Pneumococcal pneumonia is an etiological type of bacterial pneumonia caused by Streptococcus pneumoniae (Pneumococcus). The clinic of pneumococcal pneumonia is dominated by feverish intoxication (pronounced weakness, anorexia, febrile fever, chills) and bronchopulmonary (cough with sputum, shortness of breath, pain in the side) syndromes. Diagnosis is facilitated by a comprehensive assessment of physical, radiological, and laboratory data. First-line antibiotics for the treatment are penicillins, cephalosporins, macrolides; additionally, detoxification, oxygen therapy, immunocorrection, and physiotherapy are performed.
J13 Pneumonia caused by Streptococcus pneumoniae
Pneumococcal pneumonia is a form of pneumococcal infection occurring in the form of focal bronchopneumonia or croup pleuropneumonia. Pneumonia of pneumococcal etiology is the leader in the structure of bacterial pneumonia. It is believed that S. Pneumoniae causes about 30% of out-of-hospital and 5% of in-hospital pneumonia. The greatest incidence is observed among children under 5 years of age and adults over 60 years of age. In about a quarter of cases, pneumococcal pneumonia occurs with severe pulmonary (pleurisy, lung abscess, pleural empyema) and extrapulmonary (pericarditis, arthritis, sepsis) complications.
Before the beginning of the penicillin era, the mortality rate from pneumococcal pneumonia exceeded 80%, currently, thanks to vaccination and antibiotic therapy, this indicator has significantly decreased. Nevertheless, the levels of morbidity, complicated course and mortality remain high, which leads to increased alertness of specialists in the field of pediatrics and pulmonology regarding pneumococcal pneumonia.
Causes of pneumococcal pneumonia
Streptococcus pneumoniae, the causative agent of pneumococcal pneumonia, belongs to gram-positive diplococci. The bacterium is surrounded by a polysaccharide capsule, which serves as a factor determining the virulence and pathogenicity of pneumococcus, its ability to form antibiotic resistance. Taking into account the structure and antigenic properties of the polysaccharide capsule, over 90 serotypes of S.pneumoniae are isolated, 20 of which cause the most severe, invasive forms of pneumococcal infection (meningitis, pneumonia, septicemia).
Pneumococcus is a representative of the conditionally pathogenic nasopharyngeal microflora of humans. Bacterial S.pneumoniae is found in 10-25% of healthy people. The reservoir and distributor of the pathogen is a bacterial carrier or a patient with pneumococcal infection. Infection can occur in several ways:
- airborne – when inhaling sprayed mucus particles in the air containing the pathogen
- aspiration – when nasopharyngeal secretions enter the lower respiratory tract
- hematogenic – from extrapulmonary foci of pneumococcal infection.
The risk category most susceptible to pneumococcal pneumonia is children under 2 years of age, elderly people over the age of 65, immunocompromised patients, persons with asplenia, suffering from alcoholism and tobacco addiction. Factors that increase the likelihood of morbidity are hypothermia, malnutrition, hypovitaminosis, frequent acute respiratory infections, stay and close contacts in a team (in kindergarten, hospital, nursing home, etc.). Up to 50% of pneumococcal pneumonia occurs during an influenza pandemic, as the influenza virus facilitates the adhesion and colonization of the bronchial mucosa by pneumococcus.
The development of pneumococcal pneumonia proceeds with the change of four pathomorphological phases. In the first (phase of microbial edema) lasting 12-72 hours, there is an increase in blood filling of the vessels with the release of exudate into the lumen of the alveoli. Pneumococci are detected in the serous fluid. The second phase of pneumonia (red liver) is characterized by the appearance of fibrinogen and erythrocytes in the exudate. The affected lung tissue becomes dense, airless, resembling liver tissue in consistency and color. This period lasts 1-3 days. The next phase (gray hepation) lasting 2-6 days proceeds with a predominance of leukocytes in the exudate, due to which the lung acquires a grayish-yellow color. In the last period (resolution phase), the reverse development of changes begins: resorption of exudate, dissolution of fibrin, restoration of lung airiness. The duration of this period is determined by the severity of the inflammatory process, the reactivity of the macroorganism, and the correctness of therapy.
Pneumococcal pneumonia symptoms
The clinical picture of pneumococcal pneumonia consists of a number of syndromes inherent in acute pneumonia as a whole: intoxication, general inflammatory, bronchopulmonary and pleural.
