DEMAM TIFOID

Dr. dr. Shahrul Rahman, Sp.PD, FINASIM

Departemen Ilmu Penyakit Dalam

Fakultas Kedokteran
Universitas Muhammadiyah Sumatera Utara
Pendahuluan

Sinonim
Enteric fever

Typhus & parathypus abdominalis

Etiologi

Salmonella typhii
Salmonella paratyphi A,
B dan C

Koloni salmonella pada

agar McConkey.
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
Organism
Salmonella typhi, a Gram-negative bacteria.
Similar but often less severe disease is caused
by Salmonella serotype paratyphi A.
Many genes are shared with E. coli and at least
90% with S. typhimurium,
Polysaccharide capsule Vi: present in about
90% of all freshly isolated S. typhi and has a
protective effect against the bactericidal action
of the serum of infected patients.
The ratio of disease caused by S. typhi to that
caused by S. paratyphi is about 10 to
Family
Enterobacteriaceae
Motile
Somatic
Flagelar antigen
Vi

Facultative anaerobic/aerobic
Gram (-) bacteria
Rods shape
SALMONELLA
Epidemiologi (1)

Penderita 3 % carier
Endemis di Indonesia sporadis
Di Indonesia jarang menjadi epidemi
Penyakit menular dpt mewabah
Dlm 1 rumah kasus jarang > 1
Wajib dilaporkan
Sumber penularan sulit ditentukan
Epidemiologi (2)

Sumber penularan
Air minum / makanan

Tangan :
Tinja sendiri
Urine
Dahak
muntah
Epidemiologi (3)

Daya tahan hidup

Air, es, debu, tinja kering, pakaian
weeks
Kulit 1 minggu

Berkembang dlm susu susu rusak

Epidemiologi (4)

Distribusi :
Worldwide

Pengaruh iklim tidak ada

> banyak di negara berkembang di

daerah tropis
Pria = wanita

12 - 30 th 70-80 %

Ringan pada anak & glamur

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
Typhoid epidemiology
Infectious Dose : 100,000 organism ingestion
variable with gastric acidity
and size inoculum
Mode of Transmission :
1. Person-to-person
2. By contaminated food or water
3. By food contaminated by hand of carriers
4. Food contaminated by materials
5. Flies can infect food mechanical vector
Route of Transmission of Typhoid Fever

Patient Chronic carrier

Stool
Vomit
Indirect Urine Direct
Infection Infection
> 90 % < 10 %

Infected
Healthy
Water
subject
Food

Typhoid
fever
Incubation Period : 1 3 weeks
depends on :

size of infecting dose

age
gastric acidity
immunologic status
Patogenesis Mulut Usus

Reseptor vili
S. Typhi
Membiak dalam fagosit mononuklear
jaringan limfoid

Darah (bakteremia I)
Granulomatosa
Membiak dlm RES
Villi, cripte kelenjar,
Darah (bakteremia II) lam. propria, kl. limfe

Limpa,usus,v. fellea & organ lain

Multiplikasi dalam
Ves. Fellea carrier fagosit mononuklear

Usus
 Pathogenesis :

Ingestion of S.typhi Enter the small intestine

Excreted in stool MULTIPLI Infection carried in the

and Urine CATION Lymphoid follicle

Inflammation, necrosis, Draining mesenteric

Ulceration Payers patches Lymph node

Liver, GB, Spleen,BM Entering thoracic ducts

Multiply within MNPC Passed through the heart

End incubation period

Secondary bacteremia Primary bacteremia

PATOFISIOLOGI
Hubungan Salmonella typhii & Makrofag

Salmonella

Lewat CR1 & CR3

Fagosom

Lisosom

Fusi fagosom-lisosom

Substansi bakterisidal

Kuman mati
Patologi
Ileum distal

Minggu I Radang : hiperplasi plaks peyeri

Nodul tifoid

Sumbatan pemb. darah

hipoksia

Perdarahan,
Minggu II Nekrose
perforasi
Minggu III ulkus

Minggu IV Penyembuhan tanpa bekas

 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
Dugaan patogenesis
Salmonella typhii

endotoksin

makrofag

Monokins Metabolit, arakidonat,

Ox radikal
TNF, Fc antagonis
glucokortiroid, fc aktivasi
limfosit, IF-1 Nekrose sel,
gangguan vaskuler,
depresi ss. tulang,
demam,
abnormalitas lain
Gambaran klinis (1)
Masa tunas : 10 14 hr
Bervariasi : ringan - berat
Mulai = inf. Akut lain
Minggu I
Demam
Mialgia
Sefalgia
Anoreksia mual muntah
Obstipasi/diare
Abdominal discomfort
Batuk
epistaksis
Gambaran klinis (2)
Minggu II
Gejala > jelas
demam

