Pitfalls terapi pneumonia

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Pitfalls terapi pneumonia

  1. 1. Pneumonia Schidlow DV, 1996
  2. 2. Child with Pneumonia
  3. 3. Introduction Ostapchuck M et al, 2004;Greenberg D et al, 2005; McIntosh K, 2002
  4. 4. Introduction Alberta Medical Association, 2001; Jadavji T et al,1997
  5. 5. Introduction Developing country  ± 60% pneumonia cases caused by bacterial  antibiotic. In developed country  mostly viral Alberta Medical Association, 2001; Jadavji T et al,1997
  6. 6. Introduction Alberta Medical Association, 2001; Jadavji T et al,1997
  7. 7. Introduction Alberta Medical Association, 2001; Jadavji T et al,1997
  8. 8. Introduction Alberta Medical Association, 2001; Jadavji T et al,1997
  9. 9. Introduction • Recent research showed that antibiotic regimen in WHO guidelines has reduced 50% mortality in developed country, but there’s also excessive use of antibiotics (75%) Shann F et al, 1999 Need a guidelines for a Rational use of antibiotics.
  10. 10. Introduction Alberta Medical Association, 2001; Jadavji T et al,1997
  11. 11. Introduction Alberta Medical Association, 2001; Jadavji T et al,1997
  12. 12. Antibiotics for Non Severe Pneumonia Ostapchuck M et al, 2004;Greenberg D et al, 2005
  13. 13. Antibiotics for Non Severe Pneumonia Ostapchuck M et al, 2004; McIntosh K, 2002
  14. 14. Antibiotics for Non Severe Pneumonia Alberta Medical Association, 2001
  15. 15. Antibiotics for Non Severe Pneumonia WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT 2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007
  16. 16. Antibiotics for Non Severe Pneumonia WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT 2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007
  17. 17. Antibiotics for Non Severe Pneumonia WHO, 2005; Fonseca W, 2003; Pakistan MASCOT, 2002; Pakistan MASCOT 2003, ISCAP study group, 2004; Awasthi S, et al, 2004, Ayieko P et al, 2007, CATCHUP study group 2002
  18. 18. Antibiotics for Non Severe Pneumonia Kabra SK et al. 2009
  19. 19. Antibiotics for Non Severe Pneumonia Kabra SK et al. 2009
  20. 20. Antibiotics for Non Severe Pneumonia Guidelines from The British Thoracic Society (2002): • For children < 5 years old: first line drugs is amoxicillin (well tolerated, not expensive) The British Thoracic Society, 2002 Alternative antibiotics: co-amoxiclav, cephachlor, eritromycin, Chlaritromycin, and azitromycin
  21. 21. Antibiotics for Non Severe Pneumonia Guidelines , The British Thoracic Society, 2002: • In children > 5 years old most common organism is M. Pneumoniae • First line drugs is macrolide The British Thoracic Society, 2002 If S. pneumoniae suspected  amoxicillin If S. aureus suspected  macrolide or combination of flucloxacillin and amoxicillin
  22. 22. Antibiotics for Non Severe Pneumonia Monotherapy is recommended. National Guideline Clearinghouse, 2006
  23. 23. Antibiotics for Non Severe Pneumonia National Guideline Clearinghouse, 2006
  24. 24. Follow Up • Evaluation performed after 24-72 hours of treatment, if no improvement  change antibiotics National Guideline Clearinghouse, 2006 Signs of improvement: Decrease respiratory rate Lower fever Appetite improvement
  25. 25. Indication for Admission Alberta Medical Association, 2001; WHO , 2008
  26. 26. Indication for Admission Alberta Medical Association, 2001; WHO , 2008
  27. 27. Antibiotic for Admitted Pneumonia Fonseca W, 2003; Pakistan MASCOT, 2002
  28. 28. WHO, 2005 Antibiotic for Admitted Pneumonia
  29. 29. Antibiotic for Admitted Pneumonia Guideline for the Management of Community Acquired Pneumonia in childhood: The British Thoracic Society, 2002 As therapy begin, the organism causing pneumonia is unknown. Treatment based on age and specific symptoms for specific pathogen.
