Penatalaksanaan CAP

8/13/2019 Penatalaksanaan CAP

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Penatalaksanaan CAP

rawat inap

Suportif / symptomatis

Terapi oksigen

Infus utk redehidrasi, elektrolit & calori

Bila demam: kompres & antipiretik

Mukolitik / ekspektoran p.r.n.

Antibiotika harus diberikan < 8 jam setelahMRS


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3

Penatalaksanaan CAP

rawat inap ICU

Suportif / symptomatis

Terapi oksigen

Infus utk redehidrasi, elektrolit & calori

Bila demam: kompres & antipiretik

Mukolitik / ekspektoran p.r.n.

Antibiotika harus diberikan < 8 jam setelah MRS

Pasang ventilator bila ada indikasi


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Approach in CAP management

Type of

Approach

Diagnostic Syndromes Empirical

Treatment

according to Etiologicdiagnosis Clinicalsyndrome Guidelines

Advantages Etiologicdirected

treatment

practical practical

Disadvanta

ges

High rate of

diagn. failure,

specimen

contamination

High rate of

misdiagnosis

Depend on local

epidemiological

situation


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12/16/2013 Kuliah FK-UKM 5


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Selecting the initialsite of

treatment decision.

Step 1:assessment of any preexistingconditions that

compromise the

safety of home care Step 2 :calculation ofthe pneumonia PSI, witha

recommendation for homecare for patients inrisk

classes I, II,or III

Step 3 :clinical judgmentregarding the overall health

of the patient andthe suitability for homecare


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INDIKATOR YANG DIPAKAI UNTUK

IDENTIFIKASI FAKTOR RESIKO(PENDERITA RAWAT JALAN ATAU RAWAT INAP)

PENILAIAN TERHADAP KEPARAHAN

PENYAKIT MENURUT SISTIM SKOR DARIPORT

(PNEUMONIA PATIENT OUTCOME RESEARCH TEAM)


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12/16/2013 8

Patient with CAP

Is the patient over 50 years of age ?

Does the patient have any of the following comorbid

conditions :

. Neoplastic disease . Congestive heart failure

. Cerebrovascular disease . Renal disease

. Liver disease

Does the patient have any of the following abnormalities on

physical examination ?

- Altered mental status - Pulse 125 / BPM -

Respiratory rate 30/min - Systolic BP < 90 mm Hg

- Temperature < 350C (950F) or 400C( 1040F)

Assign patient to risk class I

Assign patient to risk

class II-V based on

prediction model

scoring system

YES

YES

YES

NO

NO

NO

FIG.-PREDICTION MODEL FOR CAP

PATIENT RISK ASSESMENT


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Risk-class mortality rates

Risk

class

No. of

points

No. of

patients

Mortality

%

Recommended

site of care

I 3034 0.1 Outpatient

II 70 5778 0.6 Outpatient

III 7090 6790 2.8 Outpatient orbrief inpatient

IV 91

130 13104 8.2 Inpatient

V > 130 9333 29.2 Inpatient


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Scoring system for step 2 of the prediction rule:

assignment to risk classes II-V (1)

Patient characteristic Points assigned

Demographic factor

Age

Male (> 50 years) No. of years of age

Female (> 50 years) No. of years of age

10

Nursing home resident + 10


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Comorbid illnesses

Neoplastic disease + 30

Liver disease + 20

Congestive heart failure + 10

Cerebrovascular disease + 10

Renal disease + 10


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Physical examination

finding

Altered mental status + 20

Respiratory rate > 30 /m + 20

Systolic BP < 90 mm Hg + 20

Temp < 35oC or > 40oC + 15

Pulse > 125 beats/min + 10


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Laboratory and CXR

Arterial pH < 7.35 + 30

BUN > 30 mg% + 20

Sodium < 130 mEq/L + 20

Glucose > 250 mg% + 10

Hematocrit < 30 % + 10Pa O2< 60 mm Hg + 10

Pleural effusion + 10


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Empiric management of CAP in

Australian emergencydepartments

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Antimicrobial therapy

Recommendations are providedfor pathogen-specifictreatmentincases in which anetiologic diagnosis is

establishedor strongly suspected

Ifthis information is notavailable initially but is

subsequently reported, changing tothe antimicrobialagent thatis most cost-effective, leasttoxic, and most

narrowin spectrum is encouraged.

