case sepsis ec cap (christie)

Sepsis et Causa CAP

Oleh:Christie Nur Andani

03-062

OBJECTIVESOBJECTIVES Untuk mendiskusikan sepsis ec CAP Mendiskusikan mengenai definisi, etiologi,

signs and symptoms,patofisiologi, diagnostic CAP

Mendiskusikan terapi pasien sepsis, CAP

GENERAL DATAGENERAL DATANy. MS 84 thn Perempuan Menikah tidak bekerja Islam Jl.Komplek Polri Pengadegan Rt 006 Rw 03

blok o/73

Keluhan Utama Keluhan Utama sesak 30 menit SMRS

Keluhan Tambahan

lemas,batuk tidak dapat mengeluarkan dahak

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

I mingguSMRS

• Pasien mengeluh demam hilang timbul,batuk berdahak,tetapi pasien susah mengeluarkan dahak.

• Pasien tidak berobat ke dokter

HISTORY OF PRESENT ILLNESSHISTORY OF PRESENT ILLNESS

1 hariSMRS

• 1 malam SMRS, pasien mulai ada sesak dan semakin sesak beberapa jam SMRS.

• Oleh keluarga di bawa ke UGD RS Tebet, lalu dianjurkan dirawat

AnamAnamnnesa Sistem esa Sistem General: (-) Loss of Consciousness,

(-) Weight Gain, (-) Anorexia, (-) altered sleeping habits, (+) Dizziness Kulit: purpura (-), petechae (+) , pruritus(-), pucat (-), jaundice (-) Telinga: gangguan pendengaran (-), tinnitus(-),

vertigo (-), infeksi (-), sekret (-) Hidung and sinus: epistaksis (-), napas cuping hidung (-), sinus (-) Mulut dan Tenggorok: sakit tenggorokan dan lesi pada mulut (-) Leher: benjolan (-), KGB tidak teraba, nyeri pada leher (-) Respiratori: batuk (+) , pilek (-) Cardiovascular: orthopnea (-), mudah lelah (-), nyeri dada (-), takikardi (-), sesak (+)

Anamnesa SistemAnamnesa Sistem

Genitourinaria: dysuria (-), oliguria (-), hematuria (-) Vaskularisasi perifer : kram (-) , varises vena (-) ,

kaludikasi (-), trombophlebitis (-) Hematologik: kecenderungan berdarah (-) , mudah

memar (-), reaksi transfusi (-) Musculoskeletal: nyeri otot (-), nyeri bahu (-),

bengkak atau kaku (-), gerakan atau aktivitas terbatas (-), nyeri sendi (-)

Neuropsychiatric: paralisis/paresis (-), kehilangan sensasi (-), insomnia (-), ansietas (-), keinginan bunuh diri (-)

Endokrin: intoleransi panas atau dingin (-), polidipsi (-), poliuria (-), poliphagia (-), poliuria (-)

Riwayat Penyakit DahuluRiwayat Penyakit Dahulu

Riwayat hipertensi (+) Riwayat DM (+)Riwayat asma disangkalRiwayat alergi disangkal.

Riwayat Penyakit Riwayat Penyakit KeluargaKeluarga

DM disangkalHipertensi disangkalAlergi disangkal

Riwayat Sosial Riwayat Sosial

Merokok disangkal Minum minuman beralkohol

disangkal Olahraga disangkal Minum jamu-jamuan disangkal

Pemeriksaan FisikPemeriksaan Fisik Status generalis

KU : Tampak sakit sedang Kesadaran : Compos mentis Tanda-tanda vital TD : 146/107 mmHg , HR: 110x/menit , RR : 30x/mnt TB:155 cm BB : 35kg BBI:49,5, BMI: 13,735Kalori basal : 1237,5 kal Koreksi kalori: 50% Kalori: 1856,25 kal Kulit

turgor baik,petechie(-) ,cappilary refill>2 “

Pemeriksaan FisikPemeriksaan Fisik Mata: konjungtiva hiperemis -/ -, sklera ikterik -/-,

pupil isokor diameter 3 mm refleks cahaya langsung dan tidak langsung +/+

Telinga: membran timpani intak/intak Hidung: septum nasal dalam batas normal dan tidak

ada deviasi, mukosa hidung merah muda tidak ada sekret

Mulut dan lidah: mukosa bibir lembab, mukosa bukal dalam batas normal, mukosa lidah pucat

