Pneumonia in a child

Pneumonia in a child is an acute infectious disease of predominantly bacterial nature, characterized by focal lesions of the respiratory parts of the lungs, respiratory disorders and intraalveolar exudation, as well as infiltrative changes in the lung radiographs. The presence of X-ray signs of pulmonary parenchyma infiltration is the "gold standard" for diagnosing pneumonia, which makes it possible to distinguish it from bronchitis and bronchiolitis.

ICD-10 code

• J12 Viral pneumonia, not elsewhere classified.
• J13 Pneumonia caused by Streptococcus pneumoniae.
• J14 Pneumonia caused by Haemophilus influenzae (Afanasyev-Pfeiffer's stick).
• J15 Bacterial pneumonia, not elsewhere classified.
• J16 Pneumonia caused by other infectious agents, not elsewhere classified.
• J17 Pneumonia in diseases classified elsewhere.
• J18 Pneumonia without specifying the pathogen.

Epidemiology of pneumonia in children

Pneumonia is diagnosed in approximately 15-20 cases per 1000 children of the first year of life, approximately 36-40 cases per 1000 children at preschool age, and at school and adolescence the diagnosis of "pneumonia" is established in approximately 7-10 cases per 1000 children and adolescents .

The frequency of hospital pneumonia depends on the contingent and age of patients (up to 27% of all cases of nosocomial infections), it is maximal in young children, especially in newborns and premature babies, as well as in children who underwent surgery, trauma, burns, etc.

The death rate from pneumonia (together with the flu) averages 13.1 per 100 000 population. And the highest mortality is observed in the first 4 years of life (it reaches 30.4 per 100 000 population), the smallest (0.8 per 100 000 population) is observed at the age of 10-14.

Mortality from hospital pneumonia, according to the National System for Monitoring Nosocomial Infections of the United States, was 33-37% at the turn of the past and the present century. In the Russian Federation, the mortality of children from hospital pneumonia in this period has not been studied.

[1], [2], [3], [4],

Causes of pneumonia in children

The most frequent pathogens of community-acquired pneumonia are Streptococcus pneumoniae (20-60%), Mycoplasma pneumoniae (5-50%), Chlamydia pneumoniae (5-15%), Chlamydia trachomatis (3-10%),

Haemophilus influenzae (3-10%), Enterobacteriaceae (Klebsiella pneumoniae, Escherichia coli and others 3-10%), Staphylococcus aureus (3-10%), Streptococcus pyogenes, Chlamydia psittaci, Coxiella bumeti, etc. However, that the etiology of pneumonia in children and adolescents is very closely related to age.

In the first 6 months of a child's life, the etiologic role of pneumococcus and hemophilic rod is negligible, since antibodies to these pathogens are transmitted in-between. The leading role at this age is played by E. Coli, K. Pneumoniae and S. Aureus. The etiological significance of each of them does not exceed 10-15%, but they determine the most severe forms of the disease, complicated by the development of infectious-toxic shock and destruction of the lungs. Another group of pneumonia of this age is pneumonia caused by atypical pathogens, mostly C. Trachomatis, by which children are infected from the mother intranatally, rarely in the first days of life. It is also possible to infect R. Carinii, which is especially significant for premature infants.

From 6 months to 6-7 years of pneumonia, mainly causes S. Pneumoniae (60%). Often sown and encapsulated hemophilic rod. H. Influenzae type b are less frequent (7-10%), it causes, as a rule, severe pneumonia, complicated by the destruction of the lungs and pleurisy.

Pneumonia caused by S. Aureus and S. Pyogenis is detected in 2-3% of cases, usually as complications of severe viral infections, such as influenza, chicken pox, measles and herpes. Pneumonia caused by atypical pathogens in children of this age is due mainly to M. Pneumoniae and C. Pneumoniae. It should be noted that the role of M. Pneumoniae has clearly increased in recent years. Mycoplasma infection is mostly diagnosed in the second or third year of life, and C. Pneumoniae infection in children older than 5 years.

Viruses in children of this age group can be both an independent cause of the disease, and a participant in viral-bacterial associations. The most important is the respiratory syncytial (PC) virus, which occurs in approximately half the cases of viral and viral-bacterial diseases. In a quarter of cases, parainfluenza viruses of types 1 and 3 become the etiologic factor. Influenza A and B viruses and adenoviruses play a small role. Rariviruses, enteroviruses, coronaviruses are rarely detected. Also described are pneumonia due to measles, rubella and chicken pox viruses. As already mentioned, in addition to an independent etiological significance, a respiratory-viral infection in children of early and preschool age is practically a mandatory background for the development of bacterial inflammation.

Causes of pneumonia in children older than 7 years and adolescents practically does not differ from that of adults. The most common pneumonia is caused by S. Pneumoniae (35-40%) and M. Pneumoniae (23-44%), less often S. Pneumoniae (10-17%). H. Influenzae type L, and such causative agents as Enterobacteriaceae (K. Pneumoniae, E. Coli, etc.) and S. Aureus, practically do not occur.

