Presentation Pneumonia: diagnosis and treatment. Pneumonia is an inflammation of the lungs of an infectious nature with the involvement of all structural elements of the lung tissue and obligatory damage to the lung tissue. Pneumonia. Community-acquired pneumonia presentation

Slide 2

Pneumonia (ancient Greek πνευμονία from πνεύμων) (pneumonia) - inflammation of the lung tissue, usually of infectious origin with predominant damage to the alveoli

Slide 3

Slide 4

The term “pneumonia” unites a large group of diseases, each of which has its own etiology, pathogenesis, clinical picture, radiological signs, characteristic laboratory findings and treatment features. It can occur as an independent disease or as a complication of other diseases.

Slide 5

The main diagnostic method is x-ray examination of the lungs

Slide 6

The main method of treatment is antibacterial therapy.

• Antibiotics are the cornerstone of treatment for pneumonia. The choice of antibiotic depends on the microorganism that caused the pneumonia.
• Drugs that dilate the bronchi and dilute sputum are also used - orally or in the form of inhalations, corticosteroids, intravenous saline solutions, oxygen.
• Sometimes pleural puncture and bronchoscopy are performed.
• Physiotherapy is often used: ultraviolet therapy, vibration massage, exercise therapy, paraffin, ozokerite

View all slides

Pneumonia is an acute infectious (mainly bacterial) disease, an acute infectious (mainly bacterial) disease, characterized by focal lesions of the respiratory parts of the lungs with intra-alveolar exudation, detected during physical and radiological examinations, characterized by focal lesions of the respiratory parts of the lungs with intra-alveolar exudation, detected during physical and radiological examinations examinations, accompanied by feverish reactions and intoxication expressed to varying degrees, accompanied by feverish reactions and intoxication expressed to varying degrees

Classification of pneumonia Community-acquired Typical (without pronounced immune disorders) In patients with severe immunodeficiency conditions of various origins Aspiration (lung abscess) Nosocomial Actually nosocomial Ventilator-associated Early VAP Late VAP Nosocomial pneumonia in patients with severe IDS Associated with the provision of medical care Pneumonia in residents of nursing homes Other categories of patients (ABT in the previous 3 months, hospitalization for more than 2 days in the previous 90 days, stay in long-term care facilities, etc.)

Community-acquired pneumonia is an acute disease, an acute disease that arose in a community setting, or diagnosed in the first 48 hours from the moment of hospitalization, arose in a community setting, or diagnosed in the first 48 hours from the moment of hospitalization, accompanied by symptoms of lower respiratory tract infection (fever, cough, sputum production, chest pain, shortness of breath, etc.) and accompanied by symptoms of lower respiratory tract infection (fever, cough, sputum production, chest pain, shortness of breath, etc.) and radiological signs of “fresh” focal infiltrative changes in the lungs by radiological signs of “fresh” focal infiltrative changes in the lungs in the absence of an obvious diagnostic alternative in the absence of an obvious diagnostic alternative

Nosocomial pneumonia - pneumonia that develops in a patient no earlier than 48 hours from the moment of hospitalization, not caused by an infection that was in the incubation period at the time of admission; pneumonia that develops in a patient no earlier than 48 hours from the moment of hospitalization, not caused by an infection, was in the incubation period at the time of admission

Pneumonia associated with the provision of medical care has been separately identified in recent years in foreign literature; according to the conditions of occurrence, they are community-acquired, however, the SPECTRUM OF PATIENTS AND THEIR ANTIBIOTIC RESISTANCE PROFILE is similar to the pathogens of nosocomial pneumonia; according to the conditions of occurrence, they are community-acquired, however, THE SPECTRUM OF PATIENTS AND THEIR ANTIBIOTIC RESISTANCE PROFILE is similar to pathogens of nosocomial pneumonia

Epidemiology of pneumonia The incidence of pneumonia in the Republic of Belarus averages 10.0-13.8 per 1000 population, increasing among people over 50 years of age to 17.0 per 1000 population The incidence of pneumonia in the Republic of Belarus averages 10.0-13.8 per 1000 population , increasing among people over 50 years of age to 17.0 per 1000 population in the United States, about 4 million cases of community-acquired pneumonia are registered annually in the United States, about 4 million cases of community-acquired pneumonia are registered annually in the United States, the cost of treating CAP in the USA is about 10 billion dollars per year the cost of treating VAP in the USA is about 10 billion dollars per year, pneumonia ranks first in the structure of mortality from infectious diseases in the USA, pneumonia ranks first in the structure of mortality from infectious diseases in the USA

The main pathogenetic mechanism for the development of pneumonia: aspiration of oropharyngeal secretion with colonizing microorganisms contained in it (relevant for S.pneumoniae, H.influenzae, Gr-bacteria, anaerobes) aspiration of oropharyngeal secretion with colonizing microorganisms contained in it (relevant for S.pneumoniae, H. influenzae, Gr-bacteria, anaerobes) microaspiration (often) microaspiration (often) macroaspiration (rarely in the presence of predisposing factors - stroke, chronic alcoholism, repeated vomiting) macroaspiration (rarely in the presence of predisposing factors - stroke, chronic alcoholism, repeated vomiting)

Other more rare pathogenetic mechanisms for the development of pneumonia: Inhalation of microbial aerosol (Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumoniae, etc.) Inhalation of microbial aerosol (Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella pneumoniae, etc.) Hematogenous dissemination from the extrapulmonary focus of infection Hematogenous dissemination from the extrapulmonary focus of infection Direct spread of infection from adjacent foci of pathology (intrahepatic or subphrenic abscess, etc.) Direct spread of infection from adjacent foci of pathology (intrahepatic or subphrenic abscess, etc.) Reactivation of latent infection (Pneumocystis jiroveci in the case of severe IDS) Reactivation latent infection (Pneumocystis jiroveci in case of severe IDS)

Etiology of community-acquired pneumonia (CAP): 1. Streptococcus pneumoniae – “king of CAP”, 30-50% of all cases 2. Atypical microorganisms (Chlamydophila pneumoniae, Mycoplasma pneumoniae, Legionella pneumophila) – up to 30% of all cases 3. Other rare pathogens of CAP – 3-5% of all cases: 1. Haemophilus influenzae 2. Staphylococcus aureus 3. Klebsiella pneumoniae, even less often - other Gr-bacteria of the Enterobacteriaceae family

The etiology of CAP is determined by a number of factors: the age of the patients, the severity of the disease, the presence of concomitant pathology (risk factors), etc. The etiology of CAP is determined by a number of factors: the age of the patients, the severity of the disease, the presence of concomitant pathology (risk factors), etc. In adults undergoing CAP, a mixed infection is often detected (in one clinical trial, almost every second of 346 examined patients with pneumococcal etiology of the disease showed serological signs of active infection caused by mycoplasmas or chlamydia). In adults undergoing CAP, a mixed infection is often detected (in one In clinical trials, almost every second of the 346 examined patients with pneumococcal etiology of the disease showed serological signs of active infection caused by mycoplasmas or chlamydia)

The main causative agents of CAP in outpatients: mild CAP in persons under 60 years of age without concomitant pathology; non-severe CAP in persons over 60 years of age and/or with concomitant pathology S.pneumoniae M. pneumoniae C.pneumoniae S.pneumoniae H.influenzae C.pneumoniae S. aureus Enterobacteriaceae

The main causative agents of CAP in hospitalized patients: non-severe CAP – hospitalization in the general hospital; severe CAP – hospitalization in the intensive care unit S.pneumoniae H.influenzae C.pneumoniae S. aureus Enterobacteriaceae S.pneumoniae Legionella spp. S.aureus Enterobacteriaceae

Risk factors and possible causative agents of CAP alcoholism: S.pneumoniae, anaerobes, Gr-bacteria (usually K.pneumoniae) alcoholism: S.pneumoniae, anaerobes, Gr-bacteria (usually K.pneumoniae) COPD/smoking: S.pneumoniae, H. influenzae, M. catarrhalis, Legionella spp. COPD/smoking: S.pneumoniae, H.influenzae, M.catarrhalis, Legionella spp. decompensated diabetes: S.pneumoniae, S.aureus decompensated diabetes: S.pneumoniae, S.aureus stay in nursing homes: S.pneumoniae, representatives of the family Enterobacteriaceae, H.influenzae, S.aureus, C. pneumoniae, anaerobes stay in nursing homes: S.pneumoniae, representatives of the family Enterobacteriaceae, H.influenzae, S.aureus, C. pneumoniae, anaerobes

Risk factors and possible causative agents of CAP influenza epidemic: S.pneumoniae, S.aureus, S.pyogenes, H.influenzae influenza epidemic: S.pneumoniae, S.aureus, S.pyogenes, H.influenzae CAP development against the background of bronchiectasis, cystic fibrosis: P.aeruginosa, B.cepacia, S.aureus development of PAP against the background of bronchiectasis, cystic fibrosis: P.aeruginosa, B.cepacia, S.aureus contact with air conditioners, air humidifiers, water cooling systems: L.pneumophila contact with air conditioners, air humidifiers , water cooling systems: L.pneumophila unsanitized oral cavity, expected massive aspiration: anaerobes unsanitized oral cavity, expected massive aspiration: anaerobes

“Pyramid” of lower respiratory tract infections (Macfarlane J.T. Lower respiratory tract infection and pneumoniae in the community) Died (1-2) Hospitalized in the ICU (1-2) Hospitalized for pneumonia (20) Diagnosed with community-acquired pneumonia (100) Persons those who received antibiotics (2,000) Those who sought medical help (8,000 patients) Persons with symptoms of community-acquired LRTIs (patients)

