clinvestКачественная клиническая практикаKachestvennaya Klinicheskaya Praktika = Good Clinical Practice2588-05192618-8473ООО «Издательство ОКИ10.24411/25880519-2019-10067clinvest-441Research ArticleОБЗОР ЛИТЕРАТУРЫLITERATURE REVIEWСовременные подходы к выбору антибиотика для терапии внебольничной пневмонии у различных категорий пациентовModern approaches to the rational choice of antibiotic for treatment of community-acquired pneumonia in various categories of patientshttps://orcid.org/0000-0002-6348-6867ЗыряновС. К.ZyryanovS. K.

SPIN-код: 2725-9981

д. м. н., профессор, зав. кафедрой общей и клинической фармакологии Медицинского института

Москва

SPIN code: 2725-9981

MD, professor, Head of Department of General and Clinical Pharmacology

Moscow

https://orcid.org/0000-0001-7729-2169БутрановаО. И.ButranovaO. I.

SPIN-код: 6284-0777

к. м. н., доцент кафедры общей и клинической фармакологии Медицинского института

Москва

SPIN code: 6284-0777

PhD, associate professor, Department of General and ClinicalPharmacology

Moscow

butranovaolga@mail.ruФГАОУ ВО «Российский университет дружбы народов» (Медицинский институт) ГБУ города Москвы «Городская клиническая больница № 24 Департамента здравоохранения города Москвы»РоссияDepartment of General and Clinical Pharmacology, RUDN UniversityRussian FederationФГАОУ ВО «Российский университет дружбы народов» (Медицинский институт)РоссияDepartment of General and Clinical Pharmacology, RUDN UniversityRussian Federation2019230720190197113Copyright © Зырянов С.К., Бутранова О.И., 20192019Зырянов С.К., Бутранова О.И.Zyryanov S.K., Butranova O.I.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.clinvest.ru/jour/article/view/441

Внебольничная пневмония (ВП) является лидирующим заболеванием в группе инфекций дыхательных путей. Тяжесть ВП варьирует от нетяжёлых форм, подлежащих амбулаторному лечению, до тяжёлых, требующих госпитализации. Значимое количество отрицательных исходов, включая летальный, делает актуальным регулярный анализ терапевтических тактик ведения пациентов с данной патологией, c фокусом на рациональной антибиотикотерапии. Цель обзорной статьи состоит в оценке рационального подхода к выбору эмпирического препарата для антибиотикотерапии ВП в различных популяциях пациентов. Представленный обзор включает анализ современных клинических рекомендаций по антибиотикотерапии ВП у пациентов детского возраста и взрослых с учётом текущих данных о резистентности основных возбудителей ВП и результатов клинических исследований, посвящённых эффективности применения указанных в клинических рекомендациях антимикробных препаратов. Анализ распространённости возбудителей ВП позволяет сделать вывод о сохранении лидирующих позиций Streptococcus pneumoniae и атипичной микрофлоры с тенденцией к возрастанию роли потенциально резистентных микроорганизмов — Staphylococcus aureus и грамотрицательных микроорганизмов (Pseudomonas aeruginosa, Haemophilus infl uenzae, представители семейства Enterobacteriaceae). Схемы эмпирической антибиотикотерапии ВП у взрослых и детей, согласно клиническим руководствам стран Европы, США и России, включают β-лактамы, макролиды, респираторные фторхинолоны и доксициклин. В РФ сохранён достаточно высокий уровень чувствительности основных возбудителей ВП по отношению к β-лактамам (прежде всего ингибитор-защищённым аминопенициллинам, цефалоспоринам III поколения), респираторным фторхинолонам и макролидам. Анализ клинических исследований эффективности эмпирической антибиотикотерапии свидетельствует о сохранении преимуществ аминопенициллинов в терапии амбулаторных пациентов за исключением случаев, вызванной атипичной микрофлорой, где препаратом выбора являются макролиды. Комбинация β-лактамный антибиотик плюс макролид показана пациентам с увеличением степени тяжести ВП на фоне риска атипичной микрофлоры. Ингибитор-защищённые β-лактамы, цефалоспорины II и III поколений и респираторные фторхинолоны необходимы для терапии тяжёлой ВП.

