Pneumonia(Kuliah s1) (2)

PNEUMONIA

Arto Yuwono Soeroto Sub Bag Pulmonologi

Bagian Ilmu Penyakit Dalam FK UNPAD / RSUP Dr. Hasan Sadikin

Bandung

PNEUMONIA

DEFINITION

Inflammation and consolidation of lung

tissue due to an infectious agent

CLASSIFICATION

• Community Acquired Pneumonia (CAP)- Pneumonia that develops outside hospital

• Hospital Acquired pneumonia - Pneumonia that develops72 hours or more after admission to hospital• Institution acquired pneumonia - Pneumonia that includes hospital, nursing homes, etc.

• Common disease• In USA

12 cases per 1000The 6th leading cause of death3.3 – 4 million cases/year600000 – 1000000 admissionMortality : 1% - 50%

• In Indonesia :2nd leading cause of death

• Common :– Fever– Chilling– Pleurisy chest pain– Cough– Sputum :non productive, productive,

rusty, bloody, foul odor in lung abscess

• TYPICAL – Clinically as above– Due to : Pneumococcus, staphylococcus, H

Influenzae

• ATYPICAL– More indolent illness– Non productive cough/ mucoid – Due to Legionella, mycoplasma, Chlamydia

• One cannot reliably distinguish typical and atypical

• NON RESPIRATORY MANIFESTATION– Headache– Nausea– Vomiting– Abdominal pain– Diarrhea– Myalgia– arthralgia

• Elderly complain fewer symptoms then younger patients

 Feature

Environmental Exposure to contaminated air-conditioning cooling towers,

recent travel associated with a stay in a hotel, exposure to a

grocery store mist machine, visit or recent stay in a hospital with contaminated (by L pneumophila) potable water Pneumonia after windstorm in an endemic area Outbreak of pneumonia in shelters for homeless men, jails,

military training camps  Exposure to contaminated bat caves, excavation in endemic

areas  Animal contact Exposure to infected parturient cats, cattle, sheep, or goats

Exposure to turkeys, chickens, ducks, or psittacine birds  Travel history Travel to Thailand or other countries in Southeast Asia Pneumonia in immigrants from Asia or India  

 Clues to the Etiology of Pneumonia from the History and Physical Exam

Organisrn

Legionella pneumophila    

Coccidioides immitisStreptococcus pneumoniae Mycobacterium tuberculosis S. pneumoniae Chlamydia pneumoniae Hisroplasma capsulatum  Coxiella burnetii C. psittaci  Burkholderia(Pseudvmonas) pseudomallei (melioidosisJ M. tuberculosis

 Feature

Occupational history Pneumonia in a health-care worker who

works in a large city with patients infected wit.h HIV   Host factors Diabetic ketoacidosis   Alcoholism   Chronic obstructive lung disease   Solid organ transplant recipient (pneumonia

occurring > 3 months after lransplant)    Sickle cell disease HIV infection CD4 cell count < 2(N)/uL 

Organisrn 

 M. tuberculosis S. pneumoniae Staphylococcus aureus S. pneumoniae Klebsiella pneumoniae S. aureus S. pneumoniae Hemophilus influenzae Moraxella catarrhalis S. pneumoniae H. influenzae Legionella spp. Pneumocystis carinii Cylomegalovirus Strongyloides stercvralis S. pneumvniae P. carinii S. pneumoniae H. influenzae Cryptvcoccus neoformans M. tuberculosis Rhodococcus equi

 Feature  Physical findings Periodontal disease with foul-smelling sputum Bullous myringitis Absent gag reflex, altered level of

consciousness, or a recent seizure    Encephalitis    Cerebellar ataxia   Erythema multiforme Erythema nodosum   Ecthyma gangrenosum  Cutaneous nodules (abscesses) and CNS findings

Organisrn

 Anaerobes, may be mixed aerobic- anaerobic infection Mycoplasma pneumoniae  Polymicrobial (oral aerobic and anaerobic bacteria) can be macro- or microaspiration M. pneumoniae C. burnetii L. pneumophila M. pneumoniae L pneumophila M, pneumoniae C. pneumoniae M. tuberculosis P. aeruginosa Serratia marcescens Nocardia species

• Constitutional- Fever- Hypothermia- Afebrile in 20% cases

• Thorax- Consolidation

- Dullness- Tactile fremitus- Whispering pectoriloquy- Bronchial breath sound

- additional lung sounds- Crackles- Pleural friction rub (10%)

• OPACITY ON CHEST RADIOGRAPH DD/:

Infection Hemorrhage Edema Fluid Malignancy Inflammation due to other causes

(Vascullitis, Drug Reaction)

• Certain Radiographic Patterns Commonly Associated with some Microbial Agents

Focal opacity Streptococcus pneumoniae Mycoplasma pneumoniae Legionella pneumophila Staphylococcus aureus Chlamydia pneumoniae Mycobacterium tuberculosis Blastomyces dermatitidis  Interstitial ”Viruses” M. pneumoniae Pneumocystis carinii C. psittaci

TABEL 2. Diferensial diagnosis beberapa pola gambaran radiologis yang sering ditemukan pada penderita pnemonia.

