Журнал «Здоровье ребенка» 6 (49) 2013

Introduction. Severity of pneumonia, prognosis, particularly in young children, in most cases is caused by diffuse purulent forms of endobronchitis [1, 11, 12, 15]. Determinative factor in the choice of treatment strategy in this case is studying the microbial view of the tracheobronchial tree to appropriate antimicrobial therapy [2, 9, 10, 16, 17, 18, 20]. At present, there is insufficient information about the microbial ecology of the lower respiratory tract of pneumonia in children, particularly in the bacteriological examination of bronchial lavage water. At the same time, the sensitivity of these pathogens to antimicrobial products is crucial in choosing the treatment strategy, although currently etiotropic treatment of pneumonia is empirical. [9]

Materials and methods. To analyze the course of CPN (complicated pneumonia) 380 children aged from two months to three years were examined and treated in Pediatric diagnostic department of the Ivano-Frankivsk Regional Pediatric Hospital from 2008 to 2010. Verification of the diagnosis as well as treatment of nature, prevalence of inflammation of the mucous tracheobronchial tree were carried out according to the minutes of medical care for children by speciality "child pathology" Ministry of Health of Ukraine of 13.01.2005 № 18 years [6]. The diagnosis of pneumonia in all cases was confirmed radiographically (device "X-30", "Sevkavroentgen" 1983, № 3233). In accordance with principles of the Direction basic therapy of pneumonia in children was carried out. Interpretation of results of biological research of bronchial lavage water treatment and interpretation of antybioticogram were performed according to CLSI, 2005. (In accordance to Performance Standards Dist Susceptibility tests). The severity of pneumonia in children during hospitalization was determined by index and scale of severity. At the time of admission to hospital severity index score was higher than 71 that corresponded to the index of the necessity of hospitalization [18]. Statistical analysis of the results was performed on personal computers using the statistical package programs Microsoft Excel 7.0. Digital results were statistically processed using the method of variation analysis. Significance of differences was assessed using parametric and nonparametric criteria. [7]

Results of the investigation and their discussion. Children were admitted to the hospital in serious condition, caused by the severity of endogenous intoxication, respiratory insufficiency, purulent endobronchitis and disorders of hemodynamics and microcirculation. The main symptoms of CPN in examined children were: febrile fever (86.4%), unproductive cough (76.9%), symptoms of intoxication (74.1%), dyspnea (92.5%). An important criteria for the severity of children condition were symptoms of respiratory failure (RF). In the vast majority of examined children (278 - 73.2%) the 1^st stage of RF  was diagnosed, .the rest (26.8%) had the 2^nd and 3^rd stages of RF Changes in the cardiovascular system sufficiently determined the severity of condition of children with CPN and they are mainly due to metabolic disorders resulting from prolonged hypoxia and manifestations of right ventricular failure.

Analysis of X-ray examination showed that most of them had bilateral focal pneumonia (320 - 84.2%), very rarely - lobar (37 - 9.7%) localized mainly in the inferior lobe of right lung (23-6.1 %). Rare complication of lobar pneumonia was exudative pleurisy (23-6.1%). With equal frequency segmental (mono-, dysegmental) pneumonia (23-6.1%) was diagnosed. It is important to note that, segmental pneumonia was more frequently superlobar (17-4.5%) of right lung and almost three times less - at C4, 5 of left lung (6-1.6%).

According to data of diagnostic bronchoscopy purulent endobronchitis was diagnosed in most infants: localized (28.7%) and its diffuse forms (52.5%), more rarely- catarrhal-purulent endobronchitis (18.8%). In children of the second or third year of life purulent forms of endobronchitis were observed in 2.7 times less likely (30.5%, p <0.001), with a predominance of its catarrhal-purulent forms (69.5%, p <0.001). Positive bacteriological tests were observed in the majority of children (64.3%), with no significant differences in infants and children 2-3 years of age. In almost half the children in both age groups Gram-positive cocci were seeded: Streptococcus pneumonia (49,2%), with almost twice as likely in children 2-3 years of age (64.9%) than in infants (36.2% ), Staphylococcus aureus from tracheobronchial secretions was seeded three times less likely (18.2%), almost with equal frequency in infants and 2-3 years of age children (20.3 and 15.8% of cases, respectively).In the rest children (32.5%) gram-negative bacteria were seeded: Pseudomonas aeruginosae (13.5%), seeding rate of the latter increased almost threefold at 2-3 years of age (21.1%) compared with children of the first year of life, Haemophilus Influenza (8.7%), Escherichia coli (7.1%), Enterobacter cloacae (5.5%), Proteus mirabilis (4,7%), and very rare-Klebsiella pneumonia (4.0%). Invasion of lower respiratory tract with Candida fungi was diagnosed in 11.9% of cases with a tendency to increase its frequency in children of 2-3 years of age (14.0%).