Especially it is worth mentioning pneumonia in patients with immunodeficiency. In children with primary cellular immunodeficiencies, Pneumocysticus carinii and fungi of the genus Candida, as well as M. Avium-intracellare and cytomegalovirus, are more likely to cause pneumonia in HIV-infected patients and AIDS patients. With humoral immunodeficiency, S. Pneumoniae, as well as staphylococci and enterobacteria, are most often sown, and with neutropenia - gram-negative enterobacteria and fungi.

Causes of community-acquired pneumonia in immunocompromised patients

Groups of patients	Pathogens
Patients with primary cellular immunodeficiency	Pneumocysts Mushrooms of the genus Candida
Patients with primary humoral immunodeficiency	Pneumococci Staphylococci Enterobacteria
Patients with acquired immunodeficiency (HIV-infected, AIDS patients)	Pneumocysts Cytomegaloviruses Mycobacterium tuberculosis Fungi of the genus Candida
Patients with neutropenia	Gram-negative enterobacteria Fungi of the genus Candida, Aspergillus, Fusarium

[5], [6], [7], [8], [9], [10],

Pathogenesis of pneumonia in children

Of the features of the pathogenesis of pneumonia in young children, the lowest level of anti-infective protection is most important. In addition, we can note the relative insufficiency of mucociliary clearance, especially with respiratory viral infection, which, as a rule, begins pneumonia in a child. The tendency to swelling of the mucous membrane of the respiratory tract and the formation of viscous sputum also contributes to the violation of mucociliary clearance.

There are four main causes of pneumonia:

• aspiration of the secretion of the oropharynx;
• inhalation of an aerosol containing microorganisms;
• hematogenous spread of microorganisms from the extrapulmonary focus of infection;
• direct spread of infection from neighboring affected organs.

In children the most important is the microaspiration of the secretion of the oropharynx. Aspiration of a large amount of contents of the upper respiratory tract and / or stomach is characteristic of newborns and children of the first months of life. Less frequent aspiration during feeding and / or with vomiting and regurgitation. In children of early and preschool age, airway obstruction is most significant, especially in the case of bronchial obstructive syndrome.

Factors predisposing to aspiration / microaspiration

• Encephalopathy of various genesis (posthypoxic, with malformations of the brain and hereditary diseases, convulsive syndrome).
• Dysphagia (vomiting regurgitation syndrome, esophageal tracheal fistulas, achalasia cardia, gastroesophageal reflux).
• Bronchoobstructive syndrome with respiratory, including viral, infection.
• Mechanical disturbances of protective barriers (nasogastric tube, tracheal intubation, tracheostomy, esophagogastroduodenoscopy).
• Repeated vomiting during intestinal paresis, severe infectious and somatic diseases.

What causes pneumonia?

Symptoms of pneumonia in children

Classical symptoms of pneumonia in children are nonspecific - it is shortness of breath, cough (with and without phlegm), fever, weakness, symptoms of intoxication. It should be assumed the development of pneumonia, if the child appears cough and / or dyspnea, especially in combination with an increase in body temperature. Corresponding percussion and auscultatory changes in the lungs, namely shortening of percussion sound, weakening or, on the contrary, the appearance of bronchial respiration, crepitation or small bubbling rales determine only in 50-77% of cases. It should be remembered that in early childhood, especially in children of the first months of life, these manifestations are typical for almost any acute respiratory infection, and the physical changes in the lungs in pneumonia in most cases (with the exception of lobar pneumonia) are virtually indistinguishable from changes in bronchitis.

Symptoms of hospital (nosocomial) pneumonia in children

According to the WHO, the symptoms of pneumonia in children are characterized by the following symptoms:

• febrile state with a body temperature above 38 ° C for 3 days or more;
• dyspnea (with a number of respiratory movements of more than 60 per minute for children under 3 months, more than 50 per minute - up to 1 year, more than 40 per minute - up to 5 years);
• retraction of compliant places of the chest.

Classification

Pneumonia in children is usually divided according to the conditions of their occurrence for out-of-hospital (home) and hospital (hospital, nosocomial). The exception is the pneumonia of the newborn, which is divided into congenital and acquired (postnatal). Postnatal pneumonia in turn can also be community-acquired and hospital.

Under community-acquired pneumonia (EP) is understood a disease that developed in the normal conditions of a child's life. Under hospital pneumonia (GP) - a disease that developed after a three-day stay of the child in the hospital or within the first 3 days after his discharge.

It is customary to consider ventilator-associated hospital pneumonia (VAGP) and ventilator-non-associated hospital pneumonia (HAAMP). The early WAGPs, which develop in the first 3 days of mechanical ventilation of lungs (IVL), and late, developing from 4 days of IVL, are distinguished.

Pneumonia can affect an entire fraction of the lung (lobar pneumonia), one or more segments (segmental or polysegmentary pneumonia), alveoli or groups of alveoli (focal pneumonia) adjacent to bronchial tubes (bronchopneumonia), or affect interstitial tissue (interstitial pneumonia). These differences are revealed mainly in the physical and radiological examination.

