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Curriculum VitaeCurriculum Vitae
NamaNama :: Dr. Ronald Irwanto, SpPD, KPTIDr. Ronald Irwanto, SpPD, KPTI
Pendidikan :Pendidikan :
SMA CaniiuSMA Caniiu, !akarta, "##$, !akarta, "##$
Dokter %mumDokter %mum, &K TRISAKTI, '((", &K TRISAKTI, '(("
Speiali Pen)akit Dalam *Internit+Speiali Pen)akit Dalam *Internit+, &K%I, '((#, &K%I, '((#
Konultan Su- Speiali Pen)akit Tropik dan InekiKonultan Su- Speiali Pen)akit Tropik dan Ineki, Di/ii Pen)akit, Di/ii Pen)akitTropik 0 Ineki, Departemen Ilmu Pen)akit Dalam, &K%I 1 RSCM,Tropik 0 Ineki, Departemen Ilmu Pen)akit Dalam, &K%I 1 RSCM,'("2'("2
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Mana3in3 T)p4oid &e/er in Special Cae :Mana3in3 T)p4oid &e/er in Special Cae :
Pre3nanc) andPre3nanc) andMDR1Salmonella t)p4i *MDR1ST+ InectionMDR1Salmonella t)p4i *MDR1ST+ Inection
Ronald IrwantoRonald Irwanto
Di/iion o Tropical Medicine and Inectiou DieaeDi/iion o Tropical Medicine and Inectiou DieaeDepartment o Internal MedicineDepartment o Internal Medicine
&acult) o Medicine %ni/erit) o Indoneia&acult) o Medicine %ni/erit) o Indoneia
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A56NDAA56NDA
Typhoid fever : The Epidemiology andTyphoid fever : The Epidemiology and
Microorganism CharacteristicMicroorganism Characteristic
Clinical Appearance and Diagnostic ofClinical Appearance and Diagnostic ofTyphoid FeverTyphoid Fever
Treatment of Typhoid Fever : General andTreatment of Typhoid Fever : General and
in Pregnancyin Pregnancy
Treatment of MDR-TTreatment of MDR-T
Concl!sionConcl!sion
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Typhoid fever : The EpidemiologyTyphoid fever : The Epidemiologyand Microorganism Characteristicand Microorganism Characteristic
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T)p4oid &e/erT)p4oid &e/er
T)p4oid e/er i an acute )temicT)p4oid e/er i an acute )temic
inection caued -) Salmonellainection caued -) Salmonella
enterica erot)pe t)p4i or parat)p4ienterica erot)pe t)p4i or parat)p4i
w4ic4 i alo known a Salmonellaw4ic4 i alo known a Salmonella
t)p4it)p4i
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Among "#"$ s!%&ects 'ith fever(Among "#"$ s!%&ects 'ith fever( Salmonella typhiSalmonella typhi 'as'asidentified in )) *$+, andidentified in )) *$+, and Salmonella paratyphiSalmonella paratyphiA in . */+,A in . */+,patientspatients
Paratyphoid feverParatyphoid fever'as independently associated 'ith:'as independently associated 'ith:
0 cons!mption of food from street vendorscons!mption of food from street vendors0 andand and flooding1and flooding1
Typhoid feverTyphoid fever!sing the comm!nity control gro!p 'ere mostly!sing the comm!nity control gro!p 'ere mostlyrelated to the ho!sehold( ie( to recent typhoid fever in therelated to the ho!sehold( ie( to recent typhoid fever in theho!sehold:ho!sehold:
0 no !se of soap for hand'ashing2no !se of soap for hand'ashing2
0 sharing food from the same plate(sharing food from the same plate(0 and no toilet in the ho!sehold1and no toilet in the ho!sehold1
0 also( typhoid fever 'as associated 'ith yo!ng age in years1also( typhoid fever 'as associated 'ith yo!ng age in years1
Rik actor or T)p4oid 0 Parat)p4oid &e/erRik actor or T)p4oid 0 Parat)p4oid &e/er
in !akartain !akarta
3ollaard( AM1( 4AMA1 ##52$"*",:.#6-."7
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&actor t4at Inluence Inecti/it)&actor t4at Inluence Inecti/it)
8ngestion of8ngestion of
0 "#"#77organism ca!se clinical disease in 7+organism ca!se clinical disease in 7+
