Gejala dan TandaGejala dan Tanda

– Batuk disertai dahak– Nyeri dada atau nyeri pleuritik yang dirasakan sewaktu menarik

napas dalam– Demam– Sesak napas– Sakit kepala, mual, muntah dan diare

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

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

• Usia >65 tahun• Aspirasi sekret

orofaringeal• Infeksi pernapasan oleh

virus• Sakit yang parah &

menyebabkan kelemahan• Penyakit pernapasan

kronik• Kanker• Tirah baring yang lama

• Trakeostomi atau pemakaian selang endotrakeal

• Bedah abdominal atau toraks

• Fraktur tulang iga• Pengobatan dengan

imunosupresif• AIDS• Riwayat merokok• Alkoholisme• Malnutrisi

Faktor ResikoFaktor Resiko

Pneumonia Classification 1. Clinical dan Epidemiology:

a. Community Acquired Pneumonia (CAP)b. Hospital Acquired Pneumonia (HAP)c. Aspiration Pneumoniad. Pneumonia in immunocompromised Patient

2. Etiology:a. Typical : bakteriab. Atipikal : (Mycoplasma, Legionella, Chlamydia)c. Virusd. Fungi

3. Predilection of infectiona. Pneumonia lobarisb. Bronchopneumoniac. Pneumonia Interstitial

Pneumonias – Classification

Nosocomial Pneumonias

Kieninger AN, and Lipsett PA. Hospital-Acquired Pneumonia : Pathophysio-logy, Diagnosis, and Treatment. Surg Clin N Am (89) 2009; 439-461.

Chest X Ray Patterns and Pathogens

1. Klasifikasi tradisional (ciri radiologis dan

gejala klinis)

Klasifikasi KlinisKlasifikasi Klinis

a. Pneumonia tipikalCiri: tanda2 pneumonia lobaris yang klasik awitan akut berupa gambaran radiologis berupa opasitas lobus/lobarisEtio: kuman yang tipikal terutama S. pneumoniae, Klebsiella pneumoniae atau Haemophilus influenzae

a. Pneumonia tipikalCiri: tanda2 pneumonia lobaris yang klasik awitan akut berupa gambaran radiologis berupa opasitas lobus/lobarisEtio: kuman yang tipikal terutama S. pneumoniae, Klebsiella pneumoniae atau Haemophilus influenzae

b. Pneumonia atipikalTanda: gangguan respirasi yang meningkat lambat dengan gambaran infiltrat paru bilateral yang difusEtio: organisme yang atipikal dan termasuk Mycoplasma pneumoniae, virus, Legionella pneumophila, Chlamydia psittaci dan Coxiella Burnetti

b. Pneumonia atipikalTanda: gangguan respirasi yang meningkat lambat dengan gambaran infiltrat paru bilateral yang difusEtio: organisme yang atipikal dan termasuk Mycoplasma pneumoniae, virus, Legionella pneumophila, Chlamydia psittaci dan Coxiella Burnetti

DD : PNEUMONIA TYPICAL & ATYPICAL

Sign and symptoms PNEUMONIA Typical 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 coccus gram +/- Normal flora

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2. Berdasarkan faktor lingkungan dan penjamu

Tipe klinis Epidemiologi

•Pneumonia komunitas•Pneumonia nosokomial•Pneumonia rekurens

•Pneumonia aspirasi•Pneumonia pada gangguan imun

•Sporadis; muda/tua•Didahului perawatan di RS•Terdapat dasar penyakit paru kronik•Alkoholik, usia tua•Pasien kanker, transplantasi, AIDS

Klasifikasi KlinisKlasifikasi Klinis

1. Pneumonia lobarisBila organisme berkolonisasi secara luas pada ruang alveolar, dan menyebabkan konsolidasi seluruh lobus

Klasifikasi PatologisKlasifikasi Patologis

Eksudat mengalami lisis & direabsorpsi oleh makrofag sehingga jaringan kembali pada strukturnya semula

