The paper represents the clinical guidelines for septic shock in adults, approved by the All-Russian public organization “Federation of anesthesiologists and reanimatologists” in 2023. Septic shock is a widespread condition with a high mortality rate. The recommendations cover the issues of etiology, pathogenesis, clinical signs and symptoms, methods of laboratory and instrumental diagnosis of septic shock. The clinical guidelines present initial therapy for septic shock, including approaches to vasopressor and inotropic therapy, recommendations for choosing antibacterial drugs, fluid and adjuvant therapy. The issues of surgical treatment of the infection are discussed. The article contains the criteria for the quality of medical care for the adult patients with septic shock and algorithms for the decision making in the diagnosis and intensive care of patients with septic shock.

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.

The article provides an overview of literature on severe community-acquired pneumonia (CAP) and the most recent data on the epidemiology and etiology of CAP, and describes the antibiotic susceptibility of Streptococcus pneumoniae — the leading causative agent of CAP. The article discusses demonstrative diagnostic data and emphasizes the need to determine as early as possible the oxygen saturation of arterial blood using a pulse oximeter, as well as to dynamically measure the concentration of inflammatory markers in blood and carry out a comprehensive microbiological examination. The authors argue for the advantages of computed tomography over conventional x-ray examination and point out the usefulness of ultrasound to diagnose and dynamically assess the condition of lung tissue in the course of treatment. The article also provides up-to-date recommendations for the differential antibiotic treatment of severe CAP patients based on the existence of risk factors making them susceptible to the infection with certain microorganisms, and suggests etiotropic therapy regimens for cases where the causative agent has been identified. It also emphasizes the need for a timely prescription of combined antibiotic therapy with intravenous administration, suggesting the possibility of de-escalation based on microbiological data. A substantial portion of the overview focuses on the respiratory therapy for CAP, outlining a graded algorithm for the treatment of acute respiratory failure based on stage, and describing in detail the most effective and safe invasive and non-invasive respiratory support strategies. The proposed adjuvant therapies include glucocorticosteroids if it is impossible to stabilize hemodynamics by means of adequate hydration and vasopressor support, as well as parenteral anticoagulants to prevent thromboembolic complications. Pneumococcal and influenza vaccines are suggested as CAP prevention strategies for high-risk patients. The publication seeks to highlight the most critical aspects of the draft of the updated clinical recommendations for CAP and encourage their wide discussion across the community of Russian intensive care anesthesiologists and intensivists.

Relevance. In the last decade, there has been an increase in the isolation of antibiotic-resistant microorganisms in community settings. Colonization and asymptomatic carriage of extended-spectrum beta-lactamase and carbapenemase producers can be a precursor to the development of an infectious process and a significant factor in the pathogenesis of healthcare-associated infections. Understanding the risk factors for community-acquired colonization with antibiotic-resistant microorganisms is necessary for targeted screening and timely implementation of measures to prevent the spread of resistance in hospitals.The aim. To determine significant risk factors for colonization with antibiotic-resistant gram-negative microorganisms and carriage of carbapenem resistance genes in patients admitted to a multidisciplinary hospital.Materials & Methods. A prospective single-center crosssectional study was conducted at the Moscow Multidisciplinary Clinical Center «Kommunarka» from 15.09.2022 to 15.08.2023. The study included 733 patients aged 18 to 94 years. Biological samples were taken from the rectum, upper and lower respiratory tract. The obtained samples were examined by real-time polymerase chain reaction (PCR) with hybridization-fluorescent detection of amplification products to identify carbapenemase genes and by culture method to determine colonization with carbapenemresistant bacteria. Identification of isolated microorganisms was performed using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry (MALDI-TOF MS), and antibiotic susceptibility was determined by the Kirby-Bauer disk diffusion method on Mueller-Hinton agar. The results of susceptibility testing were interpreted based on EUCAST v12.0, v13.0, and v13.1 criteria.Results. Carriage of carbapenemase genes was detected in 12.6% of patients admitted to the hospital, while colonization with carbapenem-resistant bacteria was found in 2.7%. In the majority of patients (66.7%), the rectum was the only site of gene carriage. However, only 18.1% of these patients showed rectal colonization with carbapenem-resistant bacteria. This discrepancy is likely due to the higher sensitivity of molecular genetic methods compared to culture-based techniques. From a clinical perspective, the detection of nucleic acids by PCR can serve as an equivalent to pathogen detection in biological material. Multivariate analysis identified 5 independent predictors of colonization: cytostatic therapy, transfer from another hospital, need for vasopressor support, antibiotic use in the previous 3 months, and male gender.Conclusion. The identified risk factors allow for the identification of a highrisk patient cohort for targeted screening, enabling timely administration of appropriate antibiotic therapy and implementation of measures to prevent the spread of carbapenem resistance in the hospital.

