mwvave pnevmonia mozrdilebSi

mwvave pnevmonia mozrdilebSi1. definiciapnevmonia aris alveolisa da terminaluri sasunTqi gzebis anTeba,romelic gamowveulia infeqciuri agentis hematogenuri an inhalaciurigziT filtvebSi moxvedriT da romelsac axasiaTebs mwvaverespiraciuli simptomebis, cxelebis an orives erTdroulad arsebobada gulmkerdis rentgenogramaze filtvis parenqimuli infiltraciisniSnebi. praqtikuli TvalsazrisiT, mniSvnelovania pnevmoniis dayofasazogadoebaSi SeZenil (sayofacxovrebo, ambulatorul) danozokomiur tipebad. aseTi dayofa ar aris dakavSirebuli daavadebismimdinareobis simZimesTan. ZiriTad da erTaderT ganmasxvavebelkriteriumad gvevlineba is garemoeba, sadac ganviTarda pnevmonia.sazogadoebaSi SeZenil pnevmoniaSi unda vigulisxmoT mwvave daavadeba,romelic aRmocendeba ara saavadmyofos pirobebSi, an romlisdiagnostika moxda hospitalizaciis momentidan pirvel 48 sT-Si daromelsac Tan axlavs qveda sasunTqi gzebis infeqciis simptomebi:xvela, qoSini, cxeleba, naxvelis (SesaZloa Cirqovani) gamoyofa,tkivili gulmkerdis areSi da rentgenologiuri niSnebi (filtvebSiaxali kerovan-infiltraciuli cvlilebebi).2. epidemiologiaepidemiologiuri monacemebis Tanaxmad, pnevmoniis sixSire ufrosebSi(>18 weli) farTo diapazonSi meryeobs: axalgazrda da saSualo asakispirebs Soris 1-11,6%-ia, ufros asakobriv jgufSi 25-44%. wlisganmavlobaSi ufrosi asakSi (>18 weli) avadobis saerTo raodenobam 5evropul qveyanaSi (didi britaneTi, safrangeTi, italia, germania,espaneTi) 3.000.000 adamiani Seadgina. saqarTvelos Sromis,janmrTelobis da socialuri dacvis saministros samedicinostatistikis da informaciis centris 2004 wlis monacemebiTsaqarTveloSi pnevmoniiT hospitalizebul iqna 9.757 avadmyofi,maCvenebeli 100.00 mosaxleze 223, letaloba – 0,8%.pnevmoniis dros letaloba Zalian dabalia (1-3%). Tumca 60 welze metiasakis pacientebSi, seriozuli Tanmxlebi paTologiebis arsebobisas(f.q.o.d., avTvisebiani axalwarmonaqmnebi, alkoholizmi, Saqrianidiabeti, RviZlisa da Tirkmelebis daavadebebi, gul-sisxlZarRvTadaavadebebi da a.S.), aseve pnevmoniis mZimed mimdinareobisas(multilobaluri infiltracia, meoradi baqteriemia, sunTqvissixSire>30/wT, hipotenzia da Tirkmlebis mwvave ukmarisoba),letalobis maCvenebeli 15-30%-s aRwevs.letalobis riski, romelic moicavs anamnezur, obieqtur dalaboratoriul monacemebs, warmodgenilia 1 cxrilSi. letalobismniSvnelovani faqtoria gviani mimarTva samedicino daxmarebisaTvis.3

cxrili 1monacemebialbaTobademografiamamrobiTi sqesi 1,3 (1,2-1,4)ZiriTadi daavadebis istoriagadacieba0,4 (0,2-0,7)fsiqikuri statusis Secvla2,0 (1,7-2,3)qoSini2,9 (1,9-3,8)Tanmxlebi daavadebebigulis qronikuli ukmarisoba2,4 (2,2-2.5)imunodeficituri mdgomareoba1,6 (1,3-1,8)Saqriani diabeti1,2 (1,3-1,4)koronarul sisxlZarRvTa dazianeba1,5 (1,3-1,6)onkologiuri daavadebebi2,7 (2,5-2,9)nevrologiuri daavadebebi4,4 (3,8-4,9)Tirkmlis paTologiebi2,7 (2,5-2,9)fizikuri gamokvlevebitaqipnoe2,5 (2,2-2,8)hipoTermia2,6 (2,1-3,2)hopotenzia5,4 (5,0-5,9)laboratoriuli gamokvlevebisisxlis Sardovana (>7,14mm.Hg.)2,7 (2,3-3.0)leikopenia (10×10 9/l)4,1 (3,85-4,8)hipoqsemia (PaO 2

