SOSIALISASI DIAGNOSIS DAN TATA

LAKSANA LEPTOSPIROSIS DI DKI

JAKARTA

Dr. Djati Sagoro, SpPD (K)

Dinas Kesehatan Prov DKI Jakarta
1. Introduction
1. Indonesia is one of countries with a moderate annual
incidence of leptospirosis
2. The first case of leptospirosis in Indonesia was
documented in 1918 by Schuffner in the east coast of
Sumatra Island
3. Since then, most of the main island on Indonesia such
as Java, Bali, Kalimantan and Sulawesi have reported
cases of leptospirosis. The number of leptospirosis in
Indonesia is possibly higher than that reported.

2
Broad range clinical presentations (syndromes)

 Anicteric Leptospirosis, atypical, relatively mild 80-90%

 Flu-like or as acute undifferentiated fever
 Underdiagnosed, not included in the DD of acute fever, then not
tested
 Can be misdiagnosed as other prevalent infectious diseases
 Patient may not seek medical attention

• Icteric Leptospirosis, a severe form 10-20%

• Weil`s disease, or multi-organ involvement
• More easily recognized by clinicians
• CFR (case fatality rate): 10 – 40%, LPHS~70%

Weil`s disease: icterus, AKI, hemorrhages (and arrhythmia)

MH Gasem
Sepsis-like phenotype
Mild Leptospirosis (anicteric leptospirosis)
mimicking other acute febrile illnesses

Influenza Uncomplicated malaria

Dengue HIV seroconversion illness

Hantavirus infection Rickettsiosis

Typhoid fever Mononucleosis

Meningitis Other bacterial/viral infections

 Multiorgan involvement/dysfunction in patients with
severe Leptospirosis / Weil`s disease (n: 87) #
Organ/system n (%)
Renal (oliguric or non-oliguric acute kidney injury) 87 (100)
Hepatic (hiperbilirubinemia / icterus) 87 (100)

Hematologic (thrombocytopenia with or without coagulation 85 (98)

disorders) ¥
Cardiovascular (ECG changes, heart failure, shock) 74 (87)

Gastrontestinal (“pancreatitis” , hematemesis) 16 (19)

Pulmonary (pulmonary hemorrhage, ARDS) 5 (6)
Opthalmologic (retinal bleeding $, uveitis) 4 (5)
Cerebral (unconscious, with or without hemorrhage) 4 (5)
Note: # 2005-06 & 2007-08. Confirmed with MAT; 18 patients by RDT only
¥ Not all tested for coagulation study
$ Retinal funduscopy: not routinely done Gasem MH et al 2009
Case definitions Leptospirosis in Indonesia

1. Faine or Modified Faine criteria

2. WHO SEARO 2009: the most applied def. now

- by Ministry of Health guidelines
- by PHC, hospitals
- for surveillance studies
 Leptospirosis Case definition
Suspect case
 Acute febrile illness and/or headache, with
 Myalgia
 Prostration and/or
 Conjunctival suffusion, AND

 History of exposure to Leptospira-contaminated

environment
What are the history of exposure to
Leptospira-contaminated environment ?
 Walking in flooded streets or stagnant water
 Living in flood prone areas
 Personal hygiene, wounds
 Large rat population
 Recreational exposures (water sports, triathlon etc)
 Occupational risk factors: farmers, cleaners etc

 In Central Java: Leptospirosis is an endemic disease

Leptospirosis included in differential diagnosis of acute fever
Occupational risk factors
 Leptospirosis Case definition
Probable (1)
If laboratory tests not available (i.e. in primary HC)

Suspect case plus any two of the following:

 Calf tenderness
 Cough and/or hemoptysis
 Jaundice (icteric)
 Hemorrhagic manifestations
 Anuria / oliguria and/or proteinuria
 Breathlessness
 Meningeal irritation
 Cardiac arrhythmias
 Skin rashes
Probable (1) WHO SEARO 2009
If laboratory tests not available

Suspect case
Acute fever, headache, myalgia, conjunctival suffusion
Exposure to leptospira-contaminated environment

plus any two of the following:

 Calf tenderness
 Cough and/or hemoptysis
 Jaundice (icteric)
 Hemorrhagic manifestations
 Anuria / oliguria and/or proteinuria
 Breathlessness
 Meningeal irritation
 Cardiac arrhythmias
 Skin rashes
 Leptospirosis Case definition
Probable (2)
If laboratory tests available

Suspect case plus

IgM anti-Leptospira : positive (f.i. RDT, lateral-flow)

AND / OR
Any three of the following:
1. Urinary : proteinuria, leucocyte and erythrocyte
2. Relative neutrophilia (>80%) with lymphopenia
3. Platelets < 100,000 per µL
4. Elevated serum bilirubin (>2 mg%); CPK and amylase.
 Leptospirosis Case definition

Confirmed case

Suspect case or probable case with one of :

