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Typhoid
ANIQA SUNDAS
M . PHIL PHARMACY PRACTICE
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What is Typhoid Fever?

 The name Salmonella typhi is derived from the ancient Greek word “typhos”,
an ethereal smoke or cloud that was believed to cause disease and madness.
 Typhoid fever, also known as enteric fever, is a potentially fatal multisystemic
illness caused primarily by Salmonella enterica serotype typhi and, to a lesser
extent, Salmonella enterica serotypes paratyphi A, B, and C.
 Typhoid fever has a wide variety of presentations that range from an
overwhelming multisystemic illness to relatively minor cases of diarrhea with
low-grade fever.
 It may have responsible for the Great Plague of Athens at the end of the
Peloponnesian War.
 Untreated typhoid fever may progress to delirium, obtundation, intestinal
hemorrhage, bowel perforation, and death within 1 month of onset.
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Clinical features

Typhoid fever (enteric fever) is a septicemia, illness characterized initially by

fever, bradycardia, splenomegaly, abdominal symptoms and 'rose spots'
which are clusters of pink mauls on the skin . Complications such as intestinal
hemorrhage or perforation can develop in untreated patients or when
treatment is delayed .
Paratyphoid fever can be caused by any of three serotypes of S. paratyphi A,
B and C. It is similar in its symptoms to typhoid fever, but tends to be shorter
and milder than that of typhoid fever and the onset is often more
abrupt with acute enteritis. The rash may be more abundant and the
intestinal complications less frequent
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Pathophysiology

Salmonella typhi is a
rod-shaped, gram
negative bacteria
that causes typhoid
fever. Image via:
fineartamerica
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CAUSES:

 Contaminated food
 Migration
 Decreased stomach pH as low as 1.5
 Poor hygiene
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Statistics and Incidences

 Typhoid fever occurs worldwide, primarily in developing nations whose sanitary conditions
are poor.
 Typhoid fever is endemic in Asia, Africa, Latin America, the Caribbean, and Oceania, but
80% of cases come from Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, or
Vietnam.
 Typhoid fever infects roughly 21.6 million people and kills an estimated 200, 000 people every
year.
 Treated, it has few long-term sequelae and a 0.2% risk of mortality.
 Untreated typhoid fever is a life-threatening illness of several weeks’ duration with long-term
morbidity often involving the central nervous system.
 Fifty-four percent of typhoid fever cases in the United States reported between 1999 and
2006 involved males.
 Most documented typhoid fever cases involve school-aged children and young adults.
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Clinical Manifestations

Clinical syndromes associated with Salmonella typhi and paratyphi are indistinguishable. The
following are the signs and symptoms of typhoid fever:
 Fever. The fever pattern is stepwise, characterized by a rising temperature over the course
of each day that drops by the subsequent morning; the peaks and troughs rise
progressively over time.
 Gastrointestinal symptoms. Over the course of the first week of illness, the notorious
gastrointestinal manifestations of the disease develop; these include diffuse abdominal
pain and tenderness and, in some cases, fierce colicky right upper quadrant pain
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Clinical manifestation:

 Rose spots. The patient develop rose spots, which are salmon-
colored, blanching, truncal, maculopapules usually 1-4 cm wide
and fewer than 5 in number; these generally resolve within 2-5
days.
 Abdominal distention. The abdomen becomes distended, and
soft splenomegaly is common; on the third week, abdominal
distention is severe.
 Pea soup diarrhea. Some patients experience foul, green-yellow,
liquid diarrhea
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Assessment and Diagnostic Findings

 Culture. The criterion standard of typhoid fever has long been culture
isolation of the organism; cultures are widely considered 100% specific.(2nd
and 3rd week)
 Polymerase chain reaction. PCR has been used for the diagnosis of
typhoid fever with varying success.
 Radiography. Radiography of the kidneys, ureters, and bladder is useful if
bowel perforation is suspected.
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Assessment and Diagnostic Findings

 CT scanning and MRI. These studies may be warranted to investigate for

abscesses in the liver or bones, among other sites.
 Bone marrow aspiration. The most sensitive method of isolating S typhi is
BMA culture.
 Histologic findings. The hallmark histologic finding in typhoid fever is
infiltration of tissues by macrophages that contain bacteria, erythrocytes,
and degenerated lymphocytes.
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Other investigations:
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Medical Management

Treatment for typhoid fever should not be delayed for confirmatory tests since
prompt treatment drastically reduces the risk of complications and fatalities.
 Medical care. If a patient presents with unexplained symptoms described
above within 60 days of returning from an typhoid fever endemic area or
following consumption of food prepared by an individual who is known to
carry typhoid, broad-spectrum empiric antibiotics should be started
immediately.
 Surgical care. Surgery is usually indicated in cases of intestinal perforation;
if antibiotic treatment fails to eradicate the hepatobiliary carriage, the
gallbladder should be resected.
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Medical management:

 Diet. Fluids and electrolytes should be monitored and replaced diligently;

oral nutrition with a soft digestible diet is preferable in the absence of
abdominal distention or ileus.
 Activity. No specific limitation on activity are indicated for patients with
typhoid fever; as with most systemic diseases, rest is helpful, but mobility
should be maintained if tolerable.
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Pharmacological Management

Definitive treatment of typhoid fever is based on susceptibility.

