Management of Pneumonia

Ni Ketut Donna Prisilia Deweerdt

Global Mortality in Infectious

Diseases

World Health Organization. World Health Report. 2004.

Lower Respiratory Tract Infections:The

Most Common Reason for Antibiotic
Use

Arnold FW, et al. J Manag Care Pharm. 2004;10:152-158.

Pneumonias
Classification

Nosocomial
Pneumonias

ATS/IDSA. Am J Respir Crit Care Med.

2005;171:388-416.

Community-Acquired Pneumonia
(CAP): Pneumonia which develops in
the community or within 48 hours of
hospital admission
Hospital-acquired pneumonia (HAP):
pneumonia occurs 48 hours or more after
admission, which was not incubating at the time of
admission
Ventilator-associated pneumonia (VAP):
pneumonia that arise more than 48-72 hours after
endotracheal intubation
Healthcare-associated pneumonia (HCAP)
includes any patients who was hospitalized in acute
care hospital for two or more days within 90 days of
the infection; resided in a nursing home or longterm care facility; received recent IV antibiotic
therapy, chemotherapy, or wound care within the
past 30 days of the current infection; or attended a

Diagnosis of Pneumonia
New infiltrates or progressively
infiltrates on chest X ray
with two or more:
increased cough,
change in sputum characteristic,
temperature 380C or history of fever,
sign of consolidation (bronchial sound,
creackles),
leucocyte 10.000 or 4.5000

PATIENT WITH SUSPECT

CAP

DIAGNOSIS

1.

PSI
CURB-65

2.

THE SITE OF INITIAL

TREATMENT

OUT PATIENT

3.

IN PATIENT

EMPIRICAL ANTIMICROBIAL
(EFFECTIVITY, COMPLIANCE, COST)

Selection of Antimicrobial Regimens

Based on prediction of most

likely pathogens
Knowledge of local susceptibiliy
patterns

Most common etiologies of CAP

Outpatient

Inpatient (nonICU)

Inpatient (ICU)

Streptococcus pneumoniae
Mycoplasma pneumoniae
Haemophilus influenzae
Chlamydophilia pneumoniae
Respiratory viruses
S. Pneumoniae
M. Pneumoniae
C. Pneumoniae
H. Influenza
Legionella species
Aspiration
Respiratory viruses
S. Pneumoniae
Staphylococcus auereus
Legionella species
Gram-negative bacilli
H. influenza

Etiologis of CAP
(Medan, Jakarta, Surabaya, Malang, Makasar)

Pathogen
K. pneumoniae
S. pneumoniae
S. viridans
S. auereus
Peudomonas aerugonosa
hemolitik
Enterobacter
Pseudomonas spp
Sudarsono, Ilmu penyakit

(%)
45,18
14,04
9,21
9
8,58
7,89
5,26
0,9

Pathogen in sputum cultures of CAP

patient in Sanglah Hospital -2008
181 inpatient with
CAP
Pathogen found in
28 (15,5%) cases

Suartini, Saji,IB Rai, 2009

Pathogen

N(%)

S. viridan

8(28,6)

Enterobacter

5(17,9)

Pseudomonas

4(14,3)

E. cloaca

3(10,7)

E. coli

2(7,1)

S. pneumoniae

2(7,1)

Acinetobacter

1(3,6)

Chrysemo

1(3,6)

Total

28(100)

Timing and Choice of Antibiotics

Antibiotic Timing at 4 hours cutoff:
IDSA B-III recommendation.
Empiric Antibiotic Choice of Therapy:
IDSA A-I recommendation.

Time to first antibiotic dose.

For patients admitted through the emergency

department (ED), the first antibiotic dose should
be administered while still in the ED.

(Moderate recommendation; level III evidence)

Community Acquired Pneumonia

Outpatient
Previously
Healthy

CO-MOR
BIDITIES

Inpatient

In Region
Inpatient In patient
> 25% infection Non ICU
ICU
PseudomonasCA MRSA
With high level
infection
(MIC > 16 mg/ml)
Macrolide resistant
S. pneumoniae

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Community Acquired Pneumonia

Outpatient
Previously
Healthy

No Risk DRSP
Age < 2 or > 65
lactam within previous 3 mo
Alcoholism
Medical comorbidities
Immunosupressive illness/therapy
Exposure to child in day care center
Streptococcus pneumoniae
Mycoplasma pneumonia
Hemophilus influenzae
Chlamydia pneumoniae
Respiratory viruses
A macrolide (azithromycin
Clarithromycin , erythromycin)
(Strong recommendation)
OR
Doxycycline

