Introduction
The former term for one of the oldest nosologies known to medicine, “acute pneumonia” (AP), which specifically reflected the inflammatory essence and basis of the disease, has practically ceased to be used in recent decades. Today, the majority of patients with AP appear under the term “community-acquired pneumonia” (CP), and the remaining patients with acute inflammation of the lung tissue are defined as “nosocomial pneumonia”, “ventilator-associated pneumonia”, “COVID-19 pneumonia,” etc. First of all, attention is drawn to the disappearance from the names of all these variants of the disease of such an important and characteristic feature as an indication of the acute development of the process. This circumstance, like the very appearance of the above classification of the disease, is a very symptomatic fact for modern ideas about the nature of this pathology and the established traditions of its long-term treatment.
The emergence and long-term use of antibiotics played a decisive role in the development of the current situation with medical care for patients with AP. By the time of the first clinical use of penicillin (1), it was already known about the possibility of rapid development of bacterial resistance (2,3), the serious consequences of which were warned by the founder of this therapy, Alexander Fleming (4). However, the first successes of the use of penicillin had not only a positive, but also a negative effect, for a long time overshadowing the sense of professional caution and a balanced assessment of the true benefits of the new type of treatment. In clinical circles, the prevailing desire was to preserve the primary effect of antibiotics, which was steadily declining due to the development of microbial resistance. These efforts provided the impetus for the development of new antimicrobial drugs, but the final results of this
multi-year process, quite naturally, led to results far from expected.
Today, among the consequences of antibiotic therapy, we have received not only an extensive group of resistant strains of microorganisms, which, finally, after almost 8 decades of practical use, were recognized as a global catastrophe (5). However, such an official statement about a long-obvious fact is considered as a formidable, but the only long-term result of antibiotic exposure. Such a clear manifestation of the action of antimicrobials as the constant change of AP pathogens, which began to be observed only in the era of antibiotics, has not yet attracted widespread attention of specialists, although the argumentation of this phenomenon has already been cited in available sources (6,7)
For obvious reasons, the most ignored aspect is the didactic effect of antibiotics on professional activity. It is not surprising that numerous cohorts of specialists who received firm instructions from the university bench about the dominant role of the pathogen in the emergence and development of AP, when antibiotics are presented as the main lifesaving remedy, today adhere to the concept of the disease "pathogen-antibiotic". At the same time, the synthesis of information obtained at the university meets the relevant recommendations and requirements in the course of practical activity. The limitation of professional understanding of the basics of the disease by etiology and complete inattention to a number of classical and fundamental materials of medical science are the main obstacle in solving the problem of AP, since the dominant idea of the disease in the thinking of experts determines further research directions. However, until now, this side effect of antibiotics has gone unnoticed in medical circles (7).
Some of the above provisions make it possible to explain and understand the currently established principles of first and emergency medical care for patients with AP. In recent decades, the main efforts and proposed solutions have been aimed at identifying the causative agent of the disease as early as possible and purposefully prescribing antibiotics. One of the attempts to solve this problem was the above-mentioned classification of AP depending on the situation and circumstances of the occurrence of inflammation in the lungs. The identification of nonspecific inflammatory processes in lung tissue was based on differences in the results of bacteriological examination of patients who became ill in different conditions and under different circumstances, which allowed us to make an assumption about the optimal empirical choice of antibiotics and accelerate the achievement of therapeutic success. At the moment, it is already quite obvious that such an idea has not brought revolutionary results.
The desire and attempts to restore and maintain the former effectiveness of antibiotics consisted, first of all, in improving a variety of microbiological diagnostic methods, as well as in the search for differential diagnostic criteria depending on the pathogen. All these initiatives did not bring the expected results, and meanwhile the situation in this area of medicine began to change dramatically as a result of the steady growth of viral forms of the disease, the treatment of which continued to be carried out according to established standards. Only the development of the SARS-CoV-2 pandemic forced specialists to pay alarming attention to the dramatically changed conditions of inflammatory processes in the lungs, and this is because the main and so familiar therapeutic direction in the form of antibiotics turned out to be devoid of justified indications for its use in a large flow of such patients. The usual treatment regimen for patients with AP has reached a dead end. Has the usual treatment regimen for patients with AP reached a dead end? It depends from what point of view one evaluates the observed changes.