  30. 30. 0-8 Weeks Enarson PM, 2005
  31. 31. 2-59 Months Enarson PM, 2005
  32. 32. Other Study
  33. 33. Macrolide
  34. 34. Cephalosporins and Non Cephalosporins
  35. 35. Cephalosporins • A randomized controlled trial compared 3rd generation of cephalosporins and Cephachlor  no differences (Paupe J, et all, 1992 )
  36. 36. Table 1. Therapeutic management of pneumonia Patient age Outpatient Inpatient Critically ill Birth to 20 days Admit Ampicillin IV or IM: Age <7 days: Weight <2 kg (4.4 lb): 50 to 100 mg per kg per day in divided doses every 12 hours Weight ≥2 kg: 75 to 150 mg per kg per day in divided doses every 8 hours Ampicillin IV or IM, in same dosages as for inpatients plus Gentamicin IV or IM, with or without cefotaxime IV, in same dosages as for inpatients Ostapachuk, M,.2004
  37. 37. Patient age Outpatient Inpatient Critically ill Birth to 20 days Admit Ampicillin IV or IM: Age ≥7 days: Weight <1.2 kg (2.6 lb): 50 to 100 mg per kg per day divided every 12 hours Weight 1.2 to 2 kg: 75 to 150 mg per kg per day in divided doses every 8 hours Weight >2 kg: 100 to 200 mg per kg per day in divided doses every 6 hours Table 1. Therapeutic management of pneumonia Ostapachuk, M,.2004
  38. 38. Patient age Outpatient Inpatient Critically ill Birth to 20 days Admit plus Gentamicin IV or IM: ≥37 weeks of gestation And Age zero to 7 days: 2.5 mg per kg every 12 hours Age >7 days: 2.5 mg per kg every 8 hours with or without Cefotaxime (Claforan) IV: Age ≤7 days: 100 mg per kg per day in divided doses every 12 hours Age >7 days: 150 mg per kg per day in divided doses every 8 hours Ostapachuk, M,.2004 Table 1. Therapeutic management of pneumonia
  39. 39. Patient age Outpatient Inpatient Critically ill 3 weeks to 3 months If patient is afebrile: Azithromycin (Zithromax), 10 mg per kg orally on day 1, then 5 mg per kg per day on days 2 through 5 or Erythromycin, 30 to 40 mg per kg per day orally in divided doses every 6 hours for 10 days Admit if patient is febrile or hypoxic. Erythromycin, 40 mg per kg per day IV in divided doses every 6 hours* If patient is febrile, add one of these agents: Cefotaxime, 200 mg per kg per day IV in divided doses every 8 hours* or Cefuroxime (Ceftin), 150 mg per kg per day IV in divided doses every 8 hours* Cefotaxime, 200 mg per kg per day IV in divided doses every 8 hours plus cloxacillin (Tegopen), 150 to 200 mg per kg per day IV in divided doses every 6 hours* or Cefuroxime alone, 150 mg per kg per day IV in divided doses every 8 hours* Ostapachuk, M,.2004 Table 1. Therapeutic management of pneumonia
  40. 40. Patient age Outpatient Inpatient Critically ill 4 mo to 5 years Amoxicillin, 90 mg per kg per day orally in divided doses every 8 hours for 7 to 10 days Consider initial dose of ceftriaxone (Rocephin), 50 mg per kg per day IM, up to 1 g per day. Follow with oral therapy for full course. Alternatives: amoxicillin clavulanic acid (Augmentin), azithromycin, cefaclor (Ceclor), clarithromycin (Biaxin), erythromycin Cefotaxime, 150 mg per kg per day IV in divided doses every 6 hours* or Cefuroxime, 150 mg per kg per day IV in divided doses every 8 hours* If the patient has pneumococcal infection: Ampicillin alone, 200 mg per kg per day IV in divided doses every 8 hours* Cefuroxime, 150 mg per kg per day IV in divided doses every 8 hours, plus erythromycin, 40 mg per kg per day IV or orally in divided doses every 6 hours for 10 to 14 days* or Cefotaxime, 200 mg per kg per day IV in divided doses every 8 hours, plus cloxacillin, 150 to 200 mg per kg per day IV in divided doses every 6 hours for 10 to 14 days Ostapachuk, M,.2004 Table 1. Therapeutic management of pneumonia
