Septicemia caused by Salmonella typhi, to start intestinal and blood spread through the lymphatic system. The contamination is direct (dirty hands) or indirect (contaminated water or food).
Clinical signs:
– Prolonged fever (over a week), headache, asthenia, insomnia, anorexia, epistaxis.
– Abdominal pain or heaviness, diarrhea or constipation, gurgling.
– Neuropsychiatric disorders (typhoid state), prostration.
– Moderate splenomegaly, relative bradycardia (pulse not associated with fever).
– Differential diagnosis may be difficult with: lower respiratory tract infection or urinary tract infection; malaria or dengue in endemic areas.
– Complications may occur in the status phase and during convalescence (even under treatment): bleeding or intestinal perforation, peritonitis, sepsis, myocarditis, encephalitis, coma.
Laboratory:
– Leukopenia on (the white blood cell count is normal despite septicemia).
– Detection of S. typhi in the blood (blood culture) and feces during the first 2 weeks. For blood cultures, taking at least 10 ml of blood.
– Serodiagnosis Widal is unnecessary (low sensitivity and specificity).
Treatment (in hospital):
– Isolate the patient.
– Monitor closely, moisturize and treat fever.
– Early antibiotic treatment based on the results of blood cultures may reduce mortality from 10-20% to less than 1%.The oral route is more effective than injection. If the patient can not take oral treatment, by injection and start taking the oral treatment as soon as possible.
Antibiotic treatment outside of pregnancy and breastfeeding:
• The treatment of choice is ciprofloxacin PO for 5 to 7 days
Children: 30 mg / kg / day in 2 divided doses (ciprofloxacin is usually against-indicated in children under 15, but the vital risk of typhoid instead the risk of adverse effects in the background)
Adult: 1 g / day in 2 divided doses.
Cefixime PO for 7 days is a possible alternative to ciprofloxacin in children under 15 years:
Children over 3 months: 15 to 20 mg / kg / day in 2 divided doses
Otherwise, in the absence of resistance:
PO amoxicillin for 14 days
Child: 75 to 100 mg / kg / day in 3 divided doses
Adults: 3 g / day in 3 divided doses
or
chloramphenicol PO for 10 to 14 days depending on severity
Children: 100 mg / kg / day in 3 divided doses
Adults: 3 g / day in 3 divided doses
• S. typhi quickly develops resistance to quinolones. In that case :
ceftriaxone IM or IV1 for 10 to 14 days depending on severity
Children: 75 mg / kg / once daily
Adults: 2 to 4 g / once daily
Antibiotic therapy in pregnant or breastfeeding:
In pregnant women, typhoid exposed to a major risk of maternal complications (gastrointestinal perforation, peritonitis, septicemia) and fetal (abortion, premature birth, fetal death).
• In the absence of resistance:
amoxicillin PO: 3 g / day in 3 divided doses for 14 days
• In case of resistance:
ceftriaxone IM or IV 1: 2 to 4 g / once daily for 10 to 14 days depending on severity
Otherwise, use ciprofloxacin PO (usually not recommended in pregnant or breastfeeding women, but the vital risk of typhoid instead the risk of adverse effects of ciprofloxacin in the background). For dosage, see above.
Note: fever persists 4-5 days after the start of treatment, even if antibiotic therapy is effective. It is essential to treat fever and seek the onset of maternal or fetal complications.
– In patients with severe typhoid with neurological, psychiatric (hallucinations, impaired consciousness) or gastrointestinal bleeding:
dexamethasone IV: initial dose of 3 mg / kg and 1 mg / kg every 6 hours for 2 days
Prevention:
– Disinfection of feces with a chlorine solution 2%.
– Personal hygiene (hand washing) and collective (hygiene and sanitation).
– Vaccination should be discussed: it can be useful in some cases (age risk group; hyperendemic zone) but its effectiveness is controversial.
1* The solvent of ceftriaxone for IM injection contains lidocaine. Reconstituted with the solvent, ceftriaxone should never be administered IV. For IV administration, use only water ppi.
