Typhoid Fever

Epidemiology

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

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

 Acute systemic infection, caused by:

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

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

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

 Vary: mild – severe

 Incubation: 3–30 (range 7–14) days
Clinical Manifestation

 1st week:
– Fever “step ladder temperature chart”,
 Insidious increase, unremitting, highest: end
of 1st week
– Systemic symptoms: headache, lethargy,
malaise, myalgia, nausea, vomiting,
abdominal pain
Clinical Manifestation

 2nd week:
– Hepatosplenomegaly, rose spot,
headache  stupor
– Relative bradicardia: rare in
children
Clinical Manifestation

 3rd – 4th week:

– Intestinal haemorrhage and
perforation are common
– End of 4th week: fever gradually
decline
Clinical Manifestation

 GIT symptoms: vary

– Diarrhea
– Obstipation
– Obstipation  diarrhea
 Coated tongue
Diagnosis

 Clinical Features
– Clinically mild, can be asymptomatic
– Obviously:
 Fever
 GIT distubance
– Change of level of consciousness
Diagnosis

– Constitutional symptoms: headache,

malaise, abdominal pain, hepato/
splenomegaly, altered mental status
 Fever > 7 days + GI symptoms, in
children > 5 yr, no additional symptoms
 suspect typhoid fever
Diagnosis:
 Maculopapular rash in chest and abdomen
(rose spot): in 40-80% cases for 2-3 days
 Diarrhea (39%) > constipation (15%) in child
Vomiting (26%) and nausea (42%)
 Headache (76%), abdominal pain (60%),
altered mental status (34%), also apatis (31%)
and delirium (3%)
(Rivai AT, Mulyadi T, Kustedi P, Pulungsih SP, Janas. Balai
Penerbit FKUI, 1992; 85-93. )
Diagnosis:

 Laboratory
– Culturing Salmonella
 Blood (40 – 54%),
 bone marrow (80 – 90%),
 urine (7%),
 stool (35 – 37%),
 duodenal fluid (58%), rose spot (63%)
 Laboratory
Diagnosis:

 Laboratory
– Serology
 Widal: four fold rise in O agglutinin or a titer
of ≥ 1/160  not recommended by WHO
 IgM and IgG for Salmonella, Tubex, Typhi dot
– DNA probe
– PCR
Diagnosis:

 Laboratory
– Peripheral blood exam:
 Lekopenia, relative lymphocytosis,
aneosinophilia
 Not spesific
Complication

 Intestinal haemorrhage (1 – 10%) and

perforation (0.5 – 3%)
– Decrease temperature and blood pressure
 acute abdomen signs and peritonitis
Complication

 Others:
– Typhoid hepatitis, typhoid
encephalopathy, cholecystitis,
pneumonia, septic shock, pyelonephritis,
endocarditis, osteomyelitis, meningitis,
cerebral thrombosis, ataxia, aphasia, etc
Therapy

 Causal: appropriate antibiotic

 Severe typhoid fever: hospitalized
 Supportive therapy
– Monitoring
– Fluid management
Therapy
– Detection and manage complication
 Surgery for intestinal perforation
– Dietetic
 Non fibre and digestable
 Fever (-): solid food with adequate calory

– Blood transfusion
 Intestinal haemorrhage and perforation
Therapy

ANTIBIOTIC
 Empiric therapy
– Narrow spectrum AB, good penetration, easy
to give, resistency <, minimal side effect,
clinical effication evidence
 Treatment successfull parameter: time of
defervescence
– Min. 36 hours of therapy for  fever
Therapy

ANTIBIOTIC
 1st Line
– Chloramphenicol (1st drug of choice)
– Ampicillin / amoxicillin
– Cotrimoxazole
Therapy

ANTIBIOTIC
 2nd Line
– Ceftriaxon
– Cefixim
– Fluoroquinolon  not recommended for
children
– Azythromycine
– Aztreonam
Therapy

ANTIBIOTIC
 1st Line
– Chloramphenicol
 75 – 100 mg/kgBW/day IV or PO in 2 divided
dose for 10 – 14 days
 Max. dose 2 gr/day
 CI: leukopenia (< 2000/ul)
Terapi

ANTIBIOTIC
 1st Line
– Ampicillin
 200 mg/kgBW/day PO or IV in 4 divided dose
for 10 – 14 days or,
– Cotrimoxazole
 10 mg/kgBW/day (TMP) in 2 divided dose for
14 days
Terapi

ANTIBIOTIC
 2nd Line
– Ceftriaxon
 50 – 80 mg/kgBW/day, single dose for 10
days
 Cure rate up to 90% in 3 – 5 days duration of
therapy
Therapy

ANTIBIOTIC
 2nd Line
– Cefixim
 10 – 15 mg/kgBW/day PO in 2 divided dose
for 10 - 14 days
 Cure rate in IKA RSCM 1999 – 2000: 84%
Therapy
ANTIBIOTIC
 2nd line
– Fluoroquinolone
 Superior than cephalosporin, cure rate ≈
100%, child  controversion
– Ciprofloxacine, 10 mg/kgBW/day in 2 divided dose,
– Ofloxacine 10 -15 mg/kgBW/day in 2 divided dose
– Duration: 2 – 5 day
– MDR typhoid
Therapy

Dexamethasone
 Severe case with altered mental status
 Initial dose 3 mg/kgBW  1 mg/kgBW
every 6 hr for 48 hr  mortality  from 35-
55% to 10%
Prognosis

 Mortality: developed country < 1%,

developing country > 10%
 Complication high mortality and morbidity
 AB (-)  relapse 4-8%.
 Adequate AB, clinical manifestation occur ±
2 weeks after th/ (-), ≈ acute disease,
milder & shorter.
Prognosis

 Chronic carrier 1-5%

– Billiary tr disease incidence in chronic carrier
> general population
– Treatment
 Ampicillin or amoxicillin + probenecid high dose or
TMP-SMZ for 4 – 6 weeks
 If cholecystitis or cholelithiasis (+)  cholecystectomy
after 14 days antibiotics
Prevention

 Good sanitation and personal hygiene

 Typhoid vaccination  for traveler to
endemic area