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BIO DATA
Nama
: Dr. Soroy Lardo, SpPD FINASIM
Pangkat/Nrp
: Letkol CKM/1920013110563
Kesatuan
: Departemen Penyakit Dalam RSPAD
Status
: K-3
Riwayat Penugasan :
Dokter Yonif 132/BS Kodam I/BB
Pasiwatkes Rumkit Putri Hijau Kodam I/BB
Ka Rumkitban Binjai Kodam I/BB
Ka Bangsal Paviliun Rumkit Putri Hijau Kodam I/BB
Kasidiklitbang Departemen Paru RSPAD Gatot Soebroto
Kabagyanmed Departemen Penyakit Dalam RSPAD Gatot
Soebroto
Kasub SMF Penyakit Tropik dan Infeksi DepartemenPenyakit
Dalam
Riwayat Pendidikan :
Fakultas Kedokteran UNPAD 1991
Gaster (stomach)
Enteric
(small intestine)
Colonic
(large intestine)
Etiology / Microbiology
Clinical Manifestations
Pathogenesis
Diagnosis
Treatment
Complications
SALMONELLOSIS
(Infections caused by Gram-negative bacteria)
Taxonomy :
SALMONELLAE sp. : 2000 serotypes
Human infection :
S. enterica subspesies enterica
which three serotypes :
1. S. typhi
2. S. typhimurium (S. paratyphi A and B),
now called : S. schottmulleri
3. S. choleraesuis
CHAMBERS. Infectious Diseases. In: Lawrence, et al. Current MD&T,
34th Edition. A Lange medicalbook Intl Ed. 1995;1173-9.
Clinical Patterns of
Infection
1.
2.
3.
Microbiology :
Most commonly caused by
Salmonella typhi
Salmonella paratyphi A, B, C
The other serotypes : S.choleraesuis
S.enteretidis
S.arizonae
Salmonellosis
: Enteric fever
Gastroenteritis
Sepsis
Family
Enterobacteriaceae
Motile
Somatic
Flagelar
antigen
Vi
Facultative anaerobic/aerobic
Gram (-) bacteria
Rods shape
Susceptibility to Disinfectants :
1. 1 % Sodioum hypochlorite
2. 2 % Glutaraldehyde
3. Iodine
4. Phenolics
5. Formaldehyde
Physical Inactivation :
1. Sensitive to moist heat (1210C) for at least 15 min
2. Dry heat (160 1700C) for at least 1 hour
Survival outside Host :
.Ashes 130 days
.Rabbit carcass 17 days
.Dust up to 30 days
.Feces up to 62 days
.Linoleum floor 10 hours
.Ice 240 days
Epidemiology :
Worldwide, except in industrialized regions such us the
United State, Canada, western Europe, Australia, and Japan
In the developing world, it affects about 12.5 million
persons each year
Over the past 10 years, travelers from the United States to
Asia, Africa, and Latin America have been especially at risk
Typhoid fever can be prevented and can usually be treated
with antibiotics
Multi-drug resistant strains have appeared in several areas
of word
Indonesia 760 810 cases / 100.000 / year with death rate
3.1-10.4 %
Indirect
Infection
> 90 %
Infected
Water
Food
Chronic carrier
Stool
Vomit
Urine
Healthy
subject
Typhoid
fever
Direct
Infection
< 10 %
Faktor Penentu
Virulensi
Salmonella thypi
Capsular Vi (Polysaccharide
(Vi) ada 2 determinan
antigen (O)- acetyl N acetyl
carboxyl)
Porin (Omp
B,C,D dan
OmpR)
Non
Porin
Patofisiologi
Makan
an yg
tercem
ar
Duktus
Torasiku
s
Masuk
PD ke
RES
(hati,
limpa,
SST)
Menemb
us
mukosa
usus
Kelenjar
limfe
usus
(replikas
i)
Ke
Pembul
uh
darah
BAKTEREM
IA 1
(24-72jam)
Kapsul
Vigagal
fagositosis
Replikasi pesat
(7-10hari)
