Tatalaksana PenyakitInfeksi Saluran Nafas Bawah dan

Community Acquired Pneumonia (CAP) Non-spesifik di FKTP

Yovita HartantriDepartemen Ilmu Penyakit Dalam

RSUP dr Hasan Sadikin/FKUP Bandung, 12 Juni 2021

Ilustrasi kasus : Perempuan 30 tahun

Tidak ada riwayat perjalanan, tidak ada riwayat kontak denganpasien terkonfirmasi COVID-19, sudah divaksinasi 2x

Batuk berdahak putih dan sesak sejak 7 hari SMRS, demamsejak 4 hari SMRS

Keadaan umum sakit sedang, cm, T100/60, N=HR 130, R20 saturasi 97% room air, S36,7

Riwayat

Gejala

PD

Laboratorium Foto thoraks : • Hb: 13.0• Ht: 39.1• Leukosit: 7.140• Trombosit: 159.000• Hitung jenis leukosit: 0/0/0/74/17/9• TLC : 1.21• NLR : 4.36• Swab PCR SARS-CoV2 (+), CTvalue 27

Perbedaan Upper dan Lower respiratory tract

Lower Respiratory Infections:

• Bronchitis• Bronchiolitis • Pneumonia (Community Acquired Pneumonia)

Dasaraju PV, Liu S, Medical Microbiology 1996

Etiology

• Causative agents of lower respiratory infections are viral or bacterial.• Viruses cause most cases of bronchitis and bronchiolitis. • In community-acquired pneumonias, the most common bacterial

agent is Streptococcus pneumoniae. • Atypical pneumonias are cause by such agents as Mycoplasma

pneumoniae, Chlamydia spp, Legionella, Coxiella burnetti and viruses.• Nosocomial pneumonias and pneumonias in immunosuppressed

patients have protean etiology with gram-negative organisms and staphylococci as predominant organisms.

Patogenesis

• Organisms enter the distal airway by inhalation, aspiration or by hematogenous seeding. • The pathogen multiplies in or on the epithelium, causing

inflammation, increased mucus secretion, and impaired mucociliaryfunction; other lung functions may also be affected. • In severe bronchiolitis, inflammation and necrosis of the epithelium

may block small airways leading to airway obstruction.

Clinical manifestation

• Symptoms include cough, fever, chest pain, tachypnea and sputum production. • Patients with pneumonia may also exhibit non-respiratory symptoms

such as confusion, headache, myalgia, abdominal pain, nausea, vomiting and diarrhea.

Microbiologic diagnosis

• Sputum specimens are cultured for bacteria, fungi and viruses.• Culture of nasal washings is usually sufficient in infants with bronchiolitis. • Fluorescent staining technic can be used for legionellosis. • Blood cultures and/or serologic methods are used for viruses, rickettsiae,

fungi and many bacteria. • Enzyme-linked immunoassay methods can be used for detections of

microbial antigens as well as antibodies. • Detection of nucleotide fragments specific for the microbial antigen in

question by DNA probe or polymerase chain reaction can offer a rapid diagnosis.

Pneumonia

• Pneumonia is an inflammation of the lung parenchyma. • Consolidation of the lung tissue may be identified by physical

examination and chest x-ray. • From an anatomical point of view, lobar pneumonia denotes an

alveolar process involving an entire lobe of the lung while bronchopneumonia describes an alveolar process occurring in a distribution that is patchy without filling an entire lobe. • Numerous factors, including environmental contaminants and

autoimmune diseases, as well as infection, may cause pneumonia.

Patogenesis of bacterial pneumonia

Diagnosis dan tatalaksana CAP (ATS – IDSA 2019)

Community Acquired Pneumonia

• Community-acquired pneumonia (CAP) adalah infeksi pada parenkimparu yang menyebabkan tingginya angka kesakitan dan kematian.• Merupakan kondisi klinis yang diperoleh di luar RS.• Meskipun diketahui bahwa CAP lebih sering didiagnosis tanpa

penggunaan thoraks foto, khususnya pada setting rawat jalan.

Etiologi

• Penyebab bakteri tersering pada CAP : • Streptococcus pneumoniae• Haemophilus influenzae• Mycoplasma pneumoniae• Staphylococcus aureus• Legionellaspecies• Chlamydia pneumoniae• Moraxella catarrhalis.

