UKK Infeksi & Penyakit Tropis IDAI

Update Tatalaksana Demam Tifoid

pada Anak di Indonesia
Anggraini Alam
High-risk groups:

• Single, median age 22 yo

• unemployed

• university education.

• Consumption of food from warungs

was strongly associated with risk (OR
545).

• Both cases and controls washed hands

after use of the toilet and before
meals, but cases used soap
significantly less often (OR 530)
Velema JP, t al. Trop Med Int Health. 1997
Nov;2(11):1088-94.
Pertanyaan:
Pernyataaan di bawah ini benar, kecuali:
a. Perubahan iklim juga berkontribusi terhadap naiknya kasus demam tifoid
b. Kelompok risiko tertinggi terinfeksi S.Typhi adalah masyarakat di lingkungan sanitasi
dan kurang ketersediaan air bersih
c. Kasus demam tifoid ditemukan di kota maupun desa dengan kepadatan tinggi
d. Anak memiliki kemungkinan sdemam tifoid lebih tinggi dibandingkan lansia
e. Semua jawaban benar
 Incidence rates (per 100000) of typhoid and paratyphoid fevers, by country, in 2017

Global age-specific incidence

rates (per 100000) of typhoid
and paratyphoid fevers in 2017

>100/100 000 cases per year are considered high-incidence settings

GBD 2017 Typhoid and Paratyphoid Collaborators*. Lancet Infect Dis 2019; 19: 369–81
 Geographical distribution of typhoid and paratyphoid
outbreaks reported from 1 January 1990 to 31 December 2018

The standard WHO definition of outbreaks:

“the occurrence of cases of disease in excess of what

would normally be expected in a defined community,
geographical area or season. An outbreak may occur
in a restricted geographical area, or may extend over
several countries. It may last for a few days or weeks,
or for several years”
 Typhoid and climate change

• the faeco-oral transmission of S.

typhoid fever
typhi is facilitated when the
rainfall
availability of water is reduced and
the quality of stagnant surface
water deteriorated through the
combined effects of rising
temperature, evaporation and
absence of fresh supplies

Velema JP, t al. Trop Med Int Health. 1997

Nov;2(11):1088-94.
• Mary Mallon (1869 – 1938) was the first individual
who was found to be an asymptomatic carrier of
the typhoid bacterium, and this caused the health

• Commonly known as Typhoid Mary, was an Irish-

born American cook believed to have infected
between 51 to 122 people with typhoid fever.

• The infections caused three confirmed deaths,

with unconfirmed estimates of up to 50.

• She persisted in working as a cook and thereby

exposed others to the disease. Because of that,
she was twice forcibly quarantined by authorities,
eventually for the final two decades of her life.
Mallon died after a total of nearly 30 years in
isolation
Etiology
 Klinis

Epidemiologi

Laboratorium

Diagnosis Demam tifoid

 Perbandingan
penyakit yang
disebabkan S.
typhi dan S.
paratyphi = 10 : 1
Fever pattern in typhoid fever:
 Usia Sekolah dan Masa Remaja
• Gejala klinis menyerupai pasien dewasa.
• Onset insidious
• Malaise, anoreksia, mialgia, sakit kepala, sakit daerah
abdomen (anak biasanya tidak dapat menunjukkan daerah
yang paling sakit/rasa tidak nyaman difus), keluhan ↑ pada
Neonatus minggu kedua.
• Demam sampai hari ke-4 bersifat remiten dengan pola
• Gejala timbul biasanya sesudah 3 hari pasca dilahirkan seperti anak tangga (stepwise fashion), sesudah hari ke-5
berupa muntah-muntah, diare, distensi abdomen. Suhu atau paling lambat akhir minggu pertama pola demam
berbentuk kontinua.
tubuh tidak stabil, ikterus, BB ↓, undoing well, kadang
• Diare dapat ditemukan pada hari pertama sakit, selanjutnya
disertai kejang. terjadi konstipasi.
• Bila diare terjadi sesudah minggu kedua harus dicurigai infeksi
tambahan oleh jasad renik lain.
Usia Balita
• Mual dan muntah dapat ditemukan pada awal sakit
• Relatif jarang, biasanya bersifat ringan berupa demam ringan, • bila ditemukan pada minggu kedua atau ketiga harus diwaspadai awal
dari suatu komplikasi.
malaise, dan diare. Sering misdiagnosis sebagai diare akut.
• Pada minggu kedua keluhan malaise, anoreksia, mialgia, sakit
kepala, sakit daerah abdomen bertambah berat, dapat
ditemukan disorientasi, letargi, delirium bahkan stupor.
Pedoman Diagnosis dan Terapi Edisi ke-6. UNPAD PRESS. 2020
Diagnostic test
PEMERIKSAAN LABORATORIUM

