Professional Documents
Culture Documents
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
Faktor
Resiko
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
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
Normal flora
8
Klasifikasi Klinis
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
Klasifikasi
Patologis
2. Bronkopneumonia
Bila organisme
berkolonisasi pada
bronkus dan meluas
dalam alveoli
Klasifikasi
Patologis
3.
Infeksi virus
4.
DIAGNOSIS
Anamnesa : cough , purulent sputum, fever,
shortness of breath , chest pain.
Physic Diagnostic :
Fever, T > 380C
Auscultation thorax: bronchial sound, ronchi
14
PEMERIKSAAN
PENUNJANG
PENATALAKSANAAN
TERAPI SUPORTIF
Di Tatalaksana sebagai
diagnosis lain
Rawat jalan
Rawat inap
Terapi empiris
Membaik
Memburuk
Pemeriksaan bakteriologis
R. Rawat biasa
R. rawat intensif
Membaik
Memburuk
Terapi kausatif18
I,II,III low
IV Moderate
V high
Journal Reading
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.
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.
23
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)
intensive care
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
Supine position
APACHE II > 16
Smoking
Prior hospitalization or abdominal
surgery
Reflux
DEVICE-RELATED RISK FACTORS
Tracheotomy
Tracheotomy
Nasogastric tubes
Nasogastric tubes
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
...
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
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
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
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
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.
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