«Ульяновский медико-биологический журнал»

CLINICAL MEDICINE

Download  article

DOI 10.34014/2227-1848-2021-1-57-70

 

COMMUNITY-ACQUIRED PNEUMONIA AS AN URGENT PROBLEM OF MODERN SOCIETY

 

V.A. Serov, V.V. Gnoevykh, D.V. Serova, E.R. Sakaeva

Ulyanovsk State University, Ulyanovsk, Russia

 

Community-acquired pneumonia (CAP) is one of the leading causes of morbidity and mortality worldwide. However, there are still many unresolved issues in prevention, diagnosis and treatment of the disease despite its enormous social and economic significance. Mortality associated with CAP in elderly patients is increasing, as the proportion of people over 65 is growing every year.

The purpose of this review is to consider the most significant issues in CAP diagnostics and treatment, that will improve the quality of medical care and prognosis of CAP patients.

Data from Pubmed, eLIBRARY, and other sources were used to collect the information.

The lack of an adequate etiological diagnosis of bacterial CAP has led to unjustified antibacterial therapy, which contributes to the spread of antibiotic-resistant strains of microorganisms and increase in side effects of antibiotics. During COVID-19 pandemic, it has become even more difficult etiologically to diagnose infectious respiratory diseases. The lack of knowledge about the peculiarities of managing patients with comorbid pathology has become more evident. Everyone has understood that the severity of bronchopulmonary diseases was underestimated by the population. Acute kidney injury (AKI) is one of the most formidable CAP complications. The authors describe pathogenetic mechanisms of renal dysfunction, diagnostic methods, AKI treatment and prevention in patients with CAP. Underestimation of the forecast severity, both medium-term and long-term, in patiemts with CAP leads to an insufficiently high level of immunization against influenza and pneumococcus. The authors declare that it is desirable to pay much attention to preventive health messages not only relating to cardiovascular or oncological diseases, but also infectious respiratory diseases.

Keywords: community-acquired pneumonia, microbiological diagnostics, comorbidity, preventive health messages.

Conflict of interest. The authors declare no conflict of interest.

 

References

  1. GBD 2016 Lower Respiratory Infections Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect. Dis. 2018; 18 (11): 1191–1210. DOI: 10.1016/S1473-3099(18)30310-4.

  2. McLaughlin J.M., Khan F.L., Thoburn E.A., Isturiz R.E., Swerdlow D.L. Rates of hospitalization for community-acquired pneumonia among US adults: A systematic review. Vaccine. 2020; 38 (4): 741–751. DOI: 10.1016/j.vaccine.2019.10.101.

  3. Pessoa E., Bárbara C., Viegas L., Costa A., Rosa M., Nogueira P. Factors associated with in-hospital mortality from community-acquired pneumonia in Portugal: 2000–2014. BMC Pulm. Med. 2020; 20 (1): 18. DOI: 10.1186/s12890-019-1045-x.

  4. Bilichenko T.N., Chuchalin A.G. Zabolevaemost' i smertnost' naseleniya Rossii ot ostrykh respiratornykh virusnykh infektsiy, pnevmonii i vaktsinoprofilaktika [Morbidity and mortality of the Russian population from acute respiratory viral infections, pneumonia and vaccination]. Terapevticheskiy arkhiv. 2018; 90 (1): 22–26. DOI: 10.17116/terarkh201890122-26 (in Russian).

  5. Rivero-Calle I., Cebey-López M., Pardo-Seco J., Yuste J., Redondo E., Vargas D.A., Mascarós E., Díaz-Maroto J.L., Linares-Rufo M., Jimeno I., Gil A., Molina J., Ocaña D., Martinón-Torres F. Lifestyle and comorbid conditions as risk factors for community-acquired pneumonia in outpatient adults (NEUMOES-RISK project). BMJ Open Respir. Res. 2019; 6 (1): e000359. DOI: 10.1136/bmjresp-2018-000359.

  6. Marrie T.J., Tyrrell G.J., Majumdar S.R., Eurich D.T. Invasive Pneumococcal Disease: Still Lots to Learn and a Need for Standardized Data Collection Instruments. Can. Respir. J. 2017; 2017: 2397429. DOI: 10.1155/2017/2397429.

  7. Sun G.Q., Zhang L., Zhang L.N., Wu Z., Hu D.F. Benzodiazepines or related drugs and risk of pneumonia: A systematic review and meta-analysis. Int. J. Geriatr. Psychiatry. 2019; 34 (4): 513–521. DOI: 10.1002/gps.5048.

  8. Gu C.H., Lucero D.E., Huang C.C., Daskalakis D., Varma J.K., Vora N.M. Pneumonia-Associated Hospitalizations, New York City, 2001–2014. Public Health Rep. 2018; 133 (5): 584–592. DOI: 10.1177/0033354918792009.

  9. Aliberti S., Dela Cruz C.S., Sotgiu G., Restrepo M.I. Pneumonia is a neglected problem: It is now time to act. Lancet Respir. Med. 2019; 7 (1): 10–11. DOI: 10.1016/S2213-2600(18)30470-3.

  10. Bobylev A.A., Rachina S.A., Avdeev S.N., Kozlov R.S., Sukhorukova M.V., Yatsyshina S.B., El'kina M.A., Yudanova T.A. Etiologiya vnebol'nichnoy pnevmonii u lits s khronicheskoy serdechnoy nedostatochnost'yu [Etiology of community-acquired pneumonia in patients with chronic heart failure]. Pul'monologiya. 2019; 29 (3): 293–301. DOI: 10.18093/0869-0189-2019-29-3-293-301 (in Russian).

  11. Zakharenkov I.A., Rachina S.A., Dekhnich N.N., Kozlov R.S., Sinopal'nikov A.I., Ivanchik N.V., Yatsyshina S.B., El'kina M.A., Arkhipenko M.V., Gordeeva S.A., Lebedeva M.S., Portnyagina U.S. Etiologiya tyazheloy vnebol'nichnoy pnevmonii u vzroslykh: rezul'taty pervogo rossiyskogo mnogotsentrovogo issledovaniya [Etiology of severe community-acquired pneumonia in adults: Results of the first Russian multicenter study]. Terapevticheskiy arkhiv. 2020; 92 (1): 36–42. DOI: 10.26442/00403660. 2020.01.000491 (in Russian).