Community-acquired pneumonia (CAP) is the leader among respiratory tract infections. The severity of CAP varies from mild forms (outpatient treatment) to severe, requiring hospitalization. A signifi cant number of negative clinical outcomes, including lethal, actualize regular analysis of patient’s management strategies with a focus on a rational antibiotic therapy. The purpose of the review is to evaluate a rational approach to the choice of an empirical drug for antibiotic therapy of CAP in diff erent patient populations. This review includes an analysis of modern clinical guidelines for CAP antibiotic therapy in pediatric patients and adults, considering current data on the resistance of the main pathogens and the results of clinical effi cacy trials involving antimicrobials listed in the given guidelines. Analysis of the prevalence of causative agents of CAP reveals leading positions of Streptococcus pneumoniae and atypical microfl ora with a tendency to increase of the role of potentially resistant microorganisms — Staphylococcus aureus and Gram-negatives (Pseudomonas aeruginosa, Haemophilus infl uenzae, family of Enterobacteriaceae). The schemes of CAP empiric antibiotic therapy in adults and children according to the clinical guidelines in Europe, USA, and Russia include β-lactams, macrolides, respiratory fl uoroquinolones and doxycycline. In Russian Federation, a suffi ciently high level of sensitivity of major CAP pathogens is detected for β-lactams (inhibitorprotected aminopenicillins, third-generation cephalosporins), respiratory fl uoroquinolones and macrolides (azithromycin, clarithromycin). Analysis of clinical effi cacy trials of empiric antibiotic therapy revealed benefi ts of aminopenicillins in treatment of outpatients, except in cases caused by atypical microfl ora macrolides are the drug of choice. The combination of β-lactam antibiotic plus macrolide is indicated for patients with increased CAP severity rates and risks of atypical microfl ora. Inhibitor-protected β-lactams, cephalosporins II and III generations, and respiratory fl uoroquinolones are essential to treat severe CAP.

