Escolar Documentos
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KULIAH RESPIRASI II
SEMESTER 4
FK UKWM
2013
03/09/17 BENJAMIN MARGONO 1
PNEUMONIA
Classical Atypical
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03/09/17 BENJAMIN MARGONO
PNEUMONIA CATEGORIES
CAP (Community Acquired Pneumonia):
Pneumonia in a community resident, w.o.risk factors
for HCAP
HAP ( Hospital Acquired Pneumonia)
Pulmonary infection occurring > 48 hrs after
hospitalization in patients with no previous infection.
Early onset= up to 96 hrs; late onset = > 96 hrs.
VAP ( Ventilator associated Pneumonia)
Pneumonia occurring > 48 hrs after endotracheal
intubation. Early onset = within 48-96 hrs, late onset >
96 hrs.
HCAP ( Health associated Pneumonia )
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PNEUMONIA CATEGORIES
HCAP
Pulmonary infections in a patient meeting 1 or more
the following conditions:
Infection within 90 days of a 2-day hospitalization
Infection in a nursing home or longterm-care resident
Infection withon 30 days of receiving IV antimicrobials,
chemotherapy or wound care
Infection following a hospital or hemodialysis clinic unit
Contact with MDR pathogens
Different treatment from CAP, more similar treatment to
HAP / VAP
ALL HCAP patients are considered at risk for MDR
infections
03/09/17 BENJAMIN MARGONO 6
Recommendations for
the Management of CAP
7
BEFORE THX
ATS algorithm
assessment
4 MAJOR PRINCIPLES:
DONT DELAY ADEQUATE THX
OPTIMIZING
TAILOR THX to the RESULT of LRT
CULTURES DE-ESCALATION
SHORTENING THX to MINIMAL EFFECTIVE
PERIOD MINIMIZING RESISTANCE
PREVENTIVE STRATEGIES aimed at
MODIFIABLE RISK FACTORS
03/09/17 BENJAMIN MARGONO 9
An updated of the IDSA 2003
guideline for management CAP
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 10
The Indonesian Association of
Pulmonologists Guidelines CAP- Outpatient
11
The Indonesian Association of
Pulmonologists Guidelines CAP-Inpt (Ward)
12
The Indonesian Association of
Pulmonologists Guidelines CAP - ICU
Non Pseudomonas
3 rd G Cephalosporin non pseudomonas iv + New
macrolide or respiratory fluoroquinolone iv
Pseudomonas
antipseudomonal Cephalosporin iv or carbapenem
+ antipseudomonal fluoroquinolone (ciprofloxacin)
iv or aminoglycoside iv
Suspect atypical : antipseudomonal Cephalosporin
iv or carbapenem + aminoglycoside iv + new
macrolide or respiratory fluoroquinolone iv
13
G.DRUSANO 2002
MODIFYI IDSA ATS PDPI ERS SPILF JAPAN
NG
FACTORS (FRANCE)
NO M M B-
LACTAM
AMOX AMOX PEN+
CLAV
DOXY DOXY B-LACT TETRA, M M/
CEPH,
+CLAV RESP.Q, M
TETRA
RESP.Q CLINDA/
INNITIAL EMPIRIC ANTIBIOTIC THX PN.C. VANCO+
FOR ADULT OUTPATIENT CAP AMINOG
L+Q
EMPIRIC THERAPY has
become ACCEPTED PRACTICE
LARGE NUMBER OF ORGANISMS
THAT MAY CAUSE PULMONARY
DISEASE
THE IN-EXACTNESS OF COMMONLY
USED DIAGNOSTIC TECHNIQUES
SERIOUS CONSEQUENCES OF
INAPPROPRIATE THERAPY
CONTROVERSIES :
COLONIZATION vs- INFECTION
CONTAMINATION of SPECIMEN:
Only resp.tract below larynx is normally sterile
MONO or MIXED INFECTION
QUANTITATIVE CULTURES for DEFINING
PNEUMONIA
FALSE NEGATIVE due to PREVIOUS
ANTIBIOTIC EXPOSURE
03/09/17 BENJAMIN MARGONO 16
Invasive Strategy for
Diagnosing HAP
Quantitative culture approach:
bronchoscopic protected specimen brush (103
CFU/ml)
~67% sensitive, 95% specific
bronchoalveolar lavage (104 CFU/ml)
~73% sensitive, 82% specific
quantitative endotracheal aspirate (105 CFU/ml)
38-100% sensitive, 14-100% specific
Antibiotic use more appropriate and accurate
Claim of improved survival at 28 days
(Fagon JY, Chastre J, Wolff M, et al. Ann Intern Med 2000;132:621-630)
(Craven DE, and Steger KA, et al. Infect Cont Hosp Epidemiol 1997;18:783-795)
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CAP Grams Stain of Sputum
Good sputum samples is obtained only from 39%
83% show only one predominant organism
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Pathogens Retrieved from Blood Culture
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USUAL RTI PATHOGENS( Cunha 2004)
CAP
STREP. PNEUMONIAE MOST COMMON
PATHOGEN IN HOSP.ADULTS
H.INFLUENZAE
M.CATARRHALIS COPD
M.PNEUMONIAE AMBULATORY
Chl.PNEUMONIAE YOUNG ADULTS
LEGIONELLA species ELDERLY
COMPROMISED HOST
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CAP: Empiric Therapy Principles
TREAT EARLY consensus in guidelines
TREAT MOST LIKELY PATHOGENS
Consider :
Local antibiotic resistance patterns
Infection incidence data
Patient demographic features
We cannot differentiate the etiology reliably
based only on clinical findings
ATS. Am J Respir Crit Care Med. 2001;163:1730-1754; Bartlett
26
JG, et al. CID. 2000;31:347-382; Heffelfinger JD, et al. Arch Intern
Med. 2000;160:1399-1408.
