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PNEUMONIA

Dr. Syamsudin Abdillah


Faculty of Pharmacy Pancasila
University
Postdoctoral Researcher at IIUM

E.mail: syamsudin.abdillah@yahoo.co.id

Pneumonia
Infection of the pulmonary parenchyma
caused by various bacterial species, virus,
fungi and parasites
Not a single disease, but a group of specific
infection, each having different epidemiology,
pathogenesis, clinical manifestations and
clinical
course
Not a single disease, but a group of specific

Epidemiology
Indonesia morbid------10-20% (<5 yo)
mortal ------ 6/1000

Etiology
Neonatus
o
o

Streptokokus grup B
Bakteri gram negatif seperti E. Colli,
Pseudomonas sp, atau Klebsiella sp
Chlamydia trachomatis

Children
o
o
o

Streptococcus pneumoniae
Haemophillus influenzae tipe B
Staphylococcus aureus

adult
o
o

Mycoplasma pneumoniae
Streptococcus pneumoniae

Etiology
o
o
o

Respiratory Syncytial Virus (RSV)


Rhinovirus
Virus Parainfluenzae

Pathogenesis pneumonia

Know routes of infection


Mechanisms of defense
Factors impairing defense

Know routes of infections

Aspiration
Inhalation
hematogenous

Know routes of infection

Factors that determine the etiologic agent


1.
Setting from which infection is acquired

2.
3.

Community
Hospital

Age
Comorbid condition

Community acquired infection:


Streptococcus pneumonia
Haemophilus influenza
Chlamydia pneumonia
Mycoplasma pneumonia

Hospital Acquired Pneumonia (HAP)


Staphyloccocus aureus- < 10% of HAP
Enteric Gm (-) bacilli & Pseudomonas aeruginosa>50% of HAP

Water storage system with warm temp,


stagnation and sediment accumulation:

Legionella species

Age Factor:

Infants < 6 months:


RSV
Chlamydia trachomatis

6 months to 5 years:
H. influenza

Young adults:
M. pneumonia
C. pneumonia
Hantavirus

Elderly
H. influenza
M. catarhallis

Co-morbidities
HIV

Pneumocystis carinii
M. tuberculosis

Clinical Manifestation
Community Acquired Pneumonia
Atypical
Typical

Nosocomial Pneumonia
Aspiration Pneumonia

Atypical Pneumonia
Syndrome

Typical Pneumonia
Syndrome

Etiology

M. pneumonia,
Legionella sp, C.
pneumonia,
Mycoplasma, viruses

S. pneumonia, H.
influenza,
Klebsiella sp, mixed
aerobic & anaerobic oral
flora

Onset

gradual

Abrupt

Cough

Dry cough

Productive cough

Sputum

scanty

Purulent

Pulmonary
signs and
symptom

Shortness of breath

Shortness of breath,
pleuritic chest pain, sign
of pulmonary
consolidation, rales

Extrapulmona Prominent (headache,


ry symptoms myalgia, fatigue,
nausea, vomiting,
diarrhea)

Not prominent

Laboratory Examination
A. Chest X ray (PALateral
views)

New parenchymal
infiltrate

Confirms the diagnosis

Assess the severity /


prognostication

May suggest the


etiology

Causes of Pulmonary
Cavities
INFECTIOUS
Bacteria: oral anaerobes (Bacteroides
spp.,Fusobacteria, Actinomyces spp.), enteric
aerobic Gm (-) bacilli, Pseudomonas aeruginosa,
Legionella spp., Staphylococcus aureus, Strep
pneumoniae serotype III, Mycobacterium tb,
Nocardia spp
Fungi: Histoplasma capsulatum, Coccidioides
immitis, Blastomyces spp
NON-INFECTIOUS
Neoplasm, Wegeners granulomatosis, infarction,
infected bullae and cysts

Laboratory Examination
B. Sputum Examination

Gram stain
Good specimen: >25 PMN; <10 epith cell per LPF
Sensitivity: 60-80%
Specificity: 85% in identifying pneumococcus

Culture
40-60% specificity

BAL, TTA, PSB, LA


not routinely done
Better specificity

Laboratory Examination
C. Serologic Test

Urinary antigen test


Legionella pneumophila

Indirect immunoflourescence
IgM>1:20, IgG>1:128 diagnostic for Chlamydia

pneumoniae
IgM>1:16, IgG>1:128 - diagnostic of Mycoplasma
peumoniae

D. Blood Culture- Gold standard in Dx of


Pneumonia
E. Other tests

CBC, electrolytes, liver function, creatinine

Algorithm for the management of CAP. (CAP = communityacquired pneumonia.)


Adapted with permission from Fish D. Pneumonia. PSAP,
Pharmacotherapy Self-Assessment Program. Kansas City, Mo.:

Empiric Treatment

LOW RISK CAP

Previously healthy: amoxicillin or extended macrolide,


alternative: cotrimoxazole

with stable co morbid illness: co-amoxyclav or

sultamicillin or 2nd gen cephalosporin or extended macrolide

MODERATE RISK CAP


- IV non pseudomonal B lactams w/ or w/o B lactamese inhibitor
plus macrolide OR antipneumococcal fluoroquinolone

HIGH RISK CAP


No risk for P. aeruginosa: IV non-pseudomonal B lactam w/
or w/o B lactamase inhibitor plus IV macrolide OR IV
antipneumococcal fluoroquinolone
W/ risk of P. aeruginosa: IV antipseudomonal B lactam w/
or w/o B lactamase inhibitor plus IV macrolide or IV
antipeumoccocal fluoroquinolone +/- aminoglycoside or IV
ciprofloxacin

Treatment
A. Empiric Antibiotic Therapy
B. Specific Antimicrobial based on isolated
organism culture
C. Others

Mucolytics
N-acetylcysteine (fluimucil), ambroxol

Expectorant
Glyceryl Guiacolate

Nebulization
salbutamol

References

www.usuhs.mil/fap/capcon07
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