Leher:Tidak ada limfadenopati servical, JVP 5-4 cmH2O

Pemeriksaan FisikPemeriksaan FisikThoraks/pulmo

I: pergerakan dinding dada simetris, tidak ada deformitas.P:Vocal fremitus tidak dapat dinilaiP:Sonor kanan dan kiriA:BND Vesikular, Ronki basah kasar (+/+), Wheezing (-/-)

Cardiovascular Denyut jantung normal ± 80 x/menit

dengan ritme reguler, gallop (-), murmur (-)

Pemeriksaan FisikPemeriksaan Fisik Abdomen

I: Perut tampak datar,tampak jaringan parut (-) A:Bising usus (+) normoaktif.P:Supel, nyeri tekan epigastirum (-),hepar dan lien tidak teraba membesar, ballotement -/-.P:Tympani,Nyeri ketok(-), CVA -/-

EkstremitasPitting edema (-), sianosis (-), pulsasi kuat angkat dan equal, petechiae (-)

Genitourinaria tidak diperiksa

SALIENT FEATURESSALIENT FEATURES Pasien mengeluh demam hilang timbul,batuk berdahak,tetapi

pasien susah mengeluarkan dahak. 1 malam SMRS, pasien mulai ada sesak dan semakin sesak beberapa jam SMRS.

TD : 146/107 mmHg , HR: 110x/menit , RR : 30x/mnt TB:155 cm BB : 35kg BBI:49,5, BMI: 13,735 Thoraks/pulmo

I: pergerakan dinding dada simetris, tidak ada deformitas.P:Vocal fremitus tidak dapat dinilaiP:Sonor kanan dan kiriA:BND Vesikular, Ronki basah kasar (+/+), Wheezing (-/-)

ADMITTING IMPRESSIONADMITTING IMPRESSIONSepsis ec Pneumonia

DIFFERENTIAL DIAGNOSISDIFFERENTIAL DIAGNOSISTBC Bronkhitis

lab 9/4/2010 10/4/2010

Hb 12,20

Leukosit 23,80

LED 103

B/E/B/S/L/M 1/0/0/86/9/4

Ht 34,9

Eritrosit 4,19

Retikulosit

Trombosit 334

MCV 83,2

MCH 29,1

MCHV 35

lab 9/4/2010 10/4/2010 11/4/2010 12/4/2010

SGOT 68

SGPT 24

CPK 49

CKMB 19.2

Kolesterol total 133

Trigliserida 74

HDL 43.6

LDL 74.1

lab 9/4/2010 11/4/2010 12/4/2010

AGD: pH 7.388 7.515 7.48

pCO2 43.60 32.40 34.30

PO2 267.00 120.10 95.10

SO2 97.80 97.10 98.20

Hct 25 26

Hb 8.3 8.8 12.2

Suhu 36 37 36.00

St asam basa:Beecf 1.40 3.2 2.00

Beb 2.00 4.10 3.00

SBC 26.20 28.10 27.10

HCO3 26.80 26.40 26.00

TCO2 28.20 27.40 27.10

lab 9/4/2010

10/4/2010

11/4/2010 12/4/2010

Mikrobiologi BTA

- -

HBA1C 4,8

GDS 294 253 93 89

Na 145 142

K 4.23 4.55

Cl 104 101.0

Trop T 0.01

BUN 16

kreatinin 16

1.18

lab 9/4/2010jamur

12/4/2010

pH urin 6 5

BJ 1.025 1.015

Protein ++ -

Reduksi - -

Bilirubin - -

Urobilinogen 0.2 0.2

Keton - -

Sedimen :

Leu/LPB 1-2 4-5

Eri/LPB 35-40 10-11

Silinder 0 0

Epitel 1-2 2-3

Bakteri -

Kristal -

Trichomonas -

jamur -

Tanggal 9 April 2010Pukul 17.45 • Os pindahan dari IGD dengan infeksi paru + sesak nafas• Rencana intubasi,riwayat batuk dahak>>> • Keadaan umum: tampak sakit sedang • Kesadaran : compos mentis • TD : 146/107 mmHg , HR: 110x/menit , RR : 30x/mnt• Apatis• S O2 : 80-83% afebris • (O2 nasal 4 Lpm)I: pergerakan dinding dada simetrisP: Vf sulit dinilaiP: sonor kanan= kiriA: Bnd vesikular , ronkhi +/+, whezing-/-

bj I,II N, murmur, gallop(-)

