LESSON PLAN ON

Care of patient with TYPHOID FEVER

Reg. No. 301511256
INTERNAL EXAMINER EXTERNAL EXAMINER
Institution name : COLLEGE OF NURSING, MADRAS MEDICAL COLLEGE, CHENNAI-03.

Programme : M.Sc., (N) –I Year

Subject : Nursing Education

Topic : CARE OF PATIENT WITH TYPHOID FEVER

Registration Number : 301511256

Participants : B.Sc., (N) II Year Nursing Student

Method of Teaching : Lecture cum Discussion

Teaching Aids : Black Board, Roller Board, Chart, Flannel graph, Hand out, PPT

Date & Time : 15.11.2016

INTERNAL EXAMINER EXTERNAL EXAMINER

CENTRAL OBJECTIVE:

Help the students to acquire knowledge about Typhoid Fever and to develop desirable attitude and skills in
providing care to the clients with Typhoid Fever in hospital and community settings.

SPECIFIC OBJECTIVES:

At the end of the class students will be able to

 define typhoid fever

 explain the epidemiological determinants of typhoid fever
 identify the incubation period and mode of transmission of typhoid fever
 discus the pathology and pathogenesis of typhoid fever
 enlist the clinical manifestation and diagnostic evaluation of typhoid fever
 enumerate the management and complications of typhoid fever
 describe the prevention and control of typhoid fever
INTRODUCTION:

In India, typhoid is still an endemic disease, often giving rise to epidemics. It is 5 th most common
communicable disease. It has a huge socioeconomic impact on the country, because typhoid patients require several
weeks to several months to recover and resume work. The incidence rate is about 100 to 200 cases per 100000
populations with crude fertility rate of 10% in untreated cases. Presence of typhoid is the barometer of the country or
community. Improved living conditions and the introduction of antibiotics in reduction of morbidity and mortality in
industrialized countries.

In 20th century beginning, typhoid was a global problem. In the latter half of the century, with the improvement of
quality of life and socio-economic conditions, specially with reference to protected water supply, disposal of sewage
and improvement in the sanitation, there has been a tremendous decline in all the developed countries, whereas in the
developing countries it continues to be unabated.
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1. 3mts define typhoid Definition of typhoid fever: Explaining Listening Roller What is typhoid
fever With roller board fever?
Typhoid fever has been defined as an acute board
infectious disease of the small intestine, Answering
caused by salmonella typhi, transmitted
through faecal contaminated water, food and
vegetables, usually affecting the school
children. Clinically characterized by
continuous fever for prolonged period, severe
prodromal symptoms and involvement of
lymphoid tissues.
The term ‘Enteric fever’ includes
both typhoid and paratyphoid fevers. Para-
typhoid fever caused by salmonella para-typhi
A and B.
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2. 5mts explain the Explaining Listening Power What is an

Epidemiological determinants: point
epidemiological Epidemiological
presenta
 1 ) Agent factors
determinants tion determinants?
 2 )Host factors Answering
 3 )Environmental and social factors
1 )AGENT FACTORS:

a) AGENT

b) RESERVOIR OF
INFECTION-

1-CASES

2- CARRIERS

c) SORCE OF
INFECTION
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a) AGENT
The etiological agent is salmonella typhi.
It is gram negative bacilli, capsulated,
flagellated, actively motile organism.
This organisms possess three types of
antigens, namely
 Somatic or ‘O’ antigen,(specific for
the group)
 Flagellar or ‘H’ antigen,( specific for
the type) Capsular or ‘Vi’
antigen(related to the virulence of the
organism)
 Antibodies to ‘O’antigen-Typhoid fever
 Antibodies to ‘Vi’antigen-Carriers
 Antibodies to ‘H’antigen-Immunized
persons.
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 Salmonella typhi mainly live in the

