C ase R epor por t Sessions ssi ons
SEPSIS NEONATORUM
Oleh : Budi Junio Hermawan
1740312433
Preseptor : dr. Rinang Mariko, Sp.A(K)
BAGIAN ILMU KESEHATAN ANAK FAKULTAS KEDOKTERAN UNIVERSITAS ANDALAS RSUP DR. M.DJAMIL PADANG 2018
1
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KATA PENGANTAR
Puji syukur penulis ucapkan kehadirat Tuhan Yang Maha Esa yang telah melimpahkan rahmat dan kurnia-Nya sehingga penulis dapat menyelesaikan case repport sessions ini yang berjudul Sepsis Neonatorum. Case repport sessions sessions ini ditulis dengan tujuan agar dapat menambah wawasan dan pengetahuan penulis dan pembaca mengenai Sepsis Neonatorum , selain itu juga untuk memenuhi salah satu syarat dalam menjalani kepaniteraan klinik di Bagian Ilmu Kesehatan Anak di RSUP dr. M. Djamil, Padang Fakultas Kedokteran Universitas Andalas. Penulis mengucapkan terima kasih kepada semua pihak yang telah membantu dalam menyelesaikan referat ini, terutama kepada preseptor dr. Rinang Mariko, Sp.A(K) yang telah meluangkan waktu dalam memberikan bimbingan, saran dan perbaikan kepada penulis. Dengan demikian, penulis berharap agar case repport sessions ini dapat bermanfaat dalam menambah wawasan penulis dan pembaca mengenai Sepsis Neonatorum. Padang, Oktober 2018
Penulis
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Daftar Isi
Hal. Kata Pengantar
i
Daftar Isi
ii
BAB I PENDAHULUAN
1.1 Latar Belakang
1
1.2 Tujuan Penulisan
2
1.3 Metode Penulisan
2
BAB II TINJAUAN PUSTAKA
2.1 Definisi
3
2.2 Epidemiologi
3
2.3 Klasifikasi
4
2.4 Etiologi dan Faktor Risiko
4
2.5 Patogenesis
9
2.6 Manifestasi Klinis
12
2.7 Diagnosis
15
2.8 Diagnosis Banding
17
2.9 Tatalaksana
18
2.10 Komplikasi dan Prognosis
20
2.11 Pencegahan
21
BAB III LAPORAN KASUS
22
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BAB I PENDAHULUAN 1.1
Latar Belakang
Infeksi pada neonatus sering terjadi dan menjadi penyebab tersering 1
morbiditas dan mortalitas. Menurut Konference international pediatric sepsis 2005 , sepsis neonatal didefinisikan sebagai sindrom respon inflmasi sistemik terhadap kecurigaan ataupun bukti fokus infeksi pada neonatus. Infeksi bisa disebabkan oleh bakteri, virus , jamur.Sepsis neonatus mencakup berbagai variasi infeksi sistemik
bayi baru lahir seperti septicemia, meningitis, 2
pneumonia, arthritis , osteomyelitis dan lain lain. lain.
Sepsis bertanggung jawab terhadap 30-50% kematian total neonatus di negara berkembang. Insiden sepsis neonatorum bervariasi dari 9 kasus per 1000 kelahiran hidup tapi lebih tinggi kejadiannya pada BBLR. Sepsis merupakan penyebab kematian penting pada mortalitas neonatum. WHO memperkirakan hampir 5 juta neonatus meninngal pertahun dimnan 98% terjadi pada negara berkembang.
3,4,5
Banyak agen penyebab yang menginfeksi bayi baru lahir di utero, intra dan post-partum. Infeksi dapat disebabkan oleh bakteri, virus, jamur dan 2
protozoa.
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1.2
Tujuan Penulisan
Makalah ini bertujuan untuk menambah pengetahuan dan memahami tentang sepsis pada anak dari segi definisi, epidemiologi, etiologi, patogenesis, diagnosis, tatalaksana dan prognosis. 1.3
Metode Penulisan
Metode penulisan makalah ini berupa tinjauan kepustakaan yang merujuk kepada berbagai literatur.
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BAB II TINJAUAN PUSTAKA 2.1 Definisi
Infeksi pada neonatus sering terjadi dan menjadi penyebab tersering 1
morbiditas dan mortalitas. Menurut Konference international pediatric sepsis 2005, sepsis neonatal didefinisikan sebagai sindrom respon inflmasi sistemik terhadap kecurigaan ataupun bukti fokus infeksi pada neonatus. Infeksi bisa disebabkan oleh bakteri, virus , jamur. Sepsis neonatus mencakup berbagai variasi infeksi sistemik
bayi baru lahir seperti septicemia, meningitis, 2
pneumonia, arthritis, osteomyelitis dan osteomyelitis dan lain lain. 2.2 Epidemiologi
Sepsis bertanggung jawab terhadap 30-50% kematian total neonatus di negara berkembang. Insiden sepsis neonatorum bervariasi dari 9 kasus per 1000 kelahiran hidup tapi lebih tinggi kejadiannya pada BBLR. Sepsis merupakan penyebab kematian penting pada mortalitas neonatum. WHO memperkirakan hampir 5 juta neonatus meninngal pertahun dimnan 98% terjadi pada negara berkembang.
