Siti Sajariah Munip,dr.

SpP
RSI Aisyiyah Malang
Nopember,2015
 Pneumonia :
Inflammation of the
lung parenchyma
caused by microbial
(bacteria, virus, fungi,
or paracites)
 PATOGENESIS
Inhalasi Aspirasi Hematogenous Langsung

Komorbid :
Predisposisi :
diabetes mellitus
influenzae
gagal ginjal menahun
alkoholisme gizi
jelek / kurang debiliti
Mekanisme ggan imuniti
PPOK
pertahanan paru pneumokoniosis

INFEKSI SALURAN NAFAS

BAWAH
Sekali patogen behasil
menembus mekanisme
pertahanan paru

Inflamasi

Substitusi udara di
dalam alveoli (air
spaces) oleh cairan
eksudat
(= KONSOLIDASI)

Shunting
• PERADANGAN PARENKIM PARU
• ASINUS TERISI CAIRAN EKSUDAT
• INFILTRASI SEL RADANG PADA DINDING
ALVEOLI DAN INTERSTITIUM
 CAP Community Acquired Pneumonia

HCAP Health Care Associated Pneumonia

pneumonias

pneumonias
Nosocomial
Nosocomial

HAP Hospital Acquired Pneumonia

ICUAP ICU Acquired Pneumonia

VAP Ventilator Associated Pneumonia

 COMMUNITY ACQUIRED OF PNEUMONIA
…
an acute infection of the pulmonary parenchyma that
is associated with some symptoms of acute infection,
accompanied by the presence of an acute infiltrate on
a chest radiograph, or auscultatory findings consistent
with pneumonia, in a patient not hospitalized or
residing in a long term care facility for > 14 days before
onset of symptoms.

Bartlett. Clin Infect Dis 2000;31:347-82.

 COMPLICATION
• PLEURAL EFFUSION
• EMPYEMA
• LUNG ABSCESS
• PNEUMOTHORAX
• RESPIRTORY FAILURE
• SEPTIC
 CHEST X -RAY No consolidation, consider other
Clinical fatures suggestive diagnosis
of Pneumonia

Consolidation, pneumonia likely

CURB 65 Score PNEUMONIA SEVERITY INDEX

CURB 65 Score =0 or 1 CURB 65 Score =2 CURB 65 Score=3,4 or 5

MANAGE PNEUMONA MANAGE AS SEVERE PNEUMONA MANAGE AS SEVERE PNEUMONA

OUTPATIENT IN PATIENT IN ICU
 CURB-65

• CURB-65 adalah sistem skoring yang

direkomendasikan oleh The British Thoracic Society
untuk menilai derajat keparahan pneumonia
• terdiri atas 6 skor (0-5) skor 1 bila didapatkan
– C : Confusion (GCS < 8 atau adanya disorientasi)
– U : Urea nitrogen (BUN) >19 mg/dl
– R : respiratory rate > 30x/min
– B: Blood Pressure (Tekanan darah rendah Sistolis
<90 mmHg atau diatolik pressure < 60 mmHg
- 65 : >65 tahun
 CLINICAL FACTOR POINT
Confusion 1
Blood urea nitrogen > 19 mg per dL 1
Respiratory rate > 30 breath per minute 1
Systolic blood pressure < 90 mmHg 1
Or
Diastolic blood pressure ≤ 60 mmHg
Age ≥ 65 years 1
Total point
Woodhead et al. ERJ 2005:26:1138-1180
CURB 65 Death/total (%) RECOMMENDATION
0 7/1,223(o.6) LOW RISK, consider home treatment
1 31/1,142(2.7)
2 69/1,019(6.8) Short inpatient hospitalization
3 79/563(14.0) Severe pneumonia, hospitalize and consider
4 or 5 44/158(27.8) admitting to ICU

CRB 65 Death/total (%) RECOMMENDATION

0 2/212(0.9) Very low risk of death, usually does not require
hospitalization
1 18/344(5.2) Incrased risk of death; usually consider
2 30/25(12.0) hospitalization
3 or 4 39/125(31.2) High risk of death; urgent hospitalization

Ramsdell et al. Chest 2005; 127:1752-1763

 PNEUMONIA SEVERITY INDEX

Demographics History & Laboratory

Physical find.

Age = years (male) Neoplasia (+30) pH < 7.35 (+30)

Age = years – 10 (female) CHF (+10) BUN >10.7 (+20)
Nursing home resident (+10) Renal disease (+10) Na < 130 (+20)
Liver disease (+20) Gluc>250 (+10)
Cerebrovasc. Dis. (+10) Hct<30% (+10)
Pulse ≥ 125 (+10) PO2<60 (+10)
BP ≤ 90 mm/Hg (+20) Effusion (+10)
Temp < 350C or ≥400C (+15)
Altered mental status (+20)

The Pneumonia Patient Outcomes Research Team (PORT)

 DERAJAT SKOR RISIKO CAP

Risiko Klas risiko Total skor Perawatan

Rendah I Tidak diprediksi Rawat jalan

Rendah II 70 total skor Rawat jalan
Rendah III 71-90 tot. skor Rwt inap / rwt jln
Sedang IV 91-130 tot. skor Rawat inap
Berat V > 130 tot. skor Rawat inap

