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"Latar Belakang: Infeksi dengue dan demam tifoid merupakan penyakit endemik di Indonesia. Namun pada awal awitan demam terdapat kesulitan dalam membedakan keduanya. Oleh karena itu dibutuhkan modalitas pemeriksaan penunjang yang sederhana untuk membantu diagnosis infeksi dengue dan demam tifoid. C-Reactive Protein (CRP) merupakan alat bantu diagnostik yang terjangkau, cepat dan murah untuk diagnosis penyebab demam akut. Penelitian ini bertujuan mengetahui perbedaan kadar CRP pada demam akut karena infeksi dengue dengan demam tifoid. Metode: Penelitian ini merupakan studi potong lintang pada pasien demam akut dengan diagnosis demam dengue/demam berdarah dengue atau demam tifoid yang dirawat di IGD atau ruang rawat RSCM, RS Pluit dan RS Metropolitan Medical Center Jakarta dalam kurun waktu Januari 2010 sampai dengan Desember 2013. Kadar CRP yg diteliti adalah CRP yang diperiksa 2-5 hari setelah awitan demam. Data penyerta yang dikumpulkan adalah data demografis, data klinis, pemberian antibiotik selama perawatan, leukosit, trombosit, netrofil, LED dan lama perawatan. Hasil: Sebanyak 188 subjek diikutsertakan pada penelitian ini, terdiri dari 102 pasien dengue dan 86 pasien demam tifoid. Didapatkan median (RIK) CRP pada infeksi dengue adalah 11,65 (16) mg/L dan pada demam tifoid adalah 53 (75) mg/L. Terdapat perbedaan median CRP yang bermakna antara infeksi dengue dan demam tifoid (p <0,001). Pada titik potong persentil 99%, didapatkan hasil kadar CRP infeksi dengue sebesar 45,91 mg/L dan kadar CRP demam tifoid pada level persentil 1% sebesar 8 mg/L. Simpulan: Terdapat perbedaan kadar CRP pada demam akut karena infeksi dengue dengan demam tifoid. Pada titik potong persentil 99%, kadar CRP >45,91 mg/L merupakan diagnostik CRP untuk demam tifoid, kadar CRP <8 mg/L merupakan diagnostik CRP untuk infeksi dengue. kadar CRP 8-45,91 mg/L merupakan area abu-abu dalam membedakan diagnosis keduanya.

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Background: Dengue infection and typhoid fever are endemic disease in Indonesia. But in the early days of onset sometimes it is difficult to distinguish them. A simple modality test is needed to support the diagnosis. C-Reactive Protein (CRP) is an affordable, fast and relatively less expensive diagnostic tool to diagnose the causes of acute fever. This study was aimed to determine the differences of CRP level in the acute febrile caused by dengue infection or typhoid fever.

Methods: A cross sectional study has been conducted among acute febrile patients with diagnosis of dengue fever/dengue hemorrhagic fever or typhoid fever who admitted to the emergency room or hospitalized in Cipto Mangunkusumo Hospital, Pluit Hospital, and Metropolitan Medical Center Hospital Jakarta between January 2010 and December 2013. Data obtained from medical records. CRP used in this study was examined at 2-5 days after onset of fever. The other collected data were demographic data, clinical data, use of antibiotics, leukocytes, platelets, neutrophils, ESR, and length of stay in hospital.

Results: 188 subjects met the inclusion criteria; 102 patients with dengue and 86 patients with typhoid fever. Median CRP levels in dengue infection was 11.65 (16) mg/L and in typhoid fever was 53 (75) mg/L. There were significant differences in median CRP levels between dengue infection and typhoid fever (p < 0.001). At the 99% percentile cut-off point, CRP levels for dengue infection was 45.91 mg/L and CRP levels for typhoid fever at 1% percentile was 8 mg / L.

Conclusion: There was significantly different levels of CRP in acute fever due to dengue infection and typhoid fever. At the 99% percentile cut-off point, CRP level >45.91 mg/L was diagnostic for typhoid fever, CRP level <8 mg/L was diagnostic for dengue infection. CRP level between 8 to 45.91 mg/L was a gray area for determinating diagnosis of dengue infection and typhoid fever."

"Latar belakang. Berbagai studi sebelumnya menunjukkan bahwa insidens kolonisasi dan infeksi C.difficile semakin meningkat, terutama pada pasien rawat inap yang mendapat terapi antibiotika. Namun belum ada penelitian yang mendapatkan data kedua insidens tersebut di Indonesia, terutama di RSCM. Tujuan. Untuk mengetahui insidens kolonisasi dan infeksi C.difficile pasien rawat inap yang mendapat terapi antibiotika di RSCM. Metode. Dilakukan studi kohort prospektif berbasis surveilans pada 96 pasien rawat inap yang mendapat terapi antibiotika di RSCM pada periode penelitian. Dilakukan pemeriksaan feses dengan uji kromatografi cepat C.DIFF QUIK CHEK COMPLETETM pada awal dan akhir penelitian. Dilakukan follow-up selama 5-7 hari perawatan pada semua pasien. Insidens kolonisasi strain non-toksigenik adalah pasien yang memiliki hasil pemeriksaan fesesnya konversi GDH/Toksin -/- saat awal perawatan menjadi GDH/Toksin +/-. Insidens kolonisasi strain toksigenik adalah pasien yang memiliki konversi GDH/Toksin -/- saat awal perawatan menjadi GDH/Toksin +/+. Insidens infeksi adalah pasien yang memiliki konversi GDH/Toksin -/- saat awal perawatan menjadi GDH/Toksin +/+ yang disertai satu atau lebih gejala yang berhubungan dengan infeksi C.difficile. Hasil. Dari 96 subjek penelitian, 13 subjek mengalami kolonisasi non-toksigenik; 8 subjek mengalami kolonisasi toksigenik; 9 subjek mengalami infeksi. Terdapat 11 subjek yang mengalami gejala klinis, namun hasil pemeriksaan fesesnya tidak ditemukan toksin yang positif (2 subjek hanya mengalami kolinisasi non-toksigenik dan 9 subjek tidak mengalami kolonisasi atau infeksi) sehingga dianggap bukan merupakan infeksi C.difficile. Kesimpulan. Insidens kolonisasi C.difficile adalah 22%, dimana kolonisasi strain non-toksigenik adalah 14% (IK95% 13-16) dan strain toksi.

