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Curriculum Vitae

Data Pribadi
Nama : dr. Muhammad Arifin Nawas, Sp.P(K), MARS
Nip : 140 076 093
Pangkat / Golongan : Pembina Tk.I /IVb
Tempat / Tanggal Lahir : Jambi, 26 November 1947
Agama : Islam
Alamat : Jl. Bangka XI/21, Kec. Mampang Pela, Jakarta Selatan

Riwayat Pendidikan Formal


1954-1959 : Sekolah Rakyat, di Muara Bungo, Jambi
1959-1962 : SMP Negeri I Jambi
1962-1965 : SMA Negeri I Jurusan PASPAL, Jambi
1965-1975 : Dokter Umum FK UNPAD, Bandung
1981-1986 : Dokter Spesialis Paru Fakultas Kedokteran UI, Jakarta
1996-1998 : MARS KARS UI, Jakarta
Riwayat Pekerjaan
1976-1978 : Dinas Kesehatan Kab. Sarko Jambi
1978-1981 : Dinas Kesehatan Kodya Jambi
1987-sekarang : Spesialis Paru RS Persahabatan dan Staf Bagian
Pulmonologi dan Ilmu Kedokteran Respirasi FKUI, Jakarta
1991 : Kasi. Diklat Dokter Ahli Bidang Diklat RS Persahabatan, Jakarta
1995 : Wakil Direktur Pelayanan Medik & Keperawatan RS
Persahabatan, Jakarta
20012005 : Direktur Umum & Keuangan, RS Persahabatan, Jakarta

Keanggotaan dalam Organisasi Profesi


1976-sekarang : Anggota KOPRI
1976-Sekarang : Anggota IDI
1988-1990 : Pengurus IRSJAM
1996-1999 : Wakil Ketua Dewan PDPI
1999-2002 : Ketua PDPI Cabang Jakarta
2005-2008 : Ketua Dewan Pengurus Profesi PDPI
2011 2016 : Ketua Umum PDPI Pusat
CAP :
The New PDPI Guideline 2014

Arifin Nawas
The Member of COMMUNITY ACQUIRED PNEUMONIA TEAM
The Indonesia Society of Respirology
INTRODUCTION
Pneumonia is defined as an acute infection of the
pulmonary parenchyma
This guidance is a revision of the previous guidelines
published in 2003, with some additions or changes in
accordance with the developments during this period
Empiric therapy
In developing this guideline reffered from a variety of
guidelines recommended by organizations such as ATS/
IDSA and BTS
However, treatment varies widely due to variety
etiologic, antimicrobial agents, facilities and physicians
Community Acquired Pneumonia
CAP is defined as an acute infection of the pulmonary parenchyma
in a patient who has acquired the infection in the community
CAP is a major cause of morbidity and mortality worldwide
Pneumonia
USA :
- The annual incidence rate is 6/1000 in the 18-39 age group.
This rises to 34/1000 in people aged 75 years and over.
- Admission to hospital : 20-40% and about 5-10% ICU
- Mortality 25%
In Japan pneumonia ranks fourth as the leading cause of death
In Indonesia, pneumonia included in the top 10 diseases with CFR
7.6%
Table 1. Most Common etiologies of CAP
ETIOLOGY OF CAP IN INDONESIA
(several hospital)

Klebsiella pneumoniae
Acinetobacter baumanii,
Pseudomonas aeruginosa
Streptococcus pneumoniae
Streptococcus viridans
Staphylococcus aureus
DIAGNOSIS
Based on anamnesis, physical examination, chest
radiographic and laboratory

