 |  | Clinical Guidelines and Treatment Manual (MSF, 1993, 319 p.) | ||
 |  | Chapter 7 - Bacterial infections | ||
|  | Meningitis | ||
| | Pertussis | ||
| | Tetanus | ||
| | Plague | ||
| | Leptospirosis | ||
| | Relapsing fever | ||
| | Rickettsioses | ||
| | Brucellosis | ||
| | Typhoid fever | ||
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Acute inflammation of the meninges usually of bacterial origin with risk of progressing to encephalitis.
Clinical features
ADULT AND CHILD OLDER THAN 1 YEAR
- Classical meningeal syndrome with fever, meningism, neck stiffness, Budzinski and Kernig's signs positive: the patient lying extended, involuntarily flexes the knees when the neck is flexed or when the legs are raised vertically with the knees in extension.
- If severe: febrile coma, convulsions, localising signs, purpura fulminans.
CHILD UNDER 1 YEAR
Diagnosis much more difficult as classical meningeal signs are often missing. Always think of it in a sick child:
- refusal to eat, fever with diarrhoea, vomiting, drowsiness, plaintive crying, unusual behaviour;
- generalised or focal convulsions, coma;
- infant may be hypotonic, neck is often not stiff, fontanelle bulging even when not crying;
Localising signs:
- purpura may be minimal;
- slide tests negative;
- fever may be absent.
Differential diagnosis
Where malaria is endemic, it is vital to consider cerebral malaria (thick and thin slides).
Lumbar puncture
Do lumbar puncture whenever in doubt.
Cerebro spinal fluid (CSF) normal: clear, cells < 5/mm3, proteins < 0.40 g/1 (Pandy -).
In meningitis: polymorphs > 500/mm3, proteins = about 1 g/1 (Pandy +). CSF cloudy "rice water" = meningitis.
Whenever possible, ask for gram staining and direct microscopy for white blood cells.
Causative agents
MORE THAN 3 YEARS OLD
- Meningococcus (dry season)
- Pneumococcus (often linked with another focus: pneumonia, RTI)
- Rare other pathogens
2 MONTHS TO 3 YEARS OLD
- Haemophilus Influenzae
- Pneumococcus (often linked with another focus: pneumonia, RTI)
- Meningococcus (dry season)
- Rare other pathogens
LESS THAN 2 MONTHS OLD
E. Coli Listeria, Salmonella, Streptococcus B.
MENINGITIS OUTBREAK
Meningococcus A or C, mainly in Sahel areas, but sometimes elsewhere (Rwanda, Brazil). Outbreaks occur in dry season.
Antibiotic treatment in well equiped hospital
With the exception of oil based chloramphenicol IM, the antibiotic utilisable IV (chloramphenicol, ampicillin, penicillin) are short acting which necessitates IV injections every 6 hours. If this cannot be done then 1 injection every 8 hours. The important thing is that injections are given at regular intervals.
Choose the antibiotic effective against the invading pathogen.
MENINGOCOCCUS (GRAM-COCCUS)
- During an epidemic
The treatment of choice is oil based chloramphenicol IM, 1 single injection, to be repeated 24-48 hours later.
Dosage: 100 mg/kg/injection without exceeding 3 g/injection, giving half into each buttock according to the table.
Table
If clinical signs fail to resolve by 3rd day of oil based chloramphenicol, change to ampicillin IV.
If necessary, chloramphenicol per os can be used: 100 mg/kg/d divided in 3-4 doses x 7 days.
- When no epidemic
chloramphenicol IV
Adult: 5-6 g/day
Child: 100mg/kg/day
in 3-4 IV regularly spaced; change to oral treatment as soon as possible; total duration 7 days.
Other treatments are more expensive:
ampicillin IV
Adult: 10-12 g/day
Child: 200 mg/kg/day
in 3-4 IV regularly spaced; change to oral treatment as soon as
possible; total duration 7 days.
or
penicillin G IV
Adult: 20 MIU/day
Child: 200,000 IU/kg/day
in 3-4 IV regularly spaced; change to PPF IM at the same dose in 1 IM/d (it is not possible to change to oral penicillin V); total duration 7 days.
