Enteric Fever....Prepared by Dr.Habibur Rahman

8/3/2019 Enteric Fever....Prepared by Dr.Habibur Rahman

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ENTERIC FEVER(SALMONELLA)

PRESENTED BYPRESENTED BYDR.HABIBUR RAHMAN.DR.HABIBUR RAHMAN.

ASST.REGISTRERASST.REGISTRER

DEPT.OF NEONATOLOGYDEPT.OF NEONATOLOGY

Dhaka Medical College & Hospital.Dhaka Medical College & Hospital.


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INTRODUCTION:

Typhoid fever, commonly just typhoid, is a

common worldwide illness, transmitted by the

ingestion of food or water contaminated with

the faeces of an infected person..

This fever received various names, such

as gastric fever, the bends, abdominal

typhus, infantile remittent fever, slow

fever, nervous fever,pathogenic fever, etc.


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EPIDEMIOLOGYWith an estimated 1633 million cases

of annually resulting in 216,000 deaths

in endemic area

TRANSMISSION

Flying insects feeding on feces may

occasionally transfer the bacteria through

poor hygiene habits and public sanitationconditions


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salmonella


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Typhoid fever is prevalent inTyphoid fever is prevalent in

many regions in the Worldmany regions in the World


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Typical form of enteric fever is caused by

-salmonella typhi

Similar but generally less severe illness

paratyphoid is caused by-salmonella paratyphi A,B,C

The name s.typhi is derived from ancient Greek TYPHOS

meaning an ethereal smoke or cloud causing disease.Gram ve bacilli

2sets of antigens detected by serotyping

-somatic or O

-flagellar or H


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Pathophysiology:

1.Intraluminal

dendritic cells

2.Epithelial Mcells

3.Ordinary

epithelial cells

macrophages

Mesenteric

lymph

nodes

1.Thoracic

Lymph

nodes

2.Spleen

3.Bonemarrow

4.liver

Gall bladder

Blood stream

Target

organ

feces

Urine

rare

phagocytosis


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Transmission(feco-oral

route)

Oral transmission via food orbeverages handled by

carriers

Hand tomouth

transmissionafter using

contaminated toilet

Oral transmission via seweragecontaminated water or shellfish

Flyinginsects

sitting onfeces then

on fooditems in

unhygienicconditions


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Clinical features:

Incubation period

7-14 daysIncubation period

7-14 daysIngestion to onset of fever varies

from 3-50 days.

Clinical features:


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In the first week, there is

a slowly rising temperature

A bloody nose (epistaxis) .

There is leukopenia,

The classic Widal test is negative

in the first week.


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In the second week ofthe infection,

bradycardia

Delirium is frequent.

Rose spots .

Diarrhea can occur.

The spleen and liver are enlarged

The Widal reaction is strongly positive .


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the third week :

A number of complications may arise.

These include:

Intestinal hemorrhage

Intestinal perforation

Encephalitis

Metastatic abscesses

This carries on into the fourth and final

week.


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Fever(ascends in a step wise pattern) 72.4%

Abdominal pain 71%

Headache(dull,continous) 45%Pea soup diarrhea 41%

Chills 21.4%

Anorexia 19.5%Constipation 9.3%

Malaise 6.8%

Cough,sore throat 3.1%


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Abdominal tenderness 61%

Bronchitis 56%

Coated tongue 39%Confusion 29%

Relative bradycardia

Hepatospleenomegaly 14%Lymphadenopathy

Rose spot 5%


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Carriers:

1-5% of pts with enteric fever become long

term asymptomatic,chronic carriers who shed

s.typhi in either urine or stool > 1 year.Incidence is high among women & among

persons with biliary abnormalities & GI

malignancies.


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DIAGNOSIS

Diagnosis is made by any

blood C/S, bone marrow or

stool cultures and

with the Widal test (demonstration of

salmonella antibodies )


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WIDAL TEST:

Serum agglutinins raise abruptly during the 2ndor 3rd week

The widal test detects antibodies against O andH antigens

Two serum specimens obtained at intervals of7 10 days to read the raise of antibodies.

