Pneumonia

Ida Bagus Suta

Devisi Paru Bagian/SMF Ilmu Penyakit Dalam FK UNUD/RSUP Sanglah Denpasar 2013

Pendahuluan
Pneumonia adalah proses keradangan akut parenkim

paru.
Pneumonia komunitas ( PK ) / Community Acquired

Pneumonia ( CAP ), Pneumonia nosokomial / Hospital Aequired Pneumonia (HAP )

Pneumonia komunitas ( PK ) Sering terjadi dan cenderung menjadi berat Angka kematian yang tinggi.

Di AS pneumonia menempati urutan ke-6 penyebab kematian Di Indonesia urutan ke-3 setelah penyakit kardiovaskuler dan tb paru.

Pathology of lobar pneumonia: 4 phases

Congestion

Lasts < 24 hours: Alveoli filled with oedema fluid and bacteria.

Red hepatization

Firm, 'meaty' and airless appearance of lung. Alveolar capillary dilatation. Strands of fibrin extending from one alveolus to another via interalveolar pores of Kohn. Also neutrophils in alveoli. Pleura: Fibrinous exudate.

Pathology of lobar pneumonia: 4 phases

Grey hepatization Less hyperaemia. Macrophages, neutrophils + fibrin
Resolution
Lysis and removal of fibrin via sputum +

lymphatics. Begins after 8-9 days (without antibiotics). Sudden improvement of patient's condition.

Pathogenesis
Inhalation, aspiration and hematogenous spread are

the 3 main mechanisms by which bacteria reaches the lungs Primary inhalation:
when organisms bypass normal respiratory defense

mechanisms or when the Pt inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment

Pathogenesis
Aspiration: occurs when the Pt aspirates colonized upper respiratory tract secretions Stomach: reservoir of GN that can ascend, colonizing the respiratory tract. Hematogenous: originate from a distant source and reach the lungs via the blood stream.

Pneumonias

Classification

Nosocomial

Pneumonias

ATS/IDSA.

Am J Respir Crit Care Med. 2005;171:388-416.

Community-Acquired Pneumonia (CAP):

Pneumonia which develops in the

community or within 48 hours of hospital admission Hospital-acquired pneumonia (HAP):

pneumonia occurs 48 hours or more after

admission, which was not incubating at the time of admission

Ventilator-associated pneumonia (VAP): pneumonia that arise more than 48-72 hours after endotracheal intubation
Healthcare-associated pneumonia (HCAP) includes any patients who was hospitalized in acute care hospital for two or more days within 90 days of the infection; resided in a nursing home or long-term care facility; received recent IV antibiotic therapy, chemotherapy, or wound care within the past 30 days of the current infection; or attended a hospital or hemodialysis clinic

PATIENT WITH SUSPECT CAP

1.

DIAGNOSIS
PSI CURB-65

2.

OUT PATIENT

IN PATIENT

3.

EMPIRICAL ANTIMICROBIAL
(EFFECTIVITY, COMPLIANCE, COST)

Diagnosis ditegakkan dengan:

Klinis

Radiologis
Laboratoris

Diagnosis of Pneumonia
New infiltrates or progressively infiltrates on chest X ray with two or more: increased cough, change in sputum characteristic, temperature 380C or history of fever, sign of consolidation (bronchial sound, creackles), leucocyte 10.000 or 4.5000

Manifestasi Klinis
Gejala respirasi : Nyeri dada Batuk tidak produktif produktif Batuk darah (sputa rupa) Sesak napas Gejala non-respirasi : Demam Menggigil Sakit kepala Mual, muntah, sakit perut, diare Myalgia, dan arthralgia

Manifestasi Klinis
Fisik Diagnostik :

Kesadaran : kompos-mentis koma Tanda vital :

Tensi

nadi Tempratur Frekwensi Napas Nyeri dada Status lokalis toraks: Tanda-tanda kondsolidasi

Denyut

Radiologis : Tanda-tanda konsolidasi :

Lobar or Segmental Density (alveolar opasity) Air Bronchogram No Loss of Lung Volume

KONSOLIDASI

Courtesy Prof .dr. H.M.Soebagyo Singgih,SpRad(K)

Konsolidasi

Mediastinum

window

Lung window

Webb

WR et al. High-Resolution CT of the Lung. 3rd ed, Philadelphia, Lippincott Williams & Wilkins; 2001

Laboratorium:
Darah lengkap : AGD

Kimia klinik
Mikrobiologis bakteriologis

Diagnosis Etiologi
Tantangan bagi para klinisi
Etiologi belum dapat ditentukan dalam 24

jam pertama Tidak ada test laboratorium tunggal Infeksi campuran ( mixed infection ): Tipikal dan Atipik Viral Etiologi sebagian besar PK oleh S. Pneumonia

Microbiology - Bacteriology
Smear - Gram stain Culture Susceptibility
Predicting resistance or susceptibility

Collection, Storage and Transport of Samples

Samples should be collected before the antibiotic

therapy is started and should be collected with care.

