investigasi kasus infeksi aliran darah di nicu

INVESTIGASI KASUS INFEKSI ALIRAN DARAH DI NICU

Divisi NeonatologiFKUI-RSCM

Dr Lily Rundjan SpA(K)Dr Christopher Khorazon

Pendahuluan

Tujuan utama investigasi kasus infeksialiran darah adalah menemukansumber infeksi secara efektif danterfokus sehingga tata laksanatepat sasaran dan tepat guna

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Pembahasan

•Definisi IAD• Pembagian IAD• Kolonisasi VSInfeksi• Perkiraan organisme penyebab• Investigasi

INFEKSI ALIRAN DARAH (IAD)Definisi IAD:Infeksi akibat pemasangan kateter intravena,setelah >48jamterpasang kateter intravena

Positif IADsecara laboratoriküHasil kulturdarah (+)dari 2tempat berbeda dalam waktu bersamaan ditemukanmikroorganisme yangsama

üHasil kulturdarah 2xberturut-turut padawaktu berbeda ditemukan mikroorganisme yangsama

üHasil kulturjalur sentral danperifer ditemukan mikroorganisme yangsama

CRBSI(CatheterRelatedBloodStreamInfection)• Pemasangan kateter perifer /sentral sebelum terjadinya IAD

CLABSI(CentralLineAssociatedBloodStreamInfection)• Pemasangan kateter sentral sebelum terjadinya IAD

BSI

PrimaryBSI

SecondaryBSI

Infeksi aliran darah (terbukti secara laboratorik)bukan berasal dari organ lain

Infeksi dari organ lainmenyebar ke aliran darah

o VAPo SSIo ISKo Gastrointestinalo Skininfectiono Conjunctivitis

PEMBAGIANINFEKSIALIRANDARAH

Catheter related :peripheral /central line

VAP(VentilatorAssociatedPneumonia)SSI(SurgicalSiteInfection)ISK(Infeksi Saluran Kemih)

KOLONISASI VS INFEKSIKolonisasi

• Mikroorganismeditemukan ditubuh bayi tanpagejala klinis

• Bayi sehat saat lahir terkolonisasi oleh mikrofloraendogendari vaginadan florausus ibu (transmisivertikal)

• Bayi yangdirawat lamadiRSmempunyai risiko tinggiterkolonisasi oleh multidrug-resistantGram-negativebacteria(MDRGN)ditubuh atau usus bayi

Infeksi

• Gejala klinis sepsis(+), ditunjang oleh septicmarkerdan kultur darah

• ConcordantBSI: kolonisasi berat mikroorganismepenyebab mendahului infeksi invasif

• Translokasi mikroorganismedari saluran cerna kealiran darah melalui dinding usus yangcedera

L.Folgori etal.The relationshipbetween Gram-negative colonizationandbloodstreaminfectionsinneonates:asystematic review andmeta-analysis.ClinicalMicrobiologyandInfection24(2018)251e257

MODE OF TRANSMISSIONS

Patient topatienttransmissions

Droplet transmissions

Airborne transmissions

Contact transmissions

Horizontal transmissions viahealthcare staff ’shandsàmostfrequently reported

Colonization Infection

Riskfactors

Sources /Reservoirs ofinfections

Transplacental /Vertical

transmissions

Extrinsic

Intrinsic

TransmisiInfeksi

HORISONTAL

Lingkungan

Staph aureus(MRSA,MSSA)Staph epidermidisCONSKlebsiellaPseudomonasProteusEnterobacterSerratiaCMVRotavirusRhinovirusRSVFungal

VERTIKAL

TORCHESSyphilisHIVHepatitisVaricellaParvovirusTBGonorrheaMalariaLyme

GBSE. ColiListeriaAnaerobesEnterococcusChlamydiaGonorrheaUreaplasmaMycoplasmaHepatitisHIVHSVHPVAdenovirusCoxsakie virus(Par)Echo/EnterovirusPoliovirusCandida

Awitan dini (0-72jam)

Awitan lambat (>72jam)

Investigasi• Investigasi dikerjakan berdasarkan faktor risiko bayi,organtargetyangterlibat dan peta pola kumanRS

• Metoda transmisi infeksi :transplasental /vertikal,horisontal

• Mikroorganisme penyebab pikirkan bakteri/virus/jamur• Investigasi :kultur darah,kultur urin,kultur LCS,USGabdomen/ginjal,bonesurvey,ekokardiografi,XRay,dll

• Investigasi tambahan :kultur rektal/kulit,kultur ujungkateter,ujung ETT(kolonisasi),kultur cairan infus

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Sepsis Awitan Dini VS LambatSepsis awitan diniFaktor risiko ibuq Korioamnionitisq KPD>18jamq Persalinan prematurq Ibu demam,janin takikardiq Ibu gejala gastroenteritisatau flu-likeillnessq Serologi ibu,riwayat infeksi ibu