  41. 41. Table 1. Therapeutic management of pneumonia Patient age Outpatient Inpatient Critically ill 5 years and older Azithromycin, 10 mg per kg (maximum of 500 mg) orally on day 1, followed by 5 mg per kg per day on days 2 through 5 Or Clarithromycin, 15 mg per kg per day orally in divided doses every 12 hours for 7 to 10 days Or Erythromycin, 40 mg per kg per day orally in divided doses every 6 hours for 7 to 10 days If the patient has pneumococcal infection: Amoxicillin alone, 90 mg per kg per day orally in divided doses every 8 hours Cefuroxime, 150 mg per kg per day IV in divided doses every 8 hours plus Erythromycin, 40 mg per kg per day IV or orally in divided doses every 6 hours for 10 to 14 days If pneumococcal infection is confirmed: Ampicillin alone, 200 mg per kg per day IV in divided doses every 8 hours Cefuroxime, 150 mg per kg per day IV in divided doses every 8 hours plus Erythromycin, 40 mg per kg per day IV or orally in divided doses every 6 hours for 10 to 14 days Ostapachuk, M,.2004
  42. 42. Follow Up • Every 6 hours or at least once a day • Observations consist of respiratory rate, temperature, level of consciousness and feeding National guidelines Clearinghouse, 2006 Amelioration signs : •Decreasing of respiratory rate •No chest indrawing •Lowering of fever •Better appetite
  43. 43. Follow Up cont’ • Rules of hospital discharge : – Adequately consumes oral antibiotics – Antibiotic therapy can be done at home – Family agree and understand the management at home – Support from environment for the therapy – Family should take their child to the clinician for next examination Ostapachuk, M,.2004
  44. 44. Pitfalls Management of Pneumonia in Children • Chest x-ray should not routinelly done in children with mild pneumonia. (A) • Evaluation of chest x-ray only performed if no improvement or there is worsening. (C) Enarson M, 2006The British Thoracic Society,2002
  45. 45. Pitfalls Management of Pneumonia in Children • Antibiotics administration empirically often inappropriate with the etiology  overused antibiotics . Amoxycillin is the first line antibiotic for pneumonia. Alternatives  co-amoxyclav, cephachlor, erytromycin clarytromycin and azytromycin . (B) Enarson M, 2006The British Thoracic Society,2002
  46. 46. Pitfalls Management of Pneumonia in Children • Nasogastric tube should not be applied in severe pneumonia (D) • Every pneumonia patient has to be monitored for oxygen saturation. (A) • Children with oxygen saturation below 92% must given oxygen therapy with nasal canule, head box, or facial mask, to keep the saturation above 92%. (A) The British Thoracic Society,2002
  47. 47. Pitfalls Management of Pneumonia in Children • Intravenous fluid administered for 80% from daily requirement and electrolyte examination must be done in severe pneumonia. (C) • Chest physiotherapy is not always useful (B) The British Thoracic Society,2002
  48. 48. Study design Evidence level Recomendation Advance systematic study Ia A+ One or more good study Ib A- One or more prospective study II B+ One or more retrospective study III B- Experts’ assumption formally Iva C Experts’ assumption informally or other information IVb D Table 2 . Evidence Level and Recommendation The British Thoracic Society, 2002
  49. 49. CONCLUSION • Antibiotic administration is a challenge for clinician in the management of pneumonia • Some pneumonia caused by viral infection • As we decide to give antibiotic, we must consider which antibiotic should be used (broad spectrum or narrow spectrum) • First  give antibiotic empirically based on children age • Second  observe within 24-72 hours • All of the steps above are useful to prevet pittfalls in the management of pneumonia
