Typhoid fever
– Systemic infection
due to Salmonella typhi.
The organism enters the body via the gastrointestinal tract and gains access to the bloodstream via the lymphatic system.
– Typhoid fever is acquired by ingestion of contaminated water and food or by direct contact (dirty hands).
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🔶Clinical features
– Sustained fever (lasting more than one week), headache, asthenia, insomnia, anorexia, epistaxis.
– Abdominal pain or tenderness, diarrhoea or constipation, gurgles.
– Toxic confusional state, prostration.
– Moderate
splenomegaly, relative bradycardia (normal pulse despite fever).
– Differential diagnosis may be difficult as symptoms resemble those of lower respiratory tract infections, urinary infections, and malaria or dengue fever in endemic areas.
– Complications can occur during the active phase or during convalescence (even during treatment): intestinal perforation or haemorrhage, peritonitis,myocarditis, encephalitis, coma.
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🔶Laboratory
– Relative leukopenia (normal white blood cell count despite septicaemia).
– Isolation of S. typhi from blood cultures (take at least 10 ml of blood) and stool cultures during the first 2 weeks.
– Widal's agglutination reaction is not used (both sensitivity and specificity are poor).
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🔶Treatment (at hospital level).
– Isolate the patient.
– Keep under close surveillance, hydrate, treat fever (see Fever, page 26).
– Antibiotic therapy: case-fatality rates of 10% can be reduced to less than 1% with early antibiotic treatment based on the findings of blood cultures.
The oral route is more effective than the parenteral route.
If the patient cannot take oral treatment, start by injectable route and change to oral route as soon as possible.
Antibiotic treatment (except during pregnancy or breast-feeding)
• The treatment of choice is:
▫ciprofloxacin PO for 5 to 7 days
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Children: 30 mg/kg/day in 2 divided doses (usually not recommended in children under 15 years, however, the life-threatening risk of typhoid outweighs the risk of adverse effects)
Adults: 1 g/day in 2 divided doses.
▫cefixime PO for 7 days may be an alternative to ciprofloxacine in children under 15 years:
Children over 3 months: 15 to 20 mg/kg/day in 2 divided doses
Failing that, and in the absence of resistance:
▫amoxicillin PO for 14 days
Children: 75 to 100 mg/kg/day in 3 divided doses Adults: 3 g/day in 3 divided doses or
▫chloramphenicol PO for 10 to 14 days depending on severity Children: 100 mg/kg/day in 3 divided doses Adults: 3 g/day in 3 divided doses
•S. typhi is rapidly developing resistance to quinolones. In this event, use:
▫ceftriaxone IM or IV1 for 10 to 14 days depending on severity Children: 75 mg/kg once daily Adults: 2 to 4 g once daily
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Antibiotic treatment in pregnant or breast-feeding women.
In pregnant women, typhoid carries a major risk of maternal complications (intestinal perforation, peritonitis
septicaemia) and foetal complications (miscarriage, premature delivery, intrauterine death).
• In the absence of resistance:
▫amoxicillin PO: 3 g/day in 3 divided doses for 14 days.
• If resistance:
ceftriaxone IM or IV1: 2 to 4 g once daily for 10 to 14 days depending on severity Failing that, use ciprofloxacin PO (usually not recommended for pregnant or breast- feeding women. However, the life-threatening risk of typhoid outweighs the risk of adverse effects).
For dosage, see above.
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🔶Note:
fever persists for 4 to 5 days after the start of treatment, even if the antibiotic is effective. It is essential to treat the fever and to check for possible maternal or foetal complications.
– In patients presenting severe typhoid, with toxic confusional state (hallucinations, altered consciousness) or intestinal haemorrhage:
dexamethasone IV: loading dose 3 mg/kg and then 1 mg/kg every 6 hours for 2 days.
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🔶Prevention
– Disinfection of faeces with 2% chlorine solution.
– Individual (hand washing) and collective hygiene (safe water supply, sanitation).
– The possibility of vaccination must be considered: it can be useful in some situations (high-risk age group, hyperendemic zone), but its effectiveness remains controversial.
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★The solvent of ceftriaxone for IM injection contains lidocaine.
Ceftriaxone reconstituted using this solvent must NEVER be administered by IV route. For IV administration, water for injection must always be used.
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