mwvave pnevmonia mozrdilebSi

klinikuri praqtikis erovnuli rekomendacia

(gaidlaini)
klinikuri praqtikis erovnuli rekomendacia (gaidlaini)
`mwvave pnevmonia mozrdilebSi~ miRebulia klinikuri
praqtikis erovnuli rekomendaciebis (gaidlainebi) da
daavadebaTa marTvis saxelmwifo standartebis
(protokolebi) SemuSavebis, Sefasebis da danergvis
erovnuli sabWos 2006 wlis 21 noembris #2 sxdomaze da
damtkicebulia saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis ministris 2007 wlis 21 dekembris # 363/o
brZanebiT.

2
 mwvave pnevmonia mozrdilebSi

1. definicia
pnevmonia aris alveolisa da terminaluri sasunTqi gzebis anTeba,
romelic gamowveulia infeqciuri agentis hematogenuri an inhalaciuri
gziT filtvebSi moxvedriT da romelsac axasiaTebs mwvave
respiraciuli simptomebis, cxelebis an orives erTdroulad arseboba
da gulmkerdis rentgenogramaze filtvis parenqimuli infiltraciis
niSnebi. praqtikuli TvalsazrisiT, mniSvnelovania pnevmoniis dayofa
sazogadoebaSi SeZenil (sayofacxovrebo, ambulatorul) da
nozokomiur tipebad. aseTi dayofa ar aris dakavSirebuli daavadebis
mimdinareobis simZimesTan. ZiriTad da erTaderT ganmasxvavebel
kriteriumad gvevlineba is garemoeba, sadac ganviTarda pnevmonia.
sazogadoebaSi SeZenil pnevmoniaSi unda vigulisxmoT mwvave daavadeba,
romelic aRmocendeba ara saavadmyofos pirobebSi, an romlis
diagnostika moxda hospitalizaciis momentidan pirvel 48 sT-Si da
romelsac Tan axlavs qveda sasunTqi gzebis infeqciis simptomebi:
xvela, qoSini, cxeleba, naxvelis (SesaZloa Cirqovani) gamoyofa,
tkivili gulmkerdis areSi da rentgenologiuri niSnebi (filtvebSi
axali kerovan-infiltraciuli cvlilebebi).

2. epidemiologia
epidemiologiuri monacemebis Tanaxmad, pnevmoniis sixSire ufrosebSi
(>18 weli) farTo diapazonSi meryeobs: axalgazrda da saSualo asakis
pirebs Soris 1-11,6%-ia, ufros asakobriv jgufSi 25-44%. wlis
ganmavlobaSi ufrosi asakSi (>18 weli) avadobis saerTo raodenobam 5
evropul qveyanaSi (didi britaneTi, safrangeTi, italia, germania,
espaneTi) 3.000.000 adamiani Seadgina. saqarTvelos Sromis,
janmrTelobis da socialuri dacvis saministros samedicino
statistikis da informaciis centris 2004 wlis monacemebiT
saqarTveloSi pnevmoniiT hospitalizebul iqna 9.757 avadmyofi,
maCvenebeli 100.00 mosaxleze 223, letaloba – 0,8%.
pnevmoniis dros letaloba Zalian dabalia (1-3%). Tumca 60 welze meti
asakis pacientebSi, seriozuli Tanmxlebi paTologiebis arsebobisas
(f.q.o.d., avTvisebiani axalwarmonaqmnebi, alkoholizmi, Saqriani
diabeti, RviZlisa da Tirkmelebis daavadebebi, gul-sisxlZarRvTa
daavadebebi da a.S.), aseve pnevmoniis mZimed mimdinareobisas
(multilobaluri infiltracia, meoradi baqteriemia, sunTqvis
sixSire>30/wT, hipotenzia da Tirkmlebis mwvave ukmarisoba),
letalobis maCvenebeli 15-30%-s aRwevs.
letalobis riski, romelic moicavs anamnezur, obieqtur da
laboratoriul monacemebs, warmodgenilia 1 cxrilSi. letalobis
mniSvnelovani faqtoria gviani mimarTva samedicino daxmarebisaTvis.

3
 cxrili 1

monacemebi albaToba
demografia
mamrobiTi sqesi 1,3 (1,2-1,4)
ZiriTadi daavadebis istoria
gadacieba 0,4 (0,2-0,7)
fsiqikuri statusis Secvla 2,0 (1,7-2,3)
qoSini 2,9 (1,9-3,8)
Tanmxlebi daavadebebi
gulis qronikuli ukmarisoba 2,4 (2,2-2.5)
imunodeficituri mdgomareoba 1,6 (1,3-1,8)
Saqriani diabeti 1,2 (1,3-1,4)
koronarul sisxlZarRvTa dazianeba 1,5 (1,3-1,6)
onkologiuri daavadebebi 2,7 (2,5-2,9)
nevrologiuri daavadebebi 4,4 (3,8-4,9)
Tirkmlis paTologiebi 2,7 (2,5-2,9)
fizikuri gamokvlevebi
taqipnoe 2,5 (2,2-2,8)
hipoTermia 2,6 (2,1-3,2)
hopotenzia 5,4 (5,0-5,9)
laboratoriuli gamokvlevebi
sisxlis Sardovana (>7,14mm.Hg.) 2,7 (2,3-3.0)
leikopenia (<4×10 9/l) 5,1 (3,8-6,4)
leikocitozi (>10×10 9/l) 4,1 (3,85-4,8)
hipoqsemia (PaO2<50mm.Hg.) 2,2 (1,8-2,7)
Ro-gramaze infiltraciaa 1-ze met wilSi 3,1 (1,9-5,1)

