Definisi

Pneumonia adalah inflamasi yang

mengenai parenkim paru
Sebagian besar disebabkan oleh
mikroorganisme (virus/bakteri) dan
sebagian kecil disebabkan oleh faktor lain
Pneumonia
 Pneumonia in children (< 5 years of age)
Morbidity Rate 10-20 %
Mortality Rate 6/1000
Pneumonias kill
50.000/a year
12.500/a month
416/a day = passengers of 1 jumbo jet plane
17/an hour
1/four minutes
Pneumonia is a number one killer of infants
 Klasifikasi Pneumonia

Berdasarkan Berdasarkan Berdasarkan

Sumber Infeksi
Pneumonia yg didapat di Pneum. bakterial
masyarakat
(Community-acquired pn.)
Pneumonia yg didapat di
RS (Hospital-acquired pn. )
Pneumonia Aspirasi
Pne. Immunocompr. host
Kuman penyebab Predileksi / tempat
infeksi
Pneumonia lobaris
Pneum. atipikal
Pneum. ok virus (lobar pneumonia)
Bronchopneumonia
Pneum. ok jamur
/ patogen lainnya Pneum interstitialis
(interstitial pneumonia)
 Malnutrition, poor
breast feeding
practices
Lack of immunization Vitamin A deficiency

Young Low birth

age Increased weight
risk of
ARI
Crowdin Cold weather
g or chilling

High prevalence Exposure to air pollution

of nasopharyngeal Tobacco smoke
carriage of Biomass smoke
pathogenic bacteria Environmental air pollution
Etiology differs according to :

age

(neonates, infants, children,

adolescents)
clinical setting

(community or hospital)
local epidemiology

(RSV epidemics, influenza

activity)
vaccination status

(measles, diphtheria,
pertussis, Hib)
air pollution

(industry, tobacco smoke)

host factors

(underlying diseases,
malnutrition)
immunologic status
 Mekanisme
Kuman masuk ke
pertahanan
saluran napas atas
terganggu

Terbentuk
sekret virulen

Sekret berlebih
Inflamasi turun
ke alveoli
 Stadium Kongesti
o Kapiler kongesti dan melebar

Hepatisasi merah
o Terjadi reaksi jaringan yang mempermudah
proliferasi dan penyebaran kuman ke jaringan
sekitarnya.
o Bagian paru yang terkena mengalami konsolidasi
o Ditemukan kuman di alveoli
 Hepatisasi Kelabu
o Deposisi fibrin semakin bertambah
o Terdapat fibrin dan leukosit PMN di alveoli
o Terjadi proses fagositosis yang cepat

Resolusi
o Jumlah makrofag meningkat di alveoli
o Sel akan mengalami degenerasi
o Fibrin menipis
o Kuman dan debris menghilang
 Asinus terisi eksudat dan
infiltrasi Sel radang kedalam
alveoli
 Sebagian besar gambaran klinis
pneumonia pada anak berkisar antara
ringan hingga sedang, sehingga dapat
berobat jalan saja

Hanya sebagian kecil yang berat,

mengancam kehidupan, dan mungkin
terdapat komplikasi sehingga memerlukan
perawatan di RS.
 Demam, Sakit kepala, Gelisah, Malaise,
Penurunan napsu makan, Keluhan
gastrointestinal : mual, muntah, atau diare

Batuk, Sesak napas, Retraksi dada,

Takipnea, Napas cuping hidung, Air hunger,
Merintih, Sianosis
 >> akibat transmisi vertikal (proses persalinan)

Akibat kontaminasi sumber infeksi dari ibu:

aspirasi mekonium, cairan amnion, serviks ibu.
Gejala

Serangan apnea Letargi, muntah

Sianosis Tidak mau minum
Merintih Takikardi/ bradikardi
Napas cuping Retraksi subkosta
hidung Demam
Takipnea
 Sepsis pada pneumonia neonatus dan bayi
kecil sering ditemukan sebelum 48 jam I.

