Mikroba Penyebab Infeksi

Sistem Gastrointestinal
dr. Dewi Klarita Furtuna , M.Ked.Klin.,Sp.MK
Departemen Mikrobiologi Klinik Fakultas Kedokteran Universitas
Palangka Raya
2019
Anatomi dan Flora Normal
Bakteri Penyebab Infeksi Gastrointestinal
Penyebab Utama:
1. Bakteri : Enterobacteriaceae
2. Virus
 Klasifikasi Enterobacteriaceae
• MAJOR CATEGORY I
(GRAM-NEGATIVE EUBACTERIA THAT HAVE CELL WALLS)

• Group 5 : Facultatively anaerobic Gram-negative rods

• Subgroup 1 : Family Enterobacteriaceae

Pembagian Famili Enterobacteriaceae berdasarkan
kemampuan meragi laktosa :

• Lactose Fermenters

• Non-lactose Fermenters
Famili : Enterobacteriacae
Genus :
Lactose fermenters :
• Escherichia
• Klebsiella
• Enterobacter
• Serratia
• Hafnia
Famili : Enterobacteriacae
Genus :
Non-Lactose fermenters :
• Salmonella
• Shigella
• Yersinia
• Proteus
• Morganella
• Providencia
• Citrobacter
Pembagian Enterobacteriaceae :

• True pathogen Enterobacteriaceae

• Opportunistic Enterobacteriaceae
ENTERIC PATHOGEN :  Enterobacteriaceae
Gastrointestinal disease

• Salmonella

• Shigella

• Diarrheagenic Escherichia coli

• Yersinia
 ENTEROBACTERIACEAE
(LACTOSE FERMENTERS)
Escherichia coli
FAMILY : Enterobacteriaceae

GENUS : Escherichia

SPECIES :
Escherichia albertii
Escherichia blattae
Escherichia coli
Escherichia fergusonii
Escherichia hermannii
Escherichia vulneris
MORFOLOGI :

• Batang gram negatif

• Spora (-)

• Kapsul – slime layer

• Fimbriae (Pili)
• Ikatan dengan bakteri lain, faga & sel inang
• Transfer materi genetik
SIFAT-SIFAT BIOKIMIA & PERBENIHAN :

• Fakultatif anaerob
• Meragi glukosa  asam (mixed acid pathway)
• Reduksi nitrat  nitrit
• Oksidase (-)
• Gas (+) : H2 & CO2
• Laktosa (+)
STRUKTUR ANTIGEN :

• O Ag – 164 Epidemiologi
• H Ag – 50
• K Ag – 100

O157 : H7 – Shiga like toxin – Haemorrhagic colitis

O78 : H11 Enterotoxigenic
O78 : H12
O111a, 111b : H2 – Infantile diarrhea
O124 : H30 - Enteroinvasive
 Patogenitas :
• Ag permukaan :
• Fimbriae (2 tipe)
• Mannose sensitive (common pili)
• Mannose resistant
• K1 Capsular Ag
• Enterotoksin :
• LT
• ST
• Verotoksin
• Faktor Lain :
• Hemolisin
• Kemampuan penetrasi
 DIAGNOSIS LABORATORIUM :

Spesimen :
• Urine
• Cairan tubuh
• Sputum
• Jaringan
• Pus
• Usapan rektal
• Tinja
Transport media :
• Medium Carry-blair
• Medium Stuart
• Medium Amies

Media isolasi enterik :

• Medium enrichment
• Medium diferensial
• Mac Conkey
• Medium selektif : EMB (Eosin Methylene Blue)
Escherichia coli pada media Mac CONKEY
• Uji Biokimia
• Uji Serologi
• DNA probe
• PCR
• Uji Sereny
PENGOBATAN :

• Antimikroba

• Keseimbangan cairan & elektrolit (diare)

• Profilaksis dengan Trimethoprim-Sulfamethoxazole -  insidens

Traveler’s diarrhea
Diarrheagenic Escherichia coli

• ETEC - Enterotoxigenic Escherichia coli

• EPEC - Enteropathogenic Escherichia coli
• EIEC - Enteroinvasive Escherichia coli
• VTEC - Vero cytotoxin-producing E. coli
(= EHEC - Enterohaemorrhagic Escherichia coli
= STEC - Shiga toxin-producing E. coli)
• EAEC - Enteroaggregative Escherichia coli
(= EAggEC)
 Summary