4
3. etiologia
pnevmoniis etiologia dakavSirebulia normalur mikroflorasTan,
romelic zeda sasunTqi gzebis kolonizirebas axdens. maRali
virulentoba mravalricxovani mikroorganizmebidan mxolod zogierTs
gaaCnia. maT SeuZliaT gamoiwvion sasunTqi gzebis qveda nawilebis
anTebiTi reaqcia. aseT tipur gamomwvevad iTvleba S.pneumoniae (30%-50%
daavadebis SemTxveva). pnevmoniis etiologiaSi arsebiTi mniSvneloba
aqvs e.w. atipur mikroorganizmebs (Chlamydophila pneumoniae, Mycoplasma
pneumoniae, Legionella pneumoniae) romelTa wilzec saerTo jamSi modis 8-
10%-mde. iSviaT gamomwvevebs ganekuTvneba Haemophilus influenzae, Staphilococcus
aureus, Klebsiella pneumoniae (3-5%).
iSviaTad pnevmonia SeiZleba gamoiwvios fsevdomonam (gansakuTrebiT
mukoviscidoziT daavadebulebSi, romelTac aqvT bronqoeqtazia).
aucilebelia aRiniSnos, rom mozrdil pacientebSi vlindeba Sereuli
infeqciebi. mag. pnevmokokuri pnevmoniis dros SesaZlebelia
erTdroulad aRmoCndes mikoplazmuri an qlamidiuri infeqcia.
respiraciuli virusebi (gripi A da B, paragripi, adenovirusi da rsv)
arc ise xSirad iwveven filtvebis mZime dazianebebs. respiraciuli
virusebi, da pirvel rigSi epidemiuri gripi, pnevmoniis wamyvani risk-
faqtoria. aucilebelia virusuli da baqteriuli pnevmoniis zusti
diferencireba, radgan maTi mkurnaloba gansxvavebulia.
pnevmonia SesaZloa gamowveuli iyos ucnobi etiologiis gamomwveviT,
romelic daavadebis swraf ganviTarebas iwvevs. ukanasknel wlebSi
aseTebs SeiZleba mivakuTvnoT koronavirusi, frinvelis gripis virusi,
metapnevmovirusi. zogierTi mikroorganizmisaTvis damaxasiaTebeli ar
aris filtvebis anTeba. maTi naxvelidan gamoyofa amtkicebs zemo
sasunTqi gzebis floris kontaminacias da ara am mikrobis etiologiur
mniSvnelobas. aseT mikroorganizmebs miekuTvneba: Steptococcus viridas,
Staphylococcus epidermidis da sxva koagulonegatiuri stafilokokebi,
Enterococus spp, Neisseria spp, Candida spp.
pnevmoniis etiologia gansxvavdeba avadmyofis asakis, daavadebis
simZimis da Tanmxlebi paTologiis arsebobis mixedviT. hospitalizebul
pacientebSi pnevmokokebis, mikoplazmebis da qlamidiebis wilze modis
daaxloebiT 25%. am ukanasknelebs arsebiTi mniSvneloba ara aqvT
pnevmoniis mZime formebis ganviTarebaSi. amave dros, am kategoriis
pacientebSi matulobs Legionella spp., S.aureus, gramuaryofiTi
enterobaqteriebis, K.pneumoniae-is wili.
praqtikuli poziciidan gamomdinare mizanSewonilia gamovyoT
pacientebis jgufi asakis, Tanmxlebi daavadebebis da daavadebis
mimdinareobis simZimis mixedviT. am jgufebs Soris gansxvaveba
aRiniSneba ara marto etiologiis, aramed prognozis mixedviTac.

5
 cxrili 2
pnevmoniis gamomwvevi da letaloba
gamomwvevi letaloba %
S.pneumoniae 12,3%
H.influenzae 7,4%
M.pneumoniae 1,4%
Legionella spp. 14,7%
S.aureus 31,7%
K.pneumoniae 35,7%
C.pneumoniae 9,4%

cxrili 3
pacientebis jgufebi da gamomwvevebi
jgufi pacientis daxasiaTeba gamomwvevebi
1 pnevmoniis aramZimed mimdinareoba 60 S.pneumoniae
wl-ze qvemoT pacientebSi
M.pneumonia
Tanmxlebi paTologiis gareSe
C.pneumoniae
2 daavadebis mZime mimdinareoba 60 S.pneumoniae
wl-is zemoT da/an Tanmxlebi
H.influenzae
paTologiebiT
C.pneumoniae
S.aureus
Enterobacteriaceae
3 pnevmoniis mZime mimdinareoba, S.pneumoniae
hospitaliz-ebuli pacientebi
H.influeanzae
(saerTo profilis ganyofilebaSi)
C.pneumoniae
S.aureus
Enterobacteriaceae
4 pnevmoniis mZime mimdinareoba, S.pneumoniae
hospitaliz-ebuli pacientebi
Legionella spp
(intensiuri Terapiis
ganyofilebaSi) S.aureus
Entarobacteriaceae

6
 cxrili 4
pnevmoniis gamomwvevebi
gamomwvevi literaturis mixedviT meta-analizi
baqteriebi
S.Pneumoniae 20-60 65
H.influenzae 3-10 12
S. aureus 3-5 2
atipuri 10-20 12
gamomwvevi
virusi 2-15 3
aspiraciuli 6-10
pnevmonia
daudgeneli 30-60
etiologia

4. paTogenezi
sasunTqi gzebis qveda nawilebis infeqciisagan dacvas meqanikuri
faqtorebi (aerodinamikuri filtracia, bronqebis meqanikuri ganStoeba,
xvela da cemineba, mocimcime epiTeliumis wamwamebis rxeva) da
araspecifiuri da specifiuri imunitetis meqanizmebi axorcieleben.
anTebiTi reaqciis ganviTarebis mizezi SesaZloa gaxdes rogorc
makroorganizmis dacviTi meqanizmebis efeqturobis daqveiTeba, aseve
mikroorganizmebis dozis masiuroba da/an maTi moWarbebuli
virulenturoba. pnevmoniis ganviTarebas ganapirobebs 4 paTogenezuri
meqanizmi (ZiriTadad vlindeba pirveli ori):
• aspiracia;
• mikroorganizmebis Semcveli haeris CasunTqva;
• mikroorganizmebis hematogenuri gavrceleba arafiltvismieri
kerovani infeqciisganE(endokarditi, septiuri Tromboflebiti);
• infeqciis gavrceleba uSualod mezobeli dazianebuli
kerebisagan (mag. Tirkmlis abscesis dros) an gulmkerdis Semavali
Wrilobebis inficirebis Sedegad.
aspiracia _
pnevmoniis paTogenezSi inficirebis mTavari gzaa.
normalur pirobebSi, mikroorganizmebis nawils, mag., S. pneumoniae,
SeuZliaT pir-xaxis kolonizireba, Tumca sasunTqi gzebis qveda
nawilebi steriluri rCeba. mozrdilTa naxevarSi Zilis dros pir-
xaxis sekretis mikroaspiracia fiziologiuri fenomenia. erTi mxriv,
xvelis refleqsi, mukociliaruli klirensi, alveoluri makrofagebis
antibaqteriuli aqtivoba da, meore mxriv, sekretuli
imunoglobulinebi uzrunvelyofen inficirebuli sekretis eliminacias
sasunTqi gzebis qvemo nawilebidan da maT sterilurobas.

