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API Recommendations for the Management of Typhoid Fever

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... Blood cultures are the diagnostic test of choice, and the results can be positive in 50-80% of patients, provided that a large volume of blood (typically 25-30 ml for adults) is cultured [1]. We did not go for blood culture as our patients were referred to cases from other centres where they already had received antibiotic coverage (mostly Ceftriaxone/Ciprofloxacin). ...
... Not only the investigative tools but also the clinical findings in patients of Typhoid are nonspecific and often unreliable. In the first week of typhoid fever, non-specific headache (80%), malaise and rising remittent fever are variably seen [1,9]. Patient may have constipation (16%) or diarrhoea (28%) [9]. ...
... Constipation is more common in cases of adults whereas, diarrhoea is more prominent in children [9] as in our study 9/13 cases presented with diarrhoea (8 of ileal perforation and 1 of rectal perforation). Rose spot rash is located primarily on the trunk and chest, evident in 30% of patients at the end of the first week and resolves after 2-5 days (difficult to detect in dark-skinned person and late presenters) [1,9] as in our series. Patients can have two or three crops of lesions, and Salmonella can be cultured from punch biopsies of these lesions [1]. ...
Article
Background: Any criteria (clinical, pathologic, microbiological or histo-pathologic) attributing a case of Paediatric gastrointestinal perforation to Typhoid would be of help in reaching a proper diagnosis to guide appropriate management. Aims and Objectives: To review all cases of Typhoid perforation for their clinical, pathologic and intra-operative findings. Materials and Methods: A retrospective study was conducted on all cases of typhoid perforation (gastrointestinal perforation with positive Widal test) operated at a tertiary care centre from September 2015 to September 2018. Data regarding their clinical findings, investigation results, intraoperative findings, nature of the surgical intervention, postoperative results and histopathological findings were collected from their records and analysed. Results: A total of 13 patients were operated during this period with positive Widal's test at presentation. 6/13 had single ileal perforation; two patients had multiple ileal perforations; perforation at atypical sites were found in four patients (one each at gastric, duodenal, caecal and rectal); one patient presented with Meckel's band obstruction with multiple ulcers-this patient was sick and died despite a diverting ileostomy in the postoperative period. While 8/13 patients had Original Research Article Chaubey et al.; JAMMR, 32(1): 1-8, 2020; Article no.JAMMR.54392 2 primary closure of the perforation site, diversion through ileostomy was performed in five patients. All patients did well in the post-operative period except one patient of multiple ulcers and obstructing Meckel's band who died in the post-operative period. Conclusion: On encountering a gastrointestinal perforation, no definite symptomatology or its pattern, no clinical examination findings, no intraoperative characteristics of the perforation and no biopsy can definitively point towards Typhoid as the cause. Therefore, we still have to depend on serological tests in correlation with clinical features to reach a conclusive diagnosis. Cultures and PCR, although sensitive are either time-taking or expensive to guide management. Typhoid perforation can have vivid and atypical presentation depending on the number and site of perforation.
... Sporadic cases of azithromycin and ceftriaxoneresistant S. Typhi have been reported from Pakistan, Bangladesh, and India [3,21,25,26]. Ceftriaxone-resistant Salmonella Typhi was initially detected in Hyderabad, Pakistan [27]. ICMR surveillance network reported 0.4% isolates resistant to ceftriaxone [6). ...
... Similar trends were observed in or study also. Patient demographics like age, sex, and clinical presentation of our cases were found to be similar to Qamar et al. and Yousafzai et al. [25,27]. The mean duration of fever was found to be for 14 days by Yousafzai et al. in contrast to 11.3 days in our study [25]. ...
... Lack of any relevant travel history, absence of any clustering over time and space indicated that these cases were not part of an outbreak but seem to be sporadically present in the community. This is in sharp contrast to earlier studies that have reported CRST as an outbreak [25,27]. ...
... Typhi) are notifiable [3]. Following exposure (faecal-oral transmission: contact to typhoid fever patients or chronic carriers, or ingestion of contaminated food or beverages), it takes 10-14 days (range: 3-60 days, depending on the number of bacteria ingested), until the first symptoms occur [2], [3], [4]. The initial symptoms are unspecific: general malaise, stepladder-fever (over 3-4 days), headache, sore throat, dry cough, muscle and joint pain, constipation, or diarrhoea (approximately 48% of the patients display diarrhoea on admission) [2]. ...
... The initial symptoms are unspecific: general malaise, stepladder-fever (over 3-4 days), headache, sore throat, dry cough, muscle and joint pain, constipation, or diarrhoea (approximately 48% of the patients display diarrhoea on admission) [2]. Clinical examination may reveal: relative or absolute bradycardia, high-grade fever and rose spots (rather rare) [2], [4]. Laboratory examination may corroborate the initial suspicion: normal white blood count, mild thrombocytopenia, eosinopenia or aneosinophilia, moderately elevated C-reactive protein (CRP) and lactate-dehydrogenase (LDH) [2], [4]. ...
... Clinical examination may reveal: relative or absolute bradycardia, high-grade fever and rose spots (rather rare) [2], [4]. Laboratory examination may corroborate the initial suspicion: normal white blood count, mild thrombocytopenia, eosinopenia or aneosinophilia, moderately elevated C-reactive protein (CRP) and lactate-dehydrogenase (LDH) [2], [4]. During the second week of infection, alanine-(ALT) and aspartate-aminotransferase (AST) increase. ...
Article
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In times of emerging multi-drug resistance among Gram-negative bacteria (including Salmonella enterica, Serovar Typhi), we observed relapse of typhoid fever following delayed response to treatment with meropenem, suggestive for limited clinical efficacy of the drug. Three previously published cases supported our suspicion. Within this context, we discuss the case details with a focus on potential explanations for insufficient clinical response to meropenem (e.g. limited intracellular penetration, phenomena of tolerance and persistence). Meropenem is a last-resort antimicrobial agent for the treatment of multi-drug resistant Gram-negative infections. Reliable clinical data evaluating the efficacy of meropenem for the treatment of typhoid fever are urgently needed. Future clinical studies evaluating typhoid fever outcome should also investigate the impact of (i) intracellular penetration of antibiotics, and (ii) tolerance and persistence on outcome.
... A discount rate of 3% was used to discount future cost and consequences [13,21]. The cycle length of the model was assumed to be monthly, considering the fact that the average duration of typhoid illness is around 3-4 weeks [22]. The cost effectiveness was measured as the ratio of additional (or incremental) costs to additional health benefits i.e., incremental cost effectiveness ratio, with TCV vaccination as compared to no vaccination in India. ...
... In the uncomplicated stage, children have a gradual onset of symptoms with fever, headache, malaise, anorexia, lethargy, abdominal pain, diarrhoea, constipation, rose spots etc. [25]. The children with these manifestations are usually treated on an outpatient basis [22]. Further, in some circumstances when the condition of the patient deteriorates due to worsening of the above mentioned symptoms, patient may require hospitalization in the severe stage of the disease. ...
Article
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Introduction World Health Organization has prequalified the use of typhoid conjugate vaccine (TCV) in children over six months of age in typhoid endemic countries. We assessed the cost-effectiveness of introducing TCV separately for urban and rural areas of India. Methods A decision analytic model was developed, using a societal perspective, to compare long-term costs and outcomes (3% discount rate) in a new-born cohort of 100,000 children immunized with or without TCV. Three vaccination scenarios were modelled, assuming the protective efficacy of TCV to last for 5, 10 and 15 years following immunization. Incidence of typhoid infection estimated under ‘National Surveillance System for Enteric Fever’ (NSSEFI)’ was used. The prices of vaccine and cost of service delivery were included for vaccination arm. Both health system cost and out-of-pocket expenditures for treatment of typhoid illness and its complications was included. Results TCV introduction in urban areas would result in prevention of 17% to 36% typhoid cases and deaths. With exclusion of indirect costs, the incremental cost per QALY gained was ₹ 151,346 (54,730–307,975), ₹ 61,710 (−5250 to 163,283) and ₹ 45,188 (−17,069 to 141,093) for scenario 1, 2 and 3 respectively. While, with inclusion of indirect costs, all 3 scenarios were cost saving. Further, in rural areas, TCV is estimated to reduce the typhoid cases and deaths by 19% to 36%, with ICER (incremental cost per QALY gained) ranging from ₹ 2340 (1316–4370) to ₹ 3574 (2057 – 6691) thousand (inclusive of indirect costs) among the 3 vaccination scenarios. Conclusion From a societal perspective, introduction of TCV is a cost saving strategy in urban India. Further, due to low incidence of typhoid infection, introduction of TCV is not cost-effective in rural settings of India.
... In another work, all the Salmonella Typhi isolates were less sensitive to ciprofloxacin but no resistance was seen, whereas 76% of the same isolates showed resistant to nalidixic acid. In this work, it was shown that nalidixic acid resistant isolates had decreased susceptibility to ciprofloxacin [23]. Similar work was carried out by John et al. [24], which reveals same pattern of result as in the above. ...
... Microbial resistance regarding Salmonella typhi is basically of two types, viz., Quinolone Resistant Salmonella typhi (QRST), and multidrug resistant (MDR) type. There is also a strain which is known as DCS (decreased ciprofloxacin susceptibility) strain of S. typhi causing typhoid fever [22,23]. ...
... Drug choices for severe typhoid must account for drug resistance, an important problem in the SE Asian region. The API guidelines (Upadhyay et al. 2015) suggest that fluoroquinolones (esp Ciprofloxacin and Ofloxacin) and Cephalosporins (esp third and fourth generation) are the first-line therapeutic options. However, a study conducted in many countries of SE Asia (Barkume et al. 2018) revealed a > 80% resistance to fluoroquinolones. ...
... For initial therapy, parenteral antibiotics are recommended. Current guidelines (Upadhyay et al. 2015) recommend monotherapy. The choices, keeping in view the resistance patterns, may be summarized as follows: In case of non-response (lack of defervescence by D5), combination therapy may be used. ...
Chapter
Renal infections have a spectrum of presentations, varying from minimal symptoms or asymptomatic to frank sepsis and septic shock. Urinary tract infections (UTI) are among the most common human infections and add substantial morbidity and financial burden on society. The common pathologies include acute and chronic bacterial pyelonephritis, emphysematous pyelonephritis, xanthogranulomatous pyelonephritis, renal abscess, pyonephrosis, and genitourinary tuberculosis involving the kidney. Advances in the understanding of the microbiology and the pathophysiology of UTI have improved the management of renal infections, with introduction of more effective antibiotics and better and judicious usage of drugs and combinations of endoscopic, percutaneous, or surgical interventions. In this chapter, the authors review the common pathologies and their management.
