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P n e u m o n i a
Ida Bagus Suta
Devisi Paru Bagian/SMF Ilmu Penyakit Dalam
FK UNUD/RSUP Sanglah
Denpasar
2013
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Pendahuluan Pneumonia adalah proses keradangan akut parenkim
paru. Pneumonia komunitas ( PK ) / Community Acquired
Pneumonia ( CAP ),
Pneumonia nosokomial / Hospital Aequired Pneumonia(HAP )
Pneumonia komunitas ( PK ) Sering terjadi dan cenderung menjadi berat
Angka kematian yang tinggi. Di AS pneumonia menempati urutan ke-6 penyebab
kematian Di Indonesia urutan ke-3 setelah penyakit kardiovaskuler dan
tb paru.
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Pathology of lobar pneumonia:
4 phases Congestion
Lasts < 24 hours:
Alveoli filled with oedema fluid and bacteria.
Red hepatization
Firm, 'meaty' and airless appearance of lung.
Alveolar capillary dilatation. Strands of fibrin
extending from one alveolus to another via inter-alveolar pores of Kohn.
Also neutrophils in alveoli.
Pleura: Fibrinous exudate.
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Pathology of lobar pneumonia:
4 phases Grey hepatization Less hyperaemia. Macrophages, neutrophils + fibrin
Resolution
Lysis and removal of fibrin via sputum +
lymphatics. Begins after 8-9 days (without antibiotics).
Sudden improvement of patient's condition.
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Pathogenesis Inhalation, aspiration and hematogenous spread are
the 3 main mechanisms by which bacteria reaches thelungs
Primary inhalation: when organisms bypass normal respiratory defense
mechanisms or
when the Pt inhales aerobic GN organisms that colonize
the upper respiratory tract or respiratory supportequipment
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PathogenesisAspiration:
occurs when the Pt aspirates colonized upper respiratorytract secretions
Stomach: reservoir of GN that can ascend, colonizingthe respiratory tract.
Hematogenous:
originate from a distant source and reach the lungs viathe blood stream.
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PneumoniasClassification
Nosocomial
Pneumonias
ATS/IDSA.Am J Respir Crit Care Med.
2005;171:388-416.
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Community-Acquired Pneumonia (CAP):
Pneumonia which develops in the
community or within 48 hours of hospitaladmission
Hospital-acquired pneumonia (HAP):
pneumonia occurs 48 hours or more afteradmission, which was not incubating at
the time of admission
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Ventilator-associated pneumonia (VAP):
pneumonia that arise more than 48-72
hours after endotracheal intubation
Healthcare-associated pneumonia (HCAP)
includes any patients who was hospitalizedin acute care hospital for two or more dayswithin 90 days of the infection; resided in anursing home or long-term care facility;
received recent IV antibiotic therapy,chemotherapy, or wound care within thepast 30 days of the current infection; orattended a hospital or hemodialysis clinic
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PATIENT WITH SUSPECTCAP
DIAGNOSIS
OUT PATIENT IN PATIENT
EMPIRICAL ANTIMICROBIAL
PSICURB-65
(EFFECTIVITY, COMPLIANCE, COST)
1.
2.
3.
