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CAP

COMMUNITY ACQUIRED
PNEUMONIA
Cokorda Agung Abi Baruna
1102005032

Pneumonia

CAP
CAP
HCAP
HCAP

Community Acquired

HAP
HAP
ICUAP
ICUAP

Hospital Acquired

VAP
VAP

Ventilator Acquired

Nosocomial
Nosocomial
Pneumonias

Health Care
Associated

ICU Acquired

Community Acquired
Pneumonia (CAP)
Definisi

Community acquired pneumonia (CAP)


merupakan suatu penyakit inflamasi yang
mempengaruhi alveoli, yang biasa disebabkan oleh
infeksi virus atau bakteri, yang terjadi pada
individual yang tidak memiliki riwayat masuk
rumah sakit ataupun memiliki riwayat kontak yang
sedikit dengan rumah sakit atau yang berhubungan
dengan tenaga kesehatan sebelumnya.

Bartlett. Clin Infect Dis 2000;31:347-82.

Community Acquired
Pneumonia (CAP)

Epidemiology
4-5 juta kasus annually
~500,000 dilarikan ke RS 20%
memerlukan rawat inap
~45,000 kematian
Kasus terendah pada kelompok umur
18-24
Insiden tertinggi pada <5 dan >65
tahun
Kematian terbanyak pada >65 tahun
<1% tidak memerlukan pengobatan RS
Bartlett. CID 1998;26:811-38.

CAP Pathogenesis
Inhalation
Inhalation
Aspiration
Aspiration
Hematogeno
Hematogeno
us
us

CAP Faktor Resiko Pneumonia

Umur
Obesitas
Perokok
Asma, COPD
Pasien dengan sistem imun
rendah (HIV)

ID Clinics 1998;12:723. Am J Med 1994;96:313

Tipe CAP
KLASIK
KLASIK
1.
2.

3.
4.
5.
6.

7.

Onset tiba tiba


Demam tinggi,
menggigil
Sakit dada pleuritis
Batuk berdahak
Sputum kotor / darah
Mortalitas tinggi
mencapai 20%
pasien dengan
bakteremia
S.pneumoniae
sebagai penyebab

ATIPIKAL
ATIPIKAL

Onset Gradual
Demam ringan
Batuk kering, tanpa
darah
Mortalitas rendah 1-2%
kecuali pasien dengan
Legionella
Mycoplasma, Chlamydiae,
Legionella, Ricketessiae,
Viruses are causative

CAP Pathogen
40-60% - tidak terdeteksi

2-5% - 2 atau lebih pathogen terdeteksi

4%
4%
5%
6%
6%
10%

9%

56%

S.pneumonia
e
H.influenza
Chlamydia
Legionella
spp
S.aureus
Mycoplasma
Gram Neg
bacilli

Streptococcus pneumonia
(Pneumococcus)

Penyebab tersering CAP


hampir 2/3 kasus CAP
Merupakan diplococci gram positif
Gejala tipikal (e.g. malaise,
menggigil ,demam , sputum
seperti karat, sakit dada, batuk)
Infiltrat lobar pada foto polos dada
25% akan mengalami bakteremia
efek serius

CAP Gejala Special


Typical S.pneumoniae, H.influenza, M.catarrhalis Lungs
Blood tinged sputum - Pneumococcal, Klebsiella,
Legionella
H.influenzae CAP has associated of pleural effusion
S.Pneumoniae commonest penicillin resistance
problem
S.aureus, K.pneumoniae, P.aeruginosa not in typical host
S.aureus causes CAP in post-viral influenza; Serious CAP
K.pneumoniae primarily in patients of chronic alcoholism
P.Aeruginosa causes CAP in pts with CSLD or CF, Nosocom
Aspiration CAP only is caused by multiple pathogens
Extra pulmonary manifestations only in Atypical CAP

10

CAP Insiden Berdasar


Umur
1400
1200
1000
800
600
400
200
0

11

<5

5 to 17 18-24

25-44

45-64

>65

CAP mortalitas Berdasar Umur


74.9

80
70
60
50
40

# of deaths

30
20
10
0

12

2
<40

5 to014

0
15-24

25-44

5.7
45-64

>65

CAP Risk Factors for Mortality

13

Umur > 65
Bakteremia (S.
pneumoniae)
S. aureus
Perubahan Temuan
radiologi yang memburuk
Imunitas yang memburuk
ID Clinics 1998;12:723. Am J Med 1994;96:313

CAP Bacteriology in
Hospitalized Pts

14

CAP Evaluasi pasien


Gejala, PE,
Gejala,
PE,
foto
polos
foto polos

No Infiltrat
No Infiltrat

Diagnosis
Diagnosis
lain
lain

Infiltrat / gejala
Infiltrat
/ gejala
klinis CAP
klinis CAP
Evaluasi
Evaluasi
kebutuhan
MRS/
kebutuhan
tidak MRS/
tidak
Out
Out
Patient
Patient

15

PORT &
PORT
CURB
65&
CURB 65
Ruang
Ruang
perawat
perawat
an
an

ICU
ICU

CAP Management Guidelines

16

Rational use of microbiology


laboratory
Pathogen directed antimicrobial
therapy whenever possible
Prompt initiation of Antibiotic
therapy
Decision to hospitalize based on
prognostic criteria - PORT or CURB
65

