mwvave pnevmoniis marTvis gaidlaini

koniunqtiva an respiraciuli sistema. inficirebul axalSobilTa 60%-SiviTardeba koniunqtiviti, 10-20%-Si pnevmonia, xolo 10-15%-Si daavadebsasimptomuria. qlamidiuri pnevmonia viTardeba sicocxlis pirveli oriTvis ganmavlobaSi, uxSiresad 3 kviridan 2 Tvis asakSi.sk olamdeli a sakis ba vSvebi.am asakis bavSvebSi respiraciuli infeqciis 60% samedicinodawesebulebaSi vizitiT mTavrdeba. maT Soris 80% gamowveuliavirusebiT. adamianis respiraciuli sistemis dazianeba 200-ze met virussSeuZlia. cxrilSi mocemulia virusuli infeqciis kavSiri pnevmoniasTan.pnevmoniasTan asocirebuli virusebivirusiadreuliasakiskolamdeli asakirs-virusi+++++paragripi ΙΙΙ+++paragripi Ι++++gripi A+++gripi B+/–+++paragripi ΙΙ++/–adenoviusi++wiTela++/–citomegalovirusiskolisasaki+/–+++++++/–+/–+/–+/–gripis epidemia ZiriTadad zamTris periodSi vlindeba da avadobisada sikvdilianobis maRal maCvenebels ganapirobebs. gadacemis gza haerwveTovani(person to person) kontaqtiT.respiraciul-sincitiuri virusi. rsv Paramixoviridae ojaxis virusia.axasiaTebs Zalian maRali kontagiozuroba. vrceldeba haer-wveTovanigziT, sezonuri pikiT zamTris TveebSi. bavSvebSi rsv pnevmoniis uxSiresmizezs warmoadgens. bavSvTa umravlesoba inficirdeba 5 wlamde asakSi.wiTelas virusi. wiTela aseve Paramixoviridae gvars miekuTvneba. iscnobilia rogorca gamonayriT mimdinare febriluri daavadebisgamomwvevi bavSvebSi, Tumca amasTan erTad igi respiraciul virusia daZiriTadad saSualo simZimis pnevmonias ganapirobebs. daavadeba maRalkontagiozuria,gadaecema haer-wveTovani gziT, daavadebis piki aRiniSnebagvian zamTarsa da adreul gazafxulze.adenovirusi. miekuTvneba Adenoviridae gvars. cnobilia virusis 42serotipi, amaTgan filtvis paTologiis klinikurad manifestirebul5

formebs iwvevs 3, 4, 7, 14 da 21 serotipebi. daavadeba vrceldeba haerwveTovanida kontaqturi gziT. daavadebis SemTxvevaTa ricxvi matulobszamTrisa da gazafxulis TveebSi.citomegalovirusi. cmv miekuTvneba Herpesviridae ojaxs. is erT-erTyvelaze gavrcelebul viruss warmoadgens (WHO-s monacemebiTantisxeulebi cmv-s mimarT msoflios sxvadasxva regionSi mosaxleobis40-100%-Si iqna nanaxi). uxSiresad cmv-infeqciis mimdinareoba asimptomuria.cmv pnevmoniis simZime ganpirobebulia imunosupresiis xarisxiT. daavadebagadaecema transmisiuli gziT da organizmis gamonayof siTxeebTan erTad.baqteriuli infeqciebijanmrTeli bavSvis filtvi baqteriuli infeqciebisagan mTeli rigimeqanizmebiT aris daculi, rogoricaa nawilakebis filtracia cxvirisnestoebSi, aspiraciis prevencia epigloturi refleqsis saSualebiT,xveliT aspirirebuli nawilakebis gamodevna, cilialuri ujredebis dalorwos sekreciis zemoqmedeba da sxv. baqteriuli pulmonuri infeqciaviTardeba maSin, rodesac erTi an ramdenime meqanizmi darRveulia damikroorganizmi aRwevs qveda sasunTq gzebSi.specifikuri baqteriuli etiologia damokidebulia bavSvis asakze.paTogenipnevmoniasTan asocirebuli baqteriebiasaki1 Tvemde 1 Tve-2 weli 2-5 weli 5 welze metiStreptococci B Streptococci B S.pneumoniae S.pneumoniaeC. trachomatis S.pneumonia Streptococci A Streptococci AKlebsiella pneum. Haemophilus Haemophilus MycoplasmaS.pneumoniaeinfluenza influenza pneumoniaeEnterobacteriae S.aureus MycoplasmaHaemophilus influenzapneumoniaeS. aureusaRsaniSnavia, rom bavSvTa asakis pnevmoniis uxSires baqteriulgamomwvevs S.pneumoniae warmoadgens (mtkicebuleba ΙΙ).sk olis a sakis ba vSvebiMycoplasma pneumoniae–iiT gamowveuli infeqcia bavSvTa asakis erTerTyvelaze xSir respiraciul paTologias warmoadgens. iTvleboda,rom igi iSviaTia skolamdeli asakis bavSvebSi, magram sinamdvileSi amasakSic is TiTqmis imave sixSiriT gvxvdeba, rogoric skolis asakisbavSvebSi. 4 wlamde asakis bavSvebSi pnevmoniis 5% swored Mycoplasma6

pneumoniae–aTi aris ganpirobebuli. infeqciis gadacema wveTovani gziTxdeba, infeqcia maRali kontagiozurobiT xasiaTdeba; ojaxis wevrebsSoris 75% avaddeba. daavadeba yvela geografiul zonaSi da weliwadisyvela dros gvxvdeba, Tumca yvelaze xSiria Semodgomaze, rodesacrespiraciuli infeqciis sxva tipebi ufro iSviaTia.Chlamydia pneumoniae. qlamidiebis axali klasifikaciis TanaxmadC.pneumoniae sruliad axali gvaris Chlamydophila-s warmomadgenelia. miserTaderT rezervuars adamiani warmoadgens da gavrcelebis gza person-topersonkontaqtia. iSviaTia 5 wlamde asakSi, misi maqsimumi 8-9 wlis asakSiaRiniSneba. mozrdili mosaxleobis 30-50%-s serologiuraddadasturebuli infeqcia aqvs, maTi umravlesoba subklinikuria. C.pneumoniae–a pnevmoniis 6-10%-s iwvevs.ZiriTadi debulebebi⇒ bavSvTa asakis pnevmoniis uxSires baqteriul gamomwvevs S.pneumoniaewarmoadgens (mtkicebuleba ΙΙ);⇒ asaki pnevmoniis SesaZlo gamomwvevis kargi mimaniSnebelia:• 5 wlamde asakSi pnevmoniis uxSires gamomwvevs virusebiwarmoadgenen (mtkicebuleba ΙΙ);• 5 wlis zemoT daavadebas uxSiresad iwveven baqteriuligamomwvevebi, maT SorisS.pneumoniae, Mycoplasma pneumoniae,Chlamydia pneumoniae (mtkicebuleba ΙΙ).⇒ daavadebis mniSvnelovani nawili (8-40%) ganpirobebulia miqstinfeqciiT(mtkicebuleba ΙΙ);⇒ virusi, rogorc monokauzaluri agenti, identificirdeba SemTxvevaTa 14-35%-Si (mtkicebuleba ΙΙ);⇒ 20-60%-Si gamomwvevis aRmoCena ver xerxdeba (mtkicebuleba ΙΙ).na wili II Iklinikuri niSnebipnevmoniis ZiriTadi klinikur niSnebia:• xvela (axlad dawyebuli);• taqipnoe;• cxeleba;7

• sunTqvis gaZneleba;• gulmkerdis retraqcia;• cxviris nestoebis berva;• auskultaciuri cvlilebi.WHO-s rekomendaciiT pnevmoniis ZiriTad sadiagnostiko niSnebadmiCneulia sunTqvis sixSire da gulmkerdis Cadreka (gansakuTrebiT 5wlamde).klinikuri Sefaseba:1. an am nezianamnezuri monacemebidan pnevmoniaze unda vifiqroT, Tu gamoxatulia:• xvela;• cxeleba da/an Semcivneba;• gulmkerdis da/an muclis tkivili (mozrdil bavSvebSi);• sunTqvis gaZneleba;• zogadi niSnebi: saerTo sisuste da leTargia, Tavis tkivili,gulisreva/Rebineba, mialgia.2. ri sk-faq torebi:pnevmoniis ganviTarebis xelSemwyobi faqtorebia:• zeda sasunTqi gzebis infeqcia;• Tambaqos bolis zemoqmedeba;• sabavSvo baRSi siaruli;• Tanmxlebi daavadebebi – kardiopulmonuri, imunuri, nerv-kunTovanidarRvevebi;• hospitalizaciis epizodi bolo 3 Tvis ganmavlobaSi;• kvebis deficiti (malnutricia);• dabali socialur-ekonomikuri statusi;• dRenakluloba (wlamde asakSi);• pankreasis cistofibrozi (mukoviscidozi);• imunizaciis Cavardna;• antibiotikoTerapiis epizodi wina TveSi;• infeqciur daavadebasTan kontaqti.3. obieqturi gam okvleva:8

fizikuri gasinjva iwyeba bavSvis zogadi mdgomareobisSefasebiT:• cnobierebis Sefaseba: agznebadobis an leTargia;• SeuZlia Tu ara siTxis miReba, wlamde asakis bunebriv kvebazemyof bavSvebSi F- iRebs Tu ara ZuZus;• Seupovari Rebineba;• krunCxvis epizodi mocemuli daavadebis dros;zogadi mdgomareobis Semdeg fasdeba respiraciuli niSnebisarseboba:• taqipnoe;• xmauriani sunTqva (grunting);• sunTqvaSi damxmare kunTebis monawileoba - cxviris nestoebisberva;• gulmkerdis retraqcia;• qoSini;• wheezing.filtvis qsovilis ga mkvrivebaze miuTiTebs:palpaciiT• gulmkerdis rezistentobis mateba;• bgeriTi xmianobis gaZliereba.perkusiiT• lokaluri moyrueba.auskultaciiT• Sesustebuli sunTqva;• krepitacia;• bronquli sunTqva;• plevris xaxunis xma;• bronqofoniis gaZliereba (10 wlis zemoT).sunTqvis sixSireWHO-s rekomendaciiT pnevmoniis erT-erT ZiriTad sadiagnostikoniSnad miCneulia sunTqvis sixSire (daTvla unda moxdes erTi wuTisganmavlobaSi, rodesac bavSvi mSvid mdgomareobaSia da ar tiris):• 2 Tvemde asakis bavSvebSi >60-ze wuTSi,• 2-dan 12 Tvemde asakis bavSvebSi >50-ze wuTSi,9