MAT positive with titer

 1/400 (~1/320) or higher in single sample or
 seroconversion from negative to positive or
 4-fold increase between acute & convalescent sera

PCR positive
Culture positive: Isolation of Leptospira sp from clinical specimens
Laboratory diagnosis of Leptospirosis:

 Antibody detection (RDTs, IgM ELISA, MAT)

RDTs not applicable in early 5 DPO (low sensitivity)
IgM ELISA earlier positive than MAT (need paired sera)
MAT is performed on 2 samples collected with interval 1 week
 may not useful for early diagnosis and prompt treatment

 Antigen detection by PCR (< 1 week, early diagnosis)

 Isolation / culture (unreliable)
Goris et al., J Bacteriol Parasitol 2012, 3:2
http://dx.doi.org/10.4172/2155-
9597.1000132
Case definition-Clinical Diagnosis
- Case def: WHO SEARO 2009 (suspect or probable case without RDT)
- Clin Dx: Modified Faine`s criteria 2012 (A and B, without C:
laboratory)
 Low sensitivity and moderate specificity (Bandara et al
2016)

 Utilizes RDTs will increase the sensitivity of clinical diagnosis

criteria.

RDT : simple, affordable diagnostic test, limited availability in PHCs

 low sensitivity for early diagnosis (DPO < 5 day)
 In Indonesia: RDT as standard of care for patients
Clinical management

1. Antibiotic treatment
2. Supportive care
1. Antibiotic treatment
2. Supportive care
 Clinical studies of antibiotics in Leptospirosis

Pappas G & Cascio A: International Journal of Antimicrobial Agents 28 (2006) 491–496

Antibiotic treatment of Leptospirosis in Adults
Indication Regimen

Mild leptospirosis Doxycycline (100 mg PO bid) or

Amoxicillin (500 mg PO tid) or

Azithromycin (500 mg PO od)

Severe Leptospirosis Penicillin (1.5 million unit IV or IM q6h) or

Ceftriaxone (1-2 g/d IV) or

Cefotaxime (1 g IV q8h)

All regimens are given for 7 days

1. Antibiotic treatment
2. Supportive care
 Leptospirosis
Supportive care Clinical management

 Fluids and electrolytes balance

 Diuretics in oliguric state (if needed)

 Blood transfusion as indicated: platelets and/or PRP

 Ventilator for patients with respiratory failure /

ARDS
 Dialysis (peritoneal or hemodyalisis) #
# Performed for AKI, if conservative approach failed, prerequisite
indications
 Correct volume depletion, hyper/hypokalemia, acidosis
Door-to-dialysis time (from ICU admission Mortality according to treatment group
to the initiation to dialysis)

Delayed, alternate day dialysis Prompt and daily dialysis

Andrade et al. Clin J Am Soc Nephrol2:739-44, 2007

 Methyl prednisolon for leptospirosis patients
with pulmonary involvement

Bolus methylprednisolone 1 g/day for 3 days

followed by 1 mg/kg/day of oral prednisolone for 7days
Antibiotics: Penicillin + Doxycycline Shenoy et al. Postgrad Med J. 2006 Sep; 82(971): 602–606.
Examples
Leptospirosis with pulmonary hemorrhage (LPHS) cases
treated with/without high dose methyl prednisolone

ARDS, respiratory failure ventilator  VAP

Severe Lepto case Antibiotic Methyl prednisolone Outcome
1. ARDS / LPHS ceftriaxone + No good
early VAP meropenem
2. ARDS / LPHS ceftriaxone + No good
late VAP meropenem
3. ARDS / LPHS ceftriaxone 125 mg/12 h iv (5 days) good

4. ARDS / LPHS ceftiaxone + 250 mg / 12 h iv died after 2 days

VAP meropenem
All cases # managed in ICU of Dr Kariadi Hospital, Semarang, Indonesia
(unpublished data)
Referral system for Lepto (as other febrile illness)
Mild, anicteric cases admitted to PHC, hospitals (all levels)
(as outpatient or inpatient)

Severe icteric, multi-organ dysfunctions managed in hospitals.

PHC should refer severe (predicted to be severe) to hospitals

Severe cases with pulmonary hemorrhage  admitted to ICU

Other severe cases may need ICU/HCU (decided by clinicians)

Now, based on the policies of the insurance system (BPJS):

-mild cases have been rarely admitted to hospital type A or B
-severe and mild cases referred by PHC to hospital type C
With dialysis facilities
Leptospirosis cases report from
hospitals and PHC (Puskesmas)
Kasus 1
Lelaki 63 th

Ax:
Demam 3 hari, nyeri kepala, nyeri otot, mual, muntah , nyeri perut
Tempat tinggal: Semarang kota, daerah bawah (rawan banjir).
Pekerjaan: tidak bekerja