E. coli type Symptoms Epidemiology Pathogenesis Primary site

Enterotoxigenic traveler's diarrhea worldwide; all ages; LT or ST toxins small

(ETEC) infant diarrhea; humans only pili intestine
watery, no fever, no
WBC
Enteropathogenic Fever, nausea, Important cause of adherence to small
(EPEC) vomiting. Watery pediatric diarrhea enterocytes, intestine
diarrhea, no WBC destroys villi

Enteroinvasive bloody diarrhea, and humans only plasmid-mediated large intestine

(EIEC) fever (resembles associated with invasion. Destruction
Shigella) travel of colon cells

Enterohemorrhagic Little or no fever Zoonosis Cytotoxic large intestine

(EHEC) O157:H7 Hemorrhagic colitis. foodborne Shiga-like verotoxin
HUS
Enteroaggregative Vomiting, low grade infant diarrhea in adherence to small
(EAEC) fever. Watery/bloody underdeveloped enterocytes intestine
diarrhea countries heat-stable toxin
Enterobacteriaceae
E.coli
ENTEROBACTERIACEAE
(NONLACTOSE
FERMENTERS)
• Salmonella

• Shigella

• Yersinia

• Citrobacter

• Proteus

• Morganella

• Providencia
Salmonella
FAMILY : Enterobacteriaceae

GENUS : Salmonella

SPECIES :
Salmonella Group I strain
Serotype Typhi
Serotype Choleraesuis
Serotype Paratyphi A
Serotype Gallinarum
Serotype Pullorum
Salmonella Group II strain
Salmonella Group IIIa strain
Salmonella Group IIIb strain
Salmonella Group IV strain
Salmonella Group V strain (Salmonella bongori)
Salmonella Group VI strain
Klasifikasi Salmonella
• Kauffman – White
• Species – tipe antigenik
• Bergey (1984)
• 5 subgenus (I, II, III, IV, V)
• Ewing
• Hanya 3 species :
• Salmonella choleraesuis
• Salmonella typhi
• Salmonella enteritidis
• Studi Genetika
• Salmonella enterica = Genus Salmonella + Arizona
• Studi Hibridisasi DNA
• Salmonella subgroup ……….. Subspecies …………
MAJOR CATEGORY I
(GRAM-NEGATIVE EUBACTERIA THAT HAVE CELL WALLS)

Group 5 : Facultatively anaerobic Gram-negative rods

Subgroup 1 : FAMILY ENTEROBACTERIACEAE
Genus : Salmonella
Species :
Salmonella bongori
Salmonella choleraesuis
Salmonella choleraesuis subsp. arizonae
Salmonella choleraesuis subsp. choleraesuis
Salmonella choleraesuis subsp. diarizonae
Salmonella choleraesuis subsp. houtenae
Salmonella choleraesuis subsp. indica
Salmonella choleraesuis subsp. salamae
 Salmonella choleraesuis subsp. choleraesuis

• Salmonella choleraesuis subsp. choleraesuis serovar Choleraesuis

• Salmonella choleraesuis subsp. choleraesuis serovar Gallinarum
• Salmonella choleraesuis subsp. choleraesuis serovar Paratyphi A
• Salmonella choleraesuis subsp. choleraesuis serovar Pullorum
• Salmonella choleraesuis subsp. choleraesuis serovar Typhi
• Salmonella choleraesuis subsp. choleraesuis serovar Typhimurium
 Morfologi :

• Batang Gram negatif : 0.7 – 1.5 X 2 – 5 m

• Spora (-)
• Kapsul (-)
• Motil – Peritrichous flagella, kecuali :
• Salmonella serovar Gallinarum
• Salmonella serovar Pullorum
 Sifat perbenihan :
• Fakultatif anaerob
• Medium sederhana -  2-4 mm
• Laktosa Ө
• Sukrosa Ө
• Glukosa   Gas, kecuali :
• Salmonella serovar Gallinarum
• Salmonella serovar Typhi
• Mannosa 
• Produksi H2S, kecuali :
• Salmonella serovar Paratyphi A

• Indol Ө, VP Ө, MR , Urea Ө
• Simmon’s Citrate , kecuali :
• Salmonella serovar Choleraesuis
• Salmonella serovar Gallinarum
• Salmonella serovar Paratyphi A
• Salmonella serovar Pullorum
• Salmonella serovar Typhi
• Lysine decarboxylase , kecuali :
• Salmonella serovar Paratyphi A

• Ornithine decarboxylase , kecuali :

