TYPHOID FEVER

Reported by:
Espina, Pia Xyra
Faderugao, Martina

Typhoid

Also known as Enteric fever

Fever

Is an acute illness associated with fever caused by

the Salmonella typhi bacteria.

It can also be caused by Salmonella paratyphi, a

related bacterium that usually causes a less
severe illness.
Is contracted by drinking or eating the bacteria in
the contaminated food or water.

Epidemiolo
gy
Between January 1 and November 13, 2013:
28, 244 cases of suspected or clinically diagnosed
typhoid fever in the Philippines
Two resulted in death
Case-fatality rate of 0.27%
About 10% of untreated patients will discharge bacteria
for up to three months
2 to 5% of untreated patients will become permanent
carriers

Transmission
o S typhi has no nonhuman
vectors.
via food handled by an
individual who chronically
sheds the bacteria through
stool or, less commonly,
urine
Hand-to-mouth
transmission after using a
contaminated toilet and
neglecting hand hygiene
Oral transmission via
sewage-contaminated
water or shellfish

Risk factors
Worldwide, children are at
greatest risk of getting the
disease
Work in or travel to endemic
area
Have close contact with
someone who is infected or
has recently been infected
with typhoid fever
Weak immune system such as
use of corticosteroids or
diseases such as HIV/AIDS
Drinking water contaminated
by sewage that contains S.
typhi

Prevention
Wash your hands.
Avoid drinking
untreated water.
Avoid raw fruits and
vegetables
Choose hot foods.

Vaccin
Inactivated
typhoid vaccine (shot)
es
It should not be given to children younger than two years
old
Protection is induced about 7 days after injection
It should be given at least two weeks before travel to allow
the vaccine time to work
In countries or areas at risk, the protective efficacy 1.5
years after vaccination is about 72%; after 3 years it is
about 50%.
A booster dose is needed every two years for people who
remain at risk

Live attenuated vaccine

(oral)
It should not be given to children younger than six years
old
Four doses, given two days apart, are needed for protection
The last dose should be given at least one week before
travel to allow the vaccine time to work
A booster dose is needed every five years for people who
remain at risk

DRUG
Ciprofloxacin
THERAPY
Inhibits bacterial DNA synthesis and, consequently, growth
Proven to be highly effective for typhoid and paratyphoid fevers
Defervescence occurs in 3-5 days, and convalescent carriage and
relapses are rare.
Fluoroquinolone are highly effective against multi-resistant strains
and have intracellular antibacterial activity.
Not currently recommended for use in children and pregnant
women because of observed potential for causing cartilage damage
in growing animals.

Ceftriaxone
Third-generation cephalosporin with broad-spectrum gramnegative activity against gram-positive organisms
Excellent in vitro activity against S typhi and other salmonellae
Cefotaxime
Third-generation cephalosporin with gram-negative spectrum
Arrests bacterial cell wall synthesis, which inhibits bacterial
growth
Excellent in vitro activity against S typhi and other salmonellae
and has acceptable efficacy in typhoid fever
Only IV formulations are available

Amoxicillin
Interferes with synthesis of cell wall mucopeptides
during active multiplication, resulting in bactericidal
activity against susceptible bacteria
At least as effective as chloramphenicol in rapidity of
defervescence and relapse rate.
Usually given PO with a daily dose of 75-100 mg/kg
tid for 14 days

Clinical presentation

The incubation period for typhoid

fever is 7-14 days (range 3-60 days)
If not treated, the symptoms
develop over four weeks, with new
symptoms appearing each week but
with treatment, symptoms should
quickly improve.

Clinical
manifestations
The initial period (early stage due to
bacteremia)
First week: non-specific, insidious onset of
fever

Fever up to 39-400C in 5-7 days, stepladder( now seen in < 12%), headache

chills, toxic, tired, sore throat,

cough, abdominal pain and diarrhea
or constipation.

