Sepsis et Causa CAP

Oleh:
Christie Nur Andani
03-062

OBJECTIVES
Untuk mendiskusikan sepsis ec CAP
Mendiskusikan mengenai definisi,
etiologi, signs and
symptoms,patofisiologi, diagnostic
CAP
Mendiskusikan terapi pasien sepsis,
CAP

GENERAL DATA
Ny. MS
84 thn
Perempuan
Menikah
tidak bekerja
Islam
Jl.Komplek Polri Pengadegan Rt 006
Rw 03 blok o/73

Keluhan Utama
sesak 30 menit SMRS

Keluhan Tambahan

lemas,batuk tidak dapat

mengeluarkan dahak

HISTORY OF PRESENT
ILLNESS
I minggu
SMRS

Pasien mengeluh demam

hilang timbul,batuk
berdahak,tetapi pasien
susah mengeluarkan dahak.
Pasien tidak berobat ke
dokter

HISTORY OF PRESENT
ILLNESS
1 hari
SMRS

1 malam SMRS, pasien

mulai ada sesak dan
semakin sesak beberapa
jam SMRS.
Oleh keluarga di bawa ke
UGD RS Tebet, lalu
dianjurkan dirawat

Anamnesa Sistem
General: (-) Loss of Consciousness,
(-) Weight Gain, (-) Anorexia, (-) altered sleeping habits,
(+) Dizziness
Kulit: purpura (-), petechae (+) , pruritus(-), pucat (-),
jaundice (-)
Telinga: gangguan pendengaran (-), tinnitus(-),
vertigo (-), infeksi (-), sekret (-)
Hidung and sinus: epistaksis (-), napas cuping hidung
(-), sinus (-)
Mulut dan Tenggorok: sakit tenggorokan dan lesi
pada mulut (-)
Leher: benjolan (-), KGB tidak teraba, nyeri pada leher
(-)
Respiratori: batuk (+) , pilek (-)
Cardiovascular: orthopnea (-), mudah lelah (-), nyeri
dada (-), takikardi (-), sesak (+)

Anamnesa Sistem
Genitourinaria: dysuria (-), oliguria (-), hematuria (-)
Vaskularisasi perifer : kram (-) , varises vena (-) ,
kaludikasi (-), trombophlebitis (-)
Hematologik: kecenderungan berdarah (-) , mudah
memar (-), reaksi transfusi (-)
Musculoskeletal: nyeri otot (-), nyeri bahu (-),
bengkak atau kaku (-), gerakan atau aktivitas terbatas
(-), nyeri sendi (-)
Neuropsychiatric: paralisis/paresis (-), kehilangan
sensasi (-), insomnia (-), ansietas (-), keinginan bunuh
diri (-)
Endokrin: intoleransi panas atau dingin (-), polidipsi
(-), poliuria (-), poliphagia (-), poliuria (-)

Riwayat Penyakit Dahulu

Riwayat
Riwayat
Riwayat
Riwayat

hipertensi (+)
DM (+)
asma disangkal
alergi disangkal.

Riwayat Penyakit
Keluarga
DM disangkal
Hipertensi disangkal
Alergi disangkal

Riwayat Sosial

Merokok disangkal
Minum minuman beralkohol
disangkal
Olahraga disangkal
Minum jamu-jamuan disangkal

Pemeriksaan Fisik
Status generalis
KU : Tampak sakit sedang
Kesadaran : Compos mentis
Tanda-tanda vital
TD : 146/107 mmHg , HR: 110x/menit , RR : 30x/mnt
TB:155 cm BB : 35kg BBI:49,5, BMI: 13,735
Kalori basal : 1237,5 kal
Koreksi kalori: 50%
Kalori: 1856,25 kal
Kulit
turgor baik,
petechie(-) ,cappilary refill>2

Pemeriksaan Fisik
Mata: konjungtiva hiperemis -/ -, sklera ikterik -/-,
pupil isokor diameter 3 mm refleks cahaya langsung
dan tidak langsung +/+
Telinga: membran timpani intak/intak
Hidung: septum nasal dalam batas normal dan tidak
ada deviasi, mukosa hidung merah muda tidak ada
sekret
Mulut dan lidah: mukosa bibir lembab, mukosa
bukal dalam batas normal, mukosa lidah pucat
Leher:Tidak ada limfadenopati servical, JVP 5-4
cmH2O

