Pathogens of community-acquired pneumonia in children. Effective treatment of community-acquired pneumonia in children

Community-acquired pneumonia(synonyms: home, outpatient) - acute infection lungs of various, predominantly bacterial etiologies, developing outside the hospital or in the first 48-72 hours of hospitalization, accompanied by symptoms of damage to the lower respiratory tract(fever, shortness of breath, cough and physical findings), in the presence of infiltrative changes on the radiograph. Treatment of community-acquired pneumonia in children is a pressing issue in pediatrics. The morbidity and mortality rate from this disease remains quite high. A serious problem is timely diagnosis and adequate treatment of pneumonia in outpatient settings, especially in children younger age. In recent years, new data have emerged on the etiology of pneumonia, which requires changes in approaches to etiotropic treatment of the disease.

The development of pneumonia is associated with the penetration of microorganisms into the respiratory system. Whether an inflammatory reaction occurs in the lung parenchyma depends on the number and virulence of microorganisms, the state of the protective mechanisms of the respiratory tract and the body as a whole. Pathogenic microorganisms can enter the lungs in several ways: aspiration of nasopharyngeal secretions, inhalation of an aerosol containing microorganisms, and hematogenous spread of the microorganism from an extrapulmonary source of infection. Aspiration of nasopharyngeal contents is the main route of infection of the lungs and the main pathogenetic mechanism for the development of pneumonia. Microorganisms often colonize the nasopharynx, but the lower respiratory tract remains sterile. Microaspiration of nasopharyngeal secretions is a physiological phenomenon observed in many healthy individuals, mainly during sleep. However, the cough reflex, mucociliary clearance, and the antibacterial activity of alveolar macrophages and secretory immunoglobulins ensure the elimination of pathogens from the lower respiratory tract. It is during aspiration of secretions from the nasopharynx that Streptococcus pneumoniae, as well as Haemophilus influenzae, gram-negative bacteria and anaerobes, usually enter the lungs.

The etiology of community-acquired pneumonia is associated with microflora colonizing the upper respiratory tract. The type of microorganism that caused the disease depends on the conditions in which the infection occurred, the age of the child, previous antibiotic therapy, and the presence of underlying diseases.

Community-acquired pneumonia in children in the first 6 months of life is variable and differs in clinical manifestations and etiology. Focal (focal, confluent) pneumonia is accompanied by febrile fever and most often develops in children with habitual aspiration of food (with reflux and/or dysphagia), as well as as the first manifestation of cystic fibrosis and immune defects. The main causative agents of focal pneumonia at this age are enterobacteria and staphylococci. Pneumonia with predominantly diffuse changes in the lungs occur with slightly increased or normal temperature bodies. Their causative agent is most often Chlamydia trachomatis, which infects the child during childbirth.

Community-acquired pneumonia in children over 6 months to five years of age is most often caused by S. pneumoniae (in 70-88% of cases); H. influenzae type b is rarely detected (up to 10%). Pneumonia caused by Mycoplasma pneumoniae is observed in 15% of patients, and caused by Chlamydophila pneumoniae - in 3-7%. In children over five years of age, pneumococcal pneumonia accounts for 35-40% of all cases, and pneumonia caused by M. pneumoniae and C. pneumoniae accounts for 23-44% and 15-30%, respectively. Viral respiratory infections and, above all, epidemic influenza are, of course, considered as a leading risk factor for pneumonia, since they are a kind of “conductor” of bacterial infection.

It has been established that, regardless of the severity of the patients, S. рneumoniae dominates in the etiology of community-acquired pneumonia, however, as the severity increases, the proportion of S. aureus, Legionella рneumophilae, H. influenzae and enterobacteriae increases, and the value of M. pneumoniae and C. pneumoniae decreases.

The decisive method for the timely diagnosis of pneumonia is a plain radiograph. chest, which allows you to identify the extent of the lesion and the presence of complications. However, chest radiography is of little information in differentiating bacterial and non-bacterial pneumonia. There are also no radiological signs that are pathognomonic for mycoplasma pneumonia.

The possibilities of microbiological diagnosis of community-acquired pneumonia are limited by objective reasons, and therefore are practically not carried out on an outpatient basis. A large age range - from the neonatal period to adolescence with the characteristics of each of them - also creates certain objective difficulties in etiological diagnosis. To clarify the etiology and determine treatment tactics for community-acquired pneumonia in children, it may be useful to determine the level of procalcitonin (PCT) in the blood. A number of studies have shown that a PCT value of more than 2 ng/ml is highly likely to indicate a typical etiology of infection, primarily pneumococcal. With mycoplasma pneumonia, the PCT value usually does not exceed 2 ng/ml. It has been shown that the PCT level correlates with the severity of pneumonia, and adequate therapy quickly leads to a decrease in the level. There is evidence that antibacterial therapy for pneumonia under dynamic monitoring of PCT levels can reduce the time of antibiotic use.

Treatment of pneumonia in children under 6 months is carried out in a hospital setting. In children aged 1 to 6 months with community-acquired pneumonia, broad-spectrum antibiotics are usually prescribed parenterally: inhibitor-protected penicillins or cephalosporins of the second-third generation.

Penicillins, cephalosporins, macrolides and lincosamides, and in severe cases also carbapenems, are considered as treatments for community-acquired pneumonia in children over 6 months of age caused by typical pathogens. The choice of drug for empirical therapy is carried out taking into account the most likely pathogen and its sensitivity in the region, the age of the patient, the presence of underlying diseases, as well as the toxicity and tolerability of antibiotics for a particular patient.

When choosing antibacterial therapy in children with community-acquired pneumonia, significant problems may arise, which are caused by the phenomenon of acquired resistance of pathogens to antibacterial drugs. Resistance of pathogens of community-acquired pneumonia is observed mainly in patients with chronic diseases often receiving antibiotics, and in children living in closed groups (boarding schools, orphanages).

According to the Russian study of antimicrobial resistance PeGAS-III, conducted in 2006-2009. in several dozen cities across the country, high activity Amoxicillin and amoxicillin/clavulanate remain effective against S. pneumoniae—only 0.4% of strains exhibit moderate resistance. Also, pneumococci always remain highly sensitive to ertapenem, vancomycin and respiratory fluoroquinolones. However, the first two drugs cannot be recommended for widespread use due to the presence of only a parenteral form, and the use of fluoroquinolones in pediatric practice is limited. The level of resistance (including strains with moderate resistance) to penicillin is 11.2%, to third generation cephalosporins from 1% (cefotaxime and ceftriaxone) to 6.8-12.9% (cefixime and ceftibuten), macrolides 4.6-12 %, clindamycin 4.5%, tetracycline 23.6%, chloramphenicol 7.1%, co-trimoxazole 39%. According to a similar study PeGAS-II (2004-2005), H. influenzae always remains highly sensitive to amoxicillin/clavulanate, cefotaxime, imipinem and fluoroquinolones. The resistance rate (including moderately resistant strains) to ampicillin is 5.4%, tetracycline 5%, chloramphenicol 4.7%, co-trimoxazole 29.8%. Thus, amoxicillin and inhibitor-protected aminopenicillins should be primarily considered as the optimal choice for empirical treatment of community-acquired pneumonia in children over 6 months of age caused by typical pathogens. These drugs are recommended as the first line of etiotropic treatment of pneumonia in children in a number of foreign guidelines.

Amoxicillin is a semisynthetic antibiotic penicillin from the aminopenicillin group, which has a bactericidal effect due to inhibition of bacterial wall synthesis. Just like natural penicillins, aminopenicillins are active against gram-positive cocci (staphylococci, streptococci, pneumococci, enterococci) and bacilli (listeria, diphtheria and anthrax pathogens), gram-negative cocci (meningococcus and gonococcus), spirochetes (treponema, leptospira, borrelia ), spore-forming (clostridia) and most non-spore-forming (excluding Bacteroides fragilis) anaerobic bacteria, actinomycetes. Unlike natural penicillins, aminopenicillins have an extended spectrum of action due to natural activity against a number of gram-negative bacilli: Haemophilus influenzae, Helicobacter pylori and some representatives of the Enterobacteriaceae family - Escherichia coli, Proteus mirabilis, Salmonella spp. and species of individual Shigella.

Amoxicillin is a derivative of ampicillin with significantly better pharmacokinetics: when used orally, the bioavailability of the drug is more than 90% and does not depend on food intake (for ampicillin, the bioavailability is 40% and is halved when ingesting food), as a result of which amoxicillin creates more high and stable concentrations in the blood. An important feature of amoxicillin is the creation of a high concentration of the drug in bronchial secretions, which is twice the concentration in the blood. The half-life of amoxicillin (assuming normal renal function) is approximately 1.3 hours. From 17% to 20% of amoxicillin binds to plasma and tissue proteins. About 10% of amoxicillin undergoes biotransformation in the liver. More than half of the drug (50-78%) is excreted unchanged in the urine.