The specimens for bacterial isolations are:

a. Sputum
b. Aspirate (Transtracheal and Lung aspirate)

c. Blood

 Drug resisten pneumococcus pneumoniae (DRSP)

Semakin meningkat di AS dan beberapa negara lainnya. Faktor resiko DRSP adalah Umur > 65 tahun, Terapi -lactam dalam 3 bulan terakhir Penderita imunosupresif.

Faktor resiko infeksi bakteri gram negatif:

Adanya penyakit kardiopulmoner Pemakaian antibiotik sebelumnya Penderita dari panti jompo ( nursing home)

Faktor resiko infeksi P. Auriginosa :

Penyakit paru struktural Menapat terapi kortikosteroid Terapi antibiotika spektrum luas Malnutrisi.

Penilaian Keparahan Penyakit dan Tempat Perawatan :

Rawat jalan poliklinis Perawatan di ruangan biasa Perawatan di ruang intensif (ICU)

Keputusan tempat perawatan sangat penting

Adanya faktor resiko -- angka kematian Resiko komplikasi Faktor sosio-ekonomi Beberapa pedoman klinis : Pneumonia severity index (PSI / PORT score) CURB-65 (Confusion; Urea; Respiratory rate; Blood pressure; Age 65 years).

 PSI dibagi 5 strata yaitu klas I V.

Klas I III mortalitasnya < 1% rawat jalan/obsv. Pada klas IV Klas V

9% ruangan/ICU 27% ruangan/ICU

CURB - 65 skor dari 0 5.

Skor 0 Skor 1 Skor 2 Skor 3

Skor 4
Skor 5

mortalitasnya 0,7 % 3,2 % 3 % 17 % 41,5% 57 %.

Epidemiologic Conditions Related To Specific Pathogens In Patients With Community-Acquired Pneumonia Condition Commonly Encountered Pathogens
Alcoholism

COPD / smoker
Nursing home residancy

Poor dental hygiene Expidemic Legionnaires disease Exposure to bats Exposure to birds Exposure to rabbits Travel to southwest United States Exposure to farm animals or parturient cats Influenza active in community Suspected large-volume aspiration Structural disease of lung ( bronchiectasis, cystic fibrosis, etc ) Injection drug use Endobronchial obstruction Recent antibiotic therapy

Streptococcus pneumoniae ( including DRSP ), anaerobes, gram-negative bacilli, tuberculosis S. pneumoniae, Hemophilus influenzae, Moraxella catarhalis, Legionella S. pneumoiae, gram-negative bacilli, H. influanzae, Staphylococcus oureus, anaerobes Chlamydia pnemoniae, tuberculosis Anaeroebs Legionella species Histoplasma capsulatum Chlamydia psittaci, Cryptococcus Neoformans, H. capsulatum Francisella tularensis Coccidioidomycosis Coxiella burnetii ( Q fever ) Influenza, S.pneumoniae, S. aures, H. influenza Anareobes, chemical pnemonitis, or obstruction P. auruginosa, pseudomonas cepacia,or S.aureus S. aeures, anareobes, tuberculosis,P. carinii Anaerobes Drug-resistent pneumococci, P. aeruginosa

Criteria for severe CAP

9 Minor criteria :

3 Criteria ICU

Respiratory rate 30 breaths/min PaO2/FiO2 ratiob 250 Multilobar infiltrates Confusion/disorientation Uremia (BUN level, 20 mg/dL) Leukopeniac (WBC count, 4000 cells/mm3) Thrombocytopenia (platelet count, 100,000 cells/mm3) Hypothermia (core temperature, 36C) Hypotension requiring aggressive fluid resuscitation Major criteria: 1 criteria ICU Invasive mechanical ventilation Septic shock with the need for vasopressors

Indikasi rawat ICU :

Hipotensi ( tekanan sistolik < 90 mmHg )

Ancaman gagal napas yang mebutuhkan ventilasi

mekanik Hipoksemia ( PO2 < 60 mmHg ) Status hemodinamik yang tidak stabil Gagal organ Perburukan penyakit yang merupakan ko-morbid Gagal jantung, DM, PPOK

Pengobatan Holistik : Tindakan umum : demam tinggi nyeri dada pemberian nutrisi, rehidrasi memperbaiki ventilasi Koreksi terhadap penyakit dasar Pemberian obat antibiotika

Pemilihan Antibiotik :
Pemilihan antibiotik perhatikan faktor :

Spektrum antibiotik Farkamotinetik Sensitivitas Efek samping Harga obat.