Angka mortalitas sangat tinggi di negara

maju, yaitu dilaporkan 20-50%

Angka kematian di Indonesia dan di negara

berkembang lainnya diduga lebih tinggi
 Takipnea
Retraksi subkosta (chest indrawing)
Napas cuping hidung
Ronki
Sianosis
 Ronki ditemukan bila ada infiltrat alveolar

Retraksi dan takipnea merupakan tanda klinis

pneumonia yang bermakna

Kadang-kadang timbul nyeri abdomen bila

terdapat pneumonia lobus kanan bawah yang
menimbulkan infiltrasi diafragma

Nyeri abdomen dapat menyebar ke kuadran

kanan bawah dan menyerupai apendisitis.
 Darah Perifer Lengkap (DL)
C-Reaktive Protein(CRP)
Uji Serologis
Pemeriksaan Mikrobiologis
Pemeriksaan Radiologis
 Leukositosis :15-40 K/mm3 predominan PMN
Leukopenia :<5 K/mm3
Pada infeksi Chlamydia pneumonia kadang-
kadang ditemukan eosinofilia
Pemeriksaan DL & LED tidak dapat
membedakan antara infeksi virus dan infeksi
bakteri secara pasti
 Suatu protein fase akut yang disintesis
oleh hepatosit. Sebagai respons infeksi
atau inflamasi jaringan

Secara klinis CRP digunakan sebagai alat

bantu diagnostik untuk membedakan
antara faktor infeksi dan noninfeksi, infeksi
virus dan bakteri, atau infeksi bakteri
superfisialis dan profunda
 Mendeteksi Ag dan Ab pada infeksi
bakteri tipik, sensitivitas dan spesifitas
rendah

Bermanfaat dalam mendiagnosis infeksi

bakteri atipik seperti Mikoplasma dan
Klamidia, serta beberapa virus seperti RSV,
Sitomegalo, campak, Parainfluenza 1, 2,3,
Influenza A dan B, dan Adeno
 Jarang dikerjakan, hanya 10-30% bakteri
+
Bahan/sediaan :

Darah, Cairan pleura, Spesimen dari biopsi

atau pungsi, bilasan bronkus,aspirasi paru.

Diagnosis definitif bila ditemukan kuman

dari darah, cairan pleura, aspirasi paru.
 Rekomendasi: u pneumonia berat yang dirawat
Foto ulang: klinis menetap, memburuk.
Infiltrat interstitial: corakan bronkovaskuler me
peribronchial cuffing, dan hiperaerasi
Infiltrat alveolar, merupakan konsolidasi paru-paru
dengan air bronchogram

BP: gambaran difus di kedua paru, berupa bercak2

infiltrat yang meluas hingga daerah perifer paru,
disertai dengan peningkatan corakan peribronkial.
 Female infant, 0,3 y, cxr. alveolar
infiltrates in upper right lobe ec
parainfluenza and
human herpes virus, leucocytois 17000,
ESR 8 mm/ h l, CRP 22 mg/l
Male boy, 1,9 y, cxr alveolar infiltrates in
right lobe ec. S pneumoniae: IgG
pneumolysin increased, leucocytosi 13.800,
ESR 125/h I, CRP 332 mg/l.
 Prediktor paling kuat pneumonia adalah
demam, sianosis, dan lebih dari satu
gejala respiratori sebagai berikut :
o Takipnea
o Batuk
o Napas cuping hidung
o Retraksi
o Ronki
o Suara napas melemah
 Symptom Sensitivity Specificity
Tachypnea 92 % 15 %
Cough 92 % 19 %

Toxic appearance 81 % 60 %

Crackles 44 % 80 %

Retractions 35 % 82 %

Flaring 35 % 82 %

Pallor 35 % 87 %

Grunting 19 % 94 %

Leventhal JM, 1982

 Fast breathing
(tachypnea)

Respiratory thresholds
Age Breaths/minute
< 2 months 60
2 - 12 months 50
1 - 5 years 40

Chest Indrawing
(subcostal retraction)
Bayi dan anak berusia <2 bulan

Pneumonia Bukan
Berat Pneumonia

Bila sesak + Bila sesak

Napas cepat + Napas cepat -
Harus MRS Tidak perlu
Perlu MRS
Antibiotik Tidak perlu
injeksi antibiotik
Obat simptomatis
Bayi dan anak berusia 2 bulan 5 tahun

Pneumonia Pneumonia Bukan

Berat Pneumonia

Bila sesak Bila sesak Bila sesak

+ Napas cepat Napas cepat
MRS + -
Perlu Tidak perlu Tidak perlu
Antibiotik MRS MRS
injeksi Cukup Tidak perlu
antibiotik antibiotik
oral Obat
simptomatis
 Dasar tatalaksana:
Terapi kausal: antibiotika (AB) yang sesuai