3,4,5
Insiden sepsis neonatus akibat bakteri adalah 1-4 per 1000 kelahiran hidup di negara berkembang, dengan variasi dari waktu ke waktu dan geografis. geografis. Studi menyatakan BBL laki-laki aterm memiliki insiden yang lebih tinggi dibandingkan BBL perempuan. Kejadian sepsis neonatus meningkat secara
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Insiden meningitis meningitis adalah 0,2-0,4 per 1000 kelahiran hidup BBL dan meningkat pada bayi prematur. Meningitis bakterial bisa terjadi akibat sepsis 1
neonatus atau akibat infeksi lokal. 2.3 Klasifikasi
Awalnya klasivikasi ini dibagi berdasarkan waktu terjadinya infeksi apakah sebelum atau sesudah 1 minggu kehidupan. Akan lebih berguna jika pengklasifikasian berdasarkan patogensis peripartum. peripartum. Early onset sepsis (EOS) didapat saat sebelum dan selama persalinan (transmisi ibu dan anak secara vertikal). Late onset Sepsis Sepsis berkembang setelah persalinan akibat organisme di rumah sakit atau komunitas. Waktu onset bergantung pada jumlah eksposure dan eksposure dan virulensi dari virulensi dari organisme yang menginfeksi. Very late onset sepsis (onset setelah 1 bulan kehidupan) bisa terjadi terutama pada bayi preterm BBLSR atau bayi aterm yang membutuhkan perawatan intensive care. care.
1
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oleh sifilis, oleh sifilis, rubella, citomegalovirus (CMV), toksoplasmosis, parvovirus B19 dan B19 dan Varicella. Varicella. Meskipun HSV, HIV, Hepatitis B virus, Hepatitis C virus virus dan tuberkulosis bisa menginfeksi melalui plasenta namun jalur infeksi tersering mereka adalah selama persalinan melewati jalan lahir yang terinfeksi, selama post partum, atau kontak dengan ibu atau pengasuh p engasuh yang terinfeksi atau ASI ibu yang terinfeksi HIV.
1,3
Berbagai macam organ yang berada di saluran kencing maupun saluran cerna bisa menyebabkan infeksi intrapartum dan postpartum. Penyebab bakteri tersering adalah Grup B Streptococus (GBS), organisme enterococus, gonorrhea, gonorrhea, 1
dan Clamidya. Virus tersering adalah CMV, HSV. Enterovirus, dan HIV.
Agen yang paling sering menyebabkan infeksi nosokomial adalah stafilokokus gram
negati, Basil gram negatif ( E.coli, E.coli, Kleibseila pneumoniae, pneumoniae,
Salmonella, Enterobacter, Citrobacter, Pseudomonas AerogEOSa, Serratia), 1
enterococi, S aureous, Candida.. Candida..
Kongenital pneumonia dapat disebabkan oleh CMV, virus Rubella, T.Paliidum. T.Paliidum.
Mikroorganisme
penyebab
pneumonia
yang
didapat
selama
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infl uenzae, Stafilokokus koagulase dan non-koagulase, Klebsiella,Enterobacter, 1
Pseudomonas, T. pallidum, and Mycobacterium and Mycobacterium tuberculosis .
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1
Tabel 2.3 Penyebab non-bakterial infeksi infeksi neonatus sitemik.
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korionik (chorioamnionitis (chorioamnionitis), ), cairan amnion (amnionitis (amnionitis), ), tali pusat ( funisistis) funisistis) dan plasenta (vilitis). (vilitis). Mikroorganisme bisa masuk ke ruang amnion melalui pembuluh darah plasenta, saat prosedur invasif selama kehamilan dan melalui jalur 3
asending. Faktor resiko sepsis neonatus dapat dibagi menjadi faktor maternal, 7
faktor host neonatal,dan virulensi organisme (tabel 1.5).
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2.5
Patogenesis
A. Patogenesis infeksi intrauterine Infeksi intrauterine disebabkan oleh infeksi maternal oleh berbagai agen (cytomegalovirus, treponemapallidum, toksoplasmagondii, rubella virus, virus varicella, parvovirus B19) B19) baik bergejala maupun tidak. Infeksi intrauterine juga terjadi
akibat
transmisi
hematogen
transplacental .