2. Bronkopneumonia• Bila organisme

berkolonisasi pada bronkus dan meluas dalam alveoli

Klasifikasi PatologisKlasifikasi Patologis

3. Infeksi virus– Menyebabkan respon peradangan intersisial

melalui sel-sel limfoid, yang pada banyak kasus dapat sembuh spontan

– Penyebab tersering: organisme influenza & mikoplasma

4. Infeksi fungi atau TB– Menyebabkan nekrosis pada jaringan atau

terbentuknya kavitas

Klasifikasi PatologisKlasifikasi Patologis

DIAGNOSIS• Anamnesa : cough , purulent sputum, fever, shortness of

breath , chest pain.• Physic Diagnostic :

– Fever, T > 380C– Auscultation thorax: bronchial sound, ronchi

• Lab : Leucosit ≥ 10.000 / < 4500• Chest X ray : infiltrat /consolidation with airbronchogram• Diagnosis etiology : microbiology (culture sputum)• Blood gas Analysis : hypoxemia

14

Bacterial pneumonia. A posteroanterior chest radiograph shows left lower pneumonia. Sputum Gram stain showed gram-positive diplococci.

Pemeriksaan penunjangPemeriksaan penunjang

PenatalaksanaanPenatalaksanaan

Terapi suportif

ALUR TATA LAKSANA PNEUMONIA KOMUNITIAnamnesis, Pemeriksaan Fisis, Foto Thoraks

Tidak ada Infiltrat Infiltrat + gejala klinis yang menyokong diagnosis pneumonia

Evaluasi untuk kriteria rawat jalan / rawat inapDi Tatalaksana sebagai

diagnosis lain

Rawat jalan

Terapi empiris

Membaik Memburuk

Terapi empiris dilanjutkan Memburuk Membaik Terapi kausatif

Terapi empiris (48-72jam)

R. Rawat biasa R. rawat intensif

Rawat inap

Pemeriksaan bakteriologis

18

Journal Reading 19Fine MJ, Auble TE, Yealy DM. N Engl J Med 1997; 336: 243-250.

PORT ( Pneumonia Patient Outcome Research Team) /Pneumonia Severity Index (PSI),

I,II,III low

IV Moderate

V high

DERAJAT SKOR MENURUT PORT

RESIKO KELAS RESIKO TOTAL SKOR PERAWATAN

RENDAH IIIIII

Tidak diprediksi< 70 71-90

Rawat JalanRawat Jalan

Rawat Inap/Jalan

SEDANG IV 91-130 Rawat Inap

BERAT V > 130 Rawat Inap

20

COMMUNITY ACQUIRED PNEUMONIA

INDICATION FOR HOSPITALIZATION ~ PDPI 2004

1. PORT score > 702. PORT score < 70 with sign and symptoms :

1. Respiratory rate > 30 x/m2. PaO2 / FiO2 < 250 mmHg3. Chest X Ray : bilateral infiltration4. Chest X Ray : infiltration > 2 lung lobes5. sistolic < 90 mmHg6. diastolic < 60 mmHg

3. NAPZA (Narkotik dan Zat adiktif ) Pneumonia21

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.

MODIFICATION FACTORS → Condition that increased the risk of infection by pathogen spesific

microorganism

• Penicilin-resistant Pneumococcus / β-lactam–resistant S. pneumoniae

age > 65yo, alcoholism, immunodeficiency, medical comorbidities , β-lactam therapy within the previous 3 months, immunosuppressive illness or therapy

• Enteric gram-negative Residence in a nursing home or extended care facility, heart/lung disease, multiple disease, use of antimicrobials

• Pseudomonas aeruginosa bronchiectasis, malnutrition, steroid, use of broad spectrum antibiotics > 7 days

23

Management of empiric therapy of Pneumonia (PDPI), 2004

outpatient inpatient

intensive care

• 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)

• Without Modification Factors : laktam + anti laktamase ( Amoxycicilline clavulanat I.V ) or cephalosporin G2, G3 (cefotaxim iv, ceftriaxone iv ) orrespiratory fluoroquinolon I.V (levofloxacin,moxifloxacin,gatifloxacin)

