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LAPORAN PENDAHULUAN PNEUMONIA

22.30 FARIDARAHMAWATI NO COMMENTS

A.

Pengertian
Pneumonia adalah peradangan pada paru-.paru dan bronkiolus yang disebabkan oleh bakteri,jamur ,virus, atau aspirasi karna makanan atau benda asing. Pneumonia adalah infeksi pada parenkim paru, biasanya berhubungan dengan pengisian cairan didalam alveoli hal ini terjadi akibat adanya infeksi agen/ infeksius atau adanya kondisi yang mengganggu tekanan saluran trakheabronkialis. Adapun beberapa keadaan yang mengganggu mekanisme pertahanan sehingga timbul infeksi paru misalnya, kesadaran menurun, umur tua, trakheastomi, pipa endotrakheal dan lain-lain. Dengan demikian flora endogen yang menjadi pathogen ketika memasuki saluran pernapasan.( gasrial, Pera!atan anak sakit, "##$%.

&.

'tiologi

&akteri ( streptococus pneumoniae, staphylococus aureus. )irus ( *nfluen+a, parainfluen+a, adenovirus ,amur ( -andidiasis, histoplasmosis, aspergifosis, coccidioido mycosis, cryptococosis, pneumocytis carini. Aspirasi ( .akanan, cairan, lambung. *nhalasi ( /acun atau bahan kimia, rokok, debu dan gas. Pneumonia virus bisa disebabkan oleh()irus sinsisial pernafasan, 0antavirus, )irus influen+a,)irus parainfluen+a,Adenovirus, /hinovirus, )irus herpes simpleks, .icoplasma (pada anak yang relatif besar% Pada bayi dan anak-anak penyebab yang paling sering adalah( )irus sinsisial pernafasan Adenovirus )irus parainfluen+a )irus influen+a.

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Patofisiologi
Pneumonia dapat terjadi akibat menghirup bibit penyakit di udara, atau kuman di tenggorokan terisap masuk ke paru-paru. Penyebaran bisa juga melalui darah dari luka di tempat lain, misalnya di kulit. ,ika melalui saluran napas, agen (bibit penyakit% yang masuk akan dila!an oleh berbagai sistem pertahanan tubuh manusia. .isalnya, dengan batuk-batuk, atau perla!anan oleh sel-sel pada lapisan lendir tenggorokan, hingga gerakan rambut-rambut halus (silia% untuk mengeluarkan mukus (lendir% tersebut keluar. 1entu itu semua tergantung besar kecilnya ukuran sang penyebab tersebut.

D.

.enifestasi 2linik

3ejala penyakit pneumonia biasanya didahului infeksi saluran nafas atas akut selama beberapa hari. 4elain didapatkan demam, menggigil, suhu tubuh meningkat dapat mencapai 56 derajat celsius, sesak nafas, nyeri dada, dan batuk dengan dahak kental, terkadang dapat ber!arna kuning hingga hijau. Pada sebagian penderita juga ditemui gejala lain seperti nyeri perut, kurang nafsu makan, dan sakit kepala. 1anda dan 3ejala berupa(&atuk nonproduktif, *ngus (nasal discharge%,4uara napas lemah, /etraksi intercosta, Penggunaan otot bantu nafas, Demam, /onchii, -yanosis, 7eukositosis, 1hora8 photo menunjukkan infiltrasi melebar, &atuk, 4akit kepala, 2ekakuan dan nyeri otot, 4esak nafas, .enggigil, &erkeringat, 7elah. 3ejala lainnya yang mungkin ditemukan( 2ulit yang lembab .ual dan muntah 2ekakuan sendi.

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2lasifikasi
.enurut buku Pneumonia 2omuniti, Pedoman Diagnosis dan Penatalaksanaan di *ndonesia yang dikeluarkan Perhimpunan Dokter Paru *ndonesia, 966: menyebutkan tiga klasifikasi pneumonia. &erdasarkan klinis dan epidemiologis( o Pneumonia komuniti (community-ac;uired pneumonia%. o Pneumonia nosokomial, (hospital-ac;uired pneumonia/nosocomial pneumonia%. o Pneumonia aspirasi. o Pneumonia pada penderita immunocompromised. &erdasarkan bakteri penyebab( o Pneumonia bakteri/tipikal. Dapat terjadi pada semua usia. Pneumonia bakterial sering diistilahkan dengan pneumonia akibat kuman. Pneumonia jenis itu bisa menyerang siapa saja, dari bayi hingga mereka yang telah lanjut usia. Para peminum alkohol, pasien yang terkebelakang mental, pasien pascaoperasi, orang yang menderita penyakit pernapasan lain atau infeksi virus adalah yang mempunyai sistem kekebalan tubuh rendah dan menjadi sangat rentan terhadap penyakit itu. Pada saat pertahanan tubuh menurun, misalnya karena penyakit, usia lanjut, dan malnutrisi, bakteri pneumonia akan dengan cepat berkembang biak dan merusak paru-paru. ,ika terjadi infeksi, sebagian jaringan dari lobus paru-paru, atau pun seluruh lobus, bahkan sebagian besar dari lima lobus paru-paru (tiga di paru-paru kanan, dan dua di paru-paru kiri% menjadi terisi cairan. Dari jaringan paru-paru, infeksi dengan cepat menyebar ke seluruh tubuh melalui peredaran darah. &akteri Pneumokokus adalah kuman yang paling umum sebagai penyebab pneumonia bakteri tersebut.3ejalanya &iasanya pneumonia bakteri itu

didahului dengan infeksi saluran napas yang ringan satu minggu sebelumnya. .isalnya, karena infeksi virus (flu%. *nfeksi virus pada saluran pernapasan dapat mengakibatkan pneumonia disebabkan mukus (cairan/lendir% yang mengandung pneumokokus dapat terisap masuk ke dalam paru-paru. &eberapa bakteri mempunyai tendensi menyerang seseorang yang peka, misalnya klebsiella pada penderita alkoholik, staphyllococcus pada penderita pasca infeksi influen+a. Pneumonia Atipikal. Disebabkan mycoplasma, legionella, dan chalamydia. o Pneumonia Akibat virus. Penyebab utama pneumonia virus adalah virus influen+a (bedakan dengan bakteri hemofilus influen+a yang bukan penyebab penyakit influen+a, tetapi bisa menyebabkan pneumonia juga%. 3ejalanya 3ejala a!al dari pneumonia akibat virus sama seperti gejala influen+a, yaitu demam, batuk kering, sakit kepala, nyeri otot, dan kelemahan. Dalam "9 hingga :< jam penderita menjadi sesak, batuk lebih parah, dan berlendir sedikit. 1erdapat panas tinggi disertai membirunya bibir. 1ipe pneumonia itu bisa ditumpangi dengan infeksi pneumonia karena bakteri. 0al itu yang disebut dengan superinfeksi bakterial. 4alah satu tanda terjadi superinfeksi bakterial adalah keluarnya lendir yang kental dan ber!arna hijau atau merah tua. o Pneumonia jamur, sering merupakan infeksi sekunder. Predileksi terutama pada penderita dengan daya tahan lemah (immunocompromised%. &erdasarkan predileksi infeksi( Pneumonia lobaris, pneumonia yang terjadi pada satu lobus (percabangan besar dari pohon bronkus% baik kanan maupun kiri. Pneumonia bronkopneumonia, pneumonia yang ditandai bercak-bercak infeksi pada berbagai tempat di paru. &isa kanan maupun kiri yang disebabkan virus atau bakteri dan sering terjadi pada bayi atau orang tua. Pada penderita pneumonia, kantong udara paru-paru penuh dengan nanah dan cairan yang lain. Dengan demikian, fungsi paru-paru, yaitu menyerap udara bersih (oksigen% dan mengeluarkan udara kotor menjadi terganggu. Akibatnya, tubuh menderita kekurangan oksigen dengan segala konsekuensinya, misalnya menjadi lebih mudah terinfeksi oleh bakteri lain (super infeksi% dan sebagainya. ,ika demikian keadaannya, tentu tambah sukar penyembuhannya. Penyebab penyakit pada kondisi demikian sudah beraneka macam dan bisa terjadi infeksi yang seluruh tubuh.

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Penatalaksanaan
Pengobatan diberikan berdasarkan etiologi dan uji resistensi tapi karena hal itu perlu !aktu dan pasien pneumonia diberikan terapi secepatnya ( Penicillin 3( untuk infeksi pneumonia staphylococcus. Amantadine, rimantadine( untuk infeksi pneumonia virus. 'ritromisin, tetrasiklin, derivat tetrasiklin( untuk infeksi pneumonia mikroplasma. .enganjurkan untuk tirah baring sampai infeksi menunjukkan tanda-tanda. Pemberian oksigen jika terjadi hipoksemia.

&ila terjadi gagal nafas, diberikan nutrisi dengan kalori yang cukup.

3.

Pemeriksaan Penunjang

". 4inar > ( mengidentifikasikan distribusi struktural (misal( lobar, bronchial%? dapat juga menyatakan abses%. 9. Pemeriksaan gram/kultur, sputum dan darah( untuk dapat mengidentifikasi semua organisme yang ada. :. Pemeriksaan serologi( membantu dalam membedakan diagnosis organisme khusus. 5. Pemeriksaan fungsi paru( untuk mengetahui paru-paru, menetapkan luas berat penyakit dan membantu diagnosis keadaan. @. &iopsi paru( untuk menetapkan diagnosis. <. 4pirometrik static( untuk mengkaji jumlah udara yang diaspirasi. $. &ronkostopi( untuk menetapkan diagnosis dan mengangkat benda asing.
LAPORAN PENDAHULUAN PNEUMONIA

a.

Definisi

Pneumonia adalah peradangan paru dimana asinus paru terisi cairan radang dengan atau tanpa disertai infiltrasi dari sel radang edalam dinding al!eoli dan rongga interstisium. "secara anatomis dapat tim#ul pneumonia lo#aris maupun lo#ularis $ #ronchopneumonia. Pneumonia merupa an salah satu pen%a it infe si saluran pernafasan %ang ter#an%a didapat an dan sering merupa an pen%e#a# ematian hampir di seluruh dunia. Di Indonesia #erdasar an sur!ei esehatan rumah tangga tahun &'() %ang dila u an Departemen *esehatan+ pneumonia tergolong dalam pen%a it infe si a ut saluran nafas+ merupa an pen%a it %ang #an%a di,umpai.

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-a tor.fa tor %ang men%e#a# an ter,adin%a pneumonia /

Di etahui #e#erapa fa tor %ang mempengaruhi ter,adin%a pneumonia %aitu / &. Me anisme pertahanan paru

Paru #erusaha untu mengeluar an #er#agai organisme %ang terhirup seperti parti el de#u dan #ahan.#ahan lainn%a %ang ter umpul di dalam paru. 0e#erapa #entu me anisme ini antara lain/ #entu anatomis saluran pernafasan+ refle #atu + s%stem mu osilier+ ,uga s%stem fagositosis %ang dila u an oleh sel.sel tertentu dengan mema an parti el.parti el %ang mencapai permu aan al!eoli. 0ila fungsi ini #er,alan #ai + ma a #ahan infe si %ang #ersifat infe sius dapat di eluar an dare saluran nafas+ sehingga pada orang sehat tida a an ter,adi infe si serius. Infe si saluran nafas #erulang ter,adi aa i#at #er#agai omponen s%stem pertahanan paru %ang tida #e er,a dengan #ai . 1. *olonisasi #a teri di saluran nafas

Di dalam saluran nafas atas #an%a #a teri %ang #ersifat osal. 0ila ,umlah mere a sema in mening at dan mencapai suatu onsentrasi %ang cu up+ uman ini emudian masu e saluran nafas #a2ah dan paru+ dan a i#at egagalan me anisme pem#ersihan saluran nafas eadaan ini a an #ermanifestasi se#agai pen%a it. Mi roorganisme %ang tida dapat menempel pada permu aan mu osa saluran nafas a an i ut dengan se resi saluran nafas dan ter#a2a #ersama me anisme pem#ersihan+ sehingga tida ter,adi olonisasi. Proses penempelan organisme pada permu aan mu osa saluran nafas tergantung dare s%stem pangemalan mi roorganisme terse#ut oleh sel eputel. 3. Pem#ersihan saluran nafas terhadap #ahan infe sius

4aluran nafas #a2ah dan paru #erulang ali dimasu i oleh #er#agai mi roorganisme dare saluran nafas atas+ a an tetapi tida menim#ul an sa it+ ini menin,u an adan%a suatu me anisme pertahanan paru %ang efisien sehingga dapat men%apu #ersih mi roorganisme se#elum mere a #ermultipli asi dan menim#ul an pen%a it. Pertahanan paru terhadap hal.hal %ang #er#aha%a dan infe sius #erupa refle #atu + pen%empitan saluran nafas dengan ontra si otot polos #ron us pada a2al ter,adin%a proses peradangan+ ,uga di#antu oleh respon imunitas humoral.

c.

Etiologin%a

4e#agian #esar dise#a# an oleh mi roorganisme+ a an tetapi dapat ,uga oleh #ahan.#ahan lain+ sehingga di enal/ &. 1. Lipid pneumonia / oleh arena aspirasi min%a mineral 5hemical pneumonitis / inhalasi #ahan.#ahan organic atau uap imia seperti #erilium

3. E6trinsi Allergi Al!eolitis / inhalasi #ahan.#ahan de#u %ang mengandung allergen+ seperti de#u dare pari .pa#ri gula %ang mengandung spora dare act%nomicetes thermofili . 7. 8. Drug Reaction Pneumonitis / nitrofurantion+ #usulfan+ methotre6ate Pneumonia arena radiasi sinar rontgen

). Pneumonia %ang se#a#n%a tida ,elas / des9uamati!e interstitial pneumonia+ eosinofili pneumonia :. Microorganisma

;ROUP PEN<E0A0

=<PE PNEUMONIA 0acteri

A tinom%ctes

-ungi

Ri etsia

*lamidia

Mi oplasma

>irus

Proto?oa

4treptococcos pneumonia 4treptococcus piogenes 4tafilococcus aureus *le#siella pneumonia Eseri ia oli <ersinia pestis Legionnaires #acillus

A. Israeli No ardia asteroids

*o idioides imitis Histoplasma apsulatum 0lastomises dermatitidis Aspergillus -i omisetes

*o siella 0urnett%

5hlamidia psittaci

Mi oplasma pneumonia

Infulensa !irus+ adeno!irus respirator% s%nc%tial Pneumosistis arini Pneumonia #acteri

Legionnaires disease

A tinomi osis pulmonal No ardiosis pulmonal

*o idioidomi osis Histoplasmosis 0lastomi osis Aspergilosis Mu ormi osis

@ -e!er

Psita osis+Ornitosis

Pneumonia mi oplasmal

Pneumonia !irus

Pneumonia pneumistis "pneumonia plasma selA

d.