Terapi suportif

Terapi Antibiotik secara empiris, yaitu

kemungkinan etiologi penyebab dengan
mempertimbangkan usia dan keadaan klinis
pasien serta faktor epidemiologis
Pengobatan suportif
Terapi oksigen: Via kanula nasal, masker,
head box; pertahankan sat O2 > 92%
Cairan intra vena: beri 80% kebutuhan
Koreksi keseimbangan Asam-Basa, Elektrolit,
gula darah.
Analgetik/Antipiretik
Monitor HR, temp, RR, Saturasi min. @4 jam
Penangulangan penyakit penyerta
 Berikan antibiotik lini pertama secara oral
misalnya amoksisilin atau kotrimoksazol

Dosis amoksisilin: 25 mg/KgBB

Dosis kotrimoksazol
TMP : 4 mg/kgBB
Sulfametoksazol) : 20 mg/kgBB
 Pilihan AB lini pertama dapat menggunakan
beta-laktam atau kloramfenikol

Bila tidak responsif, AB pilihan lain seperti

gentamisin, amikasin, atau sefalosporin

Terapi AB diteruskan selama 7-10 hari pada

pasien pneumonia tanpa komplikasi
 Pada neonatus dan bayi kecil: AB IV segera,
untuk mencegah sepsis atau meningitis

AB pilihan: spektrum luas kombinasi beta-

laktam/klavunalat dengan aminoglikosid, atau
sefalosporin generasi III

Bila keadaan sudah stabil, antibiotik dapat

diganti dengan antibiotik oral selama 10 hari
 Makrolide merupakan pilihan utama
Eritromisin mempunyai efektivitas klinis yang

baik u infeksi Mycoplasma pneumoniae,

tetapi tidak efektif dalam mengeradikasikan
mikroorganisme dari jaringan.

Dosis eritromisin: 30-50 mg/kgBB/hari,

diberikan setiap 6 jam selama 10-14 hari.
 Pencegahan
A. Pencegahan Non Spesifik

1. Meningkatkan derajat sosial ekonomi

Menurunkan kemiskinan
Meningkatkan tingkat pendidikan
Menurunkan Angka Kurang Gizi
Meningkatkan Derajat Kesehatan
Menurunkan morbiditas dan mortalitas

2. Lingkungan bersih bebas polusi

 pencegahan
A. Pencegahan Spesifik

1. Cegah BBLR
2. Pemberian makanan bergizi/ gizi seimbang/
Pemberian ASI Eksklusif
3. Pemberian Imunisasi
a) Vaksin Campak
b) Vaksin Pertusis
c) Vaksin Hib
d) Vaksin Pneumokokus
Tindakan Preventif
 Komplikasi

oEmpiema torasis (tersering

oPerikarditis purulenta
oPneumotoraks

o Infeksi ekstra pulmoner seperti

Meningitis purulenta dan
Miokarditis
 Pneumonia, Penyebab utama morbiditas dan mortalitas
Gambaran Klinis dari ringan hingga berat
Penyebab, virus dan predominan bakteri
Pada neonatus gejala tidak khas, berhubungan dengan
sepsis/meningitis; penyebab sesuai masing2 klp. umur
Tatalaksana
tergantung umur, pengobatan awal tergantung keadaan
klinis dan kemungkinan penyebab; pemberian antibiotik
empirik
Antibiotics :
Typical :normally respond to beta-lactam; macrolides
when unsuccessful
Atypical : not respond to beta-lactam; first choice
macrolides.
Tindakan Preventif
Trimakasih
Trimakasih
 Etiologi pada 698 anak dengan Pneumonia
S. pneumoniae 67%
Stafilokokus 11,9%
Streptococus alfa 11,9 %
Hafnia alvei 3,4 %
Stafilokokus aureus 2,8 %
Morksela kataralis 1,1 %
Hemofilus influenzae 0,6 %
Klebseilla pneumoniae 0,6 %
(Kartasasmita et al Pediatr Indones 2001;41:292-95)
 Antibiotic management of pneumonia: Outpatient
(Alberta Clinical Practice Guideline, 2002)

3 months to 5 years old

Amoxicillin Standard dose: 40 mg/kg/day PO div tid for 7-10 days, OR

High dose : 90 mg/kg/day PO div tid for 7 -10 days.
Beta-lactam allergy:
Clarithromycin 15 mg/kg/day div bid for 7 10 days .

Azithromycin 10 mg/kg PO 1st day then 5 mg/kg/day for 4 days OR

Clarithromycin 15 mg/kg/day div bid for 7 10 days .