intestine payers patches of human
beings which is the natural habitat,
they also survive intracellularly in the
tissues of various organs like heart,
kidney, bone-marrow, etc.
They can also survive in the environment like
food, water, sewage, ice-cream
b) RESERVOIR OF INFECTION: Man is
the only known reservoir of infection viz
cases and carriers.
1) CASES: The case may be mild, missed
or severe. Case is infectious as long as bacilli
appear in stools or urine.
2) CARRIERS: The carriers may be
temporary (incubatory convalescent) or
chronic.
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Convalescent carriers excrete the bacilli for 6

to 8 weeks by the end of 3 month diminish
rapidly. Persons who excrete the bacilli for
more than a year after a clinical attack are
called chronic carriers. It may develop in 2 to
5% of cases (may be as long as 50 years)
The famous case of “Typhoid Mary”
working in the food establishment. She was
responsible for 25 deaths due to typhoid more
than 1250 typhoid. Thus, she was named
“Typhoid Mary”.
c) SOURCE OF INFECTION:
 The primary sources of infection are:
Faeces and urine of cases or carrier
 The secondary sources:
Contaminated water, food, fingers,
and flies. Sputum and milk
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2 ) HOST FACTORS:

 Age incidence: Typhoid is more

common among children 5 -19 years

 Sex incidence: More cases reported

among males than females, but carriers

rate is more in females

 Immunity: There is an acquired, cell

mediated, partial immunity following a

clinical illness. Hence reinfection and

relapses are known to occur.

3 )ENVIRONMENTAL FACTORS:

The peak incidence is during monsoon

Season.
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PREDISPOSING FACTORS(SOCIAL
FACTORS):
Typhoid is called a ‘Social Disease’,
 Because, Poverty
 Illiteracy
 Ignorance
 poor standard of living
 Lack of sanitation
 Lack of personal hygiene
 open air defecation and urination
 Low standard of food hygienic
practices
 Lack of protected water supply, etc.
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identify the INCUBATION PERIOD:

3. 5mts
incubation period Usually 10-14 days, But it may be as short as
Flannel What is the
and modes of long as three weeks depending upon the dose
Explaining Listening graph
modes of
transmission of the bacilli ingested.
Answering transmission of
Typhoid fever?
MODES OF TRANSMISSION:

Faeces Fluids Mouth

Of Fruits and vegetable Of

reservoir
Suscepti
Food ble

Fingers

Flies

Fomites
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PATHOLOGY AND PATHOGENESIS:

4. 5mts discus the Explaining Listening What is the
Organism entered the body through the
pathogenesis?
pathology and
mouth, the pathogens enter the blood stream, Chart
pathogenesis
reach reticuloendothelial cells, where they
multiply and after rupture of
Answering
reticuloendothelial cells

They are poured into the blood resulting in

bacteraemia and circulate for one week

After circulation, they lodge mainly in the

peyer’s patches of ileum.

They also lodge in the spleen and

gallbladder. However, any tissue or organ
may be affected and may result in
complication
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 Ileum: peyer’s patches are the most

common site of involvement. These

patches are all inflamed resulting in

minute, innumerable ulcers with

discharge of bacilli and pus into the

lumen of the gut.

 Spleen: Lymphoid hyperplasia, resulting

in splenomegaly. Presence of organisms

in the spleen may act as a seed of future

relapse.

 Gallblader:There will be chronic

infection in the gallbladder resulting in

cholecystitis and cholelithiasis(stones)

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5. 7mts enlist the clinical CLINICAL MANIFESTATION OF Explaining Listening

manifestation and TYPHOID FEVER: Power What are the
diagnostic During the first week of illness: point clinical
evaluation of  Gradual onset of presenta manifestations
typhoid fever tion for typhoid
fever,Continuous,raises day by day in
fever?
a ‘Step ladder ‘associate with chills Answering
and severe prodromal symptoms
such as
 Head ache
 Body ache
 Malaise
 Loss of appetite
 Joint pains with occasional vomiting.
 Dry cough
Fever will be in the range of 38 to 40
degree centigrade
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During second week:

 Temperature reaches 104∙F
 Skin is dry and hot
 Tongue is coated
 Patient looks tired
 Abdomen is distended
 Spleen is enlarged and soft
 Tenderness in the right iliac fossa
 Brady cardia rashes over the abdomen
 Diarrhoea with ‘Pea- soup’ stools
During the third week: Patient will have
signs of toxaemia
 Very high temperature
 Rapid thread pulse
 Mentally dull
 Delirious
 Disoriented
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 Sleepy
 Confused
 Talks irrelevantly
 Toxic face
 Later becomes stuporous
 Develops coma and dies.
DIAGNOSTIC EVALUTION OF
TYPHOID FEVER:
During the first week of illness:
Blood for culture
During the second week of illness:
Blood for widal,total
count,(leucopenia)
During the third week of illness:
Blood for repeat widal and stool and
urine for culture
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6. 10mts enumerate the

management and MANAGEMENT OF TYPHOID FEVER: Explaining Listening
complications of General principles for the management of Handout What are the
typhoid fever drugs
typhoid. management for
typhoid fever?
MEDICAL MANAGEMENT
Answering
 Rapid diagnosis and institution of
appropriate antibiotic treatment

 Adequate rest, hydration, and correction

of fluid-electrolyte imbalance
 Antipyretic therapy as required (such as
paracetamol 120-750 mg taken orally
every 4-6 hours)
 Adequate nutrition: a soft, easily
digestible diet should be continued unless
the patient has abdominal distension or
ileus

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OBJECTIVES CONTENT TEACHER’S ACTIVITY AIDS EVALUATION
ACTIVITY

Regular follow-up and monitoring for

complications and clinical relapse Avoid
undue exposure to possible infection through
food and water (contaminated water, salads,
and street foods). Use bottled water whenever
possible, otherwise use only boiled water

Two typhoid vaccines are available, both

with proved efficacy of 60-80%, and should
be taken at least two weeks before travel
Proved efficacy of 60-80%, and should be
taken at least two weeks before travel.

Isolation: Preferably in the isolation ward till

2to3 stool culture report comes as negative. It
may take about 2 weeks.
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Concurrent Disinfection: Of mainly the

excreta by collecting it in a container
containing 10% cresol or 8% bleaching
powder.
Chemotherapy: Now the drug
Of choice is cefotaxime 200mg twice a day
for adults and 100mg twice a day for children,
about 10 days. Ceftriaxone, quinolone drugs
Antipyretics.
Treatment of carriers.(SURGICAL)
1. Biliary carriers-cholecystectomy
2. Intestinal carriers-Resection of loop of gut
3. Urinary carriers-Partial or total
Nephrectomy
Follow-up:
Examination of stools &urine-3 to 4months
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7. 5mts describe the PREVENTION AND CONTROL OF Explaining Listening Power What are the
prevention and point control measures
TYPHOID FEVER.
control of typhoid presenta for typhoid
fever. The control or elimination of typhoid fever tion fever?
is well within the scope of modern public
health. This is an accomplished fact in many Answering
developed countries. There are generally three
lines of defence against typhoid fever.
1. Control of reservoir
2. Control of sanitation
3. Immunization
Control of reservoir:
a)Cases:
 Early diagnosis Notification
 Isolation
 Treatment
 Disinfection
 Follow-up

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OBJECTIVES CONTENT TEACHER’S ACTIVITY AIDS EVALUATION
 ACTIVITY

b) carriers:
 Identification
 Treatment
 Surgery
 Surveillance
 Health education
CONTROL OF SANITATION:
 Since the mode of transmission is by
faeco-oral route, it is interrupted by
construction and use of ‘sanitation
barrier’.
 It consists of construction and use of
sanitary latrine, which prevents the access
of the pathogens from feces to six F’s
 The construction and use of sanitary
latrine will be more effective,

