FARMAKOTERAPI

INFEKSI PNEUMONIA

Lusi Agus Setiani, M.Farm., Apt

 Pneumonia
• Infeksi di ujung bronkial dan alveoli yang
dapat disebabkan oleh berbagai patogen,
seperti bakteri, virus dan parasit
 EPIDEMIOLOGI

• Penyebab Kematian
• Prevalensi 4 juta kasus/tahun (US)
Infeksi Saluran Nafas di INDONESIA:

1999 : peringkat 1
2000 : peringkat 2
2001 : pneumonia penyebab kematian tertinggi ke-2 pada bayi
Infeksi pernafasan penyebab kematian ke-2 (12,7%)

(DepKes RI, Profil Kesehatan Indonesia 2001)

 PATOGENESIS
Rute masuknya
mikroorganisme ke
Lower Respiratory
Tract :
• Inhalasi
• Bloodstream dari
extrapulmonary yang
terinfeksi.
• Aspirasi dari
oropharyngeal
 PNEUMONIA
1. Community acquired pneumonia (CAP)
pneumonia yang didapat di luar RS atau panti
jompo
2. Hospital (Nosokomial pneumonia)
–Hospital acquired pneumonia (HAP)
–Ventilator associated pneumonia (VAP)
–Healthcare associated pneumonia (HCAP)
3. Pneumonia aspirasi: akibat aspirasi sekret
oropharyngeal & cairan lambung.
Biasa terjadi pada pasien gangguan reflek
menelan dan status mental terdeprasi.
 PATOGENESIS
• CAP :
S.pneumoniae (Pneumococcus) 70% di US,
M.pneumoniae 10-20%, Legionella, C.pneumoniae,
S.Aureus.
• HAP :
G(-) aerobic bacilli
S.aureus
• Infant-children :
virus, RSV, parainfluenza, adenovirus, M.pneumoniae.
• CAAP : kombinasi flora mulut & saluran nafas atas :
Streptococci anaerob
• Mosokomial aspiration pneumonia : camp. G(-) batang +
S. aureus + anaerob
 Tanda Klinis
• Abrupt onset of fever, chills, dyspnea, productive
cough
• Rust-colored sputum or hemoptysis
• Pleuritic chest pain
• Tachypnea & tachycardia
• Dullness to percussion
• Incresed tactile fremitus, whisper pectoriloguy,
egophony.
• Chest wall retractions & grunting respirations
• Deminished breath sounds over the affected area
• Inspiratory crackles during lung expansion.
• Chest Radiograph: dense lobar or segmental
infiltrate
 Laboratory Examination
• leukocytosis with predominance of
PMN cells,
• low oxygen saturation on arterial
blood gas or plus oximetry.
 FAKTOR RESIKO
• Usia tua atau anak-anak
• Merokok
• Adanya penyakit paru yang menyertai
• Infeksi Saluran pernafasan yang disebabkan
virus
• Splenektomi (Pneumococcal Pneumonia)
• Obstruksi bronkhial
• Immunocompromise atau mendapat obat
immunosupressive
• Perubahan kesadaran (predisposisi pneumonia
aspirasi)
 Outcome Treatment
• Eradikasi organisme
• Penyembuhan sempurna secara klinis.
• Mengurangi morbiditas
 Pendekatan Umum Terapi
• Evaluasi fungsi respirasi
• Kenali tanda & symptom (terutama
dehidrasi/sepsis)
• Kasus berat  tambah oksigen, ventilasi.
• Perawatan suportif : bronkodilator, chest
physioteraphy, hidrasi adekuat, suport
nutrisi, dan kontrol demam.
 2007 ATS/IDSA CAP Guidelines
Mandell, LA et al CID 44(suppl 2) 2007
Patient screening : Determine whether to treat as
outpatient or in-patient
Objective scoring systems
– Pneumonia Severity Index
– CURB-65
– Confusion
– Urea > 7 mmol/L
– Respiratory Rate > 30 / min
– Blood pressure < 90 mm Hg & diastolic > 60 mm Hg
– Age > 65 years
ICU Admit (3 minor criteria present)
 Respiratory rate > 30 / min  Uremia
 PaO2/FIO2 < 250  Neutropenia
 Multilobar infiltrates  Thrombocytopenia
 Confusion  Hypothermia
 The initial site of treatment should
be based on a 3-step process
• assessment of preexisting conditions that
compromise safety of home care;
• calculation of the pneumonia PORT
(Pneumonia Outcomes Research Team)
Severity Index (PSI)with recommendation
for home care for risk classes I,II, and III;
• clinical judgment (A-II).
• Hospitalized patients treated with intravenous
antibiotics may be changed to oral antibiotics
when the patient is clinically improving, is able to
ingest drugs, is hemodynamically stable, and has
a functioning gastrointestinal tract (A-I).
• Discharge criteria: during the 24 h prior to
discharge to home, the patient should have no
more than 1 of the following Characteristics
(unless this represents the baseline status):
temperature, 37 0C; pulse, 100 beats/min;
respiratory rate, 24breaths/min; systolic blood
pressure, 90 mm Hg; blood oxygen saturation,
90%, and inability to maintain oral intake (B-I).
 Antibiotika pada terapi Pneumonia (Indonesia)

