TUGAS KESMAS LEPTOSPIROSIS

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BAB I PENDAHULUAN 1.1 Latar Belakang Tujuan penelitian ini adalah untuk membangun pengetahuan, sikap dan perilaku leptospirosis pasien terhadap penyakit mereka. Metode Sebuah penelitian retrospektif terhadap pasien yang menderita leptospirosis, leptospirosis dilakukan dengan menggunakan kuesioner terstruktur dan standar wawancara dalam bahasa masyarakat yang sesuai secara pribadi di tempat pasien tinggal. 1.2 Permasalahan 1. Bagaiman perilaku pada leptospirosis. 1.3 Tujuan a. Tujuan umum Mendapatkan informasi mengenai perilaku pada leptospirosis b. Tujuan khusus 1

Transcript of TUGAS KESMAS LEPTOSPIROSIS

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BAB I

PENDAHULUAN

1.1 Latar Belakang

Tujuan penelitian ini adalah untuk membangun pengetahuan, sikap dan perilaku

leptospirosis pasien terhadap penyakit mereka. Metode Sebuah penelitian retrospektif

terhadap pasien yang menderita leptospirosis, leptospirosis dilakukan dengan

menggunakan kuesioner terstruktur dan standar wawancara dalam bahasa masyarakat

yang sesuai secara pribadi di tempat pasien tinggal.

1.2 Permasalahan

1. Bagaiman perilaku pada leptospirosis.

1.3 Tujuan

a. Tujuan umum

Mendapatkan informasi mengenai perilaku pada leptospirosis

b. Tujuan khusus

1. Mendapatkan informasi mengenai perilaku pada leptospirosis

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1.4 Manfaat

1. Bagi penulis

Menambah pemahaman tentang perilaku pada leptospirosis dari ilmu

Kedokteran dan menambah pengalaman dalam membuat tulisan ilmiah yang

baik dan benar.

2. Bagi Universitas Yarsi

Diharapkan skripsi ini dapat menambah khasanah perpustakaan serta

masukan bagi civitas akademika fakultas kedokteran Universitas Yarsi.

3. Bagi masyarakat

Diharapkan skiripsi ini dapat memperkaya pemahaman mengenai

leptospirosis di kalangan masyarakat luas.

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BAB II

2.1 LEPTOSPIROSIS

2.1.1 DEFINISI

Leptospirosis adalah suatu penyakit zoonosis yang disebabkan oleh mikroorganisme Leptospira interogans tanpa memandang bentuk spesifik serotipenya. Penyakit ini pertama sekali dikemukakan oleh weil pada tahun 1886 yang membedakan penyakit yang disertai dengan ikterus. Bentuk yang beratnya yang dikenal sebagai weil’s disease. Penyakit ini dikenal dengan berbagai nama seperti mud fever, slime fever, autumnal fever, swamp fever, infectious jaundice, field fever, cane cutter fever dan lain-lain.

Leptospirosis acapkali luput didiagnosa karena gejala klinis tidak spesifik, dan sulit dilakukan konfirmasidiagnosa tanpa uji laboratorium. Kejadian luar biasa leptospirosis dalam decade terakhir dalam beberapa negaratelah menjadikan leptospirosis sebagai salah satu penyakit yang termasuk the emerging infectious disease.

2.1.2 ETIOLOGI

Leptospirosis disebabkan oleh genus leptospira, family treponemataceae, suatu mikroorganisme spirochaeta. Ciri khas organisme ini yakni berbelit, tipis, fleksibel, panjangnya 5-15um, dengan spiral yang sangat halus, lebarnya 0,1-0,2um. Salah satu ujung organisme sering membengkak, membentuk suatu kait. Terdapat gerak rotasi aktif, tetapi tidak ditemukan adanya flagella. Spirochaeta ini sangat halus sehingga dalam mikroskop lapangan gelap hanya dapat terlihat sebagai rantai kokus kecil-kecil. Dengan pemeriksaan lapangan redup pada mikroskop biasa morfologi leptospira secara umum dapat dilihat. Untuk mengamati lebih jelas gerakan leptospira menggunakan lapang gelap (darkfield microscope). Leptospira membutuhkan media dan kondisi yang khusus untuk tumbuh dan mungkin membutuhkan waktu berminggu-minggu untuk membuat kultur positif. Dengan medium Fletcher’s dapat tumbuh dengan baik sebagai obligat aerob.

Secara sederhana genus leptospira terdiri atas dua spesies : L.interrogans yang pathogen dan L.biflexa yang non pathogen / saprofit. Tujuh spesies dari leptospira pathogen sekarang ini telah diketahui dasar ikatan DNA-nya, namun lebih praktis dalam klinik dan epidemiologi menggunakan klasifikasi yang didasarkan atas perbedaan serologis. Spesies L.interrogans dibagi atas beberapa serogrup dan serogrup ini dibagi banyak serovar menurut komposisi antigennya. Saat ini telah ditemukan lebih dari 250 serovar yang tergabung dalam 23 serogrup. Beberapa serovar L.interrogans yang dapat menginfeksi manusia diantaranya: L.icterohaemorrhagiae, L.canicola, L.pomona, L.grippothyphosa, L.javanica, Lcelledoni, L.ballum, L.pyrogenes, L.automnalis, L.hebdomadis dan lain-lain.

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Menurut beberapa peneliti, yang tersering menginfeksi manusia adalah L.icterohaemorragica dengan reservoir tikus, L.canicola dengan reservoir anjing dan L.pomona dengan reservoir sapid an babi.

2.1.3 EPIDEMIOLOGI

Leptospirosis tersebar diseluruh dunia, di semua benua kecuali dibenua antrtika, namun terbanyak didapati didaerah tropis. Leptospira bisa terdapat pada binatang piaraan seperti anjing, babi, lembu, kuda, kucing, marmot, atau binatang-binatang pengerat lainnya seperti tupai, musang kelelawar, dan lain sebagainya. Di dalam tubuh binatang tersebut, leptospira hidup dalam ginjal atau air kemihnya. Tikus mempunyai vector yang utama dari L.icterohaemorrhagica penyebab leptospirosis pada manusia. Dalam tubuh tikus, leptospira akan menetap dan membentuk koloni serta berkembang biak didalam epitel tubulus ginjal tikus dan secara terus-menerus dan ikut mengalir dalam filtrate urin. Penyakit ini bersifat musiman, didaerah beriklim sedang masa puncak insidens dijumpai pada musim panas dan musim gugur karena temperature adalah factor yang mempengaruhi kelangsungan hidup leptospira, sedangkan didaerah tropis insidens tertinggi terjadi selama musim hujan.

