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PNEUMONIA

Oleh : Reyyan Al Faj


(2011730090)

peradangan yang
mengenai parenkim
paru, distal dari
bronkiolus terminalis
yang mencakup
bronkiolus respiratorius,
dan alveoli serta
menimbulkan
konsolidasi jaringan
paru dan gangguan
pertukaran gas
setempat

Gejala dan
Tanda

Batuk disertai dahak


Nyeri dada atau nyeri pleuritik yang dirasakan sewaktu menarik napas
dalam
Demam
Sesak napas
Sakit kepala, mual, muntah dan diare

Faktor
Resiko

Usia >65 tahun


Aspirasi sekret
orofaringeal
Infeksi pernapasan oleh
virus
Sakit yang parah &
menyebabkan kelemahan
Penyakit pernapasan
kronik
Kanker
Tirah baring yang lama

Trakeostomi atau pemakaian


selang endotrakeal
Bedah abdominal atau
toraks
Fraktur tulang iga
Pengobatan dengan
imunosupresif
AIDS
Riwayat merokok
Alkoholisme
Malnutrisi

PNEUMONIA
CLASSIFICATION
1. Clinical dan Epidemiology:
a. Community Acquired Pneumonia (CAP)
b. Hospital Acquired Pneumonia (HAP)
c. Aspiration Pneumonia
d. Pneumonia in immunocompromised Patient
2. Etiology:
a. Typical : bakteria
b. Atipikal : (Mycoplasma, Legionella, Chlamydia)
c. Virus
d. Fungi
3. Predilection of infection
a. Pneumonia lobaris
b. Bronchopneumonia
c. Pneumonia Interstitial

PNEUMONIAS
CLASSIFICATION

CHEST X RAY PATTERNS


AND PATHOGENS

Klasifikasi Klinis

1. Klasifikasi
tradisional
(ciri radiologis dan
gejala klinis)

a. Pneumonia tipikal
Ciri: tanda2 pneumonia lobaris yang
klasik awitan akut berupa
gambaran radiologis berupa
opasitas lobus/lobaris
Etio: kuman yang tipikal terutama S.
pneumoniae, Klebsiella pneumoniae
atau Haemophilus influenzae
b. Pneumonia atipikal
Tanda: gangguan respirasi yang
meningkat lambat dengan
gambaran infiltrat paru bilateral
yang difus
Etio: organisme yang atipikal dan
termasuk Mycoplasma
pneumoniae, virus, Legionella
pneumophila, Chlamydia psittaci

DD : PNEUMONIA
TYPICAL
& ATYPICAL
Sign and
PNEUMONIA
Typical

symptoms

PNEUMONIA
Atypical

1. Onset

Acute

Gradually

2. Temp

Febril, chill

Subfebril

3. Cough

Productive, purulent

Non
productive/mukoid

4. Systemic
symptoms

rarely

headache/otopain,
soarthroat, myalgia

5. Leucocyte

high

Normal / low

6. Liver Function
Test

Rarely abnormal

Frequently
abnormal

7. Chest X Ray

Consolidation lobar

Normal / patchy

8. Sputum gram

coccus gram +/-

Normal flora
8

Klasifikasi Klinis

2. Berdasarkan faktor lingkungan dan penjamu

Tipe klinis
Pneumonia komunitas
Pneumonia nosokomial
Pneumonia rekurens

Epidemiologi

Sporadis; muda/tua
Didahului perawatan di RS
Terdapat dasar penyakit paru
kronik
Alkoholik, usia tua
Pneumonia aspirasi
Pneumonia pada gangguan Pasien kanker, transplantasi,
AIDS
imun

Klasifikasi
Patologis

1. Pneumonia lobaris
Bila organisme berkolonisasi
secara luas pada ruang
alveolar, dan menyebabkan
konsolidasi seluruh lobus

Eksudat mengalami lisis &


direabsorpsi oleh makrofag
sehingga jaringan kembali pada
strukturnya semula

Klasifikasi
Patologis

2. Bronkopneumonia
Bila organisme
berkolonisasi pada
bronkus dan meluas
dalam alveoli

Klasifikasi
Patologis

3.

Infeksi virus

Menyebabkan respon peradangan intersisial melalui sel-sel limfoid,


yang pada banyak kasus dapat sembuh spontan
Penyebab tersering: organisme influenza & mikoplasma

4.

