SEPSIS AND SEVERE PNEUMONIA

Dr. dr. Bintang YM Sinaga, M.Ked(Paru), Sp.P(K), FAPSR

SABTU, 30 JULI 2022

TOPIK
• Epidemiologi Sepsis
• Patogenesis sepsis
• Definisi sepsis
• Penyebab sepsis
• Diagnosis sepsis
• Tatalaksana sepsis
• Definisi pneumonia
• Klasifikasi pneumonia
• Diagnosis pneumonia
• Tatalaksana antibiotik pada pneumonia komuniti dan HAP/VAP
SE PSIS
Epidemiology
• The annual incidence of severe sepsis and septic shock in the United
States is up to 300 cases per 100,000 people.
• Sepsis is also the most expensive healthcare problem in the United
States, accounting for more than $20 million (about 5.2% of the total
hospital cost) in 2011 alone.

Gyawali, B., Ramakrishna, K., & Dhamoon, A. S. (2019). Sepsis:

The evolution in definition, pathophysiology, and management.
SAGE open medicine, 7, 2050312119835043.
Epidemiology
• It is estimated that more than 30 million people are affected by sepsis
every year worldwide, resulting in potentially 6 million deaths annually.
• Mortality rates from sepsis, as per the data from the Surviving Sepsis Campaign
2012, were approximately 41% in Europe versus approximately 28.3% in the
United States.
• A multicenter study in Australia and New Zealand that included 101,064 critical
patients showed that the mortality rate in sepsis has decreased over the years
from around 35% in 2000 to about 20% in 2012.

Gyawali, B., Ramakrishna, K., & Dhamoon, A. S. (2019). Sepsis:

The evolution in definition, pathophysiology, and management.
SAGE open medicine, 7, 2050312119835043.
 SOFA SCORE

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PNEUMONIA
Peradangan akut parenkim paru yang disebabkan mikroorganisme
selain Mycobacterium tuberculosis

16
Klasifikasi Pneumonia
Klinis-Epidemiologis Etiologi Predileksi

• Pneumonia • Bakterialis tipikal • Lobaris

Komunitas (CAP) • Bakterialis atipikal • Bronkopneumonia
• Pneumonia • Virus • Interstisial
Nosokomial (HAP, • Jamur
VAP)
• Pneumonia
aspirasi
• Pneumonia pada
imunokompromais

Perhimpunan Dokter Paru Indonesia. Pedoman pneumonia komunitas: pedoman diagnosis dan penatalaksanaan di
Indonesia. 2nd ed. Jakarta: PDPI; 2014.
 How to diagnose pneumonia?
CLINICAL SYMPTOM : PHYSICAL EXAMINATION :
• Cough with purulent SPUTUM • Hipoksemia: decreased in oxygen saturation
• Body temperature > 38 or had
• Tachypnea, use of accessory muscle for breathing
fever history
• Chest pain • Sign of consolidation:
• Shortness of Breath • Increased fremitus
• In virus infection: Myalgia, • Dullness of percussion
headache and fever • Auscultation
• Bronhial soundSuara napas bronkial
BLOOD: • Crackle
• Leucocyte <4000 or >10.000 • Pleural friction rub in pleuritis
• Procalcitonin > 2 ng/l (in bacterial
infection))
CHEST X-RAY : MICROORGANISM CULTURE:
• CRP > 100 mg/l (in bacterial
• Infiltrate or air bronchogram • Sputum
infection) • New infiltrate or increased in 48 • Endotracheal aspirate
• Neurofil/Lympocyte Ratio > 7
hours infiltrate in HAP or VAP • Bronchial Washing
04/11/2022 18
 Pneumonia komuniti
Pneumonia Severity Index (PSI)
 Indikasi rawat inap :
1. Skor PSI lebih dari 70
2. Apabila skor PSI kurang dari 70, pasien
tetap perlu dirawat inap apabila
dijumpai salah satu kriteria dibawah ini:
 Frekuensi napas >30 kali/menit
 PaO2/FiO2 kurang dari 250 mmHg
 Foto toraks menunjukkan infiltrat multilobus
 Tekanan darah sistolik <90 mmHg
 Tekanan darah diastolic <60 mmHg
3. Pneumonia pada pengguna NAZPA

