Severe community-acquired pneumonia: principles of diagnostics and intensive therapy

V.I. Chernii
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 OBJECTIVE. To analyze the pathogenesis, diagnosis, and treatment of severe CAP from the modern literature data to optimize the treatment of this group of patients.
 MATERIALS AND METHODS. Bibliosemantic, comparative, and system analysis methods were used. The proposed recommendations are based on the analysis of modern literature, the results of randomized studies, and meta-analyses devoted to the investigation of the problem of diagnosis and management of severe CAP.
 RESULTS AND DISCUSSION. The problems of pathogenesis, diagnosis, and treatment of severe CAP were analyzed using modern literature data to optimize the treatment of this group of patients. CAP can be caused by various pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae, atypical bacteria (eg, Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella species), and viruses. It is quite difficult to establish the etiology of pneumonia even with the use of modern microbiological technologies, therefore, in many countries of the world, a classification is used that takes into account the conditions of the occurrence of the disease, the features of the infection of the lung tissue, as well as the immune reactivity of the patient’s organism. This classification makes it possible to predict the probable causative agent of the disease with a fairly high degree of probability. The diagnosis of CAP is considered established in the presence of radiologically confirmed focal infiltration of lung tissue and at least two of the following clinical signs: acute onset of the disease with a body temperature >38 °C, cough with sputum, physical signs (muffled or dull percussion sound, weakened and/or harsh bronchial breathing, a focus of sonorous small vesicular rales and/or crepitations), leukocytosis (>10×109 /L), and/or shift to rod nuclear cells (>10 % of them). The severity of CAP is assessed clinically, as well as using the criteria given in the scales to determine the need for the patient to be hospitalized or admitted to the intensive care unit (ICU). Patients with CAP requiring mechanical ventilation or with septic shock should be admitted to the ICU.
 CONCLUSIONS. Severe CAP is associated with high morbidity and mortality, and although there are European and non-European guidelines for CAP, there are no specific guidelines for severe CAP. These international guidelines from ERS, ESICM, ESCMID, and ALAT present evidence-based clinical recommendations for the diagnosis, empiric treatment, and antibiotic therapy of severe CAP according to the GRADE approach. In addition, existing knowledge gaps were identified and recommendations for future research were provided.","PeriodicalId":13681,"journal":{"name":"Infusion & Chemotherapy","volume":null,"pages":null},"PeriodicalIF":0.0000,"publicationDate":"2023-09-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":null,"platform":"Semanticscholar","paperid":null,"PeriodicalName":"Infusion & Chemotherapy","FirstCategoryId":"1085","ListUrlMain":"https://doi.org/10.32902/2663-0338-2023-3-7-15","RegionNum":0,"RegionCategory":null,"ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"","JCRName":"","Score":null,"Total":0}
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Abstract