  12. GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018; 392 (10159): 1736–1788. DOI: 10.1016/S0140-6736(18)32203-7.

  13. Chow E.J., Doyle J.D., Uyeki T.M. Influenza virus-related critical illness: prevention, diagnosis, treatment. Crit. Care. 2019; 23 (1): 214. DOI: 10.1186/s13054-019-2491-9.

  14. Adhikari S.P., Meng S., Wu Y.J., Mao Y.P., Ye R.X., Wang Q.Z., Sun C., Sylvia S., Rozelle S., Raat H., Zhou H. Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review. Infect. Dis. Poverty. 2020; 9 (1): 29. DOI: 10.1186/s40249-020-00646-x.

  15. Velavan T.P., Meyer C.G. The COVID-19 epidemic. Trop. Med. Int. Health. 2020; 25 (3): 278–280. DOI: 10.1111/tmi.13383.

  16. Ishida T., Ito A., Washio Y., Yamazaki A., Noyama M., Tokioka F., Arita M. Risk factors for drug-resistant pathogens in immunocompetent patients with pneumonia: Evaluation of PES pathogens. J. Infect. Chemother. 2017; 23 (1): 23–28. DOI: 10.1016/j.jiac.2016.09.002.

  17. Luan Y., Sun Y., Duan S., Zhao P., Bao Z. Pathogenic bacterial profile and drug resistance analysis of community-acquired pneumonia in older outpatients with fever. J. Int. Med. Res. 2018; 46 (11): 4596–4604. DOI: 10.1177/0300060518786915.

  18. Dominguez-Cherit G., De la Torre A., Rishu A., Pinto R., Ñamendys-Silva S.A., Camacho-Ortiz A., Silva-Medina M.A., Hernández-Cárdenas C., Martínez-Franco M., Quesada-Sánchez A., López-Gallegos G.C., Mosqueda-Gómez J.L., Rivera-Martinez N.E., Campos-Calderón F., Rivero-Sigarroa E., Hernández-Gilsoul T., Espinosa-Pérez L., Macías A.E., Lue-Martínez D.M., Buelna-Cano C., Ramírez-García Luna A.S., Cruz-Ruiz N.G., Poblano-Morales M., Molinar-Ramos F., Hernandez-Torre M., León-Gutiérrez M.A., Rosaldo-Abundis O., Baltazar-Torres J.Á., Stelfox H.T., Light B., Jouvet P., Reynolds S., Hall R., Shindo N., Daneman N., Fowler R.A. Influenza A (H1N1pdm09)-Related Critical Illness and Mortality in Mexico and Canada, 2014. Crit. Care Med. 2016; 44 (10): 1861–1870. DOI: 10.1097 /CCM.0000000000001830.

  19. MacIntyre C.R., Chughtai A.A., Barnes M., Ridda I., Seale H., Toms R., Heywood A. The role of pneumonia and secondary bacterial infection in fatal and serious outcomes of pandemic influenza a(H1N1)pdm09. BMC Infect. Dis. 2018; 18 (1): 637. DOI: 10.1186/s12879-018-3548-0.

  20. Chertow D.S., Memoli M.J. Bacterial coinfection in influenza: a grand rounds review. JAMA. 2013; 309 (3): 275–282. DOI: 10.1001/jama.2012.194139.

  21. Sukhal S., Sethi J., Ganesh M., Villablanca P.A., Malhotra A.K., Ramakrishna H. Extracorporeal membrane oxygenation in severe influenza infection with respiratory failure: A systematic review and meta-analysis. Ann. Card. Anaesth. 2017; 20 (1): 14–21. DOI: 10.4103/0971-9784.197820.

  22. Prete M., Favoino E., Catacchio G., Racanelli V., Perosa F. SARS-CoV-2 Inflammatory Syndrome. Clinical Features and Rationale for Immunological Treatment. Int. J. Mol. Sci. 2020; 21 (9): E3377. DOI: 10.3390/ijms21093377.

  23. Wang T., Chen R., Liu C., Liang W., Guan W., Tang R., Tang C., Zhang N., Zhong N., Li S. Attention should be paid to venous thromboembolism prophylaxis in the management of COVID-19. Lancet Haematol. 2020; 7 (5): e362–e363. DOI: 10.1016/S2352-3026(20)30109-5.

  24. Zhu H., Rhee J.W., Cheng P., Waliany S., Chang A., Witteles R.M., Maecker H., Davis M.M., Nguyen P.K., Wu S.M. Cardiovascular Complications in Patients with COVID-19: Consequences of Viral Toxicities and Host Immune Response. Cur. Cardiol. Rep. 2020; 22 (5): 32. DOI: 10.1007/s11886-020-01292-3.

  25. Chakraborty C., Sharma A.R., Sharma G., Bhattacharya M., Lee S.S. SARS-CoV-2 causing pneumonia-associated respiratory disorder (COVID-19): diagnostic and proposed therapeutic options. Eur. Rev. Med. Pharmacol. Sci. 2020; 24 (7): 4016–4026. DOI: 10.26355/eurrev_202004_20871.

  26. Heneghan C.J., Onakpoya I., Jones M.A., Doshi P., Del Mar C.B., Hama R., Thompson M.J., Spencer E.A., Mahtani K.R., Nunan D., Howick J., Jefferson T. Neuraminidase inhibitors for influenza: a systematic review and meta-analysis of regulatory and mortality data. Health Technol. Assess. 2016; 20 (42): 1–242. DOI: 10.3310/hta20420.

  27. Cillóniz C., Ewig S., Ferrer M., Polverino E., Gabarrús A., Puig de la Bellacasa J., Mensa J., Torres A. Community-acquired polymicrobial pneumonia in the intensive care unit: Aetiology and prognosis. Crit. Care. 2011; 15 (5): R209. DOI: 10.1186/cc10444.

  28. Gadsby N.J., Russell C.D., McHugh M.P., Mark H., Conway Morris A., Laurenson I.F., Hill A.T., Templeton K.E. Comprehensive Molecular Testing for Respiratory Pathogens in Community-Acquired Pneumonia. Clin. Infect. Dis. 2016; 62 (7): 817–823. DOI: 10.1093/cid/civ1214.

  29. Wang J., Li F., Tian Z. Role of microbiota on lung homeostasis and diseases. Sci. China Life Sci. 2017; 60 (12): 1407–1415. DOI: 10.1007/s11427-017-9151-1.