muclis (refleqsuri, diafragmis plevris gaRizianebis gamo) dagulmkerdis tkivili damaxasiaTebelia pnevmoniisTvis mozrdili asakisbavSvebSi.maRali cxelebis (>38,5 0 C), gulmkerdis Cadrekis da taqipnoes drossavaraudoa baqteriuli infeqciis arseboba.CvilebSi ucnobi etiologiis cxelebiT da sefsisis klinikurisuraTiT unda gamoiricxos pnevmoniis arseboba.ba qteriuli pne vmoniis ni Snebi• cxeleba > 38,5 0 C;• sunTqvis sixSire > 50-ze wT-Si;• gulmkerdis Cadreka;• Wheezing ar axasiaTebs;rentgenologiuri da klinikuri niSnebi miuTiTebs filtvis qsovilisgamkvrivebasa da infiltraciaze, vidre kolafsze.vi rusuli pne vmoniis ni Snebi• Cvilebi da adreuli asaki;• Wheezing;• cxeleba < 38,5 0 C;• gamoxatuli gulmkerdis Cadreka;• sunTqvis sixSire normaluri an momatebuli;Ro.grafia : filtvebis haeriT gadavseba mZime mimdinareobisas wiliskolafsimi koplazmuri pn ev moniis niS nebi• skolis asaki• xvela, Wheezing• cxeleba < 38,5 0 Crentgenologiurad intersticiuli infiltracia, wilovani gamkvriveba.klasikuri klinikuri niSnebipn evmokokuri pnevmoniacxeleba, Semcivneba, taqiopnoe da gulmkerdis/muclis tkivilimiuTiTebs pnevmokokur pnevmoniaze. xvela SesaZlebelia odnavmogvianebiT gamovlindes (mtkicebuleba ΙΙ).stafilokokuri pnevmoniasawyis etapze Zalian hgavs pnevmokokur pnevmonias, TiTqmisyovelTvis gvxvdeba CvilebSi, Tumca mozrdil bavSvebSi gripi SeiZlebagarTuldes stafilokokuri pnevmoniiT (mtkicebuleba ΙΥ).11

mikoplazmuri pnevmoniamstvinavi sunTqva, cxeleba, arTralgia, Tavis tkivili, xveleba daxixini saskolo asakis bavSvebSi miuTiTebs mikoplazmur pnevmoniaze(mtkicebuleba ΙΥ).Chlamydia trachomatis – iT gamowveuli pnevmonias axasiaTebs xvela,xixini, wheezing. mniSvnelovani niSania anamnezSi, neonatalur periodSi,Tvalidan gamonadenis arseboba.na wili IYga mokvlevebi1. ren tgenologiuri gam okvleva• bavSvebSi, romlebTac aReniSnebaT pnevmoniis kardinaluri niSnebi daromelTa zogadi mdgomareoba ar aris mZime, gulmkerdisrentgenograma ar unda gakeTdes rutinulad (rekomendacia A).• gulmkerdis rentgenografia unda Cautardes 5 wlamde asakis yvelabavSvs, romelsac aReniSneba ucnobi etiologiis cxeleba (>39 0 C) damaRali leikocitozi, miuxedavad imisa, gamoxatulia Tu ara sasunTqisistemis dazianebis niSnebi.• gulmkerdis rentgenografia unda Catardes im SemTxvevaSi, rodesacsaxezea pnevmoniis urTierTgamomricxavi niSnebi, saeWvoa garTulebisarseboba eqsudaciuri plevritis saxiT an Catarebul mkurnalobazear aris saTanado pasuxi.• normaluri rentgenograma ar gamoricxavs pnevmoniis arsebobas.• ganmeorebiTi rentgenologiuri kvleva ar aris saWirogaurTulebeli pnevmoniis dros. misi Catareba naCvenebiawilovanikolafsis, pnevmoniis mrgvali Crdilis arsebobis (simsivnisgamosaricxad) da klinikuri simptomebis gaxangrZlivebis dros(rekomendacia C).• rentgenografiuli kvleva arainformatiulia davadebis etiologiuridiagnostikisTvis, radgan wilovani gamkvriveba da intersticiuliinfiltracia SeiZleba ganviTardes rogorc baqteriuli, asevevirusuli da Sereuli etiologiis pnevmoniis dros (mtkicebuleba ΙΙ).gverdiTi rentgenogramis gadaReba ar aris rutinulad aucilebeli.2. pu ls-oqsimetriapuls-oqsimetria (Jangbadis saturaciis gansazRvra) unda CautardespnevmoniiT hospitalizebul yvela pacients (rekomandacia A). puls-12

oqsimetri advili gmosayenebelia. artefaqtebis Tavidan asacilebladpuls-oqsimetria unda Catardes mosvenebul mdgomareobaSi. maCveneblisdafiqsireba unda moxdes kargi pulsuri signalis miRebidan minimum 30wamis Semdeg stabiluri monacemebis pirobebSi.3. sisxlis sae rTo ana lizisisxlis saerTo analizi ar iZleva baqteriuli da virusulipnevmoniis gansxvavebis saSualebas. amasTan aRsaniSnavia, rombaqteriuli pnevmoniis albaToba maRalia im bavSvebSi, romelTacaReniSnebaT maRali cxeleba da maRali leikocitozi (15 . 10 12 /l).4. Sardovana da el eq trolitebiSardovanas da eleqtrolitebis raodenobis gansazRvra undamoxdes stacionarSi mZime pnevmoniis an dehidrataciis niSnebisarsebobisas.5. spe cifikuri mi krobiologiuri gam okvlevebipnevmoniis etiologiuri faqtoris dasadgenad saukeTeso meTodiamasalis aReba uSualod inficirebuli filtvis ubnidan punqciissaSualebiT, rac rTuli da invaziuri proceduraa. amitomac mimarTavenmxolod hospitalizebul pacientebSi.6. dif-di agnostikapnevmoniis dros dif-diagnostika unda gatardes SemdegdaavadebebTan: asTma, bronqiti, respiraciuli distres-sindromi,aspiraciuli pnevmonia, obstruqciuli bronqiti, bronqioliti,tuberkulozi.baqteriuli, virusuli an atipuri pnevmoniis erTmaneTisgangansxvaveba mxolod erTi parametriT (klinikuri, laboratoriuli Turentgenologiuri) SeuZlebelia.naw ili Ypne vmoniis si mZimis Se fasebaavadmyofis mdgomareobis sirTule SeiZleba meryeobdes msubuqidanmZimemde. pnevmoniis msubuqi formis drosSesaZlebelia daavadebisusafrTxod marTva binis pirobebSi, xolo mZime pnevmoniis drosaucilebelia hospitalizacia.si mZimis Se fasebamsu buqimZi meCvi li • t < 38,5 0 C• t > 38,5 0 C• RR < 50 /wT• RR > 70 /wT• sakvebs iRebssrulad• saSualo an Zlieri retraqcia• cxviris nestoebis berva13

mozrdiliasa ki• t < 38,5 0 C• RR < 50 /wT• msubuqi qoSini• Rebineba ar aris• cianozi• perioduli apnoe• “grunting“ (mkvnesare sunTqva)• sakvebs ver iRebs• t > 38,5 0 C• RR > 50 /wT• sunTqvis Zlieri gaZneleba• cxviris nestoebis berva• cianozi• “grunting“ (mkvnesare sunTqva)• dehidrataciis niSnebina wili YIhospitalizaciis Cv en ebebiTu saxezea qvemoT CamoTvlili 4 niSani, aucilebelia yvela asakisbavSvis saavadmyofoSi moTavseba:• agznebadoba/leTargia;• siTxis miRebis SeuZlebloba;• Seupovari Rebineba;• krunCxvis epizodi mocemuli daavadebis dros;pnevmoniiT daavadebul bavSvebSi hospitalizaciis ZiriTad Cvenebashipoqsemia warmoadgens. ganviTarebad qveynebSi Catarebulma kvlevamdaadastura, rom hipoqsemia zrdis sikvdilis risks. 1 wlamde asakisbavSvebSi sunTqvis sixSire 70-ze meti wuTSi an meti hipoqsemiismniSvnelovani prediqtoria.hospitalizaciis Cv en ebebi:2 Tvidan 5 wlamde as akis ba vSvebi- Jangbadis saturacia < 92 %;- cianozi;- taqipnoe > 70 wT-Si;- grunting;- perioduli, xanmokle apnoe;- xmauriani sunTqva;- cxviris nestoebis berva;- gulmkerdis retraqcia;- dehidratacia;14

- Rebineba;- sakvebis cudad miReba (normis naxevarze naklebi);- oraluri antibiotikebiT mkurnalobis araefqturoba;- araadekvaturi meTvalyuroba da movla ojaxSi.5 welze meti asa kis bavSvebi- Jangbadis saturacia < 92 %;- cianozi;- taqipnoe > 50 wT-Si;- grunting;- dehidratacia;- araadekvaturi meTvalyuroba da movla ojaxSi.naw ili YIIgar Tulebebi an war umatebeli mk urnalobaTu 48 saaTis Semdeg bavSvs aReniSneba maRali sicxe an arumjobesdeba mdgomareoba, aucilebelia mkurnalobis Tavidan Sefaseba.saWiroa pasuxis gacema Semdeg kiTxvebze:• adekvaturia medikamentis doza?• vlindeba pnevmoniis garTulebis: eqsudaciuri plevritis,empiemis an filtvis abscesis niSnebi?• xom ar aqvs pacients imunodeficiti an sxva Tanmxlebidaavadeba (mag. mukoviscidozi)?ara efeqturi mk urnalobaarsebobs mosazreba, penicilin-rezistentuli S pneumoniae-iTgamowveuli daavadebis ricxvis mateba ganapirobebs mkurnalobisaraefeqturobas. Tumca,bolo periodSi Catarebulma gamokvlevebmacxadyo, rom mkurnalobis efeqturoba ar aris damokidebuli mikrobisrezistentobaze.ple vruli gam onaJoni da em pi emaplevruli gamonaJonis arsebobis dadastureba SesaZlebeliarentgenologiiT. Tu aRiniSneba gaxangrZlivebuli cxeleba da plevrisRruSi siTxis arseboba, aucilebelia hospitalizacia. hospitalizebulpacientTa 40%-s SeiZleba plevruli gamonaJoni aRiniSnos. adekvaturiantibiotikoTerapiis fonze cxelebis gaxangrZlivebis SemTxvevaSisavaraudoa empiemis arseboba.iSviaT SemTxvevaSipnevmoniis Tanmxlebi septicemiis SedegadSesaZlebelia ganviTardes infeqciis metastazuri ubnebi, mag:osteomieliti an septiuri arTriti.15

zogierTi gam omwvevisaTvis da maxasiaTebeliga rTulebebiS aureus gamowveuli pnevmoniapnevmocele (bulebi), romelic Cveulebriv iwvevs pnevmoToraqss,xSirad viTardeba S aureus-iT gamowveuliprognozi keTilsaimedoa.mikoplazmuri pnevmoniamikoplazmuri pnevmoniis garTulebebia:pnevmoniis dros. Soreuli• gamonayari (xSiria);• stivens-jonsis sindromi (iSviaTia);• hemolizuri anemia;• poliarTriti;• pankreatiti;• hepatiti;• perikarditi, miokarditi;• nevrologiuri garTulebebi _ encefalitis, asepturimeningitis, mielitisa da mwvave fsiqozis CaTvliT.Z i r i T a d i d e b u l e b e b iTu mkurnalobis 48 saaTis Semdeg bavSvs aReniSneba maRali sicxean ar umjobesdeba mdgomareoba, aucilebelia misi ganmeorebiTiSefaseba (rekomendacia D).na wili YII Ipn ev moniis mku rnalobis zo gadi pr incipebibavSvTa asakSi pnevmoniis mkurnaloba moicavs:1. antibiotikoTerapias;2. oqsigenoTerapias;3. rehidratacias;4. temperaturisa da tkivilis marTvas.1. ant ibiotikoTerapiapnevmoniis samkurnalod antibiotikoTerapiis dawyeba daantibiotikebis SerCeva damokidebulia bavSvis asakze, etiologiur16