Diagnosis of pneumonia - subjective complaints: suspicion of pneumonia should arise with fever in combination with complaints of cough, shortness of breath, sputum production, chest pain; suspicion of pneumonia should arise with fever in combination with complaints of cough, shortness of breath, sputum production, chest pain cage in elderly patients, respiratory complaints may be absent, and in the clinic symptoms of a general nature will prevail: drowsiness during the day and insomnia at night, confusion, fatigue, heavy sweating at night, nausea, vomiting, signs of exacerbation or decompensation of concomitant diseases of internal organs in elderly patients, respiratory complaints may be absent, and in the clinic symptoms of a general nature will prevail: drowsiness during the day and insomnia at night, confusion, fatigue, heavy sweating at night, nausea, vomiting, signs of exacerbation or decompensation of concomitant diseases of internal organs

Diagnosis of pneumonia - objective data classic objective signs of pneumonia: classic objective signs of pneumonia: shortening of the percussion tone over the affected area of ​​the lung shortening of the percussion tone over the affected area of ​​the lung locally auscultated bronchial breathing locally auscultated bronchial breathing focus of sonorous fine-bubble rales or crepitus focus of sonorous fine-bubble rales or crepitus increased bronchophony and vocal tremor increased bronchophony and vocal tremor in interstitial pneumonia, characterized by the presence of dry and moist rales without signs of compaction of the lung tissue; interstitial pneumonia is characterized by the presence of dry and moist rales without signs of compaction of the lung tissue; in 20% of patients, objective signs of PAP may differ from typical ones or be absent in general, in 20% of patients, objective signs of PFS may differ from typical ones or be absent altogether

Diagnosis of pneumonia - instrumental examination almost always requires a chest x-ray to confirm the diagnosis, because Numerous studies have shown the low sensitivity and specificity of an objective clinical examination in diagnosing CAP; almost always, a chest x-ray is required to confirm the diagnosis, because Numerous studies have shown the low sensitivity and specificity of an objective clinical examination in the diagnosis of CAP in typical cases of CAP; the diagnosis criterion is the detection of focally infiltrative or interstitial changes in the lungs in typical cases of CAP; the diagnosis criterion is the detection of focally infiltrative or interstitial changes in the lungs; in some cases, changes in X-ray may be absent despite the presence of clinical and physical signs of pneumonia; in some cases, changes on the X-ray may be absent despite the presence of clinical and physical signs of pneumonia

Possible causes of clinical and radiological dissociation: deep neutropenia with the impossibility of developing a localized acute inflammatory reaction in the lung tissue; deep neutropenia with the impossibility of developing a localized acute inflammatory reaction in the lung tissue; early stages of the disease (according to stetoacoustic data, pneumonia can be recognized an hour before the appearance of pulmonary infiltrate on an x-ray) early stages of the disease (according to stetoacoustic data, pneumonia can be recognized an hour before the appearance of pulmonary infiltrate on a radiograph) in the case of Pneumocystis pneumonia in HIV-infected patients, pathological changes on the radiograph are absent in 10-20% of patients in the case of Pneumocystis pneumonia in HIV-infected patients, pathological changes on the radiograph absent in 10-20% of patients. In case of doubt, in the presence of obvious clinical symptoms of pneumonia and the absence of changes on the radiograph, computed tomography is indicated (the most sensitive for detecting interstitial changes in the lungs)

Diagnosis of pneumonia - microbiological examination The material most often is freely coughed up sputum The material most often is freely coughed up sputum The effectiveness of a microbiological examination depends on the rules for collecting the material (optimally before the start of antibacterial therapy) and the conditions of its transportation The effectiveness of a microbiological examination depends on the rules for collecting the material (optimally before the start of antibacterial therapy) and conditions of its transportation at the first stage of the study, sputum is Gram stained; if there are less than 25 polymorphonuclear leukocytes and more than 10 epithelial cells (when viewing at least 10 fields of view with a magnification of X 100), cultural examination is not advisable, because the sample is contaminated with the contents of the oral cavity; at the first stage of the study, the sputum is Gram stained; if there are less than 25 polymorphonuclear leukocytes and more than 10 epithelial cells (when viewing at least 10 fields of view with a magnification of X 100), cultural examination is not advisable, because the sample is contaminated with oral contents

Diagnosis of pneumonia - microbiological examination sputum microscopy can provide guidelines when choosing antibacterial therapy (lanceolate Gr+ diplococci - S.pneumoniae, weakly stained Gr-coccobacilli - H.influenzae, etc.) sputum microscopy can provide guidelines when choosing antibacterial therapy (lanceolate Gr+ diplococci – S.pneumoniae, weakly stained Gr- coccobacilli – H.influenzae, etc.) at the second stage of the study, sputum culture is carried out to isolate specific pathogens and determine the antibiotic resistance profile; at the second stage of the study, sputum culture is carried out to isolate specific pathogens and to determine the antibiotic resistance profile in seriously ill patients, before starting antibacterial therapy, it is also necessary to perform venous blood cultures (2 samples from 2 different veins, at least 10 ml of blood for each sample); in seriously ill patients, before starting antibacterial therapy, it is also necessary to perform venous blood cultures (2 samples from 2 different veins, at least 10 ml of blood for each sample)!!! Despite the importance of obtaining laboratory material before prescribing an antibiotic, microbiological testing should not be a reason for delaying antibacterial therapy (especially in severe patients)

Participation in the development of bronchopulmonary inflammation is not typical for a number of microorganisms: Streptococcus viridans Streptococcus viridans Staphylococcus epidermidis and other coagulase-negative staphylococci Staphylococcus epidermidis and other coagulase-negative staphylococci Enterococcus spp. Enterococcus spp. Neisseria spp. Neisseria spp. Candida spp. etc. Candida spp. etc. Isolation of this group of microorganisms from sputum indicates CONTAMINATION OF THE MATERIAL by the flora of the upper respiratory tract, and not the etiological significance of these pathogens in the development of pneumonia!!!

Diagnosis of pneumonia - laboratory data peripheral blood leukocytosis more than X 10 9 /L indicates a high probability of bacterial infection, and leukopenia below 3 X 10 9 /L or leukocytosis above 25 X 10 9 /L is an unfavorable prognostic sign peripheral blood leukocytosis more than X 10 9 /l indicates a high probability of bacterial infection, and leukopenia below 3 X 10 9 /l or leukocytosis above 25 X 10 9 /l is an unfavorable prognostic sign; detectable abnormalities in a biochemical blood test, indicating damage to certain organs/systems, have a prognostic value; detectable deviations in biochemical blood tests indicating damage to certain organs/systems have prognostic significance; a number of studies have shown that the highest concentration of C-reactive protein is observed in patients with severe pneumococcal or legionella pneumonia; a number of studies have shown that the highest concentration of C- reactive protein is observed in patients with severe pneumococcal or Legionella pneumonia

Diagnosis criteria The diagnosis of PAP is determined if the patient has radiologically confirmed focal infiltration of the lung tissue and at least two clinical signs from the following: acute fever at the onset of the disease above 38 *C acute fever at the onset of the disease above 38 *C cough with sputum cough with sputum physical signs (focus of crepitus and/or fine-bubble rales, harsh bronchial breathing, shortening of percussion sound) physical signs (focus of crepitation and/or fine-bubble rales, harsh bronchial breathing, shortening of percussion sound) leukocytosis above 10 X 10 9 /l and/or band shift (above 10%) leukocytosis above 10 X 10 9 /l and/or band shift (above 10%)

Choosing a place of treatment for patients with VBP, dividing patients with VBP into inpatient and outpatient is fundamentally important due to different approaches to diagnostic examination and tactics of antimicrobial chemotherapy; dividing patients with VBP into inpatient and outpatient is fundamentally important due to different approaches to diagnostic examination and tactics of antimicrobial chemotherapy 30-50 % of patients hospitalized for CAP are characterized as prognostically “favorable” and can be successfully treated at home 30-50% of patients hospitalized for CAP are characterized as prognostically “favorable” and can be successfully treated at home at present there are a number of clinical and laboratory scales, which, based on the assessment of the severity of VBP and prognosis, give recommendations on the choice of place of treatment; currently, there are a number of clinical and laboratory scales, which, based on the assessment of the severity of VBP and prognosis, give recommendations on the choice of place of treatment

Prognostic scale CRB-65 1C (Confusion) Impaired consciousness 2R (Respiratory rate) Respiratory rate (RR) equal to or higher than 30/min 3B (Blood pressure) Low diastolic or systolic blood pressure:

Management of patients with CAP in an outpatient setting Diagnostic minimum: medical history medical history physical examination of the patient physical examination of the patient chest radiography optimally in two projections chest radiography optimally in two projections general blood count general blood count

Based on clinical, hematological, radiological data and using generally accepted microbiological methods, as a rule, it is impossible to reliably establish the etiology of PAP. The empirical choice of antibiotics, based on the most likely sensitivity of the most likely pathogens, forms the basis of therapy

Antibiotic resistance of the main causative agents of CAP S.pneumoniae – the main problem is resistance to beta-lactams and macrolides S.pneumoniae – the main problem is resistance to beta-lactams and macrolides multidrug-resistant pneumococcus – S.pneumoniae, resistant to three or more classes of antibiotics multidrug-resistant pneumococcus – S .pneumoniae, resistant to three or more classes of antibiotics pneumococcal resistance to penicillin is usually accompanied by co-resistance to I-II generation cephalosporins, tetracyclines and co-trimoxazole pneumococcal resistance to penicillin is usually accompanied by co-resistance to I-II generation cephalosporins, tetracyclines and co-trimoxazole

