ANTIBIOTIKI PRI OKUŽBAH SPODNJIH DIHAL. Marina Praprotnik Združenje za pediatrijo, Ljubljana, 2. marec 2012
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1 ANTIBIOTIKI PRI OKUŽBAH SPODNJIH DIHAL Marina Praprotnik Združenje za pediatrijo, Ljubljana, 2. marec 2012
2 Pljučnica je vodilni svetovni vzrok smrti pri otrocih 90% smrti je v deželah v razvoju Globalna razporeditev vzrokov smrti pri otrocih pod 5 letom starosti leta Vir: Unicef/WHO 2006
3 INCIDENCA Norveška 14,7 na / leto od 0-16.leta Anglija 14,4 na / leto od 0-16.leta Senstad. CAP in children in Oslo. Acta Paediatr 2009 Clark. Epidemiology of CAP in children seen in hospital. Epidemiol Infect 2007
4 KLINIČNA SLIKA Povišana T 38,5st.C (88%), kašelj (90%), bolečina v p.k (15%), ugrezanje, tahipneja, zamolklina (60%), poki (50%), piskanje Prekrivanje klinične slike med bronhiolitisom in pljučnico zlasti pri mlajših otrocih ( okužba spodnjih dihal ) Piskanje pri majhnem otroku - verjetnost pljučnice, bolj verjetno virusna okužba (bronhiolitis) Piskanje pri večjem otroku M. pneumoniae Poki verjetnost pljučnice Korppi. Acta Paediatr 2008, Ranganathan S. Pediatr Clin N Am 2009
5 ETIOLOGIJA NOVOROJENČKI: B Streptokoki, g-, CMV, U.urealyticum, L. monocytogenes, C. trachomatis DOJENČKI: virusi, S. pneum, H. influenzae, M. pneumoniae PREDŠOLSKI: S. pneum, H. influenzae, M. pneumoniae, Chl. pneumoniae, virusi ŠOLSKI: M. pneumoniae, Chl. pneumoniae, S. pneum, virusi
6 ETIOLOGIJA PLJUČNIC-študija pri 154 otrokih 2004 by American Academy of Pediatrics Michelow I C et al. Pediatrics 2004;113:
7 DIAGNOZA DPP PREJ ZDRAV, DOMAČE OKOLJE KLINIČNA SLIKA PREISKAVE:LABORATORIJ? RTG pc? mikrobiološke preiskave?
8 ALI LAHKO PO KLINIČNI SLIKI RAZLIKUJEMO VIRUSNO BAKTERIJSKO ATIPIČNO PLJUČNICO
9 ALI LAHKO PO KLINIČNI SLIKI RAZLIKUJEMO VIRUSNO BAKTERIJSKO ATIPIČNO PLJUČNICO NE (večinoma) Korppi. The value of clinical features in differentiating between viral, pneumococcal and atypical bacterial pneumonia in children. Acta Paediatr 2008
10 VNETNI OZNAČEVALCI PRI BAKTERIJSKI IN VIRUSNI DPP Diagnostične skupine Levkociti (x109/l) Nevtrofilci (x109/l) SR (mm/h) CRP (mg/l) Bakterije (n=25) 13.5 (n=19) 48.8 (n=18) 100 (n=19) rang (5-36.5) (2.5-32) (5-120) (7-365) Virusi (n=35) 9.4 (n=29) 36.4 (n=11) 79 (n=18) rang (4-35) (1.5-31) (5-90) (4-327) p=0.042 p=0.11 p=0.32 p=0.64 Drummond P. CAP - a prospective UK study. Arch Dis Child 2000
11 VNETNI OZNAČEVALCI PRI BAKTERIJSKI IN VIRUSNI DPP CRP, L, PCT, SR-le delno v pomoč pri razlikovanju bakterijske in virusne pljučnice Če so vsi ali večina teh označevalcev povišani, je bakterijska etiologija zelo verjetna, nizke vrednosti pa je ne izključijo Korppi M. Pediatr Int. 2004, Don M. Pediatr Int. 2009
12 RTG pc Raziskava z 254 otroki 71% otrok z alveolarnim infiltratom je imelo bakterijsko pljučnico Polovica od 77 otrok, ki je imela na RTG pc intersticijske infiltrate, je imela virusno okužbo intersticijski infiltrati se lahko pojavijo pri virusni in bakterijski pljučnici Virkki R. Differentiation of bacterial and viral pneumonia in children. Thorax 2002
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14 RENTGENOGRAM pljuč VIRUS PNK ATIPIČNA 46% 67% 70% ALVEOLARNI INFILTRATI Korppi. Acta Paeditr 2008
15 12-letna, 1 teden neproduktivno kašlja, T 38,5, CRP<8 Avskultatorno: poki levo spodaj
16 15 let, T st.c, kašelj, bruhanje, CRP 144 Avskultatorno: normalno
17 2,5 letni, RSV bronhiolitis, po 1 tednu še T do 39-40st C, CRP iz 17 na 39 mg/l
18 4-letna, kašelj, T 38,8 st C, CRP 245 mg/l, RTG infiltrat v D zgornjem pljučnem režnju. Th: Amoksiklav. Dolgotrajni potek PeK.
