Download - Penatalaksanaan CAP
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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 setelahMRS
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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
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Approach in CAP management
Type of
Approach
Diagnostic Syndromes Empirical
Treatment
according to Etiologicdiagnosis Clinicalsyndrome Guidelines
Advantages Etiologicdirected
treatment
practical practical
Disadvanta
ges
High rate of
diagn. failure,
specimen
contamination
High rate of
misdiagnosis
Depend on local
epidemiological
situation
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Selecting the initialsite of
treatment decision.
Step 1:assessment of any preexistingconditions that
compromise the
safety of home care Step 2 :calculation ofthe pneumonia PSI, witha
recommendation for homecare for patients inrisk
classes I, II,or III
Step 3 :clinical judgmentregarding the overall health
of the patient andthe suitability for homecare
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INDIKATOR YANG DIPAKAI UNTUK
IDENTIFIKASI FAKTOR RESIKO(PENDERITA RAWAT JALAN ATAU RAWAT INAP)
PENILAIAN TERHADAP KEPARAHAN
PENYAKIT MENURUT SISTIM SKOR DARIPORT
(PNEUMONIA PATIENT OUTCOME RESEARCH TEAM)
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Patient with CAP
Is the patient over 50 years of age ?
Does the patient have any of the following comorbid
conditions :
. Neoplastic disease . Congestive heart failure
. Cerebrovascular disease . Renal disease
. Liver disease
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)
Assign patient to risk class I
Assign patient to risk
class II-V based on
prediction model
scoring system
YES
YES
YES
NO
NO
NO
FIG.-PREDICTION MODEL FOR CAP
PATIENT RISK ASSESMENT
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Risk-class mortality rates
Risk
class
No. of
points
No. of
patients
Mortality
%
Recommended
site of care
I 3034 0.1 Outpatient
II 70 5778 0.6 Outpatient
III 7090 6790 2.8 Outpatient orbrief inpatient
IV 91
130 13104 8.2 Inpatient
V > 130 9333 29.2 Inpatient
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Scoring system for step 2 of the prediction rule:
assignment to risk classes II-V (1)
Patient characteristic Points assigned
Demographic factor
Age
Male (> 50 years) No. of years of age
Female (> 50 years) No. of years of age
10
Nursing home resident + 10
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Scoring system for step 2 of the prediction rule:
assignment to risk classes II-V (2)
Comorbid illnesses
Neoplastic disease + 30
Liver disease + 20
Congestive heart failure + 10
Cerebrovascular disease + 10
Renal disease + 10
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Scoring system for step 2 of the prediction rule:
assignment to risk classes II-V (3)
Physical examination
finding
Altered mental status + 20
Respiratory rate > 30 /m + 20
Systolic BP < 90 mm Hg + 20
Temp < 35oC or > 40oC + 15
Pulse > 125 beats/min + 10
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Scoring system for step 2 of the prediction rule:
assignment to risk classes II-V (4)
Laboratory and CXR
Arterial pH < 7.35 + 30
BUN > 30 mg% + 20
Sodium < 130 mEq/L + 20
Glucose > 250 mg% + 10
Hematocrit < 30 % + 10Pa O2< 60 mm Hg + 10
Pleural effusion + 10
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Empiric management of CAP in
Australian emergencydepartments
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Antimicrobial therapy
Recommendations are providedfor pathogen-specifictreatmentincases in which anetiologic diagnosis is
establishedor strongly suspected
Ifthis information is notavailable initially but is
subsequently reported, changing tothe antimicrobialagent thatis most cost-effective, leasttoxic, and most
narrowin spectrum is encouraged.
Recommendations for treating patientswho require
empirical antibiotic
selection are based on
severity ofillness, pathogenprobabilities, resistance patterns ofS.
pneumoniae(the most commonlyimplicated etiologic
agent), andcomorbid conditions
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The recommendation foroutpatients
Macrolide,
Doxycycline, or
Fluoroquinolonewith enhanced activity
against S. pneumoniae
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The recommendation forhospitalized
patients
Fluoroquinolone aloneor
Extended-spectrum cephalosporin(cefotaximeor ceftriaxone) plus a
Macrolide
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The recommendation forpatients
hospitalized inthe intensive care unit(ICU)
Combination of Antibiotics :
Ceftriaxone,
Cefotaxime,
Ampicillin-sulbactam,
Piperacillin-tazobactam-lactams,other than those noted,
are not recommended
Fluoroquinolone
Macrolide
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Pergantian IV ke oral antibiotic
whenthe patient is improvingclinically
is hemodynamically stable,
is able toingest drugs
Most patientsshow a clinical responsewithin 3-5 days
Changesevident on CXR usually lag behind theclinical
response repeatedCXRis generallynot indicated for patientswho
respond
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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.
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The
failuretorespond
clinically
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Prognosis
Themost frequent causes oflethal CAP areS.
pneumoniaeand Legionella
Themost frequent reason forfailure to
respond isprogression of pathophysiological
changes,despite appropriate antibiotic
treatment
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Prognosis
Re-evaluasi setelah 72 jam mendapatkan
antibiotika
bilamana tidak ada perbaikan makaantibiotika harus diganti misalnya dari
betalaktam menjadi macrolides.
CAP dengan comorbid mempunyaiprognosa lebih buruk
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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
Rajalan RainapTx empiris
membaik memburuk
Tx empiris
dilanjutkan
Pemeriksaan Bakteriologis
R Rawat biasa ICU
Tx empiris Tx
kausatif
membaik memburuk
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Out patient
Previously healthy Preferred treatment option
No recent antibiotic therapy A Macrolide or Doxycyclin
Recent antibiotic therapy A respiratory quinolone alone,
An advanced macrolide + high
dose amoxicillin,or an advanced macrolide + high
dose amoxicillin-clavulanate
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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 quinolonealone or an advanced
macrolide + a beta-lactam
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Out patient
Preferred treatment option
Suspected aspiration with
infection
Amoxicillin-clavulanate or
clindamycin
Influenza with bacterial
superinfection
A beta-lactam or a
respiratory fluoroquinolone
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Inpatient, Medical ward
Preferred treatment option
No recent antibiotic
therapyA respiratory fluoroquinolone alone or
an advanced macrolide plus a beta-lactam
Recent antibiotic
therapyAn advanced macrolide plus a beta-
lactam or
a respiratory fluoroquinolone alone(regimen selected will depend on nature of
recent antibiotic therapy)
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Inpatient, ICU
Preferred treatment options
Pseudomonasinfection is not
an issue
A beta-lactam plus either an advanced
macrolide or a respiratory fluoroquinolone
Pseudomonasinfection is not
an issue but patient has a
beta-lactam allergy
A respiratory fluoroquinolone, with or without
clindamycin
Pseudomonasinfection 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
Pseudomonasinfection is an
issue but the patient has a
beta-lactam allergy
Either (1) aztreonam plus levofloxacin, or (2)
aztreonam plus moxifloxacin or gatifloxacin,
with or without anaminoglycoside
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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
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