Dewi Anggraini

Penyakit

yang disebabkan karena mengkonsumsi makanan atau minuman yang terkontaminasi oleh bakteri dan atau toksin yang dihasilkannya, parasit, virus ataupun bahan kimia. Pendapat lain: terbatas pada penyakit yang disebabkan oleh toksin yang dihasilkan oleh bakteri yang mengkontaminasi makanan sebelum dikonsumsi S. aureus, Cl. botulinum.

Gejala bervariasi baik derajat maupun kumpulan gejalanya nyeri abdomen, muntah, diare dan sakit kepala sindroma neurologik, hepatik dan renal yang mengancam jiwa kecacatan dan kematian Kebanyakan ringan dan membaik tanpa terapi yang spesifik. Beberapa pasien gejala yang berat dan memerlukan perawatan RS, terapi dehidrasi yang agresif dan terapi antibiotika. Wabah (KLB) food-borne didefinisikan berdasarkan 2 kriteria:

Gejala sama, kebanyakan gejala pada gastrointestinal, pada minimal 2 orang Terdapat bukti makanan sebagai sumber penyebab

Secara garis besar 2:

Tipe non inflamatori Tipe inflamatori

Diare non inflamatori:

Disebabkan kerja enterotoxin thdp mekanisme sekretori mukosa usus halus Menimbulkan feses cair (watery), volume banyak, tanpa darah dan nyeri perut hebat tidak ada Enterotoksin dapat dihasilkan sebelum makanan dikonsumsi atau dihasilkan di usus setelah makanan dikonsumsi. Contoh: Vibrio cholerae, enterotoxic Escherichia coli, Clostridium perfringens, Bacillus cereus, Staphylococcus organisms, Giardia lamblia, Cryptosporidium, rotavirus, Norwalk virus dan adenovirus.

Diare inflamatori:

Disebabkan kerja sitoksin thdp mukosa invasi dan merusak biasanya kolon atau usus halus distal juga terkena. Menimbulkan diare berdarah, mukoid dan biasanya terdapat leukosit Dehidrasi lebih jarang terjadi dibanding non inflamatori volume diare < Terdapatnya leukosit pada feses atau uji laktoferin feses (+) proses inflamasi dan terdapatnya kolitis Kadang organisme mempenetrasi mukosa dan berproliferasi di jaringan limfatik lokal menyebar sistemik. Contoh: Campylobacter jejuni, Vibrio parahaemolyticus, enterohemorrhagic and enteroinvasive E coli, Yersinia enterocolitica, Clostridium difficile, Entamoeba histolytica dan Salmonella and Shigella species.

 Muntah

dapat disebabkan oleh kerja toksin pada SSP Misal: staphylococci, B cereus Toksin botulisme menghambat pelepasan asetilkolin esterase pada ujung saraf Mekanisme patofisiologi dari keracunan makanan non infeksius (bahan alami seperti jamur atau logam berat seperti arsenik, merkuri dan timbal) belum diketahui pasti.

 AS

76 juta kejadian 325.000 rawatan 5.000 kematian Perdagangan transnational trade; travel; dan migrasi serta globalisasi produksi, pabrik dan pemasaran makanan peningkatan keracunan makanan. Riwayat perjalanan penting traveler's diarrhea onset 3 hari sampai 2 minggu sembuh dalam 5 hari penyebab tersering enterotoxigenic E coli

 Anak

< 5 tahun:

Negara maju: serangan 2 -3 x/anak/tahun Negara berkembang: minimal 5x lebih sering Negara miskin: 1 milyar kasus/tahun dan 4 6 juta kematian/tahun

Morbiditas

dan mortalitas meningkat pada usia tua penurunan imunitas, penurunan produksi asam lambung dan motilitas intestinal, malnutrisi, kurang olah raga, penggunaan antibiotika yang berlebihan kematian karena C perfringens; E coli O157; Salmonella, Campylobacter, dan Staphylococcus.