3. etiologiapnevmoniis etiologia dakavSirebulia normalur mikroflorasTan,romelic zeda sasunTqi gzebis kolonizirebas axdens. maRalivirulentoba mravalricxovani mikroorganizmebidan mxolod zogierTsgaaCnia. maT SeuZliaT gamoiwvion sasunTqi gzebis qveda nawilebisanTebiTi reaqcia. aseT tipur gamomwvevad iTvleba S.pneumoniae (30%-50%daavadebis SemTxveva). pnevmoniis etiologiaSi arsebiTi mniSvnelobaaqvs e.w. atipur mikroorganizmebs (Chlamydophila pneumoniae, Mycoplasmapneumoniae, Legionella pneumoniae) romelTa wilzec saerTo jamSi modis 8-10%-mde. iSviaT gamomwvevebs ganekuTvneba Haemophilus influenzae, Staphilococcusaureus, Klebsiella pneumoniae (3-5%).iSviaTad pnevmonia SeiZleba gamoiwvios fsevdomonam (gansakuTrebiTmukoviscidoziT daavadebulebSi, romelTac aqvT bronqoeqtazia).aucilebelia aRiniSnos, rom mozrdil pacientebSi vlindeba Sereuliinfeqciebi. mag. pnevmokokuri pnevmoniis dros SesaZlebeliaerTdroulad aRmoCndes mikoplazmuri an qlamidiuri infeqcia.respiraciuli virusebi (gripi A da B, paragripi, adenovirusi da rsv)arc ise xSirad iwveven filtvebis mZime dazianebebs. respiraciulivirusebi, da pirvel rigSi epidemiuri gripi, pnevmoniis wamyvani riskfaqtoria.aucilebelia virusuli da baqteriuli pnevmoniis zustidiferencireba, radgan maTi mkurnaloba gansxvavebulia.pnevmonia SesaZloa gamowveuli iyos ucnobi etiologiis gamomwveviT,romelic daavadebis swraf ganviTarebas iwvevs. ukanasknel wlebSiaseTebs SeiZleba mivakuTvnoT koronavirusi, frinvelis gripis virusi,metapnevmovirusi. zogierTi mikroorganizmisaTvis damaxasiaTebeli araris filtvebis anTeba. maTi naxvelidan gamoyofa amtkicebs zemosasunTqi gzebis floris kontaminacias da ara am mikrobis etiologiurmniSvnelobas. aseT mikroorganizmebs miekuTvneba: Steptococcus viridas,Staphylococcus epidermidis da sxva koagulonegatiuri stafilokokebi,Enterococus spp, Neisseria spp, Candida spp.pnevmoniis etiologia gansxvavdeba avadmyofis asakis, daavadebissimZimis da Tanmxlebi paTologiis arsebobis mixedviT. hospitalizebulpacientebSi pnevmokokebis, mikoplazmebis da qlamidiebis wilze modisdaaxloebiT 25%. am ukanasknelebs arsebiTi mniSvneloba ara aqvTpnevmoniis mZime formebis ganviTarebaSi. amave dros, am kategoriispacientebSi matulobs Legionella spp., S.aureus, gramuaryofiTienterobaqteriebis, K.pneumoniae-is wili.praqtikuli poziciidan gamomdinare mizanSewonilia gamovyoTpacientebis jgufi asakis, Tanmxlebi daavadebebis da daavadebismimdinareobis simZimis mixedviT. am jgufebs Soris gansxvavebaaRiniSneba ara marto etiologiis, aramed prognozis mixedviTac.5

pnevmoniis gamomwvevi da letalobagamomwvevi letaloba %S.pneumoniae 12,3%H.influenzae 7,4%M.pneumoniae 1,4%Legionella spp. 14,7%S.aureus 31,7%K.pneumoniae 35,7%C.pneumoniae 9,4%cxrili 2pacientebis jgufebi da gamomwvevebijgufi pacientis daxasiaTeba gamomwvevebi1 pnevmoniis aramZimed mimdinareoba 60wl-ze qvemoT pacientebSiTanmxlebi paTologiis gareSe2 daavadebis mZime mimdinareoba 60wl-is zemoT da/an TanmxlebipaTologiebiT3 pnevmoniis mZime mimdinareoba,hospitaliz-ebuli pacientebi(saerTo profilis ganyofilebaSi)4 pnevmoniis mZime mimdinareoba,hospitaliz-ebuli pacientebi(intensiuriTerapiisganyofilebaSi)S.pneumoniaeM.pneumoniaC.pneumoniaecxrili 3S.pneumoniaeH.influenzaeC.pneumoniaeS.aureusEnterobacteriaceaeS.pneumoniaeH.influeanzaeC.pneumoniaeS.aureusEnterobacteriaceaeS.pneumoniaeLegionella sppS.aureusEntarobacteriaceae6

pnevmoniis gamomwvevebicxrili 4gamomwvevi literaturis mixedviT meta-analizibaqteriebiS.PneumoniaeH.influenzaeS. aureusatipurigamomwvevi20-603-103-56512210-20 12virusi 2-15 3aspiraciulipnevmoniadaudgenelietiologia6-1030-604. paTogenezisasunTqi gzebis qveda nawilebis infeqciisagan dacvas meqanikurifaqtorebi (aerodinamikuri filtracia, bronqebis meqanikuri ganStoeba,xvela da cemineba, mocimcime epiTeliumis wamwamebis rxeva) daaraspecifiuri da specifiuri imunitetis meqanizmebi axorcieleben.anTebiTi reaqciis ganviTarebis mizezi SesaZloa gaxdes rogorcmakroorganizmis dacviTi meqanizmebis efeqturobis daqveiTeba, asevemikroorganizmebis dozis masiuroba da/an maTi moWarbebulivirulenturoba. pnevmoniis ganviTarebas ganapirobebs 4 paTogenezurimeqanizmi (ZiriTadad vlindeba pirveli ori):• aspiracia;• mikroorganizmebis Semcveli haeris CasunTqva;• mikroorganizmebis hematogenuri gavrceleba arafiltvismierikerovani infeqciisganE(endokarditi, septiuri Tromboflebiti);• infeqciis gavrceleba uSualod mezobeli dazianebulikerebisagan (mag. Tirkmlis abscesis dros) an gulmkerdis SemavaliWrilobebis inficirebis Sedegad.aspiracia _ pnevmoniis paTogenezSi inficirebis mTavari gzaa.normalur pirobebSi, mikroorganizmebis nawils, mag., S. pneumoniae,SeuZliaT pir-xaxis kolonizireba, Tumca sasunTqi gzebis qvedanawilebi steriluri rCeba. mozrdilTa naxevarSi Zilis dros pirxaxissekretis mikroaspiracia fiziologiuri fenomenia. erTi mxriv,xvelis refleqsi, mukociliaruli klirensi, alveoluri makrofagebisantibaqteriuli aqtivoba da, meore mxriv, sekretuliimunoglobulinebi uzrunvelyofen inficirebuli sekretis eliminaciassasunTqi gzebis qvemo nawilebidan da maT sterilurobas.7