It is important to note that in 37.7% of cases we observed mixed infection with positive bacteriological studies. Among the latter prevailed: Haemophilus influenza and Staphylococcus aureus - (7.1%) prevailed, Pseudomonas aeruginosae always in combination with Candida (5.6%), Staphylococcus aureus and Candida albicans (3,1%), Staphylococcus aureus+Proteus mirabilis-(3.1%) and Staphylococcus aureus +Enterobacter cloacae-(4.6%). We noted high sensitivity of Streptococcus pneumonia to the inhibitor-protected penicillins: amoxiclav (98.4%) and unazyn (95.3%), karbopenems: meropenem (98.6%), tiyenam (98.4%), ciprofloxacin (95.2 %), but susceptibility to cephalosporins of the third-generation (ceftriaxone-79.0%, ceftazidime-88.7%), amikacin (87.1%) was sharply reduced. There was also growing resistance to cefepime (9.7%).

Studying antybioticogram of Staphylococcus aureus, we established its stably high sensitivity in most cases to amoxiclav (91.3%), karbopenems (95.6%) and ciprofloxacin (95.6%). Susceptibility to cefepime (86.9%), ceftazidime (82.6%), amikacin (82.6%) and mostly to ceftriaxone (73.9%).was reduced It is important to note low sensitivity and high resistance of gram-negative bacteria. Pseudomonas aeruginosae and Klebsiella pneumonia are highly sensitive only to karbopenems. To other antibiotics of different groups sensitivity was not high, to ceftriaxone (60.0 and 64.7%), ceftazidime (70.6 80.0%) in particular. The relatively low sensitivity of Pseudomonas aeruginosae was to cefepime (88.2%) and to ciprofloxacin (Pseudomonas aeruginosae – 94.1%, Klebsiella pneumonia – 80.0%). Haemophilus influenza is highly sensitive to karbopenems (100%), sensitivity to the inhibitor-protected penicillin (90.9%), ciprofloxacin and amikacin (by 81.8%) was reduced. Only in half of the patients Naemophilus influenza is sensitive to cephalosporins of the third-generation, and somewhat more frequently to cefepime (72.7%).

It is characteristically that in the first episode of pneumonia in the vast majority of children Proteus mirabilis and Enterobacter cloacae are highly sensitive only to ciprofloxacin (100.0%), moderately sensitive to karbopenems (66.7-85.7%), amikacin (83.3-85.7%), insensitive to cephalosporins of the III-IV generations (70.6-88.2% cases respectively). Only to reserve antibiotic Escherichia coli are sensitive: highly sensitive to the inhibitor-protected penicillins, karbopenems, moderately susceptible to amikacin (77.8%), ciprofloxacin (88.9%). The highest resistance was found to ceftriaxone (55.6%), ceftazidime (33.3%). It is important to note the growth of Escherichia coli resistance to cephalosporins of the IV generation cefepime (11.1%).

Controversial results were obtained in the study of sensitivity to Candida fungi to antimycotic drugs. Due to the extensive use of their increased resistance to fluconazole increased (26.7%), to a lesser extent - to ketoconazole (13.3%) and clotrimazole (6.7%) and only nistatin revealed its high (100%) sensitivity.

Conclusions:

1. According to the results of bacteriological studies of tracheobronchial tree lavage water in the etiological structure of pneumonia in children of the early age Gram-positive cocci (Streptococcus pneumonia and Staphylococcus aureus) dominate. Among gram-negative bacteria Pseudomas-auruginosae are predominant.

2. Regardless of cultured microorganisms attention is attracted to its exceptional sensitivity to inhibitor-protected penicillin and reserve antibiotics (cephalosporins of the III, IV generation, karbopenemes, glycopeptides fluoroquinolones.

3. The obtained results of bacterial studies must be taken into consideration when choosing tactics of antibiotic therapy in giving medical attendance to children.