• Salmonella serovar Gallinarum
• Salmonella serovar Typhi

• Reduksi nitrat  nitrit

Medium Bismuth Sulfite
Koloni Salmonella serovar Typhi  jet black
KARAKTERISTIK BIOLOGIK :

• Patogen intraseluler fakultatif – survive di dalam

fagosit nonaktif sebaik sel epitel

• 2 GRUP :
• TYPHOID SALMONELLA
• NONTYPHOID SALMONELLA
 Daya tahan :
• Toleransi terhadap empedu relatif besar  media isolasi

• Tahan terhadap bahan-bahan kimia

• Brilliant green

• Sodium tetrathionate

• Sodium dioxycholate

 Salmonella serovar Choleraesuis

- Bakteri standar Uji preparat phenol

• Tahan terhadap air beku dalam waktu lama

 Struktur Antigen :
• Ag - Common Ag  group A s/d I

• H Ag – Diphasic : Phase 1 & Phase 2, kecuali a.l.:

• Salmonella serovar Typhi

• Vi Ag : - Peranan dalam klasifikasi genus kecil

• Penting dalam patogenitas Salmonella serovar Typhi 
mencegah destruksi intraseluler bakteri
 Metabolit :

• Endotoksin
• Bertanggung jawab atas terjadinya panas – stadium bakteremia

• Enterotoksin
• Serupa labile toxin dan stable toxin dari Escherichia coli

• Cytotoxin
• Mungkin penting dalam invasi seluler
 Patogenitas :
• Diperankan oleh :
• Surface antigen – Vi Ag Salmonella serovar Typhi
• Endotoksin
• Enterotoksin
• Kemampuan mengadakan invasi

• Menyerang : GI tract & Jaringan Ekstraintestinal

• Transmisi : oral route – makanan / minuman terkontaminasi

• Dosis efektif rata-rata :

•  103 Salmonella serovar Typhi

• 105-108 Salmonella lainnya

DEMAM ENTERIK – DEMAM TIFOID
• Terutama : Salmonella serovar Typhi

• Salmonella serovar Paratyphi A

• Salmonella serovar Paratyphi B

(= S. schottmuelleri)

• Gejala lebih ringan dan angka kematian lebih rendah

• Masa inkubasi : 10 – 14 hari

• Manusia : satu-satunya inang Salmonella serovar Typhi

• Angka kematian : 2 – 10%

• Mortalitas menurun pada terapi suportif yang

adekuat

• Relaps : 10% pasien tanpa pengobatan

• 3% pasien demam tifoid menjadi carrier kronik

• Terapi : cholecystectomy
 Gejala

• Minggu I : demam, lethargy, malaise dan rasa sakit

seluruh badan, konstipasi lebih sering daripada diare

• Minggu II : pasien tampak sangat sakit, suhu 40C,

delirium, nyeri abdomen, rose colored spot, diare

• Minggu III : sembuh atau terjadi komplikasi

Rose spot
 Komplikasi :

• Perforasi usus

• Perdarahan hebat

• Thrombophlebitis

• Cholecystitis

• Pneumonia

• Abscess
 Sepsis
• Terutama : Salmonella serovar Choleraesuis
• Dapat oleh Salmonella serovar lainnya
• Infeksi oral  invasi melalui aliran darah  lesi fokal pada organ-organ
• Paru : Pneumonia, Pulmonary abscess
• Tulang : Osteomyelitis
• Meningen : Meningitis
• Jantung : Endocarditis
• dll.
• Gejala : lama, demam, menggigil, anorexia, anemia dan lesi fokal, GE
seringkali absen

Biakan darah 
 Gastroenteritis - Enterokolitis
• Salmonella serovar Typhimurium

• Gejala : 18-24 jam setelah termakan

• Nausea, vomiting, headache, demam, diare profus, nyeri abdomen

• Sembuh sendiri

• Anak-anak dan orang tua : dehidrasi dan ketidak-seimbangan

elektrolit

• Biakan darah (-)

• Biakan feces (+), pada umumnya tetap (+) setelah beberapa

minggu klinis sembuh
 DIAGNOSIS :
• PEMERIKSAAN LABORATORIUM – PENTING !!!!

