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Âíåáîëüíè÷íàÿ ïíåâìîíèÿ
Íó ÷òî, ðàçâëåêàòåëüíàÿ òåìà. Êàê ìû ëå÷èì íåòÿæåëóþ íåãîñïèòàëèçèðîâàííóþ âíåáîëüíè÷íóþ ïíåâìîíèþ ó ìîëîäûõ ïàöèåíòîâ áåç îñîáåííûõ ôàêòîðîâ ðèñêà?
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#2
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À ïî÷åìó îäèí âàðèàíò? ß ðàññìàòðèâàþ èç àìîêñèöèëëèí/êëàâóëàíàò, ðåñïèðàòîðíûé ôòîðõèíîëîí, ìàêðîëèä.
Ìàêðîëèä ðåæå èç-çà âûñîêîé ÷àñòîòû ïîääåëîê àçèòðîìèöèíà. |
#3
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#4
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#5
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Ìàêðîëèä (ñóìàìåä ÷àùå) èëè ôòîðõèíîëîí.
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#6
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Ôàíàòàì ôòîðõèíîëîíîâ ("Use of fluoroquinolones in the treatment of respiratory tract infections"):
UpToDate performs a continuous review of over 375 journals and other resources. Updates are added as important new information is published. The literature review for version 15.3 is current through August 2007; this topic was last changed on August 21, 2007. The next version of UpToDate (16.1) will be released in March 2008. COMMUNITY-ACQUIRED PNEUMONIA*—*In patients with CAP, ciprofloxacin, and ofloxacin have consistently eradicated H. influenzae and Moraxella catarrhalis [3]. The clinical response in CAP caused by S. pneumoniae has been more varied with these older quinolones. Cures of pneumococcal pneumonias, including a few cases with bacteremia, have been reported with intravenous and then oral ciprofloxacin [19] and ofloxacin [20,21] and with oral ofloxacin alone [22] Some failures with both drugs have occurred Pneumococcal bacteremia has developed during ciprofloxacin therapy of pneumonia [23]. For levofloxacin (500 mg once daily), outcomes were significantly better (96 versus 90 percent) relative to ceftriaxone and/or cefuroxime axetil with or without erythromycin [24]. Levofloxacin cured 30 of 30 patients (100 percent) with S. pneumoniae isolated versus 217 of 226 patients (96 percent) in the overall study population. In this same study, all of the nine patients with pneumococcal bacteremia were cured. A higher dose of levofloxacin (750 mg once daily) given for five days was comparable to the usual dose (500 mg once daily) given for 10 days [25], but there was no comparison with the usual dose given for five days. Patients given the higher dose were more likely to defervesce by day three than those given the lower dose. Newer fluoroquinolones*—*For gatifloxacin (400 mg PO once daily), clinical and microbiological outcomes were similar overall to those with treatment with clarithromycin (500 mg twice daily), both given for 7 to 14 days [26]. Four patients in the gatifloxacin group and five in the clarithromycin group had pneumococcal bacteremia. Four of the 10 clinical failures in the clarithromycin arm were associated with resistant strains of S. pneumoniae and H. influenzae, whereas only 2 of 10 clinical failures in the gatifloxacin arm had identifiable pathogens, and resistance was not noted. Gatifloxacin (400 mg IV once daily followed by PO) and levofloxacin (500 mg IV once daily then PO) were also comparable in overall clinical and microbiological outcomes [27]. All eight patients with pneumococcal bacteremia were in the gatifloxacin arm and responded to treatment. For gatifloxacin, clinical cure rates were also high and similar (97 versus 91 percent) compared to ceftriaxone alone or with IV erythromycin (39 percent) followed by step down to clarithromycin, when given for 7 to 14 days [28]. The subgroups of patients with severe pneumonia (defined as the presence of one or more of the following: multilobar involvement, hypotension requiring pressors, hypoxia, respiratory rate of >30 breaths per min, presence in an ICU, mechanical ventilation, and/or renal failure requiring dialysis) in both studies also had similarly good outcomes. In the latter study, although patients with pneumococcal bacteremia were not specified, 40 percent of patients were in classes four or five using criteria of Fine [29]. For moxifloxacin (400 mg PO once daily), clinical outcomes and microbiologic eradication rates were comparable to those with clarithromycin (500 mg twice daily) both given for 10 days in a group of patients in whom Chlamydophila (formerly Chlamydia) pneumoniae (46 percent) and Mycoplasma pneumoniae (21 percent) were the predominant pathogens identified by serologic criteria. Only 15 to 18 percent of infections in this study were associated with S. pneumoniae and 13 to 16 percent with H. influenzae [30]. Eradication rates were as high in the subgroups with S. pneumoniae and H. influenzae as they were in the groups with