... Paradoxically, some patients excreting S. typhi have no history of TF. 12 The first-line therapeutic agents currently in use for the treatment of TF in quinolone- sensitive areas are fluoroquinolones (especially ciprofloxacin and ofloxacin) and cephalosporines (specifically those of the third and fourth generations). 14 In quinolone-resistance areas, azithromycin and cefixime should be used. For complicated TF, in addition to the first-line drugs, ampicillin, amoxicillin and chloramphenicol can also be used. ...
... Worldwide, about 21-26.9 million cases of TF, resulting in 200 000-215 000 deaths, occur each year. 14,16,21 Data from global burden of disease show that most cases of TF occur on the Indian Subcontinent and parts of Africa. 16,[21][22][23] In Africa, the burden of TF is unknown, as appropriate technology to assess this is not available. ...
Article
Full-text available
Background: Salmonella typhi (S. typhi) antibodies may be considered as biomarkers of typhoid fever, a severe febrile systemic illness caused by an invasive Gram-negative Bacterium S. typhi. Worldwide, about 21-26.9 million cases of typhoid fever and 200 000-215 000 deaths, occur annually. Between 2003 and 2005, statistics have shown a rising trend in the incidence of typhoid fever in Abia and Enugu States. The aim of the study was to determine the sero-prevalence of S. typhi antibodies in some rural communities of Abia and Enugu States as proxy indicators of prevalence typhoid fever (TF) in the two states.Methods: This was a cross-sectional study of the sero-prevalence of S. typhi antibodies in ten rural communities of Umunneochi Local Government Area (LGA) of Abia State and Ezeagu LGA of Enugu State using 421 (200 in Abia and 221 in Enugu) blood samples for the Widal test to determine the titres of these antibodies.Results: In the Abia communities the mean sero-prevalence of S. typhi antibodies was 68.2%, while in Enugu it was 87.1%. Between the two states, difference in the sero-prevalence of S. typhi antibodies was significant (p=0.03).Conclusions: The sero-prevalence of S. typhi antibodies was higher (87.1%) in the Enugu communities, compared to the Abia communities (68.2%). To reduce the incidence and prevalence of TF in the communities, access to safe domestic water, improved sanitation and good food hygiene needs to be improved. Health-seeking behaviour also needs improvement.
... However, another authority has mentioned that (according to the WHO) Widal test, the most widely available in India, is acceptable for typhoid diagnosis provided it is done after 1 week of onset of fever. 15 In our study repeat, Widal test after 7 days is done never by 89% of general practitioners. Again only 3% of general practitioners order for blood culture and that also occasionally, while 97% never do so, whereas recent evidence strongly suggests that diagnosis of typhoid fever is largely dependent on blood culture or polymerase chain reaction. ...
... 16 Associations of Physicians of India guidelines say, the limitations of use of blood culture: Lack of facilities of blood culture in rural even in many urban areas, about 20 ml (a large volume) of blood is needed for best cultures, sensitivity test is difficult to do and not reliable, and lastly even it is done it is positive only in 40-60% of cases. 15 Furthermore, typhidot test is ordered never in 88% cases and only occasionally in 12%. It has also not proved to be reliable. ...
Article
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Background: Typhoid fever is a very common infectious disease in the tropics, particularly in India with a hugely devastating mortality and morbidity fig ures. It is expected that a better understanding of the knowledge, attitude and practice of the primary care physicians should be there, in general, practitioners toward typhoid fever. Materials and Methods: The study was a non-parametric prospective non-interventional research work carried out in five places in Bihar and West Bengal, viz , Kishanganj, Raiganj, Bardhaman, Siliguri, and Kolkata. The study was performed for a period of 6-month from January 2015 to July 2015. The participants for the study are medical graduates mostly as full-time general practitioners mostly working in slum urban and rural set ups, and having no medical postgraduate qualification whatsoever. The whole study was divided into three phases - Phase 1, Phase 2, and Phase 3. Results: About 81% of the general practitioners diagnose typhoid most of the time by clinical examination alone, without taking any support from any laboratory investigation. 83% of our general practitioners give supportive care most of the time. 65% of the general practitioners most of the time and 26% always, that is 91% highly prefer to apply empirical antibiotic. 93% of general practitioners always 5% most of the time order for Widal test. Again only 3% of general practitioners order for blood culture and that also occasionally, while 97% never do so. Some often noteworthy findings in our study include 92% of general practitioners do not use thermometer, 69% do not count pulse rate, 88% do not even think of brady/tachycardia, 86% do not inspect tongue, 98% do not inspect rose spots, 77% do not palpate abdomen and 65% do not look for hepatosplenomegaly. Conclusion: The diagnosis and treatment of our general practitioners do tally with the expected norms of a general practitioner in the Indian subcontinent. However, they should improve attitude and give more importance to clinical skills
... 25 The pediatric consultant clinically suspected acute typhoid fever if a patient had acute fever (axillary temperature !38°C) for at least 3 days with nonspecific typhoid symptoms such as headache, malaise, abdominal pain, myalgia, nausea, anorexia, or constipation then referred for Widal's test. 26,27 Those with a positive Widal's test were subjected to blood cultures to confirm the diagnosis. 27 Salmonella typhi diagnosis was made in the Department of Clinical Pathology of Faculty of Medicine, Mansoura University. ...
... 26,27 Those with a positive Widal's test were subjected to blood cultures to confirm the diagnosis. 27 Salmonella typhi diagnosis was made in the Department of Clinical Pathology of Faculty of Medicine, Mansoura University. We excluded all children having diseases which may affect serum iron and hepcidin levels, for example, liver, blood, gastrointestinal, and kidney diseases, and patients receiving drugs interfering with iron metabolism. ...
Article
Objective Typhoid fever is a common systemic bacterial infection in children with a complex interplay between serum hepcidin and iron. We investigated the relationship between iron deficiency anemia (IDA) and serum hepcidin level in children with acute typhoid fever. Methods We conducted a preliminary case–control study in Mansoura University Children's Hospital, Egypt from April 2017 to May 2019 including 30 children aged 5 to 15 years with confirmed acute typhoid fever. We recruited 15 healthy nonanemic children, of comparable ages and sex as controls from the same hospital while attending for nonfebrile complaints. Typhoid fever cases were subdivided according to IDA existence into 16 cases with IDA and 14 non-IDA cases. We excluded all children having diseases which may affect serum iron and hepcidin levels, for example, liver, blood, gastrointestinal, and kidney diseases, and patients receiving drugs interfering with iron metabolism. All participants were subjected to complete blood count, serum ferritin, iron, hepcidin levels, and total iron-binding capacity (TIBC). Results In non-IDA typhoid fever group, serum iron level was significantly low, while serum hepcidin level was significantly high when compared with controls (p < 0.001 and p = 0.02, respectively). In IDA typhoid fever group, no statistically significant difference existed as regards serum hepcidin level when compared with controls (p = 0.53). No significant correlations were detected between serum hepcidin levels and hemoglobin, serum iron, ferritin, and TIBC values in each group. Conclusion Preexisting iron status could affect serum hepcidin level in patients with acute typhoid fever. Coexistence of IDA might oppose the up-regulatory effect of acute typhoid fever on serum hepcidin level.
... 19,20 The guidelines from Association of Physicians of India, published in 2015, also recommend fluoroquinolones as one of the first lines treatment. 21 However, more recently, many studies from all over the world have reported increasing resistance to fluoroquinolones. [22][23][24][25][26][27][28][29][30] Many reports have been published showing an alarmingly high incidence of S. Typhi isolates with reduced susceptibility of ciprofloxacin (MIC ≥0.125 µg/mL). ...
... [22][23][24][25][26][27][28][29][30] Many reports have been published showing an alarmingly high incidence of S. Typhi isolates with reduced susceptibility of ciprofloxacin (MIC ≥0.125 µg/mL). 21,22 A report from the United Kingdom emphasized that the extent of S. Typhi isolates with reduced ciprofloxacin susceptibility had an increase from 0.9-33% during 1991 to 1999. 24 Similar trends were reported from Japan during the year 1997-1999, where an increase from 10-31.8% was observed. ...
... The symptoms of typhoid overlap with a number of other infectious diseases important in the tropical region such as malaria, dengue fever and leptospirosis. [3]. ...
... Mortality can be reduced by some 80-90% in these high-risk patients. [1,3,7]. Once patients have clinically improved, treatment can be completed with oral antibiotics (e.g.oral ciprofloxacin). ...
Conference Paper
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... [14] Fig.2 Continuous step ladder pattern of fever classical of typhoid fever. [17] Quinolone resistance: Azithromycin 8 to 10mg/kg for 7days Ceftriaxome 75mg/kg for 10 to 14days. [18] Tuberculosis (TB): TB is a serious infection caused by bacterium Mycobacterium tuberculi. ...
Article
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Fever is an immunological response of body against various disease conditions. It is a troublesome symptom as it weakens one's own body. Fever is caused due to many disease conditions and treatment of that particular condition can subside fever and other symptoms associated with it. However, many a times we need to treat fever with appropriate medications as it is burdensome and worrying to the individual. Moreover, it is due to the corona pandemic, many people are experiencing a lot of speculations about fever and hence are in a state of panic and fear. The main aim of this article is to provide detailed information regarding the endemic condition causing fever in a language known to the laymen. In this article we elaborated the pattern of fever in malaria, dengue, typhoid, tuberculosis and discussed about the diagnosis and treatment measures. We also discussed our knowledge of fever in corona virus infection and outlined the treatment options as per the newly updated guidelines.
... Most cases of enteric fever were reported during hot weather.This is because warm and moist conditions favor the growth of the organism. Also, in summer, people are more likely to drink water outside their homes which may be of low quality (23) (24) . ...
... Hence, sensitivity and positive results are decreased in endemic areas due to the unrestrained use of antibiotics and made the grounds for what is known as 'typhoid super-bug'. 4 Until recently magnetic nanoparticles were coupled with antibodies and greater than 65% Salmonella typhi antigen was bound to nanoparticles within 30 minutes. The bacteria were separated from nanoparticles using magnets by heating it at 65°C for 45 minutes. ...
... With many reports of ceftriaxone resistance and absence of any new drug, the studies are ongoing to understand the combination of antibiotic in the treatment of typhoid fever. In an API conclave on enteric fever, it was recommended that combination therapy should be used in case of fever lasting for seven days and no clinical improvement with monotherapy 32,33 . ...