It is generally accepted that enzymatic inactivation by beta-lactamases is the most common and important mechanism of bacterial resistance to beta-lactam antibiotics. Aminopenicillins, like natural penicillins, are subject to hydrolysis by all known beta-lactamases. In recent years, there has been a steady increase in resistance to antibacterial drugs in bacterial pathogens of both nosocomial and community-acquired infections throughout the world. As a result, aminopenicillins have lost their importance in the treatment of many infections, the etiological structure of which is dominated by bacteria with a high level of secondary resistance, primarily due to the production of beta-lactamase. Thus, today aminopenicillins have completely lost their value in the treatment of staphylococcal infections, since the vast majority (more than 80%) of strains of S. aureus and other species produce beta-lactamases. Also, most E. coli strains have become resistant to aminopenicillins. In recent years, there has been an increase in the proportion of beta-lactamase-producing strains of H. influenzae.

Overcoming the effects of beta-lactamases is possible in two ways: using enzyme-resistant antibiotics and using a combination of an antibiotic with beta-lactamase inhibitors. By their structure, beta-lactamase inhibitors (clavulanic acid, sulbactam, tazobactam) are also beta-lactam compounds, which themselves are practically devoid of antibacterial activity, but are capable of irreversibly binding to bacterial enzymes, thereby protecting antibiotics from hydrolysis. When used concomitantly, beta-lactamase inhibitors significantly expand the spectrum of activity of penicillins and cephalosporins, both by restoring the activity of the antibiotic against strains of many bacteria with secondary resistance (due to acquired beta-lactamase production), and by the appearance of activity against some bacteria with primary resistance (due to the natural ability of these bacteria to produce beta-lactamases). Combination with clavulanate, firstly, restores the activity of amoxicillin against bacteria that are initially sensitive to aminopenicillins: penicillin-resistant staphylococci (but not methicillin-resistant), beta-lactamase-producing strains of gram-negative bacteria - H. influenzae, E. coli and others. Secondly, the addition of clavulanate gives amoxicillin activity against a number of microorganisms with natural resistance to aminopenicillins - bacteria of the genus Klebsiella, Proteus vulgaris, B. fragilis and some others.

For severe forms of community-acquired pneumonia or if the child is unable to take them orally (for example, due to vomiting), stepwise therapy is carried out: antibacterial drugs are prescribed intravenously, and when the condition improves, it is recommended to switch to oral antibiotics. The main idea of ​​step therapy is to reduce the duration of parenteral antibacterial therapy, which provides a significant reduction in the cost of treatment and a shortening of the patient's length of stay in the hospital while maintaining high clinical effectiveness. The most rational option for step therapy is the sequential use of two dosage forms the same antibiotic, which ensures continuity of treatment.

In case of pneumonia caused by atypical pathogens, there are no difficulties with the choice of antimicrobial therapy, since macrolides retain high, stable activity against M. pneumoniae, C. pneumoniae and Legionella pneumophilae. Other antibacterial agents for pneumonia of this etiology are not used either due to the lack of activity against these pathogens (all beta-lactam antibiotics, aminoglycosides, lincosamides) or due to age restrictions (fluoroquinolones).

Evaluation of the effect of prescribed antibacterial treatment should be carried out 24-48 hours from the start of therapy. Treatment of pneumonia requires the use of sufficient doses effective antibiotic within the optimal period of time. In recent years, there has been a tendency to reduce the duration of antibiotic use, even in severe cases of community-acquired pneumonia. The duration of antibacterial therapy should be determined taking into account concomitant diseases, the presence or absence of bacteremia, the severity and course of the disease. In most cases, the duration of treatment for community-acquired pneumonia in children ranges from 7 to 14 days.

When conducting antibacterial therapy, it is important to rationally combine antibiotics with other drugs used for community-acquired pneumonia. Quite often, children with pneumonia have an unproductive cough, which requires the use of mucolytic therapy. It has been established that the mucolytic ambroxol increases the concentration of various antibiotics (amoxicillin, cefuroxime, erythromycin) in bronchial secretions. There is also evidence that ambroxol increases the penetration of amoxicillin into lung tissue. In a randomized, placebo-controlled clinical trial, ambroxol was found to improve the clinical effectiveness of antibiotics in children with lower respiratory tract infections. Ambroxol is prescribed orally (in the form of solution, syrup or tablets) or inhalation.

In some cases, community-acquired pneumonia occurs with symptoms of bronchial obstruction. This is typical for children early age and children with atopy, as well as if pneumonia is caused by atypical pathogens (M. pneumoniae, C. pneumoniae) or developed against viral infection. Such situations require the inclusion of bronchodilators in complex therapy. In children, the use of metered-dose aerosol inhalers is often difficult due to the disadvantages of inhalation technology associated with age characteristics, the severity of the condition, which influences the dose delivered to the lungs and therefore the response. Therefore, it is preferable to use nebulizer therapy, which is easy to implement, highly effective and can be used from the first months of life. The most effective is the use of a combination drug containing a beta2-adrenergic agonist (fenoterol) and an anticholinergic drug (ipratropium bromide). The components of the drug have different points of application and, accordingly, mechanisms of action. The combination of these substances potentiates the bronchodilator effect and increases its duration. The complementary action is such that a lower dose of the beta-adrenergic component is required to achieve the desired effect, which allows almost complete avoidance side effects.

Literature

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I. K. Volkov,
N. A. Geppe, Doctor of Medical Sciences, Professor
A. B. Malakhov, Doctor of Medical Sciences, Professor
I. A. Dronov, Candidate of Medical Sciences
F. I. Kirdakov, Candidate of Medical Sciences, Associate Professor

First Moscow State Medical University named after. I. M. Sechenova,Moscow

Pneumonia in children is one of the most common diagnoses; the community-acquired form is slightly less common, but it is no less dangerous.

Description

Community-acquired pneumonia is an acute infectious and inflammatory disease of the upper respiratory tract that occurs in a small patient in the first two days after hospitalization or outside a medical institution.

Important! Most often, community-acquired pneumonia is a complication of untreated ARVI.

Children are more susceptible to this disease due to the structure of the respiratory tract; under 5 years of age they are not as developed as in adults and are more vulnerable.
The bronchi and trachea in young children are much narrower, this contributes to the stagnation of sputum, which in turn opens up favorable conditions for the development of microorganisms.

All pneumonias are divided into hospital-acquired and community-acquired, as well as:

• focal – affects a separate area;
• segmental – affects several areas;
• lobar – completely one of the lobes;
• left-handed and right-handed.

More details about the pathology can be found in the video below.

Causes

Pneumonia is most often caused by viruses, fungi and bacteria. Children are most often affected by:

• pneumococci;
• mycoplasma;
• chlamydia (pulmonary);
• staphylococci;
• streptococci;
• Klebsiella;
• hemophilus influenzae;
• coli;
• Pseudomonas aeruginosa;
• fungi;
• helminths.

Community-acquired pneumonia in children in 80% of cases is caused by mycoplasmas, staphylo- and pneumococci, and adenoviruses.

Doctors identify a number of provoking factors:

• low immunity;
• passive smoking;
• chronic respiratory tract infections;
• hypothermia or overheating;
• lack of oral hygiene;
• low activity (especially for newborns);
• poor nutrition;
• avitaminosis.

Symptoms

Symptoms of community-acquired pneumonia depend on the pathogen that caused the disease and the age of the child.

Main manifestations:

• elevated temperature, from 37.2 C° to 39 C and above;
• shortness of breath, rapid breathing;
• shallow breaths;
• lack of appetite;
• lethargy;
• moodiness;
• chest pain;
• wheezing;
• cough.

Pneumonia is characterized by an uncontrollable or difficult-to-control temperature that returns after a few hours. Doctors recommend not taking antipyretics until the temperature reaches 38.8 C°. For children under one year old, the critical point is much lower - 37.5 C°.

A cough with pneumonia begins either immediately or around the 5th day. It is usually dry, with proper treatment turns into wet, sputum discharge is facilitated. A wet cough in acute community-acquired pneumonia is accompanied by purulent yellow sputum.

Important! In young children characteristic feature pneumonia is also the sinking of the skin when inhaling into the intercostal space.

Diagnosis of community-acquired pneumonia is complicated by the fact that initial stage may be similar to a regular acute respiratory viral infection, and in the first three days a false improvement occurs.

The medication is stopped, meanwhile the disease progresses and complications begin.

Treatment

It is necessary to treat pneumonia, whether community-acquired or any other, under the supervision of a doctor. In some cases, hospitalization is not necessary and the acute period passes after two weeks of treatment and bed rest.

But in most cases, especially when it comes to children under 1 year of age, treatment at home is excluded.

Important! Pneumonia is caused by pathogenic organisms that can only be treated with properly selected antibiotics. You can't do it with herbs alone.

Medication

Treatment is carried out comprehensively, antibiotics are prescribed, antiviral drugs, mucolytic and expectorant drugs, anti-inflammatory drugs, as well as drugs to strengthen immune system, but after recovery.

Antibiotics and antifungals are drugs of different groups, depending on the pathogen:

• penicillins - “Ampicillin”, “Oxacillin”, “Amoxicillin”;
• cephalosporins - Cefazolin, Ceftriaxone, Cefuroxime;
• aminopenicillins - “Clavulanate”, “Sulbactam”;
• azithromycins - “Sumamed”, “Azitrox”;
• macrolides – “Erythromycin”, “Spiramycin”, “Clarithromycin”;
• tetracyclines – “Doxycycline”.

Antibiotics and antifungal drugs are selected based on the presence of contraindications, depending on the identified viruses and bacteria, and on the age of the patient. Prescribed in the form of tablets, suspensions, injections or droppers.