0 "#"#66
organisms ca!sed disease in 7#+organisms ca!sed disease in 7#+0 "#"#$$organisms ca!sed disease in $7+organisms ca!sed disease in $7+
trains that do not have 93i antigen are lesstrains that do not have 93i antigen are less
infective and less vir!lentinfective and less vir!lent
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6pidemiolo3) o T)p4oid &e/er6pidemiolo3) o T)p4oid &e/er
5lo-al 4ealt4 pro-lem and 4i34l) endemic in5lo-al 4ealt4 pro-lem and 4i34l) endemic inIndoneiaIndoneia
5lo-al annual incidence 22 million cae and5lo-al annual incidence 22 million cae and
"7 million deat4."7 million deat4.Incidence in Indoneia etimated 27(18"(Incidence in Indoneia etimated 27(18"(cae"((.((( population per )earcae"((.((( population per )ear
Cae atalit) rate '.81"9Cae atalit) rate '.81"9
2 o all mortalit) *7(.((( deat4)ear+2 o all mortalit) *7(.((( deat4)ear+
Seowandojo E, 1998
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". 5ram1ne3ati/e, la3ellated and
acultati/e anaero-ic -acteria
'. T4e cell en/elope contain a comple;
lipopol)acc4aride *
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Some e;ample o commonl)
=ccurin3 Salmonella erot)pe and 3roup
Gro!p erotype
A 1 paratyphi A
; 1 paratyphi ;
1 stanley
1 saintpa!l 1 agona
1 typhim!ri!m
C 1 paratyphi C
1 choleraes!is
1 vircho' 1 thompson
D 1 typhi
1 enteritidis
1 d!%lin
1 gallinari!m
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Clinical Appearance and Dia3notic oClinical Appearance and Dia3notic o
T)p4oid &e/erT)p4oid &e/er
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Clinical Preentation o T)p4oid &e/erClinical Preentation o T)p4oid &e/er
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Dia3notic criteriaDia3notic criteria
Deinite :Deinite :
Poiti/e 3all culture or PCR Salmonella t)p4iPoiti/e 3all culture or PCR Salmonella t)p4i
?idal erolo3) a33lutinin = titer?idal erolo3) a33lutinin = titer @@ "9$("9$(
or titeror titer @@""'8(""'8(
Increaed o = titer twice or moreIncreaed o = titer twice or more
Pro-a-le :Pro-a-le :
?idal erolo3) a33lutinin = titer "2'(?idal erolo3) a33lutinin = titer "2'(
or titer "9$(.or titer "9$(.
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Blood culture and PCR reult inBlood culture and PCR reult in
dia3noi o T)p4oid &e/erdia3noi o T)p4oid &e/er
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Treatment o T)p4oid &e/er : 5eneralTreatment o T)p4oid &e/er : 5eneral
and in Pre3nanc)and in Pre3nanc)
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5eneral Treatment in T)p4oid &e/er5eneral Treatment in T)p4oid &e/er
=on Pharmacologic : ;ed rest( =!trition=on Pharmacologic : ;ed rest( =!trition
PharmacologicPharmacologic
ymptomaticymptomatic
Anti%iotic :Anti%iotic :
Ampicillin@Amo>icillinAmpicillin@Amo>icillin Chloramphenicol 5>7##mgChloramphenicol 5>7##mg
Cephalosporin : Ceftria>one /-5 g@daysCephalosporin : Ceftria>one /-5 g@days
Fl!oro!inolones : Ciproflo>a>in >7## mgFl!oro!inolones : Ciproflo>a>in >7## mg
Bflo>acin >5## mgBflo>acin >5## mg
Peflo>acin ">5## mgPeflo>acin ">5## mg
Flero>acin ">7## mgFlero>acin ">7## mg
evoflo>acin ">7##mgevoflo>acin ">7##mg
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Anti%iotics d!ring pregnancy and lactationAnti%iotics d!ring pregnancy and lactation*",*",
A3entA3ent6m-r)ionic6m-r)ionic
periodperiod
PotPot6m-r)onic6m-r)onicperiodperiod
PeripartalPeripartalperiodperiod
aole *+*+ *+*+ 11 11 Teratogenic in animalTeratogenic in animale>periments( ernicter!se>periments( ernicter!s