7
traqeobronquli xis TviTgamwmendi meqanizmis dazianebisas, mag.
respiraciuli virusuli infeqciis dros, roca irRveva bronqebis
wamwamovani epiTeliumis funqcia da qveiTdeba alveoluri
makrofagebis fagocituri aqtivoba, pnevmoniis ganviTarebisaTvis
sasurveli pirobebi iqmneba. sxva SemTxvevaSi, paTogenezuri faqtori
SesaZloa iyos mikroorganizmebis dozis masiuroba an erTeuli
maRaldiferenciuli mikroorganizmebis SeRweva sasunTq gzebSi.
mikrobuli aerozolis inhalacia pnevmoniix SedarebiT iSviaTi mizezia.
is mTavar rols TamaSobs obligaturi gamomwvevebiT sasunTqi gzebis
qveda nawilebis inficirebaSi. kidev ufro naklebi mniSvneloba aqvs
infeqciis keridan gamomwvevis hematogenur (mag. Staphylococcus spp.)
gavrcelebas. Apnevmoniis paTogenezis aRwerili Taviseburebis
gaTvaliswinebiT aSkaraa, rom misi etiologia sasunTqi gzebis zeda
nawilebis mikroflorasTan aris dakavSirebuli, romlis
Semadgenlobac damokidebulia garemoze, pacientis asakze da
janmrTelobis saerTo mdgomareobaze. .

5. klinikuri simptomatika
pnevmoniis ZiriTadi klinikuri niSnebi da simptomebi SesaZloa
formulirdes Semdegi saxiT:
• daavadebis kliniko-rentgenologiuri suraTis analizis
safuZvelze umetes SemTxvevaSi ar xerxdeba pnevmoniis
etiologiis gansazRvra.
• pnevmoniix iseTi niSnebi, rogoricaa cxeleba, tkivili
gulmkerdis areSi da sxv. SesaZloa ar aRiniSnebodes,
gansakuTrebiT garTulebul SemTxvevebSi da moxucebSi. 65 wlis
zemoT daaxloebiT 25%-Si ar aRiniSneba cxeleba, leikocitozi ki
aRiniSneba mxolod 50-70%-Si. klinikuri suraTi SeiZleba
warmodgenili iyos daRlilobiT, saerTo sisustiT, gulisreviT,
anoreqsiiT, tkiviliT mucelSi, cnobierebis dakargviT.
• pnevmokokisaTvis, aseve mikoplazmisa da qlamidiisaTvis, ar aris
damaxasiaTebeli destruqciis ganviTareba. aseT dros xSiria
stafilokoki, gramuaryofiTi aerobuli baqteriebi da
anaerobebi.
• mikoplazmuri pnevmoniisaTvis damaxasiaTebelia filtvis
bazaluri wilebis retikulo-nodularuli infiltracia.
pnevmoniaze eWvi unda mivitanoT pacientebSi, romelTac aReniSnebaT
qoSini cxelebasTan erTad, naxvelis gamoyofa da/an tkivili
gulmkerdis areSi. avadmyofi, romelmac gadaitana pnevmonia, xSirad uCivis
aramotivirebul sisustes, daRlilobas da RamiT Zlier oflianobas.
pacientis fizikuri gamokvlevebiT miRebuli informacia bevr
faqtorzea damokidebuli: daavadebis simZime, pnevmoniuri infiltraciis
gavrceleba, asaki, Tanmxlebi avadmyofobebis arseboba. klasikur
obieqtur niSans warmoadgens dazianebuli segmentis doneze
perkusiuli xmianobis Sesusteba, lokalurad bronquli sunTqva,
wvrilbuStukovani xixini an krepitacia, bronqofoniis gaZliereba.

8
pnevmoniis simptomTa sixSire anamnezuri da fizikaluri monacemebis
mixedviT Semdegia:
• xvela, cxeleba, taqikardia, xixini_22-48%;
• mxolod xvela_2-15%;
• perkusiuli xmianobis moyrueba_12_20%;
• mxolod xixini_17-15%;
• mxolod cxeleba_5-20%;
• mxolod taqikardia_8-13%.

6. garTulebebi
• plevruli gamonadeni;
• plevris empiema;
• filtvis qsovilis destruqcia/abscedireba;
• mwvave respiraciuli distres-sindromi;
• sunTqvis mwvave ukmarisoba;
• septiuri Soki, meoradi baqteriemia, sefsisi;
• perikarditi, miokarditi;
• nefriti da sxva.
amaTgan yvelaze mniSvnelovania Cirqovan-destruqciuli garTulebebi.
filtvis abscesisaTvis damaxasiaTebelia SemosazRvrul RruebSi
Camoyalibeba (filtvis qsovilis nekrozisa da Cirqovani procesis
Sedegad). is dakavSirebulia anerobul gamomwvevebTan: Bacteroides spp., F.
nucleatum, Peptostreptococcus spp da sxva. iSviaTad enterobaqteriebis da
S.aureus SerwymiT.
plevris empiema (Cirqovani plevriti). damaxasiaTebelia Cirqis
dagroveba plevris RruSi. ZiriTad gamomwvevebs miekuTvneba
anaerobebi Serwymuli gram-uaryofiT aerobul baqteriebTan.

7. diagnozi, diferenciuliDdiagnozi, simZimis Sefaseba

pnevmoniis sadiagnostiko kriteriumebs miekuTvneba rentgenologiurad
pacientis filtvis qsovilis dazianebuli kerovani infiltracia da
Semdegi niSnebidan ori niSnis arseboba (rekomendacia A):
• mwvave cxeleba daavadebis dasawyisSi (T>38);
• xvela naxveliT;
• lokaluri krepitacia da/an wvrilbuStukovani xixini, uxeSi
bronquli sunTqva, perkutoruli xmianobis Sesusteba;
• leikocitozi >10X109/l da/an CxirbirTvianebis mateba (>10%).
amasTan, diagnozi unda dadasturdes rentgenologiurad.
rentgenologiuri kvlevis SeuZleblobis SemTxvevaSi diagnostika
xdeba epidanamnezis, Civilebis da lokaluri simptomebis mixedviT,
Tumca diagnozi SeiZleba iyos arazusti (rekomendacia A).
pnevmoniis nozologiuri diagnozis dasmis dros aucilebelia
gaTvaliswinebuli iyos pnevmoniis klinikis da etiologiis kavSiri