• NONTYPHOID SALMONELLA
• KULTUR TINJA
• DETERMINASI PARAMETER EPIDEMIOLOGIK (GEJALA DAN
MASA INKUBASI)
• ISOLASI DARI FOOD VEHICLE YANG DICURIGAI
• KULTUR DARAH - SEPSIS

• TYPHOID SALMONELLA
• KULTUR DARAH, TINJA ATAU URIN
• OBSERVASI KLINIS : RASH YANG KHAS PADA ABDOMEN
PASIEN (ROSE SPOT)
 Diagnosis Laboratorium
Bahan pemeriksaan
• Darah : (+) pada minggu I – Demam enterik dan sepsis

• Sumsum tulang : mungkin (+) setelah darah (-)

• Feces : (+) pada minggu I : GE dan demam tifoid (25%)

minggu II & III : demam tifoid (85%)
demam enterik

• Urine : (+) setelah minggu II

• Sputum : Pulmonary abscess

• Duodenal drainage : Carrier – saluran empedu

 Bakteriologi

• Isolasi bakteri Salmonella

• Medium enrichment : medium Selenite F / Tetrathionate
broth
• Medium differential : Mac Conkey, Deoxycholate
• Medium selektif : S.S. agar, Deoxycholate Citrate agar,
Bismuth Sulfite agar
• Direct immunofluorescence

Final identification : suspect colonies :

- Uji biokimia
- Slide agglutination test dengan antisera spesifik
Laboratory Indications
• Lysine +
• Hydrogen sulfide +
• Indole +
• Citrate +
• ONPG -
• Malonate -
• Hydrogen sulfide + Salmonella typhimuriumK

• -/+ TSI reaction (with gas)

• Growth on MacConkey's, EMB, HEK
• Uji ko-aglutinasi

• PCR

• DNA probe

• Serologi
 Serologi

• Serum aglutinin meningkat cepat

• Minggu 2 – 3 infeksi Salmonella

• Minimal diambil serum diambil 2 X

• Interval 7 – 10 hari – kenaikan titer
Macam :

1. Rapid slide agglutination test

- Identifikasi preliminar biakan
- Hasil (+) - clumping

2. Tube dilution agglutination test (Uji Widal)

- Interpretasi hasil (+) – kenaikan titer 4 X
UJI Widal

O-agglutination H-agglutination
 Pengobatan

• G.E. tanpa komplikasi :

• Tanpa antibiotik

• Obat-obatan suportif

• Cegah dehidrasi dan ketidak-seimbangan elektrolit

• Demam enterik / Sepsis

• Sulfamethoxazole-Trimethoprim

• Chloramphenicol

• Ampicillin

• Quinolone
• Chronic Salmonella serovar Typhi carriers :

• Tanpa penyakit/gangguan kandung empedu : Ampicillin

• Dengan penyakit/gangguan kandung empedu – batu : cholecystectomy

 Pencegahan :

• Sanitasi makanan dan minuman

• Carrier :
• Tidak boleh berperan sebagai food handler
• Diawasi kebersihannya
• Cholecystectomy
• Ampicillin

• Vaksinasi
Typhoid Mary
• Mary Mallon, the cook who became
known as Typhoid Mary, due to her
alarming tendency to spread typhoid
fever via the kitchens of 1904 New York
City. When she was first suspected to
be the cause of the outbreak, she
disappeared, becoming the subject of
an intense pursuit. Once caught, she
escaped, thus beginning the chase
anew ……
Epidemiologi
A. Sumber Infeksi
Makanan / minuman terkontaminasi Salmonella
1. Air
2. Susu dan produk sehari-hari (ice cream, cheese, custard)
3. Shellfish
4. Dried or frozen eggs
5. Daging dan produk daging
6. Recreational drugs
7. Animal dyes
8. Household pets : turtles, dogs, cats
B. Asal dari kontaminasi

• Feces : Kasus subklinis tak diduga

Carrier
• Binatang : sapi, rodent

Insidens demam tifoid menurun

Insidens infeksi salmonella lainnya meningkat

C. Carirers
- Kandung empedu
- Saluran empedu
- Jarang : usus & traktus urinarius
RESERVOIR DAN TRANSMISI :

NONTYPHOID SALMONELLA1
• Salmonella gastroenteritis = Salmonella food
poisoning
• Transmisi :
• Makanan
• Ingesti air terkontaminasi tinja
• Tipikal : penanganan makanan yang kurang tepat –
makanan yang kurang sempurna memasaknya
• Resiko : pasien dengan asam lambung yang rendah
atau tidak ada (hipokhlorhidria)
 NONTYPHOID SALMONELLA2