Article
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Background & objectives: Antimicrobial resistance is a major challenge in the treatment of typhoid fever with limited choices left to empirically treat these patients. The present study was undertaken to determine the current practices of antibiotic use in children attending a tertiary care hospital in north India. Methods: This was a descriptive observational study in children suffering from enteric fever as per the case definition including clinical and laboratory parameters. The antibiotic audit in hospitalized children was measured as days of therapy per 1000 patient days and in outpatient department (OPD) as antibiotic prescription on the treatment card. Results: A total of 128 children with enteric fever were included in the study, of whom, 30 were hospitalized and 98 were treated from OPD. The mean duration of fever was 9.5 days at the time of presentation. Of these, 45 per cent were culture positive with Salmonella Typhi being aetiological agent in 68 per cent followed by S. Paratyphi A in 32 per cent. During hospitalization, the average length of stay was 10 days with mean duration of defervescence 6.4 days. Based on antimicrobial susceptibility ceftriaxone was given to 28 patients with mean duration of treatment being six days. An additional antibiotic was needed in six patients due to clinical non-response. In OPD, 79 patients were prescribed cefixime and additional antibiotic was needed in five during follow up visit. Interpretation & conclusions: Based on our findings, ceftriaxone and cefixime seemed to be the first line of antibiotic treatment for typhoid fever. Despite susceptibility, clinical non-response was seen in around 10 per cent of the patients who needed combinations of antibiotics.
... Our results are consistent with the age and clinical patterns of typhoid fever mentioned in other reports. [4][5][6][7][8][9] However, some findings in this report deserve special attention as discussion of these issues will have a great implication on the control of typhoid fever in this country. ...
Article
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Objectives: We sought to describe the epidemiological and clinical features of typhoid fever in Qatar. Methods: We conducted a retrospective study of adult patients treated for typhoid fever at Hamad General Hospital and Alkhor Hospital between 2005 and 2012. Results: The mean age of the 354 patients enrolled in the study was 28.4±9.3 years; 296 (83.6%) were males. There were 42, 48, 39, 44, 46, 47, 52, and 36 cases of adults with typhoid fever in 2005, 2006, 2007, 2008, 2009, 2010, 2011, and 2012, respectively. Overall, 343 (96.9%) patients had a history of travel to endemic areas. Among them, 93.0% acquired typhoid fever in the Indian subcontinent. Fever was observed in all cases, and the other predominant symptoms were abdominal pain (38.1%), diarrhea (35.6%), and headache (33.1%). Salmonella typhi, showed high resistance to ciprofloxacin (n = 163; 46.0%), and low resistance to ceftriaxone (n = 2; 0.6%). Four patients developed intestinal perforation, which was surgically repaired in two cases. Two patients (0.6%) died. Conclusions: Typhoid fever was frequent among immigrants to endemic areas. Travelers returning from endemic areas with suspected typhoid fever should be treated empirically with third-generation cephalosporin after obtaining appropriate cultures. Moreover, preventive measurements such as education on food and water hygiene, and effective vaccination of travelers should be practiced widely among travelers to endemic areas to reduce morbidity and mortality.
... We evaluated four CPGs, but removed two due to low scores [31,32]. The highest scoring CPG (88%) was ...
... 28 Azithromycin is a preferred alternative agent in cases of uncomplicated enteric fever. 29 Conclusions Salmonella Typhi and Salmonella Paratyphi A are almost equally isolated in our region, and the majority of the isolates are NAR. The MDR rate for Salmonella Typhi is very low, and we have not encountered any MDR resistance in Salmonella Paratyphi A. Although a vaccine for Salmonella Typhi exists, the increased isolation of Salmonella Paratyphi A warrants a vaccine too. ...
Article
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Background: Enteric fever is endemic in India. Trends in antibiotic resistance in Salmonella enterica subspecies enterica serovars Typhi and Paratyphi A isolates over the past 12 years were studied. Methods: A retrospective analysis of consecutive blood culture isolates of Salmonella Typhi and Salmonella Paratyphi A was performed from 2002 to 2013. Antibiotic susceptibility testing was carried out for ampicillin, chloramphenicol, cotrimoxazole, nalidixic acid (NA), ciprofloxacin and ceftriaxone by disc diffusion. The minimum inhibitory concentration of ciprofloxacin and azithromycin was determined using E-test strips. Mantel-Haenszel extended chi-square test was used for analysis of trends across years. Results: Three thousand two hundred ninety-six Salmonella spp. were isolated; of which, 1905 were identified as Salmonella Typhi (58%) and 1393 as Salmonella Paratyphi A (42%). Multidrug resistance (chloramphenicol, ampicillin and cotrimoxazole) was relatively stable throughout the study period. NA resistance increased from 18% in 2007 to 100% in 2013 among Salmonella Paratyphi A isolates and from 67% to 82% among Salmonella Typhi isolates. Complete susceptibility to ceftriaxone and azithromycin was observed in this study. Conclusions: Knowledge of the local patterns of resistance would help in appropriate therapy for enteric fever. With increasing rates of fluoroquinolone resistance in our hospital setting, it is probably prudent to revert back to the first-line agents for treatment and save azithromycin and third-generation cephalosporins for difficult and non-responsive cases.
... The complications in the treatment of enteric fever have increased with the passage of time not only because of rising expenditure but also due to the resistant S. Typhi species against the antibiotics used for treatment purpose. In addition to this, typhoid fever is also associated with numerous nonspecific symptoms and complications that cause life-threatening effects which preserves the poverty cycle and enhances the financial burdens [1].Each year around 22 million new typhoid cases are reported and the mortality rate among the typhoid patients is rapidly increasing especially among low resource areas [2]. The major management strategy in this regard is the appropriate use of antibiotics, whilemisuse or overuse of antibiotics leads to antibiotic resistance [3]. ...
Article
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Background: The occurrence of Typhoid fever has significantly increased in the past few decades and it is now considered as the major cause of mortality in Pakistan.The treatment and diagnosis of this endemic condition is still challenging due to amplified antibiotic resistance and relapse cases. Objective: This study aims to evaluate practices of health care providers in relation to the follow-up routine of the patients, factors promoting relapse and resistance and complications observed during treatment. Methodology: This cross-sectional survey was conducted in all four provinces of Pakistan i.e. Sindh, Punjab, Baluchistan&Khyber Pakhtunkhwa during September 2018 -November 2018. Total 949 healthcare providers participated in this survey. The study was designed to collect information related to the follow-up patterns, relapse, resistance and complications of the typhoid patients. Statistical analysis was done on statistical package for social science (SPSS version 22.0). Results: A high rate of relapse cases were reported in comparison to resistance i.e. 69% vs 31%. Out of the total, around 90% clinicians recommended a follow-up visit after treatment completion. 35.6% of the patients visited health care providers after 3 weeks of discontinuing the therapy. Gastrointestinal, Neuropsychiatric, Respiratory and Cardiovascular complications were observed in health care setting during long-term typhoid treatment. Conclusion: The reason behind the increase in number of relapse cases might be due to patient careless attitude towards follow-up. Patient’s awareness regarding the relapse and management of typhoid can be the key solution.
... Enteric fever is a systemic illness and includes both typhoid and paratyphoid fevers. The causative organism for typhoid fever is 'Salmonella enterica' subspecies 'Salmonella typhi' while paratyphoid fever is caused by infection with one of three subspecies of 'Salmonella enterica' namely 'Salmonella paratyphi A', 'Salmonella paratyphi B' and 'Salmonella paratyphi C'. 1 It has a significant impact on healthcare system with an estimated annual world-wide incidence of 12-27 million cases. 2 The problem has been exacerbated in the region of Indo-Pakistan subcontinent in the last decade due to emergence of a strain of Salmonella typhi that is resistant to the previously used first and second-line antibiotics, which is termed as 'Extensively drug resistant (XDR) enteric fever'. 3 The predominant clinical manifestations of enteric fever include fever, coated tongue and gut-related signs and symptoms like nausea/vomiting, diarrhea, hepatosplenomegaly, abdominal distention, constipation and gastrointestinal bleeding. ...
Article
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We report a case of splenic infarct as a rare complication in a child with typhoid fever
... Azithromycin is a preferred alternative agent in uncomplicated enteric fever. Other supportive measures include oral or intravenous hydration, antipyretics, adequate nutrition, correction of dyselectrolytemia and blood transfusions for anaemia [1]. Gastrointestinal complications of enteric fever include gastrointestinal ulcers and bleeding, intestinal perforation, hepatic dysfunction, pancreatitis and cholecystitis. ...
Article
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Background Typhoid fever can manifest with a variety of gastrointestinal symptoms. However, in the present-day era, gastrointestinal bleeding related to bowel ulceration is becoming increasingly sporadic especially in the urban setting. Case presentation We present a rare case of life-threatening gastrointestinal bleeding from a typhoid ileal ulcer that was successfully managed with endoscopic therapy. Conclusion Though rare, this infective cause of gastrointestinal bleeding should still be considered in differential diagnosis, especially in developing countries.
... Cefotaxime is used in patients with severe typhoid fever who are quinolone-resistant. Cefotaxime and ceftriaxone are effective for the treatment of Gram-negative bacteria such as S. typhi [16]. This reason allows ceftriaxone and cefotaxime to be used at M.M. Dunda Limboto. ...
Article
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Objectives: Typhoid fever is an acute systemic infectious disease in the small intestine caused by Salmonella enterica serotype typhi (Salmonella typhi) having the symptoms of fever a week or more with impairment of the gastrointestinal tract with or without impaired consciousness. The purpose of this study was to determine the rationality of antibiotic therapy in pediatric patients at M.M Dunda Limboto Hospital.Methods: This research belongs to non-experimental descriptive with retrospective data retrieval. The data used were obtained from 83 medical records of childhood typhoid patients during 6 months (June–November 2016) at the regional general hospital of M.M Dunda Limboto. These data were analyzed using the Gyssens criteria.Results: The results showed that the most antibiotics used by physicians were ceftriaxone 39% of the use of antibiotic quality which was category IIB 9%, category IIA 13%, and category 0 (rational) 52%.Conclusion: The rationality of antibiotic therapy in children with typhoid fever at M.M Dunda Limboto Hospital was 52% of the most antibiotics used, i.e. ceftriaxone (39%).
... In our study mean age of disease 6.7 ± 4.31 years which shows high prevalence of disease among school aged children. Usually 15% of the patients affected with enteric fever develop complications 11 .However rate of complicated typhoid fever is higher in developing countries. Ninety percent of the deaths due to complicated fever occur in Asia 12 . ...