  30. Steenhuijsen Piters W.A., Sanders E.A., Bogaert D. The role of the local microbial ecosystem in respiratory health and disease. Philos. Trans. R. Soc. Lond. B. Biol. Sci. 2015; 370 (1675): 20140294. DOI: 10.1098/rstb.2014.0294.

  31. Mendez R., Banerjee S., Bhattacharya S.K., Banerjee S. Lung inflammation and disease: A perspective on microbial homeostasis and metabolism. IUBMB Life. 2019; 71 (2): 152–165. DOI: 10.1002/iub.1969.

  32. Huffnagle G.B., Dickson R.P., Lukacs N.W. The respiratory tract microbiome and lung inflammation: a two-way street. Mucosal Immunol. 2017; 10 (2): 299–306. DOI: 10.1038/mi.2016.108.

  33. Bobylev A.A., Rachina S.A., Avdeev S.N., Kozlov R.S., Dekhnich N.N. Vnebol'nichnaya pnevmoniya u patsientov pozhilogo i starcheskogo vozrasta [Community-acquired pneumonia in elderly and senile patients]. Pul'monologiya. 2015; 3: 261–276 (in Russian).

  34. Fatenkov O.V., Kuz'mina T.M., Rubanenko O.A., Svetlova G.N., Dzyubaylo A.V. Techenie vnebol'nichnoy bakterial'noy pnevmonii pri komorbidnoy patologii u pozhilykh patsientov [Community-acquired bacterial pneumonia and comorbidity in elderly patients]. Uspekhi gerontologii. 2017; 30 (3): 394–397 (in Russian).

  35. Chen L., Han X.D., Li Y.L., Zhang C.X., Xing X.Q. Incidence and risk factors for cardiovascular events in patients hospitalized with community-acquired pneumonia. Zhonghua Xin Xue Guan Bing Za Zhi. 2020; 48 (3): 228–235. DOI: 10.3760/cma.j.cn112148-20190617-00342.

  36. Serov V.A., Shutov A.M., Kuzovenkova M.Yu., Serova D.V. Klinicheskie osobennosti vnebol'nichnoy pnevmonii, assotsiirovannoy s ostrym povrezhdeniem pochek, v pozhilom i starcheskom vozraste [Clinical features of community-acquired pneumonia associated with acute kidney injury in elderly patients]. Uspekhi gerontologii. 2019; 32 (4): 633–638 (in Russian).

  37. Murugan R., Karajala-Subramanyam V., Lee M., Yende S., Kong L., Carter M., Angus D.C., Kellum J.A. Genetic and Inflammatory Markers of Sepsis (GenIMS) Investigators. Acute kidney injury in non-severe pneumonia is associated with an increased immune response and lower survival. Kidney Int. 2010; 77 (6): 527–535. DOI: 10.1038/ki.2009.502.

  38. Chawla L.S., Amdur R.L., Faselis C., Li P., Kimmel P.L., Palant C.E. Impact of Acute Kidney Injury in Patients Hospitalized with Pneumonia. Crit. Care Med. 2017; 45 (4): 600–606. DOI: 10.1097/CCM.0000000000002245.

  39. Prowle J.R., Bellomo R. Sepsis-associated acute kidney injury: macrohemodynamic and microhemodynamic alterations in the renal circulation. Seminars Nephrol. 2015; 35 (1): 64–74. DOI: 10.1016/j.semnephrol.2015.01.007.

  40. Fani F., Regolisti G., Delsante M., Cantaluppi V., Castellano G., Gesualdo L., Villa G., Fiaccadori E. Recent advances in the pathogenetic mechanisms of sepsis-associated acute kidney injury. J. Nephrol. 2018; 31 (3): 351–359. DOI: 10.1007/s40620-017-0452-4.

  41. Parikh S.M., Yang Y., He L., Tang C., Zhan M., Dong Z. Mitochondrial function and disturbances in the septic kidney. Seminars Nephrol. 2015; 35 (1): 108–119. DOI: 10.1016/j.semnephrol.2015.01.011.

  42. Strausser S.A., Nakano D., Souma T. Acute kidney injury to chronic kidney disease transition: insufficient cellular stress response. Cur. Opin. Nephrol. Hypertens. 2018; 27 (4): 314–322. DOI: 10.1097 /MNH.0000000000000424.

  43. Silver S.A., Long J., Zheng Y., Chertow G.M. Cost of Acute Kidney Injury in Hospitalized Patients. J. Hosp. Med. 2017; 12 (2): 70–76. DOI: 10.12788/jhm.2683.

  44. Mahesh E., Nallamuthu P., Kumar M., Madhyastha P.R., Konanna G. Clinical profile of geriatric acute kidney injury in a tertiary care center from south India. Saudi J. Kidney Dis. Transpl. 2017; 28 (4): 886–890.

  45. Kellum J.A., Bellomo R., Ronco C. Progress in Prevention and Treatment of Acute Kidney Injury: Moving Beyond Kidney Attack. JAMA. 2018; 320 (5): 437–438. DOI: 10.1001/jama.2018.7160.

  46. Al-Jaghbeer M., Dealmeida D., Bilderback A., Ambrosino R., Kellum J.A. Clinical decision support for in-hospital AKI. J. Am. Soc. Nephrol. 2018; 29 (2): 654–660. DOI: 10.1681/ASN.2017070765.

  47. Karsanji D.J., Pannu N., Manns B.J., Hemmelgarn B.R., Tan Z., Jindal K., Scott-Douglas N., James M.T. Disparity between Nephrologists' Opinions and Contemporary Practices for Community Follow-Up after AKI Hospitalization. Clin. J. Am. Soc. Nephrol. 2017; 12 (11): 1753–1761. DOI: 10.2215/CJN.01450217.

  48. Cillóniz C., Menéndez R., García-Vidal C., Péricas J.M., Torres A. Defining Community-Acquired Pneumonia as a Public Health Threat: Arguments in Favor from Spanish Investigators. Med. Sci. (Basel). 2020; 8 (1): E6. DOI: 10.3390/medsci8010006.

  49. Montull B., Menéndez R., Torres A., Reyes S., Méndez R., Zalacaín R., Capelastegui A., Rajas O., Borderías L., Martin-Villasclaras J., Bello S., Alfageme I., Rodríguez de Castro F., Rello J., Molinos L., Ruiz-Manzano J. Predictors of Severe Sepsis among Patients Hospitalized for Community-Acquired Pneumonia. PLoS One. 2016; 11 (1): e0145929. DOI: 10.1371/journal.pone.0145929.

