patogenesis,dignosis,& terapi terkini demam tifoid

7/23/2019 Patogenesis,Dignosis,& Terapi Terkini Demam Tifoid

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Typhoid Fever : Remaining issue

Prevention to Treatment

SUDIRMAN KATU

Division of Tropical Medicine and Infectious Diseases

Departement of Internal Medicine

Medical Faculty of Hasanuddin Univesity2013


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CURRICUUM !IT"#

Nama : dr.H.Sudirman Katu,SpPD-

KPTI

TTL : Tonasa,13 Juni 1970

Pndidi!an :

1. Do!tr umum - "K#H Ta$un 199%

&. Do!tr Spsia'is - "K#H Ta$un &00(3. Konsu'tan Pn)a!it Tropi! dan In*!si

- "K#I+S &01&


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History of Typhoid fever

1829 French Physician Pierre Louis(17871872 ! in"ro#uce# "he "er$%"y&hoi#' $ean i)e "y&hus

18*8 +rea" S"in) o, Lon#on raises,ears o, an ou"-rea) o, ,e.er

18/0 Mos" scien"is" aree "ha" "y&husan# "y&hoi# are #i,,eren"

18/1 Prince A-er" #ies o, a %-oe

,e.er' &ossi-y "y&hoi#

1870s Scien"is" sho "ha" ,oo# a"eran# cer"ain ar"ices such ashan#)erchie, an# "oe con.ey "he"y&hoi# in,ec"ion

Great Stink of London 1858


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Alexander The Great died when he was 34 years old due to acute fever

illness possily due to typhoid fever or !alaria


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"rince Alert #181$%18&1' husand of (ueen )ictoria dies due to *owel fever

#typhoid fever'


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History of Typhoid fever

1884 Scientist including GeorgeGafky (1850-1918) isolate andculture the typhoid bacillus

1894 he diagnostic !idaltest "asintroduced

1904 #ase of $arry $allon(typhoid $arry) as healthy carrierof tyhoid

19%% &acterial of typhoid na'ed as

Sal'onella typhi by aniel l'erSal'on (1850-1941)

1948 *ntroducing ofchlora'phenicolreducing 'ortalityof typhoid


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Typhoid Fever

Typhoid fever is an acute systemic

infection caused by Salmonella enterica

serotype typhi or paratyphiwhich is alsoknown as Salmonella typhi


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Typhoid fever

Global health problem and highly endemic inndonesia

Global annual incidence !! million cases and"# million deaths$ ncidence in ndonesia estimated !#%&'"%

cases("%%$%%% population per year

)ase fatality rate *$'&"+,! , of all mortality -#%$%%% death(year.

Seowandojo E, 1998


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/pidemiologic 0istribution of Typhoid Fever

/ Stron') ndmi

/2ndmi

/ Sporadi ass

1 of 2ntimicrobial )hemoth *%%3 4 + ,nfect -ev .tries *%""
http://en.wikipedia.org/wiki/Endemic_(epidemiology)http://en.wikipedia.org/wiki/Endemic_(epidemiology)


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"$ Gram&negative5 flagellated andfacultative anaerobic bacteria

*$ The cell envelope contains a comple6

lipopolysaccharide-7PS. structure$-an outer 8&polysaccharide coat5 a

middle portion5 the R core5 and an

inner lipid 2 coat.

!$ This 7PS structure is thought as an

endoto6in5 and important in

determining virulence of the

organisms$

Salmonella:Structure5 )lassification5 9 2ntigenic Types


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Some e6ample of commonly

8ccuring Salmonella serotypes and groups

Group Serotype

2 S$ paratyphi 2

S$ paratyphi

S$ stanley

S$ saintpaul S$ agona

S$ typhimurium

) S$ paratyphi )

S$ choleraesuis

S$ virchow

S$ thompson

0 S$ typhi

S$ enteritidis

S$ dublin

S$ gallinarium


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;ethod of Transmission:

Instiono* ontaminatd *ood or atr

T$ stoo's and urin o* $roni arrirs

usua'') ontains *rom 10%to 109oranisms+

a s$'' *is$ *rom po''utd atr prsnts

it$ an normous dos o* S. typhi


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Factors that nfluence nfectivity

Instion o* 104oranism aus 'inia' disas in &45

107oranisms ausd disas in 405

109oranisms ausd disas in 945

Strains t$at do not $a6 8i antin ar 'ss

in*ti6 and 'ss 6iru'nt


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Patterns of disease in )ommunity:

D6'opd ountris: ood sa and atr supp') s)stm ost ass ar sporadic or importedor an ;

traced to contact with chronic carriersD6'opin


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2mong "%"3 sub


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Pat$onsis


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Pathogenesis -continue.


