3/3/2019

Manajemen Demam
Pada Anak
Dwiyanti Puspitasari
Divisi Infeksi & Penyakit Tropik Dept. Ilmu Kesehatan Anak
FKUA dr. Soetomo

WS PRAUD, Swissbellin Hotel Surabaya, 1-3 Maret 2019

DEMAM PADA ANAK

Demam : 70% keluhan orang tua

 50% sdh menganggap demam suhu rektal < 38oC
 25% mulai memberi antipiretik pada suhu < 37,8oC
 85% membangunkan anaknya untuk memberikan antipiretik
 50% memberi antipiretik dengan dosis tidak benar
 15% memberikan dosis supraterapeutik
Demam adalah peningkatan suhu tubuh diatas 38 0C (100.4 F),
sebagai akibat perubahan di pusat termoregulator tubuh di
hipotalamus anterior dan area pre-optik
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DEMAM ? PENGUKURAN SUHU TUBUH

Normal temperatur DEMAM

Lokasi Termometer
Range, mean (oC) (oC)

Axilla Mercury, electronic 34.7 – 37.3; 36.4 37.4

Sublingual Mercury, electronic 35.5 – 37.5; 36.6 37.6
Rectal Mercury, electronic 36.6 – 37.9; 37.0 38.0
Ear Infra red emission 35.7 – 37.5; 36.6 37.6
Rekomendasi pengukuran suhu:
Umur < 4 minggu: electronic thermometer axilla
Umur >4 minggu sd 5 tahun: electronic thermometer axilla,
mercury thermometer axilla, infrared tympanic thermometer 3

PENDEKATAN KLASIFIKASI

Panas tidak sejalan dengan bakteremia

•Mungkin toksemia atau viremia
•Reaksi imunologik proses radang
•Immunologic status shifting (age)

Pendekatan dilakukan dengan pengelompokan

•penyebab: infeksi (virus atau bakteri) atau non infeksi
•usia
•ada tidaknya fokus
•severitas (tingkat keparahan sakit)
•tunggal atau dalam kombinasi

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PENYEBAB DEMAM

INFEKSI NON INFEKSI

• Bakteri: demam tifoid, • penyakit metabolik
faringitis, meningitis, • jaringan ikat,
ensefalitis, I S K, otitis media, • keganasan,
difteri, pertusis, tuberkulosis • autoimun,
• Virus: influenza, dengue, • alergi/hipersensitiviti obat, drug
chikungunya, polio, campak, fever
varicella, hepatitis, ensefalitis • dehidrasi,
• parasit: malaria, • demam rematik
toksoplasmosis • transfusion induced
• jamur: candida
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Fever Unknown
Origin in children:
The Etiology

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Anak dengan demam: pertimbangkan umur

• Semakin muda umur, resiko serious bacterial infection
(SBI) semakin tinggi
- Neonatus demam: resiko SBI ≈ 13%
- Bayi < 3 bln demam: resiko SBI ≈ 10% (1/3 karena ISK)
- Anak 3-36 bulan demam: resiko bacteremia ≈ 1.6%

Avner JR, Baker MD. Management of fever in infants and children. Emerg Med Clin
7
North Am. 2002 Feb;20(1):49-67.