PNEUMOCOCCUS (GRAM + ENCAPSULATED DIPLOCOCCUS)
- ampicillin IVAdult: 10-12 g/day
Child: 200 mg/kg/day in 3-4 IV regularly spaced
or
- chloramphenicol IV
Adult: 5-6 g/day
Child: 100 mg/kg/day in 3-4 IV regularly spaced
In both cases, change to oral treatment as soon as possible; total duration 8-10 days.
HAEMOPHILUS INFLUENZAE (GRAM-BACILLI)
- chloramphenicol IV
Adult: 5-6 g/day
Child: 100 mg/kg/day in 3-4 IV regularly spaced
or
- ampicillin IV
Adult: 12-14 g/day
Child: 200-400 mg/kg/day in 3-4 IV regularly spaced
In both cases, change to oral treatment as soon as possible; total duration 8-10 days.
If lumbar puncture is not sterile on 3rd day, treatments can be combined. The chloramphenicol must be given 1 hour after the ampicillin, otherwise antagonism will occur.
Management in isolated conditions
- Lumbar puncture if in doubt. If CSF is cloudy, it is bacterial meningitis.
- Begin treatment without delay. Prognosis depends on the speed of initiating treatment.
· If available: oil based chloramphnicol IM (see doses above). Give 2 injections while preparing to transfer to a well equiped centre.
· If not, ampicillin IV or IM, ou chloramphenicol IV or IM, or penicillin IV or IM, or PPF IM. Give same dosage as for meningococcus.
Supportive therapy
-Ensure adequate nutrition and hydration (infusions, gastric tuve if necessary).
-Convulsions: diazepam IV or IR (see "convulsions").
-Coma: nursing +++ (care against bedsores, care of mouth and eyes).
-Purpura associated with shock: treat shock by restoring blood volume (see "Shock"), plus dexamethasone IV:
Adult: 16-20 mg
Child: 0,5 mg/kg
to be repeated as necessary.
Epidemic meningitis
-In risk zones (Sahel in dry season), check weekly incidence of meningitis.
-Decide the critical treshold at which point outbreak is considered an epidemic: either twice the usual weekly incidence (difficult to ascertain) or a level of 20 cases/100,000 inhabitants/weeks (20/100,000/week).
-Inform the local authorities in order to decide public health measures to be instituted.
-Identify the causative meningococcalagent (A or C) by a rapid agglutination test.
-Mass vaccination (vaccine anti A or anti A+C), with all its associated logistic problems, can be decided for the target population: 6 months to 15 years or 25 years. A single injection is sufficient to protect for 3 years. No contraindications. The vaccine is quite stable to heat.
-WHO advises against chemoprophylaxis (sulphonamides, rifampicine). For those who have been in contact with de disease: vaccination, information and supervision +++.
-Treatment: oil based chloramphenicol IM (see above).
Whooping cough is a childhood disease characterized by paroxysmal cough and tenacious sputum and caused by Bordetella pertussis. In developing countries it contributes to malnutrition.
Clinical features
Figure 3
- The cough can recur up to one year after the initial infection.
- Infants less than 3 months may develop apneic episodes or periods of hypoxia (cyanosis) without cough which may be fatal.
COMPLICATIONS
- Anorexia may precipitate protein-calorie malnutrition.
- Sub conjunctival hemorrhages, epistaxis, hemoptysis.
- Secondary infections of the upper and lower respiratory system.
- Encephalitis.
Treatment
(dispensary)
- Some authorities recommend antibiotic treatment during the prodromal (catarrhal) stage. This will not alter the course of the disease, but may reduce the period of infectivity and thus reduce transmission.