On the chest radiographic there are the presence of an


acute infiltrate / air brochogram
Clinical symptoms:
Cough
Productive sputum
Fever > 380C
Dyspnea
Pleuritic chest pain
Laboratory
Leucocyt > 10.000 or < 4500
Recommended testing due to
clinical diagnosis
Outpatient: CXR, sputum Cx and Gram stain
not required
Inpatient: CXR, ABG, chemistry, WBC, two
sets of blood Cxs
If suspect drug-resistant pathogen or organism not
covered by usual empiric AB , obtain sputum Cx
and Gram stain.
Severe CAP: Legionella urinary antigen, consider
bronchoscopy to identify pathogen
Table 2. Clinical Indications for more extensive
diagnostic testing
Respiratory tract specimen, Gram stain
and culture
The yield of sputum bacterial cultures is variable and
strongly influenced by the quality of the entire process,
including specimen collection, transport, rapid processing,
satisfactory use of cytologic criteria, absence of prior
antibiotic therapy, and skill in interpretation.

The benefit of a sputum Gram stain :


1. It will lead to less inappropriate antibiotic
therapy
2. It can validate the subsequent sputum culture
results
Assessment Of Pneumonia Severity
PSI
1. Classification of the risk mortality
2. Increasing age leading scoring
3. Complexity of the score 20 variables

CURB Index
1. Based on acute pneumonia severity not on
age and comorbidity
2. Easier to calculate
Pneumonia Severity Index

Class Points Mortality* Site of Care


I <51 0.1% Out Patient

II 51-70 0.6% Out Patient

III 71-90 2.8% In or Out Patient

IV 91-130 9.5% Inpatient

V >130 26.7% Inpatient


Tabel 3. SCORE CURB-65
Confusion
Mental test 8 score 1
Mental test > 8 score 0
Urea
Urea > 19 mg/dL score 1
Urea < 19 mg/dL score 0
Respiratory Rate (RR)
RR > 30x/m score 1
RR < 30x/m score 0
Blood pressure (BP)
BP < 90/60 mmHg score 1
BP > 90/60 mmHg score 0
Umur
Age > 65 years score 1
Age < 65 years score 0
Mental Test Assesment
on CURB 65
Should be answered the question on mental test (each question scores 1
mark if the answer right, total 10 marks)
Age
Date of birth
Time (to nearest hour)
Year
Hospital name
Recognition of two persons (eg, doctor, nurse)
Recall address (eg, 42 West Street)
Date of independence
Name of monarchs/ president
Count backwards 20 R 1
A score of 8 or less has been used to define mental confusion in
the CURB65 severity score.
Any of :
Confusion*
Respiratory rate 30/min
Blood pressure (SBP < 90mmHg or DBP 60mmHg)
Age 65 years

Score 1 point for each feature present

CURB-65 0 1 or 2 >2
score

Likely suitable for Consider hospital Urgent hospital


Home treatment referral admission

* Defined as a Mental Test Score of 8 or less, or new disorientation in person, place or time

Figure 1. Severity assessment used to determine the management of CAP in patients in the
community(CRB-65 score) UPDATED 2004
Criteria for severe CAP
( IDSA/ATS 2007 )
Minor criteria
- Respiratory rate 30 breath /min
- PaO2/FiO2 250
- Multilobar infiltrates
- confusion/disorientation
- Uremia (BUN level 20 ml/dl)
- Leukopenia ( WBC count , 400 cell/mm3)
- Trombocytopenia (platelet count < 100,000 cell/mm3)
- Hypothermia (core temperature < 360C)
- Hypotension requiring aggressive fluid resuscitation

Major criteria
- Invasive mechanical ventilation
- Septic shock with the need for vasopressor
ICU admission decision
Direct admission to an ICU for patients with
septic shock requiring vasopressor or with
ARDS requiring intubation and mechanical
ventilation

Direct admission to an ICU or high-level


monitoring unit is recommended for patients
with 3 of the minor criteria for severe CAP
History, physical examination, chest radiography, laboratory

Noinfiltrate /air bronchogram Infiltrate / air bronchogram +, Clinical feature supporting


diagnosis of pneumonia

Evaluate for other diagnosis Further evaluation


Evaluate using CURB-65/PSI

Out patient
In patient

Emperical therapy
Microbiologicexaminati
on

Improve Deteriorate
In patient ward ICU

Emperical therapy

Empirical therapy Improve Deteriorate Causatif


is continued therapy
SELECTIONS OF EMPIRIC ANTIBIOTIC

The most likely pathogen(s).