Total poin Risiko Kelas risiko Angka kematian Perawatan

Tidak diprediksi Rendah I 0,1% Rawat jalan
< 71 II 0,6% Rawat jalan
71 – 90 III 2,8% Rawat jalan/inap
91 – 130 Sedang IV 8,2% Rawat inap
> 130 Berat V 29,2% Rawat inap
Perhimpunan Dokter Paru Indonesia. Pedoman pneumonia komunitas: pedoman diagnosis dan penatalaksanaan di Indonesia. 2nd ed. Jakarta: PDPI; 2014.
CURB-65
C : Confusion
U : Urea  BUN  ureum/2,14  > 19 mg/dL
R : Respiratory rate  >30
B : Blood pressure  <90/<60 mmHg
65 : Usia 65 tahun keatas

• Confusion/status mental dinilai dengan 10 pertanyaan

• Umur, tanggal lahir, waktu, tahun sekarang, nama rumah sakit, dapat
mengidentifikasi dua orang, alamat rumah, tanggal kemerdekaan, nama
presiden, hitung mundur dari 25
• Apabila tidak dapat menjawab 8 pertanyaan maka skor untuk C adalah 1

Total poin Risiko Angka kematian Perawatan

0-1 Rendah 1,5% Rawat jalan
2 Sedang 9,2% Rawat jalan/inap
3 Tinggi 14,0% Rawat inap
4-5 Sedang 27,8% Rawat intensif

Perhimpunan Dokter Paru Indonesia. Pedoman pneumonia komunitas: pedoman diagnosis dan penatalaksanaan di Indonesia. 2nd ed. Jakarta: PDPI; 2014.
S E V E RE PNE UM ONI A
 Definition of Severe Pneumonia
• Having 1 or more of the major criteria
• Invasive mechanical ventilation or
• Septic shock with a need for vasopressors
OR
• Having 3 or more of the minor criteria
• Respiratory rate ≥ 30 breaths/min,
• PaO2/FiO2 ≤ 250 mmHg,
• Multilobar infiltrates,
• Confusion/disorientation,
• Blood urea nitrogen (BUN) ≥20 mg/ dL,
• WBC count < 4000 cells/mm3,
• Platelet count < 100, 000 cells/mm3,
• Core temperature < 36 °C,
• Hypotension requiring aggressive fluid resuscitation)

Wongsurakiat, P., & Chitwarakorn, N. (2019). Severe community-acquired pneumonia in general medical
wards: outcomes and impact of initial antibiotic selection. BMC pulmonary medicine, 19(1), 1-10.
Strategi Perawatan Awal untuk Pasien CAP Rawat Inap berdasarkan Tingkat Keparahan dan Risiko Resistensi Obat

Strong recommendation
High quality of evidence

Strong recommendation
Moderate quality of evidence

Am J Respir Crit Care Med Vol 200, Iss 7, pp e45–e67, Oct 1, 2019
 Durasi Terapi Antibiotik untuk severe CAP
IDSA 20071
 Start parenteral antibiotic therapy ASAP after CAP considered likely
 Treat for a minimum of 5 days, afebrile for 48-72 h, and no more than 1
CAP-associated sign of clinical instability before discontinuation
 Longer duration may be needed if initial therapy not active against
the identified pathogen or if complicated by extrapulmonary infection

ERS/ECMID 20112
 Duration should generally not exceed 8 days in a responding patient
BTS 20093
 High severity, microbiologically undefined pneumonia requires 7-
10 days treatment
 May be extended to 14 or 21 days according to clinical judgment;
eg, if
S. aureus or Gram-negative enteric bacilli pneumonia suspected
or confirmed

1. Mandell LA, et al. Clin Infect Dis 2007;44 Suppl2:S27-72.

2. Woodhead M, et al. Clin Microbiol Infect 2011;17(Suppl. 6):E1–E59.
3. Lim WS, et al. Thorax 2009;64(Suppl3):iii1-55.
 Nosocomial Pneumonia
• HAP: Pneumonia that occurs 48 hours or more days after
hospitalization that was not incubating at the time of
hospitalization

• VAP: Pneumonia that occurs 48 hours after tracheal

intubation
 Faktor yang Meningkatkan Risiko HAP
Faktor Terkait Pasien Faktor Terkait Rumah Sakit dan Terapi
• Laki-laki • Kolonisasi mikroorganisme virulen di orofaring
• Usia ≥ 60 tahun • Riwayat pemberian antibiotik
• Malnutrisi • Kondisi tertentu yang dapat mencetuskan
• Penyakit akut dan kronik yang berat aspirasi pulmoner atau terhambatnya refleks batuk
• Imunosupresi
 Bedah torakoabdominal
• Perawatan di rumah sakit sebelumnya  Intubasi endotrakeal
• Luka bakar, trauma, pascabedah
 Pemasangan selang nasogastrik
• Derajat keparahan penyakit berdasarkan skor
 Tekanan pipa endotrakeal yang tidak adekuat
APACHE atau SAPS*
 Reintubasi berulang
• Acute respiratory distress syndrome
 Posisi terlentang
(ARDS)
 Pajanan terhadap peralatan respirasi yang
terkontaminasi