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OBJECTIVES CONTENT TEACHER’S ACTIVITY AIDS EVALUATION
ACTIVITY
 BREAKING THE CHANNEL OF
TRANSMISSION
6 F’s
FLUIDS

FOOD

FRUITS AND
VEGETABLES
FOMIITES
FACES

FINGERS

FLIES

When it is supplemented with the following

measures,
 Chlorination of water for drinking
purposes
 Pasteurization of milk

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 OBJECTIVES CONTENT TEACHER’S ACTIVITY AIDS EVALUATION
ACTIVITY

 Adoption of food hygiene measures

 Disinfection of fruits and vegetables
with kmno4
 Disinfection of fomites like utensils,
plates
 Adopting high standard of personal
hygienic measures
 Control of house flies by keeping the
environment clean.
PROTECTION OF SUCEPTIBLES:
Protection of susceptible is mainly by
Health promotion and Immunization:
Health promotion:
 Provision of protected water supply
 Sanitary disposal of sewage
 Health education

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 OBJECTIVES CONTENT TEACHER’S ACTIVITY AIDS EVALUATION
ACTIVITY

SPECIFIC PROTECTION IS BY
VACCINATION:
There are three types of vaccines
 Killed vaccines
 Live vaccines
 Cellular vaccines
Killed vaccines:
 Trivalent(TAB)vaccine
 Bivalent(TA) vaccine
 Monovalent antityphoid vaccine
Live vaccines:
It is first developed by Germanier and furer in
1975. It is live, lyophilized vaccine, made
available in a pack of 3 capsules each capsule
containing not less than 10’, viable,
attenuated salmonella typhi-21 a strain.

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OBJECTIVES CONTENT TEACHER’S ACTIVITY AIDS EVALUATION
ACTIVITY

 Schedule consists of one capsule, to be

swallowed, on alternate days 1 hour
before meales,irrespective age and sex,
above 6 years for 3 days
 Immunity is developed about 2 weeks
after taking the 3rd capsule and lasts for
3 years. It is 60% effective.
 Booster dose also consists of the same 3
capsule, recommended once in 3 years.
Oral antibiotics should not be given
along with oral typhoid vaccine because
they may destroy the live vaccine strain,
resulting in vaccine failure.
 The capsule is marketed as typhoral,
best stored at 2 to 8 degree C.
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Cellular extract vaccines:

It is a liquid vaccine. It contains
capsular, polysaccharide-Vi-antigen of
salmonella typhi.
Dosage 0.5ml (25 microgram Vi-
antigen), intramuscularly or
subcutaneously, irrespective of age
and sex.
Immunity is developed about 10 to15
days after the injection and lasts for 3
years.
Efficacy is 80%.It is not
recommended for children below 3
years, Booster dose is recommended
once in 3 years.
Acute febrile illness is a contra
indication. Storage 2to 8degree C.
It is marketed typhim-Vi.

TREATMENT FOR UNCOMPLICATED TYPHOID FEVER

 OPTIMAL THERAPY ALTERNATIVE THERAPY
SUCESPTIBILITY

ANTIBIOTIC DAILY DOSE DAYS ANTIBIOTIC DAILY DOSE DAYS

Mg/Kg Mg/Kg

Fully sensitive Fluoroquinolone e.g Chloramphenicol 50-75 14-21

Ofloxacin or 15 5-7 Amoxicillin 75-100 14
Ciprofloxacin TMP-SMX 8-40 14

Multi drug resistance Fluoroquinolone or 15 5-7 Azithromycin 8-10 7

Cefixime 15-20 7-14 Cefixime 15-20 7-14

Quinolone resistance Azithromycin or 8-10 7 Cefixime 20 7-14

Ceftriaxone 75 10-14

SOCIAL FACTORS
 C E
U C
L N
T O
Water
U Foods M
R I
A C
L Soil F
F Mouths A
Faces
A C
And Of
C T
Urine Well
T Flies O
persons
From
O R
R Cases Or S
S Carriers
Fingers