faqtorsa da daavadebis simZimeze.antibiotikoTerapiis Sesaxebgadawyvetilebis miReba efuZneba Semdeg ZiriTad sakiTxebs:• antibiotikoTerapiis aucilebloba;• antibiotikis SerCeva;• antibiotikis Seyvanis gzis arCeva;• antibiotikoTerapiis xangrZlivoba.antibiotikoTerapiis au cileblobaantibiotikoTerapiis saWiroebis Sesaxeb gadawyvetilebis miRebamniSvnelovani sakiTxia. baqteriuli pnevmoniis (romelsac esaWiroebaantibiotikoTerapia) diferencireba virusuli pnevmoniisagan (romelicar saWiroebs antibiotikoTerapias) sakmaod rTulia. arsebobsrandomizebuli kontrolirebadi kvleva, romelic adasturebs, rombavSvTa asakSi virusuli etiologiis pnevmoniis samkurnalodantibiotikoTerapiis gamoyeneba ar cvlis davadebis gamosavals.antibiotikis Se rCevapnevmoniis samkurnalod antibiotikis SerCeva Cveulebrivempiriulad xdeba. antibiotikis SerCevis dros gaTvaliswinebuli undaiyos:• sxvadasxva gamomwvevis gavrcelebis sixSire sxvadasxvaasakobriv jgufSi;• konkretuli gamomwvevisaTvis damaxasiaTebeli specifiuriklinikuri simptomatika.5 wlamde asakis bavSvebSi pnevmoniis ZiriTad gamomwvevswarmoadgenen: S. pneumoniae; H. influenzae; M. catarrhalis; Str. pyogenes. amitom 3Tvidan 5 wlamde asakSi pirveli rigis preparats warmoadgensamoqsicilini.am asakobriv jgufSi meore rigis preparatebsmiekuTvneba makrolidebis da cefalosporinebis jgufi.randomizirebuli kontrolirebadi kveleviT dadasturebulia pnevmoniissamkurnalod ma krolidebis efeqturoba. azitromicini iseTiveefeqturobiT xasiTdeba pnevmoniis samkurnalod, rogorc ko-amoqsiklavi,cefaklori, spiramicini. agreTve dadasturda, rom 3-5 dRiTgamoyenebuli azitromicini iseTiveroqsitromicini.efeqturia, rogorc 7-10 dRiani5 wlis da meti asakis bavSvebSi pnevmoniis ZiriTad gamomwvevebswarmoadgenen atipuri paTogenebi, rogoricaa:MMycoplasma pneumoniae;Chlamydia pneumoniae, amitom am asakobriv jgufSi I rigis preparatad17

iTvleba makrolidi. ΙΙ rigis preparats ki warmoadgenscefalosporini.farTo speqtris cefalosporinebi ar warmoadgenen I rigispreparatebs. maTi gamoyeneba mizanSewonilia mxolod daavadebis mZimemimdinareobis SemTxvevaSi.Z i r i T a d i d e b u l e b e b i5 wlamde asakis bavSvebSi pnevmoniis samkurnalo pirvelirigis preparats warmoadgens amoqsicilini. igi efeqturiayvela im gamomwvevis mimarT, romelic iwvevs daavadebas amasakobriv jgufSi, kargad aiTviseba da xarjTefeqturia.alternativas warmoadgens ko-amoqsiklavi, makrolidebi(azitromicini, spiramicini, klaritromicini) da cefaklori(rekomendacia B).5 wlis asakis Semdeg pnevmoniis ZiriTad gamomwvevswarmoadgens mikoplazma da qlamidia, ris gamoc am asakobrivjgufSi makrolidebi iTvleba I rigis empiriul samkurnalosaSualebad (rekomendacia D).Tu saeWvoa S. pneumoniae-iT gamowveuli pnevmoniis arseboba,nebismier asakSi I rigis preparatad iTvleba amoqsicilini(rekomendacia B).Tu saeWvoa stafilokokuri pnevmonia, mizanSewoniliaoqsacilini, vankomicini an kombinirebuli Terapia(rekomendacia D).antibiotikis Se yvanis gz a, oraluran tibiotikoTerapiaze ga dasvlis Cv enebebi.pnevmoniis msubuqi formis, gaurTulebeli mimdinareobisSemTxvevaSi rekomendebulia oraluri antibiotikis gamoyeneba. kvleviTdadginda, rom pnevmoniis samkurnalod oralurad miRebuliantibiotikebi (amoqsicilini) iseTive efeqturia, rogorcintramuskuluri (penicilini), daavadebis gamosavali ar arisdamokidebuli antibiotikis gamoyenebis gzaze.parenteraluri antibiotikoTerapiis Cvenebas warmoadgensdaavadebis mZimed mimdinareoba, medikamentebis peroralurad miRebisSeuZlebloba, baqteriuli pnevmoniis SemTxvevaSi daavadebis niSnebisgaxangrZliveba 5 dReze metad (rac zrdis empiemis risks).parenteraluri antibiotikoTerapia SeiZleba Seicvalos peroraluriTpacientis zogadi mdgomareobis gamoxatuli gaumjobesebis Semdeg18

axalSobilTa pnevmoniis dros aucilebelia intravenuriantibiotikoTerapia.Z i r i T a d i d e b u l e b e b ibavSvTa asakSi pnevmoniis samkurnalod oraluri antibiotikebisgamoyeneba efeqturi da usafrTxoa (rekomendacia A).parenteraluri medikamentebis gamoyenebis Cvenebaa mZimeklinikuri mimdinareoba an medikamentis peroralurad miRebisSeuZlebloba (rekomendacia D).mZime pnevmoniis mkurnaloba unda Catardes stacionarSiintravenuri antibiotikebis gamoyenebiT: ko-amoqsiklavi,ceftriaqsoni. Tu klinikuri da mikrobiologiuri monacemebiTsavaraudoa S. pneumoniea,(rekomendacia D).gamoiyeneba ampicilini an amoqsicilinipacientis zogadi mdgomareobis gamoxatuli gaumjobesebisSemTxvevaSi rekomendebulia parenteruli antibiotikoTerapiisSecvla oraluri antibiotikoTerapiiT (rekomendacia D).antibiotikoTerapiis xa ngrZlivobasaboloo rekomendaciebi am mimarTulebiT ar arsebobs. pnevmoniisantibiotikoTerapia Cveulebriv grZeldeba 7-10 dRe. msubuqi formispnevmoniis dros janmo-s rekomendaciiT mkurnalobis xangrZlivobaa 5-7dRe. mkurnalobis xangrZlivoba damokidebulia etiologiaze dadaavadebis simZimeze, agreTve gamoyenebuli antibiotikze.2. oqsigenoTerapiapacientebi, romlebsac Jangbadis saturacia aqvT 92 %-ze naklebi,saWiroeben oqsigenoTerapias _ Jangbadis Tavisufali wesiT miwodebas(rekomendacia A).cianozi hipoqsemiis SemTxvevaSi yovelTvis ar vlindeba. hipoqsemiiserT-erTi maCvenebeli SesaZlebelia iyos bavSvis agzneba. Jangbadi undamiewodos pacients, Tu mas aReniSneba cianozi, gulmkerdis Cadreka,sunTqvis gaxSireba (70-ze metad), CvilebSi mkvnesare sunTqva.Z i r i T a d i d e b u l e b e b ipacientebs, romelTac aReniSnebaT hipoqsia da Jangbadis saturacianaklebi aqvT 92 %-ze, esaWiroebaT Jangbadis miwodeba ise, romSenarCundes saturacia 92 %-ze meti.agzneba SeiZleba iyos hipoqsiis erT-erTi niSani.3. reh idratacia19

Cvilebi, romlebic ver iReben siTxis sadReRamiso moTxovnilebasda kargaven siTxes perspiraciis an Rebinebis gamo saWiroeben siTxisdamatebiT miwodebas.siTxis moTxovnileba (WHO)sxeulis wona siTxe (ml/dReSi)20 kg 50-90 ml/kgamave dros metad mniSvnelovania ar moxdes siTxiT gadatvirTva.bavSvs unda miewodos siTxis meti raodenoba peroralurad, gaizardosZuZeTi kvebis sixSire. Tu bavSvi iRebs adekvaturi raodenobis siTxes,ar aris mizanSewonili siTxis parenteralurad miwodeba annazogastraluri zondis gamoyeneba, romelic zrdis aspiraciulipnevmoniis ganviTrebis risks. Tu bavSvs ar SeuZlia siTxis miReba siTxeunda miewodos nazogastraluri zondiT.4. tempe raturis da tkivilis kontroliqveda sasunTqi gzebis infeqciis SemTxvevaSi bavSvebSi Cveulebrivvlindeba febriliteti da tkivili, maT Soris Tavis tkivili,arTralgia, muclis tkivili, tkivili gulmkerdis areSi (plevrisgaRizianebis dros). plevruli tkivilis dros bavSvs uWirs RrmasunTqva da xvela.antipiretuli da tkivilgamayuCebeli saSualebebisgamoyeneba amcirebs diskomforts da xels uwyobs xvelis aqts.pnevmoniis diagnostikisa da mkurnalobis dros mizanSewoniliaminimaluri Careva, rac amcirebs metabolur danaxarjs da JangbadismoTxovnilebas. maRali temperatura (>38.5-39) bavSvebSi xSirad iwvevsmadis daqveiTebas, agznebas, zrdis Jangbadis moxmarebas da sxv. I rigisantipiretul saSualebas warmoadgens acetaminofeni, romelicgamoiyeneba 2 Tveze meti asakis bavSvebSi Tu temperatura 38,8-39–zemetia. meore rigis preparatad SesaZlebelia miviCnioT arasteroidulianTebis sawinaaRmdego saSualebebi. ar aris mizanSewonili aspirinisgamoyeneba, romelic zrdis reis daavadebis ganviTarebis risks.Z i r i T a d i d e b u l e b e b iantipiretuli da tkivildamayuCebeli saSualebebisgamoyeneba SesaZlebelia diskomfortis mosaxsnelad daxvelis aqtis xelSesawyobad.avadmyof bavSvTan minimaluri Careva amcirebs metabolurdanaxarjs da Jangbadis moTxovnilebas.20

fizioTerapiaar arsebobs mtkicebulebebi, romelic asabuTebs pnevmoniismkurnalobis sqemaSi fizioTerapiuli procedurebis, maT Sorisposturaluri drenaJis, vibraciuli masaJis an Rrma sunTqviTivarjiSebis gamoyenebis efeqturobas.arsebobs varaudi, rom fizioTerapiis gamoyeneba zrdis cxelebisgaxangrZlivebis risks. ar arsebobs aseve mtkicebulebebi, romfizioTerapia efeqturia daavadebis reparaciis periodSi. aRsaniSnavia,rom mjdomare poziciis (sayrdeniT) gamoyeneba bavSvebSi respiraciulidistresiT, xels uwyobs filtvis ukeT gaSlas da aumjobesebsrespiraciul simptomatikas.⇒Z i r i T a d i d e b u l e b e b igulmkerdis fizioTerapiuli procedurebi araefeqturia da arunda iyos gamoyenebuli bavSvebSi pnevmoniis samkurnalod(rekomendacia B).xvelis damawynarebeli sa Sualebebixvelis damTrguneveli saSualebebis an bronqodilatatorebisgamoyeneba rutinulad ar aris rekomendebuli. Tu pnevmoniis SemTxvevaSivlindeba wheezing, igi gamowveulia bronqebis lorwovanis anTebiTidazianebiT da/an naxvelis dagrovebiT da ar pasuxobsbronqodilatatoris gamoyenebaze.monitoringiiseTi simptomebis monitoringi, rogoricaa guliscemis da sunTqvissixSire, gulmkerdis retraqcia da damxmare kunTebis monawileoba,damokidebulia bavSvis mdgomareobaze.pn evmoniis mkurnaloba binis da stacionaris pirobebSimkurnalobis taqtika damokidebulia bavSvis asakze, daavadebisetiologiasa da mimdinareobis simZimeze. msubuqi mimdinareobis drosmkurnaloba SesaZlebelia binis pirobebSi, xolo mZime SemTxvevaSiaucilebelia hospitalizacia.stacionarSi gadayvanis Sesaxeb gadawyvetilebis miRebisasgaTvaliswinebuli unda iyos Semdegi kriteriumebi:asaki

