PNEUMONIA

DEFINISI
Peradangan dan pemadatan jaringan
paru yang disebabkan oleh bahan
infeksius

PNEMONIA
KLASIFIKASI

Community Acquired Pneumonia (CAP)

- Pneumonia yang diproleh dari luar
rumah
sakit
Hospital Acquired pneumonia
- Pneumonia yg timbul 72 jam atau lebih
setelah dirawat di rumah sakit
Institution acquired pneumonia
- Pneumonia karena tindakan perawatan
di
RS, di rumah dll.

MANIFESTASI KLINIK

Tersering :
Demam
Menggigil
Pleuritic chest pain (pleuropneumonia)
Batuk
Sesak nafas
Sputum :non produktif, produktif, rusty,

berdarah, berbau pada abses paru

MANIFESTASI KLINIK

TYPICAL
Gejala klinik seperti diatas
Disebabkan oleh : Pneumococcus,

staphylococcus, H Influenzae

ATYPICAL
Geja penyakittidak khas
Batuk Non produktif/ mukoid
Disebabkan oleh Legionella, mycoplasma,

Chlamydia

Campuran antara typical and atypical

MANIFESTASI KLINIK

MANIFESTASI NON RESPIRATOR

Nyeri kepala
Mual
Muntah
Nyeri Abdomen
Diare
Nyeri otot / Myalgia
Nyeri sendi / arthralgia

Pasen tua lebih banyak keluhan dp

yang muda

PEMERIKSAAN FISIK

Suhu
- Demam
- Hypothermia
- Afebris pd 20% kasus

Thorax

INSPEKSI

- hemithorax yg sakit tertinggal

PALPASI
- vocal fremitus meningkat
PERKUSI
- sonor memendek / dull
AUSKULTASI
- sub bronkial / bronkial
- ronki basah sedang nyaring
- pleural friction rub

RADIOLOGI

PEMADATAN PD FOTO TORAKS

DD/:
Infeksi
Perdarahan
Cairan edema
Keganasan
Inflamasi penyebab lain

(Vascullitis, Drug Reaction)

Kadang gambaran radiologi khas

untuk kuman tertentu

P
N
E
U
M
O
N
I
A

ETIOLOGIC DIAGNOSIS

DUE TO :
The Cause can not be determined from the
clinical presentation
Complete microbiological studies can
isolate
only < 50 % of causative pathogen and
take
long enough time (> 48 hours)
Pathogen isolated from sputum cannot be
sure
as the causative agent

SO

Etiologic diagnosis of pneumonia

categorized as

ADMISSION/REFER DECISION
Important step after diagnosis has been made
Indication :
Risk factors for a complicated course or Mortality in
Patients with CAP
Age > 65 years
Co-morbid illnesses that are likely to be made worse
by the pneumonia, especially chronic renal failure,
ischemic heart disease, congestive heart failure, and
severe COPD
Concurrent malignancy
Postsplenectomy state
Altered mental status
Alcoholism
Immunosuppresive therapy
Respiratory rate > 30 breaths per minute
Diastolic blood pressure < 60 mm Hg : systolic blood
pressure < 90 mmHg

Hypothermia
Creatinine > 150 mm/l or BUN > 7 mm/l
Leukopenia < 3,000/ul or leucocytosis > 30,000/ul
O2 < 60 mmHg or Pco2 > 48 mmHg while breathing room air
Albumin < 30 gm/l
Hemoglobin < 9 gm/l
Pseudomonas aeruginosa or Staphylococcus aureus as the cause of the
Pneumonia
Bacteremic pneumonia
Multilobe involvement on chest radiograph
Rapid radiographic progression of the pneumonia defined as increase in
the size of the pulmonary opacity of > 50 % within 36 h

DIAGNOSTIC WORK UP

OUT PATIENTS

Chest X ray
Complete leucoyte count
Electrolyte
Creatinin
Oxygen saturation
Sputum culture and gram stain

IN PATIENTS

As above
Sputum culture and gram stain
Blood culture (twice)

