Journal Reading

Performance of Widal test and stool culture in the

diagnosis of typhoid fever among suspected patients
in Dar es Salaam, Tanzania

Lecturer : dr. Diatrie Anindyajati, M.Sc, Sp. A

Author : Shelvi Rizki Amalia - 1102015222
Literature Review
Typhoid Fever
Typhoid infection is a faecal-oral transmissible disease caused by a
Gram-negative bacterium:

• Salmonella enterica, serotype S typhi (in most regions)

• Salmonella enterica , serotype S paratyphi, species A, B, and C, which

differ in their geographical distribution

The terms 'enteric fever' and typhoid infection are used

to describe both diseases
Patophysiology

Salmonella has three antigens:

1. O antigen is present in the body
of bacteria
2. H antigen is present in the flagella
of the bacteria
3. Vi antigen is most superficial of
the somatic antigen of S. Typhi
Diagnosis

Risk Factors Symptoms

• Overcrowded conditions withno adequate sewage ➢ High fever usually occurring in the afternoon
system ➢ dull frontal headache (>80% of cases)
• Poor sanitation/untreated water in endemic areas ➢ abdominal pain
• Poor personal hygiene (no use of soap for hand ➢ apathetic-lethargic state
washing, sharing food from the same plate, and no ➢ constipation
toilet in the household) ➢ Diarrhoea
• Travel to rural areas with poor sanitation / ignoring ➢ Malaise
hygiene rules while travelling ➢ Nausea
➢ chills (uncommon)
➢ Hepatomegaly and splenomegaly (uncommon)
Diagnostic Tests
• WBC: low to normal;
• haemoglobin: mild
Full Blood Count • anaemia;
• platelets: low to normal

• will detect bacteraemia in 80% to 100% of patients

Blood Culture • May be negative if patients have started antibiotics

• may occasionally be positive even when blood culture is

negative, especially if it is taken more than 1 week after
Stool Culture the beginning of the fever
• Positive stool gives a presumptive diagnosis
Diagnostic Tests
• Should be considered in patients who have already started
bone marrow culture antibiotic treatment

• detect O and H antigens of S typhi or S paratyphi

Widal's test • low specificity and sensitivity decrease their diagnostic
utility

• Sensitivity of 68% to 88%, specificity of 68% to 95%.

IDL Tubex® test • Performance of rapid diagnostic tests are not individually
sufficient for use as sole diagnostic tools for typhoid fever

• Performance of rapid diagnostic tests are not individually

Typhidot-M® sufficient for use as sole diagnostic tools for typhoid fever
Management

• Once sensitivity assays have been returned, the antibiotic treatment regimen may be adjusted. If the
strain is sensitive to all antibiotics, ciprofloxacin should be the first-line treatment. Chloramphenicol,
ampicillin, or trimethoprim/sulfamethoxazole may be appropriate alternatives for treatment

• If the infection is resistant to fluoroquinolones, ceftriaxone should be prescribed

• Azithromycin is another alternative. This agent has shown similar results in comparison to
ciprofloxacin and ofloxacin, and oral azithromycin has even been shown to be comparable to
ceftriaxone in uncomplicated typhoid infection in children and adolescents
Management
 BACKGROUND
Typhoid fever is an infectious disease caused by Salmonella typhi

Strains of non-typhoidal Salmonella • Diarrhoea

• Fever
• Abdominal cramps
(often last 1-week or less commonly longer)