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Background. Previous studies showed that there have been a significant increasing of the incidence of C.difficile colonization and infection, particularly among hospital inpatients prescribed antibiotics. However, there is no such data available in Indonesia, mainly at Cipto Mangunkusumo Hospital.

Objective. To determine the incidence of Clostridium difficile colonization and infection among hospital inpatients prescribed antibiotics at Cipto Mangunkusumo Hospital.

Methods. A surveillance-based prospective cohort study was conducted on 96 inpatients prescribed antibiotics at Cipto Mangunkusumo Hospital during the study period. All patient was followed-up for 5-7 days hospitalization. We obtained rectal swabs or stool samples on admission and day 5-7 of hospitalization and performed a rapid chromatography test C.DIFF QUIK CHEK COMPLETETM to determine colonization or infection. Incidence of non-toxigenic colonization was defined as a conversion of baseline result GDH/toxin -/- into GDH/toxin +/- as the second result. Incidence of toxigenic colonization was defined as as a conversion of baseline result GDH/toxin -/- into GDH/toxin +/+ as the second result. Incidence of infection was defined as a conversion of baseline result GDH/toxin -/- into GDH/toxin +/+ as the second result, accompanied by one or more C.difficile infection-associated clinical symptoms.

Results. A total of 96 subjects were included in the study; 13, 8 and 9 had a non-toxigenic colonization, toxigenic colonization, and infection, respectively. 11 subjects with clinical symptoms could not be determined whether they had a C.difficile infection because of the “toxin-negative” findings from their stool examination (2 subjects had non-toxigenic colonization and 9 subjects had neither colonization nor infection).

Conclusion. The incidence of C.difficile colonization was 22%, which 14% (95% CI 13-16) was the incidence of non-toxigenic colonization and 8% (95% CI 7-10) was the incidence of toxigenic colonization. The incidence of C.difficile infection was 9% (95% CI 8-11)."

"Latar Belakang: Dalam dekade terakhir terjadi peningkatan bakterimia Multi-Drug Resistant (MDR) Gram negatif. Bakterimia MDR Gram negatif tidak hanya meningkatkan angka kematian, tetapi juga dapat dikaitkan dengan peningkatan morbiditas pasien, lama perawatan dan biaya perawatan rumah sakit. Faktor-faktor risiko terjadinya bakterimia MDR Gram negatif di ruang rawat inap penting untuk diketahui sehingga dapat dilakukan upaya pencegahan dan pengendalian terhadap faktor-faktor risiko tersebut dan menurunkan kejadian bakterimia MDR Gram negatif pada pasien rawat inap. Tujuan: Mengetahui faktor-faktor risiko yang berhubungan dengan terjadinya bakterimia MDR Gram negatif pada pasien rawat inap. Metode: Faktor risiko diidentifikasi menggunakan studi kasus kontrol. Data dikumpulkan dari catatan rekam medis pasien rawat inap RSCM yang memiliki kultur darah positif tumbuh bakteri patogen Gram negatif. Kelompok kasus adalah subjek dengan bakterimia MDR Gram negatif, kelompok kontrol adalah subjek dengan bakterimia non-MDR Gram negatif. Kedua kelompok kasus dan kontrol diambil secara konsekutif dikarenakan kurangnya sampel. Analisis bivariat dilakukan pada variabel bebas yaitu riwayat antibiotik sebelumnya, pemberian antibiotik kombinasi, fokus infeksi, riwayat hospitalisasi, lama perawatan, Charlson index >2, pemberian kemoterapi, kortikosteroid, keganasan, kolonisasi, absolute neutrophile count (ANC) <500, perawatan di ICU/HCU, prosedur medis invasif, hipoalbuminemia. Semua variabel yang mempunyai nilai p <0,25 pada analisis bivariat dimasukkan ke dalam analisis multivariat dengan regresi logistik. Hasil: Selama periode penelitian didapatkan 131 pasien yang memenuhi kriteria, 42 pasien dengan bakterimia MDR Gram negatif (kasus), dan 89 pasien dengan bakterimia non-MDR Gram negatif (kontrol). Berdasarkan hasil analisis bivariat didapatkan 2 variabel yang memiliki kemaknaan secara statistik yaitu riwayat ICU/HCU (p= 0.003) dan riwayat ventilator (p=0.030). Pada analisa multivariat lebih lanjut terdapat satu varibel bermakna secara statistik, yaitu riwayat ICU/HCU (OR: 3.118; IK 95% : 1.443 – 6.736; p=0,004). Simpulan: Riwayat ICU/HCU merupakan faktor risiko terjadinya bakterimia MDR Gram negatif pada pasien rawat inap.