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OBJECTIVE: To assess the frequency of complications of enteric fever in paediatric patients in a public sector hospital. METHODOLOGY: Children (newborns to 12 year) having positive Salmonella typhi on bacteriological culture/Typhi dot were included in study. All complications like hepatitis, perforation, bone marrow suppression, pneumonia and encephalitis were categorized according to clinical symptoms and diagnostic test reports. RESULTS: Out of 65 patients, 47.69% developed complications. Mean age for disease was 6.7 ± 4.31 years with male preponderance (61.5%). Hepatitis was the most common (21.53%) complication followed by bone marrow suppression (12.3%), pneumonia (10.7%), encephalitis (6.1%) and perforation (4.6%). Rate of complication was higher (61.9%) for those not receiving any treatment (40.9%) at time of presentation than those receiving antibiotic treatment. No significant difference (OR=1.0, P-value 0.9) was found between the patients treated with ceftriaxone and quinolone. CONCLUSIONS: Complications in enteric fever were found to be major health problem in children.
... Most cases of enteric fever were reported during hot weather.This is because warm and moist conditions favor the growth of the organism. Also, in summer, people are more likely to drink water outside their homes which may be of low quality (23) (24) . ...
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Background: Enteric fever is a serious blood stream infection caused by the bacterium Salmonella Typhi and Salmonella paratyphi. It is commonly associated with direct or indirect person-to-person transmission as a result of improper hygiene and unsafe food/water handling practices. The aims of current study were to determine if there is a source of enteric fever infection of public health concern and to stop transmission from such a source and to assess the predisposing risk factors in a hope to decrease or prevent such transmission.Methods: Ethical approval was obtained at the beginning of the study. A case-series study design was adopted to carry out the study which was conducted in private clinic in Mosul city, the center of the Nineveh governorate in the north of Iraq, over one-year period starting from1 st of April 2017, after military operation has been ended, to 1 st of April 2018. Two hundred thirtyone cases were eligible to be included in the study as they fit the criteria of case selection. Data analysis was done using computer-based Minitab 18 software. Results: Out of 4350 cases attending private clinic of gynecology and obstetrics for any cause during period of data collection, only 231 cases were eligible to be included in the study.Conclusion: the study concludes that there are many common sources of typhoid infection in Mosul community with ignorance of population about them. More health education about common sources and availability of vaccination together with health sanitation measures needed to overcome these common sources and prevent disease occurrence.
... For MDR typhoid fever (typhoid not susceptible to the first-line drugs), third-generation cephalosporins are the drugs of choice. Other alternatives include ciprofloxacin [11,12]. The excessive use of antibiotics has now led to the evolution of extensively drug-resistant (XDR) typhoid fever, which is only susceptible to azithromycin [13]. ...
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Typhoid fever is caused by Salmonella typhi, a gram-negative organism. The disease usually presents with high-grade fever, abdominal pain, and diarrhea. Gastrointestinal hemorrhage is a frequent complication of the disease. However, adequate treatment with antibiotics has lowered the rate of complications. We present the case of a 21-year-old male who was admitted to the hospital with high-grade fever and per rectal bleeding. A few hours after admission, the patient had episodes of massive per rectal bleeding which resulted in hemodynamic instability. The bleeding was then successfully controlled with endoscopic hemoclipping. Concurrently, his blood culture results showed growth of Salmonella typhi for which antibiotic therapy was initiated, and the patient's condition improved thereafter. This report highlights the rare occurrence of massive lower gastrointestinal bleeding in patients with typhoid fever. It also signifies the use of endoscopic therapy with endoclips for the management of massive lower gastrointestinal bleeding.
... 30 An open label, non-comparative study, which evaluated the efficacy and safety of Azithromycin for the treatment of uncomplicated enteric fever, found that azithromycin cured 93% of the subjects whereas the Cefixime cured 100% of the subjects. 31 Azithromycin was said to have been effective in 92.4% of the 1039 reports which included an opinion about effectiveness whereas Cefixime was said to have been effective in 94.29% of the 1039. 32 ...
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Introduction: Enteric fever is systemic infection caused by the Salmonella enteric serovarstyphi and para typhi AB and C. It is the significant cause of morbidity and mortality. It occurs in all parts of the world where water supplied and sanitation is substandard. Annually, it is estimated that more than 10 million cases and 100000 deaths are caused by typhoid fever.Regarding to the strains, a high prevalence of S. typhi and S. paratyphi. A strains in Nepal that showed resistance against the quinolone nalidixic acid (MIC> 256 mcg/ml with a corresponding decreased susceptibility against fluoroquinolones such as ciprofloxacin (MIC>0.125 mcg/ml) Objectives: The main objective of study was to compare the efficacy of Azithromycin and Cefixime in treatment of typhoid fever. Methodology: The invitro antibacterial activity of azithromycin and Cefixime against 4 isolated colonies of Salmonella typhifrom reference of salmonella typhi ATCC no. 14028 and blood culture isolates from three different hospitals was evaluated by disc diffusion (well) method. 0.25 ppm, 0.5 ppm, 4 ppm, 8 ppm, 32 ppm, 128 ppm concentration of both Azithromycin and Cefixime was used. The zone of inhibition was measured and data was analyzed using Excel. Results:In all isolates of Salmonella typhi, the zone of inhibition shown by both Azithromycin and Cefixime is same at low concentration (0.25ppm, 0.5ppm) but with increasing in concentration there is increase in difference in zone of inhibition shown by them. The zone of inhibition shown by Cefixime is greater in high concentration as compared to zone of inhibition shown by Azithromycin Conclusion: Our result indicate Cefixime is better than Azithromycin in therapeutic option for enteric fever.
Conference Paper
The aim of this study to determine relationship between behavioral prevention of family toward typhoid fever among children in Kassi-Kassi Public Health Center (Puskesmas) working area at Makassar city. The study was used analytical survey research with cross sectional research design. The population for this study was all parents especially mother of children aged between 5 and 14 years old who suffered typhoid fever and had medical record in Puskesmas. The sample sizes were 124 respondents by using exhaustive sampling technique. The result found there was significant relationship between personal hygiene behavior (p=0.000), environmental sanitation behavior (p=0.004), drinking water provision behavior (p=0.0220, food provision behavior (p=0.000) on the incidence of typhoid fever in children.
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This article is about clinical presentations of pediatric patients suffering from MDR and XDR typhoid fever
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Objective To describe the demographic, clinical, laboratory and bacteriological profile of children with diagnosis of typhoid fever over a six-year period. Methods Case record analysis of hospitalized children (≤5 y) with culture positive typhoid fever. Results Blood culture was positive in 100 (61%) of 166 suspected cases, with 78 isolates of Salmonella Typhi and 22 Salmonella Paratyphi A. Only 12 children were aged below two years. Hepatomegaly (32), splenomegaly (44), eosinopenia (42), positive widal (15, 21.1%) and positive Typhidot IgM (18, 28.1%) were not consistently observed. High susceptibility to Ampicillin, Chloramphenicol, Cotrimoxazole (87, 89, and 94, isolates, respectively), 100% susceptibility to third generation cephalosporins and Azithromycin, and high resistance to Nalidixic Acid [(S. Typhi 48 (61.5%)], S. Paratyphi A 16 (72.7%)) were observed. Conclusion We observed a high isolation rate of salmonella in blood culture, despite prior use of antibiotics. Most salmonella isolates were susceptible in vitro to standard drugs, except nalidixic acid.
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KATA PENGANTAR Puji syukur kehadirat Allah SWT atas limpahan rahmat dan hidayahNya penulis telah dapat menyelesaikan buku dengan judul "Mengenal Demam Tifoid" Tak lupa kita hanturkan salam dan sholawat atas junjungan kita Nabi Muhammad SAW beserta sahabat dan keluarganya yang telah membimbing dan menuntun kita untuk tetap istiqomah dijalanNya. Penulis bermaksud memberikan sumbangsih buku terkait penyakit demam tifoid. Hal tersebut karena tingginya angka kasus demam tifoid yang banyak terjadi bukan hanya di Indonesia tapi juga dibeberapa negara berkembang di dunia. Penulis sepenuhnya mengakui dan menyadari tidak terlepas dari bimbingan, arahan dan dukungan dari berbagai pihak, meskipun tanggung jawab akhir penulisan buku ini berada pada penulis sendiri. Dalam kesempatan ini dengan sepenuh hati penulis mengucapkan terimakasih yang tak terhingga dan penghargaan yang setinggi-tingginya kepada : 1. Suamiku yang sangat aku cintai Syarifuddin, ST,MM yang telah memberikan dukungan penuh untuk menulis buku serta selalu mendukung setiap pencapaian saya selama ini. 2. Ayahanda tercinta Drs. H. Idrus, MM dan Ummiku tersayang Hj.Hastati Hasan, SE ibunda tersayang
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Antibiotic selection should consider microbial sussceptibility, nature and severity of disease pharmacokinetics and pharmacodynamics and drug toxicity. The right antibiotic at the right time saves lives. There is no one type of antibiotic that cures every infection. Severe malaria is an important cause of morbidity and mortality, especially in tropical countries and in travelers returning from endemic areas. Patients presenting to the ICU usually have severe malaria. Despite adequate therapy, mortality rate remains around 10–20%. Treatment should be initiated on suspicion alone of Malaria.
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Acute typhoid fever is an acute systemic infectious disease caused by the microorganism Salmonella enterica serotype typhi known as Salmonella typhi. This disease is still often found in developing countries located in subtropics and tropical areas such as Indonesia. Typhoid fever (typhoid fever), which is commonly called typhus, is a disease that attacks the digestive tract. During infection, these germs multiply in mononuclear phagocytic cells and are continuously released into the bloodstream. Typhoid fever is an infectious disease listed in Law number 6 of 1962 concerning epidemics. This group of infectious diseases is a disease that is easily contagious and can attack many people so that it can cause an outbreak. Typhoid fever is also known as typhoid abdominalis, typhoid fever, or enteric fever. The term typhoid comes from the Greek word typhos which means fog, because generally sufferers are often accompanied by a mild to severe disturbance of consciousness. Typhoid fever is an acute systemic infectious disease caused by the microorganism Salmonella enterica serotype typhi known as Salmonella typhi (S. typhi). This disease is still often found in developing countries located in subtropics and tropical areas such as Indonesia. The course of S. typhi disease goes through several processes, starting with the entry of germs through contaminated food and drink through the oral-faecal route. Then the body will carry out defense mechanisms through several immune response processes, both local and systemic, specific and non-specific as well as humoral and cellular. S. typhi that enters the gastrointestinal tract will not always cause infection, because to cause S. typhi infection, it must be able to reach the small intestine. Gastric acidity (PH ≤ 3.5) is one of the important factors that prevents S. typhi from reaching the small intestine. However, most of the S. typhi bacteria can survive because they have the ATR (acid tolerance response) gene. Achlorhydria due to aging, gastrectomy, proton pump inhibitors, H2 receptor antagonist histamine treatment, or administration of antacids can reduce the infective dose that makes it easier for germs to pass into the small intestine.