Leptospirosis mengenai paling kurang 160 spesies mamalia, ada berbagai jenis pejamu dari leptospira, mulai dari mamalia yang berukuran kecil dimana manusia dapat kontak dengannya, misalnya landak, kelinci, tikus sawah, tikus rumah, tupai, musang, sampai dengan reptile (berbagai jenis katak dan ular), babi, sapi, kucing, dan anjing. Binatang pengerat terutama tikus merupakan reservoir paling banyak. Leptospira membentuk hubungan simbiosis dengan pejamunya dan dapat menetap dalam tubulus renalis selama berbulan-bulan bahkan bertahun-tahun. Beberapa serovar berhubungan dengan binatang tertentu, seperti L.icterohaemorrhagica/copenhageni dengan tikus, L.grippothyphosa dengan voles sejenis tikus, L.hardjo dengan sapi, L.canicola dengan anjing, L.pomona dengan babi.

International Leptospirosis Society menyatakan Indonesia sebagai Negara dengan insidens leptospirosis tinggi dan peringkat ketiga didunia untuk mortalitas.

Di Indonesia Leptospirosis ditemukan di DKI Jakarta, Jawa Barat, Jawa Tengah, DI Yogyakarta, Lampung, Sumatera Selatan, Bengkulu, Riau, Sumatera Utara, Bali, NTB, Sulawesi Selatan, Sulawesi Utara , Kalimantan Timur dan Kalimantan Barat. Pada kejadian banjir besar di Jakarta tahun 2002, dilaporkan lebih dari seratus kasus leptospirosis dengan 20 kematian.

Salah satu kendala dalam menangani leptospirosis berupa kesulitan dalam diagnosis awal. Sementara dengan pemeriksaan sederhana memakai mikroskop biasa dapat dideteksi adanya gerakan leptospira dalam urin. Diagnostic pasti ditegakkan dengan ditemukannya leptospirapada daerah atau rin atau ditemukannya hasil serologi positif. Untuk dapat berkembang biaknya leptospira memerlukan lingkungan yang optimal serta tergantung pada suhu yang lembab, hangat, pH air/tanah yang netral, dimana kondisi ini ditemukan sepanjang tahun didaerah tropis.

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2.1.4 PENULARAN

Manusia dapat terinfeksi melalui kontak dengan air, atau tanah, lumpur yang telah terkontaminasi oleh urin binatang yang telah terinfeksi oleh leptospira. Infeksi tersebut terjadi jika ada luka/erosi pada kulit ataupun selaput lendir. Air tergenang atau mengalir lambat yang terkontaminasi urin binatang infeksius memainkan peranan dalam penularan penyakit ini, bahkan air deraspun dapat berperan. Kadang-kadang penyakit ini bisa terjadi akibat gigitan binatang yang sebelumnya terinfeksi leptospira atau kontak dengan kultur leptospira di laboratorium. Ekspos yang lama pada genangan airyang terkontaminasi terhadap kulit yang utuh juga dapat menularkan leptospira. Orang-orang yang mempunyai resiko tinggi mendapat penyakit ini adalah pekerja-pekerja di sawah, pertanian, perkebunan, peternakan, pekerja tambang, pekerja dirumah potong hewan atau orang-orang yang mengadakan perkemahan di hutan, dokter hewan.Faktor resiko tertular Leptospirosis terdapat pada table 1:

Kelompok Pekerjaan Kelompok Aktivitas Kelompok lingkungan

- Petani dan peternak Berenang di sungai Anjing piaraan ternak- Tukang potong hewan Bersampan Genangan air hujan- Penangkap hewan Kemping Lingkungan tikus- Dokter/mantra hewan Berburu Banjir- Penebang kayu Kegiatan di hutan- Pekerja selokan- Pekerja perkebunan

2.1.5 PATOGENESIS

Leptospira masuk kedalam tubuh melalui kuli atau selaput lendir, memasuki aliran darah dan berkembang, lalu menyebar secara luas ke seluruh jaringan tubuh. Kemudian terjadi respon imunologi baik secara selular maupun humoral sehingga infeksi ini dapat ditekan dan terbentuk antibody spesifik. Walaupun demikian beberapa organisme ini masih bertahan pada daerah yang terisolasi secara imunologi seperti didalam ginjal dimana sebagian mikroorganisme akan mencapai convoluted tubulus, bertahan disana dan dilepaskan melalui urin. Leptospira dapat dijumpai dalam air kemih sekitar 8 hari sampai beberapa minggu setelah infeksi dan sampai berbulan-bulan bahkan bertahun-tahun kemudian. Leptospira dapat dihilangkan dengan fagositosis dan mekanisme humoral. Kuman ini dengan cepat lenyap dari darah setelah terbentuknya agglutinin. Setelah fase leptospiremia 4-7 hari, mikroorganisme hanya ditemukan dalam ginjal dan okuler. Leptospiruria berlangsung 1-4 minggu.

Tiga mekanisme yang terlibat pada patogenese leptospirosis : invasi bakteri langsung, factor inflamasi non spesifik dan reaksi imunologi.

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2.1.6 PATOLOGI

Dalam perjalana dalam fase leptospiremia, leptospira melepaskan toksin yang bertanggung jawab atas terjadinya keadaan patologi pada beberapa organ. Lesi yang muncul terjadi karena kerusakan pada lapisan endotel kapiler. Pada leptospirosis terdapat perbedaan antara derajat gangguan fungsi organ dengan kerusakan secara histologik. Pada leptospirosis lesi histologis yang ringan ditemukan pada ginjal dan hati pasien dengan kelainan fungsional yang nyata dari organ tersebut. Perbedaan ini menunjukkan bahwa kerusakan bukan pada struktur organ. Lesi inflamasi menunjukkan edema dan infiltrasi sel monosit, limfosit dan sel plasma. Pada kasus yang berat terjadi kerusakan kapiler dengan perdarahan yang luas dan disfungsi hepatoseluler dengan retensi bilier. Selain di ginjal leptospira juga dapat bertahan pada otak dan mata. Leptospira dapat masuk ke dalam cairan serebrospinalis pada fase leptospiremia. Hal ini akan menyebabkan meningitis yang akan merupakan gangguan neurologi terbanyak yang terjadi sebagai komplikasi leptospirosis. Organ-organ yang sering dikenai leptospirosis adalah ginjal, hati, otot, dan pembuluh darah. Kelainan spesifik pada organ :

Ginjal :Interstitial nefritis dengan infiltrasi sel mononuclear merupakan bentuk lesi pada leptospirosis yang dapat terjadi tanpa gangguan fungsi ginjal. Gagal ginjal terjadi akibat tubular nekrosis akut. Adanya peran nefrotoksin, reaksi imunologis, iskemia ginjal, hemolysis dan invasi langsung mikroorganisme juga berperan menimbulkan kerusakan ginjal.

