Tetanus Bacterial Toxins

Download as ppt, pdf, or txt
Download as ppt, pdf, or txt
You are on page 1of 35

Tetanus

= Bacterial Toxins
Kiking Ritarwan
Localized or generalized muscle stiffness
Superimposed paroxysmal tonic spasm
(tetanospasmin)
Tetanospasmin blocks inhibitory interneurons
Autonomic instability
Normal mental status

Tetanus is a toxic infection caused by the anaerobe


Clostridium tetani.
Spores exist in the soil and faeces, portal of entry
resulting in human disease include traumatic and
surgical wound, injection side (parenteral drug
abusers), skin ulcers, burn and injected umbilical cords.
Producing exotoxins (tetanospasmin and tetanolysin).
Tetanospasmin

is

very

potent

neurotoxin

probably is solely responsible for the disease.

Tetanus germs are found everywhere, usually in


soil, dust, and manure.
Enter a wound produce a poison
spreads throughout the body.
The first signs :
Headache and spasms of the jaw muscles.
Irritable
Muscle spasms : neck, arms, legs, stomach.
Convulsions broken bones.

Etiologi

Clostridium tetani

Ada 2 bentuk :
1. Vegetatif : basil gram positif, obligat anaerob
ukuran :0,5-1,7 m x 2,1-18,1 m
motil, flagel
2. Spora : bentuk squash racket
tahan terhadap panas, resisten terhadap
berbagai desinfektan, dapat hidup bertahun
Spora tumbuh saat bersentuhan dengan luka (potensial
redox )
Eksotoksin :
Tetanospasmin (Tetanus toksin)
Tetanolysin

Clostridium tetani : bentuk spora dan vegetatif


An aerobic gram positive bacillus
Noncapsulated
Sporm forming
Found in soil, house dust, animal
Intestine and human feces

Epidemiologi
Negara terbelakang, iklim tropis, lembab >>>
Seluruh usia neonatus, usia muda >>>
WHO, 1995 eradikasi : 800.000-1 juta/thn
kematian tetanus neonatal
Afrika, Asia Tenggara endemik
Insidens

18 per 100.000 populasi/ tahun


Cvjetanovic :
Afrika : 28/100.000
Asia : 15/100.000
Eropa : < 0,1/100.000
Amerika Utara : < 0,1/100.000

Patofisiologi
C.tetani masuk ketubuh melalui LUKA
dalam kondisi anaerob spora berkembang
toksin diproduksi(TETANOSPASMIN)
Retrograde intraneuronal transport/ axon terminal
Motor neuron perifer/ med spinalis/ batang otak memblokade pelepasan inhibitory
neurotransmitter glycine and GABA di terminal presinaptik

akibatnya eksitasi firing rate motor neuron meningkat tanpa ada inhibisi
sehingga otot lebih meningkat tonus dan spasmenya

Jk blokade di MNJ maka toxin menginhibisi pelepasan Ach


presinaptik bisa menjadi PARALISIS

Tahapan tetanospasmin : berikatan, internalisasi dan aktifitas

Focus of infection

Infected laceratioof puncture wound


Infected chronic wound and abscesses
Exposure via intravenous drug abuse
Neonates
No identifiable cause
Possible causes: otitis media, Burns,
Intranasal foreign bodies, corneal
abrasion, dental or surgical procedures.

Gambaran Klinis
Masa inkubasi : jumlah toksin dan status imunisasi
MI biasanya 8 hari (3 21 hari)
semakin jauh tempat trauma dari SSP MI >>
Periode of onset : 1- 7 hari
MI dan periode of onset << keparahan >>
Klasifikasi tipe klinis (4) :
Generalized tetanus (Tetanus umum)
Localized tetanus (Tetanus lokal)
Cephalic tetanus (Tetanus sefalik)
Tetanus neonatorum

Tetanus Umum
Paling umum : 80% dari kasus
Paling karakteristik :
Lock jaw/ trismus
Dapat disertai : kaku kuduk, disfagia, rigiditas abdomen,
temperatur (2-40C)
Kasus berat risus sardonicus, opisthotonos
Karakteristik : spasme akut, paroksismal, nyeri, kejang
rangsang
Problem spasme obstruksi jalan nafas apneu
Masa inkubasi : 7-21 hari (tergantung jarak luka dengan
CNS).
Pemulihan 4 minggu

Tetanus Lokal
Bentuk paling ringan
Simptom awal : kaku, spt diikat, nyeri otot
disekitar luka,
twitching & spasme singkat
Sering luka di tangan atau lengan
Manufer diagnostik

Recruitment spasm

mendahului onset Tetanus umum


Angka kematian 1%
Prognosa : Baik

Tetanus Sefalik

Bentuk yang tidak lazim


Terjadi dgn Otitis media atau trauma kepala
Disfungsi saraf kranial N.VII >>>
Berkembang tetanus umum atau tetap lokal
Masa Inkubasi : 1 atau 2 hari
Otot yang terkena paralisa
Sering fatal prognosis buruk

