Definisi

 Pneumonia adalah inflamasi yang

mengenai parenkim paru
 Sebagian besar disebabkan oleh
mikroorganisme (virus/bakteri) dan
sebagian kecil disebabkan oleh faktor lain
Pneumonia
 Pneumonia in children (< 5 years of age)
 Morbidity Rate 10-20 %
 Mortality Rate 6/1000
 Pneumonias kill
 50.000/a year
 12.500/a month
 416/a day = passengers of 1 jumbo jet plane
 17/an hour
 1/four minutes
 Pneumonia is a number one killer of infants
 Klasifikasi Pneumonia

Berdasarkan Berdasarkan Berdasarkan

Sumber Infeksi
• Pneumonia yg didapat di • Pneum. bakterial
masyarakat
(Community-acquired pn.)
• Pneumonia yg didapat di
RS (Hospital-acquired pn. )
• Pneumonia Aspirasi
• Pne. Immunocompr. host
Kuman penyebab Predileksi / tempat
infeksi
• Pneumonia lobaris
• Pneum. atipikal
• Pneum. ok virus (lobar pneumonia)
• Bronchopneumonia
• Pneum. ok jamur
/ patogen lainnya • Pneum interstitialis
(interstitial pneumonia)
 Malnutrition, poor
breast feeding
practices

Lack of immunization Vitamin A deficiency

Young age Low birth weight

Increased
risk of
ARI
Crowding Cold weather
or chilling

High prevalence Exposure to air pollution

of nasopharyngeal • Tobacco smoke
carriage of • Biomass smoke
pathogenic bacteria • Environmental air pollution
Etiology differs according to :


 age

(neonates, infants, children,

adolescents)
 clinical setting

(community or hospital)
 local epidemiology

(RSV epidemics, influenza

activity)
 vaccination status

(measles, diphtheria,
pertussis, Hib)
 air pollution

(industry, tobacco smoke)

 host factors

(underlying diseases,
malnutrition)
 immunologic status
 Mekanisme
Kuman masuk ke
pertahanan
saluran napas atas
terganggu

Terbentuk
sekret virulen

Sekret berlebih
Inflamasi turun
ke alveoli
 Stadium Kongesti
o Kapiler kongesti dan melebar

 Hepatisasi merah
o Terjadi reaksi jaringan yang mempermudah
proliferasi dan penyebaran kuman ke jaringan
sekitarnya.
o Bagian paru yang terkena mengalami konsolidasi
o Ditemukan kuman di alveoli
 Hepatisasi Kelabu
o Deposisi fibrin semakin bertambah
o Terdapat fibrin dan leukosit PMN di alveoli
o Terjadi proses fagositosis yang cepat

 Resolusi
o Jumlah makrofag meningkat di alveoli
o Sel akan mengalami degenerasi
o Fibrin menipis
o Kuman dan debris menghilang
Asinus terisi eksudat dan infiltrasi Sel
radang kedalam alveoli
 Sebagian besar gambaran klinis
pneumonia pada anak berkisar antara
ringan hingga sedang, sehingga dapat
berobat jalan saja

 Hanya sebagian kecil yang berat,

mengancam kehidupan, dan mungkin
terdapat komplikasi sehingga memerlukan
perawatan di RS.
 Demam, Sakit kepala, Gelisah, Malaise,
Penurunan napsu makan, Keluhan
gastrointestinal : mual, muntah, atau diare

 Batuk, Sesak napas, Retraksi dada,

Takipnea, Napas cuping hidung, Air hunger,
Merintih, Sianosis
 >> akibat transmisi vertikal (proses persalinan)

 Akibat kontaminasi sumber infeksi dari ibu:

aspirasi mekonium, cairan amnion, serviks ibu.
Gejala

Serangan apnea Letargi, muntah

Sianosis Tidak mau minum
Merintih Takikardi/ bradikardi
Napas cuping Retraksi subkosta
hidung Demam
Takipnea
 Sepsis pada pneumonia neonatus dan bayi
kecil sering ditemukan sebelum 48 jam I.

