ЦЕЛЬ Обновленных клинических рекомендаций состоит в представлении специалистам, в первую очередь анестезиологам-реаниматологам, современных, основанных на методах доказательной медицины данных по этиологии, эпидемиологии, способах диагностики, лечения и профилактики тяжелой внебольничной пневмонии у взрослых. При подготовке настоящего документа использованы и адаптированы научные исследования высокого уровня доказательности, систематические обзоры и метаанализы, рекомендации Американского общества инфекционных заболеваний/Американского торакального общества (IDSA/ATS), Европейского респираторного общества/Европейского общества интенсивной терапии/Европейского общества клинической микробиологии и инфекционным заболеваниям/Латиноамериканского торакального общества (ERS/ESICM/ESCMID/ALAT) и прочих ведущих профессиональных сообществ. Подробно представлены современные рекомендации по дифференцированной антибиотикотерапии пациентов с тяжелой внебольничной пневмонией (ТВП) в зависимости от наличия у них факторов риска инфицирования определенными микроорганизмами, приведены схемы этиотропной терапии при установленном возбудителе. Значительный раздел рекомендаций посвящен респираторной терапии при ТВП, сформулирован ступенчатый алгоритм лечения острой дыхательной недостаточности в зависимости от ее стадии. Детально охарактеризованы наиболее эффективные и безопасные режимы инвазивных и неинвазивных способов респираторной поддержки. В качестве методов адъювантной терапии названы глюкокортикостероиды при невозможности стабилизировать показатели гемодинамики на фоне адекватной гидратации и вазопрессорной поддержки, а также парентеральные антикоагулянты с целью предупреждения тромбоэмболических осложнений. Для профилактики ТВП у пациентов высокого риска предложены антипневмококковые и противогриппозные вакцины. Представлены критерии оценки качества медицинской помощи.

Strains of microorganisms characterized by resistance to antimicrobial drugs used in medical organizations continue to spread in most regions of the world, including Russia. This naturally affects both the effectiveness of antimicrobial therapy and the tactics of its use not only in adults but also in children. The coronavirus pandemic has highlighted the growing problems with the treatment of invasive mycoses, the selection of dosage of antibacterial agents when using sorption and dialysis therapy methods. In combination with the registration of new antibacterial drugs ABSTRACT in Russia, this necessitated the need to make adjustments to the Methodological recommendations “Diagnostics and Antimicrobial Therapy of Infections Caused by Polyresistant Strains of Microorganisms” (2nd edition), prepared by a group of leading Russian experts in 2022 [1]. The presented version was approved in December 2024 at a joint meeting of representatives of public organizations: the Russian Association of Anesthesiologists-Intensivists, the Interregional public organization “Alliance of Clinical Chemotherapists and Microbiologists”, the Interregional Association for Clinical Microbiology and Antimicrobial Chemotherapy (IACMAC), the public organization “Russian Sepsis Forum”. These recommendations reflect the interdisciplinary consensus opinion on approaches to the diagnosis and antimicrobial therapy of infections caused by polyresistant microorganisms.

The multicenter prospective randomized trial of clinical and microbiological efficacy of cefepime in combination with fluorothiazinone or placebo was conducted to expand the possibilities of empirical therapy for patients with complicated urinary tract infections. The primary endpoint of the study in the MITT population was the clinical cure and pathogen eradication on the 21st day after the conclusion of antibacterial therapy: this indicator was 75.6% in cefepim/fluorothiazinone group and 50.8% in cefepim/placebo group; 97.5% one-sided confidential interval (14.7%) exceeded the hypothesis of equal efficacy (0%), allowing an alternative hypothesis of the superiority of cefepime/fluorothiazinone over cefetime/placebo to be accepted. There was a significant (P=0.012) decrease in relapses occurrences of infection at follow-up (90 days after the start of treatment) after the use of cefepime/fluorothiazinone compared with cefepime/placebo, 3/178 (1.7%; 95% CI: 0.3–4.8) and 14/175 (8.0%; 95% CI: 4.4–13.1), respectively. Adverse events were detected in 37 (20.6%; 13.4–25.3) patients in group cefepim/fluorothiazinone and in 27 (15.2%; 8.0–18.2) patients in group cefepim/placebo; their number did not significantly differ, they were not severe and did not require drug discontinuation. The results of the study showed the clinical and microbiological advantages of cefepime/fluorothiazinone combination compared with cefepime/placebo with an equal safety profile, which makes it possible to expand the effectiveness of empirical therapy for complicated urinary tract infections.

In December 2019, in Wuhan (PRC), there was an outbreak of a new coronavirus infection (COVID-19) caused by coronavirus type 2 (SARS-CoV-2), which has a zoonotic origin. The World Health Organization announced the COVID-19 pandemic on March 11, 2020. In most cases, the disease is asymptomatic or mild. However, up to 15% of patients require hospitalization, and 5% develop a critical condition. To date, no effective antiviral drug COVID-19 has been found that can reduce mortality. Pathological changes in the lungs are manifested by diffuse alveolar damage, which is clinically manifested by increasing respiratory failure, accompanied by a decrease in saturation and oxygen concentration in arterial blood. It is assumed that autoimmune reactions play an important role in the development of multiple organ failure. Generalized inflammation is characterized by an increase in the concentration of C-reactive protein, ferritin, interleukin-1 and interleukin-6, and other markers. At the stage of development of infection in the form of a cytokine storm, proinflammatory cytokines can themselves become pathogenetic factors in the development of critical conditions, multiple organ failure and deaths. Therefore, a key challenge in treating hospitalized patients with COVID-19 is to control generalized inflammation. Glucocorticosteroid hormones (GCS) are widely used as anti-inflammatory drugs in the clinic of infectious diseases. However, until recently, there was no convincing data on the effectiveness of GCS in patients with COVID-19. Recently published results of a large randomized clinical trial (RECOVERY) showing the efficacy of GCS (dexamethasone) in the treatment of critically ill patients with COVID-19. At the same time, the feasibility and effectiveness of GCS in patients with COVID-19 outside critical conditions, the pathogenetic mechanisms that determine the effectiveness/ineffectiveness of these drugs and the validity of their use remain insufficiently studied.