Typhoid is a deadly disease

(Tifoid adalah penyakit yang mematikan)

Dr. Poerniati Koes Andrijani, SpPD

Facts a o!t Typhoid Fe"er

Typhoid fever is the clinical syndrome caused by the enteric
bacterial pathogen Salmonella enterica serotype Typhi (S . Typhi).1 Typhoid & Paratyphoid fever continue to be important causes of illness and death, endemic in many areas of Asia, Africa, and South America, here sanitation of ater supply and aste treatment is inade!uate. 1," The severity of typhoid fever is underlined by the fact that up to #"$ mortality is reported in some regions of the orld. 1 According to report of %ndonesian &o' ("(()), Typhoid is listed as top 1*th of disease caused death.#

+ef, 1) +obert A- & .ordon /., Typhoid 0ever. 1lsevier, "(()2 ") 3rump 4A & 1ric /. &int5, 3linical %nfectious /iseases "(1(2 *(,"61782 #)/ep9es, "((), Profil -esehatan %ndonesia "((:

Facts a o!t Typhoid Fe"er

%n "((;, the 3ommunicable /isease 3entre (3/3)
of %ndonesia reported a prevalence of #*:<:1( per 1((,((( population for typhoid fever ith 86$ occurring in #< to 1)<year old %n 4a9arta, typhoid fever as the second leading infectious disease after gastroenteritis and caused the highest mortality. The mortality rate varied from #.1<1(.6$ among hospitali5ed patients

+ef, &oehario, ='., 4 %nfect /ev 3tries "(()2 #(:), *;)<*:6

#istory of Typhoid fe"er

1829 French Physician Pierre Louis
(1787-1872 ) introduced the term typhoid! mean li"e typhus %ears o% an out&rea" o% %e'er

18#8 $reat Stin" o% London raises 18() *ost scientist a+ree that

typhus and typhoid are di%%erent %e'er! possi&ly typhoid

18(1 Prince ,l&ert dies o% a &o-el 187)s Scientist sho- that %ood -ater $reat Stin" o% London 18#8
and certain articles such as hand"erchie% and to-el con'ey the typhoid in%ection

#istory of Typhoid fe"er

188. Scientist includin+ $eor+e
$a%"y (18#)-1918) isolate and culture the typhoid &acillus -as introduced

189. The dia+nostic /idal test 19). 0ase o% *arry *allon

(typhoid *arry) as healthy carrier o% typhoid as Salmonella typhi &y 3aniel 4lmer Salmon (18#)-19.1) chloramphenicol reducin+ mortality o% typhoid

1911 2acterial o% typhoid named 19.8 5ntroducin+ o%

Alexander The Great died when he was 34 years old due to acute fever illness possibly due to typhoid fever or malaria

Prince Albert (181 !18"1# husband of $ueen %ictoria dies due to &owel fever (typhoid fever#

Salmonella$
Str!ct!re, %lassification, & Antigenic Types
1. .ram<negative, flagellated and facultative anaerobic bacteria ". The cell envelope contains a comple> lipopolysaccharide (=PS) structure. (an outer ?< polysaccharide coat, a middle portion, the + core, and an inner lipid A coat) #. This =PS structure is thought as an endoto>in, and important in determining virulence of the organisms.

Some e'ample of commonly (cc!rring Salmonella serotypes and gro!ps

)ro!p
A @

Serotype

S. paratyphi A S. paratyphi @ S. stanley S. saintpaul S. agona S. typhimurium S. paratyphi 3 S. choleraesuis S. vircho S. thompson S. typhi S. enteritidis S. dublin S. gallinarium

Patterns of disease in 3ommunity,

De"eloped %o!ntries$
.ood se age and ater supply system &ost cases are sporadic or imported or can be traced to contact *ith chronic carriers

De"eloping +orld$
%hronic carriers are less important in transmission Pea9 in hot dry months or rainy season The incidence of typhoid fe"er is ,- . times that of paratyphoid fe"er

/ndemic areas & )lo al Distri !tion of 0esistance to Salmonella enterica Serotype Typhi

+ef, Parry 3&, et.al., A 1ngl 4 &ed "(("2 #6;(""), 1;;(<1;:"

Method of Transmission:
Ingestion of contaminated food or water The stools of chronic carriers usually contains
from 106 to 109 organisms/g

Raw shell fish from olluted water resents

with an enormous dose of '( typhi

Factors that Influence Infectivity

Ingestion of 10! organism cause clinical disease in "!# 10$ organisms caused disease in !0# 109 organisms caused disease in 9!#

%trains that do not ha&e '(i antigen) are less infecti&e

and less &irulent

%linical Pict!re
B 0ever B 'eadache B malaise B myalgia B nausea B abdominal dis< comfort B constipation B diarrhea B dry cough B epista>is B confusion, delirium B psychosis B convulsion B coated tongue B bradicardia relative B tender abdomen B hepatomegaly B splenomegaly B rose spots B erythmatous muco papular lesion