Pemeriksaan Fisik
Thoraks/pulmo
I: pergerakan dinding dada simetris, tidak
ada deformitas.
P:Vocal fremitus tidak dapat dinilai
P:Sonor kanan dan kiri
A:BND Vesikular, Ronki basah kasar (+/+),
Wheezing (-/-)
Cardiovascular
Denyut jantung normal 80 x/menit
dengan ritme reguler, gallop (-), murmur (-)

Pemeriksaan Fisik
Abdomen
I: Perut tampak datar,tampak jaringan parut
(-) A:Bising usus (+) normoaktif.
P:Supel, nyeri tekan epigastirum (-),hepar
dan lien tidak teraba membesar, ballotement
-/-.
P:Tympani,Nyeri ketok(-), CVA -/ Ekstremitas
Pitting edema (-), sianosis (-), pulsasi kuat
angkat dan equal, petechiae (-)
Genitourinaria tidak diperiksa

SALIENT FEATURES
Pasien mengeluh demam hilang timbul,batuk
berdahak,tetapi pasien susah mengeluarkan dahak.
1 malam SMRS, pasien mulai ada sesak dan
semakin sesak beberapa jam SMRS.
TD : 146/107 mmHg , HR: 110x/menit , RR : 30x/mnt
TB:155 cm BB : 35kg BBI:49,5, BMI: 13,735
Thoraks/pulmo
I: pergerakan dinding dada simetris, tidak ada
deformitas.
P:Vocal fremitus tidak dapat dinilai
P:Sonor kanan dan kiri
A:BND Vesikular, Ronki basah kasar (+/+),
Wheezing (-/-)

ADMITTING IMPRESSION
Sepsis ec Pneumonia

DIFFERENTIAL
DIAGNOSIS

TBC
Bronkhitis

lab

9/4/2010

Hb

12,20

Leukosit

23,80

LED

103

B/E/B/S/L/M

1/0/0/86/9/4

Ht

34,9

Eritrosit

4,19

Retikulosit
Trombosit

334

MCV

83,2

MCH

29,1

MCHV

35

10/4/2010

lab

9/4/2010

SGOT

68

SGPT

24

CPK

49

CKMB

19.2

10/4/2010

11/4/2010

Kolesterol
total

133

Trigliserida

74

HDL

43.6

LDL

74.1

12/4/2010

lab

9/4/2010

11/4/2010

12/4/2010

AGD: pH

7.388

7.515

7.48

pCO2

43.60

32.40

34.30

PO2

267.00

120.10

95.10

SO2

97.80

97.10

98.20

Hct

25

26

Hb

8.3

8.8

12.2

Suhu

36

37

36.00

1.40

3.2

2.00

2.00

4.10

3.00

26.20

28.10

27.10

26.80

26.40

26.00

St asam
basa:Beecf
Beb
SBC

lab

9/4/20
10

10/4/2
010

Mikrobiolo
gi BTA

11/4/201
0

12/4/2010

HBA1C

4,8

GDS

294

Na

145

142

4.23

4.55

Cl

104

101.0

Trop T

0.01

BUN

16

kreatinin

16
1.18

253

93

89

lab

9/4/2010j
amur

12/4/2010

pH urin

BJ

1.025

1.015

Protein

++

Reduksi

Bilirubin

Urobilinoge 0.2
n

0.2

Keton

Leu/LPB

1-2

4-5

Eri/LPB

35-40

10-11

Silinder

Epitel

1-2

2-3

Bakteri

Kristal

Sedimen :

Trichomona -

Tanggal 9 April 2010

Pukul 17.45
Os pindahan dari IGD dengan infeksi paru + sesak nafas
Rencana intubasi,riwayat batuk dahak>>>
Keadaan umum: tampak sakit sedang
Kesadaran : compos mentis
TD : 146/107 mmHg , HR: 110x/menit , RR : 30x/mnt
Apatis
S O2 : 80-83% afebris
(O2 nasal 4 Lpm)
I: pergerakan dinding dada simetris
P: Vf sulit dinilai
P: sonor kanan= kiri
A: Bnd vesikular , ronkhi +/+, whezing-/bj I,II N, murmur, gallop(-)

 Intubasi 7 ujung ETT 2, penyulit (-), midazolam

2,5 mg
Pasang NGT,penyulit(-)
SpO2 meningkat:100%
Sesak napas +/+ simetris
Ventilator SIMV 12x350ml, PEEP 5, fiO2 100
A: 1. CAP pada PPOK
2. demensia
3. parkinson