Penyebab keracunan makanan dapat diperkirakan dari:

Riawayat penyakit termasuk: durasi, karakteristik dan frekuensi gerakan usus, gejala saluran cerna dan sistemik Kemungkinan sumber makanan terkontaminasi, jenis makanan spesifik, riwayat perjalanan dan penggunaan antibiotika

Gejala yang spesifik:

Diare:

Diare akut karena keracunan makanan biasanya hilang dalam < 2 minggu Bila 2- 4 minggu diare persisten > 4 minggu diare kronik

 Adanya

gejala demam penyakit invasif. Namun, kadang demam dan diare dapat disebabkan oleh infeksi di luar saluran cerna seperti malaria. Darah dan lendir pada feses invasi pada mukosa intestinal atau kolon. Jika muntah merupakan gejala utama Staphylococcus aureus, B. cereus, atau Norovirus. Reactive arthritis Salmonella, Shigella, Campylobacter, dan Yersinia infections.

 Feses

jumlah banyak seperti air cucian beras kolera. Nyeri abdomen proses inflamatori. Kram otot perut yang berat kehilangan elektrolit seperti kolera berat. Yersinia enterocolitis menyerupai apendisitis.

 Sindroma

proktitis pada shigellosis BAB sering, nyeri, feses mengandung darah, pus, lendir. Tenesmus dan rasa tidak nyaman pada rektal gejala menonjol. Mengkonsumsi daging/unggas setengah matang risiko untuk Salmonella, Campylobacter, Shiga toxin E. coli, dan C. perfringens. Mengkonsumsi makanan laut mentah risiko Norwalk-like virus, Vibrio atau hepatitis A. Mengkonsumsi makanan kaleng risiko Clostridium botulinum

 Konsumsi

keju tanpa paasterisasi risiko untuk Listeria, Salmonella, Campylobacter, Shiga toxin E coli dan Yersinia. Mengkonsumsi susu atau jus yang tidak dipasteurisasi risiko untuk Campylobacter, Salmonella, Shiga toxin E coli, dan Yersinia. Salmonella konsumsi telur mentah.

 Pemeriksaan

fisik fokus pada penilaian beratnya dehidrasi. Mulut kering, produksi keringat aksila menurun, penurunan produksi urin dehidrasi ringan. Orthostasis, tachycardia, dan hypotension dehidrasi berat. Pemeriksaan rektal toucher harus selalu dilakukan untuk melihat secara langsung feses, untuk uji occult blood, dan palpasi mukosa rektal untuk melihat adanya lesi.

CDC:
97% penangan makanan yang tidak baik 79% makanan yang dijual 21% makanan rumah

Hal yang paling sering menjadi penyebab:

Makanan siap saji disimpan di temperatur ruangan Proses pemasakan atau pemanasan yang tidak sempurna Kontaminasi silang Infeksi pada penjamah makanan Kontaminasi silang terjadi ketika makanan mentah yang terkontaminasi kontak dengan makanan lain, terutama makanan siap saji, melalui kontak langsung ataupun kontak tidak langsung pada permukaan meja saji.

Causative Agents Staphylococci

Source and Clinical Features Improperly stored foods with high salt or sugar content favor growth of staphylococci Intense vomiting and watery diarrhea start 1-4 hours after ingestion and last as long as 24-48 hours.

Pathogenesis Enterotoxin acts on receptors in gut that transmit impulses to medullary centers.

Diagnosis and Treatment Symptomatic treatment

Causative Agents B cereus

Source and Clinical Features Contaminated fried rice (emetic) Meatballs (diarrheal) Emetic: Duration is 9 hours, vomiting and cramps Diarrheal: Lasts for 24 h Mainly vomiting after 1-6 hours and mainly diarrhea after 8-16 hours after ingestion; lasts as long as 1 day

Pathogenesis Emetic enterotoxin (short incubation and duration) Poorly understood Diarrheal enterotoxin (long incubation and duration) Increasing intestinal secretion by activation of adenylate cyclase in intestinal epithelium

Diagnosis and Treatment Symptomatic treatment

Causative Agents

Source and Clinical Features

Pathogenesis Enterotoxin produced in the gut, and food causes hypersecretion in the small intestine.