Hati :Hati menunjukkan nekrosis sentilobuler fokal dengan infiltrasi sel limfosit fokal dan proliferasi sel kupfer dengan kolestasis. Pada kasus-kasus yang diotopsi, sebagian ditemukan leptospira dalam hepar. Biasanya organisme ini terdapat diantara sel-sel parenkim.

Jantung : Epikardium, endocardium, dan miokardium dapat terlibat. Kelainan miokardium dapat fokal atau difus berupa interstitial edema dengan infiltrasi sel mononuclear dan plasma. Nekrosis berhubungan dengan infiltrasi neutrophil. Dapat terjadi perdarahan fokal pada miokardium dan endocarditis.

Otot rangka :Pada otot rangka, terjadi perubahan-perubahan berupa local nekrotis, vakuolisasi dan kehilangan striata. Nyeri otot yang terjadi pada leptospira disebabkan invasi langsung leptospira. Dapat juga ditemukan antigen leptospira pada otot.

Mata :Leptospira dapat masuk ruang anterior dari mata selama fae leptospiremia dan bertahan beberapa bulan walaupun antibody yang terbentuk cukup tinggi. Hal ini akan menyebabkan uveitis.

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Pembuluh darah :Terjadi perubahan pada pembuluh darah akibat terjadinya vaskulitis yang akan menimbulkan perdarahan. Sering ditemukan perdarahan/petekie, pada mukosa, permukaan serosa, dan alat-alat viscera dan perdarahan bawah kulit.

Susunan saraf pusat :Leptospira mudah masuk kedalam cairan cerebrospinal (CSS) dan dikaitkan dengan terjadinya meningitis. Meningitis terjadi sewaktu terbentuknya respon antibody, tidak pada saat memasuki CSS. Diduga bahwa terjadinya meningitis diperantarai oleh mekanisme imunologi. Terjadi penebalan meninges dengan sedikit peningkatan sel mononuklear arakhnoid. Meningitis yang terjadi adalah meningitis aseptik, biasanya paling sering disebabkan oleh L.canicola.

Weil Disease :Weil disease adalah Leptospirosis berat yang ditandai dengan ikterus, biasanya disertai dengan perdarahan, anemia, azotemia, gangguan kesadaran dan demam tipe kontinua. Penyakit weil ini biasanya terdapat pada 1-6% kasus dengan leptospirosis. Penyebab weil disease adalah serotype icterohaemorragica pernah juga dilaporkan oleh serotype copenhageni dan bataviae. Gambaran klinis bervariasi berupa gangguan renal, hepatic, atau disfungsi vascular.

2.1.7 GAMBARAN KLINIS

Masa inkubasi 2-26 hari, biasanya 7-13 hari dan rata-rata 10 hari. Leptospirosis mempunyai 2 fase penyakit yang khas yaitu fase leptospiremia dan fase imun.

Gambaran Klinis pada LeptospirosisSering : demam, menggigil, sakit kepala, meningismus, anoreksia, myalgia, conjuctival suffusion, mual, muntah, nyeri abdomen, icterus, hepatomegaly, ruam kulit, fotopobi.Jarang : pneumonitis, hemaptoe, delirium, perdarahan, diare, edema, spleenomegali, arthralgia, gagal ginjal, peroferal neuritis, pankreatitis, parotitis, epididymitis, hematemesis, asites, miokarditis.

Fase LeptospiremiaFase ini ditandai dengan adanya leptospira didalam darah dan cairan serebrospinal, berlangsung secara tiba-tiba dengan gejala awal sakit kepala biasanya di frontal, rasa sakit pada otot yang hebat terutama pada paha, betis, dan pinggang disertai nyeri tekan. Myalgia dapat diikuti dengan hiperestesi kulit, demam tinggi yang disertai dengan menggigil, juga didapati mual dengan atau tanpa muntah disertai mencret, bahkan sekitar pada 25% kasus disertai dengan penurunan kesadaran. Pada pemeriksaan keadaan sakit berat, bradikardi relative, dan icterus (50%). Pada hari ke 3-4 dapat dijumpai adanya konjungtiva suffusion dan fotofobia. Pada kulit dijumpai rash yang berbentuk macular,

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makulopapular, atau urtikaria. Kadang-kadang dijumpai spleenomegali, hepatomegali, serta limfadenopati. Fase ini berlangsung 4-7 hari. Jika cepat ditangani pasien akan membaik, suhu akan kembali normal, penyembuhan organ-organ yang terlibat dan fungsinya kembali normal 3-6 minggu setelah onset. Pada keadaan sakit yang berat demam turun setelah 7 hari diikuti oleh bebas demam selama 1-3 hari, setelah itu terjadi demam kembali. Keadaan ini disebut fase kedua atau fase imun.

Fase ImunFase ini ditandai dengan peningkatan titer antibody, dapat timbul demam yang mencapai suhu 400C disertai menggigil dan kelemahan umum. Terdapat rasa sakit yang menyeluruh pada leher, perut dan otot-otot kaki terutama otot betis. Terdapat perdarahan berupa epistaksis, gejala kerusakan pada ginjal dan hati, uremia, ikterik. Perdarahan paling jelas terlihat pada fase ikterik, purpura, petechiae, epistaksis, perdarahan gusi merupakan manifestasi perdarahan yang paling sering. Conjunctiva injection dan conjungtival suffusion dengan icterus merupakan tanda patognomosis untuk leptospirosis.

Terjadinya meningitis merupakan tanda pada fase ini, walaupun hanya 50% gejala dan tanda meningitis, tetapi pleositosis pada CSS dijumpai pada 50-90% pasien. Tanda-tanda meningeal dapat menetap dalam beberapa minggu, tetapi biasanya menghilang setelah 1-2 hari. Pada fase ini leptospira dapat dijumpai dalam urin.