 P : - meropenem 1 gram iv bolus

lanjut 4x500mg iv
Diet cair bertahap 6x50cc
Triofusin 500 II/24 jam + RL II/24jam
OMZ 1x1 a iv
Flumucyl 3x1
Nebulizer 3x/hari k/p
ventolin : NaCl 1:1

Pukul 18.35
Tekanan darah menurun 46/31 mmHg
Loading RL loss
PEEP 3
Tekanan darah 63/42 mmHg
Lanjut loading
Tekanan darah 100/83
Pukul 19.15 fiO2 80%: Sp O2 100%
Loading RL total 1500 cc
Bila td menurun berikan dobutamin
Tekanan darah : 94/62, HR ; 76, RR: 12

Pukul 21.25: TD: 108/57, N: 72, RR :12, SpO2:100%

SIMV 12x350ml/PEEP 3/fiO2 40%

Follow up hari 1
10/4/2010
Masalah:
1. os masih dalam ventilator
2. leukositosis
3. GDS meningkat
4. kesadaran somnolent
5. EKG : inferolateral wall iskemia, poor R wave V1-V3, VES
S: O: Keadaan umum : tampak sakit sedang
Kesadaran : compos Mentis
TD: 126/74, N: 74, R= on ventilator, S: 37
sat O2: 100%
Pemeriksaan fisik:
Mata: konjungtiva tidak anemis, sklera tidak ikterik
Leher: JVP tidak meningkat
thoraks:
I: pergerakan dinding dada simetris
P: Vf sulit dinilai
P: sonor kanan= kiri
A: Bnd vesikular , ronkhi basah kasar +/+, whezing-/bj I,II N, murmur, gallop(-)

(+)

Abdomen:
I: perut tampak datar.
A: normoaktif 3X/menit.
P: supel, nyeri tekan (-),hepar dan lien tidak teraba
P: tympani, nyeri ketuk(-).
Exremitas:
akral hangat, edema (-)
Balance cairan: 600cc
A: - sepsis ec CAP on ventilator
- PPOK
- Parkinson disease

Alzheimer
- DM tipe 2

IVFD : - triofusin E 1000habis stop

Diet: DM 1500 kal (6x250 kal a 100cc) sonde saring
Total cairan : 2000cc/24 jam
- Haes 6% I
- RL I
Meropenem 4x500
Flumucyl 3x1sach
OBH 3x1C
OMZ iv 1x1 flc
Nebu(4x/hari):ventolin 1cc, bisolvon 1cc, nael 1cc
Insulin sliding scale kelipatan 3

Follow up hari 2
11 /4/ 2010
Masalah:

1. sepsis ec CAP
2. DM tipe2
3. proteinuria dan hematuria
4. Ronki basah positif
O: Keadaan umum : tampak sakit sedang
Kesadaran : compos Mentis
TD: 119/73, N: 74, S: 36,2
sat O2: 100%
Pemeriksaan fisik:

thoraks:
I: pergerakan dinding dada simetris
P: Vf sulit dinilai
P: sonor kanan= kiri
A: Bnd vesikular , ronkhi basah kasar +/+, whezing-/bj I,II N, murmur, gallop(-)

Abdomen:
I: perut tampak datar.
A: normoaktif 3X/menit.
P: supel, nyeri tekan (-),hepar dan lien tidak teraba
P: tympani, nyeri ketuk(-).
Exremitas:
akral hangat, edema (-)
Balance cairan: -200cc
A: - sepsis ec CAP
- PPOK
- Parkinson disease
- Alzheimer
- DM tipe 2

P : Diet : DM 1500 kalori (6x250kal a 100cc) sonde saring

Total cairan : 2000 cc/24 jam
Meronem 4x500
Flumucyl 3x1sach
OBH 3x1C
OMZ iv 1x1 flc
Neurobion inj 1x1a
Nebu(4x/hari):ventolin 1cc, bisolvon 1cc, nael 1cc

Follow up hari 3
12/4/ 2010
Masalah:

1.
2.
3.
4.
5.
6.