TIDAK TANDA SBI (SIANOSIS, SIRKULASI PERIFER JELEK, Management of Fever in

Umur <29 hari
IRITASI MENINGEN, PERUBAHAN NEUROLOGIS, TIDAK Children Younger than 36
YA RUAM PTEKIE Months
YA
RAWAT INAP
RAWAT INAP TEST DARAH
1-3 BLN: DL, DIFF COUNT UTK EVALUASI PERLU LP
TEST DARAH TEST DARAH 3-36 BLN: UMUMNYA TIDAK DIREKOMENDASIKAN
DL, DIFF COUNT 1-36 BLN: DL, DIFF COUNT, KULTUR DARAH TEST URIN
KULTUR DARAH TEST URIN 1-3 BLN: UL , KULTUR URIN
TEST URIN 1-3 BLN: UL , KULTUR URIN 3-24 BLN: UL , KULTUR URIN
UL , KULTUR URIN 3-24 BLN: UL , KULTUR URIN LUMBAR PUNCTURE:
LUMBAR PUNCTURE PERTIMBANGKAN PD ANAK LBH BESAR 1-3 BLN: MGK TDK PERLU BILA WBC>5000/MM
TEST FESES LUMBAR PUNCTURE: ATAU <15000, TDK ADA PYURIA ATAU BAKTERIURIA
FL, KULTUR FESES 1-3 BLN: UTK SEMUA BAYI YG TAMPAK SAKIT 3-24 BLN: TIDAK DIREKOMENDASI
BILA ADA DIARE 3-24 BLN: BILA TANDA NEUROLOGIS/ TEST FESES
FOTO THORAX RO MENINGEN + KULTUR FESES, FECAL WBC BILA ADA DIARE
TEST FESES FOTO THORAX RO
KULTUR FESES, FECAL WBC BILA ADA DIARE 1-36 BL: BILA DEMAM >39C, WBC> 20.000, ADA
MULAI ANTIBIOTIK FOTO THORAX RO TANDA RESPIRATORIK
EMPIRIS SETELAH 1-36 BL: BILA DEMAM >39C, WBC> 20.000,
KULTUR: ADA TANDA RESPIRATORIK PERTIMBANGKAN ANTIBIOTIK EMPIRIS: CEFTRI
AMPI + GENTA ATAU
(GENERAL), CEFIXIM (URINARY), AMOXICILLIN
AMPI+ CEFOTAXIM
MULAI ANTIBIOTIK EMPIRIS SETELAH DILAKUKAN (RESPIRATORY), AZITHROMYCIN (RESPIRATORY)
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KULTUR: CEFTRI ATAU CEFOTAXIM (URINARY)

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Demam pada neonatus

Suspect - serious bacterial infection (SBI)

consider hospitalization 9

Serious Bacterial Infection:

Bacteremia
Bone/joint infection
Endocarditis
Pneumonia
Gastroenteritis
Meningitis
Urinary tract infection
Soft tissue infection

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Anak dengan demam: Cari Tanda Bahaya

• Perubahan tingkah laku
• Nyeri kepala hebat
• Muntah & diare terus menerus
• Ruam kulit
• Mulut kering
• Nyeri telan yg tidak membaik
• Nyeri telinga yg tidak membaik
• Kaku kuduk
• Nyeri perut
 Pertimbangkan rawat inap RS
• Demam yg naik turun terus
• High-pitched crying
• Swelling on the soft spot on the head
• Irritable
• Unresponsive or limp
• Tidak mau makan/ minum
• Wheezing atau sulit bernafas
• Pucat
• Whimpering
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Work up in a child with fever

Differentiate viral or bacterial infection?

Fever in children mostly caused by VIRAL URTI (>80%)

Only 10-20% caused by BACTERIAL Infection, should be searched to
prevent delay in diagnosis and treatment
Presence of stomatitis, varicella, or other exanthema  clue to
diagnosis, further examination mostly not necessary
Children with impaired immune status (HIV, malignancy) considered
having BACTERIAL infection until proven otherwise

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Likely VIRAL Likely BACTERIAL

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Risk of Occult Bacteremia

Low Risk High Risk
Age >3yr <2yr
Temp <39.4ºC >40ºC(104ºF)
WBC >5000 and <5000 or >15,000
<15,000
Hx of contact with H. Flu
or N. meningitidis

OB has a low prevalence, so even though WBC is a sensitive and specific screening
test, it has a low PPV. So the test does not discriminate between children who
have FWS who are bacteremic and those who are not.
Therefore, blood culture is the gold standardstill has a high number of false
positives, take 24-48hrs, and most cases of occult pneumococcal bacteremia 14
clear without treatment.

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PROSEDUR 3 LANGKAH (3-STEP PROCEDURE)

Step 1: Mencari kausa (anamnesis dan pemeriksaan fisik)
Pemeriksaan fisik tetap sebagai alat utama
Dokumentasikan lama dan pola demam
Berapa lama anak sudah demam, dan berapa suhu maximum?
Apakah suhu bervariasi dalam sehari?
Gejala penyerta (diarrhea, rash, cough, pain)?
Apakah demam menetap lebih dari seminggu tanpa kausa yg diketahui? Bila
ya, per definisi disebut fever of unknown origin (FUO)

•Anamnesis dipandang dari sudut usia serta adanya penyakit sebelumnya yang
berarti, akan menentukan prosedur berikutnya

