PNEUMONIA

Gejala dan TandaBatuk disertai dahakNyeri dada atau nyeri pleuritik yang dirasakan sewaktu menarik napas dalamDemamSesak napasSakit kepala, mual, muntah dan diareperadangan yang mengenai parenkim paru, distal dari bronkiolus terminalis yang mencakup bronkiolus respiratorius, dan alveoli serta menimbulkan konsolidasi jaringan paru dan gangguan pertukaran gas setempat

Usia >65 tahunAspirasi sekret orofaringealInfeksi pernapasan oleh virusSakit yang parah & menyebabkan kelemahanPenyakit pernapasan kronikKankerTirah baring yang lama

Trakeostomi atau pemakaian selang endotrakealBedah abdominal atau toraksFraktur tulang igaPengobatan dengan imunosupresifAIDSRiwayat merokokAlkoholismeMalnutrisi Faktor Resiko

1. Clinical dan Epidemiology:a. Community Acquired Pneumonia (CAP)b. Hospital Acquired Pneumonia (HAP)c. Aspiration Pneumoniad. Pneumonia in immunocompromised Patient2. Etiology:a. Typical : bakteriab. Atipikal : (Mycoplasma, Legionella, Chlamydia)c. Virusd. Fungi3. Predilection of infectiona. Pneumonia lobarisb. Bronchopneumoniac. Pneumonia Interstitial

Pneumonia Classification

DD : PNEUMONIA TYPICAL & ATYPICAL*

Sign and symptomsPNEUMONIA TypicalPNEUMONIA AtypicalOnset AcuteGradually2. Temp FebrilSubfebril3. Cough Productive, purulentNon productive/mukoid4. Systemic symptomsJarang Nyeri kepala, sakit tenggorokan, myalgia5. Leucocytehigh Normal / low 6. Liver Function TestRarely abnormalFrequently abnormal7. Chest X RayConsolidation lobarNormal / patchy8. Sputum gramcoccus gram +/-Normal flora

Pneumonia lobarisBila organisme berkolonisasi secara luas pada ruang alveolar, dan menyebabkan konsolidasi seluruh lobusKlasifikasi Patologis

Eksudat mengalami lisis & direabsorpsi oleh makrofag sehingga jaringan kembali pada strukturnya semula

BronkopneumoniaBila organisme berkolonisasi pada bronkus dan meluas dalam alveoliKlasifikasi Patologis

Infeksi virusMenyebabkan respon peradangan intersisial melalui sel-sel limfoid, yang pada banyak kasus dapat sembuh spontanPenyebab tersering: organisme influenza & mikoplasma

Infeksi fungi atau TBMenyebabkan nekrosis pada jaringan atau terbentuknya kavitas

Klasifikasi Patologis

DIAGNOSISAnamnesa : Batuk, sputum purulen, demam, sesak, nyeri dadaPF : demam, T: > 380CAuskultasi : suara nafas bronkial, ronkhiLab : Leukosit 10.000 / < 4500Rontgen : infiltrat /consolidasi with airbronchogramDiagnosis : microbiologi (kultur sputum)AGD : hipoksemia*Bacterial pneumonia. A posteroanterior chest radiograph shows left lower pneumonia. Sputum Gram stain showed gram-positive diplococci.

Pemeriksaan penunjang

Penatalaksanaan

Terapi suportif

ALUR TATA LAKSANA PNEUMONIA KOMUNITIAnamnesis, Pemeriksaan Fisis, Foto ThoraksTidak ada InfiltratInfiltrat + gejala klinis yang menyokong diagnosis pneumoniaEvaluasi untuk kriteria rawat jalan / rawat inapDi Tatalaksana sebagai diagnosis lainRawat jalanTerapi empirisMembaik Memburuk Terapi empiris dilanjutkanMemburuk Membaik Terapi kausatifTerapi empiris (48-72jam) R. Rawat biasaR. rawat intensif Rawat inapPemeriksaan bakteriologis*

