Ebcr ikhsan-pediatric-slide show

Penggunaan Lactobacillus acidophilus utk mempercepat penyembuhan diare pada anak

Ikhsan*, Devaera Yǂ

EBCR:

* Program Studi Pendidikan Dokter, Fakultas Kedokteran, Universitas Indonesia

ǂ Departemen Ilmu Kesehatan Anak, Fakultas Kedokteran, Universitas Indonesia

Ilustrasi kasus • An. R, ♂, usia 2 bln, BAB cair sejak 10 hari SMRS (warna

kuning, 2-8 x/hari, lendir disertai lendir, tanpa darah) demam, mual, muntah disangkal. Nafsu makan baik, penurunan BB 500 g (7 kg 6,5 kg). Saat pemeriksaan pasien tampak ingin minum, BAK lancar, warna kuning cerah, sering.

• 1 bulan SMRS diare berair, frekuensi >3 kali/hari, namun sembuh dalam 1 hari saja. tidak ada riwayat BAB berdarah

• Lahir cukup bulan s.c. berat lahir 3300 g, langsung menangis, tidak ada kelainan

• Hanya diberi asupan ASI sejak lahir ; sudah imunisasi BCG & DTP. Sudah bisa tengkurap & mengangkat kepala. Tidak ada anggota keluarga yang sedang sakit.

Ilustrasi kasus | Latar Belakang | Metodologi | Hasil | Diskusi | Kesimpulan

Ilustrasi kasus • PF: CM, TSS, kesan gizi cukup ( BB 6,5 kg; PB 62 cm)

kurva WHO >-1Z-score.TTV d.b.n. kedua mata agak cekung, konjungtiva tidak pucat, sklera tidak anemis, bibir lembab, mukosa bukal lembab, bising usus meningkat, dan turgor kulit cukup.PF lainnya d.b.n. Hasil lab d.b.n.

• Diagnosis: diare akut dehidrasi ringan sedang

• Tx bangsal : IVFD KAEN1B, Orezinc® 1x1 sachet/hari, serta Lacto B® 2x1 sachet/hari.



• Prinsip tatalaksana diare pada anak

– Nutrisi yang adekuat

– Rehidrasi sesuai derajat rehidrasi

– Pemberian zinc

– Pemakaian antibiotik tanpa indikasi

– Pemakaian adsorban (kaolin, pectin)

– Pemakain antimotilitas (loperamide)

– ? Pemakaian probiotik?


• Probiotik?

• Lacto-B Lactobacillus acidophilus

• MIMS: Treatment of diarrhoea and lactose intolerance

Philips ML. Gut reaction: Environmental effects on the human microbiota. Environ Health Perspect. 2009; 117(5):A198-A205

Pertanyaan Klinis • Apakah penggunaan Lactobacillus acidophilus

dapat mempercepat penyembuhan diare pada anak?

• P : Children with acute diarrhea

• I : Lactobacillus acidophilus

• C : -

• O : Healing/length of hospital stay/morbidity


Metodologi Kriteria eksklusi

– Bukan artikel dalam 5 tahun terakhir

– Bukan pada manusia

– Bukan dalam bahasa Inggris

– Bukan laporan penelitian

– Diare yang disebabkan infeksi bakteri

– Objek penelitian menderita gizi

buruk/kurang

– Tidak terdapat teks lengkap yang gratis

– Level of evidence lebih rendah

Kriteria inklusi – Clinical trial atau

Systematic Review

– Objek penelitian pada anak


Bagan Alir Penelusuran


Children with

acute diarrhoea

OR acute diarrhea

OR diarrhea

Lactobacillus

acidophilus OR

Lactobacillus

OR Probiotics

Length of

hospital stay OR

healing OR

morbidity

A

N

D

A

N

D

PubMed MEDLINE ScienceDirect GoogleScholar

57 11 221 1200

313 42

English AND

Human English NOT adult NOT

chronic NOT surgery

Bagan Alir Penelusuran


Last 5 years

Clinical trial OR Systematic review

Relevancy: Screening Title & Abstract

14

PubMed : 8 RCT, 1 systematic review

MEDLINE : 2 RCT

SciDirect : 1 RCT

GoogleSccholar:3 RCT,1 sys review

19 3 99 169

2 1 20

OCEBM Levels of Evidence Working Group*. “The Oxford 2011 Levels of Evidence”. Oxford Centre for Evidence-Based Medicine. http://www.cebm. net/index.aspx?o=5653

