CAP ATS / IDSA 2007

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Informasi mengenai CAP berdasarkan ATS/IDSA 2007

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CAP ATS / IDSA 2007

  1. 1. Community Acquired Pneumonia ATS 2007 Ferdy Ferdian, dr Arto Yuwono, dr, SpPD-KP (K)
  2. 2. Slide 1 Intisari• Pembuatan guideline CAP lokal – Poin 01 Guideline lokal• Kriteria perawatan inap – Poin 04 CURB65 & PSI – Poin 06 CURB65>2 – Poin 07 ICU admission – Poin 08 ICU admission• Penegakan diagnosis – Poin 09 Penegakan diagnosis – Poin 10 Pencarian etiologi – Poin 11 Pencarian etiologi pd outpatient – Poin 13 Spesimen yang baik – Poin 14 Pada pasien dengan severe CAP
  3. 3. Slide 2 Intisari• Pemberian antibiotik – Poin 15 Pemberian AB pada outpatient – Poin 16 Pemberian AB pada outpatient + komorbid – Poin 18 Pemberian AB pada inpatient non ICU – Poin 20 Pemberian AB pada inpatient ICU – Poin 21 Pemberian AB pada inpatient ICU + Resiko pseudomonas – Poin 22 Pemberian AB pada inpatient ICU + Resiko MRSA – Poin 23 Patogen direct therapy – Poin 29 Kapan kita memulai pemberian AB – Poin 30 Kapan kita rubah dari AB IV ke AB PO
  4. 4. Slide 3 Intisari• Pemberian antibiotik – Poin 31 Discharge pasien – Poin 32 Lama pemberian AB – Poin 33 Pemberian AB jangka panjang• Tatalaksana lain – Poin 36 Intubasi• Pencegahan – Poin 46 Smoking cessation
  5. 5. Slide 4• Poin 1 Implementation of Guideline Recommendations• Locally adapted guidelines should be imple- mented to improve process of care variables and relevant clinical outcomes• (Strong recommendation; level I evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  6. 6. Slide 5• Poin 4 Hospital admission decision• Severity-of-illness scores, such as the CURB-65 criteria or prognostic models, such as the Pneumonia Severity Index (PSI), can be used to identify patients with CAP who may be candidates for outpatient treatment• (Strong recommendation; level I evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  7. 7. Slide 6CURB 651) Confusion (Disorientasi waktu, tempat, orang)2) Urea (BUN>20mg/dl)3) RR (>30x/m)4) Low BP (SBP<90,DBP<60)5) Age 65Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  8. 8. TABLE 3 Pneumonia severity indexCriteria PointsAge Slide 7 Male Age (yrs) -0 FemaleNursing home residency Age (yrs) -10Comorbidity 10 Neoplastic 30 Liver 20 Congestive heart failure Cerebrovascular disease 10 Renal disease 10Vital sign abnormality 10 Mental confusion 20 Respiratory rate 30?min-1 20 Systolic blood pressure ,90 mmHg Temperature ,35 or o40uC 20 Tachycardia o125 bpm 15Laboratory abnormalities 10 Blood urea nitrogen o11 mmol?L-1 20 Sodium ,130 mmol?L-1 Glucose o250 mg?dL-1 20 Haematocrit ,30% 10Radiographic abnormalities 10 Pleural effusion 10Oxygenation parameters 30 Arterial pH ,7,35 Pa,O2 ,60 mmHg 10 Sa,O2 ,90% 10bpm: beats per min; Pa,O2: arterial oxygen tension; Sa,O2: arterial oxygen saturation. The point scoring system is as follows. Risk class I:aged ,50 yrs, no comorbidity, no vital-sign abnormality; risk class II: f70 points; risk class III: 71–90 points; risk class IV: 91–130 points; riskclass V: .130 points.Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  9. 9. Slide 8• Poin 6 Hospital admission decision• For patients with CURB-65 scores >2, more- intensive treatment—that is, hospitalization or, where appropriate and available, intensive inhome health care services—is usually warranted.• (Moderate recommendation; level III evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  10. 10. Slide 9• Poin 7 ICU admission decision• Direct admission to an ICU is required for patients with septic shock requiring vasopressors or with acute respi-ratory failure requiring intubation and mechanical ventilation• (Strong recommendation; level II evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  11. 11. Slide 10• Poin 8 ICU admission decision• Direct admission to an ICU or high-level monitoring unit is recommended for patients with 3 of the minor criteria for severe CAP listed in table 4• (Moderate recommen-dation; level II evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  12. 12. Slide 11Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  13. 13. Slide 12• Poin 9 Diagnostic Testing• In addition to a constellation of suggestive clinical features, a demonstrable infiltrate by chest radiograph or other imaging technique, with or without supporting microbiological data, is required for the diagnosis of pneumonia.• (Moderate recommendation; level III evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  14. 14. Slide 13• Poin 10 Recommended diagnostic tests for etiology• Patients with CAP should be investigated for specific pathogens that would significantly alter standard (empirical) management decisions, when the presence of such pathogens is suspected on the basis of clinical and epidemiologic clues• (Strong recommendation; level II evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  15. 15. Slide 14• Poin 11 Recommended Diagnostic Tests for Etiology• Routine diagnostic tests to identify an etiologic diagnosis are optional for outpatients with CAP• (Moderate recommendation; level III evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  16. 16. Slide 15• Poin 13• Pretreatment Gram stain and culture of expectorated sputum should be performed only if a good-quality specimen can be obtained and quality performance measures for collection, transport, and processing of samples can be met• (Moderate recommendation; level II evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  17. 17. Slide 16• Poin 14• Patients with severe CAP, as defined above, should at least have blood samples drawn for culture, urinary antigen tests for Legionella pneumophila and Streptococcus pneumoniae performed, and expectorated sputum samples collected for culture. For intubated patients, an endotracheal aspirate sample should be obtained• (Moderate recommendation; level II evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  18. 