os dengan Tpiece + O2 6 Lpm

dahak>>
leukositosis
GDS meningkat
Ronki basah positif
Hematuria

S:
O: Keadaan umum : tampak sakit sedang
Kesadaran : compos Mentis
TD: 132/84, N: 82, R: 18, S: 36,7
sat O2: 100%
Pemeriksaan fisik:

thoraks:
I: pergerakan dinding dada simetris
P: Vf sulit dinilai
P: sonor kanan= kiri
A: Bnd vesikular , ronkhi basah kasar +, whezing-/bj I,II N, murmur, gallop(-)

Abdomen:
I: perut tampak datar.
A: normoaktif 4X/menit.
P: supel, nyeri tekan (-),hepar dan lien tidak teraba
P: tympani, nyeri ketuk(-).
Exremitas:
akral hangat, edema (-)
Balance cairan: -400cc
A: - sepsis ec CAP mT piece
- PPOK
- HHD
- Parkinson disease
- Alzheimer
- DM tipe 2

P : - Tpiece + O2 6 Lpm
- IVFD : - HAES 5%
- RL + 1a neurobion 5000
Meronem 4x500
Flumucyl 3x1sach
OBH 3x1C
Nebu(4x/hari):ventolin 1cc, bisolvon 1cc, nael 1cc
Nebu(4x/hari): bisolvon 1c, combivent1c,NaCl
Diet : DM 1800 kalori (6x300kal a 150cc) sonde saring
Total cairan : 2000 cc/24 jam
Rencana: menunggu hasil sputum MD BTA II dan III, px HBA1C
dan urine lenkap hari ini, rencana extubasi sore bila astrup baik
Jam 1300: extubasi besok, th teruskan

Follow up hari 4
13/4/ 2010
Masalah:

1.
2.
3.
4.
5.
6.

sepsis ec CAP on T piece

PPOK
HHD
Parkinson Disease
Alzheimer
DM tipe 2

S: slem (+), post suction os tenang

O: Keadaan umum : tampak sakit sedang
Kesadaran : compos Mentis
TD: 114/60, N:80, R: 20, S: 36
sat O2: 100% dengan Tpiece
Pemeriksaan fisik:

thoraks:
I: pergerakan dinding dada simetris
P: Vf sulit dinilai
P: sonor kanan= kiri
A: Bnd vesikular , ronkhi -/-, whezing-/bj I,II N, murmur, gallop(-)

Exremitas:
akral hangat, edema (-)
Balance cairan: -400cc
A: - sepsis ec CAP mT piece
- PPOK
- Parkinson disease
- Alzheimer
- DM tipe 2
P : - Tpiece + O2 6 Lpm
- IVFD : - HAES 5%
- RL + 1a neurobion 5000
Diet : DM 1800 kalori (6x300kal a 150cc) sonde
saring
Rencana: extubasi AGD:7,46/35,8/101/2,6/26/98,2

Follow up hari 6
15/4/ 2010
S: BAB +, BAK +, Batuk +
O: Keadaan umum : tampak sakit berat
Kesadaran : apatis
TD: 120/70, N:808 R: 206 S: 36 ,3
Pemeriksaan fisik:
Mata : CA +/+, SI -/-

thoraks:
I: pergerakan dinding dada simetris
P: Vf sulit dinilai
P: sonor kanan= kiri
A: Bnd vesikular , ronkhi -/-, whezing-/bj I,II N, murmur, gallop(-)
Abdomen: hepar dan lien tidak membesar, BU +, NT
Ekstremitas : akral hangat, edema-/-

A: 1. sepsis ec CAP
2. PPOK
3. HHD
4. parkinson
5. alzheimer
6.DM tipe 2
P : O2 3L/mnt
IVFD 1kolf RL+1a neurobion/24jam
Diet=DM 2500 kal
MM: OMZ 1x1
OBH 5mg 3x1
Flumucyl 3x1sach
Nebu: combivent,bisolvon, NaCl (4x/hari) , Pulmicort 2x/hari
Ciprofloxacin drip 2x200mg

16/4/2010

0010: kondisi os jelek

00.15: evaluasi os, napas tidak adekuat, pulse lemah,
soporokoma
Rencana intubasi dan pindah ICU
Mulai RJP: adrenalin 1mg IV, intubasi ETT 7, slem+++
Intubasi terpasang, lanjut RJP: pulse hilang timbul
Total adrenalin 5a/1mg
SA 4a/1mg
Lanjut RJP
Pulse -, napas spontan -,pupil midriasis lemah
00.40: gagal napas