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Enteric fever (typhoid and paratyphoid)is caused by Salmonella typhi and Salmonella paratyphi. It is spread by fecal-oral route, largely through contamination of water and foodstuff. Developing countries are the worst affected. It takes 7 - 21 days from ingestion of the organism to manifestation of symptoms which are generally Fever, relative bradycardia, and pain abdomen. Hepatosplenomegaly, intestinal bleeding, and perforation are the features at various stages of the disease. The bacteria invade the submucous layer and proliferate in the Payer's patches. Blood culture is the gold standard for diagnosis but it is only rarely positive. Fluroquinolones, cephalosporins, and azithromycin are antibiotics of choice. There is increasing evidence of the development of resistance to all antibiotics. Salmonella sepsis, though uncommon, can occur. Intestinal perforation, peritonitis, and secondary sepsis are complications that may require intensive care unit management. How to cite this article: Ray B, Raha A. Typhoid and Enteric Fevers in Intensive Care Unit. Indian J Crit Care Med 2021;25(Suppl 2):S144-S149.
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Lay Summary Enteric fever (EF) is an infection caused by the bacteria called Salmonella Typhi or Paratyphi. Infection is acquired through swallowing contaminated food or water. Most EF in England occurs in people returning from South Asia and other places where EF is common; catching EF in England is rare. The main symptom is fever, but stomach pain, diarrhoea, muscle aches, rash and other symptoms may occur. EF is diagnosed by culturing the bacteria from blood and/or stool in a microbiology laboratory. EF usually responds well to antibiotic treatment. Depending on how unwell the individual is, antibiotics may be administered by mouth or by injection. Over the past several years, there has been an overall increase in resistance to antibiotics used to treat enteric fever, in all endemic areas. Additionally, since 2016, there has been an ongoing outbreak of drug-resistant EF in Pakistan. This infection is called extensively drug-resistant, or XDR, EF and only responds to a limited number of antibiotics. Occasionally individuals develop complications of EF including confusion, bleeding, a hole in the gut or an infection of the bones or elsewhere. Some people may continue to carry the bacteria in their stool for a longtime following treatment for the initial illness. These people may need treatment with a longer course of antibiotics to eradicate infection. Travellers can reduce their risk of acquiring EF by following safe food and water practices and by receiving the vaccine at least a few weeks before travel. These guidelines aim to help doctors do the correct tests and treat patients for enteric fever in England but may also be useful to doctors and public health professionals in other similar countries.
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XDR typhoid has dominated as a culture pattern in recent years in Pakistan. We present the clinical spectrum of MDR VS XDR Typhoid fever in children
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Aims: Recently, the cefixime-ofloxacin combination is approved by drug controller general of India (DCGI) to treat typhoid fever. We sought to evaluate the antimicrobial activity of cefixime-ofloxacin combination against S. Typhi. Methods and results: 283 non-duplicate S. Typhi isolates collected during 2012 to 2014 were included in this study. Minimum inhibitory concentration (MIC) of cefixime and ofloxacin was determined by using broth microdilution method. Combinational testing was performed by using checkerboard assay. In checkerboard assay, synergistic activity was seen in 11% of isolates, while the majority of the isolate showed indifference and none of them showed antagonism. An in silico strategy, an alternative to the animal model, was carried out to understand drug interaction and toxicity. Molecular docking results elucidated that cefixime and ofloxacin are capable of inhibiting the cell wall synthesis and DNA replication respectively. Computational ADMET analysis showed no toxicity and no drug-drug interaction between cefixime and ofloxacin. Conclusion: Cefixime-ofloxacin combination could be effective against moderately susceptible fluoroquinolone S. Typhi but not fluoroquinolone-resistant isolates. Significance and impact of study: Cefixime-ofloxacin combination with no drug-drug interaction and non-toxic predicted through computational analysis didn't show antagonism against S. Typhi in in-vitro. Though the present study showed no adverse effects with the cefixime-ofloxacin combination, further studies on pharmacokinetic and pharmacodynamic (PK-PD) parameters of cefixime and ofloxacin combination are warranted. This article is protected by copyright. All rights reserved.
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Background: Typhoid fever, caused by Salmonella enterica serotype Typhi, is endemic in the Indian sub-continent including Bangladesh, South-east and Far-east Asia, Africa and South Central America. The disease can occur in all age group with highest incidence among children. Blood culture is regarded as the gold standard for diagnosis and carry 70-75% diagnostic yield in the first week of illness. However, this requires laboratory equipment and technical training that are beyond the means of most primary health care facilities in the developing world. Typhidot is a rapid dot-enzyme immune assay (EIA), which detects IgG and IgM antibodies to a specific 50 kD outer membrane protein (OMP) antigen of Salmonella enterica serotype Typhi. Typhidot becomes positive as early as in the first week of fever. The results can be visually interpreted and is available within one hour. Materials and method: Fifty blood samples, collected aseptically from patients clinically diagnosed of Typhoid fever, were evaluated by blood culture, Widal test and Typhidot. Results: Of the 50 patients, 33 (66%) were positive by blood culture. Widal test was positive in 33(66%) patients which included 26 in blood culture positive patients and 7 in blood culture negative patients. Typhidot was positive in 37 (74%) patients. Thus, in comparison to the gold standard test i:e blood culture, Typhidot and Widal test had sensitivity and specificity of 100% & 76% and 78.78% & 58.82% respectively. Conclusion: Typhidot is found to have high sensitivity and good specificity and could be applied as a good alternate in resource poor nation. Further, it is simple to perform, reliable when compared to Widal test, and rapid, with results being available in one hour when compared to 48 hours for blood culture and 18 hours for Widal test.
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Introduction: Typhoid fever still continues to be a major public health problem, particularly in developing countries. A simple, reliable, affordable, and rapid diagnostic test has been a long-felt need of the clinicians. We, therefore, prospectively evaluated the sensitivity and specificity of Typhidot (IgM), a serological test to identify IgM antibodies against Salmonella typhi. Materials and Methods: The study was carried out in the Department of Microbiology, Apollo Hospital, Bangalore between January 2009 and March 2009 on a total of 186 samples from clinically suspected febrile patients. Blood culture as well as Typhidot test was performed for each of the cases. Results: Out of 61 clinically diagnosed typhoid fever, 50 were blood culture positive for S. typhi all 50 were Typhidot (IgM) positive and 11 were missed out on both. The sensitivity, specificity, positive and negative predictive values of the test using blood culture as gold standard were 100%, 95.5%, 89.2%, and 100%, respectively for typhoid fever. Conclusion: Typhidot (IgM) test is rapid, easy to perform, and reliable for diagnosing typhoid fever, and useful for small, less equipped laboratories as well as for the laboratories with better facilities in typhoid endemic countries.
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Abstract Introduction: Typhoid fever is a major public health problem in developing countries of Africa and Asia. India has highest incidence worldwide. This disease is transmitted by faeco-oral route and it exists as an endemic disease, Asia, Africa and Latin America are having higher counts for disease. In South-East Asia, there is high incidence of morbidity and mortality due to intestinal perforation. The management of typhoid intestinal perforation poses a unique challenge to treating surgeon. Our purpose of conducting this study was to reveal our clinical experience in surgical management of enteric perforation. Materials and Method: It is a retrospective study of patients who were operated for typhoid intestinal perforation at Bundelkhand Medical College and Associated District Hospital, Sagar, India, between August 2008 and October 2013; after approval from institutional ethics committee this study was started. The data of patients who were presented with typhoid perforation was retrieved from medical records department of hospital. In all cases Widal test was positive for typhoid. Laparotomy was performed by midline incision. Management of perforation was dependant on the type of severity of disease. Results: In our study 155 patients were studied at an average of 31 cases annually. In our study male to female ratio was 6.38:1. The median age was 28.66 years. The peak incidence was between 21 to 30 years. The majority of patients came from rural area. All the patients were presented with fever and abdominal pain. 139 (89.67 %) patients presented late after 24 hour of acute abdominal pain with inadequate treatment. X-ray abdomen of 130 (83.87%) patients showed free gas under right dome of diaphragm. Widal test was positive in all the patients. All patients in this study underwent emergency laparotomy. In 90 % of the cases perforation was in terminal 25 cm of the ileum. Various type of surgical repair techniques were applied on the basis of number of perforations, degree of contamination, shock, presence of other co-morbid conditions. 34 patients underwent reoperation, 119 (76.77%) patients had post-operative complication with the most common complication being the surgical site infection. The median hospital stay was 21.56 days. Patients who had postoperative complication stayed longer in the hospital. In our study the mortality rate was 15.48%. Conclusion: Typhoid intestinal perforation is a significant health problem with high morbidity and mortality in rural India. In management of this disease, early and appropriate surgical intervention is vital, with emphasis on preventive measure of typhoid fever. Keywords: Enteric perforation; Surgical management; Complications; Morbidity; Mortality
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Infections with Salmonella are an important public health problem worldwide. Salmonella are one of the most common causes of food-borne illness in humans. There are many types of Salmonella but they can be divided into two broad categories: those that cause typhoid and those that do not. The typhoidal Salmonella (TS), such as S. enterica subsp. enterica serovars Typhi and S. Paratyphi only colonize humans and are usually acquired by the consumption of food or water contaminated with human fecal material. The much broader group of non-typhoidal Salmonella (NTS) usually results from improperly handled food that has been contaminated by animal or human fecal material. Antimicrobials are critical to the successful outcome of invasive Salmonella infections and enteric fever. Due to resistance to the older antimicrobials, ciprofloxacin [fluoroquinolone (FQ)] has become the first-line drug for treatment. Nevertheless, switch to FQ has led to a subsequent increase in the occurrence of salmonellae resistant to this antimicrobial agent. The exact mechanism of this FQ resistance is not fully understood. FQ resistance has driven the use of third-generation cephalosporins and azithromycin. However, there are sporadic worldwide reports of high level resistance to expanded-spectrum cephalosporins (such as ceftriaxone) in TS and in NTS it has been recognized since 1988 and are increasing in prevalence worldwide. Already there are rare reports of azithromycin resistance leading to treatment failure. Spread of such resistance would further greatly limit the available therapeutic options, and leave us with only the reserve antimicrobials such as carbapenem and tigecycline as possible treatment options. Here, we describe the methods involved in the genotypic characterization of antimicrobial resistance in clinical isolates of salmonellae.
