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Prof Dr Prihatini dr SpPK(K)2016 1

• 1/3
ortu 38-40ºC(100.4-104ºF), 2/3 40-41ºC(104-
106ºF), kerusakan otak >41ºC(106ºF).
• 5-20% tak ada asal & riwayat demam(-)
• Sebagian besar anak demam parah,
• Hampirsebagian kecil penyebab tersembunyi
atau berlanjut dgn infeksi bakteri

Prof Dr Prihatini dr SpPK(K)2016 2

• IL-1, IL-6, TNF-ά /cytokines DILEPAS dari
monocytes & macrophages tanggap thd infeksi
,kerusakan jaringan,obat&proses inflamasi yl .
• anterior hypothalamus mempertahankan suhu
• Normal circadian rhythm, ( 2ºC, 3ºF) ~6pm
terendah sesudah 6am. Demam ss pola
mengikuti waktu tsb.

Prof Dr Prihatini dr SpPK(K)2016 3

False’ fever, ( hyperthermia) /
• Secara tak langsung mempengaruhi suhu tubuh:
• Penyakit SSP memepengaruhi hypothalamus--ICH, infeksi .
• Penyakit yg meningkatkan suhu tubuh:D --hyperthyroidism,
malignant hyperthermia, salicylate overdose.
• Muatan Demam berlebihan meninggalkan
kendaraaan/meninggalkan tempat pemanas lama
• Mekanisme kehilangan panas teganggu : luka bakar , heat
stroke, obat mempengaruhi aliran darah dan mekanisme
keringat .
• SUHU Normal karena aktifitas fisik,ovulasi,dan suhu lingkungan

Prof Dr Prihatini dr SpPK(K)2016 4

Pengukuran suhu tubuh
• All measurements are estimates of the body’s true core
temp—central circulation=aorta and pulmonary artery.
• RECTAL—gold standard
• Esophageal—accurate but impractical
• Tactile and axillary—inaccurate, varies considerably
with environmental temperature
• Tympanic—inaccurate in age <3 years

Prof Dr Prihatini dr SpPK(K)2016 5

Benefits of fever
• The hypothalamus will not allow the temp to rise above
• WBCs work best and kill the most bacteria at 38-
• Neutrophils make more superoxide anion, and there is
more and increased activity of interferon.
• Coxsackie and polio virus replication is directly

Prof Dr Prihatini dr SpPK(K)2016 6

Fever without a source(FWS)
•5to 20% of febrile children have no localizing
signs on PE and nothing in the history to explain
the fever. By definition, less than 7 days.
• FWS(like
fever) is most common in children
younger than age 5, with a peak prevalence
between 6 and 24 months of age.
• Those <6 months retain protective maternal antibodies
against common organisms, while those 18-24 months
old are more immune competent, and are at a lower
risk of developing bacteremia

Prof Dr Prihatini dr SpPK(K)2016 7

Diagnostic Assessment in Children
• Age
is important as 1) etiologic
pathogens, 2) clinical exam, and 3)
immune system capacity changes as the
newborn ages.
• Most break them into the :
first 2-4 weeks of life(neonatal),
1-3 months, and 3 to 36 months.

Prof Dr Prihatini dr SpPK(K)2016 8

• The majority of febrile neonates presenting to the ED
have a nonspecific viral illness
• 12% have serious bacterial infections (SBI)
• Infected by more virulent bacteria
• More likely to develop serious sequelae from viral
• GBBS is associated with high rates of meningitis(39%),
non-meningeal foci(10%), and sepsis(7%)
• The most common bacterial infections are UTI and
occult bacteremia
Prof Dr Prihatini dr SpPK(K)2016 9
• Risk Factors
• Preterm
• Membrane rupture: before labor onset or prolonged>12
• Chorioamnionitis or maternal peripartum fever
• Multiple pregnancy
• Hypoxia or Apgar score <6
• Poverty or age <20

• 1/3-1/2 neonatal sepsis will have no risk factors!

