severe cap & hap
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Agus SuryantoDivision of Pulmonology Department of Internal Medicine Diponegoro University – Dr. Kariadi Hospital
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Severe CAP CAP : Pneumoni didapat di masyarakat Mortalitas di AS:
Rawat jalan 1 – 5 % Rawat inap > 20 % Severe CAP > 40 %
Penyebab: Diagnosis & management < adekuat Resistensi antibiotika CAP pada usia lanjut meningkat Komorbiditas: DM, Gagal ginjal, malignansi,
peny. Jantung, peny. Hati kronik dll. Management
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Guideline CAP : American Thoracic Sosiaty (ATS) Infectious Disease of America (IDSA) Centers of Diseases Control (CDC) British Thoracic Sosiaty (BTS) Antibiotic Selection for CAP (ASCAP) dll
Belum dapat menurunkan angka kematian
Pola kuman bervariasi Pada Severe CAP sering polimikrobial
(10 – 20 %)
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Kriteria Severe CAP
ATS : salah satu dari 9 kriteria Kriteria minor :
Laju pernafasan > 30 menit Rasio PaO2/FiO2 < 250 Bilateral / multilobar pneumonia Sistolik < 90 mmHg Diastolik < 60 mmHg
Kriteria mayor : Memerlukan ventilator mekanik Peningkatan luasnya infiltrat > 50% dalam 48 jam Septik syok atau memerlukan vasopresor > 4 jam Gagal ginjal akut (Urin output < 60 ml/4jam atau
serum kreatinin > 2 mg/dl
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Kriteria severe CAP dirawat di ICU Dua dari tiga kriteria minor dan satu
kriteria mayor Kriteria minor :
Sistolik < 90 mmHg Multilobar pneumonia Rasio PaO2/FiO2 < 250
Kriteria mayor : Memerlukan ventilator mekanik Septik syok
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Patogen penyebab CAP
CAP Rawat Jalan
Mycoplasma pneumoniaeStreptococcus pneumoniae
Chlamydophilus pneumoniaeHaemophilus influenza
Respiratory viruses
CAP Rawat Jalan
Mycoplasma pneumoniaeStreptococcus pneumoniae
Chlamydophilus pneumoniaeHaemophilus influenza
Respiratory viruses
CAP Rawat InapStreptococcus pneumoniaeMycoplasma pneumoniae
Chlamydophilus pneumoniaeHaemophilus influenzaAnaerobes (aspirasi)
Mixed infectionsRespiratory viruses
Legonella spp
CAP Rawat InapStreptococcus pneumoniaeMycoplasma pneumoniae
Chlamydophilus pneumoniaeHaemophilus influenzaAnaerobes (aspirasi)
Mixed infectionsRespiratory viruses
Legonella spp
Severe CAP Streptococcus pneumoniae
Enteric gram negatifStaphylococcus aureus
Legionella spp Mycoplasma pneumonia
Respiratory virusesPseudomonas aerugenosa
Severe CAP Streptococcus pneumoniae
Enteric gram negatifStaphylococcus aureus
Legionella spp Mycoplasma pneumonia
Respiratory virusesPseudomonas aerugenosa
Severe CAP di ICUStreptococcus pneumoniae
Legionella pneumonia Haemophilus influenza
gram negatif bacilliStaphylococcus aureusMycoplasma pneumonia
Respiratory virusesPseudomonas aerugenosa
Severe CAP di ICUStreptococcus pneumoniae
Legionella pneumonia Haemophilus influenza
gram negatif bacilliStaphylococcus aureusMycoplasma pneumonia
Respiratory virusesPseudomonas aerugenosa
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Distribution of pathogen severe CAP in Elderly
Country USA (2001) Spain(1996)
No. of patient 57 95
S. pneumoniae 21% 49%
H. Influenzae 13% 11%
Legionella 10% 8%
S. Aureus 10% 3%
Enteric gram negatif 21% 8%
P. aeruginosa 3% 8%
Athypical pathogens 5% 11%Am J Respir Crit care Med 163:650,2001
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Distribution of pathogen severe CAP in HIV patient
Country USA (2001) Spain(2000)
No. of patient 20 214
S. pneumoniae 4% 33%
H. Influenzae - 14%
Legionella 4% -
S. Aureus - 8%