 Antibiotics. Until susceptibilities are determined, antibiotics should be
empiric, for which there are various recommendations.
 Corticosteroids. Dexamethasone may decrease the likelihood of mortality
in severe typhoid fever cases complicated by delirium, obtundation,
stupor, coma, or shock if bacterial meningitis has been definitely ruled out
by cerebrospinal fluid studies
 Antipyretics. For fever management
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Anti-microbial agents
(schedule of various antibiotics)

Antibiotic Route Adult Dosage:mg/k Duration (in

dosage/day g/day days)
First-line antibiotics :
Chloramphen Oral, IV 500 mg qid 50 mg/kg in 4 14
@
icol doses
Trimethoprim- Oral, IV 160/800 mg 4-20 mg/kg: 14
Sulfamethoxa bid in 2 doses
zole
Ampicillin/Am Oral, IM, IV 1000-2000 mg 50-100 14
oxycillin qid mg/kg: in 4
doses
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Table continued

Second-line
antibiotics:
Fluoroquinolo
nes
Ciprofloxacin Oral/IV 500 mg NA 10-14
bid/200 mg
bid
Norfloxacin Oral 400 mg bid NA 10
Pefloxacin Oral, IV 400 mg bid NA 10
Ofloxacin Oral 400 mg bid NA 14
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Table continued

Cephalosporins

Ceftriaxone IM, IV 1-2 gm bid 50-75 mg/kg: 7-10

in 1-2 doses
Cefotaxime IM, IV 1-2 gm bid 40-80 mg/kg: 14
in 2-3 doses
Cefoperazone IM, IV 1-2 gm bid 50-100 14
mg/kg: in 2
doses
Cefixime Oral 200-400 mg 10 mg/kg: in 14
od/bid 1-2 doses
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Table continued

Other
antibiotics:
Aztreonam IM 1 gm/bd-qid 50-70 mg/kg: 5-7
2-4
Azithromycin Oral 1 gm od 5-10 mg/kg:1 5
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Vaccination for typhoid:

Vaccine Age Route Dosage Revaccinatio

n
Killed whole- 5 years subcutaneou 0.5 ml (0.25 3 years
cell vaccine s ml for
children <
10y)
x 2 times,
4 weeks
apart
Vi CPS 2 years subcutaneou 0.5 ml 3 years
s
Ty21 a, live 6 years Oral 1 capsule 5 years
every other
day, total of 3
capsule
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Vaccinations (how to take)
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Care Planning and Goals

The major care planning goals for typhoid fever:

 To maintain a normal fluid volume.
 To improve intake of nutritional requirements.
 To reduce or diminish pain.
 To resume ADLs.
 To maintain a normal body temperature.
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Interventions:

 Provide assistance for ADLs. Provide assistance to meet their daily needs; involve the
family in the fulfillment of ADL; and explain the purpose of bed rest to prevent
complications and speed up the healing process.
 Encourage increase in fluid intake. Monitor the status of hydration as needed; monitor
the fluid intake daily; encourage an increase in fluid intake; and collaborate with other
medical team for IV fluid administration.
 Improve nutritional intake. Monitor the amount of caloric intake; monitor weight loss;
provide a comfortable environment during meals; and encourage an increase in
protein and vitamin C intake to meet nutritional needs.
 Reduce or diminish pain. Assess the level of pain, location, duration, intensity, and
characteristics; provide warm compresses on areas with pain; and administer
analgesics as prescribed.
 Improve body temperature. Monitor patient temperature degree and patterns;
observe for chills and profuse diaphoresis; provide tepid sponge baths and avoid the
use of ice water and alcohol; and administer antipyretics as prescribed.
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Evaluation of outcomes:

 Patient was able to maintain a normal fluid volume.

 Patient was able to improve intake of nutritional requirements.
 Patient was able to reduce or diminish pain.
 Patient was able to resume ADLs.
 Patient was able to maintain a normal body temperature.
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Documentation Guidelines:

 Documentation in a patient with typhoid fever include:

 Individual findings, including factors affecting, interactions, nature of social
exchanges, specifics of individual behavior.
 Cultural and religious beliefs, and expectations.
 Plan of care.
 Teaching plan.
 Responses to interventions, teaching, and actions performed.
 Attainment or progress toward the desired outcome.
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References:

•Black, J. M., & Hawks, J. H. (2005). Medical-surgical

nursing. Elsevier Saunders,.
•Kimberlin, D. W. (2018). Red Book: 2018-2021 report of the
committee on diseases (No. Ed. 31). American academy
of pediatrics.
•Willis, L. (2019). Professional guide to diseases. Lippincott
Williams & Wilkins.
•Parks book of preventive and social medicine
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References:

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923770/
 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4923770/table/tbl1
 https://emedicine.medscape.com/article/231135-medication
 https://www.nhs.uk/conditions/typhoid-fever/treatment/
 https://www.cdc.gov/typhoid-fever/symptoms.html