• Intubasi 7 ujung ETT 2, penyulit (-), midazolam 2,5 mg• Pasang NGT,penyulit(-)• SpO2 meningkat:100%• Sesak napas +/+ simetris• Ventilator SIMV 12x350ml, PEEP 5, fiO2 100 • A: 1. CAP pada PPOK

2. demensia3. parkinson

• P : - meropenem 1 gram iv bolus → lanjut 4x500mg iv

• Diet cair bertahap 6x50cc • Triofusin 500 II/24 jam + RL II/24jam • OMZ 1x1 a iv • Flumucyl 3x1• Nebulizer 3x/hari k/p

ventolin : NaCl 1:1

Pukul 18.35 • Tekanan darah menurun 46/31 mmHg • Loading RL loss• PEEP ↓3 • Tekanan darah↑ 63/42 mmHg • Lanjut loading• Tekanan darah ↑ 100/83 Pukul 19.15 fiO2 ↓ 80%: Sp O2 100% • Loading RL total 1500 cc• Bila td menurun berikan dobutamin• Tekanan darah : 94/62, HR ; 76, RR: 12 •

Pukul 21.25: TD: 108/57, N: 72, RR :12, SpO2:100%• SIMV 12x350ml/PEEP 3/fiO2 40%

Follow up hari 110/4/2010

Masalah: 1. os masih dalam ventilator2. leukositosis3. GDS meningkat 4. kesadaran somnolent5. EKG : inferolateral wall iskemia, poor R wave V1-V3, VES (+)

S: - O: Keadaan umum : tampak sakit sedang

Kesadaran : compos MentisTD: 126/74, N: 74, R= on ventilator, S: 37sat O2: 100%

Pemeriksaan fisik: Mata: konjungtiva tidak anemis, sklera tidak ikterikLeher: JVP tidak meningkat thoraks:I: pergerakan dinding dada simetrisP: Vf sulit dinilaiP: sonor kanan= kiriA: Bnd vesikular , ronkhi basah kasar +/+, whezing-/-


Abdomen: I: perut tampak datar.A: normoaktif 3X/menit.P: supel, nyeri tekan (-),hepar dan lien tidak teraba P: tympani, nyeri ketuk(-).Exremitas: akral hangat, edema (-) Balance cairan: 600cc A: - sepsis ec CAP on ventilator

- PPOK - Parkinson disease

- Alzheimer - DM tipe 2

IVFD : - triofusin E 1000→habis →stop • Diet: DM 1500 kal (6x250 kal a 100cc) sonde saring • Total cairan : 2000cc/24 jam • - Haes 6% I • - RL I • Meropenem 4x500 • Flumucyl 3x1sach • OBH 3x1C • OMZ iv 1x1 flc • Nebu(4x/hari):ventolin 1cc, bisolvon 1cc, nael 1cc • Insulin sliding scale kelipatan 3

Follow up hari 2 11 /4/ 2010

Masalah: 1. sepsis ec CAP 2. DM tipe23. proteinuria dan hematuria 4. Ronki basah positif

O: Keadaan umum : tampak sakit sedang Kesadaran : compos Mentis

TD: 119/73, N: 74, S: 36,2 sat O2: 100%

Pemeriksaan fisik:

thoraks:I: pergerakan dinding dada simetrisP: Vf sulit dinilaiP: sonor kanan= kiriA: Bnd vesikular , ronkhi basah kasar +/+, whezing-/-


Abdomen: I: perut tampak datar.A: normoaktif 3X/menit.P: supel, nyeri tekan (-),hepar dan lien tidak teraba P: tympani, nyeri ketuk(-).Exremitas: akral hangat, edema (-) Balance cairan: -200cc A: - sepsis ec CAP

- PPOK - Parkinson disease - Alzheimer - DM tipe 2

P : Diet : DM 1500 kalori (6x250kal a 100cc) sonde saring Total cairan : 2000 cc/24 jam • Meronem 4x500 • Flumucyl 3x1sach • OBH 3x1C • OMZ iv 1x1 flc • Neurobion inj 1x1a • Nebu(4x/hari):ventolin 1cc, bisolvon 1cc, nael 1cc