Px: mata: tidak ada conjunctival suffusion

nyeri tekan gastrocnemius tidak ada
gejala/tanda klinis lain normal

Lab:
Darah: Lekosit : 12.700, Trombosit: 114.000
Lepto Tek Lateral Flow: negatif

DX: suspect Leptospirosis (non ikterik)

MAT-1 : negatif, MAT-2 : tidak dikerjakan

qPCR : positif
Dx: Leptospirosis (non-ikterik), confirmed
Kasus 2
Wanita 39 tahun
Demam tinggi, 6 hari, nyeri kepala, nyeri otot, menginggil, mual muntah,
Tempat tinggal: Semarang kota daerah bawah
Pekerjaan : Ibu rumah tangga

Px:
Dehidrasi, sclera ikterik, ada conjunctival suffusion
Nyeri tekan gastrocnemius tidak ada

Lab: Lekosit: 14.800; Trombosit: 89.000, Lepto Tek lateral Flow: positif
Ureum: 126, creatinin: 2,04, Bilirubin total: 4,1, direk 3,7

Dx: Probable Leptospirosis (ikterik)

MAT-1 : 1/160, MAT-2: tidak dikerjakan

qPCR: positif

Dx: Leptospirosis ( ikterik), confirmed

Kasus 3:
Lelaki 49 tahun

Ax
Demam akut 4 hari, nyeri otot, nyeri kepala, mual, diare,
Tempat tinggal: Demak
Pekerjaan: buruh bangunan

Px: Suhu 39,2 C, Sclera: tidak ada conjuctival suffusion

Lab: Lekosit: 12.700, trombosit: 168.000

Lepto Tek: positif

Dx : Probable Leptospirosis (non ikterik)

MAT-1 : 1/160, MAT-2: 1/640

qPCR: tidak dikerjakan

DX: Leptospirosis (non ikterik) confirmed

DIAGRAM ALUR DIAGNOSIS KLINIS DAN LAB LEPTOSPIROSIS DI PELY KESEHATAN
 SITUASI LEPTOSPIROSIS DI DKI JAKARTA
Distribusi Kasus Leptospirosis bersumber RS di DKI Jakarta 2003 - 2018
1.2

0.8
Jumlah Kasus

0.6

0.4

0.2

JUMLAH KASUS LEPTOSPIROSIS DKI JAKARTA PER WILAYAH

WILAYAH Tahun 2014 TAHUN 2015 TAHUN 2016 TAHUN 2017 TAHUN 2018

JAKARTA PUSAT 12 2 6 4 1

JAKARTA UTARA 5 2 9 3 1

JAKARTA BARAT 66 25 22 15 15

JAKARTA SELATAN 9 3 6 6 4

JAKARTA TIMUR 14 2 5 5 4

KAB KEP SERIBU 0 0 0 0 1

JUMLAH 106 34 48 33 26
 GRAFIK MINGGUAN KASUS LEPTOSPIROSIS MUSIM
45
BANJIR 2014
(CFR sd minggu 16 = 16,34%)
40

35

30

25 Puncak
musim
20
hujan
15

10

0
52 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
JUMLAH KASUS 1 1 0 0 3 14 39 8 12 10 1 6 6 1 1 1 1
Meninggal 1 1 0 0 1 7 6 0 1 1 0 0 0 0 0 0 0
Situasi leptospirosis 2019
 Sebaran Kasus Leptospirosis Jan - Des 2019 DKI Jakarta menurut
Jenis Kelamin dan Kel. Umur
25

20

15

10

0
4 - 17 th 18 - 60 th ≥ 61 th
Laki-laki 2 22 2
Perempuan 1 10 1

Distribusi Kasus Leptospirosis 2019 menurut RS yg Melaporkan

RSUD Tebet
Islam Jakpus
Firdaus
Siloam Kebon Jeruk
RSUD TARAKAN
Antam Medika
BAKTI MULIA
RSPI SULIANTI SAROSO
RSUD PASAR MINGGU
RSUD Cengkareng
PELNI PETAMBURAN

0 2 4 6 8 10 12 14 16 18
8 Tren Bulanan Kasus Leptospirosis DKI Jakarta Tahun 2019
7
7
6
6
5
5

4
3 3 3 3
3
2 2 2
2
1 1
1

0
Januari Februari Maret April Mei Juni Juli Agustus Sept Oktober Nopember Desember

Tren Mingguan Kasus Leptospirosis DKI Jakarta 2019

4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
M1 M3 M5 M7 M9 M11 M13 M15 M17 M19 M21 M23 M25 M27 M29 M31 M33 M35 M37 M39 M41 M43 M45 M47 M49
 Tren Kasus Leptospirosis DKI Jakarta 2018 - 2019
(data sd Agustus 2019)
8 Musim Hujan

7 Puncak
musim
6 hujan
5
KESIAPSIAGAAN
4

Kemarau
Kemarau