SPUTUM CULTURE AND GRAM STAIN

REPRESENTATIVE
SPECIMEN

PER LOW POWER FIELD

PMN > 25
EPHITEL < 10

METHODS
Sputum from cough
Aggressive :
Bronchoscopy
TTNA
Open lung biopsy

 SEROLOGY FOR PATHOGEN

M. Pneumoniae
C. Pneumoniae
Coxiella Bornetti
Legionella Pneumophilla
Adenovirus
Influenza/Parainfluenza
RSV

PNEUMOLYSIS S. PNEUMONIAE
If sputum can not be collected

TREATMENT

INITIAL THERAPEUTIC APPROACH IS

EMPIRICIAL
ONCE THE ETIOLOGIC DIAGNOSIS
HAS BEEN MADE
CHANGE TO THE CHEAPEST,
NARROWEST SPECTRUM AGENT
THAT SENSITIVE

COMMUNITY ACQUIRED PNEUMONIA

RAWAT JALAN

Tanpa Peny.
Kardiopolmunal
bukan perokok

- Makrolid
- Doksisiklin

Resiko

RAWAT INAP

Dengan Peny.
Kardio Pulmonal
atau perokok

Resiko

Resiko

Bangsal

Resiko

ICU

Resiko

DRSP (-) DRSP (+) DRSP (-) DRSP (+) PSA (-)
- Makrolid

-Fluorokuinolon

- Doksisiklin -Amoxicilin +
Makrolid

-Betalactam +
Makrolid/

- Cefutaxime/
Cefriaxone +

dosisiklin
makrolid
-Cefotaxime/Cefriaxo
n
Fluorokuinolon Fluorokuinolo
+
n
MAkrolidDoksisiklin

Resiko
PSA (+)

-Cefutaxime/Cefria - Makrolid + 2
xone + makrolid
Antipseudomon
-Betalaktam/Betal al Agent
ak tamase
inhibitor +
makrolid
- Fluorokuinolon

- Fluorokuinolon
+1
Antipseudomon
al Agent

NANGANAN CAP MENURUT AMERICAN THORACIC SOCIETY 200

KELOMPOK 1 :

(BEROBAT JALAN)

PENYAKIT KARDIOPOLMUNAL(-) & PENYERTA (-)

ORGANISME
S. Pneumoniae
M. Pneumoniae
C. Pneumoniae/sendiri/sgb penyerta
H. Influenzae
Virus Pernafasan
Legionella SPP
M. TBC
Jamur Endemic
Dll

PENGOBATAN
Macrolide generasi baru
al. Azithtromycin

PENANGANAN CAP MENURUT ATS 2001

KELOMPOK

II

PENY. KARDIOPULMONAL (+) & PENYERTA (+)

ORGANISME
S. Pneumoniae (termasuk
DRSP)
M. Pneumoniae
K. Pneumoniae
Infeksi Campuran
H. Influenzae
Enterik Gram (-)
Virus pernafasan
Lain-lain

PENGOBATAN
- B Laktam :
(Oral Cefadoxime,
Cefuroxime,
Dosis tinggi amoksilin,
Amoxilin/as clavulanat)
- Makrolide al. Azitromycin
- Fluroquinolone anti
pneumokokus

PENANGANAN CAP MENURUT ATS 2001

KELOMPOK

III

PENY.
KARDIOPULMONAL
S. pneumoniae
H. Influenzae
M. Pneumoniae
C. Pulmunal
Infeksi Campuran
Enteric gram
Aspirasi/anaerob
Virus
Legionella PENGOBATAN
B-lactam IV +
Lain-lain
IV/oral makrolid al
Azitromycin atau
Doxycline atau
IV fluoroquinolone
Anti pseudomonal
(monoterapi)

(RAWATTANPA
NGINAP
PENY.

KARDIOPULMONAL
S. Pneumoniae
H. Influenzae
M. Pneumoniae
C. Pneumoniae
Virus
Infeksi campuran
Legionella Spp
Lain-lain
PENGOBATAN
IV Azitromycin (monoterapi)
Atau
Doxycyline + B. Lactam
Atau Monoterapi
Anti pseudomonal
fluoroquinolone

PENANGANAN CAP MENURUT ATS 2001

IV A

KELOMPOK

RISIKO P. AUREGINOSA

S. Pneumoniae (termasuk DRSP)

Legionella SPP
H. Influenzae
Enterogram (-) basil
S. Aureus
M. Pneumoniae
Virus pernafasan
Lain-lain
PENGOBATAN
IV B-Lactam
+
IV makrolida
(Azitromycin)
Atau
IV Fluoroquinolone

IV

IV B

RAW

RISIKO P. AUREGINOSA
Organisme yang sama
+
P. Auruginosa

PENGOBATAN
IV Anti Pseudomonal B-lactam +
IV anti Pseudomonal Quionolone
Atau IV Anti Pseudomonal B-Lactam
+ IV Aminoglikosida
+ IV Makrolide al. Azitromycin atau
IV non Pseudomonal Flouroquinolone

TABEL 4. Panduan terapi empiris pada penderita

community acquired pneumonia (American Thoracic
Society 1993)
Grup I

Umur < 60 th
Ringan sedang
Rawat jalan
Tidak ada ko
POLA PATOGEN
- S. Pneumonia
- M. Pneumoniae
- Respiratory
Syncitinc virus
- C. Pneumoniae
- H. Influenzae
Lainnya :
Legionella, S. Aureus, M.
Tuberkulosis, Jamur Gram
Negative Batang (GNB)