Antibiotic resistance of the main causative agents of PEGAS (year) - a multicenter study of antibiotic resistance of pneumococcus in Russia: PEGAS (year) - a multicenter study of antibiotic resistance of pneumococcus in Russia: the level of resistance to penicillin does not exceed 10%, while most strains are moderately resistant the level of resistance to penicillin does not exceed 10%, while most strains are moderately resistant; the level of resistance to CA III (ceftriaxone, cefotaxime) is not higher than 2%; the level of resistance to CA III (ceftriaxone, cefotaxime) is not higher than 2%; resistance to 14- and 15 -membered macrolides (erythromycin, clarithromycin, azithromycin) 6-9%, to 16-membered macrolides (josamycin, spiramycin, midecamycin) and lincosamides does not exceed 4.5% resistance to 14- and 15-membered macrolides (erythromycin, clarithromycin, azithromycin) 6-9%, to 16-membered (josamycin, spiramycin, midecamycin) and lincosamides does not exceed 4.5%

Antibiotic resistance of the main pathogens of PEGAS (year) - a multicenter study of antibiotic resistance of pneumococcus in Russia: PEGAS (year) - a multicenter study of antibiotic resistance of pneumococcus in Russia: high resistance of pneumococcus is characteristic of co-trimoxazole (40.7% of strains are insensitive) and tetracyclines (29.6% of strains are insensitive) high resistance of pneumococcus is characteristic of co-trimoxazole (40.7% of strains are insensitive) and tetracyclines (29.6% of strains are insensitive) co-trimoxazole and tetracyclines should not be used as drugs of choice for empirical therapy of CAP due to the high resistance of the main causative agent to them, co-trimoxazole and tetracyclines should not be used as drugs of choice for empirical treatment of CAP due to the high resistance of the main causative agent to them

Antibiotic resistance of the main causative agents of PEGAS (year) - a multicenter study of antibiotic resistance of pneumococcus in Russia: PEGAS (year) - a multicenter study of antibiotic resistance of pneumococcus in Russia: resistance of pneumococcus to: resistance of pneumococcus to: respiratory fluoroquinolones (levofloxacin) is not registered , moxifloxacin) respiratory fluoroquinolones (levofloxacin, moxifloxacin) vancomycin vancomycin linezolid linezolid resistance to chloramphenicol (levomycetin) does not exceed 8.6% resistance to chloramphenicol (levomycetin) does not exceed 8.6% resistance to amoxicillin does not exceed 0.5%, to amoxicillin well clavulanate - 0.3% resistance to amoxicillin does not exceed 0.5%, to amoxicillin clavulanate - 0.3% all penicillin-resistant pneumococci retained 100% sensitivity to amoxicillin clavulanate all penicillin-resistant pneumococci retained 100% sensitivity to amoxicillin clavulanate

Antibiotic resistance of the main causative agents of VBP PEGAS II (year) - a multicenter study of antibiotic resistance of H. influenzae in Russia: PEGAS II (year) - a multicenter study of antibiotic resistance of H. influenzae in Russia: the main mechanism of resistance is the production of beta-lactamases that hydrolyze aminopenicillins the main mechanism of resistance is the production of beta-lactamases that hydrolyze aminopenicillins; resistance to aminopenicillins did not exceed 4.7%; resistance to aminopenicillins did not exceed 4.7%; no strains resistant to amoxicillin clavulanate, cephalosporins II-IV, carbapenems, fluoroquinolones were identified; resistant to amoxicillin clavulanate, cephalosporins II-IV, carbapenems, fluoroquinolones

Group I - patients with non-severe CAP under the age of 60 years without concomitant pathology, the most common pathogens: S.pneumoniae, M.pneumoniae, C.pneumoniae drugs of choice: amoxicillin or macrolide antibiotics (clarithromycin, azithromycin) by mouth alternative drugs: respiratory fluoroquinolones (levofloxacin , gemifloxacin, moxifloxacin) orally!!! Despite the fact that in vitro aminopenicillins are not active against “atypical” pathogens of CAP, clinical studies have not revealed differences in the effectiveness of these antibiotics, as well as individual representatives of the class of macrolides or respiratory fluoroquinolones, the spectrum of action of which includes both typical and “ atypical" pathogens

Group II – patients with non-severe CAP 60 years of age and older and/or with concomitant diseases and risk factors Chronic diseases and risk factors influencing the etiology and prognosis of CAP: chronic obstructive pulmonary disease chronic obstructive pulmonary disease diabetes mellitus diabetes mellitus congestive heart failure congestive heart disease failure chronic renal failure chronic renal failure cirrhosis of the liver cirrhosis of the liver alcoholism, drug addiction alcoholism, drug addiction body weight deficiency body weight deficiency

Group II – patients with non-severe CAP 60 years of age and older and/or with concomitant diseases and risk factors, the most common pathogens: S.pneumoniae, H.influenzae, C.pneumoniae, S.aureus, family Enterobacteriaceae drugs of choice: combination therapy amoxicillin /clavulanate or amoxicillin/sulbactam orally + macrolide (azithromycin, clarithromycin) orally alternative drugs: monotherapy with respiratory fluoroquinolones (levofloxacin, moxifloxacin, gemifloxacin) orally

Drug Average doses (for adults) Ampicillin 1.0-2.0 g IV or IM every 6 hours Amoxicillin 0.5-1.0 g orally every 8 hours Amoxicillin/clavulanate 0.625 g orally every 6-8 hours 1, 2 g IV every 6-8 hours Cefuroxime 0.75-1.5 g IV, IM every 8 hours Cefuroxime axetil 0.5 g orally every 12 hours Cefotaxime 1.0-2.0 g IV, IV /m every 8 hours Ceftriaxone 1.0-2.0 g IV, IM every 24 hours Clarithromycin 0.5 g orally every 12 hours 0.5 g IV every 12 hours Azithromycin 3-day course: 0.5 g orally every 24 hours 5-day course: 0.5 g orally on the first day, then 0.25 g every 24 hours Midecamycin 0.4 g orally every 8 hours Levofloxacin 0.5 g orally every 24 hours 0.5 g IV every 24 hours Moxifloxacin 0.4 g orally and IV every 24 hours AB, often used in outpatient practice

Management of patients with CAP in an outpatient setting parenteral blockers in the treatment of CAP on an outpatient basis do not have proven advantages over oral parenteral blockers in the treatment of CAP on an outpatient basis do not have proven advantages over oral parenteral blockers should be used only in cases of expected low compliance when taking oral medications or when refusing hospitalization or if it is impossible to carry it out in a timely manner, parenteral antibiotics should be used only in cases of expected low compliance when taking oral medications or in case of refusal of hospitalization or the impossibility of carrying it out in a timely manner; the initial assessment of the effectiveness of therapy should be carried out within an hour from the start of therapy (efficacy criteria: reduction in temperature, reduction in symptoms of intoxication, etc. . clinical manifestations of the disease), the initial assessment of the effectiveness of therapy should be carried out within an hour from the start of therapy (efficacy criteria: decrease in temperature, reduction of symptoms of intoxication and other clinical manifestations of the disease) if treatment is ineffective, the tactics of antibacterial therapy should be reconsidered and the advisability of hospitalization of the patient should be re-evaluated if treatment is ineffective it is necessary to reconsider the tactics of antibacterial therapy and re-evaluate the advisability of hospitalization of the patient in case of non-severe CAP, the average duration of ABT is 7-10 days (ABT is completed with stable normalization of body temperature for 3-4 days) in case of non-severe CAP, the average duration of ABT is 7-10 days (ABT is completed when stable normalization of body temperature within 3-4 days)

In hospitalized patients, a more severe course of CAP is implied, so it is advisable to start therapy with parenteral antibiotics. In hospitalized patients, a more severe course of CAP is implied, so it is advisable to start therapy with parenteral antibiotics after 3-4 days of treatment when body temperature normalizes, intoxication and other symptoms of the disease decrease. switching from parenteral to oral use of AB before completing the full course of therapy (stepped therapy); after 3-4 days of treatment, with normalization of body temperature, reduction of intoxication and other symptoms of the disease, it is possible to switch from parenteral to oral use of AB before completing the full course of therapy (stepped therapy) !!! In case of severe CAP, the appointment of antibiotics should be urgent - a delay in their appointment of 4 hours or more significantly worsens the prognosis of the disease, increases mortality and length of hospital stay (Houck P.M et al. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumoniae Clin Infect Dis 2003;36:)

Group I – non-severe CAP in hospitalized patients most common pathogens: S.pneumoniae, H.influenzae, C.pneumoniae, S.aureus, family Enterobacteriaceae drugs of choice: combination therapy benzylpenicillin IV, IM ± macrolide orally benzylpenicillin IV /in, intramuscular ± macrolide inside ampicillin intravenous, intramuscular ± macrolide inside ampicillin intravenous, intramuscular ± macrolide inside amoxicillin/clavulanate intravenously ± macrolide inside amoxicillin/clavulanate intravenous ± macrolide inside cefuroxime IV, IM ± macrolide orally Cefuroxime IV, IM ± macrolide orally Cefotaxime or ceftriaxone IV, IM ± macrolide orally Cefotaxime or ceftriaxone IV, IM ± macrolide orally According to series studies, the presence in the initial treatment regimen of a drug active against “atypical” microorganisms improves the prognosis and reduces the length of stay of patients in the hospital, which makes the use of combination therapy beta-lactam + macrolide justified alternative drugs: monotherapy respiratory fluoroquinolones (levofloxacin, moxifloxacin) i.v. respiratory fluoroquinolones (levofloxacin, moxifloxacin) IV azithromycin IV (can be used as monotherapy only in the absence of risk factors for antibiotic-resistant pneumococci, Gr-enterobacteria and infection caused by Ps.aeruginosa) azithromycin IV (can be used as monotherapy only in the absence of risk factors for antibiotic-resistant pneumococci, Gr-enterobacteria and infection caused by Ps.aeruginosa)