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Background Typhoid fever is a major health problem in developing countries and its diagnosis on clinical ground is difficult. Diagnosis in developing countries including Ethiopia is mostly done by Widal test. However, the value of the test has been debated. Hence, evaluating the result of this test is necessary for correct interpretation of the result. The main aim of this study was to compare the result of Widal test and blood culture in the diagnosis of typhoid fever in febrile patients. Methods Blood samples were collected from 270 febrile patients with symptoms clinically similar to typhoid fever and visiting St. Paul’s General Specialized Hospitals from mid December 2010 to March 2011. Blood culture was used to isolate S.typhi and S.paratyphi. Slide agglutination test and tube agglutination tests were used for the determination of antibody titer. An antibody titer of ≥1:80 for anti TO and ≥1:160 for anti TH were taken as a cut of value to indicate recent infection of typhoid fever. Results One hundred and eighty six (68.9%) participants were females and eighty four (31.1%) were males. 7 (2.6%) cases of S. typhi and 4 (1.5%) cases of S. paratyphi were identified with the total prevalence of typhoid fever 4.1%. The total number of patients who have indicative of recent infection by either of O and H antigens Widal test is 88 (32.6%). The sensitivity, specificity, Positive predictive Value and Negative predictive Value of Widal test were 71.4%, 68.44%, 5.7% and 98.9% respectively. Conclusions Widal test has a low sensitivity, specificity and PPV, but it has good NPV which indicates that negative Widal test result have a good indication for the absence of the disease.
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Surgical complications of typhoid fever usually involve the small gut, but infrequently typhoid fever also involves the gallbladder. Complications range from acalculous cholecystitis, gangrene to perforation. Here, we present a case of enteric fever with concomitant complication of multiple ileal perforations at its terminal part with acalculous cholecystistis with gangrenous gall bladder. The primary closure of the perforations and cholecystectomy was performed. Post-operatively patient developed low-output faecal fistula that was managed conservatively.
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Fluoroquinolones are the most commonly used group of antimicrobials for the treatment of enteric fever, but no direct comparison between two fluoroquinolones has been performed in a large randomised trial. An open-label randomized trial was conducted to investigate whether gatifloxacin is more effective than ofloxacin in the treatment of uncomplicated enteric fever caused by nalidixic acid-resistant Salmonella enterica serovars Typhi and Paratyphi A. Adults and children clinically diagnosed with uncomplicated enteric fever were enrolled in the study to receive gatifloxacin (10 mg/kg/day) in a single dose or ofloxacin (20 mg/kg/day) in two divided doses for 7 days. Patients were followed for six months. The primary outcome was treatment failure in patients infected with nalidixic acid resistant isolates. 627 patients with a median age of 17 (IQR 9-23) years were randomised. Of the 218 patients with culture confirmed enteric fever, 170 patients were infected with nalidixic acid-resistant isolates. In the ofloxacin group, 6 out of 83 patients had treatment failure compared to 5 out of 87 in the gatifloxacin group (hazard ratio [HR] of time to failure 0.81, 95% CI 0.25 to 2.65, p = 0.73). The median time to fever clearance was 4.70 days (IQR 2.98-5.90) in the ofloxacin group versus 3.31 days (IQR 2.29-4.75) in the gatifloxacin group (HR = 1.59, 95% CI 1.16 to 2.18, p = 0.004). The results in all blood culture-confirmed patients and all randomized patients were comparable. Gatifloxacin was not superior to ofloxacin in preventing failure, but use of gatifloxacin did result in more prompt fever clearance time compared to ofloxacin. Trial registration: ISRCTN 63006567 (www.controlled-trials.com).
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Salmonella cholecystitis is a rare but important complication of Salmonella typhi infection. We are reporting an 11 years old female child who presented with complaints of high-grade fever, jaundice and right sided abdominal pain (Charcot's triad). Her examination showed tender hepatomegaly. Initial blood results revealed high white cell counts with left shift, deranged liver function tests. Abdominal ultrasonography revealed distended gallbladder with minimal layer of sludge seen within its lumen along with streak of pericholecystic fluid. Blood culture grew Salmonella typhi. She was successfully treated with intravenous ceftriaxone.
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To find out the value of primary ileostomy as a life saving procedure in patients of typhoid ileal perforation. 112 diagnosed cases were included in this study with a mean age of 18.66 years with a male to female ratio of 1.5:1. After diagnosis and resuscitation, all of the patients were operated within 48 h of admission. The operative procedure was determined by the general condition of the patient, number of perforations and degree of peritoneal contamination. Primary ileostomy was done in moribund patients with massive faecal contamination of peritoneal cavity, while primary double layered closure of the perforation was attempted in clinically stable patients with a single perforation and resection followed by end- to- end anastomosis was attempted in cases where there were more than one perforations or the perforation was present too close to the ileocaecal junction. Age ranged from 8 years to 50 years and the maximum number of patients were in the age group 31-40 years, with a male dominance. On laparotomy 98 (88.5%) patients had a solitary perforation in the terminal ileum and 14 (12.5%) patients had more than one perforation. Primary double-layered closure was done in 40 (35.71%) patients; primary ileostomy in 54 (48.21%) patients and resection followed by end-to-end anastomosis was done in remaining 18 (16.07%) patients. Faecal fistula was the most dreaded and fatal complication and was found to be commonest in patients where primary closure was done (07, 17.55). Over all mortality was (7.14%) of which 6 (5.35%) died secondary to the development of faecal fistula while one patient developed severe peri-stomal excoriation and progressive malnutrition leading to septicemia and death. Minimum hospital stay was associated with primary ileostomy patients and so was the complication rate. Primary ileostomy was found to be superior to other surgical procedures as far as the morbidity and mortality is concerned and especially so in moribund patients presenting late in the course of illness, where it proved to be a life saving procedure. We recommend that primary ileostomy is a safe way of managing typhoid ileal perforation.
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Background & objectives: Typhoid fever caused by Salmonella Typhi continues to be a major health problem in spite of the use of antibiotics and the development of newer antibacterial drugs. Inability to make an early laboratory diagnosis and resort to empirical therapy, often lead to increased morbidity and mortality in cases of typhoid fever. This study was aimed to optimize a nested PCR for early diagnosis of typhoid fever and using it as a diagnostic tool in culture negative cases of suspected typhoid fever. Methods: Eighty patients with clinical diagnosis of typhoid fever and 40 controls were included in the study. The blood samples collected were subjected to culture, Widal and nested PCR targeting the flagellin gene of S. Typhi. Results: The sensitivity of PCR on blood was found to be 100 per cent whereas the specificity was 76.9 per cent. The positive predictive value (PPV) of PCR was calculated to be 76.9 per cent with an accuracy of 86 per cent. None of the 40 control samples gave a positive PCR. Interpretation & conclusions: Due to its high sensitivity and specificity nested PCR can be used as a useful tool to diagnose clinically suspected, culture negative cases of typhoid fever.
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Typhoid has been reported to be a common and significant cause of morbidity in pre-school and school-age children in the endemic countries like India. The incidence of typhoid has been reported to be as high as 27.3 per 1000 person-years in children less than 5 years of age. Serious complications occur in about 10% of cases requiring hospitalization. The mean cost of treatment per episode of blood culture-confirmed typhoid fever has been calculated as INR 3,597 (1996 prices) in an outdoor setting, whereas in case of hospitalization, the cost of illness increases by several folds (INR 18,131). Vi polysaccharide vaccine is safe, efficacious and affordable for use as a cost-effective public health tool to protect children from typhoid and related complications, when given at 2 and 5 years of age as a part of National Immunization Schedule.
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Multidrug-resistant typhoid fever (MDRTF) is defined as typhoid fever caused by Salmonella enterica serovar Typhi strains (S. Typhi), which are resistant to the first-line recommended drugs for treatment such as chloramphenicol, ampicillin and trimethoprim-sulfamethoxazole. Since the mid-1980s, MDRTF has caused outbreaks in several countries in the developing world, resulting in increased morbidity and mortality, especially in affected children below five years of age and those who are malnourished. Two methods were used to gather the information presented in this article. First PubMed was searched for English language references to published relevant articles. Secondly, chapters on typhoid fever in standard textbooks of paediatric infectious diseases and preventive and social medicine were reviewed. Although there are no pathognomonic clinical features of MDRTF at the onset of the illness, high fever ( > 104°F), toxaemia, abdominal distension, abdominal tenderness, hepatomegaly and splenomegaly are often reported. The gold standard for the diagnosis of MDRTF is bacterial isolation of the organism in blood cultures. Ciprofloxacin and ceftriaxone are the drugs most commonly used for treatment of MDRTF and produce good clinical results. MDRTF remains a major public health problem, particularly in developing countries. Mass immunization in endemic areas with either the oral live attenuated Typhi 21a or the injectable unconjugated Vi typhoid vaccine, rational use of antibiotics, improvement in public sanitation facilities, availability of clean drinking water, promotion of safe food handling practices and public health education are vital in the prevention of MDRTF.
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An open-labelled, non-comparative study was conducted in 117 children aged 2-12 years to evaluate the efficacy and safety of azithromycin (20mg/ kg/day for 6 days) for the treatment of uncomplicated typhoid fever. Of the patients enrolled based on a clinical definition of typhoid fever, 109 (93.1%) completed the study.Mean (SD) of duration of fever at presentation was 9.1(4.5) days. Clinical cure was seen in 102 (93.5%) subjects, while 7 were withdrawn from the study because of clinical deterioration. Mean day of response was 3.45±1.97. BACTEC blood culture was positive for Salmonella typhi in 17/109 (15.5%) and all achieved bacteriological cure. No serious adverse event was observed. Global well being assessed by the investigator and subjects was good in 95% cases which was done at the end of the treatment. Azithromycin was found to be safe and efficacious for the management of uncomplicated typhoid fever.
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In this study, nested PCR using H1-d primers, which is specific for Salmonella enterica serovar Typhi, was compared to blood culture and the single-tube Widal test. Results indicate that nested PCR can be used as a gold standard to determine the cutoff titer of the Widal test for diagnosis of typhoid fever.