traqeobronquli xis TviTgamwmendi meqanizmis dazianebisas, mag.respiraciuli virusuli infeqciis dros, roca irRveva bronqebiswamwamovani epiTeliumis funqcia da qveiTdeba alveolurimakrofagebis fagocituri aqtivoba, pnevmoniis ganviTarebisaTvissasurveli pirobebi iqmneba. sxva SemTxvevaSi, paTogenezuri faqtoriSesaZloa iyos mikroorganizmebis dozis masiuroba an erTeulimaRaldiferenciuli mikroorganizmebis SeRweva sasunTq gzebSi.mikrobuli aerozolis inhalacia pnevmoniix SedarebiT iSviaTi mizezia.is mTavar rols TamaSobs obligaturi gamomwvevebiT sasunTqi gzebisqveda nawilebis inficirebaSi. kidev ufro naklebi mniSvneloba aqvsinfeqciis keridan gamomwvevis hematogenur (mag. Staphylococcus spp.)gavrcelebas. Apnevmoniis paTogenezis aRwerili TaviseburebisgaTvaliswinebiT aSkaraa, rom misi etiologia sasunTqi gzebis zedanawilebis mikroflorasTan aris dakavSirebuli, romlisSemadgenlobac damokidebulia garemoze, pacientis asakze dajanmrTelobis saerTo mdgomareobaze. .5. klinikuri simptomatikapnevmoniis ZiriTadi klinikuri niSnebi da simptomebi SesaZloaformulirdes Semdegi saxiT:• daavadebis kliniko-rentgenologiuri suraTis analizissafuZvelze umetes SemTxvevaSi ar xerxdeba pnevmoniisetiologiis gansazRvra.• pnevmoniix iseTi niSnebi, rogoricaa cxeleba, tkiviligulmkerdis areSi da sxv. SesaZloa ar aRiniSnebodes,gansakuTrebiT garTulebul SemTxvevebSi da moxucebSi. 65 wliszemoT daaxloebiT 25%-Si ar aRiniSneba cxeleba, leikocitozi kiaRiniSneba mxolod 50-70%-Si. klinikuri suraTi SeiZlebawarmodgenili iyos daRlilobiT, saerTo sisustiT, gulisreviT,anoreqsiiT, tkiviliT mucelSi, cnobierebis dakargviT.• pnevmokokisaTvis, aseve mikoplazmisa da qlamidiisaTvis, ar arisdamaxasiaTebeli destruqciis ganviTareba. aseT dros xSiriastafilokoki, gramuaryofiTi aerobuli baqteriebi daanaerobebi.• mikoplazmuri pnevmoniisaTvis damaxasiaTebelia filtvisbazaluri wilebis retikulo-nodularuli infiltracia.pnevmoniaze eWvi unda mivitanoT pacientebSi, romelTac aReniSnebaTqoSini cxelebasTan erTad, naxvelis gamoyofa da/an tkiviligulmkerdis areSi. avadmyofi, romelmac gadaitana pnevmonia, xSirad uCivisaramotivirebul sisustes, daRlilobas da RamiT Zlier oflianobas.pacientis fizikuri gamokvlevebiT miRebuli informacia bevrfaqtorzea damokidebuli: daavadebis simZime, pnevmoniuri infiltraciisgavrceleba, asaki, Tanmxlebi avadmyofobebis arseboba. klasikurobieqtur niSans warmoadgens dazianebuli segmentis donezeperkusiuli xmianobis Sesusteba, lokalurad bronquli sunTqva,wvrilbuStukovani xixini an krepitacia, bronqofoniis gaZliereba.8