• Penyebab healthcare-associated pneumonia adalah : • Methicillin-resistant S aureus (MRSA) dan Pseudomonas aeruginosa

Penyebab CAP berdasarkan tipepasien

IDSA/ATS - 2007

Patogen penyebabCAP berdasarkanfaktor risiko

IDSA-ATS 2007

Rekomendasi - Diagnosis

• Haruskah dilakukan pewarnaan gram dan kultur?• Tidak selalu pada setting rawat jalan (strong recommendation, very low quality of

evidence)

• Direkomendasikan sebelum pengobatan pada CAP dengan setting perawatan di RS• CAP berat, terutama bila terintubasi (table 1)• Yang secara empirik diobati dengan MRSA atau P. aeruginosa• Riwayat terinfeksi MRSA atau P. aeruginosa, khususnya karena infeksi saluran

pernafasan• Dalam perawatan mendapat antibiotik parenteral, di 90 hari terakhir

Kriteria CAP berat

1 kriteria major3 atau lebih kriteria minor

Rekomendasi - Diagnosis

• Haruskah dilakukan kultur darah?• Tidak direkomendasikan pemeriksaan kultur darah untuk setting

rawat jalan (strong recommendation, very low quality of evidence)• Untuk setting rawat inap, tidak rutin melakukan kultur darah• Direkomendasikan pada keadaan : • CAP berat (tabel 1)• Secara empirik diobati untuk MRSA atau P. aeruginosa• Riwayat Infeksi MRSA atau P. aeruginosa khususnya yang dengan infeksi

respirasi• Dalam perawatan mendapat antibiotik parenteral, di 90 hari terakhir

Antibiotik apa yang direkomendasikan sebagai terapiempirik CAP dengan setting rawatjalan ?

ATS/IDSA - 2019

Tatalaksana pasienrawat inap

IDSA/ATS - 2007

Bila tes influenza positif, haruskah mendapat antivirus?

• Rekomendasi :• Pemberian antiinfluensa (oseltamivir) pada pasien CAP dengan tes influensa

yang positif, tidak tergantung dari lamanya sakit sebelum diagnosis ditegakkan (strong recommendation, moderate quality of evidence)• Juga diberikan pada pasien rawat jalan (conditional recommendation, low quality of

evidence)• Belum ada studi klinik yang mengevaluasi efek antiinfluensa pada pasien

rawat jalan.• Diduga bahwa oseltamivir menurunkan risiko kematian pasien yang dirawat.

Berapa lama terapi diberikan?

• Rekomendasi• Berdasarkan perbaikan klinis (tanda vital membaik, nadi, respirasi, tekanan

darah, temperature dan saturasi oksigen)• Napsu makan membaik• Kondisi mental normal• Antibiotik dilanjutkan hingga pasien stabil, tidak kurang dari 5 hari (strong

recommendation, moderate quality of evidence)• Meta-analisis menunjukkan efikasi terapi 5-7 hari

Kriteria klinis :

IDSA/ATS 2007

Haruskah dilakukan pemeriksaan imaging untuk follow up?

• Rekomendasi : • Gejela CAP akan membaik dalam 5-7 hari• Pemeriksaan imaging untuk follow up tidak rutin (conditional

recommendation, low quality of evidence)

PatofisiologiCOVID-19 :

Case Definitions

© World Health Organization 2020. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence.WHO reference number: WHO/2019-nCoV/Surveillance_Case_Definition/2020.2

Suspected case of SARS-CoV-2 infection Probable case of SARS-CoV-2 infection

WHO COVID-19: Case DefinitionsUpdated in Public health surveillance for COVID-19, published 16 December 2020

A

Note: Clinical and public health judgment should be used to determine the need for further investigation in patients who do not strictly meet the clinical or epidemiological criteria.Surveillance case definitions should not be used as the sole basis for guiding clinical management.

A patient who meets clinical criteria above AND is a contact of a probable orconfirmed case, or linked to a COVID-19 cluster3

B

C

D

A suspect case with chest imaging showing findings suggestive of COVID-19 disease4

A person with recent onset of anosmia (loss of smell) or ageusia (loss of taste) in the absence of any other identified cause.Death, not otherwise explained, in an adult with respiratory distress preceding deathAND was a contact of a probable or confirmed case or linked to a COVID-19 cluster3

4 Typical chest imaging findings suggestive of COVID-19 include the following:• Chest radiography: hazy opacities, often rounded in morphology, with peripheral and

lower lung distribution• Chest CT: multiple bilateral ground glass opacities, often rounded in morphology, with

peripheral and lower lung distribution• Lung ultrasound: thickened pleural lines, B lines (multifocal, discrete, or confluent),

consolidative patterns with or without air bronchograms.See Antigen detection in the diagnosis of SARS-CoV-2 infection using rapid immunoassays

B

Clinical Criteria:• Acute onset of fever AND cough; OR

• Acute onset of ANY THREE OR MORE of the following signs or symptoms:Fever, cough, general weakness/fatigue1, headache, myalgia, sore throat,coryza, dyspnoea, anorexia/nausea/vomiting1, diarrhoea, altered mentalstatus.