  50. 50. Cochrane Database of Systematic Review 2008 To determine the equivalence in effectiveness and safety of oral antibiotics compared to parenteral antibiotics Oral Antibiotics vs Parenteral Antibiotics for Severe Pneumonia Rojas-Reyes MX, Rugeles CG, 2006
  51. 51. Cochrane Database of Systematic Review 2008 Published or unpublished randomized controlled trials (RCTs) comparing any oral and parenteral antibiotic  children 3 months to 5 years Oral therapy  effective and safe alternative to parenteral antibiotics in hospitalized children Rojas-Reyes MX, Rugeles CG, 2006
  52. 52. Cochrane Database of Systematic Review 2008 Short –course vs Long-course antibiotic therapy for non-severe community-acquired pneumonia Results: Analysis of three days of treatment with the same antibiotic non significant differences in clinical cure, treatment failure, and relapse rate after seven days of clinical cure Haider BA, Saeed MA, Bhutta ZA, 2007
  53. 53. Cochrane Database of Systematic Review 2008 Conclusion A short course (3 days) of antibiotic therapy is as effective as a longer treatment (5 days) for non severe pneumonia in children under five years of age. Haider BA, Saeed MA, Bhutta ZA, 2007
  54. 54. Cochrane Database of Intervention Review To identify effective antibiotic drug therapy for community acquired pneumonia in children by comparing various antibiotics. Antibiotics for CAP in Children Kabra SK, Lodha R, Pandey RM, 2009
  55. 55. Cochrane Database of Intervention Review • Cotrimoxazole is inferior to amoxycillin and prokain penicillin • Penicillin in conjunction with gentamycin better than chloramphenicol alone. • Co-amoxyclavulanic acid was better than amoxycillin alone • No difference between injectable penicillin and oral amoxycillin Kabra SK, Lodha R, Pandey RM, 2009
  56. 56. Cochrane Database of Intervention Review No differences between • Injectable penicillin and oral amoxycillin • Azithromycin and erythromycin • Cefpodoxime and amoxycillin • Azithromycin and co-amoxyclavulanic acid. Kabra SK, Lodha R, Pandey RM, 2009
  57. 57. Conclusion Ambulatory patients • Amoxycillin was better than co-trimoxazole • No difference between azithromycin and erythromycin • No difference between cefpodoxime and co- amoxyclavulanic Cochrane Database of Intervention Review Kabra SK, Lodha R, Pandey RM, 2009
  58. 58. Cochrane Database of Intervention Review • Hospitalized patients • Procain penicillin was better than cotrimoxazole • Penicillin + gentamycin better than chloramphenicol alone • Injectable penicillin and oral amoxycillin similar failure rates Kabra SK, Lodha R, Pandey RM, 2009
  59. 59. Cochrane Database of Intervention Review Over-the-counter (OTC) medications to reduce cough as an adjunct to antibiotics for acute pneumonia in children and adults To evaluate the efficacy of OTC cough medications as an adjunct to antibiotics in children and adults with pneumonia Chang CC, Cheng AC, Chang AB, 2009
  60. 60. Cochrane Database of Intervention Review • Insufficient evidence to decide whether OTC medications for cough associated with acute pneumonia are beneficial. • Mucolytics may be beneficialinsufficient evidence • Codeine and antihistamines should not be used in young children Chang CC, Cheng AC, Chang AB, 2009
  61. 61. Buku saku pelayanan kesehatan anak di rumah sakit rujukan tingkat pertama di kabupaten/kota
  62. 62. Technical updates of the guidelines on the Integrated Management of Childhood Illness (IMCI)

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