Selection of Antimicrobial Regimens

Based on prediction of most likely

pathogens Knowledge of local susceptibiliy patterns

Most common etiologies of CAP

Streptococcus pneumoniae Mycoplasma pneumoniae Haemophilus influenzae Chlamydophilia pneumoniae Respiratory viruses S. Pneumoniae M. Pneumoniae C. Pneumoniae H. Influenza Legionella species Aspiration Respiratory viruses S. Pneumoniae Staphylococcus auereus Legionella species Gram-negative bacilli H. influenza

Outpatient

Inpatient (non-ICU)

Inpatient (ICU)

Etiologis of CAP
(Medan, Jakarta, Surabaya, Malang, Makasar)
Pathogen K. pneumoniae S. pneumoniae (%) 45,18 14,04

S. Viridans
S. auereus Peudomonas aerugonosa hemolitik

9,21
9,00 8,58 7,89

Enterobacter Pseudomonas spp

Sudarsono,

5,26 0,90
Ilmu penyakit Paru,2010

Pathogen in sputum cultures of CAP patient in Sanglah Hospital -2008

181 inpatient with CAP
Pathogen S. viridan Enterobacter Pseudomonas E. cloaca E. coli S. pneumoniae Acinetobacter Chrysemo
Suartini,

N(%) 8(28,6) 5(17,9) 4(14,3) 3(10,7) 2(7,1) 2(7,1) 1(3,6) 1(3,6) 28(100)

Pathogen found in 28 (15,5%) cases

Saji,IB Rai, 2009

Total

Timing and Choice of Antibiotics

Antibiotic Timing at 4 hours cutoff:

(IDSA B-III recommendation) Empiric Antibiotic Choice of Therapy:

(IDSA A-I recommendation)

Time to first antibiotic dose.

For patients admitted through the emergency department (ED), the first antibiotic dose should be administered while still in the ED.
(Moderate recommendation; level III evidence)

Community Acquired Pneumonia

Outpatient
Previously Healthy CO-MOR BIDITIES In Region > 25% infection With high level (MIC > 16 mg/ml) Macrolide resistant S. pneumoniae

Inpatient
Inpatient Non ICU In patient ICU

Pseudomonas CA MRSA infection

IDSA/ATS

CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Community Acquired Pneumonia

Outpatient
Previously Healthy
No

Risk DRSP Age < 2 or > 65 lactam within previous 3 mo Alcoholism Medical comorbidities Immunosupressive illness/therapy Exposure to child in day care center
Streptococcus

pneumoniae Mycoplasma pneumonia Hemophilus influenzae Chlamydia pneumoniae Respiratory viruses

macrolide (azithromycin Clarithromycin , erythromycin) (Strong recommendation) OR Doxycycline

IDSA/ATS

CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Community Acquired Pneumonia

Outpatient
CO-MOR BIDITIES

< 2 or > 65 lactam within previous 3 mo, Alcoholism Medical comorbidities, Immunosupressive illness/therapy, Exposure to child in day care center + Comorbid (Chronic heart, Lung Liver, renal disease DM, Alcoholism, malignancy etc
Age Streptococcus

pneumoniae,Mycoplasma Pneumoniae, Hemophilus influenzae, Chlamydia pneumoniae, Respiratory viruses + Gram negative + DRSP

A respiratory fluoroquinoloe (moxifloxacin, GemifloxacinLevofloxacin 750 mg) (strong recommendation) A lactam + a macrolide (strong recommendation) Amoxicillin (3x1gr). Co amoxyclave (2x2gr). Cefriaxone, cefodoxime, cefuroxime. Doxy (alternative)
IDSA/ATS

CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Community Acquired Pneumonia

Outpatient
In Region > 25% infection With high level (MIC > 16 mg/ml) Macrolide resistant S. pneumoniae

respiratory fluoroquinolone
(moxifloxacin,

Gemifloxacin, Levofloxacin 750 mg)

(strong recommendation)

a B lactam + a macrolide (strong recommendation):

Amoxicillin

(3x1gr). Co amoxyclave (2x2gr).