Mucolytics and expectorants help cough, thin mucus, and make breathing easier - Bromhexine, Fluimucil, Ambroxol, Ambrobene.

Robotics are an integral part of treatment; they are prescribed in combination with antibiotics to maintain microflora and as a prevention of dysbacteriosis - “Bifiform”, “Yogurt”, “Hilak Forte”, “Bifidumbacterin”.

Important! Antitussive drugs for community-acquired pneumonia are prohibited!

Inhalations

Inhalations are indicated as additional measures in some cases.

Basic rules for the procedure:

• 2 hours before meals or 2 hours after;
• duration no more than 10 minutes;
• do not talk, do not interrupt the procedure;
• choose clothes with an open neck;
• inhale through the mouth, exhale through the nose;
• inhale slowly, hold your breath for 5 seconds, exhale slowly;
• do not go outside after the procedure for 3 hours;
• after inhalation, lie motionless for 20 minutes.

Herbal inhalations and other folk compositions will perfectly help with community-acquired pneumonia and reinforce the effect of medications.

1. Calendula
   1 tbsp. pour 1 cup of flowers cold water, place over low heat, bring to a boil, stirring constantly. Cook covered for 10 minutes. Let cool for 5 minutes.
2. Baking soda and sea salt
   For a glass of boiling water, 1 tbsp. soda and sea ​​salt, stir until dissolved. Pour the mixture into a bowl or nebulizer.
   Essential oils For 250 ml. boiling water, take 10 drops each of juniper and pine oil, 5 drops each of spruce and fir.

Important! Inhalations are contraindicated for children with a temperature above 37.5 C°.

Massage

Preventive and therapeutic massage can be performed independently. Such manipulations will help:

• strengthen the muscles of the lungs and bronchi;
• improve breathing;
• normalize lung ventilation;
• relieve expectoration;
• accelerate the resorption of the source of pneumonia.

Canning

1. Lubricate the baby's chest with oil, cream or Vaseline.
2. Heat the jar over the fire for a few seconds.
3. Place the jar on the body, a vacuum should form.
4. Perform circular movements clockwise without breaking the vacuum.
5. The second stage is the same, but now on the patient’s back.

Spot

The massage is performed by pressing on certain points and massaging for 2 minutes.

1. Deepening of the jugular cavity.
2. Under the 7th cervical vertebra, on the back.
3. Between the thumb and index finger, on the outside of both hands alternately.
4. Base of the phalanx thumbs hands
5. Massage is carried out every other day.

Percussion

Before and after the procedure, actively rub the baby’s chest and back.

1. Place your left palm on the baby's chest.
2. With the fist of your right hand, rhythmically, but not too hard, tap your hand.
3. Tap alternately in the subclavian zone and under the lower costal arch with 3 claps.
4. Turn the baby onto his stomach.
5. Perform the same manipulations under, between and above the shoulder blades.
6. Massage for 10 minutes 2 times a day.

You can learn more about how to properly perform percussion massage from the video:

Breathing exercises

Regular exercise will help you quickly recover from your illness. respiratory system child.

Basic exercises

1. Purse your lips tightly, take a deep breath through your nose and exhale through your mouth, without opening your lips - there is resistance to the air, the lungs tense up and begin to work more actively.
2. Inhale deeply through your nose, hold your breath for 3-5 seconds. Exhale through your mouth, without puffing out your cheeks, in short bursts.
3. The exercise is performed in the same way as the previous one, only the pronunciation of any sounds is added to the exhalation pushes.

Prevention

Pneumonia is a serious and dangerous disease, therefore it is better to pay attention to prevention rather than treating it later.

Basic measures:

• vaccination against Haemophilus influenzae, pneumococcus, whooping cough and measles;
• breastfeed newborns (this will provide good nominal protection);
• balanced and nutritious nutrition;
• walks in the fresh air, active lifestyle;
• regular ventilation of the room;
• lack of carpets in the child’s bedroom;
• regular wellness, visits to the sea, forest areas, mountains;
• protect your child from tobacco smoke;
• maintaining good hygiene, especially in the mouth and hands;
• timely treatment of colds and flu.

»» 10/2002 V. K. Tatochenko, Doctor of Medical Sciences, Professor, Scientific Center for Children's Diseases of the Russian Academy of Medical Sciences, Moscow

How is pneumonia classified?
What is the spectrum of pathogens causing acute pneumonia in children depending on age?
How to choose the right starting antibiotic?

According to the classification accepted in Russia, pneumonia in children is defined as an acute infectious disease of the pulmonary parenchyma, diagnosed by the syndrome of respiratory distress and/or physical findings in the presence of focal or infiltrative changes on an x-ray. The presence of these radiological signs (“gold standard”, according to WHO) with a high degree of probability indicates the bacterial etiology of the process and allows us to exclude from the range of diseases defined as pneumonia, most lesions of the lower respiratory tract (bronchitis, including obstructive ones) caused by respiratory viruses and not requiring antibacterial treatment.

The selection of antibiotics for the treatment of pneumonia is optimal when deciphering its etiology; however, express methods are not always reliable and accessible. An acceptable alternative is to determine the most likely pathogen - taking into account the obvious symptoms, as well as the age of the patient, time and place of development of the disease. The information below regarding the spectrum of bacterial pathogens of pneumonia is based on generalized data obtained by the author and his colleagues during the treatment of more than 5,000 children with pneumonia (1980–2001), as well as gleaned from materials of foreign authors. These data are quite comparable, although they were obtained different methods: by identifying the pathogen or its antigen in pleural exudate, identifying the pathogen in lung punctates, as well as antibodies to chlamydia, mycoplasma and pneumococcal immune complexes. As for the data of a number of foreign authors regarding the predominance of viral pneumonia, they are based on materials from studies of patients in whom only fine bubbling rales in the absence of infiltrative or focal changes were considered as criteria for pneumonia.

Indicators of the incidence of pneumonia in children: in Russia (with proper radiological criteria) this figure ranges from 4 to 12 per 1000 children aged 1 month to 15 years; foreign sources provide the same data regarding the incidence of “X-ray positive pneumonia” (4.3 per 1000 children), but with broader criteria for defining pneumonia, the incidence rate is an order of magnitude higher.

In recent years, Russian scientists have repeatedly discussed this problem taking into account the principles of evidence-based medicine. Amendments to the Classification of Nonspecific Respiratory Diseases in Children were approved, recommendations for antimicrobial therapy of acute community-acquired pneumonia in children were formulated, and a consensus was adopted within the framework of the Acute respiratory diseases in children" of the Union of Pediatricians of Russia.

According to the accepted classification, pneumonia is divided into community-acquired and hospital-acquired, developing in persons with immunodeficiency conditions, and pneumonia in patients on mechanical ventilation (early - the first 72 hours and late). Community-acquired pneumonia occurs in a child under normal conditions, nosocomial pneumonia occurs after 72 hours of hospital stay or within 72 hours after discharge from there. Pneumonia of newborns is also distinguished (including intrauterine pneumonia, which developed in the first 72 hours of a child’s life), but we will not touch on this issue in this article.

In practice, it is important to distinguish between “typical” forms with a clear, homogeneous appearance, focus or infiltrate on an x-ray and “atypical” - with inhomogeneous changes that do not have clear boundaries. The severity of pneumonia is determined by pulmonary heart failure, toxicosis and the presence of complications (pleurisy, pulmonary destruction, infectious-toxic shock). With adequate treatment, most uncomplicated pneumonia resolves in 2–4 weeks, complicated ones - in 1–2 months; a protracted course is diagnosed in the absence of reverse dynamics within a period of 1.5 to 6 months.

Diagnostics. Classic auscultatory and percussion signs of pneumonia, described in textbooks, are detected in only 40 - 60% of patients; fever, shortness of breath, cough, wheezing in the lungs are often recorded in other respiratory diseases. Signs (in addition to the classic ones) that allow one to suspect the presence of pneumonia have a specificity and sensitivity of about 95%:

• temperature above 38.0°C for more than 3 days;
• shortness of breath in the absence of signs of bronchial obstruction (>60/min in children under 2 months, >50 at the age of 2 - 12 months and >40 in children 1 - 5 years);
• asymmetry of moist rales.

Etiology. Since most pneumonia in children is caused by pathogens that usually grow in the respiratory tract, the detection of these pathogens in sputum does not indicate their etiological role. Semi-quantitative methods of sputum culture are more reliable, as well as methods that allow the detection of the pathogen or its antigen in the internal environments of the body, but some of these methods (PCR) are so sensitive that they detect the normal flora of the respiratory tract. Detection of viruses, mycoplasmas, chlamydia, fungi, pneumocystis by any method in the absence clinical picture corresponding pneumonia is not evidence of their etiological role, nor, indeed, of the presence of pneumonia itself. Detection of IgM antibodies to chlamydia and mycoplasma has diagnostic value, but they are often absent during the first week from the onset of mycoplasma-induced pneumonia.

In practice, a presumptive etiological diagnosis is made taking into account the likelihood of the presence of a particular pathogen in a given form of pneumonia in a given age group (see Table 1, Table 2).