QULITY OF LIFE

DYNAMICS OF TYPHOID FEVER TRANSMISSION

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 OBJECTIVES CONTENT TEACHER’S ACTIVITY AIDS EVALUATION
ACTIVITY

COMPLICATIONS:
Recognized complications are mainly three
Relapse
Haemorrhage -Malena(from the intestinal
ulcers) and
Perforation-acute peritonitis
 Cerebral dysfunction
 Meningitis
 Parotitis
 pneumonia
 Myocarditis
 Gallstones
 Hepatitis
 Pyelonephritis
 Osteomyelitis
 Arthritis
 Thrombophlebitis
 Septicaemia and others
SUMMARY
Definition of typhoid fever:

Typhoid fever has been defined as an acute infectious disease of the small intestine, caused by salmonella typhi, transmitted through faecal
contaminated water, food and vegetables, usually affecting the school children. The term ‘Enteric fever’ includes both typhoid and paratyphoid
fevers. Para-typhoid fever caused by salmonella para-typhi A and Epidemiological determinants: Agent factors Host factors Environmental
factors, a) Agent: The etiological agent is salmonella typhi. It is gram negative bacilli, capsulated, flagellated, actively motile organism. This
organisms possess three types of antigens, namely Somatic or ‘O’ antigen,(specific for the group) Flagellar or ‘H’ antigen,( specific for the type)
Capsular or ‘Vi’ antigen(related to the virulence of the organism) Antibodies to ‘O’antigen-Typhoid fever Antibodies to ‘Vi’antigen-Carriers
Antibodies to ‘H’antigen-Immunized persons. Host factors: Age incidence, Sex incidence, Immunity. 3) Environmental factors: The peak
incidence is during monsoon Season. Incubation Period: Usually 10-14 days, But it may be as short as long as three weeks depending upon the
dose of the bacilli ingested. Clinical Manifestation Of Typhoid Fever: Gradual onset of fever, Continuous,raises day by day in a ‘Step ladder
‘associate with chills and severe prodromal symptoms such as Head ache Body ache Malaise Loss of appetite Joint pains with occasional
vomiting Dry cough Fever will be in the range of 38 to 40 degree centigrade Medical Management Rapid diagnosis and institution of
appropriate antibiotic treatment Adequate rest, Antipyretic therapy Adequate nutrition,Isolation,Folowup.control and prevention Control of
reservoir Control of sanitation Immunization Complications: Relapse Haemorrhage -Malena(from the intestinal ulcers) and Perforation-acute
peritonitis.

CONCLUSION
 Improved living conditions and the introduction of antibiotics in reduction of morbidity and mortality in industrialized
countries with the improvement of quality of life and socio-economic conditions, specially with reference to protected
water supply, disposal of sewage and improvement in the sanitation.

Assignment:
  Write in detail about typhoid fever.

Recaptulization:

 What is typhoid fever?

 What is an Epidemiological determinant?
 What is the mode of transmission for typhoid fever?
 What is the pathogenesis?
 What are the clinical manifestations for typhoid fever?
 What are the drugs management of typhoid fever?
 What are the control measures for typhoid fever?

BIBLIOGRAPHY
 1. AlkaGupta .(1997) ,“ Community health care for nurses and health workers”, Mumbai : Vora medical publication 329-331.
2. Basavanthappa B.T. “Community health nursing “3rdedision Jaypee publishers New Delhi.
3. BRUNNER & SUDDHRTH (1995) “Text book of medical- surgical nursing” , 9th editio ; Lippincot Publication, Philadelphia.
4. K.PARK (2007),”Text book of preventive and social medicine “, 19th edition by m/s banarsidas publishers, Jabalpur 213-216.
5. Kasturi sunder Rao “Text book of community health nursing “2nd (2003) jaypee publishers New Delhi.
6. Park , K . (2011) .” Preventive and Social Medicine”. 21ST EDITION. Jabalp , Banarsidas Bhanot publishers.
7. Stanhope Lancaster , (1992) , “ Community Health Nursing “ 3rd edition , St . Louis mosby year book .
8. Sundarlal“ Community Medicine “ 2 nd edition jaypee publishers New Delhi.