maRali febriliteti (>38.5 C), Rebineba da sakvebisa da siTxismiRebisSeuZlebloba;gaxSirebuli sunTqva cianoziT an mis gareSe;Tanmxlebi paTologia (imunodeficiti, filtvis qronikulipaTologia);socialur aspeqti – mSoblebis unari adekvaturad mouaronbavSvsbinaze;mZime respiraciuli distresi, romelic saWiroebsoqsigenoTerapias;ucvleli zogadi mdgomareoba 48 sT-iani antibiotikoTerapiisSemdeg.binaze mkurnalobabinis pirobebSi mizanSewonilia msubuqi pnevmoniis mkurnaloba.aseT SemTxvevaSi rekomendebulia oraluri antibiotikebis gamoyeneba:mSoblebs unda mieceT rekomendacia:• ganaxorcielon siTxis damatebiTi miwodeba;• akontrolon sxeulis temperatura;• dauyovnebliv mimarTon eqims, Tu bavSvs gamoexata Semdegi niSnebi:sunTqva gaxda ufro gaZnelebuli;daewyo FRebineba yoveli kvebis Semdeg;ver iRebs siTxeebs;gamoixata zogadi mZime mdgomareoba – daTrgunva,Zilianoba;2 dRiani antibiotikoTerapiis miuxedavad maRalifebriliteti grZeldebapacientis binaze mkurnalobis SemTxvevaSi 48 saaTis Semdegaucilebelia ganmeorebiTi konsultacia. am periodSi dgindeba I rigisantibiotikis gamoyenebis efeqturoba. Tu pacientis mdgomareoba(obieqturad, laboratoriulad) ar umjobesdeba, rekomendebuliaantibiotikis Secvla meore rigis preparatiT.na wili IX22

pr eve ncia da pi rveladi ja ndacvis Zi riTadi sakiTxebipre venciabolo aswleulis ganmavlobaSi janmrTelobis dacvis sferoSiarsebulma miRwevebma didi wvlili SeitanesprofilaqtikaSi. sacxovrebelipnevmoniispirobebis gaumjobeseba, Tambaqosbolis zemoqmedebis Semcireba, Haemophilus influenzae, Bordatella pertusis-is(yivanaxvela) da wiTelas winaaRmdeg mosaxleobis regularulivaqcinacia mniSvnelovnad amcirebs pnevmoniis ganviTarebis risks.gripis virusi warmoadgens bavSvebSi sasunTqi gzebis daavadebebis,maT Soris pnevmoniis, erT-erT uxSires gamomwvevs. pnevmoniis riskisSesamcireblad gripis sawinaaRmdego sayovelTao vaqcinaciisefeqturoba jerjerobiT maRali mtkicebulebis mqone kvlevebiTdadasturebuli ar aris.pnevmokoki cnobilia, rogorc pnevmoniis gamomwvevi erT-erTiuxSiresi mizezi. ukanasknel wlebSi Seqmnilia axali koniugirebulivaqcina, romelic efeqturia pnevmokokuri genezis daavadebaTaprevenciisaTvis. Tumca rutinulad am vaqcinaciis aucileblobajerjerobiT maRali mtkicebulebis mqone kvlevebiT dadasturebuli araris..pir veladi jandacvis eqi mis rolipnevmoniiT daavadebul pacientTa umravlesoba pirvel rigSimimarTavs pirveladi jandacvis eqims. am ukanasknelis movaleobaadaadginos mwvave respiraciuli infeqciis arseboba, Seafasos daavadebissimZime, saWiroebis SemTxvevaSi daiwyos mkurnaloba an ganaxorcielospacientis referali, avadmyofis monitoringi, uzrunvelyos pacientida/an misi mSobeli Sesabamisi informaciiT.23

avSvTa asa kis pnevmoniis ma rTvisprotokolinozologiis mokle ganmarteba. daavadebis klinikuri definiciaemyareba pnevmoniis niSnebsa da simptomebs im bavSvebSi, romlebicdaavadebamde janmrTelebi iyvnen da romlebmac infeqciuri agenti SeiZinesda avad gaxdnen saavadmyofos gareT, sazogadoebaSi. zogadad, pnevmoniaSeiZleba ganimartos, rogorc alveolisa da terminaluri sasunTqi gzebisanTeba, romelic gamowveulia infeqciuri agentis hematogenuri aninhalaciuri gziT filtvebSi moxvedriT da romelsac axasiaTebs mwvaverespiraciuli simptomebis, cxelebis an orives erTdroulad arseboba dagulmkerdis rentgenogramaze filtvis parenqimuli infiltraciis niSnebi.daa vadebis damadasturebeli kriteriumebi. WHO pnevmoniisdiagnostikis safuZvlad miiCnevs inspeqciiT miRebul klinikur niSnebs dasunTqvis sixSiris maCveneblebs. daavadebis definicia gansakuTrebiT rTuliaadreuli asakis bavSvebSi, vinaidan pnevmoniis da bronqiolitis klinikuriniSnebi xSirad msgavsia. ganviTarebul qveynebSi xSirad iyeneben termins"qveda sasunTqi gzebis mwvave daavadeba", riTic Tavidan icileben pnevmoniisada bronqiolitis diferencirebis aucileblobas. xSirad saWiro xdeba zemosasunTqi gzebis da pnevmoniis diferencireba. zemo sasunTqi gzebis infeqciasadasturebs: avadmyofis damakmayofilebeli zogadi mdgomareoba daobieqturi gamokvlevisas lokaluri paTologiuri cvlilebebis ararsebobafiltvebSi. pnevmoniis dros zogadi mdgomareoba saSualo simZimisaa an mZime,aRiniSneba respiraciuli distresi (xvela, taqipnoe) da perkusiiT daauskultaciiT lokaluri paTologiuri cvlilebebis arseboba.24

simptomebi da ni Snebi.pnevmoniis ZiriTadi klinikuri niSnebia: xvela; taqipnoe; cxeleba;sunTqvis gaZneleba; gulmkerdis retraqcia; cxviris nestoebis berva;auskultaciuri cvlilebi; zogadi niSnebi: saerTo sisuste daleTargia, Tavis tkivili, gulisreva/Rebineba, mialgia.pa lpaciiT• gulmkerdis rezistentobis mateba; bgeriTi xmianobisgaZliereba.perkusiiT• lokalurad yru xma.au skultaciiT• Sesustebuli sunTqva; krepitacia (mgrZnobeloba dabalia dameryeobs 33-60% Soris); bronquli sunTqva; plevris xaxunis xma;bronqofoniis gaZliereba (10 wlis zemoT)sunTqvis sixSireWHO-s rekomendaciiT pnevmoniis erT-erT ZiriTad sadiagnostikoniSnad miCneulia sunTqvis sixSire (daTvla unda moxdes erTi wuTisganmavlobaSi, rodesac bavSvi mSvid mdgomareobaSia da ar tiris):• 2 Tvemde asakis bavSvebSi >60-ze wuTSi,• 2-dan 12 Tvemde asakis bavSvebSi >50-ze wuTSi,• 12 Tvidan 5 wlamde asakis bavSvebSi >40-ze wuTSi,• 5 welze meti asakis bavSvebSi >30 -ze wuTSi.gulmkerdis retraqcia: WHO-s rekomendaciiT gulmkerdisretraqcia (gulmkerdis qveda mesamedis Cazneqva sunTqvis procesSi)miCneulia mZime pnevmoniis erT-erT sadiagnostiko niSnad, TumcagaTvaliswinebuli unda iyos, rom msubuqi retraqcia damaxasiaTebeliaaxalSobilebsa da Cvil bavSvTa asakisTvis da iTvleba normad.Tu yvela klinikuri niSani – sunTqvis sixSire, sunTqvis gaZnelebada auskultaciuri fenomenebi – uaryofiTia, naklebad savaraudoagulmkerdis rentgenografiis Sedegebis pozitiuroba.ba qteriuli pne vmoniis ni Snebi• cxeleba > 38,5 0 C;• sunTqvis sixSire > 50-ze wT-Si;• gulmkerdis Cadreka;• Wheezing ar axasiaTebs.vi rusuli pne vmoniis ni Snebi• Cvilebi da adreuli asaki;25

• Wheezing;• cxeleba < 38,5 0 C;• gamoxatuli gulmkerdis Cadreka;• sunTqvis sixSire normaluri an momatebuli.at ipuri pn ev moniis niS nebi• skolis asaki;• Wheezing;• cxeleba < 38,5 0 C.diagnostikur-laboratoriuli testebi.sisxlis saerTo analizi (pirvel 24 saaTSi):baqteriuli pnevmoniis albaToba maRalia im bavSvebSi, romelTacaReniSnebaT maRali cxeleba, maRali leikocitozi (15 X 10 9 /l) daneitrofilozi.gulmkerdis rentgenografia• bavSvebSi, romlebTac aReniSnebaT pnevmoniis kardinaluri niSnebi daromelTa zogadi mdgomareoba ar aris mZime, gulmkerdisrentgenograma ar unda gakeTdes rutinulad.• gulmkerdis rentgenografia unda Catardes im SemTxvevaSi, rodesacsaxezea pnevmoniis urTierTgamomricxavi niSnebi, saeWvoa garTulebisarseboba eqsudaciuri plevritis saxiT an Catarebul mkurnalobazear aris saTanado pasuxi.• normaluri rentgenograma ar gamoricxavs pnevmoniis arsebobas.puls-oqsimetriapuls-oqsimetria, Jangbadis saturaciis gansazRvra, unda CautardespnevmoniiT hospitalizebul yvela pacients.mkurnaloba.bavSvTa asakis ambulatoriuli pnevmoniis mkurnaloba moicavs:5. antibiotikoTerapias;6. rehidratacias;7. temperaturisa da tkivilis marTvas.antibiotikoTerapia.antibiotikoTerapiis saWiroebis Sesaxeb gadawyvetilebis miRebamniSvnelovani sakiTxia. baqteriuli pnevmoniis (romelsac esaWiroebaantibiotikoTerapia) diferencireba virusuli pnevmoniisagan (romelicar saWiroebs antibiotikoTerapias) sakmaod rTulia. bavSvTa asakSivirusuli etiologiis pnevmoniis samkurnalod antibiotikoTerapiisgamoyeneba ar cvlis davadebis gamosavals.26