Journal Reading*Fine MJ, Auble TE, Yealy DM. N Engl J Med 1997; 336: 243-250.PORT ( Pneumonia Patient Outcome Research Team) /Pneumonia Severity Index (PSI),I,II,III lowIV ModerateV high

DERAJAT SKOR MENURUT PORT*

RESIKOKELAS RESIKOTOTAL SKORPERAWATANRENDAHIIIIIITidak diprediksi< 70 71-90Rawat JalanRawat JalanRawat Inap/JalanSEDANGIV91-130Rawat InapBERATV> 130Rawat Inap

Kriteria Pneumonia berat menurut ATS

PreventionThe most important preventive tool available is using a polyvalent pneumococcal vaccine in those with chronic lung diseases, chronic liver diseases, splenectomy, diabetes mellitus and aged > 65 yo.All persons 50 years of age, others at risk for influenza complications, household contacts of high-risk persons, and health care workers should receive inactivated influenza vaccine as recommended by the Advisory Committee on Immunization Practices, Centers for Disease Control and Prevention.

MODIFICATION FACTORS Condition that increased the risk of infection by pathogen spesific microorganismPenicilin-resistant Pneumococcus / -lactamresistant S. pneumoniae age > 65yo, alcoholism, immunodeficiency, medical comorbidities , -lactam therapy within the previous 3 months, immunosuppressive illness or therapyEnteric gram-negative Residence in a nursing home or extended care facility, heart/lung disease, multiple disease, use of antimicrobialsPseudomonas aeruginosa bronchiectasis, malnutrition, steroid, use of broad spectrum antibiotics > 7 days *

Management of empiric therapy of Pneumonia (PDPI), 2004outpatientinpatientintensive care Without Modification Factors : laktam / laktam + anti laktamase (Amoxycicilline clavulanat) With Modification Factors: lactam + anti lactamase or respiratory Fluoroquinolon ( Levofloksasin, moxifloxasin, gatifloksasin) If atypical pneumonia is suspected : new macrolide (roxitromycin,claritromycin, azitromycin)

Without Modification Factors : laktam + anti laktamase ( Amoxycicilline clavulanat I.V ) or cephalosporin G2, G3 (cefotaxim iv, ceftriaxone iv ) orrespiratory fluoroquinolon I.V (levofloxacin,moxifloxacin,gatifloxacin) With Modification Factors: cephalosporin G2,G3 I.V or respiratory fluoroquinolon IV

If atypical pneumonia is suspected : new macrolide + (added)(roxitromycin,claritromycin,azitromycin)

intensive carea. Without Risk Factors of Pseudomonal infection - Cephalosporin G3 iv non pseudomonas plus + new macrolide or respiratory fluoroquinolon iv b. With Risk Factors to pseudomonal infection - Cephalosporin antipseudomonal iv or carbapenem iv plus Fluoroquinolon antipseudomonal (ciprofloxacin iv) / aminoglycosida iv (gentamicin) - If suspects atypical bacterial infection : add new macrolide or Fluoroquinolon respirasi iv

HAP (Hospital Acquired Pneumonia) : pneumonia yang terjadi setelah 48 jam di rawat di RS dan disingkirkan semua penyebab infeksi lain yang terjadi sebelum masuk RSHCAP (Health Care Associated Pneumonia) : pasien dengan perawatan RS >2hari karena infeksi yang terjadi selama 90 hari, dirawat dirumah jangka panjang. Mendapat antibiotik IV, kemoterapi, perawatan luka infeksi selama 30 hari dan datang untuk HD ke RSVAP (Ventilator Associated Pneumonia) : pneumonia yang terjadi > 48 jam setelah pasien diintubasi. early-onset : within 4 days late-onset : after > 5 daysPneumonia Nosocomial DEFINITION

Risk Factors of Nosocomial Pneumonia :