Group II – severe PAP in hospitalized patients, the most common pathogens: S.pneumoniae, Legionella spp., S.aureus, family Enterobacteriaceae drugs of choice: combination therapy amoxicillin/clavulanate IV + macrolide IV amoxicillin/clavulanate IV + macrolide IV cefotaxime IV + macrolide IV cefotaxime IV + macrolide IV ceftriaxone IV + macrolide IV ceftriaxone IV + macrolide IV alternative drugs: combination therapy respiratory fluoroquinolones (levofloxacin , moxifloxacin) IV + III generation cephalosporins IV respiratory fluoroquinolones (levofloxacin, moxifloxacin) IV + III generation cephalosporins IV In the presence of risk factors for infection caused by Pseudomonas aeruginosa (bronchiectasis, taking systemic corticosteroids, therapy with broad-spectrum antibiotics effects for more than 7 days during the last month, exhaustion) drugs of choice are ceftazidime, cefepime, cefoperazone/sulbactam, ticarcillin/clavulanate, piperacillin/tazobactam, carbapenems (meropenem, imipenem)

Management of patients with CAP in inpatient conditions, the initial assessment of the effectiveness of therapy should be carried out 48 hours after the start of treatment, and in the case of severe disease - 24 hours later (efficacy criteria: reduction in temperature, reduction of symptoms of intoxication and respiratory failure) the initial assessment of the effectiveness of therapy should be carried out 48 hours after the start of treatment, and in case of severe disease - 24 hours later (efficacy criteria: reduction in temperature, reduction in symptoms of intoxication and respiratory failure) if treatment is ineffective (maintenance of high fever and intoxication or progression of disease symptoms), the tactics of antibacterial therapy should be reconsidered if treatment is ineffective (maintenance of high fever and intoxication or progression of disease symptoms), the tactics of antibacterial therapy should be reconsidered for non-severe CAP; the average duration of ABT is 7-10 days (ABT is completed with persistent normalization of body temperature within 3-4 days); for non-severe CAP, the average duration of ABT 7-10 days (ABT ends with persistent normalization of body temperature within 3-4 days) for severe PAP, a 10-day course of ABT is recommended for severe PAP, a 10-day course of ABT is recommended if there is evidence of mycoplasma or chlamydial etiology for PAP, antibacterial therapy is extended until 14 days if there is evidence of a mycoplasma or chlamydial etiology for CAP, antibacterial therapy is extended to 14 days for CAP of staphylococcal etiology or CAP caused by gram-negative enterobacteria, as well as for legionella CAP, the duration of ABT should be from 14 to 21 days for CAP of staphylococcal etiology or CAP, caused by gram-negative enterobacteria, as well as with legionella CAP, the duration of ABT should be from 14 to 21 days

Typical errors in antibiotic therapy for CAP: errors in choosing a drug aminoglycosides - gentamicin and other aminoglycosides are inactive against pneumococcus and atypical microorganisms aminoglycosides - gentamicin and other aminoglycosides are inactive against pneumococcus and atypical microorganisms ampicillin orally - has low bioavailability when taken orally, amoxicillin is used orally ampicillin orally – has low bioavailability when taken orally, amoxicillin is used orally; first generation cephalosporins (cefazolin, etc.) are inactive against most pathogens of respiratory infections, and are inferior in antipneumococcal activity to aminopenicillins and most cephalosporins of later generations; penicillin-resistant pneumococci are cross-resistant to first generation cephalosporins; activity against H. influenzae is not clinically significant; sensitive to beta-lactamases, which produce almost 100% of M. catarrhalis strains. First generation cephalosporins (cefazolin, etc.) are inactive against most pathogens of respiratory infections, and are inferior in antipneumococcal activity to aminopenicillins and most cephalosporins of later generations; penicillin-resistant pneumococci are cross-resistant to first generation cephalosporins; activity against H. influenzae is not clinically significant; sensitive to beta-lactamases, which are produced by almost 100% of M. catarrhalis strains co-trimoxazole - high resistance to this drug S. pneumoniae and H. influenzae, frequent allergic skin reactions, the presence of safer drugs co-trimoxazole - high resistance to this drug S.pneumoniae and H.influenzae, frequent skin allergic reactions, the presence of safer drugs ciprofloxacin and other fluoroquinolones of the second generation - has low activity against S.pneumoniae and atypical pathogens; if used rashly, it forms resistance to fluoroquinolones of all generations, including respiratory ciprofloxacin and other fluoroquinolones of the second generation - has low activity against S.pneumoniae and atypical pathogens; if used rashly, it forms resistance to fluoroquinolones of all generations, including respiratory ones

Typical mistakes in antibiotic therapy for CAP: late start of antibacterial therapy: prescribing antibiotics later than 4 hours after the diagnosis of community-acquired pneumonia leads to an increase in mortality; late start of antibacterial therapy: prescribing antibiotics later than 4 hours after the diagnosis of community-acquired pneumonia leads to an increase in mortality; frequent changes of antimicrobial medications during treatment; “explained” by the danger of developing resistance, frequent changes in AMPs during treatment, “explained” by the danger of developing resistance. There are clear indications for replacing AMPs: clinical ineffectiveness, which can be judged after an hour of therapy; clinical ineffectiveness, which can be judged after an hour of therapy; development of serious adverse reactions; requiring discontinuation of AMPs development of serious adverse reactions requiring discontinuation of AMPs high potential toxicity of AMPs (for example, aminoglycosides), limiting the duration of their use high potential toxicity of AMPs (for example, aminoglycosides), limiting the duration of their use continuation of antibiotic therapy while certain radiological and/or laboratory changes persist until until their complete disappearance, continuation of antibiotic therapy while maintaining individual radiological and/or laboratory changes until their complete disappearance. The main criterion for discontinuing antibiotics is regression of clinical symptoms. The persistence of individual laboratory and/or radiological changes is not an absolute indication for continued antibiotic therapy

Prolonged PFS in the majority of patients with PFS, by the end of 3-5 days after the start of effective ABT, body temperature normalizes and other clinical manifestations of the disease regress, while radiological recovery, as a rule, lags behind the clinical one in the majority of patients with PFS by the end of 3-5 days after the start of effective ABT normalizes body temperature and regresses other clinical manifestations of the disease, while radiological recovery, as a rule, lags behind the clinical one if, against the background of an improvement in the clinical picture, by the end of the 4th week from the onset of the disease it is not possible to achieve complete radiological resolution of focal infiltrative changes in the lungs, we should talk about protracted or non-resolving (slowly resolving) PFS if, against the background of an improvement in the clinical picture, by the end of the 4th week from the onset of the disease it is not possible to achieve complete radiological resolution of focal infiltrative changes in the lungs, we should talk about protracted or non-resolving (slowly resolving) PFS

Risk factors for the development of prolonged CAP: age over 65 years age over 65 years alcoholism alcoholism presence of concomitant disabling diseases of internal organs (COPD, congestive heart failure, renal failure, malignant neoplasms, diabetes mellitus, etc.) presence of concomitant disabling diseases of internal organs (COPD, congestive heart failure, renal failure, malignant neoplasms, diabetes mellitus, etc.) severe CAP severe CAP multilobar infiltration multilobar infiltration highly virulent pathogens (L.pneumophila, S.aureus, gram-negative enterobacteria) highly virulent pathogens (L.pneumophila, S .aureus, gram-negative enterobacteria) smoking smoking clinical ineffectiveness of initial therapy (persisting leukocytosis and fever) clinical ineffectiveness of initial therapy (persisting leukocytosis and fever) secondary bacteremia secondary bacteremia secondary resistance of pathogens to antibiotics secondary resistance of pathogens to antibiotics

Algorithm for examining a patient with protracted community-acquired pneumonia syndrome: in the presence of risk factors for a protracted course of the disease, a control radiographic examination after 4 weeks. In the case of persistent pneumonic infiltration, an additional examination of the patient (CT, fibrobronchoscopy, etc.) is indicated in the presence of risk factors for a protracted course of the disease - a control radiographic examination after 4 weeks. In the case of persistent pneumonic infiltration, additional examination of the patient is indicated (CT, fibrobronchoscopy, etc.) in the absence of risk factors for a protracted course of the disease, the patient needs additional examination in the absence of risk factors for a protracted course of the disease, the patient needs additional examination

Compliance (adherence) - the patient’s agreement to follow the doctor’s recommendations Compliance (adherence) - the patient’s agreement to follow the doctor’s recommendations Incompliance - any deviation of the patient from medical instructions Incompliance - any deviation of the patient from medical instructions

To use presentation previews, create a Google account and log in to it: https://accounts.google.com

Slide captions:

PNEUMONIA

STRUCTURE OF THE HUMAN RESPIRATORY SYSTEM

PNEUMONIA is an acute infectious disease in which damage to the alveoli occurs, accompanied by exudation and infiltration of parenchyma inflammatory cells as a response to the introduction and proliferation of microorganisms into normally sterile parts of the respiratory tract

AVL CORNELIUS CELUS (1st century BC) – the first mention of inflammation in the respiratory parts of the respiratory tract; WILLIS (1684) - described in detail the symptoms of acute fever, cough and difficulty breathing; LAENNEQ (1781-1826) - described the auscultatory picture of pneumonia. ROKITANSKY (1804-1878) - identified 2 morphological variants of pneumonia - lobar and bronchopneumonia. X-RAY (1845-1923) - discovered X-rays and studied their properties.