NET REFERENCE

 Centers for Disease Control and Prevention (www.cdc.gov/travel)

 World Health Organization (www.who.int/ith)
 International Society of Travel Medicine (www.istm.org)
 Travel Doctor (www.traveldoctor.co.uk/diseases.htm
 www.medline.com
 www.wikipedia.com

Journal: Typhoid journal

Treatment and prevention of typhoid fever

Author
Elizabeth L Hohmann, MD
Section Editor
Stephen B Calderwood, MD
Deputy Editor
Allyson Bloom, MD

INTRODUCTION

Typhoid fever and paratyphoid fever (also known as enteric fever, but collectively referred to here as typhoid fever) are
severe systemic illnesses caused by Salmonella typhi and Salmonella paratyphi, respectively, and are characterized by
sustained fever and abdominal symptoms. The treatment and prevention of typhoid fever will be reviewed here. The
epidemiology, pathogenesis, clinical manifestations, and diagnosis of typhoid fever are discussed separately.
(See "Pathogenesis of typhoid fever" and "Epidemiology, microbiology, clinical manifestations, and diagnosis of typhoid
fever".)

ANTIMICROBIAL RESISTANCE

Treatment of typhoid fever has been complicated by the development and rapid dissemination of typhoidal organisms
resistant to ampicillin, trimethoprim-sulfamethoxazole, and chloramphenicol. Additionally, development of increasing
resistance to fluoroquinolones is a growing challenge.
Multidrug resistance — Multidrug-resistant (MDR) strains (ie, those resistant to ampicillin, trimethoprim-
sulfamethoxazole, and chloramphenicol) are prevalent worldwide.
MDR strains of S. typhi and S. paratyphi have caused numerous outbreaks in endemic regions, including South and
Southeast Asia, China, and Africa [1-3]. Because of this, ampicillin, trimethoprim-sulfamethoxazole, and chloramphenicol
 have no longer been used as first-line agents for treatment of typhoid fever. Subsequently, some locations have reported a
decrease in the prevalence of MDR strains. As an example, in a surveillance study from Kolkata, India conducted from
2009 to 2013, 18 percent of S. typhi and no S. paratyphiisolates were MDR [4]. Nevertheless, MDR strains remain frequent
worldwide. In locations such as Bangladesh, Vietnam, and Cambodia, MDR isolates account for the vast majority of S.
typhi [5,6]. Prevalence of MDR strains varies throughout Africa, the Middle East, and Central Asia, from 10 to 80 percent,
depending on the country [7,8]. Genome sequencing and analysis of international isolates has identified a predominant
MDR S. typhi strain, H58, that has disseminated throughout Asia and Africa, displacing more susceptible strains and driving
ongoing MDR epidemics [9].
These patterns of resistance are reflected in travelers returning to nonendemic regions. In an analysis of over 1000 isolates
submitted to the United States Centers for Disease Control and Prevention (CDC) between 2008 and 2012, most of which
were from infections acquired in South Asia, 12 percent of S. typhi and no S. paratyphi isolates were MDR strains [10]. A
similar prevalence of MDR strains was reported from a surveillance study in Switzerland between 2002 and 2013 [11].

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 References
Top

1. Kariuki S, Gordon MA, Feasey N, Parry CM. Antimicrobial resistance and management of invasive Salmonella
disease. Vaccine 2015; 33 Suppl 3:C21.