C. pneumoniae and M. pneumoniae infections, but spontaneous improvement in infections with the latter two organisms makes interpretations of apparent drug-related responses more difficult. Moxifloxacin (400 mg PO once daily) has also been compared to high-dose amoxicillin (1 g PO thrice daily) for treatment of patients suspected of having pneumococcal pneumonia [31]. Forty-nine patients in each arm had documented pneumococcal infection with equivalent clinical responses of 88 percent in both groups, including those with strains with reduced susceptibility to penicillin (cures: penicillin intermediate strains 11 of 11 with moxifloxacin, 9 of 11 with amoxicillin; penicillin resistant strains six of seven with moxifloxacin, four of four with amoxicillin). Bacteriologic eradication rates were 43 of 48 (90 percent) for moxifloxacin and 39 of 46 (82 percent) for amoxicillin. In a randomized, unblinded trial, moxifloxacin (400 mg IV or PO once daily) had significantly superior clinical (93 versus 85 percent) and microbiologic (94 versus 82 percent) responses compared to amoxicillin-clavulanate (1.2 g IV thrice daily) with or without clarithromycin [32]. Resolution of fever occurred one day sooner in the moxifloxacin arm. In patients with documented pneumococcal infection, all 29 patients in the moxifloxacin arm were cured, including 11 patients with pneumococcal bacteremia. For gemifloxacin (320 mg PO once daily for seven to 14 days), clinical and microbiologic outcomes were similar to those with trovafloxacin (its use was later limited because of toxicity), although gemifloxacin appeared somewhat more effective in eradicating pneumococci, including cures of four patients with bacteremia [33]. Gemifloxacin for seven days was comparable to amoxicillin-clavulanate (500 to 125 mg PO thrice daily) for 10 days [34]. Courses of gemifloxacin of less than seven days appear to reduce the risk of the development of rash, which was seen particularly in young women. Because of the increasing resistance of S. pneumoniae to penicillins, cephalosporins, and macrolides, fluoroquinolones with enhanced activity against S. pneumoniae have been included as an initial choice in guidelines for treatment of community-acquired pneumonia [35]. (See "Treatment of community-acquired pneumonia in adults"). However, acquisition of fluoroquinolone resistance in S. pneumoniae will need to be monitored with increasing use of these agents for the treatment of respiratory tract infections. Reports from Ontario, Canada have demonstrated increasing resistance to fluoroquinolones among pneumococcal isolates [36], and four cases of treatment failure with levofloxacin have been published [37]. In three of these cases, resistance developed on therapy and cross-resistance to gatifloxacin and moxifloxacin was detected. (See "Resistance of Streptococcus pneumoniae to the fluoroquinolones, doxycycline and trimethoprim-sulfamethoxazole"). À òàê ëè÷íî ìíå áëèçêà âîò ýòà òî÷êà çðåíèÿ: No comorbidities or recent antibiotic use*—*For uncomplicated pneumonia in patients who do not require hospitalization, have no significant comorbidities and/or use of antibiotics within the last three months, and where there is not a high prevalence of macrolide resistant strains, we recommend any one of the following oral regimens: Azithromycin (500 mg on day one followed by four days of 250 mg a day); 500 mg a day for three days, or 2 g single dose (microsphere formulation) are acceptable alternative regimens Clarithromycin XL (two 500 mg tablets daily) for five days or until afebrile for 48 to 72 hours Doxycycline (100 mg twice a day) for seven to 10 days (ýòî âîò íå áëèçêî ) The use of fluoroquinolones in ambulatory CAP without comorbid conditions or recent antimicrobial use is discouraged (unless there is a high prevalence of high-level macrolide resistant S. pneumoniae in the local community). |
#7
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Âñå ïðàâèëüíî, ôòîðõèíîëîíû, â òîì ÷èñëå è "ðåñïèðàòîðíûå" â îñíîâíûõ ðåêîìåíäàöèÿõ (ÑØÀ, íàøè) ñòîÿò íà âòîðîì ìåñòå, êàê àëüòàðíàòèâà àìèíîïåíèöèëëèíàì è ìàêðîëèäàì (ïðåæäå âñåãî àçèòðîìèöèíó). Íî íàäî ó÷èòûâàòü òîò ôàêò, ÷òî ó íàñ â ñòðàíå ïðàêòè÷åñêè íåò ðåçèñòåíòíîñòè ïíåâìîêîêêà ê àçèòðîìèöèíó. Ïîýòîìó ó ìîëîäûõ ëþäåé ñ êëèíè÷åñêèì ïðèçíàêàìè, ïîäîçðèòåëüíûìè íà ìèêîïëàçìåííóþ ïíåâìîíèþ, âïîëíå ïîçâîëèòåëüíî ïðîâåñòè êîðîòêèé êóðñ ëå÷åíèÿ ìàêðîëèäàìè.
Ñ óâàæåíèåì Àíòèïèí Àëåêñàíäð Íèêîëàåâè÷. |
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#8
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Öèòàòà:
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#9
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Ïîêà ïðîêîëîâ íå áûëî, äà è ÷åñòíî ãîâîðÿ (íåîôèöèàëüíî) ÷àñòü òàêèõ ïàöèåíòîâ âûçäîðàâëèâàþò è áåç íàøåãî âìåøàòåëüñòâà.