Hasil Pencarian


Telaah Kritis Komponen penilaian Salari P, et.al Applegate JA, et.al

1. PICO jelas + +

2. Missed literature + (English only) - (All languanges)

3. Kriteria inklusi & eksklusi

Trials, children, Uncontrolled, Different

goals

RCT, Anak <5 tahun, diare akut, Outcome: mortality, hospitaliza

-tion, severity, duration No breastfed, Not all etiology, Antibiotic, Not probiotics alone

4. Validitas literatur Jadad score (17)High(3)low GRADE guidelines (8)low/moderate

5.Similar from each study /Heterogenity

Cochrane Q-Test Non-heterogen : durasi

demam (P = 0.7116) Heterogen (P<0.0001)

Durasi diare: Average difference -14.0

6. Pemaparan hasil Foster size plot + Funnel

bias plot Foster size plot


OCEBM Levels of Evidence Working Group*. “The Oxford 2011 Levels of Evidence”. Oxford Centre for Evidence-Based Medicine. http://www.cebm. net/index.aspx?o=5653.

Diskusi

Salari, et.al • PICO jelas: P: diarrhea, I: probiotics, O: actual benefit di

abstrak

• kriteria inklusi & ekslusi jelas artikel berbahasa inggris saja

• 17/20 artikel berkualitas tinggi (Jadad Score >2)

• Foster plot (heterogenecity) & Funnel plot (Bias)

• Non-heterogen dan unlikely bias pada indikator durasi demam saja (The Cochrane Q-test P = 0.7166)

• Heterogen (P<0.0001) : durasi diare, durasi muntah, jumlah tinja, lama rawat inap

• Tidak ada bias finansial


Diskusi

Applegate, et.al • PICO jelas: P: diarrhea, I: probiotics, O: actual benefit di

abstrak

• kriteria inklusi & ekslusi jelas artikel berbahasa inggris saja

• artikel berkualitas low to moderate (GRADE guidelines)

• Foster plot (heterogenecity)

• Non-heterogen pada indikator durasi diare saja (low quality)

• Bill &Melinda Gates Foundation – UNICEF


Diskusi Salari, et.al “there is still doubt and no sufficient evidence for the

efficacy of probiotics in different types of diarrhea in children or adults”

Applegate, et.al “there is no evidence for mortality. There is no evidence

for an effect on diarrhea hospitalizations. Diarrhea duration & stool frequency are mild outcomes with low & moderate/low quality evidence”


Diskusi Systematic Review Salari, et.al dibanding Applegate, et.al:

• Applegate, et.al tidak terbatas bahasa Inggris

• Salari et.al banyak artikel dengan kualitas Tinggi (17/20) Jadad score

• Applegate, et.al low /low to moderate quality (8) GRADE guidelines

• foster size plot & funnel bias plot pada Salari et.al

o Non-heterogen : durasi demam (Salari, et.al)& durasi diare (Applegate, et.al)

o Tidak ada kecocokan untuk perubahan rawat inap

o Terdiri dari bebeberapa RCT dari beberapa wilayah dengan beberapa macam pasien sesuai dgn pasien


Diskusi Lacto-B® : Rp 140.000,00/box

isi 40 sachet

Orezinc® : Rp 10.000,00/box isi 10 sachet 10mg/sachet


*http://apotik.berkahanugrah.net/ **MIMS Indonesia. "Lacto-B". 2013 (Disitasi : Okt 2013). Dapat diunduh dari: http://www.mims.com/Indonesia/drug/info/Lacto-B/?q=Lacto-B&type=brief

Anak R penggunaan 10 hari 1x1 sachet Orezinc® 10 sachet 2x1 sachet Lacto-B® 20 sachet

-Orezinc® saja: Rp 10.000,00 -Orezinc®+Lacto-B® :

Rp 80.000,00-Rp 150.000,00

Kesimpulan

Preparat oral probiotik Lactobacillus acidophilus:

• bermanfaat menurunkan durasi demam & kemungkinan efek penurunan durasi diare.