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Background: Over the past decade, the numbers of bloodstream infections caused by multidrug-resistant (MDR) Gram-negative bacteria have risen sharply. MDR Gramnegative bacteremia increases not only mortality, but may also be associated with increased patient morbidity, length of treatment and hospitalization costs. It is important to identify risk factors of MDR Gram-negative bacteremia among hospitalized patients in order to prevent and to control these risk factors and thus to lower the incidence of MDR Gram-negative infections among hospitalized patients.

Aim: To identify the risk factors associated with the occurrence of MDR Gramnegative bacteremia among hospitalized patients.

Method: Risk factors were identified by a case-control study. Data was collected from inpatients medical record that had positive blood cultures of Gram negative bacterial pathogens. Both case and control samples were collected consecutively due to lack of samples available. The case group was subjects who had MDR Gram-negative bacteremia, and the control group was subjects who had non-MDR Gram negative bacteremia. Bivariate analysis was performed on several independent variables, which were previous antibiotic history, antibiotic combination, source of infection, history of hospitalization, duration of hospitalization, Charlson index> 2, administration of chemotherapy, use of corticosteroid, malignancy, colonization, ANC <500, history of treatment in ICU / HCU, invasive medical procedures and hypoalbuminemia. All variables that had a value of p <0.25 on bivariate analysis were included in multivariate analysis using logistic regression.

Result: During the study period, there were 131 patients fulfilled the criteria, which consisted of 42 patients who had MDR Gram-negative pathogen bacteremia (case) and 89 patients who had non-MDR Gram-negative pathogen bacteremia patients (control group). Based on the bivariate analysis, there were two variables statistically significance, which were history of treatment in ICU / HCU (p=0.003) and history of ventilator (p=0.030). Further multivariate analysis showed that there was one variable statistically significance, which was history of treatment in ICU / HCU (OR: 3.118; CI 95% : 1.443 – 6.736; p=0,004).

Conclusion: History of treatment in ICU / HCU was risk factor of MDR Gram negative bacteremia among hospitalized patients."

"Heparin-induced thrombocytopenia (HIT) adalah salah satu efek samping penggunaan heparin, yang dicurigai bila terdapat penurunan trombosit ≥50% pada hari ke-5 sampai ke-10 pascaheparinisasi dan dapat disertai komplikasi tromboemboli. Mekanisme HIT melibatkan pembentukan antibodi terhadap kompleks PF4-heparin (anti-PF4). Pemeriksaan diagnostik HIT terdiri dari uji fungsional dan immunoassay. Pemeriksaan immunoassay, yang mendeteksi anti- PF4 dengan metode ELISA memiliki sensitivitas tinggi dan paling sering digunakan untuk deteksi HIT. Angka kejadian HIT sangat bervariasi karena banyak faktor yang mempengaruhi. Tujuan penelitian ini adalah untuk mengetahui proporsi kejadian HIT dan proporsi pasien yang memiliki anti-PF4 pada pemberian terapi heparin di RSCM. Penelitian ini melibatkan 120 pasien rawat inap yang mendapat drip heparin atas indikasi profilaksis atau pengobatan, dengan dosis minimal 10.000 U/24 jam. Pasien yang memenuhi kriteria masukan dan tolakan dilakukan pencatatan data usia, jenis kelamin, diagnosis klinis, riwayat pemakaian heparin 3 bulan terakhir, dan dosis heparin yang dipakai. Pada hari ke-7 dan ke-10 pascaheparinisasi (H7 dan H10) dilakukan pengambilan darah untuk pemeriksaan hitung trombosit dan anti-PF4. Diagnosis HIT didasarkan atas penurunan hitung trombosit ≥50% pada H7 atau H10 yang disertai adanya antibodi anti-PF4. Hasil uji ketelitian within-run dan uji ketepatan pemeriksaan anti-PF4 mendapatkan CV 7,73% dan penyimpangan (d) 2,5-17,4%. Pada 19 dari 120 subjek (15,8%) ditemukan anti-PF4, tetapi kejadian HIT tidak ditemukan. Berdasarkan klasifikasi risiko terjadinya HIT menurut American College of Chest Physician (ACCP), terdapat 46/120 subjek (38,3%) berisiko rendah, 65/120 subjek (54,2%) berisiko tinggi, 8/120 subjek (6,7%) berisiko sangat tinggi, dan 1 orang tidak terklasifikasi. Uji statistik menunjukkan tidak ada hubungan antara temuan anti-PF4 dengan penurunan trombosit ≥50% (p=0,588). Hal ini diduga karena kurangnya jumlah subjek penelitian yang diperlukan. Antibodi anti-PF4 lebih sering ditemukan pada subjek perempuan dan dengan riwayat heparinisasi. Proporsi ditemukannya anti-PF4 berturut-turut lebih banyak pada pasien pascabedah vaskular dan ortopedi, trombosis arteri dan vena, kemudian pasien medis yang mendapat profilaksis heparin. Tidak ada perbedaan bermakna proporsi anti-PF4 positif pada subjek dengan atau tanpa riwayat heparinisasi (p=0,293), perbedaan dosis heparin (p=0,141), dan populasi risiko HIT rendah, tinggi, dan sangat tinggi (p=0,662). Empat dari 19 subjek yang memiliki anti-PF4 positif mengalami penurunan trombosit 20-46% pada H7 dan H10.