• With Modification Factors: cephalosporin G2,G3 I.V or respiratory fluoroquinolon IV

• If atypical pneumonia is suspected : new macrolide + (added)(roxitromycin,claritromycin,azitromycin)

a. Without Risk Factors of Pseudomonal infection - Cephalosporin G3 iv non pseudomonas plus +

new macrolide or respiratory fluoroquinolon iv

b. With Risk Factors to pseudomonal infection - Cephalosporin antipseudomonal iv or carbapenem iv

plus Fluoroquinolon antipseudomonal (ciprofloxacin iv) / aminoglycosida iv

(gentamicin) - If suspects atypical bacterial infection :

add new macrolide or Fluoroquinolon respirasi iv

intensive care

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

Pneumonia Nosocomial DEFINITION

Risk Factors of Nosocomial Pneumonia :

Sundaram R. Nosocomial pneumonia. AnaesthesiaUK. 2006. http//www.AnaesthesiaUK.com/WorldAnaesthesia

PATOPHYSIOLOGY

Risk Factors of Nosocomial Pneumonia :

Kollef MD. Appropriate Empiric Antimicrobial Therapy of Nosocomial Pneumonia: The Role of the Carbapenems. Respir Care 2004; 49(12);1532

HAP VAPPATIENT-RELATED RISK FACTORS

Advanced age (> 60 years) Supine position

Comorbid disease (eg. chronic lung disease) Comorbid disease (eg. chronic lung disease)

Previous antibiotik therapy Previous antibiotik therapy

Cardiothoracic or abdominal surgery Stress ulcer prophylactic with gastric pH-altering agents

APACHE II > 16

Smoking

Prior hospitalization or abdominal surgery

Reflux

DEVICE-RELATED RISK FACTORS

Tracheotomy Tracheotomy

Nasogastric tubes Nasogastric tubes

Short duration of nasotracheal or orotracheal intubation

Prolonged duration of Mechanical Ventilation

Long duration of nasotracheal or orotracheal intubation

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

... Cont Pathophysiology

Dandagi GL. Nosocomial pneumonia in critically ill patients. Lung India. 2010; Vol 27:151

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

MRSA Risk Factors : COPD, ventilator >>, antibiotics exposure, corticosteroid, bronchoscopy

Enterobacteriaceae (E. coli, Klebsiella sp, Enterobacter sp) ESBL (Carbapenem : firts choice)

Pseudomonas aeruginosa common isolate in ventilator > 4 days

Kieninger & Lipsett. Hospital-Acquired Pneumonia : Pathophysiology, Diagnosis, and Treatment. Surg Clin N Am (89) 2009; 439-461

... Etiology Pathogens of Nosokomial Pneumonia

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)

Patogen Onset Pneumonia Frekuensi (%)

Streptococcus pneumoniae early 10 – 20

Haemophilus influenzae early 5 – 15

Anaerobic bacteria early 10 – 30

Staphylococcus aureus early / late 20 – 30

Basil gram-negatif late 30 – 60

- Pseudomonas aeruginosa 17

- Klebsiella pneumoniae 7

- Acinetobacter spp. 3

- Escherichia coli 6

- Enterobacter spp. 10

Legionella pneumophila late 0 – 15

Terapi Antibiotik Inisial Empirik utk HAP/VAP onset-dini pada pasien tanpa faktor resiko patogen MDR (ATS, 2005)

Patogen Potensial Antibiotik yg Direkomendasikan

Streptococcus pneumoniaeHaemophilus influenzaeMSSABasil Gram-negatif yg sensitif-antibiotik : E. coli, K. pneumoniae Proteus sp., S. marcescens

- Ceftriaxone; atau- Levofloxacin , Moxifloxacin, atau Ciprofloxacin; atau- Ampicillin/sulbactam; atau- Ertapenem

Terapi Antibiotik Inisial Empirik utk HAP onset-dini (Asian HAP Working Group, 2008)

Patogen Potensial Antibiotik yg Direkomendasikan

Streptococcus pneumoniaeHaemophilus influenzaeMSSABasil Gram-negatif yg sensitif-antibiotik : E. coli, K. pneumoniae Proteus sp., S. marcescens