  50. Cilloniz C., Dominedò C., Ielpo A., Ferrer M., Gabarrus A., Battaglini D., Bermejo-Martin J., Meli A., Garcia-Vidal C., Liapikou A., Singer M., Torres A. Risk and Prognostic Factors in Very Old Patients with Sepsis Secondary to Community-Acquired pneumonia. J. Clin. Med. 2019; 8 (7): E961. DOI: 10.3390/jcm8070961.

  51. Eitze S., Fleischmann-Struzek C., Betsch C., Reinhart K. Vaccination 60+ study group. Determinants of sepsis knowledge: A representative survey of the elderly population in Germany. Crit. Care. 2018; 22 (1): 273. DOI: 10.1186/s13054-018-2208-5.

  52. Corrales-Medina V.F., Alvarez K.N., Weissfeld L.A., Angus D.C., Chirinos J.A., Chang C.C., Newman A., Loehr L., Folsom A.R., Elkind M.S., Lyles M.F., Kronmal R.A., Yende S. Association between hospitalization for pneumonia and subsequent risk of cardiovascular disease. JAMA. 2015; 313 (3): 264–274. DOI: 10.1001/jama.2014.18229.

  53. O sostoyanii sanitarno-epidemiologicheskogo blagopoluchiya naseleniya v Rossiyskoy Federatsii v 2018 g.: gosudarstvennyy doklad [Sanitary and epidemiological well-being of Russian population in 2018: State report]. Moscow: Federal'naya sluzhba po nadzoru v sfere zashchity prav potrebiteley

    i blagopoluchiya cheloveka; 2019 (in Russian).

  54. Almirall J., Blanquer J., Bello S. Community-acquired pneumonia among smokers. Arch. Bronconeumol. 2014; 50 (6): 250–254. DOI: 10.1016/j.arbres.2013.11.016.

  55. Li K.J., Chen Z.L., Huang Y., Zhang R., Luan X.Q., Lei T.T., Chen L. Dysbiosis of lower respiratory tract microbiome are associated with inflammation and microbial function variety. Respir. Res. 2019; 20 (1): 272. DOI: 10.1186/s12931-019-1246-0.

  56. Torres A., Blasi F., Dartois N., Akova M. Which individuals are at increased risk of pneumococcal disease and why? Impact of COPD, asthma, smoking, diabetes, and/or chronic heart disease on community-acquired pneumonia and invasive pneumococcal disease. Thorax. 2015; 70 (10): 984–989. DOI: 10.1136 /thoraxjnl-2015-206780.

  57. Bello S., Menéndez R., Antoni T., Reyes S., Zalacain R., Capelastegui A., Aspa J., Borderías L., Martin-Villasclaras J.J., Alfageme I., de Castro F.R., Rello J., Luis M., Ruiz-Manzano J. Tobacco smoking increases the risk for death from pneumococcal pneumonia. Chest. 2014; 146 (4): 1029–1037. DOI: 10.1378/chest.13-2853.

  58. Beatty J.A., Majumdar S.R., Tyrrell G.J., Marrie T.J., Eurich D.T. Current Smoking and Reduced Mortality in Bacteremic Pneumococcal Pneumonia: A Population-Based Cohort Study. Chest. 2016; 150 (3): 652–660. DOI: 10.1016/j.chest.2016.04.020.

  59. Baskaran V., Murray R.L., Hunter A., Lim W.S., McKeever T.M. Effect of tobacco smoking on the risk of developing community acquired pneumonia: A systematic review and meta-analysis. PLoS One. 2019; 14 (7): e0220204. DOI: 10.1371/journal.pone.0220204.

  60. Nhung N.T.T., Amini H., Schindler C., Kutlar Joss M., Dien T.M., Probst-Hensch N., Perez L., Künzli N. Short-term association between ambient air pollution and pneumonia in children: A systematic review and meta-analysis of time-series and case-crossover studies. Environ. Pollut. 2017; 230: 1000–1008. DOI: 10.1016/j.envpol.2017.07.063.

  61. Pirozzi C.S., Jones B.E., VanDerslice J.A., Zhang Y., Paine R., Dean N.C. Short-Term Air Pollution and Incident Pneumonia. A Case-Crossover Study. Ann. Am. Thorac. Soc. 2018; 15 (4): 449–459. DOI: 10.1513/AnnalsATS.201706-495OC.

  62. Chanderraj R., Dickson R.P. Rethinking pneumonia: A paradigm shift with practical utility. Proc. Natl. Acad. Sci. USA. 2018; 115 (52): 13148–13150. DOI: 10.1073/pnas.1819024116.

Received 18 January 2021; accepted 16 February 2021.

 

Information about the authors

Serov Valeriy Anatol'evich, Doctor of Sciences (Medicine), Professor, Chair of Therapy and Occupational Diseases, Ulyanovsk State University. 432017, Russia, Ulyanovsk, L. Tolstoy St., 42; e-mail: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра., ORCID ID: http://orcid.org/0000-0002-8262-8816

Gnoevykh Valeriy Viktorovich, Doctor of Sciences (Medicine), Head of the Chair of Propedeutics of Internal Diseases, Ulyanovsk State University. 432017, Russia, Ulyanovsk, L. Tolstoy St., 42; e-mail: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра., ORCID ID: http://orcid.org/0000-0002-8009-0557

Serova Diana Valer'evna, Candidate of Sciences (Medicine), Associate Professor, Chair of Therapy and Occupational Diseases, Ulyanovsk State University. 432017, Russia, Ulyanovsk, L. Tolstoy St., 42; e-mail: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра., ORCID ID: http://orcid.org/0000-0001-7729-552X

Sakaeva El'vira Raisovna, Teaching Assistant, Chair of Therapy and Occupational Diseases, Ulyanovsk State University. 432017, Russia, Ulyanovsk, L. Tolstoy St., 42; e-mail: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра., ORCID ID: http://orcid.org/0000-0003-1646-3213

 