pnevmoniis simptomTa sixSire anamnezuri da fizikaluri monacemebismixedviT Semdegia:• xvela, cxeleba, taqikardia, xixini_22-48%;• mxolod xvela_2-15%;• perkusiuli xmianobis moyrueba_12_20%;• mxolod xixini_17-15%;• mxolod cxeleba_5-20%;• mxolod taqikardia_8-13%.6. garTulebebi• plevruli gamonadeni;• plevris empiema;• filtvis qsovilis destruqcia/abscedireba;• mwvave respiraciuli distres-sindromi;• sunTqvis mwvave ukmarisoba;• septiuri Soki, meoradi baqteriemia, sefsisi;• perikarditi, miokarditi;• nefriti da sxva.amaTgan yvelaze mniSvnelovania Cirqovan-destruqciuli garTulebebi.filtvis abscesisaTvis damaxasiaTebelia SemosazRvrul RruebSiCamoyalibeba (filtvis qsovilis nekrozisa da Cirqovani procesisSedegad). is dakavSirebulia anerobul gamomwvevebTan: Bacteroides spp., F.nucleatum, Peptostreptococcus spp da sxva. iSviaTad enterobaqteriebis daS.aureus SerwymiT.plevris empiema (Cirqovani plevriti). damaxasiaTebelia Cirqisdagroveba plevris RruSi. ZiriTad gamomwvevebs miekuTvnebaanaerobebi Serwymuli gram-uaryofiT aerobul baqteriebTan.7. diagnozi, diferenciuliDdiagnozi, simZimis Sefasebapnevmoniis sadiagnostiko kriteriumebs miekuTvneba rentgenologiuradpacientis filtvis qsovilis dazianebuli kerovani infiltracia daSemdegi niSnebidan ori niSnis arseboba (rekomendacia A):• mwvave cxeleba daavadebis dasawyisSi (T>38);• xvela naxveliT;• lokaluri krepitacia da/an wvrilbuStukovani xixini, uxeSibronquli sunTqva, perkutoruli xmianobis Sesusteba;• leikocitozi >10X10 9 /l da/an CxirbirTvianebis mateba (>10%).amasTan, diagnozi unda dadasturdes rentgenologiurad.rentgenologiuri kvlevis SeuZleblobis SemTxvevaSi diagnostikaxdeba epidanamnezis, Civilebis da lokaluri simptomebis mixedviT,Tumca diagnozi SeiZleba iyos arazusti (rekomendacia A).pnevmoniis nozologiuri diagnozis dasmis dros aucilebeliagaTvaliswinebuli iyos pnevmoniis klinikis da etiologiis kavSiri9

(rekomendacia B da C). ase magaliTad, pnevmokokuri pnevmoniisaTvisdamaxasiaTebelia mwvave dasawyisi, maRali cxeleba, gulmkerdistkivili. legionelurisaTvis: diarea, nevrologiuri simptomatika,daavadebis mZime mimdinareoba, Tirkmlis funqciis darRveva.mikoplazmurisTvis: kunTebis da Tavis tkivili, zeda sasunTqi gzebisinfeqciis simptomebi.qvemoT mowodebulia algoriTmi, romelic asaxavs pnevmoniisgarTulebis da letaluri gamosavalis ganviTarebis risks:pnevmoniaaraasaki 50 wlis zemoTaraTanarsebuli daavadebebiavTvisebianiaxalwarmonaqmnebigulis SegubebiTiukmarisobacerebrovaskularulidaavadebebiTirkmlis daavadebebiRviZlis daavadebebiaramaRali riski(letaloba 0,5-29%)obieqturi dalaboratoriulidarRvevebicnobierebis darRvevapulsi ≥ 125sunTqvis sixSire ≥ 30sistoluri wneva < 90mm.vcx.svtemperatura < 35C an ≥40 Caradabali riski(letaloba 0,1%)10

8. gamokvlevis sqemarentgenologiuri kvlevapnevmoniis diagnostika praqtikulad yovelTvis gulisxmobs filtvebSikerovan-infiltraciuli cvlilebebis aRmoCenas, Serwymuls qvemosasunTqi gzebis infeqciasTan. rentgenografia saSualebas gvaZlevsaseve SevafasoT paTologiuri procesis dinamika. cvlilebebirentgenogramaze (infiltraciis gavrceleba, plevraluri gamonadeni,Rrus destruqcia) Seesabameba daavadebis simZimes da gvexmarebaantibaqteriuli mkurnalobis SerCevaSi.laboratoriuli diagnostikasisxlis saerTo analizi pnevmoniis gamomwvevis gansazRvrissaSualebas ar gvaZlevs, Tumca leikocitozi 12-15×10 9 /l da metimigviTiTebs baqteriuli infeqciis maRal albaTobaze. 3×10 9 /l-zedabali leikopenia an 25×10 9 /l-ze maRali leikocitozi arasaxarbieloprognozuli niSania.infeqciis serologiuri diagnostika (sisxlis Sratis aReba daavadebismwvave da Semdeg rekonvalescenciis periodSi, daavadebis dawyebidanramdenime kviris Semdeg), gamokvlevebis aucilebel meTodad ganixilebahospitalizebul avadmyofebSi.hospitalizaciisTanave unda Catardes bioqimiuri kvlevebic:Sardovanas, eleqtrolitebis da RviZlis funqciebis gansazRvrasaSualebas iZleva Sefasdes daavadebis simZime da Tirklmlisa daRviZlis Tanarsebuli paTologia (rekomendacia C).Jangbadis saturacia - klinikaSi moTavsebisas pnevmoniiT daavadebulyvela avadmyofSi unda ganisazRvros Jangbadis saturacia. TumaCvenebeli 92%-ze naklebia unda Sefasdes arteriuli sisxlis gazebic(rekomendacia C).mikrobiologiuri kvlevasisxlis kultura Seswavlili unda iqnes yvela hospitalizebulpacientSi, sasurvelia antibiotikoTerapiis dawyebamde (rekomendacia D).naxvelis gamokvleva unda Catardes im pacientebSi, romelTac SeuZliaTCirqovani naxvelis amoxveleba da adre ar miuRiaT antibiotikebi, aseveim pacientebSi, romelTanac Catarebuli mkurnaloba uefeqtoa(rekomendacia D).diagnostikis invaziuri meTodebi: fibrobronqoskopia an invaziuridiagnostikis sxva meTodebi (transtraqealuri aspiracia,transTorakaluri biofsia da a.S.) tardeba stacionarSi filtvebistuberkulozze an bronqogenul karcinomaze eWvis dros.11