The severity of the course, the degree of defeat of the pulmonary parenchyma, the presence of intoxication and complications are distinguished by mild and severe, uncomplicated and complicated pneumonia.

The complications of pneumonia include infectious-toxic shock with the development of multi-organ failure, the destruction of the lung parenchyma (bullae, abscesses), the involvement of the pleura in the infectious process with the development of pleurisy, empyema or pneumothorax, mediastinitis, etc.

Types of pneumonia

[11], [12], [13],

Complications of pneumonia in children

[14], [15], [16], [17],

Intra-pulmonary destruction

Intrapulmonary destruction is a suppuration with the formation of bullae or abscesses at the site of cellular infiltration in the lungs caused by some pneumococcal serotypes, staphylococci, H. Influenzae type b, hemolytic streptococcus, Klebsiella, Pseudomonas aeruginosa. Pulmonary suppurations are accompanied by fever and neutrophilic leukocytosis until the time of emptying, which occurs either in the bronchial tubes, accompanied by increased coughing, or into the pleural cavity, causing pyopneumothorax.

Sinpneumonic pleurisy

Synpneumonic pleurisy can cause any bacteria and viruses, beginning with pneumococcus and ending with mycoplasma and adenovirus. Purulent exudate is characterized by low pH (7.0-7.3), cytosis above 5000 leukocytes in 1 μl. In addition, the exudate can be fibrinous-purulent or hemorrhagic. With adequate antibacterial therapy, the exudate loses purulent character and pleurisy is gradually resolved. However, full recovery occurs after 3-4 weeks.

Metapneumonic pleurisy

Metapneumonic pleurisy usually develops at the stage of resolution of pneumococcal, less often - hemophilic pneumonia. The main role in its development belongs to immunological processes, in particular the formation of immune complexes in the pleural cavity on the background of the disintegration of microbial cells.

As already mentioned, metapneumonic pleurisy develops in the resolution of pneumonia in 1-2 days of normal or subnormal temperature. The body temperature again rises to 39.5-40.0 ° C, a violation of the general state is expressed. The feverish period lasts an average of 7 days, and antibiotic therapy has no effect on it. X-ray reveals pleurisy with fibrin flakes, in some children, echocardiography reveals pericaditis. In the analysis of peripheral blood, the number of leukocytes is normal or decreased, and the ESR is increased to 50-60 mm / h. The resorption of fibrin occurs slowly, within 6-8 weeks, due to low fibrinolytic activity of the blood.

Piopevneumotorax

Pyopneurmotorax develops as a result of a breakthrough of an abscess or bulla into the pleural cavity. There is an increase in the amount of air in the pleural cavity and, as a consequence, displacement of the mediastinum.

Piopnevmotorax usually develops unexpectedly: acute pain syndromes, breathing disorders up to respiratory failure. With strained valve pyopneumothorax, urgent decompression is indicated.

Symptoms of pneumonia

Diagnosis of pneumonia in children

In the physical examination, special attention is paid to identifying the following symptoms:

• shortening (blunting) percussion sound over the affected area of the lung;
• local bronchial breathing, sonorous small bubbling rales, or inspiratory crepitations in auscultation;
• increased bronhophony and voice tremor in older children.

In most cases, the severity of these symptoms depends on many factors, including the severity of the disease, the prevalence of the process, the age of the child, the presence of concomitant diseases. It should be remembered that physical symptoms and cough may be absent in about 15-20% of patients.

The analysis of peripheral blood should be carried out to all patients with suspected pneumonia. The number of leukocytes around 10-12x10 ⁹ / l indicates a high probability of bacterial infection. Leukopenia less than 3х10 ⁹ / l or leukocytosis more than 25х 10 ⁹ / l - unfavorable prognostic signs.

Radiography of chest organs is the main method of diagnosing pneumonia. The main diagnostic sign is an inflammatory infiltrate. In addition, the following criteria are evaluated, which indicate the severity of the disease and help in choosing antibiotic therapy:

• infiltration of the lungs and its prevalence;
• presence or absence of pleural effusion;
• presence or absence of destruction of the pulmonary parenchyma.

Repeated radiography allows to evaluate the dynamics of the process against the background of the treatment and the completeness of recovery.

Thus, clinical-radiologic criteria for the diagnosis of community-acquired pneumonia consider the presence of changes in lung infiltrative character, revealed by radiography of chest organs, combined with at least two of the following clinical signs:

• acute febrile onset of the disease (T> 38.0 ° C);
• cough;
• auscultative signs of pneumonia;
• leukocytosis> 10x10 ⁹ / l and / or a stab shift> 10%. It is important to remember that clinico-radiologic diagnosis can not be equated with an etiological diagnosis!

Biochemical blood analysis is a standard method of examining children with severe pneumonia who need to be hospitalized. Determine the activity of liver enzymes, the level of creatinine and urea, electrolytes in the blood. In addition, the acid-base state of the blood is determined. Pulse oxymetry is performed in young children.

Blood sowing is performed only with severe pneumonia and, if possible, before the use of antibiotics for the purpose of setting an etiological diagnosis.