Mortaliti : I (0,1%) ; II (0,6%); III (2,8%) ; IV ( 8,2%) ; V (29,2%)

MINOR CRITERIA
Respiratory rate ≥ 30 breaths/min
PaO2/FiO2 ratio ≤ 250
Multilobar infiltrate
Confusion / disorientation
Uremia ( BUN level, ≥ 20 mg/dL)
Leucopenia ( WBC count, < 4000 cells/mm3)
Thrombocytopenia ( platelet count, < 100,000 cells/mm3)
Hypothermia (core temperature, < 360C)
Hypotension requiring aggressive fluid resuscitation
MAJOR CRITERIA
Invasive mechanical ventilation
Septic shock with the need for vasopressors
IDSA/ATS Guidelines for CAP in Adults • CID 2007:44 (Suppl 2)
There are at least 1 of 2 Major Criteria :
 A need for mechanical ventilation
 Septic shock > 4 hour
or 2 of 3 Minor Criteria :
 PaO2/FiO2 < 250
 Bilateral / multilobar pneumonia
 Systolic pressure < 90 mmHg

Indonesian Association of Pulmonologist Consensus on CAP, 2003

 We always required
“ Early Appropriate-Adequate Antimicrobial Treatment “
Appropriate
Appropriate : - sensitivity and timing
- the use of an antibiotic
→ the etiologic of micro
organism is sensitive and
in a correct time

Best
Adequate : Outcome
- the correct dose for the
correct duration with
advantageous pk/pd
parameter at the site of
infection
- combination if possible Optimal
Adequate
- penetration
 Mortaliti pneumonia yang tinggi
 penundaan pemberian antibiotik > 4 jam setelah
px MRS meningkatkan mortaliti
 Sulitnya menemukan kuman patogen
meskipun dg metode invasif
 30-60% kuman tidak teridentifikasi
 Keterbatasan tes-tes diagnostik untuk
identifikasi kuman patogen

IDSA/ATS Guidelines for CAP in Adults • CID 2007:44 (Suppl 2)

 !!
Initial therapy Broad spectrum
High dose

Re-evaluation & 48-72 h

Change Antibiotic: -  dose
-  antibiotic class Re-evaluation &
48-72 h - change antibiotic class Change Antibiotic:
Targeted (narrow)
spectrum
Initial Therapy
Rawat •Tanpa faktor modifikasi:
jalan A. Macrolide (azithromycin, clarithromycin, or
erythromycin) (strong recommendation; level I)
B.Doxycycline (weak recommendation:level 3)
•Dg faktor komorbid : CHF, lung, liver or renal
disease; DM ; alcoholism; malignancies; asplenia;
immunosuppressing conditions or use of
immunosuppressing drugs; or use of AB the previous
3 months
A.Respiratory fluoroquinolone (moxifloxacin,or
levofloxacin 750 mg) (strong recommendation )
B.Ab-lactam + macrolide (strong recommendation;
level I evidence) (High-dose amoxicillin [e.g 1 g 3
times daily] or amoxicillin-clavulanate [2 g 2x/daily]
alternatives : cefpodoxime, and cefuroxime
Rawat • A respiratory fluoroquinolone
inap non • β-lactam (cefotaxime, ceftriaxone,
ICU and ampicillin; ertapenem for se-
lected patients;
+ macrolide
+ doxycycline [level III evidence] as
an alternative to the macrolide.
Dx IDSA 2007
Ruang Tanpa faktor resiko pseudomonas:
rawat •Sefalosporin non pseudomonas +
Intensif/ Fluoroquinolon respirasi iv
Ada faktor risiko infeksi pseudomonas:
severe •Anti pseudomonas β-lactam (piperacillin-
pneumo tazobactam) atau
nia Antipsedomonas cephalosporins(Cefepime)
atau
Antipsedomonas Carbapenems (imipenem,
atau meropenem)
+ ciprofloxacin or levofloxacin (750-mg
dose) atau
+ aminoglycoside and azithromycin
 TERAPI SULIH (SWITCH TERAPHY)
Perubahan obat suntik ke oral harus memperhatikan
ketersediaan antibiotik iv dan oral, efektiviti obat
oral dapat mengimbangi efektiviti antibiotik iv .
Perubahan meliputi:
• Terapi sekuensial (obat sama, potensi sama):
levofioksasin, moksifloksasin, gatifloksasin
• Switch over (obat berbeda, potensi sama) :
seftasidin iv ke siprofloksasin oral
• Step down (obat sama atau berbeda, potensi lebih
rendah) amoksisilin, sefuroksim, sefotaksim iv ke
cefiksim oral.
 KRITERIA TERAPI INJEKSI KE ORAL
• Tidak ada indikasi untuk pemberian suntikan
lagi
• Tidak ada kelainan pada penyerapan saluran
cerna
• Penderita sudah tidak panas ± 8 jam Gejala
klinik membaik (mis : frekuensi pernapasan,
batuk)
• Leukosit menuju normal/normal