Enteric gram negatif 4% 6%
P. aeruginosa 14% 20%
Athypical pathogens 23% 2%
Clin Infec Dis 23;724,1996
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Pola kuman di Indonesia ? PDPI melaporkan dari 5 kota besar dengan
bahan, cara dan derajat penyakit berbeda: Klebsiella pneumonia 45,18% Streptococcus pneumonia 14,04% Streptococcus viridans 9,21% Staphilococcus aureus 9 % Pseudomonas aeruginosa 8,56% Streptococcus hemolyticus 7,89% Enterobacter 5,26%
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Pengelolaan
CAPCAP
MILD CAPMILD CAP MODERATE CAPMODERATE CAP SEVERE CAP SEVERE CAP
OUTPATIENTOUTPATIENT INPATIENTINPATIENT Distress respirasiGgn hemodinamik
Distress respirasiGgn hemodinamik
I C UI C U
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Pengelolaan…
Hemodinamik : cairan adekuat Oksigenasi & ventilasi : ventilator
mekanik? Pemberian antibiotika:
Terapi empirik Diberikan kurang dari 8 jam Disesuaikan dengan hasih kultur Lama pemberian 10 – 14 hari Sulih terapi
Evaluasi
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Pemilihan antibiotika pada severe CAP
BTS 2001 ATS 2001 IDSA 2000 CDC 2000 CTS 2000
Cefuroxim orCefotaxim orCeftriaxone + Makrolide
Cefotaxim,Ceftriaxon +Makrolid,Fluoroquinolone
Cefotaxim orCeftriaxon orAmpicillin/ subaktam+ makrolida orFluoroquinolone
Ceftriaxon orCefotaxim +Makrolida orFluoroquinolone
Cefotaxim orCeftriaxonOrbetalaktam
betalaktamase inhibitor +
FluoroquinoloneOr makrolida
Fluoroquinolone:Levofloxacin,Gatifloxacin,Moxifloxacin
Pseudomonas Risk :Antipseudomonas beta-
laktam (Meropenem, cefepime, piperacilin-tozabactam) +
Ciprofloxacin orAminoglikosida orFluoroquinolone
Pseudomonas Risk :AntipseudomonasBeta laktam +Ciprofloxacin orAntipseudomonasBeta laktam +Aminoglikosida +Fluoroquinolone orMakrolida
Fluoroquinolone PseudomonasRisk:Ciprofloxacin +Antipseudomon
asBeta laktam orAminoglikosida
or + makrolida
Beta laktam alergi:Fluoroquinolone +Clindamycin or
aztreonam
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IDSA / ATS Consensus Guidelines on the Management of CAP in Adults (2005)Outpatient Inpatient non
ICUInpatient ICU MRSA
1. Previously healthy
Macrolide (level 1)
Doxycycline (level III)
1. Presence comorbidities
-Respiratory fluoroquinolone (level I)
MoxifloxacinLevofloxacin-Beta lactam +
macrolide (level I)
Respiratory fluoroquinolone (level I)
MoxifloxacinLevofloxacin-Beta lactam +
macrolide (level I)
Respiratory fluoroquinolone (level I)
MoxifloxacinLevofloxacin-Beta lactam +
macrolide (level II)
Pseudomonas Risk
-Antipseudomonal Beta lactam (Meropenem, cefepime, piperacilin-tozabactam) plus either ciprifloxacin or levofloxacin (level I) or
Beta lactam + aminoglycoside +Azithromycine
VancomycinLinezolid (level III)
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Risk factors of P.aeruginosa Prolonged broad spectrum antibiotic
(>7d) Presence of bronchiectasis Malnutrition Neutrophil dysfunction HIV infection Diabetes Renal failure
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Evaluasi pengobatan
Tidak respon pengobatan
Diagnosis salah Diagnosis benar
Faktor Penderita:-Obstruksi-Empiema-Superinfeksi dll.
Faktor Obat:-Tdk tepat-Dosis salah-cara pemberian-Interaksi obat dll.
Faktor Kuman:-Resisten-Patogen lain-non bakteri(jamur, virus)
IDSA 2001
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Sulih terapi
Kriteria : Perbaikan batuk, sesak, panas Jumlah leukosit menurun Fungsi gastrointestinal baik
Terapi sulih Terapi sekuensial: obat sama, potensi
sama Switch over : obat beda, potensi sama Switch down: obat sama/beda, potensi
lebih rendah.