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Heparin-induced thrombocytopenia (HIT) is an adverse effect of heparin, that suspected when platelet count fall ≥50% in 5 to 10 days following heparin initiation and may be accompanied with thromboembolic complications. Mechanism of HIT is mediated by the formation of PF4-heparin complex antibody. There are 2 kind of diagnostic test for HIT, functional assay and immunoassay. Immunoassays, that detect anti-PF4 antibody using ELISA method, have high sensitivity and considered the most frequent assay for detecting HIT. The incidence of HIT varies due to many factors.

The aim of this research is to find the proportion of HIT events and also the proportion of anti-PF4-heparin antibody positive in patients with full-dose heparin in Cipto Mangunkusumo hospital. One hundred and twenty participants, who were our hospital in-patients given heparin infusion with minimal dose of 10.000U/24 h for profilactic or treatment indication, participated in this research. Patients met the inclusion and exclusion criteria were noted for age, gender, clinical diagnosis, heparin exposure in the last 3 months, and heparin dose. On day 7 and 10 after heparin initiation, blood sample were collected for platelet count and anti-PF4 antibody assay. Diagnosis of HIT was based on platelet count fall ≥50% on day 7 or 10 after heparin initiation accompanied with anti-PF4 antibody in the circulation.

Within run precision and accuracy tests for anti-PF4 assay showed a CV of 7,73% and deviations of -2,5 – 17%. Nineteen of 120 subjects (15,8%) had anti-PF4 antibodies, but HIT was not found. Based on the risk classification of HIT from American College of Chest Physician (ACCP), 46 subjects (38,3%) categorized as low risk to HIT, 65 (54,2%) high risk, 8 (6,7%) very high risk, and 1 as unclassified. Statistics showed there was no significant relationship between anti-PF4 antibodies in the circulation with platelet count fall of ≥50% (p=0,588). This was probably due to inadequate sample size for this study. Anti-PF4 antibodies were detected more frequent in females and subjects with past heparin exposure.

The proportion of positive anti-PF4 antibodies were highest in postoperative vascular or orthopedic surgery patients, followed by arterial or venous thrombosis patients, then medical patients using profilactic dose of heparin. There were no significant difference of positive anti-PF4 antibodies in subjects with vs without past heparin exposure (p=0,293), in subjects using 10.000U/24h vs >10.000U/24h heparin dose (p=0,141), and in subjects with low vs high vs very high risk of HIT (p=0,662). Four of 19 subjects having anti-PF4 antibodies had platelet count fall 20-46% on day 7 and day 10."

"Sepsis merupakan tantangan besar di dunia kedokteran. Terdapat banyak penelitian yang mencari penanda sepsis yang handal dan soluble Cluster of Differentiation-14 subtype (sCD14-ST) mulai banyak diteliti sebagai penanda sepsis. Kadar sCD14-ST meningkat secara bermakna di dalam sirkulasi pada fase awal inflamasi dan sepsis. Saat ini belum terdapat data mengenai apakah sCD14- ST dapat digunakan sebagai penanda prognostik sepsis. Tujuan penelitian ini dilakukan untuk mengetahui apakah sCD14-ST dapat digunakan sebagai penanda prognostik pada pasien sepsis yang datang di instalasi gawat darurat. Desain penelitian potong lintang, terdiri dari 65 pasien sepsis dibagi bedasarkan mortalitas 28 hari, yaitu 37 pasien hidup dan 28 pasien meninggal. Diagnosis sepsis berdasarkan modifikasi definisi sepsis oleh International Sepsis Definitions Conference 2001. Kadar sCD14-ST didapatkan menggunakan pemeriksaan dengan prinsip noncompetitive chemiluminescent enzyme immunoassay pada alat Pathfast. Pada kedua kelompok tersebut dicatat data karakteristik subyek dan dilakukan pemeriksaan sCD14-ST. Median kadar sCD14-ST pada pasien hidup adalah 618,00 pg/mL dengan rentang 349,50 - 1628 pg/mL dan median kadar sCD14-ST pada pasien yang meninggal adalah 1287,00 pg/mL dengan rentang 720,75 - 2738,00 pg/mL. Terdapat perbedaan bermakna kadar sCD14-ST pada kedua kelompok dengan nilai p 0,005. Ditentukan nilai cut-off sCD14-ST 677,00 pg/mL untuk menentukan prognosis pasien sepsis, dengan AUC 0,706 (IK 95% 0,582 - 0,831), sensitivitas 82,1%, dan spesifisitas 54,1%. Kurva Kapplan Meier berdasarkan nilai cut-off 677,00 pg/mL menunjukkan gambar yang memenuhi asumsi proporsional hazard dengan rasio hazard 3,794 (IK 95% 1,437 - 10,013), p 0,007. Kami menyimpulkan kadar sCD14-ST pasien sepsis dapat digunakan untuk memprediksi pasien yang meninggal dilihat dari mortalitas 28 hari, dengan nilai AUC sedang. Cut-off kadar sCD14-ST 677,00 pg/mL dapat digunakan sebagai cut-off dalam tatalaksana pasien sepsis.