Follow up hari 3 12/4/ 2010

Masalah: 1. os dengan Tpiece + O2 6 Lpm 2. dahak>>3. leukositosis 4. GDS meningkat 5. Ronki basah positif 6. Hematuria

S: O: Keadaan umum : tampak sakit sedang

Kesadaran : compos MentisTD: 132/84, N: 82, R: 18, S: 36,7 sat O2: 100%

Pemeriksaan fisik:

thoraks:I: pergerakan dinding dada simetrisP: Vf sulit dinilaiP: sonor kanan= kiriA: Bnd vesikular , ronkhi basah kasar +, whezing-/-


Abdomen: I: perut tampak datar.A: normoaktif 4X/menit.P: supel, nyeri tekan (-),hepar dan lien tidak teraba P: tympani, nyeri ketuk(-).Exremitas: akral hangat, edema (-) Balance cairan: -400cc A: - sepsis ec CAP mT piece

- PPOK - HHD - Parkinson disease - Alzheimer - DM tipe 2

P : - Tpiece + O2 6 Lpm- IVFD : - HAES 5%

- RL + 1a neurobion 5000 • Meronem 4x500 • Flumucyl 3x1sach • OBH 3x1C • Nebu(4x/hari):ventolin 1cc, bisolvon 1cc, nael 1cc • Nebu(4x/hari): bisolvon 1c, combivent1c,NaCl Diet : DM 1800 kalori (6x300kal a 150cc) sonde saring Total cairan : 2000 cc/24 jam Rencana: menunggu hasil sputum MD BTA II dan III, px HBA1C dan urine

lenkap hari ini, rencana extubasi sore bila astrup baik Jam 1300: extubasi besok, th teruskan


Masalah: 1. sepsis ec CAP on T piece 2. PPOK3. HHD4. Parkinson Disease5. Alzheimer 6. DM tipe 2

S: slem (+), post suction os tenang O: Keadaan umum : tampak sakit sedang

Kesadaran : compos MentisTD: 114/60, N:80, R: 20, S: 36 sat O2: 100% dengan Tpiece

Pemeriksaan fisik:

thoraks:I: pergerakan dinding dada simetrisP: Vf sulit dinilaiP: sonor kanan= kiriA: Bnd vesikular , ronkhi -/-, whezing-/-


Exremitas: akral hangat, edema (-) Balance cairan: -400cc A: - sepsis ec CAP mT piece

- PPOK - Parkinson disease - Alzheimer - DM tipe 2

P : - Tpiece + O2 6 Lpm- IVFD : - HAES 5%

- RL + 1a neurobion 5000 Diet : DM 1800 kalori (6x300kal a 150cc) sonde saring Rencana: extubasi AGD:7,46/35,8/101/2,6/26/98,2


S: BAB +, BAK +, Batuk + O: Keadaan umum : tampak sakit berat

Kesadaran : apatisTD: 120/70, N:808 R: 206 S: 36 ,3

Pemeriksaan fisik: Mata : CA +/+, SI -/-

thoraks:I: pergerakan dinding dada simetrisP: Vf sulit dinilaiP: sonor kanan= kiriA: Bnd vesikular , ronkhi -/-, whezing-/-

bj I,II N, murmur, gallop(-)Abdomen: hepar dan lien tidak membesar, BU +, NT –Ekstremitas : akral hangat, edema-/-

A: 1. sepsis ec CAP2. PPOK3. HHD 4. parkinson5. alzheimer 6.DM tipe 2

P : O2 3L/mnt • IVFD 1kolf RL+1a neurobion/24jam • Diet=DM 2500 kal • MM: OMZ 1x1 • OBH 5mg 3x1 • Flumucyl 3x1sach• Nebu: combivent,bisolvon, NaCl (4x/hari) , Pulmicort 2x/hari• Ciprofloxacin drip 2x200mg

16/4/2010• 0010: kondisi os jelek• 00.15: evaluasi os, napas tidak adekuat, pulse lemah, soporokoma• Rencana intubasi dan pindah ICU • Mulai RJP: adrenalin 1mg IV, intubasi ETT 7, slem+++• Intubasi terpasang, lanjut RJP: pulse hilang timbul• Total adrenalin 5a/1mg• SA 4a/1mg• Lanjut RJP• Pulse -, napas spontan -,pupil midriasis lemah• 00.40: gagal napas

Sepsis

Definisi

Systemic Inflammatory Response Syndrome :Pasien yang memiliki 2 atau lebih kriteria sebagai

berikut : • Suhu> 38°C atau < 36°C• Denyut jantung > 90 x/menit • Respirasi > 24 x/menit atau Pa CO2 < 32 mmHg• Hitung leukosit > 12000/mm3 atau < 4000/mm3

atau > 10% sel imatur (band)

• Sepsis adalah SIRS dengan pembuktian ataupun suspect dari etiologi mikrobial.

