PEMERIKSAAN DEMAM • 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
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DEMAM SESUNGGUHNYA(TRUE FEVER) • IL-1, IL-6, TNF-ά /cytokines DILEPAS dari monocytes & macrophages tanggap thd infeksi ,kerusakan jaringan,obat&proses inflamasi yl . • anterior hypothalamus mempertahankan suhu 36ºC(98.6ºF). • Normal circadian rhythm, ( 2ºC, 3ºF) ~6pm terendah sesudah 6am. Demam ss pola mengikuti waktu tsb.
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False’ fever, ( hyperthermia) / DEMAM PALSU • 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 .
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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
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Benefits of fever • The hypothalamus will not allow the temp to rise above 41.5ºC(107ºF). • WBCs work best and kill the most bacteria at 38- 40ºC(100.4-104ºF). • Neutrophils make more superoxide anion, and there is more and increased activity of interferon. • Coxsackie and polio virus replication is directly inhibited.
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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
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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.
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Neonates • 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 infections • 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 Neonates • Risk Factors • Preterm • Membrane rupture: before labor onset or prolonged>12 hours • Chorioamnionitis or maternal peripartum fever • UTI • 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 Neonatal • 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
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Neonates • 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)
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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, Enterobacteriaceae • Bone and joint infections • UTI • 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, 1) Ceftriaxone 50mg/kg IM (to 1g), and return for reevaluation within 24 hours. • 2) Blood, Urine Cultures and careful observation
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Infants 1 to 3 months • Follow-up of low risk infants • If all cultures negative: afebrile, well appearingCareful observation • Blood cultures negative: well appearing, febrileCareful observation, may consider second dose of Ceftriaxone • Blood culture positiveadmit for sepsis workup and parenteral antibiotics pending results • Urine culture positive: if persistent feveradmit for sepsis workup, parenteral antibiotics pending results. If afebrile and welloutpatient antibiotics Prof Dr Prihatini dr SpPK(K)2016 16 Occult Bacteremia 5 % of children with FWS have OCCULT BACTEREMIA • 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.
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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.
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Risk of Occult Bacteremia Low Risk High Risk Age >3yr Temp <39.4ºC <2yr WBC >5000 & >40ºC(104ºF) <15,000 <5000 or >15,000
Hx of contact with H. Flu
or N. meningitidis
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Risk of Occult Bacteremia Therefore, blood culture is the gold standardstill has a high number of false positives, take 24-48hrs, and most cases of occult pneumococcal bacteremia clear without treatment.
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Risk of Occult Bacteremia • Empiric antibiotics should be targeted against S. pneumoniae, N. meningitidis, and H. influenza • Amoxicillin • Augmentin, Bactrim, 2nd or 3rd gen Cephalosporins • Single dose Ceftriaxone 50-75mg/kg