• Reservoir zoonotik :
• Poultry
• Poultry products (telur)
• Susu pasteurisasi yang kurang tepat
• Hewan peliharaan : kura, anjing, kucing
• Dosis infeksius : >106
• Penyebaran juga dari orang ke orang melalui rute fekal-oral
• Carrier
A recent Salmonella in
peanut butter outbreak
(Late 2008 through 2009)
Shigella
FAMILY : ENTEROBACTERIACEAE

GENUS : SHIGELLA
SPECIES :
SHIGELLA DYSENTERIAE - SEROGROUP A
SHIGELLA FLEXNERI - SEROGROUP B
SHIGELLA BOYDII - SEROGROUP C
SHIGELLA SONNEI - SEROGROUP D

SHIGELLA SPECIES :
- Dapat didiferensiasi berdasarkan antigen O dan reaksi
biokimia
- Penyebab penyakit gastrointestinal = disentri basiler =
SHIGELLOSIS
- BERAT RINGAN PENYAKIT

BERVARIASI PADA SETIAP SPESIES

- MORTALITAS

- EPIDEMIOLOGI
MORFOLOGI & IDENTIFIKASI

• BATANG GRAM NEGATIF

• TIDAK BERGERAK

• TIDAK BERSPORA

• FAKULTATIF ANAEROB, TETAPI TUMBUH BAIK DALAM

SUASANA AEROB

• 24 JAM : KOLONI BULAT, KONVEKS, TRANSPARAN,  2 mm

• LAKTOSA (-), KECUALI SHIGELLA SONNEI
• SALICIN (-)
• GLUKOSA (+), GAS (-), KECUALI S. FLEXNERI 6
• H2S (-)
• LYSINE DECARBOXYLASE (-)
• MANNITOL (+) – S. FLEXNERI, S. BOYDII, S. SONNEI
• MANNITOL (-) – S. DYSENTERIAE
 DAYA TAHAN

• < RESISTEN TERHADAP AGEN FISIK & KIMIA

• RUSAK OLEH ASAM

• TOLERANS - SUHU RENDAH DAN LEMBAB

• TAHAN > 6 BULAN DALAM AIR PADA SUHU KAMAR

 STRUKTUR ANTIGEN

• 4 GROUP ANTIGENIK O MAYOR :

• A - 12
• B-6
• C - 18
• D-1
• MINOR ANTIGEN : A, B, C  SUBGROUP
• ANTIGEN K / ENVELOPE :
• SEROLOGIC TYPING (-)
• MEMPENGARUHI REAKSI SEROLOGI DARI ANTIGEN O
• H ANTIGEN (-)
• FIMBRIAE (+) – SEROGROUP B – SEROTIPE 1 – 5
• FIMBRIAE (-) – SEROGROUP B – SEROTIPE 6, DLL.
O Ag
• LPS :

• SMOOTH – TIPE KOLONI FASE I

• SHIGELLA SONNEI & SHIGELLA FLEXNERI
• PLASMID – BESAR, 120 – 140 Mda
•  O-SPECIFIC SIDE CHAINS

• ROUGH – TIPE KOLONI FASE II

• PLASMID (-) - AVIRULEN
TOKSIN SHIGA
• GENE UNTUK PROTEIN TOKSIN ADA PADA
KHROMOSOM

• NEUROTOKSIK, SITOTOKSIK & ENTEROTOKSIK

• BM. 70.000 :
• 1 SUBUNIT A – 32.000 BM
• 5 SUBUNIT B – 6. 500 BM
FAKTOR-FAKTOR VIRULENSI
• ENDOTOKSIN
• LPS – BERPERAN PADA INFLAMASI USUS
• PROTEIN Ipa
• MEDIASI INVASI
• PROTEIN Mxi-Spa
• TERLIBAT DALAM SEKRESI DARI PROTEIN Ipa
• MUNGKIN TERLIBAT PADA PERLEKATAN DARI SHIGELLA PADA SEL
HOSPES
• PROTEINS IcsA DAN IcsB
• TERLIBAT DALAM PENYEBARAN INTERSELULER DARI SHIGELLA
• SHIGA TOXIN
• HANYA OLEH Shigella dysenteriae
• BERPERAN DENGAN MENGHAMBAT SINTESA PROTEIN SEL HOSPES –
SEBUAH EFEK YANG MENYUMBANG PERKEMBANGAN KERUSAKAN
MUKOSA KOLON SELAMA SHIGELLOSIS
 KLINIS
• MASA TUNAS : 1 – 3 HARI
• KAKU PERUT / CRAMPS, DEMAM, MENGGIGIL,
KEJANG, TENESMUS, TINJA CAIR, LENDIR & DARAH
• ORANG SEHAT : 2 – 7 HARI SEMBUH
• INDIVIDU MUDA / TUA / MALNUTRISI  LEBIH LAMA
• KEMATIAN :
• DEHIDRASI & KETIDAK SEIMBANGAN ELEKTROLIT
• SHIGELLA DYSENTERIAE
 DISENTERI