9
(rekomendacia B da C). ase magaliTad, pnevmokokuri pnevmoniisaTvis
damaxasiaTebelia mwvave dasawyisi, maRali cxeleba, gulmkerdis
tkivili. legionelurisaTvis: diarea, nevrologiuri simptomatika,
daavadebis mZime mimdinareoba, Tirkmlis funqciis darRveva.
mikoplazmurisTvis: kunTebis da Tavis tkivili, zeda sasunTqi gzebis
infeqciis simptomebi.
qvemoT mowodebulia algoriTmi, romelic asaxavs pnevmoniis
garTulebis da letaluri gamosavalis ganviTarebis risks:

pnevmonia

ara

asaki 50 wlis zemoT

ara

Tanarsebuli daavadebebi
maRali riski
avTvisebiani
axalwarmonaqmnebi (letaloba 0,5-
gulis SegubebiTi 29%)
ukmarisoba
cerebrovaskularuli
daavadebebi
Tirkmlis daavadebebi
RviZlis daavadebebi
ara

obieqturi da
laboratoriuli
darRvevebi

cnobierebis darRveva
pulsi ≥ 125
sunTqvis sixSire ≥ 30
sistoluri wneva < 90
mm.vcx.sv
temperatura < 35C an ≥40 C

ara

dabali riski
(letaloba 0,1%)

10
8. gamokvlevis sqema
rentgenologiuri kvleva
pnevmoniis diagnostika praqtikulad yovelTvis gulisxmobs filtvebSi
kerovan-infiltraciuli cvlilebebis aRmoCenas, Serwymuls qvemo
sasunTqi gzebis infeqciasTan. rentgenografia saSualebas gvaZlevs
aseve SevafasoT paTologiuri procesis dinamika. cvlilebebi
rentgenogramaze (infiltraciis gavrceleba, plevraluri gamonadeni,
Rrus destruqcia) Seesabameba daavadebis simZimes da gvexmareba
antibaqteriuli mkurnalobis SerCevaSi.

laboratoriuli diagnostika
sisxlis saerTo analizi pnevmoniis gamomwvevis gansazRvris
9
saSualebas ar gvaZlevs, Tumca leikocitozi 12-15×10 /l da meti
migviTiTebs baqteriuli infeqciis maRal albaTobaze. 3×109/l-ze
dabali leikopenia an 25×109/l-ze maRali leikocitozi arasaxarbielo
prognozuli niSania.
infeqciis serologiuri diagnostika (sisxlis Sratis aReba daavadebis
mwvave da Semdeg rekonvalescenciis periodSi, daavadebis dawyebidan
ramdenime kviris Semdeg), gamokvlevebis aucilebel meTodad ganixileba
hospitalizebul avadmyofebSi.
hospitalizaciisTanave unda Catardes bioqimiuri kvlevebic:
Sardovanas, eleqtrolitebis da RviZlis funqciebis gansazRvra
saSualebas iZleva Sefasdes daavadebis simZime da Tirklmlisa da
RviZlis Tanarsebuli paTologia (rekomendacia C).
Jangbadis saturacia - klinikaSi moTavsebisas pnevmoniiT daavadebul
yvela avadmyofSi unda ganisazRvros Jangbadis saturacia. Tu
maCvenebeli 92%-ze naklebia unda Sefasdes arteriuli sisxlis gazebic
(rekomendacia C).
mikrobiologiuri kvleva
sisxlis kultura Seswavlili unda iqnes yvela hospitalizebul
pacientSi, sasurvelia antibiotikoTerapiis dawyebamde (rekomendacia D).
naxvelis gamokvleva unda Catardes im pacientebSi, romelTac SeuZliaT
Cirqovani naxvelis amoxveleba da adre ar miuRiaT antibiotikebi, aseve
im pacientebSi, romelTanac Catarebuli mkurnaloba uefeqtoa
(rekomendacia D).
diagnostikis invaziuri meTodebi:
fibrobronqoskopia an invaziuri
diagnostikis sxva meTodebi (transtraqealuri aspiracia,
transTorakaluri biofsia da a.S.) tardeba stacionarSi filtvebis
tuberkulozze an bronqogenul karcinomaze eWvis dros.

11
9. mkurnalobis sqema
zogadi marTva
pacientis stacionarSi referalis sakiTxi unda gadawydes zogadi
mdgomareobis da simZimis kriteriumebis Sefasebis mixedviT. avadmyofis
mZime zogadi mdgomareobis SemTxvevaSi pacienti dauyovnebliv unda
gadaigzavnos saavadmyofoSi.
pnevmoniaze eWvis SemTxvevaSi maT unda mieceT rCeva woliTi reJimis,
sigaretis mowevis Sewyvetis, siTxis sakmarisi raodenobiT miRebis
Sesaxeb (rekomendacia D).
plevruli tkivilis sawinaaRmdegod sakmarisia martivi analgetikebis
miReba, rogoricaa, magaliTad, paracetamoli (rekomendacia D).
yvela pacients unda Cautardes oqsigenoTerapia Jangbadis saturaciis
gansazRvriT da SaO2 >92% doneze SenarCunebiT. maRali koncentraciis
Jangbadi SeiZleba pacients mieces gaurTulebeli pnevmoniis drosac
(rekomendacia D).
aucilebelia saWiroebis SemTxvevaSi moxdes siTxis intravenuri
Sevseba (rekomendacia C).
sxeulis temperatura, sunTqvis sixSire, pulsi, sxeulis wneva,
cnobiereba, Jangbadis saturacia unda Sefasdes minimum orjer dReSi
an ufro xSirad, Tu pacientis mdgomareoba mZimea (rekomendacia C).
CRP donis gansazRvra da gulmkerdis rentgenografia unda Catardes
ganmeorebiT (rekomendacia B), Tu pacientis mdgomareobis gaumjobeseba
dinamikaSi ar Seesabameba Catarebul mkurnalobas (rekomendacia C).
empiriuli antibiotikoTerapia aramZime pnevmoniis dros
hospitalizebul pacientebSi
pacientTa umravlesobis mkurnaloba SesaZlebelia per-os misaRebi
antibiotikebiT (rekomendacia C). amoqsiciliniT monoTerapia
SesaZlebelia, Tu pacienti adre ar iyo namkurnalebi antibiotikebiT
an Tu pacienti hospitalSi moxvda araklinikuri mizezebis gamo (mag.
moxucebi an socialurad izolirebulebi).
Tu pacientis hospitalizaciis mizezi klinikuri mizezebia,
mizanSewonilia amoqsicilinis da makrolidis (eriTromicini,
klaritromicini, spiramicini) kombinacia (rekomendacia D).
makrolidiT monoTerapia daniSnul unda iqnes, rodesac
hospitalizaciamde Catarebuli amoqsicilinis adeqvaturi kursi
uefeqto aRmoCnda. Tumca amoqsiciliniT Terapiis adeqvaturoba Zneli
Sesafasebelia, amitom aseT SemTxvevebSi mizanSewonilia kombinirebuli
Terapia (rekomendacia D).
axali ftorqinolonebi ar gamoiyeneba, rogorc pirveli rigis
preparati, isini sasargeblo alternatiul saSualebas warmoadgenen
garkveuli kategoriis pacientebSi (rekomendacia C).