Multifocal opacities

S. aureus Coxiella burnelii L pneumophila S. pneumoniae    Miliary M. tuberculosis Histoplasma capsulatum C. immitis B. dermatitid.is Varicella zoster

Interstitial pneumonia with lymphadenopathy Epstein-Rarr virus Francisella tularensis C. psittaci M. pneumoniae Fungi  Cavitation Mixed aerobic anaerobic (lung abscess)

Aerobic gram-negative bacilli M. tuberculosis L. pneumophila Cryptococcus neoformans Nocardia asteroides Actinomyces israelii Coccidioides immitis P. carinii Bulging fissure Klebsiella pneumoniae L. pneumophila

Segmental or lobar pneumonia with lymphadenopathy M. tuberculosis (primary infection) Atypical rubeola    Pneumatoceles S. aureus S. pyogenes P. carinii   ”Round’* pneumnnia C. burnetii S. pneumoniae L pneumophila S. aureus

• DUE TO : The Cause can not be determined from the clinical presentation Complete microbiological studies can isolate only < 50 % of causative pathogen and take long enough time (> 48 hours) Pathogen isolated from sputum cannot be

sure as the causative agent

• SO : Etiologic diagnosis of pneumonia

categorized as definite or probable

Definite Blood cultures positive for a pathogen Pleural fluid positive for a pathogen Presence of Pneumocystis carinii in induced sputum or in bronchoalveolar lavage fluid A fourfold or greater rise in antihody titer to Mycoplasma pneurnoniae, Chlamydia pneumoniae .Isolation of Legionella pneunrophila or a fourfold rise in antibody titer or positive urinary antigen test for Legionella Positive direct fluorescence antibody test for Legionella plus an antibody titer of 1:256 for Legionella Serum or urine positive for Streptococcus pneurnoniae antigen Isolation of Mycobacterium tuberculosis from sputum  

Probable Heavy or moderate growth of a predominant bacterial pathogen on sputum culture and a compatible Gram’s stain Light growth of a pathogen in which sputum Gram’s stain reveals a bacterium compatible with the culture results

TABEL 3. Guidelines for Determining the Etiology of CAP

ADMISSION DECISION Important step after diagnosis has been

made Indication for admission :Risk factors for a complicated course or Mortality in Patients

with CAPAge > 65 years Co-morbid illnesses that are likely to be made worse by the

pneumonia, especially chronic renal failure, ischemic heart disease, congestive heart failure, and severe COPD

Concurrent malignancy Postsplenectomy state Altered mental status Alcoholism Immunosuppresive therapy Respiratory rate > 30 breaths per minute Diatolic blood pressure < 60 mm Hg : systolic blood

pressure < 90 mmHg

Hypothermia Creatinine > 150 mm/l or BUN > 7 mm/lLeukopenia < 3,000/ul or leucocytosis > 30,000/ulO2 < 60 mmHg or Pco2 > 48 mmHg while breathing

room air Albumin < 30 gm/lHemoglobin < 9 gm/lPseudomonas aeruginosa or Staphylococcus aureus as

the cause of the Pneumonia Bacteremic pneumoniaMultilobe involvement on chest radiograph Rapid radiographic progression of the pneumonia

defined as increase in the size of the pulmonary opacity of > 50 % within 36 h

• OUT PATIENTS Chest X ray Complete leucocyte count Electrolyte Creatinine Oxygen saturation Sputum culture and gram stain

• IN PATIENTSAs above Sputum culture and gram stain Blood culture (twice)

SPUTUM CULTURE AND GRAM STAIN

• REPRESENTATIVE SPECIMEN PMN > 25 EPHITEL < 10

• METHODS Sputum from cough Aggressive :

Bronchoscopy Transthoracic needle biopsy Open lung biopsy

PER LOW POWER FIELD

• SEROLOGY FOR PATHOGEN M. Pneumoniae C. PneumoniaeCoxiella Bornetti Legionella PneumophillaAdenovirus Influenza/ParainfluenzaRSV

• PNEUMOLYSIS S. PNEUMONIAE If sputum can not be collected

• INITIAL THERAPEUTIC APPROACH IS EMPIRICIAL

• ONCE THE ETIOLOGIC DIAGNOSIS HAS BEEN MADE

CHANGE TO THE CHEAPEST,NARROWEST SPECTRUM AGENTTHAT SENSITIVE

Umur < 60 th Ringan – sedang Rawat jalan Tidak ada ko

POLA PATOGEN - S. Pneumonia - M. Pneumoniae - Respiratory Syncitinc virus- C. Pneumoniae- H. InfluenzaeLainnya : Legionella, S. Aureus, M. Tuberkulosis, Jamur Gram Negative Batang (GNB) 

