
disease
inside

Comments

Non-severe CAPS. pneumoniae

in patients overH . influenzae
60 years of ageS. aureus
and
/
orEnterobacle comorbidities
nacea

Amoxicillin clavulanate Respiratory

in or
fluoroquinolones
Amoxicillin + sulbactam(levofloxacin,
inside
moxifloxacin,
gemifloxacin)
inside

Concomitant
diseases
affecting
the
etiology
and
prognosis
of
COPD
VP,
diabetes,
congestive heart
insufficiency,
cirrhosis,
alcohol abusetion,
the
depletion

Note. * Preference should be given a macrolide antibiotic with improved

pharmacokinetic
properties
(clarithromycin,
roxithromycin,
azithromycin,
spiramycin). Macrolide antibiotics are the treatment of choice for suspected atypical
pneumonia etiology ( M . pneumoniae , S. pneumoniae ) .
Doxycycline can be administered ** for suspected atypical etiology VP
( M . pneumoniae , S. pneumoniae ), but consider the high (> 25%), the level of resistance of
pneumococci to him in Russia.
Pulmonology: National guidelines / Ed. AG Chuchalina, 2009.

Table 4
COMMUNITY-ACQUIRED PNEUMONIA antibacterial therapy in
hospitalized patients
Group
Non-severe
pneumonia
flow

The most frequent

pathogens
S.pneumoniae
H.influenzae
C.pneumoniae
S.aureus
Enterobacteriaceae

The recommended treatment regimen

Drugs of choice
Alternative
medications
Benzylpenicillin in / in / m Respiratory
macrolide inside;
fluoroquinolones
Ampicillin
/
in
/ (levofloxacin,
m

macrolide moxifloxacin) in /
inside
Azithromycin in /
Amoxicillin + Clavulanic
acid macrolide inside
Cefotaxime in / in /
m
macrolide inside
Ceftriaxone in / in /

Pneumonia
heavy
flow

S.pneumoniae
Legionella spp.
S.aureus
Enterobacteriaceae

m
macrolide inside
Amoxicillin + Clavulanic
acid macrolide in /
Cefotaxime in / in /
m
macrolide
in /
Ceftriaxone in / in /
m
macrolide in /

Respiratory
fluoroquinolones
(levofloxacin,
moxifloxacin) in /
+
III
generation
cephalosporins in /

Note. should be preferred macrolide antibiotics with improved pharmacokinetic

properties (clarithromycin, azithromycin, spiramycin).
Pulmonology: National guidelines / Ed. AG Chuchalina, 2009.

Dosing regimen of antibiotics for the empirical treatment of CAP in

adults is presented in Table 5.
Table 5
Dosing regimen of antibiotics for the empirical treatment of CAP in
adults (at A.G.Chuchalinu, 2008).
PM