18. Slide 17• Poin 15 Outpatient treatment• Previously healthy and no risk factors for drug-resistant S. pneumoniae (DRSP) infection:• A. A macrolide (azithromycin, clarithromycin, or erythromycin) (strong recommendation; level I• evidence)• B. Doxycycline (weak recommendation; level III• evidence)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  19. 19. Slide 18• Poin 16• Presence of comorbidities, such as chronic heart, lung, liver, or renal disease; diabetes mellitus; alcoholism; malignancies; asplenia; immunosuppressing conditions or use of immunosuppressing drugs; use of antimicrobials within the previous 3 months (in which case an alternative from a different class should be selected); or other risks for DRSP infection:• A. A respiratory fluoroquinolone (moxifloxacin, gemifloxacin, or levofloxacin *750 mg]) (strong recommendation; level I evidence)• B. A b-lactam plus a macrolide (strong recommendation; level I evidence) (High- dose amoxicillin [e.g., 1 g 3 times daily] or amoxicillin-clavulanate [2 g 2 times daily] is preferred; alternatives include ceftriaxone, cefpodoxime, and cefuroxime [500 mg 2 times daily]; doxycycline [level II evidence] is an alternative to the macrolide.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  20. 20. Slide 19• Inpatient, non-ICU treatment• Poin 18• A respiratory fluoroquinolone (strong recommendation; level I evidence)• Poin 19• A b-lactam plus a macrolide (strong recommendation; level I evidence) (Preferred b-lactam agents include cefotaxime, ceftriaxone, and ampicillin; ertapenem for selected patients; with doxycycline [level III evidence] as an alternative to the macrolide. A respiratory fluoroquinolone should be used for penicillin-allergic patients.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  21. 21. Slide 20• Poin 20 Inpatient, ICU treatment• A b-lactam (cefotaxime, ceftriaxone, or ampicillin- sulbactam) plus either azithromycin (level II evidence) or a fluoroquinolone (level I evidence) (strong recommendation) (For penicillin-allergic patients, a respiratory fluoroquinolone and aztreonam are recommended.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  22. 22. Slide 21• Poin 21 Inpatient, ICU treatment• For Pseudomonas infection, use an antipneumococcal, antipseudomonal b -lactam (piperacillin-tazobactam, cefepime, imipenem, or meropenem) plus either ciprofloxacin or levofloxacin (750-mg dose) or the above b -lactam plus an aminoglycoside and azithromycin• or• the above b-lactam plus an aminoglycoside and an antipneumococcal fluoroquinolone (for penicillin-allergic patients, substitute aztreonam for the above b-lactam).• Moderate recommendation; level III evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  23. 23. Slide 22• Poin 22• For community-acquired methicillin-resistant Staphylococcus aureus infection, add vancomycin or linezolid.• (Moderate recommendation; level III evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  24. 24. Slide 23• Poin 23 Pathogen-directed therapy• Once the etiology of CAP has been identified on the basis of reliable microbiological methods, antimicrobial therapy should be directed at that pathogen. (Moderate• recommendation; level III evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  25. 25. Slide 24• Poin 29 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.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  26. 26. Slide 25• Poin 30 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.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  27. 27. Slide 26• Poin 31• Patients should be discharged as soon as they are clinically stable, have no other active medical problems, and have a safe environment for continued care. Inpatient observation while receiving oral therapy is not necessary.• (Moderate recommendation; level II evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  28. 28. Slide 27• Poin 32 Duration of antibiotic therapy.• Patients with CAP should be treated for a minimum of 5 days (level I evidence), should be afebrile for 48–72 h, and should have no more than 1 CAP-associated sign of clinical instability (table 10) before discontinuation of therapy• (level II evidence). (Moderate recommendation.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  29. 29. Slide 28Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  30. 30. Slide 29• Poin 33• A longer duration of therapy may be needed if initial therapy was not active against the identified pathogen or if it was complicated by extrapulmonary infection, such as meningitis or endocarditis• (Weak recommendation; level III evidence.)
  31. 31. Slide 30• Poin 36• Patients with hypoxemia or respiratory distress should receive a cautious trial of noninvasive ventilation unless they require immediate intubation because of severe hypoxemia (PaO2/FiO2 ratio < 150) and bilateral alveolar infiltrates• (Moderate recommendation; level I evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  32. 32. Slide 31• Poin 46 Prevention• Smoking cessation should be a goal for persons hospitalized with CAP who smoke.• (Moderate recommendation; level III evidence.)Infectious Diseases Society of America/American Thoracic Society Consensus Guidelines on the Management ofCommunity-Acquired Pneumonia in Adults, Clinical Infectious Diseases 2007; 44:S27–72
  33. 33. Terimakasih Victor FranklEVERYONE has his owon spesific vocation or mission in life, everyone must carry out aconcrete assignment that demand fulfillment.Therein he cannot be replaced, nor can his lifebe repeated, thus, everyones task is unique as his spesific opportunity

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