;am#aran *linis

;am#aran linis #iasan%a didahului ole infe si saluran nafas a ut #agian atas selama #e#erapa hari+ emudian dii uti dengan demam+ suhu tu#uh adang. adang mele#ihi 7B dera,at 5+ sa it tenggoro + n%eri otot dan sendi. Cuga disertai #atu + dengan sputum mu oid atau purulen+ adang. adang #erdarah.

Pada pemeri saan fisi dada terlihat #agian sa it tertinggal 2a tu #ernafas dengan suara nafas #ronchial adang. adang melemah. Didapat an ron i #asah halus+ %ang emudian men,adi ron i #asah asar pada stadium resolusi. &. 5ommunit% Ac9uired Pneumonia %aitu+ pneumonia %ang didapat an di mas%ara at+ ter,adin%a infe si di luar rumah sa it. 1. Hospital Ac9uirted Pneumonia %aitu+ pneumonia %ang didapat selama penderita dira2at di rumah sa it. Hampir & D dare penderita %ang dira2at di rumah sa it mendapat an pneumonia selama dalam pera2atan dan &$3n%a mung in a an meninggal. Demi ian pula haln%a dengan penderita %ang dira2at di I5U le#ih dare )B D menderita pneumonia. 3. Pneumonia in the immunocompromised host %aitu+ %ang ter,adi a i#at terganggun%a s%stem e e#alan tu#uh. Macula ini sema in mening at dengan penggunaan o#at.o#atan sitoto si dan imunosupresif+ hal ini a i#at dare merning atn%a ema,uan di #idang pengo#atan pen%a it eganasan dan transplantasi organ.

e.

;am#aran Patogenesis

Dalam eadaan sehat+ paru tida a an ter,adi pertum#uhan mi roorganisme+ eadan ini dise#a# an oleh adan%a me anismer pertahanan paru. =erdapatn%a #a teri di dalam paru merupa an a i#at etida seim#angan antara da%a than tu#uh+ mi roorganisme+ dan ling uingan sehingga mi roorganisme dapat #er em#ang #ia dan #era i#at tim#uln%a sa it. Masu n%a mi roorganisme e saluran nafas dan paru dapat melalui #er#agai cara+ %aitu / . . . . Inhalsi langsung dare udara Aspirasi dare #ahan.#ahan %ang ada di nasofaring dan orfaring Perluasan langsung dare tempat.tempat lain Pen%e#aran secara hematogen

;am#aran patologis dalam #atas.#atas tertentu+ tergantung pada pen%e#a#n%a. Di antaran%a %aitu / &. Pneumonia #a teri

Ditandai oleh e sudat intra al!eolar supuratif disertai onsolidasi. Proses infe si dapat di lasifi asi an #erdasar an anatomi. =erdapat onsolidasi dare seluruh lo#us pada pneumonia lo#aris+ sedang an pneumonia lo#ularis atau #roncopneumonia menun,u an

pen%e#aran daerah infe si %ang #er#eca dengan diameter se itar 3.7 cm+ mengelilingi dan mengenai #roncus. 1. Pneumonia Pneumo o us

Pneumo o us mencapai al!eolus.al!eolus dalam #entu perci an mucus atau sali!a. Lo#us paru #a2ah paling sering terserrang+ arena pengaruh ga%a tari #umi. 0ila sudah mencapai dan menetap di al!eolus+ ma a pneumo o us menim#ul an patologis %ang has %ang terdiri dare 7 stadium %ang #erurutan / . ongesti "7.&1 ,am pertamaAe sudat serusa masu dalam al!eolus.al!eolus dare pem#uluh darah %ang #ocor dan dilatasi . hepatisasi merah "7( ,am #eri utn%aA paru.paru tampa merah dan tampa #ergranula arena sel darah merah+ fi#rin+ dan leu osit polimorfonu lear mengisi al!eolus. al!eolus . hepatisasi ela#u "3.( hariA paru.paru# tampa a#u.a#u arena leu osit dan fi#rin mengalami onsolidasi dalam al!eolus %ang terserang. . Resolusi ":.&& hariA e sudat mengalami lisis dan direa#sor#si oleh mi rofag sehingga ,aringan em#ali pada stru turn%a semula. =im#uln%a pneumonia pneumo o us merupa an suatu e,adian %ang ti#a.ti#a+ disertai menggigil+ demam+ rasa sa it pleuriti + #atu dan sputum %ang #er2arna seperti arat. Pneumonia pneumo o us #iasan%a tida disertai ompli asi dan ,aringan %ang rusa dapat diper#ai i ema#ali. *ompli asi tentang sering ter,adi adalah efusi plura ringan. Adan%a #a terimia mempengaruhi prognosis pneumonia. Adan%a #a terimia menduga adan%a lo alisasi proses paru.paru %ang tida efe tif. A i#at #a terimia mung in #erupa lesi metastati %ang dapat menga i#at an eadaan seperti meningitis+ endo ariditis #acterial dan peritonitis. 4udah ada !a sin untu merla2an pneumonia pneumo o us. 0iasan%a di#eri an pada mere a %ang mempun%ai resi o fatal %ang tinggi+ seperti anemia sic le.sell+ multiple mietoma+ sindroma nefroti + atau dia#etes mellitus. 3. Pneumonia 4tafilo o us

Mempun%ai prognosis ,ele 2alaupun dio#ati dengan anti#ioti a. Pneumonia ini menim#ul an erusa an paren im paru.paru %ang #erat dan sering tim#ul ompli asi seperti a#ses paru.paru dan empiema. Merupa an infe si se under %ang sering men%erang pasien %ang dira2at di rumah sa it+ pasien lemah dan paling sering men%e#a# an #roncopneumonia. 7. Pneumonia *le#siella $ -riedlander

Penderita ini #erhasil mempertahan an hidupn%a+ a hirn%a menderita pneumonia roni disertai o#stru si progresif paru.paru %ang a hirn%a menim#ul an elumpuhan pernafasann%a. Cenis ini %ang has %aitu+ pem#entu an sputum ental seperti sele ismis merah "red currant ,ell%A. *e#an%a an ter,adi pada lela i usia pertengahan atau tua+ pecandu alcohol roni atau %ang menderita pen%a it roni lainn%a. 8. Pneumonia pseudomonas

4ering ditemu an pada orang %ang sa it parah %ang dira2at di rumah sa it atau %ang mnenderita supresi s%stem pertahanan tu#uh "misaln%a mere a %ang menderita leu emia atau transplantasi gin,al %ang menerima o#at imunosupresif dosis tinggiA. 4ering ali dise#a# an arena ter ontaminasi peralatan !entilasi. ). Pneumonia >irus

Ditandai dengan peradangan interstisial disertai penim#unan infiltrat dalam dinding al!eolus mes ipun rongga al!eolar sendiri #e#as dare e sudat dan tida ada onsolidasi. Pneumonia !irus 8B D dare semua pneuminia a ut ditandai oleh ge,ala sa it epala+ demam dan rasa sa it pada otot.otot %ang men%eluruh+ rasa lelah se ali dan #atu ering. *e#an%a an pneumonia ini ringan dan tida mem#utuh an pera2atan di rumah sa it dan tida menga i#at an erusa an paru.paru %ang permanen. Pengo#atan pneumonia !irus #ersifat s%mpomati dan paliatif+ arena anti#ioti tida efe tif terhadap !irus. Cuga dapat menga i#at an pneumonitis #er#eca %ang fatal atau pneumonitis difus. :. Pneumonia Mi oplasma

4erupa dengan pneumonia !irus influen?a+ disertai adan%a pneumonitis interstitial. 4angat mudah menular tida seperti pneumonia !irus+ dapat mem#eri an respon terhadap tetrasi lin atau eritromisin. (. Pneumonia Aspirasi

Merupa an pneumonia %ang dise#a# an oleh aspirasi isi lam#ung. Pneumonia %ang dia i#at ann%a se#agian #ersifat imia+ arena dia i#at an oleh rea si terhadap asam lam#ung+ dan se#agian #ersifat #acterial+ arena dise#a# an oleh organisme %ang mendiami mulut atau lam#ung. Aspirasi paling sering ter,adi selama atau sesudah anestesi "terutama pada pasien o#streti dan pem#edahan darurat arena urang persiapan pem#edahanA+ pada ana .ana dan pada setiap pasien %ang disertai pene anan refle #atu atau refle muntah. Inhalasi isi lam#ung dalam ,umlah %ang cu up #an%a dapat menim#ul an ematian %ang ti#a.ti#a+ arena adan%a o#stru si+ sedang an aspirasi isi lam#ung dalam ,umlah %ang sedi it dapat menga i#at an oedema paru.paru %ang men%e#ar luas dan egagalan pernafasan. 0eratn%a respon peradangan le#ih tergantung dare pH dare ?aat %ang diaspirasi an. Aspirasi pneumonia selalu ter,adi apa#ila pH dan ?at %ang diaspirasi 1+8 atau urang. Aspirasi pneumpnia sering menim#ul an omplio asi a#ses+ #ronchiectase+ dan gangrean. Muntah #u an sarat masu n%a isi lam#ung edalam ca#ang tracheo#ronchial+ arena regurgitasi dapat ,uga ter,adi secara diam.diam pada pasien %ang di#eri anestesi. Paling penting pasien harus ditempat an pada posisi %ang tepat agar secret orofarengeal dapat eluar dare mulut. '. Pneumonia H%postati

Pneumonia %ang sering tim#ul pada dasar paru %ang dise#a# an oleh nafas %ang dang al dan terus menerus dalam posisi %ang sama. Da%a tari #umi men%e#a# an darah tertim#un pada #agian #a2ah paru dan infe si mem#antu tim#uln%a pneumonia %ang sesungguhn%a &B. Pneumonia Camur

=ida sesering #a teri. 0e#erapa ,amur dapat men%e#a# an pen%a it paru supuratif granulomentosa %ang sering ali disalah tafsir an se#agai =05. 0an%a dare infe si ,amur #ersifat endemic pada daerah tertentu. 5ontohn%a di U4+ h%stoplasmosis "#arat #agian tengah dan timurA+ o si#iodomi osis "#arat da%aA dan #lastomi osis "tenggaraA. 4pora ,amur ini ditemu an dalam tanah dan terinhalasi. 4pora %ang ter#a2a masu e#agian paru %ang le#ih difagositosis ter,adi rea si peradangan disertai pem#entu an a!erne. 4emua peru#ahan patologis ini mirip se ali dengan =05 sehingga per#edaan urang dapat ditentu an dengan menemu an dan pem#ia an ,amur dare ,aringan paru.tes serologi serta tes h%persensitifitas ulit %ang lam#at #elum menun,u an tanda positif sampai #e#erapa minggu sesudah ter,adi infe si+ #ah an pada pen%a it %ang #erat tes mung in negatif. Pneumonia ,amur sering menim#ul an ompli asi pada stadium tera hir pen%a it terse#ut+ terutama pada pen%a it %ang sangat #erat+ misaln%a 5a atau leu emia+ candida alicans adalah se,enis ragi %ang sering ditemu an pada sputum orang %ang sehat dan dapat men%erang ,aringan paru. Penggunaan anti#ioti %ang lama ,uga dapat mengu#ah flora normal tu#uh dan memung in an infasi candida. Amfotinsin 0 merupa an o#at terpilih untu infe si ,amur pada paru.

f.

Pemeri saan La#oratorium

Pada pemeri saan la#oratorium terdapat pening atan ,umlah leucosit+ #iasan%a E &B.BBB$Fl adang mencapai 3B.BBB ,i a dise#a# an !irus atau mi oplasma ,umlah leucosit dapat normal+ atau menurun dan pada hitung ,enis leucosit terdapat pergeseran e iri ,uga ter,adi pening atan LED. *ultur darah dapat positif pada 1B G 18 pada penderita %ang tida dio#atai. *adang didapat an pening atan ureum darah+ a an tetapi teatinin masih dalah #atas normal. Analisis gas darah menun,u an h%po semia dan h%percardia+ pada stadium lan,ut dapat ter,adi asidosis respiratori .

g.

;am#aran Radiologi

-oto tora s merupa an pemeri saan penun,ang %ang sangat penting. -oto tora s sa,a tida dapat secara has menentu an pen%e#a# pneumonia+ han%a merupa an petun,u earah diagnosis etiologi. ;am#aran onsolidasi dengan air #ronchogram "pneumonia lo#arisA+ tersering dise#a# an oleh streptococcus pneumonia. ;am#aran radiologis pada pneumonia %ang dise#a# an cle#si#ella sering menun,u an adan%a onsolidasi %ang ter,adi pada lo#us atas anan+ adang dapat mengenai #e#erapa lo#us. ;am#aran lain%a dapat #erupa #erca daan ca!itas. *elainan radiologis lain %ang has %aitu pene#alan "#ulgingA fisura inter lo#ar. Pneumonia %ang dise#a# an uman pseudomonas sering memperlihat an adan%a infiltrasi #ilateral atau gam#aran #ronchopneumonia. -irus dan m%coplasma sering men%e#a# an pneumonia interstisial terutama radang sptum al!eola. Pada pemeri saan radiologis terlihat gam#aran reti uler %ang difus. h. & 1 Penatala sanaan *ore si elainan %ang mendasari. =irah #aring.