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)linical Picture

Fever Headache malaise

myalgia nausea abdominal discomfort constipation

diarrhea dry cough epista6is

confusion5 delirium psychosis convulsion

coated tongue bradicardia relative tender abdomen hepatomegaly

splenomegaly rose spots erythmatous muco

papular lesion


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% # ? ">

"6r pattrn in T)p$oid "6r

High fever

Headache2bdominal discomfort

0iarrhea or constipation

Relative bradicardia

7eucopenia

;ild thrombocytopenia

Relative neutrofilia2neosinofilia


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Fever pattern : typhoid fever

Typhus nversus Pattern

7owest early in the morningHighest about #$!% to +$!% pm

)an be found in typhoid fever

tuberculosis

Pulse Temperature dissosiation n normal temperature !?o) -33oF. pulse '% beats(min

ncreased 3 beats(min every "oF

Relative bradicardia can be found in

enteric(typhoid fever

mycoplasma5 malaria falciparum

0evervescence :!&? days after treatment

usually on *ndor !rdweeks


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7aboratory /6amination

Peripheral blood count leucopenia5 leucocytosis normal @) count

mild anemia

thrombocytopenia

increased /SR

nflammatory increased )RP

Serum transaminase increased 27T and 2ST

2lbumin Hypoalbuminemia

Serology @idal5Typhidot

Tube6 -Salmonella g;.lood culture Gall -Salmonela Shigella.

P)R Salmonella typhi


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7aboratory 0iagnosis: )ulture

)ulture: is essentialfor diagnosis$A loodculture

A one marrow aspirate culture

A Brineculture

A Stoolculture

Failureto isolate the organism usually due to:

A the limitations of laboratory media$

A the presence ofantibioticsdue to early empiric treatment

A small volume of the specimen cultured

A the time of collection


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0iagnostic criteria

D*init: Positive gall culture or P)R Salmonella typhi

@idal serology agglutinin 8 titer C "(+>%

or H titer C"("*'%ncreased of 8 titer twice or more

Pro;a;':

@idal serology agglutinin 8 titer "(!*%

or H titer "(+>%$


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Relapse of typhoid fever: "D! weeks after temperature has reached normal$

milder pattern to the primary attach$

lood culture is positive$

Recurrence of typhoid fever: !D>ms after the illness$

lood culture is positive$

2ntibiotic resistance of typhoid fever: the abilityof a salmonella typhi to surviveandreproducein

the presence of antibiotic doses that were

previously thought effective against them

2$

0iagnostic criteria


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Treatment

Non P$armao'oi : >d rst, Nutrition P$armao'oi S)mptomati ?nti;ioti :

?mpii''in+?mo@ii''in

$'oramp$nio' A@400m p$a'osporin : *tria@on 3-A +da)s "'uoroBuino'ons : ipro*'o@a@in &@400 m C*'o@ain &@A00 m

P*'o@ain 1@A00 m "'ro@ain 1@400 m L6o*'o@ain 1@400m


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Global distribution of ;0RST-;ulti 0rug Resistant Salmonella Typhi.

!%

Viet Nam (1997)Quinolone-

Resistant S.typhi

USA (1996-2003)Nalidixic Acid Resistance

S.TyphiSA (2005) !e"tio"u#-Resistant Salmonella

Aust#alia (2006)Anti$iotic#esistantSalmonella in"ectionsin

Cuba(2006)%Mexico (2007)&ultid#u'-#esistantsalmonella

!anada (2009)!e"oxitin-#esistant

Salmonella

aa#ta*+,RS!&(1990-199 ) /#esistant o"S.typhi infection9%.

&aassa#(2007)/ #esistant o"S.typhi infection6,8.

tio4ia(2011) 5 6. multi4l#esistant to t#im-sul4a% ce"t#%clo#am and 'enta% ci4#o8.

!lin.,n"ect.iseases 19975 o" Antimic#o$ial !emot 20Commun Dis ntell 20065 Antimic#o$ial a'ents and cemot. 2

Antimic#o$ial a'ents and cemot.! nfect De" Ct#ies


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A #u' #esistance in most cases is te #esult

o" /E 'enetic can'e (c#omosomal mutation in

te o#'anism)

E :lasmid mediated #esistanceA;4es 4idel in Asia.

A;e la#'e 4lasmids can ten $e t#ans"e##ed toand "#om ente#ic '#am ne'ati?e $acte#ium sucas $che#ichia coli, %le&siella pneumoniae an' S.ente#ica, es4eciall >en antimic#o$ials a#e$ein' administe#ed.

!"

Mechanisms of MDRST

;asatomo : 2ntimicrobial agents and chemotherapy *%"%

Getenet : + ,nfect -ev .tries *%""+-haka 0ed .oll/ 228


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E A &ulti-#u' Resistant Salmonella t4i

E (&RS;) >as a44ea#ed $ te 4#esent o"

E '#A and ;&-1 'ene.

MDRST

)r ?

n

T2-1n

"'uoroBuino'on

sistan

>ta'atamas>ut not 2S>L

Pnii''ins rsistan

*tria@on rsistan

oon H15 )ho SH5 im SH5 2 case of ;0R Salmonella enterica serovar typhi treated with a bench to bedside2pproach5 onsei 1 ;ed5 *%%3 : #%-". : ">?"