Inside

Parenteral

2,000,000 units 4-6

times / day

Amoxicillin

0.5 -1 g 3 times / day

Ampicillin

Not recommended

1g four times a day

0.625 g 3 times a day

1.2 g 3 times a day

Ticarcillin + clavulanic
acid

3.2 g 3 times a day

Piperacillin +

4.5 g 3 times a day

Benzylpenicillin

Amoxicillin +
Clavulanic acid

tazobactam
Cefuroxime

0.75 g 3 times a day

Cefotaxime

1 -2 g 3-4 times a day

Ceftriaxone

1 -2 g 1 time / day

Cefepime

2 g 2 times a day

Cefoperazone +

2 -4 g 2 times / day

Imipenem

0.5 g 3 times a day

Meropenem

0.5 g 3 times a day

Ertapenem

1 g 1 time a day

Clarithromycin

0.5 g 2 times a day

0.5 g 2 times a day

Midekamitsin

0.4 g 3 times a day

Roxithromycin

0.15 g 2 times a day

Spiramycin

3 MU 2 times / day

1.5 million IU 3 times /

day

Erythromycin

0.5 g 4 times a day

0.6 g 3 times a day

sulbactam

Clindamycin

0.3 - 0.45 g 4 times / day

0.6 g 4 times a day

Lincomycin

0.5 g 3 times a day

0.3 - 0.6 g3 times / day

Doxycycline

0.1 g 2 times a day

0.1 g 2 times a day

Ciprofloxacin

Not recommended

0.2 -0.4 g 2 times a day

Ofloxacin

Not recommended

0.4 g 2 times a day

Levofloxacin

0.5 g 1 time a day

0.5 g 1 time a day

Moxifloxacin

0.4 g 1 time a day

0.4 g 1 time a day

Gentamicin

3-5 mg / kg, 1 time a day

Amikacin

15 mg / kg, 1 time a day

Rifampicin

0.3 -0.45 g 2 times / day

0.5 g 3 times a day

0.5 g 3 times a day

Metronidazole

Initial assessment of the effectiveness of antibiotic therapy should be

carried out in the hospital 48 hours after the start of treatment (in severe cases
after 24 hours). main performance criteria are:
- Reduction of body temperature;
- Reducing the symptoms of intoxication;
- Reduction of respiratory failure.
If the above listed symptoms persist, you should review the treatment
strategy.
Duration of antibiotic therapy.

When mild EP antimicrobial therapy can be completed on reaching

stable normalization of body temperature (within 3-4 days). In this approach,
the duration of treatment is usually7.10days. In the case of clinical and / or
epidemiological data on mycoplasma and chlamydial etiology VP, duration of
therapy should be 14 days. When severe CAP unknown etiology recommended
10-day course of antibiotic therapy. In the same period, usually the
disappearance of leukocytosis.
In the case of clinical and / or epidemiological evidence of
mycoplasmal or chlamydial etiology of the EP, the duration of therapy should
be 14 days.
Longer courses of antibiotic therapy is indicated for VP or VP
staphylococcal etiology caused by Gram-negative enterobacteria, - from 14 to
21 days.
When showing Legionella pneumonia duration of antibiotic therapy is
21 days.
Indications for hospitalization:
1. physical examination data : respiratory rate > 30/min, di astolicheskoe blood
pressure <60 mm Hg, systolic blood pressure < 90 mmHg, heart rate > 125 / min,
body temperature <35,0 C or> 40,0 C, impaired consciousness.
2. Laboratory and X-ray data : the number of leuco peripheral blood
lymphocytes <4,0 10 9 / L or> 25,0 10 9 / L; SaO 2 <92% (according to data of
the pulse oximetry), PaO 2 <60 mmHg and / or PaCO 2 >50 mm Hg while
breathing room air, serum creatinine> 176.7 mmol / L, or BUN> 7.0 mmol / L
(BUN = urea, mmol / l / 2.14), pneumonic infiltration, localized Bo Lee than
one lobe, the presence of a cavity (cavities) decay; pleural effusion, rapid
progression of the focal-infiltrativechanges in the lungs (increase in the size of
infiltration> 50% within the next 2 days), hematocrit <30% or hemoglobin <90 g /
l, extrapulmonary sites of infection (meningitis, septic arthritis, etc.), sepsis or
multiple organ failure, manifested metabolicacidosis (pH <7.35), coagulopathy.
3. Inability to perform adequate care of all medical prescriptions in the
home.
The question of preference for hospital treatment because VI can also be seen
in the following cases:
1. the age of 60 years;
2. associated diseases ( COPD, bronchiectasis, cancer, diabetes mellitus,
chronic kidney disease III - IV Art., congestive heart failure, chronic alcoholism,
drug abuse, expressed underweight, cerebrovascular disease);
3. Inefficiency starting antibiotic therapy;
4. Desire patient and / or family members.
In cases where the patient have the signs of severe ones tion AM
(tachypnea > 30/min, systolic blood pressure
< 90 mmHg, bilateral or mnogodolevaya pneumonic infiltration tration, the rapid
progression of the focal-infiltrative changes in the lungs, septic shock or need

vazopres sors> 4 hours, acute renal failure) requires immediate hospitalization

in the ICU.