For citation

Serov V.A., Gnoevykh V.V., Serova D.V., Sakaeva E.R. Vnebol'nichnaya pnevmoniya – aktual'naya problema sovremennogo obshchestva [Community-acquired pneumonia as an urgent problem of modern society]. Ul'yanovskiy mediko-biologicheskiy zhurnal. 2021; 1: 57–70. DOI: 10.34014/2227-1848-2021-1-57-70 (in Russian)

 

Скачать статью

УДК 616.24-002.14

DOI 10.34014/2227-1848-2021-1-57-70

 

ВНЕБОЛЬНИЧНАЯ ПНЕВМОНИЯ - АКТУАЛЬНАЯ ПРОБЛЕМА СОВРЕМЕННОГО ОБЩЕСТВА

 

В.А. Серов, В.В. Гноевых, Д.В. Серова, Э.Р. Сакаева

ФГБОУ ВО «Ульяновский государственный университет», г. Ульяновск, Россия

 

Внебольничная пневмония (ВП) является одной из главных причин заболеваемости и смертности населения во всем мире. Однако несмотря на огромную социально-экономическую значимость этой патологии остается большое количество нерешенных вопросов по профилактике, диагностике и лечению данного заболевания. Особую тревогу вызывает увеличение смертности от ВП у пациентов пожилого возраста, так как во всех развитых странах удельный вес лиц старше 65 лет с каждым годом растет.

Целью настоящего обзора является рассмотрение наиболее значимых проблем диагностики и лечения ВП, решение которых позволит повысить качество оказания медицинской помощи и улучшить прогноз пациентов с ВП.

В качестве источников информации использовались данные электронных библиотек Pubmed, eLIBRARY и др.

Отсутствие адекватной этиологической диагностики бактериальной ВП привело к серьезной опасности необоснованной антибактериальной терапии, которая способствует распространению антибиотикорезистентных штаммов микроорганизмов и росту частоты побочного действия антибиотиков. В период коронавирусной пандемии особенно ярко проявились трудности этиологической диагностики инфекционных заболеваний дыхательных путей, недостаточность знаний об особенностях ведения больных с коморбидной патологией, недооценка населением серьезности бронхолегочных заболеваний. Одним из наиболее грозных осложнений ВП является острое повреждение почек (ОПП). Авторы описывают патогенетические механизмы нарушения функции почек, методы диагностики, тактику лечения и профилактики ОПП при ВП. Недооценка серьезности прогноза, в т.ч. средне- и долгосрочного, при ВП ведет к недостаточно высокому уровню использования вакцин против гриппа и пневмококка. Обращает на себя внимание необходимость усиления санитарно-просветительской работы с населением в отношении не только сердечно-сосудистых или онкологических заболеваний, но и инфекционных заболеваний дыхательных путей.

Ключевые слова: внебольничная пневмония, микробиологическая диагностика, коморбидность, санитарное просвещение.

 

Литература

  1. GBD 2016 Lower Respiratory Infections Collaborators. Estimates of the global, regional, and national morbidity, mortality, and aetiologies of lower respiratory infections in 195 countries, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Infect. Dis. 2018; 18 (11): 1191–1210. DOI: 10.1016/S1473-3099(18)30310-4.

  2. McLaughlin J.M., Khan F.L., Thoburn E.A., Isturiz R.E., Swerdlow D.L. Rates of hospitalization for community-acquired pneumonia among US adults: A systematic review. Vaccine. 2020; 38 (4): 741–751. DOI: 10.1016/j.vaccine.2019.10.101.

  3. Pessoa E., Bárbara C., Viegas L., Costa A., Rosa M., Nogueira P. Factors associated with in-hospital mortality from community-acquired pneumonia in Portugal: 2000–2014. BMC Pulm. Med. 2020; 20 (1): 18. DOI: 10.1186/s12890-019-1045-x.

  4. Биличенко Т.Н., Чучалин А.Г. Заболеваемость и смертность населения России от острых респираторных вирусных инфекций, пневмонии и вакцинопрофилактика. Терапевтический архив. 2018; 90 (1): 22–26. DOI: 10.17116/terarkh201890122-26.

  5. Rivero-Calle I., Cebey-López M., Pardo-Seco J., Yuste J., Redondo E., Vargas D.A., Mascarós E., Díaz-Maroto J.L., Linares-Rufo M., Jimeno I., Gil A., Molina J., Ocaña D., Martinón-Torres F. Lifestyle and comorbid conditions as risk factors for community-acquired pneumonia in outpatient adults (NEUMOES-RISK project). BMJ Open Respir. Res. 2019; 6 (1): e000359. DOI: 10.1136/bmjresp-2018-000359.

  6. Marrie T.J., Tyrrell G.J., Majumdar S.R., Eurich D.T. Invasive Pneumococcal Disease: Still Lots to Learn and a Need for Standardized Data Collection Instruments. Can. Respir. J. 2017; 2017: 2397429. DOI: 10.1155/2017/2397429.

  7. Sun G.Q., Zhang L., Zhang L.N., Wu Z., Hu D.F. Benzodiazepines or related drugs and risk of pneumonia: A systematic review and meta-analysis. Int. J. Geriatr. Psychiatry. 2019; 34 (4): 513–521. DOI: 10.1002/gps.5048.

  8. Gu C.H., Lucero D.E., Huang C.C., Daskalakis D., Varma J.K., Vora N.M. Pneumonia-Associated Hospitalizations, New York City, 2001–2014. Public Health Rep. 2018; 133 (5): 584–592. DOI: 10.1177/0033354918792009.

  9. Aliberti S., Dela Cruz C.S., Sotgiu G., Restrepo M.I. Pneumonia is a neglected problem: It is now time to act. Lancet Respir. Med. 2019; 7 (1): 10–11. DOI: 10.1016/S2213-2600(18)30470-3.

  10. Бобылев А.А., Рачина С.А., Авдеев С.Н., Козлов Р.С., Сухорукова М.В., Яцышина С.Б., Елькина М.А., Юданова Т.А. Этиология внебольничной пневмонии у лиц с хронической сердечной недостаточностью. Пульмонология. 2019; 29 (3): 293–301. DOI: 10.18093/0869-0189-2019-29-3-293-301.

  11. Захаренков И.А., Рачина С.А., Дехнич Н.Н., Козлов Р.С., Синопальников А.И., Иванчик Н.В., Яцышина С.Б., Елькина М.А., Архипенко М.В., Гордеева С.А., Лебедева М.С., Портнягина У.С. Этиология тяжелой внебольничной пневмонии у взрослых: результаты первого российского многоцентрового исследования. Терапевтический архив. 2020; 92 (1): 36–42. DOI: 10.26442 /00403660.2020.01.000491.