 Angka mortalitas sangat tinggi di negara

maju, yaitu dilaporkan 20-50%

 Angka kematian di Indonesia dan di negara

berkembang lainnya diduga lebih tinggi
 Takipnea
 Retraksi subkosta (chest indrawing)
 Napas cuping hidung
 Ronki
 Sianosis
 Ronki ditemukan bila ada infiltrat alveolar

 Retraksi dan takipnea merupakan tanda klinis

pneumonia yang bermakna

 Kadang-kadang timbul nyeri abdomen bila

terdapat pneumonia lobus kanan bawah yang
menimbulkan infiltrasi diafragma

 Nyeri abdomen dapat menyebar ke kuadran

kanan bawah dan menyerupai apendisitis.
 Darah Perifer Lengkap (DL)
 C-Reaktive Protein(CRP)
 Uji Serologis
 Pemeriksaan Mikrobiologis
 Pemeriksaan Radiologis
 Leukositosis :15-40 K/mm3 predominan PMN
 Leukopenia :<5 K/mm3
 Pada infeksi Chlamydia pneumonia kadang-
kadang ditemukan eosinofilia
 Pemeriksaan DL & LED tidak dapat
membedakan antara infeksi virus dan infeksi
bakteri secara pasti
 Suatu protein fase akut yang disintesis
oleh hepatosit. Sebagai respons infeksi
atau inflamasi jaringan

 Secara klinis CRP digunakan sebagai alat

bantu diagnostik untuk membedakan
antara faktor infeksi dan noninfeksi, infeksi
virus dan bakteri, atau infeksi bakteri
superfisialis dan profunda
 Mendeteksi Ag dan Ab pada infeksi
bakteri tipik, sensitivitas dan spesifitas
rendah

 Bermanfaat dalam mendiagnosis infeksi

bakteri atipik seperti Mikoplasma dan
Klamidia, serta beberapa virus seperti RSV,
Sitomegalo, campak, Parainfluenza 1, 2,3,
Influenza A dan B, dan Adeno
 Jarang dikerjakan, hanya 10-30% bakteri +
 Bahan/sediaan :

 Darah, Cairan pleura, Spesimen dari biopsi

atau pungsi, bilasan bronkus,aspirasi paru.

 Diagnosis definitif bila ditemukan kuman

dari darah, cairan pleura, aspirasi paru.
 Rekomendasi: u pneumonia berat yang dirawat
 Foto ulang: klinis menetap, memburuk.
 Infiltrat interstitial: corakan bronkovaskuler me↑
peribronchial cuffing, dan hiperaerasi
 Infiltrat alveolar, merupakan konsolidasi paru-paru
dengan air bronchogram

 BP: gambaran difus di kedua paru, berupa bercak2

infiltrat yang meluas hingga daerah perifer paru,
disertai dengan peningkatan corakan peribronkial.
Female infant, 0,3 y, cxr. alveolar infiltrates Male boy, 1,9 y, cxr alveolar infiltrates in
in upper right lobe ec parainfluenza and right lobe ec. S pneumoniae: IgG
human herpes virus, leucocytois 17000, ESR pneumolysin increased, leucocytosi 13.800,
8 mm/ h l, CRP 22 mg/l ESR 125/h I, CRP 332 mg/l.
 Prediktor paling kuat pneumonia adalah
demam, sianosis, dan lebih dari satu
gejala respiratori sebagai berikut :
o Takipnea
o Batuk
o Napas cuping hidung
o Retraksi
o Ronki
o Suara napas melemah
 Symptom Sensitivity Specificity
Tachypnea 92 % 15 %
Cough 92 % 19 %

Toxic appearance 81 % 60 %

Crackles 44 % 80 %

Retractions 35 % 82 %

Flaring 35 % 82 %

Pallor 35 % 87 %

Grunting 19 % 94 %

Leventhal JM, 1982

 Fast breathing
 (tachypnea)

Respiratory thresholds
 Age Breaths/minute
 < 2 months 60
 2 - 12 months 50
 1 - 5 years 40

Chest Indrawing (subcostal

retraction)
Bayi dan anak berusia <2 bulan

Pneumonia Berat Bukan Pneumonia

• Bila sesak + • Bila sesak –

•Napas cepat + •Napas cepat -
• Harus MRS • Tidak perlu
• Perlu MRS
Antibiotik • Tidak perlu
injeksi antibiotik
• Obat simptomatis
Bayi dan anak berusia 2 bulan – 5 tahun

Pneumonia Pneumonia Bukan

Berat Pneumonia

• Bila sesak + • Bila sesak – • Bila sesak –

• MRS •Napas cepat + •Napas cepat -
• Perlu • Tidak perlu • Tidak perlu
Antibiotik MRS MRS
injeksi • Cukup • Tidak perlu
antibiotik oral antibiotik
• Obat
simptomatis
 Dasar tatalaksana:
 Terapi kausal: antibiotika (AB) yang sesuai

