Dr. dr. Allen Widysanto, Sp.

P, CTTS, FAPSR
Medical Faculty, Pelita Harapan University
Boulevard Raya, Lippo Village, Tangerang, Banten 15811
Phone: +62-21-54210133
Pulmonology Departement, Siloam Hospitals Lippo Village
Siloam 6, Lippo Village, Tangerang, Banten 15811
Phone: +62-21-5460055
E-mail: allenwidy@yahoo.co.id
 Educational Background: • Personal Achievement:
 Medical Doctor, Medical Faculty of Atma Jaya, Jakarta, 1994 • National Champion of Pulmonary
 Pulmonology and Respiratory Dept., Medical Faculty University of Indonesia, Jakarta, Case Report, 2005
2007 • Best teacher of Medical Faculty,
 Doctoral Program, Medical Doctor, Medical Faculty, Hasanuddin University, Makassar Pelita Harapan University, 2008
2012
 Tobacco Treatment Specialist: Mssissippi University, Mississippi 2014 Abstract accepted/Papers Presented:
• The association of Oxygen Desaturation
 Professional Organization: Index and Lipoprotein Phosholipase A2
towards Coronary Artery Disease in
 Member of International Relationship Perhimpunan Dokter Paru Indonesia Pusat 2017 Obstructive Sleep Apnea Male Subjects
(APSR, Bali, 2014)
 Member of Indonesian Medical Association (IDI)
• Severity of Obstructive Sleep Apnea is
 Member of Asian Pacific Society of Respiratory Correlated with The Measurement of Neck
 Member of European Respiratory Society circumference in Asian Population (APSR,
Shanghai, 2011)
 Member of INA-Sleep
• Asthma Control Assesment Post
 Member of Sleep Asia Budesonide Intervention using Asthma
 Member of Tobacco Treatment ACT, Mississippi Control Test Questionnaire in Presistent
Asthma (XX World Congress of Asthma,
Athens, 2010)
Appointments:
Head of Curriculum Evaluation, Medical Faculty, Pelita Harapan University
2002-2003: Persahabatan Hospital, Jakarta
2003-2007: Moewardi Hospital, Surakarta
2007-2011: Pulmonology Department, Awal Bros Hospital, Cikokol, Tangerang
2007-present: Pulmonology Department, Siloam Hospital Lippo Village
2016-present: Head of SMF Pulmonology and Respiratory Medicine, Siloam Hospital Lippo
Hospital Lippo Village
2017-present: Head of Pulmonology and Respiratory Medicine, Siloam Hospital Lippo Village
Lippo Village
2010-2016: Head of Medical Education, Medical Faculty, Pelita Harapan University, Lippo
University, Lippo Village, Tangerang, Indonesia
2012-present: Vice Dean Medical Education, Medical Faculty, Pelita Harapan University,
University, Lippo Village
2007-present: Respiratory Block Coordinator, Medical Faculty, Pelita Harapan University,
University, Lippo Village
2007-present: Lecturer and Preceptor, Medical Faculty, Pelita Harapan University, Lippo
Lippo Village Curriculum Vitae - Dr. dr. Allen Widysanto, Sp. P, CTTS, FAPSR
Fellowship Training:
Sleep Medicine Course and Workshop, Jakarta, 2009
Asia Asthma Forum, Phillippine, 2009
3rd National Interventional Pulmonology Course, Sabah, Malaysia, 2009
Spirometry Workshop, Bogor, 2009
Inhalation Therapy Workshop, Banten,2009
Introductory Polysomnographic Technology Course, Singapore, 2009
Mechanical Ventilator Training Course, Shanghai, 2010
Asthma Course, Athens, 2010
Sleep Apnea: from Bench to Bed Workshop, Shanghai, 2011
Pulmonary Medicine Board Review Course American College of Chest Physician,
Physician, Texas, 2011
Tobacco Treatment Specialist, Mississippi University, Mississippi, 2014
Smoking Cessation Training, Persahabatan Hospital, Universitas Indonesia, 2017
Indonesia, 2017
Curriculum Vitae - Dr. dr. Allen Widysanto, Sp. P, CTTS, FAPSR
 4

Management of Sepsis in Hospital-acquired

Pneumonia

Dr. dr. Allen Widysanto, spP, CTTS, FAPSR

Pneumonia is the most common cause of sepsis
5
HAP is a pneumonia
that develops at least
48 hours following
hospitalization
HAP in sepsis is associated with higher LOS and hospital fees

Length of stay (days) Hospital fees ($)