Bradikardi relatif

Lidah tifoid (tengah kotor, tepi hiperemis, tremor)

Hepatomegali

Splenomegali

Meteorismus

Gangguan mental : apati, somnolen, stupor,

delirium, koma, psikosis
Roseola jarang
Clinical Manifestations (1):

Febril illness 5 to 21 days

Abdominal pain
chills
constitutional symptoms
in developed country : travelers or visitors from
endemic area
Gambaran klasik demam tifoid
Clinical Manifestations (2):

Anorexia

Nausea

Vomiting

Diarrhea Pea soup stool

 Typhoid fever ( enteric fever )

Enteric fever Fever Chills

syndrome
Headache Malaise Abdominal pain
Anorexia Weight loss weakness
Rose spots DIC Hepatomegaly
Splenomegaly Bacteremia 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
Laboratorium(1)
Lekosit : lekopeni normal lekositosis
Biakan darah :
Positif : diagnosis pasti
Negatif : mungkin +/-
Tergantung dari
Tehnik
Jumlah kuman 10/cc drh perlu diambil 5-10 cc
R/ sebelumnya
Langsung ditanam kirim
Diambil waktu demam
Saat pemeriksaan
Terbaik minggu pertama selanjutnya
Vaksinasi biakan negatif
R/ antibiotik biakan negatif
Laboratorium(2)

Reaksi widal
Reaksi aglutinasi Ag-Ab
Mencari aglutinin dalam serum
Aglutinin O tubuh kuman : 6 bl (+)
Aglutinin H flagella kuman : 1-2 th (+)

Aglutinin Vi simpai kuman

Laboratorium(3)

Fc yg mempengaruhi Rx. widal

Penderita
Gizi buruk
Saat pemeriksaan : minimal mg II peak mg V
R/ antibiotik
Penyakit penyerta : agammaglobulinemia,
lekemia, Ca advance
R/ immunosupresi / kortikosteroid
Vaksinasi kotipa/tipa
Inf. Klinis/subklinis salmo. Sebelumnya
Rx anamnestis :
Laboratorium(4)

Fc yg mempengaruhi Rx. widal

Tehnis
Rx. Silang dg species lain
Konsentrasi suspensi antigen

Jenis strain salmonella

Widal Test
O antibodies appear on days 6-8 and H antibodies on days
10-12
Negative in up to 30% of culture-proven cases of typhoid
fever
S. typhi shares O and H antigens with other Salmonella
serotypes and has cross-reacting epitopes with other
Enterobacteriacae, and this can lead to false-positive
results. Such results may also occur in other clinical
conditions, e.g. malaria, typhus, bacteraemia caused by
other organisms, and cirrhosis
This is acceptable so long as the results are interpreted
with care in accordance with appropriate local cut-off
values for the determination of positivity.
Anemia
Leucopenia or leucocytosis
Thrombocytopenia
Abnormal liver function
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
2. Detection of antigen in body fluid :

- Coagglutination

- Latex agglutination

- ELISA

- CIEP

Urine test Typhidot

3. Detection of antibodies :

- Widal tube test

- Widal slide test
- IHA
- CIEP
- RIA
- ELISA
1.Clinical Signs and Symptoms
2.Laboratory findings
3.Isolation of the organism
4.Detection of microbial antigen
5.Titration of antibody against
causative agent
Penatalaksanan