Most reliable diagnostic methods • Blood

• Bone marrow (gold standard)
• Stool culture

Definitive diagnosis of typhoid requires isolation of S. typhi

from blood or stool

Blood and stool cultures
Widal test
Widal test has been associated
with some controversies :
BACKGROUND
less frequently used in cost and requirement of highly
due to
developing countries trained professionals
• Laboratory services are not advanced
• Easy
• Cheaper
• Does not need highly trained laboratory personnel.
➢ Inherent variabilities of the test
➢ Difficulty in establishing a steady-state baseline titre for the
population
➢ Repeated exposures to S. typhi in endemic regions
➢ Cross-reactivity with other non-Salmonella organisms
➢ Lack of reproducibility of the test result
 Objective
• To compare performance of the Widal test and stool culture using
blood culture as reference test
• To evaluate the agreement between Widal, stool and blood culture.
Study design
• a cross-sectional study
Study Area
• in Amana, Temeke and Kinondoni Regional Referral Hospitals in Dar es salaam,
Tanzania
Study population
• consecutively enrolled 158 patients with Widal test requests from physicians
after obtaining an informed verbal and written consent
• Patients aged 5–82 years attending clinic at Dar es Salaam Referral hospital
suspected to have typhoid fever by their attending clinicians.
Times
• conducted from June to September 2018
 Laboratory testing typhoid

A drop of O antigens and H Inoculated onto MacConkey

antigens was added in the agar plates and xylose, lysine
test tubes, equal amount in deoxycholate and incubated at
all. 37 °C for 48 h.
Widal Stool
Test Culture
Cut Off Value to Indicates • We subjected to Gram
Recent Infection : an stained suspected
antibody titre of 1:80 and Salmonella colonies
higher for anti TO and 1:160 • Presumptively identified
and higher for anti TH using Kligler Iron Agar
antibodies (Difco™), urease test
(Himedia ltd.India), Indole,
Oxidase Citrate, Motility
 Laboratory testing typhoid
• The broth was prepared from 10% oxgall/Columbia agar—broth in
distilled water. (Add 5 ml of whole blood to 50 ml of sterile ox-bile
medium)

• After the overnight incubation, sub culturing and biochemical

identification was performed from the 10% ox-gall/ Columbia on XLD
Blood agar (OXOID, England).
Culture

In XLD agar: H2S producing

In MacConkey agar: salmonella
salmonella formed pink red
produced non-lactose fermenting
colonies of 3–5 mm in
pale coloured colonies
diameter with black centres
 Biochemical Identification
Salmonella was presumptively identified using Kligler Iron
Agar, (Difco™), urease test (Himedia ltd. India), Indole,
Oxidase Citrate, Motility

Quality Control
• Standard operational procedures were followed during
processing of each sample. All the instruments used for sample
processing were checked every morning for proper functioning.

• E. coli ATCC 25922 was used as a reference strain.

 Data analysis and management

• Data were cleaned and analysed using Statistical Package for Social Sciences (SPSS)
version 23.0
• The association between other independent and dependent variables was determined
using Chi-square or kappa Test
• The value of kappa, < 0.09; 0.1–0.19 were considered poor; 0.2–0.49 moderate; and >
0.5 strong and almost perfect agreement respectively
• p value of < 0.05 was considered statistically significant.
Results Patients response on not using of antibiotics in 2
weeks 93 (58.5%)
➢ sickness response was 74 (46.4%)
➢ 8 of 93 non-antibiotics user 2 weeks before
hospital visit, 8 were blood culture positive

Patients response on not using of antibiotics in 1

week 47 (28.9%)
➢ sickness response was 47 (29.6%)

Patients response on not using of antibiotics in 3

days respectively 13 (8.2%)
➢ sickness response was 7 (4.4%)
Results
➢ 1 of 13 antibiotic user 1 week before coming to
hospital was blood culture positive
➢ 2 of 46 who used antibiotics in 2 weeks before
coming to hospital were blood culture positive

• The mean (standard deviation) duration of sickness was 6

➢ Among 74 patients who fell sick within 1 week only
eight were blood culture positive
➢ 47 in 2 weeks only six were positive
➢ 25 who started feeling sick in 3 weeks only 3 were
blood culture positive

Out of the 158 blood specimens cultured, 16 (10.1%)

were positive for S. typhi (overall prevalence)
 Results
prevalence was
Widal prevalence was Stool 11% where isolates
Test 80.5% Culture in the stool were
not serotyped