AND

Epidemiological Criteria:• Residing or working in an area with high risk of transmission of virus: closed

residential settings, humanitarian settings such as camp and camp-like settingsfor displaced persons; anytime within the 14 days prior to symptom onset; or

• Residing or travel to an area with community transmission anytime within the14 days prior to symptom onset; or

• Working in any health care setting, including within health facilities or withinthe community; any time within the 14 days prior of symptom onset.

A patient with severe acute respiratory illness:(SARI: acute respiratory infection with history of fever or measured fever of ≥ 38C°; and cough; with onset within the last 10 days; and requires hospitalization).

A person who meets the clinical AND epidemiological criteria:

Asymptomatic person not meeting epidemiologic criteria with a positiveSARS-CoV-2 Antigen-RDT2

1 Signs separated with slash (/) are to be counted as one sign.

C

2 NAAT is required for confirmation, see Diagnostic testing for SARS-CoV-2

A

3 A group of symptomatic individuals linked by time, geographic location and common exposures, containing at least one NAAT-confirmed case or at least two epidemiologically linked, symptomatic (meeting clinical criteria of Suspect case definition A or B) persons with positive Ag-RDTs (based on ≥97% specificity of test and desired >99.9% probability of at least one positive result being a true positive)

Confirmed case of SARS-CoV-2 infection

A person with a positive Nucleic Acid Amplification Test (NAAT)A

B

C

A person with a positive SARS-CoV-2 Antigen-RDT AND meeting either theprobable case definition or suspect criteria A OR B

An asymptomatic person with a positive SARS-CoV-2 Antigen-RDT who is acontact of a probable or confirmed case

Implementation of Antigen RDT (Ag-RDT) to detect COVID-19 cases in Indonesia

• WHO recommends the use of Ag-RDT to diagnose SARS-CoV-2 infection in settings where NAAT is unavailable or where prolonged turnaround precludes clinical utility.• Although there are several Ag-RDT kits available on the market, only

few of them have passed WHO’s prequalification process• This would require an Ag-RDT to have ≥ 80% sensitivity and ≥ 97-

100% specificity compared to an NAAT reference assay.

• Sensitivitas antigen rapid test (tes cepat antigen) untuk SARS-CoV-2 berdasarkanberbagai merk antigen yang diteliti menunjukkan variasi dengan rentang 0 - 94%, namun spesifisitasnya tinggi (>97%) • Panduan interim WHO tanggal 11 September 2020 merekomendasikan

penggunaan antigen rapid test (tes cepat antigen): • Bila nucleic acid amplification tests (NAAT) akses sulit atau tidak tersedia; atau waktu

ketersediaan hasil lama, dengan syarat tes cepat antigen SARS-CoV-2 mempunyai sensitivitas≥80% dan spesifisitas ≥97%

• Antigen rapid test (tes cepat antigen) tidak direkomendasikandilakukan pada: • Tempat atau populasi dengan prevalensi penyakit yang diperkirakan rendah

(misalnya: skrining di pintu masuk bandara atau perbatasan negara, skriningdonor darah, bedah elektif), terutama jika tes konfirmasi NAAT tidak langsungtersedia. • Persyaratan biosafety dan kontrol infeksi tidak terpenuhi• Kasus nol atau hanya sporadik• Asimptomatik, kecuali terdapat kontak dengan kasus konfirmasi

Kelebihan dan kekurangan Rapid Ag

Tatalaksana : NIH (national institute of health) sd Juni 2021

Untuk pasien rawat inap

NIH, 24 June 2021

Hospitalized patient

Ringkasan

• Infeksi saluran nafas bagian bawah atau pneumonia adalah inflamasipada parenkim paru, yang dapat disebabkan oleh bakteri, virus dan jamur. • COVID-19 merupakan infeksi virus yang dapat menimbulkan

manifestasi pada paru dan di luar paru karena adanya inflamasisistemik• Pada kasus ringan atau tanpa gejala belum ada obat definitive yang

tersedia saat ini di Indonesia

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