• Sepsis berat : sepsis yang berkaitan dengan disfungsi organ, kelainan hipoperfusi(asidosis laktat, oliguria, perubahan akut pada status mental), atau hipotensi.

• Bakteremia : terdapat bakteri di dalam darah, yang didukung oleh kultur darah yang positif

• Septikemia : terdapat mikroba ata toksinnya di dalam darah

Sepsis berat• Kardiovaskular: tekanan darah sistolik ≤ 90mmHg atau mean

arterial pressure ≤ 70 mmHg yang membutuhkan cairan IV.• Renal: output urine < 0,5 mL/kg per jam walaupun dengan

resusitasi cairan yang adekuat• Respirasi: PaO2/FIO2 ≤ 250, atau if the lung is the only

dysfunctional organ, ≤ 200• Hematologi : platelet count <80000/mikroL atau 50% penurunan

platelet count selama 3 hari• Unexplained metabolic asidosis: pH ≤ 7.30 atau base defisit ≥ 5.0

mEq/L dan plasma lactate level >1.5 kali di atas normal • Resusitasi cairan yang adekuat: pulmonary artery wedge pressure ≥

12mmHg atau CVP ≥ 8 mmHg

• Septik shock : sepsis dengan hipotensi( tekanan darah arteri < 90 mmHg sistolik, atau 40mmHg kurangnya dari pasien normal) selama 1 jam walaupun sudah diberi terapi cairan resusitasi adekuat.

Atau • Membutuhkan vasopresor untuk mengontrol

tekanan darah arteri ≥ 90 mmHg atau mean arterial pressure ≥ 70mmHg.

• Refractory septic shock : septik shock yang terjadi lebi dari 1 jam dan tidak berespon dengan cairan ataupun pressor.

• Multiple organ dysfunction syndrome (MODS) : disfungsi lebih dari satu organ, yang dibutuhkan untuk maintain homeostasis

Patogenesis

• endothelial injury , fluid extravasation• Culprit cytokines, increase TNF alpha,

interleukin 1B dan 8

Diagnosis

• There is no specific diagnostic test for the septic response

• Diagnostically sensitive findings in a patient with suspected or proven infection include fever or hypothermia, tachypnea, tachycardia, and leukocytosis or leukopenia

Manifestasi klinis hiperventilasi :sering muncul pada awal sepsis,

disorientasi, bingung.Hipotensi dan DIC Cellulitis, pustul,bullae, lesi hemoragik: pada

bakteri hematogenous dan jamur yang ada di jaringan lunak

Purpura/petechiae cutaneus →infeksi neisseria meningitidis

Manifestasi GI tract: nausea, vomitus, diare, ileus

laboratorium• Sepsis awal: leukositosis dengan shift to the left,

trombositopenia, hiperbilirubinemia, proteinuria, leukopenia. Hiperventilasi menimbulkan alkalosis respiratori.

• Selanjutnya : trombositopenia memburuk disertai perpanjangan waktu trombin, penurunan fibrinogen, dan keberadaan d dimer yang menunjukkan DIC. Azotemia dan hiperbilirubinemia meningkat,aminotranferase meningkat, asidosis metabolik terjadi setelah alkalosis respiratorikhiperglikemia diabetik dapat menimbulkan diabetik

Komplikasi

• ARDS ( Adult Respiratory Disease Syndrom) • Koagulasi intravaskular Diseminata • Gagal ginjal akut • Perdarahan usus • Gagal hati • Disfungsi sistem saraf pusat • Gagal jantung • Kematian

Pengobatan

Antimicrobial Agents• Antimicrobial chemotherapy should be initiated as

soon as samples of blood and other relevant sites have been cultured

Removal of the Source of Infection

Hemodynamic, Respiratory, and Metabolic Support• to restore adequate oxygen and substrate delivery to the tissues. Initial

management of hypotension should include the administration of IV fluids, typically beginning with 1–2 L of normal saline over 1–2 h. To avoid pulmonary edema, the pulmonary capillary wedge pressure should be maintained at 12–16 mmHg or the central venous pressure at 8–12 cm H2O. The urine output rate should be kept at >0.5 mL/kg per hour by continuing fluid administration

