Treatment of hospital-acquired pneumonia

The regimen is prescribed taking into account the severity of pneumonia and the age of the child. It is necessary to provide maximum access to fresh air (aerotherapy). Frequent ventilation, exercise rooms - in winter, walks at an air temperature of at least -10 C. In wards and at home in the summer, the windows must be kept open almost constantly. The child's position in the crib should be elevated, for which its head end is raised. This position facilitates the function of breathing and blood circulation. Carrying out general hygiene measures. It is necessary to create a protective regime for the central nervous system: sufficient night and daytime sleep in a calm environment, the necessary minimum of injections and manipulations, attentive affectionate treatment. In case of hospitalization, it is necessary for the mother to be in the hospital with the child and take care of him, this is of great importance for the state of the central nervous system and maintaining the emotional tone of the child. Diet - the child's nutrition is carried out taking into account the age and severity of the condition. The child should receive a sufficient amount of liquid, including fruit, berry and vegetable juices, decoctions of raisins, prunes, dried apricots, cranberries, lingonberries, and rose hips.

Etiological therapy. Antibiotics are prescribed taking into account the patient's medical history: what antibiotics he received earlier, whether there were any allergic reactions to the administration of antibiotics.

For community-acquired (“outpatient”, “home”) pneumonia caused primarily by pneumococcus, the drug of choice may be amoxiclav, co-amoxiclav, unazin, cefuroxime axetil (administered 2 times a day), cefaclor (3 times a day).

In children with a burdened allergic anamnesis, second-generation macrolides (azithromycin, roxithromycin, clarithromycin) or "intermediate" group macrolides (between old and "new") are used: midecamycin (prescribed from 2 months of age, 2 times a day), deecosamycin (from 3 months, 3 times a day). "Protected" aminopenicillins have a good effect: co-amoxiclav (a combination of amoxicillin with clavulanic acid), sultamicillin (a chemical compound of ampicillin and subactam). For children in the first 3 months of life, co-amoxiclav is prescribed 2 times a day in a single dose of 30 mg / kg, over 3 months of life - in the same single dose 3 times a day (in severe infections - 4 times a day). For children of any age, there are special dosage forms of these antibiotics in the form of powder for the preparation of a sweet suspension.

The course of treatment for pneumonia at home is 7-10 days.

If outpatient treatment of community-acquired pneumonia is ineffective or if the course is moderate or severe (initially), treatment is carried out in a hospital. Antibiotics administered intravenously or intramuscularly are used, such as third-generation cephalosporins - ceftriaxone, cefotaxime, which affect gram-positive and gram-negative microorganisms. Macrolides taken orally (roxithromycin), clarithromycin, azithromycin (sumamed), midecamycin (macropen) are added to them.

In the context of immunodeficiency; until the pathogen is identified in a sputum smear, treatment should be carried out with aminoglycosides, effective against Pseudomonas aeruginosa, carbenicillin or ticarcillin.

In hospital-acquired (hospital) pneumonia, which includes pneumonia that manifests clinically and radiologically 48-72 hours after hospitalization, the pathogens are much more resistant to antibiotic therapy and often cause severe infections, which requires parenteral administration of antibiotics in combinations. Currently, stepwise antibiotic therapy is recommended, the essence of which is as follows: at the beginning of the course of treatment, the antibiotic is prescribed parenterally, and with positive dynamics of the patient's condition (after 3-5 days), they switch to its oral use. Considering that the main role in the etiology of hospital-acquired pneumonia is played by staphylococcus, intestinal and pseudomonas aeruginosa, Klebsiella, antibiotics are used parenterally that "cover" the entire possible spectrum of pathogens: third-generation cephalosporins (cefotaxime, ceftriaxone), ceftibuten (cedex) or those that also affect pseudomonas aeruginosa - the best (ceftazidime) in combination with an aminoglycoside (amikacin). Carbapenems (tienam, meronem) or parenteral fourth-generation cephalosporin (cefepime) can be prescribed as antibacterial monotherapy.

After receiving the results of the bacteriological examination, targeted therapy is prescribed.

So, for pneumococcus - amoxicillin, augmentin (clavulanic acid), co-amoxicillin (amoxicillin + clavulanic acid), cephalosporins of the III (ceftriaxone, cefotaxime, cedex) and IV (cefepime) generations; macrolides (azithromycin, rovamycin, macropen, clarithromycin, fromilid).

For staphylococcus - macrolides (azithromycin, clarithromycin, roxithromycin), carbopenems (thienal and meropenem), rifampicin, vancomycin.

For Haemophilus influenzae - amoxicillin, co-amoxicillin, augmentin, oral cephalosporins of the 3rd (ceftriaxone, cefotaxime) and 4th (cefepime) generations; macrolides (especially azithromycin, clarithromycin, roxithromycin, mizacamycin, josamycin); as reserve antibiotics - monobactams (aztreonam intravenously and intramuscularly), carbapenems (tienam, meropenem).

For pseudomonas infection - ceftazidime (has no equal in its effect on this microbe), cefepime, carbenicillin, especially ticarcillin, tienam amikacin; in severe cases, the use of antipseudomonal ureidopenicillins (piperacillin) in combination with beta-lactamase inhibitors is recommended.

For chlamydial infection - the use of modern macrolides: azithromycin (sumamed), roxithromycin (rulid), clarithromycin, medicamycin (macropen), spiramycin (rovamycin), fromilid (a form of clarithromycin).

In the treatment of pneumonia caused by gram-negative microorganisms, aminoglycosides (amikacin, gentamicin) and fluoroquinolones are usually used. In the presence of fungal flora - diflucan, nizoral, avelox.

Metronidazole, clindamycin, cefepime, and carbapenems are active against anaerobic flora, which is often responsible for aspiration pneumonia.