• Dapat didefinisikan dalam berbagai cara yang berbeda

• Diare dalam volume kecil yang sering berisi darah dan

lendir
the petechial hemorrhages in the cecum of a Rhesus
monkey due to Shigella sp. bacteria.
the appearance of the intestinal mucosa in a case of colitis
due to Shigella sp. bacteria in a Rhesus monkey.
This man developed necrosis of the intestines due to
a Shigellosis infection resulting in his death.
 DIAGNOSIS LABORATORIUM

• SPESIMEN :
• TINJA
• USAP REKTAL - SIGMOIDOSCOPY

• PEMERIKSAAN MIKROSKOPIK
• ADANYA JUMLAH LEKOSIT YANG
MENINGKAT
DIAGNOSIS LABORATORIUM

• KULTUR
• DIAGNOSIS SPESIFIK
• IDENTIFIKASI DARI ISOLAT DENGAN UJI
BIOKIMIA DAN SEROLOGI

• SEGERA :
• MEDIA ISOLASI
• MEDIUM TRANSPOR BUFFER
 KULTUR
• Dapat tumbuh pada
• simple media
• nutrient agar
 KULTUR

• enriched media
• blood agar
• Koloni : konveks sirkuler
transparan dengan tepi
intak
• Ukuran : 1-2 mm
colonial morphology displayed by Gram-negative Shigella
bacteria on a blood agar plate (BAP).
 KULTUR
• media selektif
• MacConkey’s agar
• NON lactose fermenting
colonies
• MacConkey agar : koloni
colorless
Desoxycholate Citrate Agar

Lactose Lactose non

fermenter fermenter
SHIGELLA
colonial morphology displayed by Shigella boydii bacteria
cultivated on a Hektoen enteric (HE) agar surface; colonies of
S. bacteria grown on HE agar display a raised, green, and
moist appearance.
Lysine iron agar tests
for the detection of
both lysine
decarboxylase
(LDC), and hydrogen
sulfide (H2S)
production, when
attempting to identify
members of the
family
Enterobacteriaceae,
especially for
Salmonella spp. and
Arizona spp..
 PENGOBATAN

• REHIDRASI

• ANTIBIOTIK
• AMPICILLIN / AMOXYCILLIN
• TRIMETHOPRIM – SULFAMETHOXAZOLE
 MENGURANGI DERAJAT BERATNYA PENYAKIT DAN DURASI
DARI GEJALA SHIGELLOSIS
• PERAWATAN SUPORTIF
• PENGGANTIAN CAIRAN

• OBAT ANTISPASMODIK
• MISAL : LOMOTIL
• KONTRAINDIKASI UNTUK SHIGELLOSIS DAN
DIARE INVASIF LAINNYA – CENDERUNG
UNTUK MENIMBULKAN EKSASERBASI
GEJALA
 EPIDEMIOLOGI

• MANUSIA – RESERVOIR SATU-SATUNYA

• PENULARAN : 4 F – FOOD, FINGERS, FECES, FLIES

 PENCEGAHAN
• LIVE ATTENUATED SHIGELLA VACCINE

• PRAKTEK SANITASI YANG BAIK

• PEMBUANGAN SAMPAH YANG ADEKUAT
• PENGOLAHAN AIR YANG BAIK - KHLORINASI AIR
• CUCI TANGAN YANG FREKUEN
• PEMAKAIAN SARUNG TANGAN OLEH PERSONIL PADA
FASILITAS PERAWATAN JALAN

• DETEKSI & PENGOBATAN “CARRIER”