• a reasonable goal is to maintain a mean arterial blood pressure of >65 mmHg (systolic pressure, >90 mmHg) and a cardiac index of 4 L/min per m2

• Immunocompetent adult• The many acceptable regimens include (1) ceftriaxone (2 g

q24h) or ticarcillin-clavulanate (3.1 g q4–6h) or piperacillin-tazobactam (3.375 g q4–6h); (2) imipenem-cilastatin (0.5 g q6h) or meropenem (1 g q8h) or cefepime (2 g q12h). Gentamicin or tobramycin (5–7 mg/kg q24h) may be addedto either regimen. If the patient is allergic to -lactam agents, use ciprofloxacin (400 mg q12h) or levofloxacin (500–750 mg q12h) plus clindamycin (600 mg q8h). If the institution or the community has a high prevalence of MRSA isolates, add vancomycin (15 mg/kg q12h) to each of the above regimens.

• Neutropeniaa (<500 neutrophils/L)Regimens include (1) imipenem-cilastatin (0.5 g q6h) ormeropenem (1 g q8h) or cefepime (2 g q8h); (2) ticarcillin-clavulanate (3.1 g q4h) or piperacillin-tazobactam (3.375 g q4h) plus tobramycin (5–7 mg/kg q24h). Vancomycin (15 mg/kg q12h) should be added if the patient has an infected vascular catheter, if staphylococci are suspected, if the patient has received quinolone prophylaxis, if the patient has received intensive chemotherapy that produces mucosal damage

Splenectomy• Cefotaxime (2 g q6–8h) or ceftriaxone (2 g

q12h) should be used. If the local prevalence of cephalosporin-resistant pneumococci is high, add vancomycin. If the patient is allergic to -lactam drugs, vancomycin (15 mg/kg q12h) plus ciprofloxacin (400 mg q12h) or levofloxacin (750 mg q12h) or aztreonam (2 g q8h) should be used.

• IV drug user• Nafcillin or oxacillin (2 g q8h) plus gentamicin

(5–7 mg/kg q24h). If the local prevalence of MRSA is high or if the patient is allergic to -lactam drugs, vancomycin (15 mg/kg q12h) with gentamicin should be used.

• AIDS• Cefepime (2 g q8h), ticarcillin-clavulanate (3.1 g

q4h), or piperacillin-tazobactam (3.375 g q4h) plus tobramycin (5–7 mg/kg q24h) should be used. If the patient is allergic to -lactam drugs, ciprofloxacin (400 mg q12h) or levofloxacin (750 mg q12h) plus vancomycin (15 mg/kg q12h) plus tobramycin should be used

• General Support• Other Measures

Obat sesuai sumber sepsis • Pneumonia dapatan komunitas : seftriakson atau sefepim diberikan

dengan aminoglikosida • Pneumonia nosokomial : sefipim atau iminem silastatin dan

aminoglikosida • Infeksi abdomen nosokomial : imipenem silastatin dan

aminoglikosida atau pipersilin tazobaktam dan amfoterisin B. • Kulit/ jaringan lunak: vankomisin dan im ipenem silastatin atau

piperasilin tazobaktam• Infeksi traktus urinarius : siprofloxacin dan aminoglikosida• Infeksi traktus urinarius nosokomial: vankomisin dan sefipim• Infeksi SSp : vankomisin dan sefalosporin generasi ketiga atau

meropenem• Infeksi SSP nosokomial: meropenem dan vankomisin

Prognosis

• Approximately 20–35% of patients with severe sepsis and 40–60% of patients with septic shock die within 30 days. Others die within the ensuing 6 months. Late deaths often result from poorly controlled infection, immunosuppression, complications of intensive care, failure of multiple organs, or the patient's underlying disease.

Prevention

• by limiting the use (and duration of use) of indwelling vascular and bladder catheters, by reducing the incidence and duration of profound neutropenia (<500 neutrophils/L), and by more aggressively treating localized nosocomial infections.

