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Nama : dr. Muhammad Arifin Nawas, Sp.P(K), MARS
Nip : 140 076 093
Pangkat / Golongan : Pembina Tk.I /IVb
Tempat / Tanggal Lahir : Jambi, 26 November 1947
Agama : Islam
Alamat : Jl. Bangka XI/21, Kec. Mampang Pela, Jakarta Selatan
Arifin Nawas
The Member of COMMUNITY ACQUIRED PNEUMONIA TEAM
The Indonesia Society of Respirology
INTRODUCTION
Pneumonia is defined as an acute infection of the
pulmonary parenchyma
This guidance is a revision of the previous guidelines
published in 2003, with some additions or changes in
accordance with the developments during this period
Empiric therapy
In developing this guideline reffered from a variety of
guidelines recommended by organizations such as ATS/
IDSA and BTS
However, treatment varies widely due to variety
etiologic, antimicrobial agents, facilities and physicians
Community Acquired Pneumonia
CAP is defined as an acute infection of the pulmonary parenchyma
in a patient who has acquired the infection in the community
CAP is a major cause of morbidity and mortality worldwide
Pneumonia
USA :
- The annual incidence rate is 6/1000 in the 18-39 age group.
This rises to 34/1000 in people aged 75 years and over.
- Admission to hospital : 20-40% and about 5-10% ICU
- Mortality 25%
In Japan pneumonia ranks fourth as the leading cause of death
In Indonesia, pneumonia included in the top 10 diseases with CFR
7.6%
Table 1. Most Common etiologies of CAP
ETIOLOGY OF CAP IN INDONESIA
(several hospital)
Klebsiella pneumoniae
Acinetobacter baumanii,
Pseudomonas aeruginosa
Streptococcus pneumoniae
Streptococcus viridans
Staphylococcus aureus
DIAGNOSIS
Based on anamnesis, physical examination, chest
radiographic and laboratory
CURB Index
1. Based on acute pneumonia severity not on
age and comorbidity
2. Easier to calculate
Pneumonia Severity Index
CURB-65 0 1 or 2 >2
score
* Defined as a Mental Test Score of 8 or less, or new disorientation in person, place or time
Figure 1. Severity assessment used to determine the management of CAP in patients in the
community(CRB-65 score) UPDATED 2004
Criteria for severe CAP
( IDSA/ATS 2007 )
Minor criteria
- Respiratory rate 30 breath /min
- PaO2/FiO2 250
- Multilobar infiltrates
- confusion/disorientation
- Uremia (BUN level 20 ml/dl)
- Leukopenia ( WBC count , 400 cell/mm3)
- Trombocytopenia (platelet count < 100,000 cell/mm3)
- Hypothermia (core temperature < 360C)
- Hypotension requiring aggressive fluid resuscitation
Major criteria
- Invasive mechanical ventilation
- Septic shock with the need for vasopressor
ICU admission decision
Direct admission to an ICU for patients with
septic shock requiring vasopressor or with
ARDS requiring intubation and mechanical
ventilation
Out patient
In patient
Emperical therapy
Microbiologicexaminati
on
Improve Deteriorate
In patient ward ICU
Emperical therapy
Inpatient
1. Non ICU Treatment A respiratory fluoroquinolone A
respiratory fluoroquinolone
(levofloxacin 750mg or
moxifloxacin )
A -lactam plus a macrolide
Inpatients Antibiotic
Outpatient Antibiotic
1. Previously healthy and no use of A macrolide level I
antimicrobials within the previous 3 Doxycycline level III
months
2. Presence of comorbidities or use anti- A respiratory fluoroquinolone
microbials within the previous 3 months (moxifloxacin, gemifloxacin or
levofloxacin (750mg); level I
A -lactam plus a macrolide;
level I
3. In regions with a high rate
(<25%) of infection with high-
level (MIC > 16g/mL)
macrolide-resistant Streptococcus
consider use of alternative
agents listed above in (2)
Inpatients Antibiotic
The best and most practical resolution to this issue was that the
initial dose be given in the ED
Duration of antibiotic therapy
(IDSA/ATS 07)
Patients with CAP should be treat for a minimum of
5 days, should be afebrile for 48-72h, and should
have no more than CAP associated sign of clinical
instability before discontinuation of therapy
A more longer duration of therapy may be needed
if initial therapy was not active against the
identified pathogen or if it was complicated by
extrapulmonary infection, such as meningitis,
endocarditis
HOSPITAL DISCHARGE CRITERIA
During 24 hours to discharge to home patients
should not have more than 1 of the following;
- elevated temp > 37,80 C
- pulse > 100/ minute
- respiratory rate > 24/ minute
- systolic blood pressure < 90 mmHg
- blood oxygen saturation < 90%
- inability to maintain oral intake
Non responding Patient
Non respon is not uncomon
CAP show clinical improvement within 72 hours
of initial antibiotic treatment
1 6 to 15 % do not respond
In patients initially admitted to an ICU the risk
failure was high ( 40% )
Mortality nonresponding patient is increased
(49%)
Mortality in early failure was 27%
Two general patterns of nonresponse have been described
in patients with CAP