Diagnosis and Treatment Culture of clostridia in food and stool Symptomatic treatment

C. Inadequately cooked perfringens meat, poultry Acute onset of abdominal cramps with diarrhea starts 8-24 hours after ingestion. Vomiting is rare. It lasts less than 1 day. Enteritis necroticans associated with C perfringens type C in improperly cooked pork (40% mortality)

Causative Agents C botulinum

Source and Clinical Features

Pathogenesis

Diagnosis and Treatment Toxin present in food, serum, and stool. Respiratory support Intravenous trivalent antitoxin from CDC

Canned foods (eg, Toxin absorbed from smoked fish, mushrooms, the gut blocks the vegetables, honey) release of acetylcholine in the Descending weakness neuromuscular and paralysis start 1-4 junction. days after ingestion, followed by constipation. Mortality is very high.

Causative Agents

Source and Clinical Features

Pathogenesis Highly motile, heatresistant, grampositive organism

Diagnosis and Treatment CSF or blood culture Must treat with antibiotics if bacteremic

Listeria Raw and pasteurized monocyto milk, soft cheeses, raw genes vegetables, shrimp Systemic disease associated with bacteremia Intestinal symptoms precede systemic disease Can seed meninges, heart valves, and other organs Highest mortality among bacterial food poisonings

Causative Agents

Source and Clinical Features

Pathogenesis Enterotoxin causes hypersecretion in small and large intestine via guanylate cyclase activation.

Diagnosis and Treatment Supportive treatment No antibiotics

Enterotoxic Contaminated water E coli (eg, and food (eg, salad, traveler's cheese, meat) diarrhea) Acute-onset watery diarrhea starts 24-48 hours after ingestion. Concomitant vomiting and abdominal cramps may be present. It lasts for 1-2 days

Causative Agents

Source and Clinical Features

Pathogenesis Cytotoxin results in endothelial damage and leads to platelet aggregation and microvascular fibrin thrombi

Diagnosis and Treatment Diagnosis with stool culture Supportive treatment

Enterohemor Improperly cooked rhagic E coli hamburger meat and (eg, E coli previously spinach O157:H7) Most common isolate pathogen in bloody diarrhea starts 3-4 days after ingestion. Usually progresses from watery to bloody diarrhea. It lasts for 3-8 days

No antibiotics

Causative Agents Enteroinvasive E coli

Source and Clinical Features Contaminated imported cheese Usually watery diarrhea (some may present with dysentery)

Pathogenesis Enterotoxin produces secretion Shiga-like toxin facilitates invasion.

Diagnosis and Treatment Supportive treatment No antibiotics

Causative Agents

Source and Clinical Features

Pathogenesis

Diagnosis and Treatment Ciprofloxacin may shorten duration and eradicate the organism

Enteroaggre- Implicated in traveler's Bacteria clump on gative E coli diarrhea in developing the cell surfaces countries Can cause bloody diarrhea

Causative Agents V cholera

Source and Clinical Features Contaminated water and food

Pathogenesis

Diagnosis and Treatment

Enterotoxin causes Positive stool hypersecretion in culture small intestine. Large amount of Prompt nonbloody diarrhea Infective dose replacement of starts 8-24 hours after usually is 107 -109 fluids and ingestion. It lasts for organisms. electrolytes (oral 3-5 days. rehydration solution) Tetracycline (or fluoroquinolones) shortens the duration of symptoms and excretion of Vibrio.

Causative Agents V parahaemolyticus

Source and Clinical Features

Pathogenesis

Diagnosis and Treatment Positive stool culture Prompt replacement of fluids and electrolytes Sensitive to tetracycline, but unclear role for antibiotics

Raw and improperly Enterotoxin causes cooked seafood (ie, hypersecretion in mollusks and crustaceans) small intestine. Explosive watery diarrhea Hemolytic toxin is starts 8-24 hours after lethal. ingestion. It lasts for 3-5 days. Infective dose usually is 107 -109 organisms.

Causative Agents

Source and Clinical Features

Pathogenesis Polysaccharide capsule Growth correlates with availability of iron (esp. transferrin saturation >70%)

Diagnosis and Treatment Culture of characteristic bullous lesions or blood Immediate antibiotics if suspected (eg, doxycycline and ceftriaxone)

V Wound infection in salt vulnificus water or consumption of raw oysters Can be lethal in patients with liver disease (50% mortality)

Causative Agents C jejuni

Source and Clinical Features Domestic animals, cattle, chickens Fecal-oral transmission in humans

Pathogenesis Uncertain about endotoxin production and invasion

Diagnosis and Treatment Culture in special media at 42C Erythromycin for invasive disease (fever)

Foul-smelling watery diarrhea followed by bloody diarrhea

Abdominal pain and fever also may be present. It starts 1-3 days after exposure and recovery is in 5-8 days.