This is not practical except during epidemics, when all "colds" can be assumed to be prodromal pertussis.
erythromycin(PO): 50 mg/kg/d divided in 3 doses x 7
days
or
chloramphenicol(PO): 50 mg/kg/d divided in 3 doses x 7 days
- During the paroxysmal stage, antibiotics are of no use. Advise the mother to ensure adequate hydration, to humidify the air if possible, to remove the tenacious strands of sputum from the oropharynx, and, most important, to continue good nutrition, in spite of the child's anorexia and even if there is vomiting with each coughing spasm (feed the child again after the episode of vomiting).
(hospital)
- Secondary infections: antibiotics PO, IM or IV depending on severity:
ampicillin (PO): 100 mg/ kg/ d divided in 3 doses x 5-10
days
or
chloramphenicol(PO): 50 to 75 mg/kg/d divided in 3 doses x 5-10
days
or
cotrimoxazole (PO): 40 mg of SMX/kg/d divided in 2 doses x 5-10
days
- Infants less than 3 months of age should be admitted to hospital, if possible, and observed 24 hours a day.
Prevention
- Immunization (part of the routine program).
- During epidemics selective immunization of non-immune infants not manifesting clinical illness who have been in contact with pertussis cases.
Disease characterized by involuntary muscle spasms, usually fatal if untreated, caused by the tetanus bacillus. The portal of entry is either a wound, or in the case of neonates, the umbilical stump if this has been sectioned with a contaminated instrument. The tetanus victim is usually not immunized (importance of mass immunization programme).
Clinical picture
- Incubation period from 2 to 60 days following wound contamination.
- Trismus, muscle spasms, dysphagia.
- The least stimulus can incite paroxysmal muscle spasms.
Portals of entry
- Dirty wounds.
- Traditional practices during childbirth (e.g. circumcision, ear piercing).
- Surgery.
- Obstetric interventions; neonatal (2-14 days after delivery) and obstetric forms.
- Unsterile intramuscular injections.
Prevention (dispensary)
- Neonatal tetanus
· Sterile instruments for delivery and cutting of the cord.
· Training of and provision of equipment for traditional birth attendants.
· Immunization: 2 injections during pregnancy, the first as early as possible (during the first antenatal visit) and the second at least 1 month after the first and no later than 1 month before delivery.
- Routine immunization of all children (EPI).
- Correct wound toilet.
- Prophylaxis: often tetanus antiserum or booster doses of tetanus toxoid are not readily available. When they are, however, apply the following protocol:
· Patient fully immunized, having had a booster within the 10 previous years: no further treatment necessary.
· Patient fully immunized but last booster was more than 10 years ago: give single booster dose of tetanus toxoid (0.5 ml).
· Patient never fully immunized:
equine antitetanus
immunoglobulin 250 to 1,500 IU given SC. (Different sources give very different
doses.) At the same time start a full course (2 to 3 injections) of tetanus
toxoid.
-If serotherapy is not available, when there is a dirty wound in an non-immunized or inadequately immunised subject, clean and protect the wound, plus peni V or procaine penicillin in the usual doses for 5 days.
Treatement (hospital)
-Nurse the patient in a place with minimal sensory stimuli.
-IV fluids: maintain proper hydration.
-Nasogastric tube feeding.
-Equine tetanus immunoglobulin
Adult: 10,000 IU SC or IM. Start with a small challenge dose in case of allergic reactions.
Child: half the adult dose
Neonate: 1,500 IU SC or IM
Equine tetanus immunoglobulin is sometimes given intrathecally: e.g. for neonates, 1,500 IU via either lumbar or suboccipital puncture.
Reactions to equine tetanus immunoglobulin are treated with: dexamethasone (IV): 4 mg as needed.
-Penicillin G is given in order to eliminate any tetanus bacilli still releasing toxin in the wound:
penicillin G (IV): 100,000 IU/kg/d divided in 4 injections
-Control of muscle spasms:
diazepam (IV): 1 to 5 mg/kg/d by infusion
Further sedation if needed:
phenobarbitone (PO): 3 mg/kg/d divided in 2 doses by nasogastric tube.