  12. GBD 2017 Causes of Death Collaborators. Global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet. 2018; 392 (10159): 1736–1788. DOI: 10.1016/S0140-6736(18)32203-7.

  13. Chow E.J., Doyle J.D., Uyeki T.M. Influenza virus-related critical illness: prevention, diagnosis, treatment. Crit. Care. 2019; 23 (1): 214. DOI: 10.1186/s13054-019-2491-9.

  14. Adhikari S.P., Meng S., Wu Y.J., Mao Y.P., Ye R.X., Wang Q.Z., Sun C., Sylvia S., Rozelle S., Raat H., Zhou H. Epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (COVID-19) during the early outbreak period: a scoping review. Infect. Dis. Poverty. 2020; 9 (1): 29. DOI: 10.1186/s40249-020-00646-x.

  15. Velavan T.P., Meyer C.G. The COVID-19 epidemic. Trop. Med. Int. Health. 2020; 25 (3): 278–280. DOI: 10.1111/tmi.13383.

  16. Ishida T., Ito A., Washio Y., Yamazaki A., Noyama M., Tokioka F., Arita M. Risk factors for drug-resistant pathogens in immunocompetent patients with pneumonia: Evaluation of PES pathogens. J. Infect. Chemother. 2017; 23 (1): 23–28. DOI: 10.1016/j.jiac.2016.09.002.

  17. Luan Y., Sun Y., Duan S., Zhao P., Bao Z. Pathogenic bacterial profile and drug resistance analysis of community-acquired pneumonia in older outpatients with fever. J. Int. Med. Res. 2018; 46 (11): 4596–4604. DOI: 10.1177/0300060518786915.

  18. Dominguez-Cherit G., De la Torre A., Rishu A., Pinto R., Ñamendys-Silva S.A., Camacho-Ortiz A., Silva-Medina M.A., Hernández-Cárdenas C., Martínez-Franco M., Quesada-Sánchez A., López-Gallegos G.C., Mosqueda-Gómez J.L., Rivera-Martinez N.E., Campos-Calderón F., Rivero-Sigarroa E., Hernández-Gilsoul T., Espinosa-Pérez L., Macías A.E., Lue-Martínez D.M., Buelna-Cano C., Ramírez-García Lu­na A.S., Cruz-Ruiz N.G., Poblano-Morales M., Molinar-Ramos F., Hernandez-Torre M., León-Gutiér­rez M.A., Rosaldo-Abundis O., Baltazar-Torres J.Á., Stelfox H.T., Light B., Jouvet P., Reynolds S., Hall R., Shindo N., Daneman N., Fowler R.A. Influenza A (H1N1pdm09)-Related Critical Illness and Mortality in Mexico and Canada, 2014. Crit. Care Med. 2016; 44 (10): 1861–1870. DOI: 10.1097/CCM.0000000000001830.

  19. MacIntyre C.R., Chughtai A.A., Barnes M., Ridda I., Seale H., Toms R., Heywood A. The role of pneumonia and secondary bacterial infection in fatal and serious outcomes of pandemic influenza a(H1N1)pdm09. BMC Infect. Dis. 2018; 18 (1): 637. DOI: 10.1186/s12879-018-3548-0.

  20. Chertow D.S., Memoli M.J. Bacterial coinfection in influenza: a grand rounds review. JAMA. 2013; 309 (3): 275–282. DOI: 10.1001/jama.2012.194139.

  21. Sukhal S., Sethi J., Ganesh M., Villablanca P.A., Malhotra A.K., Ramakrishna H. Extracorporeal membrane oxygenation in severe influenza infection with respiratory failure: A systematic review and meta-analysis. Ann. Card. Anaesth. 2017; 20 (1): 14–21. DOI: 10.4103/0971-9784.197820.

  22. Prete M., Favoino E., Catacchio G., Racanelli V., Perosa F. SARS-CoV-2 Inflammatory Syndrome. Clinical Features and Rationale for Immunological Treatment. Int. J. Mol. Sci. 2020; 21 (9): E3377. DOI: 10.3390/ijms21093377.

  23. Wang T., Chen R., Liu C., Liang W., Guan W., Tang R., Tang C., Zhang N., Zhong N., Li S. Attention should be paid to venous thromboembolism prophylaxis in the management of COVID-19. Lancet Haematol. 2020; 7 (5): e362–e363. DOI: 10.1016/S2352-3026(20)30109-5.

  24. Zhu H., Rhee J.W., Cheng P., Waliany S., Chang A., Witteles R.M., Maecker H., Davis M.M., Nguyen P.K., Wu S.M. Cardiovascular Complications in Patients with COVID-19: Consequences of Viral Toxicities and Host Immune Response. Cur. Cardiol. Rep. 2020; 22 (5): 32. DOI: 10.1007/s11886-020-01292-3.

  25. Chakraborty C., Sharma A.R., Sharma G., Bhattacharya M., Lee S.S. SARS-CoV-2 causing pneumonia-associated respiratory disorder (COVID-19): diagnostic and proposed therapeutic options. Eur. Rev. Med. Pharmacol. Sci. 2020; 24 (7): 4016–4026. DOI: 10.26355/eurrev_202004_20871.

  26. Heneghan C.J., Onakpoya I., Jones M.A., Doshi P., Del Mar C.B., Hama R., Thompson M.J., Spencer E.A., Mahtani K.R., Nunan D., Howick J., Jefferson T. Neuraminidase inhibitors for influenza: a systematic review and meta-analysis of regulatory and mortality data. Health Technol. Assess. 2016; 20 (42): 1–242. DOI: 10.3310/hta20420.

  27. Cillóniz C., Ewig S., Ferrer M., Polverino E., Gabarrús A., Puig de la Bellacasa J., Mensa J., Torres A. Community-acquired polymicrobial pneumonia in the intensive care unit: Aetiology and prognosis. Crit. Care. 2011; 15 (5): R209. DOI: 10.1186/cc10444.

  28. Gadsby N.J., Russell C.D., McHugh M.P., Mark H., Conway Morris A., Laurenson I.F., Hill A.T., Templeton K.E. Comprehensive Molecular Testing for Respiratory Pathogens in Community-Acquired Pneumonia. Clin. Infect. Dis. 2016; 62 (7): 817–823. DOI: 10.1093/cid/civ1214.