Recommendations for treating patientswho require

empirical antibiotic

selection are based on

severity ofillness, pathogenprobabilities, resistance patterns ofS.

pneumoniae(the most commonlyimplicated etiologic

agent), andcomorbid conditions


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The recommendation foroutpatients

Macrolide,

Doxycycline, or

Fluoroquinolonewith enhanced activity

against S. pneumoniae


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The recommendation forhospitalized

patients

Fluoroquinolone aloneor

Extended-spectrum cephalosporin(cefotaximeor ceftriaxone) plus a

Macrolide


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The recommendation forpatients

hospitalized inthe intensive care unit(ICU)

Combination of Antibiotics :

Ceftriaxone,

Cefotaxime,

Ampicillin-sulbactam,

Piperacillin-tazobactam-lactams,other than those noted,

are not recommended

Fluoroquinolone

Macrolide


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Pergantian IV ke oral antibiotic

whenthe patient is improvingclinically

is hemodynamically stable,

is able toingest drugs

Most patientsshow a clinical responsewithin 3-5 days

Changesevident on CXR usually lag behind theclinical

response repeatedCXRis generallynot indicated for patientswho

respond


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Switch therapy(terapi sulih)

Sequential, obat sama potensi sama:

levofloxacine, gatifloxacine, moxifloxacine

Switch over, obat berbeda potensi sama:

ceftazidime i.v. ke ciprofloxacine p.o.

Step Down, obat sama atau berbeda,

potensi lebih rendah: Amoxycillin,

Cefuroxime, Cefotaxime i.v. ke cefixime p.o.

Antibiotika i.v. selama 3 hari dilanjutkan p.o.


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The

failuretorespond

clinically


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Prognosis

Themost frequent causes oflethal CAP areS.

pneumoniaeand Legionella

Themost frequent reason forfailure to

respond isprogression of pathophysiological

changes,despite appropriate antibiotic

treatment


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Prognosis

Re-evaluasi setelah 72 jam mendapatkan

antibiotika

bilamana tidak ada perbaikan makaantibiotika harus diganti misalnya dari

betalaktam menjadi macrolides.

CAP dengan comorbid mempunyaiprognosa lebih buruk


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Alur Tatalaksana Pneumonia Komuniti

Anamnesis, pemeriksaan fisis, foto toraks

Infiltrat (-)

Tatalaksana sbg

Dx lain

Infiltrat + Gejala klinis menyokong Dx pneumonia

Evaluasi utk kriteria Rajal / Ranap

Rajalan RainapTx empiris

membaik memburuk

Tx empiris

dilanjutkan

Pemeriksaan Bakteriologis

R Rawat biasa ICU

Tx empiris Tx

kausatif

membaik memburuk


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Out patient

Previously healthy Preferred treatment option

No recent antibiotic therapy A Macrolide or Doxycyclin

Recent antibiotic therapy A respiratory quinolone alone,

An advanced macrolide + high

dose amoxicillin,or an advanced macrolide + high

dose amoxicillin-clavulanate


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Out patient

Comorbidities

(COPD, diabetes, renal or

congestive heart failure or

malignancy)

Preferred treatment option

No recent antibiotic therapy An advanced macrolide or A

respiratory quinolone

Recent antibiotic therapy A respiratory quinolonealone or an advanced

macrolide + a beta-lactam


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Out patient


Suspected aspiration with

infection

Amoxicillin-clavulanate or

clindamycin

Influenza with bacterial

superinfection

A beta-lactam or a

respiratory fluoroquinolone


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Inpatient, Medical ward


No recent antibiotic

therapyA respiratory fluoroquinolone alone or

an advanced macrolide plus a beta-lactam

Recent antibiotic

therapyAn advanced macrolide plus a beta-

lactam or

a respiratory fluoroquinolone alone(regimen selected will depend on nature of

recent antibiotic therapy)


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Inpatient, ICU

Preferred treatment options

Pseudomonasinfection is not

an issue

A beta-lactam plus either an advanced

macrolide or a respiratory fluoroquinolone

Pseudomonasinfection is not

an issue but patient has a

beta-lactam allergy

A respiratory fluoroquinolone, with or without

clindamycin

Pseudomonasinfection is an

issue

Either (1) an antipseudomonal agent plus

ciprofloxacin, or

(2) an antipseudomonal agent plus an

aminoglycoside plus a respiratory

fluoroquinolone or a macrolide

Pseudomonasinfection is an

issue but the patient has a

beta-lactam allergy

Either (1) aztreonam plus levofloxacin, or (2)

aztreonam plus moxifloxacin or gatifloxacin,

with or without anaminoglycoside


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Criteria for severe CAP.

Minor criteria

Respiratory rate > 30 breaths/min

PaO2/FiO2 ratio > 250

Multilobar infiltrates

Confusion/disorientation

Uremia (BUN level, > 20 mg/dL)

Leukopenia (WBC count, < 4000 cells/mm3)

Thrombocytopenia (platelet count, < 100,000 cells/mm3)

Hypothermia (core temperature, < 36C)

Hypotension requiring aggressive fluid resuscitation

Major criteria Invasive mechanical ventilation

Septic shock with the need for vasopressors


Penatalaksanaan CAP

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