Table 1.
Choice of starting drug for community-acquired pneumonia

Table 2.
Antibiotics for nosocomial pneumonia

Community-acquired pneumonia. At the age of 1–6 months, atypical forms are often observed (20% of cases or more) caused by Chlamydia trachomatis (a consequence of perinatal infection), and quite rarely (in premature infants) - Pneumocystis carinii. In more than half of the patients, typical pneumonia is associated with aspiration of food, cystic fibrosis, and primary immunodeficiency; their pathogens are gram-negative intestinal flora, staphylococci. Pneumonia caused by pneumococci and Haemophilus influenzae type b occurs in 10% of children; usually these are children who become ill as a result of contact with an older sibling or adult family member with an acute respiratory infection.

In children 6 months - 6 years old, the most common (more than 50%) causative agent of pneumonia is pneumococcus; it is responsible for 90% of complicated pneumonias. H. influenzae type b causes up to 10% of complicated forms. Staphylococcus is rarely detected. Acapsular H. influenzae is found in lung punctures quite often, usually in combination with pneumococcus, but their role is not completely clear. Atypical pneumonia caused by M. pneumoniae is observed in this age group in no more than 10–15% of patients, Chl. pneumoniae - even less common.

At the age of 7–15 years, the main bacterial causative agent of typical pneumonia is pneumococcus (35–40%), rarely - pyogenic streptococcus, the proportion of atypical pneumonia exceeds 50% - they are caused by M. pneumoniae (20–60%) and Chl. pneumoniae (6–24%).

Viral infection precedes bacterial pneumonia in approximately half of the cases and the more often the younger the child. Pneumonia of only viral etiology with a slight pulmonary infiltrate occurs in 8-20% of cases, but in such patients bacterial superinfection is observed quite often. Pneumonia in children caused by Legionella pneumophila is apparently rare in Russia, since air conditioning is not widespread in our country.

Hospital-acquired pneumonia differs both in the range of pathogens and in their resistance to antibiotics. In the etiology of these diseases, either hospital flora (staphylococci, Escherichia coli, Klebsiella pneumoniae, Proteus sp., Cytrobacter, during manipulations - Pseudomonas aeruginosa, Serratia sp., anaerobes) or the patient’s autoflora plays a certain role (see Table 2). In most cases, these pneumonias develop as a complication of acute respiratory viral infections.

Pneumonia that developed in the first 72 hours of mechanical ventilation in newly admitted patients is usually caused by autoflora - pneumococcus, H. influenzae, M. pneumoniae, starting from the 4th day of mechanical ventilation they are replaced by S. aureus, P. aeruginosa, Acinetobacter, K. pneumoniae, Serratia. If mechanical ventilation was started after the 3rd - 5th day of hospitalization, the more likely pathogen is nosocomial flora.

Pneumonia in patients with immunodeficiencies, including those on immunosuppression, is caused by both normal and opportunistic microflora (P. carinii, Candida fungi). In children infected with HIV and patients with AIDS, as well as with long-term glucocorticosteroid therapy (> 2 mg/kg/day or >20 mg/day for more than 14 days), pneumonia caused by P. carinii, cytomegalovirus, M. avium-intercellulare and fungi is not uncommon.

The sensitivity of pathogens to antibiotics depends both on their genetic properties and on previous contact with antibiotics. In many countries, 20–60% of pneumococci have become resistant to penicillins, many cephalosporins and macrolides, and H. influenzae has become resistant to ampicillin. In Russia, 95% of pneumococcal strains circulate that are sensitive to penicillins, cephalosporins, macrolides, but resistant to cotrimoxazole, gentamicin and other aminoglycosides. Staphylococci (community-acquired strains) remain sensitive to oxacillin, protected penicillins (augmentin), lincomycin, cefazolin, macrolides, and rifampicin. and aminoglycosides.

H. influenzae in Russia is sensitive to amoxicillin, protected penicillins (augmentin), azithromycin, cephalosporins of the second and third generations, aminoglycosides, chloramphenicol, doxycycline and rifampicin. However, this pathogen, both in Russia and abroad, has lost sensitivity to erythromycin; Only a few strains are sensitive to “new” macrolides (roxithromycin, spiramycin, josamycin, midecamycin). On the contrary, Moraxella catarrhalis is sensitive to “new” macrolides, as well as to augmentin, ceftriaxone, and aminoglycosides. Mycoplasmas and chlamydia are sensitive to macrolides and doxycycline.

Selection of starting antibacterial drug. Domestic recommendations, based on both the age of the child and the form of pneumonia (Table 1, Table 2), differ slightly from foreign ones - they take into account differences regarding the sensitivity of the flora. When using them, a rapid (24–36 hour) effect of treatment occurs in 85–90% of cases; if the starting drug is ineffective, they switch to alternative ones. If there is uncertainty about the etiology, a drug or a combination of two drugs with a broader spectrum can be used.

For uncomplicated typical pneumonia oral medications are used - amoxicillin, amoxicillin/clavulanate (Augmentin), cefuroxime-axetil (Zinnate), which act on both pneumococci and Haemophilus influenzae. Phenoxymethylpenicillin-benzathine (syrup of smallpox) and first-generation cephalosporins suppress only the coccal flora, so they are best used in older children.

For atypical pneumonia, macrolides and azithromycin are the drugs of choice. Since they also act on the coccal flora, these drugs can be used in persons allergic to b-lactams, but their widespread use is undesirable due to their stimulation of drug resistance in the flora.

In case of complicated pneumonia, treatment begins with parenteral drugs, replacing them with oral ones when the effect occurs (stepwise method).

Experience shows that more than 85% of all community-acquired pneumonia in children can be cured without a single injection of antibiotic; On average, a child with pneumonia receives less than 4 injections during treatment.

Doses of antibacterial drugs used to treat pneumonia are usually adjusted according to manufacturers' recommendations. Taking into account the possibility of increasing the resistance of pneumococcus, it is justified to prescribe penicillins - both regular and protected - in doses of about 100 mg/kg/day, at which their level in tissues will be several times higher than the MIC of even resistant strains.

The effectiveness of treatment is assessed after 24, 36 and 48 hours of treatment. The full effect is recorded when the temperature drops below 38.0°C (without antipyretics) and the general condition improves and appetite appears; the x-ray picture may improve or remain the same. This indicates the sensitivity of the pathogen to the drug, therefore, treatment with this drug should be continued. A partial effect is registered with an improvement in general condition and appetite, as well as the absence of negative dynamics in the lesion, but with the preservation of febrile temperature; this picture is observed in the presence of a purulent focus (destruction) or an immunopathological process (metapneumonic pleurisy). In this case, the antibiotic is not changed; the full effect occurs later - when the abscess is emptied or anti-inflammatory drugs are prescribed. If the patient continues to have a febrile temperature, infiltration in the lungs and/or general disorders increases, it is generally accepted that there is no effect; in these cases, an immediate change of antibiotic is required.

The duration of treatment for mild pneumonia is 5 - 7 days, for complicated forms - 10 - 14 days (2 - 3 days after the temperature drops). In case of nosocomial pneumonia, the drug is replaced according to bacteriological data or empirically after 24 - 36 hours - at the first signs of ineffectiveness. In children over 12 years of age and in extremely severe cases in younger patients with resistance to enterobacillary, pseudomonas and atypical flora, fluoroquinolones are used. For anaerobic processes, metronidazole is used, for processes of fungal etiology - fluconazole, ketoconazole.

Other types of therapy. In the acute period, children practically do not eat; restoration of appetite is the first sign of improvement in severe processes with prolonged fever. Vitamins are administered to children who did not eat properly before illness; other medications are prescribed if there are appropriate indications. With the right choice of antibacterial drug, rapid improvement in the patient’s condition allows one to abandon the use of other drugs.

It is important to adhere to the drinking regime (1 l/day or more), using tea, juices, decoctions or rehydration solutions diluted by half. A feature of the treatment of severe forms of the disease is the limitation of intravenous fluid administration, since pneumonia is accompanied by a massive release of antidiuretic hormone, which causes oliguria. A decrease in blood volume (by 20–30%) is also a compensatory mechanism that does not require immediate correction. If necessary, no more than 1/6 of the calculated daily fluid requirement is administered intravenously, that is, no more than 15–20 ml/kg/day.

Recommendations in the literature regarding “general restorative” treatment are generally not based on the results of rigorous therapeutic trials. The use of so-called pathogenetic therapy for pneumonia - from vitamins to immunomodulators, as well as “detoxification”, “stimulating” and others similar drugs, including infusions of plasma, blood, g-globulin, hemodez, not only does not improve the outcome of pneumonia, but often causes complications and superinfection, and also significantly increases the cost of treatment. Such drugs should be used according to strict indications; for example, protein preparations are administered in case of hypoproteinemia, blood - in case of a sharp drop in hemoglobin (50 g/l), iron and vitamins - in case of persistence of anemia and asthenia of the child during the period of convalescence. Physiotherapeutic procedures on the chest (iontophoresis, microwave, etc.), including during the reparation period, are ineffective.