Infeksi fungi atau TB

Menyebabkan nekrosis pada jaringan atau terbentuknya kavitas

DIAGNOSIS
Anamnesa : cough , purulent sputum, fever,
shortness of breath , chest pain.
Physic Diagnostic :
Fever, T > 380C
Auscultation thorax: bronchial sound, ronchi

Lab : Leucosit 10.000 / < 4500


Chest X ray : infiltrat /consolidation with
airbronchogram
Diagnosis etiology : microbiology (culture sputum)
Blood gas Analysis : hypoxemia

14

PEMERIKSAAN
PENUNJANG

PENATALAKSANAAN

TERAPI SUPORTIF

ALUR TATA LAKSANA PNEUMONIA


KOMUNITIAnamnesis, Pemeriksaan Fisis, Foto Thoraks
Tidak ada Infiltrat

Infiltrat + gejala klinis yang menyokong diagnosis pneumonia

Di Tatalaksana sebagai
diagnosis lain

Evaluasi untuk kriteria rawat jalan / rawat inap

Rawat jalan

Rawat inap

Terapi empiris

Membaik

Memburuk

Pemeriksaan bakteriologis

R. Rawat biasa

R. rawat intensif

Terapi empiris (48-72jam)


Terapi empiris
dilanjutkan

Membaik

Memburuk

Terapi kausatif18

PORT ( Pneumonia Patient Outcome Research Team) /Pneumonia Severity


Index (PSI),

I,II,III low

IV Moderate

V high

Journal Reading

Fine MJ, Auble TE, Yealy DM. N Engl J Med


19
1997; 336: 243-250.

DERAJAT SKOR MENURUT


PORT
RESIKO

KELAS RESIKO

TOTAL SKOR

PERAWATAN

RENDAH

I
II
III

Tidak diprediksi
< 70
71-90

Rawat Jalan
Rawat Jalan
Rawat Inap/Jalan

SEDANG

IV

91-130

Rawat Inap

BERAT

> 130

Rawat Inap

20

COMMUNITY ACQUIRED
PNEUMONIA
1. INDICATION
PORT score > 70
FOR
2. HOSPITALIZATION
PORT score < 70 with sign and symptoms :
1.
2.
3.
4.
5.
6.

3.

Respiratory rate > 30 x/m


PaO2 / FiO2 < 250 mmHg
Chest X Ray
: bilateral infiltration
Chest X Ray
: infiltration > 2 lung lobes
sistolic < 90 mmHg
diastolic < 60 mmHg

NAPZA (Narkotik dan Zat adiktif ) Pneumonia

21

PREVENTION
The most important preventive
tool
available is
using a
polyvalent pneumococcal vaccine
in those with
chronic
lung
diseases, chronic liver diseases,
splenectomy,
diabetes mellitus
and aged > 65 yo.
All persons 50 years of age, others
at risk for influenza complications,
household contacts of high-risk
persons, and health care workers
should receive inactivated influenza
vaccine as recommended by the
Advisory Committee on Immunization
Practices, Centers for Disease Control
and Prevention.

MODIFICATION FACTORS CONDITION


THAT INCREASED THE RISK OF INFECTION
BY PATHOGEN SPESIFIC MICROORGANISM
Penicilin-resistant Pneumococcus / -lactamresistant S.
pneumoniae
age > 65yo, alcoholism, immunodeficiency, medical
comorbidities , -lactam therapy within the previous 3 months,
immunosuppressive illness or therapy
Enteric gram-negative
Residence in a nursing home or extended care facility, heart/lung
disease, multiple disease, use of antimicrobials
Pseudomonas aeruginosa
bronchiectasis, malnutrition, steroid, use of broad spectrum
antibiotics > 7 days

23

MANAGEMENT OF EMPIRIC THERAPY


OF PNEUMONIA
inpatient

outpatient
Without Modification Factors :
laktam / laktam + anti
laktamase (Amoxycicilline
clavulanat)
With Modification Factors:
lactam + anti lactamase or
respiratory Fluoroquinolon
( Levofloksasin
, moxifloxasin, gatifloksasin)
If atypical pneumonia is suspected :
new macrolide
(roxitromycin,claritromycin,
azitromycin)