2.1.8 DIAGNOSIS

Pada umumnya diagnosis awal leptospirosis sulit, karen pasien biasanya datang dengan meningitis, hepatitis, nefritis, pneumonia, influenza, sindroma syok toksik, demam yang tidak diketahui asalnya dan diatetesis haemorragic, bahkan beberapa kasus datang sebagai pankreatitis. Pada anamnesis, penting diketahui tentang riwayat pekerjaan pasien, apakah termasuk kelompok resiko tinggi. Gejala/keluhan didapati demam yang muncul mendadak, sakit kepala terutama di bagian frontal, nyeri otot, mata merah/fotofobia, mual/muntah. Pada pemeriksaan fisik dijumpai demam, bradikardia, nyeri tekan otot, hepatomegaly dan lain-lain. Pada pemeriksaan laboratorium darah rutin bias dijumpai leukositosis, normal atau sedikit menurun disertai gambaran neutrofilia dan lahu endap darah yang meninggi. Pada urin dijumpai proteinuria, leukositoria dan torak (cast). Bila organ hati terlibat, bilirubin direk meningkat tanpa peningkatan transaminase. BUN, ureum, dan kreatinin bisa meninggi bila terjai komplikasi pada ginjal. Trombositopenia terdapat pada 50% kasus. Diagnosa pasti dengan isolasi leptospira dari cairan tubuh dan serologi.

Kultur :Dengan mengambil specimen dari darah atau CSS segera pada awal gejala. Dianjurkan untuk melakukan kultur ganda dan mengambil spesimen pada fase leptospiremia serta belum diberi antibiotic. Kultur urin diambil setelah 2-4 minggu onset penyakit. Pada specimen yang terkontaminasi, inokulasi hewan dapat digunakan

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Serologi :Jenis uji serologi dapat dilihat pada pembahasan dibawah :

Microscopic Agglutination Test (MAT):Uji carik celup :

- Lepto Dipsttick- Lepto Tekanan lateral flowAgglutination latex kering(Lepto Tekanan Dry-dot)Indirect fluorescent antibody test (IFAT)Indirect Haemagglutination Test (IHT)Uji aglutinasi LateksComplement fixation test (CFT)

Macroscopic Slide Agglutination Test (MSAT)Enzyme linkedImmunosorbant assay (ELISA)Microcapsule agglutination testPatoc- slide agglutination test (PSAT)Sensitized erythrocyte lysis test (SEL)Counter immune electrophoresis (CIE)

Pemeriksaan untuk mendeteksi adanya leptospira dengan cepat adalah pemeriksaan Polymerase Chain Reaction(PCR), silver stain atau fluroscent antibody stain dan mikroskop lapangan gelap.

2.1.9 PENGOBATAN

Pengobatan suportif denganobservasi ketat untuk mendeteksi dan mengatasi keadaan dehidrasi, hipotensi, perdarahan dan gagal ginjal sangat penting untuk leptospirosis. Gangguan fungsi ginjal umumnya dengan spontan akan membaik dengan membaiknya kondisi pasien. Namun pada beberapa pasien membutuhkan tindakan hemodialisa temporer.

Pemberian antibiotic harus dimulai secepat mungkin, biasanya pemberian 4 hari setelah onset cukup efektif. Untuk kasus leptospirosis berat, pemberian intravena penisilin G, amoksisilin, ampisilin atau eritromisin dapat diberikan. Sedangkan untuk kasus-kasus ringan dapat diberikan antibiotic oral tetrasiklin, doksisiklin, ampisilin atau amoksisilin maupun sefalosporin.

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Pengobatan dan kemoprofilaksis leptospirosisIndikasi Regimen DosisLeptospirosis Doksisiklin 2x100mgRingan Ampisilin 4x500-750mg

Amoksisilin 4x500mg

Leptospirosis Penisilin G 1,5juta unit/6jam(i.v)Sedang Ampisilin 1 gram/6 jam(i.v)Berat Amoksisilin 1 gram/ 6 jam(i.v)

Kemoprofilaksis Doksisiklin 200mg/minggu

Sampai saat ini penisilin masih merupakan antibiotika pilihan pertama, namun perlu diingat bahwa antibiotika bermanfaat jika leptospira masih didarah (fase leptospiraemia). Pada pemberian penisilin dapat muncul reaksi Jarisch-Herxherimer 4 sampai 6 jam setela pemberian intravena, yang menunjukkan adanya aktivitas anti leptospira. Tindakan suportif diberikan sesuai dengan tingkat keparahan penyakit dan kompikasi yang timbul. Keseimbangan cairan, elektrolit dan asam-basa diatur sebagaimana pada penanggulangan gagal ginjal secara umum. Kalau terjadi azotemia/uremia berat sebaiknya dilakukan dialysis.

2.1.10 PROGNOSIS

Jika tidak ada icterus, penyakit jarang fatal. Pada kasus dengan icterus, angka kematian 5% pada umur dibawah 30 tahun dan pada usia lanjut mencapai 30-40%.

2.1.11 PENCEGAHAN

Pencegahan leptospirosis terutama didaerah tropis sangat sulit. Banyaknya hospes perantara dan jenis serotype sulit untuk dihapuskan. Bagi mereka yang mempunyai resiko tinggi untuk tertular leptospirosis harus diberikan perlindungan berupa pakaian khusus yang dapat melindunginya dari kontak dengan bahan-bahan yang telah terkontaminasi kemih binatang reservoir. Pemberian doksisiklin 200mg perminggu dikatakan bermanfaat untuk mengurangi serangan leptospirosis bagi mereka yang mempunyai resiko tinggi dan terpapar dalam waktu singkat. Penelitian terhadap tentara Amerikadihutan panama selama 3 minggu ternyata dapat mengurangi serangan leptospirosis dari 4-2% menjadi 0,2% dan efikasi pencegahan 95%.

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Vaksinasi terhadap hewan-hewan tersangka reservoir sudah lama direkomendasikan, tetapi vaksinasi terhadap manusia belum berhasil dilakukan, masih memerlikan penilitian lebih lanjut.

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BAB III

JURNAL LEPTOSPIROSIS

Leptospirosis, an infectious disease that affects humans and animals, is considered the most common zoonosis in the world.[1] Leptospirosis is often referred to as swineherd's disease, swamp fever, or mud fever. The organism enters the body when mucous membranes or abraded skin come in contact with contaminated environmental sources.

The infection causes a systemic illness that often leads to renal and hepatic dysfunction. The disease was first recognized as an occupational disease of sewer workers in 1883. In 1886, Weil described the clinical manifestations in 4 men who had severe jaundice, fever, and hemorrhage with renal involvement. Inada et al identified the causal agent in Japan in 1916.[2]

Occupational exposure probably accounts for 30-50% of human cases. The main occupational groups at risk include farm workers, veterinarians, pet shop owners, field agricultural workers, abattoir workers, plumbers, meat handlers and slaughterhouse workers, coal miners, workers in the fishing industry, military troops, milkers, and sewer workers.