  29. Wang J., Li F., Tian Z. Role of microbiota on lung homeostasis and diseases. Sci. China Life Sci. 2017; 60 (12): 1407–1415. DOI: 10.1007/s11427-017-9151-1.

  30. Steenhuijsen Piters W.A., Sanders E.A., Bogaert D. The role of the local microbial ecosystem in respiratory health and disease. Philos. Trans. R. Soc. Lond. B. Biol. Sci. 2015; 370 (1675): 20140294. DOI: 10.1098/rstb.2014.0294.

  31. Mendez R., Banerjee S., Bhattacharya S.K., Banerjee S. Lung inflammation and disease: A perspective on microbial homeostasis and metabolism. IUBMB Life. 2019; 71 (2): 152–165. DOI: 10.1002/iub.1969.

  32. Huffnagle G.B., Dickson R.P., Lukacs N.W. The respiratory tract microbiome and lung inflammation: a two-way street. Mucosal Immunol. 2017; 10 (2): 299–306. DOI: 10.1038/mi.2016.108.

  33. Бобылев А.А., Рачина С.А., Авдеев С.Н., Козлов Р.С., Дехнич Н.Н. Внебольничная пневмония у пациентов пожилого и старческого возраста. Пульмонология. 2015; 3: 261–276.

  34. Фатенков О.В., Кузьмина Т.М., Рубаненко О.А., Светлова Г.Н., Дзюбайло А.В. Течение внебольничной бактериальной пневмонии при коморбидной патологии у пожилых пациентов. Успехи геронтологии. 2017; 30 (3): 394–397.

  35. Chen L., Han X.D., Li Y.L., Zhang C.X., Xing X.Q. Incidence and risk factors for cardiovascular events in patients hospitalized with community-acquired pneumonia. Zhonghua Xin Xue Guan Bing Za Zhi. 2020; 48 (3): 228–235. DOI: 10.3760/cma.j.cn112148-20190617-00342.

  36. Серов В.А., Шутов А.М., Кузовенкова М.Ю., Серова Д.В. Клинические особенности внебольничной пневмонии, ассоциированной с острым повреждением почек, в пожилом и старческом возрасте. Успехи геронтологии. 2019; 32 (4): 633–638.

  37. Murugan R., Karajala-Subramanyam V., Lee M., Yende S., Kong L., Carter M., Angus D.C., Kellum J.A. Genetic and Inflammatory Markers of Sepsis (GenIMS) Investigators. Acute kidney injury in non-severe pneumonia is associated with an increased immune response and lower survival. Kidney Int. 2010; 77 (6): 527–535. DOI: 10.1038/ki.2009.502.

  38. Chawla L.S., Amdur R.L., Faselis C., Li P., Kimmel P.L., Palant C.E. Impact of Acute Kidney Injury in Patients Hospitalized with Pneumonia. Crit. Care Med. 2017; 45 (4): 600–606. DOI: 10.1097 /CCM.0000000000002245.

  39. Prowle J.R., Bellomo R. Sepsis-associated acute kidney injury: macrohemodynamic and microhemodynamic alterations in the renal circulation. Seminars Nephrol. 2015; 35 (1): 64–74. DOI: 10.1016/j.semnephrol.2015.01.007.

  40. Fani F., Regolisti G., Delsante M., Cantaluppi V., Castellano G., Gesualdo L., Villa G., Fiaccadori E. Recent advances in the pathogenetic mechanisms of sepsis-associated acute kidney injury. J. Nephrol. 2018; 31 (3): 351–359. DOI: 10.1007/s40620-017-0452-4.

  41. Parikh S.M., Yang Y., He L., Tang C., Zhan M., Dong Z. Mitochondrial function and disturbances in the septic kidney. Seminars Nephrol. 2015; 35 (1): 108–119. DOI: 10.1016/j.semnephrol.2015.01.011.

  42. Strausser S.A., Nakano D., Souma T. Acute kidney injury to chronic kidney disease transition: insufficient cellular stress response. Cur. Opin. Nephrol. Hypertens. 2018; 27 (4): 314–322. DOI: 10.1097 /MNH.0000000000000424.

  43. Silver S.A., Long J., Zheng Y., Chertow G.M. Cost of Acute Kidney Injury in Hospitalized Patients. J. Hosp. Med. 2017; 12 (2): 70–76. DOI: 10.12788/jhm.2683.

  44. Mahesh E., Nallamuthu P., Kumar M., Madhyastha P.R., Konanna G. Clinical profile of geriatric acute kidney injury in a tertiary care center from south India. Saudi J. Kidney Dis. Transpl. 2017; 28 (4): 886–890.

  45. Kellum J.A., Bellomo R., Ronco C. Progress in Prevention and Treatment of Acute Kidney Injury: Moving Beyond Kidney Attack. JAMA. 2018; 320 (5): 437–438. DOI: 10.1001/jama.2018.7160.

  46. Al-Jaghbeer M., Dealmeida D., Bilderback A., Ambrosino R., Kellum J.A. Clinical decision support for in-hospital AKI. J. Am. Soc. Nephrol. 2018; 29 (2): 654–660. DOI: 10.1681/ASN.2017070765.

  47. Karsanji D.J., Pannu N., Manns B.J., Hemmelgarn B.R., Tan Z., Jindal K., Scott-Douglas N., James M.T. Disparity between Nephrologists' Opinions and Contemporary Practices for Community Follow-Up after AKI Hospitalization. Clin. J. Am. Soc. Nephrol. 2017; 12 (11): 1753–1761. DOI: 10.2215 /CJN.01450217.

  48. Cillóniz C., Menéndez R., García-Vidal C., Péricas J.M., Torres A. Defining Community-Acquired Pneumonia as a Public Health Threat: Arguments in Favor from Spanish Investigators. Med. Sci. (Basel). 2020; 8 (1): E6. DOI: 10.3390/medsci8010006.

  49. Montull B., Menéndez R., Torres A., Reyes S., Méndez R., Zalacaín R., Capelastegui A., Rajas O., Borderías L., Martin-Villasclaras J., Bello S., Alfageme I., Rodríguez de Castro F., Rello J., Molinos L., Ruiz-Manzano J. Predictors of Severe Sepsis among Patients Hospitalized for Community-Acquired Pneumonia. PLoS One. 2016; 11 (1): e0145929. DOI: 10.1371/journal.pone.0145929.