Goldstandard:kulturdarahPendukung (bila kulturdarah negatif)q Swab/kultur dan PAplasentaq Kultur cairan OGT(kolonisasi)q Swabkulit belakang telinga (kolonisasi)

Sepsis awitan lambatFaktor risiko intrinsik (bayi)o Kateter intravaskular:perifer dan sentralo ETTo Orogastric tubeo Kateter urino Chestdrain,drainintraabdominalo PostsurgeryFaktor risiko ekstrinsik (lingkungan)o Keluarga yangsakit – viralinfectiono Infeksi dari bayi laino Gastrointestinal:diareo Urine,ASI,transfusi darah – CMVpostnatal

Rekomendasi jumlah darah untuk kultur darah

Blood cultures contaminated with skin flora during collec-tion are common, but contamination rates should not exceed3%. Laboratories should have policies and procedures for ab-breviating the work-up and reporting of common blood culturecontaminants (eg, coagulase-negative staphylococci, viridansgroup streptococci, diphtheroids, Bacillus species other than B.anthracis). These procedures may include abbreviated identifi-cation of the organism, absence of susceptibility testing, and acomment that instructs the clinician to contact the laboratory ifthe culture result is thought to be clinically significant and re-quires additional work-up and susceptibility results.

Physicians should expect to be called and notified by the lab-oratory every time a blood culture becomes positive becausethese specimens often represent life-threatening infections. Ifthe physician wishes not to be notified during specific times, ar-rangements must be made by the physician for a delegatedhealthcare professional to receive the call and relay the report.

Key points for the laboratory diagnosis of bacteremia/funge-mia:

• Volume of blood collected, not timing, is most critical.• Disinfect the venipuncture site with chlorhexidine or 2%

iodine tincture in adults and children >2 months old (chlorhex-idine NOT recommended for children <2 months old).

• Draw blood for culture before initiating antimicrobialtherapy.

• Catheter-drawn blood cultures have a higher risk of con-tamination (false positives).

• Do not submit catheter tips for culture without an ac-companying blood culture obtained by venipuncture.

• Never refrigerate blood prior to incubation.• Use a 2–3 bottle blood culture set for adults, at least one

aerobic and one anaerobic; use 1–2 aerobic bottles for children.• Streptococcus pneumoniae and some other gram-positive

organisms may grow best in the anaerobic bottle.

B. Infections Associated With Vascular CathetersThe diagnosis of catheter-associated BSIs often is one of exclu-sion, and a microbiologic gold standard for diagnosis does notexist. Although a number of different microbiologic methodshave been described, the available data do not allow firm con-clusions to be made about the relative merits of these variousdiagnostic techniques [8, 9]. Fundamental to the diagnosis ofcatheter-associated BSI is documentation of bacteremia. Theclinical significance of a positive culture from an indwellingcatheter segment or tip in the absence of positive blood culturesis unknown. The next essential diagnostic component is dem-onstrating that the infection is caused by the catheter. Thisusually requires exclusion of other potential primary foci forthe BSI.

Numerous diagnostic techniques for catheter cultures havebeen described and may provide adjunctive evidence of cathe-ter-associated BSI; however, all have potential pitfalls that makeinterpretation of results problematic. Routine culture of intrave-nous (IV) catheter tips at the time of catheter removal has noclinical value and should not be done [10]. Although not per-formed in most laboratories, the methods described include thefollowing:

• Time to positivity (not performed routinely in most labo-ratories): Standard blood cultures (BCs) obtained at the sametime, one from the catheter or port and one from peripheral ve-nipuncture, processed in a continuous-monitoring bloodculture system. If both BCs grow the same organism and theBC drawn from the device becomes positive more than 2 hoursbefore the BC drawn by venipuncture, there is a high probabili-ty of catheter-associated BSI [11].• Quantitative BCs (not performed routinely in most labora-tories): one from catheter or port and one from peripheral veni-puncture obtained at the same time using lysis-centrifugation(Isolator) or pour plate method. If both BCs grow the same or-ganism and the BC drawn from the device has 5-fold more

Table I-1a. Recommended Volumes of Blood for Culture in Pediatric Patients (Blood Culture Set May Use Only 1 Bottle)

Weight ofPatient (kg)

Total Patient BloodVolume (mL)

Recommended Volume of Bloodfor Culture (mL)

Total Volume forCulture (mL)

% of TotalBloodVolume

Culture SetNo. 1

Culture SetNo. 2

≤1 50–99 2 . . . 2 41.1–2 100–200 2 2 4 42.1–12.7 >200 4 2 6 312.8–36.3 >800 10 10 20 2.5>36.3 >2200 20–30 20–30 40–60 1.8–2.7

When 10 mL of blood or less is collected, it should be inoculated into a single aerobic blood culture bottle.