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3-STEP PROCEDURE
Step 2: Critical assessment serta keputusan ttg langkah-langkah berikutnya
yg diambil (MRS atau Rawat jalan)
•Suhu tubuh diukur setepat mungkin. Bila pemeriksaan fisik tdk menemukan apa-
apa, disebut fever without source
•Kesan umum dokter merupakan faktor terpenting menentukan rawat inap/ jalan
•Anak demam yang aktif, dapat rawat jalan, tdk perlu periksa darah, selama
anamnesis, klinis serta pemeriksaan fisis menyingkirkan infeksi secara bermakna
di saluran nafas atas atau bawah, appendicitis, dan meningitis
•Perlu dilakukan urinalisis, evaluasi anak dalam 1-2 hari
•Edukasi lengkap pd ortu tentang warning signs, shg dpt dicegah periksa ke dokter
serta pemberian obat antibiotik yg tdk perlu
•Bila anak tampak sakit, klinis ditemukan capillary refill time ≥ 3 detik, cyanosis,
somnolent, dyspnea, edema, dehidrasi, oliguria, meningeal irritation, mobilitas
terganggu [mis., anak tdk dpt berjalan lagi], kejang, muntah), atau terdapat faktor
resiko lain perlu MRS 16

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Step 3: Re-evaluasi dan uji laboratorium khusus serta studi tambahan,

bila diperlukan
•Anak dng demam menetap selama observasi poliklinis  reevaluasi
•Anak yg pernah MRS dilakukan uji diagnostik: UL ulang, differential blood
count, C-reactive protein (CRP), dan, atas indikasi, foto toraks utk
menyingkirkan infiltrat, efusi, atau pembesaran kelenjar hilus
•Tujuan utama evaluasi diagnostik utk mengidentifikasi pathogen; harus
dilakukan kultur darah dan urin anaerob dan aerob. Tergantung tampilan klinis
anak, dilakukan LP. Pulse oximetry bila anak tampak sakit berat
•Pada neonatus, termasuk bayi prematur, gejala klinis sepsis sangat
nonspecific atau bahkan tdk ada

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clinically relevant findings in the

physical examination of a child
with fever

Niehues T: The febrile child: diagnosis and

treatment. Dtsch Arztebl Int 2013; 110(45):
764−74

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WORK UP IN CHILDREN WITH FEVER

 DO: Gradual Laboratory examination

Step 1 WBC, blood smear, blood cell morphology

Chest x-ray
Thick blood smear (endemic malaria)
BSR, CRP
Urine analysis
LCS, other body fluid depend on indication
Blood, urine, stool, nasopharyngeal swab culture
Tuberculin test
Liver function test
* Note: in serious case, lab procedure should be performed more rapidly 22

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Laboratory examination (2)

Step 2 Serological test: Salmonella, toxoplasma, leptospira,
mononucleosis, CMV, histoplasma
Ultrasonography: abdominal, skull
Step 3 Bone marrow puncture
Intravenous pyelography
Paranasal sinus photography
Antinuclear antibody (ANA)
Barium enema examination
Scanning examination
Liver biopsy
Laparatomy diagnostic
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DON’T: Laboratory examination

Don’t tests or give antibiotics if infant or young child looks well and
no possible bacterial source is identified
• Schedule a follow-up appointment within 24-48 hours and sooner if the
condition worsens
Don’t test serological antibody in fever< 5 days

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MANAGEMENT IN CHILDREN WITH FEVER

DO: Fever Management: ANTIBIOTIC

As clinical diagnosis of bacterial infection is rarely possible within the
first 2-3 days of fever  prescribing antibiotic is not recommended
during this period
For most community infections, oral amoxycillin, or cotrimoxazole is
sufficient (first line drugs)
If the response to the first antibiotic is poor, another drug may be
tried. If two drugs have failed, it is logical to reconsider the diagnosis
rather than change the antibiotic

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Antibiotic prescription in bacterial infection

Bacterial infection Guess

Culture
Cured (Gram stain)
Empirical
therapy
Narrow spectrum of Pathogen
antibiotic identification

Definitive
therapy
Confirmation

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DON’T: Fever Management: ANTIBIOTIC

Do not prescribe an antibiotic without presumptive diagnosis

- Routine investigations must be carried out to support it
Do not try empirical treatment for tuberculosis except in life
threatening situations
Injectable antibiotics are almost never needed in office practice
Newer antibiotics are not recommended for routine community
acquired infections
Steroids should never be used for undiagnosed fever
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KASUS SBI
SERIOUS BACTERIAL INFECTION
(1)