- Zoonosis infecting many rodents and transmitted to man by fleas.
Plague was formally responsible for pandemics in Europe which caused high mortality.
- Large animal reservoirs persist: South-East Asia, Central Asia, East Africa, Madagascar, South America, USA. Human infection is becoming less common.
- Transmission to humans can be:
· direct, by the bite of an infected rodent,
· vector-bome (flea) from a rodent host. Both these modes of transmission give rise to sporadic cases only.
· Epidemics, however, arise when interhuman transmission occurs via flea vectors or, more important, by direct air-borne spread (pneumonic plague).
Clinical features
-Incubation
· 1 to 6 days for bubonic plague
· several hours to
2 days for pneumonic plague
-Bubonic form
High fever; painful buboes (adenitis) which are often inguinal (as fleas tend to bite the lower limbs) and produce a sero-sanguineous discharge. Without treatment the case fatality rate is high.
-Septicemic form
A rapidly fatal complication of the bubonic form.
-Pneumonic form
Severe pneumonia with hemoptysis, rapidly fatal. Highly contagious. Occurs either as a complication of the bubonic form or subsequent to primary air-borne pulmonary infection.
Diagnosis
-Identification of Yersinia pestis (staff must take great care not to innoculate themselves accidentally) by:
· aspiration of a bubo,
· sputum
examination,
· blood culture.
-Serology becomes positive early.
Treatment (hospital)
- Sulphonamides, streptomycin, tetracyclines and chloramphenicol but not the penicillins.
- Usual choice:
streptomycin (IM)
Adult: 500 mg every 4 hours for the first 2 days, then every 6 hours x 5-7 days
Child: 10 mg/kg every 4 hours for 2 days, then every 6 hours for 5 days
- If therapy is begun early the prognosis is good.
- chloramphenicol IV can also be used
60 mg/kg/d divided in
3-4 injections x 10 days
Prevention
- If cases are suspected, it is vital to:
· confirm the diagnosis bacteriologically,
· advise
local health authorities.
- Where possible plague patients should be isolated.
- Conduct concurrent and terminal disinfection of bedding, clothes...
- Take extreme care when handling exudates and cadavres.
- Give chemoprophylaxis for household contacts and health personnel during the entire period of exposure:
sulphonamides (PO): 40 mg/kg/d during period of
contact
or
tetracycline (PO): 20 mg/kg/d during period of contact
- Use appropriate insectides to control fleas.
- There is a plague vaccine which is effective for 6 months. Protection begins 7 days after vaccination.
- Long term prevention requires rat control, sanitation and good public hygiene.
- A zoonosis due to certain spirochetes also known as Weil's disease. In humans it may cause a febrile illness and acute hepatorenal failure.
- The main reservoir is animal usually rodents (especially the sewer rat), cattle, pigs, dogs, horses, wild animals.
- Infected rats, whether diseased or healthy carriers, excrete leptospirae in their urine and thus contaminate water and soil (bathing, poor hygiene and sewers...). The portal of entry being either mucous membranes, cuts or scratches on the skin.
Clinical features
-Incubation period of 7 to 10 days. Illness often biphasic. Fever, jaundice, meningism, proteinuria, hematuria and oliguria, hepatosplenomegaly, polyadenopathies.
-Can be associated with:
· Pulmonary symptoms: cough, pneumonia,
hemoptysis;
· diffuse haemorrhagic disorder: purpura, ecchymosis,
epistaxis...;
· severe renal insuficciency: oligo-anuria;
·
cardiac insufficiency (cardiac collapse).
-The meningeal signs may predominate (the CSF is macroscopically clear with raised lymphocytes and raised protein of 1 g/l). May progress to encephalitis.
Figure 4
Diagnosis aids
- WBC: frank leucocytosis excludes viral hepatitis.
- Urine: proteinuria, abundant pus cells, hematuria, and casts.