PORT Scoring PSI


PORT Scoring PSI

Clinical Parameter

Scoring

Age in years

Example

For Men (Age in yrs)

50

For Women (Age -10)

(50-10)

NH Resident

10 points

Co-morbid Illnesses

17

Neoplasia

30 points

Liver Disease

20 points

CHF

10 points

CVD

10 points

Renal Disease (CKD)

10 points

18

Classification of Severity - PORT

Class
Class
I
I Predictor
Predictor
s Absent
s Absent

Class
Class
II
II

Class
Class
IV
IV 91 - 130
91 - 130

19

70
70

Class
Class
III
III 71 90

Class
Class
V
V
> 130
> 130

71 90

CAP Management based on


PSI Score
PORT
Class

20

PSI Score

Mortalit
y%

Treatment
Strategy

Class I

No RF

0.1 0.4

Out patient

Class II

70

0.6 0.7

Out patient

Class III

71 - 90

0.9 2.8

Brief
hospitalization

Class IV

91 - 130

8.5 9.3

Inpatient

Class V

> 130

27
31.1

IP - ICU

CURB 65 Rule Management of


CAP
CURB 65
CURB 65
Confusio
Confusio
n
n
BUN > 30
BUN > 30
RR > 30
RR > 30
BP SBP
BP SBP
<90
<90
DBP <60
DBP <60
Age > 65
Age > 65

21

CURB
CURB 00 or
or
11

Home
Home Rx
Rx

CURB
CURB 22

Short
Short Hosp
Hosp

CURB
CURB 33

Medical
Medical
Ward
Ward

CURB
CURB 44 or
or
55

ICU
ICU care
care

Algorithmic Approach
Step
Step 11
< 50
< 50
Years
Years
CAP
CAP
Patient
Patient

No
No
CoComorbidity
morbidity
CoComorbidity
morbidity
Present
Present

50
50
Years
Years

22

Step
Step 22

PORT
PORT

Step
Step 44

Step
Step 33
No
No
CURB
CURB

Class I
Class I

Only OP
Only OP

CURB +
CURB +

OP / IP/
OP
ICU/ IP/
ICU
Class II-V
Class II-V

Who Should be
Hospitalized?
Class
Class II and
and IIII Usually
Usually do
do not
not require
require
hospitalization
hospitalization
Class
Class III
III May
May require
require brief
brief hospitalization
hospitalization
Class
Class IV
IV and
and VV Usually
Usually do
do require
require hospitalization
hospitalization

Severity
Severity of
of CAP
CAP with
with poor
poor prognosis
prognosis
RR
RR >
> 30;
30; PaO
PaO22/FiO2
/FiO2 <
< 250,
250, or
or PO
PO22 <
< 60
60 on
on
room
room air
air
Need
Need for
for mechanical
mechanical ventilation;
ventilation; Multi
Multi
lobar
lobar involvement
involvement
Hypotension;
Hypotension; Need
Need for
for vasopressors
vasopressors
Oliguria; Altered
Altered mental
mental status
status
23 Oliguria;

CAP Criteria for ICU Admission

24

Major criteria
Ventilasi mekanik invasive diperlukan
Septik syok yang memerlukan
vasopressor
Minor criteria (least 3)
disorientasi
Blood urea nitrogen 20 mg%
RR 30 / min; temp < 36C
Hipotensi berat ; PaO2/FiO2 ratio
250
Infiltrat multilobar
WBC < 4000 cells; Platelets <100,000

CAP Pemeriksaan penunjang

25

CXR PA &
CXR PA &
lateral
lateral
CBC
CBC
BUN dan
BUN dan
Creatinine
Creatinine
FBG, PPBG
FBG, PPBG
Liver enzymes
Liver enzymes

Serum electrolytes
Serum electrolytes
Gram stain of
Gram stain of
sputum
sputum
Culture of sputum
Culture of sputum
Pre Rx. blood
Pre Rx. blood
cultures
cultures
Oxygen saturation
Oxygen saturation

CAP Chest Radiography


Diagnostic
Diagnostic
Indikator prognosis
Indikator prognosis
Eksklusi diagnosis
Eksklusi diagnosis
pembanding
pembanding
Dapat membantu
Dapat membantu
menentukan
menentukanetiology
etiology

J Chr Dis 1984;37:215-25

26

Infiltrate Patterns and Pathogens


CXR
Pattern
Lobar
Patchy
Interstitial
Cavitatory
Large
effusion

27

Possible Pathogens
S.pneumo, Kleb, H. influ,
Gram Neg
Atypicals, Viral,
Legionella
Viral, PCP, Legionella
Anerobes, Kleb, TB,
S.aureus, Fungi
Staph, Anaerobes,
Klebsiella

CAP Grams Stain of


Sputum
Good sputum samples is obtained

Good sputum samples is obtained


only
only from
from 39%
39%
83%
83% show
show only
only one
one predominant
predominant
S.
H.
organism
organism
Efficiency of test
pneumoni influenz
ae
a

