FEBRIS TYPHOID

BUDI RAHARDJO SARDJOENI

RSUD TEMANGGUNG
7AGUSTUS 2019
 Typoid- Paratyphoid fever ( Enteric
Fever)

 Insiden
didunia febris typhoid 21,7 juta ,217. 000
mengalami kematian.
 Febris
paratyphoid th 2000 populasinya 5,7 juta dan tidak
ada kematian
 Di Indonesia insidens / kasus , kira2 100.000 kasus/tahun
 DIAGNOSIS OF TYPHOID FEVER

 CLINICAL MANIFESTATION IS DIFFICULT OR NON SPESIFIC AND MOST

ATYPICAL.
 GOLD STANDARD STANDARD NOW : BLOOD CULTUR OR CULTUR
FROM BONE MARROW PUNCTION.
 BUT CULTURE METHODS ARE NOT WIDELY AVAILABLE IN INDONESIA.
 BLOOD CULTURE SENSITIVE IS ABOUT 50 – 60 %. BONE MARROW
CULTUR IS MORE SENSITIVE AT ABOUT 80 – 90 %
 THE OTHER FOR DIAGNOSIS GOLD STANDARS IS PCR
 HOW ABOUT WIDAL FOR DIAGNOSIS
OF FEBRIS TYPHOID?

 WIDAL AGGLUTINATION TEST DEVELOVED BY F WIDAL IN 1896

 OVER 100 YEARS SINCE THIS INTRODUCTION AS TEST FOR DETECTING FOR
FEBRIS TYPHOID
 WIDAL NOW IS TO BE PLAGUED WITH CONTROVERSION INVOLVING THE
QUALTY OF THE ANTIGEN USED AND THE INTERPRETATION OF THE
RESULT,PARTICULARLY IN ENDEMIC AREA . Alternating of diagnosiic
must done.
 WIDAL IS SO DETECTING IN CROWDED AREA OR ENDEMIC AREA
 WIDAL TEST MUST BE CHECK IN TWISE IN THE OTHER DAY BUT IT IS NOT
PRACTICAL
CONCLUTION OF WIDAL TEST

 THE DIAGNOSIS OF ENTERIC FEVER DEPENDS

UPON TECHNIQUES, BLOOD CULTURE AND PCR
WHICH ARE NOT AVAILABLE IN THE VERY AREA
WERE THE DISEASES IS MOST COMMONT
 THE WIDAL TEST AND THE OTHER SEROLOGICAL
DIAGNOSIS TOOLS HAVE LIMITATION BECAUSE
OF THEIR LOW SENSITIVITY OR SPECIVITY

 WAIN J AND HOSOGLUU S , 2010

 HOW THE TUBEX TF TEST

 THE TEST IS INVITRO SEMI QUANTITATIVE TEST. INHIBITION ELISA USING A

METHODE OF MAGNETING BINDING INHIBITION IMMUNOASSAY.
 MEASURE THE ABILITY OF ANTIBODY IN SERUM TO INHIBIT REACTION BETWEEN
ANTIGEN ( MAGNETIC LATEX PARTICLE ) AND MONOCLONAL ANTIBODY OF
SAMONELLA TYPHI.
 THIS IS A SIMPLE TEST AND RAPID DIAGNOSTIC TEST ( RESULT IN 10 MINUTES )
 THE TEST IS DETECT SPECIFIC ANTIBODY . IF IgM ANTIBODY S- TYPHY LPS 09
MEANS ACUTE PHASE
 SENSITIVITY AND SPECIVITY > 90 %.
 CROSS REACTION IS VERY RARE, USUALLY FOR SALMONELLA ENTERIDIS
INTERPRETATION OF THE TUBEX TEST
 INTERPRETASI TUBEX TEST

Skor Nilai Interpretasi

<2 Negatif Tidak menunjukkan infeksi tifoid aktif

3 Borderline Pengukuran tidak dapat disimpulkan. Ulangi
pengujian, apabila masih meragukan lakukan
pengulangan beberapa hari kemudian

4-5 Positif Menunjukkan infeksi tifoid aktif

>6 Positif Indikasi kuat infeksi tifoid
Interpretasi Tubex Test
COMMON CLINICAL FEATURE OF TF IN
CHILDHOOD IN HOSPITAL AND
COMMUNITY SETTING IN KARACHI
( Butto,ZA BMJ,2006 )
No. Name hospitalized comunity
(n 1158) (n 340)
1. High grade fever 1044(95) 338( 99)
2. Anorexia 811(70) 811(70)
3. Vomiting 811(70) 11(3)
4. Hepatomegaly 471(40) 68(20)
5. Diarhae 409(35) 26(8)
6. Toxicity 377(33) 1(0,3)
7. Abdominal Pain 320(28) 65(19)
8. Splenomegaly 226(20) 17(5)
9. Constipation 127(11) 1(0,3)
10. Jaudice 138(12) 26(8)
11. Jaundice 23(2) 0
12. Obtudantion 23(2) 1(0,3)
13. Lieus 12(1) 1(0,3)
14. Int-perforation 58(0,5) 1(0,3)
15. Myalgia 174(15) 15(4,4)
 Culture confirmed TF in community
health in Demak district, central Java(
SM Abduh,Husen G,Suharyono et al )
 May-November 2005, a fever study incommunity of
Karangawen and Mranggen Demak district 150 out patient
with acut fever were included on this study. Blood collected to
Bactec culture method
 Blood culture positive in 37 ( 24, 7 % ) of 150 patient.Samonella
typhi was detected in 10 ( 27 %) patients ( mean age 10,3 year,
range 11-14)
 The presenting symptoms were acute fever >/ 3 days,
headache, myalgia, constipation, cough etc
 Most of subjects were initially diagnosed as having upper
repiratory tract infection
 Laboratory parameters at presentation for enteric
fever attending the Sihanouk Hospital centre 0f
Hope in Pnom Penh ( Kuljpers LMF, etal, 2017)
,cambodia