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Diagnosis ditegakkan dengan:
Klinis Radiologis
Laboratoris
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Diagnosis of Pneumonia New infiltrates or progressively infiltrates on chest
X ray
with two or more:
increased cough,
change in sputum characteristic,
temperature 380C or history of fever, sign of consolidation (bronchial sound,
creackles),
leucocyte 10.000 or 4.5000
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Manifestasi Klinis Gejala respirasi :
Nyeri dada Batuk tidak produktif produktif Batuk darah (sputa rupa) Sesak napas
Gejala non-respirasi :
Demam Menggigil Sakit kepala Mual, muntah, sakit perut, diare Myalgia, dan arthralgia
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Manifestasi Klinis Fisik Diagnostik :
Kesadaran : kompos-mentis komaTanda vital :
Tensi Denyut nadi Tempratur Frekwensi Napas
Nyeri dadaStatus lokalis toraks: Tanda-tanda kondsolidasi
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Radiologis :
Tanda-tanda konsolidasi : Lobar or Segmental Density (alveolar opasity)
Air Bronchogram
No Loss of Lung Volume
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KONSOLIDASI
Courtesy Prof .dr. H.M.Soebagyo Singgih,SpRad(K)
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Konsolidasi
Mediastinum window Lung window
Webb WR et al. High-Resolution CT of the Lung. 3rd ed, Philadelphia, Lippincott Williams &
Wilkins; 2001
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Laboratorium: Darah lengkap :
AGD Kimia klinik
Mikrobiologis bakteriologis
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Diagnosis Etiologi
Tantangan bagi para klinisi
Etiologi belum dapat ditentukan dalam 24jam pertama
Tidak ada test laboratorium tunggal Infeksi campuran ( mixed infection ):
Tipikal dan Atipik
ViralEtiologi sebagian besar PK oleh S.
Pneumonia
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Microbiology - Bacteriology
Smear - Gram stain
Culture
Susceptibility Predicting resistance or susceptibility
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Collection, Storage and Transport of Samples
Samples should be collected before the antibiotictherapy is started and should be collected with care.
The specimens for bacterial isolations are:a. Sputum
b. Aspirate (Transtracheal and Lung aspirate)
c. Blood
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Drug resisten pneumococcus pneumoniae(DRSP) Semakin meningkat di AS dan beberapa negara lainnya.
Faktor resiko DRSP adalah Umur > 65 tahun, Terapi -lactam dalam 3 bulan terakhir Penderita imunosupresif.
Faktor resiko infeksi bakteri gram negatif: Adanya penyakit kardiopulmoner Pemakaian antibiotik sebelumnya Penderita dari panti jompo ( nursing home)
Faktor resiko infeksi P. Auriginosa : Penyakit paru struktural Menapat terapi kortikosteroid Terapi antibiotika spektrum luas
Malnutrisi.
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Penilaian Keparahan Penyakit dan TempatPerawatan :
Rawat jalan poliklinis Perawatan di ruangan biasa
Perawatan di ruang intensif (ICU)
Keputusan tempat perawatan
sangat penting Adanya faktor resiko -- angka kematian Resiko komplikasi
Faktor sosio-ekonomi
Beberapa pedoman klinis : Pneumonia severity index (PSI / PORT score)
CURB-65 (Confusion; Urea; Respiratory rate; Blood pressure;Age 65 years).
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PSI dibagi 5 strata yaitu klas I V.
Klas I III mortalitasnya < 1% rawat jalan/obsv.
Pada klas IV 9% ruangan/ICU Klas V 27% ruangan/ICU
CURB - 65 skor dari 0 5. Skor 0 mortalitasnya 0,7 % Skor 1 3,2 %
Skor 2 3 %
Skor 3 17 % Skor 4 41,5%
Skor 5 57 %.
