Enteric Fever


Dr N Gnanamurthy    16 January 2018

  1. Globally, typhoid fever incidence is 3.6/1,000 population. In India, it is anywhere near 3-10/1,000 population. About 50% incidence is seen in children below 12 years, of which 10% are below 2 years. A more alarming finding is that 15% of culture proved typhoid fever happens to be multidrug resistant (MDR) typhoid fever; of this majority are preschool aged children.
  2. MDR S. typhi infection is a more severe clinical illness with higher rates of toxicity, complications, and case fatality rates, especially in infancy. In a study in Pondicherry, 337 isolates of S. typhi were investigated. Nearly 22% were MDR.
  3. Clinical picture in young children – Relative bradycardia is rare in children; fever may not be step-ladder; diarrhea may be present in earlier stages of illness, which may be followed by constipation. The early stage of the disease may be difficult to differentiate from other endemic diseases. The presentation may be tempered by coexisting morbidities and administration of antibiotics. D/D include acute bacterial infections, brucellosis, dengue fever, infl uenza, malaria, rickettsial diseases, TB, typhus.
  4. Investigations – The gold standard test is culture from blood or another anatomic site. Although bone marrow cultures may increase the likelihood of bacteriologic confirmation of typhoid, collection of the specimens is diffi cult and relatively invasive. Bone marrow culture may be positive even if antibiotic has been given. Stool culture can be done during later part of illness. Complete blood count is a nonspecifi c test. If Hb is very low, think of internal bleed. Thrombocytopenia may be a marker of severe illness and may accompany DIC. Leukopenia is more common. Eosinopenia is more common and characteristic.
  5. Serologic and antigen tests – Widal test, typhidot test, tubex test, antigen detection tests, PCR. Widal test as a diagnostic modality has suboptimal sensitivity and specificity, and thus not recommended. Typhidot test scores over widal by its strong negative predictive value. Antigen detection tests detect somatic/fl agellar/Vi antigen of S. typhi but not of S. paratyphi. PCR targets fl agellar gene, somatic gene, Vi antigen gene RNA and other genes. It has excellent sensitivity and specifi city. It can be positive even in culture negative typhoid.
  6. Treatment involves appropriate antibiotics, adequate supportive measures, anticipation of complications and evaluation for treatment failure.
  7. Oral cefixime can be used as effectively as parenteral ceftriaxone for management of typhoid fever in children. Typhoid fever due to MDR S. typhi with reduced susceptibility can be successfully treated with azithromycin. Ceftriaxone/cefi xime is an ideal antibiotic but should be used adequately only in confi rmed typhoid cases. Chloramphenicol is a promising drug in developing countries. Azithromycin is the best among the lot without relapse but to be reserved as rescue antibiotic.
  8. Treatment failure criteria – If it takes >7 days; need for rescue treatment of azithromycin; culture positive on 8th day; manifestation of complications during or within 28 days; relapse within 28 days. Treatment for carriers – Amoxicillin 100 mg/kg for 8-12 weeks with probenicid 30 mg/kg, OR cotrimoxazole with trimethoprim at 8-10 mg/kg for 8-12 weeks.

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