PneumoniaRegi Septian

Pneumonia is an inflammatory condition of the lung—affecting primarily the microscopic air sacs known as alveoli. It is usually caused by infection with viruses or bacteria and less commonly other microorganisms, certain drugs and other conditions such as autoimmune diseases.[1]

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Typical symptoms include a cough, chest pain, fever, and difficulty breathing.

Globally, pneumonia affects approximately 450 million people per year, seven percent of population, and results in about 4 million deaths, mostly in third world countries.

Although pneumonia was regarded by William Osler in the 19th century as "the captain of the men of death",[5] the advent of antibiotic therapy and vaccines in the 20th century improvements in survival.

In developing countries, and among the very old, the very young and the chronically ill, pneumonia remains a leading cause of death.

CDC definition of pneumonia

Horan TC, Andrus M, Dudreck MA. CDC/NHSN surveillance definition of health-care associated infection and criteria for specific types of infection in the acute care setting

Classification• Pneumonia yang berkembang di luar rumah sakitCommunity

Acquired Pneumonia (CAP)

• Pneumonia yang berkembang di luar rumah sakit, pasien yang dirawat dalam perawatan akut, selama 2 hari atau lebih karena infeksi dalam waktu 90 hari terakhir; tinggal di panti wreda / fasilitas perawatan jangka panjang lainnya; menerima terapi antibiotik IV, kemoterapi / perawatan luka dalam waktu 30 hari terakhir/ mendapatkan hemodialisis baik diklinik maupun RS

Healthcare Associated Pneumonia

(HCAP)

• Pneumonia yang berkembang setelah 48 jam setelah masuk rumah sakit dan tidak dalam masa inkubasi pada saat pasien masuk

Hospital Acquired Pneumonia (HAP)

• Pneumonia yang timbul dalam waktu 48-72 jam setelah inkubasi endotrakeal

Ventilator Associated

Pneumonia (VAP)

Area of The Lung AffectedPneumonia Lobaris• Biasanya mencakup keseluruhan lobus secara homogen• Terdapat 4 tahapan : kongesti, red hepatization, grey hepatization,

resolusi Bronkhopneumonia• Konsolidasi “bercak” yang mencakup satu atau beberapa lobus,

biasanya mencakup bagian inferior dan posterior paru—pola yang sesuai dengan distribusi aspirasi orofaring akibat gravitasi.

Pneumonia interstitialis• Proses inflamasi (bercak atau difusa) mencakup interstitial secara

dominan, termasuk, dinding alveolus dan jaringan ikat di sekitar bronchovascular tree.

• Alveoli tidak mengandung eksudat, melainkan membran hialin kaya protein (mirip dengan ARDS)

Pneumonia milier• Gambaran lesi berukuran 2-3 cm, difus, menyerupai tuberkulosis

milier.• Diakibatkan oleh penyebaran patogen ke paru melalui aliran darah

Pneumonia Severity ScoresCURB-65

Pneumonia Severity Index

Clinical Pulmonary Infection Score

CauseBacteria

Streptococcus pneumoniae isolated in nearly 50% of cases

Haemophilus influenzae in 20%

Chlamydophila pneumoniae in 13%,

Mycoplasma pneumoniae in 3%

Staphylococcus aureusMoraxella catarrhalisLegionella pneumophila gram-negative bacilli.

VirusesRhinovirusesCoronavirusesinfluenza virusrespiratory syncytial virus (RSV)AdenovirusParainfluenzaHerpes simplex virus is a rare cause of

pneumonia, except in newbornsPeople with weakened immune systems are at

increased risk of pneumonia caused by cytomegalovirus (CMV).

FungiHistoplasma capsulatumBlastomycesCryptococcus neoformansPneumocystis jiroveciCoccidioides immitis.

• Parasites Toxoplasma gondii Strongyloides stercoralis Ascariasis

ImagingX-ray

bacterial community acquired pneumonia lung consolidation of one lung segmental lobe

Aspiration pneumonia bilateral opacities primarily in the bases of the lungs and on the right side

Differential diagnosis

chronic obstructive pulmonary disease (COPD)

Asthmapulmonary edemaBronchiectasislung cancer pulmonary emboli

Management Hospitalization Antibiotics

Cephalosporins Carbapenems Fluoroquinolones Aminoglycosides Vancomycin

• Antiviral Neuraminidase inhibitors Rimantadine,amantadine Influenza A oseltamivir, zanamivir or peramivir Influenza A or B

Rest simple analgesics fluids

Prevention of Health Care1. Staff education and Involvement in Infection

Prevention2. Infection and microbiologic surveillance

3. Prevention of transmission of microorganisms Sterilization or desinfection & maintance of equipment & devices Prevention of person to person transmission of bacteria

4. Modifying host risk for infection Increasing host defense against infection: administration of

immune modulators Precautions for prevention of aspiration Prevention of postoperative pneumonia Other prophylactic procedures for pneumonia

Treatment

American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.

Treatment- Early onset VAP with no risk factors, any disease severity

American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.

Treatment- Late onset or risk factors for MDR or all disease severity

American Thoracic Society, Infectious Diseases Society of America. Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia.

Antibiotic Doses

Cephalosporin anti-pseudomonal

- Cefepime 1-2 g / 8-12 hour

- Ceftazidime 2 g/ 8 hour

Carbapenem

- Imipenem 500 mg/6 hour or 1 g/8 hour

- Meropenem 1 g/8 hour

Beta Lactam/Inhibitor Beta Lactamase

- Piperacillin-tazobactam 4,5 g/6-8 hour

Aminoglycoside

- Gentamycin 7 mg/kg/day

- Tabramycin 7 mg/kg/day

- Amikasin 20 mg/kg/day

Quinolone-anti-pseudomonal

- Levofloxacin 750 mg/day

- Ciprofloxacin 400 mg/ 8 hour

Vancomycin 15 mg/kg/ 12 hour

Linezolid 600 mg/12 hour

Patogen Bacteria MDRAcinetobacter ( carbapenem,

sulbactam,colistin & polymixin)ESBL enterobacteriaceae (Carbapenem)MRSA ( Vancomycin; alternatif Linezolid)

ComplicationPleural effusionEmpyemaAbscessRespiratory failure Need Mechanical

ventilationCirculatory failure Intrevenous fluids and

medications

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