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Anak A, laki laki, 5 th, 14 kg

Keluhan Utama: Demam
• Demam sangat tinggi 39-40oC sejak 3 hari SMRS.
• Pasien datang karena demam tinggi dan tidak mau makan, kembung.
Demam terutama sore
• Ada kencing berdarah, nyeri saat pipis dan harus mengedan.
• Tidak ada diare tapi BAB lembek 1 kali sehari
• Batuk ringan
• Masih memakai diapers sepanjang hari

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PEMERIKSAAN FISIK
STATUS PRESENT
• Keadaan umum: lemah, tidak tampak sakit berat
• Kesadaran : compos mentis GCS (E4V4M5)
• Nadi : 88 kali/menit isi cukup
• Respirasi : 24 x/menit
• Suhu axilla : 39 °C
• Skala nyeri: 4-5
• Lain- lain dalam batas normal

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Diagnosis
Apakah diagnosis penyakit pada pasien ini?

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Diagnosis Kerja :
•Suspek Infeksi saluran kemih dengan hematuria

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Tatalaksana

Pemeriksaan apa yang diperlukan ?

Pemberian antibiotic empiris apa yang bisa diberikan ?

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TATALAKSANA

•Infus D5%, 20 tts/menit makro

•Paracetamol sirup 10 mg/kgBB/kali bila suhu > 38 oC
•Injeksi Ceftriaxon 1 x 1500 gram iv

Pemeriksaan :
•Darah tepi lengkap, urin lengkap
•Kultur darah
•Kultur urin
•USG ginjal ?
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HASIL LABORATORIUM HARI 1

• Lab Darah tepi lengkap Hb 12, Leukosit 16.430, neutrofil segmen 86%,
limfosit 14,5%, Trombosit 338.000, CRP 20
• Urin lengkap: darah samar ++, keton +, WBC 15-20/LPB,
eritrosit 2-4/LPB, leukosit esterase ++, nitrit +

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Hari ke 3 Perawatan
• Klinis masih demam tinggi, tidak mau makan karena kembung dan disuri
• Lab Hb 12, Leukosit 16.000, segmen 82%, Trombosit 285.000, CRP 20
• Hasil kultur darah: steril
• Hasil kultur urin: kuman E.coli 100.000/cc
• Resisten: Ampicillin, Amoxicillin clavulanat, ceftriaxon, ceftazidim,
cefotaxim
• Sensitif: Amikasin, Meropenem

Diagnosis pasti: ISK atas/ pielonefritis

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TINDAK LANJUT
Pertanyaan:
1.Apakah pemberian antibiotika pertama masih dapat diberikan ?
2.Bila tidak, antibiotika definitif apa yang akan diberikan berdasarkan
klinis dan hasil kultur urin ?

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Rencana selanjutnya:
•Konsultasi Divisi Infeksi
•Antibiotic ceftriakson diganti menjadi amikacin injeksi 1x 200 mg iv drip
•USG ginjal: dalam batas normal

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Hari rawat ke-6

• Demam turun bertahap setelah 1 hari penggantian antibiotika
• Makan mulai sedikit-sedikit setelah kembung berkurang. Pipis tidak
merah lagi
• Darah tepi ulangan: WBC 8500, neutrofil segmen 38%, limfosit 24%
• Hasil urinalisa ulangan: WBC 2-3/LPB, eritrosit 0-1/LPB, leukosit
esterase -

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Discharge planning?

• Pasien direncanakan rawat jalan dengan anjuran untuk kunjungan

follow up 3 hari setelah keluar RS, dengan membawa hasil ulangan
urinalisa dan kultur
• Edukasi: mencegah faktor predisposisi agar penyakit tidak berulang
• Terapi medikamentosa yang diberikan saat pulang: melanjutkan
antibiotik sampai dengan total 7 -10 hari

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Most UTIs in children are from

ascending bacteria
E. coli (60-80%), Proteus,
Klebsiella, Enterococcus, and BMJ Best practice,
coag. neg. staph. Assassment fever in
children,
June 2018 41

Antibiotic for Parenteral Treatment of a Urinary Tract Infection

Drug Dosage and Route Comment

50-75 mg/kg/day IV/IM as a single dose Do not use in infants < 6 wk of age;
Ceftriaxone or divided q12h parenteral antibiotic with long half-life; may
displace bilirubin from albumin

