Typhoid Fever

Epidemiology

 Incidence
US, Western Europe, Japan: 0.2 – 0.7 /
100.000
Southern Europe: 4.3 – 14.5 / 100.000
Developing country: 10 – 540 / 100.000
Indonesia: 350 – 810 / 100.000 =
600.000 – 1.5 million cases/yr
Epidemiology

 Transmission
Contaminated drinking water or food.
Large epidemics: most often related to fecal
contamination of water supplies or street
vended foods.
A chronic carrier stateexcretion of the
organism for more than 1 yearoccurs in
approximately 5% of infected persons.
Etiology

 Acute systemic infection, caused by:

Salmonella typhi (96%) A photomicrograph
of Salmonella
typhosus bacteria

Others: S.paratyphi
using a Flagellar
stain technique
(1979)

 Salmonellae:
gram-negative bacilli, Enterobacteriaceae
family, non-spore-forming, nonencapsulated,
flagella.
Etiology
Killed by heating to 130°F (54.4°C) for
1 hr or 140°F (60°C) for 15 min.
Remain viable at ambient or reduced
temperatures for days, survive for weeks in
sewage, dried foodstuffs, pharmaceutical
agents, and fecal material.
Pathogenesis
 Clinical Manifestation

 Vary: mild – severe

 Incubation: 3–30 (range 7–14) days
 1st week:
Fever “step ladder temperature chart”,
 Insidious increase, unremitting, highest: end
of 1st week
Systemic symptoms: headache, lethargy,
malaise, myalgia, nausea, vomiting,
abdominal pain
 2nd week:
Hepatosplenomegaly, rose spot,
headache  stupor
Relative bradicardia: rare in
children
 3rd – 4th week:
Intestinal haemorrhage and
perforation are common
End of 4th week: fever gradually
decline
 GIT symptoms: vary
Diarrhea
Obstipation
Obstipation  diarrhea
 Coated tongue
 Diagnosis

 Clinical Features
Clinically mild, can be asymptomatic
Obviously:
 Fever
 GIT distubance
Change of level of consciousness
 Constitutional symptoms: headache,
malaise, abdominal pain, hepato/
splenomegaly, altered mental status
 Fever > 7 days + GI symptoms, in
children > 5 yr, no additional symptoms
 suspect typhoid fever
 Maculopapular rash in chest and abdomen (rose
spot): in 40-80% cases for 2-3 days
 Diarrhea (39%) > constipation (15%) in child
Vomiting (26%) and nausea (42%)
 Headache (76%), abdominal pain (60%),
altered mental status (34%), also apatis (31%)
and delirium (3%)
(Rivai AT, Mulyadi T, Kustedi P, Pulungsih SP, Janas. Balai
Penerbit FKUI, 1992; 85-93. )
 Laboratory
Culturing Salmonella
 Blood (40 – 54%),
 bone marrow (80 – 90%),
 urine (7%),
 stool (35 – 37%),
 duodenal fluid (58%), rose spot (63%)
 Laboratory
 Laboratory
Serology
 Widal: four fold rise in O agglutinin or a titer
of ≥ 1/160  not recommended by WHO
 IgM and IgG for Salmonella, Tubex, Typhi dot
DNA probe
PCR
 Laboratory
Peripheral blood exam:
 Lekopenia, relative lymphocytosis,
aneosinophilia
 Not spesific
 Complication

 Intestinal haemorrhage (1 –
10%) and perforation (0.5 – 3%)
Decrease temperature and blood
pressure  acute abdomen signs and
peritonitis
 Others:
Typhoid hepatitis, typhoid
encephalopathy, cholecystitis, pneumonia,
septic shock, pyelonephritis, endocarditis,
osteomyelitis, meningitis, cerebral
thrombosis, ataxia, aphasia, etc
 Therapy
 Causal: appropriate antibiotic
 Severe typhoid fever: hospitalized
 Supportive therapy
Monitoring
Fluid management
Detection and manage complication
 Surgery for intestinal perforation
Dietetic
 Non fibre and digestable
 Fever (-): solid food with adequate calory

Blood transfusion
 Intestinal haemorrhage and perforation
Therapy

ANTIBIOTIC
 Empiric therapy
Narrow spectrum AB, good penetration, easy
to give, resistency <, minimal side effect,
clinical effication evidence
 Treatment successfull parameter: time of
defervescence
 Min. 36 hours of therapy for  fever
ANTIBIOTIC
 1st Line
Chloramphenicol (1st drug of choice)
Ampicillin / amoxicillin
Cotrimoxazole
ANTIBIOTIC
 2nd Line
Ceftriaxon
Cefixim
Fluoroquinolon  not recommended for
children
Azythromycine
Aztreonam
ANTIBIOTIC
 1st Line
Chloramphenicol
 75 – 100 mg/kgBW/day IV or PO in 2 divided
dose for 10 – 14 days
 Max. dose 2 gr/day
 CI: leukopenia (< 2000/ul)
ANTIBIOTIC
 1st Line
Ampicillin
 200 mg/kgBW/day PO or IV in 4 divided dose
for 10 – 14 days or,
Cotrimoxazole
 10 mg/kgBW/day (TMP) in 2 divided dose for
14 days
ANTIBIOTIC
 2nd Line
Ceftriaxon
 50 – 80 mg/kgBW/day, single dose for 10
days
 Cure rate up to 90% in 3 – 5 days duration of
therapy
ANTIBIOTIC
 2nd Line
Cefixim
 10 – 15 mg/kgBW/day PO in 2 divided dose
for 10 - 14 days
 Cure rate in IKA RSCM 1999 – 2000: 84%
ANTIBIOTIC
 2nd line
Fluoroquinolone
 Superior than cephalosporin, cure rate ≈
100%, child  controversion
Ciprofloxacine, 10 mg/kgBW/day in 2 divided dose,
Ofloxacine 10 -15 mg/kgBW/day in 2 divided dose
Duration: 2 – 5 day
MDR typhoid
Dexamethasone
 Severe case with altered mental status
 Initial dose 3 mg/kgBW  1 mg/kgBW
every 6 hr for 48 hr  mortality  from 35-
55% to 10%
 Prognosis

 Mortality: developed country < 1%,

developing country > 10%
 Complication high mortality and morbidity
 AB (-)  relapse 4-8%.
 Adequate AB, clinical manifestation occur ±
2 weeks after th/ (-), ≈ acute disease,
milder & shorter.
 Chronic carrier 1-5%
Billiary tr disease incidence in chronic carrier
> general population
Treatment
 Ampicillin or amoxicillin + probenecid high dose or
TMP-SMZ for 4 – 6 weeks
 If cholecystitis or cholelithiasis (+)  cholecystectomy
after 14 days antibiotics
Prevention

 Good sanitation and personal hygiene

 Typhoid vaccination  for traveler to
endemic area