• Tidak bermanfaat mempercepat penyembuhan pasien/menurunkan lama rawat inap

• Tidak harus diberikan pada pasien ini.


Daftar Pustaka

1. World Health Organization. The Treatment of diarrhoea: a manual for physicians and other senior health. 4th rev. Geneva: WHO Press; 2005. p.3-16

2. World Health Organization. Pedoman pelayanan kesehatan anak di rumah sakit rujukan tingkat pertama di kabupaten/WHO. Jakarta: WHO Indonesia; 2008. h.131-42

3. Sastroasmoro S, (ed.) et.al. Panduan pelayanan medis departemen ilmu penyakit anak RSCM. Jakarta: RSCM; 2007.h.75-9

4. Patel A, Mamtani M, Dibley MJ, Badhoniya N, Kulkarni H. Therapeutic Value of Zinc Supplementation in Acute and Persistent Diarrhea: A Systematic Review.PLoS ONE. 2010; 5(4): e10386. doi:10.1371/journal.pone.0010386

Daftar Pustaka 5. Agustina R, Lukito W, Firmansyah A, Suhardjo HN, Murniati D,

Bindels J. The effect of early nutritional supplementation with a mixture of probiotic, prebiotic fiber and micronutrients in infants with acute diarrhea in Indonesia. Asia Pac. J. Clin. Nutr., 2007; 16(3), 435-42.

6. Lee MC, Lin LH, Hung KL, Wu HY: Oral bacterial therapy promotes recovery from acute diarrhea in children. Acta Paediatr Taiwan. 2001; 42:301-305.

7. Misra S, Sabui TK, Pal NK. A randomized controlled trial to evaluate the efficacy of Lactobacillus GG in infantile diarrhea. J. Pediatr. 2009; 155:129-32

8. Straus SE, Glasziou P, Richardson WS, Haynes RB. Evidence-based medicine: How to practice and teach it. 4th ed. Edinburgh: Churchill-Livingstone Elsevier; 2011.p.98-108.

Daftar Pustaka

9. Medical Education Unit. Clinical epidemiology & evidence-ased medicine 2011-2012 : Exercise book. Jakarta: MEU FKUI; 2012.p.62-3.

10. OCEBM Levels of Evidence Working Group*. “The Oxford 2011 Levels of Evidence”. Oxford Centre for Evidence-Based Medicine. http://www.cebm. net/index.aspx?o=5653.

11. Salari P, Nikfar S, Abdollahi M. A meta-analysis and systematic review on the effect of probiotics in acute diarrhea. Inflamm Allergy Drug Targets.2012; 11(1):3–14

12. Jadad AR, et.al. McQuay. Assessing the quality of reports of randomized clinical trials: Is blinding necessary?.Control. Clin. Trials.1996;1(17):1-12

Daftar Pustaka

13. Applegate JA, Walker CLF, Ambikapathi R, Black RE. Systematic review of probiotics for the treatment of community-acquired acute diarrhea in children. BMC Public Health. 2013; Suppl 3(13): S16

14. Moal VLL, Sarrazin-Davila LE, Servin AL. An experimental study and a randomized double-blind placebo-controlled clinical trial to evaluate the antisecretory activity of Lactobacillus acidophilus strain LB against nonrotavirus diarrhea. Pediatrics..2007;120:e795

15. Teran CG, Teran-Escalera CN, Villarroel P. Nitazoxanide vs probiotics for the treatment of acute rotavirus diarrhea in children: a randomized single-blind controlled trial in Bolivian children. Int. J. Infect. Dis., 2009; 13, 518-23

Ebcr ikhsan-pediatric-slide show

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