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Epidemiologic Conditions Related To Specific Pathogens In Patients
With Community-Acquired Pneumonia
Condition Commonly Encountered Pathogens
Alcoholism
COPD / smoker
Nursing home residancy
Poor dental hygieneExpidemic Legionnaires disease
Exposure to bats
Exposure to birds
Exposure to rabbits
Travel to southwest United States
Exposure to farm animals or parturient catsInfluenza active in community
Suspected large-volume aspiration
Structural disease of lung
( bronchiectasis, cystic fibrosis, etc )
Injection drug use
Endobronchial obstruction
Recent antibiotic therapy
Streptococcus pneumoniae ( including DRSP ),
anaerobes, gram-negative bacilli, tuberculosis
S. pneumoniae, Hemophilus influenzae, Moraxella
catarhalis, Legionella
S. pneumoiae, gram-negative bacilli, H. influanzae,
Staphylococcus oureus, anaerobes Chlamydia
pnemoniae, tuberculosis
AnaeroebsLegionella species
Histoplasma capsulatum
Chlamydia psittaci, Cryptococcus
Neoformans, H. capsulatum
Francisella tularensis
Coccidioidomycosis
Coxiella burnetii ( Q fever )Influenza, S.pneumoniae, S. aures, H. influenza
Anareobes, chemical pnemonitis, or obstruction
P. auruginosa, pseudomonas cepacia,or S.aureus
S. aeures, anareobes, tuberculosis,P. carinii
Anaerobes
Drug-resistent pneumococci, P. aeruginosa
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Criteria for severe CAP 9 Minor criteria : 3 Criteria ICU
Respiratory rate 30 breaths/min PaO2/FiO2 ratiob 250 Multilobar infiltrates Confusion/disorientation Uremia (BUN level, 20 mg/dL)
Leukopeniac (WBC count, 4000 cells/mm3) Thrombocytopenia (platelet count, 100,000 cells/mm3) Hypothermia (core temperature, 36C) Hypotension requiring aggressive f luid resuscitation
Major criteria: 1 criteria ICU Invasive mechanical ventilation Septic shock with the need for vasopressors
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Indikasi rawat ICU :
Hipotensi ( tekanan sistolik < 90 mmHg )
Ancaman gagal napas yang mebutuhkan ventilasimekanik
Hipoksemia ( PO2 < 60 mmHg ) Status hemodinamik yang tidak stabil
Gagal organ
Perburukan penyakit yang merupakan ko-morbid
Gagal jantung, DM, PPOK
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Pengobatan
Holistik :
Tindakan umum :
demam tinggi
nyeri dada
pemberian nutrisi, rehidrasi
memperbaiki ventilasi
Koreksi terhadap penyakit dasar
Pemberian obat antibiotika
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Pemilihan Antibiotik :
Pemilihan antibiotik perhatikan faktor : Spektrum antibiotik
Farkamotinetik
Sensitivitas Efek samping
Harga obat.
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Selection of Antimicrobial Regimens
Based on prediction of most likelypathogens
Knowledge of local susceptibiliypatterns
Most common etiologies of CAP
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Streptococcus pneumoniaeMycoplasma pneumoniaeHaemophilus influenzaeChlamydophilia pneumoniaeRespiratory viruses
S. PneumoniaeM. Pneumoniae
C. PneumoniaeH. InfluenzaLegionella species
AspirationRespiratory viruses
S. PneumoniaeStaphylococcus auereusLegionella speciesGram-negative bacilli
H.influenza
Outpatient
Inpatient(non-ICU)
Inpatient (ICU)
Most common etiologies of CAP
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Etiologis of CAP(Medan, Jakarta, Surabaya, Malang, Makasar)
Pathogen (%)
K. pneumoniae 45,18
S. pneumoniae 14,04
S. Viridans 9,21
S. auereus 9,00
Peudomonas aerugonosa 8,58
hemolitik 7,89Enterobacter 5,26
Pseudomonas spp 0,90
Sudarsono, Ilmu penyakit Paru,2010
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Pathogen in sputum cultures of CAP
patient in Sanglah Hospital -2008
181 inpatient with CAP
Pathogen found in 28(15,5%) cases
Pathogen N(%)
S. viridan 8(28,6)
Enterobacter 5(17,9)
Pseudomonas 4(14,3)
E. cloaca 3(10,7)
E. coli 2(7,1)
S. pneumoniae 2(7,1)Acinetobacter 1(3,6)
Chrysemo 1(3,6)
Total 28(100)Suartini, Saji,IB Rai, 2009
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Timing and Choice of Antibiotics
Antibiotic Timing at 4 hours cutoff:
(IDSA B-III recommendation)
Empiric Antibiotic Choice of Therapy:
(IDSA A-I recommendation)
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For patients admitted through theemergency department (ED), the first
antibiotic dose should be administered
while still in the ED.