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ownloaded from

Mermel LA,etal.ClinicalPracticeGuidelines fortheDiagnosisandManagementofIntravascularCatheter-Related Infection.

InfectiousDiseasesSociety ofAmerica. 2009

Methods for the diagnosis of acute fever for a suspected short-term CVC infection or arterial cathether infection.

MermelLA,etal.ClinicalPracticeGuidelinesfortheDiagnosisandManagementofIntravascularCatheter-RelatedInfection.InfectiousDiseases

SocietyofAmerica.2009

Approach to the management of patients with short-term CVC-related or arterial catheter-related bloodstream infection.

MermelLA,etal.ClinicalPracticeGuidelinesfortheDiagnosisandManagementofIntravascularCatheter-RelatedInfection.

InfectiousDiseasesSocietyofAmerica.2009

Approach to treatment of a patient with a long term CVC or port (P) related BSI.

Mermel, et al 2009Kultur darah untuk S.aureus,Coagulase-negativeStaphylococci,atau Candida species+tidak adasumber infeksi lainyangterdeteksiàkecurigaan CRBSImeningkat

Perbaikan gejala dalam 24jamsetelahpencabutan kateter menandakan(tetapi tidak memastikan)bahwakateter merupakan sumber infeksi.

Coating antimicrobialdapatmemberikan hasil false negative

Organisme PenyebabTersering CRBSI

Kateter percutaneous Kateter surgicallyimplanted&CVCperifer

Coagulase-negativeStaphylococci

Coagulase-negativeStaphylococci

S.aureus Entericgram-negativebacilli

Candida species S.aureus

Entericgram-negativebacilli

P.aeruginosa

CatheterrelatedBSI• Pada kecurigaan CRBSIà kultur darah perifer dan akses sentral• Kultur ujung kateter tidak rutin dikerjakan – menunjukkan kolonisasi,bermakna bila kultur darah positif dengan kuman yangsama• Eksudat dari tempat insersià swab,kultur dan gram• Setiap kalimengganti antibiotik harus kultur darah• Pasien yangdiobati tanpa pencabutan kateter harus dipantau denganevaluasi klinis dan kultur darah ulang.Apabila terjadi perburukanklinis atau CRBSIpersistenà harus segera cabut kateter

Mermel LA,etal.Clinical Practice Guidelines fortheDiagnosisandManagementofIntravascularCatheter-Related Infection.InfectiousDiseasesSocietyofAmerica.2009

Coagulase-negativeStaphylococcusspecies• Investigasi CONSà perhatikan ada kateter /benda asing lainnya• Kultur darah ulangperlu diambil dari 2tempat :kateter sentral dan perifersebelum pemberian antibiotik ataupencabutan kateter.

• Bila infeksi CONSpersisten,investigasi ke arah :• Septicembolià angiogram,MRI• Endocarditisà transesophageal echocardiograph(TEE)5-7hari setelahonset bakteremiauntukmeminimalisir kemungkinanhasil false-negative.TEEulang dilakukanapabila pasienmemiliki demamatau IAD>72jamsetelah pencabutan kateter

• Absesà USGabdomen,kepala

• Management• Cabut kateterà pemasangan kateterbaru dapat dilakukan ketika kulturdarah berikutnyabersih

• Terapi :Vankomisin,kombinasi antikoagulan (bila terdapat trombus)

MRSA

•MRSA(susah eradikasinya) - Staphaureus CRBSImempunyairisiko tinggi hematogen à bila MRSApersisten investigasi kearah:• Infectiveendocarditis, vegetation• Bonescan– septicartritis• Softtissue• Paru

Mermel LA,etal.Clinical Practice Guidelines fortheDiagnosisandManagementofIntravascularCatheter-Related Infection.InfectiousDiseases SocietyofAmerica.2009

Enterococcus CRBSI

• Enterococcus CRBSI– investigasi ke arah:• Newmurmurorembolicphenomena– endocarditis (lowrisk)• Septicpulmonaryembolià pulmonaryangiography• Bila bakteremia persisten (>72jamsetelah inisiasi terapiantibiotik)à ulang kultur darah dan pencabutan kateter

Mermel LA,etal.Clinical Practice Guidelines fortheDiagnosisandManagementofIntravascularCatheter-Related Infection.InfectiousDiseases SocietyofAmerica.2009

GramnegativeCRBSI• Enterobacter (saluran cerna):E.coli,Serratia sp,Klebsiella sp• Nonfermenter(hostbukan manusia,ada dilingkungan):Acinetobacter,Pseudomonas, Burkholderia cepacia, Stenotropomonas, Citrobacter freundii• Pada pasien dengan CRBSIgram-negative yangmenyangkut pemakaiankateter jangka panjang dan bakteremia persisten atau sepsisberatà kateterharus dicabut,investigasi endokarditis dan organlain• Bayi dengan short-gut syndromelebih rentan terhadap CRBSIakibat bacilligram-negative.• MDRgramnegativebacili yangmemproduksi biofilm: A.baumannii,Pseudomonassp,Stenotrophomonas maltophilia