Pada kecurigaan demam tifoid, harus dilakukan pemeriksaan kultur sebelum pemberian antibiotik.

Biakkan Salmonella
● Kultur darah : > positif pada minggu pertama dan awal minggu kedua (60-80%)
● Kultur feses & urin : > positif pada minggu 2 & 3
● Kultur sumsum tulang : invasif, sehingga tidak rutin dilakukan

Laboratorium
● Leukopenia, tapi jarang <2500/mm3, disertai limfositosis relatif dan aneosinofil
● Trombositopenia
● Anemia normokrom-normositer
● Peningkatan transaminase hepar & bilirubin serum (apabila ada hepatitis tifosa)
● Hiponatremia dan hipokalemia (pada penderita gizi kurang/buruk)

Pedoman Diagnosis dan Terapi Edisi ke-6. UNPAD PRESS. 2020

Lab diagnostic of Typhoid Fever • The best: blood culture during 1st
and 2nd week

• Stool culture during the later part

of the 2nd week and early part of 4th
week

• Urine culture done in 2nd and 3rd

week (weak)

• Serological test:
• Widal: O-antibody appears >7-10 d

• Highst positive results are during 3 –

4 weeks
• Widal test cannot be expected to give a reliable diagnostic result in
endemic regions for the following reasons:
• the inherent variabilities of the test
• difficulty in establishing a steady-state baseline titre for the population
• repeated exposures to S typhi in endemic regions
• cross-reactivities with other non-Salmonella organisms
• lack of reproducibility of the test result.

Olopoenia LA, et al. Postgrad Med J. 2000 Feb;76(892):80-4.

Complications
Azmatullah A, et al. J Glob Health.
2015 Dec;5(2):020407.
Tatalaksana Kasus Berat dengan Gangguan
01 02 Kesadaran, sirkulasi dan gejala
berkepanjangan

Deksametason:
Rawat Inap?
Inisial 3mg/KgBB
Lanjutan 1mg/KgBB tiap 6 jam
Apabila : selama 48 jam
Muntah persisten, diare berat,
distensi abdomen, dan
komplikasi lainnya Terapi Antipiretik
Umum Khusus
● Isolasi
● Tirah rebah selama ● Eradikasi kuman Acetaminophen 10-15
panas ● Terapi komplikasi mg/kgBB setiap 4-6 jam PO
● Diet makanan lunak ● Kortikosteroid apabila dibutuhkan
yang mudah dicerna

Kliegman, Robert., et al. Nelson Textbook of Pediatrics. Edition 20. Phialdelphia, PA: Elsevier, 2016
Antibiotic therapy
Pedoman Diagnosis dan Terapi Edisi ke-6. UNPAD PRESS. 2020
Treatment Options for Different Resistance Classes of S. Typhi
Pencegahan
• Kecukupan air bersih
• Sanitasi yang baik melalui sistem pembuangan yang teratur, penjernihan
dan klorinasi
• Menghindari makanan dan minuman kurang terjamin kebersihannya
• Makan dan minum yang sudah matang
• Mencuci tangan
• Imunisasi
Characteristics of Different Typhoid Vaccines

World Health Organization/Global Market Study 2 Global Market Study Typhoid Vaccines
Working Document. November 2020
Anggraini Alam

Vaksin tifoid polisakarida

diberikan mulai umur 2 tahun dan diulang setiap 3 tahun
Thank you