PREVALENCE 3-15 PEOPLE PER 1000 POPULATION MORTALITY from community-acquired pneumonia – 5%; from nosocomial pneumonia – 20%; in the elderly – 30% ERRORS IN DIAGNOSIS 20% DIAGNOSIS OF PNEUMONIA IN THE FIRST 3 DAYS IS PLACED IN 35% OF SICK PATIENTS

ETIOLOGY Mycoplasma pneumoniae Streptococcus pneumoniae Haemophilus influenza Chlamydia pneumoniae Legionella pneumoniae Staphylococcus aureus

COMMUNITY-ACQUIRED PNEUMONIA Streptococcus pneumoniae (30-90%); Mycoplasma pneumoniae (up to 30% under 45 years of age and up to 9% over 45 years of age); Haemophilus influenza (5-18%); Chlamydia pneumoniae (2-8%); Legionella pneumoniae (2-10%); Staphylococcus aureus (less than 5%); Gram-negative microorganisms (rare); Influenza virus (during an epidemic); 20-30% etiology of pneumonia is not established ETIOLOGICAL CLASSIFICATION. 1

ETIOLOGY Pseudomonas aeruginosa Klebsiella pneumoniae Enterobacter spp. Staphylococcus aureus

VN MORNING HOSPITAL PNEUMONIA Develops 48 hours or more after the patient is admitted to the hospital Gram-negative aerobic microorganisms, especially: Pseudomonas aeruginosa; Klebsiella pneumoniae; Enterobacter spp. Gram-positive: Staphilococcus aureus ETIOLOGICAL CLASSIFICATION. 2

PNEUMONIA IN PERSONS WITH IMMUNODEFICIENCY Cytomegalovirus; Pathogenic fungi; HIV-associated pneumonia: Pneumocystis carinii; Mycobacterium tuberculosis; Streptococcus pneumoniae; Haemophilus influenze. ETIOLOGICAL CLASSIFICATION. 3

PATHOGENESIS Etiological factors Release of endo- and exotoxins Colonization of epithelial cells Clinical manifestations of the disease Inflammation of the alveoli and bronchioles Invasion and intracellular persistence of the pathogen Adhesion to epithelial cells Activation of opportunistic microflora Violation of the lungs. blood circulation Decrease in general non-specialty. protection Suppression of local protective mechanisms Promoting factors and risk factors Formation of antibodies and immune complexes

CLASSIFICATION (International consensus and Russian therapeutic protocol, order of the Ministry of Health of the Russian Federation No. 300, 1998). IN-HOSPITAL PNEUMONIA (HOSPITAL, NOSOCOMIAL). COMMUNITY-ACQUIRED PNEUMONIA (PRIMARY, HOME-BASED). ASPIRATION PNEUMONIA. PNEUMONIA IN PERSONS WITH IMMUNODEFICIENCY (congenital or acquired).

CLINICAL CLASSIFICATION Focal pneumonia (bronchopneumonia) Lobar pneumonia Interstitial pneumonia

STEPS OF DIAGNOSIS OF PNEUMONIA Establish the presence of pneumonia. Conduct differential diagnosis in order to exclude syndromatically similar conditions. Tentatively (empirically) determine the etiological variant to select the optimal treatment program.

CLINICAL PICTURE GENERAL SYMPTOMS (EXTRAPULMONARY): weakness, lethargy, adynamia, loss of appetite, fever, chills, sweating, headache, symptoms of damage to organs and systems during infectious-toxic manifestations. LOCAL SYMPTOMS (PULMONARY): cough, presence of sputum, its nature (mucous, purulent, mucopurulent, rusty, hemoptysis), chest pain, its connection with breathing, shortness of breath.

CLINICAL PICTURE of lobar pneumonia PHYSICAL DATA: EXAMINATION: pallor of the skin, blush on the side of the affected lungs, herpes, lag of the affected side of the chest when breathing

Forced position of the patient Herpes nasalis, labialis Blush on the side of the affected lungs

CLINICAL PICTURE of lobar pneumonia PHYSICAL DATA: PALPATION: increased vocal tremor, PERCUSSION: - dullness of percussion sound (in stages I and III), dull (femoral) percussion sound (in stage II), AUSCULTATION: - bronchovesicular (hard) breathing (in stage I and stage III), bronchial breathing (in stage II), crepitus (in stages I and III), pleural friction noise (in stage II), increased bronchophony

CLINICAL PICTURE of focal pneumonia PHYSICAL DATA: PALPATION: increased vocal tremor, PERCUSSION: dullness of percussion sound AUSCULTATION: bronchovesicular (hard) breathing, ringing fine bubbling rales, increased bronchophony

INSTRUMENTAL DIAGNOSTIC METHODS - X-RAY OF THE CHEST ORGANS in 2 projections (prescribed also in case of an incomplete set of clinical symptoms)

INSTRUMENTAL DIAGNOSIS METHODS CLINICAL BLOOD ANALYSIS MICROBIOLOGICAL STUDY: - Gram stain; - culture of sputum to isolate the pathogen and determine its sensitivity to antibiotics Staphylococcus aureus in pus. Gram stain. Culture sensitive (left) and insensitive (right) to the antibiotic

DISEASES AND SYNDROMES FOR DIFFERENTIAL DIAGNOSIS OF PNEUMONIA Lung cancer Lung infarction Atelectasis Pulmonary contusion Pulmonary tuberculosis ARVI Bronchitis "Non-pneumonic" pleural effusion Pneumonitis (drug-induced, toxic, radiation, with systemic vasculitis) Infectious diseases (typhoid)

ADDITIONAL OBJECTIVE CRITERIA FOR DIFFERENTIAL DIAGNOSIS OF PNEUMONIA - X-ray tomography, computed tomography (in case of damage to the upper lobes, lymph nodes, mediastinum, reduction in the volume of the lobe, suspected abscess formation, with ineffectiveness of adequate antibacterial therapy). - Microbiological examination of sputum, pleural fluid, urine, blood, including mycological examination in case of ongoing febrile condition, suspicion of sepsis, tuberculosis, superinfection, AIDS. - Serological study (determination of antibodies to fungi, mycoplasma, chlamydia, legionella, cytomegalo virus) for atypical pneumonia in the risk group of alcoholics, drug addicts, immunodeficiency (including AIDS), and the elderly.

PNEUMOCOCCAL PNEUMONIA (30-95%) Most often in winter and early spring During epidemics of acute respiratory viral infections and influenza In patients with chronic lung diseases Most often the lower lobes and posterior segments of the upper lobe are affected Often the “classic” picture of lobar pneumonia Up to 25% of such pneumonia occurs with bacteremia and these cases are fatal.

STAPHYLOCOCCAL PNEUMONIA Often complicates viral infections Often nosocomial and develops in patients with a severe underlying disease, after a recent operation Development as multifocal broncho-pneumonia with peribronchial easily draining abscesses Often complicated by pleurisy and pyopneumo-thorax Hospital strains of staphylococcus are resistant to most antibiotics

MYCOPLASMA PNEUMONIA Develops more often in childhood, adolescence and young adulthood Epidemic outbreaks in organized groups (schoolchildren, military personnel) At the onset of the disease, ARVI symptoms Often extrapulmonary symptoms - chills, muscle and headaches, ARVI symptoms Often cervical lymphadenopathy, polymorphic skin rash, d epatosplenomegaly Physical symptoms are scanty: there is often no change in percussion sound, locally fine wheezing B rapid decompensation of concomitant diseases progression of pneumonia ATYPICAL PNEUMONIA 1

CHLAMYDIAL PNEUMONIA C. trachomona – isolated cases of pneumonia in newborns C. psittaci – lung damage as part of psittacosis (ornithosis) C. pneumoniae is one of the main causative agents of AP. Onset of the disease with a dry cough, sore throat, hoarseness (pharyngitis, laryngitis), malaise Fever On X-ray examination, it is often small-focal in size 2-3 cm, often multifocal infiltration Lobar infiltration, formation of cavities and pleural effusion atypical, not severe, but protracted course ATYPICAL PNEUMONIA 3

LEGIONELLA SIGNIFICANT PNEUMONIA More often observed in large buildings (hotels, hospitals) People of middle and old age are more likely to get sick Clinical debut is characterized by unmotivated general weakness, anorexia, lethargy, persistent headaches Hemoptysis and chest pain in every 3rd patient Febrile fever, shortness of breath Physical symptoms: dullness, bronchial breathing, crepitus, moist rales ATYPICAL PNEUMONIA 5

LEGIONELLA ESSENTIAL PNEUMONIA Cases of sinusitis, paraproctitis, pancreatitis, brain abscess have been described. X-ray at the beginning - focal infiltrates, subsequently their consolidation. Infiltrates adjacent to the pleura may resemble pulmonary infarction. Pleural effusion in 1/3 of patients Often bradycardia, hypotension May be urinary syndrome ATYPICAL PNEUMONIA 6

