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What is typhoid fever?
* Typhoid fever is a bacterial infection of the intestinal tract and
occasionally the bloodstream.

* The disease rarely occurs in developed countries. It is most

commonly seen in countries with poor sanitary conditions and
contaminated water supplies.

* Most of the cases are acquired during foreign travel to

underdeveloped countries.
• Outbreaks are rare.

• The germ that causes typhoid is a unique

human strain of Salmonella called Salmonella
• It is caused by infection with Salmonella typhi –
a bacteria found in infected animals and transmitted
to persons in contaminated food or fluids. It is most
often found in countries with poor sanitary conditions
or contaminated water supplies. Boiling water and
thoroughly cooking food can kill the microorganism.
The infection can also be spread asymptomatic
carriers. These are people who have the bacteria in
their gastrointestinal tract, but do not have symptoms.
How does the bacteria cause
• After the ingestion of contaminated food or water, the
Salmonella bacteria invade the small intestine and enter
the bloodstream temporarily. The bacteria are carried by
white blood cells in the liver, spleen, and bone marrow.
The bacteria then multiply in the cells of these organs
and reenter the bloodstream. Patients develop
symptoms, including fever, when the organism reenters
the bloodstream. Bacteria invade the gallbladder, biliary
system, and the lymphatic tissue of the bowel. Here,
they multiply in high numbers. The bacteria pass into the
intestinal tract and can be identified for diagnosis in
cultures from the stool tested in the laboratory.
Who gets typhoid fever?

• Anyone can get typhoid fever but the greatest

risk exists to travelers visiting countries where
the disease is common.
• Occasionally, local cases can be traced to
exposure to a person who is a chronic carrier.

• Infants and persons over 60 usually have the

severest cases.
• Ingestion of contaminated food

• Typhoid germs are passed in the feces and, to some

extent, the urine of infected people.

• The germs are spread by eating or drinking water or

foods contaminated by feces from the infected
Epidemiology: Incidence
• World: 17 million cases per year
• U.S.: 400 cases per year (70% in travelers)
• (Nov 2006) 478 in Agusan del Sur.
• (May 2004) 292 in Bacolod City
Risk factors

• Travel to developing country or refugee

• Highly dense living conditions
What are the symptoms?

• The symptoms may occur rapidly, particularly in children.

• However, in adults, they usually come on slowly

• Relapses are common.

• Fatalities are less than 1% with antibiotic treatment.

• Symptoms generally appear one to three weeks after exposure.

• Incubation (first 7-14 days after ingestion)
• Usually asymptomatic
• Diarrhea may occur
• Active infection
• Severe Headache
• Generalized Abdominal Pain
• Anorexia
• Constipation more common than Diarrhea
• Fever [usually higher in the evening]
• Intermittent Fever initially
• Sustained Fever to high temperatures later
• Pulse-Temperature Dissociation (uncommon)
• Rose Spots (Pathognomonic, present in 25% of
• Blanching pink macular spots 2-3 mm over
• Complications: (occurs in 10-15% of cases)
• Gastrointestinal Bleeding (2-10% of cases)
• Bowel perforation
• Typhoid encephalopathy
For how long can an infected
person carry the typhoid germ?
• The carrier stage varies from a number of
days to years.
• Only about 3% of cases go on to become
lifelong carriers of the germ and
• This tends to occur more often in adults
than in children.
Laboratory Exam
• Blood Culture
• Best Test Sensitivity in first week
• Bone Marrow culture
• Higher sensitivity than Blood Culture
• Fecal culture
• Low sensitivity (~33%)
• Salmonella serology (Widal's Test)
• Poor Test Specificity
• Low Test Sensitivity (70%)
Should infected people be isolated?

• Because the germ is passed in the feces of infected people, only

people with active diarrhea who are unable to control their bowel
habits (infants, certain handicapped individuals) should be isolated.

• Most infected people may return to work or school when they

have recovered, provided that they carefully wash hands after toilet

• Children in daycare, health care workers, and persons in other

sensitive settings must obtain the approval of the local or state
health department before returning to their routine activities.

• Food handlers may not return to work until three consecutive
negative stool cultures are confirmed.
Is there a vaccine for typhoid?

• A vaccine is available
• but is generally reserved for people
traveling to underdeveloped countries where
significant exposure may occur. Strict
attention to food and water precautions
while traveling to such countries is the most
effective preventive method.
Management: Antibiotics
Specific antibiotics are often used to treat cases of typhoid.