3 O#at.o#at simptomatis seperti/ parasetamol "pada hipere siaA+ morfin "pada n%eri he#atA. 7 Caga eseim#angan cairan dan ele trolit dengan #atuan infus+ de strose 8D+normal salin atau RL. 8 ) : Pemilihan o#at.o#at anti infe si/ tergantung uman pen%e#a#. Pertahan an ,alan nafas o sigenasi

DIA;NO4A *EPERAHA=AN &. 0ersihan ,alan nafas tida efe tif #erhu#ungan dengan inflamasi tra eo#ron ial+ pem#entu an edema+ pening atan produ si sputum. "Doenges+ &''' / &))A 1. ;angguan pertu aran gas #erhu#ungan dengan peru#ahan mem#ran al!eolus apiler+ gangguan apasitas pem#a2a a sigen darah+ ganggguan pengiriman o sigen. "Doenges+ &''' / &))A 3. Pola nafas tida efe tif #erhu#ungan dengan proses inflamasi dalam al!eoli. "Doenges+ &''' /&::A 7. ;angguan eseim#angan cairan dan ele trolit #erhu#ungan dengan ehilangan cairan #erle#ih+ penurunan masu an oral. "Doenges+ &''' / &:1A 8. Nutrisi urang dari e#utuhan tu#uh #erhu#ungan dengan e#utuhan meta#oli se under terhadap demam dan proses infe si+ anore sia %ang #erhu#ungan dengan to sin #a teri #au dan rasa sputum+ distensi a#domen atau gas." Doenges+ &''' / &:&A ). Intoleransi a tifitas #erhu#ungan dengan insufisiensi o sigen untu a tifitas sehari. hari. "Doenges+ &''' / &:BA

-O*U4 IN=ER>EN4I &. 0ersihan ,alan nafas tida efe tif #erhu#ungan dengan inflamasi tra eo#ron ial+ pem#entu an edema+ pening atan produ si sputum =u,uan / . . Calan nafas efe tif dengan #un%i nafas #ersih dan ,elas Pasien dapat mela u an #atu efe tif untu mengeluar an se ret

Hasil %ang diharap an / . . . Mempertahan an ,alan nafas paten dengan #un%i nafas #ersih$ ,elas Menun,u an perila u untu memper#ai i #ersihan ,alan nafas Misaln%a/ #atu efe tif dan mengeluar an se ret.

Inter!ensi / a. Aus ultasi #un%i nafas+ catat adan%a #un%i nafas. Misaln%a/ mengi+ re els dan ron i.

Rasional/ 0ersihan ,alan nafas %ang tida efe tif dapat dimanifestasi an dengan adan%a #un%i nafas ad!entisius

#.

*a,i$ pantau fre uensi pernafasan+ catat rasio inspirasi$ e spirasi

Rasional/ =a ipnea #iasan%a ada pada #e#erapa dera,at dan dapat ditemu an pada penerimaan atau selama stres$ adan%a proses infe si a ut. Pernafasan dapat melam#at dan fre uensi e spirasi meman,ang di#anding inspirasi. c. 0eri an posisi %ang n%aman #uat pasien+ misaln%a posisi semi fo2ler

Rasional/ Posisi semi fo2ler a an mempermudah pasien untu #ernafas d. Dorong$ #antu latihan nafas a#domen atau #i#ir

Rasional/ Mem#eri an pasien #e#erapa cara untu mengatasi dan mengontrol dipsnea dan menurun an ,e#a an udara e. O#ser!asi ara teristi #ati + #antu tinda an untu memoer#ai i eefe tifan upa%a #atu . Rasional/ 0atu dapat menetap+ tetapi tida efe tif. 0atu paling efe tif pada posisi dudu tinggi atau epala di #a2ah setelah per usi dada. f. 0eri an air hangat sesuai toleransi ,antung.

Rasional/ Hidrasi menurun an e entalan se ret dan mempermudah pengeluaran. 1. ;angguan pertu aran gas #erhu#ungan dengan peru#ahan mem#ran al!eolus apiler+ gangguan apasitas pem#a2a o sigen darah+ gangguan pengiriman o sigen. =u,uan / . Per#ai an !entilasi dan o sigenasi ,aringan dengan ;DA dalam rentang normal dan tida ada distres pernafasan. Hasil %ang diharap an / . . Menun,u an adan%a per#ai an !entilasi dan o sigenasi ,aringan 0erpartisispasi pada tinda an untu mema simal an o sigenasi

Inter!ensi / a. a,i fre uensi+ edalaman+ dan emudahan pernafasan

Rasional /Manifestasi distres pernafasan tergantung pada dera,at eterli#atan paru dan status esehatan umum #. O#ser!asi 2arna ulit+ mem#ran mu osa dan u u. 5atat adan%a sianosis

Rasional /4ianosis menun,u an !aso ontri si atau respon tu#uh terhadap demam$ menggigil dan ter,adi hipo semia.

c.

*a,i status mental

Rasional /;elisah+ mudah terangsang+ #ingung dapat menun,u an hipo semia. d. A2si fre uensi ,antung$ irama

Rasional /=a i ardi #iasan%a ada arena a i#at adan%a demam$ dehidrasi. e. A2asi suhu tu#uh. 0antu tinda an en%amanan untu mengurangi demam dan menggigil Rasional /Demam tinggi sangat mening at an e#utuhan meta#oli dan e#utuhan o sigen dan mengganggu o sigenasi seluler. f. =inggi an epala dan dorong sering mengu#ah posisi+ nafas dalam+ dan #atu efe tif

Rasional /=inda an ini mening at an inspirasi ma simal+ mening at an pengeluaran se ret untu memper#aia i !entilasi. g. *ola#orasi pem#erian o sigen dengan #enar sesuai dengan indi asi

Rasional /Mempertahan an PaO1 di atas )B mmHg. 3. Pola nafas tida efe tif #erhu#ungan dengan proses inflamasi dalam al!eoli

=u,uan/ . Pola nafas efe tif dengan fre uensi dan edalaman dalam rentang normal dan paru ,elas$ #ersih Inter!ensi / a. *a,i fre uensi+ edalaman pernafasan dan e spansi dada.

Rasional /*ecepatan #iasan%a mening at+ dispnea+ dan ter,adi pening atan er,a nafas+ edalaman #er!ariasi+ e spansi dada ter#atas. #. Aus ultasi #un%i nafas dan catat adan%a #un%i nafas ad!entisius.

Rasional /0un%i nafas menurun$ tida ada #ila ,alan nafas terdapat o#stru si ecil.

c.

=inggi an epala dan #entu mengu#ah posisi.

Rasional /Dudu tinggi memung in an e spansi paru dan memudah an pernafasan. d. O#ser!asi pola #atu dan ara ter se ret.

Rasional /0atu #iasan%a mengeluar an sputum dan mengindi asi an adan%a elainan. e. 0antu pasien untu nafas dalam dan latihan #atu efe tif.

Rasional /Dapat mening at an pengeluaran sputum. f. *ola#orasi pem#erian o sigen tam#ahan.

Rasional /Mema simal an #ernafas dan menurun an er,a nafas. g. 0eri an humidifi asi tam#ahan

Rasional /Mem#eri an elem#a#an pada mem#ran mu osa dan mem#antu pengenceran se ret untu memudah an pem#ersihan. h. 0antu fisioterapi dada+ postural drainage

Rasional /Memudah an upa%a pernafasan dan mening at an drainage se ret dari segmen paru e dalam #ron us. 7. ;angguan eseim#angan cairan dan ele trolit #erhu#ungan dengan ehilngan cairan #erle#ih+ penurunan masu an oral. =u,uan / Menun,u an eseim#angan cairan dan ele trolit Inter!ensi / a. *a,i peru#ahan tanda !ital+ contoh /pening atan suhu+ ta i ardi++ hipotensi.

Rasional /Untu menun,u an adn%a e urangan cairan sisitemi #. *a,i turgor ulit+ elem#a#an mem#ran mu osa "#i#ir+ lidahA.

Rasional /Indi ator langsung eade uatan masu an cairan c. 5atat lapporan mual$ muntah.

Rasional /Adan%a ge,ala ini menurun an masu an oral d. Pantau masu an dan haluaran urine.

Rasional /Mem#eri an informasi tentang eade uatan !olume cairan dan e#utuhan penggantian e. *ola#orasi pem#erian o#at sesuai indi asi.

Rasional /Memper#ai i ststus esehatan 8. Nutrisi urang dari e#utuhan tu#uh #erhu#ungan dengan pening atan e#utuhan meta#oli se under terhadap demam dan proses infe si+ anore sia+ distensi a#domen.

=u,uan / . . Menun,u an pening atan nafsu ma an Mempertahan an$ mening at an #erat #adan

Inter!ensi / a. Identifi asi fa tor %ang menim#ul an mual$ muntah.

Rasional /Pilihan inter!ensi tergantung pada pen%e#a# masalah

#. 0eri an 2adah tertutup untu sputum dan #uang sesering mung in+ #antu e#ersihan mulut. Rasional /Menghilang an #aha%a+ rasa+ #au+dari ling ungan pasien dan dapat menurun an mual c. Cad2al an pengo#atan pernafasan sedi itn%a & ,am se#elum ma an.

Rasional /Menurun an efe mual %ang #erhu#ungan dengan pengo#atan ini d. Aus ultasi #un%i usus+ o#ser!asi$ palpasi distensi a#domen.

Rasional /0un%i usus mung in menurun #ila proses infe si #erat+ distensi a#domen ter,adi se#agai a i#at menelan udara dan menun,u an pengaruh to sin #a teri pada saluran gastro intestinal e. 0eri an ma an porsi ecil dan sering termasu ma anan ering atau ma anan %ang menari untu pasien. Rasional /=inda an ini dapat mening at an masu an mes ipun nafsu ma an mung in lam#at untu em#ali f. E!aluasi status nutrisi umum+ u ur #erat #adan dasar.

Rasional /Adan%a ondisi ronis dapat menim#ul an malnutrisi+ rendahn%a tahanan terhadap infe si+ atau lam#atn%a responterhadap terapi ). Intoleransi a tifitas #erhu#ungan dengan insufisiensi o sigen untu a tifitas hidup sehari.hari. =u,uan / Pening atan toleransi terhadap a tifitas. Inter!ensi / a. E!a uasi respon pasien terhadap a ti!itas.

Rasional /Menetap an emampuan$ e#utuhan pasien dan memudah an pilihan inter!ensi #. 0eri an ling ungan %ang tenang dan #atasi pengun,ung selama fase a ut.

Rasional /Menurun an stres dan rangsangan #erle#ihan+ mening at an istirahat c. Celas an pentingn%a istitahat dalam rencana pengo#atan dan perlun%a eseim#amgan a ti!itas dan istirahat. Rasional /=irah #aring dipertahan an untu menurun an e#utuhan meta#oli d. 0antu a ti!itas pera2atan diri %ang diperlu an.

Rasional /Meminimal an elelahan dan mem#antu eseim#angan suplai dan e#utuhan o sigen DA-=AR PU4=A*A

0ar#ara Engram "&''(A+ Rencana Asuhan *epera2atan Medi al G 0edah Cilid I+ Peneri#it 0u u *edo teran E;5+ Ca arta.

0ar#ara 5. Long "&'')A+ Pera2atan Medi al 0edah/ 4uatu Pende atan Proses *epera2atan+ =he 5.> Mos#% 5ompan% 4t. Louis+ U4A.

Huda I ;allo "&'':A+ *epera2atan *ritis/ Pende atan Holisti >olume I+ Pener#it 0u u *edo etran E;5+ Ca arta.

Can =am#a%onmg "1BBBA+ Patofisiologi Unut *epera2atan+ Pener#it 0u u *edo etran E;5+ Ca arta.

Mar%lin E. Doenges "1BBBA+ Rencana Asuhan *epera2atan/ Pedoman Untu Perencanaan dan Pendo umentasian Pera2atan Pasien edisi 3+ Pener#it 0u u *edo etran E;5+ Ca arta.

