Guidelines for Treating Uncomplicated Typhoid Fever
Cross River State Ministry of Health
Clinical Guidelines & Audit Unit
June 2004
Typhoid Fever is an infection caused by Salmonella typhi. It is prevalent where there is poor supply of water and indiscriminate disposal of faeces. Public health control measures like provision of safe water, proper sewage disposal and personal hygiene, would drastically reduce its prevalence, which is estimated to be high in Nigeria.
The clinical symptoms usually mimic that of malaria, and oftentimes health care providers have difficulty in differentiating typhoid from malaria. This has contributed to wrong treatment and over-diagnosis of typhoid fever. The aim of this guideline is to correct this difficulty, and provide adequate management of typhoid in an endemic area such as Nigeria.
1ST LEVEL OF CARE[1]
Goal of care at this first level of care is to identify all suspected cases of uncomplicated typhoid fever and refer to second level of care where facilities for confirming diagnosis are available.
Clinical Presentation
The symptoms of typhoid fever are similar to malaria and include – fever, headache, lethargy, anorexia, abdominal pain or discomfort, and a coated tongue.
There may be associated vomiting and diarrhoea. The fever in typhoid is usually prolonged for more than 4 days and does not respond to antimalarials.
If this happens, suspect resistant malaria or typhoid
Action => Refer to next level of care
2ND LEVEL OF CARE[2]
CLINICAL PRESENTATION:
Symptoms:
Symptoms of uncomplicated typhoid as described above.
Signs:
Fever is the most common sign. Other signs that may be present are lethargy, abdominal tenderness, hepatomegaly, and splenomegaly.
Investigations:
1 Thick and thin blood film for malaria parasite (MP)
If positive: treat as malaria treatment failure (with second line antimalarial drugs). Still carry out laboratory tests for typhoid fever.
If negative: Carry out laboratory tests and give empirical treatment for typhoid.
2 Blood culture: This is expected to be positive for S. typhi from the first week. It is also the confirmatory test for typhoid.
3 Serological diagnosis of typhoid fever (Widal Test):
Test is considered significant (suggestive of infection by the S. typhi or S. paratyhi) if:
There is 4-fold or more increase in the titre of somatic (O) and flagella (H) antibodies between acute and convalescent sera of 7 to 10 days interval.
OR
A baseline titre of 160 or more for O and H antibodies going by the evidence on background immunity in this endemic area.[1C]
4 Urine culture for S. typhi:- This is positive in the second to third week.
5 Full Blood Count: decrease in WBC counts with relative monocytosis.
DRUG TREATMENT
Oral
1st Line Treatment
Chloramphenicol
OR
Amoxycillin
— if sensitive for the area (Increasing incidence of resistance to antimicrobials is responsible for many cases of treatment failures)
2nd Line Treatment (If first line treatment fails).
Quinolones (for adults) e.g. Ofloxacin, Ciprofloxacin, Peflaxcin
OR
Oral Azithromycin (Zithromax®)2[A2]
Parenteral
When oral intake is not possible
Ceftriazone for minimum of 14 days (short course could cause relapse)3[A2]
COMPLICATED TYPHOID FEVER
This guideline is for uncomplicated typhoid fever but it is important to recognize complicated cases early for appropriate treatment or referral.
Symptoms
Symptoms of uncomplicated typhoid fever in addition to any of the following: prostration (critically ill), lethargy, severe vomiting, severe abdominal pains, diarrhoea or constipation.
Signs
Commonest signs are abdominal tenderness, guarding, distension. These signs are suggestive of intestinal perforation with peritonitis. Gastrointestinal bleeding and generalized bleeding may occur due to erosion of intestinal vessels or disseminated intravascular coagulopathy respectively.
Action
Refer all cases
of complicated typhoid fever to a hospital or medical center with adequate
personnel and facilities for intensive care and surgical intervention.
References
1 Opara, AA and Nweke AE. Baseline values of Salmonella agglutinins in parts of south east Nigeria. J. Med Lab Sc 1991; 1: 52-58
2 Frenck RW. Jr., Nakhla I, Sultan Y, Bassily SB, Girgis YF, David J, Butler TC, Girgis NI, Morsy M. Azithromycin versus Ceftriaxone for the teatment of uncomplicated typhoid fever in children.Clinical Infectious Diseases 2000; 31: 1134 – 1138
3 Bhutta ZA, Khan IA, Shadmani M. Failure of short-course Ceftriazone chemotherapy for multidrug-resistant typhoid fever in children: a randomized controlled trial in Pakistan. Antimicrobial Agents and Chemotherapy, 2000; 44(2): 450-2
APPENDIX
Levels of Evidence
A1 Systematic review of randomised controlled trials
A2 Individual RCTs with narrow confidence intervals and > 80% follow up
B Systematic reviews of cohort or case-control studies with homogeneity, large individual cohort or case –control study, RCTs with <80% follow up.
C Case-series and poor quality cohort or case-control studies.
D Expert opinion without explicit critical appraisal.
ACKNOWLEDGEMENTS
Guidelines Development Group
1. Dr Angela Oyo-Ita Community Physician, UCTH
2. Dr Philip E. Bassey Asst. Director Public Health MOH
3. Dr Esu Oyo-Ita Director of Medical Services MOH
4. Dr Charles Iwara Assistant Director Medical Services MOH.
5. Dr Victor Ansa Consultant Physician, UCTH
6. Dr A.E Offiong Chief Medical Officer, MOH
7. Dr Kuma P. Senior Medical Officer, General Hospital, Calabar
8. Dr Martin Meremikwu Associate Professor Paediatrics Unical (EHCAP Nigeria Coordinator)
Consultant
Dr Cyprian Okoro of London School of Hygiene & Tropical Medicine and EHCAP, Liverpool School of Tropical Medicine.
Peer Review
This guideline (Treating of Uncomplicated Typhoid Fever was peer-reviewed by Prof. S.J. Utsalo, Department of Microbiology, University of Calabar, Calabar Nigeria.
Support
The Cross River State Ministry of Health
Effective Health Care Alliance Programme, Liverpool School of Tropical Medicine*
The UK Department for International Development (DFID) supports EHCAP
Institute of Tropical Diseases Research and Prevention
[2] 1st level of care refers to clinics and health centres without facilities for standard laboratory tests and in-patient care
[2] 2nd level of care refers to hospital and medical centres with facilities for standard laboratory tests and in-patient care