Without Modification Factors :


laktam + anti laktamase
( Amoxycicilline clavulanat I.V )
or cephalosporin G2, G3
(cefotaxim iv, ceftriaxone iv ) or
respiratory fluoroquinolon I.V
(levofloxacin,moxifloxacin,gatiflox
acin)
With Modification Factors:
cephalosporin G2,G3 I.V or
respiratory fluoroquinolon IV
If atypical pneumonia is
suspected : new macrolide +
(added)
(roxitromycin,claritromycin,azitro
mycin)
intensive care

intensive care

a. Without Risk Factors of Pseudomonal infection


- Cephalosporin G3 iv non pseudomonas plus +
new macrolide or respiratory
fluoroquinolon iv
b. With Risk Factors to pseudomonal infection
- Cephalosporin antipseudomonal iv or carbapenem
iv
plus Fluoroquinolon antipseudomonal
(ciprofloxacin iv) / aminoglycosida iv (gentamicin)
- If suspects atypical bacterial infection :
add new macrolide or Fluoroquinolon respirasi iv

PNEUMONIA NOSOCOMIAL
DEFINITION
HAP (Hospital Acquired Pneumonia) : pneumonia
that occurs 48 hours or more after admission, which
was not incubating at the time of admission
HCAP (Health Care Associated Pneumonia) : any
patient who was hospitalized in an acute care hospital
for > 2 days within 90 days of the infection; resided in
a nursing home or long-term care facility; received
recent intravenous antibiotic therapy, chemotherapy,
or wound care within the past 30 days of the current
infection; or attended a hospital or hemodialysis clinic
VAP (Ventilator Associated Pneumonia) : pneumonia
occurring > 48 hours after patients have been
intubated and received mechanical ventilation
early-onset : within 4 days
late-onset : after > 5 days

PATOPHYSIOLOGY
Risk Factors of Nosocomial Pneumonia :

... CONT

PATHOPHYSIOLOGY

HAP

VAP
PATIENT-RELATED RISK FACTORS

Advanced age (> 60 years)

Supine position

Comorbid disease (eg. chronic lung


disease)

Comorbid disease (eg. chronic lung


disease)

Previous antibiotik therapy

Previous antibiotik therapy

Cardiothoracic or abdominal surgery

Stress ulcer prophylactic with gastric


pH-altering agents

APACHE II > 16
Smoking
Prior hospitalization or abdominal
surgery
Reflux
DEVICE-RELATED RISK FACTORS
Tracheotomy

Tracheotomy

Nasogastric tubes

Nasogastric tubes

Short duration of nasotracheal or


orotracheal intubation

Prolonged duration of Mechanical


Ventilation

Long duration of nasotracheal or


orotracheal intubation

Reintubation

... CONT

PATHOPHYSIOLOGY

Pathogenesis :
There must be 3 factors :
(1) impaired host defence
(2) access of pathogenic bacteria in
sufficient number to lower
respiratory tract
(3) virulence of the organism
Access into the lung :
- microaspiration of
oropharyngeal secret
- aspiration of gastric content
- inhalation
- hematogenous spread
- exogenous penetration (e.g.
pleural space)
- direct inoculation from
contaminated ICU staff to
intubated airway

ETIOLOGY
Common Pathogen :
-aerobic gram-negatif bacilli : Pseudomonas aeruginosa, E.
coli, Klebsiella pneumoniae, Acinetobacter sp.
-coccus gram-positif : Methicillin-resistant S. aureus (MRSA)
-anaerobic bacteria : uncommon cause in HAP
-virus & fungal : uncommon in immunocompetent patient

MRSA Risk Factors : COPD, ventilator >>, antibiotics


exposure, corticosteroid, bronchoscopy
Enterobacteriaceae (E. coli, Klebsiella sp, Enterobacter
sp) ESBL (Carbapenem : firts choice)
Pseudomonas aeruginosa common isolate in
ventilator > 4 days

Etiology Pathogens of Nosokomial Pneumonia

...

Patogen

Onset
Pneumonia

Frekuensi
(%)

Streptococcus pneumoniae

early

10 20

Haemophilus influenzae

early

5 15

Anaerobic bacteria

early

10 30

early / late

20 30

late

30 60

Staphylococcus aureus
Basil gram-negatif
- Pseudomonas aeruginosa

17

- Klebsiella pneumoniae

- Acinetobacter spp.