Fe"er pattern in Typhoid Fe"er

'igh fever 'eadache Abdominal discomfort /iarrhea or constipation +elative bradicardia

=eucopenia &ild thrombocytopenia +elative neutrofilia Aneosinofilia

16

1a oratory /'amination
Peripheral blood count leucocytosis leucopenia, normal C@3 count mild anemia thrombocytopenia increased 1S+ increased 3+P increased A=T and AST 'ypoalbuminemia Cidal,Typhidot Tube> (Salmonella .all (Salmonela Salmonella typhi

%nflammatory Serum transaminase Albumin Serology %g&) @lood culture Shigella) P3+

0isk factors for Typhoid & Paratyphoid Fe"er in 2akarta

Among 1(1) subDects ith fever, Salmonella typhi
consumption of food from street vendors and flooding.

as identified in :: ()$) and Salmonella paratyphi A in "8 (#$) patients Paratyphoid fever as independently associated ith,

Typhoid fever using the community control group ere mostly related
to the household, ie, to recent typhoid fever in the household,
no use of soap for hand ashing2 sharing food from the same plate, and no toilet in the household. also, typhoid fever as associated ith young age in years.

Eollaard, A&., 4A&A. "((62")1("1),"8(;<"81*

0isk factors for Typhoid Fe"er in Semarang .asem &', et.al. ("((1) reported that incidence
of typhoid fever in Semarang as associated ith poor housing and inade!uate food and personal hygiene.

Aever or rarely *ashing hands efore eating

(?+ F #.);2 )*$ 3% F 1.""<1".)#) and eing !nemployed or ha"ing a part-time jo (?+ F #1.#2 )*$ 3% F #.(:<#1;.6) also ere ris9 factors

+ef, .asem &', et.al., Trop &ed %nt 'ealth. "((1 4un28(8),6:6<)(.

 /etermination of the different ris9 factors of typhoid fever ith

complications after the tsunami in Aceh after Tsunami are availability of clean ater and drugs Gogya9arta after the earth!ua9e are the education level and avoiding contact ith other typhoid patients These result has emphasi5es the need for rapid public health intervention in comple> disasters compared ith normal circumstances in %ndonesia.

+ef, Sutiono et al. @&3 +esearch Aotes "(1(, #,1(8

Treatment
Aon Pharmacologic , @ed rest, Autrition Pharmacologic
Symptomatic Antibiotic ,
Ampicillin HAmo>icillin 3hloramphenicol 6>*((mg 3ephalosporin , 3eftria>one #<6 gHdays 0luoro!uinolones , %iproflo'a'in ,'344 mg (recommended) ?flo>acin ">6(( mg Peflo>acin 1>6(( mg 0lero>acin 1>*(( mg =evoflo>acin 1>*((mg

&ulti /rug +esistant (&/+) strains of S. typhi,

5!inolones are the only effective oral treatment

0elapse after treatment$

1(< "*$ in patients receiving
chloramphenicol

6- 78 patients recei"ing ne*er

anti iotics (cephalosporins and F9)

&ostly relapses occur during "<6 ee9s

after end of antibiotic therapy.

+etreatment should be performed

%omplications
%ntestinal complication intestinal perforation gastrointestinal hemorrhage hepatitis, pancreatitis, paralytic ileus e>traintestinal 3ardiovascular , shoc9, myocarditis Aeuropsychiatric , encephalopathy, delirium, psychosis +espiratory , bronchitis, pneumonia, pleuritis 'ematology , anemia, /%3 -idney , glemerulonephritis, pyelonephritis ?thers , osteomyelitis, focal abscess

%hronic %arrier$
A person ho e>cretes the organism in stools 1" months
after the initial illness.

.8 go on to ecome carriers (range 6-78)

,48 at , months 648 at . months

3hronic carriage more fre!uent ith typhoid than non<

typhoid strains

'igher prevalence in females and ith gall stones "*$ could not give a history compatible ith typhoid
fever.

 Ao .all<Stones,

Treatment of 3hronic 3arriers of S. typhi,

?ral Ampicillin H amo>icillinHT&P<S&I for # months

Presence of .all<stones,
Try above regimen prior to surgery %n most cases antibiotic plus cholecystectomy re!uired %iproflo'acin :34mg P( ;<D or Aorflo>acin 6((mg @%/ for ": days

3hronic urinary carriers,

Treat schistosomiasis first, if present, before antibiotics

=otes on anti acterial selection

Antibiotics *hloram henicol Dosage & Duration !0 +g / ,, / daydi&ided . times / day Trimetho rim1 160/:00 mg 4id .1 %ulfametho5a9ole "0 mg/+g: in " doses /m icillin //mo5ycillin 10001"000 mg 7id !01100 mg/+g: in . doses

Notes

/ high rela se rate 0101"!#23 a high rate of continued and chronic carriage3 4one marrow to5icity3 and a high mortality rate in some series from the de&elo ing world are other concerns with chloram henicol6 In addition to the wides read resistance to chloram henicol3 amo5icillin3 and trimetho rim3 these drugs also re7uire e5tended treatment for " 8 wee+s with four times a day oral regimen for full effecti&eness

+ef, -han A&, et.al., .omal 4ournal of &edical Sciences 4uly7/ec., "((6, "("),*)<8#2 -ingsley +A & .ordon /, Typhoid 0ever. 1lsevier "(().

