17 Espina, Pia Xyra A.

18 Faderugao, Martina D.

Pharmaceutical Care 2

Typhoid fever (Enteric fever)

-is an acute illness associated with fever caused by the Salmonella typhi bacteria. It can also
be caused by Salmonella paratyphi, a related bacterium that usually causes a less severe
illness.
-is contracted by drinking or eating the bacteria in contaminated food or water. People with
acute illness can contaminate the surrounding water supply through stool, which contains a
high concentration of the bacteria. Contamination of the water supply can, in turn, taint the
food supply.
Epidemiology
Between 1 January and 13 November 2013, 28 224 cases of suspected or clinically
diagnosed typhoid fever were recorded in the Philippines. Two of these cases resulted in
death, yielding a case-fatality rate of 0.27%
During the same time period in Regions 6, 7, and 8 and the National Capital Region, there
were 5 637 suspected or clinically diagnosed cases and 60 laboratory-confirmed cases.
People can transmit the disease as long as the bacteria remain in their system; most people
are infectious prior to and during the first week of convalescence. About 10% of untreated
patients will discharge bacteria for up to three months; 2 to 5% of untreated patients will
become permanent carriers.
Establish the factors that cause the disease and those that modify to prevent
occurrence or spread of disease
Transmission
S typhi can be transferred:
via food handled by an individual who chronically sheds the bacteria through stool or,
less commonly, urine
Hand-to-mouth transmission after using a contaminated toilet and neglecting hand
hygiene
Oral transmission via sewage-contaminated water or shellfish
Risk Factors
Worldwide, children are at greatest risk of getting the disease
Work in or travel to endemic area
Have close contact with someone who is infected or has recently been infected with
typhoid fever
Weak immune system such as use of corticosteroids or diseases such as HIV/AIDS
Drinking water contaminated by sewage that contains S. typhi
Prevention

Wash your hands.

Avoid drinking
untreated water.
Avoid raw fruits and
vegetables
Choose hot foods.

Vaccines
Inactivated typhoid vaccine (shot)
Should not be given to children younger than two years old. One dose provides protection. It
should be given at least two weeks before travel to allow the vaccine time to work. A booster
dose is needed every two years for people who remain at risk.
Protection is induced about 7 days after the injection. In countries or areas at risk, the
protective efficacy 1.5 years after vaccination is about 72%; after 3 years it is about 50%.
Live typhoid vaccine (oral)
Should not be given to children younger than six years old. Four doses, given two days
apart, are needed for protection. The last dose should be given at least one week before
travel to allow the vaccine time to work.
A booster dose is needed every five years for people who remain at risk.
Drug therapy
Ciprofloxacin
Inhibits bacterial DNA synthesis and, consequently, growth. Proven to be highly
effective for typhoid and paratyphoid fevers. Defervescence occurs in 3-5 days, and
convalescent carriage and relapses are rare. Fluoroquinolone are highly effective
against multi-resistant strains and have intracellular antibacterial activity.
Not currently recommended for use in children and pregnant women because of
observed potential for causing cartilage damage in growing animals.
Ceftriaxone
Third-generation cephalosporin with broad-spectrum gram-negative activity against
gram-positive organisms; Excellent in vitro activity against S typhi and other
salmonellae.
Cefotaxime
Arrests bacterial cell wall synthesis, which inhibits bacterial growth. Third-generation
cephalosporin with gram-negative spectrum. Excellent in vitro activity against S typhi
and other salmonellae and has acceptable efficacy in typhoid fever. Only IV
formulations are available. Recently, emergence of domestically acquired
ceftriaxone-resistant Salmonella infections has been described.
Amoxicillin
Interferes with synthesis of cell wall mucopeptides during active multiplication,
resulting in bactericidal activity against susceptible bacteria. At least as effective as
chloramphenicol in rapidity of defervescence and relapse rate. Usually given PO with
a daily dose of 75-100 mg/kg tid for 14 days.
Establish Clinical Diagnosis of disease
Clinical presentation
The incubation period for typhoid fever is 7-14 days (range 3-60 days)
If not treated, the symptoms develop over four weeks, with new symptoms appearing
each week but with treatment, symptoms should quickly improve.
Clinical manifestations
The initial period (early stage due to bacteremia)
First week: non-specific, insidious onset of fever
Fever up to 39-400C in 5-7 days, step-ladder( now seen in < 12%), headache
chills, toxic, tired, sore throat, cough, abdominal pain and diarrhea or constipation.
The fastigium stage
second and third weeks.