Sepsis

Definisi
Systemic Inflammatory Response Syndrome :
Pasien yang memiliki 2 atau lebih kriteria
sebagai berikut :
Suhu> 38C atau < 36C
Denyut jantung > 90 x/menit
Respirasi > 24 x/menit atau Pa CO2 < 32
mmHg
Hitung leukosit > 12000/mm3 atau <
4000/mm3 atau > 10% sel imatur (band)

 Sepsis adalah SIRS dengan pembuktian

ataupun suspect dari etiologi mikrobial.
Sepsis berat : sepsis yang berkaitan dengan
disfungsi organ, kelainan hipoperfusi(asidosis
laktat, oliguria, perubahan akut pada status
mental), atau hipotensi.
Bakteremia : terdapat bakteri di dalam
darah, yang didukung oleh kultur darah yang
positif
Septikemia : terdapat mikroba ata toksinnya
di dalam darah

Sepsis berat
Kardiovaskular: tekanan darah sistolik 90mmHg
atau mean arterial pressure 70 mmHg yang
membutuhkan cairan IV.
Renal: output urine < 0,5 mL/kg per jam walaupun
dengan resusitasi cairan yang adekuat
Respirasi: PaO2/FIO2 250, atau if the lung is the only
dysfunctional organ, 200
Hematologi : platelet count <80000/mikroL atau 50%
penurunan platelet count selama 3 hari
Unexplained metabolic asidosis: pH 7.30 atau base
defisit 5.0 mEq/L dan plasma lactate level >1.5 kali
di atas normal
Resusitasi cairan yang adekuat: pulmonary artery
wedge pressure 12mmHg atau CVP 8 mmHg

 Septik shock : sepsis dengan

hipotensi( tekanan darah arteri < 90
mmHg sistolik, atau 40mmHg kurangnya
dari pasien normal) selama 1 jam walaupun
sudah diberi terapi cairan resusitasi
adekuat.
Atau
Membutuhkan vasopresor untuk
mengontrol tekanan darah arteri 90
mmHg atau mean arterial pressure
70mmHg.

 Refractory septic shock : septik shock

yang terjadi lebi dari 1 jam dan tidak
berespon dengan cairan ataupun
pressor.
Multiple organ dysfunction syndrome
(MODS) : disfungsi lebih dari satu
organ, yang dibutuhkan untuk
maintain homeostasis

Patogenesis
endothelial injury , fluid
extravasation
Culprit cytokines, increase TNF alpha,
interleukin 1B dan 8

Diagnosis
There is no specific diagnostic test
for the septic response
Diagnostically sensitive findings in a
patient with suspected or proven
infection include fever or
hypothermia, tachypnea,
tachycardia, and leukocytosis or
leukopenia

Manifestasi klinis
hiperventilasi :sering muncul pada awal
sepsis, disorientasi, bingung.
Hipotensi dan DIC
Cellulitis, pustul,bullae, lesi hemoragik:
pada bakteri hematogenous dan jamur
yang ada di jaringan lunak
Purpura/petechiae cutaneus infeksi
neisseria meningitidis
Manifestasi GI tract: nausea, vomitus,
diare, ileus

laboratorium
Sepsis awal: leukositosis dengan shift to the
left, trombositopenia, hiperbilirubinemia,
proteinuria, leukopenia. Hiperventilasi
menimbulkan alkalosis respiratori.
Selanjutnya : trombositopenia memburuk
disertai perpanjangan waktu trombin,
penurunan fibrinogen, dan keberadaan d
dimer yang menunjukkan DIC. Azotemia dan
hiperbilirubinemia
meningkat,aminotranferase meningkat,
asidosis metabolik terjadi setelah alkalosis
respiratorikhiperglikemia diabetik dapat
menimbulkan diabetik

Komplikasi
ARDS ( Adult Respiratory Disease
Syndrom)
Koagulasi intravaskular Diseminata
Gagal ginjal akut
Perdarahan usus
Gagal hati
Disfungsi sistem saraf pusat
Gagal jantung
Kematian

Pengobatan
Antimicrobial Agents
Antimicrobial chemotherapy should be
initiated as soon as samples of blood and
other relevant sites have been cultured
Removal of the Source of Infection