Common to all atypical pneumonias - Inability to detect the pathogen in sputum - Specific serological data (enzyme immunoassay with detection of specific IgG, IgM) - Ineffectiveness of ß-lactam antibiotics - Efficiency of macrolides, tetracyclines, fluoroquinolones

FORMULATION OF DIAGNOSIS 1 NOSOLOGICAL FORM: Focal pneumonia (bronchopneumonia) (the inflammatory process involves individual areas of the lung tissue - the alveoli and adjacent bronchi.) Croupous (lobar) pneumonia (characterized by the rapid involvement of a lobe or part and the adjacent area of ​​the pleura in the process.) Interstitial pneumonia (caused by predominant damage to the connective (interstitial) tissue of the lungs) COMMUNITY or INTRAPAIN - NATIONAL

FORMULATION OF DIAGNOSIS 2 ETIOLOGICAL OPTION (approximate or verified) PREVALENCE DEGREE OF SEVERITY PRESENCE OF COMPLICATIONS (pulmonary and extrapulmonary) PHASE OF THE DISEASE (height, resolution, prolonged course)

TACTICS OF TREATMENT OF PATIENTS WITH ACUTE PNEUMONIA The choice of place of treatment (outpatient or inpatient) is determined by the severity of the condition, including the presence of concomitant diseases and the degree of their compensation. The choice of the initial AB is determined by: the clinical and epidemiological situation, the previous trip, the stay in the hospital in age, the background pathology with the degree of radiological severity picture of the results of bacteriological examination of sputum

ALGORITHM FOR TREATING A PATIENT WITH IN-HOSPITAL PNEUMONIA, CONSIDERING THE SEVERITY OF THE DISEASE CLINICAL AND RADIOLOGICAL SIGNS OF PNEUMONIA AND ASSESSMENT OF THE SEVERITY AND PROGNOSIS OF PULMONARY PNEUMONIA Oral a/b therapy MACROLIDES, RESPIRATORY FLUOROQUINOLONE SEVERE AND MODERATE PNEUMONIA Parenteral a/b therapy CEPHALOSPORINS III + MACROLIDES

ANTIMICROBIAL DRUGS 1 PENICILLINS: NATURAL - benzylpenicillin SEMISYNTHETIC - methicillin, oxacillin, cloxacillin, ampicillin, amoxicillin, carbenicillin, azlocillin, etc. Combined antibiotics (ampiox, amoxiclav, augmentin)

ANTIMICROBIAL DRUGS 2 CEPHALOSPORINS: CPS 1 – highly active in relation to gram (+), stable to the action of staphylococcal beta-lactamase, but hydrolyzed by beta-lactamases of gram (-) bacteria (cefazolin) CPS II – highly active in relation to gram (-) ( cefamandol, cefataxime - claforan, etc.) CPS III - with the greatest activity against Pseudomonas aeruginosa (ceftazidime - fortum) CPS IV - active against bacteroides and other anaerobes, stable to the action of beta-lactamases (moxalactam - moxam)

ANTIMICROBIAL DRUGS 3 CARBAPENEMS: Highly active against gram (-), including pathogens of hospital pneumonia (imipenem - celastin, meropenem) GLYCOPEPTIDES: Act on gram (+) - vancomycin, ristomycin AMINOGLICOSIDES: wide spectrum of action, including gram ( -). 1st generation (monomycin) 2nd generation (gentamicin) 3rd generation (amikacin)

ANTIMICROBIAL DRUGS 4 MACROLIDES: Accumulate inside the cell and are used for atypical pneumonia (erythromycin, spiramycin, sumamed, rulide, etc.) TETRACYCLINES: Broad spectrum of action, including on intracellular microorganisms (doxycycline, monocycline, etc.) FLUOROQUINOLONES: Broad spectrum of action (ciprofloxacin, abactal, etc.)

DURATION OF A/B THERAPY FOR COMMUNITY-ACQUIRED PNEUMONIA Determined by the response to therapy, severity of pneumonia, presence of complications, etiological variant In case of uncomplicated pneumonia caused by S. pneumoniae or H. influence duration of a/b therapy 7-10 days For pneumonia caused by intracellular pathogens, in the presence of complications (abscess, etc.), the duration of treatment can reach 21 days

RADIOLOGICAL RESOLUTION OF PNEUMONIA AND NORMALIZATION OF ESR OCCUR LATER THAN THE DISAPPEARANCE OF SIGNS OF INTOXICATION AND PHYSICAL SYMPTOMS

1 slide

2 slide

Pneumonia is an acute infectious disease, predominantly of bacterial etiology, characterized by focal damage to the respiratory parts of the lungs, the presence of intra-alveolar exudation, detected during physical and/or instrumental examination, expressed in varying degrees by a febrile reaction and intoxication

3 slide

The prevalence of pneumonia In the Russian Federation, the incidence is 10-15%. Mortality from pneumonia is: 18/100,000 Mortality from community-acquired pneumonia: in young people - 1-3% in older people - 30% Mortality from hospital-acquired pneumonia - 20% In the USA - morbidity - 3,000,000 cases per year mortality - 60,000 per year Correct diagnosis at the outpatient stage - 20% Diagnosis in the first 3 days of illness - in 35% of patients

5 slide

Classification of pneumonia II. According to the place of occurrence of the disease, taking into account the characteristics of infection and the state of the body’s immunological reactivity. Community-acquired. Arose outside of a medical institution. Synonyms: home, outpatient. Hospital. Arose in a medical institution. Synonyms: nosocomial, nosocomial. VAP (early and late) Aspiration pneumonia Pneumonia in persons with immune deficiency. (HIV infections, chronic hepatitis, iatrogenic immunosuppression, old age)

6 slide

Classification of pneumonia III. According to the extent of the lesion Lobular Subsegmental Segmental Lobar Unilateral Bilateral Pleuropneumonia

7 slide

8 slide

Slide 9

IV. According to the course of the disease, acute - up to 4 weeks protracted Classification of pneumonia Reasons for the protracted course of pneumonia: Local obstruction of the respiratory tract (cancer, adenoma, mucoid blockage, etc.) Bronchiectasis Cystic fibrosis Immunity impairment Forming lung abscess Recurrent aspiration Activation of latent tuberculosis infection Inadequate antibacterial therapy

10 slide

Classification of pneumonia V. By severity mild t - less than 38°C RR less than 20/min HR= +10 beats/min per 1°С leukocytes less than 10,000 moderate severe t - more than 39°C RR more than 30/min HR more 120 per minute and does not correlate with t Oliguria Hypotension Blood pressure less than 100/60 mm Hg Leukocytosis more than 25,000 or less than 4,000 Pa O2 less than 60 mm Hg, Pa CO2 more than 50 mm Hg. lobar pneumonia presence of pleural effusion presence of other complications 9 9 9

11 slide

Causes of pneumonia Reduced effectiveness of the host’s defenses Massive dose of the microorganism Increased virulence

12 slide

Pathogenesis of the development of pneumonia Aspiration of oropharyngeal secretions Inhalation of an aerosol containing microorganisms Hematogenous route (Hematogenous spread from an extrapulmonary focus - endocarditis of the tricuspid valve, septic thrombophlebitis of the pelvic veins) Translocation route: direct spread of infection from adjacent affected tissues (liver abscess) or penetrating wounds of the chest. Lymphogenic (from foci of infection - tonsils)

Slide 13

Elimination of infected secretions and sterility of the lower respiratory tract are ensured by: 1. Cough reflex 2. Mucociliary clearance 3. Antibacterial activity of alveolar macrophages and secretory immunoglobulins Aspiration of oropharyngeal secretions and inhalation of an aerosol containing microorganisms are the main routes of infection of the respiratory sections of the lungs

Slide 14

The etiology of pneumonia is directly related to the normal microflora that colonizes the upper respiratory tract. The species composition of the microflora of the upper respiratory tract depends on the nature of the environment, the age of the patient, and immunity. This led to the division of pneumonia into intra- and community-acquired.

16 slide

Escherichia coli, Klebsiella pneumoniae< 5% заболеваний. В первую очередь при сахарном диабете, ХПН, циррозе, гепатите Staphylococcus aureus Менее 5% заболеваний. Наркоманы, хронический гемодиализ, на фоне ОРВИ Legionella pneumoniae Грамотриц. микроорганизм. Менее 2% заболеваний. Вторая по частоте причина летальных исходов Нетипичные, неактуальные, редкие возбудители внебольничной пневмонии

Slide 17

Clinical manifestations of pneumonia Symptoms: Onset - acute. Fever, usually with chills. May be absent in weakened patients and the elderly. Cough. Appears from the first hours of illness. Dry at first, then productive. The color and volume of sputum matter. Chest pain. Associated with breathing, the result is the involvement of the pleura in the process. "Minor symptoms." Headache, muscle pain, weakness, loss of appetite, fatigue are not specific and indicate the severity of intoxication.

18 slide

Clinical manifestations of pneumonia Shortness of breath... Occurs with severe damage. Allows you to assess the severity of the condition. Tachycardia. Heart rate ranges from normal values ​​to 140 beats per minute. Correlates with the severity of the condition. Assessment of DN by clinical manifestations DN I - shortness of breath on exertion DN II - shortness of breath at rest DN III - shortness of breath at rest is accompanied by the involvement of auxiliary respiratory muscles.