Studies in sewer workers show greater prevalence of leptospira antibodies than in controls. Infected rats may contaminate sewer water. Partial or total immersion in mud and water plays a role in facilitating infection in sewer workers and rice field workers.

Milkers may be splattered in the face, causing subsequent infection via the conjunctivae. Infection of military troops occurs as a result of direct exposure to infected urine or indirect contact with contaminated soil and water. Seroprevalence surveys of livestock workers have shown ranges of positive antibody titers at 8-29%.

Although leptospirosis continues to be predominantly an occupational disease since 1970, it has also increasingly been recognized as a disease of recreation. Recreational activities that present some risk include traveling to tropical areas, canoeing, hiking, kayaking, fishing, windsurfing, swimming, waterskiing, wading, riding trail-bikes through puddles, white-water rafting, and other outdoor sports played in contaminated water. Camping by and traveling to endemic areas also add some risk.

An outbreak of an acute febrile illness occurred among athletes competing in the Eco-Challenge-Sabah 2000 in Malaysia; 44% of those who reported feeling ill met the case definition of leptospirosis.[3] Significant risk factors included kayaking and swimming in and swallowing water from the Segama River. In 1998, athletes who participated in a triathlon in Springfield, Illinois, and who swam in Lake Springfield developed leptospirosis.[4] Other athletes who participated in the same event, although asymptomatic, were found to have laboratory evidence of the disease. Prolonged water exposure, in the form of a 1.5-mile swim in Lake Springfield, was the

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epidemiologic association among the sick athletes. In 1997, US travelers who visited Costa Rica and engaged in white-water rafting contracted the disease.[5]

Leptospirosis may be spread epidemically in large populations in conditions of widespread flooding, as occurred in Nicaragua in 1995.[6] In Brazil, the highest incidence of leptospirosis occurs during the summer months when heavy rains and floods occur in urban areas. Flooding in the Philippines in 2009 led to more than 2000 cases of leptospirosis infection, resulting in more than 100 deaths. Flooding on a smaller scale may also lead to individuals contracting the disease. For example, in 2004, a stream overflowed and caused flooding on the University of Hawaii campus.[7] Leptospirosis cases were found among those involved in the clean-up process.

Urban dwellers are also at increased risk because these residents may be sporadically exposed to rat urine as inner cities deteriorate. The incidence is increasing in urban children. However, human disease remains mainly related to occupation. The prevalence is higher in males because they tend to be engaged in outdoor work more frequently than females.

Leptospirosis is caused by pathogenic spiral bacteria that belong to the genus Leptospira, the family Leptospiraceae, and the order Spirochaetales. These spirochetes are finely coiled, thin, motile, obligate, slow-growing anaerobes.

A scanning electron micrograph depicting Leptospira atop a 0.1-µm polycarbonate filter. (This image is in the public domain and thus free of any copyright restrictions. Courtesy of the Centers for Disease Control/Rob Weyant.)

Their flagella allow them to burrow into tissue. The genus Leptospira was originally thought to comprise only 2 species: L interrogans, which is pathogenic, and L biflexa, which is saprophytic. More recent work has identified 7 distinct species of pathogenic leptospires, which appear as more than 250 serologic variants (serovars).

Most leptospiral serovars have their primary reservoir in wild mammals, which continually reinfect domestic populations. The organism affects at least 160 mammalian species and has been recovered from rats, swine, dogs, cats, raccoons, cattle, and other animals. The most important reservoirs are rodents, and rats are the most common source worldwide. In the United States, important leptospiral sources include dogs, livestock, rodents, wild animals, and cats. Many serovars are associated with particular animals. For example, L pomona and L interrogans are seen in cattle and pigs; L grippotyphosa is seen in cattle, sheep, goats, and voles; L ballum and L

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icterohaemorrhagiae are associated with rats and mice; and L canicola is associated with dogs. Other important serotypes include autumnalis, hebdomidis, and australis.

Urinary shedding of organisms from infected animals is the most important source of these bacterial pathogens. Contact with the organism via infected urine or urine-contaminated media results in human infection. Such media include animal bedding, soil, mud, and aborted tissue. The organism enters the body via abraded skin or mucous membranes, such as the conjunctiva or alimentary tract. Occasionally, the organism may even enter the body through intact skin. Infection has occurred after animal and rodent bites, after contact with abortion products of infected animals, and after ingestion of contaminated food and water. The latter route of infection is believed to occur via the mucosa of the mouth and the esophagus because leptospires cannot survive in an acidic environment.

Leptospirosis in animals is often subclinical. Leptospires may persist for long periods in the renal tubules of animals by establishing a symbiotic relationship with no evidence of disease or pathological changes in the kidney. As a result, animals that serve as reservoirs of host-adapted serovars can shed high concentrations of the organism in their urine without showing clinical evidence of disease.

This leptospiruria in animals often occurs for months after the initial infection. Leptospiruria also has been found to occur in healthy immunized dogs. Leptospiruria in humans is more transient, rarely lasting more than 60 days. Humans and nonadapted animals are incidental hosts. With rare exceptions, man represents a dead end in the chain of infection because person-to-person spread of the disease is rare.

Most cases occur in the warm season and in rural areas because leptospires can persist in water for many month. The leptospires from infected animals contaminate the warm lake water. They survive best in freshwater, damp alkaline soil, vegetation, and mud with temperatures higher than 22°C.

Mucous surfaces of the mouth, pharynx, and esophagus may be crossed easily by pathogenic leptospires, as are mucous membranes of the bronchial tree and lung alveoli. A waterborne outbreak occurred in Italy in the summer of 1984 when a contaminated water fountain was used as a source of drinking water.[8]

Transmission via laboratory accidents may occur but is rare.

Pathophysiology

After the organism gains entry via intact skin or mucosa, it multiplies in blood and tissue. The resulting leptospiremia can spread to any part of the body but particularly affects the liver and kidney.

After the organism gains access to the kidney, it migrates to the interstitium, renal tubules, and tubular lumen, causing interstitial nephritis and tubular necrosis. When renal failure develops, it is usually due to tubular damage, but hypovolemia from dehydration and from altered capillary permeability can also contribute to renal failure.

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Liver involvement is seen as centrilobular necrosis with proliferation of Kupffer cells. Jaundice may occur as a result of hepatocellular dysfunction.