 fever reaches a plateau at 39-40. Last 10-14 days.

more toxic and anorexic with significant weight loss. The conjunctivae are injected,
and the patient is tachypneic with a thready pulse and crackles over the lung bases.
Abdominal distension is severe. Some patients experience foul, green-yellow, liquid
diarrhea (pea soup diarrhea). The( typhoid state) is characterized by apathy,
confusion, and even psychosis. Necrotic Peyer patches may cause bowel perforation
and peritonitis. This complication may be masked by corticosteroids. At this point,
overwhelming toxaemia, myocarditis, or intestinal haemorrhage may cause death.
Signs and symptoms:
relative bradycardia.
Splenomegaly, hepatomegaly
rash ( rose-spots): 30%, maculopapular, a faint pale color, slightly raised round or
lenticular, fade on pressure 2-4 mm in diameter, less than 10 in No. on the trunk,
disappear in 2-3 days.
Defervescence stage
By the fourth week of infection:
If the individual survives , the fever, mental state, and abdominal distension slowly improve
over a few days. Intestinal and neurologic complications may still occur. Weight loss and
debilitating weakness last months. Some survivors become asymptomatic carriers and have
the potential to transmit the bacteria indefinitely
Convalescence stage
the fifth week: disappearance of all symptoms, but can relapse
A typical manifestations :
Mild infection: very common seen recently symptom and signs are mild good general
condition temperature is 380C short period of disease recovery expected in 1~3
weeks seen in early antibiotic users in young children more common easy to
misdiagnose
Persistent infection: disease continue > 5 weeks
Ambulatory infection: mild symptoms,early intestinal bleeding or perforation.
Fulminant infection: rapid onset, severe toxemia and septicemia. High fever, chill,
circulatory failure, shock, delirium, coma, myocarditis, bleeding and other
complications, DIC.
In the aged temperature not high, weakness common, more complications and high
mortality.
Blood cultures in Typhoid fever
In Adults 5-10 ml of Blood is inoculated into 50 100 ml of Bile broth ( 0.5 % ).
Larger volumes 10-30 ml and clot cultures increase sensitivity
Blood culture is positive as follows:
st
1 week in 90%
2nd week in 75%
3rd week in 60%
4th week and later in 25%
Bone marrow culture: the most sensitive test, even in patients pretreated (up to 5 days)
with antibiotics.
Urine and stool cultures: increase the diagnostic yield, positive less frequently and stool
culture better in 3rd~4th weeks
Duodenal string test: to culture bile useful for the diagnosis of carriers.
Community containment and public health management
Close collaboration between the infectious disease consultant, microbiologist, public health
physician and general practitioner helps to prevent the spread of S. typhi and S. paratyphi
through the community.

 Collection and treatment of sewage, especially during the rainy season, must be
implemented.
Appropriate facilities for human waste disposal must be available for all the
community. In an emergency, pit latrines can be quickly built.
In areas where typhoid fever is known to be present, the use of human excreta as
fertilizers must be discouraged.
Health education is paramount to raise public awareness on all the above mentioned
prevention measures.
Evaluate the effectiveness of health care program of the government
Despite the Effort of WHO and DOH in mass vaccination and spreading awareness about
typhoid fever. Typhoid fever remained common in Asian and African countries. Most of the
countries plagues with this disease are those that lack clean source of water and sanitation.
In the Philippines in 2008, the Department of Health (DOH) encouraged the public to follow
safety measures against typhoid fever. Same year, the Department of Health declared a
typhoid outbreak in Calamba, Laguna. More than 1,400 people displayed typhoid symptoms.
The bacteria was said to may have been spread by a contamination in the water system.
Water samples were taken from various points (sources and outlets) and were found positive
for fecal coliform. It later turned out that the San Jose local waterworks system was built
some forty years ago and only irregular chlorination was being done. Moreover, its springs
were kept unprotected from bacteria and germs. Same Outbreak also occur in Cebu (2014).
Cases of typhoid fever are up slightly in 2015. Health officials report nearly 11,000 suspected
and confirmed cases of the bacterial disease. 11 people have died from typhoid. Region X,
or Northern Mindanao reported 2,656 cases accounting for nearly a quarter of all cases.
During the first six months of 2014, 10,597 cases of typhoid were reported
This only goes to show that most Asian countries like the Philippines and India, the
government are implementing health care programs poorly.