BAKTEREM
IA2
Bakteremia
ke-2
Endotok
sin (LPS)
C3a,
C5a
IL
2
Sel Plasma
Limfosit B
& Agglutinin
O
Sel Plasma
&
Limfosit B
Limfosit
Agglutinin H &
T
Agglutinin Vi
T-helper
pirogen
IL1
Hipotalamu
s demam
Imunopatogenesis
Terdapat 4 komponen antigenic penting pada S typhi:
1. Kapsular Vi
2. Lapisan luar (antigen O)
3. Flagella protein (antigen H)
4. Outer Membrane Protein (OMP)
S typhi
Resists the low pH of stomach
Reach SMALL
INTESTINE
Clinical
manifestation
Bacteremia, endotoxin
release
Communicability :
As long as typhoid bacilli appear in excreta
Usually 1st week throughout convalescence
10 % of patients discharge bacilli for 3 months
after onset
2 5 % become chronic carriers may shed
bacteria for years
Enteric
fever
syndrome
Headache
Anorexia
Rose spots
Splenomega
ly
Fever
Chills
Malaise
Weight loss
DIC
Bacteremia
Abdominal pain
weakness
Hepatomegaly
hypotension
Classic presentations :
First week of illness : stepwise fever &
bacteriemia
Second week : abdominal pain and rash
Third week : hepatosplenomegaly, intestinal
bleeding and perforation, secondary bacteriemia
and peritonitis
periode
10-12 days
S. Typhi
Mouth
Peyers patch
Blood stream
V.Velea
Intestine
Peyers patch
Normal
Week1
Week2
Week3
Week4
Chronic
periode
Relaps or
Carrier
Tripple Cross
--- Blood pressure
--- Temperature
--- Pulse
Adapted from Syafruddin ARL RSPAD 2005
Pathogenesis :
Ingestion of S.typhi
MULTIPLI
CATION
Excreted in stool
and Urine
Inflammation, necrosis,
Ulceration Payers patches
Draining mesenteric
Lymph node
Secondary bacteremia
Primary bacteremia
Pathology :
Payers patches :
Hyperplasia during the first week
Necrosis in second week
Ulceration during third week
Healing takes place without scarring
during forth week
The ulcer are oval shaped,
in the long axis of lower ileum
Separation of the sloughs hemorrhage and
perforation
Diagnosis :
1.Isolation of Organism :
- Blood cultures : positive in 40 80 % patients
during the first 7 10 days
- Culturing stool
- urine
- rose spots
- duodenal contents via string capsule : positive in
30 40 % patients
- bile
- faeces
3. Detection of antibodies :
- Widal tube test
- Widal slide test
- IHA
- CIEP
- RIA
- ELISA
Laboratory Findings :
Anemia
Leucopenia or leucocytosis
Thrombocytopenia
Abnormal liver function
Diagnosis :
Dari hasil pemeriksaan klinis pada saat penderita masuk RS diambil data-data
sesuai dengan yang diajukan oleh Nelwan (1991). Ketepatan diagnosis demam tifoid
dihitung dengan skor:
No
Gejala Klinis
Skor
Sefalgia (pusing)
Rasa lemah
Mual
Nyeri perut
Anoreksia
Susah tidur
Splenomegali
Gejala Klinis
Skor
10
Hepatomegali
11
Muntah
12
13
Apatis
14
Lidah tifoid
15
Bradikardi relatif
16
Feses hitam
Skor Maksimal
20
Nilai ramal demam tifoid = skor/20 x 100% menunjukkan persentase kemungkinan terjangkitnya
pasien dengan salmonella typhi atau paratyphi. Dari studi yang dilakukan skor 13 ke atas sudah
mengarah ke diagnosis demam tifoid, sedangkan skor di bawah 7 kecil kemungkinan penderita
terjangkit demam tifoid.