Leptospires may also invade skeletal muscle, causing edema, vacuolization of myofibrils, and focal necrosis. Muscular microcirculation is impaired and capillary permeability is increased, with resultant fluid leakage and circulatory hypovolemia.

In severe disease, a disseminated vasculitic syndrome may result from damage to the capillary endothelium.

Leptospires may invade the aqueous humor of the eye, where they may persist for many months, occasionally leading to chronic or recurrent uveitis.

Despite the possibility of severe complications, the disease is most often self-limited and nonfatal. Over time, a systemic immune response may eliminate the organism from the body but may also lead to a symptomatic inflammatory reaction that can produce secondary end-organ injury.

Epidemiology

Frequency

United States

Leptospirosis is a zoonosis with worldwide distribution. Specific serovars vary with locality. The incidence varies from sporadic in temperate zones to endemic in a few tropical countries.

The disease has a seasonal incidence. Most cases occur during the rainy season in the tropics and during the late summer or early fall in Western countries, when the soil is moist and alkaline.

The incidence of leptospirosis within the United States steadily increased during the first decades of the 20th century but has remained stable more recently. From 1987-1993, 43-93 cases were reported annually. Leptospirosis is generally underdiagnosed and underreported because many cases are asymptomatic or mildly symptomatic, self-limited, and nonfatal.

In 1995, the Council of State and Territorial Epidemiologists and the US Centers for Disease Control and Prevention (CDC) removed leptospirosis from the US list of notifiable diseases. Because reliable diagnostic testing was not readily available and organized reporting had not resulted in implementation of methods to control the disease, many states stopped reporting leptospirosis.

International

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Leptospirosis is generally associated with tropical countries and heavy rainfall, but most cases actually occur in temperate climates, probably because of underreporting in some countries.

Sex

Most cases occur in middle-aged men, probably because they are employed in at-risk occupations. However, with the change in social roles and the increased exposure during leisure activities, more cases are now reported in women.

Leptospirosis infection has protean manifestations. As a result, it is frequently misdiagnosed. Approximately 15-40% of exposed patients who do not become ill have serologic evidence of past infection. This statistic includes 15% of abattoir workers, packinghouse workers, and veterinarians.

HISTORY

The incubation period is usually 7-12 days, with a range of 2-20 days. Approximately 90% of patients manifest a mild anicteric form of the disease,

and approximately 5-10% have the severe form with jaundice, otherwise known as Weil disease.

The natural course of leptospirosis falls into 2 distinct phases: septicemic and immune. During a brief period of 1-3 days between the 2 phases, the patient shows some improvement.

o First stage This stage is called the septicemic or leptospiremic stage

because the organism may be isolated from blood cultures, cerebrospinal fluid (CSF), and most tissues.

During this stage, which lasts about 4-7 days, the patient develops a nonspecific flulike illness of varying severity.

It is characterized by fever, chills, weakness, and myalgias, primarily affecting the calves, back, and abdomen.

Other symptoms include sore throat, cough, chest pain, hemoptysis, rash, frontal headache, photophobia, mental confusion, and other symptoms of meningitis.

Because of the abrupt nature of the onset, the patient can often tell exactly when the symptoms started.

During the 1-3 day period of improvement that follows the first stage, the temperature curve falls and the patient may become afebrile and relatively asymptomatic. The fever then recurs, indicating the onset of the second stage when clinical or subclinical meningitis appears.

o Second stage This stage is called the immune or leptospiruric stage because

circulating antibodies may be detected or the organism may be isolated from urine; it may not be recoverable from blood or CSF.

This stage occurs as a consequence of the body's immunologic response to infection and lasts 0-30 days or more.

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Disease referable to specific organs is seen. These organs include the meninges, liver, eyes, and kidney. An example of leptospirosis affecting the liver is seen in the image below.

Silver stain, liver, fatal human leptospirosis. (This image is in the public domain and thus free of any copyright restrictions. Courtesy of the Centers for Disease Control/Dr. Martin Hicklin.)

Nonspecific symptoms, such as fever and myalgia, may be less severe than in the first stage and last a few days to a few weeks.

Many patients (77%) experience headache that is intense and poorly controlled by analgesics; this often heralds the onset of meningitis.

Aseptic meningitis is the most important clinical syndrome observed in the immune anicteric stage. Meningeal symptoms develop in 50% of patients. Cranial nerve palsies, encephalitis, and changes in consciousness are less common. Mild delirium may also be seen. Symptoms may be nonspecific, and a viral etiology may be suspected. Meningitis usually lasts a few days but occasionally lasts 1-2 weeks. Death is extremely rare in the anicteric cases.

Leptospires may be isolated from the blood for 24-48 hours after jaundice appears. Abdominal pain with diarrhea or constipation (30%), hepatosplenomegaly, nausea, vomiting, and anorexia are also seen.

Uveitis (2-10%) can develop early or late in the disease and has been reported to occur as late as one year after initial illness. Iridocyclitis and chorioretinitis are other late complications that may persist for years. These symptoms first manifest 3 weeks to 1 month after exposure. Subconjunctival hemorrhage is the most common ocular complication of leptospirosis, occurring in as many as 92% of patients. Leptospires may be present in the aqueous humor.

Renal symptoms (eg, azotemia, pyuria, hematuria, proteinuria, and oliguria are seen in 50% of patients with leptospirosis. Leptospires may be present in the kidney.

Pulmonary manifestations occur in 20-70% of patients, usually have a benign course, and may occur in both the icteric and anicteric forms of the disease. However, pulmonary involvement is the main cause of death due to leptospirosis in some countries, usually as a result of pulmonary hemorrhage or acute respiratory distress syndrome. Indeed, the severe

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pulmonary form of leptospirosis (SPFL) is considered to be one of the major causes of death in patients with severe leptospirosis.

Adenopathy, rashes, and muscular pain are also seen. Clinical syndromes are not specific to the serotype, although some

manifestations may be seen more commonly with some serotypes. Often, the serovar helps determine some of the more characteristic clinical

manifestations, but any leptospiral serovar can lead to the signs and symptoms seen with this disease. For example, jaundice is seen in 83% of patients with L icterohaemorrhagiae infection and in 30% of patients infected with L pomona. A characteristic pretibial erythematous rash is seen in patients with L autumnalis infection. Similarly, GI symptoms predominate in patients infected with L grippotyphosa. Aseptic meningitis commonly occurs in those infected with L pomona or L canicola.