Following Titers of antibodies against theantigens are significant when single

sample is testedO > 1 in 160H > 1 in 320


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Limitations of Widal test:

Classically, a four-fold rise of antibody in

paired sera Widal test is considered

diagnostic of typhoid fever. However, paired

sera are often difficult to obtain and specificchemotherapy has to be instituted on the

basis of a single Widal test. Furthermore, in

areas where fever due to infectious causes is

a common occurrence the possibility exists

that false positive reactions may occur as a

result of non-typhoid


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Slide agglutination tests

In slide agglutination tests a known serum andunknown culture isolate is mixed, clumping

occurs within few minutes


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BactekBactek and Radiometric basedand Radiometric based

methodsmethods

Bactek methods inisolation

of Salmonella is a rapidandsensitive method inearly

diagnosis of Entericfever.


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Emerging Methods in Diagnosis

of Enteric fevers.Detection of circulatingantigen by

Co - agglutination

methods with use ofCowans strain

Staphylococcus coated

with antibodies

PCR.The advent of PCRtechnology has provided

unparalleled sensitivity &

specificity for the

diagnosis of typhoid


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TREATMENT:


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Oral rehydration

Antibiotics (previuosly chloremphenicol but because ofplasma-mediated resistance it is not used.Other antibiotics include ampicillin(1g orally/6hrly),

trimethoprim-sulfamethoxazole

1st choice of treatment is floroquinolones

-ciprofloxacin 500mg orally 1 BD

-levofloxacin 500mg orally 1 OD

-ofloxacin 10-15 mg/kg BD for 2 daysThird generation cephalosporin i.e ceftriaxone 2g I/V

OD 7days or cefixime can also be used.

(5-7days for uncomlicated & 10-14 days for sever infection)


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MDR typhoid:

Select an antibiotic to which organism is

susceptible in vitro.

Ceftriaxone 4g/day I/V for 10-14 days

Azithromycin 500mg orally for 7 days

or 1g orally OD for 5 days

or 1g orally on 1st day

then 500mg orally OD for 6 days.Azithromycin is better in resistant populations

because it reduces relapse rates compared with

ceftriaxone.


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Treatment of carriers:

Treatment with ampicillin, ciprofloxacin,

Norfloxacin may be successful

Ciprofloxacin 750mg orally BD for 4 weeks has

proved to be 80% effective.

Cholecystectomy may also achieve the goal.


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COMPLICATIONS:Occur in abt 30% of untreated cases & account for

75% of deaths.

Int hemorrhage (sudden drop intemp,signs of shock,

dark or fresh blood in stool)

Int perforation(abd pain & tendernesss)


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RARE COMPLICATIONS:

Urinary retention

Pneumonia

Thrombophlebitis

MyocarditisPsychosis

nephritis

Cholecystitis

Osteomylitis

meningitis


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PROGNOSIS:

Mortality rate of typhoid is about 2% in treated

cases

> in elderly & debilitated personsWith complications, poor prognosis

RELAPSE:

Occurs in 15% of pts.


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Vaccines:

Two types of vaccines are availableOralInject able

Two types of vaccines are availableOralInject able


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Oral live vaccine

No antibiotics should be taken during the period ofadministration of vaccine

Vaccine

name

How

given

Number

of doses

Time

B/w

doses

Total

time

minimum

age

booste

r

Oral

(vivotif

Berna,

Swiss

serum)

1

capsule

by

mouth

4 2 days 2

week

5 years 5

years


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The injectable vaccine, ( typhim vi)

contains purified Vi polysaccharide

antigen derived from S.typhi strain ty21.

Vaccinename Howgiven Numberof doses TimeB/w

doses

Totaltime minimumage booster

Injection

(typhim

Vi,Pasteur

Meriuex)

S/C

I/M

1 - 2

weeks

2 years 2 years


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Oregon 1984: a religious cult known as the Rajneeshees, a Buddhist cult

sought to run the whole country by wining the local election in 1984 using

salmonella bacteria. They brewed a "salsa" of salmonella and sprinkled it

on the town's restaurant salad bars. Ten restaurants were hit and more than

700 people got sick.


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Salmonella as a Bioterrorist Weapon

ontaminating unguarded food supplies

Some terrorist acts may be designed purely

to spread panic: contaminating the food

supply could bring economic and

agricultural production to a standstill

EX. If numerous food-borne outbreaks occurred

across the country, people would soon fear their

meals.


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PREVENTION:

Sanitation and hygiene are the critical measure that

can be taken to prevent typhoid.

Typhoid can only spread in environments where

human faeces or urine are able to come in contact with

food or drinking water.

Careful food preparation and washing of hands are

crucial in preventing typhoid.


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Simple hand hygiene and washing

can reduce several cases of Typhoid


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THANK YOU

Enteric Fever....Prepared by Dr.Habibur Rahman

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