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TUBEX (IDL Biotech) is a 5 min semiquantitative colorimetric test for typhoid fever, a widely endemic disease. TUBEX detects anti-Salmonella O9 antibodies from a patient's serum by the ability of these antibodies to inhibit the binding between an indicator antibody-bound particle and a magnetic antigen-bound particle. Herein, we report that TUBEX could also be used to specifically detect soluble O9 lipopolysaccharide in antigen-spiked buffer by the ability of the antigen to inhibit the same binding between the particles. Sensitivity of antigen detection was improved (8-31 mug ml(-1)) by using a modified protocol in which the test sample was mixed with the indicator particles first, rather than with the magnetic particles as for antibody detection. The antigen was also detectable in spiked serum and urine samples, albeit less well (2-4-fold) than in buffer generally. However, no antigen was detected from six typhoid sera examined, all of which had anti-O9 antibodies. In addition, whole organisms of Salmonella Typhi (15 strains) and Salmonella Enteritidis (6 strains) (both O9(+) Salmonella), grown in simulated blood broths or on MacConkey agar, were also detectable by TUBEX when suspended at >9 x 10(8) organisms ml(-1). Expectedly, Salmonella Paratyphi A (7 strains), Salmonella Typhimurium (1 strain) and Escherichia coli (2 strains) were negative in the test. Thus, the same TUBEX kit may be used in several ways both serologically and microbiologically for the rapid diagnosis of typhoid fever. However, validation of the newer applications will require the systematic examination of real patient and laboratory materials.
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Salmonella typhi and S. paratyphi are important causes of bacteremia in children, especially those from the developing world. There is a lack of standardized treatment protocols for such patients in the literature, and there are also reports of therapeutic failure related to resistance to commonly used antibiotics. We analyzed the epidemiological, clinical, and antimicrobiological sensitivity patterns of disease in patients diagnosed with blood culture-positive typhoid fever over a 6-month period in a tertiary-care pediatric hospital in western India. Data were retrospectively analyzed for all patients with Salmonella isolates on blood culture between January 1 and June 30, 2011 at the Synergy Neonatal and Pediatric Hospital. Susceptibility of isolates to antimicrobials and minimum inhibitory concentrations were determined. Demographic data, symptoms and signs, basic laboratory results, treatment courses, and clinical outcomes were collected from clinical charts. All of the 61 isolates of S. typhi were sensitive to cefepime (fourth-generation cephalosporin), 96% to third-generation cephalosporins, and 95% to quinolones. There was intermediate sensitivity to ampicillin (92%) and chloramphenicol (80%). Notably, azithromycin resistance was observed in 63% of isolates. All patients ultimately made full recoveries. There is an urgent need for large scale, community-based clinical trials to evaluate the effectiveness of different antibiotics in enteric fever. Our antimicrobial susceptibility data suggest that quinolones and third-generation cephalosporins should be used as first-line antimicrobials in enteric fever. Although fourth-generation cephalosporins are useful, we feel their use should be restricted to complicated or resistant cases.
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The efficacy of latex agglutination test in the rapid diagnosis of typhoid fever was studied and the result compared with that of blood culture. This study included 80 children suffering from typhoid fever, among which 40 were confirmed by blood culture isolation and 40 had possible typhoid fever based on high Widal's titre (a four-fold rise in the titre of antibody to typhi "O" and "H" antigen was considered as a positive Widal's test result). Eighty children, 40 with febrile illness confirmed to be other than typhoid and 40 normal healthy children were used as negative controls. The various groups were: (i) Study group ie, group I had 40 children confirmed by culture isolation of Salmonella typhi(confirmed typhoid cases). (ii) Control groups ie, (a) group II with 40 febrile controls selected from paediatrics ward where cause other than S typhi has been established, (b) group III with 40 afebrile healthy controls that were siblings of the children admitted in paediatric ward for any reason with no history of fever and TAB vaccination in the last one year, and (c) group IV with 40 children with high Widal's titre in paired sera sample. Widal's test with paired sera with a one week interval between collections were done in all 40 patients. Latex aggtutination test which could detect 900 ng/ml of antigen as observed in checker board titration, was positive in all 40 children from group I who had positive blood culture and in 30 children from group IV who had culture negative and had high Widal's titre positive. Latex agglutination test was positive in 4 children in group II and none in group III. Using blood culture positive cases as true positive and children in groups II and III as true negative, the test had a sensitivity of 100% and specificity of 96%. Latex agglutination test was found to be significantly sensitive (100%) and specific (96%) and could detect 75% more cases in group IV (possible typhoid cases). Thus latex agglutination test can be used for rapid diagnosis of typhoid fever though it cannot replace conventional blood culture required for isolation of organism to report the antibiotic sensitivity.
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Infection caused by ingestion of human-restricted Salmonella enterica serovars Typhi and Paratyphi predominantly affects the most impoverished sections of society. In this review, we describe recent advances made in estimating the burden of illness and the important role improved diagnostic tests may have in controlling infection and report the development of a new human challenge model of typhoid infection. Typhoid continues to be a major cause of morbidity, particularly in children and young adults in south east Asia, although accurate assessments are still hindered by the lack of reliable surveillance data. Recent reports of high rates of infection in Africa and the dominance of paratyphoid in several geographic areas are of particular concern. Diagnosis of enteric fever remains frustrated by the nonspecific clinical presentation of cases and the lack of test sensitivity. Methods to improve diagnostic accuracy are hindered by the incomplete understanding of immunobiological mechanisms of infection and lack of a suitable animal infection model. Enteric fever is a major global problem, the burden of which has only partially been recognized. Control strategies utilizing cheap accurate diagnostics and effective vaccines are urgently required, and their development should be accelerated by the use of a human challenge model.
Article
Objective: To compare the efficacy and safety of azithromycin with ofloxacin in patients with uncomplicated typhoid fever. Material and methods: Forty adult patients with bacteriologically or serologically diagnosed, uncomplicated typhoid fever were included from Medicine out-patient department at Government medical college, Amritsar, India. They were randomized into 2 groups of 20 patients each. Group I: patients received ofloxacin 200mg orally twice daily for 7 days. Group II: Patients received Azithromycin orally 1 gm on day 1 and then 500 mg daily from day 2 to day 6. The following parameters were noted a) fever clearance time b) cure rate c) adverse drug reaction d) recurrence of symptoms, if any, during 4 weeks follow up. Results: Nineteen out of 20 patients from group I were cured with mean fever clearance time of 3.68 days while all 20 patients from group II were cured with mean fever clearance time of 3.65 days. No significant side effects were noted in any of the patients. No relapse was recorded in the present study in a follow up period of 4 weeks in both study groups. Conclusion: Both ofloxacin and Azithromycin are almost equally efficacious and safe in treatment of typhoid fever with no major adverse effect. Azithromycin is an effective alternative in conditions where ofloxacin is contraindicated i.e., children, pregnant women and quinolone resistant cases of typhoid fever.
Article
For effective management of typhoid, diagnosis of the disease must be done with speed and accuracy. Development of such a test would require antigens that are specific for typhoid diagnosis. Attempts at finding the specific antigen have been carried out throughout the years. The finding of such an antigen can lead to carrier detection as well. Candidate antigens have been used in the development of antigen or antibody detection tests with variation in sensitivity and specificity. Further characterization and understanding of the candidate antigens combined with use of innovative technologies will allow for the ideal test for typhoid and typhoid carriers to be within reach.
Article
Sir, The emergence of multidrug resistant S.Typhi (MDRST) and concern about delayed response to quinolones have resulted in a lot of anxiety among treating physicians. We carried out a comparative analysis of 62 cases of enteric fever proven by blood culture during 2001 to 2002, out of which 37 (59%) cases received a single drug (either a quinolone or cephalosporin) and 25 (40.3%) cases received 2 drugs simultaneously. The clinical course, complications, total duration of fever, time taken for defervescence of fever after starting therapy were analyzed retrospectively. Majority (29) of the cases (46.78%) belonged to the age group above 5 years and 9 cases (14.4 %) were below 1yr. The male and female distribution of cases was 21 (34%) and 41 (66%) respectively. Gastro-intestinal symptoms were observed in 46 (75%) cases with jaundice, with bleeding manifestations occurring in 4 of them. Hepatomegaly and splenomegaly were observed in 28 (46%) and 23 (37%) cases respectively, and hepatosplenomegaly was present in 22 (36%) cases. Regarding the drug therapy given, single drug therapy with a quinolone was given in 15 cases and 22 children received Ceftriaxone alone. Only one child received Ciprofloxacin as a single drug. In the group of 25 cases who received multidrug therapy, 19 (30.6%) cases received a combination of Ceftriaxone with Ofloxacin, with the other combinations being cefixime with ofloxacin in 2 (3.22%), Cefotaxime with Ofloxacin in 3 (4.83%) and Ceftriaxone with Ciprofloxacinin 1(1.6%).
Article
Typhoid has an estimated global burden of greater than 27 million cases per annum with a clinical relapse rate of 5% to 20%. Despite the large relapse burden, the factors associated with relapse are largely unknown. We have followed a protocol for the diagnosis and management of pediatric typhoid since 1988. We report factors associated with relapse of culture-proven enteric fever in 1,650 children presenting to the Aga Khan University Medical Center, Karachi, Pakistan, over a 15-year period. In those infected with multiple drug resistant (MDR) strains, factors associated with subsequent relapse include constipation at presentation and presentation within 14 days of fever onset. Diarrhoea in those children infected with drug sensitive strains had an association with decreased subsequent relapse, as was quinolone therapy. Multiple clinical factors at presentation are associated with subsequent typhoid fever relapse. These factors may be postulated to be associated with subsequent relapse due to alterations in the reticuloendothelial system organism load. These data will be valuable in developing algorithms for clinical follow-up in children infected with MDR enteric fever.
Article
Clin Microbiol Infect 2011; 17: 959–963 Emergence of multidrug resistance and decreased ciprofloxacin susceptibility (DCS) in Salmonella enterica serovar Typhi in South Asia have rendered older drugs, including ampicillin, chloramphenicol, trimethoprim–sulphamethoxazole, ciprofloxacin, and ofloxacin, ineffective or suboptimal for typhoid fever. Ideally, treatment should be safe and available for adults and children in shortened courses of 5 days, cause defervescence within 1 week, render blood and stool cultures sterile, and prevent relapse. In this review of 20 prospective clinical trials that enrolled more than 1600 culture-proven patients, azithromycin meets these criteria better than other drugs. Among fluoroquinolones, which are more effective than cephalosporins, gatifloxacin appears to be more effective than ciprofloxacin and ofloxacin for patients infected with bacteria showing DCS. Ceftriaxone continues to be useful as a back-up choice, and chloramphenicol, despite its toxicity for bone marrow and history of plasmid-mediated resistance, is making a comeback in developing countries that show their bacteria to be susceptible to it.