Meanwhile, if we carefully analyze current events and ongoing research, then in their manifestation and results we will be able to find factors and characteristics that have not attracted attention for many years, but which allow us to look at seemingly well-known elements and positions from a different point of view. For example, after repeated unsuccessful attempts at differential diagnosis of bacterial forms of AP depending on the pathogen, attempts to find differential criteria between bacterial and viral variants of lung tissue inflammation turned out to be equally unsuccessful (8-10). Clinical observations show the identity of the disease picture, regardless of the etiology of the process. The latter circumstance refutes the leading role of the pathogen in the development and dynamics of AP and indicates a violation of lung functions as a result of damage to its structures by the inflammatory process. This interpretation brings us back to the classical materials of medical science and, in particular, to the pathophysiology of inflammation.
Another argument against the leading role of the pathogen in the development of AP is the comparative materials of treatment of patients with bacterial forms of CAP and coronavirus pneumonia during the SARS-CoV-2 pandemic. For example, in recent years, for bacterial CAP, 80% of patients were successfully treated on an outpatient basis and only 20% required hospitalization (11,12). At the same time, the mortality rate of outpatients ranged from 1% to 5%, among hospitalized patients it increased to 10-12%, and among those transferred to the intensive care unit it already reached 30-50% (11-16). It should be recalled that in this case we are talking about patients who received etiotropic treatment in the form of antibiotics, which is so important in the modern understanding.
Another argument against the leading role of the pathogen in the development of AP is the materials of the SARS-CoV-2 pandemic. For example, a couple of decades ago, when AP was thought to be predominantly bacterial in nature, 80% of patients were successfully treated as outpatients and only 20% required hospitalization (11,12). At the same time, the mortality rate of outpatients did not exceed 1-5%, among hospitalized patients it increased to 10-12%, and among those transferred to the intensive care unit it had already reached 30-50% (11-16). It should be recalled that in this case we are talking about patients who received basic etiotropic treatment. During the pandemic, among those infected with coronavirus, 80% underwent this “meeting” on an outpatient basis, of which from 20 to 40% learned about infection only on the basis of tests, and in the remaining observations, patients received only symptomatic therapy on an outpatient basis. 20% of patients with COVID-19 pneumonia required hospitalization, of whom 5% were admitted to intensive care units (). Mortality was _____ in general wards and increased to ___ in intensive care units (). As can be seen from the presented materials, the distribution of patients according to treatment conditions and achieved results is quite comparable, regardless of the presence or absence of etiotropic therapy.
During the SARS-CoV-2 pandemic, practical medicine, due to the large flow of coronavirus pneumonia, suddenly lost the logical prerequisites for the use of antibiotics. An atmosphere of uncertainty and disappointment gripped even proven professionals (17-20). The fear of coronavirus was understandable. The loss of hope for the usual help of antibiotics has transformed into the prospect of a high probability of illness and the absence of any guarantees of cure in case of infection with coronavirus. During the most active period of the pandemic, few people paid attention to the fact that there were fewer cases and deaths than expected. Thus, up to 80% of people had contact with the pathogen in an outpatient setting, and from 20 to 40% of them had no clinical manifestations, having learned about their infection only on the basis of tests. Outpatients with signs of respiratory disease received only symptomatic medications without etiotropic therapy, and on average 20% of patients were hospitalized for pneumonia caused by COVID-19. Overall mortality among hospitalized patients ranged from 6% to 21Conflict of interest
the author states that he has no conflict of interest.