Grup II
Umur > 60 th
Atau < 60 th
Ringan sedang
Rawat jalan
Komorbid (+)
POLA PATOGEN
-

S. Pneumoniae
RSU
H. Influenzae
GNB
S. Aureus
Lainnya : M.
Catarhalis,
legionella, M.
Tuberculosis,
Jamur

Grup III

Grup IV

Semua umur
Sedang
Rawat jalan
Komorbid +/-

Semua umur
Berat
Rawat inap
Komorbid +/-

POLA
PATOGEN
- S. Pneumoniae

POLA
PATOGEN
- S. Pneumoniae

- H. Influenzae
- Polimikrobial
(termasuk
anaerob GNB)
- Legionella Sp
- S. Aureus
- C. Pneumoniae
- RSV
- Lainnya : M.
Pneumoniae,
Moraxella,

- Legionella
- GNB
- H. Influenzae
- M.
Pneumoniae
- RSV
- Lainnya : > M.
TBC Jamur

Grup I

ANTIBIOTIK
- Makrolid
- Terasiklin

Makrolid :
Eritromisin
Kalau intoleran thd
eritromisin atau ada
kecurigaan H.
Influenzae berikan
makrolid generasi
baru : klaritromisin,
Azitromisin

Grup II

ANTIBIOTIK
- Sefalosporin
generasi II
- Trimetroprimsulfametoxazol
- Betalaktam/
betalaktamase
inhibitor +
Eritromisin atau
makrolid lainnya

Grup III

ANTIBIOTIK
- Sefalosporin
generasi II/IV
- Beta
laktam /
betalaktamas
e
inhibitor +
makrolid

Grup IV

ANTIBIOTIK
- Makrolid +
- Sefalosporin
Gen
III dengan
aktivitas anti
Pseudomonas
atau
anti
Pseudomonas
lainnya
(Ciprofloxacin
imibenem/Clitasta
in)

PENGOBATAN EMPIRIS UNTUK CAP

(INFECTIOUS DISEASES SOCIETY OF
AMERICA 2000)

Pasien Rawat Jalan :

- Fluorokuinolon
- Doksisiklin
- Makrolida

Pasien Rawat Inap :

Kamar rawat umum :
- Sefalosporin spektrum luas + makrolida
- Inhibitor B laktamase/B laktam + makrolida
- Fluorokuinolon tunggal
ICU :
- Sefalosporin spektrum luas atau inhibitor B laktamase/ Blaktam + makrolida atau fluorokuinolon

EMPIRIC THERAPY FOR

HOSPITAL ACQUIRED
PNEUMONIA (HAP)

PATIENTS WITH MILD TO MODERATE HAP, NO

UNUSUAL RISK FACTORS, ONSET ANY TIME OR
PATIENTS WITH SEVERE HOSPITAL ACQUIRED
PNEUMONIA WITH EARLY ONSET

CORE ORGANISMS
Enteric gram-negative bacilli
(non Pseumomonal)
Enterobacter
- E. Coli
- Klebsiella
- Proteus
- Serratia
- Hemophilus
- Methicillin-sensitive S.
Aureus
- Streptococcus pneumoniae

CARE ANTIBIOTICS
Cephalosporin
Second Generation
Or non pseudomonal third
generation
Beta-lactam/beta-lactamase
inhibitor
if allergic to penicillin :
fluoroquinolone or
clindamycin +
aztreonam

PATIENTS WITH MILD TO MODERATE HAP,

WITH RISK FACTORS, ONSET ANY TIME
CORE ORGANISMS
Anaerobes (resent
abdominal surgery,
withnessed aspiration)
Staphylococcus aureus
(coma, head trauma,
diabetes mellitus,
renal failure)
Legionella (high-dose
steroids)
Pseudomonas
aeruginosa (prolonged
ICU stay, steroids,
structural lung
disease)

CORE ANTIBIOTICS
Clindamycin or beta-lactam/betalactamase inhibitor
+/- Vancomycin (until methicillinresistant S. Aureus is ruled out)
Erythromycin +/- rifampin
Treat as severe hospital acquired
pneumonia

PATIENTS WITH SEVERE HOSPITALACQUIRED PNEUMONIA WITH RISK FACTORS

EARLY ONSET OR PATIENTS WITH SEVERE
HAP, LATE ONSET
CORE ORGANISMS,
PLUS
P. Aeruginosa
Acinetobacter
species
Consider MRSA

THERAPY
Aminoglycoside or ciprofloxacin
Plus one of the following
Antipseudomonal penicillin
Beta-lactam/beta-lactamase inhibitor
Ceftazidime or cefoperazone
Impinem
Aztreonam *
+/- Vancomycin

Excludes patients with immunosuppression

Aztreonam efficacy is limited to enteric gram negative bacilli and
should not
be used in combination with an aminoglycoside if gram positive or