Slide 19

Physical examination Percussion. In case of focal pneumonia it is not very informative. With lobar pneumonia, the significance increases. Characterized by a dull sound. Auscultation. Sounding moist (fine-bubble) rales are characteristic. Bronchial breathing and crepitus are characteristic of lobar pneumonia. Palpation. Diagnostically significant for: identifying exudate of lobar pneumonia

20 slide

Instrumental studies Chest X-ray. Later 10-12 hours - infiltrative shadows. General blood analysis. Leukocytosis, shift to the left, toxic granularity of neutrophils, rare leukemoid reaction (poor prognosis), increased ESR. Sputum - Gram staining of a smear, cultural examination External respiration function - abnormal characteristics indicate the severity of the condition, restrictive disorders. Blood Gas Study

21 slides

Classification of DN by blood gases Ra O2, mm Hg. Pa CO2, mm Hg. DN I 80-95 30-40 DN II less than 70 40-60 DN III about 50 more than 60

22 slide

Features of the clinical picture of pneumonia Pneumococcal pneumonia Characterized by an acute onset, high fever Pneumonia caused by Klebsiella Very severe course. Occurs in weakened people and alcoholics. Poor auscultatory picture. Rapid progression, formation of abscesses, gangrene of the lung. Sputum the color of blackcurrant jelly. High mortality rate.

Slide 23

Features of the clinical picture of pneumonia Pneumonia in the elderly The first place is taken by the paucity of symptoms, the large role of “brain” manifestations Pneumonia caused by mycoplasma Characterized by a gradual onset, more common in people under 30 years of age. Often in organized teams, the nature of the infection is epidemic, intoxication is pronounced Pneumonia caused by Legionella When the work is traveling (hotels, hostels), work in warehouses, in offices. Frequent polysegmental lesions.

24 slide

The main complications of pneumonia Exudative effusion Pleural empyema Destruction of lung tissue, abscess formation Infectious-toxic shock Acute respiratory distress syndrome Acute respiratory failure Septic shock Bacteremia, sepsis Myocarditis, pericarditis, nephritis Bronchospastic syndrome

25 slide

Complications of pneumonia 1. Exudative pleurisy. Requires puncture when the fluid level is above the IV-V rib and identification of the nature of the fluid. The issue of intrapleural administration of antibiotics is being discussed. 2. Lung abscess. Ineffectiveness of antibacterial therapy. Severe intoxication. Formation of a round shadow. The issue of drainage is being discussed. If there is a breakthrough into the bronchus - therapeutic bronchoscopy. 3. Gangrene of the lung. Extremely difficult prognosis. Typical for patients with previous pathology. The issue of lung resection is being discussed.

26 slide

Slide 27

Criteria for hospitalization of a patient with pneumonia age over 70 years Concomitant diseases: CHF COPD Chr. hepatitis, chronic nephritis Diabetes mellitus alcoholism, drug addiction immenoid deficiency Ineffectiveness of outpatient treatment for 3 days Severe clinical condition of the patient: confusion or decreased consciousness possibility of aspiration RR more than 30 per minute unstable hemodynamics septic shock, abscess formation infectious metastases multilobar lesions, exudative pleurisy leukopenia, severe leukocytosis, anemia, signs of chronic renal failure Social indications

28 slide

Organizing treatment at home 1st visit to the patient, making a diagnosis based on clinical history and medical history, determining the degree of severity and indications for hospitalization, prescribing treatment and examination (x-ray, blood tests, sputum tests) 2nd visit to the patient (3rd day of illness) assessment radiographs and blood tests clinical assessment of the effectiveness of treatment and the need for hospitalization (decrease in temperature and intoxication, absence of respiratory failure) 3rd visit to the patient (6th day of illness) assessment of sputum analysis clinical assessment of the effectiveness of treatment and the need for hospitalization, if necessary, change the antibiotic again examination of blood, sputum, x-ray 4th visit to the patient (7-10 days of illness) clinical assessment of the effectiveness of treatment and the need for hospitalization, assessment of x-ray and blood and sputum tests

Slide 29

Course of pneumonia I. Acute course When therapy is started on the 1st day of the disease, radiographically detectable infiltration of the lung tissue disappears by 21 days. Clinical symptoms subside within 4-7 days. II. Protracted clinical and radiographic signs persist for more than 4 weeks. It is typical for elderly patients, alcoholics, smokers, and when antibacterial therapy is ineffective.

30 slide

Possible formulation of the diagnosis 1. Community-acquired (pneumococcal) bronchopneumonia in the 4th and 5th segments of the right lung, mild course. DN I. 2. Community-acquired (pneumococcal) lobar pneumonia of the lower lobe of the right lung (8-10 segments), severe, protracted course. Complications: infectious-toxic shock, right-sided exudative pleurisy, DN III. 3. Nosocomial (staphylococcal) bronchopneumonia in 8-9 segments of the left lung, moderate, prolonged course, DN II.

31 slides

Differential diagnosis of acute pneumonia If there are no positive changes on radiography on days 7-10 and the antibacterial drug has been changed, the differential diagnosis is made with: focally infiltrative tuberculosis carcinoma sarcoidosis recurrent pulmonary embolism The examination plan includes: tomography of the lungs computed tomography bronchoscopy obtaining and culture of bronchial lavage fluids

32 slide

Empirical treatment of community-acquired pneumonia Mild pneumonia in people under 60 years of age without concomitant diseases 1. The most likely pathogens are S. Pneumoniae, M. Pneumoniae, H. influenzae, C. Pneumoniae Main: Oral aminopenicillins (amoxicillin) or oral macrolides Alternative: Oral doxycycline Fluoroquinolones ( levofloxacin, moxifloxacin) orally

Slide 33

Empirical treatment of community-acquired pneumonia Pneumonia in persons over 60 years of age and/or with concomitant diseases (diabetes mellitus, COPD, CHF, liver cirrhosis, alcoholism, drug addiction) 2. The most likely pathogens S. Pneumoniae, H. influenzae, S. aureus, Enterobacteriaceae Main : Amoxicillin/clavulanate orally II generation cephalosporins (cefuroxime axetil) orally Alternative: Fluoroquinolones (levofloxacin, moxifloxacin) orally

Slide 34

Empirical therapy of hospitalized patients 3. Non-severe pneumonia The most likely pathogens are S. Pneumoniae, H. influenzae, C. Pneumoniae, S.aureus, Enterobacteriaceae Main: Benzylpenicillin IV, IM Ampicillin IV, IM Amoxicillin/clavulanate IV Cefuroxime IV, IM Ceftriaxone IV, IM Alternative: Fluoroquinolones (IV levofloxacin, IV moxifloxacin)

35 slide

Empirical therapy of hospitalized patients Clinically severe pneumonia 4. Most likely pathogens S. Pneumoniae, Legionella spp, S.aureus, Enterobacteriaceae Main: Amoxicillin/clavulanate + macrolide IV Cefotaxime + macrolide IV Ceftriaxone + macrolide IV Alternative: Fluoroquinolones – IV levofloxacin, IV moxifloxacin, IV ciprofloxacin + III generation cephalosporins Carbapenems

36 slide

Duration of antibacterial therapy for community-acquired pneumonia Community-acquired pneumonia is not complicated - completion of therapy upon achieving stable normalization of temperature within 4-5 days. 10 days. Community-acquired pneumonia, mycoplasma, chlamydia - 14 days. Community-acquired legionella pneumonia - 21 days Achieving the initial effect within these periods is not a reason to cancel antibacterial therapy. Persistent laboratory and radiographic indicators are not a basis for maintaining antibacterial therapy. Any complication requires individual therapy.

Slide 37

Hospital-acquired pneumonia The appearance of a pulmonary infiltrate 48 hours after hospitalization with confirmation of its infectious nature (leukocytosis, fever, sputum) with the exclusion of infection that could be in the incubation period Sources of infection: Another person in the hospital (cross-infection) Contaminated objects (infection from environment) The patient himself is a carrier of the flora (autoinfection)

Slide 38

Pathogens of hospital pneumonia Gram-negative flora Pseudomonas aeroginoza – 16% Klebsiella spp. – 11.6% Enterobacter spp. – 9.4% E. Coli – 8% Proteus spp.- 5% Gram-positive flora S. aureus - 12.9% S. Pneumoniae – 5% Polymicrobial etiology - 40% Typical Atypical S. Viridans S. Epidermidis Micricocci Candida Enterococcus spp .

Slide 39

From the moment of hospitalization, colonization of the upper respiratory tract with new (nosocomial) flora begins. Factors that determine colonization include: length of hospital stay, previous antibacterial therapy, concomitant pathology, specificity of the medical institution, Quantitative assessment of isolated mucous membranes to differentiate colonization and infection, Sputum, Endotracheal aspirate, Bronchoalveolar lavage, 106 CFU/ml, 106 CFU/ml, 104 CFU/ml, infection.

40 slide

“Early” nosocomial pneumonias are caused by the normal microflora of the upper respiratory tract. “Late” ones or those that arose during treatment with antibacterial drugs are more often caused by Klebsiella, Enterobacter spp., Pseudomonas aerugenosa, Staphylococcus spp. These strains are characterized by resistance to the main classes of antibacterial drugs.