Empiric Management of Community Acquired

Pneumonia:the 2001 ATS

Consensus Guidelines

PNEUMONIA

• Infection of the lung parenchyma that can be cause by bacteria, viruses, fungi, and parasites

• Non-infectious causes include aspirated food, gastric acid, foreign bodies; hypersensitivity reactions; drug and radiation-induced

Community Acquired Pneumonia

• Is a lower respiratory tract infection acquired in the community within 24 hours to less than 2 weeks.

• Acute infection of the pulmonary parenchyma accompanied by symptoms of acute illness accompanied by abnormal chest findings.

Etiology

• Streptococcus Pneumonia- most frequent organism isolated in community acquired pneumonia in both immunocompetent and immunocompromised individuals

• H. Influenzae• Staphylococus Aureus• Mycoplasma Pneumoniae • Others

Pathophysiology

How do pulmonary pathogens reach the lungs?

• Direct inhalation of infectious respiratory droplets

• Aspiration of oropharyngeal contents• Direct spread along the mucosal membrane

surface from the upper to the lower respiratory system

• Hematogenous spread

PathologyLobar Pneumonia

Streptococcus pneumonia

Intraalveolar exudate resulting in consolidation.Entire lobe

Bronchopneumonia

S.Aureus, H. influenzae, K. pneumoniae, S. pyogenes

Acute inflammatory infiltrates extending from bronchioles into adjacent alveoliPatchy distribution involving one or more lobes

Interstitial Pneumonia

Viruses, mycoplasma pneumoniae

Diffuse, patchy, localized to interstitial areas of alveolar wallsOne or more lobes

Clinical Manifestations:

• Fever, cough, pleuritic chest pain, chills and shortness of breath

• Physical examination: - tachypnea - dullness to percussion

- increased tactile and vocal fremitus- crackles

The diagnosis of Pneumonia based on physical examination has a sensitivity of 47 to 69% and a specificity of 58 to 75%; thus a clinical diagnosis should be confirmed by

CXR

What is the value of Chest radiograph in the diagnosis of CAP?

• For diagnostic certainty• Chest X –Ray is also essential in assessing

severity of disease and in prognostication• It may suggest possible etiology and help

differentiate pneumonia from other conditions

Diagnostics:

• CBC• Blood Culture• Sputum Gram stain• Sputum Culture• Serology• Polymerase Chain Reaction

Patient Stratification

I. Outpatients with no history of cardiopulmonary disease and no modifying factors

II. Outpatients with cardiopulmonary disease and/or other modifying factors (risk factors for DRSP or Gram negative bacteria)

III. Inpatients, not admitted to the ICU, who have the following:a. Cardiopulmonary disease and/or other modifying factors

(including being from a nursing home)b. No cardiopulmonary disease, and no other modifying factorsIV. ICU admitted patients who have the following:

a. No risks for Pseudomonas Aeruginosab. Risks for Pseudomonas Aeruginosa

Determining factors to hospitalize the patient

• >65y/o• Presence of coexisting illnesses• History of hospitalization within the past year • Physical Exam:

RR>30, DBP <60/SBP <90, pulse >125, fever <35 or >40C, decreased levels of consciousness

• Labs:- WBC <4 or >30- PaO2 <60 or PaCo2 >50- Crea >1.2mg/dl, BUN >20mg/dl- CXR - HCT <30%, Hgb <9mg/dl- Sepsis or organ dysfuntion- Arterial PH< 7.35

Criteria in admitting to ICU

• Major Criteriaa. Need for mechanical ventilationb. Septic shock• Minor Criteriaa. SBP <90b. Multilobar diseasec. PaO2/Fio2 <250

Most patients w/ uncomplicated bacterial pneumonia will respond to treatment within 24-72 hrs

• fever declines w/in 72 hrs; temperature normalizes within 5 days

• respiratory signs, esp. tachypnea, return to normal

A follow-up CXR is NOT necessary to confirm that A follow-up CXR is NOT necessary to confirm that infiltrate has cleared for low-risk CAP patientsinfiltrate has cleared for low-risk CAP patients

How do we assess response to initial Rx ?

When to switch to Oral Therapy?