- Escherichia coli

Koulenti & Rello. Hospital-acquired pneumonia in the 21st century : a review of existing treatment options and their impact on
patient care. Expert Opin. Pharmacother. 2006; 7(12): 1556)

- Enterobacter spp.
Legionella pneumophila

10
late

0 15

PNEUMONIA NOSOCOMIAL
TREATMENT
Terapi Antibiotik Inisial Empirik utk HAP/VAP onset-dini pada pasien tanpa
faktor resiko patogen MDR (ATS)
Patogen Potensial

Antibiotik yg Direkomendasikan

Streptococcus pneumoniae
Haemophilus influenzae
MSSA
Basil Gram-negatif yg sensitif-antibiotik :
E. coli, K. pneumoniae
Proteus sp., S. marcescens

- Ceftriaxone; atau
- Levofloxacin , Moxifloxacin,
atau Ciprofloxacin; atau
- Ampicillin/sulbactam; atau
- Ertapenem

Terapi Antibiotik Inisial Empirik utk HAP


onset-dini
(Asian HAP
Working Group)

Terapi Antibiotik Inisial Empirik utk VAP


onset-dini
(Asian HAP Working
Group)

Patogen
Potensial

Antibiotik yg
Direkomendasikan

Patogen
Potensial

Regimen AB yg
Direkomendasikan

Streptococcus
pneumoniae
Haemophilus
influenzae
MSSA
Basil Gram-negatif
yg sensitif-antibiotik
:
E. coli, K.
pneumoniae
Proteus sp., S.
marcescens

- Cephalosporin gen. ke3 : (Ceftriaxone,


Cefotaxim) ; atau
- Fluoroquinolones
(Moxifloxacin,
Levofloxacin) ; atau
- -lactam/-lactam
inhibitor
(Amoxicillin/clavulanic
acid,
Ampicillin/sulbactam) ;
atau
- Carbapenems
(Ertapenem) ; atau

Patogen-patogen
spt pd tabel
sebelumnya, dan
Patogen MDR :
Pseudomonas
aeruginosa
K. pneumoniae
(ESBL)
Acinetobacter sp.

- Cephalosporin
Antipseudomonas :
(Cefepime) ; atau
- Carbapenem
Antipseudomonas :
(Imipenem, Meropenem) ;
atau
- -lactam/-lactam
inhibitor
(Piperacillin/tazobactam)
plus / - Fluoroquinolones
(Ciprofloxacin,
Levofloxacin) ; atau

PNEUMONIA NOSOCOMIAL TREATMENT


Terapi Antibiotik Inisial Empirik utk HAP,VAP, & HCAP onset-lambat atau dgn
faktor resiko patogen MDR (ATS)
Patogen
Potensial

Antibiotik yg Direkomendasikan

Patogen-patogen
spt pd tabel
sebelumnya, dan
Patogen MDR :
P. aeruginosa
K. pneumoniae
(ESBL)
Acinetobacter sp.
MRSA
Terapi Legionella
Antibiotik Inisial
pneumo-phila
onset-lambat

Working Group)

- Cephalosporin
Antipseudo-monas :
(Cefepime,
Ceftazidime) ; atau
- Carbapenem
Antipseudo-monas :
(Imipenem,
Meropenem) ; atau
- -lactam/-lactamase
inhibitor utk HAP
Empirik
(Piperacillin/tazobact
(Asian HAP
am)

Pl
u
s

- Fluoroquinolones
Anti-pseudomonas
(Ciprofloxacin,
Levofloxacin) atau
- Aminoglycoside
(Amikacin,
Gentamycin,
Tobramycin)

Pl
u
s
/
-

Linezolid
atau
Vancomyci
n

Terapi Antibiotik Inisial Empirik utk VAP


onset-lambat
(Asian
HAP Working Group)

Patogen
Potensial

Regimen AB yg
Direkomendasikan

Patogen
Potensial

Regimen AB yg
Direkomendasikan

Patogen-patogen
spt pd tabel
sebelumnya, dan
Patogen MDR :
P. aeruginosa
K. pneumoniae
(ESBL)
Acinetobacter sp.

Spt Rekomendasi ATS 2005 ;


atau :

Patogen MDR :
P. aeruginosa
K. pneumoniae
(ESBL)
Acinetobacter
sp.

- Carbapenem Antipseudomonas
: (Imipenem, Meropenem) ;
atau
- -lactam/-lactamase inhibitor
(Piperacillin/tazobactam)
Plus/- Fluoroquinolones
(Ciprofloxacin, Levofloxacin)
atau
- Aminoglycoside (Amikacin,
Gentamycin, Tobramycin) ;
atau :
- Spt Rekomendasi Asian

MRSA

- Cefoperazon/sulbactam,
plus Fluoroquinolones, atau
Aminoglycosides,
plus Ampicillin/sulbactam;
atau :
- Fluoroquinolone
(Ciprofloxacin), plus
Aminoglycoside

TERIMA KASIH

Sama Sama