• Antibiotic Resistance is increasing

• First-Line: Fluoroquinolones
• Alternative antibiotics (resistance is common)
– Chloramphenicol
– Amoxicillin
– Trimethoprim-Sulfamethoxazole (Septra)
• Choose foods processed for safety
• Prepare food carefully
• Foods prepared by others (avoid if possible)
• Keep food contact surfaces clean (3 wash cycle)
• Eat cooked food as soon as possible
• Maintain clean hands
• Steam or boil shellfish at least 10 minutes
• All milk and dairy products should be pasteurized
• Control fly populations
Causative Agent: Salmonella typhi
Salmonella Typhi possesses 3 main antigenic factors:
1. the O, or somatic antigen;
2. the Vi, or encapsulation antigen; and
3. the H, or flagellar antigen
Virulence Factors:
S. typhi has a combination of characteristics that make it
an effective pathogen. This species contains an
endotoxin typical of Gram negative organisms, as well as
the Vi antigen which is thought to increase virulence. It
also produces and excretes a protein known as “invasin”
that allows non-phagocytic cells to take up the
bacterium, where it is able to live intracellularly. It is also
able to inhibit the oxidative burst of leukocytes, making
innate immune response ineffective.
Salmonella typhi
(more commonly known as the bacteria responsible for typhoid fever)
can be very dangerous if not taken care of properly.
-only live in the bloodstream or intestinal tract of humans,
-but is also found in sewage.

Even though most people either die or use antibiotics to stop the growth of these
bacteria, a very small percentage of the people who get typhoid fever have certain
antibodies that are able to restrict the growth of salmonella typhi and therefore are
able to live.
These people plus the people that are cured through antibiotics are called carriers
because even though they will have no more symptoms of typhoid fever, they will
still have the bacteria inside of them.
Since salmonella typhi is passed through bodily fluids, you can contract it by eating
some food or a drink handled by a carrier. You can also contract these bacteria by
having food or water that has been contaminated with sewage containing salmonella
• Humans in countries where the water is contaminated with sewage, which can
sometimes contain salmonella typhi.

• Usually found contracted in the developing nations of the world such as the Latin
American, African, and Asian countries. The reason for this is that the water in these
countries is contaminated often with sewage that on some occasions is carrying
Salmonella typhi.

• Typhoid fever can cause a variety of symptoms to occur to the person that has
contracted Salmonella typhi. Some of the most common symptoms are severe
headaches, abdominal pains, fevers, and diarrhea. Sometimes, rose-colored spots can
appear on the abdomen and chest. One severe long-term effect that can occur is that
the bacteria can produce ulcers on the intestinal walls. This can later lead to holes
forming in the intestine walls and the allowing of the contents of the intestine to spill
into the abdomen, causing severe abdominal pain and infection.
• The symptoms of typhoid fever can begin to occur one to three weeks after the
person has contracted Salmonella typhi. These symptoms then usually get the
worst during the third week of symptoms and then subside. By the fourth
week, many people do not have any of the symptoms of typhoid fever.

• Typhoid fever affects about 400 people in the United States each year. Of
these 400 people, 70% of them got the Salmonella typhi while traveling
internationally. In developing nations though, 12.5 million people are affected
by this disease each year.


• Today, there are many antibiotics that are available to restrict the growth of
Salmonella typhi. Some of these are ampicillin, trimethoprim-
sulfamethoxazole, and ciprofloxacin. The most effective weapon against
Salmonella typhi though is good personal hygiene and public sanitation.
Nursing Care
*Monitor patient temperature degree and •Fever pattern may aids in diagnosing
patterns. underlying disease.

*Observe for shaking chills and profuse •Chills often precede during high temperature
diaphoresis. and in presence of generalized infection.

*Wash hands with anti-bacterial soap before •Reduces cross contamination and prevents
and after each care of activity and encourage the spread of infection.
proper hygiene.
•May help reduce fever. Use of ice water and
•Provide tepid sponge baths and avoid the alcohol may cause chills and can elevate
use of ice water and alcohol. temperature.
•Monitor for signs of deterioration of •May reflect inappropriate antibiotic
condition or failure to improve with therapy.

•Used to reduce fever by its central
•Administer antipyretics action
as on the hypothalamus.

•Administer antibiotics •To control the

as spread of
prescribed Infection.