- Diagnosis is confirmed if spirochaetes are found in blood, urin or CSF; direct examination difficult; possible with fresh specimen using dark ground microscopy or very low light levels; otherwise Giemsa stain.
- Serodiagnosis: immunofluorescence or Elisa.
Treatment (hospital)
- Rest.
- Treat fever with paracetamol (not acetysalicylic acid, owing to risk of hemorrhagic disease).
- Antibiotics:
Must be commenced early in the illness if they
are to be effective:
Oral penicillin (or IV when serious neurological symptoms). Not IM because of risk of haematoma
Adult: 5-6 MIU / d divided in 3 doses x 7 days
Child: 100,000 IU/kg/d divided in 3 doses x 7 days
If allergic:
tetracycline (PO)
Adult: 1.5-2 g/d divided in 3 doses
Child > 8 years: 50 mg/kg/d divided in 3 doses
or
erythromycin: same doses as above x 7 jours
Prevention
- Rat control, sanitation and hygiene.
- Avoid swimming in endemic regions
- A vaccine exists for highly exposed individuals (farm workers etc).
Relapsing fever or borreliosis is a febrile illness caused by spirochaetes and transmitted to humans by lice or ticks. Immunity does not exceed 1 year.
There are two forms of the disease:
- Louse-borne caused by Borrelia recurrentis, worldwide distribution and transmitted by body lice. The reservoir is infected humans. The diseases tends to spread in epidemic fashion under conditions of crowding and hardship (e.g. war, refugees, cold and poor hygiene). Pockets notably in Ethiopia, Rwanda and Burundi.
Pockets notably in Ethiopia, Rwanda and Burundi.
- Tick-borne caused by many different strains of borrelia which are specific for each geographical region. Reservoir are humans but more importantly infected rodents. Spread by the bites of various ticks and therefore tends to present sporadically rather than epidemically.
Louse-borne fever is often associated with typhus (see Rickettsioses).
Clinical features
LOUSE-BORNE FEVER
Relapsing syndrome of fever, malaise, gastro-intestinal disturbances, jaundice, petechiae, meningism and hepatosplenomegaly.
Figure 5
Complications: hepatorenal syndrome, encephalitis, myocarditis, hemorrhage and miscarriage.
TICK-BORNE FEVER
Similar clinical picture.
Diagnosis
Thick and thin blood films during the fever peaks (Giemsa stain).
Treatment (dispensary - hospital)
- Same therapy for both forms: either tetracycline, chloramphenicol or erythromycin.
tetracycline (PO)
Adult: 1.5 g/d divided in 3 doses x 7 days
Child: 50 mg/ kg / d divided in 3 doses x 7 days
In severe disease, or < 8 years:
chloramphenicol
(PO)
75 ma/ kg/ d divided in 3 doses x 7 days
Single dose of doxycycline (PO) is also effective:
Adult: 200 mg
Child: 50 mg
For pregnant women:
penicillin V: 1.2 MIU/d divided in 3
doses x 7-10 days (beware of procaine penicillin: risk of haematoma).
- Therapy sometimes induces a Herxheimer reaction after the
first dose of antibiotics with fever, hypotension and neurological disturbances.
Therapy should therefore be supervised. Reactions are treated
with:
dexamethasone: 20 mg IM or IV
and/or
digoxine (IV) (see "Cardiac
failure")
The following regimen may reduce the chance of reaction:
Day
1: PPF(ou procain penicillin): 400,000 IU (IM)
Days 2 to 7: tetracycline (PO)
as above.
Prevention
LOUSE-BORNE FEVER
- Control of body lice: powder body and clothes with an
effective insecticide, usually:
1% lindane
If resistance, use:
malathion (powder) 1 %
or
propaxur
(Baygon)
or
deltamethine (K-othrine)
Use extreme care with these substances (toxic); handlers need instructions and supervision. Ask the MOH for guidance.
- In order to be effective the above measure should be applied to the entire population and repeated once after two weeks. This obviously requires good organization.
