Sie sind auf Seite 1von 26
Nama TTL Riwayat Pendidikan :  Patologi Klinik, FKUI (2001) Riwayat Pekerjaan  RSUD Kota

Nama TTL Riwayat Pendidikan :

Patologi Klinik, FKUI (2001)

Riwayat Pekerjaan

RSUD Kota Bekasi

RS Elisabeth, Bekasi

: Dr. Abbas Suherli, Sp. PK : Sukabumi, 21 Jan 1967

:

Dr. Abas Suherli, Sp.PK RSUD Kota Bekasi RS St Elisabeth Bekasi

Dr. Abas Suherli, Sp.PK RSUD Kota Bekasi RS St Elisabeth Bekasi

DemamDemam perluperlu diwaspadai!!!diwaspadai!!!

Demam Demam perlu perlu diwaspadai!!! diwaspadai!!! Demam : Suhu Tubuh > 37,8 o C Merangsang BENDA

Demam :

Suhu Tubuh > 37,8 o C

Merangsang BENDA ASING (Virus, bakteri, Jamur, parasit dll) Ditangkap SEL FAGOSIT Produksi PIROGEN - ENDOGEN
Merangsang
BENDA ASING
(Virus, bakteri,
Jamur, parasit
dll)
Ditangkap
SEL FAGOSIT
Produksi
PIROGEN -
ENDOGEN
Enzim
Cyclo-oxygenase
Menggigil,
pembuluh darah
menyempit
Set-point
Pembentukan
HIPOTALAMUS
PROSTAGLANDIN
meningkat

Suhu Normal :

36,5 - 37,2 o C

Mengapa Demam Perlu Diwaspadai ??

Menandakan adanya infeksi/penyakit yang sedang menyerang tubuh

DEMAM
DEMAM
 PCT Points 9  IL-6 9  WBC 5  HLA-DR 4  Protein

PCT

Points

9

IL-6

9

WBC

5

HLA-DR

4

Protein C

4

CRP

3

IL-10

3

IL-8

3

HMG-1

2

D-Dimer

2

e-Selectin 2

* 80 possible sepsis biomarkers

 

Points

Tissue factor

2

TNF

2

Thrombocytes

2

Cholesterol

1

Elastase

1

C3a

1

IL-1ra

1

Thrombomodulin 1

Neopterin

1

Cortisol

1

 500,000 new cases of sepsis per year in North America  Sepsis develops in

500,000 new cases of sepsis per year in North America

Sepsis develops in approximately 1% of hospitalized patients

Sepsis mortality rate of 35% to 45%

New therapeutics near approval will require patient selection

Established markers show poor differentiation between severe sepsis and other critical conditions

 PCT is the 116-amino acid prohormone of calcitonin – selectively responds to systemic and

PCT is the 116-amino acid prohormone of calcitonin – selectively responds to systemic and septic infections.

Early and reliable diagnosis.

Increase in sepsis is not accompanied by an increase in calcitonin levels.

An increase in PCT concentration can be detected in as little as 2 to 3 hours after the onset of septic infection.

Does not accumulate in severe renal dysfunction

Easily measured by immunoassay.

1 57 60 91 116 = N-ProCT = Calcitonin 96 = Katacalcin = cleavage by
1
57
60
91
116
= N-ProCT
= Calcitonin
96
=
Katacalcin
= cleavage by endopeptidases
PCT (ng/mL) Normal subjects <0.2 Chronic inflammatory processes and autoimmune diseases <0.5 Viral

PCT (ng/mL)

Normal subjects

<0.2

Chronic inflammatory processes and autoimmune diseases

<0.5

Viral infections

<0.5

Mild to moderate localized bacterial infections

<0.5

SIRS, multiple trauma, burns

0.5 – 2

Severe bacterial infections, sepsis, multiple organ failure

>2

(often 10 – 100)

 Monitoring patients at risk of systemic bacterial infection  Assess severity of septic processes