12
empiriuli antibiotikoTerapia mZime pnevmoniis dros hospitalizebul
pacientebSi
mZime pnevmoniis SemTxvevaSi parenteraluri antibiotikoTerapia unda
daiwyos dauyovnebliv diagnozis dasmis Semdeg (rekomendacia B).
Terapia unda Catardes farTo speqtris beta-laqtamuri antibiotikebiT,
rogoricaa ko-amoqsiklavi an meore (cefuroqsimi) an mesame Taobis
(cefotaqsimi, ceftriaqsoni) cefalosporini makrolidTan
(klaritromicini an eriTromicini) erTad (rekomendacia C).
im pacientebSi, romelTac aReniSnebaT beta-laqtamebis an makrolidebis
autanloba mizanSewonilia respiraciuli ftorqinolonis
(levofloqsacini) da intravenuri benzilpenicilinis kombinacia
(rekomendacia D).

antibiotikis Seyvanis wesi

antibiotikis Seyvanis gza per-oraluria aramZime pnevmoniebis dros
(rekomendacia B).
pacientebi, romlebic Tavidan parenteralur antibiotikoTerapias
iRebdnen, SeiZleba gadayvanil iqnen dasalevi antibiotikebis reJimze
maSinve, rodesac klinikuri mdgomareoba gaumjobesdeba da tempera-
tura normaluri iqneba 24 saaTis ganmavlobaSi (rekomendacia B).

ZiriTadi antimikrobuli preparatebis jgufebi

pnevmoniis mkurnalobaSi B-laqtamuri antibiotikebs mniSvnelovani
roli ekuTvnis, rac ganpirobebulia maTi mkveTri baqteriociduli
moqmedebiT gamomwvevebis, pirvel rigSi S.pneumoniae-s mimarT, dabali
toqsiurobiT, usafrTxoebiT da efeqturobiT.
mniSvneloba aqvs mkurnalobas aminopenicilinebiT (amoqsicilini), aseve
amoqsicilinis kombinacias laqtamazas ingibitorebTan
(amoqsicilini/klavulanti). amoqsicilins axasiaTebs S.pneunomiae mimarT
maRali aqtivoba, moqmedebs H.influenzae Stamebze. ampicilinTan SedarebiT
gaaCnia ufro maRali bioSeRwevadoba sakvebis miRebisagan
damoukideblad, iSviaTad iwvevs kuW_nawlavis mxriv arasasurvel
movlenebs. amoqsicilini da amoqsicilin/klavulanti inarCunebs
aqtivobas penicilin-rezistentuli Stamebis mimarT.
amoqsicilin/klavulantis forma, amoqsicilinis momatebuli doziT da
klavulantis naklebi wiliT (875/125mg) saSualebas gvaZlevs
gamoviyenoT preparati 2-jer dReSi. B-laqtamebis ZiriTad uaryofiT
Tvisebaa atipiuri mikroorganizmebis mimarT aqtivobis ararseboba.
benzilpenicilini inarCunebs maRal aqtivobas pnevmokokebTan
damokidebulebaSi.
makrolidebis Rirsebaa maRali aqtivoba S.pneumoniae-is, atipuri
mikroorganizmebis mimarT. azitromicini da spiramicini aqtiurni arian
H.ineluenzae mimarT. Tanamedrove makrolidebi kargad gadian bronqul
sekretSi da filtvis qsovilSi, xasiaTdebian usafrTxoebiT da
araalergiulobiT. pnevmoniis mkurnalobaSi arCevis preparatebia

13
azitromicini, spiramicini, klaritromicini, roqsitromicini. maT Soris
inficirebul filtvis qsovilSi da alveolarul makrofagebSi yvelaze
maRali koncentracias aRwevs spiramicini.
ftorqinolonebi
mocemuli jgufis preparatebs Soris, sayuradReboa II-III Taobis
ftorqinolonebi (ciprofloqsacini, ofloqsacini, levofloqsacini, da
sxv.). am jgufisagan gansakuTrebiT aRsaniSnavia III Taobis, e.w.
“respiraciuli ftorqinoloni” – levofloqsacini. is moqmedebs gram-
dadebiT da gram-uaryofiT gamomwvevebze, penicilin-rezistentulebis
CaTvliT. misi aqtivoba mikoplazmasTan, qlamidiebTan, legionelebTan
da mimarTebaSi arsebiTad maRalia e.w. “klasikur”, II Taobis
ftorqinolonebTan SedarebiT. preparati iniSneba 1-jer dReSi,
damaxasiaTebelia maRali koncentracia da bioSeRwevadoba,
gaxangrZlivebuli naxevardaSlis periodi. peroraluri da
parenteraluri levofloqsacini hospitalizebul pacientebSi
pnevmoniis safexureobrivi mkurnalobis saSualebas gvaZlevs. evropuli
da amerikuli respiraciuli da qimioTerapiuli sazogadoebebis mier
levofloqsacini miCneuli mozrdilTa arahospitaluri pnevmoniis
mkurnalobis arCevis preparatad.
tetraciklinebs Soris, Tu gaviTvaliswinebT farmakokinetikur
Tvisebebs, gadatanas da miRebis moxerxebulobas, ufro misaRebia
doqsiciklini. is xasiaTdeba kargi aqtivobiT atipuri
mikroorganizmebis mimarT.
mkurnalobis adgilis arCeva
pnevmoniis mkurnaloba SesaZlebelia saxlis pirobebSi. gansakuTrebiT
mniSvneloba aqvs hospitalizaciis kriteriumis gansazRvras. cnobilia
rigi klinikur-laboratoriuli Skalebi, romlebic dafuZnebulia
pnevmoniis simZimis Sefasebasa da/an prognozze. yvelaze gavrcelebuli
Skalaa PORT (Pneumoniae Outcomes Research Team), romelic iTvaliswinebs 20
klinikur da laboratoriul parametrs, romelTa safuZvelzec
dgindeba pnevmoniis simZimis indeqsi (PSI: Pneumonia Severiti Index), xdeba
letalobis riskis prognozireba da mkurnalobis adgilis gansazRvra.
PSI-is gansazRvrisaTvis aucilebelia mTeli rigi bioqimiuri
parametrebi, Sardis analizi, natriumi, glukoza, hematokriti,
arteriuli sisxlis pH, rac yovelTvis ar aris SesaZlebeli
ambulatorul-poliklinikur dawesebulebaSi.
dReisaTvis pnevmoniis mkurnalobis adgilis gansazRvra dakavSirebulia
prognozuli Skalis CURB-65/CRB-65 gamoyenebasTan. britaneTis
Torakaluri sazogadoebis Skala iTvaliswinebs 5 an 4 parametrs:
1 C cnobierebis dakargva
2 U sisxlis SardmJava azoti > 7mmol/l
3 R sunTqvis sixSire > 30/wT
4 B dabali sistoluri (<90mm.vcx.sv) an diastoluri
wneva (<60mm.vcx. sv).
5 65 asaki > 65welze