4%l!ia A. Price "&''8A+ Patofisiologi/ *onsep *linis Proses.proses Pen%a it Edisi 7 0u u 1+ Pener#it 0u u *edo etran E;5+ Ca arta

;u%ton I Hall "&'':A+ 0u u A,ar -isiologi *edo teran Edisi '+ Pener#it 0u u *edo etran E;5+ Ca arta

Abstract

The first poi t of a !oo" "ia! ostic strate!# for hea$thcare%associate" p e&'o ia (HCA)* is correct c$assificatio of patie ts +ith specific criteria, as s&!!este" b# the $ast A'erica Thoracic Societ#- I fectio&s Diseases Societ# of A'erica (ATS-IDSA* !&i"e$i es. Ho+e.er, c$i ica$ practice a " rece t $iterat&re ha.e s&!!este" e+ ris/ factors for '&$ti"r&!%resista t i fectio (MRI*0 the prese ce of per'a e t i "+e$$i ! "e.ices, prior a tibiotic &se i the $ast 3 'o ths, chro ic a " a".a ce" p&$'o ar# "iseases (chro ic obstr&cti.e p&$'o ar# "isease, bro chiectasis, etc.*, histor# of a$coho$is', a " i''& os&ppressio . The c$i ica$ prese tatio i HCA) patie ts is ofte & &s&a$ ('i$" respirator# s#'pto's a " fre1&e t e2trap&$'o ar# 'a ifestatio s* "&e to "iffere t factors0 a".a ce" a!e, e&ro$o!ica$ "isor"ers, a " '&$tip$e chro ic co'orbi"ities. Moreo.er, HCA) co''o $# prese ts a +orse c$i ica$ co&rse tha co''& it#%ac1&ire" p e&'o ia, a pro$o !e" $e !th of sta#, a " a 'orta$it# rate c$ose to hospita$%ac1&ire" p e&'o ia. Chest ra"io!raph# a " ro&ti e $aborator# 'ar/ers (i c$&"i ! C% reacti.e protei * are a$+a#s ee"e" for c$i ica$ e.a$&atio a " se.erit# assess'e t. The c$i ica$ &se of e+ bio'ar/ers of i fectio a " sepsis (proca$cito i , etc.* is c&rre t$# bei ! i .esti!ate". E2te si.e 'icrobio$o!ica$ testi ! to o.erco'e the hi!h pre.a$e ce of MRI i HCA), i c$&"i ! &ri ar# a ti!e s for Legionella a " Streptococcus pneumoniae3 b$oo" c&$t&res3 4ra' stai i ! a " $o+ respirator# tract secretio s (sp&t&', tracheobro chia$ aspirate, fibrobro chia$ aspirate, protecte" speci'e br&sh, bro choa$.eo$ar $a.a!e*3 a " c&$t&res for aerobic, a aerobic, '#cobacteria$, a " f& !a$ patho!e s are reco''e "e", +hereas the i "icatio for sero$o!# tests for respirator# .ir&ses a " at#pica$ patho!e s is $o+. 5# co trast, the e+ po$#'erase chai reactio % base" tech i1&es for the rapi" i"e tificatio (2 to 6 ho&rs* of 'icrobia$ patho!e s i respirator# sa'p$es ( asophar# !ea$ s+ab, bro choa$.eo$ar $a.a!e* see' to be the 'ost i o.ati.e f&t&re perspecti.e i the "ia! ostics of HCA)

Defi itio of Hea$thcare%associate" ) e&'o ia


Table 1 Risk Factors for Multi ru!"Resista#t Pat$o!e#s %ausi#! Hos&ital"Ac'uire P#eu(o#ia) Healt$care"Associate P#eu(o#ia) a# *e#tilator"Associate P#eu(o#ia
A ti'icrobia$ therap# i prece"i ! 70 "a#s C&rre t hospita$i8atio of 9 "a#s or 'ore

Hi!h fre1&e c# of a tibiotic resista ce i the co''& it# or i the specific hospita$ & it )rese ce of ris/ factors for HCA)0 Hospita$i8atio for 2 or 'ore "a#s i the prece"i ! 70 "a#s Resi"e ce i a &rsi ! ho'e or e2te "e" care faci$it# Ho'e i f&sio therap# (i c$&"i ! a tibiotics* Chro ic "ia$#sis +ithi 30 "a#s Ho'e +o& " care Fa'i$# 'e'ber +ith '&$ti"r&!%resista t patho!e I''& os&ppressi.e "isease a "-or therap#
Fro' Refere ce :, +ith per'issio .

Table + A itio#al Risk Factors for Multi ru!"Resista#t I#fectio#s i# Healt$care" Associate P#eu(o#ia
)rese ce of chro ic i "+e$$i ! "e.ice )rior a tibiotic &se i the $ast 3 'o ths Chro ic a " a".a ce" p&$'o ar# "iseases (chro ic obstr&cti.e p&$'o ar# "isease, bro chiectasis, etc.* Histor# of a$coho$is' a " i''& os&ppressio (i.e., s#ste'ic corticosteroi"s, i''& os&ppressi.e therap#, etc.

I the $ast 2 "eca"es the $iterat&re has "escribe" a !ro&p of patie ts co''o $# resi"i ! i $o !%ter' care faci$ities (;TCFs* ( &rsi ! ho'es, he'o"ia$#sis ce ters, etc.* or +ith so'e co tact +ith the hea$thcare e .iro 'e t, +hose p e&'o ia &s&a$$# sho+s a +orse c$i ica$ co&rse a " o&tco'es <'orta$it#, $e !th of sta# (;OS*, <=>3? etc.? tha that of patie ts +ith co''& it#%ac1&ire" p e&'o ia (CA)*. These fi "i !s ha.e $e" to the "e.e$op'e t of the e+ co cept of hea$thcare%associate" p e&'o ia (HCA)*.

No ethe$ess, it is & certai +hether the pre.io&s c$i ica$ co "itio s (o$"er a!e, i'paire" f& ctio a$ stat&s, hi!h &'ber of co'orbi"ities, etc.* or a "iffere t 'icrobio$o!ica$ etio$o!# tha CA) ca be co si"ere" as the 'ai ca&se of these fi "i !s. A$tho&!h the "efi itio criteria for HCA) ha.e ot bee c$ear$# estab$ishe", it is e.i"e t that 'ore atte tio is ee"e" o this iss&e beca&se the &'ber of patie ts atte "i ! o&tpatie t hea$th care setti !s (;TCFs, "o'ici$iar# care pro!ra's, etc.* is i creasi ! +or$"+i"e. <6,9? The first poi t of a !oo" "ia! ostic strate!#, i the co te2t of the i itia$ e.a$&atio ('e"ica$ histor# co$$ectio a " ph#sica$ e2a'i atio *, is the correct c$assificatio of patie ts +ith HCA). The $ast A'erica Thoracic Societ#-I fectio&s Diseases Societ# of North A'erica (ATS-IDSA* !&i"e$i es for the 'a a!e'e t of hospita$%ac1&ire" p e&'o ia (HA)* "efi e specific criteria ( Tab$e = * to i"e tif# HCA) patie ts a " reco''e " a ti'icrobia$ therap# si'i$ar to that a"'i istere" i cases of HA). <:? Ho+e.er, c$i ica$ practice a " rece t $iterat&re ha.e s&!!este" that a$$ patie ts +ith per'a e t i "+e$$i ! "e.ices (e.!., per'a e t &ri ar# a " other per'a e t catheters, !astrosto'#, aso!astric t&be, etc.* are at ris/ of '&$ti"r&!%resista t i fectio s (MRIs*. <@? Therefore, it is $i/e$# that this a""itio a$ criterio sho&$" be co si"ere" to i"e tif# HCA) patie ts beca&se it represe ts a stro ! ris/ factor for MRI a " co&$" co siste t$# i f$&e ce the "ia! ostic a " therape&tic approach. Accor"i !$#, to "etect HCA) patie ts +ith ta !ib$e ris/ factors for MRI, it is stro !$# reco''e "e" to co si"er, a$o !si"e the ATS-IDSA criteria, the factors sho+ i Tab$e 2 . Act&a$$#, "&e to the $ac/ of i for'atio , a+are ess abo&t HCA) see's i a"e1&ate a " "oes ot faci$itate the reco! itio of MRI ris/ factors a'o ! patie ts f&$fi$$i ! the ATS-IDSA criteria for HCA). I "ee", "espite the ba" pro! osis of p e&'o ia i this set of patie ts, ot a$$ HCA)s rea$$# ha.e to be e'pirica$$# treate" for osoco'ia$ 'icroor!a is's beca&se this co&$" $ea" to the o.er&se of a tibiotics, +ith the res&$ti ! possibi$it# of e'er!e t resista ces a " i a"e1&ate a tibiotic co.era!e of so'e co''& it# patho!e s s&ch as Legionella spp. <A? a " Chlamydia pneumoniae. <7? Co se1&e t$#, +i"e "ia! ostic testi ! is reco''e "e" to opti'i8e the i itiatio a " "o+ sca$i ! of a tibiotic therap#, "espite the fre1&e t practica$ "iffic&$ties,

s&ch as the fact that 'a # patie ts are ot ab$e to pro.i"e a !oo" sp&t&' speci'e for a a$#sis, a " it is ofte i'possib$e to "isti !&ish bet+ee chro ic air+a# co$o i8atio a " a e+ i fectio ca&si ! p e&'o ia.

C$i ica$ )rese tatio


The c$i ica$ prese tatio of HCA) patie ts is fre1&e t$# & &s&a$ a " o c$assica$ as a co se1&e ce of "iffere t co "itio i ! factors, i c$&"i ! a".a ce" a!e, the prese ce of e&ro$o!ica$ "isor"ers, a "-or '&$tip$e chro ic co'orbi"ities. I re!ar" to p e&'o ia i e$"er$# patie ts, it Os$er "escribe" as Ba pai $ess a " ofte $etha$ e.e tB3 <=0? i "ee", the c$assic respirator# s#'pto's of p e&'o ia, s&ch as co&!h, e2pectoratio , "#sp ea, a " p$e&ritic chest pai , are co''o $# 'i$" <==,=2? a " $ess fre1&e t tha i #o& !er patie ts. O the other ha ", e2trap&$'o ar# 'a ifestatio s, i c$&"i ! 'e ta$ co f&sio a " !astroi testi a$ "isor"ers (a ore2ia, a&sea, .o'iti !, ab"o'i a$ pai , etc.*, are .er# fre1&e t a " ofte pre"o'i ate o.er respirator# s#'pto's. <=3? It has a$so bee obser.e" that i o$"er CA) patie ts 'a # s#'pto's (co&!h, sp&t&', fati!&e, a ore2ia, '#a$!ias, etc.* are $o !er $asti ! tha i #o& !er patie ts. <=6? Ri1&e$'e et a$ reporte" "#sp ea to be the 'ost fre1&e t s#'pto' i o$"er patie ts +ith CA), +hereas =7C of the patie ts "i" ot prese t co&!h, sp&t&', or p$e&ritic pai , a " a$tere" 'e ta$ stat&s +as prese t i a$'ost 69C of this !ro&p. <=9? I a""itio , it is / o+ that fe.er is $ess co''o $# prese t i o$"er <=9,=:? co'pare" +ith #o& !er CA) patie ts, $i/e$# as a res&$t of a a$tere" ther'ore!&$ator# capacit# to pro"&ce a " respo " to e "o!e o&s p#ro!e s. <=@? I their rece t re.ie+ Nie"er'a a " 5rito pro.i"e a .er# !oo" "escriptio of the c$i ica$ feat&res of p e&'o ia i the e$"er$#. <=A? A .ariab$e proportio of HCA) patie ts ha.e e&ro$o!ica$ a " cerebro.asc&$ar "isor"ers +ith fre1&e t i'pair'e t i s+a$$o+i ! or co&!h ref$e2es that i'p$ies a e$e.ate" i ci"e ce of bro choaspiratio . <=7?The reporte" i ci"e ce of "#spha!ia, partic&$ar$# i &rsi ! ho'es, is bet+ee 90 a " @9C. <20,2=? The "efi itio of bro choaspiratio i'p$ies the aspiratio of a co si"erab$e i oc&$&' of patho!e s fro' a pre.io&s co$o i8e" orophar# 2 or of a $itt$e i oc&$&' i the prese ce of pre"isposi ! co "itio s that 'a/e the c$eara ce of the aspirate" secretio s "iffic&$t, s&ch as a hi!h .ir&$e t bacteria$ b&r"e , force$ess co&!hi !, i s&fficie t ci$iar# tra sport, or a$tere" i''& orespo se. I "ee", Der!is et a$ i"e tifie" +it esse" aspiratio a " se"ati.e 'e"icatio s as the 'ost i'porta t ris/ factors for p e&'o ia i ;TCFs, <22? a " Ei/&chi a " co$$ea!&es "e'o strate"

the occ&rre ce of aspiratio i @=C of e$"er$# patie ts +ith CA) co'pare" +ith =0C i hea$th# a!e%'atche" co tro$ s&bFects. <23? Moreo.er, "#sphasia ca si! ifica t$# hi "er the i terpretatio of si! s a " s#'pto's "&ri ! 'e"ica$ e.a$&atio . The c$i ica$ prese tatio of p e&'o ia i patie ts +ith '&$tip$e chro ic co'orbi"ities (chro ic obstr&cti.e p&$'o ar# "isease, co !esti.e heart fai$&re, re a$ fai$&re, etc.* 'a# s&!!est a ac&te e2acerbatio of a co'orbi"it# rather tha p e&'o ia. <==,26? I co c$&sio , i patie ts +ith rece t co tact +ith the hea$thcare e .iro 'e t a " +ith s&spicio of p e&'o ia, pro'pt a " +e$$%orie te" "ia! ostic testi ! is f& "a'e ta$ beca&se a & &s&a$ c$i ica$ prese tatio (o$"er a!e, e&ro$o!ica$ "isor"ers, co'orbi" i$$ esses* a " the fre1&e t pre"o'i a ce of the s#'pto's of co'orbi"ities ca ca&se a co si"erab$e "e$a# i the first "ose of a tibiotic, <==,29,2:?the a"'i istratio of +hich is !e era$$# co si"ere" a pre"ictor of o&tco'e <2@,2A? i p e&'o ia.

C$i ica$ Co&rse


Despite the !reat "iffere ces a'o ! the st&"ies p&b$ishe" o the 'icrobia$ etio$o!# of HCA), <=,27,30? it has bee & a i'o&s$# "escribe" that, co'pare" +ith CA), HCA) patie ts co''o $# ha.e a +orse c$i ica$ prese tatio (h#po2e'ia, ee" for 'echa ica$ .e ti$atio s&pport, '&$ti$obar i fi$tratio * b&t ot a "iffere t i ci"e ce of co'p$icatio s (p$e&ra$ eff&sio , '#ocar"ia$ i farctio , etc.*. <2,3=,32? I a""itio , a pro$o !e" ;OS <=,3,36? a " a 'orta$it# rate c$ose to HA) are a$so reporte". <=,2,=2,3=

Dia! ostic Tests


Radiology
A$o ! +ith a correct histor# a " a e2te si.e c$i ica$ e.a$&atio , chest ra"io!raph# (preferab$# posteroa terior a " $atera$ positio s* is a$+a#s ee"e" to "efi e the prese ce of a e+ p&$'o ar# i fi$trate, the se.erit# of the "isease, a " the prese ce of co'p$icatio s. <33? It is i'porta t to be a+are of the e2iste ce of "iffere t patho$o!ica$ co "itio s, s&ch as the prese ce of ate$ectasis, p&$'o ar# e"e'a (car"io!e ic a " o car"io!e ic*, p$e&ra$ eff&sio , he'orrha!e, eop$astic $esio s, i fectio&s a " 'a$for'ati.e c#sts, p&$'o ar# i farctio (i.e., p&$'o ar# thro'boe'bo$is'*, "r&!%i "&ce" p&$'o ar# $esio s (o2#!e , che'otherap# a!e ts, a'io"aro e, etc.*, "iff&se a$.eo$ar "a'a!e <a"&$t

respirator# "istress s# "ro'e (ARDS*?, or!a i8i ! p e&'o ia <bro chio$itis ob$itera s or!a i8i ! p e&'o ia (5OO)*?, that ca erro eo&s$# be i terprete" as p e&'o ia. I case of "o&bt or re$e.a t "isa!ree'e t bet+ee the c$i ica$ prese tatio a " the ra"io$o!ica$ fi "i !s, it is reco''e "e" to perfor' a co'p&te" to'o!raphic (CT* sca .

