Curriculum

Vitae
Name : Tatar Sumandjar
Institution : Medical Staff Division Tropical
Medicine and
Infectious Diseases, Dept. of
Internal Medicine
Medical Faculty University of
Sebelas Maret/
Dr. Moewardi Hospital, Surakarta
Graduates:
MD : FK UGM : 1983
Internist : FK UGM : 2000
Consultant : FK UI : 2008
Occupation:
Puskesmas in Purworejo, Central Java 1984 -
1990
 SEPSIS OF
UNKNOWN SOURCE
Tatar Sumandjar
Division of Tropical medicine and Infectious Disease,
Department of Internal Medicine
Faculty of Medicine
University of Sebelas Maret
Surakarta
 INTRODUCTION
Immunosuppressed patients were younger and
more likely to have underlying liver or lung
disease, and nosocomial infection or bloodstream
infection of unknown source when presenting with
sepsis.
Sepsis among patients immunosuppressed prior
to the onset of sepsis was associated with higher
mortality than in immunocompetent
Poutsiaka, patients.
D D, 2009; Scandinavian Journal
of Infectious Diseases
 Genetic Susceptibility

Predispositio R
Resistance to Antimicrobial
Coexisting health complications

n U
T Pathogen, toxicity and immunity
Infection N Location and compartmentalization

Response G Increased biomarkers / biomediators

Manifested physiologic symptoms

Organ Number of failing organs

Dysfunction
Optimum Individualized Treatment
 bacterial Cardiac surgery

Asphyxia/Hypoxia
viral sepsis Systemic
inflammatory
fungal response Trauma and burns
(SIRS)
parasital Neonatal lung
Severe affectionS
sepsis or SIRS
others shock Others
(Bone,1992)
Infective cause Noninfective cause

ROLE OF CYTOKINES
IL1,TNFa, IL6, IL8, IL-10
netrofil
ENDOTHEL (Guntur 2000)
The Third International
Consensus Definitions for Sepsis
and Septic Shock (Sepsis-3),
2016
Sepsis is defined as life-threatening organ dysfunction due to
dysregulated host response to infection

Organ dysfunction is defined as an acute change in total Sequential

Organ Failure Assessment (SOFA) score greater than 2 points
secondary to the infection cause

This new 2016 definition, also called Sepsis-3, eliminates the

requirement for the presence of systemic inflammatory response
syndrome (SIRS) to define sepsis, and it removed the severe sepsis
definition
The Sepsis Six

One such bundle dealing with basic therapies, the

Sepsis Six, has been shown to improve outcomes in
septic patients. If the 6 factors are completed within the
first hour following recognition of sepsis, the associated
mortality has been reported to reduce by as much as
50%. [60] The 6 factors are as follows:
 Administer high-flow oxygen to maintain target oxygen
saturations greater than 94%
Take blood cultures
Give intravenous antibiotics
Start intravenous fluid resuscitation
Check lactate level
Monitor hourly urine output.
Epidemiology
Respiratory infections account for approximately 30% to
50% of cases
Urinary tract infections account for approximately 10% to
20% of cases.
Abdominal sources accounts for approximately 20% to
25% of cases
Soft-tissue and Joint source accounts for approximately 5%
to 10% of cases
CNS sources accounting for under 5% of cases.
Sepsis of unknown origin
 EPIDEMIOLOGY
Incidence Septic Shock

Data collected over an 8-year period from 22 hospitals (Annane et al Am J Respir Crit Care Med
2003; 168:165-72)

2
3 Source of
Septic Shock

Kumar et al, Crit Care Med 2010; 38:177385)

Sepsis of unknown origin

Intensive efforts, including imaging

Urgent broad-spectrum coverage to all common
pathogens
Antibiotics listed are suggested as guidance only.
Local or national policy, which may take into account
specialist knowledge of sensitivity patterns
Carbapenems give appropriately broad cover, with
imipenem or meropenem being suitable choices.
Piperacillin/tazobactam with gentamicin is an
alternative.
 Bacterial Pattern in dr. Moewardi Hospital
(Geographic Location)
Bacterial Pattern PUS BLOOD SPUTUM URINE
Citobacter sp 6

E. Coli sp 4 4

Enterobacter sp 25 9 10 8
Klebsiella sp 5 1 15 7
Gr - 59 25 31 22
Proteus sp 9 57.28% 32.05% 3 23.30% 1 30.13%

Pseudomonas sp 16 4 3 2

Salmonella sp 4

Serratia sp 1

Staphylococcus sp 16 20 7 20 7 30 8 10
Gr +
Streptococcus sp 4 42.72% 13 67.95% 23 76.70% 2 69.87%

amount which grow 79 (76.69%) 45 (57.69%) 61 (45.86%) 32 (43.84%)

amount of patient 103 78 133 73

(Guntur, 2005)
Blood Culture and Sensitibility (RSDM Solo)

Guntur,2008
Ronald, JADE 2016