Croup pneumonia manifests acutely, with a sudden rise in temperature to 38-40 ° C, tremendous chills, feverish blush on the cheeks. Signs of intoxication are significantly pronounced: weakness, headache, myalgia, loss of appetite. Shortness of breath and tachycardia appear. Patients note chest pain on the affected side when breathing and coughing. Dry, painful at first, the cough soon becomes moist, with a brownish (“rusty”) separation sputum. The course of croup pneumococcal pneumonia is severe. Complications often occur in the form of acute respiratory failure, pleurisy, lung abscess, pleural empyema. Extrapulmonary and generalized complications develop less often: meningitis, endocarditis, nephritis, sepsis.
The onset of focal pneumococcal pneumonia is usually preceded by an episode of ARVI. General weakness, high fatigue, severe sweating persists. The symptoms are generally similar to croup pleuropneumonia, but less pronounced. Fever is less high and prolonged, cough is moderate and not so painful. The course of focal pneumonia is usually moderate, complications occur relatively rarely. However, bronchopneumonia is more prone to a prolonged course – often infiltrative changes in the lungs persist for longer than one month.
Pneumococcal pneumonia is characterized by certain physical data that change in accordance with the pathomorphological phase of the disease. At the stage of exudation, the dulling of the percussion sound, hard breathing, dry wheezing, initial crepitation is determined. In the stage of opechenia, bronchophonia appears, the noise of pleural friction is heard. For the resolution stage, various-sized wet wheezes, sonorous crepitation, hard breathing, turning into vesicular, are typical.
X-ray examination (lung x-ray in two projections) allows you to visualize the pneumonic infiltration of lung tissue (in the form of intense darkening of the lobe or focal shadow), to determine the presence of pleural effusion. For the purpose of differential diagnosis with lung cancer, tuberculosis, atelectasis, linear and computed tomography (CT of the lungs) is used.
In pneumococcal pneumonia, changes in peripheral blood tests are pronounced. Neutrophilic leukocytosis is typical, a sharp shift of the formula to the left, an increase in ESR. In the biochemical study of blood, the activity of the inflammatory reaction is indicated by a positive CRP, an increase in sialic acids, fibrinogen, haptoglobin, gamma globulins.
Etiological verification of pneumococcal pneumonia is carried out by microscopic examination of sputum: in preparations stained by Gram, clusters of pneumococci are determined. Bacteriological sputum culture, serological reactions are also carried out (anti-pneumococcal At titers in paired blood serums increase on the 10th-14th day of the disease).
Treatment for pneumococcal pneumonia
The modern approach to the treatment of pneumococcal pneumonia consists of basic, etiotropic, pathogenetic and symptomatic therapy. Hospitalization in the hospital is carried out according to clinical indications (children of the first year of life, elderly patients, persons with chronic concomitant diseases). For the period of fever, bed rest is prescribed, a full-fledged, calorie-balanced diet is recommended, and the use of a sufficient amount of fluid.
Etiotropic therapy of pneumococcal pneumonia consists in the use of antibacterial drugs with the greatest activity against S.pneumoniae. First of all, these are inhibitor-protected penicillins, second- and third-generation cephalosporins, macrolides, carbapenems. Vancomycin is used to influence antibiotic-resistant strains of pneumococcus.
The pathogenetic approach to the treatment of pneumococcal pneumonia is based on detoxification therapy, the use of bronchodilators, cardioprotectors, anti-inflammatory and diuretics. Symptomatic therapy involves taking antipyretic, antitussive, expectorant drugs, conducting distracting and local therapy (inhalation, irrigation of the throat with antiseptic solutions). In the resolution phase, rehabilitation measures are added to drug treatment: respiratory gymnastics, physiotherapy, chest massage, vitamin therapy. The total duration of treatment for pneumococcal pneumonia should be at least 3 weeks with dynamic X-ray control.
Prognosis and prevention
Pneumococcal pneumonia of moderate severity, as a rule, proceeds favorably and resolves within two to four weeks. Severe forms of infection are observed in young children, people with severe intercurrent diseases and can end fatally due to the addition of various pulmonary and extrapulmonary complications.
In order to reduce the incidence and adverse outcomes, mandatory vaccination against pneumococcal infection has been included in the national calendar of preventive vaccinations since 2014. In addition to developing specific immunity, vaccination allows sanitizing the upper respiratory tract from colonization by pneumococcus and reducing the number of bacterial carriers. Non-specific prevention of pneumococcal pneumonia consists of isolating patients, increasing overall resistance to infections, and timely treatment of acute respiratory viral infections.
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