=otes on anti acterial selection

Antibiotics

Dosage & Notes Duration *i roflo5acin !00 mg 4id/"00 *i roflo5acin has ro&ed highly effecti&e- no ' mg 4id- for $110 typhi carriers emerged6 *i roflo5acin has also 4een found to 4e highly days effecti&e thera y for infections due to M;R ' <flo5acin .00 mg 4id for typhi and ' paratyph 1. days *i roflo5acin was effecti&e and well tolerated Ae&oflo5acin !00 mg 4id for for treatment of ty hoid fe&er in children <ther 7uinolones3 including oflo5acin3 1. days norflo5acin3 eflo5acin3 le&oflo5acin3 ha&e 4een effecti&e in small clinical trials3 howe&er those are not yet a ro&ed 4y ,=<M > ?%1@;/

+ef, -han A&, et.al., .omal 4ournal of &edical Sciences 4uly7/ec., "((6, "("),*)<8#2 Ael an +'', et.al., Southeast Asian 4 Trop &ed Public 'ealth "((82 #;(1), 1"8<1#(

=otes on anti acterial selection

Antibiotics *eftria5one Dosage & Duration 11" gm 4id !01$! mg/+g: in 11" doses for $110 days 11" gm 4id .01:0 mg/+g: IM3 in "18 doses for 1. days *efota5ime

Notes

%uch as cefota5ime3 ceftria5one3 and cefo era9one ha&e 4een used successfully to treat ty hoid fe&er6 B5cellent res onse rates ha&e 4een re orted with ceftria5one when administered for ! to $ days3 4ut the rela se rate remains incom letely defined6

*efo era9one 11" gm 4id !01100 mg/+g: in " doses 1. These drugs should 4e reser&ed for days 7uinolone resistant cases6 It is *efi5ime "001.00 mg od/4id 10 recommended to treat with ceftria5one for mg/+g: in 11" doses 1011. days6 for 1. days
+ef, -han A&, et.al., .omal 4ournal of &edical Sciences 4uly7/ec., "((6, "("),*)<8#

To pre"ent eing infected$ Cash your hands Avoid drin9ing untreated ater Avoid ra fruits and vegetables 3hoose hot foods

Pre"ention steps to a"oid typhoid fe"er

To pre"ent infecting others$ Cash your hands often 3lean household items daily Avoid handling food -eep personal items separate

+ef, &ayo3linic, accessed from http,HHedition.cnn.comH'1A=T'HlibraryHtyphoid<feverH/S((*#:.html

>accination

+ef, 3rump 4A & 1ric /&, 3linical %nfectious /iseases "(1(2 *(,"6178

Scientific Proof to #and +ashing

'and ashing interrupts the transmission of
disease agents and so can significantly reduce diarrhea and respiratory infections, as ell as s9in infections and trachoma. suggests that hand ashing ith soap, particularly after contact ith feces (post< defecation and after handling a childJs stool), can reduce diarrheal incidence by 6"<6; percent, hile ongoing or9 by +abie et al. suggests a #( percent reduction in respiratory infections is possible through hand ashing

A recent revie (3urtis and 3airncross "((#)

?enc!ci Tangan Dengan ;enar

"

@sapkan %airan #and 0! pd ked!a telapak tangan hingga merata

)osok p!ngg!ng dan sela-sela jari tangan kiri dgn tangan kanan & se aliknya

)osok ked!a telapak tangan dan ked!a-d!a jari hingga merata

Sela-sela jadi dan ked!a tangan saling meng!nci & saling digosokkan

)osok i ! jari kiri dengan gerakan erp!tar dlm genggaman tangan kanan & lak!kan se aliknya

)osok telapak tangan kiri dengan mem!tar !j!ng jarijari kanan dan se aliknya

%oncl!sion
&anagement of typhoid fever continues to pose a
challenge for us, especially in %ndonesia. Personal hygiene and health environment incl. facility to clean ater and sanitation are important factor to prevent the outbrea9 of Typhoid. Eaccination & Antibiotic treatment are one of modality of Typhoid management. 3iproflo>acin (%ipro'in) is still the gold standard treatment for Typhoid & Paratyphoid 0ever.

+ef, 1) +obert A- & .ordon /., Typhoid 0ever. 1lsevier, "(()2 ") 3rump 4A & 1ric /. &int5, 3linical %nfectious /iseases "(1(2 *(,"61782 #)/ep9es, "((), Profil -esehatan %ndonesia "((:2 #) &oehario, ='., 4 %nfect /ev 3tries "(()2 #(:), *;)< *:6

Thank you !