 Terapi suportif

 Terapi Antibiotik secara empiris, yaitu

kemungkinan etiologi penyebab dengan
mempertimbangkan usia dan keadaan klinis
pasien serta faktor epidemiologis
Pengobatan suportif
 Terapi oksigen: Via kanula nasal, masker,
head box; pertahankan sat O2 > 92%
 Cairan intra vena: beri 80% kebutuhan
 Koreksi keseimbangan Asam-Basa, Elektrolit,
gula darah.
 Analgetik/Antipiretik
 Monitor HR, temp, RR, Saturasi min. @4 jam
 Penangulangan penyakit penyerta
 Berikan antibiotik lini pertama secara oral
misalnya amoksisilin atau kotrimoksazol

 Dosis amoksisilin: 25 mg/KgBB

 Dosis kotrimoksazol
 TMP : 4 mg/kgBB
 Sulfametoksazol) : 20 mg/kgBB
 Pilihan AB lini pertama dapat menggunakan
beta-laktam atau kloramfenikol

 Bila tidak responsif, AB pilihan lain seperti

gentamisin, amikasin, atau sefalosporin

 Terapi AB diteruskan selama 7-10 hari

pada pasien pneumonia tanpa komplikasi
 Pada neonatus dan bayi kecil: AB IV segera,
untuk mencegah sepsis atau meningitis

 AB pilihan: spektrum luas → kombinasi beta-

laktam/klavunalat dengan aminoglikosid, atau
sefalosporin generasi III

 Bila keadaan sudah stabil, antibiotik dapat

diganti dengan antibiotik oral selama 10 hari
 Makrolide merupakan pilihan utama
 Eritromisin mempunyai efektivitas klinis yang

baik u’ infeksi Mycoplasma pneumoniae,

tetapi tidak efektif dalam mengeradikasikan
mikroorganisme dari jaringan.

 Dosis eritromisin: 30-50 mg/kgBB/hari,

diberikan setiap 6 jam selama 10-14 hari.
 Pencegahan
A. Pencegahan Non Spesifik

1. Meningkatkan derajat sosial ekonomi

• Menurunkan kemiskinan
• Meningkatkan tingkat pendidikan
• Menurunkan Angka Kurang Gizi
• Meningkatkan Derajat Kesehatan
• Menurunkan morbiditas dan mortalitas

2. Lingkungan bersih bebas polusi

 …pencegahan
A. Pencegahan Spesifik

1. Cegah BBLR
2. Pemberian makanan bergizi/ gizi seimbang/
Pemberian ASI Eksklusif
3. Pemberian Imunisasi
a) Vaksin Campak
b) Vaksin Pertusis
c) Vaksin Hib
d) Vaksin Pneumokokus
Tindakan Preventif
 Komplikasi

oEmpiema torasis (tersering

oPerikarditis purulenta
oPneumotoraks

o Infeksi ekstra pulmoner seperti

Meningitis purulenta dan
Miokarditis
 Pneumonia, Penyebab utama morbiditas dan mortalitas
 Gambaran Klinis dari ringan hingga berat
 Penyebab, virus dan predominan bakteri
 Pada neonatus gejala tidak khas, berhubungan dengan
sepsis/meningitis; penyebab sesuai masing2 klp. umur
 Tatalaksana
tergantung umur, pengobatan awal tergantung keadaan
klinis dan kemungkinan penyebab; pemberian antibiotik
empirik
 Antibiotics :
Typical :normally respond to beta-lactam; macrolides
when unsuccessful
 Atypical : not respond to beta-lactam; first choice
macrolides.
Tindakan Preventif
…Trimakasih
…Trimakasih
 Etiologi pada 698 anak dengan Pneumonia
 S. pneumoniae 67%
 Stafilokokus 11,9%
 Streptococus alfa 11,9 %
 Hafnia alvei 3,4 %
 Stafilokokus aureus 2,8 %
 Morksela kataralis 1,1 %
 Hemofilus influenzae 0,6 %
 Klebseilla pneumoniae 0,6 %
 (Kartasasmita et al Pediatr Indones 2001;41:292-95)
 Antibiotic management of pneumonia: Outpatient
(Alberta Clinical Practice Guideline, 2002)

3 months to 5 years old

Amoxicillin Standard dose: 40 mg/kg/day PO div tid for 7-10 days, OR

High dose : 90 mg/kg/day PO div tid for 7 -10 days.
Beta-lactam allergy:
Clarithromycin 15 mg/kg/day div bid for 7 – 10 days .

Azithromycin 10 mg/kg PO 1st day then 5 mg/kg/day for 4 days OR

Clarithromycin 15 mg/kg/day div bid for 7 – 10 days .