Tetanus Neonatorum
= tetanus umum akibat infeksi pada neonatus
Di negara miskin dari seluruh kematian neonatus
MI : 3 10 hari sesudah lahir

Disease of the seventh day


Terjadi karena imunitas maternal
Tanah, kotoran hewan tali pusat
tehnik aseptik yang kurang
Tanda-tanda : lemah, tidak mampu menghisap
spasme, rigiditas opisthotonos
Angka kematian : > 70%

Tingkat keparahan
Table 1. Klasifikasi keparahan tetanus : Kriteria Patel-Joag
Kriteria 1 : Lockjaw, isolaterd spasm ,dysphasia, stiffness of muscle back
Kriteria 2 : Spasme, tanpa mempertimbangkan frekuensi atau keparahan
Kriteria 3 : Masa inkubasi tujuh hari (waktu diantara trauma dan tanda pertama)
Kriteria 4 : Periode of onset 48 jam (waktu antara tanda pertama(lockjaw) dan

kejang pertama)
Kriteria 5 : Peningkatan temperature : rectal 100 0F, atau aksiler 990F
Grading :
Grade 1 : Kasus ringan : terdapat satu criteria, biasanya kriteria 1 atau 2 (tidak ada
kematian)
Grade 2 : Kasus sedang : terdapat 2 kriteria, biasanya kriteria 1 dan 2. Biasanya
masa inkubasi lebih dari 7 hari dan onset lebih dari 48 jam (kematian 10%)
Grade 3 : Kasus berat : terdapat 3 kriteria, biasanya masa inkubasi kurang dari 7
hari atau onset kurang dari 48 jam (kematian 32%)
Grade 4 : Kasus sangat berat : terdapat 4 kriteria (kematian 60%)
Grade 5 : Calculated mortality : kelima criteria, termasuk puerperal dan tetanus
neonatorum (kematian 84%)

DIAGNOSA
Hanya secara klinis
Tes untuk konfirmasi (-)
Studi bakteriologi

1/3 pasien

Tetanus lokal mengenai


> 1saraf cranial

Penyebab nerve
palsy lain

TEST SPATULA

Diagnosa Banding
1.
2.
3.
4.
5.
6.
7.
8.

Keracunan striknin
Reaksi Distonia
Meningitis
Penyakit temporomandibuler joint, proses inflamasi
gigi, mulut, tonsil dan faring
Rabies
Tetani
Stiff-man syndrome
Psychogenic disorders

Tabel 2. Diagnosa banding tetanus


Simptom
Trismus
Kaku kuduk

Disfagia
Spasme
Neonatal tetanus

Diagnosa banding
Alveolar/dental patologi
Temporo-mandibular disease
Muscle spasm
Meningitis
Acute pharyngeal disease
Keracunan striknin
Lesi intrakranial
Drug-induced dystonic reactions
Sepsis
Meningitis
Konvulsi

PENATALAKSAAN
Rawat di ICU
Ruang rawat yang tenang stimulasi <<<
Prinsip manejemen :
eradikasi kuman
netralisit toksin diluar SSP
minimalisir efek toksin di SSP
Portal of entry
eksisi luka
gangren (+) amputasi
debridement spasme terkontrol

Imunoterapi

pengobatan untuk menetralisir Tetanospasmin


imunisasi aktif

Human Tetanus Immunoglobulin (HTIG)


3.000 5.000 IU/ i.m.
Equine Antitetanus serum (ATS)
uji hipersensitifitas, desensitisasi
harga lebih murah
Sebaiknya 20.000 U diberikan IM sedgkan 10.000 U
diberikan IV sesudah 48 jam pemberian pertama
Intravenous Immune globulin (IVIG)
pemberian antitoksin sebelum debridement

Kontrol Jalan nafas dan Ventilasi


spasme tetanik obstruksi jalan nafas
Endotracheal tube (ETT)
Trakeostomi moderate & severe

Antibiotika

mengurangi bentuk vegetatif


Sensitif Metronidazole, PNC, Sefalosporin,
Imipenem, makrolid, tetrasiklin
PNC central GABA antagonist => sdh ditinggalkan
Dosis : 100.000-200.000 IU/kg/hari
Metronidazole antibiotik pilihan
Dosis : 500 mg/ 8 jam/IV + dgn
clindamisin, erithromisin, tetrasiklin, vancomysin

Kontrol Rigiditas & Spasme

Benzodiazepine : agonis GABA


dosis ~ 500 mg/ hari
tetanus neonatorum 15-40mg/kg/hr
Diazepam,Lorazepam, Midazolam
Diazepam 0,1 mg/kg IV/ 4 jam (dewasa
500 mg/ hr dan neonatus 15-40 mg/ hr),
atau midazolam 0,1 mg/ kgBB IV/ IM/ 4
jam, atau midazolam 2- 10 mg/ jam IV,
atau propanolol infuse 1-10 mg / jam.

