Pneumonie

tratament
Anton Adrian
Grupa 11 , an 4
Tratament
 Ambulator
 Necesita spitalizare
 Infectii nosocomiale
 Alegerea intre a trata ambulator un
pacient cu pneumonie si a-l interna se
face tinand cont de varsta sa,
comorbiditati , severitatea simptomelor
urmarind un indexul de severitate al bolii
Pneumonia Severity Index Patient
Characteristics Points
Demographics
 Male Age (years)
 Female Age (years) – 10
 Nursing home resident + 10
 Comorbid illness
 Neoplastic disease + 30
 Liver disease + 20
 Congestive heart failure +10
 Cerebrovascular disease + 10
 Renal disease
 Physical examination findings
 Altered mental status + 20
 Respiratory rate >30 breaths per minute +20
 Systolic blood pressure < 90 mm Hg + 20
 Temperature < 35°C (95°F) or >40°C (104°F) +15
 Pulse rate >125 beats per minute + 10
 Laboratory and radiographic findings
 Arterial pH < 7.35 +30
 Blood urea nitrogen >64 mg per dL (22.85 mmol per L)
+ 20
 Sodium < 130 mEq per L (130 mmol per L) + 20
 Glucose >250 mg per dL(13.87 mmol per L) + 10
 Hematocrit < 30 percent + 10
 Partial pressure of arterial oxygen < 60 mm Hg or oxygen
percent saturation < 90 percent + 10
 Pleural effusion + 10
 Total points:
 Point total Risk Risk class Mortality % (No. of patients)
Recommended site of care
 Total points:
 Point total Risk Risk class Mortality % (No. of
patients) Recommended site of care

 No predictors Low 0.1 Outpatient

 ≤ 70 Low II 0.6 (5,778) Outpatient
 71 to 90 Low III 2.8 (6,790)Inpatient (briefly)
 91 to 130 ModerateIV 8.2 Inpatient
 >130 High 29.2 (9,333) Inpatient
 Tratament

Tratament

Ambulator: -de cele mai multe empirica

- trebuie sa acopere infectia cu :

 Streptococpneumoniae,
 Mycoplasma pneumoniae,
 Chlamydia pneumoniae
Tratament
Tratament
 Tratament

Antibiotice pt S. pneumoniae
 Amoxicilina- 1g/8h
 Augmentin( amoxicilina + clavulanat)-
1g/12h
 Cefalosporinele – cefuroxima 500mg/12h
 Moxifloxacina (floroquinolone) 400mg/12h
sau levofloxacine – 750mg
 Tratament

Antibiotice active pe
mycoplasma/ chlamydia
Macrolide

 Eritromicina – 500mg/6h
 Claritromicina – 500mg/12h
 Azitromicina – 500mg/zi

 De rezerva – doxiciclina 200mg – prima zi,

apoi 100mg/zi
 Tratament

 La
varstnici cu BPOC – tratament
antibiotic initial: augmentin /
cefalosporine po

 Latineri: macrolide noi – claritromicina,

azitromicina
 Tratament

Durata tratamentului

 Pneumococ – 7-10 zile

 Mycoplasma/chlamydia – 14 zile
 Legionella – 21 zile
 Tratament

Tratament in spital:
Parenteral

 β lactamine –
 augmentin 1,2g/12h sau
 cefalosporine
 ceftriaxona 1g/12h ,
 cefuroxim 2g/12h) + macrolid – po

 fluorochinolone
 ciprofloxacina – 400mg/12h , o
 floxacina, pefloxacina

 Durata tratamentului – 10 – 14 zile

 Tratament

Situatii speciale
 Pneumonia de aspiratie cu anaerobi:
 augmentin + metronidazol (1g/zi)/clindamicina
(1,8g/zi)

 Pneumonia cu G-negativi:
 cefalosporine
 cefotaxim – 2g/8h,
 ceftriaxona 2g/24h
 Combinatiile ticarcilina/clavulanat (4,5g/,
 piperacilina/tazobactam(1,5g/6h),
 meropenem(1g/8h),
 Tratament

 Pneumonia cu pseudomonas aeruginosa

(asociere):

1. Fluorochinolone + β lactamina antipiocianica

 ceftazidim,
 aztreonam,
 imipenem,
 ticarcilina/clavulanat,
 piperacilina/tazobactam)