Umur > 60 th Atau < 60 thRingan – sedang Rawat jalan Komorbid (+)

POLA PATOGEN - S. Pneumoniae - RSU- H. Influenzae - GNB- S. Aureus- Lainnya : M. Catarhalis, legionella, M. Tuberculosis, Jamur

TABEL 4. Panduan terapi empiris pada penderita community acquired pneumonia (American Thoracic

Society 1993)

Semua umurSedang Rawat inap bangsalKomorbid +/-

POLA PATOGEN - S. Pneumoniae

- H. Influenzae - Polimikrobial (termasuk anaerob GNB)- Legionella Sp- S. Aureus - C. Pneumoniae- RSV- Lainnya : M. Pneumoniae, Moraxella, Catarrhalis M. TBC Jamur

Semua umur Berat Rawat inap ICUKomorbid +/-

POLA PATOGEN - S. Pneumoniae

- Legionella - GNB- H. Influenzae- M. Pneumoniae - RSV- Lainnya : > M. TBC Jamur

Grup I Grup II Grup III Grup IV

ANTIBIOTIK - Makrolid- Terasiklin  Makrolid : Eritromisin Kalau intoleran thd eritromisin atau ada kecurigaan H. Influenzae berikan makrolid generasi baru : klaritromisin, Azitromisin 

ANTIBIOTIK - Sefalosporin generasi II- Trimetroprim- sulfametoxazol- Betalaktam/ betalaktamase inhibitor + Eritromisin atau makrolid lainnya

ANTIBIOTIK - Sefalosporin generasi II/IV- Beta laktam / betalaktamase inhibitor + makrolid

ANTIBIOTIK- Makrolid + - Sefalosporin Gen III dengan aktivitas anti Pseudomonas atau anti Pseudomonas lainnya (Ciprofloxacin imipenem/Cilastin)

Grup I Grup II Grup III Grup IV

 Pasien Rawat Jalan :- Fluorokuinolon - Doksisiklin - Makrolida  Pasien Rawat Inap :Kamar rawat umum :- Sefalosporin spektrum luas + makrolida - Inhibitor B – laktamase/B – laktam + makrolida

- Fluorokuinolon tunggal ICU :- Sefalosporin spektrum luas atau inhibitor B – laktamase/ B- laktam + makrolida atau fluorokuinolon

TABEL 5. PENGOBATAN EMPIRIS UNTUK CAP (INFECTIOUS DISEASES SOCIETY OF AMERICA

2000)

PATIENTS WITH MILD TO MODERATE HAP, NO UNUSUAL RISK FACTORS, ONSET ANY

TIME OR PATIENTS WITH SEVERE HOSPITAL ACQUIRED PNEUMONIA WITH

EARLY ONSET

CORE ORGANISMSEnteric gram-negative bacilli (non Pseumomonal) Enterobacter

- E. Coli - Klebsiella - Proteus - Serratia - Hemophilus - Methicillin-sensitive S. Aureus - Streptococcus pneumoniae

CARE ANTIBIOTICS Cephalosporin Second Generation Or non pseudomonal third generation Beta-lactam/beta-lactamase inhibitor if allergic to penicillin : fluoroquinolone or clindamycin + aztreonam

PATIENTS WITH MILD TO MODERATE HAP, WITH RISK FACTORS, ONSET ANY TIME

CORE ORGANISMSAnaerobes (resent

abdominal surgery, withnessed aspiration)

Staphylococcus aureus (coma, head trauma, diabetes mellitus, renal failure)

Legionella (high-dose steroids)

Pseudomonas aeruginosa (prolonged ICU stay, steroids, structural lung disease)

CORE ANTIBIOTICSClindamycin or beta-lactam/beta-lactamase inhibitor

+/- Vancomycin (until methicillin-resistant S. Aureus is ruled out)

Erythromycin +/- rifampin

Treat as severe hospital acquired pneumonia

PATIENTS WITH SEVERE HOSPITAL-ACQUIRED PNEUMONIA WITH RISK

FACTORS EARLY ONSET OR PATIENTS WITH SEVERE HAP, LATE ONSET

CORE ORGANISMS, PLUS P. Aeruginosa Acinetobacter species Consider MRSA

THERAPYAminoglycoside or ciprofloxacin Plus one of the following Antipseudomonal penicillinBeta-lactam/beta-lactamase inhibitor Ceftazidime or cefoperazone ImpinemAztreonam *+/- Vancomycin • Excludes patients with immunosuppression

• Aztreonam efficacy is limited to enteric gram negative bacilli and should not be used in combination with an aminoglycoside if gram positive or H. Influenzae infection is of concern.