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%)
Others: S.paratyphi
Salmonellae:
gram-negative bacilli, Enterobacteriaceae
family, non-spore-forming, nonencapsulated,
flagella.
A photomicrograph of
Salmonella typhosus
bacteria using a
Flagellar stain
technique (1979)
Etiology
Killed by heating to 130F (54.4C) for
1hr or 140F (60C) for 15min.
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: 330 (range 714) days
Clinical Manifestation
1
st
week:
Fever step ladder temperature chart,
Insidious increase, unremitting, highest: end
of 1
st
week
Systemic symptoms: headache, lethargy,
malaise, myalgia, nausea, vomiting,
abdominal pain
Clinical Manifestation
2
nd
week:
Hepatosplenomegaly, rose spot,
headache stupor
Relative bradicardia: rare in
children

Clinical Manifestation
3
rd
4
th
week:
Intestinal haemorrhage and
perforation are common
End of 4
th
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