Monitoring patients at risk of systemic bacterial infection

Assess severity of septic processes

Prognosis – response to therapy

Assess Fever of Unknown Origin (FUO)

Guidance for Antibiotics therapy

Area under ROC Curve (95% confidence interval) PCT 0.94 (0.90 to 0.96) CRP 0.89 (0.85

Area under ROC Curve (95% confidence interval)

PCT

0.94

(0.90 to 0.96)

CRP

0.89

(0.85 to 0.92)

IL-6

0.78

(0.71 to 0.83)

Median PCT Levels n=46 18 16 14 12 10 8 6 4 n=78 2 n=236

Median PCT Levels

n=46

18 16 14 12 10 8 6 4 n=78 2 n=236 0 Local Bact Inf
18
16
14
12
10
8
6
4
n=78
2
n=236
0
Local Bact Inf
Invasive Inf
Viral Inf
PCT (ng/mL)
 IL6 stimulates hepatocytes to produce CRP; also stimulates acute phase response  Occurs in

IL6 stimulates hepatocytes to produce CRP; also stimulates acute phase response

Occurs in response to many stimuli (not only bacterial infection)

IL6 rises rapidly after infection, prior to CRP

IL6 10x cost of CRP assay

 255 neonates investigated for suspected sepsis  IL6 at presentation and after 24 hours

255 neonates investigated for suspected sepsis

IL6 at presentation and after 24 hours

Babies divided into categories of infection

for suspected sepsis  IL6 at presentation and after 24 hours  Babies divided into categories
12000 10000 8000 6000 4000 2000 0 None Possible Probable Definite IL6 (0 IL6(24)

12000

10000

8000

6000

4000

2000

0

None Possible Probable Definite
None
Possible
Probable
Definite

IL6 (0IL6(24)

IL6(24)IL6 (0

IL6 (0) Sensitivity Specificity PPV NPV < 20 73 56 28 90 pg/ml < 50

IL6 (0)

Sensitivity

Specificity

PPV

NPV

<

20

73

56

28

90

pg/ml

<

50

59

72

33

88

pg / ml

Median IL-6 Levels n=29 500 400 300 200 100 n=50 n=156 0 Local Bact Inf

Median IL-6 Levels

n=29

500 400 300 200 100 n=50 n=156 0 Local Bact Inf Invasive Inf Viral Inf
500
400
300
200
100
n=50
n=156
0
Local Bact Inf
Invasive Inf
Viral Inf
IL-6 (pg/mL)
 Good correlation between IL6 at 0 hours and CRP at 24 hours  Best

Good correlation between IL6 at 0 hours and CRP at 24 hours

Best prediction of infection with IL6 at 0 hours and CRP at 24 hours

IL6 not a reliable single marker

Initial IL6 < 20 pg/ml may allow antibiotics to be withheld

CRP at 24 hours  IL6 not a reliable single marker  Initial IL6 < 20
 Acute phase reactant synthesis by liver  Released at 4- 6 hours, peaks at

Acute phase reactant synthesis by liver

Released at 4- 6 hours, peaks at 24- 48 hours

Rise and fall correlates with infection

CRP at 24 hours is a good marker of bacterial sepsis

>50mg/l distinguishes infection from inflammation but LOW specificity

CRP assay is cheap – inexpensive

 SERIAL measurements of CRP  Excellent negative predictive value– Rule out sepsis  Reverse

SERIAL measurements of CRP

Excellent negative predictive value– Rule out sepsis

Reverse is not true – non specific, poor positive predictive value

Do not treat raised CRP in

isolation – rely

on clinical condition and culture results

Median CRP Levels n=46 140 120 100 80 n=78 60 40 20 n=236 0 Local

Median CRP Levels

n=46 140 120 100 80 n=78 60 40 20 n=236 0 Local Bact Inf Invasive
n=46
140
120
100
80
n=78
60
40
20
n=236
0
Local Bact Inf
Invasive Inf
Viral Inf
CRP (mg/L)