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Comparison of hospitalization rates in patients with community-acquired pneumonia treated with telithromycin for 5 or 7 days or clarithromycin for 10 days. Current Medical Research and Opinion. 2004;20(5):739—747. DOI:10.1185/030079904125003610.Tellier G, Chang JR, Asche CV, Lavin B, Stewart J, Sullivan SD. Comparison of hospitalization rates in patients with community-acquired pneumonia treated with telithromycin for 5 or 7 days or clarithromycin for 10 days. Current Medical Research and Opinion. 2004;20(5):739—747. DOI:10.1185/030079904125003610.Tellier G, Chang JR, Asche CV, Lavin B, Stewart J, Sullivan SD. Comparison of hospitalization rates in patients with community-acquired pneumonia treated with telithromycin for 5 or 7 days or clarithromycin for 10 days. Current Medical Research and Opinion. 2004;20(5):739—747. DOI:10.1185/030079904125003610.Léophonte P, Choutet P, Gaillat J, et al. Effi cacy of a ten day course of ceft riaxone compared to a shortened fi ve day course in the treatment of community-acquired pneumonia in hospitalized adults with risk factors. Medecine et Maladies Infectieuses. 2002;32(7):369—381.Léophonte P, Choutet P, Gaillat J, et al. Effi cacy of a ten day course of ceft riaxone compared to a shortened fi ve day course in the treatment of community-acquired pneumonia in hospitalized adults with risk factors. Medecine et Maladies Infectieuses. 2002;32(7):369—381.Léophonte P, Choutet P, Gaillat J, et al. Effi cacy of a ten day course of ceft riaxone compared to a shortened fi ve day course in the treatment of community-acquired pneumonia in hospitalized adults with risk factors. Medecine et Maladies Infectieuses. 2002;32(7):369—381.Léophonte P, Choutet P, Gaillat J, et al. Effi cacy of a ten day course of ceft riaxone compared to a shortened fi ve day course in the treatment of community-acquired pneumonia in hospitalized adults with risk factors. Medecine et Maladies Infectieuses. 2002;32(7):369—381.Uranga A, España PP, Bilbao A, et al. Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multicenter Randomized Clinical Trial. JAMA Intern Med. 2016;176(9):1257—65. DOI: 10.1001/jamainternmed.2016.3633.Uranga A, España PP, Bilbao A, et al. Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multicenter Randomized Clinical Trial. JAMA Intern Med. 2016;176(9):1257—65. DOI: 10.1001/jamainternmed.2016.3633.Uranga A, España PP, Bilbao A, et al. Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multicenter Randomized Clinical Trial. JAMA Intern Med. 2016;176(9):1257—65. DOI: 10.1001/jamainternmed.2016.3633.Uranga A, España PP, Bilbao A, et al. Duration of Antibiotic Treatment in Community-Acquired Pneumonia: A Multicenter Randomized Clinical Trial. JAMA Intern Med. 2016;176(9):1257—65. DOI: 10.1001/jamainternmed.2016.3633.Nascimento-Carvalho AC, Nascimento-Carvalho CM. Clinical management of community-acquired pneumonia in young children. Expert OpinPharmacother. 2019;20(4):435—442. DOI: 10.1080/14656566.2018.Nascimento-Carvalho AC, Nascimento-Carvalho CM. Clinical management of community-acquired pneumonia in young children. Expert OpinPharmacother. 2019;20(4):435—442. DOI: 10.1080/14656566.2018.Nascimento-Carvalho AC, Nascimento-Carvalho CM. Clinical management of community-acquired pneumonia in young children. Expert OpinPharmacother. 2019;20(4):435—442. DOI: 10.1080/14656566.2018.Nascimento-Carvalho AC, Nascimento-Carvalho CM. Clinical management of community-acquired pneumonia in young children. Expert OpinPharmacother. 2019;20(4):435—442. DOI: 10.1080/14656566.2018.Nascimento-Carvalho CM, Andrade DC, Vilas-Boas AL. An update on antimicrobial options for childhood community-acquired pneumonia: a critical appraisal of available evidence. ExpertOpinPharmacother. 2016;17(1):53—78. DOI: 10.1517/14656566.2016.1109633.Nascimento-Carvalho CM, Andrade DC, Vilas-Boas AL. An update on antimicrobial options for childhood community-acquired pneumonia: a critical appraisal of available evidence. ExpertOpinPharmacother. 2016;17(1):53—78. DOI: 10.1517/14656566.2016.1109633.Nascimento-Carvalho CM, Andrade DC, Vilas-Boas AL. An update on antimicrobial options for childhood community-acquired pneumonia: a critical appraisal of available evidence. ExpertOpinPharmacother. 2016;17(1):53—78. DOI: 10.1517/14656566.2016.1109633.Nascimento-Carvalho CM, Andrade DC, Vilas-Boas AL. An update on antimicrobial options for childhood community-acquired pneumonia: a critical appraisal of available evidence. ExpertOpinPharmacother. 2016;17(1):53—78. DOI: 10.1517/14656566.2016.1109633.Quaak CH, Cové E, Driessen GJ, Tramper-Stranders GA. Trends in paediatric inpatient antibiotic therapy in a secondary care setting. Eur J Pediatr. 2018;177(8):1271—1278. DOI: 10.1007/s00431-018-3185-z.Quaak CH, Cové E, Driessen GJ, Tramper-Stranders GA. Trends in paediatric inpatient antibiotic therapy in a secondary care setting. Eur J Pediatr. 2018;177(8):1271—1278. DOI: 10.1007/s00431-018-3185-z.Quaak CH, Cové E, Driessen GJ, Tramper-Stranders GA. Trends in paediatric inpatient antibiotic therapy in a secondary care setting. Eur J Pediatr. 2018;177(8):1271—1278. DOI: 10.1007/s00431-018-3185-z.Quaak CH, Cové E, Driessen GJ, Tramper-Stranders GA. Trends in paediatric inpatient antibiotic therapy in a secondary care setting. Eur J Pediatr. 2018;177(8):1271—1278. DOI: 10.1007/s00431-018-3185-z.

The authors declare that there are no conflicts of interest present.