2. Fluorochinolone + aminoglicozida
 tobramicina,
 gentamicina
 Tratament

Tratament adjuvant
 Hidratare corecta
 Antitusive centrale – accese severe de
tuse
 Oxigenoterapie – hipoxemie
 Ventilatie asistata – in caz de
hipoventilatie alveolara- hipercapnie cu
acidoza respiratorie
Penicilinele
 au o structura beta- lactamica
 beta lactaminele inhiba sinteza peretelui
bacterian (inhiba transpeptidazele
bacteriene)
 Bactericide de tip degenerativ (pot
actiona doar in faza de multiplicare)
 nu se asociaza cu antibiotice
bacteriostatice
Peniciline
 Amoxicilina

 aminopenicilina cu spectru larg

 se absoarbe mult mai bine din intestin
 Nu determina dismicrobisme intestinale
 R.adversa – eruptii cutanate la bolnavii cu
mononucleoza infectioasa
Inhibitori de penicilinaza
 sunt antibiotice beta lactamice, slab
active ca antimicrobiene dar utole in
asociatie cu alte beta lactamine in
infectiile cu germeni secretori
 se fixeaza ireversibil de beta lactamaze
 Augmentin = Acis clavulanic+ Amoxicilina
 Unasyn = Sulbactam+ Ampicilina
Cefalosporine
 antibiotice beta lactamice
 actiune bactericida degenerativa
 Spectru : Stafilococi meticilina rezistenti,
Pneumococ ,Streptococi, H. influenze E.
Coli, Klebsiella ( P. aeruginosa)
 Cefalosporine gen II – Cefuroxim
 Cefalosporine gen III- Cefotaxima ,
Ceftriaxona – antibiotice de rezerva
indicate in infectii grave rezistente la alte
antibiotice , septicemii, infectii
intraspitalicesti
Cefalosporine- Reactii adverse
 au structura asemanatoare anti-
coagulantelor cumarinice si prezinta
actiuni similare de scadere semnificativa
a activitatii protrombinice
 suprainfectii _ deoarece multe
cefalosporine de generatia II si III sunt
ineficace fata de unele bacterii Gram
pozitiv care pot prolifera in timpul terapiei
Aminoglicozide( Tobramicina,
Gentamicina)
 actiune la nivel ribozomal 30 S- inhiba
ireversibil sinteza proteica bacteriana
 Bactericid absolut
 Spectru

M.tuberculosis

Bacili Gram –
E. Coli
Klebsiella
Coci si bacili Gram
+
 Reactii adverse
 Nefrotoxicitate

 Ototoxicitate

 Bloc neuromuscular
Macrolide
( Eritromicina,Claritromicina,
Azitromicina)
 au proprietati bacteriostatice sau
bactericide in functie de concentratia
antibioticului si de specia microbiana
 Spectru:

Bacterii Gram + aerobe Germeni

Streptococi rezistenti la
Pneumococi peniciline
Coci gram negativ Chlamydia
aerobi M. Pneumoniae
Bacterii anaerobe Stafilococi
Etc. etc
 indicata ca alternativa la pacientii cu
alergie la peniciline
 de prima alegere in pneumonia u
Mycoplasma Pneumoniae
 se poate administra oral sau injectabil
 Reactii adverse: fenomene iritative
digestive , hepatita colestatica ,
tromboze dupa administrarea i.v
 Asociere cu antihistaminice anti H1 –
poate cauza torsada varfurilor

 Asocierea cu ergotamina sau alte

substante vasoconstrictoare - poate
provoca ischemii grave
Fluorochinolone
 au spectru larg ( bacterii Gram pozitiv,
negativ, Mycoplasme, Chlamydii,
Rickettsii,Mycobacterii)
 actiune bactericida prin inhibarea AND-
girazei bacteriene
 Ciprofloxacina,Mefloxacina indicate in
infectii sistemice cu germeni sensibili
 Ciprofloxacina este fluorochinolona de
electie in adm i.v in bronhopneumonii cu
bacterii Gram -
Fluorochinolona- Reactii
adverse
 tulburari digestive: greata , voma
 simptome nervos-centrale ( convulsii,
delir, halucinatii)
 reactii alergice( fotosensibilizare)
 evitate la copii deoarece pot afecta
cartilajele de crestere
(artropatii,tendinite)
 Contraindicate in sarcina si alaptare
Tratament infectii
nosocomiale Antibiotice
Cefalosporine II
Microorganisme
Cefalosporine III
Fluorochinolone
Enterobacter
Fluorochinolone
E. coli Fluorochinolone
Klebsiella βlactamine/inhibi
Proteus tor de βlactamaze
Serratia (ticarcilina /clavulanat,
Haemophilus piperacilina/ tazobactam)
Staphyloccocus aureus Vancomicina
MR (15mg/kg /12h
/linezolid 600mg/12
 La pacientii imunodeprimati ( HIV,
corticoterapie prelungita, afectiuni
hematologice) pot aparea infectii cu
 1.Cryptococ – fluconazol
 2.Candida – fluconazol, itraconazol
 3.Aspergilus - ketoconazol
 4.Pneumocistis carinii - biseptol
 5.CMV - ganciclovir
Preventie
infectii nosocomiale
1.Aspiratia secretiilor
2.Pozitie semisezind (30º - 40º)
3.Administrare de cefuroxim la pac intubati
4.Nutritie enterala
5.Evitarea sedarii excesive
6.Decontaminare digestiva cu AB
Tratament pneumonii virale
 Amantadina(200 mg/zi)- preventia
infectiei cu gripa A
 Ribavirin ( infectie cu virus sincitial
respirator)
 Acyclovirul i.v (pneumonie variceloasa)
 Imunoglobuline administrate intravenos+
Ganciclovir_ pneumonie cu CMV