Clinical trials proving efficacy.
Risk factors for antimicrobial resistance
Comorbidities
Rational use of microbiology laboratory
Pathogen directed antimicrobial therapy whenever
possible
Prompt initiation of therapy
Decision to hospitalize based on prognostic criteria
pharmacokinetic and pharmacodynamic properties,
safety profile, and cost .
Risk factors for drug-resistant
S. pneumoniae in adults include
Age >65 years
Beta-lactam, macrolide, or fluoroquinolone
therapy within the past three to six months
Alcoholism
Medical comorbidities
Immunosuppressive illness or therapy
Exposure to a child in a day care center
Table 3. Recommended empirical antibiotics for CAP
(Guideline of The Indonesia Society of Respirology )
Outpatient Antibiotic
1. Previously healthy and no use of A -lactam or -lactam plus
antimicrobials within the previous 3 anti -lactamase
months New macrolid
2. Presence of comorbidities or use anti- A respiratory fluoroquinolone
microbials within the previous 3 months (levofloxacin 750mg or
moxifloxacin )
A -lactam or -lactam plus
anti -lactamase
A -lactam plus a macrolide;

Inpatient
1. Non ICU Treatment A respiratory fluoroquinolone A
respiratory fluoroquinolone
(levofloxacin 750mg or
moxifloxacin )
A -lactam plus a macrolide
Inpatients Antibiotic

2. ICU Treatment A -lactam (cefotaxime, ceftriaxone, or ampicillin-


Non Pseudomonas sulbactam) plus either new macrolid or
respiratory fluoroquinolone (levofloxacin 750mg or
moxifloxacin )

3. Special Concern An antipneumococcal, antipseudomonal -lactam


* If Psedomonas is a (piperacillin-tazobactam, cefepime, imipenem, or
consideration meropenem) plus eiter ciprofloxacin or
levofloxacin (750mg)
Or
The above -lactam plus an aminoglycoside and
azithromycin
Or
The above -lactam plus an aminoglycoside and
an antipneumococcal fluoroquinolone (for
penicillin- allergic patients, substitute aztreonam
for above -lactam) (level III)
* If CA MRSA is a add vancomycin or linezolid (level III)
considerate
Table 4. Recommended empirical antibiotics for CAP (IDSA/ATS 2007)

Outpatient Antibiotic
1. Previously healthy and no use of A macrolide level I
antimicrobials within the previous 3 Doxycycline level III
months
2. Presence of comorbidities or use anti- A respiratory fluoroquinolone
microbials within the previous 3 months (moxifloxacin, gemifloxacin or
levofloxacin (750mg); level I
A -lactam plus a macrolide;
level I
3. In regions with a high rate
(<25%) of infection with high-
level (MIC > 16g/mL)
macrolide-resistant Streptococcus
consider use of alternative
agents listed above in (2)
Inpatients Antibiotic

