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Penatalaksanaan CAP
Penatalaksanaan CAP
Suportif / symptomatis
Istirahat ditempat tidur Minum secukupnya utk mengatasi dehidrasi Bila demam: kompres & antipiretik Mukolitik / ekspektoran p.r.n.
Antibiotika harus diberikan < 8 jam setelah MRS Pasang ventilator bila ada indikasi
3
Diagnostic
Syndromes Empirical
Treatment according to
Etiologic diagnosis
Etiologic directed treatment High rate of diagn. failure, specimen contamination
Clinical syndrome
practical
Guidelines
practical
12/16/2013
Kuliah FK-UKM
PORT
(PNEUMONIA PATIENT OUTCOME RESEARCH TEAM)
7
NO
Does the patient have any of the following comorbid conditions : . Neoplastic disease . Cerebrovascular disease . Liver disease . Congestive heart failure . Renal disease Assign patient to risk class II-V based on prediction model scoring system
YES
NO
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) -
YES
NO
Assign patient to risk class I
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Outpatient
II
III IV V
70
70 90 91 130 > 130
5778
6790 13104 9333
0.6
2.8 8.2 29.2
Outpatient
Outpatient or brief inpatient Inpatient Inpatient
9
Scoring system for step 2 of the prediction rule: assignment to risk classes II-V (1)
Patient characteristic Demographic factor Points assigned
Age
Male (> 50 years) Female (> 50 years)
Nursing home resident
+ 10
10
Scoring system for step 2 of the prediction rule: assignment to risk classes II-V (2)
Comorbid illnesses Neoplastic disease + 30
+ 20 + 10 + 10
+ 10
11
Scoring system for step 2 of the prediction rule: assignment to risk classes II-V (3)
Physical examination finding Altered mental status Respiratory rate > 30 /m Systolic BP < 90 mm Hg Temp < 35oC or > 40oC Pulse > 125 beats/min
+ 20 + 20 + 20 + 15 + 10
12
Scoring system for step 2 of the prediction rule: assignment to risk classes II-V (4)
Laboratory and CXR Arterial pH < 7.35 BUN > 30 mg% Sodium < 130 mEq/L Glucose > 250 mg% Hematocrit < 30 % Pa O2 < 60 mm Hg Pleural effusion
+ 30 + 20 + 20 + 10 + 10 + 10 + 10
13
14
Antimicrobial therapy
Recommendations are provided for pathogen-specific treatment in cases in which an etiologic diagnosis is established or strongly suspected If this information is not available initially but is subsequently reported, changing to the antimicrobial agent that is most cost-effective, least toxic, and most narrow in spectrum is encouraged. Recommendations for treating patients who require empirical antibiotic selection are based on severity of illness, pathogen probabilities, resistance patterns of S. pneumoniae (the most commonly implicated etiologic agent), and comorbid conditions
16
17
18
The recommendation for patients hospitalized in the intensive care unit (ICU)
Combination of Antibiotics :
Ceftriaxone, Fluoroquinolone Cefotaxime, Ampicillin-sulbactam, Macrolide Piperacillin-tazobactam
22
Prognosis
The most frequent causes of lethal CAP are S. pneumoniae and Legionella The most frequent reason for failure to respond is progression of pathophysiological changes, despite appropriate antibiotic treatment
23
Prognosis
Re-evaluasi setelah 72 jam mendapatkan antibiotika bilamana tidak ada perbaikan maka antibiotika harus diganti misalnya dari betalaktam menjadi macrolides. CAP dengan comorbid mempunyai prognosa lebih buruk
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Infiltrat (-)
Tatalaksana sbg Dx lain
Tx empiris
membaik memburuk
Rajalan
Rainap
Pemeriksaan Bakteriologis
R Rawat biasa
ICU
Tx empiris dilanjutkan
Tx empiris
Tx kausatif
membaik
12/16/2013 Kuliah FK-UKM
memburuk
25
Out patient
Previously healthy
No recent antibiotic therapy
12/16/2013
Kuliah FK-UKM
26
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 quinolone alone or an advanced macrolide + a beta-lactam
Kuliah FK-UKM 27
12/16/2013
Out patient
Preferred treatment option
Suspected aspiration with Amoxicillin-clavulanate or infection clindamycin Influenza with bacterial superinfection A beta-lactam or a respiratory fluoroquinolone
12/16/2013
Kuliah FK-UKM
28
an advanced macrolide plus a betalactam An advanced macrolide plus a betalactam or a respiratory fluoroquinolone alone
Inpatient, ICU
Preferred treatment options
Pseudomonas infection is not A beta-lactam plus either an advanced an issue macrolide or a respiratory fluoroquinolone Pseudomonas infection is not A respiratory fluoroquinolone, with or without an issue but patient has a clindamycin beta-lactam allergy Pseudomonas infection 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 Either (1) aztreonam plus levofloxacin, or (2) aztreonam plus moxifloxacin or gatifloxacin, with or without an aminoglycoside
Kuliah FK-UKM 30
Major criteria
Invasive mechanical ventilation Septic shock with the need for vasopressors
12/16/2013
Kuliah FK-UKM
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