5 to 16 years old

Azithromycin 10 mg/kg (max 500 mg) PO 1st day then 5 mg/kg/day

for 4 days OR
Clarithromycin 15 mg/kg PO div bid for 7-10 days OR
Erythromycin 40 mg/kg/day div qid for 7 -10 days
 Management of pneumonia in children
(Alberta Clinical Practice Guideline, 2002)

Signs and symptoms

(resp distress: tachypnea, cough,
crackles + decreased breath sounds)

History of Physical findings of

•Fever + chills
•New onset of cough
•Chest pain and/or abdominal pain
•Difficulty breathing
•Constitutional symptoms
(malaise and lethargy, headache,
nausea/vomiting, myalgias)
•Temperature > 38,5oC
•Tachypnea*:
-< 11 months > 50 X/min
-> 11 months to 5 yrs > 40 X/min
-5 to 16 yrs > 28 X/min
•Signs of accessory muscle use
•Signs of consolidation

Investigations
Management of pneumonia in children (con’t)
(Alberta Clinical Practice Guideline, 2002)

Investigations
•Chest X-ray is considered gold standard
•Pulse oximetry for child with signs of tachypnea or hypoxemia
•CBC with differential and blood cultures
•Gram stain and culture of sputum (older children)
•Mycoplasma IgM may be considered ( > 2 yrs old)
•Cold agglutinins are limited value in the diagnosis of M pneumonia
•RSV testing is not routinely recommended

Bacterial pneumonia (?)

No Yes
 1. Diffuse alveolar and interstitial pneumonia
(perivascular and interalveolar changes)
 2.  Bronchopneumonia
(inflammation of airways and parenchyma)
 3.  Lobar pneumonia
(consolidation in a whole lobe)
 4.  Nodular, cavity or abscess lesions
(esp.in immunocompromised patients)
Management of pneumonia in children (con’t)
(Alberta Clinical Practice Guideline, 2002)

Bacterial pneumonia (?)

No Yes

General Management
•Analgesic/antipyretics Decision to hospitalize and
•Hydration in-patient management
•Oxygen therapy
•Patient with pleural effusion Out-patient management (3 mos - 5 yrs)
should be referred Amoxicillin (standard or high dose)*
•Pleural empyema should Beta-lactam allergy:
be drained Azithromycin OR
•Chest physiotherapy is Clarithromycin
controversial + Out-patient management (5 to 16 yrs)
•Cough suppressants are NOT Azithromycin OR
routinely recommended Clarithromycin OR
•Mukolitik ? Erythromycin

Follow up
In patients with uncomplicated pneumonia, repeat chest X-rays are unwarranted
In patients with pleural effusions, pneumatoceles or pulmonary abscess,
a repeat chest X-rays should be done
 Antibiotic management of pneumonia: In-patient
(Alberta Clinical Practice Guideline, 2002)
In hospital 1 to 3 months – pneumonitis syndrome Critically Ill
Azithromycin : 10 mg/kg PO 1st day then
 Azithromycin 10 mg/kg IV (max 500 mg)
5 mg/kg/day for 4 days OR
1st day then 5-10 mg/kg/day IV
Clarithromycin 15 mg/kg/day PO
 for 4 days OR
div bid for 10-14 days OR
Erythromycin 40 mg/kg/day IV div Q6h for
Erythromycin 40 mg/kg/day PO
10 to 14 days
div qid for 10-14 days

1 to 3 months – bacterial pneumonia

Cefuroxime 150 mg/kg/day IV div Q8h for
Cefuroxime 150 mg/kg/day IV 10 -14 days OR
div Q8h for 10 -14 days [Cefotaxime 200 mg/kg/day IV Q8h PLUS
Cloxacillin 150-200 mg/kg/day div Q6h for
10 -14 days]

3 months to 5 years
[Cefuroxime 150 mg/kg/day IV div Q8h PLUS
Cefuroxime 150 mg/kg/day IV Erythromycin 40 mg/kg/day IV div Q6h for
div Q8h for 10-14 days 10-14 days] OR
[Cefotaxime 200 mg/kg/day IV div Q8h PLUS
Cloxacillin 150-200 mg/kg/day IV div Q6h for
10 to 14 days]
5 to 16 years