daavadebis msubuqi, gaurTulebeli mimdinareobisas rekomendebu-liaperoraluri antibiotikebis gamoyeneba.5 wlamde asakSi uxSires baqteriul gamomwvevs S. pneumoniaewarmoadgens, amitom mizanSewonilia amoqsicilinis gamoyeneba (25-50mg/kg/dReSi sam miRebaze).5 welze ufrosi asakis bavSvebSi uxSiresi gamomwvevi atipuripaTogenia (mikoplazma, qlamidia), amitom mizanSewonilia makrolidisgamoyeneba: azitromicini 3-5 dRe (sumamedi), spiramicini (rovamicini) 7-10dRe da sxva.Tu daavadeba mimdinareobs mZimed, avadmyofi ver iRebs peroralurantibiotikebs, daavadebis niSnebi grZeldeba 5 dReze meti (empiemisriskis zrda!) unda gamoviyenoT parenteraluri antibiotikebi. 5 wlamdeasakSi mizanSewonilia amoqsicilini an ampicilini, 5 wlis zemoTamoqsicilinis da makrolidis (azitromicini, spiramicini,klaritromicini) kombinacia. alternativas warmoadgens meore-mesameTaobis cefalosporini an e.w daculi penicilinebi (augmentini, unazini).farTo speqtris cefalosporinebi ar warmoadgenen pirveli rigispreparatebs. isini unda gamoviyenoT mxolod daavadebis mZimemimdinareobis dros.mdgomareobis gaumjobesebis SemTxvevaSi 2-4 dRis SemdegSesaZlebelia peroralur antibiotikze gadasvla.rehidrataciaCvilebi, romlebic ver iReben siTxis sadReRamiso moTxovnilebasda kargaven siTxes perspiraciis an Rebinebis gamo saWiroeben siTxisdamatebiT miwodebas.siTxis moTxovnileba (WHO)sxeulis wona siTxe (ml/dReSi)20 kg 50-90 ml/kgbavSvs unda miewodos siTxis meti raodenoba peroralurad,gaizardos ZuZeTi kvebis sixSire. Tu bavSvi iRebs adekvaturiraodenobis siTxes, ar aris mizanSewonili siTxis parenteraluradmiwodeba an nazogastraluri zondis gamoyeneba, romelic zrdisaspiraciuli pnevmoniis ganviTrebis risks.temperaturis da tkivilis kontrolipnevmoniis SemTxvevaSi bavSvebSi xSirad vlindeba febriliteti daTavis tkivili, arTralgia, muclis tkivili, tkivili gulmkerdis areSi27

(plevris gaRizianebis dros). plevruli tkivilis dros bavSvs uWirsRrma sunTqva da xvela. antipiretuli da tkivilgamayuCebelisaSualebebis gamoyeneba amcirebs diskomforts da xels uwyobs xvelisaqts. maRali temperatura (>38.5-39) bavSvebSi xSirad iwvevs madisdaqveiTebas, agznebas, zrdis Jangbadis moxmarebas da sxv. I rigisantipiretul saSualebas warmoadgens acetaminofeni (paracetamoli),romelic gamoiyeneba 2 Tveze meti asakis bavSvebSi Tu temperatura 38,5–ze metia. meore rigis preparatia arasteroiduli anTebis sawinaaRmdegosaSualebebi. ar aris mizanSewonili aspirinis gamoyeneba, vinaidan iszrdis reis daavadebis ganviTarebis risks.stacionarSi gadayvanis Sesaxeb gadawyvetilebis miRebisasgaTvaliswinebuli unda iyos Semdegi kriteriumebi:asaki 38.5 C), Rebineba da sakvebisa da siTxismiRebis SeuZlebloba;gaxSirebuli sunTqva cianoziT an mis gareSe;Tanmxlebi paTologia (imunodeficiti, filtvis qronikulipaTologia);socialur aspeqti – mSoblebis unari adekvaturad mouaron bavSvsbinaze;mZime respiraciuli distresi, romelic saWiroebs oqsigenoTerapias;ucvleli zogadi mdgomareoba 48 sT-iani antibiotikoTerapiisSemdeg.mSoblebs unda mieceT rekomendacia:• ganaxorcielon siTxis damatebiTi miwodeba;• akontrolon sxeulis temperatura;• dauyovnebliv mimarTon eqims, Tu bavSvs gamoexata Semdegi niSnebi:sunTqva ufro gauZnelda;daewyo FRebineba yoveli kvebis Semdeg;ver iRebs siTxeebs;gamoixata daTrgunva, Zilianoba;2 dRiani antibiotikoTerapiis miuxedavad maRalifebriliteti grZeldeba.28

pacientis binaze mkurnalobis SemTxvevaSi 48 saaTis Semdegaucilebelia ganmeorebiTi konsultacia. am periodSi dgindeba I rigisantibiotikis gamoyenebis efeqturoba. Tu pacientis mdgomareoba(obieqturad, laboratoriulad) ar umjobesdeba, rekomendebuliaantibiotikis Secvla meore rigis preparatiT.protokoli eyrdnoba saqarTvelos respiraciuli asociaciisbavSvTa pnevmoniis marTvis gaidlains.pn ev mon ia mo zrdilebSiSesavalisazogadoebaSi SeZenili pnevmonia erT-erT yvelaze gavrcelebuldaavadebas miekuTvneba. igi infeqciuri daavadebebs Sorissikvdilianobis erT-erT xSiri mizezia.daavadebis definiciapraqtikuli TvalsazrisiT, mniSvnelovania pnevmoniis dayofasazogadoebaSi SeZenil (ambulatorul) da nozokomiur tipebad. aseTidayofa ar aris dakavSirebuli daavadebis mimdinareobis simZimesTan.ZiriTad da erTaderT ganmasxvavebel kriteriumad gvevlineba isgaremoeba, sadac ganviTarda pnevmonia.29

sazogadoebaSi SeZenil pnevmoniaSi unda vigulisxmoT mwvavedaavadeba, 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, tkiviligulmkerdis areSi da rentgenologiuri niSnebi (filtvebSi axalikerovan-infiltraciuli cvlilebebi).epidemiologiaepidemiologiuri monacemebis Tanaxmad, pnevmoniis sixSireufrosebSi (>18 weli) farTo diapazonSi meryeobs: axalgazrda dasaSualo asakis pirebs Soris 1-11,6%-ia, ufros asakobriv jgufSi 25-44%.wlis ganmavlobaSi ufrosi asakSi (>18 weli) avadobis saerToraodenobam 5 evropul 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 hospitalizebul iqna 9.757 pnevmoniiT avadmyofi,maCvenebeli 100.00 mosaxleze 223, letaloba – 0,8%.pnevmoniis dros letaloba Zalian dabalia (1-3%). Tumca 60 welzemeti asakis pacientebSi, seriozuli Tanmxlebi paTologiebisarsebobisas (f.q.o.d., avTvisebiani axali warmonaqmnebi, alkoholizmi,Saqriani diabeti, RviZlisa da Tirkmelebis daavadebebi, gulsisxlZarRvTadaavadebebi da a.S.), aseve pnevmoniis mZimedmimdinareobisas (multilobaluri infiltracia, meoradi baqteriemia,sunTqvis sixSire>30/wT, hipotenzia da Tirkmlebis mwvave ukmarisoba),letalobis maCvenebeli 15-30%-s aRwevs.letalobis riski, romelic moicavs anamnezur, obieqtur dalaboratoriul monacemebs, warmodgenilia I cxrilSi. letalobis erTerTmniSvnelovani faqtoria gviani mimarTva samedicinodaxmarebisaTvis.monacemebidemografiamamrobiTi sqesiZiriTadi daavadebis istoriagadaciebafsiqikuri statusis SecvlaqoSiniTanmxlebi daavadebebigulis qronikuli ukmarisobaimunodeficituri mdgomareobaSaqriani diabeticxrili 1albaToba1,3 (1,2-1,4)0,4 (0,2-0,7)2,0 (1,7-2,3)2,9 (1,9-3,8)2,4 (2,2-2.5)1,6 (1,3-1,8)1,2 (1,3-1,4)30

koronarul sisxlZarRvTa dazianebaonkologiuri daavadebebinevrologiuri daavadebebiTirkmlis paTologiebifizikuri gamokvlevebitaqipnoehipoTermiahopotenzialaboratoriuli gamokvlevebisisxlis Sardovana (>7,14mm.Hg.)leikopenia (10×10 9/l)hipoqsemia (PaO 2

mniSvnelobas. 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. TerapiulganyofilebaSi hospitalizebul pacientebSi pnevmokokebis, mikoplazmebisda qlamidiebis wilze modis daaxloebiT 25%. am ukanasknelebs arsebiTimniSvneloba ara aqvT pnevmoniis mZime formebis ganviTarebaSi. amavedros, am kategoriis pacientebSi matulobs Legionella spp., S.aureus,gramuaryofiTi enterobaqteriebis, 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.pnevmoniis gamomwvevi da letalobacxrili 2gamomwvevi 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%pacientebis jgufebi da gamomwvevebicxrili 3jgufi pacientis daxasiaTeba gamomwvevebi1 pnevmoniis aramZimed mimdinareoba 60 wl-ze S.pneumoniaeqvemoT pacientebSi Tanmxlebi paTologiis M.pneumoniagareSe2 daavadebis mZime mimdinareoba 60 wl-is zemoTda/an Tanmxlebi paTologiebiT3 pnevmoniis mZime mimdinareoba, hospitalizebulipacientebi (saerTo profilisganyofilebaSi)4 pnevmoniis mZime mimdinareoba, hospitalizebulipacientebi (intensiuri TerapiisganyofilebaSi)C.pneumoniaeS.pneumoniaeH.influenzaeC.pneumoniaeS.aureusEnterobacteriaceaeS.pneumoniaeH.influeanzaeC.pneumoniaeS.aureusEnterobacteriaceaeS.pneumoniaeLegionella sppS.aureusEntarobacteriaceae32

pnevmoniis gamomwvevebicxrili 4gamomwvevi literaturis mixedviT meta-analizibaqteriebiS.Pneumoniae20-6065H.influenzae3-1012S. aureus3-52atipuri10-20 12gamomwvevivirusi 2-15 3aspiraciuli6-10pnevmoniadaudgeneli30-60etiologiapaTogenezisasunTqi gzebis qveda nawilebis infeqciisagan dacvas axorcielebenmeqanikuri faqtorebi (aerodinamikuri filtracia, bronqebis meqanikuriganStoeba, xvela da cemineba, mocimcime epiTeliumis wamwamebis rxeva),aseve araspecifiuri da specifiuri imunitetis meqanizmi. anTebiTireaqciis ganviTarebis mizezi SesaZloa gaxdes rogorc makroorganizmsdacviTi meqanizmebis efeqturobis daqveiTeba, aseve mikroorganizmebisdozis masiuroba da/an maTi moWarbebuli virulenturoba. SesaZloagamoiyos 4 paTogenezuri meqanizmi (ZiriTadad vlindeba pirveli ori),romlebic ganapirobeben pnevmoniis ganviTarebas:• aspiracia;• mikroorganizmebis Semcveli haeris CasunTqva;• mikroorganizmebis hematogenuri gavrceleba arafiltvismierikerovani infeqciisganE(endokarditi, septiuri Tromboflebiti);• infeqciis gavrceleba uSualod mezobeli dazianebuli kerebisagan(mag. Tirkmlis abscesis dros) an gulmkerdis SemavaliWrilobebis inficirebis Sedegad.aspiracia_inficirebis mTavari gzaa pnevmoniis paTogenezSi.normalur pirobebSi, mikroorganizmebis nawils, magaliTad Streptococcuspneumoniae, SeuZliaT pirxaxis kolonizireba, Tumca sasunTqi gzebisqveda nawilebi steriluri rCeba. mozrdilTa naxevarSi Zilis drospirxaxis sekretis mikroaspiracia fiziologiuri fenomenia. erTi mxriv,xvelis refleqsi, mukociliaruli klirensi, alveoluri makrofagebisantibaqteriuli aqtivoba da, meore mxriv, sekretuli imunoglobulinebiuzrunvelyofen inficirebuli sekretis eliminacias sasunTqi gzebisqvemo nawilebidan da maT sterilurobas.33