QUINOLONE
11.0% MACROLIDEs
CIPROFL. ERYTHRO
OFLOXAC. 17.4% SPIRA
ANTIBIOTIC
RESP.Q
X- RAY RESOLV.
NORMALIZING WBC
2 wks ( 50.6 %)
day 4
4 wks ( 66.7 %)
Do NOT
03/09/17
CHANGE Tx < 72BENJAMIN
hrs, w.o. CLINICAL DETERORIATION
MARGONO 29
SYMPTOMS CYTOKINE RELEASE : TNF & Il-1.
ASSESSMENT of NON-
RESPONDERS
D
iagnosis
Atelectasis, emboli,
ARDS, Ca
O
rganism
Drug resistant pathogen
FUNGAL infection
C
omplication
Empyema, abscess
Drug fever
03/09/17 BENJAMIN MARGONO 30
NOT ALL PATHOGEN BACTERIA
CANDIDA ALBICANS
03/09/17 BENJAMIN MARGONO 31
In BLOODSMEAR
DE-ESCALATION THERAPY
SWITCH from
INNITIAL
BROADSPECTRUM
HIGH DOSE
EMPIRIC COVERAGE
RE ASSESS WHEN
MICROBIOLOGICAL
DATA AVAILABLE
STOP EARLY
PATIENT
03/09/17 3 SAFE Ps
BENJAMIN MARGONO
POCKET
PLANET34
Mortality Associated With Initial
Inadequate Therapy In Critically Ill Patients
With Serious Infections in the ICU
PLANET :
HIGHLY BACTERICIDAL DEAD BUGS
DO NOT
RESISTENCE RARE MUTATE
POCKET :
EFFECTIVENESS : HIGH
THE MOST EXPENSIVE THERAPY
FAILED THERAPY
03/09/17 BENJAMIN MARGONO 40
Take home
messages
The decision to use an
antimicrobial agent is not only
relied onwhat is
recommended in the
guidelines but consideration in
the LOCAL SUSCEPTIBLE
PATTERN OF THE PATHOGEN
of interest is also important.
03/09/17 BENJAMIN MARGONO 41
A WORD of CAUTION
(lancet infect dis: jan 20, 2011- publ.online)
(Kett D.H.)
Study of 4 US Academic Medical Centers:
Incl.criteria : HAP in ICU, MDR risk factors (+),
ATS / IDSA GDLN:
TRIPLE DRUG within 1 d of PNEU DX
CEPHALOSP./ CARBAPENEM / BL+BLI
AMINOGLICOSIDE or FLUOROQUINOLONE
LINEZOLID or VANCOMYCIN
compliant to ATS/IDSA guideline: mortality: 34 %
NON compliant : mortality 20 % (28 days) p=-0042)
PROBABLE CAUSE: ANTIBIOTIC SPECIFIC TOXICITY eg
AMINOGLYCOSIDE ( colistin) : ACUTE RENAL FAILURE,
POLYNEURO-MYOPATHY
QUINOLONES : NEUROTOXICITY, QT INTERV.PROLONGATION-
LEADING TO VENTRIC.ARRYTHMIAS
03/09/17 BENJAMIN MARGONO 42
SUMMARY
1. THE ANTIMICROBIAL REGIMEN :
early-appropriate-adequate-empirical thx reduce
mortality by 50%
re-assess after 48 - 72 h based on microbiological
& clinical data
2. .The decision to use an antimicrobial agent is not only relied on
what being recommended in the guidelines but consideration in
the local susceptible pattern of the pathogen of interest is also
important
3. ONCE A CAUSATIVE PATHOGEN is identified:
MONOTHERAPY : NO evidence that combination
therapy is more effective
4 DE-ESCALATION THERAPY
to prevent the development of resistance,
to reduce toxicity & costs.
5. DURATION OF THERAPY :
7 to 10 days and guided by clinical response.
.
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