5 to 16 years old

Azithromycin 10 mg/kg (max 500 mg) PO 1st day then 5 mg/kg/day

for 4 days OR
Clarithromycin 15 mg/kg PO div bid for 7-10 days OR
Erythromycin 40 mg/kg/day div qid for 7 -10 days
 Management of pneumonia in children
(Alberta Clinical Practice Guideline, 2002)

Signs and symptoms

(resp distress: tachypnea, cough,
crackles + decreased breath sounds)

History of Physical findings of

Fever + chills
New onset of cough
Chest pain and/or abdominal pain
Difficulty breathing
Constitutional symptoms
(malaise and lethargy, headache,
nausea/vomiting, myalgias)
Temperature > 38,5oC
Tachypnea*:
-< 11 months > 50 X/min
-> 11 months to 5 yrs > 40 X/min
-5 to 16 yrs > 28 X/min
Signs of accessory muscle use
Signs of consolidation

Investigations
Management of pneumonia in children (cont)
(Alberta Clinical Practice Guideline, 2002)

Investigations
Chest X-ray is considered gold standard
Pulse oximetry for child with signs of tachypnea or hypoxemia
CBC with differential and blood cultures
Gram stain and culture of sputum (older children)
Mycoplasma IgM may be considered ( > 2 yrs old)
Cold agglutinins are limited value in the diagnosis of M pneumonia
RSV testing is not routinely recommended

Bacterial pneumonia (?)

No Yes
 1. Diffuse alveolar and interstitial pneumonia
(perivascular and interalveolar changes)
2. Bronchopneumonia
(inflammation of airways and parenchyma)
3. Lobar pneumonia
(consolidation in a whole lobe)
4. Nodular, cavity or abscess lesions
(esp.in immunocompromised patients)
Management of pneumonia in children (cont)
(Alberta Clinical Practice Guideline, 2002)

Bacterial pneumonia (?)

No Yes

General Management
Analgesic/antipyretics
Hydration
Oxygen therapy
Patient with pleural effusion
should be referred
Pleural empyema should
be drained
Chest physiotherapy is
controversial
Cough suppressants are NOT
routinely recommended
Mukolitik ?
Decision to hospitalize and
in-patient management
Out-patient management (3 mos - 5 yrs)
Amoxicillin (standard or high dose)*
Beta-lactam allergy:
Azithromycin OR
Clarithromycin
+ Out-patient management (5 to 16 yrs)
Azithromycin OR
Clarithromycin OR
Erythromycin

Follow up
In patients with uncomplicated pneumonia, repeat chest X-rays are unwarranted
In patients with pleural effusions, pneumatoceles or pulmonary abscess,
a repeat chest X-rays should be done
 Antibiotic management of pneumonia: In-patient
(Alberta Clinical Practice Guideline, 2002)
In hospital 1 to 3 months pneumonitis Critically Ill
syndrome
Azithromycin : 10 mg/kg PO 1st day then
Azithromycin 10 mg/kg IV (max 500 mg)
5 mg/kg/day for 4 days OR
1st day then 5-10 mg/kg/day IV
Clarithromycin 15 mg/kg/day PO
for 4 days OR
div bid for 10-14 days OR
Erythromycin 40 mg/kg/day IV div Q6h for
Erythromycin 40 mg/kg/day PO
10 to 14 days
div qid for 10-14 days

1 to 3 months bacterial
pneumonia
Cefuroxime 150 mg/kg/day IV div Q8h for
Cefuroxime 150 mg/kg/day IV 10 -14 days OR
div Q8h for 10 -14 days [Cefotaxime 200 mg/kg/day IV Q8h PLUS
Cloxacillin 150-200 mg/kg/day div Q6h for
10 -14 days]

3 months to 5
years
[Cefuroxime 150 mg/kg/day IV div Q8h PLUS
Cefuroxime 150 mg/kg/day IV Erythromycin 40 mg/kg/day IV div Q6h for
div Q8h for 10-14 days 10-14 days] OR
[Cefotaxime 200 mg/kg/day IV div Q8h PLUS
Cloxacillin 150-200 mg/kg/day IV div Q6h for
10 to 14 days]
5 to 16
years
[Cefuroxime 150 mg/kg/day IV div Q8h PLUS [Cefuroxime 150 mg/kg/day IV div Q8h PLUS
Erythromycin 40 mg/kg/day IV/PO div Q6h for Erythromycin 40 mg/kg/day IV/PO div
10 to 14 days] Q6h for 10 to 14 days]
 Atypical pneumonia
History:
Since Pasteur isolated S pneumoniae (1880) and Frankel
described D pneumoniae (1884) as a cause of pneumonia, the
clinical picture of pneumonia was recognized as typical:
1) sudden onset of fever and shaking chills, pleuritic chest pain and
production of rust-colored sputum and
2) radiologic evidence of segmental or lobar consolidation.
3) examination of sputum showed gram-positive diplococci in
chains, both intracellulary and extracellulary.
The typical patients evolved in recognizable result , either death or
recovered. Death was as result of crisis, during which temp rose
suddenly, reaching 39,4 to 40 oC and accompanied with severe
delirium, respiratory failure. Or patient could be recovered by lysis
mechanism: fever gradually diminished, dropping to normal
temperature and slowly regained to previous health.

