KATA PENGANTAR

Alhamdulillahirabbil’aalamiin.
Kami panjatkan puji syukur kepada Tuhan Yang Maha Esa, atas segala rahmat
dan hidayah-Nya sehingga penulis dapat menyelesaikan referat Referatjournal reading
”BACTEREMIA” dalam rangka memenuhi tugas penulis dalam menjalani kepaniteraan
klinik di bagian Bedah RSU Haji Surabaya.
Dengan rasa hormat yang tinggi, penulis menyampaikan banyak terimakasih
kepada pihak-pihak yang telah membantu kelancaran pembuatan referat ini. Kami
ucapkan terimakasih kepada dr. Bambang Arianto, Sp.B yang berkenan menjadi dokter
pembimbing kami serta memberikan dukungan dan motivasi dalam menyelesaikan
referat ini.

Penulis menyadari bahwa referat ini jauh dari kesempurnaan. Oleh karena itu,
saran dankritik yang bersifat membangun sangat penulis harapkan untuk memperbaiki
referat ini maupun penulisan selanjutnya. Semoga referat ini berguna dan memberikan
informasi yang bermanfaat bagi kami dan pembaca.

Surabaya, 20 Agustus 2018

Penulis
 BACTEREMIA

Introduction
Bacteremia in the strictest sense refers to viable bacteria in the blood. Asymptomatic
bacteremia can occur in normal daily activities such as conducting oral hygiene and
after minor medical procedures. In a healthy person, these clinically benign infections
are transient and cause no further sequelae. However, when immune response
mechanisms fail or become overwhelmed, bacteremia becomes a bloodstream infection
which can evolve into many clinical spectrums and is differentiated as septicemia.
Untreated and clinically significant bacteremia progresses to systemic inflammatory
response syndrome (SIRS), sepsis, septic shock, and multiple organ dysfunction
syndrome (MODS).

Etiology
Determining the primary source of infection is critical in the management of a patient
with bacteremia, as well as in the identification of the affected patient population.
Common sources in hospitalized patients include the respiratory tract and indwelling
catheters, specifically central venous catheters. Untreated urinary tract infections most
commonly cause community-acquired bacteremia. Soft tissue and intraabdominal
infections are not as common and are more prevalent in the post-operative surgical
setting. Escherichia coli is the most common cause of gram-negative associated
bacteremia, while Staphylococcus aureus is the most common gram-positive organism.

Epidemiology
Geographic region, patient population, drug resistance, and infection prevention
practices at each institution drive the causative organisms of bloodstream infections.
Taking into account that older patients with multiple comorbidities are more likely to
reside in community centers and be hospitalized, it is no surprise that they are at an
increased risk of developing bacteremia. Traditionally gram-negative bacilli were the

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driving force for most hospital-acquired bloodstream infections in the United States and
are still the most common organism associated with community-acquired bacteremia.
However, with the onset of an aging population and device-related procedures, gram-
positive aerobes have seen an increase in prevalence over the last two decades.

Pathophysiology
All bacterial infections are dependent on the host immune system which is affected by
its genetic signature, as well as congenital and acquired deficiencies. Cellular innate
and adaptive immune responses are responsible for initial microbe clearance, while the
liver and spleen filter active bacteria in the circulating blood. In its most basic form
bacteria will begin to colonize at its primary source of location. At this point, the bacteria
may become transient and clinically insignificant or can escape the host immune
response and increase in number and become a local infection that can eventually
migrate to other parts of the body. If the bacteria are viable and enter the circulating
bloodstream, the infection still may spontaneously clear or progress to septicemia. The
first barrier to bacterial invasion is the skin and mucosal surfaces. Conditions which
interfere with these natural defense barriers commonly include medical procedures that
pass through the skin and anatomical lumina. Additionally, events can precipitate
defense breakdown via trauma, burns, ulcers, and the natural elements of aging.

History and Physical

The classical presentation in a bacteremic patient is the presence of a fever. Chills
and/or rigors do not need to present; however, the presence of such signs should clue
the provider that a febrile patient is now bacteremic. The development of septicemia
leading to sepsis and septic shock will commonly cause hypotension, altered mental
status, and decreased urine output due to hypovolemia from leaking capillaries. As the
infection disseminates, other organs can become affected causing acute respiratory
distress syndrome (ARDS) and acute kidney injury (AKI).

Evaluation
Identifying or presuming the source of infection will dictate the diagnostic measures
taken. There should be a low threshold for ordering labs and imaging since time is of

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the essence in preventing septicemia. Initial labs in all presumed bacteremic patients
should include a lactate level and blood cultures; ideally two sets assessing for aerobic
and anaerobic organisms from each arm. In the hospital setting, most patients at a
minimum will require a chest x-ray and urinalysis with culture. A surgical patient may
require CT imaging of the location of their surgery to assess for abscess or collection
formation, as well as wound cultures for surgical site infections. Likewise, an intubated
or patient presenting with the pulmonary disease will require sputum cultures. Patients
with indwelling venous catheters, hemodialysis catheters, or ports should have their
lines removed and tips cultured.

Treatment / Management
Bacteremia requires urgent and appropriate antibiotics. Delay in the administration of
appropriate antibiotics is associated with increased morbidity and mortality. Empiric
antibiotics should follow a logical approach based on the patient's history and current
disposition, for example, is the infection community or hospital acquired, what is the
patient's recent healthcare exposure, recent medical or surgical treatment, and what is
the local antibiotic resistance. Gram stain, if applicable. Before a Gram stain is finalized,
all patients should receive broad-spectrum antibiotics covering gram-positive and gram-
negative bacteria which include extended-generation cephalosporins or a beta-
lactamase inhibitor. Pseudomonas coverage is applicable for hospital-acquired
bacteremia, as well as in a patient with recent health care exposure. Additionally,
vancomycin should be added to cover resistant gram-positive organisms most notably
methicillin-resistant resistant Staphylococcus aureus (MRSA). When the
practitioner obtains the final cultures, antibiotics should be titrated to directed therapy
starting with the gram stain, and eventually, antimicrobial susceptibility. There is no
optimal duration of treatment. In most cases, antibiotic treatment should continue for
seven to 14 days and should always be administered parenterally. Oral agents are
recommended when patients have been afebrile for at least 48 hours and are otherwise
clinically stable.

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Pearls and Other Issues
As with most infectious diseases, preventive practice is critical in the outpatient and
inpatient setting. At the rudimentary level, basic hand hygiene and the adherence to
clean and sterile techniques is critical in preventing and decreasing the prevalence of
blood stream infections. Preventative practice starts not only at the beginning of a
procedure but also throughout daily maintenance of line care. Even with strict
adherence to infection control, many patients will succumb to a blood stream infection.
Recognizing the predominant organisms associated within each clinical setting can
prevent mortality as blood stream pathogens such as S.aureus,
Pseudomonas aeruginosa, and Enterobacter species are associated with a higher
mortality rate. Prevention also includes judicious use of antibiotics which must take into
effect the risk and reward of antibiotic use. The rising prevalence of multi-drug-resistant
bacteria has complicated treatment over the years and will continue to do so. This rise
makes education, prevention, and adherence to protocol a necessity to counter the
debilitating effects of blood stream infections.

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 DAFTAR PUSTAKA

David A. Smith; Sara M. Nehring, 2017. Bacterimia. Salus University/PVAMC. St

Bernards Medical Center, October 6, 2017