Literature

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2. Tatochenko V.K., Katosova L.K., Fedorov A.M. Etiological spectrum of pneumonia in children // Pulmonology. 1997. 2: 29-35.
3. Acute respiratory infections in children: Case management in small hospitals in developing countries. A manual for doctors and other senior health workers. WHO/ARI/90.5. World Health Organization. Geneva.
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9. Black S., Shinefield H. R., Ray P. et al. Efficacy of heptavalent conjugate pneumococcal vaccine in 37,000 infants and children: impact on pneumonia: otitis media and an update of the disease results in Northern California//39th Interscience Conference, Sept. 26-29, 1999, Washington D.C. American Society for Microbiology, 1999: 379 (#1398).
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15. Strachunsky L. S., Belousov Yu. B., Kozlov S. N. (eds). Antibacterial therapy. M., 2000.

1 State Budgetary Institution of Children's City Clinical Hospital named after. Z. A. Bashlyaeva DZM, Moscow
2 Federal State Budgetary Educational Institution of Further Professional Education “Russian Medical Academy of Continuing Professional Education” of the Ministry of Health of the Russian Federation, Moscow; GBUZ "Children's City Clinical Hospital named after. BEHIND. Bashlyaeva" DZ Moscow

For quotation: Koroid N.V., Zaplatnikov, Mingalimova G.A., Glukhareva N.S. Community-acquired pneumonia in children: diagnosis and treatment // Breast Cancer. 2011. No. 22. S. 1365

Pneumonia is an acute infectious inflammation of the pulmonary parenchyma, diagnosed on the basis of characteristic clinical and radiographic signs.