 Vibrio species
Campylobacter species
Helicobacter pylori

Eddy Bagus Wasito

 Vibrio species
• Family Vibrionaceae : Vibrio, Aeromonas, Plesiomonas
• Vibrio : V. cholerae, V. parahaemolyticus
• Curved rods, Gram negatif,
spore -, capsul -, motil (single
polar flagellum), 0,5 x 1,5-2 u
Vibrio cholerae
• Culture : grow on simple
media, fakultatif anaerob, pH
7-9, 19-37oC, sensitive
against dryness
• Biochemical : Oksidase +
• Antigenic structure : O (1-
139), H; O1 : Serotype O, I, H;
O1: biotype eltor, classic
• Virulence factor : CT, pili,
mucinase
 Clinical manifestation
• Cholera (O1, O139)
• Incubation period : 2-3 days
• Disease course : sudden
• Sign : rice watery diarrhea (painless), vomit, dehydration
 Pathophysiology
• CT (labile toxin), BM 80.000-98.000 Da (98% protein), Subunit A1, A2,
B, Receptor mono sialo ganglioside
• Stimulate adenyl cyclase --- stimulate cyclic AMP --- hypersecretion
 Laboratory Diagnosis
• Specimen : rice watery stool ----- Cary Blair / Amies ; Tissue paper ;
APW/TTPB ; TCBS / TTGA
• TCBS : yellow colony
• TTGA : dark center, cloudy zone
• Biochemical identification : observe well during laboratory practice
• Serotyping and biotyping : learn from the laboratory guiding book
 Epidemiology
• Carrier rate : 1% - 20%
• Source : shellfish
• Transmission : oral
 Management
• In-patiented
• Rehydration
• Tetracycline : number V. cholerae in stool, water & electrolyte loss,
water & electrolyte need, carrier rate
• Prevention : Hygiene sanitation
 Vibrio parahaemolyticus
• Curved rod, Gram negatif, spore -, capsul +, motil (single polar
flagellum), 0,5 x 1,5-2 u
• Culture : fakultatif anaerob, pH 7,6-9, 19-37oC, sensitive against
dryness & refrigeration, halofilik (2% NaCl)
• Biochemical : Oksidase +
• Antigenic structure : O, H, K
• Virulence factor : Cytotoxin, pili
Clinical manifestation
• Acute Gastro Enteritis (Food Poisoning syndrome)
• Incubation period : 12 jam
• Disease course : sudden
• Sign : watery diarrhea sometimes bloody, abdominal cramp, nausea
vomit, fever, headache, dehydration
 Patophysiology
• Heat Stable Hemolysin --- hemolyse rabbit/human blood (Kanagawa
+)
• Fatty infiltration & cloudy swelling of liver cell
 Laboratory Diagnosis
• Specimen : watery stool ----- Cary Blair / Amies ; Tissue paper ;
APW/TTPB (supplement 2% NaCl); TCBS / TTGA
• TCBS : blue green colony
• Biochemical identification : observe well during laboratory practice
• Serotyping : learn from the laboratory guiding book
 Epidemiology
• Source : sea food (96% clinical isolates are Kanagawa + while 1%
environment isolates are Kanagawa -)
• Occurrence : Japan 25%; SEA 2-11%
• Transmission : oral
 Management
• In-patiented
• Rehydration
• Tetracycline, Chloramphenicol, Gentamicin, Kanamycin
• Prevention : Hygiene sanitation, refrigeration
 Campylobacter species
• Family Spirillaceae : Campylobacter, Spirillum
• Campylobacter : C. jejuni, C. fetus, C. coli
• Curved rods, S, spiral, Gram
negatif, spore -, capsul -, Campylobacter
motil (single polar / bipolar
flagellum), 0,2-0,5 x 1,5-5 u jejuni
• Culture : grow on simple
media, microaerophilic
(5%O2,10%CO2,85%N2), pH
7, 37-42oC, sensitive against
dryness, disinfectan
• Biochemical : Oksidase +,
Catalase +, Nitrate +,
Hippurate +, Nalidxic acid
sensitive
• Antigenic structure : O, H
• Virulence factor :
invasiveness
 Clinical manifestation
• Acute Gastro Enteritis
• Incubation period : 2-3 hari
• Disease course : sudden
• Sign : diarrhea sometimes bloody, abdominal cramp, dehydration
• Complication : intractable / persistence diarrhea --- intolerance ---
malnutrition --- growth & development impairment
• Late complication : GB syndrome, Reactive arthritis
 Patophisiology

