BRONKHITIS

PNEUMONIAElisabeth KasihDefinisiInfeksi parenkim paruDibedakan menjadi:CAP (community-acquired pneumonia)HAP (hospital-acquired pneumonia)VAP (ventilator-associated pneumonia)

oHCAPKlasifikasi PneumoniaBerdasarkan etiologiKlasifikasi PneumoniaBerdasarkan tempat

PatofisiologiEtiologi

Barrier Pertahanan Tubuhflora normal+reflexbatuk+Manifestasi KlinisFebrileTakikardiaKeringat dinginBatuk dg/ tanpa dahak kental berdarahNafas dg bantuan otot pernafasan tambahanGangguan GITTerdengar bebunyian ketika bernafas (rales)PemeriksaanRiwayat Pemeriksaan klinisPemeriksaan laboratorisPemeriksaan radiografiDiagnosis

CAPBakteri Penyebab

Note:M. Pneumoniae, C. Pneumoniae & Legionella spp. resisten thdp -lactam solusi: macrolide/ fluoroquinolon/ tetracyclineBakteri PenyebabInfeksi akibat bakteri anaerob ditemukan jika aspirasi yg terjadi sdh berhari-hari s/d berminggu-minggu sebelum tanda-tanda pneumonia muncul

Potensi Resistensi CAPManajemen Terapi CAP

Manajemen Terapi CAP

Infectious Disease Society of America; American Thoracic Society; Canadian Infectious Disease Society; Canadian Thoracic SocietyCatatanRiwayat penggunaan macrolide/ fluoroquinolon dlm waktu < 3 bulan berpotensi menimbulkan resistensi lakukan kombinasi Tx

Severity of Illness Scores CURB-65 (confusion, uremia, respiratory rate, low blood pressure, age 65 or greater)Faktor lain kemampuan untuk menelan obat per oral, kemampuan bekerjaCURB-65 2/ lebih butuh perawatan intensifKapan Harus MRS?Major criteria:Septic shock requiring vasopressorsAcute respiratory failure requiring intubation & mechanical ventilationMinor Criteria:Respiratory rate > 30PaO2/FiO2 ratio < 250Multilobar infiltratesConfusionBUN > 20Leukopenia, thrombocytopeniaHypothermiaKapan Harus Masuk ICU?Px sehat & tidak memiliki faktor risiko resistensi obat akibat S. pneumoniae:Macrolide (azithromycin)DoxycyclineTerapi KRSTerapi KRSPx dgn komorbid (spt: sakit jantung kronis, paru-paru, ginjal, DM, malignansi, asplenia, menggunakan obat-obat imunosuppresan/ ada faktor risiko resistensi obat akibat S. pneumoniae):Fluoroquinolone-lactam + macrolide/ amoxiclavFluoroquinolone-lactam + macrolideDosis pertama antibiotika harus diberikan di UGD segera setelah pengambilan darah.Terapi MRS (Non ICU)-lactam + azithromycin (atau fluoroquinolone)Untuk Pseudomonas gunakan:-lactam + fluoroquinolone/-lactam + aminoglycoside + azithromycin/-lactam + aminoglycoside + fluoroquinoloneTerapi MRS (ICU)Harus dilakukan ketika Px sudah:Stabil hemodinamisnyaMengalami perbaikan klinisMampu meminum obat per oralPx harus segera dikeluarkan dari RS segera setelah stabil secara klinis & tanpa disertai gangguan-gangguan lain.Penggantian Dosis IV OralMinimum 5 hariAfebrile selama 48-72 jamTanda-tanda ketidak-stabilan klinis terkait CAP tidak lebih dari 1Durasi Penggunaan Antibiotika

HAPEtiologi HAP (Patogen Aerob)Bakteri Penyebab

Faktor yang MempengaruhiPatogenesis HAPMempengaruhi kolonisasi bakteriPemeriksaanMinimal 2 temuanManajemen Terapi HAP

Manajemen Terapi HAP Tanpa Faktor Risiko

Manajemen Terapi HAP dg Faktor Risiko MDR

Note:Linezolid adalah alternatif dari vancomycin untuk Tx MRSADitemukan juga bahwa linezolid lebih superior & aman u/ ginjalPenicillin resistance is increasing in the USCurrent national statistics:Susceptibility 60%Intermediate resistance 20%Resistant 20%Amoxicillin resistance < 5%.

Streptococcus pneumoniae Resistance

Semisynthetic B-lactams derived from chemical side chains added to 7-aminocephalosporanic acid.Generally more resistant to B-lactamases.

CephalosporinesAdverse reactions:5-10% cross-sensitivity with penicillin allergic pts.1-2% hypersensitivity reactions in non-penicillin allergic pts.Broader spectrum leads to opportunistic infections (candidiasis, C. difficile colitis).

CephalosporinesCefazolin, CephalexinSpectrum: Most gram positive cocci (Strep, S. aureus), E. coli, Proteus, Klebsiella. Use: S. aureus infection, surgical prophylaxis.First GenerationCefuroxime:Increased activity against H. flu, Enterobacter, Neisseria, proteus, E. coli, Klebsiella, M. catarrhalis, anaerobes and B. fragilis.Not as effective against S. aureus as the 1st generation.Cefpodoxime and Cefuroxime active against intermediate level resistant strep pneumo.Second Generation40aureusSpectrum: gram () > gram (+).Ceftriaxone:Useful for meningitis.Ceftriaxone used for highly resistant and multi drug resistant S. pneumoniae along with vancomycin.Ceftazidime active against pseudomonas.

Third GenerationCefepimeActive against Strep, Staphylococcus aureus (MRSA), aerobic gram negatives (enterobacter, E. coli, Klebsiella, Proteus and Pseudomonas).Fourth GenerationNeomycin, Gentamicin, Tobramycin, Amikacin.Binds the 30S subunit.Only active against anaerobes because an oxygen dependent system is required to transport the molecules into the cell.Synergism with cell wall inhibitors is seen because they increase the permeability of the cell.

AminoglycosidesAntibacterial spectrum:Gram negatives: Pseudomonas, Proteus, Serratia, E. coli, KlebsiellaNeomycinS. aureus and ProteusPseudomonas and Strep are resistantResistance decreased uptake, decreased binding affinity, enzymes (plasmids).

AminoglycosidesAdverse effects:Ototoxic associated with high peak levels and prolonged therapy. Pts on loop diuretics, vancomycin and cisplatin are at higher risk.Cochlear and vestibular.Concentrates in endolymph and perilymph.Nephrotoxic.Proximal tubule damage.

AminoglycosidesIDSA/ ATS GuidelinesClinical Infectious Disease 2007; 44: S27-72Referensi

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