Laboratory Tests
Ro&ti e $aborator# 'ar/ers are a f& "a'e ta$ part of the c$i ica$ e.a$&atio for "eci"i ! the site of care a " se.erit# assess'e t. Reco''e "e" assess'e ts i c$&"e b$oo" ce$$ co& t, e$ectro$#tes, hepatic a " re a$ f& ctio , arteria$ b$oo" !ases, C%reacti.e protei (CR)* a " proca$cito i ()CT* $e.e$s. CR) is a ac&te i f$a''ator# 'e"iator that is re$ease" fro' the $i.er b# i ter$e&/i %: (I;%:* sti'&$atio , after tiss&e "a'a!e as part of s#ste'ic i f$a''ator# respo se. It is a &sef&$ 'ar/er of sepsis, i fectio , a " respo se to treat'e t. <36? G fort& ate$#, there are so'e $i'itatio s to its &se0 ser&' CR) $e.e$s s$o+$# i crease (at $east 26 ho&rs after the o set of i fectio * a " "o ot re$iab$# corre$ate +ith the se.erit# of the "isease. I a""itio , CR) $e.e$s a$so i crease i o i fectio&s i f$a''ator# processes s&ch as coro ar# s# "ro'e or postoperati.e perio"s. No specific e.a$&atio s ha.e bee 'a"e i HCA) patie ts b&t it has bee "e'o strate" that hi!h ser&' $e.e$s of CR) i e$"er$# patie ts +ith p e&'o ia are a &sef&$ pro! ostic 'ar/er of "isease se.erit#. <39? )CT is a e+ 'ar/er of bacteria$ i fectio that has bee +i"e$# i .esti!ate" i the $ast "eca"e si ce the first "escriptio i =77: of e$e.ate" ser&' $e.e$s of )CT, the prohor'o e of ca$cito i , i i ha$atio a$ b&r i F&r#, i se.era$ sepsis s# "ro'es, a " i e "oto2e'ia. <3:? It is a pepti"e s# thesi8e" i 'o oc#tes & "er!oi ! a"hesio processes b&t ot i circ&$ati ! po$#'orpho &c$ear ce$$s. Tiss&e ce$$s pro"&ce )CT o $# +he i teracti ! +ith acti.ate" 'o oc#tes. Differe t st&"ies ha.e "e'o strate" that )CT is he$pf&$ to "iffere tiate bacteria$ i fectio s fro' other i f$a''ator# (i.e., ARDS, a&toi''& e "iseases* or i fectio&s (i.e., .ira$* "iseases <3@>37? for its c#to/i e%$i/e ro$e i host "efe se .ers&s bacteria$ i fectio s. <3@? )CT 'o itori !, therefore, ca ot o $# $i'it the o.er&se of a tibiotics <3A,60,6=?b&t ca a$so co trib&te to a ear$# e.a$&atio of "isease se.erit#. <3@? F&rther'ore, hi!h $e.e$s of )CT at a"'issio a " at "a# 3 are a !oo" pre"ictor of treat'e t fai$&re. <3A?I "ee", i a atte'pt to i'pro.e c&rre t sepsis "efi itio s, the )IRO (pre"ispositio , i s&$t i fectio , respo se, or!a "#sf& ctio * co cept reco''e "s the &se of rea"i$# 'eas&rab$e circ&$ati ! bio'ar/ers as a

a""itio a$ too$ for the ti'e$# assess'e t a " se.erit# c$assificatio of septic patie ts a " the pre"ictio of 'orta$it#. <62? No specific st&"ies o the &ti$it# of )CT 'eas&re'e ts i HCA) patie ts are a.ai$ab$e i the $iterat&re, b&t it is $i/e$# that i patie ts +ith a at#pica$ c$i ica$ prese tatio <'i$" a " & &s&a$ s#'pto's of $o+er respirator# tract i fectio (;RTI*?, bio$o!ica$ 'ar/ers 'a# ha.e a !reater ro$e i achie.i ! the "ia! osis of p e&'o ia. Ho+e.er, for the "ia! osis of i fectio s, the "ia! ostic acc&rac# of )CT has a pri'ar# i'porta ce0 +hereas )CT $e.e$s $o+er tha 0.= !-"; s&!!est the abse ce of bacteria$ i fectio a " i terr&ptio of a tibiotic therap# (+he pre.io&s$# i itiate"* a " $e.e$s of )CT H 0.9 !-"; are c$ear$# associate" +ith bacteria$ i fectio , )CT $e.e$s bet+ee 0.2: a " 0.9 !-"; ca sti$$ i "icate a possib$e bacteria$ i fectio a " ca be of "ia! ostic .a$&e i co "itio s other tha sepsis. <3@,6=? Er&!er a " co$$ea!&es i "icate a c&toff $e.e$ of 0.22A !-'; to pre"ict patie ts at $o+ ris/ of "eath fro' CA) i a$$ se.erit# score c$asses. <63? As a co se1&e ce, .er# se siti.e assa#s (+ith a f& ctio a$ "etectio $i'it $ess tha 0.9 !-';* are reco''e "e". No ethe$ess, "espite the e.i"e ce%base" reco''e "atio to 'o itor )CT $e.e$s i critica$$# i$$ patie ts +ith sepsis, <66? it re'ai s & c$ear +hether a a$tere" i''& orespo se seco "ar# to "iseases, "r&!s, or a!i ! ca affect the e2pressio of )CT i respirator# bacteria$ i fectio s. Therefore, 'ore i for'atio is ee"e" o the pathoph#sio$o!# of )CT a ", co se1&e t$#, o its "ia! ostic .a$&e i specific cate!ories of patie ts, s&ch as the .er# e$"er$# a " i''& os&ppresse" i "i.i"&a$s (che'otherap#, corticosteroi"s, he'atopoietic "isor"ers, etc.* +ho 'a# be hi!h$# represe te" a'o ! HCA). Other e+ i f$a''ator# bio'ar/ers, i c$&"i ! )ro%a"re o'e"&$$i , pro%atria$ atri&retic pepti"e (AN)*, carba'o#$ phosphate si thase%= (C)S%=*, pro% e "othe$i %= (pro%ET%=*, a " copepti e (pro%.asopressi e*, are c&rre t$# bei ! i .esti!ate" as possib$e he$pf&$ bio'ar/ers for i "i.i"&a$ ris/ assess'e t a " o&tco'e pre"ictio i sepsis a " se.ere i fectio a " to "etect car"io.asc&$ar ab or'a$ities i p e&'o ia patie ts. <3@,69>6@?

Etiologic Diagnosis
A .ariet# of 'icrobio$o!ica$ tests, +ith .ario&s i "icatio s a " $i'itatio s, are co''o $# a.ai$ab$e to i .esti!ate the 'icrobia$ etio$o!# of p e&'o ia. Ne.erthe$ess, the "ia! ostic .a$&e of 'a # speci'e s obtai e" ro&ti e$#, as +e$$

as those achie.e" thro&!h 'ore i .asi.e proce"&res (fiber%bro choscop#, etc.* is co tro.ersia$ e.e i critica$$# i$$ patie ts. 5$oo" c&$t&res are &s&a$$# reco''e "e" for 'ore se.ere patie ts <6A? a " for those +ho ha.e ot pre.io&s$# recei.e" a tibiotics. <67? Meters/# a " co$$ea!&es "e'o strate" that i these patie ts fa$se%positi.e res&$ts +ere $ess $i/e$# tha i patie ts +ith 'i$" i$$ ess a " i those +ho ha" pre.io&s$# bee a"'i istere" a tibiotics. <90? Differe t st&"ies ha.e e.a$&ate" the co trib&tio of b$oo" c&$t&re to c$i ica$ 'a a!e'e t of hospita$i8e" patie ts +ith CA) a " ha.e fo& " b$oo" c&$t&res to be of poor &ti$it# i "irecti ! a tibiotic therap#, rare$# cost sa.i !, a " +ea/ fro' a epi"e'io$o!ica$ poi t of .ie+. <9=,92? 5# co trast, +e sho&$" co si"er that HCA) patie ts are 'ore si'i$ar to HA) patie ts i +ho' b$oo" c&$t&res are stro !$# reco''e "e". I "ee", the 'icrobia$ patter ca co si"erab$# "iffer fro' CA) (& &s&a$ a ti'icrobia$ resista ce, prese ce of at#pica$-& co''o patho!e s*, a ", as a co se1&e ce, the e'pirica$ a tibiotic therap# is 'ore $i/e$# to be i a"e1&ate. Th&s a !reater effort to achie.e the etio$o!ica$ "ia! osis is F&stifie" i HCA), "espite the possib$e i crease i costs. Sp&t&' is the 'ost co''o speci'e obtai e" i ;RTI, b&t it is a$so the 'ost prob$e'atic. First, 'a # patie ts "o ot ha.e pro"&cti.e co&!h or are too +ea/ to pro.i"e a "eep respirator# sa'p$e. Seco ", .er# strict scree i ! criteria for 'icroscopic e2a'i atio of sp&t&' '&st be fo$$o+e" to e s&re the 1&a$it# of the 'icrobio$o!ica$ "eter'i atio (proportio of epithe$ia$ a " po$#'orpho &c$ear ()MN* ce$$s, etc.*. <93,96? A .ariet# of s&!!estio s to i'pro.e sp&t&' 1&a$it# i c$&"e o i !estio of foo" for = to 2 ho&rs, ri si ! the 'o&th +ith +ater or sa$i e so$&tio , rapi" tra sport of speci'e s to the $aborator#, a " pro'pt i oc&$atio of c&$t&re 'e"ia. <99? Ho+e.er, there is o c$ear e.i"e ce that a # of these proce"&res i'pro.e the &ti$it# of the sp&t&' speci'e . Sp&t&' i "&ctio +ith a 3C NaC$ so$&tio , s&!!este" i the past to obtai speci'e s $ess co ta'i ate" fro' the &pper respirator# tract, is c&rre t$# ot reco''e "e" beca&se o be efits ha.e bee "e'o strate" for the etio$o!ica$ i .esti!atio <9:? a " beca&se of the ris/ of pro.o/i ! bro chia$ obstr&ctio . No ethe$ess, the .is&a$i8atio of a pre"o'i a t bacteria$ 'orpho$o!# i 4ra' stai i ! of $o+er respirator# tract (;RT* secretio s 'a# be &sef&$ i pre"icti ! the etio$o!ic a!e t, especia$$# i i te si.e care setti !s +here the pro'pt ess i achie.i ! a etio$o!ica$ "ia! osis a " i "irecti ! the a tibiotic therap# to+ar" !ra'%positi.e or % e!ati.e 'icroor!a is's is f& "a'e ta$ a " 'a# be $ife%sa.i ! i so'e circ&'sta ces.

A$tho&!h the se siti.it# a " specificit# of 4ra' stai i ! of ;RT secretio s ra !es +i"e$# bet+ee 9@ a " 79C a " bet+ee 6A a " A@C, respecti.e$#, accor"i ! to the t#pe a " 1&a$it# of speci'e s, e!ati.e 4ra' stai s a " c&$t&res i patie ts +ho ha.e ot pre.io&s$# recei.e" a tibiotics ha.e a hi!h e!ati.e pre"icti.e .a$&e (76C*, s&!!esti ! that other o i fectio&s ca&ses of p&$'o ar# i fi$trates sho&$" be i .esti!ate" (p&$'o ar# e"e'a, eop$asia, etc.* Whereas the i'porta ce of 4ra' stai i ! a " sp&t&' c&$t&re i the e.a$&atio of p e&'o ia i hospita$i8e" patie ts is c$ear, their ro$e i patie ts +ith p e&'o ia ot se.ere e o&!h to re1&ire hospita$i8atio is "ebate" beca&se the o.era$$ #ie$" is $o+ a " beca&se the i'pact o c$i ica$ care is i fre1&e t. <33,9@>:=? Ho+e.er, a st&"# b# M&sher a " co$$ea!&es o p e&'ococca$ p e&'o ia "e'o strate" that, +ith the e2c$&sio of patie ts +ho ha.e recei.e" a tibiotics +ithi the $ast 26 ho&rs, the se siti.ities of 4ra' stai i ! a " sp&t&' c&$t&re +ere A0C a " 73C, respecti.e$#, s&!!esti ! that, +ith proper 'a a!e'e t ( o prior a tibiotic &se, !oo" speci'e 1&a$it#, a " rapi" tra sport to the $aborator#* these proce"&res ha.e a i crease" &ti$it#. <:2? These co c$&sio s ca be partic&$ar$# tr&e i HCA) patie ts +ith '&$tip$e ris/ factors for MRI beca&se the ATS !&i"e$i es for the 'a a!e'e t of HA), .e ti$ator%associate" p e&'o ia (DA)*, a " HCA) c$ear$# "e$i eate a specific i "icatio for sp&t&' c&$t&re +he it co&$" $i/e$# cha !e the i "i.i"&a$ a tibiotic 'a a!e'e t. <:? The retrospecti.e a a$#sis of Mice/ et a$ <32? i :37 c&$t&re%positi.e patie ts +ith p e&'o ia sho+s that the 'icrobio$o!ica$ "ia! osis +as obtai e" 'ore +ith sp&t&' (:3.9C of CA) patie ts, @3.AC of HCA) patie ts* 'ore tha +ith b$oo" c&$t&res (CA), 3@.9C3 HCA), 30.7C*, 5A; (CA), 6.3C3 HCA), 6.7C* or &ri ar# a ti!e for Legionella (CA), 3.6C3 HCA), 0.2C*. Despite the $i'itatio of a retrospecti.e a a$#sis of o $# positi.e%c&$t&re p e&'o ia, these res&$ts are e co&ra!i ! to co si"er sp&t&' a !oo" speci'e , partic&$ar$# fro' the epi"e'io$o!ica$ poi t of .ie+. Si'i$ar$#, i E$ So$h et a$Is series of e$"er$# patie ts +ith CA), the 'icrobia$ etio$o!# +as obtai e" i 97C of cases b# sp&t&' e2a'i atio a " i 6=C b# other tech i1&es. <:3? Ho+e.er, it is i'porta t to re'e'ber that HCA) patie ts, partic&$ar$# those resi"i ! i ;TCFs, ha.e a hi!h pre.a$e ce of co$o i8atio of the &pper respirator# tract fro' patho!e 'icroor!a is's, a " this fi "i ! ca serio&s$# hi "er the etio$o!ica$ "ia! osis a " 'is$ea" a tibiotic therap#.