14
minimaluri qula aris 0, maqsimaluri - 4 an 5 qula. praqtikulobis
TvalsazrisiT met yuradRebas ipyrobs CRB-65 Skala, romelic
SesaZlebelia gamoyenebuli iqnas ambulatorul pirobebSi.
nebismieri prognozuli Skala mkurnalobis adgilis SesarCevi
orientiria, yovel konkretul SemTxvevaSi es sakiTxi unda gadawydes
mkurnali eqimis da pacientis mier individualurad. pacientis
hospitalizaciisaTvis gaTvaliswinebuli unda iyos Semdegi Cvenebebi:
¾ sunTqvis sixSire >30/wT: diastoluri wneva <60 mm.vcx. sv;
sistoluri wneva <90 mm.vcx.sv; guliscemis sixSire >125/wT,
temperatura <35,0 an >40.0; cnobierebis darRveva.
¾ laboratoriuli da rentgenologiuri monacemebi: periferiul
sisxlSi leicocitebis <4,0*10 9/l an >25,0*10 9/l; pnevmoniuri
infiltracia lokalizebiT erTze met wilSi; plevraluri
gamonadenis arseboba; kerovan-infiltraciuli cvlilebebis
filtvebSi swrafad gavrceleba (infiltraciis zomebis zrda
>50% uaxloesi 2 dRis manZilze).
¾ hematokriti <30% an hemoglobini <90g/l;
¾ sefsisi an poliorganuli ukmarisoba, metaboluri acidozis
gamovleniT (PH < 7,35);
¾ koagulopaTia.

antibaqteriuli Terapiis efeqturobis kriteriumebi

peroraluri Terapiis dasawyisi efeqturoba unda Sefasdes
mkurnalobis dawyebidan 48-72 sT-is Semdeg (ganmeorebiTi gasinjva).
misaRebia pacientTan satelefono kontaqti mkurnalobis dawyebidan me-
2 dRes. efeqturobis ZiriTad kriteriumad iTvleba temperaturis
daqveiTeba, intoqsikaciis, qoSinis da sunTqvis ukmarisobis sxva
simptomebis Semcireba. Tu narCundeba maRali cxeleba da intoqsikacia,
an simptomatika progresirebs, maSin mkurnaloba unda miviCnioT
araefeqturad. am SemTxvevaSi aucilebelia gadaixedos antibaqteriuli
mkurnalobis taqtika da meoradad Sefasdes pacientis hospitalizaciis
mizaSewoniloba.

antibaqteriuli mkurnalobis xangrZlivoba

pnevmoniis msubuqi formis dros antibaqteriuli Terapiis Sedegad
sxeulis temperaturis normalizacia SesaZloa 3-4 dRis Semdeg.
mkurnalobis xangrZlivoba Seadgens 7-10 dRes. amave periodSi
aRiniSneba leikocitozis Semcireba. mikoplazmuri an qlamidiuri
etiologiis SemTxvevaSi mkurnaloba 14 dRes grZeldeba. Tumca,
arsebobs klinikuri monacemebi ufro xanmokle efeqturi
antibaqteriuli mkurnalobis Sesaxeb.

15
 cxrili 5

antibiotikoTrapiis xangrZlivoba mkurnalobis adgilis, zogadi

mdgomareobis da gamomwvevis mixedviT

adgili/simZime/gamomwvevi mkurnalobis xangrZlivoba

(dReebSi)
binaze mkurnaloba, aramZime (daudgeneli 7
etiologia)
stacionaruli mkurnaloba, aramZime 7
(daudgeneli etiologia)
legioneluri 10
atipuri (qlamidia, mikoplazma) 14-21
pnevmokokuri (gaurTulebeli) 14
stafilokokuri 14-21
gram-uaryofiTi 14-21

pnevmoniis antibaqteriuli Terapiis adeqvaturobis kriteriumebi.

• temperatura<37,5;
• intoqsikaciis ararseboba;
• sunTqvis ukmarisobis ararseboba;
• naxvelis ararseboba;
• sisxlSi leikocitebis, neitrofilebis normalizacia;
• rentgenogramaze uaryofiTi dinamikis ararseboba
.
klinikuri, laboratoriuli an rentgenologiuri niSnebis SenarCuneba
warmoadgens antibaqteriuli Terapiis gagrZelebis an misi
modifikaciis absolutur Cvenebas. rentgenografiuli kontroli ar
warmoadgens antibaqteriuli Terapiis xangrZlivobis gansazRvris
kriteriums.
antibaqteriuli Terapiis SerCeva
pnevmoniis mZime mimdinareobis dros mizanSewonilia Terapia daiwyos
parenteraluri antibiotikebiT 3-4 dRis ganmavlobaSi, temperaturis
normalizaciis, intoqsikaciis da daavadebis sxva simptomebis
Semcirebamde. mkurnalobis sruli kursis damTavrebamde SesaZloa
gadasvla parenteraluridan peroralur mkurnalobaze.
gaxangrZlivebuli antibaqteriuli mkurnaloba
aramZime pnevmoniis dros antibaqteriuli mkurnaloba SesaZloa
Sewydes sxeulis temperaturis normalizaciis miRwevidan 3-4 dRis
manZilze. am midgomiT mkurnalobis xangrZlivoba Seadgens 7-10 dRes.
dauzustebeli etiologiis SemTxvevaSi, rekomendebulia 10-dRiani
kursi. mikoplazmuri da qlamidiuri etiologiis pnevmoniis dros