Review Article Current Trends in the Management of Typhoid Fever Lt Gen SP Kalra AVSM Bar* , Lt Col N Naithani+,
Col SR Mehta VSM# , Sqn Ldr AJ Swamy** MJAFI 2003; 59 : 130-135

Introduction Typhoid (cloudy) fever is a systemic infection, caused mainly by Salmonella typhi found only in man. It is
characterized by a continuous fever for 3-4 weeks, relative bradycardia, with involvement of lymphoid tissue and
considerable constitutional symptoms. In western countries, the disease has been brought very close to eradication levels. In
the UK, there is approximately one case per 100,000 population per year. Each year, the world over, there are at least 13-17
million cases of typhoid fever, resulting in 600,000 deaths. 80% of these cases and deaths occur in Asia alone. In South East
Asian nations, 5% or more of the strains of the bacteria may already be resistant to several antibiotics [1]. Antibiotics
resistance, particularly emergence of multidrug resistant (MDR) strains among Salmonellae is also a rising concern and has
recently been linked to antibiotic use in livestock. Many S typhi strains contain plasmids encoding resistance to
chloramphenicol, ampicillin and co-trimoxazole, the antibiotics that have long been used to treat enteric fever. In addition,
resistance to ciprofloxacin also called nalidixic-acidresistant S typhi (NARST) strain either chromosomally or plasmids
encoded, has been observed in Asia. A significant number of strains from Africa and the Indian subcontinent are MDR type.
A small percentage of strains from Vietnam and the Indian subcontinent are NARST strains [2]. The changing pattern of
multi drug resistance in typhoid fever was studied in Delhi in 1993 [3]. Out of 76 patients, 12 patients responded to a
combination of chloramphenicol and gentamicin, 51 to ciprofloxacin while the remaining 9 responded to combination of
cefotaxime and amikacin. This study re-emphasizes the changing pattern, and role of quinolone especially ciprofloxacin in
the management of drug resistant typhoid fever, but at the same time indicates that ciprofloxacin is not the drug of choice in
all cases of typhoid fever and resistance to it may be seen in some cases, where other drugs have to be used. 100 children
(consecutive) with positive blood culture for S typhi were studied for clinical profile in Ahmedabad in 2000. 80%
Salmonella isolates were resistant to amoxycillin, chloramphenicol and cotrimoxazole, but all were sensitive to
ciprofloxacin and ceftriaxone [4]. In another study from Rourkela in 2000, out of 5410 blood samples 715 samples, were
found positive for S typhi. The number of MDR strains of S typhi constituted almost 16.1% of the total isolates. In this
study, chloramphenicol sensitivity was found quite high (86.5%) and ceftriaxone showed 100% sensitivity. Resistance to
ciprofloxacin was found in 2.5% cases [5]. In the extended typhoid epidemic that affected more than 24,000 people in
Tajikistan from 1996 through 1998, more than 90% of the organisms were MDR and 82% were resistant to ciprofloxacin.
This is the first reported epidemic of quinolones-resistant typhoid fever [6]. Atypical and varied presentations often confuse
the picture in enteric fever. Neuropsychiatric manifestations in particular, often may be mistaken for encephalitis,
meningitis, cerebral malaria, psychosis, etc [7]. Recurrent salmonellosis (usually S typhimurium) is an AIDS defining
criterion in HIV positive patients, though for reasons unknown this is rarely due to S typhi. HIV positive patients are more
prone to develop enteric fever and its frequent relapses. Diagnosis Laboratory diagnosis of typhoid fever is based on three
principles : Isolation of organism Detection of microbial antigen Titration of antibody against causative organism Definitive
diagnosis of enteric fever requires the isolation of S typhi or S paratyphi. Cultures of blood, stool, urine, rose spots, the
blood mononuclear cellplatelet fraction, bone marrow, and gastric or intestinal secretions may each be useful in establishing
the diagnosis. The duodenal string test is especially useful as a noninvasive technique to sample duodenal * Commandant,
AMC Centre and School, Lucknow-2, +Associate Professor, Department of Medicine, # Professor and Head, Department of
Medicine, Armed Forces Medical College, Pune - 411 040, **Graded Specialist (Medicine), 12 Air Force Hospital,
Gorakhpur. MJAFI, Vol. 59, No. 2, 2003 Management of Typhoid Fever 131 secretions.