Kondisi Patogen Terapi Dosis Ped Dosis dewasa

Klinik 9mg/kg/hari) (dosis
total/hari)
Sebelumnya Pneumococcus, Eritromisin 30-50;15;10 pd 1-2 g
sehat Mycoplasma Klaritromisisn hari I, diikuti 5 0,5-1 g
Pneumoniae Azitromisin mg selama 4
hari
Komorbiditas S. Pneumoniae. H. Cefuroksin 50-75 1-2 g
(manula, influenzae, Cefotaksim
DM, gagal Moraxella Ceftriakson
ginjal, gagal catarrhalis,
jantung, Mycoplasma,
keganasan) Chlamydia
pneumoniae,
legionella
Aspirasi : Anaerob mulut Ampi/amoks, 100-200 2-6 g
Community Klindamisin, 8-20 1,2-1,8 g

Hospital Anaerob mulut. S. +aminoglikosida sda sda

aureus, G(-)enterik
 Kondisi Patogen Terapi Dosis Ped Dosis dewasa
Klinik 9mg/kg/hari) (dosis
total/hari)
Pneumonia K.pneumoniae cefuroksim., Sda Sda
ringan, , cefotaksim, Sda Sda
onset<5 hari, P.aeruginosa, ceftriakson, Sda Sda
resiko Enterobacter, Amp-
rendah S.aureus 100-200 4-8 g
sulbakt,Tikarsilin-
klav,Gatifloksasin,lev 200-300 12 g
ofloksasin, Klinda- 0,4 g
azitro 0,5-0,75 g

Pneumonia K.pneumoniae Genta/tobramisin/cipr 7,5/-/150 4-6 mg/kg/

berat, , oflok)* + 0,5-1,5 g/2-6g
onset>5 hari, P.aeruginosa, ceftazidime / 100-150 2-4g
resiko tinggi Enterobacter, cefepime/tikarc-klav,
S.aureus meronem/aztreonam