traqeobronquli xis TviTgamwmendi meqanizmis dazianebisas, mag.,respiraciuli virusuli infeqciis dros, roca irRveva bronqebiswamwamovani epiTeliumis funqcia da qveiTdeba alveoluri makrofagebisfagocituri aqtivoba, pnevmoniis ganviTarebisaTvis sasurveli pirobebiiqmneba. sxva SemTxvevaSi, paTogenezuri faqtori SesaZloa iyosmikroorganizmebis dozis masiuroba an erTeuli maRaldiferenciulimikroorganizmebis SeRweva sasunTq gzebSi.mikrobuli aerozolis inhalacia pnevmoniix SedarebiT iSviaTimizezia. is mTavar rols TamaSobs obligaturi gamomwvevebiT sasunTqigzebis qveda nawilebis inficirebaSi. kidev ufro naklebi mniSvnelobaaqvs infeqciis keridan gamomwvevis hematogenur (mag., Staphylococcus spp.)gavrcelebas. Apnevmoniis paTogenezis aRwerili TaviseburebisgaTvaliswinebiT aSkaraa, rom misi etiologia sasunTqi gzebis zedanawilebis mikroflorasTan aris dakavSirebuli, romlis Semadgenlobacdamokidebulia garemoze, pacientis asakze da janmrTelobis saerTomdgomareobaze. .klinikuri simptomatika:pnevmoniis ZiriTadi ZiriTadi klinikuri niSnebi da simptomebiSesaZloa formulirdes Semdegi saxiT:• daavadebis kliniko-rentgenologiuri suraTis analizis safuZvelzeumetes SemTxvevaSi ar xerxdeba pnevmoniis etiologiis gansazRvra.• pnevmoniix iseTi niSnebi, rogoricaa cxeleba, tkivili gulmkerdisareSi da sxv. SesaZloa ar aRiniSnebodes, gansakuTrebiT garTulebulSemTxvevebSi da moxucebSi. 65 wlis zemoT daaxloebiT 25%-Si araRiniSneba cxeleba, leikocitozi ki aRiniSneba mxolod 50-70%-Si.klinikuri suraTi SeiZleba warmodgenili iyos daRlilobiT, saerTosisustiT, gulisreviT, anoreqsiiT, tkiviliT mucelSi, cnobierebisdakargviT.• pnevmokokisaTvis, aseve mikoplazmisa da qlamidiisaTvis, ar arisdamaxasiaTebeli destruqciis ganviTareba. aseT dros xSiriastafilokokuri infeqciebi, gramuaryofiTi aerobuli baqteriebi daanaerobebi.• mikoplazmuri pnevmoniisaTvis damaxasiaTebelia filtvis bazaluriwilebis retikulo-nodularuli infiltracia.pnevmoniaze eWvi unda mivitanoT im pacientebSi, romelTacaReniSnebaT qoSini cxelebasTan erTad, naxvelis gamoyofa da/an tkiviligulmkerdis areSi. avadmyofi, romelmac gadaitana pnevmonia, xSirad34

uCivis aramotivirebul sisustes, daRlilobas da RamiT Zlieroflianobas.pacientis fizikuri gamokvlevebiT miRebuli informacia,damokidebulia bevr faqtorze: daavadebis simZime, pnevmoniuriinfiltraciis gavrceleba, asaki, Tanmxlebi avadmyofobebis arseboba.klasikur obieqtur niSans warmoadgens dazianebuli segmentis donezeperkusiuli xmianobis Sesusteba, lokalurad bronquli sunTqva,wvrilbuStukovani xixini an krepitacia, bronqofoniis gaZliereba.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%.garTulebebi•plevraluri 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-destruqciuligarTulebebi.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. arCevis antibiotikia amoqsicilini/klavulantiintravenurad. alternatiul preparats miekuTvneba: III Taobis35

cefalosporinebi, ciprofloqsacini da levofloqsacini,metronidazoli an karbapenemi. mkurnalobis xangrZlivoba moicavs 3-4kviras.plevris empiema (Cirqovani plevriti). damaxasiaTebelia Cirqisdagroveba plevris RruSi. ZiriTad gamomwvevebs miekuTvneba anaerobebiSerwymuli gram-uaryofiT aerobul baqteriebTan. saWiroa dainiSnossavaraudo gamomwvevis (S.pneumoniae, S.pyogenus, S.aureus, H.influenzae) mimarTaqtiuri antibiotikebi, upirvelesad III-IV Taobis cefalosporinebi.empiemis qvemwvave/qronikuli mimdinareobis dros xSiradetiologiuri mniSvneloba aqvs anaerobul streptokokebs da gramuaryofiTenterobaqteriebs. aseT SemTxvevebSi gamoiyenebaamoqsicilini/klavulanti, alternativas warmoadgens III-IV Taobiscefalosporinebi, karbapenemebi. rogorc wesi, antibaqteriulmkurnalobasTan erTad saWiroa Torakotomiuri drenireba da, iSviaTSemTxvevaSi, Torakotomia. filtvis abscesis mkurnalobaSiperspeqtiul preparats warmoadgens ampicilin/sulbaqtami, romelsacgaaCnia maRali aqtivoba anaerobebis mimarT.diagnozi, diferenciuliDdiagnozi, simZimis Sefasebapnevmoniis sadiagnostiko kriteriumebs miekuTvnebarentgenologiurad pacientis filtvis qsovilis dazianebuli kerovaniinfiltracia da Semdegi niSnebidan ori niSnis arseboba (mtkicebulebaA):• 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 diagnostika xdebaepidanamnezis, Civilebis da lokaluri simptomebis mixedviT, Tumcadiagnozi SeiZleba iyos arazusti (mtkicebuleba A).pnevmoniis nozologiuri diagnozis dasmis dros aucilebeliagaTvaliswinebuli iyos pnevmoniis klinikis da etiologiis kavSiri(mtkicebuleba B da C ). ase magaliTad, pnevmokokuri pnevmoniisaTvisdamaxasiaTebelia mwvave dasawyisi, maRali cxeleba, gulmkerdis tkivili.legionelurisaTvis: diarea, nevrologiuri simptomatika, daavadebis mZimemimdinareoba, Tirkmlis funqciis darRveva. mikoplazmurisTvis: kunTebisda Tavis tkivili, zeda sasunTqi gzebis infeqciis simptomebi.36

mowodebulia algoritmi, romelic asaxavs pnevmoniis garTulebisda letaluri gamosavalis ganviTarebis risks:pnevmoniaaraasaki 50 wlis zemoTaraTanarsebuli daavadebebiavTvisebianiaxalwarmonaqmnebigulis SegubebiTiukmarisobacerebrovaskularulidaavadebebiTirkmlis daavadebebiRviZlis daavadebebimaRali riski(letaloba 0,5-29%)araobieqturi dalaboratoriuli darRvevebicnobierebis darRvevapulsi ≥ 125sunTqvis sixSire ≥ 30sistoluri wneva < 90mm.vcx.svtemperatura < 35C an ≥40 Caradabali riski(letaloba 0,1%)gamokvlevis sqemalaboratoriuli diagnostikasisxlis analizi pnevmoniis gamomwvevis gansazRvris saSualebas argvaZlevs, Tumca leikocitozi 12-15×10 9 /l da meti migviTiTebs baqteriuliinfeqciis maRal albaTobaze. 3×10 9 /l-ze dabali leikopenia an 25×10 9 /l-zemaRali leikocitozi arasaxarbielo prognozuli niSania.37

mikrobiologiuri diagnostikis Sedegianoba didad arisdamokidebuli klinikuri masalis aRebis sisworeze. yvelaze xSiradgamosakvlevi masala naxvelia.naxveli aucilebelia Segrovdes diliT sakvebis miRebamde;naxvelis Segrovebamde aucilebelia kbilebis gaxexva, loyebis Sidagarsis gawmenda da pirSi wylis gamovleba;pacientebs aucilebelia mivceT instruqcia Rrma amoxvelebisaucileblobaze, rom miviRoT is SigTavsi, rac sasunTqi gzebis qvedanawilebSia da ara pirsa da cxvir-xaxaSi;naxvelis Segroveba aucilebelia sterilur konteinerSi, romelicmikrobiologiur laboratoriaSi unda iqnes mitanili 2 saaTisganmavlobaSi.mikrobiologiuri gamokvlevebis pirvel etapad gvevlineba naxvelisSeRebva gramis wesiT. 25-ze naklebi polimorfulbirTviani leikocitebisda 10-ze meti epiTeluri ujredebis arsebobisas Seswavlili masalamniSvnelovnad kontamizirebulia piris garsis SemadgenlobiT.Nnaxvelis baqterioskopiis da kulturaluri gamokvlevebis Sedegebisinterpretacia unda moxdes klinikuri monacemebis gaTvaliswinebiT.laboratoriuli masalis (sisxli, naxveli) mikrobiologiurigamokvlevebi antibaqteruli Terapiis Seferxebis mizezad ar unda arunda gvevlinebodes.infeqciis serologiuri diagnostika (sisxlis Sratis aRebadaavadebis mwvave da Semdeg rekonvalescenciis periodSi, daavadebisdawyebidan ramdenime kviris Semdeg), hospitalizebul avadmyofTagamokvlevebis aucilebel meTodad ganixileba.diagnostikis invaziuri meTodebi: fibrobronqoskopia an invaziuridiagnostikis sxva meTodebi (transtraqealuri aspiracia,transTorakaluri biofsia da a.S.) rekomendebulia mxolod filtvebistuberkulozze an bronqogenul karcinomaze eWvis dros.rentgenologiuri kvlevapnevmoniis diagnostika praqtikulad yovelTvis gulisxmobsfiltvebSi kerovan-infiltraciuli cvlilebebis aRmoCenas, Serwymulsqvemo sasunTqi gzebis infeqciasTan. rentgenografia gvaZlevs asevesaSualebas SevafasoT paTologiuri procesis dinamika. cvlilebebirentgenogramaze (infiltraciis gavrceleba, plevraluri gamonadeni,Rrus destruqcia) Seesabameba daavadebis simZimes da gvexmarebaantibaqteriuli mkurnalobis SerCevaSi.38