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Sepsis is a major challenge in the medicine world. Many studies try to find

reliable sepsis marker and scientists start to explore soluble Cluster of Differentiation-14 subtype (sCD14-ST) as sepsis marker. Concentration of sCD14-ST significantly increases in circulation on early phase of inflammation and sepsis. Nowadays there is no data whether sCD14-ST can be used as prognostic marker of sepsis.

The objective of this study is to investigate the prognostic value of sCD14-ST in sepsis patients presenting at the emergency department. This was a cross-sectional study, from 65 sepsis patient grouped based on 28-day mortality, 37 patients are survivors and 28 patients are nonsurvivors. Sepsis diagnosis is made based on modified sepsis definition from International Sepsis Definitions Conference 2001. The concentration sCD14-ST was analysed using Pathfast analyzer with noncompetitive chemiluminescent enzyme immunoassay test method. Baseline characteristics of subjects were recorded and sCD14-ST concentration were measured in study subjects.

Median of sCD14-ST in the survivors group is 618,00 pg.mL with range of 349,50 - 1628,00 pg/mL and the median in the nonsurvivors group is 1287,00 pg/mL with range of 720,75 - 2738,00 pg/mL. The difference between the two groups is significant with p 0,005. sCD14-ST cut-off of 677,00 pg/mL is found with AUC 0,706 (CI 95% 0,582 - 0,831), sensitivity 82,1%, and specificity 54,1%. Kapplan Meier curve based on 677,00 pg/mL cut-off demonstrates that hazard proportion is fulfilled with hazard ratio 3,794 (CI 95% 1,437 - 10,013), p 0,007.

It is concluded that sCD14-ST concentration in sepsis patients can be used to predict nonsurvivors based on 28-day mortality, with moderate AUC. Cut-off sCD14-ST of 677,00 pg/mL can be used as cut-off for sepsis patient management."

"Latar belakang : Peresepan antibiotik (AB) yang tidak tepat umum terjadi di seluruh dunia dan berkontribusi pada meningkatnya organisme yang resisten. Diperlukan sistem surveilans untuk memantau penggunaan AB dan resistensi untuk pengambilan keputusan yang tepat.Indonesia belum pernah menerapkan Point prevalence survey (PPS) dalam evaluasi AB dan resistensi. Tujuan: untuk mengetahui profil penggunaan antibiotik dan resistensi mikroorganisme di rumah sakit menggunakan metode PPSMetode : penelitian potong lintang. Dilakukan pengumpulan data demografi, penggunaan antibiotik dan kultur resistensi mikroorganisme menggunakan formulir PPS.Hasil : Pada hari penelitian dilakukan survei terhadap 451 pasien, ditemukan 244 (54,1%) pasien mendapatkan AB dengan diagnosis paling banyak adalah pneumonia (25%). Alasan penggunaan antibiotik adalah untuk tatalaksana infeksi dari komunitas sebanyak 50,8%, infeksi dari fasilitas kesehatan sebanyak 15,5%, penggunaan AB sebagai profilaksis sebanyak 30,7% dan 3% tidak ditemukan alasan indikasi penggunaan AB. Diresepkan 368 AB, di manahanya 46 (12,5%) AB yang digunakan sebagai terapi definitif. Tiga AB yang paling sering digunakan adalah ceftriaxone (15,5%), levofloxacin 9,2% and ampicillin sulbactam 7,9%. Tanggal evaluasi penggunaan AB hanya tertulis pada 88 (22,3%) AB. Tidak tersedia pedomantatalaksana lokal sebanyak 83 (22,6%) penggunaan AB dan hanya 214 (58,2%) AB yang diresepkan sesuai dengan pedoman tata laksana lokal. Kami melakukan evaluasi terhadap 244 pasien yang menggunakan AB dan hanya 91 (38%) pasien yang dilakukan pemeriksaan kultur dan tes resistensi. Didapatkan 222 sampel, dimana 81 (36,5%) adalah steril. Tiga mikroorganisme terbanyak adalah Klebsiella pneumoniae 47 (20,7%), Pseudomonas aeruginosa 22 (9,9%) dan Escherichia coli 20 (9%). Jumlahmikroorganisme extended-spectrum β-lactamase (ESBL) didapatkan sebesar 21,4%, resisten terhadap karbapenem 12,5% dan Multiple drug resistance (MDR) sebesar 17,7%.Kesimpulan : lebih dari setengah pasien yang disurvei menggunakan AB dan angka kepatuhan penggunaan antibiotik masih belum baik, evaluasi resistensi kuman terbatas karena jumlah sampel yang diperiksa kurang. Pelaksanaan PPS terbukti efektif dan efisien.

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Background: Inappropriate antibiotic prescribing appears to be common worldwide and is contributing to the selection of resistant organisms. Surveillance systems to monitor antimicrobial use and resistance are needed to improve decision making and assess the effect of interventions. Point prevalence surveys (PPSs) in Indonesian hospitals have not yet been applied. Aim : to evaluate the antibiotic prescribing trends and microorganism resistance using PPS methods Methods: A one day, cross-sectional PPS was performed whereas total of 10 days were taken. Data on demographics, antimicrobial use and culture/resistance test of all adult inpatients were collected using a data collection form. Results: On the day of the study 451 adults patients were surveyed, 244 (54.1%) were received

368 antibiotics and the most common diagnosis was pneumonia (25%). Reasons of using the antibiotics were to treat community acquired infection (CAI) 50.8%, hospital acquired infection (HAI) 15.5%, prophylaxis 30.7% and 3% was unknown. 368 antibiotics prescriptions were issued, of which 46 (12.5%) were used for definitive therapy. The top three antibiotics prescribed were ceftriaxone (15.5%), levofloxacin 9.2% and ampicillin sulbactam 7.9%.