Article
Enteric fever is a major public health problem in developing countries. Ciprofloxacin resistance has now become a norm in the Indian subcontinent. Novel molecular substitutions may become frequent in future owing to selective pressures exerted by the irrational use of ciprofloxacin in human and veterinary therapeutics, in a population endemic with nalidixic acid-resistant strains. The therapeutics of ciprofloxacin-resistant enteric fever narrows down to third- and fourth-generation cephalosporins, azithromycin, tigecycline and penems. The first-line antimicrobials ampicillin, chloramphenicol and co-trimoxazole need to be rolled back. Antimicrobial surveillance coupled with molecular analysis of fluoroquinolone resistance is warranted for reconfirming novel and established molecular patterns for therapeutic reappraisal and for novel-drug targets. This review explores the antimicrobial resistance and its molecular mechanisms, as well as novel drugs in the therapy of enteric fever.
Article
An 18-year old female patient was admitted to the Emergency Department with complaints of fever and fatigue beginning 15 days ago associated with headache, weakness, palpitation, abdominal pain, and diarrhea a week later. The patient who apathic confused and discordant was transferred to the Department of Infectious Diseases. There was also hypocalcemia, hypopotassemia, pancytopenia, intestinal hemorrhage, and hepatic involvement. S. typhi was grown in the blood culture. The patient was discharged with full recovery after ciprofloxacin treatment in addition to electrolyte replacement. Typhoid fever is a widespread infectious disease in our country and should be taken into consideration in differential diagnosis of many diseases because it may involve a number of systems and may present with a variety of complications.
Article
A prospective study of the prevalent aetiology of enteric fever was undertaken at a tertiary care hospital in North India at intervals of every 3 years. Salmonella spp. were isolated from 174 (7%) patients. Amongst these, 140 (80%) patients were infected by Salmonella enterica subspecies enterica serovar Typhi (S. Typhi) and 16 (9%) by S. enterica serovar Paratyphi A; the remaining 11% were infected by other S. enterica serogroups, Typhimurium, Paratyphi C and Senftenberg, and other group E salmonella. A significantly greater number of S. Typhi were isolated in the summer and monsoon months. Multidrug resistance (resistance to chloramphenicol, ampicillin and co-trimoxazole) sequentially increased from 34% in 1999 to 66% in 2005. Increasing resistance was also noticed to the other antibiotics, especially to the cephalosporins. Moreover 8% of the S. Typhi isolates were found to be presumptive extended spectrum beta-lactamase producers. There was a gradual development of resistance to fluoroquinolones over the 7 years. No resistance was observed to fluoroquinolones in 1999, while in 2005 4.4% resistance was observed to sparfloxacin, 8.8% resistance to ofloxacin and a high resistance, 13%, to ciprofloxacin. This is an alarming development and it is of paramount importance to limit unnecessary use of fluoroquinolones and third generation cephalosporins so that their efficacy against salmonella is not jeopardized further.
Article
Enteric fever is endemic in Mumbai and its diagnosis poses several problems. Our main aim was to study the clinical profile, haematological features of culture proven typhoid cases, the antimicrobial susceptibility pattern of the isolates and the time to defervescence with the treatment received. This was a retospective chart review of all cases of culture proven enteric fever carried out at a tertiary care private hospital in Mumbai over the period January 2003 to September 2005. Culture positivity in our study was 52.6%. Sixty one percent of the isolates were Salmonella typhi while 39% were Salmonella paratyphi A. An absolute eosinopenia was seen in 76.9% of the patients. Before being admitted to the hospital, 46.2% received antibiotics. The mean time to defervescence in patients who received prior antibiotics was 4.5 days while that in those who did not receive prior antibiotics was 5.1 days. A high culture positivity despite prior or ongoing antibiotic treatment was seen. Absolute eosinophil count of 0% could be an important marker of typhoid. High prevalence of nalidixic acid resistance, a marker of resistance to fluoroquinolones was observed. Combination treatment was not found to be superior to treatment with a single antibiotic.
Article
The relative efficacy of cultures made from duodenal contents (obtained by string capsules), bone marrow, blood and rectal swab was compared in 118 pediatric patients, 2 to 13 years old with suspected typhoid fever. Only 47% of children 2 to 6 years old tolerated the string device, as compared with 89% in children 7 to 13 years old (P less than 0.05). The four culture techniques were performed and at least one was positive for Salmonella typhi in 43 patients. Bone marrow cultures were positive in 84% of the confirmed cases, a sensitivity significantly greater than for duodenal contents (42%), blood (44%) and stool (65%) cultures. Higher recovery rates for blood cultures were found during the first week of illness than later (70 vs. 22%). Bone marrow cultures remain the most effective method for the recovery of S. typhi. Stool cultures appear to be more effective in children than in adults. Duodenal contents cultures offer little advantage in young (2 to 6 years old) children.
Article
Cultures were made from blood, bone marrow, stool and duodenal contents (obtained with string capsules) from 36 patients with bacteriologically proven typhoid fever on admission to hospital. Duodenal content cultures proved to be as sensitive in diagnosis (86%) as bone marrow (75%) and more effective than blood (42%) and stool (26%) cultures in recovery of Salmonella typhi The sensitivity of duodenal content cultures was not modified by the duration of illness at admission or by previous antibacterial therapy. Even on the seventh day of effective treatment with chloramphenicol, the culture of duodenal contents remained positive in 8 of 17 patients, whereas salmonellae were isolated from stool cultures in only 2 of the same patients. The results obtained with the string capsule, together with the simplicity, economy and acceptability of the procedure, the fact that it can be performed with minimal facilities and the advantages of bacteriological recovery for antibiotic sensitivity testing, suggest that its adoption would be very helpful in efforts to control this disease.
Barber protein sensitized latex particles were used in the latex agglutination test for the diagnosis of typhoid fever and the result compared with that of Widal 'O' and 'H' agglutination test. The latex agglutination test was positive in all 20 bacteriologically proved typhoid patients, in 81 of 85 (95.3%) typhoid suspected patients, and only in 2 of 85 (2.3%) blood donors. In contrast, the positive rates were 60% for both 'O' and 'H' Widal agglutinations in bacteriologically proved typhoid patients, 34.2% and 71.7% respectively in typhoid suspected patients, and none of blood donors were positive. The sensitivity and specificity of the latex agglutination test were 100% and 97.6% respectively with positive and negative predictive values of 90.9% and 100% respectively. The latex agglutination test may be particularly useful for the presumptive diagnosis of typhoid fever in remote health centres.
Article
As society grapples with contemporary moral questions raised by the barring of HIV-infected people from jobs and even crossing some national borders, it is probably useful to re-examine the case of Typhoid Mary. The case of Mary Mallon shows how an earlier age resolved the conflict that arises when society's right to protect itself from unnecessary exposure to disease impinges on the liberty of individual citizens.
Article
Typhoid fever, the generalized infection of the reticuloendothelial system (spleen, liver, and bone marrow), gut-associated lymphoid tissue, and gall bladder caused by the highly human host restricted pathogen Salmonella enterica serovar Typhi (S. Typhi), is the quintessential infectious disease associated with inadequate sanitation and lack of protected drinking water. The pediatric (school-age) and young adult populations in endemic areas bear the brunt of the clinical disease burden worldwide. Typhoid fever also represents a risk for pediatric and adult travelers from industrialized countries who visit the developing countries (Steinberg et al., 2004). In endemic areas, chronic gall bladder carriers (usually adult females who excrete large numbers of typhoid bacilli) constitute an important reservoir of infection (Levine et al., 1982). Where sanitation is deficient, fecal contamination from inapparent carriers (chronic or temporary) and clinically ill patients can contaminate water supplies. If treatment of water sources is inadequate or unavailable, water can serve as an important vehicle of transmission (Mermin et al., 1999). Consumption of contaminated water and food vehicles by susceptible subjects leads to clinical or sub-clinical infection, depending on the dose ingested, the precise vehicle conveying the typhoid bacilli, and the host susceptibility factors (Hornick et al., 1970). Depending on the age of the infected patient, the presence of pre-existent gall bladder pathology, and the specific antibiotic treatment administered, up to a few percent of infected persons can become chronic gall bladder carriers, thereby maintaining the reservoir of infection. A fairly long incubation period (8–14 days) follows the ingestion of typhoid bacilli before the onset of clinical disease. The typical general features of typhoid fever include fever (that increases in step-wise fashion and persists for weeks if improperly treated), headache, and abdominal discomfort.
Article
In order to evaluate clinical and bacteriological efficacy of Cefpodoxime Proxetil (CP) in typhoid fever in comparison to cefixime (CF), we assessed 140 children with suspected typhoid fever. Fulfilling inclusion criteria finally 40 culture confirmed typhoid fever were allocated in randomized double blind clinical trial (RCT) to receive therapy with either oral CP (16 mg/kg/day, n = 21) or oral CF (20 mg/kg/day, n = 19) for 10 days. The two groups were comparable in their clinical and baseline characteristics. The clinical efficacy was similar in the two groups with only 2 (one in each group) clinical failures and all showing bacteriological eradication on subsequent blood culture. The time of defervescence was comparable in both groups (4.87 Fluconazole Prophylaxis against Fungal Colonization and Invasive Fungal Infection in Very Low Birth Weight Infants 2.33 vs 4.27 +/- 2.28 days, P = 0.308), with no relapse during 3 months follow up and no significant adverse effect. CP reduced the treatment cost by 33% in comparison to cefixime. Our study suggests CP is effective, safe and cheaper oral option for treatment of typhoid fever in children.
Epidemiological and clinical aspects of human typhoid feverSalmonella' Infections: Clinical, Immunological and Molecular Aspects [Internet]
  • Cm Parry
Parry CM. Epidemiological and clinical aspects of human typhoid fever. In: Mastroeni M, Maskell D, eds. 'Salmonella' Infections: Clinical, Immunological and Molecular Aspects [Internet]. Cambridge University Press, 2005 [cited 2015 April 7]. Available from: http://www.langtoninfo. com/web_content/9780521835046_ excerpt.pdf