(Moderate recommendation; level III evidence)
Time to first antibiotic dose.
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Community Acquired Pneumonia
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Community Acquired Pneumonia
Outpatient Inpatient
Previously
Healthy
CO-MOR
BIDITIES
In Region
> 25% infectionWith high level
(MIC > 16 mg/ml)Macrolide resistantS. pneumoniae
Inpatient
Non ICU
In patient
ICU Pseudomonasinfection
CA MRSA
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
Community Acquired Pneumonia
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IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
Streptococcus pneumoniae
Mycoplasma pneumonia
Hemophilus influenzaeChlamydia pneumoniae
Respiratory virusesA macrolide (azithromycin
Clarithromycin , erythromycin)
(Strong recommendation)
OR
Doxycycline
Community Acquired Pneumonia
Outpatient
Previously
Healthy
No Risk DRSP
Age < 2 or > 65
lactam within previous 3 mo Alcoholism
Medical comorbidities
Immunosupressive illness/therapy
Exposure to child in day care center
Community Acquired Pneumonia
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Streptococcus pneumoniae,Mycoplasma Pneumoniae,
Hemophilus influenzae, Chlamydia pneumoniae, Respiratory viruses
+ Gram negative + DRSP
A respiratory fluoroquinoloe (moxifloxacin, GemifloxacinLevofloxacin 750 mg)(strong recommendation)
A lactam + a macrolide (strong recommendation) Amoxicillin (3x1gr). Co amoxyclave (2x2gr). Cefriaxone, cefodoxime, cefuroxime. Doxy (alternative)
Outpatient
CO-MOR
BIDITIES
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
Community Acquired Pneumonia
Age < 2 or > 65 lactam within previous 3 mo, AlcoholismMedical comorbidities, Immunosupressive illness/therapy,
Exposure to child in day care center+ Comorbid (Chronic heart, Lung Liver, renal disease DM,Alcoholism, malignancy etc
Community Acquired Pneumonia
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a respiratory fluoroquinolone
(moxifloxacin, Gemifloxacin, Levofloxacin 750 mg)
(strong recommendation)
a B lactam + a macrolide (strong recommendation):
Amoxicillin (3x1gr). Co amoxyclave (2x2gr).
Cefriaxone, cefrodoxime, ceforoxime. Doxy (alternative)
Outpatient
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
Community Acquired Pneumonia
In Region
> 25% infectionWith high level
(MIC > 16 mg/ml)Macrolide resistantS. pneumoniae
Community Acquired Pneumonia
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a respiratory Fluoroquinolonoe (strong recommendation) a B lactam + A macrolide (strong recommendation)Prefered : cefotaxime, Ceftrioxone, ertapenemDoxycyclin alternative for macrolide esisen
Inpatient
Inpatient
Non ICU
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
Community Acquired Pneumonia
S. pneumoniae M. pneumoniae C. pneumoniae H. Influenzae
Legionella species Aspiration Respiratory viruses
Community Acquired Pneumonia
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S. PneumoniaeStaph aureusLegionella spesiesGram negative bacilli
H. Influenzae
a B lactam(cefotaxime, cefriaxone or ampicillin sulbactam)+
Azythromycin or Fluoroquinolone(strong recommendation)
Penicillin allergicFluoroquinolone + Azetreonam
Inpatient
In patient
ICU
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
Community Acquired Pneumonia
Community Acquired Pneumonia
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Structural lung disease Severe COPD with frequent Steroid and/or antibiotic use prior Antibiotic therapy
Antipneumococcal, antipseudomonal B lactam (piperacillin-tazobactamcefepime, imipenem, meropenem)
+Ciprofloxacin or levofloxacin750mgOR
The above B lactam + an aminoglycoside And an antipneumococcalFluoroquinolone/azithromycin (moderate recommendation)
Inpatient
Pseudomonasinfection
In patient
ICU
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
Community Acquired Pneumonia
Community Acquired Pneumonia
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ESRDInjection drug abuserPrior influenzaePrior antibiotic th/ (especially fluoroquinolone)
Add vancomycin or Linezolid(moderate recommendation)
Inpatient
CA MRSA
In patient
ICU
IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)
Community Acquired Pneumonia
CA MRSA Com. A qwuired MetslinResisten Pneunobia
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Patients should be switched from intravenous tooral therapy when:
hemodynamically stable improving clinically,
are able to ingest medications,
have a normally functioning gastrointestinaltract.