Weil syndrome is the severe form of leptospirosis and primarily manifests as profound jaundice, renal dysfunction, hepatic necrosis, pulmonary dysfunction, and hemorrhagic diathesis.

o It occurs at the end of the first stage and peaks in the second stage; however, the patient's condition can deteriorate suddenly at any time. Often, the transition between the stages is obscured.

o Fever may be marked during the second stage.o Criteria to determine the development of Weil disease are not well

defined.o Pulmonary manifestations include cough, dyspnea, chest pain,

bloodstained sputum, hemoptysis, and respiratory failure.o Vascular and renal dysfunction accompanied by jaundice develop 4-9

days after onset of disease, and jaundice may persist for weeks. o Patients with severe jaundice are more likely to develop renal failure,

hemorrhage, and cardiovascular collapse. Hepatomegaly and tenderness in the right upper quadrant may be present.

o Oliguric or anuric acute tubular necrosis may occur during the second week due to hypovolemia and decreased renal perfusion.

o Multiorgan failure, rhabdomyolysis, adult respiratory distress syndrome, hemolysis, splenomegaly, congestive heart failure, myocarditis, and pericarditis may also occur.

o Weil syndrome carries a mortality rate of 5-10%. The most severe cases of Weil syndrome, with hepatorenal involvement and jaundice, have a case-fatality rate of 20-40%. The mortality rate is usually higher for older patients.

Leptospirosis may present with a macular or maculopapular rash, abdominal pain that resembles acute appendicitis, or generalized enlargement of lymphoid glands, resembling infectious mononucleosis. It may also present as aseptic meningitis, encephalitis, or fever of unknown origin.

Leptospirosis should be considered when a patient has a flulike disease with aseptic meningitis or disproportionately severe myalgia.

Physical

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First stage: Common physical findings include fever; subconjunctival suffusion; pharyngeal injection; splenomegaly; hepatomegaly; mild jaundice; muscle tenderness; lymphadenopathy; and a macular, maculopapular, erythematous, urticarial, or hemorrhagic rash.

Second stage: Physical findings depend on organ involvement. o General - Adenopathy, rash, fever, bleeding, signs of

hypovolemia/cardiogenic shocko Icteric - Jaundice, hepatomegaly, abdominal tenderness, signs of

coagulopathyo Pulmonary - Cough, hemoptysis, dyspnea, respiratory distresso Neurologic - Cranial nerve palsies, confusion, changes in

consciousness, delirium, other signs of meningitiso Ocular - Subconjunctival hemorrhage, uveitis, signs of iridocyclitis or

chorioretinitiso Hematologic - Bleeding, petechiae, purpura, ecchymosis,

splenomegaly, abdominal tendernesso Cardiac - Signs of congestive heart failure, pericarditis

Differentials

Dengue Fever Encephalitis Hantavirus Cardiopulmonary Syndrome Hepatitis Malaria Meningitis Mononucleosis

Laboratory Studies

Definitive diagnosis is suggested by isolation of the organism by culture or a positive result on the microscopic agglutination test (MAT). An example of this is shown in the image below.

Darkfield microscopy of leptospiral microscopic agglutination test. (This image is in the public domain and thus free of any copyright restrictions. Courtesy of the Centers for Disease Control/Mrs. M. Gatton.)

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Only specialized laboratories perform serologic tests; hence, the decision to treat should not be delayed while waiting for the test results.

Cultures o Isolating the organism by culture allows definitive diagnosis.o Leptospires remain viable in anticoagulated blood for as long as 11

days; hence, specimens can be mailed to a reference laboratory for culture. The infecting serovar can be isolated only by culture.

o Blood cultures may be negative if drawn too early or too late. Leptospires may not be detected in the blood until 4 days after the onset of symptoms (7-14 d after exposure). Once the immune system is activated, blood cultures may again become negative.

o Leptospires may be isolated from the cerebrospinal fluid (CSF) within the first 10 days.

o Leptospires may be isolated from the urine for several weeks after the initial infection. In some patients, urine cultures may remain positive for months or years after the onset of illness. Positive urine cultures may take as long as 8 weeks to grow.

MAT o A 4-fold rise in convalescent titers is considered a positive result.o A presumed diagnosis is made by observing an antibody titer of greater

than or equal to 1:100 in the MAT in conjunction with symptoms consistent with the disease.

o The MAT uses a battery of live leptospiral strains.o The antibody response does not reach detectable levels until the second

week of illness, and it can be affected by treatment. Macroscopic slide agglutination test

o This test allows a presumptive diagnosis.o Clinical illness consistent with leptospirosis must be present to support

the diagnosis.o This test, which uses killed antigen, is useful for screening but is not

specific. Other tests: Other tests include an indirect hemagglutination test, a

microcapsule agglutination test, an immunoglobulin M (IgM) enzyme-linked immunoabsorbent assay (ELISA), and a dark-field examination of blood or urine.

o More recently, rapid commercial tests have been made available, such as the Dip-S-Ticks (PanBio, Inc; Baltimore, Maryland), which detects leptospira antibodies.

o Nucleic acid amplification (polymerase chain reaction [PCR])–based techniques have been developed to diagnose leptospirosis. PCR-based techniques are unable to identify the infecting serovar. This factor reduces its epidemiologic and public health value

o The dark-field examination frequently leads to misdiagnosis and should not be used.

o The ELISA uses a broadly reactive antigen and is a standard serologic procedure, as is the MAT.[9] Because it detects IgM, it may be useful for diagnosis of new infections within 3-5 days.

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Laboratory studies (general) o In patients with mild disease, elevated erythrocyte sedimentation rates

and peripheral leukocytosis (3,000-26,000 x 109/L) with a left shift are noted.

o Aminotransferases may be mildly elevated up to 200 U/L; serum bilirubin and alkaline phosphatase levels may also be elevated.

o Urinalysis may reveal the following: Proteinuria may be present. Leukocytes, erythrocytes, hyaline casts, and granular casts may

be present in the urinary sediment.o CSF studies may reveal the following:

When the CNS becomes involved, polymorphonuclear leukocytes initially predominate and are later replaced by monocytes.

CSF protein may be normal or elevated, whereas glucose levels remain normal.

CSF pressure is normal, but a lumbar puncture can relieve the headache.

Laboratory studies (Weil disease) o Patients may exhibit mild thrombocytopenia (as many as 50%), which

is often accompanied by renal failure.o Azotemia and renal failure are other prominent characteristics.o Marked leukocytosis may be present.o Prothrombin times may be elevated.o Creatine phosphokinase (CPK) levels are elevated in as many as 50%

of patients; acutely, jaundice in Weil disease is associated with very high CPK level, but transaminases are only modestly elevated.

