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KAKHA VACHARADZE, Doctor of Medicine, M.D.
TSMU phthisiatric department, Professor.
Georgian Respiratory Association, Vice-President.
European Respiratory Association, Real member.
Georgian Phthisiatric Association, Board Member.
Member of Georgian Surgery Association.
Founder of Georgian Bronchopulmonologists Association.
Pneumonia is an inflammation of the terminal airways and alveoli, which is caused by the hematogenous or inhalational spread of the infection agent. It is characterized by acute respiratory symptoms or fever, or both of them and lung parenchymal infiltration signs on the chest roentgenogram. Pneumonia may be:
- nonhospital (acquired in the population) pneumonia
- hospital aquired (nosocomial) pneumonia
- pneumonia developed in immunodeficient state.
From the practical view, it is important to divide pneumonias into nosocomial and population acquired types. The main and defining criterion is the area where the pneumonia has developed.
In the population acquired pneumonia we should imply the acute disease, which is not originated in hospital or which is diagnosed within the 24 hours of hospitalization and which is accompanied by lower airways infection symptoms: cough, dyspnoea, fever, sputum production, chest pain and x-ray findings (new lesions of local infiltration).
Incidence of pneumonia greatly varies in adults (>18years). The mean prevalence of pneumonia is 5-11 cases per each adult inhabitant.
Hospitalization is needed in 22-42% of patients with pneumonia and 5-10% of them need treatment in the intensive care unit.
There are not even two resources where etiology of pneumonia will be the same. The difference is caused by several factors: age, concomitant diseases, immune state of the organism, investigation factors, etc.

causative factor
according to data
S. Pneumonie
H. influenzae
S. aureus
atypical cause
aspirational pneumonia
unknown etiology
Pneumonia may be caused by four pathologic mechanisms: 1. aspiration,                            2. microorganism inhalation 3. hematogenous spread of the organism from nonpulmonary infection site. 4. infection spread from the adjacent lesions or by penetration through the open chest wound.
Based on the physical examination and patient history symptoms of pneumonia occur in the following frequency:
- cough, fever, tachycardia, rales – 22-48%
- only cough –2-15%
- shortening of percutorial sound –12-20%
- only rales – 15-17%
- only fever – 5-20%
- only tachycardia – 8-13 %
Complications are: pleural effusion, pleural empiema, destruction/abscess formation of the lung tissue, acute respiratory distress syndrome, acute respiratory failure, septic shock, secondary bacteraemia, pericarditis etc.
Lung abscess is characterized by forming the outlined cavities (from the destruction of the lung tissue and suppuration). It is caused by anaerobic organisms: Bacteroides spp. (including Bacteroides fragilis), Peptococcus spp., Peptostreptococcus spp. etc. Rarely may be caused by coinfection of Enterococci and S. aureus. The drug of choice is Bactamed (ampicillin/sulbactam). Alternative preparations are: third-generation cephalosporines, ciprofloxacine and levofloxacine, metronidazole or carbapenems. The treatment duration is 3-4 weeks.
Pleural empyema: is characterized by suppuration of pleural cavity. The main causative organisms are anaerobic bacteria combined with Gram-negative aerobic organisms. It is necessary to conduct treatment with antibiotics effective against presumable causative (S. pneumoniae, S. pyogenes, S. aureus, H. influenzae), for example, combination of beta-lactamase resistant aminopenicillines (Bactamed) and aminoglicosides.
Etiologic factors of subacute / chronic empiema are anaerobic streptococci and Gram negative enterobacteria. For the treatment of such infection Bactamed is used, alternative antibiotic may be III-IV generation cephalosporines, carbapenems. Along with the antibacterial treatment, the thoracic drainage must be conducted, rarely thoracotomy may be needed. Because of its high activity against the anaerobic microorganisms, Bactamed is the perspective antibiotic in the treatment of lung abscess.
Antimicrobial chemotherapy is the main part in the treatment of pneumonia. The etiologic factor rarely is diagnosed in the first stage of the disease, and antibacterial therapy is conducted empirically. It is possible to diagnose etiologic factor in hospitalized patient and to modify empirical treatment method. The antibiotic resistance must be taken in view, especially in the case of pneumococcus, which is the main bacterial cause of the pneumonia.
Empirical therapy of the mild form of pneumonia:
Empirical treatment is mainly against pneumococcus. Other bacterial microorganisms, but the micoplasma, rarely cause pneumonia. Also epidemic micoplasmal pneumonia occurs in every 4-5 years and is more common in young age groups. Based on this fact empirical strategy that is directed to the micoplasma is not rational. Besides this, it should be taken in view that pneumococcus often produces beta-lactamase which is reason for its resistance to sensitive antibiotics. That’s because beta-lactamase resistant aminopenicillines are considered the drug of choice. It is used as per oral so as parenteral forms, for example ampicillin in combination with beta-lactamase inhibitor – sulbactam (ampicillin/sulbactam). On the basis of mentioned, and also based on experience, price, high quality and good tolerance, Bactamed is considered to be the best preparation.
The main causative of mild pneumonia in hospitalised patients is pneumococcus, but in 20% of cases the disease is caused by atypical pathogens. Because of this the treatment must be combined: Bactamed plus macrolide. Alternatively may be used respiratory fluoroquinolons (Levofloxacine).
Empirical treatment in sever pneumonia:
In the severe form of pneumonia it is wise to begin treatment with parenteral antibiotics for 3-4 times a day until the temperature is normalized, intoxication and other symptoms of the disease are decreased. To the end of the treatment course it is possible to change parenteral treatment method by per oral. It is recommended to begin parenteral treatment with beta-lactamase resistant aminopenicillines (Bactamed), II- III generation cephalosporines or respiratory fluoroquinolons.
In the severe form of pneumonia antibiotics should be given immediately, because delay in treatment worsens process. The drugs of choice are I.V. II-III generation cephalosporines, beta-lactamase resistant aminopenicillines parenterally (Bactamed) with the combination of macrolides (azithromycine, spiramicine, clarithromicine) and respiratory fluoroquinolons. Bactamed and its combination with macrolides completely cover the whole spectrum of the potential causative organisms (such typical as atypical).
Step-therapy of the pneumonia:
This method means treatment with antibiotics by two steps: beginning of the treatment with parenteral preparations and change them with per oral preparations as soon as the clinical state is stabilized. The main idea of this treatment is to decrease the parenteral antibiotic usage time, for example the whole course of treatment with Bactamed is 5-14 days. Based on the step-therapy method  Bactamed may be given 1, 5 g to the adult patient twice daily for 5-7 days and after the patient is stabilized and clinical picture is improved per oral antibiotic are given. Bactamed, which have not per oral form, may be changed with the similar antimicrobial preparations.
And at last, we should mention regimens of Bactamed usage: for the intramuscular preparation 1,5 g or 0,75 g Bactamed is dissolved in accordingly 3,5 or 1,8 ml 0,5% lidocaine solution. For intramuscular usage it is normal to use injection fluid (0.75 g-2 ml;1,5 g-4 ml) or 0,5% novocaine solution, or isotonic solution of NaCl. For the intravenous use 1,5 g Bactamed is dissolved in sodium chloride isotonic solution of 10-20 ml, and 0,75g-5-10 ml. For adults 1,5 g of Bactamed is prescribed twice a day. The daily dose may be increase on the basis of patient state. Maximal daily dose is 12 g in adults. The duration of treatment is 5- 14 days.