Community Acquired Pneumonia (CAP) by

Community Acquired PneumoniaCokorda Agung Abi Baruna1102005032CAP

#1PneumoniaNosocomial Pneumonias#Community Acquired Pneumonia (CAP)DefinisiCommunity acquired pneumonia (CAP) merupakan suatu penyakit inflamasi yang mempengaruhi alveoli, yang biasa disebabkan oleh infeksi virus atau bakteri, yang terjadi pada individual yang tidak memiliki riwayat masuk rumah sakit ataupun memiliki riwayat kontak yang sedikit dengan rumah sakit atau yang berhubungan dengan tenaga kesehatan sebelumnya.Bartlett. Clin Infect Dis 2000;31:347-82.#3Community Acquired Pneumonia (CAP)Epidemiology4-5 juta kasus annually~500,000 dilarikan ke RS 20% memerlukan rawat inap~45,000 kematianKasus terendah pada kelompok umur 18-24 Insiden tertinggi pada 65 tahunKematian terbanyak pada >65 tahun 65Bakteremia (S. pneumoniae)S. aureusPerubahan Temuan radiologi yang memburukImunitas yang memburukID Clinics 1998;12:723. Am J Med 1994;96:313#13CAP Bacteriology in Hospitalized Pts

#CAP Evaluasi pasien#CAP Management Guidelines Rational use of microbiology laboratoryPathogen directed antimicrobial therapy whenever possiblePrompt initiation of Antibiotic therapyDecision to hospitalize based on prognostic criteria - PORT or CURB 65

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PORT Scoring PSI

Clinical ParameterScoringAge in yearsExampleFor Men (Age in yrs)50For Women (Age -10)(50-10)NH Resident10 pointsCo-morbid IllnessesNeoplasia30 pointsLiver Disease20 pointsCHF10 pointsCVD10 pointsRenal Disease (CKD)10 points#

#Classification of Severity - PORT#CAP Management based on PSI ScorePORT ClassPSI ScoreMortality %Treatment StrategyClass INo RF0.1 0.4Out patientClass II 700.6 0.7Out patientClass III71 - 900.9 2.8Brief hospitalizationClass IV91 - 1308.5 9.3InpatientClass V> 13027 31.1IP - ICU#CURB 65 Rule Management of CAP#Algorithmic ApproachStep 1Step 2Step 3Step 4#Who Should be Hospitalized?Class I and II Usually do not require hospitalizationClass IIIMay require brief hospitalizationClass IV and VUsually do require hospitalizationSeverity of CAP with poor prognosis RR > 30; PaO2/FiO2 < 250, or PO2 < 60 on room airNeed for mechanical ventilation; Multi lobar involvementHypotension; Need for vasopressorsOliguria; Altered mental status#CAP Criteria for ICU AdmissionMajor criteriaVentilasi mekanik invasive diperlukanSeptik syok yang memerlukan vasopressorMinor criteria (least 3)disorientasiBlood urea nitrogen 20 mg%RR 30 / min; temp < 36CHipotensi berat ; PaO2/FiO2 ratio 250Infiltrat multilobarWBC < 4000 cells; Platelets 25%) of infection with Macrolideresistant S. pneumoniae1. Respiratory FQ Levoflox, Gemiflox or Moxiflox2. Beta-lactam (High dose Amoxicillin, Amoxicillin- Clavulanate is preferred; Ceftriaxone, Cefpodoxime, Cefuroxime) plus a Macrolide or Doxycycline

#Empiric Treatment Inpatient Non ICU1. A Respiratory Fluoroquinolone (FQ) Levo or2. A Beta-lactam plus a Macrolide (or Doxycycline) (Here Beta-lactam agents are 3 Generation Cefotaxime, Ceftriaxone, Amoxiclav)3. If Penicillin-allergic Respiratory FQ or Ertapenem is another option

#Empiric Treatment: Inpatient in ICU1. A Beta-lactam (Cefotaxime, Ceftriaxone, or Ampicillin-Sulbactam) plus either Azithromycin or Fluoroquinolone2. For penicillin-allergic patients, a respiratory Fluoroquinolone and Aztreonam

#Duration of TherapyMinimum of 5 daysAfebrile for at least 48 to 72 hLonger duration of therapy If initial therapy was not active against the identified pathogen or complicated by extra pulmonary infection

#CAP Summary of Empiric TreatmentOutpatient Rx any one of the threeMacrolide or Doxycycline or FluoroquinolonePatients in General Medical Ward3rd Generation Cephalosporin + MacrolideBetalactum / B-I + Macrolide or B / B-I + FQFluroquinolone alonePatients in ICU3GC + Macrolide or 3GC + FQB/B-I + Macrolide or B/B-I + FQ

IDSA guidelines: Clin Infect Dis 2000;31:347-82#Prevention CAPVaksin Influenza dapat memberikan proteksi setinggi 90% dan menurunkan mortalitas 80%Vaksin pneumococcalmembantu melindungi dari 23 tipe pneumococcal dan menurunkan mortalitas pada kelompok umur 19-64 tahun dengan co morbidity tinggi pneumonia. #Pergantian Oral Therapy4 kriteriaPerkembangan daripada batuk, dyspnea, dan gejala klinis Afebril lebih dari 8 jam per2 hari WBC menurun mendekati normal GI tract yang fungsional untuk pengobatan oral.#CAP Complications3-5% Pleural effusion; fluid jernih + sel pus1% Empyema thorakis pus di pleural spcaeLung abscess destruction of lungMultiple Pyemic Abscesses#CAP ResumeEarly antibiotic administration Empiric antibiotic Rx. as per guidelines (IDSA / ATS)PORT PSI scoring and Classification of casesEarly hospitalization in Class IV and VChange Abx. as per pathogen & sensitivity patternArterial oxygenation assessment in the first 24 hBlood culture collection in the first 24 h prior to Abx.Pneumococcal & Influenza vaccination;

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