Typhoid Fever

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Typhoid fever (enteric fever) is a severe bacterial illness, which occurs where sanitary conditions are poor permitting contamination of food or water with faeces. The bacteria which are spread by the faeco-oral route invade the intestinal wall and spread through the bloodstream to all organs. They are passed into the stool and urine of infected patients. Organisms may continue to be present in the stool of healthy carriers, i.e. patients with positive stool cultures, 12 months after treatment or those with long-term subclinical disease.

If improperly treated typhoid fever may result in complications such as intestinal perforation with peritonitis, bloody stools, acute psychosis and severe intravascular haemolysis leading to acute kidney injury (especially in G6PD deficiency).

Public education on good personal hygiene, hand washing and appropriate disposal of solid waste would often prevent the disease. Screening of food handlers by carrying out stool cultures to exclude carrier status and safe handling of food, fruits and vegetables are also helpful preventive measures.

Cause

• Salmonella typhi and paratyphi

Symptoms

• Fever which increases gradually to a high fever and persists for weeks (fever does not respond to antimalarials)
• Constipation in the early stages
• Abdominal pain and diarrhoea in the second week of illness
• Severe headache
• Dry cough
• Psychosis and confusion may occur

Signs

• High fever with a relatively slow pulse rate (occasionally pulse is fast especially with myocarditis or intestinal perforation)
• Abdominal tenderness
• Hepato-splenomegaly (tender)
• Confusion
• Signs of chest infection (pneumonitis)

Investigations

• FBC, differential,
• RDT / blood film for malaria parasite (to exclude malaria)
• Blood culture
• Stool culture
• Urine culture

Diagnosis of typhoid fever is based on a strong clinical suspicion backed by

• Blood cultures, positive during first 10 days of fever
• Stool cultures, positive after 10th day up to 4th or 5th week
• Urine cultures, positive during 2nd and 3rd week

The above tests are superior to the Widal test, which is unreliable and rarely useful in confirming a diagnosis of typhoid fever

TreatmentTreatment Objectives

• To eradicate the infection
• To detect and manage complications
• To prevent transmission of infection to other people

Non-pharmacological treatment

• Tepid sponging to reduce body temperature if required

Pharmacological treatment

Evidence Rating: [B]

• Ciprofloxacin, oral,
  Adults:  500 mg 12 hourly for 10-14 days
  Children:  10 mg/kg 12 hourly for 10-14 days
  Or
• Ciprofloxacin, IV, (to be administered over 60 minutes)
  Adults: 400 mg 8-12 hourly for 10-14 days
  Children: 10 mg/kg (max. 400 mg) 12 hourly for 10-14 days

Ciprofloxacin should be used with caution in children. Ciprofloxacin may rarely cause tendinitis. At the first sign of pain or inflammation, patients must discontinue treatment and alternative treatment (e.g. Azithromycin/Ceftriaxone) started.

2nd Line Treatment
Evidence Rating: [B]

• Ceftriaxone, IV,
  Adults:  2-4 g daily for 7-10 days
  Children:  100 mg/kg daily for 7-10 days
  Or
• Azithromycin, oral,
  Adults:  500 mg daily for 7 days
  Children:  10-20 mg/kg for 7 days

Referral Criteria

Refer very ill patients and those with complications such as intestinal perforation, intravascular haemolysis and peritonitis to the appropriate specialist. Healthy carriers should also be referred for specialist management.