Perawatan
Diet
Medikamentosa
Cairan & elektrolit
Penatalaksanan perawatan

Suspek d. tifoid
Tirah baring absolut : dulu
Isolasi
Observasi
Pengobatan
Kesadaran posisi dubah-ubah
Bab & bak diperhatikan
Mobilisasi bertahap (RSCM)
Hari ke 2 apireksi duduk waktu makan
Hari ke 7 apireksi mulai berdiri
Hari ke 10 apireksi jalan
Hari ke 13-15 apireksi pulang
Penatalaksanan perawatan

Suspek d. tifoid
Mobilisasi bertahap (RSWS-makassar)
Hari ke 3 apireksi duduk
Hari ke 7 apireksi jalan

Hari ke 10 apireksi pulang

 Penatalaksanan perawatan

Pola perawatan konvensional : mulai

dengan bubur saring
Lama perawatan 21 hari apireksia
MRS APIREKSIA

Hari perawatan ? 7 3 3 3 5
Mobilisasi Baring Duduk Jalan

Diet Bubur saring Bubur biasa Nasi

 Penatalaksanan perawatan

Pola perawatan singkat : mulai dengan nasi

Lama perawatan : 10 hari apireksia

MRS APIREKSIA

Hari perawatan ? 3 4 3
Mobilisasi Baring Duduk Jalan

Diet Nasi
 Penatalaksanan perawatan

Pola perawatan sangat singkat : mulai

dengan nasi
Lama perawatan : 7 hari apireksia
MRS APIREKSIA

Hari perawatan ? 3 4
Mobilisasi Baring Duduk/Jalan

Diet Nasi
Penatalaksanan diet
diet konvensional bubur saring
Maksud bubur saring :
Memudahkan pencernaan/absorbsi
beban kerja usus
Makan kurang merangsang : perdarahan &
perforasi
Netralisasi asam lambung
Syarat bubur saring
Mudah dicerna, porsi kecil, seringkali
Protein cukup
Tidak merangsang
Memenuhi kebutuhan normal
Penatalaksanan diet
Makanan padat
Melancarkan defekasi bulk forming
Supaya BB cepat naik

Sudah jadi bubur di ileum terminalis

Meningkatkan selera makan

Disiapkan : mudah,murah,singkat

Jumlah kalori segera terpenuhi

Lebih menyenangkan penderita

Lamanya perawatan lebih singkat

Pengobatan
Kloramfenikol DOC
Mortalitas < 12 % 1 %
Murah
Kekurangan :
Relaps Pengidap
Resistensi Mual, muntah
Glositis Enterokolitis
Lekopeni Anemi aplastik
Trombositopeni Agranulositosis
Dosis :
50 -60 mg/kg.BB tiap 4-6 jam
4 x 500 mg/hr spi 10 hari apireksia
Pengobatan
Rata-rata pulang 14 hr bebas panas
4 x 250 mg spi 3 hr apireksia
Istirahat 7 hari
4 x 250 mg selama 5 hr
Rata-rata pulang 15 hr apireksia
4 x 400 mg spi 7 hr apireksia
3 x 500 mg spi 7 hr apireksia
Rata-rata pulang 10 hr apireksia
Pengobatan
Tiamfenikol identik kloramfenikol
Dosis :
4 x 500 mg spi 5 hr apireksia
Konsentrasi > dlm darah
> lama dlm badan/empedu
Toksisitas
Kompl. Hematologis
Pengobatan
Ampisilina dan Amoksisilina
Dosis :
2 x 1500 mg = kloramfenikol
3 4 x 1000 mg selama 14 hr
4 x 1000 mg selama 14 hr
2 x 1000 mg selama 21 hr
Rata-rata perawatan 14 hr
Pengobatan
Kotrimoksazole
Dosis :
2 x 2 tablet spi 7 hr apireksia
Ceftriakson
Generasi ke-3 sefalosporin
Dosis :
4 gr /hr selama 2-3 hr
Pefloxacin
Quinolon
Dosis :
400 mg/hr selama 5 7 hr
Pengobatan
Obat-obat lain
Ciprofloxacin 500 mg (single dose)
Ofloxacin 400 mg
Norfloxacin 400 mg
Kortikosteroid
Kontroversi toksis
Membran sel & lisosom hambat enzym
hidrolase
Dosis :
Dexamethasone : 3 mg/kg.BB 1 mg/kg.BB.
6 jam slm 2 hr
Pengobatan khusus
Wanita hamil
Trimester I : kloramfenikol
Trimester III : tiamfenikol
Amoksisilin selalu aman
Kloram pd trimester III tdk boleh diberi
karena :
Partus prematur
Kematian fetus intrauterin

