FAQ Laboratory Study in Sepsis

Nina Dwi Putri

Hemoglobin-Anemia

• blood loss• decreased production (hypoproliferative ane-

mia)– a reticuloendothelial block in iron transport– decreased sensitivity of the erythron to

erythropoietin– shortened red blood cell survival.

• increased destruction (hemolytic anemia) of red blood cells

• Neutrophils: phagocytosing infectious organisms, crystalline material (e.g., uric acid), and immune complexes

• Leucocytosis: – recruitment of mature neutrophils from the marginating pool

into the circulating pool– mobilization of mature and developing neutrophils from the

bone marrow– eventually increased leukopoiesis

• Neutropenia: exhaustion of BM progenitors, maturation arrest, imbalance extravasation and production

Leucocyte

Platelet

ESR

• Non-specific marker of tissue injury • More useful than leukocyte count in identifying

inflammatory conditions • Differentiating mild versus severe states of

inflammation• Detection of inflammatory diseases and

malignancy • Less useful in categorizing the etiology behind

the highly inflamed patients

protein fase akut yang dibentuk oleh sel hepatosit akibat rangsangan sitokin anti-inflamasi

CRP meningkat dalam 4-6 jam8 jam: 2x lipat Puncaknya 36-50 jam

Penyembuhan: penurunan kadar CRP secara cepat CRP memiliki masa paruh 4 sampai 7 jam Sangat baik untuk menilai aktivitas penyakit dalam keadaan akut.

C-REACTIVE PROTEIN (CRP)

Peningkatan CRP dapat dijumpai pada kondisi selain infeksiMAJOR ELEVATIONa. Bacterial infection

b. Hypersensitivity complications of infections

c. Inflammatory disease

d. Transplantatione. Cancerf. Necrosis

g. trauma

- pyelonephritis, pelvic infections, meningitis, endocarditis-Rheumatic fever, erythema nodosum

- rheumatoid arthritis, juvenile chronic arthritis, ankylosing spondylitis, psoriatic arthritis, systemic vasculitis, polymialgia rheumatica, reiter’s disease, Crohn’s disease, familial mediterranian fever- renal transplantation- lymphoma , sarcoma- myocardial infarction, tumor embolisation, acute pancreatitis- burn, fractures

MINOR OR NO ELEVATIONa. Inflammatory disease

b. Transplantationsc. Cancer

-SLE, systemic sclerosis, dermatomycosis, ulcerative colitis, Sjogren’s syndrome- graft vs host disease- leukemia

Nobre V et al. Am J Respiir Crit Care Med, 2008;117:498-505

…sepsis

CRP LEVELNormal concentration in healthy human serum < 10 mg/L (increasing with aging).

CRP (mg/L)

10 – 40 Mild inflammation, viral or bacterial infection, late pregnan woman

40 - 100 Moderate inflammation, viral orbacterial infection

100 – 200 Marked inflmmation, bacterial infection

> 200 Severe bacterial infection or extensive trauma

Nobre V et al. Am J Respiir Crit Care Med, 2008;117:498-505

It takes 6-12 hours, even up to 24 hours for CRP to rise following onset infection. Sensitivity 40%, 60% of subsequently proven sepsis episodes will have an initial CRP (compared to 80% sensitivity of immature to total neutrophil ratio)

PROCALCITONIN

Asal SpesimenSeharusnya steril• Darah• Sumsum tulang• Cairan sendi• Jaringan• Saluran napas bawah• Kandung kemih

Ada flora normal komensal• Saluran napas atas• Kulit• Saluran gastrointestinal• Saluran genital perempuan• Uretra

Pada bagian tubuh yang seharusnya steril, apabila ditemukan m.o:- Telah terjadi infeksi- Cara koleksi dan waktu pengiriman tidak tepat- Laboratorium terlambat memulai pemeriksaanBila spesimen diambil dari tempat dengan flora normal:- Kuantitas/jumlah spesimen perlu diperhatikan- Kondisi pasien: imunokompromais/imunokompeten

Murray PR. Medical Microbiology 2002.

Bakteri skin nose faring Mouth Lower GI

Staphylococcus epidermidis ++ ++ ++ ++ +

Staphylococcus aureus + + + + ++

Enterococcus fecalis + ++

Streptoccuc pneumonia + +

Pseudomonas spp. +

Volume Darah untuk Pemeriksaan Kultur

IDSA guidelines 2013

Increased volume Increased Yield10 ml 20 ml 30 % 40 %20 ml 30 ml 10 % 15 %NOTE: Pediatric volume guide: usually draw 1 mL/year of age.

Biakan Darah

Remove the cap and disinfect the septum with an alcohol swab and allow to dry. Do not use iodine as it may damage the septum.

Remember to hold the needle down onto the vial (WHO)

Diambil pd 2 sisi berbeda (Clin Microbiol. Rev19:788-802, 2006) Jumlah volume darah sangat menentukan hasil Waktu bakteremia (penting) 2 kultur diambil dari vena dan kateter :

Keduanya vena (PPV 98 %) Keduanya kateter ( 50 %) Satu vena, satu kateter ( 96 % )

Number

• 1 blood culture is rarely, if ever, sufficient or advisable. – A positive result on a single culture is difficult to

interpret, unless an unequivocal pathogen is isolated.

• 2 blood cultures are usually adequate when continuous bacteraemia is anticipated

• 3 blood cultures are reasonable when intermittent bacteraemia is suspected

S Afr Med J 2010; 100: 839-843.

Timing

• The ideal: ranging from one to several hours– 2 separate sites within minutes of each other from

patients who are acutely ill or those in whom the likelihood of continuous bacteraemia is high

• Intermittent bacteraemia:– multiple blood cultures 6 - 36 hours apart

Biakan Tinja dan UrinBiakan Tinja :

2 sampel berturut-turut Tidak boleh >3 hari

Biakan Urin: Pengumpulan spesimen minimal kontaminasi Pengambilan pagi hari Pengambilan sebelum pemberian antibiotik Segera dikirmkan untuk diproses, kemas dengan es Jika tidak segera dikirim masukkan almari es ( 40C ) Bakteriuria bermakna :

Suprapubik : berapapun Kateter : 10.000 Mid stream : 100.000

TERIMA KASIH