Bayi UG38minggu,BL3740g

Usia 5hari:• Suhu 39oC,distensi abdomen,letargis• Abdominal+ChestX-ray:normal• Hasillab:Leukosit 13,5x109/L(86%segmenter)

• Antibiotik:IVAmoksisilin +seftazidim

Usia 9hari:• Perburukan kondisi dankultur darahnegatif

• Eritromisin dan asiklovir diberikan untukpatogen atipikal dan HSV

Usia 10hari:• Masuk ke NICUà intubasi karena gagalnafas

• Paru:terdengar krepitasi bilateral;x-raymenunjukkan infiltrat bilateraldanefusipleura

• CRP91mg/L,leukosit normal• Nasofaringeal swabà Adenovirustype7• Kulturdarah danaspirasi bronkial tetapnegatif

• Diagnosis:severeAdenoviruspneumonia• Terapi:gamma-globulinsingledose(300mg/kg);terapi antibiotik dihentikan

Usia 14hari:Perbaikan gejalaUsia 29hari:EkstubasiUsia 58hari :Pasiendipulangkan

Persalinan pervaginam,Nilai Apgar9/9,pulang ke rumah hari ke2

Bayi UG38minggu,BL3740g

• Sampel feses dari kakak pasien (usia 2tahun)terdapat adenovirus7à kemungkinan terjadi cross-infection• Titer antibodi bayi• Usia 10hari=1:128• Usia 17hari=1:1024

• Titer antibodi ibu• Saat bayi usia 16hari=1:2048

Kemungkinan ibu terinfeksi adenovirus saat persalinan,karena apabila ibu terinfeksi lebih awal,antibodi titer

bayi saat awal akan lebih tinggi.

PENTINGAdenovirus tipe 7penyebab pneumonia berat,metoda transmisi aerosol, inhalasi dari jalan lahir atau transplasenta.Tanyakan riwayat infeksi saluran napas pada ibu/keluarga menjelang persalinan

Bayi dengan infeksi Enterovirus

• Bayi dengan infeksi enterovirus (EV)• Semua bayimenunjukkan letargis danpoorfeeding padausia 5-10hari• Riwayat ibu sakit menjelang persalinan,transmisi fecal-oral, respiratory• Gejala seperti acutesepsislikesyndrome,meningitis/meningoensefalitis danhepatitis,koagulopati,trombositopenia

• Komplikasi :PVL,miokarditis,hepatitis• Miokarditis diterapi dengan IVIG3-5g/kg.

• Kesimpulan:bayi yangtampak septik tanpa penyebab infeksi bakteri àcek LCSPCR.Bayi dengan infeksi EVharus diinvestigasi lebih lanjut untukmencari tanda PVLatau miokarditis

Morriss FH,etal.2016

Parechovirus• Mayoritas infeksi dari Humanparechovirus (HPeV)àpada anak /dewasa :influenzalikeillness,diare (viral)

• Gejala yanglebih khas pada bayi :demam,irritabledanterkadang terdapat ruammerah (“red,hotandangry”)

• Gejala berat:sepsisberat (syok),meningoensefalitis(10%),trombositopenia,neutropenia

• 77%butuh ventilasi mekanik,40%butuh inotropik,kejang,apnu sentral (meningoensefalitis),acuteabdomen,perforasi,gagal hati

• Tes LCSdan feses PCR(sangat sensitif)pada kecurigaandengan gejala diatas

• Saat ini terapi masihhanyaberupa suportif,contactprecaution

Britton PN,etal.Parechovirus: animportant emerging infection inyounginfants. MJA208(8). 2018

SIMPULANInvestigasi infeksi alirandarah dikerjakanberdasarkan perkiraantargetorgan/faktor risiko /jenis kumanpenyebab :o Selalu pikirkan penyebab virus/bakteri/jamuro Bayi terpasang jalur intravena perifer /sentralà kultur darah

perifer dan sentralo Kultur ujung PICC/umbilikal/CVC- kolonisasio Fullsepticworkup:kultur darah/urin/LCS,Rontgentoraks /

abdomeno Pascabedah GI:USGabdomen,FNAB,pungsi cairano Terintubasi – VAPà kulturujung ETT,kultur cairanaspirat

bronkialo Chestdrain– kultur cairan pleurao Bila kultur darahnegatif à Viralpanel(respiratory, LCSPCR)o Bila trombositopenià CMVo Bila antibiotik lama,pemasangankaterà kulturdarah jamur



Jenis kuman penyebab :CONSMRSA

EnterococcusGramnegative

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