Prof Dr Prihatini dr SpPK(K)2016 10
• PE is felt to be unreliable in detecting many serious bacterial
infections. Meningitis should always be considered—up to 10%
appear well, only 15% have a bulging fontanelle, and 10-15% have
nuchal rigidity. So, a high index of suspicion is important!!! ~20%
will not have fever initially.
• Hyperthermia or hypothermia
• Lethargy or irritability
• Poor feeding or vomiting
• Apnea
• Dyspnea
• Jaundice
• Hypotension
• Diarrhea or abdominal distension
• Bulging fontanelle
• seizures

Prof Dr Prihatini dr SpPK(K)2016 11

• Screening tests: WBC<5000 or >20,000, PMN
<4000, I:T>.2, Plt<100,000, CRP>1, LFTs
elevated(suggest HSV)
• So, if <28 days of age and rectal temp> 38ºC
• Admit
• Blood Culture
• Urine Culture—cath specimen
• Lumbar Puncture
• Cell count, protein, glucose, culture, PCR
• Parenteral Antibiotics
• Ampicillin + Gentamicin(Cefotaxime), consider Acyclovir(primary
maternal infxn, esp if delivered vaginally, PROM, fetal scalp
electrodes, skin eye or mouth lesions, seizures, CSF pleocytosis)

Prof Dr Prihatini dr SpPK(K)2016 12

Infants 1 to 3 months
• Causes
• HSV(17% are 15 days to 6 weeks of age)
• Bacterial sepsis/meningitis
• Group B Strep, S. Pneumoniae, H. influenza, N. meningitidis,
• Bone and joint infections
• Bacterial enteritis(esp Salmonella)
• Pneumonia
• Enterovirus sepsis/meningitis(July-October)
• The risk of bacteremia/meningitis is 3.3%, pneumonia, bone/joint
infections and bacterial enteritis is 13.7%
• 30-50% of those who are ultimately diagnosed with bacterial
meningitis have been seen by a physician within the prior
week(usually 1-2 days before) and were diagnosed as having a
trivial illness and discharged on oral
Prof Dr Prihatini antibiotics.
dr SpPK(K)2016 13
Infants 1 to 3 months
• Rochester Criteria/Low Risk Criteria
• Nontoxic—most critical and difficult
• Previously healthy, not low birth weight
• No focal bacterial infection on PE except Otitis Media
• WBC 5,000-15,000/mm3 (normal)
• Bands<1500/mm3 (normal)
• Normal urinalysis, including gram stain
• If diarrhea, must be non-bloody and WBC<5/hpf.
• If respiratory symptoms present, normal CXR

• Negative predictive value 98.9%

Prof Dr Prihatini dr SpPK(K)2016 14
Infants 1 to 3 months
• If
all of the criteria are met, then there are 2
options for outpatient management:
• Blood, Urine Cultures, LP,
Ceftriaxone 50mg/kg IM (to 1g), and
return for reevaluation within 24
• 2) Blood, Urine Cultures and careful

Prof Dr Prihatini dr SpPK(K)2016 15

Infants 1 to 3 months
• Follow-up of low risk infants
• If all cultures negative: afebrile, well
appearingCareful observation
• Blood cultures negative: well appearing,
febrileCareful observation, may consider second
dose of Ceftriaxone
• Blood culture positiveadmit for sepsis workup and
parenteral antibiotics pending results
• Urine culture positive: if persistent feveradmit for
sepsis workup, parenteral antibiotics pending results.
If afebrile and welloutpatient antibiotics
Prof Dr Prihatini dr SpPK(K)2016 16
Occult Bacteremia
5 % of children with FWS have OCCULT
• The presence of a positive blood culture in
kids who look well enough to be treated as
outpatients and in whom the positive results
are not anticipated.

Prof Dr Prihatini dr SpPK(K)2016 17

Occult Bacteremia
• Streptococcus pneumonia is responsible for 2/3
to ¾ of all cases.
• Peak prevalence between 6 and 24 months
• Association with high fever(39.4ºC or 103ºF)
• High WBC count(>15,000)
• Absence of evident focal soft tissue infection.

• Neisseria meningitidis, Haemophilus influenzae

type b, and salmonellae account for most of the
remaining cases.

Prof Dr Prihatini dr SpPK(K)2016 18

Risk of Occult Bacteremia
Low Risk High Risk
Age >3yr
Temp <39.4ºC
WBC >5000 & >40ºC(104ºF)
<5000 or >15,000

Hx of contact with H. Flu

or N. meningitidis

Prof Dr Prihatini dr SpPK(K)2016 19

Risk of Occult Bacteremia
Therefore, blood culture is the gold
standardstill has a high number of false
positives, take 24-48hrs, and most cases
of occult pneumococcal bacteremia clear
without treatment.

Prof Dr Prihatini dr SpPK(K)2016 20

Risk of Occult Bacteremia
• Empiric antibiotics should be targeted against
S. pneumoniae, N. meningitidis, and H. influenza
• Amoxicillin
• Augmentin, Bactrim, 2nd or 3rd gen
• Single dose Ceftriaxone 50-75mg/kg

• Followup is essential!

Prof Dr Prihatini dr SpPK(K)2016 21

Prof Dr Prihatini dr SpPK(K)2016 22