Pitfalls terapi pneumonia
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Pneumonia
Schidlow DV, 1996
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Child with Pneumonia
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Introduction
Ostapchuck M et al, 2004;Greenberg D et al, 2005; McIntosh K, 2002
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Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997
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IntroductionDeveloping country ± 60% pneumonia cases caused by bacterial antibiotic.
In developed country mostly viral
Alberta Medical Association, 2001; Jadavji T et al,1997
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Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997
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Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997
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Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997
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Introduction• Recent research showed
that antibiotic regimen in WHO guidelines has reduced 50% mortality in developed country, but there’s also excessive use of antibiotics (75%)
Shann F et al, 1999
Need a guidelines for a Rational use of antibiotics.
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Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997
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Introduction
Alberta Medical Association, 2001; Jadavji T et al,1997
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Antibiotics for Non Severe Pneumonia
Ostapchuck M et al, 2004;Greenberg D et al, 2005
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Antibiotics for Non Severe Pneumonia
Ostapchuck M et al, 2004; McIntosh K, 2002
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Antibiotics for Non Severe Pneumonia
Alberta Medical Association, 2001
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Antibiotics for Non Severe Pneumonia
WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT 2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007
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Antibiotics for Non Severe Pneumonia
WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT 2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007
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Antibiotics for Non Severe Pneumonia
WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT 2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007, CATCHUP study group 2002
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Antibiotics for Non Severe Pneumonia
Kabra SK et al. 2009
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Antibiotics for Non Severe Pneumonia
Kabra SK et al. 2009
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Antibiotics for Non Severe Pneumonia Guidelines from The British Thoracic Society
(2002):• For children < 5 years old: first line drugs is
amoxicillin (well tolerated, not expensive)
The British Thoracic Society, 2002
Alternative antibiotics:co-amoxiclav, cephachlor,
eritromycin, Chlaritromycin, and azitromycin
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Antibiotics for Non Severe Pneumonia
Guidelines , The British Thoracic Society, 2002:• In children > 5 years old most common
organism is M. Pneumoniae• First line drugs is macrolide
The British Thoracic Society, 2002
If S. pneumoniae suspected amoxicillinIf S. aureus suspected macrolide or
combination of flucloxacillin and amoxicillin
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Antibiotics for Non Severe Pneumonia
Monotherapy is recommended.
National Guideline Clearinghouse, 2006
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Antibiotics for Non Severe Pneumonia
National Guideline Clearinghouse, 2006
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Follow Up• Evaluation performed after
24-72 hours of treatment, if no improvement change antibiotics
National Guideline Clearinghouse, 2006
Signs of improvement:Decrease respiratory rateLower feverAppetite improvement
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Indication for Admission
Alberta Medical Association, 2001; WHO , 2008
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Indication for Admission
Alberta Medical Association, 2001; WHO , 2008
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Antibiotic for Admitted Pneumonia
Fonseca W, 2003; Pakistan MASCOT, 2002
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WHO, 2005
Antibiotic for Admitted Pneumonia
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Antibiotic for Admitted PneumoniaGuideline for the Management of Community
Acquired Pneumonia in childhood:
The British Thoracic Society, 2002
As therapy begin, the organismcausing pneumonia is unknown.
Treatment based on age and specific symptoms for specific pathogen.
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0-8 Weeks
Enarson PM, 2005
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2-59 Months
Enarson PM, 2005
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Other Study
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Macrolide
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Cephalosporins and Non Cephalosporins
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Cephalosporins• A randomized controlled trial compared
3rd generation of cephalosporins and Cephachlor no differences
(Paupe J, et all, 1992 )
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Table 1. Therapeutic management of pneumoniaPatient age Outpatient Inpatient Critically ill
Birth to20 days
Admit Ampicillin IV or IM:Age <7 days:Weight <2 kg (4.4 lb): 50 to 100 mg per kg per day in divided doses every 12 hoursWeight ≥2 kg: 75 to 150 mg per kgper day in divided doses every 8 hours
Ampicillin IV or IM, in same dosages as for inpatientsplusGentamicin IV or IM, with or without cefotaxime IV, in same dosages as for inpatients
Ostapachuk, M,.2004
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Patient age Outpatient Inpatient Critically ill
Birth to20 days
Admit Ampicillin IV or IM:Age ≥7 days:Weight <1.2 kg (2.6 lb): 50 to 100mg per kg per day divided every12 hoursWeight 1.2 to 2 kg: 75 to 150 mg perkg per day in divided doses every8 hoursWeight >2 kg: 100 to 200 mg perkg per day in divided doses every6 hours
Table 1. Therapeutic management of pneumonia
Ostapachuk, M,.2004
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Patient age
Outpatient Inpatient Critically ill
Birth to20 days
Admit plusGentamicin IV or IM:≥37 weeks of gestationAnd Age zero to 7 days: 2.5 mg per kg every 12 hoursAge >7 days: 2.5 mg per kg every8 hourswith or withoutCefotaxime (Claforan) IV:Age ≤7 days: 100 mg per kg per day in divided doses every 12 hoursAge >7 days:150 mg per kg per day in divided dosesevery 8 hours
Ostapachuk, M,.2004
Table 1. Therapeutic management of pneumonia
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Patient age
Outpatient Inpatient Critically ill
3 weeks to3 months
If patient is afebrile:Azithromycin (Zithromax),10 mg per kg orally on day 1, then 5 mg per kg per day on days 2 through 5orErythromycin, 30 to 40 mg per kg per day orally in divided doses every 6 hours for 10 daysAdmit if patient is febrile orhypoxic.