Patients should be switched to oral therapy if they meet four criteria:– improvement in cough and dyspnea,– afebrile on two occasions 8 h apart, – white blood cell count decreasing, – functioning gastrointestinal tract with adequate

oral intake

Recommended Hospital Discharge Criteria:

During the 24 hours before discharge, the patient should have the following characteristics:

1. Temp of 36 – 37.5 C2. Pulse <100/min3. RR 16 -244. Systolic BP > 90mm Hg5. Blood Oxygen saturation > 90%6. With a functioning gastrointestinal tract

Empiric Management of Community Acquired

Pneumonia:the 2007 ATS/IDSA

Consensus Guidelines

IDSA/ATS Consensus Guidelines on the Management of CAP

• Implementation of Guideline Recommendations

• Site of Care Decisions• Diagnostic Testing• Antibiotic Treatment• Other Treatment Considerations• Non Responding Pneumonia• Prevention

To improve process of care variables and relevant clinical outcomes (Level I)

Implementation of Guideline Recommendations

ALL PATIENTS• Initiation of antibiotic therapy• Antibiotic selection• Admission Decision Support• Assessment of oxygentation• ICU Admission Support• Smoking cessation• Immunizations

INPATIENTS• Diagnostic studies• Prophylaxis against VTE• Early mobilization• Thoracentesis for patients with

significan parapneumonic effusions

• Discharge decision support• Patient education

Site of Care DecisionsHOSPITAL ADMISSION

DECISION– Severity-Of-Illness

Scores (Level I)– Physician

Determination of Subjective Factors (Level 2)

– CURB 65 >2: hospitalize (Level 3)

ICU ADMISSION DECISION• Direct to ICU: Septic shock,

Acute Respiratory Failure (Level 2)

• ICU or high level monitoring unit if w/ 3 of the minor criteria or severe CAP. (Level 2)

CURB-65 AND CRB-65 SEVERITY SCORES FOR COMMUNITY-ACQUIRED PNEUMONIA

Criteria For Severe CAP

Major criteria (any one)• Invasive mechanical ventilation• Septic shock with the need for vasopressors

Minor criteria (3 or more)• Respiratory rate >30 /min

• PaO2/FiO2 ratio < 250

• Multi-lobar infiltrates

• Confusion/disorientation

• Uremia (BUN level, 20 mg/dL)

• Leukopenia (WBC < 4,000 / mm3)

• Thrombocytopenia (<100,000 / mm3)

• Hypothermia (core temp, < 36C)

• Hypotension requiring aggressive fluid resuscitation

Diagnostic Testing

• Presence of select clinical features: – Cough, fever, sputum production, pleuritic chest

pain…• PE of rales/bronchial breath sounds are helpful

but less specific than CXR• Supported by Lung Imaging (e.g., CXR) (Level 3)

– If initially negative but w/ strong suspicion, treat presumptively and rpt CXR in 24-48h

• Screening with pulse oximetry

Modifiers Affecting CAP Bacteriology

Drug-Resistant Strepcoccus Pneumonia Age > 65 yrs, ß-lactam Rx within 3 mos, alcoholism,

immune suppression (e.g. steroids), multiple medical co-morbidities, exposure to child in day care

Enteric Gram-negatives Nursing home residence, underlying cardiopulmonary

disease, multiple medical co-morbidities, recent ABT Pseudomonas aeruginosa

Structural lung disease (bronchiectasis), CS (> 10 mg prednisone/day), broad-spectrum antibiotics for > 7 days within the past month, malnutrition

Previously Healthy Co-morbidities

Macrolide (L1)OR

Doxycycline (L3)

Resp FQAlone (L1)

orβ-lactam

(high dose) +Macrolide (L1)

No recentantibiotic

Recentantibiotic

OutpatientOutpatient Inpatient (wards)Inpatient (wards) ICU ICU

add vancomycin or linezolid

CA-MRSA suspect

No PseudomonasRisk

-lactam +

Azithro (L2) or Resp FQ (L1)

*PCN allergy:Resp FQ + aztreonam

Pseudomonas Risk

Anti-pneumo, anti- pseudo-lactam*

+Cipro/ Levo (750

mg)or

AminoG with azithro or Resp

FQ

*Aztreonam if PCN allergic

ANTIBIOTIC THERAPY

Criteria for CAP clinical stability

• Temperature <37.8C• Heart rate <100 beats/min• Respiratory rate <24 breaths/min• Systolic blood pressure >90 mm Hg• Arterial O2 sat >90% or pO2 >60 mm Hg on

room air• Normal mental status

Prevention

• Annual inactivated influenza vaccination• Pnemococcal polysaccharide vaccination• Smoking cessation• Coordination with local health department• Respiratory hygiene measures

case sepsis ec cap (christie)

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