Pneumonia presentation for intensive care and hospital based

1. Regi Septian

2.  Pneumonia is an inflammatory condition of
the lung—affecting primarily the microscopic air
sacs known as alveoli. It is usually caused by
infection with viruses or bacteria and less
commonly other microorganisms,
certain drugs and other conditions such
as autoimmune diseases.[1][3]
 Typical symptoms include a cough, chest
pain, fever, and difficulty breathing.

3.  Globally, pneumonia affects approximately 450 million
people per year, seven percent of population, and
results in about 4 million deaths, mostly in third world
countries.
 Although pneumonia was regarded by William
Osler in the 19th century as "the captain of the men of
death",[5] the advent of antibiotic therapy and vaccines
in the 20th century  improvements in survival.
 In developing countries, and among the very old, the
very young and the chronically ill, pneumonia remains
a leading cause of death.

5. CDC definition of pneumonia
Horan TC, Andrus M, Dudreck MA. CDC/NHSN surveillance definition of health-care
associated infection and criteria for specific types of infection in the acute care setting

6. Classification
• Pneumonia yang berkembang di luar rumah sakit
Community Acquired
Pneumonia (CAP)
• Pneumonia yang berkembang di luar rumah sakit, pasien yang
dirawat dalam perawatan akut, selama 2 hari atau lebih karena
infeksi dalam waktu 90 hari terakhir; tinggal di panti wreda /
fasilitas perawatan jangka panjang lainnya; menerima terapi
antibiotik IV, kemoterapi / perawatan luka dalam waktu 30 hari
terakhir/ mendapatkan hemodialisis baik diklinik maupun RS
Healthcare Associated
Pneumonia (HCAP)
• Pneumonia yang berkembang setelah 48 jam setelah masuk rumah
sakit dan tidak dalam masa inkubasi pada saat pasien masukHospital Acquired
Pneumonia (HAP)
• Pneumonia yang timbul dalam waktu 48-72 jam setelah inkubasi
endotrakealVentilator Associated
Pneumonia (VAP)

7. Area of The Lung Affected
Pneumonia Lobaris
• Biasanya mencakup keseluruhan lobus secara homogen
• Terdapat 4 tahapan : kongesti, red hepatization, grey hepatization, resolusi
Bronkhopneumonia
• Konsolidasi “bercak” yang mencakup satu atau beberapa lobus, biasanya
mencakup bagian inferior dan posterior paru—pola yang sesuai dengan distribusi
aspirasi orofaring akibat gravitasi.
Pneumonia interstitialis
• Proses inflamasi (bercak atau difusa) mencakup interstitial secara dominan,
termasuk, dinding alveolus dan jaringan ikat di sekitar bronchovascular tree.
• Alveoli tidak mengandung eksudat, melainkan membran hialin kaya protein
(mirip dengan ARDS)
Pneumonia milier
• Gambaran lesi berukuran 2-3 cm, difus, menyerupai tuberkulosis milier.
• Diakibatkan oleh penyebaran patogen ke paru melalui aliran darah

9. Pneumonia Severity Scores
 CURB-65

10. Pneumonia Severity Index

12. Clinical Pulmonary Infection Score

13. Cause
 Bacteria
 Streptococcus
pneumoniae isolated in
nearly 50% of cases
 Haemophilus influenzae
in 20%
 Chlamydophila
pneumoniae in 13%,
 Mycoplasma pneumoniae
in 3%
 Staphylococcus aureus
 Moraxella catarrhalis
 Legionella pneumophila
 gram-negative bacilli.

14.  Viruses
 Rhinoviruses
 Coronaviruses
 influenza virus
 respiratory syncytial virus (RSV)
 Adenovirus
 Parainfluenza
 Herpes simplex virus is a rare cause of
pneumonia, except in newborns
 People with weakened immune systems are at increased
risk of pneumonia caused by cytomegalovirus (CMV).

15.  Fungi
 Histoplasma capsulatum
 Blastomyces
 Cryptococcus neoformans
 Pneumocystis jiroveci
 Coccidioides immitis.
• Parasites
 Toxoplasma gondii
 Strongyloides stercoralis
 Ascariasis

16. Imaging
 X-ray
 bacterial community acquired pneumonia  lung
consolidation of one lung segmental lobe
 Aspiration pneumonia bilateral opacities primarily in
the bases of the lungs and on the right side

18. Differential diagnosis
 chronic obstructive pulmonary disease (COPD)
 Asthma
 pulmonary edema
 Bronchiectasis
 lung cancer
 pulmonary emboli

19. Management
 Hospitalization
 Antibiotics
 Cephalosporins
 Carbapenems
 Fluoroquinolones
 Aminoglycosides
 Vancomycin
• Antiviral
 Neuraminidase inhibitors
 Rimantadine,amantadine  Influenza A
 oseltamivir, zanamivir or peramivir  Influenza A or B
 Rest
 simple analgesics
 fluids

20. Prevention of Health Care
1. Staff education and Involvement in Infection Prevention
2. Infection and microbiologic surveillance
3. Prevention of transmission of microorganisms
- Sterilization or desinfection & maintance of equipment & devices
- Prevention of person to person transmission of bacteria
4. Modifying host risk for infection
- Increasing host defense against infection: administration of
immune modulators
- Precautions for prevention of aspiration
- Prevention of postoperative pneumonia
- Other prophylactic procedures for pneumonia

21. Treatment
American Thoracic Society, Infectious Diseases Society of America. Guidelines for the
management of adults with hospital-acquired, ventilator-associated, and healthcare-
associated pneumonia.

22. Treatment- Early onset VAP with no risk
factors, any disease severity
American Thoracic Society, Infectious Diseases Society of America. Guidelines for
the management of adults with hospital-acquired, ventilator-associated, and
healthcare-associated pneumonia.

23. Treatment- Late onset or risk factors for MDR
or all disease severity
American Thoracic Society, Infectious Diseases Society of America. Guidelines for
the management of adults with hospital-acquired, ventilator-associated, and
healthcare-associated pneumonia.

24. Antibiotic Doses
Cephalosporin anti-pseudomonal
- Cefepime 1-2 g / 8-12 hour
- Ceftazidime 2 g/ 8 hour
Carbapenem
- Imipenem 500 mg/6 hour or 1 g/8 hour
- Meropenem 1 g/8 hour
Beta Lactam/Inhibitor Beta Lactamase
- Piperacillin-tazobactam 4,5 g/6-8 hour
Aminoglycoside
- Gentamycin 7 mg/kg/day
- Tabramycin 7 mg/kg/day
- Amikasin 20 mg/kg/day
Quinolone-anti-pseudomonal
- Levofloxacin 750 mg/day
- Ciprofloxacin 400 mg/ 8 hour
Vancomycin 15 mg/kg/ 12 hour
Linezolid 600 mg/12 hour

25. Patogen Bacteria MDR
 Acinetobacter ( carbapenem, sulbactam,colistin &
polymixin)
 ESBL enterobacteriaceae (Carbapenem)
 MRSA ( Vancomycin; alternatif Linezolid)

26. Complication
 Pleural effusion
 Empyema
 Abscess
 Respiratory failure  Need Mechanical ventilation
 Circulatory failure  Intrevenous fluids and
medications

28. TERIMA KASIH