Grey syndrome pd neonatus

Pengobatan khusus
Carierr/symptomless excretor
Tanpa keluhan
symptomless excretor : salmonella (+) dl
feses/urine < 3 bl
Carier > 3 bl
Prev. > 3 %
Usia menengah
Wanita > pria
U/ diagnos : kultur 3-6 x
R/ :
Ampisilin/amoksisilin : 4 x 1 gr/6 jam 4 mg
Kotrimoksazole : 2 x 2 tab(480) 4 mg
Ciprofloxacin : 2 x 750 mg 4 mg
Kombinasi dengan kolesistektomi
Treatment of
uncomplicated typhoid
Oral drugs

Ofloxacin: 15-20 mg / kg for 7-14 days

Azithromycin:8-10 mg/kg for 7 days
Cefixime: 20 mg /day for 7-14 days
Chloramphenicol: 50-75 mg /kg/day
for 14-21 days
Fluoroquinolones
Optimal for the treatment of typhoid fever
Relatively inexpensive, well tolerated and more rapidly and
reliably effective than the former first-line drugs, viz.
chloramphenicol, ampicillin, amoxicillin and trimethoprim-
sulfamethoxazole.
The majority of isolates are still sensitive.
Attain excellent tissue penetration, kill S. typhi in its
intracellular stationary stage in monocytes/macrophages
and achieve higher active drug levels in the gall bladder
than other drugs.
Rapid therapeutic response, i.e. clearance of fever and
symptoms in three to five days, and very low rates of post-
treatment carriage.
 Chloramphenicol
The disadvantages of using chloramphenicol include a
relatively high rate of relapse (57%), long treatment
courses (14 days) and the frequent development of a
carrierstate in adults.
The recommended dosage is 50 - 75 mg per kg per
day for 14 days divided into four doses per day, or for
at least five to seven days after defervescence.
Oral administration gives slightly greater bioavailability
than intramuscular (i.m.) or intravenous (i.v.)
administration of the succinate salt.
Cephalosporins

Ceftriaxone: 50-75 mg per kg per day

one or two doses
Cefotaxime: 40-80 mg per kg per day
in two or three doses
Cefoperazone: 50-100 mg per kg per
day
Multi drugs Resistance Salmonella typhi
(MDRST)

Resistance to :
Chloramphenicol
Amoxycillin
Cotrimoxazole
 Relapse

5-20% of typhoid fever cases that have

apparently been treated successfully.
A relapse is heralded by the return of fever
soon after the completion of antibiotic
treatment. The clinical manifestation is
frequently milder than the initial illness.
Cultures should be obtained and standard
treatment should be administered.
Pencegahan
Usaha terhadap lingkungan hidup
Penyediaan air minum yg sehat
Sistim pembuangan kotoran yg higienes
Pemberantasan lalat
Pengawasan thd rumah makan & penjual
makanan
Usaha terhadap manusia
Imunisasi
Menemukan & mengawasi carierr
Pendidikan kesehatan pd masyarakat
 Typhoid Vaccines :

1. Parenteral killed whole cell vaccines

* Heat and phenol killed
* Acetone killed and dried
2. Live attenuated Ty21a vaccine (TYPHORAL@ )
3. Polysaccharide subunit vaccine (TYPHIM V@)
 Vaccination
Vi polysaccharide, is given in a single dose
Protection begins seven days after injection,
maximum protection being reached 28 days after
injection when the highest antibody concentration is
obtained.
Protective efficacy was 72% one and half years after
vaccination and was still 55% three years after a single
dose.
In Asian countries where Vi-negative strains have been
reported at the low average level of 3%.
 live oral vaccine Ty2la
three doses two days apart on an empty stomach.
Protection as from 10-14 days after the third dose.
> 5 years.
Protective efficacy of the enteric-coated capsule
formulation seven years after the last dose is still
62% in areas where the disease is endemic;
Antibiotics should be avoided for seven days before
or after the immunization
Komplikasi
Intestinal
Perdarahan usus
Perforasi
Ileus paralitik
Ekstraintestinal
Kardiovaskuler
Darah
Paru
Hepar & vesika fellea
Ginjal
Tulang
neuropsikiatrik
 Komplikasi : multisystem organ
* Neuropsikiatri
* Perdarahan
* Perforasi
* Miokarditis, Pankreatitis,
* Hepatitis
* Syok septik