9. mkurnalobis sqemazogadi marTvapacientis stacionarSi referalis sakiTxi unda gadawydes zogadimdgomareobis da simZimis kriteriumebis Sefasebis mixedviT. avadmyofismZime zogadi mdgomareobis SemTxvevaSi pacienti dauyovnebliv undagadaigzavnos saavadmyofoSi.pnevmoniaze eWvis SemTxvevaSi maT unda mieceT rCeva woliTi reJimis,sigaretis mowevis Sewyvetis, siTxis sakmarisi raodenobiT miRebisSesaxeb (rekomendacia D).plevruli tkivilis sawinaaRmdegod sakmarisia martivi analgetikebismiReba, rogoricaa, magaliTad, paracetamoli (rekomendacia D).yvela pacients unda Cautardes oqsigenoTerapia Jangbadis saturaciisgansazRvriT da SaO2 >92% doneze SenarCunebiT. maRali koncentraciisJangbadi SeiZleba pacients mieces gaurTulebeli pnevmoniis drosac(rekomendacia D).aucilebelia saWiroebis SemTxvevaSi moxdes siTxis intravenuriSevseba (rekomendacia C).sxeulis temperatura, sunTqvis sixSire, pulsi, sxeulis wneva,cnobiereba, Jangbadis saturacia unda Sefasdes minimum orjer dReSian ufro xSirad, Tu pacientis mdgomareoba mZimea (rekomendacia C).CRP donis gansazRvra da gulmkerdis rentgenografia unda CatardesganmeorebiT (rekomendacia B), Tu pacientis mdgomareobis gaumjobesebadinamikaSi ar Seesabameba Catarebul mkurnalobas (rekomendacia C).empiriuli antibiotikoTerapia aramZime pnevmoniis droshospitalizebul pacientebSipacientTa umravlesobis mkurnaloba SesaZlebelia per-os misaRebiantibiotikebiT (rekomendacia C). amoqsiciliniT monoTerapiaSesaZlebelia, Tu pacienti adre ar iyo namkurnalebi antibiotikebiTan Tu pacienti hospitalSi moxvda araklinikuri mizezebis gamo (mag.moxucebi an socialurad izolirebulebi).Tu pacientis hospitalizaciis mizezi klinikuri mizezebia,mizanSewonilia amoqsicilinis da makrolidis (eriTromicini,klaritromicini, spiramicini) kombinacia (rekomendacia D).makrolidiT monoTerapia daniSnul unda iqnes, rodesachospitalizaciamde Catarebuli amoqsicilinis adeqvaturi kursiuefeqto aRmoCnda. Tumca amoqsiciliniT Terapiis adeqvaturoba ZneliSesafasebelia, amitom aseT SemTxvevebSi mizanSewonilia kombinirebuliTerapia (rekomendacia D).axali ftorqinolonebi ar gamoiyeneba, rogorc pirveli rigispreparati, isini sasargeblo alternatiul saSualebas warmoadgenengarkveuli kategoriis pacientebSi (rekomendacia C).12

empiriuli antibiotikoTerapia mZime pnevmoniis dros hospitalizebulpacientebSimZime pnevmoniis SemTxvevaSi parenteraluri antibiotikoTerapia undadaiwyos dauyovnebliv diagnozis dasmis Semdeg (rekomendacia B).Terapia unda Catardes farTo speqtris beta-laqtamuri antibiotikebiT,rogoricaa ko-amoqsiklavi an meore (cefuroqsimi) an mesame Taobis(cefotaqsimi, ceftriaqsoni) cefalosporini makrolidTan(klaritromicini an eriTromicini) erTad (rekomendacia C).im pacientebSi, romelTac aReniSnebaT beta-laqtamebis an makrolidebisautanloba mizanSewonilia respiraciuli ftorqinolonis(levofloqsacini) da intravenuri benzilpenicilinis kombinacia(rekomendacia D).antibiotikis Seyvanis wesiantibiotikis Seyvanis gza per-oraluria aramZime pnevmoniebis dros(rekomendacia B).pacientebi, romlebic Tavidan parenteralur antibiotikoTerapiasiRebdnen, SeiZleba gadayvanil iqnen dasalevi antibiotikebis reJimzemaSinve, rodesac klinikuri mdgomareoba gaumjobesdeba da temperaturanormaluri iqneba 24 saaTis ganmavlobaSi (rekomendacia B).ZiriTadi antimikrobuli preparatebis jgufebipnevmoniis mkurnalobaSi B-laqtamuri antibiotikebs mniSvnelovaniroli ekuTvnis, rac ganpirobebulia maTi mkveTri baqteriocidulimoqmedebiT gamomwvevebis, pirvel rigSi S.pneumoniae-s mimarT, dabalitoqsiurobiT, usafrTxoebiT da efeqturobiT.mniSvneloba aqvs mkurnalobas aminopenicilinebiT (amoqsicilini), aseveamoqsicilinis kombinacias laqtamazas ingibitorebTan(amoqsicilini/klavulanti). amoqsicilins axasiaTebs S.pneunomiae mimarTmaRali aqtivoba, moqmedebs H.influenzae Stamebze. ampicilinTan SedarebiTgaaCnia ufro maRali bioSeRwevadoba sakvebis miRebisagandamoukideblad, iSviaTad iwvevs kuW_nawlavis mxriv arasasurvelmovlenebs. amoqsicilini da amoqsicilin/klavulanti inarCunebsaqtivobas penicilin-rezistentuli Stamebis mimarT.amoqsicilin/klavulantis forma, amoqsicilinis momatebuli doziT daklavulantis naklebi wiliT (875/125mg) saSualebas gvaZlevsgamoviyenoT preparati 2-jer dReSi. B-laqtamebis ZiriTad uaryofiTTvisebaa atipiuri mikroorganizmebis mimarT aqtivobis ararseboba.benzilpenicilini inarCunebs maRal aqtivobas pnevmokokebTandamokidebulebaSi.makrolidebis Rirsebaa maRali aqtivoba S.pneumoniae-is, atipurimikroorganizmebis mimarT. azitromicini da spiramicini aqtiurni arianH.ineluenzae mimarT. Tanamedrove makrolidebi kargad gadian bronqulsekretSi da filtvis qsovilSi, xasiaTdebian usafrTxoebiT daaraalergiulobiT. pnevmoniis mkurnalobaSi arCevis preparatebia13