Pneumonia berat : + gagal nafas, penggunaan ventilasi, sepsis berat, gagal ginjal
* :dikombinasi dg salah satu AB di bawahnya
 NOSOKOMIAL
• Pola resistensi invitro dan invivo pada RS
• Tergantung Rs (mengacu pada tabel CAP)
 TERAPI PENDUKUNG
• Oksigen : jika sesak nafas, hipoksemia
• Bronkodilator : jika bronkospasme
• Fisioterapi dada : untuk pengeluaran
sputum
• Nutrisi
• Hidrasi cukup
• Antiperik : jika demam
 KASUS
Bapak VJ (78 th, BB 60 kg), sering merasa pusing dan timbul
batuk yang makin memburuk sejak 3 hari yang lalu dan
mulai kesulitan bernafas.
Riwayat Penyakit Dahulu :
– Bapak VJ merokok sejak usia 18 tahun hingga sekarang
– Menderita bronkitis kronis sejak 10 tahun yang lalu
– Menderita hipertensi sejak 15 tahun yang lalu.
Riwayat Pengobatan :
– Combivent MDI puff Q.i.d
– Albuterol MDI puff Q.i.d (prn)
– Atenolol 100 mg Q.D dan HCT 5 mg Q.D
Pemeriksaan Fisik :
– Suhu : 37,5 C (normal) RR : 28x/menit
– TD : 130/90mmHg Nadi : 100x/menit
Data laboratorium :
– Na : 134 mEq/L Leukosit : 7,7 x 103 per mm3
–K : 3,4 mEq/L Hb : 13,8 g/dl
– Cl : 96 mEq/L Hct : 37 %
– BUN : 17 mg/dl Kreatinin: 1,6 mg/dl
– Fotothoraks menunjukkan abnormalitas
Diagnosa : Pneumonia dan hipoksemia
Pertanyaan :
• Bagaimana penatalaksanaan kasus diatas ? Lakukan
evaluasi terhadap obat yang dipakai pasien!
• Informasi apa saja yang perlu disampaikan agar
pengobatan pasien optimal ?
 Terapi Empiris Pneumonia pada ADULTs
Clinical Usual Pathogen Presumptive
Setting Therapy
Previously healty, Pneumococcus, Macrolide/azalide,
ambulatory patient M.pneumoniae tetracyclin
Elderly Pneumococcus,G(-) Piperacillin/tazobactam,
bacilli: Klebsiella cephalosporin, carbapenem
pneumoniae), S.aureus,
H.influenzae
Chronic Pneumococcus, Amoxicillin, tetracyclin, TMP-
bronchitis H.influenzae, SMZ, cefuroxim,
M.catarrhalis amoxicillin/clavulanat, macrolid-
azalid, fluoroquinolon
Alcoholism Pneumococcus, Klebsiella Ticarcillin-clavulanat,
pneumoniae, S.aureus, Piperacillin-tazobactam,
H.influenzae, possibly mouth
+ aminoglikosida;
anaerobes
carbapenem;fluoroquinolon
Clinical Usual Pathogen Presumptive
Setting Therapy
Aspiration mouth anaerobes Penicilllin or
(community) clindamycin
Aspiration mouth anaerobes, Clindamycin,
(hospital) S.aureus, G(-)enteric Ticarcillin-clavulanat,
Piperacillin-
tazobactam,
+ aminoglikosida
Nosocomial G(-)bacilli (Klebsiella Piperacillin-tazobactam,
pneumoniae, carbapenem,
cephalosporin spektrum
Enterobacter spp., luas + aminoglikosida,
P.aeruginosa), fluoroquinolon
S.aureus
 Terapi Empiris Pneumonia pada Pediatric
Age Usual Pathogen
1 month Group b
sterptococcus,H.influenzae,
E.Coli, S.aureus, Listeria,
CMV, RSV, adenovirus
1-3 month Chlamydia, possibly ureaplasma,
CMV, Pneumocystis carinii
(afebrile pneumonia syndrome),
RSV, pneumoniae), S.aureus,
3 month – 6 Pneumococcus, H.influenzae,
years RSV, adenovirus,
parainfluenza
>6 years Pneumococcus, Klebsiella
pneumoniae, S.aureus,
H.influenzae, possibly mouth
anaerobes
Presumptive Therapy
Ampicillin-sulbactam,
cephalosporin,
carbapenem. Ribavirin for
RSV
Macrolide/azalde
Piperacillin/tazobactam,
cephalosporin, carbapenem
Amoxicillin or cephalosporin,
Ampicillin-sulbactam,
amoxicillin-clavulanat,
Ribavirin for RSV
Ticarcillin-clavulanat,
Piperacillin-tazobactam,
+ aminoglikosida;
carbapenem;fluoroquinolon
 Dosis Antibiotik untuk Terapi Pneumonia Bakterial
Antibiotic Antibiotic Daily Antibiotic Dose
Class
Pediatric Adult (total
(mg/kg/day) dose/day)
Macrolide Clarithromycin 15 0,5-1 g
Erythromycin 30-50 1-2 g
Azalide Azitromycin 10 mg/kg x1 500 mg day
day, then 250 mg/day x 4
then 5 mg/kg days
x 4 days
Tetracycli Tetracycline HCl 25-50 1-2 g
ne Oxytetracyclin 15-25 0,25 -0,3 g
Penicillin Ampicillin 100-200 2-6 g
Amox-clav 40-90 0,75-1 g
Piperacillin-tazobactam 200-300 12g
Ampicillin-sulbactam 100-200 4-8 g
 Dosis Antibiotik untuk Terapi Pneumonia Bakterial
Antibiotik Antibiotic Daily Antibiotic Dose
Class
Pediatric Adult (total
(mg/kg/day) dose/day)
Extended- Ceftriaxone 50-75 1-2 g
spectrum Ceftazidime 150 2-6 g
cephalosporins Cefepime 100-150 2-4 g

Fluoroquinolon Gatifloxacin 10-20 0,4 g

Levofloxacin 10-15 0,5-0,75 g
Ciprofloxacin 20-30 0,5-1,5 g

Aminoglycosid Gentamicin 7,5 3-6 mg/kg

es Tobramycin 7,5 3-6 mg/kg
 PREVENTION
• risk for influenza complications, and household
contacts of high-risk persons  inactivated
influenza vaccine,
• The injected inactivated  persons at risk of
complications associated with influenza, for
household contacts of high-risk persons, and for
health care workers (A-1).
• The intranasally administered live (FluMist; Aventis)
is an alternative vaccine  persons aged 5–49
years without chronic underlying diseases,
including immunodeficiency, asthma, and chronic
medical conditions (C-I).
 PREVENTION
• Influenza vaccine should be offered to
persons at hospital discharge or
during outpatient treatment during the
fall and winter (C-III).
• Health care workers in inpatient and
outpatient settings and long-term care
facilities should receive annual
influenza immunization (A-I).
 Evaluasi Outcome Terapi
• Perbaikan gejala dan tanda klinis dalam 2
hari dan progresif dalam 5-7 hari
(biasanya <10 hari).