Pneumonia is one of the most serious diseases in children, the population frequency of which and prognosis are directly related to socio-economic conditions. Thus, in countries with a low cultural and socio-economic level, an unstable political situation and ongoing military conflicts, the incidence of pneumonia in children in the first 5 years of life exceeds 100 cases per 1000, and the mortality rate reaches 10%. At the same time, in economically prosperous countries, children of the indicated age category pneumonia occurs significantly (almost 10 times!!!) less often, and the mortality rate does not exceed 0.5-1%. It should be especially emphasized that in the Russian pediatric population, morbidity and mortality from pneumonia are comparable to those of the leading world powers.
A favorable prognosis for pneumonia is determined by early diagnosis, timely treatment and an adequate choice of initial antibiotic therapy. At the same time, timely diagnosis is based on the results of a detailed and consistent analysis of clinical, anamnestic and radiological data.
The main clinical manifestations that allow one to suspect pneumonia in a child are symptoms of toxicosis (fever, decreased appetite, refusal to drink, decreased diuresis, etc.) and respiratory failure (tachypnea, shortness of breath, cyanosis), as well as typical physical findings. The latter include shortening of the percussion sound over the area of ​​lung damage and auscultatory changes localized here (weakening or intensification of breathing with the subsequent appearance of crepitating or moist bubbling rales). It should be noted, however, that with pneumonia in young children it is often difficult to identify auscultatory asymmetry in the lungs. This is due to the fact that in children of the first years of life, inflammation of the pulmonary parenchyma is rarely isolated and, as a rule, develops against the background of bronchitis. In this case, dry and/or moist rales of various sizes may be heard throughout both lungs, which is why the typical auscultatory picture of pneumonia, especially small-focal pneumonia, may not be detected. In addition, if the technique of listening to the lungs in young children is violated, auscultatory changes may not be detected at all.
In general, if a febrile child experiencing an acute respiratory infection, there is at least one of the following signs: toxicosis, shortness of breath, cyanosis and typical physical findings, it is necessary to conduct an X-ray examination of the chest organs. At the same time, the detection in the lungs of homogeneous infiltrative changes of a focal, focal-confluent or segmental nature allows us to confirm the clinical assumption of the development of pneumonia caused by typical pathogens (pneumococcus, etc.). Small inhomogeneous infiltrates, which have bilateral localization and are detected against the background of an enhanced vascular-interstitial pattern, as a rule, indicate an atypical etiology of pneumonia (mycoplasmosis, chlamydia, pneumocystosis). X-ray confirmation of pneumonia is a mandatory criterion for the “gold standard” for diagnosing this disease.
When pneumonia is detected in a child, the first step is to decide whether hospitalization is necessary. The absolute criteria for emergency hospitalization are respiratory and/or cardiovascular failure, convulsive, hyperthermic, hemorrhagic and others pathological syndromes. Demonstrations for inpatient treatment children with pneumonia, in addition to severe forms of the disease, are also neonatal and infancy of the child and his aggravated premorbitis (severe congenital or acquired pathology of the respiratory, circulatory, nervous, immune and other systems). It should be especially noted that absolute indications hospitalization includes all cases where pneumonia develops in children from the “social risk group”. Thus, hospitalization of children with pneumonia is indicated in all cases where the severity of the condition and the nature of the disease require intensive care or there is a high risk of complications. In all other cases, treatment of pneumonia can be carried out at home. It should be especially noted that regardless of where the treatment is carried out (outpatient or inpatient), therapeutic measures must be comprehensive and include adequate care for the child, correct mode day and nutrition, rational use of etiotropic and symptomatic drugs. The key to this is adequate antibacterial therapy.
The choice of antibacterial drugs for pneumonia, as for other infectious and inflammatory diseases, should be determined primarily by the characteristics of the etiology of the disease. However, in the vast majority of cases, a correct microbiological examination of children with pneumonia is not carried out, despite the fact that, in accordance with the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-X), the classification of pneumonia should be based strictly on etiological principle. The lack of data on the etiology of the disease leads to the fact that pneumonia, as a rule, is encrypted under the code J18 (“Pneumonia without specifying the causative agent”), and antibacterial therapy, accordingly, is carried out blindly. In some cases, the initial choice of antibiotics may be incorrect, which determines the lack of effect of the treatment. To reduce errors in antibacterial therapy for pneumonia in children, in recent years, recommendations have been developed for the empirical selection of starting antibiotics. The fundamental principle of the developed algorithms is the choice of drugs depending on the epidemiological conditions and age of the sick, since it has been established that the etiology of pneumonia directly depends on these factors (Fig. 1). At the same time, the epidemiological classification of pneumonia involves the identification of community-acquired, hospital-acquired and intrauterine forms of the disease.
Community-acquired pneumonia is spoken of in cases where the infection and illness of a child is not associated with his stay in a medical institution. This emphasizes that the development of pneumonia occurred in a normal microbial environment. This makes it possible to suggest with a high degree of probability the etiology of the disease, since it has been established that the main causative agent of pneumonia in this case is Streptococcus pneumoniae. Less commonly, community-acquired pneumonia is caused by Haemophilus influenzae, Mycoplasmae pneumoniae, chlamydia (Chlamydia trachomatis - in children in the first months of life and Chlamydia pneumoniae - in subsequent age periods) and respiratory viruses. In cases where infection and development of pneumonia occurred 48-72 hours after the child was admitted to the hospital or within 48-72 hours after his discharge from the hospital, it is classified as nosocomial. Moreover, the etiology of hospital-acquired pneumonia depends on the epidemiological conditions prevailing in a given medical institution. Thus, it has been established that nosocomial pneumonia can be caused by various, often multidrug-resistant representatives of enterobacteria, Pseudomonas aeruginosa, Staphylococcus aureus and other hospital microorganisms. Intrauterine pneumonia includes such variants of the disease in which infection occurred in the ante- or intrapartum period, and the implementation of infectious inflammation no later than the first 72 hours of the child’s life. In this case, potential causative agents of intrauterine pneumonia can be various viruses, as well as Chlamydia trachomatis, Streptococcus (group B), Staphylococcus aureus, Enterobacteriaceae (Klebsiella, Proteus, Escherihia) and other microorganisms. Epidemiological classification of pneumonia has a clear practical focus, since it takes into account the peculiarities of the etiology of various forms of the disease and allows empirical selection of adequate antibacterial therapy immediately after diagnosis.
The most common form of acute infectious pneumonia in children is community-acquired pneumonia. In this case, it is necessary to pay Special attention that community-acquired pneumonia may be characterized by varying degrees gravity. Moreover, in some cases, the disease may be accompanied by the development of both pulmonary (destruction, abscess, pneumothorax, pyopneumothorax) and extrapulmonary complications (infectious-toxic shock, disseminated intravascular coagulation syndrome, cardiopulmonary failure, etc.). Therefore, it is a mistake to believe that community-acquired pneumonia is a mild form of the disease, the treatment of which can always be carried out on an outpatient basis. Thus, the term “community-acquired pneumonia” should be used solely for indicative characterization of the etiology of the disease, and not to assess its severity and prognosis.
For an adequate empirical choice of initial antibiotic therapy, in addition to epidemiological characteristics, a detailed analysis of the child’s individual data (age, background conditions, concomitant pathology) and clinical features of the disease is necessary. It was noted that the etiology of pneumonia, in addition to epidemiological factors, is significantly influenced by the patient’s age and premorbid condition. So, frequent use antibiotics in children with chronic infectious and inflammatory diseases (pyelonephritis, tonsillitis, otitis media, etc.) can lead to the selection of resistant strains of microorganisms. If pneumonia develops in such children, the etiology of the disease may be represented by antibiotic-resistant pathogens. A similar situation can occur when pneumonia occurs in children with unfinished courses of antibacterial therapy or who received antibiotics in inappropriately low doses. The presence of regurgitation syndrome in a child creates the preconditions for aspiration and the development of pneumonia caused not only by aerobic (streptococci, enterobacteria, staphylococci, etc.), but also by non-spore-forming anaerobic (bacteroides, fusobacteria, peptostreptococci, peptococci, etc.) bacteria. The given examples, which are only a part of possible clinical situations, indicate the importance of detailed clarification of anamnestic data in each specific case.
Initial etiotropic therapy for community-acquired pneumonia in children in the first months of life. In patients of this age group, the etiology of pneumonia can be associated with a very wide range of pathogens (viruses, chlamydia, streptococci, staphylococci, Proteus, Klebsiella, E. coli, etc.). Taking this into account, in order to adequately select initial therapy, we first empirically determine what caused the disease: typical or atypical microorganisms? To do this, clinical and anamnestic data are assessed and the results of an X-ray examination are analyzed. At the same time, symptoms such as fever, toxicosis, clear physical findings, as well as focal and/or confluent radiological changes in the lungs allow us to more reliably assume a typical bacterial etiology of pneumonia. In these cases, treatment begins with broad-spectrum antibiotics, which, given the high risk of developing severe forms of the disease, should be administered parenterally. Aminopecillins and cephalosporins are used as starting drugs, and in severe cases of pneumonia, their combination with short courses of aminoglycosides is used. This choice of antibiotics is explained by the need to target a range of gram-positive and gram-negative bacteria that can cause disease in children of this age. Pay attention to high levelβ-lactamase-producing strains among potential pathogens, preference should be given to inhibitor-protected aminopenicillins and third-generation cephalosporins.
In severe cases it is necessary to use intravenous administration antibiotics. In this case, amoxicillin/clavulanate is used in a dose (as amoxicillin): 30-60 mg/kg/day, and basic 3rd generation cephalosporins (derivatives of ceftriaxone and cefotaxime) in a dose of 50-100 mg/kg/day. 3rd generation cephalosporins are active against bacteria that produce broad-spectrum β-lactamases, and also suppress strains whose antibiotic resistance is due to other mechanisms.
If pneumonia develops in a child who has a history of genital chlamydia in the mother, indications of prolonged conjunctivitis in the child, which does not respond to the use of beta-lactam antibiotics, it is necessary to exclude the possibility of an atypical etiology of the disease. At the same time, the presence of a dry cough with a gradual increase in intensity and frequency, the slow development of other symptoms of the disease and the predominance of interstitial changes on the radiograph make one think about the possible etiological role of C. trachomatis. Verification of chlamydial pneumonia determines the need to prescribe modern macrolide antibiotics(midecamycin acetate, clarithromycin, roxithromycin, etc.), since the use of erythromycin is often accompanied by the development of side effects. In this case, macrolide therapy (with the exception of azithromycin) is carried out for 14 days. In those cases when in immunodeficient patients, as well as in premature or somatically weakened children, against the background of nonspecific symptoms of intoxication, a gradual increase in tachypnea is observed, exceeding the pulse rate at the height of the disease (!), and during X-ray examination a “cotton lung”, “wings” are revealed butterflies" (diffuse bilateral enhancement of the interstitial pattern, heterogeneous focal shadows with unclear contours, areas of localized swelling, minor atelectasis, less often - partial pneumothorax) it is necessary to exclude Pneumocystis pneumonia. In this case, the drug of choice is co-trimoxazole at a dose of 6-8 mg/kg/day. (for trimethoprim). In severe forms of Pneumocystis pneumonia, co-trimoxazole should be administered intravenously at a dose of 15-20 mg/kg/day. (trimethoprim) in two doses over 2-3 weeks.
Initial etiotropic therapy of community-acquired pneumonia in children before school age. Treatment of children of this age with mild pneumonia is carried out, as a rule, on an outpatient basis. At the same time, the most common bacterial causative agent of community-acquired pneumonia is S. pneumoniae; less commonly, the disease is caused by H. influenzae. Considering that pneumococcus and Haemophilus influenzae have increasingly shown resistance to natural penicillins in recent years, it is recommended to start antibacterial therapy with aminopenicillins (amoxicillin, amoxicillin/clavulanate). Since the treatment of mild and moderate forms of pneumonia, as a rule, does not require parenteral administration of antibiotics, preference is given to oral forms of drugs. In cases where pneumonia develops in a child who has not previously received penicillin, amoxicillin is the drug of choice. Typically, amoxicillin is prescribed at a dose of 10-20 mg/kg per dose with an interval of 8 hours ( daily dose- 30-60 mg/kg/day). It has been established that more low doses the drug is insufficient to eradicate the main pathogens of pneumonia and therefore should not be used. It should also be noted that in cases where the development of the disease is associated with penicillin-resistant pneumococcus, amoxicillin is recommended to be prescribed in higher doses (up to 90 mg/kg/day) or to use basic 3rd generation cephalosporins (ceftriaxone and cefotaxime) in normal doses. Contraindications for prescribing aminopenicillins are anamnestic indications of an allergy to penicillin. In these cases, macrolides or 2-3 generation cephalosporins are used (the risk of cross-allergy with penicillin is 1-3%).
If an atypical etiology of pneumonia is suspected (chlamydia, mycoplasma), therapy is carried out with modern macrolide antibiotics (josamycin, spiramycin, midecamycin, clarithromycin, roxithromycin, etc.). The basis for the assumption of an atypical etiology of pneumonia in children is such clinical and anamnestic data as the presence of people around the child who cough for a long time, subacute onset of the disease, prolonged low-grade fever, gradually increasing and long-lasting cough (often spastic in nature), recurrent broncho-obstructive syndrome, as well as bilateral changes with small inhomogeneous foci and an enhanced vascular-interstitial pattern on the radiograph. Chlamydia may also be supported by lymphadenopathy accompanying the underlying disease.
Initial antibacterial therapy for community-acquired pneumonia in school-age children. The main causative agents of community-acquired pneumonia in children of this age category are pneumococcus (S. pneumoniae) and mycoplasma (M. pneumoniae). It has been established that every 4-8 years, during epidemic increases in the incidence of M. pneumoniae infection, the frequency of mycoplasma pneumonia increases significantly (up to 40-60% of all pneumonia in school-age children). Clinically, mycoplasma pneumonia is characterized by an acute onset, often with febrile fever. However, despite hyperthermia, the symptoms of intoxication in a child are usually mild, which is one of the few specific signs of the disease. A few days after the onset of the disease, a cough appears - dry, obsessive, often paroxysmal. The cough may persist for a long time, but gradually becomes productive. Scattered dry and varied moist rales may be heard in the lungs. X-ray examination reveals bilateral foci of inhomogeneous infiltration in the lungs. It has been established that 10% of children with mycoplasma pneumonia have a transient maculopapular rash. In the vast majority of cases, the disease is not severe, characterized by a smooth course and the absence of respiratory failure or its mild severity.
Since mycoplasmas, like chlamydia, are naturally resistant to beta-lactam antibiotics, but are highly sensitive to macrolides, the latter are the drugs of choice in these clinical situations. Thus, taking into account the peculiarities of the etiology of community-acquired pneumonia in school-age children (maintaining leading positions in S. pneumoniae and a significant increase in the role of M. pneumoniae), aminopenicillins (for diseases caused by typical pneumotropic pathogens) and macrolides can be used as starting antibiotics - mainly with atypical etiology of pneumonia. In some cases, when there are contraindications for the prescription of macrolide antibiotics, treatment of mycoplasma and chlamydial pneumonia in children over 8 years of age can be carried out with doxycycline.
The effectiveness of initial antibacterial therapy is assessed primarily by the dynamics of the temperature reaction and the reduction in the manifestations of intoxication during the first 24-48 hours from the start of treatment. With timely administration and adequate choice of starting antibiotic, and strict adherence to the recommended dosage regimen, improvement, as a rule, is noted already on the 2-3rd day of treatment. At the same time, the child becomes more active, his appetite and well-being improve, and his body temperature tends to normalize. If during this period there is no positive clinical dynamics or a worsening of the condition is noted, then the antibiotic should be changed. Moreover, if treatment was started with amoxicillin, then the following questions are resolved: is it possible to continue therapy with other beta-lactam antibiotics or is it necessary to use macrolides. If a detailed analysis of epidemiological, clinical, anamnestic and radiological data does not give reason to consider the etiology of pneumonia to be atypical, then treatment can be continued with inhibitor-protected aminopenicillins (amoxicillin/clavulanate, ampicillin/sulbactam) or 2-3 generation cephalosporins. In cases where initial therapy is carried out with macrolides, but there is no clinical effect, most likely, the etiology of the disease is not associated with such atypical pathogens. In these situations, macrolides must be replaced with beta-lactam antibiotics.
The criterion for stopping antibiotic therapy in the treatment of mild and moderate forms of pneumonia is clinical recovery. So, if there is complete and persistent regression clinical symptoms diseases, then antibacterial drugs should be discontinued after completing the full course, even in situations where residual radiological changes still persist. It should be especially emphasized that if the course of pneumonia is favorable, there is no need to carry out so-called “x-ray monitoring” of the effectiveness of treatment. In this case, special attention should be paid to the inadmissibility of early (on the 3-5th day) cessation of antibiotic therapy (except for azithromycin), since this not only does not achieve complete eradication of pathogens, but also potentiates the development of antibiotic resistance in them. In general, the duration of the course of antibiotic therapy for mild and moderate forms of pneumonia is usually 7-10 days. It should be noted that in the treatment of pneumonia of atypical (chlamydial, mycoplasma) etiology, a 14-day course of macrolide therapy may be justified, except in cases where azithromycin is used.
An indispensable condition for effective treatment of a child with pneumonia, along with ongoing antibacterial therapy, is strict adherence to the regimen, a rational diet, adequate care and rational symptomatic therapy. Symptomatic therapy for pneumonia can be used to reduce those clinical manifestations(fever, cough) that interfere with the child’s well-being. It should be remembered that with the systematic prescription of antipyretics it is impossible to adequately assess the effectiveness of the antibacterial therapy. In this regard, in the absence of aggravating factors in the child, an increase in axillary temperature within the range of 38.5-39°C, as a rule, does not require the use of antipyretics. At the same time, in children at risk for the development of complications (age - first 2 months of life, severe diseases of the respiratory system, circulatory system, central nervous system, hereditary metabolic disorders, history of febrile convulsions), antipyretics should be prescribed even with a low rise in body temperature ( up to 38.0°C). The drugs of choice are paracetamol and ibuprofen (per os or per rectum). In young children, it is recommended to use paracetamol in a dose of 10-15 mg/kg body weight per dose, ibuprofen - 5-10 mg/kg body weight per dose. In case of severe toxicosis, antipyretics should be administered parenterally (metamizole - 5 mg/kg per 1 administration in infants and 50-75 mg/year per 1 administration in children over 1 year of age; paracetamol - 10-15 mg/kg per 1 administration).
The choice of cough medicines in children with pneumonia should be based on a detailed analysis of clinical features (frequency, intensity, pain, presence of sputum and its nature, etc.). When coughing with thick, viscous, difficult to separate sputum, the use of mucolytics is indicated. In cases where the cough is rare and the sputum is not highly viscous, expectorants can be used. At the same time, expectorant drugs should be used with great caution in young children, because excessive stimulation of the vomiting and cough centers can lead to aspiration, especially if the child has central nervous system damage. The prescription of antitussive drugs may be justified when there is a dry, obsessive, frequent cough.
It is advisable to emphasize that if it is necessary to prescribe antitussive drugs, preference should be given to non-narcotic antitussive drugs that do not have a depressing effect on the respiratory center and are not addictive. At the same time, as an alternative to non-narcotic and codeine-containing antitussive drugs in the treatment of non-productive cough, the complex homeopathic drug Stodal® can be offered. The active components of the drug are Pulsatilla C6, Rumex crispus C6, Bryonia C3, Ipeca C3, Spongia tosta C3, Sticta pulmonaria C3, Antimonium tartaricum tartaricum) C6, Myocarde (myocarde) C6, Coccus cacti (coccus cacti) C3, Drosera (drosera) MT (according to Hahnemann). The drug Stodal® has proven to be an effective and safe drug for the treatment of cough in children, which was confirmed in our study. Thus, the results of our study in 61 children aged from 2 years to 5 years 11 months 29 days with frequent, intense, unproductive cough against the background of acute respiratory infection showed that the clinical effectiveness of the drug under study is not inferior to a codeine-containing drug ( Fig. 2 and 3). At the same time, we found that when using the drug Stodal® (main group, n = 32), the dynamics and rate of decrease in cough intensity did not differ from similar indicators in the comparison group (n = 31), in which they used combination drug, containing codeine, as well as extracts of expectorant and anti-inflammatory herbs (Fig. 2). At the same time, it was shown that if in the main group the night cough was stopped by the end of the 5th day of therapy, then in the comparison group it was stopped only on the 7th day. A more rapid reduction in coughing episodes at night made it possible to more quickly normalize sleep in children taking the drug Stodal®. In addition, the cough in children of the main group became productive much faster, which also had a beneficial effect on the course of the disease (Fig. 3). Of particular note is the good tolerability of the drug Stodal® - adverse reactions and no adverse events were noted, which is also consistent with the results of other authors.
In conclusion, it is necessary to emphasize once again that the determining factors for the favorable course and outcome of pneumonia in children are early diagnosis of the disease and timely prescribed rational therapy, the basic principles of which are outlined in this report.