41 slides

Risk factors for hospital-acquired pneumonia Older age COPD Impaired consciousness Trauma Severity of disease Aspiration Endotracheal intubation Thoracic and abdominal surgery Nasogastric intubation Neuromuscular disease

42 slide

Criteria for the diagnosis of hospital-acquired pneumonia Criteria Clinical signs X-ray Clinical (2 or more signs are required) Physical Laboratory Microbiological Lobar or focal infiltration Temperature 38°C or more Respiratory rate more than 20 per minute Appearance or intensification of cough Presence of purulent sputum Impaired consciousness Moist, sonorous fine-bubble rales, weakened breathing , crepitus Dullness of percussion sound Bronchial breathing Leukocytosis more than 12*109 /l or leukopenia less than 4*109 /l Shift of the leukocyte formula to the left or absolute neutrophilia Isolation of the pathogen from sputum, blood culture in a diagnostically significant titer

43 slide

Criteria for severe hospital-acquired pneumonia Severe respiratory failure (RR>30/min) Rapid negative radiographic dynamics, multilobar lesions or abscess formation) Clinical signs of severe sepsis with hypotension (SBP)< 90 мм рт.ст., ДАД

44 slide

Risk factors for death in hospital-acquired pneumonia Old age Hypotension or shock Neutropenia Diabetes mellitus Bilateral lesions Bacteremia Previous use of antibiotics Inadequate antibiotic therapy Pathogen Pseudomonas aerugenosa Ventilator-associated pneumonia

45 slide

Diagnostic minimum examination of a patient with suspected hospital-acquired pneumonia X-ray of the lungs in 2 projections Microbiological examination of sputum with Gram staining and microscopy Cultural examination of sputum with quantitative assessment of the isolated pathogen Double seeding of blood culture in 2 bottles (aerobes + anaerobes) at the height of fever Blood test ( hemoglobin, hematocrit, leukocytes, formula, platelets) Blood biochemistry (urea, creatinine, electrolytes) pH, pO2, pCO2

46 slide

Empirical therapy for hospital-acquired pneumonia Not severe, no risk factors, no previous antibiotic therapy 1. Most likely pathogens Str. Pneumoniae, Staph. Aureus, Enterobacteriaceae 1st line drugs Main: Cefuroxime + Gentamicin Amoxiclav + Gentamicin Alternative: Cefotaxime Ceftriaxone 2nd line drugs (reserve) Cefepime, Ofloxacin, Pefloxacin

Slide 47

Empirical therapy for hospital-acquired pneumonia Severe course or the presence of risk factors, or previous antibacterial treatment 2. The most likely pathogens are Enterobacteriaceae, Staph. Aureus, Str. Pneumoniae, Acinetobacter spp. 1st line drugs Main Cefotaxime Ceftriaxone (+/- Aminoglycoside) Alternative Ticarcillin/clavulanate Piperacillin/Tazobactam 2nd line drugs (reserve) Cefepime, Ciprofloxacin, Imipenem, Meropenem

48 slide

Empirical therapy for hospital-acquired pneumonia Any course and the presence or absence of risk factors, P.aerugenosa 3. The most likely pathogens are P.aerugenosa, Enterobacteriaceae, Staph. Aureus, Str. Pneumoniae 1st line drugs Main: III generation cephalosporins Ceftazidime Cefoperazone (+/- Aminoglycoside) Alternative Cefepime Ciprofloxacin (+ aminoglycoside) 2nd line drugs (reserve) Imipenem+Amikacin, Meropenem, Polymyxin

Slide 49

Empirical therapy for hospital-acquired pneumonia Risk of aspiration or abscess formation 4. Most likely pathogens Str. Pneumoniae, Staph. Aureus, K. Pneumoniae, Anaerobes 1st line drugs Basic Lincomycin +/- Aminoglycoside Amoxicillin/clavulanate Alternative Cephalosporin III + Lincomycin or metronidazole Ticarcillin/clavulanate 2nd line drugs (reserve) Cefepime or fluoroquinolone (+ metronidazole) Imipenem Meropenem

50 slide

Ventilator-associated pneumonia (VAP) This is hospital-acquired pneumonia that occurs 48 hours or more after tracheal intubation and mechanical ventilation in the absence of signs of pneumonia at the time of intubation Early Late 5-7 days mechanical ventilation Enterobacteriaceae H. Influenzae S. aureus The likelihood of antibiotic resistance is low P aerugenosa Actinobacter spp., S. aureus Very high resistance to antibiotics The probable pathogen is assessed based on the leading flora of a particular institution.

51 slides

Risk factors for VAP and conditions that contribute to their implementation Factors Conditions Reduced body resistance Young children, elderly people, severe concomitant diseases, immunosuppression Colonization of the oropharynx and stomach Antibacterial therapy, hospitalization in the intensive care unit, chronic lung diseases, coma Conditions that facilitate aspiration or gastric reflux Endotracheal intubation, nasogastric tube, horizontal position on the back Difficulty in normal sanitation of the trachea Surgeries on the head, neck, chest and upper abdominal organs, immobilization

Slide 53

Duration of antibacterial therapy for hospital-acquired pneumonia The duration of antibacterial treatment is selected individually, depending on the severity of the disease, the speed of onset of the clinical effect and the type of pathogen. AVERAGE DURATION OF ANTIBACTERIAL THERAPY 7-14 DAYS STAPHYLOCOCCAL PNEUMONIA 14-21 DAYS IN PATIENTS WITH CYSTIC FIDOSIS – 21 DAYS

54 slide

Stepped antibacterial therapy for pneumonia. Parenteral stage Oral stage Goal: reducing the cost of treatment and hospital stay. The method is the use of two dosage forms: the same drug, drugs that are similar in the antimicrobial spectrum. Transition criteria: decrease in cough intensity, shortness of breath, decrease in sputum volume, normal body temperature with 2 measurements with an interval of 8 hours.

Slide 57

Average periods of temporary disability during the treatment of pneumonia Mild course of pneumonia, the minimum period of inpatient treatment is 15 days, the period of convalescence in an outpatient setting is 6-7 days. That. the total period of labor loss is 21-22 days. The course of moderate pneumonia, the duration of inpatient treatment is 21-22 days, the period of convalescence in an outpatient setting is 5-6 days. That. the total period of labor loss is 28 days. The course of severe pneumonia, the duration of inpatient treatment is 35-50 days, the period of convalescence in an outpatient setting is 10-15 days. That. total period of labor loss – 60-65 days

58 slide

Criteria for restoration of working capacity Persistent elimination of all clinical symptoms Normalization of temperature within 10-14 days Normalization of auscultation patterns Disappearance of signs of intoxication Normalization of laboratory clinical parameters (persistent tendency to decrease and normalize ESR) Disappearance of X-ray infiltrative shadow in lung tissue

Slide 59

Clinical examination of patients after pneumonia Patients after pneumonia are actively observed for 6 months, examined twice during this time: on the 1st and 6th month after discharge from the hospital. These visits are controlled by: Clinical blood test Clinical sputum analysis Spirography Fluorography

60 slide

Scheme of outpatient follow-up treatment for patients after pneumonia 1st month 2nd month For all patients - physical therapy for patients who have suffered severe pneumonia - prescription of oral anti-inflammatory drugs for 14 days Minor immunomodulators (Eleutherococcus), vitamin therapy 3rd month Hardening procedures for patients who have suffered severe pneumonia - massage, physiotherapy 6th month Recovery in a sanatorium, hardening procedures In the absence of relapses or other inflammatory diseases, the patient is removed from the dispensary register

61 slides

Indications for referral to MSEC Patients who have suffered severe destructive pneumonia Patients who have suffered severe pneumonia with pleurisy, pleural empyema, pneumothorax Patients who have suffered severe pneumonia with the formation of chronic respiratory or cardiopulmonary failure

Pneumonia

Epidemiology of pneumonia

EPIDEMIOLOGY

Etiological classification of pneumonia

Clinical and etiological classification of pneumonia (according to conditions of occurrence)

Diagnostic criteria for community-acquired pneumonia

Diagnostic criteria for nosocomial pneumonia

Etiology: community-acquired pneumonia

Etiology: atypical pneumonia

Etiology: nosocomial pneumonia

Etiology: pneumonia in immunocompromised individuals

Etiology: aspiration pneumonia

Routes of infection

Pneumonia is the “friend” of older people

Risk factors: Community-acquired pneumonia

Risk factors: Pneumonia in immunocompromised individuals

Pneumonia problems

Syndromes with pneumonia

Complaints

Physical examination findings

Mandatory (screening) studies in a hospital setting

Studies performed according to indications

Methods for identifying the pathogen

X-ray picture

Focal pneumonia

Causes of false negative results during X-ray examination of the OGK

Diagnostic criteria for community-acquired pneumonia (RPO, 2003)

Pneumococcal pneumonia can occur in two morphological forms: lobar and focal

Lobar pneumonia

Features of the clinic of lobar pneumonia (lobar, pleuropneumonia)

Atypical pneumonia

Complications of pneumonia

Complications of pneumonia

Management tactics: hospitalization or outpatient treatment?

Indications for hospitalization for community-acquired pneumonia

Severity of pneumonia according to the CURB-65 scale

Organization of treatment at home (order No. 300)

Organization of treatment at home (order No. 300)

Formulation of the diagnosis of pneumonia

Principles of treatment of pneumonia

Non-pharmacological measures

Antibiotics

Antibacterial therapy

Beta-lactam antibiotics

Beta-lactam antibiotics

Beta-lactam antibiotics: protected

Antibacterial therapy

Azitrox® acts specifically at the site of infection

Fluoroquinolones

ERRORS IN ANTIBACTERIAL THERAPY

Typical mistakes in antibacterial therapy

Tactics for choosing an antibiotic for community-acquired pneumonia

Community-acquired pneumonia: antibacterial therapy for a known pathogen

Treatment of pneumonia in people with immunodeficiency