Cefotaxime 150 mg/kg/day IV/IM divided q6-8h Safe to use in infants < 6 wk of age; used
with ampicillin in infants aged 2-8 wk

Used with gentamicin in neonates < 2 wk of

Ampicillin 100 mg/kg/day IV/IM divided q8h age; for enterococci and patients allergic to
cephalosporins

Term neonates < 7 days: 3.5-5 mg/kg/

dose IV q24h
Infants and children < 5 years: 2.5
mg/kg/dose IV q8h or single daily dosing Monitor blood levels and kidney function if
Gentamicin with normal renal function of 5-7.5 therapy extends >48 h
mg/kg/dose IV q24h
Children ≥5 y: 2-2.5 mg/kg/dose IV q8h or
single daily dosing with normal renal
function of 5-7.5 mg/kg/dose IV q24h
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Pediatric Urinary Tract Infection Treatment & Management, emedicine 2018

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KASUS SBI
SERIOUS BACTERIAL INFECTION
(2)

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S, perempuan, 5 hari, 2950 gram

Keluhan utama: Demam dan sesak
• Demam sejak 3 hari sebelum MRS
• Sesak 2 hari sebelum MRS
• BAB dan BAK normal
• Riwayat kelahiran: spontan, langsung menangis, di bidan, BBL 3000
gram, AS 7-9

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Pemeriksaan
Pemeriksaan Fisik:
•Suhu: 38.5C HR: 160x/mnt RR 60x/mnt
•Gerak tangis lemah
•Retraksi intercostal +/+, rhonki basah halus +/+

Pemeriksaan Lab: Thorax Ro:

Hb: 17.5 Kesan pneumonia
WBC: 15.380 u/L
PLT: 394.000 u/L
CRP: 0.12
Procalcitonin: 0.17
SGOT/SGPT: 42/23
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Diagnosis
Apakah diagnosis penyakit pada pasien ini?
Rencana pemeriksaan?
Terapi? Antibiotika empiris ?

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Diagnosis: neonatal pnemonia

Rencana pemeriksaan? Kultur darah dan sputum
Terapi? Antibiotika empiris ?
PTx:
O2 NCPAP
– Infus D10% 0,18 NS:300 cc/24 jam
– Injeksi Ampicillin sulbactam 2 x 150 mg iv
– Injeksi Gentamycin 1 x15mg iv diencerkan

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Hari ke 8 perawatan (demam hari ke-10)

• Klinis masih demam dan sesak
• Lab: Hb 11,4, WBC 28.630, PLT 210.000, CRP 12,06
• Kultur sputum: Klebsiella pneumonia
• Resisten: Ampicillin, Cefotaxim, Ceftazidim, gentamycin
• Sensitif: Amikacin, Kotrimoksazol, cefo sulbactam, Meropenem
• Kultur darah: steril

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Tatalaksana
selanjutnya?

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CAP Pathogen Accoding to Age

Neonates 1-2 months 3-12 months 1-5 years >5 years
Streptococcus Chlamydia Viruses Viruses S pneumoniae
group B trachomatis
Enteric gram Ureaplasma Streptococcs S pneumoniae M pneumoniae
negative urealyticum pneumoniae
Viruses H influenzae Mycoplasma C pneumoniae
pneumoniae
Bordetella S aureus Chlamydia
pertussis pneumoniae
Moraxella
catharrhalis

Disorders of resp tract in children, Kendig’s,

2012 50

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CAP, community-acquired pneumonia.

*Preferred treatments of choice change in areas of
high S pneumoniae resistance. Refer to the
complete guidelines for specific recommendations.
†The guidelines do not fully address the controversy
concerning the use of quinolones in children. The
use of quinolones in infants and children is
considered a risk
vs benefit decision

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CAP, community-acquired pneumonia.

*The addition of clindamycin 40 mg/kg/d IV divided
every 6-8 hours or vancomycin 40-60 mg/kg/day IV
divided every 6-8 hours is recommended for
suspected or
confirmed community-acquired methicillin-resistant
Staphylococcus aureus.
†The guidelines do not fully address the
controversy concerning the use of quinolones in
children. Use of quinolones in infants and children
is considered a risk vs
benefit decision

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Take home message

• Attention should be paid to toddlers (below three years of age)
with high fever for detect SBI
• History taking, physical examination, proper diagnostic could
help to detect the serious infection
• Antibiotic only used for bacterial infections

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Thank you
for
your attention

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