16
antibaqteriuli mkurnaloba unda gagrZeldes 14 dRes, Tumca arsebobs
klinikuri monacemebi Sedegis ufro mokle droSic miRwevis Sesaxeb.
ufro xangrZlivi Terapia (14 dRidan 21 dRemde) naCvenebia
stafilokokuri etiologiis an gramuaryofiTi enterobaqteriebiT
gamowveuli pnevmoniis dros.
sxva saSualebebi
dResdReobiT ar arsebobs monacemebi biogenuri stimulatorebis,
antihistaminuri preparatebis, vitaminebis, imunomodulatorebis da
arasteroiduli anTebis sawinaaRmdego saSualebebis da
aranarkotikuli analgetikebis daniSvnis saWiroebis Sesaxeb.
dasaxelebuli samkurnalo saSualebebis efeqturoba da usafrTxoeba
ar aris dazustebuli randomizirebuli klinikuri gamokvlevebiT.

10. prevencia
pnevmoniis profilaqtikis mizniT gamoiyeneba pnevmokokuri da
gripuli vaqcina. pnevmokokuri vaqcinis gamoyenebis mizanSewoniloba
aixsneba imiT, rom dResdReobiT S.pneumoniae pnevmoniis wamyvan
gamomwvevad rCeba.
gripuli vaqcinis efeqturoba moxucebSi sakmaod maRalia. vaqcinacia
mizanSewonilia Semdeg jgufebSi:
• pirebi, romlebic xangrZlivad cxovroben moxucTa saxlSi;
• 65 welze meti asakis pacientebSi sasunTqi, saSarde, RviZlis da
gul-sisxlZarRvTa sistemis qronikuli,daavadebebiT (rekomendacia C);
• mozrdilebi, romlebic saWiroeben uwyvet samedicino
zedamxedvelobas da imyofebian stacionarSi mkurnalobis mizniT
(Saqriani dibeti, Tirkmlis daavadebebi, hemoglobinopaTiebi,
imunodeficituri mdgomareoba aiv infeqciis CaTvliT);
• II-III trimestris fexmZimeebi;
• eqimebi, eqTnebi;
• ojaxis wevrebi (bavSvebis CaTvliT)
• medicinis muSakebi, romlebic binaze uvlian avadmyofebs.

11. gaidlainis miRebis wyaro

winamdebare gaidlaini warmoadgens sxvadasxva gaidlainebis (ix.
literatura) Sejerebis da adaptaciis Sedegs.

12. alternatiuli gaidlaini ar arsebobs

13. gaidlainis gadasinjvis da ganaxlebis vada _ 2 weli

17
14. gamoyenebuli literatura
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2. Hawker J et al - Communicable diseases control handbook – 2001
3. Management of the child with a serious infection or severe malnutrition – Guidelines for
care at the first-referral level in developing countries – 2000
4. Community-Acquired Pneumonia in Children - Kenneth McIntosh, M.D, New England
journal of Medicine, Volume 346:429-437 February 7, 2002 Number 6
5. A new system for grading recommendations in evidence based guidelines - Harbour R,
Miller J.. BMJ 2001;323:334-6
6. Red book: report of the Committee on Infectious Diseases. 25th ed. Elk Grove Village,
Ill.: - Pickering LK, ed. 2000 American Academy of Pediatrics, 2000.
7. Community-Acquired Pneumonia in Children: Quantifying the Burden on Patients and
Their Families Including Decrease in Quality of Life. Shoham, Y., Dagan, R., Givon-
Lavi, N., Liss, Z., Shagan, T., Zamir, O., (2005). Pediatrics 115: 1213-1219
8. Epidemiology and Clinical Characteristics of Community-Acquired Pneumonia in
Hospitalized Children. - Michelow, I. C., Olsen, K., Lozano, J., Duffy, L. B., Ziegler, T.,
Kauppila, J., Leinonen, M., McCracken, G. H. Jr (2004). Pediatrics 113: 701-707
9. Pneumonia in Children - Berti, I., Faraguna, D., McIntosh, K. (2002).. N Engl J Med 346:
10. Scottish Intercollegiate Guidelines Network. SIGN 50: a guideline developers' handbook.
Edinburgh: SIGN, 2001
11. Guidelines for the Management of Community Acquired Pneumonia in Adults
2001 BTS GUIDELINES. Thorax 2001; 56: (suppl IV) – 2004 update.
12. Cochrane Methods Working Group on Systematic Review of Screening and Diagnostic
Tests. Recommended methods. Updated 6 June 1996
13. Community acquired pneumonia – a prospective UK study. Drummond P, Clark J,
Wheeler J, Galloway A, Freeman R (2000), Arch Dis Child, 83(5), Nov, pp 408-12
14. Mandell LA, Marrie TJ, Grossman RF, Chow AW, Hyland RH. Canadian guidelines for
the initial management of community-acquired pneumonia: an evidence-based update by
the Canadian Infectious Diseases society and the Canadian Thoracic Society. Clinical
Infectious Diseases 2000; 31:383-421.
15. Bartlett JG, Dowell SF, Mandell LA, File TM, Musher DM, Fine MJ. Practice guidelines
for the management of community-acquired pneumonia in adults (American guidelines).
Clinical Infectious Diseases 2000; 31:347- 82.
16. Community-acquired pneumonia guidelines: much guidance, but not much evidence M.
Woodhead. Eur Respir J 2002; 20: 1–3
17. Consensus development methods, and their use in clinical guideline development – MK
Murphy Health Technology Assessement 1998 vol.2 #3
18. Fortnightly Review: Management of community acquired lower respiratory tract infection
- H S R Hosker, G M Jones, P Hawkey - BMJ 1999;308:701-705 (12 March)
19. Community-Acquired Pneumonia in Infants and Children – M. OSTAPCHUK, M.D., D.
M. ROBERTS, M.D., Am Fam Physician 2004;70:899-908.
20. Community management of Lower respiratory tract infections in adults, a national
clinical guideline – Scottish Intercollegiate Guidelines Network, June 2002

