Professional Documents
Culture Documents
Pneumonias
Classification
Nosocomial
Pneumonias
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 longterm care facility; received recent IV antibiotic
therapy, chemotherapy, or wound care within the
past 30 days of the current infection; or attended a
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
DIAGNOSIS
1.
PSI
CURB-65
2.
OUT PATIENT
3.
IN PATIENT
EMPIRICAL ANTIMICROBIAL
(EFFECTIVITY, COMPLIANCE, COST)
Inpatient (nonICU)
Inpatient (ICU)
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
Etiologis of CAP
(Medan, Jakarta, Surabaya, Malang, Makasar)
Pathogen
K. pneumoniae
S. pneumoniae
S. viridans
S. auereus
Peudomonas aerugonosa
hemolitik
Enterobacter
Pseudomonas spp
Sudarsono, Ilmu penyakit
(%)
45,18
14,04
9,21
9
8,58
7,89
5,26
0,9
Pathogen
N(%)
S. viridan
8(28,6)
Enterobacter
5(17,9)
Pseudomonas
4(14,3)
E. cloaca
3(10,7)
E. coli
2(7,1)
S. pneumoniae
2(7,1)
Acinetobacter
1(3,6)
Chrysemo
1(3,6)
Total
28(100)
CO-MOR
BIDITIES
Inpatient
In Region
Inpatient In patient
> 25% infection Non ICU
ICU
PseudomonasCA MRSA
With high level
infection
(MIC > 16 mg/ml)
Macrolide resistant
S. pneumoniae
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
A macrolide (azithromycin
Clarithromycin , erythromycin)
(Strong recommendation)
OR
Doxycycline
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
2007: 44 (SUPPL 2)
for macrolide
a B lactam
(cefotaxime, cefriaxone
or ampicillin sulbactam)
+
Azythromycin
or
Fluoroquinolone
(strong recommendation)
Penicillin allergic
Fluoroquinolone
+
Azetreonam
Pseudomonas
infection
Antipneumococcal, antipseudomonal
B lactam (piperacillin-tazobactam
cefepime, imipenem, meropenem)
+
Ciprofloxacin or levofloxacin750mg
OR
The above B lactam +
an aminoglycoside
And an antipneumococcal
2007: 44 (SUPPL 2)Fluoroquinolone/azithromycin
(moderate recommendation)
In patient
ICU
CA MRSA
ESRD
Injection drug abuser
Prior influenzae
Prior antibiotic th/
(especially fluoroquinolone)
Add vancomycin or
Linezolid
(moderate recommendation)
No
Yes
Hours
Cultures -
Cultures +
Cultures -
Cultures +
Adjust antibiotic
therapy, search
for other
pathogens,
complications,
other diagnoses
or other sites of
Consider stopping
antibiotics.
De-escalate
antibiotics, if
possible. Treat
selected patients
for 7-8 days &
reassess.
Antibiotic Selection
General Approach (clinical decision initiate therapy)
HAP or VAP Suspected
(All Disease Severity)
Late Onset or Risk Factors for
Multi-drug Resistant (MDR)
Pathogens
No
Limited Spectrum
Antibiotic
Therapy
Ye
s
Broad Spectrum
Antibiotic
Therapy
For MDR
Pathogens
POTENTIAL PATHOGEN
ANTIBIOTIC
Streptococcus
pneumoniae
Haemophilus influenza
Methicillin-sensitive
Staphylococcus aureus
Antibiotic-sensitive enteric
gram-negative
bacillii
Escherichia coli
Klebsiella
pneumoniae
Enterobacter species
Serratia marcessens
RECOMMENDED
Ceftriaxone
or
Levofloxacin,
moxifloxacin,
or ciprofloxacin
or
Ampicillin/sulbacta
m
or
Ertapenem
COMBINATION ANTIBIOTIC
Antipseudomonal
cephalosporin (cefepime,
ceftazidime)
or
Antipseudomonal
carbepenem (imipenem or
meropenem)
or
Methicillin-resistant
Staphylococcus aureus
Legionella
(MRSA) pneumophila
-Lactam/-lactamase
inhibitor (piperacillintazobactam)
plus
Antipseudomonal
fluiroquinolone
(ciprofloxacin or
levofloxacin)
or
Aminoglycoside (amikacin,
gentamicin. or
tobramycin)
ATS. AJRCCM 2005; 171:388-416
Dosage
1-2 g every 8-12h
2 g every 8 h
500 every 6 h or 1 g
1 g every
4.5 g every 6 h
7 mg/kg per d
Tobramycin
7 mg/kg per d
Amicain
Antipseudomonal
quinolones
Levofloxacin
Ciprofloxacin
Vancomycin
h
Linezolid
20 mg/kg per d
750 mg every d
400 mg every 8 h
15 mg/kg every 12
600 mg every 12 h
ATS. AJRCCM 2005; 171:388-416
THANK YOU