Imaging Studies

In severe disease, a patchy alveolar pattern may be revealed on lung radiography findings, corresponding to alveolar hemorrhage.

Most radiographic changes occur in the periphery of the lower lobes.

Other Tests

Electrocardiographic (ECG) abnormalities are common during the leptospiremic phase of Weil syndrome.

In severe cases, congestive heart failure and cardiogenic shock may occur.

Emergency Department Care

Treatment of leptospirosis should be started as soon as possible and may be effective even after the first 4 days of illness.

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Antimicrobial therapy is indicated for the severe form of leptospirosis, but its use is controversial for the mild form of leptospirosis. The Cochrane Database of Systematic Reviews concluded that evidence from randomized clinical trials is insufficient to provide clear guidelines for the treatment of leptospirosis.[10] The trials suggest that antibiotics could be useful. The Cochrane Database of Systematic Reviews also concluded that prophylaxis may be achieved by administering doxycycline to soldiers training in endemic areas with a high risk of exposure to leptospirosis. They were unable to extrapolate prophylaxis to other settings.

A Jarisch-Herxheimer reaction rarely develops. It should be treated supportively if it does develop.

Patients with renal failure may require dialysis; renal function is restored in most.

Those with Weil syndrome may need transfusions of whole blood, platelets, or both.

Supportive therapy and careful management of renal, hepatic, hematologic, and CNS complications are important.

Medication Summary

Currently, no human vaccine against leptospirosis is available.

Mild leptospirosis is treated with doxycycline, ampicillin, or amoxicillin.

For severe leptospirosis, the primary therapy is penicillin G, which is used widely in clinical practice. Alternative regimens are ampicillin, amoxicillin, or erythromycin. Several other antibiotics, including cephalosporins, may be useful, but clinical experience with these is more limited.

Antibiotics

Class Summary

Therapy must cover all likely pathogens in the context of the clinical setting.

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View full drug information

Doxycycline (Bio-Tab, Doryx, Vibramycin)

 Should be considered for treatment of mild cases. Hepatobiliary and renally excreted.

Ampicillin (Omnipen, Marcillin)

 Some ampicillin metabolized by liver, although primarily renally excreted.

Amoxicillin (Amoxil, Polymox, Trimox)

 Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible bacteria.

Penicillin G (Pfizerpen)

 Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms.

Erythromycin (EES, E-Mycin, Ery-Tab)

 Inhibits RNA-dependent protein synthesis, possibly by stimulating dissociation of peptidyl t-RNA from ribosomes. This inhibits bacterial growth. Excreted into bile via liver.

Deterrence/Prevention

Prevention of leptospirosis is difficult because the organism has not been eradicated from wild animals, which constantly infect domestic animals.

o Important control measures include control of livestock infection with good sanitation, immunization, and proper veterinary care.

o Preventing infected animals from urinating in waters where humans have contact, disinfecting contaminated work areas, providing worker education, practicing good personal hygiene, and using personal protective equipment (PPE) when handling infected animals or tissues are important actions for prevention of the disease. Examples of PPE include gloves and face shields for veterinarians and rubber boots for sewer workers and agricultural workers who wade in rodent urine-contaminated water.

o Public health measures include investigation of cases in an effort to detect common source outbreaks and implementation of appropriate control measures to prevent further cases. Other public health measures include identification of contaminated water supplies, rodent control, prohibition of swimming in streams where risk of infection may be

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high, and informing people of risk when they are involved in recreational activities.

Vaccines are offered to high-risk workers in some European and Asian countries (eg, rice workers in Italy). Vaccines are not used in the United States.

o Human vaccines are serovar specific and must be repeated yearly. They are associated with painful swelling, especially after revaccination.

o Vaccinations are available to domestic livestock and to help prevent infection in animals. This intervention has reduced transmission in the United States, although one study in Australia showed no difference in seroprevalence between farmers associated with vaccinated herds and those with unvaccinated herds.

o However, renal infection and persistent leptospiruria can occur in immunized dogs. Human infection has occurred from asymptomatic immunized dogs that still shed leptospires in their urine.

o Also, these animal vaccines are serovar specific and useful where one or a few serovars are present. Hence, the vaccine given should contain the serovars known to be prevalent in the area.

Doxycycline, in the dose of 200 mg every week, has demonstrated efficacy of 95% against leptospirosis and may be given to help prevent the disease in those exposed. This regimen is recommended for those with short-term exposure and is not for repeated exposure over protracted periods of time.

Most patients with leptospirosis recover. The highest mortality rates are in elderly patients and in those with Weil

syndrome. Pregnant women also face a high rate of fetal mortality because infected

women have a higher-than-normal incidence of spontaneous abortion if the infection is acquired in the early months of pregnancy.

Patients with hepatic dysfunction and renal failure have a good chance of recovering renal and hepatic dysfunction in the long term.

BAB IV

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KESIMPILAN DAN SARAN

4.1 KESIMPULAN

Leptospirosis adalah suatu penyakit zoonosis yang disebabka leptospira. Manusia dapat terinfeksi melalui kontak dengan leptospira incidental. Gejala klinis yang timbul mulai dari ringan sampai berat bahkan kematian, bila terlambat mendapat pengobatan. Diagnosis dini yang tepat dan penatalaksanaan yang cepat akan mencegah perjalanan penyakit menjadi berat. Akan mencegah perjalanan penyakit menjadi berat. Pencegahan dini terhadap mereka yang terpapar, diharapkan dapat melindungi mereka dari serangan leptospirosis.

4.2 SARAN

Kita harus selalu melihat bagaimana keadaan sekitar kita, yang menyebabkan Indonesia terkena Leptospirosis karena perilaku manusia yang membuang sampah sembarangan sehingga banjir terjadi dan menyebabkan adanya leptospirosis yang menyerang manusia ataupun hewan peliharaan, Jagalah kesehatan demi terjaganya Lingkungan yang bersih dari semua penyakit terutama leptospirosis.

DAFTAR PUSTAKA

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http://emedicine.medscape.com/article/788751-overview#showall

http://access.health.qld.gov.au/hid/InfectionsandParasites/BacterialInfections/leptospirosis_fs.asp

http://www.cdc.gov/ncidod/dbmd/diseaseinfo/leptospirosis_g.htm

W.Sudoyo, Aru.dkk(2006).Buku ajar ilmu penyakit dalam. Jakarta. Penerbit : Departemen Ilmu Penyakit dalam Fakultas Kedokteran Universitas Indonesia.

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