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2

Community Acquired Pneumonia

Outpatient
CO-MOR
BIDITIES

Age < 2 or > 65 lactam within previous 3 mo, Alcoholism

Medical comorbidities, Immunosupressive illness/therapy,
Exposure to child in day care center
+ Comorbid (Chronic heart, Lung Liver, renal disease DM,
Alcoholism, malignancy etc
Streptococcus pneumoniae,Mycoplasma Pneumoniae,
Hemophilus influenzae, Chlamydia pneumoniae, Respiratory viruses
+ Gram negative + DRSP
A respiratory fluoroquinoloe (moxifloxacin, Gemifloxacin
Levofloxacin 750 mg) (strong recommendation)
A lactam + a macrolide (strong recommendation) Amoxicillin
(3x1gr). Co amoxyclave (2x2gr). Cefriaxone, cefodoxime,
cefuroxime. Doxy (alternative)

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2

Community Acquired Pneumonia

Outpatient
In Region
> 25% infection
With high level
(MIC > 16 mg/ml)
Macrolide resistant
S. pneumoniae

a respiratory fluoroquinolone (moxifloxacin,

Gemifloxacin, Levofloxacin 750 mg)
(strong recommendation)
a B lactam + a macrolide (strong recommendation)
Amoxicillin (3x1gr). Co amoxyclave
(2x2gr). Cefriaxone, cefrodoxime,
ceforoxime. Doxy (alternative)

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

Community Acquired Pneumonia

IDSA/ATS CONSENSUS 2007. Clin Infect Dis

Inpatient
Inpatient
Non ICU

S. pneumoniae
M. pneumoniae
C. pneumoniae
H. Influenzae
Legionella species
Aspiration
Respiratory
viruses

a respiratory
Fluoroquinolonoe
(strong recommendation)
a B lactam + A macrolide
(strong recommendation)
Prefered : cefotaxime
Ceftrioxone, ertapenem
Doxycyclin alternative
2007: 44 (SUPPL 2)
for macrolide

Community Acquired Pneumonia

Inpatient
In patient
ICU
S. Pneumoniae
Staph aureus
Legionella spesies
Gram negative bacilli
H. Influenzae

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

a B lactam
(cefotaxime, cefriaxone
or ampicillin sulbactam)
+
Azythromycin
or
Fluoroquinolone
(strong recommendation)
Penicillin allergic
Fluoroquinolone
+
Azetreonam

Community Acquired Pneumonia

Inpatient
In patient
ICU

Pseudomonas
infection

Structural lung disease

Severe COPD with frequent
Steroid and/or antibiotic use
prior Antibiotic therapy

IDSA/ATS CONSENSUS 2007. Clin Infect Dis

Antipneumococcal, antipseudomonal
B lactam (piperacillin-tazobactam
cefepime, imipenem, meropenem)
+
Ciprofloxacin or levofloxacin750mg
OR
The above B lactam +
an aminoglycoside
And an antipneumococcal
2007: 44 (SUPPL 2)Fluoroquinolone/azithromycin
(moderate recommendation)

Community Acquired Pneumonia

Inpatient

IDSA/ATS CONSENSUS 2007. Clin Infect Dis 2007: 44 (SUPPL 2)

In patient
ICU

CA MRSA

ESRD
Injection drug abuser
Prior influenzae
Prior antibiotic th/
(especially fluoroquinolone)

Add vancomycin or
Linezolid
(moderate recommendation)

Switch from intravenous to oral therapy

Patients should be switched from intravenous to
oral therapy when they are hemodynamically
stable and improving clinically, are able to ingest
medications, and have a normally functioning
gastrointestinal tract.
(Strong recommendation; level II evidence)

Criteria for clinical stability

Temperature 37.8C
Heart rate 100 beats/min
Respiratory rate 24 breaths/min
Systolic blood pressure >90 mm Hg
Arterial oxygen saturation >90% or pO2>60
mm Hg on room air
Ability to maintain oral intake
Normal mental status
NOTE. Criteria are from [268, 274, 294]. pO2, oxygen partial
pressure. a Important for discharge or oral switch decision but
not necessarily for determination of nonresponse.

Duration of antibiotic therapy

Patients with CAP should be treated for a
minimum of 5 days (level I evidence), should be
afebrile for 4872 h, and should have no more
than 1 CAP-associated sign of clinical instability
(previous table) before discontinuation of
therapy
(level II evidence; Moderate recommendation)

HAP, VAP or HCAP Suspected

Obtain Lower Respiratory Tract (LRT) Sample for
Culture (Quantitative or Semi-quantitative) &
Microscopy
High Clinical Suspicion for Pneumonia
Begin Empiric Antimicrobial Therapy Using Algorithm & Local
Microbiologic Data
Days 2 & 3: Check Cultures & Assess Clinical
Response
(Temperature, WBC, Chest X-ray, Oxygenation,
Purulent Sputum, Hemodynamic Changes & Organ
Function) at 48-72
Clinical Improvement

No

Yes

Hours

Cultures -

Cultures +

Cultures -

Cultures +

Search for other

pathogens,
complications,
other diagnoses
or other sites of
infection.