Sindrom klinis berupa gangguan kesadaran,

dengan atau tanpa gangguan neurologis, dan
dalam pem. Cairan otak masih dalam batas
normal Tifoid Toksik
KOMPLIKASI

1. INTESTINAL
Perdarahan usus

Perforasi usus

Ileus paralitik
2. EKSTRAINTESTINAL
Kardiovaskular

Hematologi

Paru

Hepar, saluran empedu, pankreas

Ginjal

Tulang, sendi, otot

Neuropsikiatri >>>
 Komplikasi
Kardiovaskular
o Miokarditis 1-5%, paling sering pada anak-
anak
o Klinis: takikardia, protodiastolic gallop, desah
sistolik apikal, edema perifer
o EKG: perubahan segmen ST dan gel. T, QT
memanjang dan low QRS voltage
o Bisa menimbukan abses miokarditis, jika
ruptur tamponade jantung
 Trombi mural
Emboli sistemik dan pulmonal

Aneurisma

Perikarditis

Kolaps vaskular perifer>>

Trombosis vena dan arteri.

 Komplikasi Darah

Anemia >>. Khosla 80% kasus, morfologi

normositik normokrom, 2 pasien mikrositer
hipokrom, anemia hemolitik 1 pasien.
Hongkong; G6PD Def. atau
hemoglobinopathi
Lekopenia dan limfositosis relatif jarang

Lekositosis

Trombositopenia (Jakarta 61,5%)

 Perdarahan akut
Hemolytic uremic syndrome (HUS)

Koagulasi intravaskular diseminata

Komplikasi Paru

Stadium awal ; bronkitis typhoid

lobar pneumonia (pneumo-typhoid)

jarang (minggu II/III)
1-3%
 Efusi pleura
Pneumothrax

empiema

Abses paru <<<

 Komplikasi hepar, kandung
empedu dan pankreas

Tifoid hepatitis asimptomatis

Hepatomegali

Kriteria tifoid hepatitis menurut Khosla :

1. Hepatomegali
2. Ikterus
3. Kelainan lab (Bilirubin > 30,6umol/l, SGOT/SGPT
meningkat, indeks waktu protrombin menurun)
4. Kelainan histopatologi
:3 atau lebih gejala : Hepatitis tifosa
 Pohan dkk (Jakarta): 4,8% kasus,
Suling dkk (Manado) 6,2%
Nelwan RHH; Pankreatitis tifosa

Kolesistitis akut

Kolesistitis kronik
Komplikasi Renal

Fungsional atau patologis

Akibat gangguan glomerulus
sementara atau GGA karena hemolisis
Khosla typhoid-nephritis 0,7%,
proteinuria 61,34%, pyuria 22%
Pohan dkk 75,2% proteinuria,
lekosituria 5,7%
 Retensi urin
glomerulonefritis

Pielonefritis

Sistitis

Orkhitis

Basiluria asimptomatis stadium dini

Imune complex-mediated glomerulonephritis

thypoid-nephritis / nephrotyphoid
Komplikasi neuropsikiatri

Paling sering
Insiden berbeda-beda tiap negara

Khosla ; 36,7%

Indonesia dan Vietnam 10-40%

Tabel 1. Komplikasi neuropsikiatri pada demam tipoid (224 kasus). 24
No Manifestasi Jumlah kasus

1 Delirium 140
i) Tanpa konvulsi 80
ii) Dengan konvulsi 60
2 Semicoma/coma 84
3 Parkinsonian rigidity/Transient Parkinsonism 84
4 Acute Brain Syndrome 24
5 Generelasid Myoclonus 12
6 Meningismus 28
7 Skizoprenia katatonia 6
8 Maniak akut 4
9 Pseudo Bulbar Palsy 2
10 Polyneuropathy 2
11 Hypomania 2
12 Encephalomyelitis 1
Komplikasi lainnya :
depresi

tuli

transverse myelitis

gangguan ekstrapyramidal

pseudo tumor cerebri

Komplikasi tulang, sendi
dan otot
Typhoid osteomyelitis
Typhoid spine (diagnosa banding tbc)
Typhoid arthritis
Insiden 2%
Periostitis
Ruptur otot
Komplikasi lain-lain

