pneumonia fkw 13

7/29/2019 Pneumonia Fkw 13

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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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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)



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Streptococcus pneumoniae

Mycoplasma pneumonia

Hemophilus influenzaeChlamydia pneumoniae

Respiratory virusesA macrolide (azithromycin

Clarithromycin , erythromycin)

(Strong recommendation)

OR

Doxycycline


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



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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



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



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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



In Region

> 25% infectionWith high level

(MIC > 16 mg/ml)Macrolide resistantS. pneumoniae



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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



S. pneumoniae M. pneumoniae C. pneumoniae H. Influenzae

Legionella species Aspiration Respiratory viruses



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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





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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





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ESRDInjection drug abuserPrior influenzaePrior antibiotic th/ (especially fluoroquinolone)

Add vancomycin or Linezolid(moderate recommendation)

Inpatient

CA MRSA

In patient

ICU



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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pneumonia fkw 13

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