Hemodynamic, Respiratory, and Metabolic Support

to restore adequate oxygen and substrate delivery to the
tissues. Initial management of hypotension should include
the administration of IV fluids, typically beginning with 12
L of normal saline over 12 h. To avoid pulmonary edema,
the pulmonary capillary wedge pressure should be
maintained at 1216 mmHg or the central venous pressure
at 812 cm H2O. The urine output rate should be kept at
>0.5 mL/kg per hour by continuing fluid administration
a reasonable goal is to maintain a mean arterial blood
pressure of >65 mmHg (systolic pressure, >90 mmHg) and
a cardiac index of 4 L/min per m2

 Immunocompetent adult
The many acceptable regimens include (1) ceftriaxone
(2 g q24h) orticarcillin-clavulanate (3.1 g q46h)
orpiperacillin-tazobactam (3.375 g q46h); (2)
imipenem-cilastatin (0.5 g q6h) ormeropenem (1 g
q8h) orcefepime (2 g q12h).
Gentamicinortobramycin (57 mg/kg q24h) may be
addedto either regimen. If the patient is allergic to
-lactam agents, use ciprofloxacin (400 mg q12h)
orlevofloxacin (500750 mg q12h) plusclindamycin
(600 mg q8h). If the institution or the community has a
high prevalence of MRSA isolates, add vancomycin (15
mg/kg q12h) to each of the above regimens.

Neutropeniaa (<500 neutrophils/L)

Regimens include (1) imipenem-cilastatin (0.5 g q6h)
ormeropenem (1 g q8h) orcefepime (2 g q8h); (2)
ticarcillin-clavulanate (3.1 g q4h) orpiperacillin-tazobactam
(3.375 g q4h) plustobramycin (57 mg/kg q24h).
Vancomycin (15 mg/kg q12h) should be added if the patient
has an infected vascular catheter, if staphylococci are
suspected, if the patient has received quinolone
prophylaxis, if the patient has received intensive
chemotherapy that produces mucosal damage

Splenectomy
Cefotaxime (2 g q68h) orceftriaxone (2 g
q12h) should be used. If the local
prevalence of cephalosporin-resistant
pneumococci is high, addvancomycin. If
the patient is allergic to -lactam drugs,
vancomycin (15 mg/kg q12h)
plusciprofloxacin (400 mg q12h)
orlevofloxacin (750 mg q12h)
oraztreonam (2 g q8h) should be used.

 IV drug user
Nafcillin or oxacillin (2 g q8h)
plusgentamicin (57 mg/kg q24h). If
the local prevalence of MRSA is high
or if the patient is allergic to -lactam
drugs, vancomycin (15 mg/kg q12h)
with gentamicin should be used.

 AIDS
Cefepime (2 g q8h), ticarcillin-clavulanate
(3.1 g q4h), orpiperacillin-tazobactam
(3.375 g q4h) plustobramycin (57 mg/kg
q24h) should be used. If the patient is
allergic to -lactam drugs, ciprofloxacin
(400 mg q12h) orlevofloxacin (750 mg
q12h) plusvancomycin (15 mg/kg q12h)
plustobramycin should be used

 General Support
Other Measures

Obat sesuai sumber sepsis

Pneumonia dapatan komunitas : seftriakson atau sefepim
diberikan dengan aminoglikosida
Pneumonia nosokomial : sefipim atau iminem silastatin
dan aminoglikosida
Infeksi abdomen nosokomial : imipenem silastatin dan
aminoglikosida atau pipersilin tazobaktam dan
amfoterisin B.
Kulit/ jaringan lunak: vankomisin dan im ipenem silastatin
atau piperasilin tazobaktam
Infeksi traktus urinarius : siprofloxacin dan aminoglikosida
Infeksi traktus urinarius nosokomial: vankomisin dan
sefipim
Infeksi SSp : vankomisin dan sefalosporin generasi ketiga
atau meropenem
Infeksi SSP nosokomial: meropenem dan vankomisin

Prognosis
Approximately 2035% of patients with
severe sepsis and 4060% of patients
with septic shock die within 30 days.
Others die within the ensuing 6 months.
Late deaths often result from poorly
controlled infection, immunosuppression,
complications of intensive care, failure of
multiple organs, or the patient's
underlying disease.

Prevention
by limiting the use (and duration of
use) of indwelling vascular and
bladder catheters, by reducing the
incidence and duration of profound
neutropenia (<500 neutrophils/L),
and by more aggressively treating
localized nosocomial infections.