BACKGROUND. Pneumonia is an important medical and social problem due to its high prevalence, high rates of disability and mortality, and significant economic losses due to this disease. In Ukraine in 2017, the incidence of pneumonia among adults was 384.0 cases per 100,000 population, and the mortality rate was 11.7 per 100,000 population, i. e. more than 3 % of those who had pneumonia died. Community-acquired pneumonia (CAP) is the leading cause of morbidity and mortality from pneumonia among all age groups worldwide: 3-4 million people suffer from CAP with high morbidity and mortality. OBJECTIVE. To analyze the pathogenesis, diagnosis, and treatment of severe CAP from the modern literature data to optimize the treatment of this group of patients. MATERIALS AND METHODS. Bibliosemantic, comparative, and system analysis methods were used. The proposed recommendations are based on the analysis of modern literature, the results of randomized studies, and meta-analyses devoted to the investigation of the problem of diagnosis and management of severe CAP. RESULTS AND DISCUSSION. The problems of pathogenesis, diagnosis, and treatment of severe CAP were analyzed using modern literature data to optimize the treatment of this group of patients. CAP can be caused by various pathogens, such as Streptococcus pneumoniae, Haemophilus influenzae, atypical bacteria (eg, Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella species), and viruses. It is quite difficult to establish the etiology of pneumonia even with the use of modern microbiological technologies, therefore, in many countries of the world, a classification is used that takes into account the conditions of the occurrence of the disease, the features of the infection of the lung tissue, as well as the immune reactivity of the patient’s organism. This classification makes it possible to predict the probable causative agent of the disease with a fairly high degree of probability. The diagnosis of CAP is considered established in the presence of radiologically confirmed focal infiltration of lung tissue and at least two of the following clinical signs: acute onset of the disease with a body temperature >38 °C, cough with sputum, physical signs (muffled or dull percussion sound, weakened and/or harsh bronchial breathing, a focus of sonorous small vesicular rales and/or crepitations), leukocytosis (>10×109 /L), and/or shift to rod nuclear cells (>10 % of them). The severity of CAP is assessed clinically, as well as using the criteria given in the scales to determine the need for the patient to be hospitalized or admitted to the intensive care unit (ICU). Patients with CAP requiring mechanical ventilation or with septic shock should be admitted to the ICU. CONCLUSIONS. Severe CAP is associated with high morbidity and mortality, and although there are European and non-European guidelines for CAP, there are no specific guidelines for severe CAP. These international guidelines from ERS, ESICM, ESCMID, and ALAT present evidence-based clinical recommendations for the diagnosis, empiric treatment, and antibiotic therapy of severe CAP according to the GRADE approach. In addition, existing knowledge gaps were identified and recommendations for future research were provided.
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严重社区获得性肺炎:诊断原则和强化治疗
背景。肺炎是一个重要的医疗和社会问题,因为它的高患病率、高致残率和死亡率,以及由这种疾病造成的重大经济损失。2017年,乌克兰成人肺炎发病率为每10万人384.0例,死亡率为每10万人11.7例,即超过3%的肺炎患者死亡。社区获得性肺炎(CAP)是全世界所有年龄组肺炎发病率和死亡率的主要原因:300万至400万人患有CAP,发病率和死亡率很高。目标。从现代文献资料中分析重症CAP的发病机制、诊断及治疗,以优化该组患者的治疗。 材料和方法。采用文献语义学、比较法和系统分析法。所提出的建议是基于对现代文献的分析,随机研究的结果,以及对严重CAP的诊断和管理问题的荟萃分析。 结果和讨论。利用现代文献资料分析重症CAP的发病机制、诊断及治疗问题,优化该组患者的治疗方案。CAP可由多种病原体引起,如肺炎链球菌、流感嗜血杆菌、非典型细菌(如肺炎衣原体、肺炎支原体、军团菌)和病毒。即使使用现代微生物学技术,也很难确定肺炎的病因,因此,在世界上许多国家,采用的分类考虑到疾病发生的条件、肺组织感染的特征以及患者机体的免疫反应性。这种分类使得以相当高的概率预测疾病的可能病原体成为可能。若有影像学证实的肺组织局灶性浸润,且至少有以下两种临床体征,则可诊断为CAP:急性起病,体温38℃,咳嗽伴痰,体征(低沉或沉闷的叩击声,支气管呼吸减弱和/或刺耳,有清晰的小水疱声和/或心音),白细胞增多(10×109 /L),和/或向棒状核细胞转移(占10%)。临床评估CAP的严重程度,并使用量表中给出的标准来确定患者是否需要住院或入住重症监护病房(ICU)。需要机械通气或感染性休克的CAP患者应入住ICU。 结论。严重的CAP与高发病率和死亡率相关,尽管有欧洲和非欧洲的CAP指南,但没有针对严重CAP的具体指南。这些来自ERS、ESICM、ESCMID和ALAT的国际指南根据GRADE方法为严重CAP的诊断、经验性治疗和抗生素治疗提供了循证临床建议。此外,还确定了现有的知识差距,并为未来的研究提供了建议。
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