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Diferensial diagnosis
Edema paru Infark paru Acute respiratory distress syndrome Hemoragik paru Malignansi Atelektasis Pneumonitis radiasi Alergi obat dll.
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Hospital Acquired Pneumonia (HAP) HAP adalah pneumonia yang terjadi
setelah dirawat di Rumah sakit lebih dari 48 jam. HAP dapat terjadi di tempat perawatan biasa maupun di ICU
Termasuk HAP adalah Healthcare-associated pneumonia (HCAP) dan Ventilator-associated pneumonia (VAP).
Insiden di AS 5-10 per 1000 pasien yang dirawat, meningkat 9 – 25% bila dirawat di ICU
Morbilitas 25 -50%
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Patogen yang sering dijumpai pada HAP
Pseudomonas aerugenosa Escherichia coli Klebsiella pneumoniae Acinetobacter Staphylococcus aureus Methicillin resistant S. Aureus (MRSA)
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Faktor risiko HAP
Usia lanjut Penyakit paru yang mendasari Kegagalan multi organ Penggunaan pipa entotrakheal Pemakaian mekanikal ventilator Pemberian enteral feeding Perawatan yang tidak memenuhi standar
( misal kebiasaan cuci tangan dll.) Penggunaan antibiotika spektrum luas
sebelumnya. Penggunaan alat – alat invasif lainnya.
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Pemilihan antibiotik pada HAP
Patogen potensial Rekomendasi antibiotik
Streptococcus pneumoniaeHaemophilus influenzaeMethicilin-sensitive staphylococcus aureus.Escherichia coliKlebsiella pneumoniaeEnterobacter speciesProteus speciesSerratia marcescens
CeftriaxoneAtauLevofloxacin, moxifloxacinAtauAmpicilin / sulbactamAtauErtapenem
Terapi antibiotik awal pada HAP, VAP dan HCAP pada pasien tanpa risiko MDR, early onset dan untuk semua serajat pneumonia
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Terapi antibiotik awal HAP, VAP dan HCAP pada pasien dengan risiko MDR, late onset untuk semua derajat pneumonia
Patogen potensial Terapi antibiotika kombinasi
patogen MDRPseudomonas aeruginosaKlebsiella pneumoniaeAcinetobacter sp.
Methicillin-resistant Staphylococcus aureus (MRSA)Legionella pneumophila
Antipseudomonal cephalosporin (cefefim, ceftazidime), atau
Antipseudomonal carbepenem ( meropenem atau imipenem), atau
Β-laktam/β-laktamase inhibitor ( piperacillin- tazobactam ) plusAntipseudomonal fluoroquinolone( ciprofloxacin atau levofloxacin ) atau
Aminoglycoside ( amikasin, gentamicin atau tobramycin)PlusLinezolid atau vancomycin
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Terapi intravena antibiotika empirik pada HAP, VAP dan HCAP pada late-onset pneumonia atau dengan faktor risiko MDRAntibiotika Dosage*
Antipseudomonal cephalosporin-Cefepim-CeftazidimeCarbepenems-ImipenemMeropenem Β-laktam/β-laktamase inhibitor piperacillin- tazobactam Aminoglycoside Amikasin gentamicin tobramycinAntipseudomonal fluoroquinoloneCiprofloxacinlevofloxacin Linezolid vancomycin
1-2 g every 8-12 h2 g every 8 h
500 mg every 6 h or 1 g every 8 h1 g every 8 h
4,5g every 6 h
20 mg/kg per d7 mg/kg per d7 mg/kg per d
400 mg every 8 h750 mg every d600 mg every 12 h15.g/kg every 12 h
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Ringkasan Severe CAP dan HAP memiliki angka
kematian yang sangat tinggi Pola kuman CAP dan HAP bervariasi
menurut, umur, komorbiditas, derajat beratnya penyakit.
Pola kuman lokal akan lebih baik. Pemberian antibiotika sedini mungkin
< 8 jam dapat menurunkan angka kematian CAP dan HAP.
Memodifikasi faktor risiko HAP dapat menurunkan mortalitas