Other 'ore i .asi.e b&t re$iab$e respirator# speci'e s are tracheobro chia$ aspirates (T5AS*, fibrobro chia$ aspirates (F5AS*, protecte" speci'e br&sh ()S5*, a " bro choa$.eo$ar $a.a!e (5A;*, co''o $# preferre" to sp&t&' +he a.ai$ab$e (i t&bate" or tracheosto'i8e" patie ts*, for better 4ra' stai se siti.it# a " specificit# as +e$$ as the possibi$it# of perfor'i ! 1&a titati.e c&$t&res that ca "iffere tiate patho!e i fectio s fro' 'icrobia$ co$o i8atio (c&toff .a$&e J =0 9 CFG -';*. The co$$ectio of T5AS is the si'p$est a " $east i .asi.e tech i1&e to obtai respirator# sa'p$es i i t&bate" patie ts at a re$ati.e$# $o+ cost. K&a$itati.e c&$t&re has a $i'ite" .a$&e beca&se, "espite ha.i ! acceptab$e se siti.it# (70 to =00C*, its specificit# for i fectio is .er# poor (=6 to 6@C*. Ho+e.er, 1&a titati.e c&$t&res of T5AS, +ith a c&toff poi t of =0 9 CFG-'; ha.e sho+ a acc&rac# si'i$ar to that of bro choscopic sa'p$i ! 'etho"s <:6? a " +ith the a".a ta!e of a hi!h e!ati.e pre"icti.e .a$&e i case of patie ts +ho ha.e ot pre.io&s$# recei.e" a tibiotics. The st&"# b# E$ So$h a " co$$ea!&es <:9?a a$#8e" the "ia! ostic .a$&e of T5AS c&$t&res i co'pariso +ith )S5 a " 5A; i @9 patie ts +ith se.ere &rsi ! ho'e%ac1&ire" p e&'o ia a"'itte" to the i te si.e care & it (ICG*. The# obtai e" a etio$o!ica$ "ia! osis i 67 patie ts (:9C*, either +ith 5A; or +ith )S5, +ith a abso$&te co cor"a ce i 33 cases (:@C* bet+ee the t+o tech i1&es. I co'pariso , the acc&rac# of T5AS +as fa.orab$e at a c&toff poi t of =0 6 CFG-'; (se siti.it# of 70C a " specificit# of @@C*, +ith the res&$ts coi ci"i ! +ith )S5 a " 5A; i 30 cases (:=C*. K&a titati.e F5AS a$so see's to obtai res&$ts si'i$ar to i .asi.e sa'p$i ! 'etho"s i ter's of "ia! ostic #ie$" a " c$i ica$ o&tco'e. <::? The )S5 tech i1&e a$$o+s ;RT sa'p$i ! b# a".a ci ! a catheter co tai i ! a sea$e" sa'p$i ! br&sh thro&!h the +or/i ! cha e$ of the bro choscope a$$o+i ! 0.0= '; of secretio s to be co$$ecte" for 'icrobia$ i .esti!atio . The se$ecte" thresho$" to "iscri'i ate co$o i8atio a " i fectio s is =0 3 CFG-';, a " )S5 has sho+ a hi!h se siti.it# (abo.e @0C* a " specificit# (A0 to 70C* for i fectio . It sho&$" be poi te" o&t that the "ia! ostic #ie$" "ecreases 'ar/e"$# if the sa'p$e is obtai e" & "er a tibiotic treat'e t. This tech i1&e is si'p$e a " the sa'p$i ! fast, 'i i'i8i ! si"e effects of the proce"&re. 5A; is perfor'e" thro&!h the i sertio of the bro choscope a " ca co$$ect sa'p$es fro' both "ista$ bro chi a " a $ar!e a$.eo$ar area. After b$oc/i ! the tip of the bro choscope i a se!'e ta$ or s&bse!'e ta$ bro ch&s, =00 to =90 '; of sa$i e are i sti$$e" a " aspirate" co sec&ti.e$#. K&a titati.e c&$t&re of 5A;, +ith a c&toff poi t at =0 6 CFG-';, has .er# !oo" se siti.it# a " specificit#

(approachi ! =00C*. The &ti$it# of 5A; i i''& os&ppresse" patie ts +ith p&$'o ar# i fi$trates has bee c$ear$# "e'o strate", +ith the ear$# &se of the i for'atio pro.i"e" b# this 'etho" i this specific pop&$atio bei ! re$ate" to a better o&tco'e. <:@? I CA) there is o fir' i for'atio s&pporti ! its &se a " possib$e si"e effects, a " co trai "icatio s are +ei!hte" i "i.i"&a$$# i each patie t. A$ter ati.e$#, there are Bb$i "B tech i1&es to obtai ;RT secretio s thro&!h the i sertio of a catheter i a "ista$ bro ch&s +itho&t the he$p of fibrobro choscop#. I this case, the se siti.it# a " specificit# are @6 to 7@C a " @6 to =00C, respecti.e$#, for 5AS, a " :3 to =00C a " :: to 7:C for 5A;. E$ So$h a " co$$ea!&es <30,:A? st&"ie" the 'icrobia$ etio$o!# i o$"er patie ts (H @9 #ears* +ith se.ere p e&'o ia a"'itte" to the ICG0 9@ i "i.i"&a$s +ere resi"i ! i the co''& it# a " 6@ i &rsi ! ho'es. A si'i$ar "ia! ostic #ie$" (5A;, )S5 perfor'e" b$i "$# or .ia bro choscopic !&i"e* +as "escribe" i both !ro&ps of CA) a " &rsi ! ho'e%ac1&ire" p e&'o ia, s&!!esti ! that the acc&rac# a " "ia! ostic .a$&e of the i .asi.e tech i1&es to obtai ;RT secretio s are co'parab$e i both !ro&ps. I a""itio , i .asi.e bro chia$ sa'p$i ! i this series <:A? $e" to a cha !e i 'icrobia$ therap# i 60C of cases a " "isco ti &atio of a tibiotics i =0C of "efi ite p e&'o ia, +ith o "iffere ces i 'orta$it# or i the i ci"e ce of co'p$icatio s bet+ee patie ts +ho & "er+e t a bro choscop# a " those +ho "i" ot. Ho+e.er, "&e to the se.erit# of & "er$#i ! 'e"ica$ i$$ esses, the ris/s of i .asi.e "ia! ostic approaches (bro choscop# or ee"$e aspiratio * 'a/e their app$icatio i the practice 'ore i fre1&e t. Ne.erthe$ess, a ;RT sa'p$e sho&$" a$+a#s be co$$ecte" i i t&bate" or tracheosto'i8e" patie ts. It is reco''e "e" to test a$$ the respirator# sa'p$es for '#cobacteria$ (Lieh$% Nie$se a " a&ra'i e stai s3 '#cobacteria$ c&$t&re* as +e$$ as f& !a$ patho!e s, partic&$ar$# i patie ts +ith bro chiectasis or s&specte" i''& os&ppressio beca&se the &'ber of i''& os&ppresse" patie ts a'o ! HCA) cases ca be co si"erab$# hi!her tha i CA) cases, as sho+ i the $ar!e HCA) series fro' the !ro&p i St. ;o&is, Misso&ri, +here i''& os&ppresse" patie ts ra !e" bet+ee 23 a " 37C of a$$ HCA) patie ts +ith positi.e c&$t&res. <2,32? A "ia! ostic thorace tesis sho&$" a$+a#s be perfor'e" i patie ts +ith $ar!e p$e&ra$ eff&sio to i .esti!ate parap e&'o ic eff&sio a " e'p#e'a, co'p$icatio s that ca 'a/e the treat'e t co si"erab$# "iffic&$t a " "e$a# the achie.e'e t of c$i ica$ stabi$it#. <:? 4ra' stai i ! a " c&$t&re for aerobic a "

a aerobic bacteria a " p e&'ococca$ a ti!e tests sho&$" be perfor'e" i the p$e&ra$ $i1&i". A retrospecti.e co'parati.e st&"# of e'p#e'a i ==6 co''& it#% resi"i ! a " 99 &rsi ! ho'e%resi"i ! patie ts <:7? "escribe" that the $atter patie ts ha" a "e$a#e" c$i ica$ prese tatio a " a hi!her #ie$" of a aerobic or!a is's co'pare" +ith i "i.i"&a$s fro' the co''& it#. These fi "i !s s&!!est that partic&$ar atte tio is ecessar# +ith HCA) patie ts beca&se the c$i ica$ prese tatio is ofte 'is$ea"i ! i "efi i ! the se.erit# a " etio$o!# of the "isease, a " 'ore e2te si.e "ia! ostic proce"&res are ee"e" i these patie ts. Tests for the "eter'i atio of &ri ar# a ti!e s for Legionella pneumophila a " Streptococcus pneumoniae are &s&a$$# a.ai$ab$e i e'er!e c# "epart'e ts (EDs* at a $o+ cost a " +ith !oo" feasibi$it#. ) e&'ococca$ testi ! (a$$ serot#pes* has a !oo" se siti.it# (M@0C* a " specificit# (M70C*, b&t it has so'e $i'itatio s0 fa$se%positi.e res&$ts ha.e bee reporte" i i "i.i"&a$s +ho ha" recei.e" specific .acci atio or +ith bro chia$ co$o i8atio . I a""itio , a positi.e res&$t ca be obser.e" &p to 29 +ee/s after the i fectio , therefore 'a/i ! 'ore it "iffic&$t to "iffere tiate ac&te i fectio fro' S. pneumoniae. O the other ha ", ot+ithsta "i ! its hi!h se siti.it# (@0 to 70C* a " specificit# (J 70C*, the &ri ar# a ti!e test for Legionella, +hich is positi.e fro' the thir" "a# of i fectio , is ab$e to "etect o $# serot#pe =, acco& ti ! for @9 to 70C of a$$ i fectio s for Legionella, a " ot serot#pes 6 a " :, +hich a$so ca&se i fectio s i h&'a s. <@0? A$ter ati.e "ia! ostic tests for Legionella are ;RT c&$t&re, "irect f$&oresce t a tibo"# (DFA* stai i ! i respirator# secretio s a " tiss&e sa'p$es (rapi" b&t tech ica$$# "e'a "i !*, seroco .ersio (titers H =0=2A*, or &c$eic aci" a'p$ificatio . ;ar!e epi"e'io$o!ica$ st&"ies ha.e c$ear$# "e'o strate" that o$"er a"&$ts $i.i ! i ;TCFs are at a hi!her ris/ for i .asi.e p e&'ococca$ "isease a " "eath tha co''& it#%$i.i ! o$"er a"&$ts, <@=? a " o&tbrea/s of '&$ti"r&!%resista t (MDR* p e&'ococci <@2,@3? a " of Legionella <@6? a'o ! &rsi ! ho'e resi"e ts ha.e bee +i"e$# "escribe". These "ata co fir' the re$e.a ce of $o+%cost a " eas#%to% perfor' "eter'i atio s for p e&'ococca$ a " Legionella i fectio s i this pop&$atio . Nasophar# !ea$ s+ab is a a""itio a$ eas#%to%perfor' a " $o+%cost test, &sef&$ for the "eter'i atio of respirator# .ir&s (i f$&e 8a .ir&ses A a " 5, parai f$&e 8a .ir&s, respirator# s# c#tia$ .ir&s, a"e o.ir&s, coro a.ir&s, a " rhi o.ir&s*. Dira$ "ia! ostic 'etho"s i c$&"e c&$t&re, rapi" a ti!e "etectio , rea$ ti'e po$#'erase chai reactio (RT%)CR*, a " sero$o!ic testi !, +ith a.ai$abi$it#

