COMMMUNITY ACQUIRED PNEUMONIA

(CAP)
 PNEUMONIA
(Radang Paru - Paru)
• Adalah suatu penyakitpada paru - paru di
mana Pulmonary alveolus (alveory) yang
bertanggung jawab menyerap oksigen dari
atmosfer meradanf dan terisi oleh cairan.
Radang paru paru bisa disebabkan oleh
beberapa penyebab termasuk infeksi oleh
bakteri, virus, jaur atau pasilan (parasite) atau
sebagai akibat dari penyakit lain seperti kanker
paru paru atau berlebihan minum alkohol
 Klasifikasi Pneumonia
• CAP ( Community Acquired Pneumonia)
• Hospitalized (Hospital-acquired pneumonia (HAP)
Beberapa tipe pneumonia lain
• Severe acute respiratory syndrome (SARS)

• Bronchiolitis obliterans organizing pneumonia (BOOP)

• Chemical pneumonia
• Aspiration pneumonia
• Dust pneumonia
• Necrotizing pneumonia,
• Opportunistic pneumonia
 COMMMUNITY ACQUIRED PNEUMONIA
(CAP)
Faktor Resiko
• Umur di atas 65 tahun
• HIV
• Resistensi antibiotik
• Asma
• Penyakit cerebrovaskular
• Penyumbatan paru paru kronik
• Gagal ginjal kronik
• Gagal jantung Congestive
• Diabetes
• Liver
• Kanker
• Risk Factors (contd.)
– Men: age and smoking, weight gain
– RR 1.5 for age 50-54, 4.17 for > 70
– Smoking, current: RR 1.5; heavy: 2.54; Quit <10 yrs: 1.5
– Weight gain >40 lbs since age 21
– Women: smoking, BMI, weight gain
– BMI 25-26.9, RR 1.53: BMI >30, RR 2.22
– Exercise protective: RR 0.66 for most active
– Alcohol consumption NOT associated with increased risk in men or women
• Risk Factors for Mortality
– age
– bacteremia (for S. pneumoniae)
– extent of radiographic changes
– degree of immunosuppression
– amount of alcohol
• Risk Factors in Patients Requiring Hospitalization
– older, unemployed, unmarried
– common cold in the previous year
– asthma, COPD; steroid or bronchodilator use
– Chronic disease
– amount of smoking
– alcohol NOT related to increased risk
 Faktor Penyebab
• Bakteri
• Spesies Chlamydia
• Influenza haemophilis
• Spesies Legionella
• Mycoplasma pneumonia
• Staphylococcus aureus
• Streptococcus pneumonia
• Adenovirus
• Influenza A dan B
• Para influenza
 COMMMUNITY ACQUIRED PNEUMONIA
(CAP)
Mikrobiologi

– S. pneumoniae: 20-60% – Legionella spp. 2-

– H. influenzae: 3-10% 8%
– Chlamydia – S. aureus: 3-5%
pneumoniae: 4-6% – Gram negative
– Mycoplasma bacilli: 3-5%
pneumonaie: 1-6% – Viruses: 2-13%
 COMMMUNITY ACQUIRED PNEUMONIA
(CAP)
Epidemiology
• Epidemiology:
– 4-5 million cases annually
– ~500,000 hospitalizations
– ~45,000 deaths
– Mortality 2-30%
• <1% for those not requiring hospitalization
• Laboratory Tests:
• CXR
• CBC with differential
• BUN/Cr
• glucose
• liver enzymes
• electrolytes
• Gram stain/culture of sputum
• pre-treatment blood cultures
• oxygen saturation
Diagnostic Evaluation
• CXR
– usually needed to establish diagnosis
– prognostic indicator
– rule out other disorders
– may help in etiological diagnosis
• Only 3% of outpatients and 28% of ER patients with
suggestive signs and symptoms actually have pneumonia
Management
• Rational use of microbiology laboratory
• Pathogen directed antimicrobial therapy
whenever possible
• Prompt initiation of therapy
• Decision to hospitalize based on prognostic
criteria
• Empiric Treatment
• Outpatient:
– macrolide
– doxycycline
– Fluoroquinolone
NOT IN ANY SPECIFIC ORDER
 Concerns about multiply resistant
pneumococcus:
• 25-40% overall penicillin resistance
• intermediate resistance of questionable significance
• high level resistance associated with in vitro
macrolide and 3GC resistance
• clinical failures not really documented
 (Newer)Fluoroquinolones
• Active against 98% of resistant
pneumococcus
• Resistance has begun to increase
• Choice of Initial Antimicrobial Regimen
– Second generation generation cephalosporin plus
a macrolide, non-pseudomonal third generation
cephalosporin plus a macrolide, or a
fluoroquinolone alone were all associated with a
lower 30 day mortality in patients with CAP.
• Macrolide Use and LOS:
– Patients who received macrolides within first 24
hours of admission had a shorter LOS (2.8 days
vs. 5.3 days)
• IV followed by Oral Azithromycin
– 615 patients: Azithromycin given to 414
– 202 in a comparison trial with ATS recommended
cefuroxime + erythromycin
– 77% vs 74% clinical cure or improvement
– Microbiological cure rates similar or better in
azithromycin group
• Azithromycin vs. Cefuroxime + Erythromycin
– prospective, randomized trial
– 145 patients
– Clinical cure 91% in each group.
– 4 S. pneumoniae strains with MIC 0.064-2 ug/ml:
1/1 in azithromycin group cured, 2/3 in
cef/erythro group cured
 Clarithromycin ER
• Head-to-head comparison with FQ
– Vs. Levofloxacin1
• 252 patients
• Clinical cure 88% in Clarithro; 86% levo
• Radiographic success 95% vs. 88%
– Vs. Trovafloxacin2
• Clinical cure 87% vs. 95%
• Radiographic success 95% vs. 95%