Erythromycin, 40 mg per kg per day IV individed doses every 6 hours*If patient is febrile, add one of these agents:Cefotaxime, 200 mg per kg per day IV in divided doses every 8 hours*orCefuroxime (Ceftin), 150 mg per kg per day IV in divided doses every8 hours*
Cefotaxime, 200 mg per kg per dayIV in divided doses every 8 hoursplus cloxacillin (Tegopen), 150to 200 mg per kg per day IV individed doses every 6 hours*orCefuroxime alone, 150 mg per kgper day IV in divided doses every8 hours*
Ostapachuk, M,.2004
Table 1. Therapeutic management of pneumonia
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Patient age
Outpatient Inpatient Critically ill
4 mo to5 years
Amoxicillin, 90 mg per kg per day orally in divided doses every 8 hours for 7 to 10 daysConsider initial dose ofceftriaxone (Rocephin),50 mg per kg per day IM, up to 1 g per day. Follow with oral therapy for full course.Alternatives: amoxicillin clavulanic acid (Augmentin), azithromycin, cefaclor(Ceclor), clarithromycin(Biaxin), erythromycin
Cefotaxime, 150 mg per kg per day IV in divided doses every 6 hours*orCefuroxime, 150 mg per kg per day IV in divided doses every 8 hours*If the patient has pneumococcal infection:Ampicillin alone, 200 mg per kg per day IV in divided doses every 8 hours*
Cefuroxime, 150 mg per kg per day IV in divided doses every 8 hours,plus erythromycin, 40 mg per kg per day IV or orally in divided doses every 6 hours for 10 to 14 days*orCefotaxime, 200 mg per kg per day IV in divided doses every 8 hours,plus cloxacillin, 150 to 200 mg per kg per day IV in divided doses every 6 hours for 10 to 14 days
Ostapachuk, M,.2004
Table 1. Therapeutic management of pneumonia
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Table 1. Therapeutic management of pneumoniaPatient age
Outpatient Inpatient Critically ill
5 yearsand older
Azithromycin, 10 mg perkg (maximum of 500 mg)orally on day 1, followedby 5 mg per kg per day ondays 2 through 5Or Clarithromycin, 15 mg per kg per day orally in divided doses every 12 hours for 7 to 10 daysOr Erythromycin, 40 mg per kg per day orally in divideddoses every 6 hours for 7 to10 days If the patient haspneumococcal infection:Amoxicillin alone, 90 mgper kg per day orally individed doses every 8 hours
Cefuroxime, 150 mg per kg per day IV in divided doses every 8 hoursplusErythromycin, 40 mg per kg per day IV or orally in divided doses every 6 hours for10 to 14 daysIf pneumococcal infection is confirmed:Ampicillin alone, 200 mg per kg per day IV in divided doses every 8 hours
Cefuroxime, 150 mg per kg per dayIV in divided doses every 8 hoursplusErythromycin, 40 mg per kg per dayIV or orally in divided doses every6 hours for 10 to 14 days
Ostapachuk, M,.2004
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Follow Up• Every 6 hours or at
least once a day• Observations consist
of respiratory rate, temperature, level of consciousness and feeding
National guidelines Clearinghouse, 2006
Amelioration signs :•Decreasing of respiratory rate•No chest indrawing•Lowering of fever•Better appetite
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Follow Up cont’• Rules of hospital discharge :
– Adequately consumes oral antibiotics – Antibiotic therapy can be done at home– Family agree and understand the
management at home– Support from environment for the therapy– Family should take their child to the
clinician for next examination
Ostapachuk, M,.2004
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Pitfalls Management of Pneumonia in Children
• Chest x-ray should not routinelly done in children with mild pneumonia. (A)
• Evaluation of chest x-ray only performed if no improvement or there is worsening. (C)
Enarson M, 2006The British Thoracic Society,2002
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Pitfalls Management of Pneumonia in Children
• Antibiotics administration empirically often inappropriate with the etiology overused antibiotics . Amoxycillin is the first line antibiotic for pneumonia. Alternatives co-amoxyclav, cephachlor, erytromycin clarytromycin and azytromycin . (B)
Enarson M, 2006The British Thoracic Society,2002
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Pitfalls Management of Pneumonia in Children
• Nasogastric tube should not be applied in severe pneumonia (D)
• Every pneumonia patient has to be monitored for oxygen saturation. (A)
• Children with oxygen saturation below 92% must given oxygen therapy with nasal canule, head box, or facial mask, to keep the saturation above 92%. (A)
The British Thoracic Society,2002
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Pitfalls Management of Pneumonia in Children
• Intravenous fluid administered for 80% from daily requirement and electrolyte examination must be done in severe pneumonia. (C)
• Chest physiotherapy is not always useful (B)
The British Thoracic Society,2002