ÀÀÍ |
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#11
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Ãîëîñîâàë çà àìîêñèêëàâ
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#13
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Íó äà, ôòîðõèíîëîíû "äîðåñïèðàòîðíûõ" ïîêîëåíèé â äàííîé îáëàñòè íåíàäåæíû, ýòî èçâåñòíî. Íî íå âñåì.  íàøåé ÷óäî-ïîëèêëèíèêå ïíåâìîíèè, à òàêæå îòèòû è ÷óòü ëè íå îñòåîìèåëèòû ïðîäîëæàþò íåðåäêî ëå÷èòü, âû áóäåòå ñìåÿòüñÿ (èëè ïëàêàòü), íîðôëîêñàöèíîì.  îòâåò íà ìîè âîçðàæåíèÿ ÿ âûñëóøèâàë 2 àðãóìåíòà: 1)óêàçûâàëîñü íà ìíîãî÷èñëåííûå ïðåöåäåíòû èçëå÷åíèÿ óêàçàííûì ïðåïàðàòîì (âèäèìî, ÷àñòü ñëó÷àåâ îáúÿñíÿëàñü ñïîíòàííûì âûçäîðîâëåíèåì, ÷àñòü - ãèïåðäèàãíîñòèêîé ïíåâìîíèè îòèòà è ò.ï., à ÷àñòü, âîçìîæíî, è äåéñòâèåì íîðôëîêñàöèíà, ó êîòîðîãî âñå æå íå 100% êèøå÷íî-ìî÷åâûâîäÿùàÿ êèíåòèêà); 2)ïðåäúÿâëÿëàñü èíñòðóêöèÿ ê óêðàèíñêîìó íîðôëîêñàöèíó, ãäå, äåéñòâèòåëüíî, ðåêîìåíäóåòñÿ ïðèìåíÿòü ïðåïàðàò ïðè èíôåêöèÿõ ëþáûõ ëîêàëèçàöèé, âêëþ÷àÿ óõî-ãîðëî-íîñ è ìåíèíãèò. Ïå÷àëüíî, ÷òî èíñòðóêöèÿ îò ïðîèçâîäèòåëÿ ïðåïàðàòà ñëóæèò îñíîâíûì èñòî÷íèêîì èíôîðìàöèè äëÿ âðà÷à. Íî ïå÷àëüíà è ïîäïèñü ïðåäñåäàòåëÿ ôàðìêîìèòåòà ïîä óçàêîíåííîé èíñòðóêöèåé, íå ñîîòâåòñòâóþùåé, ìÿãêî ãîâîðÿ, ñîâðåìåííûì ïðåäñòàâëåíèÿì.
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Ïî 0,5 - 3 ðàçà.
Êñòàòè, íàñ÷åò ìàêðîëèäîâ. Åñëè íåò äîâåðèÿ ê îðèãèíàëüíîñòè ñóìàìåäà, òî ñêëàäûâàåòñÿ âïå÷àòëåíèå, ÷òî çèòðîëèä âñå-òàêè ðàáîòàåò - ÈÌÕÎ, ðàçóìååòñÿ Íàñ÷åò ðåñïèðàòîðíûõ õèíîëîíîâ - ïî âñåì ãàéäàì âðîäå áû ýòî âòîðàÿ ëèíèÿ. È ëè÷íî ÿ, ÷åñòíî ãîâîðÿ, íå âèæó îñíîâàíèé ýòî äèñêóòèðîâàòü. À âîîáùå òî, êàê Âû ïîíèìàåòå, ÿ íå òàê ÷àñòî ëå÷ó àìáóëàòîðíûå ïíåâìîíèè. Ýòî îáû÷íî ðîäñòâåííèêè/çíàêîìûå. Ãîðàçäî ÷àùå ïðèõîäèòñÿ èìåòü äåëî ñ ïíåâìîíèåé ãîñïèòàëüíîé èëè âíåáîëüíè÷íîé-ãîñïèòàëèçèðîâàííîé. |
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Àìîêñèöèëëèí\êëàâóëàíàò (ðåæå - àìîêñèöèëëèí), ëþáëþ ãðàìîâûé (875\125) â 2 ïðèåìà. Èëè - ìàêðîëèä (àçèòðîìèöèí èëè êëàðèòðîìèöèí) - ïî ñèòóàöèè.
Åñëè ïîäëåæèò ãîñïèòàëèçàöèè, íî ïî êàêèì-òî ïðè÷èíàì íå ãîñïèòàëèçèðóåòÿ - öåôòðèàêñîí. Êñòàòè, íàøà "ñêîðàÿ" ïðè óñòàíîâëåíèè äèàãíîçà "ïíåâìîíèÿ" (èëè ïðè ïîäîçðåíèè íà ïíåâìîíèþ) ââîäèò ãðàìì öåôòðèàêñîíà, (íó,åñëè òÿæåëûé + âñÿêî-äðóãîå) è ïîñëå ýòîãî -â ñòàöèîíàð. Ýòî ïîêà òîëüêî â Ìèíñêå. Ãîâîðÿò, çà íåñêîëüêî ìåñÿöåâ òàêîãî ýêñïåðèìåíòà íå áûëî íè îäíîãî ëåòàëüíîãî ñëó÷àÿ.
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Çäîðîâüÿ Âàì è Âàøèì áëèçêèì. |