Most typhoid infections occur in developing countries where sanitary conditions remain poor and water supplies are not treated.
Humans are the only known reservoir, and transmission occurs through food and water contaminated by acutely ill or chronic carriers of the organism.
Seen in developed countries mainly among travellers returning from endemic countries.
Highest incidence is in the Indian subcontinent and among travellers returning from that area.
Prolonged febrile illness with normal white blood cell count in returnees from an endemic area should increase suspicion.
Definitive diagnosis is by blood culture.
Presumptive antibiotic treatment in the traveller should depend upon the country of origin.
The current vaccines available offer only moderate protection against Salmonella typhi and almost no protection against S paratyphi, which has become a more dominant pathogen.
With the current vaccine efficacy and the increase in multidrug-resistant and extensively drug-resistant strains, cases are expected to continue to increase and become ever more challenging to treat.
Typhoid infection is a faecal-oral transmissible disease caused by the bacterium Salmonella enterica, serotype S typhi. A similar clinical syndrome is caused by Salmonella enterica, serotype S paratyphi, and the terms 'enteric fever' and typhoid infection are used to describe both diseases. Unless otherwise stated, the information presented here will relate to both diseases (S typhi and S paratyphi) described by the term typhoid infection.
History and exam
Key diagnostic factors
- presence of risk factors
- high fever
Other diagnostic factors
- dull frontal headache
- abdominal pain
- apathetic-lethargic state
- relative bradycardia
- rose spots
- overcrowded living in endemic areas
- poor sanitation/untreated water in endemic areas
- poor personal hygiene in endemic areas
- visiting endemic countries (e.g., Indian subcontinent, Mexico)
- travel to areas with poor sanitation within endemic countries
- ignoring hygiene rules while travelling in endemic countries
- travel to the Indian subcontinent
- longer duration of stay in endemic country
1st investigations to order
- serum transaminases
- blood culture
- stool culture
- urine culture
- bone marrow culture
Investigations to consider
- rose spot culture
- Widal's test
- IDL Tubex® test
- sodium dodecyl sulfate polyacrylamide gel electrophoresis (SDS-PAGE)/immunoblot
isolate sensitive to all antibiotics
isolate multidrug-resistant but sensitive to fluoroquinolones
isolate multidrug-resistant but sensitive to cephalosporins
isolate resistant to both cephalosporins and fluoroquinolones
isolate extensively drug-resistant
- Public health operational guidelines for typhoid and paratyphoid (enteric fever)
- Canadian immunization guide part 4 - active vaccines: typhoid vaccine
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