mxedvelobaSi unda miviRoT, rom gulmkerdis rentgenografiiTyovelTvis ver xerxdeba infiltraciuli keris vizualizacia, aseT drosgamarTlebulia kompiuteruli tomografiis daniSvna:pacientSi, pnevmoniis aSkara klinikuri simptomatikiT, magramSeusabamo rentgenogramiT;rodesac rentgenogramaze savaraudo pnevmoniiT, aReniSneba amdaavadebisaTvis aratipuri cvlilebebi (obturaciuli ateleqtazi,filtvebis infarqti filtvis arteriis TromboemboliursafuZvelze, filtvis abscesi da a.S.)morecidive pnevmoniis dros, romlis drosac infiltraciulicvlilebebi warmoCindeba imave wilSi (segmentSi), rac daavadebiswina epizodSi;gaxangrZlivebuli pnevmoniis dros, rodesac infiltraciulicvlilebebis xangrZlivoba filtvis qsovilSi aRemateba 4 kviras.mkurnalobis sqemaZiriTadi 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),aseve amoqsicilinis kombinacias laqtamazas ingibitorebTan(amoqsicilini/klavulanti). amoqsicilins axasiaTebs maRal aqtivobasS.pmeunomiae mimarT, moqmedebs H.influenzae Stamebze. ampicilinTanSedarebiT gaaCnia ufro maRali bioSeRwevadoba sakvebis miRebisagandamoukideblad, iSviaTad iwvevs arasasurvel movlinebs kuW_nawlavismxriv. amoqsicilini da amoqsicilin/klavulanti inarCunebs aqtivobaspenicilin-rezistentuli Stamebis mimarT. amoqsicilin/klavulantisforma, amoqsicilinis momatebuli doziT da klavulantis naklebiwiliT (875/125mg) saSualebas gvaZlevs gamoviyenoT preparati 2-jerdReSi. B-laqtamebis ZiriTad uaryofiT Tvisebaa atipiurimikroorganizmebis mimarT aqtivobis ararseboba.mZime pnevmoniis mkurnalobaSi gamoiyeneba III-IV Taobiscefalosporinebi: ceftriaqsoni, cefuroqsimi, cefotaqsimi, cefepimi.ceftriaqsoni xasiaTdeba naxevardaSlis xangrZlivi periodiT, racsaSualebas gvaZlevs gamoviyenoT dReSi erTjer.benzilpenicilini inarCunebs maRal aqtivobas pnevmokokebTandamokidebulebaSi. cefuroqsimi da amoqsicilin/klavulanti (augmentini),39

aseve ampicilini/sulbaqtami (unazini) SeiZleba gamoyenebul iqnas,rogorc safexureobrivi Terapia pnevmoniis gamo hospitalizebulpirebSi.makrolidebis Rirsebad warmoadgens maRali aqtivoba S.pneumoniaeis,atipuri mikroorganizmebis mimarT. azitromicini da spiramiciniaqtiurni arian H. ineluenzae mimarT. Tanamedrove makrolidebi kargadgadian bronqul sekretSi da filtvis qsovilSi, xasiaTdebianusafrTxoebiT da araalergiulobiT. pnevmoniis mkurnalobaSi arCevispreparatebia azitromicini, spiramicini, klaritromicini,roqsitromicini. maT Soris inficirebul filtvis qsovilSi daalveolarul makrofagebSi yvelaze maRali koncentacias aRwevsspiramicini (rovamicini).ftorqinolonebimocemuli jgufis preparatebs Soris, sayuradReboa II-III Taobisftorqinolonebi (ciprofloqsacini, ofloqsacini levofloqsacini, dasxv.). am jgufisagan gansakuTrebiT aRsaniSnavia III Taobis, e.w.“respiraciuli ftorqinoloni” – levofloqsacini (tavaniki). ismoqmedebs gram-dadebiT da gram-uaryofiT gamomwvevebze, penicilinrezistentulebisCaTvliT. misi aqtivoba mikoplazmasTan, qlamidiebTan,legionelebTan da mimarTebaSi arsebiTad maRalia e.w. “klasikur”, IITaobis ftorqinolonebTan SedarebiT. preparati iniSneba 1-jer dReSi,damaxasiaTebelia maRali koncentracia da bioSeRwevadoba,gaxangrZlivebuli naxevardaSlis periodi. peroraluri daparenteraluri levofloqsacini hospitalizebul pacientebSi pnevmoniissafexureobrivi mkurnalobis saSualebas gvaZlevs. evropuli daamerikuli 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 atipuri mikroorganizmebismimarT.sxva jgufis preparatebikarbapenemebs Soris yvelaze perspeqtiul saSualebas warmoadgensertapenemi. aqtivobis da gramdadebiT da gramuaryofiTmikroorganizmebTan urTierTobis mixedviT is utoldeba imipenems dameropenems. preparatis klinikuri da mikrobiologiuri efeqturobadamtkicebulia hospitalizirebul pacientebSi. misi Rirsebaa miRebissixSire dReSi erTjer. linezolidi da ertapenemi ar arian aqtiurni40

atipiuri gamomwvevebis mimarT (M.pneumoniae, Chlamydophila pneumoniae,Legionella spp.)antimikrobuli saSualebebis axali samkurnalo formebigemifloqsacini (saqarTveloSi registrirebuli ar aris)warmoadgens ftorqinolonebis axal peroralur saSualebas,damaxasiaTebeli maRali aqtivobiT S.pneumoniae da sxva gramdadebiTi dagramuaryofiTi mikroorganizmebis, aseve atipuri gamomwvevebis mimarT.hospitalizebul pacientebSi efeqturobis mixedviT ar Camouvardebaceftriaqsoni/cefuroqsimi+makrolidi kombinacias.telitromicini (keteki) warmoadgens pirvel preparats ketolidebisjgufidan (saqarTveloSi registrirebuli ar aris), misi aqtiurobisspeqtri makrolidebis Tanabaria, Tumca is ufro aqtiuria gram-dadebiTimikroorganizmebis mimarT, S.pneumomiae Stamebis CaTvliT. preparatixasiaTdeba xangrZlivi naxevardaSlis periodiT: miiReba 1-jer dReSi.2004 wlisTvis daregistrirda azitromicinis i/v samkurnalo forma;rekomendirebuli doza Seadgens 0.5g-s dReSi 1-jer.mizanmimarTuli etiotropuli mkurnaloba.S.pneumoniae - arCevis preparatia benzilpenicilini, aminopenicilini(ampicilini/sulbaqtami, amoqsicilin/klavulanti) da II-III Taobiscefalosporinebi (cefotaqsimi, ceftriaqsoni). maT mimarT alergiisSemTxvevaSi arCeviT an alternatiul preparatebs warmoadgenenmakrolidebi. S.pneumoniae–is mimarT maRali aqtivobiT xasiaTdeba aseverespiraciuli ftorqinolonebi (levofloqsacini, mikrofloqsacini),vankomicini da linezolidi. aminoglikozidebi (gentamicini da sxv.) argamoiyeneba S.pneumoniae-is samkurnalod.H.influenzae-is mkurnalobis arCeviT preparats warmoadgensaminopenicilini (amoqsicilini, ampicilini-parenteralurad),amoqsicilin/klavulanti (aqtiuria β-laqtamazas Stamebis mimarT), II-IIITaobis cefalosporinebi, ftorqinolinebi (levofloqsaciniciprofloqsacini, ofloqsacini).M.pneumoniae, C.pneumoniae, Legionella spp.: atipuri gamomwvevebis mimarTaqtiuria makrolidebi, tetraciklini (doqsiciklini), respiraciuliftorqinolinebi (levofloqsacini, mikrofloqsacini).S.aureus: oqsacilini, alternatiuli SesaZloa iyosamoqsicilin/klavulanti. I Taobis cefalosporinebi, linkozamidi.rekomendebulia aseve vankomicini da linezolidi.41

Enterobacteriaceae: am gamomwvevis mimarT maRali aqtivobiT xasiaTdebaamoqsicilin/klavulanti, II-IV Taobis cefalosporinebi, karbapenebi,ftorqinolonebi.mkurnalobis adgilis arCeva.pnevmoniis mkurnaloba SesaZlebelia saxlis pirobebSi.gansakuTrebiT mniSvneloba aqvs hospitalizaciis kriteriumisgansazRvras. cnobilia rigi klinikur-laboratoriuli Skalebi,romlebic dafuZnebulia pnevmoniis simZimis Sefasebasa da/an prognozze.yvelaze gavrcelebuli Skalaa PORT (Pneumoniae Outcomes Research Team),romelic iTvaliswinebs 20 klinikur da laboratoriul parametrs,romelTa safuZvelzec dgindeba pnevmoniis simZimis indeqsi (PSI: PneumoniaSeveriti Index), xdeba letalobis riskis prognozireba da mkurnalobisadgilis gansazRvra. PSI-is gansazRvrisaTvis aucilebelia mTeli rigibioqimiuri parametrebi, Sardis analizi, natriumi, glukoza, hematokriti,arteriuli sisxlis PH, rac yovelTvis ar aris SesaZlebeliambulatorul-poliklinikur dawesebulebaSi.dResdReobiT, pnevmoniis mkurnalobis adgilis gansazRvradakavSirebulia prognozuli Skalis CURB-65/CRB-65 gamoyenebasTan.britanuli Torakaluri sazogadoebis modificiuri Skala iTvaliswinebs5 an 4 parametrs:1 C cnobierebis dakargva2 U sisxlis SardmJava azoti > 7mmol/l3 R sunTqvis sixSire > 30/wT4 B dabali sistoluri (30/wT: diastoluri wneva < 60 mm.vcx. sv;sistoluri wneva < 90 mm.vcx.sv; guliscemis sixSire > 125/wT,temperatura 40.0; cnobierebis darRveva.42

laboratoriuli da rentgenologiuri monacemebi: periferiulsisxlSi leicocitebis 25,0*10 9/l; PaO250mmHg. oTaxis haeris sunTqvis dros; kreatinini sisxlisSratSi > 176,7 mkmol/l an azoti SardSi > 7,0mmol/l; pnevmoniuriinfiltracia lokalizebiT erTze met wilSi; plevralurigamonadenis arseboba; kerovan-infiltraciuli cvlilebebisfiltvebSi swrafad gavrceleba (infiltraciis zomebis zrda >50%uaxloesi 2 dRis manZilze).hematokriti