azitromicini, spiramicini, klaritromicini, roqsitromicini. maT Sorisinficirebul filtvis qsovilSi da alveolarul makrofagebSi yvelazemaRali koncentracias aRwevs spiramicini.ftorqinolonebimocemuli jgufis preparatebs Soris, sayuradReboa II-III Taobisftorqinolonebi (ciprofloqsacini, ofloqsacini, levofloqsacini, dasxv.). am jgufisagan gansakuTrebiT aRsaniSnavia III Taobis, e.w.“respiraciuli ftorqinoloni” – levofloqsacini. is moqmedebs gramdadebiTda gram-uaryofiT gamomwvevebze, penicilin-rezistentulebisCaTvliT. misi aqtivoba mikoplazmasTan, qlamidiebTan, legionelebTanda mimarTebaSi arsebiTad maRalia e.w. “klasikur”, II TaobisftorqinolonebTan SedarebiT. preparati iniSneba 1-jer dReSi,damaxasiaTebelia maRali koncentracia da bioSeRwevadoba,gaxangrZlivebuli naxevardaSlis periodi. peroraluri daparenteraluri levofloqsacini hospitalizebul pacientebSipnevmoniis safexureobrivi mkurnalobis saSualebas gvaZlevs. evropulida amerikuli respiraciuli da qimioTerapiuli sazogadoebebis mierlevofloqsacini miCneuli mozrdilTa arahospitaluri pnevmoniismkurnalobis arCevis preparatad.tetraciklinebs Soris, Tu gaviTvaliswinebT farmakokinetikurTvisebebs, gadatanas da miRebis moxerxebulobas, ufro misaRebiadoqsiciklini. is xasiaTdeba kargi aqtivobiT atipurimikroorganizmebis mimarT.mkurnalobis adgilis arCevapnevmoniis mkurnaloba SesaZlebelia saxlis pirobebSi. gansakuTrebiTmniSvneloba aqvs hospitalizaciis kriteriumis gansazRvras. cnobiliarigi klinikur-laboratoriuli Skalebi, romlebic dafuZnebuliapnevmoniis simZimis Sefasebasa da/an prognozze. yvelaze gavrcelebuliSkalaa PORT (Pneumoniae Outcomes Research Team), romelic iTvaliswinebs 20klinikur da laboratoriul parametrs, romelTa safuZvelzecdgindeba pnevmoniis simZimis indeqsi (PSI: Pneumonia Severiti Index), xdebaletalobis riskis prognozireba da mkurnalobis adgilis gansazRvra.PSI-is gansazRvrisaTvis aucilebelia mTeli rigi bioqimiuriparametrebi, Sardis analizi, natriumi, glukoza, hematokriti,arteriuli sisxlis pH, rac yovelTvis ar aris SesaZlebeliambulatorul-poliklinikur dawesebulebaSi.dReisaTvis pnevmoniis mkurnalobis adgilis gansazRvra dakavSirebuliaprognozuli Skalis CURB-65/CRB-65 gamoyenebasTan. britaneTisTorakaluri sazogadoebis Skala iTvaliswinebs 5 an 4 parametrs:1 C cnobierebis dakargva2 U sisxlis SardmJava azoti > 7mmol/l3 R sunTqvis sixSire > 30/wT4 B dabali sistoluri (