Length of stay (days) Hospital fees…
13.7 151.65
P <0.001
112.55
P <0.001

12.2

HAP CAP in patient HAP CAP in patient

Guiliano et al, 2017

SENTRY Antimicrobial Surveillance Program, 2004–2008
7

10,081 cases
HAP has a long history of
causative pathogens dominated
by S. aureus, nonfermentative
gram-negative bacilli,
and Enterobacteriaceae species
Sepsis pathophysiology
8
How to diagnose ?
HAP 9
Sepsis-3 Definition
10
Infectio Severe Septic
SIRS Sepsis
n sepsis shock
SEPSIS SEPTIC SHOCK
•Life threatening organ dysfunction caused •sepsis with circulatory and
by a dysregulated host response to cellular/metabolic dysfunction
infection
• requiring vasopressors to maintain
•Suspected or documented infection MAP ≥ 65 mmHg
•Acute infection ( ≥ 2 qSOFA) •Serum lactate > 2 mmol/L despited
•Hospital mortality >10% adequate resuscitation
•Hospital mortality >40%
How to diagnose ?
SEPSIS 11

The Surviving Sepsis Campaign Bundle:

2018 Update
Surviving sepsis campaign bundle 2016
12
13
SSC update 2018
1- HOUR BUNDLE 14
SSC bundles 3-h and
6-h bundles have
been combined into a
single “hour-1
bundle”

Begin resuscitation
and management
immediately.
Surviving sepsis campaign update 2018
1 HOUR BUNDLE 15
• We suggest guiding resuscitation to normalize lactate
in patients with elevated lactate levels as a marker of
tissue hypoperfusion.(Weak recommendation; low
quality of evidence)
• re-measured within 2−4 h to guide resuscitation to
normalize lactate.
Surviving sepsis campaign update 2018
1 HOUR BUNDLE 16

1. We recommend that appropriate routine

microbiologic cultures (including blood) be obtained
before starting antimicrobial therapy in patients with
Blood suspected sepsis and septic shock if doing so results in
sample no substantial delay in the start of antimicrobials.
(BPS)
Remarks: Appropriate routine microbiologic
Sputum cultures always include at least two sets of blood
sample cultures (aerobic and anaerobic).
Surviving sepsis campaign update 2018
1 HOUR BUNDLE 17

We suggest empiric combination therapy (using at least two antibiotics

of different antimicrobial classes) aimed at the most likely bacterial
pathogen(s) for the initial management of septic shock.

(Weak recommendation; low quality of evidence)

Treatment alogaritm
 19
•Prior intravenous antibiotic use within 90
days
•Hospitalization in a unit > 20% S.aureus 
MRSA
Risk factor for MRSA
•Prevalene of MRSA is not known
Anti MRSA :
•High risk for mortality
vancomycin linezolid • Need for ventilatory support due to HAP
• Septic shock
Pseudomonas aeruginosa treatment in HAP
•Antibiotic choice
for P.aeruginosa is
definitive (not
empiric)
•Recommend
against
aminoglycoside
monotherapy
•Septic shock or high
mortality  2
antibiotic
combination
Empiric treatment for HAP
21
7 day-
course

De-
escalation
De-escalation therapy
22

• Empiric broad-spectrum therapy  narrowed once

pathogen identification and sensitivites are
established

• Discontinued when patient does not have infection

De-escalation therapy
23
Suspect HAP
Sputum sample and culture Empirical antibiotic therapy

Clinical evaluation 2-4 days

-Body temperature, sputum production, hemodynamic change
- Leukocyte, PaO2/FiO2, procalcitonin, chest xray
- Culture result

Clinical improvement in 48-72 hours

No Ya

Culture (-) Culture (+) Culture (-) Culture (+)

-Wrong diagnosis -Antibiotic adjustment Consider to - De-escalation

-Wrong organism - Further diagnosis : STOP antibiotic antibiotic
-Complication Wrong diagnosis, wrong - Duration : 7 days
organism, complication
PCT and clinical criteria is used for antibiotic discontinuation

Antibiotic duration •Discontinued on the basis of PCT

(days) levels + clinical criteria had a
Antibiotic duration (days) shorter duration of antibiotic
12.1 therapy
9.1 •No difference in mortality and
treatment failure
•Reduced cost and side effects
PCT + clinical clinical criteria
criteria

Stolz D, et al, 2009; Bouadma L, 2010

SEPSIS in hospitalized CAP at Siloam Hospital, Karawaci
25
212 patient (2015-2016) Sepsis status in hospitalized
CAP patient
PCT PCT was Total
evaluated not
evaluated
Sepsis 28 51 79
Non sepsis 40 93 133 sepsis
37%
Mean PCT non
Sepsis 12.1 sepsis
63%
Empiric treatment for HAP
26
7 day-
course

De-
escalation
 27
• HAP in sepsis increase morbidity, mortality, length of
stay and hospital fee
• Early management with adequate ANTIBIOTIC is
crucial
Take Home • Antibiotic de-escalation
Message • Discontinued on the basis of PCT levels + clinical
criteria had a shorter duration of antibiotic therapy
THANK YOU