28

Sensitivity

57 %

82 %

Specificity

97 %

99 %

Positive
Predictive Value
Negative
Predictive Value

95 %

93 %

71 %

96 %

Antibiotics of choice for


CAP
Macrolide -M
Macrolide -M

Azithromycin
Azithromycin
Clarithromycin
Clarithromycin
Erythromycin
Erythromycin
Telithromycin
Telithromycin
Doxycycline
Doxycycline

29

FluroquinoloneFluroquinoloneFQ
FQ

Levofloxacin
Levofloxacin
Moxifloxacin
Moxifloxacin
Gatifloxacin
Gatifloxacin
Trovafloxacin
Trovafloxacin

Betalactum - B
Betalactum - B
Ceftriaoxone
Ceftriaoxone
Cefotaxime
Cefotaxime
B Inhibitor - BI
B Inhibitor - BI

Sulbactam
Sulbactam
Tazobactam
Tazobactam
Piperacillin
Piperacillin

30

Antibiotic

Dosage, Route, Frequency and


Duration

Doxyclycline

100-200 mg PO/IV BID for 7 to 10


days

Azithromyci
n

500 mg OD IV 3 days + 500 mg OD


PO for 7-10 days

Clarithromy
cin

250 500 mg BID PO for 7 14 days

Telithromyci
n

800 mg PO OD for 7 10 days

Levofloxacin

750 mg PO/IV OD for 5 days

Gatifloxacin

400 mg PO or IV OD for 5 to 7 days

Moxifloxacin

400 mg PO or IV OD for 5 to 7 days

Gemifloxaci
n

320 mg PO OD for 5 7 days

Amoxyclav

2 g of Amoxi +125 mg of Clauv PO


BID for 7 to 10 days

Ceftriaxone

2 g IV BID for 3 to 5 days + PO 3G CS

Ertapenum

1 g OD IV or IM for 7 to 14 days

Empiric Treatment Outpatient


Healthy and no risk factors for DR
S.pneumoniae
1. Macrolide or Doxycycline
Presence of co-morbidities, use of
antimicrobials
within the previous 3 months, and regions with
a
high rate (>25%) of infection with Macrolide
resistant S. pneumoniae
1. Respiratory FQ Levoflox, Gemiflox or Moxiflox
2. Beta-lactam (High dose Amoxicillin, AmoxicillinClavulanate is preferred; Ceftriaxone, Cefpodoxime,
Cefuroxime) plus a Macrolide or Doxycycline

31

Empiric Treatment Inpatient Non


ICU
1. A Respiratory Fluoroquinolone (FQ) Levo or
2. A Beta-lactam plus a Macrolide (or
Doxycycline)
(Here Beta-lactam agents are 3
Generation
Cefotaxime, Ceftriaxone, Amoxiclav)
3. If Penicillin-allergic Respiratory FQ or
Ertapenem is another option

32

Empiric Treatment: Inpatient in


ICU
1. A Beta-lactam (Cefotaxime,
Ceftriaxone,
or Ampicillin-Sulbactam) plus
either Azithromycin or Fluoroquinolone
2. For penicillin-allergic patients, a
respiratory
Fluoroquinolone and Aztreonam

33

Duration of Therapy

Minimum of 5 days

Afebrile for at least 48 to 72 h

Longer duration of therapy


If initial therapy was not active against
the identified pathogen or complicated by
extra pulmonary infection

34

CAP Summary of Empiric


Treatment

35

Outpatient Rx any one of the three


Macrolide or Doxycycline or
Fluoroquinolone
Patients in General Medical Ward
3rd Generation Cephalosporin +
Macrolide
Betalactum / B-I + Macrolide or B /
B-I + FQ
Fluroquinolone alone
Patients in ICU
3GC + Macrolide or 3GC + FQ
B/B-I + Macrolide or B/B-I + FQ
IDSA guidelines: Clin Infect Dis 2000;31:347-82

Prevention CAP
Vaksin Influenza
dapat memberikan proteksi setinggi
90% dan menurunkan mortalitas 80%
Vaksin pneumococcal
membantu melindungi dari 23 tipe
pneumococcal dan menurunkan
mortalitas pada kelompok umur 1964 tahun dengan co morbidity tinggi
pneumonia.

36

Pergantian Oral Therapy

4 kriteria

37

Perkembangan daripada batuk,


dyspnea, dan gejala klinis
Afebril lebih dari 8 jam per2 hari
WBC menurun mendekati normal
GI tract yang fungsional untuk
pengobatan oral

CAP Complications

38

3-5% Pleural effusion; fluid jernih +


sel pus
1% Empyema thorakis pus di pleural
spcae
Lung abscess destruction of lung
Multiple Pyemic Abscesses

CAP Resume

39

Early antibiotic administration


Empiric antibiotic Rx. as per guidelines
(IDSA / ATS)
PORT PSI scoring and Classification of cases
Early hospitalization in Class IV and V
Change Abx. as per pathogen & sensitivity
pattern
Arterial oxygenation assessment in the first
24 h
Blood culture collection in the first 24 h prior
to Abx.
Pneumococcal & Influenza vaccination;