Microbiological examination of sputum in pediatrics is not widely used due to the technical difficulties of sputum collection in children younger than 7-10 years old. It is carried out mainly with bronchoscopy. As a material for the study take cough phlegm, aspirates from the nasopharynx, tracheostomy and endotracheal tube, sowing the punctate pleural contents.

Serological methods of research are also used to determine the etiology of the disease. Increasing the titers of specific antibodies in paired sera taken in the acute period and during the recovery period may indicate a mycoplasmal, chlamydial or legionella infection. This method, however, does not affect the tactics of treatment and has only epidemiological significance.

Computer tomography has a 2-fold higher sensitivity in detecting foci of infiltration in the lower and upper lobes of the lungs. Use it when conducting differential diagnosis.

Fibroblochoscopy and other invasive techniques are used to obtain material for microbiological examination in patients with severe immunity disorders and in differential diagnosis.

[18], [19], [20]

Differential diagnosis

Differential diagnosis of pneumonia in children is closely related to the child's age, since it is determined by the features of pulmonary pathology in different age periods.

In infancy, the need for differential diagnosis occurs in diseases that are difficult to treat. In these cases, it should be remembered that, firstly, pneumonia can complicate other pathologies, and secondly, the clinical manifestations of respiratory failure may be due to other conditions:

• aspirate;
• foreign body in the bronchi;
• not previously diagnosed with tracheoesophageal fistula, gastroesophageal reflux;
• malformations of the lung (shared emphysema, coloboma), heart and large vessels;
• cystic fibrosis and a deficiency of aganthitrypsin.

In children 2-3 years of age and in an older age should be deleted:

• Kartagener's syndrome;
• hemosiderosis of the lungs;
• nonspecific alveolitis;
• selective immunodeficiency IgA.

Diagnostic search in patients of this age is based on endoscopic examination of the trachea and bronchi, scintigraphy and angiography of the lungs, tests for cystic fibrosis, determination of the concentration of aganthitrypsin, etc. Finally, in all age groups it is necessary to exclude tuberculosis of the lungs.

In patients with severe immunity defects in the appearance of dyspnea and focal-infiltrative changes in the lungs, it is necessary to exclude:

• progression of the underlying disease;
• involvement of the lungs in the main pathological process (for example, in systemic diseases of connective tissue);
• the consequences of ongoing therapy (drug damage to the lungs, radiation pneumonitis).

Diagnosis of pneumonia

[21], [22], [23], [24], [25], [26], [27]

Treatment of pneumonia in children

Treatment of pneumonia in children begins by determining the place where it will be carried out (with community-acquired pneumonia) and the immediate administration of antibiotic therapy to any patient with suspected pneumonia.

Indications for hospitalization in pneumonia in children are the severity of the disease, as well as the presence of risk factors for adverse disease (modifying risk factors). These include:

• the child's age is less than 2 months, regardless of the severity and extent of the process;
• the child's age is up to 3 years with the lobar character of the lungs lesion;
• defeat of two or more lobes of the lungs (regardless of age);
• children with severe encephalopathy of any genesis;
• children of the first year of life with intrauterine infection;
• children with hypotrophy of II-III degree of any genesis;
• children with congenital malformations, especially with congenital heart defects and large vessels;
• children suffering from chronic lung diseases (including bronchopulmonary dysplasia and bronchial asthma), cardiovascular system, kidneys, as well as oncohematological diseases;
• patients with immunodeficiency (taking long-term glucocorticoids, cytostatics);
• inability to adequately care for and fulfill all medical prescriptions at home (socially disadvantaged families, poor social conditions, religious beliefs of parents, etc.);

The indication for hospitalization in the intensive care unit (ICU) or Intensive Care Unit (ICU), regardless of modifying risk factors, is a suspicion of pneumonia in the presence of the following symptoms:

• frequency of respiratory movements is more than 80 per minute for children of the first year of life and more than 60 per minute for children older than one year;
• retraction of the fossa in the breathing;
• moaning breathing, violation of the rhythm of breathing (apnea, guspsy);
• signs of acute cardiovascular insufficiency;
• non-curable or progressive hypothermia;
• impaired consciousness, seizures.

Indications for hospitalization in the surgical department or in the ICU / ICU with the possibility of providing adequate surgical care - the development of pulmonary complications (synpneumonic pleurisy, metapneumonic pleurisy, empyema of the pleura, destruction of the lungs, etc.).

Antibacterial treatment of pneumonia in children

The main method of treatment of pneumonia in children is antibacterial therapy, which is prescribed empirically before the results of bacteriological examination. As is known, the results of bacteriological examination become known after 2-3 days or more after collection of the material. In addition, in the overwhelming majority of cases of a mild course of illness, children are not hospitalized and carry out bacteriological research. That is why it is so important to know about the probable etiology of pneumonia in different age groups.

Indication for the replacement of antibiotic / antibiotics - the lack of clinical effect for 36-72 hours, as well as the development of side effects.

Criteria for lack of antibacterial therapy:

• preservation of body temperature over 38 ° C;
• deterioration of the general condition;
• an increase in changes in the lungs or in the pleural cavity;
• an increase in dyspnea and hypoxemia.