2N2?L 2H?NIS o* DST


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A T$ possi;i'it) o* D-ST s$od ;)'inia' imprssion in $i$ t$rs no

ood rsponsa*tr mpiria' adBuat

t$rap) ;) :A Pnii''in : ?mo@)i''in, ?mpii''in

A "'uoroBuino'ons : ipro*'o@ain

L6o*'o@ain

A p$a'osporins : *tria@on

onsei ;ed 1 #%-".:">? & "#"5 *%%3

;e :ossi$ilit o" &RS;


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DST 1: ipro*'o@ain + L6o*'o@ain

T$ird nration p$a'osporin

DST & : ono;atam ?EtronamF -G India , Kors'

ar;apnm

TR/2T;/T 8F ;0RST

1ohn @ine5 + ,nfect -evelopin .ountries *%%'

onsei ;ed 1 #%-".:">? & "#"5 *%%3


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Pr6ntion

2void risky food or drinks Hand washing =accination 0etection of carrier state in food handler


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Prevention & General

nra' sanitation spia'') *or atr supp'), astdisposa' and inst ontro'.

Ha't$ duation and sanitar) 'i* st)'

T$ oranism is suspti;' to ;oi'in and ommon

disin*tants.

Idnti*iation and tratmnt o* arrirs spia'') in

*ood$and'rs spi*i stoo' u'tursF. ?nti;iotis ar

**ti6 in radiation o* arrir stat. T$ ;st isipro*'o@ain740m >ID *or A !s. ?mpii''in, o-

trmo@aEo' and $'ramp$nio' ar 'ss **ti6.

$o')sttom) ma) ; rBuird.


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Prevention & specific 8aination is indiatd *or tra6'rs to ndmi aras

and ar somtims usd on a 'imitd sa' in prsn

o* out;ra!s. To parntra' and on ora' 6ains ar

a6ai'a;'.

8i po')sa$arid, is i6n in a sin' I dos. Prottion;ins s6n da)s a*tr intion, ma@imum prottion

;in ra$d &( da)s a*tr intion $n t$ $i$st

anti;od) onntration is o;taind.

Protti6 **ia) as 7&5 on and $a'* )ars a*tr6aination and as sti'' 445 t$r )ars a*tr a sin'

dos. 8i-nati6 strains $a6 ;n rportd in som

?sian ountris in up to 35 o* iso'ats. 8i 6ain is

not **ti6 *or t$s strains.


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Prevention & specific

Li6 ora' 6ain T)&'a T$r doss to da)s apart on an mpt) stoma$.

Prottion starts *rom 10-1A da)s a*tr t$ t$ird dosand ontinus *or G4 )ars.

Protti6 **ia) o* t$ ntri-oatd apsu'*ormu'ation s6n )ars a*tr t$ 'ast dos is sti''%&5 in ndmi aras.

?nti;iotis s$ou'd ; a6oidd*or 7 da)s ;*or ora*tr t$ immuniEation. >oostr doss s$ou'd ;i6n 6r) 3-4 )ars.


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ndication for hospitaliIation :

Severe ;anifestations

Poor intake

To6ic typhoid

Perforation symptoms


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'aps a*tr tratmnt:

10- &45 in patints ri6in $'oramp$nio'

1- %5 patints ri6in nr anti;iotis

p$a'osporins and "Fost') r'apss our durin &-A !s a*tr

nd o* anti;ioti t$rap).

tratmnt s$ou'd ; pr*ormd


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$roni arrir:

? prson $o @rts t$ oranism instoo's 1& mont$s a*tr t$ initia' i''nss.

*%, at * months "%, at ! months

!, go on to become carriers -range "&+,.$roni arria mor *rBunt it$ t)p$oid

t$an non-t)p$oid strainsHi$r pr6a'n in *ma's and it$ a''

stons&45 ou'd not i6 a $istor) ompati;' it$

t)p$oid *6r.


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Treatment of )hronic )arriers of S/ typhi:

o Gall&Stones: Cra' ?mpii''in+amo@ii''in+TP-S *or 3

mont$sPresence of Gall&stones:

Tr) a;o6 rimn prior to surr) In most ass anti;ioti p'us

$o')sttom) rBuird ipro*'o@ain 740m PC >ID or Nor*'o@ain

A00m >ID *or &( da)s)hronic urinary carriers: Trat s$istosomiasis *irst, i* prsnt,

;*or anti;iotis


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)onclusionsTyphoid fever : acute systemic illness due to

Salmonella typhi and paratyphiTransmission : fecal oral : food E water

)linical manifestation :

Fever5 G symptoms5 systemic symptomsTreatment : Supportive and symptomatic

2ntimicrobial : 2mpicillin5 )hloramphenicol

FJ : )iproflo6acin5 etc

!rdGen )ephalosporine

Prevention : hand washing5 avoiding non hygiene

food5 vaccination and detection carrier


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Thank you

patogenesis,dignosis,& terapi terkini demam tifoid

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