Sensitivity 81.2% Sensitivity 31.3%

Specificity 18.3% Specificity 91.5

positive negative positive negative

predictive value predictive value predictive value predictive value
(PPV) 10.1% (NPV) 89.7% (PPV) 29.4% (NPV) 92.2%
 Discussion
• The actual prevalence of typhoid fever was found to be 10.1%, meaning for every 10 patient who are
tested positive, and only one was truly suffering from typhoid
• The consequences of false positive results include misuse of antibiotics, likely danger of increasing the
antibiotic resistance, increased cost of treatment due increased hospital stay for inpatients and missing
of fatal disease of febrile illnesses.
• Widal test had very low specificity and positive predictive value
➢Low specificity means patients might be suffering from other causes of diseases
➢Low PPV value means majority of those who tested to have disease are not truly diseased by the
suspected cause
Discussion
• The study found, stool culture had low sensitivity, it may be associated with the sample collection
time
• Stool is not sensitive in early infection
• Widal performed better in terms of sensitivity (81.2%) compared to stool culture (31.3%). This
means Widal test can be useful in excluding disease free cases and stool can be used in
confirming suspected cases
Discussion
• Statistically, there was a fair agreement (kappa = 0.33) between stool culture and blood culture
• Poor agreement (kappa = 0.01) between Widal titration and stool culture
• This indicates that the result of Widal test in diagnosis of typhoid fever less likely agrees with stool
culture
Conclusion
• Using single Widal test as the only laboratory test for the diagnosis of typhoid fever will
produce wrong diagnosis
• Widal test has poor agreement with the blood culture and stool culture
• Stool culture as good agreement with the blood culture

• The high NPV value meant that Widal test could only be useful for knowing non-diseased
in the population.
• The low PPV value meant that Widal test could only be useful for excluding the diseases
from the population
• Stool culture had high sensitivity a specificity and PPV, stool culture performed better
than Widal test
Limitations
• The Widal false negative results can be probably because blood was collected in
early disease processes
• Previous antibiotic treatment may also contribute to negative blood culture test
• The original Widal agglutination test was described using paired sera obtained 10
days to 2 weeks apart
CLINICAL APPRAISAL
 Patients • Patients suspected to have thyphoid fever

Intervention • Widal test

• Stool Culture
Comparison • Blood Culture

• To compare performance of the Widal test and

Outcome stool culture using blood culture as reference test
 Validity
Was the diagnostic test evaluated in a Representative spectrum of
patients (like those in whom it would be used in practice)?
• Yes
Was the reference standard applied regardless of the index test
result?
• Yes
Was there an independent, blind comparison between the index test
and an appropriate reference ('gold') standard of diagnosis?
• Unclear, but there is a reference gold standard : blood culture
 Importance

What is the measure?

• Sensitivity (Sn) = the proportion of people with the condition who have a positive test result

• Specificity (Sp) = the proportion of people without the condition who have a negative test result

• Positive Predictive Value (PPV) = the proportion of people with a positive test who have the
condition

• Negative Predictive Value (NPV) = the proportion of people with a negative test who do not have
the condition
 Importance

What does it mean?

• Sensitivity of Widal test 81.2% and stool culture 31.3% the test is
fairly good at identifying people with the condition and the rest
were falsely identified as not having it

• Specificity of Widal test 18.3% and stool culture 91.5% the test is
only moderately good at identifying people without the condition
 Importance
What does it mean?
• Positive Predictive Value (PPV) of Widal test 10.1% and stool culture
29.4%. The people who had a positive test result with widal test 10.1% will
actually typhoid fever and 29.4% with stool culture will actually typhoid
fever
• Negative Predictive Value (NPV) Widal test 89.7% and stool culture 92.2%.
The people who had a positive test result with widal test 89.7% will not
have typhoid fever and 92.2% with stool culture will not have typhoid
fever
 Applicability

Were the result and interpretation of these

diagnostic instruments can be applied to the
patient?
• Yes