 Atypical pneumonia
In 1934, Gallagher described an outbreak of bronchopneumonia in
a group of 16 boys living at a preparatory school. He stressed
that these children did not have pneumococcal pneumonia but
something different something atypical.
In 1938, Reimann also described a group of eight patients with
chest infection but atypical clinical presentations and no chest
pain such as a gradual onset, a prodromal consisting headache,
photophobia, sore throat and dry cough.
Although the patients were not feeling well, they were not
critically ill. Their sputum was scanty and did not contain
pneumococci;white blood cell counts was normal and without
neutrophilic preponderance and shift to the left.
He called the term atypical pneumonia
 Atypical pneumonia
1944: Eaton et al isolated a filtrable agent from a patient with
atypical pneumonia known as Eaton agent.
1960 1963 : Chanock et al were able to grow the Eaton agent
and transmit it to human volunteers.They designated the
organism as a member of a new genus and named it Mycoplasma
pneumoniae.
After that many agent were recognized causing atypical
pneumonia such as :
Chlamydia spp,
Legionella pneumophilia.
Ureaplasma urealyticum
Etc.
 Atypical pneumonia
Characterized by
Insidious onset, fever, nonproductive cough, and
prominent constitutional signs ( severe headache,
malaise, myalgias)
CXR interstitial inflammation, patchy infiltrates
Less common leucocytosis
Lesser mortality, walking pneumonia
Routine culture fails to reveal microbial causes
Do not respond to common antibiotics used
Initial empirical treatment based on age
and severity of pneumonia

Outpatients
Age Inpatients (Moderate) Inpatients (Severe)
(Mild to Moderate)

Amoxicillin with or
Ceftriaxone or cefotaxime
3 - 6 mos without clavulanate Ceftriaxone or cefotaxim
+ vancomycin
Erythromycin

6 mos Amoxicillin with or Ceftriaxone, cefotaxime,

Ceftriaxone or cefotaxime
to without clavulanate or
+ macrolide + vancomycin
5 yrs Erythromycin Cefuroxime + macrolide

Ceftriaxone or cefotaxime
5 18 yrs Macrolide Ceftriaxone or cefotaxime
+ macrolide + macrolide + vancomycin

Hsiao G et al, 2001

PARU-PARU
Etiologi
Neonatus dan bayi kecil
o Streptokokus grup B
o Bakteri gram negatif seperti E. Colli,
Pseudomonas sp, atau Klebsiella sp
o Chlamydia trachomatis
Bayi yang lebih besar dan anak balita
o Streptococcus pneumoniae
o Haemophillus influenzae tipe B
o Staphylococcus aureus
Viral Pneumonia
Penyebab utama pneumonia di negara maju
Etiologi virus tersering :
o Respiratory Syncytial Virus (RSV)
o Rhinovirus
o Virus Parainfluenzae
Secara klinis, umumnya pneumonia bakteri
sulit dibedakan dengan pneumonia virus.
 Etiologi berdasrkan kelompok umur
Newborns
Chemical : Aspiration Toddlers and preschool children
Viral : Varicella-zoster Viral :Adeno,
Bacterial : Streptococcus G or D Parainfluenza,
S. Pneumoniae Influenza A or B
Coliform bacteria
TORCH,
Bacterial :S. Pneumoniae
Hemophilus influenzae
Infants Streptococci A,
Viral : Adeno, Staphylococcus aureus,
Coxsackie, Chlamydia
Parainfluenza,
Influenza A or B, School age and adolescents
Respiratory Syncytial Virus
Viral :Adeno,
Bacterial : B streptococci,
E coli,
Parainfluenza,
P aeruginosa, Influenza A or B
Klebsiella, Bacterial :S. Pneumoniae
S pneumoniae, Streptococci A,
S aureus, Mycoplasma
Chlamydia