Penyebaran
secara
transplasental dapat terjadi diselama umur gestasi berapa saja. Tanda dan gejala infeksi bisa muncul saat lahir atau terjadi sebulan atau setahun kemudian. Bentuk infeksi pada neonatus dapat early spontaneous abortion, malformasi kongenital, gangguan pertumbuhan intrauterin, kelahiran prematur, penyakit pada periode neonatus baik segera maupun tertunda atau dapat berupa infeksi persistent infeksi persistent yang yang asimptomatik dengan sekuele pada akhir kehidupan. Pada beberapa kasus tidak
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Gambar 2.2
1
Jalur asending infeksi intrapartum.
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C. Patogenesis Late Patogenesis Late Onset Sepsis Setelah lahir neonatus terpapar oleh agen infeksius di bangsal atau di komunitas. Infeksi post-natal bisa ditularkan secara langsung oleh petugas kesehatan, orang tua, keluarga, dari air susu ibu (HIV,CMV) atau dari benda tak hidup seperti peralatan yang terkontaminasi. Penyebab tersering dari infeksi post1
natal adalah kontaminasi tangan petugas. 2.6 Manifestasi Klinis
Infeksi agen penyebab sepsis yang melewati plasenta (CMV, T.Palidum, T. Gondi, rubella, parvovirus B19) bisa bersifat asimptomatik saat lahir atau bisa menyebakan spektrum penyakit dari gelaja ringan sampai keterlibatan multiorgan berat yang memiliki komplikasi yang mengancam nyawa. Pada beberapa agen
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Gambar 2.5 Kriteria diagnosis untuk SIRS dan Sep sis Gejala klinis neonatus yang memiliki EOS dan LOS tidak spesifik dan biasanya ketidakteraturan suhu, gangguan pernafasan, apnue, susah menyusu
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2.7 Diagnosis
Riwayat ibu terpapar infeksi, status imunisasi (alamiah atau didapat), memiliki faktor resiko kehamilan (prematuritas, ketuban pecah dini lama, korioamnionitis) merupakan informasi yang penting dalam menegakkan 1
diagnosis sepsis. Riwayat penyakit menular seksual juga perlu ditanyakan.
Pemeriksaan kultur darah merupakan gold standar untuk mendiagnosis sepsis. Pengambilan 2 sampel kultur darah penting dilakukan, untuk mencegah
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Pemeriksaan penunjang laboratorium yang dapat dilakukan antara lain Creaktif protein, prokalsitonin, haptoglobin, fibrinogen, proteomik markers pada cairan amnion, citokinin inflamasi (IL-6, IL-8 IL-8 dan TNFα) dan marker antigen permukaan sel.Ketika anamnesis dan pemeriksaan fisik ditemukan infeksi, namun lokasi infeksi tidak jelas, pemeriksaan penunjang lain yang dilakukan antara lain 1
kultur darah, lumbar punksi, pemeriksaan urin, dan rontgen toraks. Tabel 1.9 menunjukan evaluasi infeksi atau sepsis BBL.
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2.8 Diagnosis Banding
Berbagai macam kondisi non-infeksi bisa terjadi bersamaan dengan sepsis neonatus atau membuat diganosis sepsis lebih sulit. Respiraory distress syndrom akibat defisensi surfaktsn bisa terjadi bersamaan dengan pneumonia bakterial. Karena sepsis bakterail sangan cepat mengalami progresif, petuga kesehatan harus waspada akan gejala dan tanda sepsis. Diferensial doagnosis untuk sepsis antara lain di tabel 1
1.10.
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2.9 Tatalaksana
Terapi terhadap kecurigaan sepsis ditentukan oleh pola penyakit dan organisme sesua dengan umur neonatus dan flora yang ada di bangsal. Ketika hasil kultur sudah diperoleh pemberian terapi antibiotik harus segera dilakukan baik secara intravena maupun intramuskular (jarang). Terapi empirik awal untuk early onset of sepsis
adalah ampisilin dan aminoglikosida (biasanya
gentamisin),dimana efektif melawan patogen seperti GBS, bakteri gram negatif
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Terapi dilanjutkan sampai hari ke 7 atau ke 10 atau paling sedikit 5 sampai 7 hari setelah didapatkan respon klinis. Kemudian kultur darah 24-48 jam
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2.10 Komplikasi dan Prognosis
Komplikasi sepsis neonatorum akbiat bakteri anatar lain endokarditis,
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2.11 Pencegahan
GBS sudah dinyatakan sebagai penyebab utama early neonatal sepsis
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BAB III
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Sesak napas sejak 1 hari yll, riwayat tersedak disangkal
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BAK sedikit sejak 12 jam yll, warna agak p ekat
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