Causati ve Agents
Shigella

Source and Clinical Features

Potato, egg salad, lettuce, vegetables, milk, ice cream, and water Abrupt onset of bloody diarrhea, cramps, tenesmus, and fever starts 12-30 hours after ingestion. Usually self-limited in 3-7 days

Pathogenesis

Diagnosis and Treatment

Polymorphonuclear leukocytes (PMNs), blood, and mucus in stool Positive stool culture Oral rehydration is mainstay. Trimethoprimsulfamethoxazole (TMP-SMX) or ampicillin for severe cases No opiates

Organisms invade epithelial cells and produce toxins. Infective dose is 102 -103 organisms. Enterotoxinmediated diarrhea followed by invasion (dysentery/colitis)

Causative Agents Salmonella

Source and Clinical Features Beef, poultry, eggs, and diary products Abrupt onset of moderate-tolarge amount of diarrhea with low-grade fever; in some cases, bloody diarrhea Abdominal pain and vomiting also present, beginning 6-48 hours after exposure and lasts 7-12 days

Pathogenesis

Diagnosis and Treatment

Invasion but no toxin Positive stool production culture Antibiotic for systemic infection

Causative Agents Yersinia

Source and Clinical Features Pets; transmission in humans by fecal-oral route or contaminated milk or ice cream Acute abdominal pain, diarrhea, and fever (enterocolitis) Incubation period not known Polyarthritis and erythema nodosum in children May mimic appendicitis

Pathogenesis Gastroenteritis and mesenteric adenitis Direct invasion and enterotoxin

Diagnosis and Treatment PMNs and blood in stool Positive stool culture

No evidence that antibiotics alter the course but may be used in severe infecti

Causative Agents Aeromon as

Source and Clinical Features Untreated well or spring water Diarrhea may be bloody. May be chronic up to 42 days in the United States

Pathogenesis Enterotoxin, hemolysin, and cytotoxin

Diagnosis and Treatment Positive stool culture Fluoroquinolon es or TMP/SMX for chronic diarrhea

 Pewarnaan

Gram dan Loeffler methylene blue melihat leukosit dapat membedakan proses invasif dan non invasif. Pemeriksaan mikroskopik feses untuk melihat telur/parasit. Kultur bakteri untuk melihat patogen enterik seperti Salmonella, Shigella, dan Campylobacters, terutama jika feses positif mengandung leukosit atau darah atau jika pasien menderita demam atau gejala yang menetap lebih dari 3 4 hari.

 Periksa

kultur darah jika pasien demam sangat tinggi. Jumlah leukosit, hitung jenis, elektrolit serum, kreatinin menilai respon inflamasi dan derajat dehidrasi. Pemeriksaan C. difficile membantu menyingkirkan antibiotic-associated diarrhea pada pasien yang mendapat antibiok atau dengan riwayat penggunaan antibiotik. Pemeriksaan bakteriologik makanan sumber keracunan

 Higiene

pribadi ketat Proses memasak adekuat Hindari kontaminasi silang makanan mentah dan siap saji Simpan makanan pada suhu yang sesuai (misalnya <4C untuk makanan dingin dan >60C untuk makanan panas)

Susu, unggas, telur, daging, makanan laut mentah atau setengah matang sebaiknya dihindari. Badan kesehatan setempat harus mencatat jika terjadi wabah keracunan makanan. Untuk mengambil langkah yang tepat untuk mencegah penyebaran keracuanan makananan. Iradiasi makanan (seperti penggunaan radiasi atau energi ionisasi untuk makanan yng dibugnkus) dapat mengatasi food-borne pathogens:

Setiap tahun, lebih dari setengan juta ton makanan di radiasi di seluruh dunia. Iradiasi pada daging dan unggas mentah dapat meneliminasi bakteri seperti E coli O157:H7, Salmonella dan Campylobacter. Tidak ada bukti efek samping bagi kesehatan.

 Profilaksis

traveler's diarrhea tidak direkomendasikan secara rutin karena risiko efek samping obat (eg, rash, anaphylaxis, vaginal candidiasis) dan berkembangnya flora usus resisten.