Cefriaxone, cefrodoxime, ceforoxime. Doxy (alternative)

IDSA/ATS

CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Community Acquired Pneumonia

Inpatient
Inpatient Non ICU

S. pneumoniae M. pneumoniae C. pneumoniae H. Influenzae Legionella species Aspiration Respiratory viruses

a respiratory Fluoroquinolonoe (strong recommendation) a B lactam + A macrolide (strong recommendation) Prefered : cefotaxime, Ceftrioxone, ertapenem Doxycyclin alternative for macrolide esisen
IDSA/ATS

CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Community Acquired Pneumonia

Inpatient
In patient ICU S. Pneumoniae Staph aureus Legionella spesies Gram negative bacilli H. Influenzae

a B lactam (cefotaxime, cefriaxone or ampicillin sulbactam) + Azythromycin or Fluoroquinolone (strong recommendation) Penicillin allergic Fluoroquinolone + Azetreonam
IDSA/ATS

CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Community Acquired Pneumonia

Inpatient

In patient ICU

Pseudomonas infection

Structural lung disease Severe COPD with frequent Steroid and/or antibiotic use prior Antibiotic therapy

Antipneumococcal, antipseudomonal B lactam (piperacillin-tazobactam cefepime, imipenem, meropenem) + Ciprofloxacin or levofloxacin750mg OR The above B lactam + an aminoglycoside And an antipneumococcal Fluoroquinolone/azithromycin (moderate recommendation)
IDSA/ATS

CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Community Acquired Pneumonia

Inpatient
In patient ICU

CA MRSA

ESRD Injection drug abuser Prior influenzae Prior antibiotic th/ (especially fluoroquinolone) Add vancomycin or Linezolid (moderate recommendation)

IDSA/ATS

CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2) CA MRSA Com. A qwuired MetslinResisten Pneunobia

Switch from intravenous to oral therapy

Patients should be switched from intravenous to oral therapy when:

hemodynamically stable improving clinically, are able to ingest medications, have a normally functioning gastrointestinal tract.
(Strong recommendation; level II evidence)

Criteria

for clinical stability

Temperature 37.8C Heart rate 100 beats/min Respiratory rate 24 breaths/min Systolic blood pressure >90 mm Hg

Arterial oxygen saturation >90% or pO2>60 mm Hg on room air

Ability to maintain oral intake Normal mental status

NOTE.

Criteria are from [268, 274, 294]. pO2, oxygen partial pressure. a Important for discharge or oral switch decision but not necessarily for determination of nonresponse.

Tempo, Lama, dan Respon Pemberian AB:

Antibiotik berikan sedini mungkin -- IRD

Bila melampaui 4 jam mortalitas

Lama pemberian belum ada kesepakatan

Antibiotik IV umumnya selama 7 hari Lama pemberian antibiotik 7-14 hari.

Switch therapy segera setelah kondisi stabil Pemilihan antibiotik dan dosis yang cermat kegagalan terapi.

Apabila terjadi perburukan maka analisis :

1. Apakah diagnosis awal sudah benar. 2. Bila benar analisis berikutnya : Faktor host :
Obstruksi saluran napas, Respon imun yang tidak adekuat, Super infeksi

Faktor antibiotik Faktor patogen penyebab. 3. Apabila perbaikan klinis tidak terjadi 1 2 hari ganti / tambahkan antibiotika lain

Terapi sulih ( Switch therapy)

Merubah pemberian antibiotik IV ke oral yang sama

efektifitasnya.

stepdown therapi : antibiotik yang sama dengan bentuk IV sequential therapy : mengganti ke antibiotik oral lain (sefalosporin I.V ke makrolid oral)

Indikasi switch therapi adalah pada pasien yang

memberikan respon klinik yang cepat terhadap antibiotik IV.

 Kriteria klinik terapi sulih ( Switch

therapy):

Tidak ada indikasi klinik untuk melanjutkan terapi IV Tidak ada kelainan absorpsi saluran cerna Afebril sekurang-kurangnya 8 jam Gejala batuk dan sesak mereda Hitung leukosit menurun C-reactive protein kembali normal

Duration of antibiotic therapy

Patients with CAP should be treated for a minimum of 5 days (level I evidence), should be afebrile for 4872 h, and should have no more than 1 CAPassociated sign of clinical instability (previous table) before discontinuation of therapy

(level II evidence; Moderate recommendation)

Ringkasan
Infeksi parenkim paru yang terjadi di masyarakat dikenal

sebagai pneumonia komunitas (CAP).

Diagnosis ditegakkan dengan:
Klinis Radiologis Labotatoris :

Patogen sangat sulit ditentukan, Epidemiologis umumnya disebabkan oleh : S H M L

Penentuan tempat rawat :

Severity of illness score seperti curb 65 (confution, Uremic,

Respiratory rate, low Blood pressure, age 65 years or greater) Psi (pneumonic severity index) Pertimbangan psiko-sosio-ekonomi

Pemilihan antibiotik secara emfirik

Complications of lobar pneumonia 1. Abscess formation 2. Empyema 3. Failure of resolution intra-alveolar scarring ('carnification') permanent loss of ventilatory function of affected parts of lung. 4. Bacteraemia:
Infective endocarditis
Cerebral abscess / meningitis Septic arthritis