- Chemoprophylaxis:
doxycycline (PO): 200 mg/week in single
dose during epidemic.
Note that healthy carriers of relapsing fever are at risk of developing a Herxeimer reaction under chemoprophylaxis.
TICK-BORNE FEVER
Control of ticks: insecticides and personal protection.
- Group of diseases caused by Rickettsia spp, transmitted to humans by an arthropod vector.
- Transmission depends on the presence of:
· Reservoir of infection: human or animal.
· Vector: e.g. body lice, often associated with conditions of poor hygiene and sanitation.
· Crowding: such as in refugee camps.
Table 14
There are numerous other rickettsioses:
- scrub typhus
- Rocky Mountain spotted fever
- boutounneuse fever
- Q fever...
Their occurrence may be sporadic or epidemic.
Clinical features
-The different forms have a certain common core of clinical features
· high fever of sudden onset,
· severe headache,
chills, body pains,
· macular rash,
· prostration and coma.
-Evolution of the illness can be cyclical. After 2 weeks, there is a terminal crisis when the signs become more severe then resolve.
-Without therapy, grave and sometimes fatal complications may ensue: encephalitis, myocarditis and hemorrhagic disease.
Diagnosis
Confirmation can only be made by serology.
Treatment (hospital)
- Symptomatic for fever, dehydration... Not aspirin.
- Antibiotics:
tetracycline (PO)
Adult: 1-1.5 g/d divided in 3 doses x 7 days
Child: 50 mg/kg/d divided in 3 doses x 7 days
or
cloramphenicol (P O)
Adult: 2 g/d divided in 3 doses x 7 days
Child: 50 mg/kg/ d divided in 3 doses x 7 days
- Epidemic louse-borne typhus can be managed by giving a single oral dose of doxycycline: 200 mg (but risk of relapse).
- Therapy of typhus should not normally provoke a Herxheimer reaction (see louseborne relapsing fever) however, in some regions such as Ethiopia, the two diseases may sometimes co-exist in the same patient and a reaction is thus possible.
Prophylaxis
LOUSE-BORNE TYPHUS
- Control of body lice
· Powder body and clothes with an effective insecticide, usually 1% lindane.
· If resistance, use 1% malathion.
· Use extreme care with these substances: handlers need instructions and supervision. Ask the MOH for guidance.
· In order to be effective, the above measure should be applied to the entire population and repeated after two weeks. This obviously requires good organization.
- Chemoprophylaxis
doxycycline (PO): 200 mg/week in a single
dose during epidemic.
Risk of Herxheimer reaction in asymptomatic carriers of
relapsing fever.
FLEA-BORNE TYPHUS
Control of rats and fleas.
- A systemic illness due to the gram negative Brucella. Transmitted to humans from infected cattle, sheep, goats or pigs, either by direct contact with infected tissues or by ingestion of milk.
- Often underdiagnosed, it is probably frequent among animal herders. It tends to occur predominantly among young males, who often have most contact with animals.
Clinical features
- Incubation period from 5 to 30 days.
- Acute brucellosis with septicemia
Oscillating fever,
sweats, flitting pains in the bones, joints and muscles.
Fever then plateaus
at 39 to 40°C, with tachycardia.
Defervescence after 10 to 14
days.
Hepatosplenomegaly and generalized adenopathy occur often with a group
of nodes gathered around a single larger one.
- Subacute brucellosis with focalization
Localized foci of
infection that persist and evolve autonomously. But mainly osteoarticular
(sternocostal, knee, tibia, spine, sacro-iliac).
Also meningeal and
encephalitic foci occur.
Note: brucellosis can minic Pott's disease, osteitis
or tuberculosis meningitis.
- Chronic brucellosis
Low grade fever, fatigue, vague pains
and sometimes infectious foci (such as arthritis).
Diagnosis
- Leucopenia with relative lymphocytosis
- Reaction to intradermal antigen
- Serology: rising titres in Wright's haemagglutination test or the Rose Bengal card test.