Review date of using antibiotics were performed in 88 (22.3%). Local guidelines was not available for 83 (22.6%) of prescribed antibiotics and among prescribed antibiotics with local guidelines available compliance was 214 (58.2%). We evaluate the culture test among those received antibiotics (244), 91 (38%) patients were

performed culture and resistance test. From these 222 samples of culture, 81 (36.5%) was sterile. The most three growth microorganisms were Klebsiella pneumoniae 47 (20.7%), Pseudomonas aeruginosa 22 (9.9%) and Escherichia coli 20 (9%). The number of extendedspectrum β-lactamase (ESBL) recorded at 21.4%, Carbapenem Resistanculture ce was 12.5% and Multiple drug resistance was 17.7%. Conclusions: more than half-of-patients surveyed by PPS in an hospital in Indonesia were on antibiotics, has a limitation due to availability of result and sample. Conducting PPS in teaching hospital proved to be effective and efficient. "

"ABSTRAKLatar Belakang:Kandidemia merupakan infeksi aliran darah dengan morbiditas dan mortalitas yang tinggi. Gambaran klinis kandidemia sulit dibedakan dengan pasien sepsis sehingga sering terlambat didiagnosis. Kultur darah sebagai baku emas diagnostik kandidemia memiliki beberapa keterbatasan, sedangkan prediktor yang ada saat ini sulit diaplikasikan dalam praktik klinis sehari-hari. Telah ada penelitian tentang faktor risiko kandidemia di luar negeri dan Indonesia, tetapi belum ada yang membahas khusus pada pasien sepsis dewasa non neutropenia.Tujuan:Mengetahui faktor risiko kandidemia pada pasien sepsis non neutropenia.Metode:Desain kasus kontrol dengan mengambil data rekam medik pasien sepsis sejak Januari 2011 sampai Juli 2015 di Rumah Sakit Cipto Mangunkusumo. Penilaian faktor risiko dilakukan dengan metode Chi-square dan dilanjutkan dengan analisis regresi logistik multivariat dengan mengikutsertakan variabel perancu.Hasil:Dari 51 kasus dan 153 kontrol didapatkan faktor risiko yang berhubungan dengan kejadian kandidemia adalah kateter urin [adjusted OR=5,239 (IK 95% 2,141 ? 12,819), p<0,001], nutrisi parenteral [adjusted OR=2,583 (IK 95% 1,297 ? 5,144), p=0,007], kortikosteroid [adjusted OR=2,183 (IK 95% 1,002 ? 4,755), p=0,049], dan antibiotik spektrum luas [adjusted OR=4,047 (IK 95% 1,178 ? 13,904), p=0,026].Kesimpulan:Kateter urin, nutrisi parenteral, kortikosteroid, dan antibiotik spektrum luas merupakan faktor risiko penting karena dapat meningkatkan risiko kejadian kandidemia pada pasien sepsis non neutropenia.

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ABSTRACT

Background:

Candidemia is a bloodstream infection with high morbidity and mortality. Clinical manifestations of candidemia resemble with sepsis patients so that diagnosis was delayed. Blood culture as a diagnostic gold standard had some limitations, while the current predictors difficult to apply in daily clinical practice. There were studies about risk factors of candidemia in other countries and Indonesia, but no one had studied specifically in adult non-neutropenic sepsis patients.

Objective:

To identify the risk factors for candidemia in non-neutropenic sepsis patients.

Method:

A case-control study from medical records of septic patients was conducted during the period January 2011 ? July 2015 in Cipto Mangunkusumo Hospital. We analyzed risk factors using Chi-square method followed by multivariate logistic regression adjusted with confounding factors.

Results:

A total 51 cases and 153 controls were analyzed to identify the risk factors of candidemia. After adjustment, candidemia was associated with urinary catheter [adjusted OR=5,239 (95% CI 2,141 ? 12,819), p<0,001], parenteral nutrition [adjusted OR=2,583 (95% CI 1,297 ? 5,144), p=0,007], corticosteroids [adjusted OR=2,183 (95% CI 1,002 ? 4,755), p=0,049], and broad spectrum antibiotics [adjusted OR=4,047 (95% CI 1,178 ? 13,904), p=0,026].

Conclusion:

Urinary catheter, parenteral nutrition, corticosteroids, and broad spectrum antibiotics are important risk factors that can increase the risk of candidemia in non-neutropenic sepsis patients."