  50. Cilloniz C., Dominedò C., Ielpo A., Ferrer M., Gabarrus A., Battaglini D., Bermejo-Martin J., Meli A., Garcia-Vidal C., Liapikou A., Singer M., Torres A. Risk and Prognostic Factors in Very Old Patients with Sepsis Secondary to Community-Acquired pneumonia. J. Clin. Med. 2019; 8 (7): E961. DOI: 10.3390/jcm8070961.

  51. Eitze S., Fleischmann-Struzek C., Betsch C., Reinhart K. Vaccination 60+ study group. Determinants of sepsis knowledge: A representative survey of the elderly population in Germany. Crit. Care. 2018; 22 (1): 273. DOI: 10.1186/s13054-018-2208-5.

  52. Corrales-Medina V.F., Alvarez K.N., Weissfeld L.A., Angus D.C., Chirinos J.A., Chang C.C., Newman A., Loehr L., Folsom A.R., Elkind M.S., Lyles M.F., Kronmal R.A., Yende S. Association between hospitalization for pneumonia and subsequent risk of cardiovascular disease. JAMA. 2015; 313 (3): 264–274. DOI: 10.1001/jama.2014.18229.

  53. О состоянии санитарно-эпидемиологического благополучия населения в Российской Федерации в 2018 г.: государственный доклад. М.: Федеральная служба по надзору в сфере защиты прав потребителей и благополучия человека; 2019.

  54. Almirall J., Blanquer J., Bello S. Community-acquired pneumonia among smokers. Arch. Bronconeumol. 2014; 50 (6): 250–254. DOI: 10.1016/j.arbres.2013.11.016.

  55. Li K.J., Chen Z.L., Huang Y., Zhang R., Luan X.Q., Lei T.T., Chen L. Dysbiosis of lower respiratory tract microbiome are associated with inflammation and microbial function variety. Respir. Res. 2019; 20 (1): 272. DOI: 10.1186/s12931-019-1246-0.

  56. Torres A., Blasi F., Dartois N., Akova M. Which individuals are at increased risk of pneumococcal disease and why? Impact of COPD, asthma, smoking, diabetes, and/or chronic heart disease on community-acquired pneumonia and invasive pneumococcal disease. Thorax. 2015; 70 (10): 984–989. DOI: 10.1136/thoraxjnl-2015-206780.

  57. Bello S., Menéndez R., Antoni T., Reyes S., Zalacain R., Capelastegui A., Aspa J., Borderías L., Martin-Villasclaras J.J., Alfageme I., de Castro F.R., Rello J., Luis M., Ruiz-Manzano J. Tobacco smoking increases the risk for death from pneumococcal pneumonia. Chest. 2014; 146 (4): 1029–1037. DOI: 10.1378/chest.13-2853.

  58. Beatty J.A., Majumdar S.R., Tyrrell G.J., Marrie T.J., Eurich D.T. Current Smoking and Reduced Mortality in Bacteremic Pneumococcal Pneumonia: A Population-Based Cohort Study. Chest. 2016; 150 (3): 652–660. DOI: 10.1016/j.chest.2016.04.020.

  59. Baskaran V., Murray R.L., Hunter A., Lim W.S., McKeever T.M. Effect of tobacco smoking on the risk of developing community acquired pneumonia: A systematic review and meta-analysis. PLoS One. 2019; 14 (7): e0220204. DOI: 10.1371/journal.pone.0220204.

  60. Nhung N.T.T., Amini H., Schindler C., Kutlar Joss M., Dien T.M., Probst-Hensch N., Perez L., Künzli N. Short-term association between ambient air pollution and pneumonia in children: A systematic review and meta-analysis of time-series and case-crossover studies. Environ. Pollut. 2017; 230: 1000–1008. DOI: 10.1016/j.envpol.2017.07.063.

  61. Pirozzi C.S., Jones B.E., VanDerslice J.A., Zhang Y., Paine R., Dean N.C. Short-Term Air Pollution and Incident Pneumonia. A Case-Crossover Study. Ann. Am. Thorac. Soc. 2018; 15 (4): 449–459. DOI: 10.1513/AnnalsATS.201706-495OC.

  62. Chanderraj R., Dickson R.P. Rethinking pneumonia: A paradigm shift with practical utility. Proc. Natl. Acad. Sci. USA. 2018; 115 (52): 13148–13150. DOI: 10.1073/pnas.1819024116.

Поступила в редакцию 18.01.2021; принята 16.02.2021.

 

Авторский коллектив

Серов Валерий Анатольевич – доктор медицинских наук, профессор кафедры терапии и профессиональных болезней, ФГБОУ ВО «Ульяновский государственный университет». 432017, Россия, г. Ульяновск, ул. Л. Толстого, 42; e-mail: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра., ORCID ID: http://orcid.org/0000-0002-8262-8816

Гноевых Валерий Викторович – доктор медицинских наук, заведующий кафедрой пропедевтики внутренних болезней, ФГБОУ ВО «Ульяновский государственный университет». 432017, Россия, г. Ульяновск, ул. Л. Толстого, 42; e-mail: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра., ORCID ID: http://orcid.org/0000-0002-8009-0557

Серова Диана Валерьевна – кандидат медицинских наук, доцент кафедры терапии и профессиональных болезней, ФГБОУ ВО «Ульяновский государственный университет». 432017, Россия, г. Ульяновск, ул. Л. Толстого, 42; e-mail: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра., ORCID ID: http://orcid.org/0000-0001-7729-552X

Сакаева Эльвира Раисовна – ассистент кафедры терапии и профессиональных болезней, ФГБОУ ВО «Ульяновский государственный университет». 432017, Россия, г. Ульяновск, ул. Л. Толстого, 42; e-mail: Этот адрес электронной почты защищён от спам-ботов. У вас должен быть включен JavaScript для просмотра., ORCID ID: http://orcid.org/0000-0003-1646-3213

 

Образец цитирования

Серов В.А., Гноевых В.В., Серова Д.В., Сакаева Э.Р. Внебольничная пневмония – актуальная проблема современного общества. Ульяновский медико-биологический журнал. 2021; 1: 57–70. DOI: 10.34014/2227-1848-2021-1-57-70