Blokade NMJ
Obat GABAergik gagal blok NMJ
Vecuronium (0,1 mg/kg IV 6-8mg/jam)
Pancuronium : takikardi, hipertensi, CO
mengaburkan efek otonom
Terapi disfungsi otonom
sympathetic overactivity (SOA)
Labetolol, esmolol, clonidine, morfin sulfat
Magnesium sulfat

Nutrisi
aktifitas otot & otonom kebutuhan nutrisi >>
ganggguan gastric emptying time nutrisi vena sentral

Komplikasi
komplikasi penyakit & komplikasi terapi
komplikasi pernafasan
komplikasi kardiovaskuler dan otonom
komplikasi sistemik lain

Tabel 3. Komplikasi tetanus


Sistim
Komplikasi
Jalan nafas
Aspirasi *
Laryngospasm/obstruction*
Sedative associated obstruction*
Respirasi
Apnu*
Hipoksia*
Gagal nafas tipe I* (atelektasis, aspirasi,pneumonia)
Gagal nafas tipe II* (spasme laring, prolonged
truncal spasm, sedasi berlebihan)
ARDS*
Komplikasi ventilasi bantuan yang lama
(mis.pneumonia)
Komplikasi trakeostomi (mis.stenosis trakea)
Kardiovaskuler Takikardi* Hipertensi* Iskemia*
Hipotensi* Bradikardi*
Takiaritmia, bradiaritmia*
Asistole*
Gagal jantung*

Tabel 3. (lanjutan)
Ginjal

High output renal failure*


Oliguric renal failure*
Urinary stasis and infection

Gastrointestinal

Gastric stasis
Ileus
Diare
Pendarahan*

Lain-lain

Berat badan menurun*


Tromboemboli*
Sepsis dan multiple organ failure*
Fraktur vertebra selama spasme
Avulsi tendon selama spasme

Pencegahan
Imunisasi Aktif Profilaksis
Tetanus Toksoid imunitas 5 thn
Imunisasi ibu hamil mencegah tetanus
neonatorum
Imunitas ditransfer secara pasif : ibu fetus
Imunisasi paska trauma
Rekomendasi profilaksis : - kondisi luka
- riwayat imunisasi
Antitoksin : HTIG 250 unit
ATS 1500 unit

TABLE 12.1 Immunization against tetanus


---------------------------------------------------------------------------------------------------------------------------------------Subject/vaccine and dose
Age/interval
---------------------------------------------------------------------------------------------------------------------------------------Children (age less than 7 years)*
1-DPT
6-8 weeks of age
2-DPT
4-8 weeks after previous dose
3-DPT
4-8 weeks after previous dose
4-DPT
1 year after previous dose
Booster DPT
4-6 years of age
Booster Td
every 10 years after previous dose
Adults and children older than 7 years not previously immunized*
1-Td
first encounter
2-Td
4-8 weeks after previous dose
3-Td
6 months1 year after previous dose
Booster-Td every 10 years after previous dose
Pregnant women*
Previously immunized :
Booster TT
during first 6 months of pregnancy (optimal)
Or as late as 6 weeks before delivery
Previously unimmunized :
1-TT
first encounter during pregnancy
2-TT
4 weeks after previous dose
---------------------------------------------------------------------------------------------------------------------------------------* American Academy of Pediatrics (Peter et al. 1994); * World Health Organization, Expanded
Programme on Immunization (Whitman et al. 1992)
Abbreviations ; DPT, diphtheria and tetanus toxoids and pertussis vaccine adsorbed : Td, tetanus and
reduced-dose diphtheria toxoids adsorbed; TT, tetanus toxoid.

TABLE 12.2. Guidelines for tetanus prophylaxis in wound management


______________________________________________________________________
Vaccination status
Clean, minor wounds
Tetanus-prone wounds*
Td+
TIG
Td+
TIG++
______________________________________________________________________
Unknown or <3 doses
3 doses
Last booster < 5 years
Last booster 5-10 years
Last booster > 10 years

Yes

No

Yes

No

No
No
Yes

No
No
No

No
Yes
Yes

No
No
Yes

Recommendations of the Advisory Committee on Immunization Practices-United States


(CDC, 1992).
* Wounds contaminated with dirt, faeces, soil, saliva; puncture wounds; avulsions; and
wounds resulting from missiles, crushing, burns and frostbite. Wounds presenting
after delay or requiring debridementdue to the presence of necrotic tissue.
* Td : tetanus and reduced-dose diphthetia toxoids adsorbed; for children less than 7
years, DPT (diphtheria and tetanus toxoids and pertussis vaccine adsorbed) is
preffered.
++ 250-500 units human tetanus immune globulin; given intramuscularly in another area
than the Td.

Prognostic Score for Tetanus of Gallais et al


Parameter

Finding

Score

incubation

< 7 days

>= 7 days

< 2 days

>= 2 days

intramuscular injections

umbilical uterine surgical burn compound fracture

all other portals or unknown

>= 4 per hour

present but < 4 per hour

> 38.4 C

<= 38 C

adults > 120 neonate > 150

adults <= 120 neonate <= 150

extension

portal of entry

paroxysms

rectal temperature

pulse in beats per minute

Score
0
1
2
3
4
5
6
7

Mortality Rate
0%
4.22%
13.63%
30.43%
57.14%
70.73%
94.73%
100%

You might also like