"Pada sepsis terjadi inflamasi sistemik yang menyebabkan ketidakseimbangan mekanisme hemostasis, yaitu, peningkatan aktivasi koagulasi, penurunan antikoagulan alamiah, dan penurunan aktivitas fibrinolisis. Ketidakseimbangan ini bermanifestasi pada pembentukan trombus mikrovaskular yang menyebabkan perfusi jaringan menurun, terjadi disfungsi organ dan kematian. Tujuan penelitian ini mengetahui peranan kadar D-dimer, kadar FDP dan rasio FDP/D-dimer dalam memprediksi mortalitas 14 hari pada pasien sepsis. Penilaian skor Acute physiology and Chronic Health Evaluation II (APACHE II) digunakan untuk memprediksi morbiditas dan mortalitas. Desain penelitian potong lintang, penyajian data secara deskriptif. Subjek penelitian berjumlah 55 orang yang terdiri dari 32 laki-laki dan 23 perempuan dengan rerata usia 51,62 tahun. Pada subjek penelitian, dinilai korelasi kadar FDP, kadar D-dimer, dan rasio FDP/D-dimer dengan skor APACHE II. Pada hasil penelitian, didapatkan 20 pasien hidup dan 35 pasien meninggal. Median kadar FDP (12,9μg/mL) dan kadar D-dimer (7μg/mL) subjek meninggal lebih tinggi dibandingkan median kadar FDP (10,9μg/mL) dan kadar D-dimer (5,2 μg/mL) subjek hidup. Median rasio FDP/D-dimer subjek meninggal (1,9) lebih rendah dibandingkan subjek hidup (2,1). Koefisien korelasi Spearman antara kadar FDP, kadar D-dimer, dan rasio FDP/D-dimer dengan skor APACHE II berturut-turut 0,176, 0,187, dan -0,182. Ketiga korelasi itu secara statistik tidak bermakna (p ≥ 0,05). Pada penelitian ini disimpulkan bahwa kadar FDP, kadar D-dimer, dan rasio FDP/D-dimer tidak dapat digunakan sebagai prognosis keluaran sepsis pada mortalitas 14 hari.

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Systemic inflamation in sepsis could leads to an imbalance homeostatic mechanisms including elevated coagulation activity, decreasing level of natural anticoagulant, and decreased fibrinolysis activity. This could leads to formation of microvascular thrombus which eventually will cause tissue hypoperfusion, organ dysfunction and death. The aim of this research is to understand the role of d-dimer and fibrin degradation products (FDP) and FDP/d-dimer ratio in predicting 14-days mortality rate on sepsis patient. The morbidity and mortality rate on this research were based on APACHE II scoring system. This is a cross sectional research and all data are presented in a descriptive report. Participant of this research was 55 people (32 male and 23 female), average age was 51,62 years old. This research evaluate the correlation between FDP level, d-dimer level and FDP/d-dimer ratio with APACHE II scoring system. From all the participant we had 20 subject alive and 35 died during this research. The median level of FDP (12,9μg/mL) and d-dimer (7μg/mL) in those who die were higher than those who live (10,9μg/mL and 5,2 μg/mL). The median FDP/d-dimer ratio in those who die (1,9) was lower comparing to those who live (2,1). Spearman coefficient of correlation between FDP level, d-dimer level and FDP/d-dimer ratio with APACHE II scoring system were 0.176; 0.187; and – 0.182 repectively. This was not significant statistically (p ≥ 0,05). This research has come to a conclusion that FDP and d-dimer level, and FDP/d-dimer ratio cant be used as a prognostic outcome in sepsis on 14 days mortality."

"Latar Belakang: Sepsis merupakan masalah kesehatan global dan memiliki morbiditas dan mortalitas yang tinggi. Rasio neutrofil-limfosit merupakan pemeriksaan sederhana yang dapat dilakukan di fasilitas terbatas dan tidak memerlukan biaya besar, tetapi belum ada studi yang meneliti perannya dalam memprediksi mortalitas 28 hari pada pasien sepsis, menggunakan kriteria sepsis-3 yang lebih spesifik. Tujuan: Mengetahui peran rasio neutrofil-limfosit dalam memprediksi mortalitas 28 hari pada pasien sepsis. Metode: Penelitian ini menggunakan desain kohort retrospektif terhadap pasien sepsis yang dirawat di RSCM pada tahun 2017. Data diambil dari rekam medis pada bulan Maret-Mei 2018. Nilai rasio neutrofil-limfosit yang optimal didapatkan menggunakan kurva ROC. Subjek kemudian dibagi menjadi dua kelompok yang di bawah dan di atas titik potong. Kedua kelompok kemudian dianalisis menggunakan analisis kesintasan dengan program SPSS. Hasil: Dari 326 subjek, terdapat 12 subjek loss to follow-up. Rerata usia sampel 56,4 + 14,9 tahun, dengan fokus infeksi terbanyak di saluran napas (59,8%), dan penyakit komorbid terbanyak adalah keganasan padat (29,1%). Nilai titik potong rasio neutrofil-limfosit yang optimal adalah 13,3 (AUC 0,650, p < 0,05, sensitivitas 63%, spesifisitas 63%). Pada analisis bivariat menggunakan cox regression didapatkan kelompok dengan nilai rasio neutrofil-limfosit> 13,3 memiliki crude HR sebesar 1,84 (IK 95% 1,39-2,43) dibandingkan dengan kelompok yang nilai rasio neutrofil-limfosit < 13,3. Setelah menyingkirkan kemungkinan faktor perancu, didapatkan adjusted HR untuk kelompok dengan nilai rasio neutrofil-limfosit tinggi adalah 1,60 (IK 95% 1,21-2,12). Simpulan: Nilai rasio neutrofil-limfosit memiliki akurasi lemah dalam memprediksi mortalitas 28 hari pasien sepsis dengan nilai titik potong optimal 13,33. Kelompok dengan nilai rasio neutrofil-limfosit > 13,3 memiliki risiko mortalitas 28 hari yang lebih tinggi dibandingkan dengan kelompok nilai rasio neutrofil-limfosit < 13,3.