If the prognosis is poor, the treatment is carried out according to the de-escalation principle, i.e. Begin with antibacterial drugs with the widest possible spectrum of action, followed by a transition to a narrower spectrum.

Peculiarities of the etiology of pneumonia of children of the first 6 months of life are made by drugs of choice even in the case of mild pneumonia, inhibitor-protected amoxicillin (amoxicillin + clavulanic acid) or cephalosporin of the second generation (cefuroxime or cefazolin), in severe pneumonia, cephalosporins of the third generation (ceftriaxone, cefotaxime) in monotherapy or in combination with aminoglycosides, or in combination amoxiclav + clavulanic acid with aminoglycosides.

In a child up to 6 months with normal or subfebrile temperature, especially in the presence of obstructive syndrome and indications of vaginal chlamydia in the mother, one can think of pneumonia due to C. Trachomatis. In these cases, it is expedient to immediately appoint a macrolide antibiotic (azithromycin, roxithromycin or spiramycin) inside.

Preterm infants should be aware of the possibility of pneumonia caused by R. Carinii. In this case, along with antibiotics appoint co-trimoxazole. When confirming the pneumocystis etiology, they switch to monotherapy with co-trimoxazole lasting not less than 3 weeks.

When pneumonia is aggravated by the presence of modifying factors or with a high risk of adverse outcome, the drugs of choice are inhibitor-protected amoxicillin in combination with aminoglycosides or cephalosporins III or IV generation (ceftriaxone, cefotaxime, cefepime) in monotherapy or in combination with aminoglycosides depending on the severity of the disease , carbapenems (imipenem + cilastatin from the first month of life, meropenem from the second month of life). With staphylococcal etiology, linezolid or vancomycin is administered alone or in combination with aminoglycosides depending on the severity of the disease.

Alternative drugs, especially in cases of development of destructive processes in the lungs, - linezolid, vancomycin, carbapenems.

The choice of antibacterial drugs in children in the first 6 months of life with pneumonia

Form of pneumonia	Drugs of choice	Alternative Therapy
Moderate, severe pneumonia	Amoxicillin + clavulanic acid or cephalosporins of the second generation	Cephalosporins II and III generations in monotherapy
Severe typical pneumonia	Amoxicillin + clavulanic acid + aminoglycoside or cephalosporins of III or IV generation in monotherapy or in combination with aminoglycosides. Linezolid or vancomycin in monotherapy or in combination with aminoglycosides	Carbapenems
Atypical pneumonia	Macrolide antibiotic	-
Atypical pneumonia in a premature baby	Co-trimoxazole

At the age of 6-7 months to 6-7 years, when choosing the starting antibacterial therapy, three groups of patients are distinguished:

• patients with mild pneumonia who do not have modifying factors or who have modifying factors of the social plan;
• patients with severe pneumonia and patients with modifying factors, weighting the prognosis of the disease;
• patients with severe pneumonia and a high risk of adverse outcome.

Patients of the first group are most advisable to prescribe antibacterial drugs inside (amoxicillin, amoxicillin + clavulanic acid or cefalosporin II generation cefuroxime). But in some cases (the lack of confidence in the performance of appointments, the rather serious condition of the child, the parents' refusal to admit hospitalization, etc.), a stepwise method of treatment is justified: in the first 2-3 days, antibiotics are administered parenterally, and then, with improvement or stabilization of the condition, the same drug is prescribed inside. To do this, use amoxicillin + clavulanic acid, but it must be administered intravenously, which is difficult at home. Therefore, more commonly prescribed cefuroxime.

In addition to ß-lactams, treatment can be carried out with macrolides. But, given the aetiological significance of the hemophilic rod (up to 7-10%) in children of this age group, the drug of choice for starting empirical therapy is only azithromycin, to which H. Influenzae is sensitive. Other macrolides are an alternative for intolerance to ß-lactam antibiotics or if they are ineffective, for example, pneumonia caused by atypical pathogens M. Pneumoniae and C. Pneumoniae, which is rare at this age. In addition, if the drugs of choice are ineffective, third-generation cephalosporins are used.

Patients of the second group are shown the parenteral administration of antibiotics or the use of a stepwise method. The drugs of choice, depending on the severity and extent of the process, the nature of the modifying factor - amoxicillin + clavulanic acid, ceftrexone, cefotaxime and cefuroxime. Alternative drugs with ineffectiveness of starting therapy - cephalosporins III or IV generation, carbapenems. Macrolides in this group are rarely used, since the overwhelming number of pneumonias caused by atypical pathogens is not very serious.

Patients with a high risk of adverse outcome or with severe purulent-destructive complications are prescribed antibacterial drugs according to the de-escalation principle, which presupposes the use of linezolid at the beginning of treatment alone or in combination with an aminoglycoside, as well as a combination of glycopeptide or cephalosporin IV generation with aminoglycosides. An alternative is the administration of carbapenems.

