2. pemeriksaan laboratorium terkini pada demam akibat - dr abas
TRANSCRIPT
Nama : Dr. Abbas Suherli, Sp. PKTTL : Sukabumi, 21 Jan 1967Riwayat Pendidikan : Patologi Klinik, FKUI (2001)Riwayat Pekerjaan : RSUD Kota Bekasi RS Elisabeth, Bekasi
Dr. Abas Suherli, Sp.PKRSUD Kota Bekasi
RS St Elisabeth Bekasi
Demam perlu diwaspadai!!!Demam perlu diwaspadai!!!Demam :Suhu Tubuh > 37,8 oC
Suhu Normal :36,5 - 37,2 oC
Mengapa Demam Perlu Diwaspadai ??
Menandakan adanya infeksi/penyakit yang sedang menyerang tubuh
MerangsangProduksi PIROGEN -ENDOGEN
DitangkapSEL FAGOSIT
Menggigil,pembuluh darahmenyempit
Set-pointHIPOTALAMUSmeningkat
DEMAM
BENDA ASING(Virus, bakteri, Jamur, parasitdll)
PembentukanPROSTAGLANDIN
Enzim Cyclo-oxygenase
Points PCT 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
Points Tissue factor 2 TNF 2 Thrombocytes 2 Cholesterol 1 Elastase 1 C3a 1 IL-1ra 1 Thrombomodulin 1 Neopterin 1 Cortisol 1
* 80 possible sepsis biomarkers
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 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.
= N-ProCT
= Calcitonin
= Katacalcin= cleavage by endopeptidases
57
60
1
91
96
116
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)
PCT (ng/mL)
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
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)
Area under ROC Curve(95% confidence interval)
Median PCT Levels
Local Bact Inf Invasive Inf Viral Inf
PCT
(ng/
mL)
0
2
4
6
8
10
12
14
16
18
n=78
n=46
n=236
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
Babies divided into categories of infection
0
2000
4000
6000
8000
10000
12000
None Possible Probable Definite
IL6 (0IL6(24)
IL6 (0) Sensitivity Specificity PPV NPV
< 20 pg/ml
73 56 28 90
< 50 pg / ml
59 72 33 88
Median IL-6 Levels
Local Bact Inf Invasive Inf Viral Inf
IL-6
(pg/
mL)
0
100
200
300
400
500
n=50
n=29
n=156
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
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 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
Local Bact Inf Invasive Inf Viral Inf
CR
P (m
g/L)
0
20
40
60
80
100
120
140
n=78
n=46
n=236