Professional Documents
Culture Documents
Ceva W Pitoyo
Pulmonology Division -Internal Medicine Dept.
High Care Unit
Faculty of Medicine Univ Indonesia
Cipto Mangunkusumo Central General Hospital
Pneumonia
! Community acquired :
- Outpatient
- Inpatient
- Intensive care unit admitted
! Hospital acquired :
- Health care associated
- Hospital acquired (in ward)
- Ventilatory associated
Criteria of severity
! Guidelines vary about the features
used to identify a patient with severe
CAP at the time of admission to
hospital
Severe Pneumonia Criteria : BTS
! CURB65 Score : ≥ 2
- Confussion : score 1
- Uremia (BUN) > 19 mg/dl : score 1
- Respiratoty rate ≥ 30 : score 1
- Blood pressure : S < 90 or
D ≤ 60 : score 1
- ≥ 65 years : score 1
Pneumonia Severity Index (PSI) :
PORT
! Class I : Score : 0
! Class II : Score : ≤ 70
! Class III : Score : 71 – 90
! Class IV : Score : 91 – 130
! Class V : Score : > 130
Severe Pneumonia : ATS-IDSA
Major Criteria :
! Mechanical Ventilation
! Septic shock ( with vasopresor )
Minor Criteria :
! RR ≥30 x/mnt
! PaO2/FiO2 ≤ 250
! Multilobar infiltrate
! Decrease of consiousness / disorientation
! Uremia ( BUN ≥ 20 mg/dL)
! Leucopenia ( < 4000 /dL)
! Thrombocytopenia ( < 100.000 /dL)
! Hypothermia ( < 36 C)
! Hypotention (need of agresive fluid rescucitation)
Consensus on the management of Community-Acquired Pneumonia Infectious
Disease Society of America (IDSA) and American Thoracic Society (ATS) 2007
! Australian model called SMART-COP
attempted to predict receipt of
mechanical ventilation (whether
invasive or noninvasive) or
vasopressors, without regard for
location of care, and has been
externally validated in patients under
the age of 50 years
! Spanish model called CURXO-80.
Problems in definition of severity
! Ideally a definition of severity should show
physicians what they have to do to save
patients
! The definition of severity in pneumonia
that deny the need of specific treatment
may fail to identify patients likely to
benefit from other therapy and vice versa
! Eg. A definition that rule out the need for
ICU may fail to identify patients likely to
benefit from specific antibiotic coverage.
! PSI and CURB-65 do not perform well at
predicting which patients will require ICU
admission or intensive therapy. They tend
to overestimate severity in patients with
advanced age or chronic organ failure and
underestimate severity in younger patients
! Angus DC, Marrie TJ, Obrosky DS, et al. Severe community-acquired pneumonia: use of intensive
care services and evaluation of American and British Thoracic Society Diagnostic criteria. Am J
Respir Crit Care Med 2002; 166:717–723
! Ewig S, de Roux A, Bauer T, et al. Validation of predictive rules and indices of severity for
community acquired pneumonia. Thorax 2004; 59:421–427
! Riley PD, Aronsky D, Dean NC. Validation of the 2001 American Thoracic Society criteria for severe
community-acquired pneumonia. Crit Care Med 2004; 32:2398–2402
! Kamath A, Pasteur MC, Slade MG, Harrison BD. Recognising severe pneumonia with simple clinical
and biochemical measurements. Clin Med 2003; 3:54–56
The ATS guidelines outperformed SMART-
COP, CURXO-80, and CURB-65 (P<0.05)
based on a health services reference definition of SCAP on
! Brown SM, Jones BE, Jephson AR, Dean NC. Validation of the Infectious
Disease Society of America/American Thoracic Society 2007 guidelines for
severe community-acquired pneumonia. Crit Care Med 2009; 37:3010–
3016.
! A prospective follow-on study by the
authors of the PSI suggested slightly
better prediction of 30-day mortality
than CURB or CURB-65
! PSI is more weighted toward age and
comorbidity and the CURB-65 is
more weighted toward acute
physiological dysfunction
Indication of ICU admission in
Pneumonia
! CURB65 score : 4
or
! PSI class V
or
! Ibrahim EH, Sherman G, Ward S, et al. The influence of inadequate antimicrobial treatment
of bloodstream infections on patient outcomes in the ICU setting. Chest 2000; 118:146–155
! All three CAP management guidelines published
recently from North America1-3 recommend
combination antibiotic therapy initially for
patients with severe pneumonia, typically an
intravenous B-lactamase-stable B-lactam with
an intravenous macrolide or intravenous
“antipneumococcal” fluoroquinolone.
! 1 Mandell LA, Marrie TJ, Grossman RF, et al. Canadian guidelines for the initial management of
community-acquired pneumonia: an evidence-based update by the Canadian Infectious Diseases
Society and the Canadian Thoracic Society. Clin Infect Dis 2000; 31: 383–421.
! 2 Bartlett JG, Dowell SF, Mandell LA, File Jr TM, Musher DM, Fine MJ. Practice guidelines for the
management of communityacquired pneumonia in adults. Clin Infect Dis 2000; 31: 347–82.
! 3 ATS Board of Directors. Guidelines for the management of adults with community-acquired
pneumonia. Am J Respir Crit Care Med 2001; 163: 1730–54.
! Severe bacteriemic pneumococcal
pneumonia have a significantly
greater risk of death (odds ratio 6·4,
95% CI 1·9–21·7) if they receive a
single antibiotic rather than
combination antibiotics on the first
day of admission
! Waterer GW, Somes GW, Wunderink RG. Monotherapy may be suboptimal for severe
bacteraemic pneumococcal pneumonia. Arch Intern Med 2001; 161: 1837–42
An#bio#c
Sensi#vity
Non
ICU
Pneumonia
Cipto
Mangunkusumo
Hopital
20013
No Microbacteria Gram Antibiotic
CM
Rumende.
Procalcitonin
dan
LBP
sebagai
prediktor
dan
petanda
prognos#k
VAP
di
ICU/HCU
RSCM
2006-‐2007
The Most Common Etiology of HAP (Non VAP)
In Cipto Mangunkusumo 2013
The Most Common Etiology of VAP
in Cipto Mangunkusumo 2013
Risks for MDR
American
Thoracic
Society,
Infec#ous
Diseases
Society
of
America.
Guidelines
for
the
management
of
adults
with
hospital-‐acquired,
ven#lator-‐associated,
and
healthcare-‐associated
pneumonia.
The
Most
Sensi#ve
An#bio#cs
for
VAP
in
ICU
Cipto
Mangunkusumo
2013
No Kuman Gram Antibiotik
American
Thoracic
Society,
Infec#ous
Diseases
Society
of
America.
Guidelines
for
the
management
of
adults
with
hospital-‐acquired,
ven#lator-‐associated,
and
healthcare-‐associated
pneumonia.
Prophylaxys ‘Bundle’
! Head up 30 degree
! Oral care 4x/D
! Sterile Suction
! ‘Stress ulcer’ Prophylaxis
! ‘Hit hard and early weaning’
AlhamduliLlah
Thank You