•sisxlSi leikocitebis, neitrofilebis normalizacia;•rentgenogramaze uaryofiTi dinamikis ararseboba.klinikuri, laboratoriuli an rentgenologiuri niSnebisSenarCuneba warmoadgens antibaqteriuli Terapiis gagrZelebis an misimodifikaciis absolutur Cvenebas. rentgenografiuli kontroli arwarmoadgens antibaqteriuli Terapiis xangrZlivobis gansazRvriskriteriums.mZime mimdinareobis kriteriumebi da reanimaciisa daintensiuri Terapiis ga nyofilebaSi pacientis ga dayvanisaucileblobastacionarSi moTavsebis dros aucilebelia pirvel rigSi Sefasdesmisi mdgomareobis simZime da gadawydes mkurnalobis adgilis sakiTxi(zogadi Terapiis Tu reanimaciis ganyofileba). mZime formis pnevmoniavlindeba sunTqvis ukmarisobiT da/an mZime sefsisis simptomebiT anseptiuri SokiT, xasiaTdeba cudi prognoziT da moiTxovs intensiurTerapias.antibaqteriuli Terapiis SerCevapnevmoniis mZime mimdinareobis dros mizanSewonilia Terapiadaiwyos parenteraluri antibiotikebiT 3-4 dRis ganmavlobaSi,temperaturis normalizaciis, intoqsikaciis da daavadebis sxvasimptomebis Semcirebamde. mkurnalobis sruli kursis damTavrebamdeSesaZloa gadasvla parenteraluridan peroralur mkurnalobaze.hospitalizebul pacientebSi pnevmoniis saSualo simZimis drosrekomendebulia benzilpenicilinis, ampicilinis, daculiaminopenicilinebis (amoqsicilin/klavulanti, ampicilin-sulbaqtami), II-IIITaobis cefalosporinebis parenteraluri miReba an “respiraciuliftorqinolonebi” – levofloqsacini. rigi kvlevebiT, atipurimikroorganizmebis mimarT aqtiuri antibiotikebiT Terapiis dawyebaamcirebs pacientis stacionarSi dayovnebis xangrZlivobas.pnevmoniis mZime formis dros antibiotikis daniSvna unda moxdesswrafad, dagvianeba arsebiTad auaresebs process. arCeviT preparatswarmoadgens II-III Taobis cefalosporinebis i/v daniSvna, daculipenicilini (amoqsicilini/klavulanti) kombinaciiT makrolidebTan(azitromicini, spiramicini, klaritromicini) da “respiraciuliftorqinoloni” – levofloqsacini. aRniSnuli antibiotikebi anantibiotikebis kombinaciebi praqtikulad Trgunaven pnevmoniispotenciuri gamomwvevebis mTel speqtrs (rogorc tipurs, ise atipurs).klasikuri ftorqinolonebi (ciprofloqsacini da sxv.) sustiantipnevmokokuri aqtivobiT xasiaTdebian. upiratesoba miekuTvneba44

espiraciuli ftorqinolonebis (levofloqsacini, mikrofloqsacini) i/vgamoyenebas. isini xasiaTdebian gazrdili antipnevmokokuri aqtivobiT dafaraven gamomwvevebis praqtikulad mTel speqtrs. mZime mimdinareobisdros SesaZlebelia maTi kombinacia cefalosporinebTan (cefotaqsimi,ceftriaqsoni).gaxangrZlivebuli antibaqteriuli mkurnalobaaramZime pnevmoniis dros antibaqteriuli mkurnaloba SesaZloaSewydes sxeulis temperaturis normalizaciis miRwevidan 3-4 dRismanZilze. am midgomiT mkurnalobis xangrZlivoba Seadgens 7-10 dRes.dauzustebeli etiologiis SemTxvevaSi, rekomendirebulia 10-dRianikursi. amave vadebSi aRiniSneba leikocitebis gaqroba. mikoplazmuri daqlamidiuri etiologiis pnevmoniis dros antibaqteriuli mkurnalobaunda gagrZeldes 14 dRes, Tumca arsebobs klinikuri monacemebi Sedegisufro mokle droSic miRwevis Sesaxeb. ufro xangrZlivi Terapia (14dRidan 21 dRemde) naCvenebia stafilokokuri etiologiis angramuaryofiTi enterobaqteriebiT gamowveuli pnevmoniis dros.pnevmoniis safexureobrivi mkurnalobasafexureobrivi antibiotikoTerapia iTvaliswinebs antibiotikebismiRebas 2 etapad: mkurnalobis dawyeba parenteraluri preparatebiT daSemdeg gadasvla peroralur miRebaze, rogorc ki stabilizirdebaklinikuri mdgomareoba. safexureobrivi mkurnalobis ZiriTadi ideaparenteraluri antibaqteriuli Terapiis Semcirebaa, rac uzrunvelyofsstacionarSi dayovnebis xangrZlivobis Semcirebas. optimalur variantswarmoadgens erTi da igive antibiotikis 2 samkurnalo formis(parenteraluris da peroraluris) gamoyeneba. parenteraluridanoralurze gadasvla unda moxdes pacientis mdgomareobis stabilizaciisda klinikuri suraTis gaumjobesebis dros.mizanSewonilia gamoviyenoT Semdegi kriteriumebi:•temperaturis normalizacia (

peroraluri samkurnalo forma, SeiZleba Secvla monaTesaveantimikrobuli speqtris preparatebiT.dResdReobiT ar arsebobs monacemebi biogenuri stimulatorebis,antihistaminuri preparatebis, vitaminebis, imunomodulatorebis daarasteroiduli anTebis sawinaaRmdego saSualebebis da aranarkotikulianalgetikebis daniSvnis saWiroebis Sesaxeb. dasaxelebuli samkurnalosaSualebebis efeqturoba da usafrTxoeba ar aris dazustebulirandomizirebuli klinikuri gamokvlevebiT.prevenciapnevmoniis profilaqtikis mizniT gamoiyeneba pnevmokokuri dagripuli vaqcina. pnevmokokuri vaqcinis gamoyenebis mizanSewonilobaaixsneba imiT, rom dResdReobiT S.pneumoniae pnevmoniis wamyvangamomwvevad rCeba. gripuli vaqcinis efeqturoba moxucebSi sakmaodmaRalia. vaqcinaciis mizanSewonilia Semdegi jgufis pirebSi:•50 wlis zemoT;•pirebi, romlebic xangrZlivad cxovroben moxucTa saxlSi;•pacientebi filtvebis qronikuli, bronqebis da gulsisxalZarRvTadaavadebebiT;•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.pnevmoniis ma rTvis algoritmisamedicino dawesebulebaSi mimarTvadiagnozis rentgenologiuri dadasturebadaavadebis gamosavalis riskis Sefaseba46

dabali riski(mkurnalobasaxlis pirobebSi)maRali riski(mkurnalobastacionarSi)sisxlis daTesvanaxvelis daTesvagamomwveviganisazRvraeTiotropuliantibiotikoTerapiagamomwvevi verganisazRvraintensiuri Terapiis gan-ba:beta-laqtamebi + makrolidebian respiraciuliftorqonoloniTerapiuli gan-ba:respiraciuli ftorqonolonianbeta-laqtamebi + makrolidebirespiraciuli ftorqonolonian makrolidebipnevmokokze eWvis dros:amoqsicilini, cefuroqsimi,amoqsicili/klavulanati,ampicilini/sulbaqtamiperoralur antibiotikzegadasvlis Cveneba: SenarCunebuligastrointestinaluri Sewova +temperatura < 38-ze; R

• hospitalur (nozokomiur) pnevmonias;• imunodeficitis fonze ganviTarebul pnevmonias.damadasturebeli kriteriumebi:Civilebi: respiraciuli niSnebi (xvela naxveliT an mis gareSe),cxeleba, intoqsikaciis gamovlinebani.obieqturi: lokaluri krepitacia, perkutoruli xmianobis moyrueba.laboratoriul-instrumentuli: cvlilebebi sisxlis analizSi(leikocitozi baqteriuli pnevmoniis dros) da retngenologiuradkerovani infiltraciis niSnebis arseboba.klinikuri simptomebi da niSnebipnevmoniaze eWvi unda mivitanoT im pacientebSi, romelTacaReniSnebaT cxeleba Serwymuli qoSinTan, naxvelis gamoyofasTan da/antkivilTan gulmkerdis areSi. avadmyofi, romelmac gadaitana pnevmonia,xSirad uCivis aramotivirebul sisustes, daRlilobas da RamiT Zlieroflianobas. klasikur obieqtur niSans warmoadgens dazianebulisegmentis doneze perkusiuli xmianobis Sesusteba, lokaluradbronquli sunTqva, wvrilbuStukovani xixini an krepitacia,bronqofoniis gaZliereba.• umetes SemTxvevebSi, daavadebis klinikur-rentgenologiurisuraTis analizis safuZvelze ar xerxdeba pnevmoniis etiologiisgansazRvra.• pnevmoniis iseTi niSnebi, rogoricaa mwvave 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 mikoplazmebisa da qlamidiebisaTvis, araris damaxasiaTebeli destruqciis ganviTareba. aseT dros xSiriastafilokokuri infeqciebi, gram-uaryofiTi aerobuli baqteriebida anaerobebi.• mikoplazmuri pnevmoniisaTvis damaxasiaTebelia filtvisbazaluri wilebis retikulur-nodularuli infiltracia.pnevmoniis simptomTa sixSire anamnezuri da fizikaluri monacemebismixedviT Semdegia:• xvela, cxeleba, taqikardia, xixini – 22-48%-Si;• mxolod xvela – 2-15%;48

• perkusiuli xmianobis moyrueba – 12-20%;• mxolod xixini – 15-17%;• mxolod cxeleba – 5-20%;• mxolod taqikardia – 8-13%.pn evmoniis garTulebebi• plevruli gamonadeni;• plevris empiema;• filtvis qsovilis destruqcia/abscedireba;• mwvave respiraciuli distress-sindromi;• sunTqvis mwvave ukmarisoba;• septiuri Soki;• meoradi baqteriemia, sefsisi;• perikarditi, miokarditi;• nefriti da sxv.diagnostikur-laboratoriuli testebi da specialistTakonsultaciebi:a) pirvel 4 saaTSi• sisxlis saerTo analizi;• gulmkerdis organoebis rentgenologiuri kvleva(rentgenografia, rentgenoskopia)b) pirvel 24 saaTSi• sisxlis saerTo analizi;• Sardis saerTo analizi;• gulmkerdis rentgenologiuri kvleva;• ekg.g) pirvel 3 dReSi• sisxlis saerTo analizi;• Sardis saerTo analizi;• gulmkerdis rentgenologiuri kvleva;• ganavlis analizi Wiis kvercxebze;• piris Rrusa da naxvelis nacxis analizi meoradfloraze da antibiotikograma;49

• naxvelis analizi mgb-ze da citologia;• ekg;• ultrabgeriTi kvleva.specialistTa konsultacia:• yel-yur-cxviris specialisti;• kardiologi, qirurgi, fTiziatri da a.S. (CvenebismixedviT).mkurnalobaa) I alternativa (gaurTulebeli SemTxveva)antibiotikoTerapia: penicilinis jgufi, SesaZlebelia, klavulinismJavasTan erTad kombinaciaSi; makrolidebi da I Taobiscefalosporinebi. zemoT aRniSnul mkurnalobaSi SesaZlebelia CaerTossimptomuri saSualebebi (temperaturis damwevi, amosaxvelebeli, sagulesaSualebebi da a.S.).b) II alternativa (garTulebuli SemTxveva, Tu hospitalizaciaSeuZlebelia)antibiotikoTarapia: penicilinis jgufi, SesaZlebelia klavulinismJavasTan erTad kombinaciaSi; III Taobis cefalosporinebi;respiraciuli ftorqinolonebi; aminoglikozidebi; karbapenemi.SesaZlebelia kombinirebuli antibiotikoTerapia 2 da 3 preparatisgamoyenebiT:• penicilinebi+aminoglikozidi;• I Taobis cefalosporini+aminoglikozidi;• III Taobis cefalosporini+makrolidi;• cefalosporini+aminoglikozidi+klindamicini.zemoT aRniSnul mkurnalobaSi SesaZlebelia CaerTos simptomurisaSualebebi.hospitalizaciis Cvenebebiasaki 70 welze meti;filtvis qronikuli obstruqciuli daavadeba;gulis SegubebiTi ukmarisoba;Tanarsebuli qronikuli paTologia (nefriti, hepatiti, diabeti,alkoholozmi);mkurnalobis uefeqtoba 72 saaTis Semdeg;leikopenia (4.10 9 naklebi) an leikocitozi (20.10 9 ) meti;50

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