The choice of antibacterial drugs for the treatment of pneumonia in children from 6-7 months to 6-7 years

Form of pneumonia	The drug of choice	Alternative Therapy
Severe pneumonia	Amoxicillin. Amoxicillin + clavulanic acid. Cefuroxime. Azithromycin	Cephalosporins of the second generation. Macrolides
Severe pneumonia and pneumonia with modifying factors	Amoxicillin + clavulanic acid. Cefuroxime or ceftriaxone. Cefotaxime	Cephalosporins III or IV generation alone or in combination with an aminoglycoside. Carbapenems
Severe pneumonia with a high risk of adverse outcome	Linezolid alone or in combination with an aminoglycoside. Vancomycin alone or in combination with an aminoglycoside. Cefepime alone or in combination with an aminoglycoside	Carbapenems

At a choice of antibacterial preparations at a pneumonia at children is more senior 6-7 years and teenagers allocate two groups of patients:

• with mild pneumonia; 
• with severe pneumonia requiring hospitalization, or with pneumonia in a child or adolescent who has modifying factors.

Antibiotics of choice for the first group are amoxicillin and amoxicillin + clavulanic acid or macrolides. Alternative drugs - cefuroxime or doxycycline, as well as macrolides, if previously prescribed amoxicillin or amoxicillin + clavulanic acid.

Antibiotics of choice for the second group are amoxicillin + clavulanic acid or cephalosporins of the second generation. Alternative drugs - cephalosporins III or IV generation. Macrolides should be preferred for intolerance of ß-lactam antibiotics and for pneumonia, presumably caused by M. Pneumoniae and C. Pneumoniae.

The choice of antibacterial drugs for the treatment of pneumonia in children and adolescents (7-18 years)

Form of pneumonia	The drug of choice	Alternative Therapy
Severe pneumonia	Amoxicillin, amoxicillin 4-clavulanic acid. Macrolides	Macrolides. Cefuroxime. Doxacycline
Severe pneumonia, pneumonia in children and adolescents, with modifying factors	Amoxicillin 4-clavulanic acid. Cephalosporins of the second generation	Cephalosporins of III or IV generation

In pneumonia in patients with impaired immunity, empirical therapy is started with cephalosporins of the third or fourth generation, vancomycin or linezolid in combination with aminoglycosides. Then, as the pathogen is clarified, or the therapy is started, for example, if pneumonia is caused by Enterobacteriaceae (K. Pneumoniae, E. Coli, etc.), S. Aureus or Streptococcus pneumoniae, or co-trimoxazole (20 mg / kg trimethoprim ) in the detection of pneumocystosis, or appoint fluconazole in candidiasis and amphotericin B in other mycoses. If pneumonia is caused by viral agents, then antiviral drugs are prescribed.

The duration of the course of antibiotics depends on their effectiveness, the severity of the process, the complication of pneumonia and premorbid background. The usual duration is 2-3 days after obtaining a stable effect, i.e. About 6-10 days. Complicated and severe pneumonia usually require a course of antibiotic therapy for at least 2-3 weeks. In patients with impaired immunity, the course of antibacterial drugs is at least 3 weeks, but may be longer.

Selection of antibacterial drugs for pneumonia in patients with impaired immunity

The nature of immunodeficiency	Etiology of pneumonia	Drugs for therapy
Primary cellular immunodeficiency	Pneumocysta carinii. Mushrooms of the genus Candida	Co-trimoxazole 20 mg / kg trimethoprim. Fluconazole 10-12 mg / kg or amphotericin B in increasing doses, starting at 150 U / kg and up to 500 or 1000 U / kg
Primary humoral immunodeficiency	Enterobacteria (K. Pneumoniae E. Coli, etc.). Staphylococcus (S. Aureus, S. Epidermidis, etc.). Pneumococci	Cephalosporins 111 or IV generation in monotherapy or in combination with aminoglycosides. Linezolid or vancomycin in monotherapy or in combination with aminoglycosides. Amoxicillin + clavulanic acid in monotherapy or in combination with aminoglycosides
Acquired immunodeficiency (HIV-infected, AIDS patients)	Pneumocystis. Cytomegalovirus. Herpesviruses. Mushrooms of the genus Candida	Co-trimoxazole 20 mg / kg trimethoprim. Ganciclovir. Acyclovir. Fluconazole 10-12 mg / kg or amphotericin B in increasing doses, starting at 150 U / kg and up to 500 or 1000 U / kg
Neutropenia	Gramnegative enterobacteria. Fungi of the genus Candida, Aspergillus, Fusarium	Cephalosporins III or IV generation in monotherapy or in combination with aminoglycosides. Amphotericin B in increasing doses, starting from 150 U / kg and up to 500 or 1000 U / kg

Doses, routes and multiplicity of administration of antibacterial drugs for community-acquired pneumonia in children and adolescents