Management :
Suspect Typhoid cases
General Nursing care and Diet
Specific antibiotic therapy
Treatment of Chronic carriers
Management of complications
Antibiotic Therapy :
Chlaramphenicol 4 X 500 mg 11-14 days
Ampicillin 50 -100 mg /kg BW/ day
Trimetropin sulfametoksazole 2 x 2 tab
Ceftriaxone 50 100 mg/ kg BW / day
Cefoperazone 100 mg/kg BW/ day
Cefotaxim 2 3 x 1 gr
Ciprofloxacin 2 x 500 mg
Fleroksasin 1 x 400 mg
Ofloxacin 1 x 600 mg
Perfloxacin 1 x 400 mg
Levofloxacin 1 x 500 mg
DISKUSI
Tabel 1. Perbandingan
(Defervescence)
Demam
Komplikata Fluorokuinolon
Reda Demam
Tifoid
Non-
Nama Obat
Disis
Lama
Pemberian
Penurunan
Demam
Siprofloksasin (5)
500 BID
6 hari
3,60 hari
Ofloksasin (6)
600 mg OD
7 hari
3,40 hari
Pefloksasin (7)
400 mg OD
7 hari
3,10 hari
Fleroksasin (8)
400 mg OD
5 hari
3,40 hari
Levofloxacine (9)
500 mg OD
7 hari
2,43 hari
DISKUSI
Tabel 2. Betalaktam
demam tifoid
untuk
pengobatan
Beta Laktam
Dosis
Lama Pemberian
Ampisilin
Dua minggu
Amoksisilin
50150mg/kgBB/hari
Dua minggu
Sefiksim
Seftriakson
4 gram/hari
Tiga hari
3 gram/hari
Empat hari
2 gram/hari
Enam hari
DISKUSI
Tabel 3. Berbagai jenis antimikroba untuk
demam tifoid
Antimikroba
Dosis
Kloramfenikol
Hari ke 1 4x250
IV/oral
Lama Pemberian
Hari ke 2 4x500
IV/oral
2 minggu
Kotrimoksazol
2 x 2 tab oral
2 minggu
Azitromisin
2 x 500 mg IV/oral
1 minggu
Aztreonam
3 x 1 gram IV
1 minggu
Resistance to :
Chloramphenicol
Amoxycillin
Cotrimoxazole
Kardiovaskuler
Neuropsikiatri
Respirasi
Bronkhitis
Pneumonia
Hematologi
Anemia
Koagulasi intravaskular Diseminata (KID)
Lain lain
Abses Lokal
Faringitis
Relaps
Karier khronis
Nama peneliti
Komplikasi
Hendarwanto
Loehoeri
Darmanik
Herdiman
Ratih
(%)
1979
1994
1994
1997
2002
Yogya
Perdarahan
Perforasi
Syok septik
Pneumonia
DIC
Hepatitis
Meningitis
Tifoid toksik
Artritis
14,1
5,4
2,2
2,2
1,1
-
3,07
0,44
4,33
4,38
18,4
-
Denpasar
8
1,8
0,9
7,1
1,8
-
44,4
11,1
16.6
11,1
27,7
-
24,4
16,3
24,4
10,2
36,7
2
> 20 hari
6.1
4
16 - 20 hari
22.4
11 - 15 hari
57.1
6 - 10 hari
10.2
1 - 5 hari
10
20
30
40
50
60
Carriers :
Biliary carriers
Urinary carriers
Intestinal carriers (faecal)
1- 5 % thypoid patient
Problem : cholelitiasis dan
nephrolitiasis
Prevention
Decontamination
Louse
: Hospitalization
control:
Bathing and laundering of clothes
in hot water with detergent
Reduction of exposure
Identification and eradication
Prevention of transmission
Protection of the risk infection
Typhoid Vaccines :
TERIMA
KASIH
References :
1. Hohmann, L.E : Approach to the patient with typhoid fever, @2000
UpToDate.www.uptodate.com.(800)998-6374.(781)273-4788
2. Salmonella typhi, From : http://www.medinfo.ufl.edu/year2/mmid/bms5300/bugs/saltyphi.html
3. Material Safety Data Sheet Infections Substances, Section I : Infectious Agent, From :
http://www.hc-sc.gc.ca/pphb-dgspsp/msds-ftss/msds134e.html
4. Typhoid Fever, From : http://www.cdc.gov/ncidod/dbmd/diseaseinfo/typhoidfever_g.htm
5. Ichhpujani, R.L , Bhatia, R : Typhoid Fever, Top Publications, 4093, Nai Sarak, Delhi 110 006,
India, 1997.
6. Zulkarnaen,I : Pola Kepekaan Salmonella typhi terhadap beberapa antibiotika,Demam Tifoid,
Peran Mediator, Diagnosis dan Terapi, Subbgian Penyakit Tropik dan Infeksi FK UI, Jakarta,
2000
7. Suhendro, Inada,K , Hendarwanto, Zulkarnain,I : Patterns of Cytokine and Nitric Oxide in
Typhoid Fever, Demam Tifoid, Peran Mediator, Diagnosis dan Terapi, Subbgian Penyakit
Tropik dan Infeksi FK UI, Jakarta, 2000
8. Nasronudin. Demam Tifoid. Dalam Penyakit Infeksi di Indonesia dan Solusi Kini dan
Mendatang. Edisi ke 2. Airlangga University Press. 2011 , Surabaya. h: 187 -190
9. Nasronudin. Imunopatogenesis, Diagnosis dan Tata Laksana Demam Tifoid Masa Kini.
Dalam Penyakit Infeksi di Indonesia dan Solusi Kini dan Mendatang. Edisi ke 2. Airlangga
University Press. 2011 , Surabaya. h: 191-208
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