Literature
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Diagnosis of pneumonia is clinical and radiological, based on identifying clinical signs of parenchymal inflammation, laboratory signs of inflammation and radiologically proven signs of lung damage. A generally accepted method for approximate identification of the pathogen is microscopic examination of sputum, Gram-stained to quantify microbial contamination. Sputum for examination is obtained after coughing. If sputum is not detected, then the cough is provoked by endotracheal administration of saline solution using a laryngeal syringe or inhalation. In cases of bronchoscopic examination, sputum can be aspirated with a catheter. Sputum collected in violation of the requirements mainly contains saliva, which is not suitable for research.

Criteria in favor of pneumonia:

General symptoms:

temperature above 38 0 C;

temperature above 38 0 C for more than 3 days;

• groaning breath;

  tachycardia;

  shortness of breath without obstructive syndrome;

Local symptoms:

localized moist rales, crepitus;

hard or weakened bronchial breathing;

bronchophony;

shortening of percussion sound.

Laboratory data:

neutrophilic leukocytosis more than 910 9 /l;

ESR more than 20 mm/hour.

X-ray signs:

local infiltration of lung tissue.

Treatment

Indications for hospitalization:

severe or complicated course of pneumonia;

ineffectiveness of therapy in an outpatient setting for 24-36 hours;

pneumonia in young children;

a group of frequently ill children suffering from repeated pneumonia and a history of acute respiratory infections;

children from rural areas;

children who have been in contact with infectious patients;

unfavorable social and housing conditions;

inability to provide treatment and care for the child at home.

Indications for hospitalization during treatment:

addition of intrapulmonary and extrapulmonary complications (pleurisy, atelectasis);

spread of inflammation to other parts of the lungs;

the addition of a viral infection that aggravates the course of pneumonia;

lack of effect from treatment in the first 3-4 days, persistence high temperature bodies.

Children of preschool and school age with uncomplicated pneumonia can be treated on an outpatient basis if certain conditions are met:

daily medical supervision;

good living conditions and child care;

providing the necessary examination and treatment.

In the acute period of the disease it is indicated bed mode, and then a gentle regime with mandatory daytime sleep.

Nutrition should be complete, with sufficient amounts of proteins, fats, carbohydrates and vitamins. In the first days of the disease with fever and intoxication, food should be liquid or semi-liquid. It is recommended to drink plenty of fluids: tea, fruit juices, mineral water, broth.

Before body temperature normalizes, additional fluid administration is necessary (for young children, “food + fluid” should be 140-150 ml/kg/day).

Antibacterial therapy

Pneumonia in newborns. Treatment of pneumonia in a newborn child is almost always carried out in a hospital. Antibiotics are administered parenterally (Table 3). For intrauterine pneumonia, the drugs of choice are ampicillin, ampicillin/sulbactam in combination with aminoglycosides. For listeriosis, the drug of choice is ampicillin in combination with gentamicin. It should be emphasized that Listeria is resistant to cephalosporins. Therefore, it is permissible to combine cephalosporins with ampicillin. In treatment

For nosocomial pneumonia, especially late CAP, a combination of inhibitor-protected penicillins or third-generation cephalosporins with aminoglycosides is preferable. If Pneumocystis infection is suspected, co-trimoxazole is used, and for fungal etiology, fluconazole is used.

Table 3

The choice of antibiotics in the treatment of pneumonia in newborns

Community-acquired pneumonia. The empirical choice of antibiotics in the treatment of community-acquired pneumonia is presented in Table. 4. The drugs listed in the “Antibiotics of choice” column have approximately the same effectiveness. The choice between them is based on material capabilities.

For uncomplicated pneumonia, especially in an outpatient setting, it is preferable to administer antibiotics orally. If therapy was started with parenteral administration of drugs, then once the effect is achieved, one should switch to oral administration of the antibiotic (stepped therapy). The effectiveness of simultaneous administration of antifungal drugs (nystatin, levorin) and antihistamines has not been proven.

Treatment of children first 6 months of life in typical forms, it is usually carried out in a hospital setting using parenteral administration of antibiotics. For typical pneumonia, amoxicillin clavulanate, ampicillin/sulbactam, and parenteral ampicillin are prescribed. Alternative antibiotics are cephalosporins of the second and third generations or cefazolin in combination with aminoglycosides. The drugs of choice for atypical forms are modern macrolides. For anaerobic infections, inhibitor-protected penicillins, lincomycin, clindamycin, and metronidazole are effective.