A drug	Doses	The route of administration	Multiplicity of the introduction
Penicillin and its derivatives
[Amoxicillin	25-50 mg / kg body weight. For children over 12 years of 0.25-0.5 g every 8 hours	Inside	3 times a day
Amoxicillin + clavulanic acid	20-40 mg / kg body weight (for amoxicillin). For children older than 12 years with mild pneumonia, 0.625 g every 8 hours or 1 g every 12 h	Inside	2-3 times a day
Amoxicillin + clavulanic acid	30 mg / kg body weight (for amoxicillin). For children over 12 years of age, 1.2 g every 8 or 6 hours	In / in	2-3 times a day
Cephalosporins I and II generations
Cefazolin	60 mg / kg body weight. For children over 12 years of age, 1-2 g every 8 hours	V / m, in / in	3 times a day
Cefuroxime	50-100 mg / kg body weight. For children over 12 years of age, 0.75-1.5 g every 8 hours	V / m, in / in	3 times a day
Cefuroxime	20-30 mg / kg body weight. For children older than 12 years, 0.25-0.5 g every 12 hours	Inside	2 times a day
Third generation cephalosporins
Cefotaxime	50-100 mg / kg body weight. For children over 12 years, 2 g every 8 hours	V / m, in / in	3 times a day
Ceftriaxone	50-75 mg / kg body weight. For children over 12 years, 1-2 grams 1 time per day	V / m, in / in	1 time per day
Cephalosporins of the fourth generation
Cefepim	100-150 mg / kg body weight. For children over 12 years, 1-2 g every 12 hours	In / in	3 times a day

Carbapenems
Imipenem	30-60 mg / kg body weight. For children over 12 years, 0.5 g every 6 hours	V / m, in / in	4 times a day
Meropenem	30-60 mg / kg body weight. For children over 12 years of age, 1 g every 8 hours	V / m, in / in	3 times a day
Glycopeptides
Vancomycin	40 mg / kg body weight. For children over 12 years of age, 1 g every 12 hours	V / m, in / in	3-4 times a day
Oxazolidinones
Linezolid	10 mg / kg body weight	V / m, in / in	3 times a day
Aminoglycosides
Gentamicin	5 mg / kg body weight	V / m, in / in	2 times a day
Amikacin	15-30 mg / kg body weight	V / m, in / in	2 times a day
Nethylmycin	5 mg / kg body weight	V / m, in / in	2 times a day
Macrolides
Erythromycin	40-50 mg / kg body weight. For children over 12 years of age, 0.25-0.5 g every 6 hours	Inside	4 times a day
Spiramycin	15 000 IU / kg body weight. For children over 12 years of 500 000 IU every 12 hours	Inside	2 times a day
Roxithromycin	5-8 mg / kg body weight. For children older than 12 years, 0.25-0.5 g every 12 hours	Inside	2 times a day
Azithromycin	10 mg / kg of body weight in the first day, then 5 mg / kg of body weight per day for 3-5 days. For children over 12 years, 0.5 grams 1 time per day every day	Inside	1 time per day

Tetracyclines
Doxycycline	5 mg / kg body weight. For children older than 12 years, 0.5-1 g every 8-12 hours	Inside	2 times a day
Doxycycline	2.5 mg / kg body weight. For children older than 12 years, 0.25-0.5 g every 12 hours	In / in	2 times a day
Antibacterial drugs of different groups
Co-trimoxazole	20 mg / kg body weight (according to trimethoprim)	Inside	4 times a day
Amphotericin B	Begin with 100 000-150 000 units, gradually increasing by 50 000 units for 1 introduction 1 every 3 days to 500 000-1 000 000 units	In / in	1 time in 3-4 days
Fluconazole	6-12 mg / kg body weight	In / in, inside	1 per day

[28], [29], [30],

Antiviral treatment of pneumonia in children

Antiviral drugs are prescribed in the following cases:

• convincingly substantiated laboratory or clinically viral etiology of pneumonia;
• severe viral-bacterial pneumonia.

With established or highly probable influenza aetiology, children older than one year are prescribed rimantadine. In addition, from the first days of life, recombinant alpha interferon-viferon can be used. Indication for its use - rhino, corona, PC- and adenovirus infections, influenza and parainfluenza. Viferon is prescribed to children under 3 years of 150 IU ME 2 times a day in suppositories for 5 days, children over 3 years of 500 IU ME 2 times a day in suppositories for 5 days. Such courses should be 2-3 with an interval of 5 days.

[31], [32], [33], [34], [35], [36]

Immunocorrective therapy

Recommendations for the appointment of immunocorrecting drugs in the treatment of pneumonia in children are still under study.

Indications for the appointment of immunocorrective therapy:

• age up to two months;
• the presence of modifying factors, with the exception of social and social conditions;
• high risk of an unfavorable outcome of pneumonia;
• complicated pneumonia, especially destructive.

In these cases, along with antibiotics, replacement immunotherapy with freshly frozen plasma and immunoglobulins for intravenous administration is necessarily used. Immunoglobulins are prescribed as early as possible - in the 1-2 days. They are administered at usual therapeutic doses (500-800 mg / kg), a minimum of 2-3 injections per course, daily or every other day. It is desirable to achieve an increase in the patient's blood level of more than 800 mg / DL.

In destructive pneumonia, the introduction of immunoglobulins containing МM is shown, i.e. Pentaglobin4.