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20 RTG pljuč Ne rutinsko če ni potrebna hospitalizacija Premalo senzitiven za razlikovanje med virusno, bakterijsko in atipično pljučnico Kontrolni RTG pc: ne, če je otrok sicer zdrav in potek običajen da, če gre za okroglo pljučnico, atelektazo ali vztrajajoče simptome BTS guidelines for the management of community acquired pneumonia in children:update 2011
21 TOREJ Pokazatelji akutnega vnetja ne ločijo zanesljivo med virusno in bakterijsko pljučnico CRP ne koristi pri obravnavi otroka z nezapleteno DPP RTG pc ni nujna preiskava pri otroku z DPP, ki ni hospitaliziran RTG pc ne loči zanesljivo med virusno in bakterijsko pljučnico BTS guidelines for the management of community acquired pneumonia in children:update 2011
22 MIKROBIOLOŠKE PREISKAVE bakterije Omejenost dostopnosti do ustreznih kužnin: HK-redko pozitivna (10-30%) sputum; bris žrela na bakterije-ni informativno Pnk Ag v urinu-lažno pozitiven BAL Bris NF na M.pn, Chl. pn. Plevralni punktat-pogosto ni rasti Pnevmolizin-PCR virusi PCR na viruse-če pozitiven, zniža uporabo antibiotikov Ob dokazani virusni okužbi majhna verjetnost težje bakterijske okužbe; sočasne okužbe dokazane v 23% serologija
23 OCENA STOPNJE POSLABŠANJA Blaga do zmerna Težka Dojenčki T <38,5 C T 38,5 C FD <50/min, blago ugrezanje FD 70/min, zmerno-hudo ugrezanje normalno hranjenje SpO2 pod 94%, dihalni premori stokanje, odklanjanje tekočine, tahikardija kapilarni povratek 2 sec Starejši otroci T<38,5 C T 38,5 C FD <50/min, blago ugrezanje ne bruha BTS guidelines for the management of CAP in children:update 2011 FD 70/min, močno oteženo dihanje cianoza, stokanje DH, tahikardija kapilarni povratek 2 sec
24 INDIKACIJA ZA NAPOTITEV V BOLNIŠNICO Teža bolezni (težko poslabšanje) Starost <3-6 mes: nižji prag Prisotnost dejavnikov tveganja: kronične srčne/pljučne bolezni, imunske pomanjkljivosti Socialni dejavniki/oddaljenost/strah staršev BTS guidelines for the management of CAP in children:update 2011
25 ZDRAVLJENJE Z ANTIBIOTIKI Ali zdraviti z antibiotikom (bakterijska/virusna) Kateri antibiotik in po kakšni poti Kdaj iz i.v. preiti na p.o. zdravljenje Trajanje zdravljenja Malo raziskav, večinoma iz dežel v razvoju, različne opredelitve pljučnice, različni cepilni programi ter odpornost bakterij
26 ANTIBIOTIKI-način dajanja Antibiotiki dani preko ust so varni in učinkoviti Antibiotike damo v žilo le pri težki pljučnici, bruhanju, sepsi ali zapletih Prehod iz i.v. na oralno zdravljenje-ko je otrok v klinično izboljšanem stanju BTS guidelines for the management of CAP in children.thorax:update 2011 Drummond P. CAP-a prospective UK study. Arch Dis Child 2000
27 ANTIBIOTIKI- AMBULANTNO ZDRAVLJENJE Antibiotiki niso nujno potrebni pri predšolskih otrocih z DPP, ker so virusi najpogostejši vzrok Amoksicilin zdravilo izbora pri prej zdravem, ustrezno cepljenem predšolskem in šolskem otroku ter adolescentu z blago-zmerno pljučnico s sumom na bakterijsko okužbo (ustrezno pokrije S.pn.) Makrolidi ob utemeljenem sumu na okužbo z atipično bakterijo Vsi otroci z jasno klinično sliko pljučnice naj bi dobili antibiotik, ker je težko ločiti bakterijsko in virusno pljučnico Otroci<2 letom s simptomi okužbe spodnjih dihal običajno nimajo pljučnice, zato zdravljenje z atb večinoma ni potrebnokontrola, če simptomi vztrajajo Amoksicilin zdravilo izbora za p.o. zdravljenje, saj je učinkovit za večino patogenov, ki povzročajo DPP Makrolidi ob utemeljenem sumu na okužbo z atipično bakterijo The Management of CAP in Infants and Children: Guidelines by the Pediatric Infectious Diseases Society of America; CID 2011 BTS guidelines for the management of CAP in children: update 2011