 Typhoid fever, Paratyphoid fever:

 lekositosis : 2- 10 %
 leukopenia : 6 – 9 %
 Trombocytopenia : 16 – 21
 Laboratory finding of 504 typhoid
fever patient ( culture confirm )
Complicated TF Complicated TF TF non complicated
 Onadmision During hospitalization N = 336
N= 28 n= 80
Hemoglobin(g/dl) 10,3 ± 1,6 11,2 ± 2,0 11,8 ± 1,7
Leucocyte x 10³ /mm 4,3 ± 1,6 5,1 ± 2,5 4,8 ± 1,7
% lympocytes 23,6 ± 7,4 25,0 ± 8,7 27,1 ± 2,7
Trombocytopenia S 10 (37%) 15 (19%) 27(8%)

S: <100 x 10³/ml
Clinical data from Dr
Kariadi Hospital
 Laboratory support for diagnosis
typhoid Fever
Diagnostic test Faskes I Faskes II

Complete blood count available available

RDT Ig M and Not available Available(or NA)

antisalmonella typhi

BLOOD CULTURE NA NA
 When the time for test Laboratory

Complete blood count on

admission repeat minimum every
2 days
Recuest RTD after 4 day of onset
fever ( Tubex or other )
Blood culture on first week of
illness( Bactec )
 ANTI MYCROBIAL THERAPY FOR TYPHOID FEVER

Optimal Therapy Alternative effective drugs

Susceptibility Antibiotic Daily Days Antibiotic Daily Days
dose dose
mg/kg mg/k
g
Fully sensitive Fluoroquinolone 15 5-7 Chloramphenicol 50-70 14
Faskes 1&2 Ciprofloxacin or 2x500 Amoxicilin 100 14
Levofloxacin 1x500 TMP/SMK 8/40 14
Multidrug Fluoroquinolone 15 5-7 Azitromycin # 8-10 14
resistance or Cefixime 15-20 7-14
Quinolon Ceftriaxone or 75 10 Cefixime 15-20 7-14
Resistance ¶ Azithromycin # 8-10 7
# For adult or periatric cases with MDR or with reduced susceptibility to quinolones.
¶ The optimum therapy for quinolone-resistant TF has not been determined. Azithromycin, the 3rd
generation Cephalosporins, or 10-14 day course of high-dose Fluoroquinolon is effective.
 Culture-confirmed typhoid fever in community
health centers (puskesmas / faskes 1)of
Demak district, Central Java
During a fever study in community health centers of Karangawen and
Mranggen, Demak district, Central Java (May-November 2005), 150
out patients with acute fever were included in the study, blood
samples were collected from all patients and cultured by BACTEC
method.
Blood cultures were positive in 37 (24,7%) of 150 partients. Of those with
positive blood culture, Salmonella enterica servovar Typhi was
detected in 10 (27%) patients (mean age: 10,3 yr; range 11-14yr).
The presenting symptoms were acute fever ≥ 3 days, headache,
myalgia, constipation, cough etc.
Most of subjects were initially diagnosed as having upper respiratory
 Fluoroquinolones in thypoid fever
Advantages
 Ciprofloxacin & other FQ’s have added values, more than their anti-
infective activity:
1)Immunomodulatory activities
2)Higher capacity in the elimination of Salmonella from bone-marrow
3)Low fecal carrier and low relapse rates
Disadvantages
 Widespread use of FQ’s may cause a decrease susceptibility of
Salmonella strains to FQ’s
 Increases NARST related infection
 It could be associated with poor clinical outcomes of TF
RESEARCH A comparison of Fluoroquinolones versus other
antibiotics for treating enteric fever: meta-
analysis
Durrane Thavet, research medical officer.1 Anta K M Zaidi, professor.1Julia Crrchley. Senior lecturer in
epidemiology.2 Asma Azmatullah research medical officer.1 Syed Ali Madri. Reseach medical
officer.1 Zulfiqar A Bhutta, professor and chair1

Conclusions :
In typhoid/paratyphoid fever, fluoroquinolones
are better than:
 Chloramphenicol for reducing clinical relapse
 Cefixime for reducing clinical failure & relapse
 Ceftriaxone for reducing clinical failure