1. Non ICU Treatment A respiratory fluoroquinolone; level I


A -lactam plus a macrolide; level I

2. ICU Treatment A -lactam (cefotaxime, ceftriaxone, or ampicillin-


Non Pseudomonas sulbactam) plus either azithromycin (level II) or
respiratory fluoroquinolone (level I). If allergy
penicillin respiratory fluoroquinolone, azithromycin
3. Special Concern An antipneumococcal, antipseudomonal -lactam
* If Psedomonas is a (piperacillin-tazobactam, cefepime, imipenem, or
consideration meropenem) plus eiter ciprofloxacin or
levofloxacin (750mg)
Or
The above -lactam plus an aminoglycoside and
azithromycin
Or
The above -lactam plus an aminoglycoside and
an antipneumococcal fluoroquinolone (for
penicillin- allergic patients, substitute aztreonam
for above -lactam) (level III)
* If CA MRSA is a add vancomycin or linezolid (level III)
considerate
Switch from intravenous to oral therapy
(IDSA/ATS 07)
Patient should be switched from iv to oral therapy
when :
- hemodynamically stable
- improving clinically
- able to ingest medication
- normally functioning GIT
Patients should be discharged as soon as they are
clinically stable, have no other active medical
problems and have a safe environment for continued
care. In patient observation while receiving oral
therapy is not necessary
Criteria for clinical stability
(IDSA/ATS 2007)
Temperature 37.8 0C
Heart rate 100 beats/min
Respiratory rate 24 breaths/min
Systolic blood pressure 90 mmHg
Arterial oxygen saturation 90% or pO2 60
mmHg on room air
Ability to maintain oral intake
Normal mental status
Time to First Antibiotic Dose
For patients admitted through the ED, the first antibiotic dose
should be administered while still in the ED level III

Delay in beginning antibiotic treatment during the transition


from the ED is not uncommon. Especially with the frequent use
of once-daily antibiotics for CAP, timing and communication
issues may result in patients not receiving antibiotics for 18 h
after hospital admission.

The best and most practical resolution to this issue was that the
initial dose be given in the ED
Duration of antibiotic therapy
(IDSA/ATS 07)
Patients with CAP should be treat for a minimum of
5 days, should be afebrile for 48-72h, and should
have no more than CAP associated sign of clinical
instability before discontinuation of therapy
A more longer duration of therapy may be needed
if initial therapy was not active against the
identified pathogen or if it was complicated by
extrapulmonary infection, such as meningitis,
endocarditis
HOSPITAL DISCHARGE CRITERIA
During 24 hours to discharge to home patients
should not have more than 1 of the following;
- elevated temp > 37,80 C
- pulse > 100/ minute
- respiratory rate > 24/ minute
- systolic blood pressure < 90 mmHg
- blood oxygen saturation < 90%
- inability to maintain oral intake
Non responding Patient
Non respon is not uncomon
CAP show clinical improvement within 72 hours
of initial antibiotic treatment
1 6 to 15 % do not respond
In patients initially admitted to an ICU the risk
failure was high ( 40% )
Mortality nonresponding patient is increased
(49%)
Mortality in early failure was 27%
Two general patterns of nonresponse have been described
in patients with CAP

Progressive pneumonia or actual clinical deterioration


with acute rep failure requirement for ventilator
support and/or septic shock usually occurring within
the first 72 hours
Deterioration after 72 hours : complication,
progression of the underlying infection, or a
superimposed nosocomial infection

Persistent or nonresponding pneumonia, defined


as the absence of or delay in achieving clinical
stability after 72 hours of antibiotic therapy
PROGNOSIS
CURB 65 PSI

Total Score Score 2 Score Not Score Score Score Score


>2 predicted
Score 01 < 70 71 - 91 > 130
90 130

Severity Group Group Group Class I Class II Class Class Class


I II III
III IV V

Risk class Low Modert High Low Modera High


e te
Mortality % 1.5% 9.2% 22% 0.1% 0.6% 2.8% 8.2% 29.2%
PREVENTION
a. Vaccination
- All persons 50 years of age, others at risk for influenza
complications, household contacts of high-risk persons, and
health care workers
- Pneumococcal polysaccharide vaccine is recommended for
persons 65 years of age and for those with selected high-
risk concurrent diseases
b. Smoking cessation should be a goal for persons hospitalized
with CAP who smoke
c. Respiratory hygiene measures, including the use of hand
hygiene and masks or tissues for patients with cough
d. Implementing standard precautions and isolation in special
cases
TERIMA KASIH
Perhimpunan Dokter Paru Indonesia
Sekretariat:Gedung Asma Lantai 2 RS Persahabatan
Jl. Persahabatan No. 1 Rawamangun Jakarta
Tlp. & Fax: 021-470 5685
Website: www.klikpdpi.com
Email: sekretariar@klikpdpi.com