1 Contraindicated ornot recommended
*+ onl) i clearl)indicated
ae or ue w4en indicated
A to -e precri-edonl) in e;ceptional cae
6m-r)onic period *"tto "'t4wk. o pre3nanc)+ Potem-r)onic period *"2t4to 2#t4wk. opre3nanc)+ Peripartal period *$(t4wk. o pre3nanc) till deli/er) +
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Antibiotics during pregnancy andlactation(2)
A3entA3ent6m-r)ionic6m-r)ionicperiod period
PotPot6m-r)onic6m-r)onic
period period
PeripartalPeripartalperiod period
periments
MetronidaoleMetronidaole AA AA AA AA Teratogenic in animalTeratogenic in animale>perimentse>periments
AmphotericinAmphotericin;;
11 A*+A*+ A*+A*+ A%ortion and foetalA%ortion and foetalretardation reportedretardation reported
6m-r)onic period *"tto "'t4
wk. o pre3nanc)+
Potem-r)onic period *"2t4to 2#t4
wk. o pre3nanc)+
Peripartal period *$(t4wk. o
pre3nanc) till deli/er) +
1 Contraindicatedor
notrecommended
*+onl) i clearl)
indicated
ae or ue w4en indicated
A to -e precri-ed
onl) in e;ceptionalcae
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Comm!nica%le Disease Control and provincial a%oratory ervices( 'a!l! =atal
Dept1 of
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Treatment of MDR-TTreatment of MDR-T
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?4at i MDR1STE?4at i MDR1STE
MDR-T is almonella typhi 'hich has aMDR-T is almonella typhi 'hich has a
m!tagen *Gyr-A or TEM-", that canm!tagen *Gyr-A or TEM-", that can
resistant to fl!or!inolens or partially toresistant to fl!or!inolens or partially to
%eta-lactam *not all,%eta-lactam *not all,
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The possi%ility of MDR-T sho'ed %yThe possi%ility of MDR-T sho'ed %y
clinical impressionclinical impressionin 'hich theres no goodin 'hich theres no good
response after empirical ade!ate therapyresponse after empirical ade!ate therapy
;y :;y :
- Penicillin- Penicillin : Amo>ycillin( Ampicillin: Amo>ycillin( Ampicillin
- Fl!or!inolones- Fl!or!inolones :: Ciproflo>acinCiproflo>acin
evoflo>acinevoflo>acin- Cephalosporines- Cephalosporines : Ceftria>one: Ceftria>one
MDR Salmonella T)p4i*MDR1ST+
Cae Poi-ilit)
Hoon
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A M!lti-Dr!g Resistant almonella typhiA M!lti-Dr!g Resistant almonella typhi
*MDRT, 'as appeared %y the present of*MDRT, 'as appeared %y the present of
gyrA and TEM-" gene1gyrA and TEM-" gene1
MDRT
5)r A
5ene
T6M1"5ene
&luorFuinolone
Reitance
BetalactamaeBut not 6SBhi%ited s!periorse>hi%ited s!periors
antimicro%ial activity compared to other anti%iotics(antimicro%ial activity compared to other anti%iotics(
incl!dingincl!ding ceftaidimeceftaidime'ith M8C$#+ #()!g @ ml *M8C'ith M8C$#+ #()!g @ ml *M8C#(#7 to "(7. !g @ ml,#(#7 to "(7. !g @ ml,
Hoon
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ConcluionConcluion
"1"1 Typhoid fever : ac!te systemic illness d!e to almonellaTyphoid fever : ac!te systemic illness d!e to almonellatyphi and paratyphityphi and paratyphi
1 Treatment : !pportive and symptomatic1 Treatment : !pportive and symptomatic
Antimicro%ial : Ampicillin( ChloramphenicolAntimicro%ial : Ampicillin( Chloramphenicol Fl!or!inolonesFl!or!inolones
//rdrdGen CephalosporineGen Cephalosporine
/1 Treatment choices in pregnancy : Penicillin and/1 Treatment choices in pregnancy : Penicillin and
CephalosporinesCephalosporines51 Treatment option for MDR-T : AteronamICar%apenem51 Treatment option for MDR-T : AteronamICar%apenem
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