minimaluri qula aris 0, maqsimaluri - 4 an 5 qula. praqtikulobisTvalsazrisiT met yuradRebas ipyrobs CRB-65 Skala, romelicSesaZlebelia gamoyenebuli iqnas ambulatorul pirobebSi.nebismieri prognozuli Skala mkurnalobis adgilis SesarCeviorientiria, yovel konkretul SemTxvevaSi es sakiTxi unda gadawydesmkurnali eqimis da pacientis mier individualurad. pacientishospitalizaciisaTvis gaTvaliswinebuli unda iyos Semdegi Cvenebebi:‣ sunTqvis sixSire >30/wT: diastoluri wneva 50% uaxloesi 2 dRis manZilze).‣ hematokriti

cxrili 5antibiotikoTrapiis xangrZlivoba mkurnalobis adgilis, zogadimdgomareobis da gamomwvevis mixedviTadgili/simZime/gamomwvevibinaze mkurnaloba, aramZime (daudgenelietiologia)stacionaruli mkurnaloba, aramZime(daudgeneli etiologia)mkurnalobis xangrZlivoba(dReebSi)legioneluri 10atipuri (qlamidia, mikoplazma) 14-21pnevmokokuri (gaurTulebeli) 14stafilokokuri 14-21gram-uaryofiTi 14-2177pnevmoniis antibaqteriuli Terapiis adeqvaturobis kriteriumebi.• temperatura

antibaqteriuli mkurnaloba unda gagrZeldes 14 dRes, Tumca arsebobsklinikuri monacemebi Sedegis ufro mokle droSic miRwevis Sesaxeb.ufro xangrZlivi Terapia (14 dRidan 21 dRemde) naCvenebiastafilokokuri etiologiis an gramuaryofiTi enterobaqteriebiTgamowveuli pnevmoniis dros.sxva saSualebebidResdReobiT ar arsebobs monacemebi biogenuri stimulatorebis,antihistaminuri preparatebis, vitaminebis, imunomodulatorebis daarasteroiduli anTebis sawinaaRmdego saSualebebis daaranarkotikuli analgetikebis daniSvnis saWiroebis Sesaxeb.dasaxelebuli samkurnalo saSualebebis efeqturoba da usafrTxoebaar aris dazustebuli randomizirebuli klinikuri gamokvlevebiT.10. prevenciapnevmoniis profilaqtikis mizniT gamoiyeneba pnevmokokuri dagripuli vaqcina. pnevmokokuri vaqcinis gamoyenebis mizanSewonilobaaixsneba imiT, rom dResdReobiT S.pneumoniae pnevmoniis wamyvangamomwvevad rCeba.gripuli vaqcinis efeqturoba moxucebSi sakmaod maRalia. vaqcinaciamizanSewonilia Semdeg jgufebSi:• pirebi, romlebic xangrZlivad cxovroben moxucTa saxlSi;• 65 welze meti asakis pacientebSi sasunTqi, saSarde, RviZlis dagul-sisxlZarRvTa sistemis qronikuli,daavadebebiT (rekomendacia C);• mozrdilebi, romlebic saWiroeben uwyvet samedicinozedamxedvelobas da imyofebian stacionarSi mkurnalobis mizniT(Saqriani dibeti, Tirkmlis daavadebebi, hemoglobinopaTiebi,imunodeficituri mdgomareoba aiv infeqciis CaTvliT);• II-III trimestris fexmZimeebi;• eqimebi, eqTnebi;• ojaxis wevrebi (bavSvebis CaTvliT)• medicinis muSakebi, romlebic binaze uvlian avadmyofebs.11. gaidlainis miRebis wyarowinamdebare gaidlaini warmoadgens sxvadasxva gaidlainebis (ix.literatura) Sejerebis da adaptaciis Sedegs.12. alternatiuli gaidlaini ar arsebobs13. gaidlainis gadasinjvis da ganaxlebis vada _ 2 weli17

14. gamoyenebuli literatura1. Berhman et al - Nelson Textbook of Pediatrics 17 th edition – 20042. Hawker J et al - Communicable diseases control handbook – 20013. Management of the child with a serious infection or severe malnutrition – Guidelines forcare at the first-referral level in developing countries – 20004. Community-Acquired Pneumonia in Children - Kenneth McIntosh, M.D, New Englandjournal of Medicine, Volume 346:429-437 February 7, 2002 Number 65. A new system for grading recommendations in evidence based guidelines - Harbour R,Miller J.. BMJ 2001;323:334-66. Red book: report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village,Ill.: - Pickering LK, ed. 2000 American Academy of Pediatrics, 2000.7. Community-Acquired Pneumonia in Children: Quantifying the Burden on Patients andTheir Families Including Decrease in Quality of Life. Shoham, Y., Dagan, R., Givon-Lavi, N., Liss, Z., Shagan, T., Zamir, O., (2005). Pediatrics 115: 1213-12198. Epidemiology and Clinical Characteristics of Community-Acquired Pneumonia inHospitalized Children. - Michelow, I. C., Olsen, K., Lozano, J., Duffy, L. B., Ziegler, T.,Kauppila, J., Leinonen, M., McCracken, G. H. Jr (2004). Pediatrics 113: 701-7079. Pneumonia in Children - Berti, I., Faraguna, D., McIntosh, K. (2002).. N Engl J Med 346:10. Scottish Intercollegiate Guidelines Network. SIGN 50: a guideline developers' handbook.Edinburgh: SIGN, 200111. Guidelines for the Management of Community Acquired Pneumonia in Adults2001 BTS GUIDELINES. Thorax 2001; 56: (suppl IV) – 2004 update.12. Cochrane Methods Working Group on Systematic Review of Screening and DiagnosticTests. Recommended methods. Updated 6 June 199613. Community acquired pneumonia – a prospective UK study. Drummond P, Clark J,Wheeler J, Galloway A, Freeman R (2000), Arch Dis Child, 83(5), Nov, pp 408-1214. Mandell LA, Marrie TJ, Grossman RF, Chow AW, Hyland RH. Canadian guidelines forthe initial management of community-acquired pneumonia: an evidence-based update bythe Canadian Infectious Diseases society and the Canadian Thoracic Society. ClinicalInfectious Diseases 2000; 31:383-421.15. Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practice guidelinesfor the management of community-acquired pneumonia in adults (American guidelines).Clinical Infectious Diseases 2000; 31:347- 82.16. Community-acquired pneumonia guidelines: much guidance, but not much evidence M.Woodhead. Eur Respir J 2002; 20: 1–317. Consensus development methods, and their use in clinical guideline development – MKMurphy Health Technology Assessement 1998 vol.2 #318. Fortnightly Review: Management of community acquired lower respiratory tract infection- H S R Hosker, G M Jones, P Hawkey - BMJ 1999;308:701-705 (12 March)19. Community-Acquired Pneumonia in Infants and Children – M. OSTAPCHUK, M.D., D.M. ROBERTS, M.D., Am Fam Physician 2004;70:899-908.20. Community management of Lower respiratory tract infections in adults, a nationalclinical guideline – Scottish Intercollegiate Guidelines Network, June 200218

