Typhoid Fever

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Introduction

  • A multisystemic illness caused primarily by Salmonella enterica serotype typhi and, to a lesser extent, S. enterica serotypes paratyphi A, B, and C
  • It is usually spread through contaminated food or water
  • Once Salmonella typhi bacteria are eaten or drunk, they multiply and spread into the bloodstream
  • Risk is higher in populations that lack access to safe water and adequate sanitation.
  • Humans are the only reservoir for salmonella.
  • Incidence of chronic carriage is higher among women and persons with biliary abnormalities: gall stones, carcinoma of the gall bladder; also higher in persons with gastrointestinal malignancies

Clinical features

  • Incubation period ranges from 3 - 21 days
  • Prolonged fever (38.8C to 40.5-C)
  • A prodrome of non-specific symptoms:
    • Chills
    • Headache
    • Anorexia
    • Cough
    • Weakness
    • Sore throat
    • Dizziness
    • Muscle pains
    •  Gastro-intestinal:
      • Diarrhoea or constipation
      • Abdominal pain Rash (rose spots)
    •  Hepato-splenomegaly
    • Epistaxis
    • Relative bradycardia

Complications

  • Neuropsychiatric symptoms
  • Intestinal perforation
  • Gastro-intestinal haemorrhage
  • Pancreatitis
  • Hepatitis
  • Splenic abscesses
  • Meningitis
  • Nephritis
  • Pneumonia
  • Osteomyelitis
  • Chronic carrier state

Investigations

  • A positive culture is the 'gold standard' for the diagnosis of typhoid fever
  • Specimens for culture may be obtained from the blood, stool, urine, bone marrow; gastric and intestinal secretions
  • There are no diagnostic tests other than positive cultures

Non-specific

Full Blood Count

  • Leucopenia, neutropenia, leucocytosis can develop early, especially in children; late if complicated by intestinal perforation or secondary infection

Liver function tests

  • Values may be elevated

Electrocardiography:

  • ST and T wave abnormalities may be present

Serological tests

Widal test gives high rates of false positives and negatives

Treatment goals

  • Eliminate S. typhi and S. paratyphi
  • Prevent complications
  • Prevent chronic carrier status

Drug treatment

Ceftriaxone

Adult: 1 g daily by deep intramuscular injection or by intravenous injection over at least 2 - 4 minutes; 2 - 4 g daily in severe infection

May also be given by intravenous infusion

Child:

Neonate, 20 - 50 mg/kg daily by intravenous injection over 60 minutes;

Infant and child under 50 kg: 20 - 50 mg/kg daily; up to 80 mg/kg in severe infection;

Over 50 kg: adult dose

Doses of 50 mg/kg and above should be given by intravenous infusion only

Intramuscular doses over 1 g should be divided between more than one site; single intravenous doses above 1 g should be given by intravenous infusion only

Or:

Ciprofloxacin

Adult: 500 - 750 mg orally every 12 hours

Or:

200 - 400 mg every 12 hours by intravenous injection over 30 - 60 minutes

Child and adolescent: not recommended

Parenteral fluid administration

Treat complications

Notable adverse drug reactions, contraindications and caution

Ciprofloxacin:

  • Diarrhoea, nausea, vomiting, abdominal discomfort, headache (which are themselves features of the disease)
  • Should be given with caution in pregnancy and during breastfeeding
  • Not recommended for children or adolescents

Non-drug treatment

  • Nursing care
  • Enteral or parenteral nutrition

Prevention

  • Eliminate Salmonella by effective treatment of cases, improved sewage management, improved water treatment and improved food hygiene (production, transit, storage and utilization)
  • Typhoid immunization is recommended for those at risk
    • Not a substitute for scrupulous personal and environmental hygiene
  • Identify, and treat chronic carriers with amoxicillin or ciprofloxacin daily for 4 - 6 weeks
    • In patients with urolithiasis and schistosomiasis appropriate treatment should be instituted
  • Correct anatomic abnormalities associated with the disease surgically
    • Cholecystectomy may be required in some cases