Empiric Management
of Community
Acquired Pneumonia:
the 2001 ATS
Consensus Guidelines

PNEUMONIA
Infection of the lung parenchyma
that can be cause by bacteria,
viruses, fungi, and parasites
Non-infectious causes include
aspirated food, gastric acid, foreign
bodies; hypersensitivity reactions;
drug and radiation-induced

Community Acquired
Pneumonia
Is a lower respiratory tract infection
acquired in the community within 24
hours to less than 2 weeks.
Acute infection of the pulmonary
parenchyma accompanied by
symptoms of acute illness
accompanied by abnormal chest
findings.

Etiology
Streptococcus Pneumonia
- most frequent organism isolated in
community acquired pneumonia in both
immunocompetent and immunocompromised
individuals
H. Influenzae
Staphylococus Aureus
Mycoplasma Pneumoniae
Others

Pathophysiology
How do pulmonary pathogens reach
the lungs?
Direct inhalation of infectious
respiratory droplets
Aspiration of oropharyngeal contents
Direct spread along the mucosal
membrane surface from the upper to
the lower respiratory system
Hematogenous spread

Pathology
Lobar
Pneumonia

Streptococcus
pneumonia

Intraalveolar exudate
resulting in consolidation.
Entire lobe

Bronchopneu
monia

S.Aureus, H.
influenzae, K.
pneumoniae, S.
pyogenes

Acute inflammatory
infiltrates extending from
bronchioles into adjacent
alveoli
Patchy distribution
involving one or more
lobes

Interstitial
Pneumonia

Viruses,
mycoplasma
pneumoniae

Diffuse, patchy, localized

to interstitial areas of
alveolar walls
One or more lobes

Clinical Manifestations:
Fever, cough, pleuritic chest pain,
chills and shortness of breath
Physical examination:
- tachypnea
- dullness to percussion
- increased tactile and vocal fremitus
- crackles

The diagnosis of Pneumonia based

on physical examination has a
sensitivity of 47 to 69% and a
specificity of 58 to 75%; thus a
clinical diagnosis should be
confirmed by CXR

What is the value of Chest radiograph

in the diagnosis of CAP?

For diagnostic certainty

Chest X Ray is also essential in
assessing severity of disease and in
prognostication
It may suggest possible etiology and
help differentiate pneumonia from
other conditions

Diagnostics:

CBC
Blood Culture
Sputum Gram stain
Sputum Culture
Serology
Polymerase Chain Reaction

Patient Stratification
Outpatients with no history of cardiopulmonary
disease and no modifying factors
II. Outpatients with cardiopulmonary disease and/or
other modifying factors (risk factors for DRSP or
Gram negative bacteria)
III.Inpatients, not admitted to the ICU, who have the
following:
a. Cardiopulmonary disease and/or other modifying
factors (including being from a nursing home)
b. No cardiopulmonary disease, and no other
modifying factors
IV. ICU admitted patients who have the following:
a. No risks for Pseudomonas Aeruginosa
b. Risks for Pseudomonas Aeruginosa
I.

Determining factors to hospitalize the

patient

>65y/o
Presence of coexisting illnesses
History of hospitalization within the past year
Physical Exam:
RR>30, DBP <60/SBP <90, pulse >125, fever <35 or
>40C, decreased levels of consciousness
Labs:
WBC <4 or >30
PaO2 <60 or PaCo2 >50
Crea >1.2mg/dl, BUN >20mg/dl
CXR
HCT <30%, Hgb <9mg/dl
Sepsis or organ dysfuntion
Arterial PH< 7.35

Criteria in admitting to ICU

a.
b.

a.
b.
c.

Major Criteria
Need for mechanical ventilation
Septic shock
Minor Criteria
SBP <90
Multilobar disease
PaO2/Fio2 <250

How do we assess response to

initial Rx ?

Most patients w/ uncomplicated

bacterial pneumonia will respond to
treatment within 24-72 hrs
fever declines w/in 72 hrs;
temperature normalizes within 5 days
respiratory signs, esp. tachypnea,
return to normal

A follow-up CXR is NOT necessary to confirm

that infiltrate has cleared for low-risk CAP
patients

When to switch to Oral

Therapy?
Patients should be switched to oral
therapy if they meet four criteria:
improvement in cough and dyspnea,
afebrile on two occasions 8 h apart,
white blood cell count decreasing,
functioning gastrointestinal tract with
adequate oral intake

Recommended Hospital Discharge

Criteria:
During the 24 hours before discharge,
the patient should have the following
characteristics:
1. Temp of 36 37.5 C
2. Pulse <100/min
3. RR 16 -24
4. Systolic BP > 90mm Hg
5. Blood Oxygen saturation > 90%
6. With a functioning gastrointestinal
tract