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Background: Sepsis is a global health problem with high morbidity and mortality. Neutrophil to lymphocyte ratio is a simple test which can be done in limited facility, but there is no study conducted to know its potential in predicting 28-day-mortality in septic patients, using the more specific sepsis-3 criteria.

Objectives: To investigate neutrophil to lymphocyte ratio as a predictor of 28-day-mortality in septic patients.

Methods: A retrospective cohort study was conducted using medical records in Cipto Mangunkusumo Hospital for septic patients who were admitted in 2017. Neutrophil to lymphocyte ratio cut off was determined using ROC curve, then subjects were divided into two groups according to its neutrophil to lymphocyte ratio value. The groups were analyzed using survival analysis with SPSS.

Result: From 326 subjects, 12 subjects were loss to follow-up. Age mean was 56.4 + 14.9 years. Lung infection (59.8%) was the most frequent source of infections and solid tumor (29.1%) was the most frequent comorbidities. The optimal cut off value for neutrophil to lymphocyte ratio was 13.3 (AUC 0.650, p < 0.05, sensitivity 63%, specificity 63%). Bivariate analysis using cox regression showed that group with neutrophil to lymphocyte ratio > 13.3 had greater risk for 28-day-mortality than group with neutrophil to lymphocyte ratio < 13.3 with crude HR 1.84 (95% CI 1.39-2.43). After adjustment for possible confounding, adjusted HR for group with higher neutrophil to lymphocyte ratio was 1.60 (95% CI 1.21-2.12).

Conclusion: Neutrophil to lymphocyte ratio had poor accuracy in predicting 28-day-mortality in septic patients with 13.3 as the optimal cut off value. Group with neutrophil to lymphocyte ratio > 13.3 had greater significant risk for mortality in 28 days than group with neutrophil to lymphocyte ratio < 13.3."

"ABSTRAKBerbagai studi terkini menunjukkan hubungan antara vitamin D dan sepsis. Vitamin D berperan sebagai stimulator produksi peptida antimikroba dan mencegah inflamasi yang berlebihan. Insufisiensi dan defisiensi vitamin D berhubungan dengan risiko terjadinya sepsis. Saat ini belum terdapat data mengenai hubungan status vitamin D dengan pasien infeksi tanpa sepsis, sepsis, dan sepsis berat. Tujuan penelitian ini dilakukan untuk mendapatkan hubungan antara proporsi status vitamin D dengan pasien infeksi tanpa sepsis, sepsis, dan sepsis berat.Desain penelitian potong lintang, terdiri dari 60 pasien infeksi terbagi menjadi kelompok infeksi tanpa sepsis, sepsis, dan sepsis berat masing-masing 20 pasien. Diagnosis sepsis berdasarkan modifikasi SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference 2001. Status vitamin D ditetapkan menurut rekomendasi Holick. Pada ketiga kelompok tersebut dicatat data karakteristik subjek dan dilakukan pemeriksaan 25(OH)D.Status vitamin D pada subjek penelitian ini didapatkan sebanyak 5 (8,33%) orang insufisiensi dan 55 (91,67%) orang defisiensi vitamin D Proporsi insufisiensi pada kelompok infeksi tanpa sepsis adalah 5%, sepsis 10%, dan sepsis berat 10%. Proporsi defisiensi pada kelompok infeksi tanpa sepsis adalah 95%, sepsis 90%, dan sepsis berat 90%. Didapatkan perbedaan tidak bermakna proporsi insufisiensi dan defisiensi vitamin D pada kelompok infeksi tanpa sepsis, sepsis, dan sepsis berat.Kami menyimpulkan status vitamin D tidak berhubungan dengan beratnya sepsis. Proporsi insufisiensi dan defisiensi pada pasien infeksi tanpa sepsis, sepsis, dan sepsis berat masing-masing didapatkan 5% dan 95%; 10% dan 90%; 10% dan 90%.

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ABSTRACTRecent studies have shown that there is a relationship between vitamin D and sepsis. Vitamin D has a a role as a potent stimulator of antimicrobial peptides and prevent an over reaction of the inflammatory response. Insufficiency and deficiency of vitamin D have been associated with sepsis event. Nevertheless, there is no data about the relationship between vitamin D status with infection without sepsis, sepsis, and severe sepsis patient. The aim of this study was to obtain the relationship between proportions of vitamin D with infection without sepsis, sepsis, and severe sepsis patient.This was a cross-sectional study, 60 patients with infection were divided into groups of infection without sepsis, sepsis, and severe sepsis, each consisted of 20 patients. Diagnosis of sepsis was based on modified SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference 2001. Vitamin D status was defined according to Holick recommendations. Baseline characteristics of subjects were recorded and 25(OH)D concentrations were measured in subjects of each groups.According to status of Vitamin D, 5 (8,33%) subjects were insufficiency and 55 (91,67%) were deficiency. The proportions of vitamin D insufficiency at infection without sepsis group were 5%, sepsis 10%, and severe sepsis 10%. The proportions of vitamin D deficiency at infection without sepsis group were 95%, sepsis 90%, and severe sepsis 90%. The proportions of insufficiency and deficiency at infection without sepsis, sepsis, and severe sepsis patient were not significantly different (p > 0.05).It is concluded that vitamin D status were not related to infection severity. The proportions of vitamin D insufficiency and deficiency at infection without sepsis, sepsis, and severe sepsis, i.e. 5% and 95%; 10% and 90%; 10% and 90%, respectively."