The review is devoted to the problem of antibiotic resistance of the leading pathogens of nosocomial infections. The authors analyze current data on the prevalence and mechanisms of resistance of microorganisms in the Russian Federation. A particular attention is paid to carbapenem-resistant strains. Antibiotics for the treatment of infections caused by carbapenem-resistant pathogens are described. The authors assessed clinical use of ceftazidime-avibactam and its advantages compared to traditional treatment regimens, including polymyxins, tigecycline, aminoglycosides and other antibiotics. High efficacy of monotherapy with ceftazidime-avibactam against infections caused by enterobacteria releasing serine carbapenemases is noted. Importance of early administration of ceftazidime-avibactam to realize its maximum therapeutic potential is emphasized. The authors propose some measures optimizing the use of this antibiotic including modern methods of microbiological diagnosis, analysis of sensitivity of pathogens to inhibitor-protected cephalosporins, deciphering the mechanisms of resistance and inclusion of ceftazidime-avibactam in empirical therapy regimens for patients with risk factors for carbapenem resistance.

Background. Carbapenem-resistant Enterobacteriaceae have a major impact on ICU-stay and treatment outcomes. Objective. To identify the risk factors of colonization by CPE (carbapenemase-producing Enterobacterales) in ICU patients. Material and methods. We enrolled 94 ICU patients between November 2020 and January 2021 and divided then into 3 groups: group 1 (n=63) — all patients not colonized by CPE, group 2 (n=31) — colonized upon admission, group 3 (n=31) — colonized after 5-day ICU-stay. All patients underwent microbiological and molecular genetic testing via real-time PCR (AmpliSens MDR MBL-FL and AmpliSens MDR KPC/OXA-48-FL reagent kits) of rectal smear samples. Results. We found CPEs in rectal smear samples that mainly released carbapenemases OXA-48, NDM, KPC and their combinations. Pre-hospital risk factors for intestinal colonization by CPE were identified: male gender (OR=0.28, CI 95% [0.11, 0.74], p=0.010), hospital-stay within previous 3 months (OR=4.22, CI 95 % [1.38; 12.9], p=0.011) and previous antimicrobial therapy (OR=2.23, CI 95% [0.76; 6.54], p=0.145). There were the following risk factors after 5-day hospital-stay: primary colonization (OR=15.64, CI 95% [4.64; 52.73], p<0.0001), female gender (OR=2.51, CI 95% [0.96, 6.56], p<0.059), age (OR=0.969, CI 95% [0.931; 1.007], p=0.112), use of vasopressors (OR=27.11, CI 95% [2.43; 302.11], p=0.007), CRP (OR=0.997, CI 95% [0.992; 1.001], p=0.162), central venous catheter (OR=3.56, CI 95% [1.36; 9.30], p=0.010), proton pump inhibitors (OR 0.38, CI 95% [0.13; 1.11], p=0.077). Conclusion. Early detection of CPE and carbapenemases and their monitoring are necessary to improve the effectiveness of antimicrobial therapy in ICU patients.