Disertasi

Faktor Risiko Terjadinya Diare Melanjut pada Anak Kurang dari Dua Tahun dengan Diare Akut: Pengembangan dan Pengujian Sistem Skor. = Risk Factors for the Occurrence of Prolonged Diarrhea in Children Less than Two Years-old with Acute Diarrhea: Developing and Testing the Scoring System.

Diare merupakan masalah global karena menyebabkan tingginya angka kesakitan dan kematian pada bayi dan anak. Diare yang belangsung 7–13 hari disebut diare melanjut, dan akan meningkatkan risiko terjadinya diare persisten 6 kali lebih tinggi. Penelitian ini bertujuan untuk mengkaji faktor-faktor risiko terjadinya diare melanjut pada anak < 2 tahun, membuat dan menerapkan sistem skor untuk memprediksi kejadian diare melanjut, dan mengetahui apakah faktor etiologi diare persisten telah ditemukan pada diare melanjut. Suatu penelitian operasional dengan rancangan nested case control, pada anak < 2 tahun dengan diare akut yang dirawat di ruang rawat inap RSUP Fatmawati. Subjek direkrut dengan metode consecutive sampling pada September 2015– Maret 2016. Subjek dieksklusi bila mendapat pengobatan imunosupresi, menderita HIV, penyakit metabolik, penyakit keganasan, mengalami disentri, mengalami diare saat dirawat di rumah sakit, ada penyakit penyerta, dan subjek pasca mengalami operasi pada organ saluran cerna. Evaluasi luaran penelitian dilakukan sejak subjek masuk perawatan di rumah sakit sampai subjek pulang rawat. Sebanyak 62 subjek untuk tiap kelompok kasus dan kontrol mengikuti penelitian. Seluruh faktor risiko dianalisis secara bivariat dan multivariat regresi logistik. Faktor risiko terjadinya diare melanjut yang didapatkan adalah riwayat penggunaan antibiotik, defisiensi seng, leukosit tinja, peningkatan kadar AAT tinja dan malnutrisi. Model skor prediksi diare melanjut terdiri dari 2 model. Model 2 lebih dapat diterapkan di fasilitas kesehatan primer. Sensitivitas, spesifisitas, nilai duga positif, nilai duga negatif, rasio kemungkinan positif, dan rasio kemungkinan negatif dari validasi skoring model 2 berturut-turut adalah 73%, 95%, 94%, 76%, 14,6, dan 0,28. Area di bawah kurva ROC pada validasi 0,898. Faktor etiologi diare persisten telah ditemukan pada diare melanjut (intoleransi laktosa, malabsorpsi lemak, dan infeksi Clostridium difficile). Sebagai simpulan, faktor risiko terjadinya diare melanjut pada anak < 2 tahun dengan diare akut yang berperan paling bermakna adalah riwayat penggunaan antibiotik, defisiensi seng, leukosit tinja, peningkatan kadar AAT tinja dan malnutrisi. Selain itu, faktor etiologi diare persisten telah ditemukan pada diare melanjut, dan model skor yang dibuat dapat dipertimbangkan digunakan dalam praktek klinik sehari-hari.
Kata kunci : defisiensi seng, diare melanjut, leukosit tinja, malnutrisi, peningkatan kadar AAT tinja, riwayat penggunaan antibiotik.


Diarrhea has been a global problem since it has high morbidity and mortality rate in infants and children. Diarrhea lasting for 7–13 days is called prolonged diarrhea, and the risk of progressing into persistent diarrhea will be 6 times higher. The aim of this study was to assess the risk factors for prolonged diarrhea in children below 2 years old, to establish and apply a scoring system to predict the occurence of prolonged diarrhea, and to determine whether the etiologic factor of persistent diarrhea have already been found in prolonged diarrhea. An operational study with a nested case control design, in children < 2 years old with acute diarrhea hospitalized in the inpatient wards of Fatmawati Hospital. Subjects were recruited using the consecutive sampling method from September 2015 to March 2016. Subjects were excluded when they were receiving immunosupressive treatment, suffering from HIV, metabolic disease, malignancy, dysentery, just had diarrhea during hospitalization, comorbidities, and had underwent digestive surgery. Evaluation of the research outcome was started when the subject admitted to the hospital until the subject being discharged. The number of subjects included was 62 for each case and control group. All risk factors were analyzed using bivariate and multivariate logistic regression. We found that the risk factors for the occurrence of prolonged diarrhea are: history of antibiotic use, zinc deficiency, fecal leukocytes, elevated level of stool AAT, and malnutrition. The prolonged diarrhea prediction score model had 2 models. Model 2 is more applicable in primary health care. The sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio of scoring model 2 validation were 73%, 95%, 94%, 76%, 14.6, and 0.28 respectively. The area under the ROC curve for validation is 0.898. The etiologic factor of persistent diarrhea have already been found in prolonged diarrhea (lactose intolerance, fat malabsorption, Clostridium difficile infection). In conclusion, the most significant risk factors for prolonged diarrhea in children below 2 years old are the history of antibiotic use, zinc deficiency, fecal leukocytes, elevated levels of stool AAT, and malnutrition. In addition, etiologic factors of persistent diarrhea have already been found in prolonged diarrhea and scoring model can be considered be used in daily clinical practice.
Keywords. Elevated levels of stool AAT, fecal leukocytes, history of antibiotic use, malnutrition, prolonged diarrhea, zinc deficiency.