a " se siti.it# .ar#i ! o the basis of the specific .ir&s. Respirator# secretio s appropriate for testi ! i c$&"e asa$ s+ab or +ash speci'e s, sp&t&' speci'e s, a " 5A; f$&i" sa'p$es. <@9? St&"ies o CA) i a"&$ts i "icate a .ira$ etio$o!# i = to 23C of cases, +ith the i f$&e 8a .ir&s bei ! the 'ost co''o , <@:? +hereas the i for'atio abo&t .ir&ses i HCA) is re"&ce", +ith the fre1&e c# of .ira$ "etectio ra !i ! bet+ee 0 a " =6C of a$$ cases +ith a / o+ etio$o!ica$ "ia! osis. <30,@@? To"a#, p&re .ira$ p e&'o ia is & co''o , perhaps beca&se prior i fectio a " .acci atio ha.e i "&ce" i''& it# a'o ! o$"er perso s. The tr&e i ci"e ce of seco "ar# bacteria$ p e&'o ia "&ri ! i f$&e 8a is & / o+ , b&t it is c$ear that "&a$ .ira$% bacteria$ i fectio s are 'ore se.ere tha .ira$ i fectio s a$o e, as e.i"e ce" b# hi!her rates of i te si.e care &se a " 'orbi"it#. <@9? A obser.atio a$ 3%#ear st&"# i ;TCFs i .esti!ate" sero$o!# for .ira$ i fectio s i 3A2 patie ts. A tota$ of 206 .ira$ i fectio s +ere i"e tifie" i =9@ s&bFects3 the h&'a 'etap e&'o.ir&s (=3C* a " coro a.ir&s (==C* +ere the 'ost fre1&e t$# iso$ate" .ir&ses. <@A? The prese ce of bro chitis, p e&'o ia, a " a # ;RTIs +as stro !$# associate" +ith the prese ce of a .ira$ i fectio . This +or/ & "o&bte"$# "e'o strates that a +i"e ra !e of respirator# .ir&ses circ&$ate a'o ! ;TCFs, co trib&ti ! to the 'orbi"it# of respirator# i$$ esses. A specific asophar# !ea$ s+ab is i "icate" for 'ethici$$i % resista t Staphylococcus aureus (MRSA* "etectio +he s&specte". No ethe$ess, it 'a# be "iffic&$t to "isti !&ish bet+ee MRSA co$o i8atio (hea$th# carriers*, +hich is re$ati.e$# fre1&e t i +ea/e e" patie ts, a " e+ MRSA i fectio s. I "ee", "iffere t a&thors ha.e "escribe" that S. aureus i fectio s as re$ati.e$# co''o i the &rsi ! ho'e pop&$atio , <@7,A0? especia$$# i i "i.i"&a$s +ith i "+e$$i ! "e.ices, <@? a " these fi "i !s ha.e rei force" the i"ea of e+ o&tbrea/s of co''& it#%ac1&ire" MRSA. I o&r e2perie ce co''& it# MRSA i fectio s are a ec"ota$, a " co tact +ith the hea$thcare e .iro 'e t sho&$" be i .esti!ate" beca&se it see's to be the 'ost fre1&e t so&rce of s&ch i fectio s. The s&spicio of Bat#pica$ p e&'o iaB sho&$" be ta/e i to acco& t +he "ea$i ! +ith o$"er a " &rsi ! ho'e patie ts beca&se epi"e'ic episo"es ha.e bee "escribe" i these pop&$atio s. <A,7,A=?Sero$o!# testi ! is a.ai$ab$e for Chlamydia pneumoniae a " Mycoplasma pneumoniae, <A2? acco& ti ! for a .ariab$e &'ber of p e&'o ia cases (&p to 2=C of CA), <A3? 2 to 2@C of HCA) statistics <=2,30? *, b&t a$so for .ir&s (see before*. The &ti$it# of sero$o!# i ro&ti e testi ! is poor "&e to the "e$a# i obtai i ! res&$ts, a$tho&!h it has a i'porta t ro$e i pop&$atio a$

st&"ies a " for epi"e'io$o!ica$ p&rposes. <A6,A9? Ho+e.er, the e'pirica$ a tibiotic treat'e t of HCA) sho&$" a$+a#s co.er at#pica$ patho!e s ('acro$i"es, 1&i o$o es, etc.*. <33? Nasophar# !ea$ s+ab has a$so rece t$# bee &se", +he a.ai$ab$e, for )CR "eter'i atio of a i creasi ! &'ber of 'icroor!a is's. <A:? I .ie+ of s&ch a +i"e pa e$ of 'icrobio$o!ica$ tests the "ecisio of the ph#sicia is !&i"e" b# specific c$i ica$ i "icatio s, proce"&ra$ ris/s, the c$i ica$ co "itio s of patie ts, ti'e to res&$ts, a " so forth. I "icators for 'ore e2te si.e "ia! ostic tests sho&$" be co si"ere", i c$&"i ! (=* ear$# fai$&re, (2* p$e&ra$ eff&sio , (3* ca.itatio , (6* rece t tra.e$ to e2otic p$aces, a " (9* histor# of i''& os&ppressio (&r!e t fiberbro choscop# <F5S?*. <=A?
Table , Mai# %auses of Recurre#t P#eu(o#ia
So&rces of aspiratio D#spha!ia a " co&!h ref$e2 "isor"ers
<=7,A7?

Hiata$ her ia as a ca&se of repetiti.e oct&r a$ bro choaspiratio (!astric re!&r!itatio * De ta$ p$a1&e a " phar# !ea$ co$o i8atio b# patho!e ic 'icroor!a is's S$eep ap ea%re$ate" bro co%aspiratio s
<76,79? <=7,72,73?

<70,7=?

5ro chiectasis0 i"iopathic a " seco "ar# <7:? H&'ora$ i''& it# "isor"ers (i.e., co''o .ariab$e i''& o"eficie c# <7@? *. Mi""$e $obe s# "ro'e <7A? Obstr&cti.e p e&'o ia a " ca cer <77?

Hea$thcare%Associate" ) e&'o ia
Fac&$t# a " Disc$os&res CME-CE Re$ease"0 0:-29-200@3 Da$i" for cre"it thro&!h 0:-29-200A

%ME-%E I#for(atio#

INTRODU%TION
Hea$thcare%associate" p e&'o ia (HCA)*, a e+$# reco! i8e" for' of p e&'o ia, +as i c$&"e" i the 2009 A'erica Thoracic Societ# (ATS*-I fectio&s Diseases Societ# of A'erica (IDSA* !&i"e$i es for osoco'ia$ p e&'o ia.<=? HCA) refers to patie ts +ith p e&'o ia, at a # ti'e i their hospita$ sta# (o a"'issio or ac1&ire" i the hospita$*, +ho ha.e a histor# of rece t hospita$i8atio i the past 70 "a#s, resi"e ce i a &rsi ! ho'e or e2te "e" care faci$it#, treat'e t +ith chro ic he'o"ia$#sis, receipt of ho'e +o& " care, or e2pos&re to a fa'i$# 'e'ber +ith "r&!%resista t patho!e i fectio . There re'ai s co f&sio abo&t ho+ to best "efi e this e tit#, +hat the $i/e$# patho!e s are, a " ho+ to opti'a$$# approach therap# a " pre.e tio . I a""itio , the !&i"e$i es co si"ere" that patie ts +ith HCA) are at ris/ for i fectio +ith '&$ti"r&!%resista t (MDR* !ra' e!ati.es a " 'ethici$$i %resista t Staphylococcus aureus (MRSA*. Th&s, the c&rre t reco''e "atio is to treat HCA) patie ts +ith '&$ti"r&! broa"%spectr&' e'pirica$ therap#, a practice that 'a# pro'ote f&rther a tibiotic resista ce, partic&$ar$# if s&ch broa"%spectr&' therap# is ot ee"e" for a$$ affecte" i "i.i"&a$s. At the 200@ ATS 'eeti !, a s#'posi&' +as he$" to "isc&ss HCA) a " the co tro.ersies i 'a a!e'e t a " pre.e tio . Topics "isc&sse" i c$&"e" "efi i ! HCA) epi"e'io$o!# a " bacterio$o!#, the approach to "ia! osis, therap# a " pre.e tio , a " e.a$&atio of the best +a# to &se effecti.e therap# +hi$e 'i i'i8i ! the pro'otio of a ti'icrobia$ resista ce, $ea"i ! to opti'a$ patie t o&tco'es.

E&i e(iolo!. a# /acteriolo!.


;i/e co''& it#%ac1&ire" p e&'o ia (CA)*, HCA) ca be prese t +he the patie t is first a"'itte" to the hospita$, b&t & $i/e CA), a " si'i$ar to osoco'ia$ p e&'o ia, the etio$o!ic patho!e s ca be MDR !ra' e!ati.es a " MRSA. A st&"# b# Eo$$ef a " co$$ea!&es<2? ote" that this "iffere ce i bacterio$o!# is $i/e$# a co se1&e ce of the fact that HCA) patie ts ha.e 'ore co'orbi" i$$ ess tha patie ts +ith CA). These co'orbi"ities i c$&"e i''& os&ppressio , "iabetes, chro ic re a$ "isease, heart "isease, a " stro/e. Marcos I$ Restropo, MD, fro' the G i.ersit# of Te2as, Sa A to io, "isc&sse" & p&b$ishe" "ata fro' his o+ i stit&tio +here a$$ HCA) patie ts ha" MDR ris/ factors, +hich i c$&"e" prior a tibiotics, resi"e ce i a &rsi ! ho'e, chro ic re a$ fai$&re, a " i''& os&ppressio . O e other & p&b$ishe" st&"# fro' Washi !to G i.ersit# i St. ;o&is, Misso&ri, fo& " that HCA) +as 'ore co''o tha CA), a " that :3C of these patie ts ha" bee rece t$# hospita$i8e"3 3=C +ere i''& os&ppresse"3 =AC +ere &rsi ! ho'e resi"e ts3 a " :C +ere & "er!oi ! he'o"ia$#sis. Dr. Restropo "escribe" st&"ies "oc&'e ti ! the bacterio$o!# of HCA) to i c$&"e a hi!h fre1&e c# of MRSA a "Pseudomonas aeruginosa.<2? I o e st&"#, the fre1&e c# of MRSA +as 9@C b&t 29C ha" P aeruginosa,<2? +hereas i a other st&"# of patie ts +ith MDR !ra'

e!ati.es prese t o a"'issio , there +as a hi!h fre1&e c# of HCA) ris/ factors, i c$&"i ! rece t a tibiotics a " resi"e ce i a $o !%ter' care faci$it#. <3? Whe patie ts +ith MRSA +ere co'pare" +ith those +ith 'ethici$$i %s&sceptib$e S aureus (MSSA* i fectio i a other st&"# &si ! a case%co tro$ 'etho"o$o!#, o ce a!ai , prior hospita$i8atio , ho'e &rsi ! care, a " tra sfer fro' a &rsi ! ho'e +ere a$$ associate" +ith the prese ce of MRSA.<6? The hi!her fre1&e c# of these "iffic&$t patho!e s i patie ts +ith HCA) 'a# e2p$ai +h# their 'orta$it# rate of =2C to 23C is hi!her tha that of patie ts +ith CA). To 'i i'i8e this 'orta$it# ris/, Dr. Restropo &r!e" the &se of ear$# a " a!!ressi.e appropriate e'pirica$ therap#, +ith a broa"%spectr&' a ti'icrobia$ approach fo$$o+e" b# "e%esca$atio to fe+er "r&!s a " arro+er spectr&' a!e ts, as c&$t&re a " c$i ica$ "ata beco'e a.ai$ab$e. I a""itio , he reco''e "e" &se of therap# at proper "oses, as s&!!este" i the ATS-IDSA !&i"e$i es, a " he reco''e "e" $i e8o$i" o.er .a co'#ci for the therap# of MRSA .e ti$ator%ac1&ire" p e&'o ia (DA)*.<=? O e a""itio a$ s&!!estio that he "isc&sse" +as to &se short%"&ratio therap#, citi ! a Fre ch st&"# that "oc&'e te" the efficac# of A%"a# therap# of DA) ca&se" b# or!a is's other tha o fer'e ti ! !ra' e!ati.es, s&ch as P aeruginosa.<9?

Pat$o!e#esis a# Pre0e#tio# of H%AP


Da.i" Ost, MD, fro' Ne+ Nor/ G i.ersit# Schoo$ of Me"ici e, Ne+ Nor/, NN, "isc&sse" the patho!e esis a " &se of ris/ factors to !&i"e the pre.e tio of DA), i a effort to & "ersta " ho+ to a.oi" other osoco'ia$ p e&'o ia s# "ro'es, i c$&"i ! HCA). He cite" the i'pact of DA) o hospita$ sta#, +hich i creases sta# b# @%7 "a#s, +hi$e a""i ! a cost of ear$# O=2,000 per episo"e.<:? Dr. Ost poi te" o&t the i'precisio of c$i ica$ "efi itio s of DA), sho+i ! that "epe "i ! o the &'ber of criteria &se", the fre1&e c# of i fectio ca .ar# fro' AC to 30C, b&t that b# a # "efi itio , DA) $ea"s to a".erse o&tco'es. I a""itio , the fre1&e c#, +he e2presse" as a "ai$# ris/ rate, fa$$s +ith i creasi ! "&ratio of 'echa ica$ .e ti$atio , e'phasi8i ! the ee" for pre.e tio st&"ies to stratif# patie ts b# the "&ratio of 'echa ica$ .e ti$atio . 4i.e this i'porta t i'pact of DA), pre.e tio co&$" ha.e a hi!h re+ar", a " efforts sho&$" be base" o a & "ersta "i ! of both 'o"ifiab$e a " & 'o"ifiab$e ris/ factors %% a " 'i!ht re"&ce the i ci"e ce b# as '&ch as 90C.<@? O the basis of a & "ersta "i ! of 'o"ifiab$e ris/s, the effecti.e strate!ies for pre.e tio that Dr. Ost reco''e "e" i c$&"e" rapi" +ea i ! fro' the .e ti$ator, i c$&"i ! "ai$# i terr&ptio of se"atio 3 &se of o i .asi.e .e ti$atio +he possib$e3 positio i ! patie ts +ith the hea" of the be" e$e.ate"3 &si ! ope $& ! .e ti$atio if possib$e3 a.oi"a ce of asotrachea$ i t&batio i fa.or of orotrachea$ i t&batio 3 treat'e t i a a"e1&ate$# staffe" i te si.e care & it (ICG*3 caref&$ co si"eratio of se$ecti.e "i!esti.e "eco ta'i atio (+ith topica$ a " s#ste'ic a tibiotics, b&t ot topica$ a$o e* to re"&ce the ris/ for !ra'% e!ati.e i fectio 3 co si"eratio of ch$orhe2i"i e baths3 a " co si"eratio of s&cra$fate for i testi a$ b$ee"i ! proph#$a2is. Dr. Ost e'phasi8e" the "iffere ce bet+ee efficac# i c$i ica$ tria$s a " tr&e c$i ica$ effecti.e ess i Brea$%+or$"B sit&atio s. He state" that the &se of s&b!$ottic secretio "rai a!e +ith specia$ e "otrachea$ t&bes a " specific e tera$ fee"i ! 'etho"s co&$" ot be specifica$$# reco''e "e".