(Strong recommendation; level II evidence)
Switch from intravenous to oral therapy
C i i f li i l bili
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Temperature 37.8C
Heart rate 100 beats/min
Respiratory rate 24 breaths/min
Systolic blood pressure >90 mm Hg
Arterial oxygen saturation >90% orpO2>60 mm Hg on room air
Ability to maintain oral intake
Normal mental status
Criteria for clinical stability
NOTE. Criteria are from [268, 274, 294]. pO2, oxygen partial pressure.a Important for discharge or oral switch decision but not necessarily fordetermination of nonresponse.
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Tempo, Lama, dan Respon Pemberian AB:
Antibiotik berikan sedini mungkin -- IRD
Bila melampaui 4 jam mortalitas
Lama pemberian belum ada kesepakatan Antibiotik IV umumnya selama 7 hari
Lama pemberian antibiotik 7-14 hari.
Switch therapysegera setelah kondisi stabil Pemilihan antibiotik dan dosis yang cermat
kegagalan terapi.
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Apabila terjadi perburukan makaanalisis :
1. Apakah diagnosis awal sudah benar.2. Bila benar analisis berikutnya :
Faktor host : Obstruksi saluran napas,
Respon imun yang tidak adekuat, Super infeksi
Faktor antibiotik Faktor patogen penyebab.
3. Apabila perbaikan klinis tidak terjadi 1 2 hari
ganti / tambahkan antibiotika lain
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Terapi sulih ( Switch therapy)
Merubah pemberian antibiotik IV ke oral yang samaefektifitasnya.
stepdown therapi : antibiotik yang sama dengan bentuk IV
sequential therapy : mengganti ke antibiotik oral lain(sefalosporin I.V ke makrolid oral)
Indikasi switch therapi adalah pada pasien yang
memberikan respon klinik yang cepat terhadapantibiotik IV.
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Kriteria klinik terapi sulih ( Switchtherapy): Tidak ada indikasi klinik untuk melanjutkan terapi IV Tidak ada kelainan absorpsi saluran cerna
Afebril sekurang-kurangnya 8 jam
Gejala batuk dan sesak mereda
Hitung leukosit menurun
C-reactive protein kembali normal
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Patients with CAP should be treated fora minimum of 5 days (level I evidence),
should be afebrile for 4872 h, and
should have no more than 1 CAP-associated sign of clinical instability(previous table) before discontinuation
of therapy
(level II evidence; Moderate
recommendation)
Duration of antibiotic therapy
Ri k
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Ringkasan Infeksi parenkim paru yang terjadi di masyarakat dikenal
sebagai pneumonia komunitas (CAP).
Diagnosis ditegakkan dengan: Klinis Radiologis Labotatoris :
Patogen sangat sulit ditentukan, Epidemiologis umumnya disebabkan oleh : S H M L
Penentuan tempat rawat : Severity of illness score seperti curb 65 (confution, Uremic,
Respiratory rate, low Blood pressure, age 65 years or greater) Psi (pneumonic severity index) Pertimbangan psiko-sosio-ekonomi
Pemilihan antibiotik secara emfirik
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Complications of lobar pneumonia
1. Abscess formation
2. Empyema3. Failure of resolution intra-alveolar scarring
('carnification') permanent loss of ventilatoryfunction of affected parts of lung.
4. Bacteraemia: Infective endocarditis
Cerebral abscess / meningitis
Septic arthritis
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