Penatalaksanaan CAP rawat jalan

Suportif / symptomatis
Istirahat ditempat tidur Minum secukupnya utk mengatasi dehidrasi Bila demam: kompres & antipiretik Mukolitik / ekspektoran p.r.n.

Antibiotika harus diberikan < 8 jam

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 setelah MRS

2

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
3

Approach in CAP management

Type of Approach

Diagnostic

Syndromes Empirical

Treatment according to

Etiologic diagnosis
Etiologic directed treatment High rate of diagn. failure, specimen contamination

Clinical syndrome
practical

Guidelines
practical

Advantages Disadvanta ges

High rate of Depend on local misdiagnosis epidemiological

situation

12/16/2013

Kuliah FK-UKM

Selecting the initial site of treatment decision.

Step 1: assessment of any preexisting conditions that compromise the safety of home care Step 2 : calculation of the pneumonia PSI, with a recommendation for home care for patients in risk classes I, II, or III Step 3 : clinical judgment regarding the overall health of the patient and the suitability for home care

INDIKATOR YANG DIPAKAI UNTUK IDENTIFIKASI FAKTOR RESIKO

(PENDERITA RAWAT JALAN ATAU RAWAT INAP)

PENILAIAN TERHADAP KEPARAHAN PENYAKIT MENURUT SISTIM SKOR DARI

PORT
(PNEUMONIA PATIENT OUTCOME RESEARCH TEAM)
7

Patient with CAP

Is the patient over 50 years of age ?

FIG.-PREDICTION MODEL FOR CAP PATIENT RISK ASSESMENT YES

NO
Does the patient have any of the following comorbid conditions : . Neoplastic disease . Cerebrovascular disease . Liver disease . Congestive heart failure . Renal disease Assign patient to risk class II-V based on prediction model scoring system

YES

NO
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) -

YES

NO
Assign patient to risk class I
12/16/2013 8

Risk-class mortality rates

Risk class No. of points No. of patients 3034 Mortality % 0.1
Recommended site of care

Outpatient

II
III IV V

70
70 90 91 130 > 130

5778
6790 13104 9333

0.6
2.8 8.2 29.2

Outpatient
Outpatient or brief inpatient Inpatient Inpatient
9

Scoring system for step 2 of the prediction rule: assignment to risk classes II-V (1)
Patient characteristic Demographic factor Points assigned

Age
Male (> 50 years) Female (> 50 years)
Nursing home resident

No. of years of age

No. of years of age 10

+ 10
10

Scoring system for step 2 of the prediction rule: assignment to risk classes II-V (2)
Comorbid illnesses Neoplastic disease + 30

Liver disease Congestive heart failure Cerebrovascular disease

Renal disease

+ 20 + 10 + 10
+ 10
11

Scoring system for step 2 of the prediction rule: assignment to risk classes II-V (3)
Physical examination finding Altered mental status Respiratory rate > 30 /m Systolic BP < 90 mm Hg Temp < 35oC or > 40oC Pulse > 125 beats/min

+ 20 + 20 + 20 + 15 + 10
12

Scoring system for step 2 of the prediction rule: assignment to risk classes II-V (4)
Laboratory and CXR Arterial pH < 7.35 BUN > 30 mg% Sodium < 130 mEq/L Glucose > 250 mg% Hematocrit < 30 % Pa O2 < 60 mm Hg Pleural effusion

+ 30 + 20 + 20 + 10 + 10 + 10 + 10
13

Empiric management of CAP in Australian emergency departments

14

Antimicrobial therapy
Recommendations are provided for pathogen-specific treatment in cases in which an etiologic diagnosis is established or strongly suspected If this information is not available initially but is subsequently reported, changing to the antimicrobial agent that is most cost-effective, least toxic, and most narrow in spectrum is encouraged. Recommendations for treating patients who require empirical antibiotic selection are based on severity of illness, pathogen probabilities, resistance patterns of S. pneumoniae (the most commonly implicated etiologic agent), and comorbid conditions
16

The recommendation for outpatients

Macrolide, Doxycycline, or Fluoroquinolone with enhanced activity against S. pneumoniae

17

The recommendation for hospitalized patients

Fluoroquinolone alone or Extended-spectrum cephalosporin (cefotaxime or ceftriaxone) plus a Macrolide

18

The recommendation for patients hospitalized in the intensive care unit (ICU)

Combination of Antibiotics :
Ceftriaxone, Fluoroquinolone Cefotaxime, Ampicillin-sulbactam, Macrolide Piperacillin-tazobactam

-lactams, other than those noted, are not recommended

19

Pergantian IV ke oral antibiotic

when the patient is improving clinically is hemodynamically stable, is able to ingest drugs
Most patients show a clinical response within 3-5 days Changes evident on CXR usually lag behind the clinical response repeated CXR is generally not indicated for patients who respond
20

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.
21

The failure to respond clinically

22

Prognosis
The most frequent causes of lethal CAP are S. pneumoniae and Legionella The most frequent reason for failure to respond is progression of pathophysiological changes, despite appropriate antibiotic treatment

23

Prognosis
Re-evaluasi setelah 72 jam mendapatkan antibiotika bilamana tidak ada perbaikan maka antibiotika harus diganti misalnya dari betalaktam menjadi macrolides. CAP dengan comorbid mempunyai prognosa lebih buruk
24

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

Tx empiris
membaik memburuk

Rajalan

Rainap
Pemeriksaan Bakteriologis

R Rawat biasa

ICU

Tx empiris dilanjutkan

Tx empiris

Tx kausatif

membaik
12/16/2013 Kuliah FK-UKM

memburuk
25

Out patient
Previously healthy
No recent antibiotic therapy

Preferred treatment option

A Macrolide or Doxycyclin A respiratory quinolone alone, An advanced macrolide + high dose amoxicillin, or an advanced macrolide + high dose amoxicillin-clavulanate

Recent antibiotic therapy

12/16/2013

Kuliah FK-UKM

26

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 quinolone alone or an advanced macrolide + a beta-lactam
Kuliah FK-UKM 27

12/16/2013

Out patient
Preferred treatment option

Suspected aspiration with Amoxicillin-clavulanate or infection clindamycin Influenza with bacterial superinfection A beta-lactam or a respiratory fluoroquinolone

12/16/2013

Kuliah FK-UKM

28

Inpatient, Medical ward

Preferred treatment option
No recent antibiotic A respiratory fluoroquinolone alone or therapy

Recent antibiotic therapy

an advanced macrolide plus a betalactam An advanced macrolide plus a betalactam or a respiratory fluoroquinolone alone

(regimen selected will depend on nature of recent antibiotic therapy)

12/16/2013 Kuliah FK-UKM 29

Inpatient, ICU
Preferred treatment options
Pseudomonas infection is not A beta-lactam plus either an advanced an issue macrolide or a respiratory fluoroquinolone Pseudomonas infection is not A respiratory fluoroquinolone, with or without an issue but patient has a clindamycin beta-lactam allergy Pseudomonas infection 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 Either (1) aztreonam plus levofloxacin, or (2) aztreonam plus moxifloxacin or gatifloxacin, with or without an aminoglycoside
Kuliah FK-UKM 30

Pseudomonas infection is an issue but the patient has a beta-lactam allergy

12/16/2013

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

12/16/2013

Kuliah FK-UKM

31