*APACHE (Acute Physiology and Chronic Health Evaluation); SAPS(Simplified Acute Physiology Score)

PDPI. Hospital Acquired Pneumonia (HAP) dan Ventilator Associated Pneumonia (VAP). 2018.
Faktor Risiko Patogen MDR
• Faktor risiko VAP MDR
– Penggunaan antibiotik iv sebelumnya dalam 90 hari terakhir
– Syok sepsis saat VAP
– ARDS
– Telah dirawat di RS >5 hari sebelum terjadi VAP
– Acute renal replacement therapy sebelum awitan VAP
• Faktor risiko HAP MDR
– Penggunaan antibiotik iv sebelumnya dalam 90 hari terakhir
• Faktor risiko HAP/VAP MRSA
– Penggunaan antibiotik iv sebelumnya dalam 90 hari terakhir
• Faktor risiko HAP/VAP Pseudomonas MDR
– Penggunaan antibiotik iv sebelumnya dalam 90 hari terakhir

1. ATS IDSA. Management of Adults with HAP/VAP. 2016;63(5):575-82.

2. PDPI. Hospital Acquired Pneumonia (HAP) dan Ventilator Associated Pneumonia (VAP). 2018.
Recommended Initial Empiric Antibiotic Therapy for
HAP (Non-VAP)
Depend on :
1. Not at High Risk of Mortality and no Factors Increasing the likelihood of MRSA
2. Not at High Risk of Mortality but with Factors Increasing the likelihood of MRSA
3. High Risk of Mortality or Receipt of Intravenous Antibiotics During the Prior 90 d

ATS IDSA. Management of Adults with HAP/VAP. 2016;63(5):575-82.

Risk of Mortality
• Need for ventilatory support due to pneumonia
• Septic shock

ATS IDSA. Management of Adults with HAP/VAP. 2016;63(5):575-82.

Factors Increasing the likelihood of MRSA
• Intravenous antibiotic treatment during the prior 90 days, and
• Treatment in a unit where the prevalence of MRSA among S. aureus isolates is not
known, or
• Treatment in a unit where the prevalence of MRSA among S. aureus isolates is >20%.

ATS IDSA. Management of Adults with HAP/VAP. 2016;63(5):575-82.

 HAP

RISK OF MORTALITY (-) RISK OF MORTALITY (-) RISK OF MORTALITY (+)

RISK FACTORS OF MRSA (-) RISK FACTORS OF MRSA (+) RISK FACTORS OF MRSA (+)

Piperacillin tazobactam 4.5 g IV q6 h Piperacillin tazobactam 4.5 g IV q6 h Piperacillin tazobactam 4.5 g IV q6 h

Or Or Or
Cefepim 2 g IV Cefepim 2 g IV q8h
Cefepim 2 g IV q8h Or
q8h
Imipenem 500 mg IV q6h
Or
Or Meropenem 1 g IV 8h
Levofloxacin 750
IV daily Levofloxacin 750
Or Plus
IV daily
Imipenem 500 mg IV q6h Or
Meropenem 1 g IV q8h Levofloxacin 750 IV daily
Ciprofloxacin 400
Ciprofloxacin 400 mgIV q8h
mg IV q8h
Or Or
Amikacin 15-20 mg/kg IV daily
Imipenem 500 mg IV q6h Gentamisin 5-7 mg/kg IV daily
Meropenem 1 g IV 8h Tobramycine 5-7 mg/kg IV daily
t
Plus Plus
Vancomycine 15 mg/kg IV q8-12h
Or Vancomycine 15 mg/kg IV q8-12h
Lineezolid 600 mg IV q12h Or
Linezolid 600 mg IV q12h

ATS IDSA. Management of Adults with HAP/VAP. 2016;63(5):575-82.

 VAP
Prior intravenous antibiotic use within 90 d*
Septic shock at time of VAP
ARDS preceding VAP
≥ 5 days of hospitalization prior to the occurrence of VAP
Acute renal replacement therapy prior to VAP onset

Yes No

Double antipseudomonal antibiotics Mono

from different classes Plus (if*) antipseudomonal
Vancomycine/Linezolide antibiotic
ATS/IDSA 2016, Suggested therapy for VAP

ATS IDSA. Management of Adults with HAP/VAP. 2016;63(5):575-82.

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