Treatment of patients with pneumonia at home, in addition to prescribing a regimen, diet and antibiotics, involves the oral use of vitamins C, B1, B2, B6, PP and B15 (improving tissue oxygen consumption). Vitamin E is prescribed as an antioxidant. Metabolic therapy agents (phosphaden, lipamide, lipoic acid, carnitine chloride, calcium pantothenate) can be used to normalize metabolism. If sputum discharge is difficult and to improve bronchial drainage, the following are recommended: for a strong and unproductive cough, use agents that do not reduce sputum discharge - these are libexin, marshmallow root, tusuprex; To reduce the viscosity of sputum, you can prescribe ambroxol, lazolvan - a bronchosecretolytic that regulates pathologically altered secretion formation at the intracellular level, dissolves thickened secretions, stimulates mucociliary clearance and, which is important for young children, lazolvan stimulates the formation of surfactant. It is prescribed in syrup to children under 2 years old at 2.5 ml 2 times a day, from 2 to 5 years - the same dose 3 times a day. You can use bromhexine, which helps reduce the viscosity of secretion due to the breakdown of acidic mucopolysaccharides and "softening" of secretion granules in goblet cells.

During the reparation period, patients with asthenic syndrome and vegetative dysfunction are prescribed adaptogens for 2-3 weeks - tinctures of eleutherococcus, ginseng, biogenic stimulants - aloe, apilak. Exercise therapy and massage are carried out. Staying in the fresh air for at least 3-4 hours is mandatory, frequent ventilation of the rooms where the child is.

The pediatrician visits the child daily during the acute period of pneumonia until the child's condition has improved steadily, then every 1 and 2 days, alternating visits with a nurse who evaluates the child's general condition, compliance with the prescribed therapy and procedures. In the first days of the disease, chest X-rays, blood and urine tests are taken. Blood and urine tests are repeated after 2-3 weeks.

Treatment of a patient with pneumonia in a hospital. Pathogenetic therapy is aimed primarily at providing access to fresh air and oxygen. For this purpose, in addition to aerotherapy, oxygen therapy is prescribed in case of severe respiratory failure.

In case of I-II degree respiratory failure, oxygen tents are used; in case of II-III degree respiratory failure, a method of spontaneous breathing with an oxygen-enriched gas mixture with positive pressure on inhalation and exhalation is used. By preventing the collapse of the pulmonary alveoli and disruption of alveolar ventilation, this method helps eliminate hypoxia. A nasal catheter can be used for oxygen therapy; oxygen for humidification is passed through the Bobrov apparatus. To improve vascular permeability, vitamins C, B1, B2, B6, PP, rutin (vitamin P), and glutamic acid are prescribed to the child. Cocarboxylase, dimphosphone, and oralite are used as a drink to correct acidosis.

Indications for infusion therapy: severe toxicosis, decreased circulating blood volume (CBV), impaired microcirculation, risk of DIC syndrome, neurotoxicosis, purulent infection.

To improve the drainage function of the bronchi, inhalations with alkaline mineral water (Borjomi, Essentuki No. 17), steam-oxygen inhalations of herbal decoctions (chamomile, sage, coltsfoot, wild rosemary, eucalyptus leaf), and aerosols of 10% N-acetylcysteine solution are used.

In case of energetic-dynamic insufficiency of the heart - canangin, cocarboxylase, riboxin, polarizing mixture of Labori: 10% glucose solution - 10 mg/kg, insulin 2 U for every 100 ml of 10% glucose solution, panangin 5-10 ml, cocarboxylase - 0.1-0.2 g, vitamins B6 and C 2 ml each. To reduce hypertension in the pulmonary circulation, pentamine or benzohexonium are prescribed to eliminate the centralization of blood circulation.

From the first days, distraction therapy is used in young children in the form of mustard wraps, physiotherapy - UHF, microwave; after a course of UHF or microwave, electrophoresis with calcium, ascorbic acid is prescribed. Exercise therapy is of great importance.

In case of protracted pneumonia, antimicrobial therapy is carried out for 6-8 weeks with a change of drugs taking into account the sensitivity of the flora. Oral drugs are most often used: amoxiclav, cefuroxime axetil, cefaclor, cedex, in children with a history of allergies - azithromycin, clarithromycin or spiramycin, josamycin, macropen. Drugs that improve the drainage function of the bronchi are prescribed (see acute bronchitis). Aerosol inhalations of bronchodilator mixtures and mucolytic drugs are recommended: 2% solution of sodium bicarbonate and sodium chloride, 10% solution of N-acetylcysteine, proteolytic enzymes (chemopsin, trypsin, chemotrypsin). Exercise therapy and chest massage.

A pediatrician and a pulmonologist carry out a one-year outpatient observation of a young child who has had pneumonia. Children of the first 3 years of life are observed twice a month during the first half of the year from the onset of the disease, and once a month during the second half of the year. Children from 3 months to one year and older - once a month. An individual outpatient observation plan is drawn up for each child, taking into account concomitant diseases and the body's reactivity. It is important to spend as much time in the fresh air as possible, eat a complete diet taking into account the age with the introduction of complete protein, unsaturated fatty acids, and eat seasonal vegetables and fruits. It is necessary to continue massage and exercise therapy. Hardening is carried out taking into account the child's age. Multivitamins are prescribed in courses. In the presence of allergies, Tavegil, Claritin, Fenkarol are prescribed for 2-3 weeks with a change of drugs every 7 days.

A child who has been taking antibiotics for a long time or had dyspeptic disorders during the illness can be prescribed bifidumbacterin, lactobacterin, bificol for a course of 3 to 6 weeks.

The criteria for removal from the dispensary register are satisfactory condition, good emotional tone, and the absence of clinical and radiological signs of disease.