The fastigium stage

second and third weeks.
fever reaches a plateau at 39-40. Last 10-14
days.
more toxic and anorexic with significant
weight loss. The conjunctivae are injected, and
the patient is tachypneic with a thready pulse
and crackles over the lung bases. Abdominal
distension is severe. Some patients experience
foul, green-yellow, liquid diarrhea (pea soup
diarrhea). The( typhoid state) is characterized
by apathy, confusion, and even psychosis.
Necrotic Peyer patches may cause bowel
perforation and peritonitis. This complication
may be masked by corticosteroids. At this

 Signs and symptoms:

relative bradycardia.
Splenomegaly, hepatomegaly
rash ( rose-spots):30%, maculopapular
a faint pale color, slightly raised
round or lenticular, fade on pressure
2-4 mm in diameter, less than 10 in No.
on the trunk, disappear in 2-3 days.

Rash in Typhoid
Rose- spots
Appear in crops
of upto a dozen
at a time

defervescence stage
By the fourth week of infection:
If the individual survives , the fever, mental
state, and abdominal distension slowly
improve over a few days. Intestinal and
neurologic complications may still occur.
Weight loss and debilitating weakness last
months. Some survivors become
asymptomatic carriers and have the
potential to transmit the bacteria
indefinitely

convalescence stage
the fifth week: disappearance of all
symptoms, but can relapse

Atypical manifestations :
Mild infection:
very common seen recently
symptom and signs are mild
good general condition
temperature is 380C
short period of disease
recovery expected in 1~3 weeks
seen in early antibiotic users
in young children more common
easy to misdiagnose

 Persistent infection:
disease continue > 5 weeks
Ambulatory infection:
mild symptoms,early intestinal bleeding or
perforation.

 Fulminant infection:
rapid onset, severe toxemia and
septicemia.
High fever, chill, circulatory failure,
shock, delirium, coma, myocarditis,
bleeding and other complications, DIC.

 In the aged
temperature not high, weakness
common.
More complications.
High mortality.

mplications
Intestinal bleeding
or perforation
The most serious
complication of typhoid
fever

Other, less common

Myocarditis
Pneumonia
pancreatitis
UTI
Osteomyelitis
Meningitis
Psychiatric problems

Blood cultures in Typhoid

fever
In Adults 5-10 ml of Blood is inoculated into
50 100 ml of Bile broth ( 0.5 % ).
Larger volumes 10-30 ml and clot cultures
increase sensitivity
Blood culture is positive as follows:
1st week in 90%
2nd week in 75%
3rd week in 60%
4th week and later in 25%

 Bone marrow culture

the most sensitive test
even in patients pretreated (up to 5 days) with
antibiotics.

Urine and stool cultures

increase the diagnostic yield
positive less frequently
stool culture better in 3rd~4th weeks

Duodenal string test

to culture bile
useful for the diagnosis of carriers.

Community containment and public health

management
Close collaboration between the infectious disease
consultant, microbiologist, public health physician and
general practitioner helps to prevent the spread of S. typhi
and S. paratyphi through the community.
Collection and treatment of sewage, especially during the
rainy season, must be implemented.
Appropriate facilities for human waste disposal must be
available for all the community. In an emergency, pit latrines
can be quickly built.
In areas where typhoid fever is known to be present, the use
of human excreta as fertilizers must be discouraged.
Health education is paramount to raise public awareness on
all the above mentioned prevention measures.

Evaluate the effectiveness of health care

program of the government
Despite the Effort of WHO and DOH in mass vaccination
and spreading awareness about typhoid fever. Typhoid
fever remained common in Asian and African countries.
Most of the countries plagues with this disease are
those that lack clean source of water and sanitation.
In the Philippines in 2008, the
Department of Health (DOH) encouraged the public to
follow safety measures against typhoid fever. Same
year, the Department of Health declared a typhoid
outbreak in Calamba, Laguna. More than 1,400 people
displayed typhoid symptoms. Same Outbreak also occur
in Cebu (2014) and Leyte (2009).

 Cases of typhoid fever are up slightly in 2015.

Health officials report nearly 11,000 suspected
and confirmed cases of the bacterial disease.
11people have died from typhoid. Region X,
or Northern Mindanao reported 2,656 cases
accounting for nearly a quarter of all cases.
During the first six months of 2014, 10,597
cases of typhoid were reported
This only goes to show that most Asian
countries like the Philippines and India, the
government are implementing health care
programs poorly.