Empiric Management
of Community
Acquired Pneumonia:
the 2007 ATS/IDSA
Consensus Guidelines

IDSA/ATS Consensus
Guidelines on the
Management of CAP
Implementation of Guideline
Recommendations
Site of Care Decisions
Diagnostic Testing
Antibiotic Treatment
Other Treatment Considerations
Non Responding Pneumonia
Prevention

Implementation of
Guideline Recommendations
To improve process of care variables and relevant clinical outcomes (Level I)

ALL PATIENTS
Initiation of antibiotic
therapy
Antibiotic selection
Admission Decision Support
Assessment of
oxygentation
ICU Admission Support
Smoking cessation
Immunizations

INPATIENTS
Diagnostic studies
Prophylaxis against VTE
Early mobilization
Thoracentesis for patients
with significan
parapneumonic effusions
Discharge decision
support
Patient education

Site of Care Decisions

HOSPITAL ADMISSION
DECISION
Severity-Of-Illness
Scores (Level I)
Physician
Determination of
Subjective Factors
(Level 2)
CURB 65 >2:
hospitalize (Level
3)

ICU ADMISSION
DECISION
Direct to ICU: Septic
shock, Acute
Respiratory Failure
(Level 2)
ICU or high level
monitoring unit if w/
3 of the minor criteria
or severe CAP. (Level
2)

CURB-65 AND CRB-65 SEVERITY SCORES

FOR COMMUNITY-ACQUIRED PNEUMONIA

Criteria For Severe CAP

Major criteria (any one)

Invasive mechanical ventilation

Septic shock with the need for vasopressors

Minor criteria (3 or
more)

Leukopenia (WBC < 4,000 / mm3)

Thrombocytopenia (<100,000 /

Respiratory rate >30 /min

mm3)
PaO2/FiO2 ratio < 250
Hypothermia (core temp, < 36C)
Multi-lobar infiltrates
Confusion/disorientation Hypotension requiring aggressive
fluid resuscitation
Uremia (BUN level, 20
mg/dL)

Diagnostic Testing
Presence of select clinical features:
Cough, fever, sputum production, pleuritic
chest pain

PE of rales/bronchial breath sounds are

helpful but less specific than CXR
Supported by Lung Imaging (e.g., CXR)
(Level 3)
If initially negative but w/ strong suspicion,
treat presumptively and rpt CXR in 24-48h

Screening with pulse oximetry

Modifiers Affecting CAP Bacteriology

Drug-Resistant Strepcoccus Pneumonia
Age > 65 yrs, -lactam Rx within 3 mos,
alcoholism, immune suppression (e.g. steroids),
multiple medical co-morbidities, exposure to child
in day care

Enteric Gram-negatives
Nursing home residence, underlying
cardiopulmonary disease, multiple medical comorbidities, recent ABT

Pseudomonas aeruginosa
Structural lung disease (bronchiectasis), CS (> 10
mg prednisone/day), broad-spectrum antibiotics
for > 7 days within the past month, malnutrition

ANTIBIOTIC
THERAPY
Outpatient
Previously Healthy
No recent
antibiotic

Inpatient (wards)

Co-morbidities

No Pseudomonas
Risk

-lactam
+
Azithro (L2) or
Resp FQ (L1)

Recent
antibiotic

Macrolide (L1)
OR
Doxycycline (L3)

ICU

Resp FQ
Alone (L1)
or
-lactam
(high dose) +
Macrolide (L1)

*PCN allergy:
Resp FQ +
aztreonam
CA-MRSA suspect

add
vancomycin or
linezolid

Pseudomonas Risk

Anti-pneumo,
anti- pseudo
-lactam*
+
Cipro/ Levo
(750 mg)
or
AminoG with
azithro or
Resp FQ
*Aztreonam if
PCN allergic

Criteria for CAP clinical

stability

Temperature <37.8C
Heart rate <100 beats/min
Respiratory rate <24 breaths/min
Systolic blood pressure >90 mm Hg
Arterial O2 sat >90% or pO2 >60 mm
Hg on room air
Normal mental status

Prevention
Annual inactivated influenza
vaccination
Pnemococcal polysaccharide
vaccination
Smoking cessation
Coordination with local health
department
Respiratory hygiene measures