Table 4

Antibacterial therapy for community-acquired pneumonia

	Etiology	Antibiotics
			Alternative
1-6 months, typical.	Viruses, E.coli, Enterobacteriaceae, S.aureus, S.pneumoniae, H. influenzae.	Parenterally: amocicillin/clavulanate, ampicillin/sulbac-tam. Inside: amoxicillin/clavulanate.	Parenteral: cefazolin, cefuroxime, ceftriaxone, cefotaxime, lincomycin, carbapenems*. All drugs can be prescribed in combination with aminoglycosides.
1-6 months, atypical	Viruses, Ch. trachomatis.	inside: modern macrolide.**	inside: erythromycin.
6 months - 6 years, typical, uncomplicated.	Viruses, S. pneumoniae, H. influenzae.	inside: amoxicillin and/or modern macrolide.**	inside: amoxicillin/clavulanate, ce-furoxime, phenoxymethylpenicillin, erythromycin. Parenterally: ampicillin, cefuro-xime, cefotaxime, ceftriaxone, cefoperazone.
6-15 years old, typical, uncomplicated.		inside: amoxicillin and/or modern macrolide.**	inside: amoxicillin/clavulanate, cefuroxime, phenoxymethylpenicillin. Parenteral: penicillin, lincomycin, cefuroxime, cefotaxime, ceftriaxone, cefoperazone.
6-15 years, atypical, uncomplicated.	M.pneumoniae, Ch.pneumoniae	inside: modern macrolide.**	inside: erythromycin, doxycycline (children over 12 years old).
6 months - 15 years, complicated by pleurisy or destruction.	S.pneumoniae, H.influenzae, Enterobacteriaceae.	Parenterally: amocicillin/clavulanate or ampicillin/sul-bactam.	Parenterally: cephalosporins of II-IV generations (cefuroxime, cefotaxime, ceftriaxone, cefoperazone, cefipime), cefazolin + aminoglycoside, lincomycin + aminoglycoside, carbapenem.
*Meropenem is approved for use in children aged 3 months and older. ** Modern macrolides: azithromycin, clarithromycin, midecamycin, roxithromycin, spiramycin.

In children aged 6 months to 6 years Treatment of mild, uncomplicated pneumonia is carried out on an outpatient basis with the prescription of oral medications. The first choice antibiotics are amoxicillin and macrolides, alternatives are amoxicillin/clavulanate, cefuroxime/axetil. In children with a tendency to allergic reactions it is preferable to prescribe modern macrolides.

In children aged 6 to 15 years Mild pneumonia is treated mainly at home using oral medications. In the typical form, amoxicillin, modern macrolides, etc. are indicated. In case of atypical pneumonia, it is advisable to start treatment with macrolides.

Severe forms Pneumonia in children of all ages is usually an indication for hospitalization. In a hospital setting, it is advisable to carry out stepwise therapy. Inhibitor-protected penicillins and cephalosporins of II–III generations are preferred. If necessary, to expand the spectrum of activity, b-lactam antibiotics (penicillins, cephalosporins, carbapenems) can be combined with macrolides, and in case of gram-negative etiology - with aminoglycosides.

Nosocomial pneumonia. In a pediatric hospital, there is a fairly clear dependence of the type of pathogen and its sensitivity on previous therapy. Replacement with an alternative drug is carried out on the basis of bacteriological data or empirically if there is no effect from the first-choice drug within 36–48 hours. In severe forms, intravenous administration of drugs is mandatory. In selected cases, for infections caused by gram-negative microflora, and in the absence of an alternative, drugs from the group of fluoroquinolones (ciprofloxacin, ofloxacin) can be used. For anaerobic infections, inhibitor-protected penicillins, metronidazole, lincosamides, and carbapenems are used. For fungal etiology, antifungal drugs are prescribed.

Ventilation pneumonia. For early ventilation pneumonia (without previous antibiotic therapy), inhibitor-protected penicillins (amoxicillin/clavulanate, ampicillin/sulbactam, ticarcillin/clavulanate) or cefuroxime are prescribed. Third generation cephalosporins and aminoglycosides are alternative drugs. When choosing an antibiotic, previous therapy is taken into account. If mechanical ventilation is started on the 3rd–4th day of hospital stay, the choice of antibiotic is determined by the algorithm for prescribing it for nosocomial pneumonia. For late ventilation pneumonia, inhibitor-protected antipseudomonal penicillins (ticarcillin/clavulanate, piperacillin/tazobactam) or cephalosporins of III–IV generations with antipseudomonal activity (ceftazidime, cefoperazone, cefepime) with aminoglycosides (netilmicin, amikacin) are prescribed. Alternative drugs are carbapenems (imipenem, meropenem).

Pneumonia in children with immunodeficiency. This group of patients requires the provision of gnotobiological conditions at the peak of immunosuppression, as well as preventive antibiotic therapy. In addition, constant monitoring of microflora is advisable, which allows for etiotropic treatment. For empirical therapy in persons with bacterial pneumonia, cephalosporins of III–IV generations or vancomycin in combination with aminoglycosides (netilmicin, amikacin) are used. For pneumocystis etiology of pneumonia, co-trimoxazole is used in high doses, for fungal infections - antifungal drugs (fluconazole, amphotericin B), for herpes infections - acyclovir, for cytomegalovirus infections - ganciclovir. The duration of therapy is at least 3 weeks, for protozoal and fungal pneumonia - 4–6 weeks or more.

Criteria for the effectiveness of antibiotic therapy. The primary effect of the prescribed antibiotic can be assessed after 48 hours, since during the first day the growth and reproduction of sensitive microorganisms is suppressed, then in response to a decrease in intoxication, the first positive symptoms in the clinical condition and laboratory parameters occur. The absence of positive dynamics 72 hours after the start of antibacterial therapy indicates the need to adjust the treatment regimen.

Full effect: a drop in body temperature below 37.5 0 C after 24–48 hours for uncomplicated pneumonia and after 3–4 days for complicated pneumonia against the background of improved general condition and appetite, and decreased shortness of breath. During these periods, radiological changes do not increase or decrease.

Partial effect: preservation of febrile body temperature after the above periods with a decrease in the severity of toxicosis, shortness of breath, improved appetite and the absence of negative x-ray dynamics. It is usually observed with destructive pneumonia and/or with metapneumonic pleurisy. Does not require changing antibiotics.

No effect: persistence of fever with deterioration of general condition and/or increase in pathological changes in the lungs or pleural cavity (increase in the volume of effusion and its cytosis). With chlamydia and pneumocystosis, an increase in shortness of breath and hypoxemia is noted. Lack of effect requires changing the antibiotic.

Some features of the choice of antibiotics. The general rule for choosing antibiotics in children is to prescribe not only the most effective, but also the safest drug. In this case, preference should be given to drugs for oral administration and those having pediatric dosage forms.

When prescribing antibiotics, especially in children in serious condition, it is necessary to evaluate the functions of the kidneys and liver and, if necessary, adjust age-related doses.

Duration of antibiotic use. Etiotropic therapy for pneumonia, if the diagnosis is established or if the patient’s condition is serious, begins immediately. If there is doubt about the exact diagnosis in a child who is not seriously ill, it is preferable to obtain radiographic confirmation. In all cases, if technically possible, material should be collected for microbiological (sputum, blood, pleural fluid) and serological studies. The selection of material for microbiological research must be carried out before the use of antibiotics. The choice of the primary antibacterial agent and its replacement if ineffective is almost always carried out empirically. Indications for switching to alternative drugs are the lack of clinical effect from the first-choice drug within 48–72 hours for mild pneumonia and 36–48 hours for severe pneumonia, as well as the development of serious adverse drug reactions. The duration of therapy should be sufficient to suppress the vital activity of the pathogen, the elimination of which is completed by the immune system. With an adequate choice of antibiotic and a rapid onset of effect, 6–7 days are sufficient. In severe and complicated forms, treatment lasts longer. It is generally accepted that parenteral treatment should be continued for at least 2 days after the onset of the effect of the therapy. After the effect appears, you should switch to oral administration of drugs (step therapy).

Expectorants. At the onset of the disease, for a dry cough, marshmallow infusion, mucaltin, licorice root, bromhexine, and ammonia-anise drops are prescribed. After the cough has become wet, thermopsis tincture and chest preparations should be prescribed (Table 5). It should be remembered that if there is insufficient fluid intake into the child’s body, the use of expectorants may be ineffective.

Phytotherapy can be prescribed for pneumonia in children over 1 year of age during various periods of the disease. Shown are chest charges that have both

disinfectant (St. John's wort, birch leaves, Icelandic moss), and expectorant, cough softening properties (coltsfoot, thyme, elecampane, sage, licorice root, marshmallow, etc.).

Distraction therapy used after normalization of body temperature. Hot general and foot baths, mustard plasters, mustard foot baths are indicated (in the absence of an allergy to mustard). Vitamin therapy. Prescribe vitamin C (100-300 mg/day), vitamin A (1-2 drops 3 times a day), vitamin E (5-10 mg 2 times a day), vitamin B 1 (up to 15 mg/day), B 2 (5-10 mg/day), B 6 (2-6 mg/day).

Physiotherapy. In the acute period, when body temperature decreases, ultraviolet irradiation, microwave, UHF, diathermy, alkaline and alkaline-salt inhalations with potassium iodide are indicated. During the resorption period, heat treatment, paraffin, ozokerite applications, electrophoresis of magnesium, calcium, aloe, and potassium iodide are prescribed.

Syndrome therapy includes assistance with respiratory and heart failure, hyperthermia, neurotoxicosis, and convulsive syndrome.

Table 5

Expectorants

The criteria for cure of pneumonia are:

stable normalization of body temperature;

satisfactory general state, good appetite and sleep;

absence of shortness of breath, cough, physical changes in the lungs (vesicular breathing, percussion-pulmonary sound, wheezing is not audible);

normalization of blood tests;

normalization of the X-ray picture of the lungs.