[Cefuroxime 150 mg/kg/day IV div Q8h PLUS [Cefuroxime 150 mg/kg/day IV div Q8h PLUS
Erythromycin 40 mg/kg/day IV/PO div Q6h for Erythromycin 40 mg/kg/day IV/PO div
10 to 14 days] Q6h for 10 to 14 days]
 Atypical pneumonia
 History:
 Since Pasteur isolated S pneumoniae (1880) and Frankel
described D pneumoniae (1884) as a cause of pneumonia, the
clinical picture of pneumonia was recognized as “typical”:
 1) sudden onset of fever and shaking chills, pleuritic chest pain and
production of rust-colored sputum and
 2) radiologic evidence of segmental or lobar consolidation.
 3) examination of sputum showed gram-positive diplococci in
chains, both intracellulary and extracellulary.
 The typical patients evolved in recognizable result , either death or
recovered. Death was as result of crisis, during which temp rose
suddenly, reaching 39,4 to 40 oC and accompanied with severe
delirium, respiratory failure. Or patient could be recovered by lysis
mechanism: fever gradually diminished, dropping to normal
temperature and slowly regained to previous health.

 Atypical pneumonia
 In 1934, Gallagher described an outbreak of bronchopneumonia in
a group of 16 boys living at a preparatory school. He stressed
that these children did not have pneumococcal pneumonia but
something different– something “atypical”.
 In 1938, Reimann also described a group of eight patients with
chest infection but atypical clinical presentations and no chest pain
such as a gradual onset, a prodromal consisting headache,
photophobia, sore throat and dry cough.
 Although the patients were not feeling well, they were not
critically ill. Their sputum was scanty and did not contain
pneumococci;white blood cell counts was normal and without
neutrophilic preponderance and shift to the left.
 He called the term “atypical pneumonia”
 Atypical pneumonia
 1944: Eaton et al isolated a filtrable agent from a patient with
atypical pneumonia known as Eaton agent.
 1960 – 1963 : Chanock et al were able to grow the Eaton agent
and transmit it to human volunteers.They designated the
organism as a member of a new genus and named it Mycoplasma
pneumoniae.
 After that many agent were recognized causing atypical
pneumonia such as :
 Chlamydia spp,
 Legionella pneumophilia.
 Ureaplasma urealyticum
 Etc.
 Atypical pneumonia
 Characterized by
 Insidious onset, fever, nonproductive cough, and
prominent constitutional signs ( severe headache,
malaise, myalgias)
 CXR interstitial inflammation, patchy infiltrates
 Less common leucocytosis
 Lesser mortality, “ walking pneumonia”
 Routine culture fails to reveal microbial causes
 Do not respond to common antibiotics used
Initial empirical treatment based on age
and severity of pneumonia

Outpatients
Age Inpatients (Moderate) Inpatients (Severe)
(Mild to Moderate)

Amoxicillin with or
Ceftriaxone or cefotaxime
3 - 6 mos without clavulanate Ceftriaxone or cefotaxim
+ vancomycin
Erythromycin

6 mos Amoxicillin with or Ceftriaxone, cefotaxime,

Ceftriaxone or cefotaxime
to without clavulanate or
+ macrolide + vancomycin
5 yrs Erythromycin Cefuroxime + macrolide

Ceftriaxone or cefotaxime Ceftriaxone or cefotaxime

5 – 18 yrs Macrolide
+ macrolide + macrolide + vancomycin

Hsiao G et al, 2001

PARU-PARU
Etiologi
 Neonatus dan bayi kecil
o Streptokokus grup B
o Bakteri gram negatif seperti E. Colli,
Pseudomonas sp, atau Klebsiella sp
o Chlamydia trachomatis
 Bayi yang lebih besar dan anak balita
o Streptococcus pneumoniae
o Haemophillus influenzae tipe B
o Staphylococcus aureus
Viral Pneumonia
 Penyebab utama pneumonia di negara maju
 Etiologi virus tersering :
o Respiratory Syncytial Virus (RSV)
o Rhinovirus
o Virus Parainfluenzae
 Secara klinis, umumnya pneumonia bakteri
sulit dibedakan dengan pneumonia virus.
 Etiologi berdasrkan kelompok umur
Newborns
Chemical : Aspiration Toddlers and preschool children
Viral : Varicella-zoster Viral :Adeno,
Bacterial : Streptococcus G or D Parainfluenza,
S. Pneumoniae Influenza A or B
Coliform bacteria
TORCH,
Bacterial :S. Pneumoniae
Hemophilus influenzae
Infants Streptococci A,
Viral : Adeno, Staphylococcus aureus,
Coxsackie, Chlamydia
Parainfluenza,
Influenza A or B, School age and adolescents
Respiratory Syncytial Virus
Viral :Adeno,
Bacterial : B streptococci,
E coli,
Parainfluenza,
P aeruginosa, Influenza A or B
Klebsiella, Bacterial :S. Pneumoniae
S pneumoniae, Streptococci A,
S aureus, Mycoplasma
Chlamydia