- Cephalosporin gen. ke-3 : (Ceftriaxone, Cefotaxim) ; atau

- Fluoroquinolones (Moxifloxacin, Levofloxacin) ; atau

- β-lactam/β-lactam inhibitor (Amoxicillin/clavulanic acid, Ampicillin/sulbactam) ; atau

- Carbapenems (Ertapenem) ; atau

- Cephalosporin gen. ke-3 plus Macrolide ; atau

- Monobactam + Clyndamycin (utk pasien alergi β-lactam)

Terapi Antibiotik Inisial Empirik utk VAP onset-dini (Asian HAP Working Group, 2008)

Patogen Potensial Regimen AB yg Direkomendasikan

Patogen-patogen spt pd tabel sebelumnya, dan Patogen MDR :Pseudomonas aeruginosaK. pneumoniae (ESBL)Acinetobacter sp.

MRSA

- Cephalosporin Antipseudomonas : (Cefepime) ; atau

- Carbapenem Antipseudomonas : (Imipenem, Meropenem) ; atau

- β-lactam/β-lactam inhibitor (Piperacillin/tazobactam)

plus / -- Fluoroquinolones (Ciprofloxacin,

Levofloxacin) ; atau- Aminoglycoside (Amikacin,

Gentamycin, Tobramycin) plus / -Linezolid; atau Vancomycin

Pneumonia Nosocomial Treatment

Terapi Antibiotik Inisial Empirik utk HAP,VAP, & HCAP onset-lambat atau dgn faktor resiko patogen MDR (ATS, 2005)

Patogen Potensial Antibiotik yg Direkomendasikan

Patogen-patogen spt pd tabel sebelumnya, dan Patogen MDR :P. aeruginosaK. pneumoniae (ESBL)Acinetobacter sp.MRSALegionella pneumo-phila

- Cephalosporin Antipseudo-monas : (Cefepime, Ceftazidime) ; atau

- Carbapenem Antipseudo-monas : (Imipenem, Meropenem) ; atau

- β-lactam/β-lactamase inhibitor (Piperacillin/tazobactam)

Plus

- Fluoroquinolones Anti-pseudomonas (Ciprofloxacin, Levofloxacin) atau

- Aminoglycoside (Amikacin, Gentamycin, Tobramycin)

Plus/-

LinezolidatauVancomycin

Terapi Antibiotik Inisial Empirik utk HAP onset-lambat (Asian HAP Working Group, 2008)

Patogen Potensial Regimen AB yg Direkomendasikan

Patogen-patogen spt pd tabel sebelumnya, dan Patogen MDR :P. aeruginosaK. pneumoniae (ESBL)Acinetobacter sp.

MRSALegionella pneumo-phila

Spt Rekomendasi ATS 2005 ; atau :

- Cefoperazon/sulbactam,

plus Fluoroquinolones, atau Aminoglycosides,

plus Ampicillin/sulbactam; atau :- Fluoroquinolone (Ciprofloxacin),

plus Aminoglycoside

Plus/-Linezolid; atau VancomycinPlus/-x) Azithromycin, atau

Fluoroquinolone

Terapi Antibiotik Inisial Empirik utk VAP onset-lambat (Asian HAP Working Group, 2008)

Patogen Potensial Regimen AB yg Direkomendasikan

Patogen MDR :P. aeruginosaK. pneumoniae (ESBL)Acinetobacter sp.

MRSA

- Carbapenem Antipseudomonas : (Imipenem, Meropenem) ; atau

- β-lactam/β-lactamase inhibitor (Piperacillin/tazobactam)

Plus/-- Fluoroquinolones (Ciprofloxacin,

Levofloxacin) atau- Aminoglycoside (Amikacin,

Gentamycin, Tobramycin) ; atau : - Spt Rekomendasi Asian HAP Working

Group 2008 utk HAP late-onset ; kecuali x)

Plus/-Linezolid; atau Vancomycin

Pneumonia Nosocomial Treatment