Sundaram R. Nosocomial pneumonia. AnaesthesiaUK. 2006. http//www.AnaesthesiaUK.com/WorldAnaesthesiaPATOPHYSIOLOGY

Risk Factors of Nosocomial Pneumonia :

Kollef MD. Appropriate Empiric Antimicrobial Therapy of Nosocomial Pneumonia: The Role of the Carbapenems. Respir Care 2004; 49(12);1532

HAP VAPPATIENT-RELATED RISK FACTORSAdvanced age (> 60 years)Supine positionComorbid disease (eg. chronic lung disease)Comorbid disease (eg. chronic lung disease)Previous antibiotik therapyPrevious antibiotik therapyCardiothoracic or abdominal surgeryStress ulcer prophylactic with gastric pH-altering agentsAPACHE II > 16 SmokingPrior hospitalization or abdominal surgeryRefluxDEVICE-RELATED RISK FACTORSTracheotomyTracheotomyNasogastric tubesNasogastric tubesShort duration of nasotracheal or orotracheal intubationProlonged duration of Mechanical VentilationLong duration of nasotracheal or orotracheal intubation Reintubation

Pathogenesis :There must be 3 factors : (1) impaired host defence (2) access of pathogenic bacteria in sufficient number to lower respiratory tract (3) virulence of the organism Access into the lung : - microaspiration of oropharyngeal secret - aspiration of gastric content - inhalation - hematogenous spread - exogenous penetration (e.g. pleural space) - direct inoculation from contaminated ICU staff to intubated airwayDandagi GL. Nosocomial pneumonia in critically ill patients. Lung India. 2010; Vol 27:151

Etiologi Berhubungan dengan daya tahan tubuh: penyakit kronik seperti penyakit jantung, PPOK, DM, alkoholisme, perawatan di RS yang lama menggunakan intubasi endotrakela, malnutrisi, usia lanjutBerhubungan dengan potensial tercemar bakteri dalam jumlah banyak: pemakaian obat tidur, koma, petugas RS tidak mencuci tangan dengan baik, pemakaian antasid, B bloker, NGT

... Etiology Pathogens of Nosokomial Pneumonia

Koulenti & Rello. Hospital-acquired pneumonia in the 21st century : a review of existing treatment options and their impact on patient care. Expert Opin. Pharmacother. 2006; 7(12): 1556)

PatogenOnset PneumoniaFrekuensi (%)Streptococcus pneumoniaeearly10 20Haemophilus influenzaeearly5 15Anaerobic bacteriaearly10 30Staphylococcus aureusearly / late20 30Basil gram-negatiflate30 60 - Pseudomonas aeruginosa17- Klebsiella pneumoniae7- Acinetobacter spp.3- Escherichia coli6- Enterobacter spp.10Legionella pneumophilalate0 15

Pneumonia Nosocomial Treatment

Terapi Antibiotik Inisial Empirik utk HAP/VAP onset-dini pada pasien tanpa faktor resiko patogen MDR (ATS, 2005)Patogen PotensialAntibiotik yg DirekomendasikanStreptococcus pneumoniaeHaemophilus influenzaeMSSABasil Gram-negatif yg sensitif-antibiotik : E. coli, K. pneumoniae Proteus sp., S. marcescens- Ceftriaxone; atau Levofloxacin , Moxifloxacin, atau Ciprofloxacin; atau- Ampicillin/sulbactam; atau- Ertapenem

Terapi Antibiotik Inisial Empirik utk HAP onset-dini (Asian HAP Working Group, 2008)Patogen PotensialAntibiotik yg DirekomendasikanStreptococcus pneumoniaeHaemophilus influenzaeMSSABasil Gram-negatif yg sensitif-antibiotik : E. coli, K. pneumoniae Proteus sp., S. marcescens- Cephalosporin gen. ke-3 : (Ceftriaxone, Cefotaxim) ; atau- Fluoroquinolones (Moxifloxacin, Levofloxacin) ; atau- -lactam/-lactam inhibitor (Amoxicillin/clavulanic acid, Ampicillin/sulbactam) ; atau- Carbapenems (Ertapenem) ; atau- Cephalosporin gen. ke-3 plus Macrolide ; atau- Monobactam + Clyndamycin (utk pasien alergi -lactam)

Terapi Antibiotik Inisial Empirik utk VAP onset-dini (Asian HAP Working Group, 2008)Patogen PotensialRegimen AB yg DirekomendasikanPatogen-patogen spt pd tabel sebelumnya, dan Patogen MDR :Pseudomonas aeruginosaK. pneumoniae (ESBL)Acinetobacter sp.