Treatment
ANTIBIOTICS
- Tetracycline (PO)
Adult: 2-3 g/ d divided in 3 doses
Child > 8 years: 50 mg/kg/d divided in 3 doses
- Cotrimoxazole (PO): tab 400 mg of SMX + 80 mg of TMP
Adult: 6 cp/ d divided in 2 doses
Child: 60-70 mg of SMX/kg/d (or 15 mg of TMP/kg/d) divided in 2 doses
- Streptomycin(IM)
Adult: 1 g/d in 1 injection
Child: 15 mg/kg/d in 1 injection
- Rifampicine (PO)
Adult: 900 mg/d in 1 dose
Child: 20 mg/kg/d in 1 dose
- Doxycycline and chloramphenicol also effective. Streptomycin can be replaced by gentamicin. Never use streptomycin or rifampicine alone.
RECOMMENDED MANAGEMENT
1. First treatment: tetracyclines x 6 weeks + streptomycin for
first 3 weeks.
2. Second treatment: cotrimoxazole for 2-3 months.
3. Third
treatment: tetracyclines+ rifampicine x 45 days.
INDICATIONS
- Acute brucellosis
Use first treatment.
- Brucellosis affecting bones
Use first treatment but
continue tetracyclines a further 45 days or better:
tetracyclines+
rifampicine for 3 months when possible.
- Neurologic attack
Add rifampicine to combined
tetracyclines-streptomycin.
- Pregnancy, breast feeding or children < 8 years
Use
cotrimaxazole, or rifampicine + streptomycin (if illness does not resolve).
- Relapse
Use first treatment if not already tried. If used
before, add rifampicine or change to cotrimoxazole (never use cotrimoxazole and
rifampicine together: antagonism).
- Chronic brucellosis
Only give antibiotic therapy if
persistent focus of infection, otherwise only analysis.
Prophylaxis
- Veterinary measures.
- Washing of hands and clothes after
contact with animals.
- Boil milk, avoid fresh cheeses and partially cooked
meat in endemic
zones.
Systemic illness caused by Salmonella typhi with foci of infection in the lymph and intestine. Transmitted either directly (unwashed hands) or indirectly (contaminated food or water).
Clinical features
- High fever, severe headache, insomnia, prostration, epistaxis.
- Either diarrhea or constipation, abdominal pain, bloated abdomen
- Splenomegaly, rose spots, pulse not in accord with fever.
- Complications (which may appear even during convalescence under therapy): GIT perforation or hemorrhage, peritonitis, septicemia, myocarditis, encephalitis.
- Leucopenia.
- Widal test (serology) becomes positive around the 8-lOth day (for the O antigen non-specific test).
- S. typhi can be isolated from blood or stool during the first two weeks.
Treatment (hospital)
- Close observation for complications.
- Treat fever and hydrate.
- Oral antibiotics are more effective than IV or IM (since the focus of infection is in the lymph nodes of the small intestine).
· First choice
chloramphenicol (PO)
Adult: 2 g/d divided in 3-4 doses
Child: 75 to 100 mg/kg/d divided in 3-4 doses
Start initially with half the dose the first day, and increase progressively.
· Alternatives (if resistance or contra-indication to
chloramphenicol):
ampicillin (PO) (progressive dose)
Adult: 4 to 6 g/ d divided in 3-4 doses
Child: 100 mg/kg/d divided in 3-4 doses
cotrimoxazole (PO) (1/2 dose and increase progressively over 3-4 doses)
Adult: 1,600 mg of SMX / d divided in 2 doses
Child: 40 mg of SMX/kg/d divided in 2 doses
- If patient cannot take antibiotics by mouth give IV initially but change to oral route as soon as possible.
- Continue treatment for 2 weeks after patient is apyrexial.
Prevention
- Isolation of cases
- Disinfection of excrete with chlorine
solution 2% or cresol 4%.
- Personal hygiene: hand washing and careful food
preparation.
- Community hygiene: water, sanitation and health
education.
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