28 ANTIBIOTIKI- AMBULANTNO ZDRAVLJENJE Starost Povzročitelji Antibiotik Dnevni odmerek mg/kg/dan 3 mes-5 let Virusi,SP,HI,MP I: amoksicilin 40:3 7 A: penicilin V* amoksiklav :3-4 Trajanje zdravljenj a 7 azitromicin (sum na AP) 10:1 prvi dan, nato dan 5: let (tipična) SP, HI I: penicilin V* amoksicilin IE:3-4 40: let (atipična) MP, CP,CP, virusi makrolidiazitromicin 10:1 prvi dan, nato dan 5:1 * Cepljen HiB vsaj 2x Čižman M. Priročnik za ambulantno predpisovanje protimikrobnih zdravil,
29 ANTIBIOTIKI PRI DPP Zdravljenje lahke (non-severe) pljučnice doma: oralni amoksicilin (tri študije, 3952 otrok) enak uspeh zdravljenja (OR 0,92; 95%CI 0,58-1,47) Zdravljenje težke pljučnice brez hipoksemije v bolnišnici: amoksicilin oralno je pokazal enak uspeh zdravljenja kot penicilin i.v. (tri študije, 3942 otrok) (OR 0.95; 95% CI 0.78 to 1.15) Zdravljenje težke-zelo težke pljučnice v bolnišnici: penicilin G/ampicilin+genta Kabra SK. Antibiotics for community-acquired pneumonia in children.cochrane Database Syst Rev. 2010
30 PRIMERJAVA ZDRAVLJENJA DPP AMOKSICILIN PERORALNO VS PENICILIN INTRAVENSKO (PIVOT študija) Atkinson. A multicentre randomised trial comparing oral amoxicillin and intravenous benzyl penicillin for CAP in children. Thorax 2007
31 ANTIBIOTIKI- BOLNIŠNIČNO ZDRAVLJENJE Starost Povzročitelj Antibiotik Dnevni odmerek mg/kg/dan Trajanje zdravljenja Otroci 3 tedne-3 m S.pn, S.agalact, SA I: amoksiklav A: cefotaksim 120 : 4 150: Otroci 3 m-5 let lažja oblika S. pn, H.infl. I: amoksicilin A: penicilin V* 40 (45)-100: :3-4 7 Otroci 3 m-5 let huda oblika S.pn, H.infl. I: amoksiklav penicilin G* 120: IE i.v.: let, tipična pljučnica 5-18 let, sum na atipično p *2xHiB S.pn, H.infl. I: penicilin G* M.pn, C.pn, C.psittaci A: amoksiklav I: midekamicin A: azitromicin IE i.v.:4 120: : Čižman M. Kako predpisujemo protimikrobna zdravila v bolnišnicah, 2007
32 ZAPLETI PRI DPP PLJUČNI plevralni izliv/empiem pljučni absces pnevmotoraks nekrotizirajoča pljučnica akutna dihalna odpoved METASTATSKI MG, absces v CŽS perikarditis, endokarditis OM, septični artritis SISTEMSKI sistemski vnetni odgovor (SIRS) HUS BTS guidelines for the management of community acquired pneumonia in children:update 2011
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34 ZAKLJUČEK Otrok z blago doma pridobljeno pljučnico je lahko zdravljen v domačem okolju Diagnozo večinoma postavimo na osnovi klinične slike Označevalci akutne faze vnetja in RTG pc niso nujno potrebne preiskave pri blagi, nezapleteni pljučnici, če otrok ni hospitaliziran Pogosto ni možno zanesljivo ločiti med virusno, bakterijsko in atipično pljučnico na osnovi klinične slike, laboratorijskih preiskav ali RTG pc Antibiotiki (v večini primerov): amoksicilin/penicilin G POZOR: otrok z vročinskim stanjem brez lokaliziranih znakov bolezni; otrok z LRTI brez odziva na antibiotik-spremljanje, DODATNA DIAGNOSTIKA!
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