MANAGEMENT SEPSIS IN CHILDREN

ANGGRAINI ALAM
Divisi Infeksi & Penyakit Tropik Dep. IKA
FK Universitas Padjadjaran/RS Hasan Sadikin
UKK Infeksi & Penyakit Tropis PP IDAI
 Pokok Bahasan
• Pemeriksaan “pembuktian sepsis” SEPSIS 3
• Pemberian antibiotik
• Pemberian antijamur
• Evaluasi dan tindak lanjut
Right first time!
 Antibiotic:
Right first time!

Curr Infect Dis Rep. 2015 July ; 17(7): 493

Crit Care Med. 2014 November ; 42(11): 2409–2417

Semin Respir Crit Care Med 2015;36:154–166

 PENGGUNAAN ANTIBIOTIK EMPIRIK

Pedoman Nasional Pelayanan Kedokteran Ikatan Dokter Anak Indonesia

Diagnosis dan Tata Laksana Sepsis pada Anak. 2016
Pedoman Nasional Pelayanan Kedokteran Ikatan Dokter Anak Indonesia
Diagnosis dan Tata Laksana Sepsis pada Anak. 2016
 There has been and still is debate regarding the benefits of combination v.s
monotherapy in the empiric management of infection in critically ill patients.

EMPIRIC
combination or
monotherapy?
Individual basis:
Vincent et al. Critical Care (2016) 20:133 - severity of the disease
- likely causative mo
- concomitant diseases
Current Guidelines - Local microbiological &
Combination therapy is suggested for: resistance patterns
- neutropenic patients with sepsis,
- patients with infections caused by MDR pathogens
- patients with severe respiratory infections and septic shock
Intensive Care Med. 2013;39:165–228.
Lancet Infect Dis. 2014 June ; 14(6): 498–509
 The effect of pathophysiology on pharmacokinetics in the critically ill patient —
Concepts appraised by the example of antimicrobial agents.

Advanced Drug Delivery Reviews 77 (2014) 3

 Physicochemical properties of antimicrobial agents

β-lactams are hydrophilic drugs with a

low Vd, a low intracellular penetration,
and predominant renal CL

Vd may be increased because of a

capillary leak syndrome,
hypoalbuminemia, and therapeutic
procedures (fluid replacement,
mechanical ventilation,
extracorporeal circuits, surgical
drains).

*Need for dose reductions only indicated in case of severe hepatic failure Advanced Drug Delivery Reviews 77 (2014) 3
IDSA/ATS. CID 2016
 Pseudomonas
aeruginosa

Enterobacteria Acinetobacter
ceae baumannii

MDR Diinaktivasi oleh

& XDR β-lactamase
Enterobacteriaceae
inhibitors:
clavulanic acid,
sulbactam,
tazobactam,
resistance atau
carbapenem

Extended-spectrum β-lactamases
fluoroquinolones
and Hydrolyze
aminoglycosides
Cefotaxime, ceftriaxone, cefuroxime, ceftazidime, and cefepime
Monobactam (aztreonam)
Cefoxitin and cefotetan
 Enterobacter spp., Serratia spp.,
Citrobacter spp., Morganella
morganii, Proteus vulgaris, and
Providencia spp.

complete
resistance
to
cephalospor resistance inhibited by cefepime,
in within 3– cefpirome, β-lactamase
4 days of
AmpC-Cephalosporinases inhibitors,
treatment carbapenems
resistance

Hydrolyze

penicillins, 3rd cephalosporins, aztreonam, and cephamycins

CEFEPIME should be considered a drug of choice

against pathogens carrying cephalosporinases,
in order to limit the use of carbapenems
amoxicillin/clavulanic acid
or Carbapenem-resistant
piperacillin/tazobactam Enterobacteriaceae

MEMBRANE IMPERMEABILITY CARBAPENEMASES

resistance resistance

low-level resistance to carbapenems high level resistance to carbapenems

and
higher minimum inhibitory
concentration (MIC)
only to ertapenem
and
a true increased MIC to ertapenem & imipenem
resistance
aminoglycosides, fluoroquinolones
 Enterobacteriaceae

resistance

K. pneumoniae carbapenemaseproducing (KPC)

optimized
all β-lactams, carbapenem
including carbapenems dosing,
Tigecycline,
colistin

Infection and Drug Resistance 2014:7 261–271

Pedoman Nasional Pelayanan Kedokteran Ikatan Dokter Anak Indonesia
Diagnosis dan Tata Laksana Sepsis pada Anak. 2016
 Take Home Messages
• Pemeriksaan “pembuktian sepsis”
• Pemberian antibiotik secara bijaksana
• Evaluasi dan tindak lanjut
TERIMA KASIH