Typhoid Fever is caused by the bacterium Salmonella Typhi. It spreads through contaminated food or water and causes symptoms like sustained fever, abdominal pain, and headaches. Complications can include intestinal perforation or bleeding. Diagnosis involves blood or stool cultures. Treatment is with antibiotics like fluoroquinolones for 2 weeks. Prevention involves food and water safety as well as vaccination.

1. Typhoid Fever Presented by: Dave Jay S. Manriquez, BSN, RN

2. Other names: Enteric Fever Bilious Fever Yellow Jack

3. Causative Agent Salmonella Typhi

4. 3 main antigenic factors: the O, or somatic antigen the Vi, or encapsulation antigen the H, or flagellar antigen

5. Epidemiology World: 17 million cases per year U.S.: 400 cases per year (70% in travelers)‏ Philippines: (Nov 2006) 478 in Agusan del Sur; (May 2004) 292 in Bacolod City

6. Incidence of Typhoid Fever red - strongly endemic; orange – endemic; gray - sporadic cases

7. Mode of Transmission Ingestion of contaminated food or water; rarely from person to person transmission through fecal-oral route.

8. Incubation Period First 7-14 days after ingestion

9. Symptoms Diarrhea may occur Active infection Severe Headache Generalized Abdominal Pain Anorexia

10. Symptoms Fever [usually higher in the evening] - Intermittent Fever initially - Sustained Fever to high temperatures later

11. Symptoms Severe cases ulcers on the intestinal wall shock delirium stupor

12. Pathognomonic Sign Rose Spots Blanching pink macular spots 2-3 mm over trunk

13. Complications Intestinal perforation, gastrointestinal hemorrhage and peritonitis may occur in the 3rd and 4th week of illness; rarely pancreatitis, hepatic and splenic abscesses, disseminated intravascular coagulation, myocarditis, meningitis, encephalitis.

14. Pathophysiology Salmonella Typhi survives the acidity of the stomach invades the Peyer’s Patches of the intestinal wall macrophages (Peyer’s Patches)‏ the bacteria is within the macrophages and survives bacteria spreads via the lymphatics while inside the macrophages

15. Pathophysiology access to Reticuloendothelial system, liver, spleen, gallbladder and bone marrow First week: elevation of the body temperature Second week: abdominal pain, spleen enlargement and rose spots Third week: necrosis of the Peyer’s Patches leads to perforation, bleeding and, if left untreated, death is imminent

16. Diagnostics CBC (normal WBC despite fever), platelet count Tourniquet Test

17. Diagnostics Typhi dot test (if illness is 4 days or longer)‏ Interpretation: Ig M Ig G (+) (- ) Acute infection (+) (+) Recent infection (- ) (+) Equivocal: Past infection or acute infection

18. Diagnostics Malarial smear (Differential diagnosis)‏ Chest X-ray Urinalysis

19. Diagnostics First Week of illness: Blood C/S Second Week of illness: Urine G/S, C/S Third Week of illness: Stool C/S

20. Management A. Prevention: Choose foods processed for safety Prepare food carefully Foods prepared by others (avoid if possible)‏

21. Management Keep food contact surfaces clean Eat cooked food as soon as possible Maintain clean hands

22. Management Steam or boil shellfish at least 10 minutes All milk and dairy products should be pasteurized Control fly populations

23. Management B. Antibiotics For uncomplicated cases, use Conventional Therapy: 1. Chloramphenicol 3-4 gm per day PO in 4 divided doses x 14 days (50-100 mg/kg BW) except it with low WBC. 2. Co-trimoxazole forte or double-strength tab BID PO x 14 days 3. Amoxicillin 4-6 gm per day PO in 3 divided doses x 14 days

24. Management For cases with complications, presence of severe symptoms, or clinical deterioration despite conventional therapy, use Empiric Therapy for Suspected Resistant Typhoid Fever: 1. Ceftriaxone (Rocephin) 3 gm IV infusion OD x 5-7 days Ceftriaxone may be used for pregnant women and children. 2. Fluoroquinolones: Ciprofloxacin (Ciprobay) 500 mg tab PO BID x 7-10 days Ofloxacin (Inoflox) 400 mg tab PO BID x 7-10 days Perfloxacin (Floxin) 400 mg tab PO BID x 7-10 days

25. Management C. Vaccines 5 years 1 capsule every other day, total of 3 capsules Oral 6 years Ty21 a, live 3 years 0.5 ml Subcutaneous 2 years Vi CPS 3 years 0.5 ml (0.25 ml for children < 10y)‏ x 2 times, 4 weeks apart Subcutaneous 5 years Killed whole-cell vaccine Revaccination Dosage Route Age Vaccine

26. Management D. Public Health Nursing Responsibility - Teach members of the family how to report all symptoms to the attending physician especially when patient is being cared for at home.

27. Management - Teach, guide and supervise members of the family on nursing techniques which will contribute to the patient’s recovery.

28. Management - Interpret to family nature of disease and need for practicing preventive and control measures.

29. Management E. Nursing Care - Demonstrate to family how to give bedside care, such as tepid sponge bath, feeding, changing of bed linen, use of bedpan and mouth care.

30. Management - Any bleeding from the rectum, blood in stools, sudden acute abdominal pain, restlessness, falling of temperature should be reported at once to the physician or the patient should be brought at once to the hospital.

31. Management - Take TPR, I&O and teach family members how to take and record same.

32. Historical Background Mary Mallon (September 23, 1869 – November 11, 1938)

33. Thank you!