Adjust antibiotic
therapy, search
for other
pathogens,
complications,
other diagnoses
or other sites of

Consider stopping
antibiotics.

De-escalate
antibiotics, if
possible. Treat
selected patients
for 7-8 days &
reassess.

Antibiotic Selection
General Approach (clinical decision initiate therapy)
HAP or VAP Suspected
(All Disease Severity)
Late Onset or Risk Factors for
Multi-drug Resistant (MDR)
Pathogens
No

Limited Spectrum
Antibiotic
Therapy

Ye
s
Broad Spectrum
Antibiotic
Therapy
For MDR
Pathogens

American Thoracic Society. Am J Respir Crit Care Med 2005;171:388416

RISK FACTORS FOR MDR PATHOGENS CAUSING

HAP, HCAP, AND VAP
Antimicrobial therapy in preceding 90 d
Current hospitalization of 5 d or more
High frequency of antibiotic resistance in the
community or in the specific hospital unit
Presence of risk factors for HCAP:
Hospitalization for 2 d or more in the preceding 90 d
Residence in a nursing home or extended care facility
Home infusion therapy (including antibiotics)
Chronic dialysis within 30 d
Home wound care
Family member with MDR pathogen
Immunosuppressive disease and/or therapy

INITIAL EMPIRIC ANTIBIOTIC THERAPY FOR

HAP, VAP IN PATIENTS WITH NO KNOWN RISK
FACTORS FOR MDR, EARLY ONSET, AND ANY
DISEASE SEVERITY

POTENTIAL PATHOGEN
ANTIBIOTIC

Streptococcus
pneumoniae
Haemophilus influenza
Methicillin-sensitive
Staphylococcus aureus
Antibiotic-sensitive enteric
gram-negative
bacillii
Escherichia coli
Klebsiella
pneumoniae
Enterobacter species
Serratia marcessens

RECOMMENDED

Ceftriaxone
or
Levofloxacin,
moxifloxacin,
or ciprofloxacin
or
Ampicillin/sulbacta
m
or
Ertapenem

ATS. AJRCCM 2005; 171:388-416

INITIAL EMPIRIC ANTIBIOTIC THERAPY FOR HAP, VAP, AND

HCAP IN PATIENTS WITH LATE-ONSET DISEASE OR RISK
FACTORS FOR MDR PATHOGENS AND ALL DISEASE SEVERITY
POTENTIAL PATHOGEN
TH/
Pathogens list in table A and
MDR pathogens
Pseudomonas aeruginosa
Klebsiella pneumoniae
(ESBL) Acinetobacter
species

COMBINATION ANTIBIOTIC

Antipseudomonal
cephalosporin (cefepime,
ceftazidime)
or
Antipseudomonal
carbepenem (imipenem or
meropenem)
or

Methicillin-resistant
Staphylococcus aureus
Legionella
(MRSA) pneumophila

-Lactam/-lactamase
inhibitor (piperacillintazobactam)
plus
Antipseudomonal
fluiroquinolone
(ciprofloxacin or
levofloxacin)
or
Aminoglycoside (amikacin,
gentamicin. or
tobramycin)
ATS. AJRCCM 2005; 171:388-416

INITIAL IV, ADULTS DOSES OF ANTIBIOTICS FOR EMPIRIC THERAPY OF

HAP, INCLUDING VAP, AND HCAP IN PATIENTS WITH LATE ONSET
DISEASES OR RISK FACTORS FOR MDR PATHOGENS
Antibiotic
Antipseudomonals
cephalosporin
Cefepime
Ceftazidine
Carbepenems
Imipenem
every 8h Meropenem
8h
Beta-lactam/beta-lactamase
inhibitor
Piperacillin-tazobactam
Aminoglycosides
Gentamicin

Dosage
1-2 g every 8-12h
2 g every 8 h
500 every 6 h or 1 g
1 g every
4.5 g every 6 h
7 mg/kg per d

Tobramycin

7 mg/kg per d

Amicain
Antipseudomonal
quinolones
Levofloxacin
Ciprofloxacin
Vancomycin
h
Linezolid

20 mg/kg per d
750 mg every d
400 mg every 8 h
15 mg/kg every 12
600 mg every 12 h
ATS. AJRCCM 2005; 171:388-416

THANK YOU

 Pasien laki2 45 th dgn keluhan batuk berdahak

kuning, darah (-) sejak 3 hari yll bertambah
berat disertai sesak yg tdk dipengaruhi oleh
posisi. Demam 2 hari yll hilang timbul, membaik
dengan minum paracetamol.
RPD: Riwayat CKD on HD regular, MRS 2 minggu
lalu
PF: TD dbn, RR: 26 x/m, N: 98 x/m, t: 38,2 C,
Ronchi bilateral paracardial kanan
Lab: WBC: 16.000, HB: 8 gr/dl, Thorax PA:
Infiltrat paracardial kanan