Symptomatic treatment of pneumonia in children

Anti-tussive therapy is one of the main directions of symptomatic therapy. Drugs of choice - mucolytics, which well dilute the bronchial secret due to a change in the structure of mucus (ambroxol, acetylcysteine, bromhexine, carbocysteine). They are used inside and in inhalations for 7-10 days.

Antipyretic therapy

Currently, the list of antipyretic drugs used in children is limited by paracetamol and ibuprofen. Indications for their use are febrile fever (over 38.5 ° C). At a body temperature above 40 ° C, use a lytic mixture (aminazine 0.5-1.0 ml of 2.5% solution + 0.5-1.0 ml of a solution of pipolpene intramuscularly or intravenously). In severe cases, 0.2 ml per 10 kg of a 10% solution of analgin is added to the mixture.

[37], [38], [39], [40], [41], [42], [43],

Evaluation of the effectiveness of treatment of pneumonia in children

The ineffectiveness of therapy and the high risk of an unfavorable prognosis of the disease should be noted if within the next 24-48 hours they are noted:

• increase in respiratory insufficiency, decrease in the ratio of PaO2 / P1O2;
• a drop in systolic pressure, which indicates the development of an infectious shock;
• increase in the size of pneumonic infiltration by more than 50% compared with the initial one;
• other manifestations of multiple organ failure.

In these cases, after 24-48 hours, the transition to alternative drugs and the strengthening of functional support of organs and systems are indicated.

Stabilization of the state during the first 24-48 hours from the beginning of treatment and some regression of radiologic changes and homeostatic disorders on 3-5 days of therapy testify to the success of the chosen tactics.

The transition to taking antibacterial drugs inside shows:

• with persistent normalization of body temperature;
• with a decrease in dyspnea and cough;
• with a decrease in leukocytosis and neutrophilia in the blood.
• It is usually possible with severe pneumonia on days 5-10 of treatment.

X-ray examination in dynamics in the acute period of the disease is carried out only in the presence of progression of symptoms of lung damage or when signs of destruction and / or involvement of the pleura in the inflammatory process appear.

With a distinct positive dynamics of clinical manifestations, confirmed by dynamic radiographs, there is no need for control radiography at discharge. It is more expedient to spend it out-patiently not earlier than 4-5 weeks from the onset of the disease. Mandatory X-ray control before discharge from the hospital is justified only in cases of complicated pneumonia.

In the absence of positive dynamics of the process within 3-5 (maximum 7) days of therapy, prolonged flow, torpidity of the therapy, it is necessary to expand the scope of the examination both in terms of identifying unusual pathogens (C. Psittaci, P. Aerugenoza, Leptospira, C. Burneti), and in terms of identifying other lung diseases.

Read also: Treatment of pneumonia Treatment of hospital pneumonia

[44], [45], [46], [47],

Prevention of pneumonia in children

The basis for the prevention of community-acquired pneumonia is the adequate treatment of upper respiratory tract infection, especially in frequently ill children and in children with bronchial obstructive syndrome. Special attention in the treatment of ARI should also be given to children with encephalopathies, congenital malformations, children with grade II-III hypotrophy. In addition, children suffering from chronic lung diseases (bronchopulmonary dysplasia, bronchial asthma), diseases of the cardiovascular system, kidneys (nephritis), oncohematological diseases and patients with immunodeficiency.

Bibliography

Tatochenko VK, Sereda EV, Fedorov AM Antibacterial therapy of pneumonia in children: A Manual for Physicians. - M., 2001.

Rational pharmacotherapy of childhood diseases: A guide for practicing physicians: Book. 1 / Under total. Ed. A.A. Baranova, N.N. Volodina, G.A. Samsygin. - Moscow: Litterra, 2007. - P. 451 - 168.

Infections of the respiratory tract in young children, Ed. G.A. Samsygin. - M .: Miklos, 2006. - P. 187-250.

Technical basis for WHO recommendations for the management of children with pneumonia: Document WHO / ARI / 91/20. - Geneva: WHO, 1991.

Buckingham SC Incidence and etiology of complicated pneumonic effusion in children 1996-2001 // Pediatr. Infect. Dis. J. - 2003. - Vol. 22, No. 6.-P. 499-504.

Juven T., Mertsola J., Waris M. Et al. Etiology of community-acquired pneumonia in 254 hospitalized children // Pediatr. Infect. Dis. J. - 2000. - Vol. 19. - P. 293-296.

Henrickson KJ // Seminars in Pediatric Infection Diseases. - 1998. - Vol. 9, No. 3 (July) - P. 217-233.

Guidelines for the manadegment of the adult community. European Study on Community-acquired Pneumonia (ESOCAP) // Committee. Eur. Resp. J. - 1998. - Vol. 14. - P. 986-991.

Bush A., Carlsen R.-H., Zach MS Growing up with lung disease: ERTP. - 2002. - P. 189-213.

Tatokhenko VK, Samsygina GA, Sinopalnikov AI, Uchaikin VF Pneumonia in children // Pediatric Pharmacology. - 2006. - T. 3, No. 3. - P. 38-46.

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