• Invasion to enterocyte --- epithelial damage

--- focal lesion --- fluid efflux, villi crypt
ratio decrease
 Laboratory Diagnosis
• Specimen : diarrheal stool ----- Cary Blair / Amies; selective media
(Skirrow, Butzler, Campy BAP, Preston)
• Incubation period : 24-48 hrs, confluent growth tendency
• Biochemical identification : oxidase, catalase, hippurate
• Susceptibility testing : nalidixic acid
 Epidemiology
• Source : Bird(s)
• Population : children
• Transmission : oral
• Isolation rate among in-patient children under 2 years : 5%; among
out-patient children under 2 years : 10%
 Management
• Not necessarily in-patiented
• Rehydration
• Erithromycin, Aminoglycoside, Tetracycline, Chloramphenicol
• Prevention : Hygiene sanitation
 Helicobacter species
• Family : Helicobacteriaceae (Helicobacter, Wolinella, Flexispira,
Sulfurimonas, Thiomicrospora, Thiovulum)
• Gastric Helicobacter species (H.pylori, H.felis, H mustelae,
H.acinonychis, H.heilmannii)
• Enterohepatic Helicobacter species (H.hepaticus)
• Spiral, Gram negatif, spore -,
capsul -, motil (4-6 unipolar Helicobacter pylori
flagellum), 0,5-1 x 2,5-5 u
• Culture : grow on riched
media, glucose, amino acid,
microaerophilic
(5%O2,10%CO2,85%N2), pH
7, 30-37oC,
• Biochemical : Oxidase +,
catalase +, urease + (Ni)
• Antigenic structure : O, H
• Virulence factor : urease,
motility, CagA (140 kDa),
VacA (95 kDa)
 Clinical manifestation
• Acute & Chronic Gastritis; Peptic Ulcer; Non Ulcer dyspepsia; Gastric
cancer; Gastric MALT lymphoma; GERD; Extraduodenal disorders
• Acute symptom : dyspepsia (fullness, nausea vomit)
• Chronic / Peptic ulcer (high acid production) / Atrophic gastritis (low
acid production) --- gastric cancer
 Pathophysiology
• Gastric lumen --- mucus layer of gastric pits / crypts --- surface of
gastric mucosa
• Inflammatory response Th1, PMN, MN --- epithelial damage
 Laboratory Diagnosis
• Bacteriologic : specimen gastric biopsy --- “selective” media (Skirrow,
Butzler, Campy BAP, Preston) / gram staining
• Incubation period : 5-7 days
• Biochemical identification : oxidase, catalase, hippurate
• Urea test; PCR; HistoPA (Giemsa/WS/Trichrome)
• Serologic (ELISA); breath test
 Epidemiology
• Source : patient / water environment
• Populasi : all age (half of the world population)
• Transmission : oral (oro oral / fecal oral)
 Management
• Not necessarily in-patiented
• Antibiotic (Bismuth, Metronidazole, Tetracycline --- 85% cure rate)
• 3-2-1 (Mach 1) Metronidazole, Amoxicillin, Clarithromycin, H.pylori
• Erithromycin, Clarithromycin, Chloramphenicol
• Prevention : Hygiene sanitation
Viruses Associated With Gastroenteritis
 VIRAL AGENTS CAUSING
GASTROENTERITIS
Major Viruses
1. Rotavirus
2. Enteric adenoviruses
3. Noroviruses :
a. Norwalk-like viruses
b. Calicivirus
c. Astrovirus
 Viruses associated with
gastroenteritis
Other viruses (minor): (cont) :

• Coronaviruses
• Parvoviruses
• Pestiviruses
• Toroviruses
Mechanism of diarrhea
• Watery diarrhea due to net secretion of intestinal fluid

• Activation of the enteric nervous system -possible role of enterotoxin

Clinical Features (contd.)

• Dehydration is the main contributor to mortality.

• Secondary malabsorption of lactose and fat, and

chronic diarrhea are possible
Recovery is usually complete.

However, severe diarrhea without

fluid and electrolyte

Replacement may result in

dehydration and death .
 •Temporary lactose intolerance may occur.

•NSP4 protein may act in a toxin-like manner

Neuronal Release of Calcium ion

alteration in neuronal influx into
water absorption activators enterocytes

•Loss of the ability to absorb water net secretion

of water and loss of ions watery diarrhea

Watery diarrhea dehydration (most commonly

isotonic) and may lead to metabolic acidosis and

death .
 Diagnosis
• Antigen detection in stool by ELISA, Latex Agglutination (for Group A
rotavirus)
• Culture- Group A rotaviruses can be cultured in monkey kidney cells
• Serology for epidemiologic studies
 Treatment and Prevention
• Treatment-
Supportive - oral, IV rehydration

• Prevention-
Handwashing and disinfection of surfaces
Terima Kasih