21. Appraisal of guidelines for research&evaluation – AGREE Instrument Training Material –The AGREE Collaboration, January 200322. Community-Acquired Pneumonia (CAP) Year 2002 Antibiotic Selection andManagement Update — The ASCAP Panel* Consensus Report, 200223. Evidence-based Guidelines for the Management of Children Presenting with AcuteBreathing Difficulty, Paediatric Accident & Emergency Research Group - September200424. British Guideline on the Management of Community Acquired Pneumonia in Children.British Thoracic Society Scottish Intercollegiate Guidelines Network. 200225. Treatment of pneumonia in children EBM Guidelines 03.05.200026. Indications for and interpretation of chest x-ray in a child with symptoms of an infectionEBM Guidelines 18.6.200427. McCracken GH Jr. Diagnosis and management of pneumonia in children. Pediatr InfectDis J 2000;19:924-8.28. Korppi M, Heiskanen-Kosma T, Leinonen M, Halonen P. Antigen and antibody assays inthe aetiological diagnosis of respiratory infection in children. Acta Paediatr 1993;82:137-41.29. Principi N, Esposito S. Emerging role of Mycoplasma pneumoniae and Chlamydiapneumoniae in paediatric respiratory-tract infections. Lancet Infect Dis 2001;1:334-44.30. Esposito S, Bosis S, Cavagna R, Faelli N, Begliatti E, Marchisio P, et al. Characteristicsof Streptococcus pneumoniae and atypical bacterial infections in children 2-5 years of agewith community-acquired pneumonia. Clin Infect Dis 2002;35:1345-52.31. Bradley JS, Nelson JD. 2002-2003 Nelson’s pocket book of pediatric antimicrobialtherapy. 15th ed. Philadelphia: Lippincott, Williams & Wilkins;2002:31-5.32. Nelson JD. Community-acquired pneumonia in children: guidelines for treatment. PediatrInfect Dis J 2000;19:251-3.33. Gibson NA, Hollman AS, Paton JY. Value of radiological follow up of childhoodpneumonia. BMJ 1993;307:1117.34. McCracken GH Jr. Etiology and treatment of pneumonia. Pediatr Infect Dis J2000;19:373-7.35. Mandell GL, Douglas RG, Bennett JE, Dolin R. Mandell, Douglas, and Bennett’sprinciples of practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingstone,2000:2416-7.36. Community-Acquired Pneumonia (CAP) Year 2002 Antibiotic Selection andManagement Update Evaluation, Risk Stratification, and Current Antimicrobial TreatmentGuidelines for Hospital-Based Management of CAP: Outcome-Effective Strategies Basedon New NCCLS Breakpoints and Recent Clinical Studies — The ASCAP Panel*Consensus Report, 200237. Schonwald S, Barsic B, Klinar I, Gunjaca M. Three-day azithromycin compared with tendayroxithromycin treatment of atypical pneumonia. Scand J Infect Dis 1994;26:706-71038. Schonwald S, Barsic B, Klinar I, Gunjaca M. Three-day azithromycin compared with tendayroxithromycin treatment of atypical pneumonia. Scand J Infect Dis 1994;26:706-71039. Lode H, Schaberg T. Azithromycin in lower respiratory tract infections. Scand J InfectDis 1992 (suppl);83:26-3319

⇒ a. nanuaSvili _ antimikrobuli qimioTerapiis samsaxurisxelmZRvaneli, antibiotikebis racionaluri gamoyenebismsoflio aliansis xelmZRvaneli, mmk, asocirebuliprofesori;⇒ v. qacarava _ z/cxakaias sax. Sps “Torako-abdominuri klinikis”xelmZRvaneli, mmk.⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa dasocialuri dacvis saministros janmrTelobis dacvisdepartamenti;⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa dasocialuri dacvis saministros janmrTelobis dacvisdepartamenti.21