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21. Appraisal of guidelines for research&evaluation – AGREE Instrument Training Material –
The AGREE Collaboration, January 2003
22. Community-Acquired Pneumonia (CAP) Year 2002 Antibiotic Selection and
Management Update — The ASCAP Panel* Consensus Report, 2002
23. Evidence-based Guidelines for the Management of Children Presenting with Acute
Breathing Difficulty, Paediatric Accident & Emergency Research Group - September
2004
24. British Guideline on the Management of Community Acquired Pneumonia in Children.
British Thoracic Society Scottish Intercollegiate Guidelines Network. 2002
25. Treatment of pneumonia in children EBM Guidelines 03.05.2000
26. Indications for and interpretation of chest x-ray in a child with symptoms of an infection
EBM Guidelines 18.6.2004
27. McCracken GH Jr. Diagnosis and management of pneumonia in children. Pediatr Infect
Dis J 2000;19:924-8.
28. Korppi M, Heiskanen-Kosma T, Leinonen M, Halonen P. Antigen and antibody assays in
the aetiological diagnosis of respiratory infection in children. Acta Paediatr 1993;82:137-
41.
29. Principi N, Esposito S. Emerging role of Mycoplasma pneumoniae and Chlamydia
pneumoniae in paediatric respiratory-tract infections. Lancet Infect Dis 2001;1:334-44.
30. Esposito S, Bosis S, Cavagna R, Faelli N, Begliatti E, Marchisio P, et al. Characteristics
of Streptococcus pneumoniae and atypical bacterial infections in children 2-5 years of age
with community-acquired pneumonia. Clin Infect Dis 2002;35:1345-52.
31. Bradley JS, Nelson JD. 2002-2003 Nelson’s pocket book of pediatric antimicrobial
therapy. 15th ed. Philadelphia: Lippincott, Williams & Wilkins;2002:31-5.
32. Nelson JD. Community-acquired pneumonia in children: guidelines for treatment. Pediatr
Infect Dis J 2000;19:251-3.
33. Gibson NA, Hollman AS, Paton JY. Value of radiological follow up of childhood
pneumonia. BMJ 1993;307:1117.
34. McCracken GH Jr. Etiology and treatment of pneumonia. Pediatr Infect Dis J
2000;19:373-7.
35. Mandell GL, Douglas RG, Bennett JE, Dolin R. Mandell, Douglas, and Bennett’s
principles of practice of infectious diseases. 5th ed. Philadelphia: Churchill Livingstone,
2000:2416-7.
36. Community-Acquired Pneumonia (CAP) Year 2002 Antibiotic Selection and
Management Update Evaluation, Risk Stratification, and Current Antimicrobial Treatment
Guidelines for Hospital-Based Management of CAP: Outcome-Effective Strategies Based
on New NCCLS Breakpoints and Recent Clinical Studies — The ASCAP Panel*
Consensus Report, 2002
37. Schonwald S, Barsic B, Klinar I, Gunjaca M. Three-day azithromycin compared with ten-
day roxithromycin treatment of atypical pneumonia. Scand J Infect Dis 1994;26:706-710
38. Schonwald S, Barsic B, Klinar I, Gunjaca M. Three-day azithromycin compared with ten-
day roxithromycin treatment of atypical pneumonia. Scand J Infect Dis 1994;26:706-710
39. Lode H, Schaberg T. Azithromycin in lower respiratory tract infections. Scand J Infect
Dis 1992 (suppl);83:26-33

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40. Isaacs D. Problems in determining the etiology of community-acquired childhood
pneumonia. Pediatr Infect Dis J 1989;8:143–8.
41. Wubbel L, Muniz L, Ahmed A, et al. Etiology and treatment of community-acquired
pneumonia in ambulatory children. Pediatr Infect Dis J 1999;18:98–104.
42. Gendrel D, Raymond J, Moulin F, et al. Etiology and response to antibiotic therapy of
community-acquired pneumonia in French children. Eur J Clin Microbiol Infect Dis
1997;16:388–91.
43. Harris JA, Kolokathis A, Campbell M, et al. Safety and efficacy of azithromycin in the
treatment of community-acquired pneumonia in children. Pediatr Infect Dis J
1998;17:865–71.
44. Palafox M, Guiscafre H, Reyes H, et al. Diagnostic value of tachypnoea in pneumonia
defined radiologically. Arch Dis Child 2000;82:41–5.
45. Pereira JC, Escuder MM. The importance of clinical symptoms and signs in the diagnosis
of community-acquired pneumonia. J Trop Pediatr 1998;44:18–24.
46. Margolis P, Gadomski A. Does this infant have pneumonia? JAMA 1998;279:308–13.
47. Swingler GH, Zwarenstein M. Chest radiograph in acute respiratory infections in children.
Cochrane Database Syst Rev2000;2.
48. Mandell LA, Marrie TJ, Grossman RF, Chow AW, Hyland RH. Canadian guidelines for
the initial management of community-acquired pneumonia: an evidence-based update by
the Canadian Infectious Diseases society and the Canadian Thoracic Society. Clinical
Infectious Diseases 2000; 31:383-421.
49. M. Woodhead Community-acquired pneumonia guidelines: much guidance, but not much
evidence Eur Respir J 2002; 20: 1–3
50. Cincinnati Children's Hospital Medical Center. Evidence-based care guideline for
community acquired pneumonia in children 60 days through 17 years of age. Cincinnati
(OH): Cincinnati Children's Hospital Medical Center; 2005 Dec. 16 p. [80 references]

15. avtorTa jgufi:

saqarTvelos respiraciuli asociacia

⇒ i.CxaiZe;
⇒ T.maRlakeliZe;
⇒ k.vaWaraZe;

eqspertebi:
⇒ i. qarosaniZe _ saojaxo medicinis profesionalTa kavSiri;
⇒ T. lobJaniZe _ Tssu diplomisSemdgomi samedicino ganaTlebis
institutis Sinagan sneulebaTa kaTedris profesori, mmd.
⇒ d. maRalaSvili _ Tssu qirurgiul sneulebaTa departamentis
asistent-profesori, mmd.

20
⇒ a. nanuaSvili _ antimikrobuli qimioTerapiis samsaxuris
xelmZRvaneli, antibiotikebis racionaluri gamoyenebis
msoflio aliansis xelmZRvaneli, mmk, asocirebuli
profesori;
⇒ v. qacarava _ z/cxakaias sax. Sps “Torako-abdominuri klinikis”
xelmZRvaneli, mmk.
⇒ lela woworia _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros janmrTelobis dacvis
departamenti;
⇒ Tea TavidaSvili _ saqarTvelos Sromis, janmrTelobisa da
socialuri dacvis saministros janmrTelobis dacvis
departamenti.

21