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Study design Evidence
level
Recomendation
Advance systematic study Ia A+
One or more good study Ib A-
One or more prospective study II B+
One or more retrospective
study
III B-
Experts’ assumption formally Iva C
Experts’ assumption informally
or other information
IVb D
Table 2 . Evidence Level and Recommendation
The British Thoracic Society, 2002
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CONCLUSION• Antibiotic administration is a challenge for clinician in the
management of pneumonia• Some pneumonia caused by viral infection • As we decide to give antibiotic, we must consider which
antibiotic should be used (broad spectrum or narrow spectrum)
• First give antibiotic empirically based on children age• Second observe within 24-72 hours• All of the steps above are useful to prevet pittfalls in the
management of pneumonia
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Cochrane Database of Systematic Review 2008
To determine the equivalence in effectiveness and safety of oral antibiotics compared to parenteral antibiotics
Oral Antibiotics vs Parenteral Antibiotics for Severe Pneumonia
Rojas-Reyes MX, Rugeles CG, 2006
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Cochrane Database of Systematic Review 2008
Published or unpublished randomized controlled trials (RCTs) comparing any oral and parenteral antibiotic children 3 months to 5 years
Oral therapy effective and safe alternative to parenteral antibiotics in hospitalized children
Rojas-Reyes MX, Rugeles CG, 2006
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Cochrane Database of Systematic Review 2008
Short –course vs Long-course antibiotic therapy for non-severe community-acquired pneumonia
Results:Analysis of three days of treatment with the same antibiotic non significant differences in clinical cure, treatment failure, and relapse rate after seven days of clinical cure
Haider BA, Saeed MA, Bhutta ZA, 2007
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Cochrane Database of Systematic Review 2008
Conclusion
A short course (3 days) of antibiotic therapy is as effective as a longer treatment (5 days) for non severe pneumonia in children under five years of age.
Haider BA, Saeed MA, Bhutta ZA, 2007
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Cochrane Database of Intervention Review
To identify effective antibiotic drug therapy for community acquired pneumonia in children by comparing various antibiotics.
Antibiotics for CAP in Children
Kabra SK, Lodha R, Pandey RM, 2009
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Cochrane Database of Intervention Review • Cotrimoxazole is inferior to amoxycillin and
prokain penicillin• Penicillin in conjunction with gentamycin
better than chloramphenicol alone.• Co-amoxyclavulanic acid was better than
amoxycillin alone• No difference between injectable penicillin and
oral amoxycillinKabra SK, Lodha R, Pandey RM, 2009
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Cochrane Database of Intervention Review No differences between• Injectable penicillin and oral amoxycillin• Azithromycin and erythromycin • Cefpodoxime and amoxycillin• Azithromycin and co-amoxyclavulanic
acid.
Kabra SK, Lodha R, Pandey RM, 2009
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ConclusionAmbulatory patients• Amoxycillin was better than co-trimoxazole• No difference between azithromycin and
erythromycin• No difference between cefpodoxime and co-
amoxyclavulanic
Cochrane Database of Intervention Review
Kabra SK, Lodha R, Pandey RM, 2009
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Cochrane Database of Intervention Review • Hospitalized patients• Procain penicillin was better than
cotrimoxazole• Penicillin + gentamycin better than
chloramphenicol alone• Injectable penicillin and oral amoxycillin
similar failure rates
Kabra SK, Lodha R, Pandey RM, 2009
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Cochrane Database of Intervention Review
Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults
To evaluate the efficacy of OTC cough medications as an adjunct to antibiotics in
children and adults with pneumonia
Chang CC, Cheng AC, Chang AB, 2009
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Cochrane Database of Intervention Review• Insufficient evidence to decide whether
OTC medications for cough associated with acute pneumonia are beneficial.
• Mucolytics may be beneficialinsufficient evidence
• Codeine and antihistamines should not be used in young children
Chang CC, Cheng AC, Chang AB, 2009
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Buku saku pelayanan kesehatan anak di rumah sakit rujukan tingkat pertama di kabupaten/kota
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Technical updates of the guidelines on the Integrated Management of Childhood Illness (IMCI)
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