Dia!#osi#! Nosoco(ial P#eu(o#ia


Ee eth D. ;eeper, MD, fro' the E'or# Schoo$ of Me"ici e i At$a ta, 4eor!ia, "isc&sse" the co tro.ersies s&rro& "i ! i .asi.e .s o i .asi.e "ia! osis of DA). His 'aFor foc&s +as to e2a'i e +hich approach co&$" 'i i'i8e the i'pact of DA) o 'orta$it#, $e !th of sta#, a tibiotic &se, a tibiotic resista ce, a " "&ratio of 'echa ica$ .e ti$atio . He first "isc&sse" the rece t$# p&b$ishe", Ca a"ia , '&$tice ter c$i ica$ tria$ co'pari ! i .asi.e a " o i .asi.e "ia! ostic 'etho"s, a " "e'o strati ! o i'pact o 'orta$it#.<A? He critici8e" the tria$ beca&se it "i" ot e ro$$ 'a # patie ts +ith MDR patho!e s.

I tr#i ! to "efi e the 'ost cost%effecti.e approach to DA) "ia! osis, Dr. ;eeper first e2a'i e" o i .asi.e strate!ies. He poi te" o&t that the c$i ica$ "efi itio of p e&'o ia has a re$ati.e$# $o+ se siti.it# a " specificit# i so'e st&"ies, b&t that if too se siti.e a "efi itio +ere &se", it co&$" $ea" to the o.er&se of a tibiotics a " a fai$&re to reco! i8e o p e&'o ic ca&ses of fe.er. He poi te" o&t the pote tia$ .a$&e of the C$i ica$ )&$'o ar# I fectio Score (C)IS* to e ha ce the o i .asi.e "ia! osis of DA), a " cite" a st&"# b# Si !h a " co$$ea!&es<7? i +hich a tibiotic cost, a tibiotic resista ce, a " 'orta$it# +ere re"&ce" +he a protoco$ e'p$o#i ! seria$ 'eas&re'e ts of C)IS +as &se" to !&i"e a tibiotic therap#, +he co'pare" +ith &s&a$ c$i ica$ 'a a!e'e t. He a$so sho+e" ho+ c$i ica$ 'a a!e'e t co&$" be &se" to !&i"e "&ratio of therap#, a " $ea" to $ess s#ste'ic a tibiotic &se. ;oo/i ! at the p&tati.e a".a ta!es of a i .asi.e "ia! ostic approach, Dr. ;eeper cite" the pote tia$ to a.oi" & ecessar# a " i appropriate a tibiotic therap#, a " to be ab$e to arro+ a " foc&s a tibiotics o ce c&$t&re "ata fro' 1&a titati.e c&$t&res of $o+er respirator# tract secretio s beco'e a.ai$ab$e. He "isc&sse" a re.ie+<=0? that reporte" the se siti.it# of bro choscopic "ia! osis to be bet+ee 62C a " 73C, +ith a specificit# .ar#i ! bet+ee 69C a " =00C. Ear$# st&"ies "oc&'e te" the safet# of +ithho$"i ! therap# i patie ts +ith e!ati.e 1&a titati.e c&$t&res a " a $o+ c$i ica$ s&spicio of i fectio , b&t a $ar!e Fre ch '&$tice ter st&"# co'pari ! a i .asi.e bro choscopic approach +ith a o i .asi.e strate!# for a tibiotic &se sho+e" a re"&ctio i =6%"a# 'orta$it# a " a tibiotic &se.<==? O e a$ter ati.e to bro choscopic c&$t&res is b$i " 'i ibro choa$.eo$ar $a.a!e (5A;* "o e thro&!h a e "otrachea$ t&be, a " o e "ecisio a a$#sis sho+e" that the best approach to 'a2i'i8e DA) s&r.i.a$, +hi$e 'i i'i8i ! cost a " a tibiotic &se, +as to !i.e e'pirica$ therap# +ith 3 a tibiotics a " the a"F&st o the basis of 'i i%5A; c&$t&re "ata.<=2? Dr. ;eeper a".ocate" this approach, b&t state" that at his i stit&tio the "ecisio to start therap# +as a$so !&i"e" b# C)IS, b&t the "ecisio to co ti &e or 'o"if# therap# +as, i part, base" o the res&$ts of a repeat 'i i%5A;, "o e after 6 "a#s of therap#.

Ma#a!i#! H%AP a# Re uci#! t$e Risk for A#ti(icrobial Resista#ce


There are .ario&s +a#s to $i'it a tibiotic resista ce b# 'a a!i ! ris/ factors i the patie t +ith HCA). Not o $# ha.e the resista ce rates i osoco'ia$ p e&'o ia bee risi ! i rece t #ears, especia$$# if i fectio is ca&se" b# P aeruginosa or MRSA, b&t i o e rece t 4er'a st&"#, i fectio +ith these patho!e s +as a i "epe "e t ris/ factor for 'orta$it#, &si ! '&$tip$e $o!istic re!ressio a a$#sis.<=3? A &'ber of factors ha.e $e" to risi ! rates of resista ce, i c$&"i ! i appropriate &se of a tibiotics, & "er"osi ! of /e# a ti'icrobia$ a!e ts, &si ! a broa"er spectr&' of therap# tha is ee"e", & ecessar# treat'e t of air+a# co$o i8atio , e2cessi.e$# pro$o !e" therap#, a " fai$&re of i fectio co tro$ 'etho"s. Co''o to 'a # of these factors is the &sa!e of a tibiotics, a " 'a # i .esti!atio s ha.e sho+ that &sa!e +ithi 2 +ee/s of the o set of DA) is a ris/ for s&bse1&e t resista ce to the pre.io&s$# &se" a tibiotic.<=6,=9? I a "isc&ssio , +hich I $e" at this 'eeti !, I hi!h$i!hte" a &'ber of pote tia$$# effecti.e strate!ies to $i'it resista ce, +hich i c$&"e" i fectio co tro$, s&r.ei$$a ce respirator# c&$t&res, a.oi"i ! 'o otherap# +ith certai a ti'icrobia$ a!e ts, a.oi"i ! broa"er a ti'icrobia$ therap# tha is ecessar#, a ti'icrobia$ Bste+ar"ship,B "e%esca$atio of therap# +he possib$e, a " 'ore effecti.e B&p%fro tB therap#. I fectio co tro$ is a & i.ersa$ ee", a " it ca $i'it the sprea" of resista t patho!e s fro' o e patie t to a other. I a""itio , i fectio co tro$ practitio ers ca faci$itate a !oo" / o+$e"!e of $oca$ (specific for each ICG* 'icrobio$o!#. A st&"# b# the D&/e G i.ersit# I fectio Co tro$ Net+or/, co$$ecti ! s&ch "ata a " shari ! best practices, $e" to a re"&ctio i the fre1&e c# of DA) a " of i fectio s ca&se" b# MRSA.<=:? A &'ber of strate!ies ha.e $e" to the &se of fe+er a " 'ore foc&se" a tibiotics, a " beca&se &sa!e is the 'aFor factor "ri.i ! resista ce, these strate!ies co&$" be .er#

.a$&ab$e. These ha.e i c$&"e" the co$$ectio of trachea$ aspirate s&r.ei$$a ce c&$t&res, +hich ca be &se" to !&i"e i itia$ DA) e'pirica$ therap#, a " i o e st&"# this practice $e" to the &se of $ess broa"%spectr&' therap# tha the &se of i ter atio a$ !&i"e$i es.<=@? Caref&$ se$ectio of specific a ti'icrobia$s is a$so a effecti.e strate!# to $i'it resista ce, beca&se 'o otherap# +ith thir"%!e eratio cepha$ospori s ca pro'ote the e'er!e ce of e2te "e"% spectr&' beta%$acta'ases a " the e'er!e ce of i "&cib$e t#pe = chro'oso'a$ beta% $acta'ases "&ri ! therap#.<=,=A? I a""itio , 1&i o$o es ca pro'ote a ti'icrobia$ resista ce, ot o $# to 1&i o$o es, b&t a$so to '&$tip$e other a!e ts, a ", th&s, I s&!!este" that i the ICG, these a!e ts sho&$" !e era$$# be reser.e" for a seco " episo"e of i fectio %% a " ot the first ac1&ire" i fectio %% beca&se the $atter practice 'a# 'a/e it i'possib$e to ha.e a # effecti.e a!e ts for s&bse1&e t i fectio .<=9? I a effort to a.oi" the &se of broa"er spectr&' therap# tha is abso$&te$# ecessar#, +e e2a'i e" the reco''e "atio of c&rre t !&i"e$i es to treat a$$ HCA) patie ts +ith a 3%"r&! re!i'e !eare" at resista t !ra' e!ati.es a " MRSA.<=? Citi ! a st&"#, fro' 5&ffa$o, Ne+ Nor/, of AA patie ts +ith se.ere &rsi ! ho'e%ac1&ire" p e&'o ia, he poi te" o&t that resista t or!a is's +ere o $# prese t i =7C, a " that the# +ere prese t o $# if patie ts ha" '&$tip$e ris/ factors, i a""itio to se.ere i$$ ess.<=7? 5eca&se arro+%spectr&' therapies ha.e bee effecti.e for so'e &rsi ! ho'e pop&$atio s, he reco''e "e" that trip$e therap# be reser.e" for patie ts +ith at $east 2 of the 3 /e# ris/ factors, a " that patie ts +itho&t these ris/s be treate" +ith a arro+er spectr&' re!i'e . These ris/ factors +ere se.ere i$$ ess, rece t a tibiotic therap#, a " poor f& ctio a$ stat&s. A rece t IDSA p&b$icatio e2a'i e" the practices of a ti'icrobia$ ste+ar"ship, e'phasi8i ! the '&$ti"iscip$i ar# at&re of this effort, +hich ca be "o e thro&!h prospecti.e a&"its a " i ter.e tio s or b# for'&$ar# restrictio s.<20?The reco''e "atio for for'&$ar# restrictio s +as ot stro !, b&t the st&"# a&thors "i" reco''e " &se of therap# !&i"e$i es that are base" o $oca$ bacterio$o!ic "ata, "e%esca$atio of therap# +he possib$e, a " "ose opti'i8atio . A ti'icrobia$ c#c$i ! a " a tibiotic or"er for's +ere ot stro !$# reco''e "e". I c$osi !, I reco''e "e" a &'ber of other strate!ies to $i'it resista ce, i c$&"i ! shorter "&ratio s of therap#. O e +a# to faci$itate this approach 'a# be to fo$$o+ seria$ 'eas&re'e ts of bio$o!ica$ 'ar/ers, s&ch as C%reacti.e protei a " proca$cito i . O e other pro'isi ! strate!# that +as "isc&sse" is the &se of a"F& cti.e aeroso$i8e" a'i o!$#cosi"es to opti'i8e the i itia$ therap# of MDR !ra' e!ati.es. I "escribe" & p&b$ishe" "ata fro' a '&$tice ter st&"# of aeroso$i8e" a'i/aci , !i.e b# a specia$ proprietar# eb&$i8er, i a b$i "e" p$acebo%co tro$$e" fashio , a$o ! +ith s#ste'ic a ti'icrobia$s (a$$ patie ts recei.e" this $atter therap#*. The "ata sho+e" that at the e " of @ "a#s, patie ts !i.e aeroso$ a tibiotic therap# +ere &si ! $ess s#ste'ic a tibiotics tha patie ts !i.e a p$acebo aeroso$, raisi ! the possibi$it# that this approach ca era"icate i fectio rapi"$# a " 'i i'i8e the ee" for pro$o !e" s#ste'ic therap#.

Usi#! Pat$o&$.siolo!. a# Risk Factors to O&ti(i1e H%AP Outco(es


Richar" 4. W& "eri /, MD, FCC), fro' Fei ber! Schoo$ of Me"ici e, North+ester G i.ersit#, Chica!o, I$$i ois, foc&se" o +a#s to i'pro.e the o&tco'es, especia$$# 'orta$it#, "&ratio of ICG sta#, "&ratio of 'echa ica$ .e ti$atio , a " the "e!ree of or!a "#sf& ctio i patie ts +ith HCA). He referre" to a st&"# of MRSA DA) i +hich the &se of $i e8o$i", rather tha .a co'#ci , $e" to a re"&ctio i 'orta$it#.<2=? The 'aFor foc&s of the "isc&ssio +as to e.a$&ate a ti'icrobia$ treat'e t fai$&re a " rec&rre t i fectio as si! s of i''& os&ppressio i the critica$$# i$$ patie t, especia$$# as a co se1&e ce of i''& e para$#sis at the ti'e of se.ere i fectio . Dr. W& "eri / co si"ere" 2 possib$e t#pes of e2p$a atio s for this i''& e "#sf& ctio , both +ith s&pporti ! "ata0 te'porar# "isease%re$ate" i''& e i'pair'e t a " fi2e" i''& e i'pair'e t as a co se1&e ce of !e etic po$#'orphis's i the i''& e respo se. He a".ocate" the &se of

bio'ar/ers to fo$$o+ the co&rse of the i''& e respo se to i fectio . He be$ie.e" that the 'aFor foc&s for the f&t&re +o&$" be to & "ersta " this i''& e para$#sis a " reco! i8e it +he prese t, so that i ter.e tio s co&$" be 'a"e to i'pro.e o&tco'es. C&rre t$#, beca&se +e "o ot ha.e s&ch i ter.e tio s, +e are $i'ite" to cha !i ! a tibiotics i the face of & co tro$$e" i fectio , fi "i ! & reco! i8e" sites of i fectio , a " rep$aci ! i''& o!$ob&$i s i patie ts +ho are "eficie t. Supported by an independent educational grant from GlaxoSmithKline Refere ces < C;OSE WINDOW ?

Refere#ces
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