MRSA- Cephalosporin Antipseudomonas : (Cefepime) ; atau- Carbapenem Antipseudomonas : (Imipenem, Meropenem) ; atau-lactam/-lactam inhibitor (Piperacillin/tazobactam) plus / -- Fluoroquinolones (Ciprofloxacin, Levofloxacin) ; atauAminoglycoside (Amikacin, Gentamycin, Tobramycin) plus / -Linezolid; atau Vancomycin

Pneumonia Nosocomial Treatment

Terapi Antibiotik Inisial Empirik utk HAP,VAP, & HCAP onset-lambat atau dgn faktor resiko patogen MDR (ATS, 2005)Patogen PotensialAntibiotik yg DirekomendasikanPatogen-patogen spt pd tabel sebelumnya, dan Patogen MDR :P. aeruginosaK. pneumoniae (ESBL)Acinetobacter sp.MRSALegionella pneumo-phila- Cephalosporin Antipseudo-monas : (Cefepime, Ceftazidime) ; atau- Carbapenem Antipseudo-monas : (Imipenem, Meropenem) ; atau-lactam/-lactamase inhibitor (Piperacillin/tazobactam) Plus- Fluoroquinolones Anti-pseudomonas (Ciprofloxacin, Levofloxacin) atauAminoglycoside (Amikacin, Gentamycin, Tobramycin) Plus/-LinezolidatauVancomycin

Terapi Antibiotik Inisial Empirik utk HAP onset-lambat (Asian HAP Working Group, 2008)Patogen PotensialRegimen AB yg DirekomendasikanPatogen-patogen spt pd tabel sebelumnya, dan Patogen MDR :P. aeruginosaK. pneumoniae (ESBL)Acinetobacter sp.

MRSALegionella pneumo-philaSpt Rekomendasi ATS 2005 ; atau :

Cefoperazon/sulbactam, plus Fluoroquinolones, atau Aminoglycosides, plus Ampicillin/sulbactam; atau :Fluoroquinolone (Ciprofloxacin), plus Aminoglycoside

Plus/-Linezolid; atau VancomycinPlus/-x) Azithromycin, atau Fluoroquinolone

Terapi Antibiotik Inisial Empirik utk VAP onset-lambat (Asian HAP Working Group, 2008)Patogen PotensialRegimen AB yg DirekomendasikanPatogen MDR :P. aeruginosaK. pneumoniae (ESBL)Acinetobacter sp.

MRSA- Carbapenem Antipseudomonas : (Imipenem, Meropenem) ; atau-lactam/-lactamase inhibitor (Piperacillin/tazobactam)Plus/-- Fluoroquinolones (Ciprofloxacin, Levofloxacin) atauAminoglycoside (Amikacin, Gentamycin, Tobramycin) ; atau : - Spt Rekomendasi Asian HAP Working Group 2008 utk HAP late-onset ; kecuali x)Plus/-Linezolid; atau Vancomycin

*******************APACHE II (Acute Physiology and Chronic Health Evaluation) ICU mortality/ICU scoring systems/ a severity of disease classification system-Does the patirnt have history of chronic organ insuff or immunocomp-Does the patient have acute renal failure-Age-Temperature rectal-MAP-HR-RR-Sodium serum-Potasium serum-Creatinin serum-Hematocrit-Leucocyt-GCS-A-a gradient-PaO2

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