Hiperkalsemia
ulserasi dekubitus

Parotitis

Alopesia

Furunkulosis

Spontaneus spleen rupture

Abortus
DEMAM TIFOID BERAT

=> Sindroma klinis berupa gangguan

atau penurunan kesadaran akut
(kesadaran berkabut, apatis, delirium,
sopor dan koma) dengan atau tanpa
disertai kelainan neurologis lainnya.

= Demam Tifoid Toksik, Demam

Tifoid ensefalopati, Demam Tifoid
dengan toksemia
 Patofisiologi belum jelas
Hornick dan Greisman; endotoksin
toksemia

inflamasi makrofag monokin,

asam arakhidonat, radikal bebas
Demam Tifoid Berat
PENGOBATAN

ANTIBIOTIKA
PERAWATAN YANG BAIK

NUTRISI

CAIRAN DAN ELEKTROLIT

PENCEGAHAN KOMPLIKASI

KORTIKOSTEROID ?
ANTIBIOTIKA
Kloramfenikol (500 mg / 6 jam selama 14
hari) dapat menurunkan angka kematian dari
10-15% menjadi 1-4% resisten, tidak
efektif terhadap karier, aplastik anemi
Amoxysillin 1 gr/8 jam selama 14 hari

Ampicillin

Cotrimoxazole

Tiamfenikol
 Fluorokuinolon paling efektif, waktu
singkat, pilihan pertama, angka stool
carriage lebih rendah
Azithromycine

Sefalosporin generasi ketiga

 Penanganan Demam Tifoid Berat
Makanan (tinggi kalori dan rendah
serat) melalui IV atau sonde
Mencegah dan mengawasi perforasi,
perdarahan dan syok
Keseimbangan cairan dan elektrolit
 Pada keadaan adanya komplikasi (renal,
kardiovaskular, Pernafasan,
neuropsikiatri, tulang, hematologi) =>
Prosedur medik yang berlaku
 Tabel 3. Terapi Demam Tipoid Berat
Sensitifitas Obat parenteral lini pertama Obat parenteral lini kedua
Antibiotika Dosis Lama Antibiotika Dosis Lama
harian (hari) harian (hari)
(mg/kg) (mg/kg)
Sensitif Fluorokuinolon 15 10-14 Kloramfenikol 100 14-21
(cth, ofloxacin)* Amoksisillin 100 10-14
Trimethoprim- 8 10-14
Sulphamethoxazole
40
Multidrug- Fluorokunolon 15 10-14 Ceftriakson atau 60 10-14
resistant cefotaksim 80
Quinolone- Cefriakson atau 60 10-14 Fluorokuinolon 20 10-14
resistant** cefotaksim 80
Treatment of severe
typhoid
Kortikosteroid
Kontroversial
Hoffman dkk; deksametason menurunkan
angka kematian 55,6% menjadi 10%
Gaol LM (Medan); pemberian deksametason
dosis tinggi dan rendah tidak ada perbedaan
bermakna
Widodo (Jakarta); Deksametason 3 X 5 mg hasil
klinis sama dengan dosis tinggi
Hook ; tidak setuju pemberian kortikosteroid
(banyak efek samping)
Dexamethasone for CNS
complication
Should be immediately be treated with
high-dose intravenous dexamethasone
in addition to antimicrobials
Initial dose of 3 mg/kg by slow i.v.
infusion over 30 minutes
1 mg/kg 6 hourly for 2 days
Mortality can be reduced by some 80-
90% in these high-risk patients
Prognosis
Umur
Kekebalan penderita
Juml. & virulensi salmonella
Cepat & tepatnya terapi
Keadaan umum
Differensial diagnosa
Influenza
Disentri basiler
Peny. Dgn demam yang lama
Malaria
tuberkulosis