Enteric fever: Difference between revisions

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===Microbiology===
  
===Microbiology===
   
−
*Caused by ''[[Salmonella enterica]]'' subsp. ''typii'' and ''paratyphii''
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*Caused by ''[[Salmonella enterica]]'' subspecies ''enterica'' serotypes Typhi and Paratyphi
 
*Virulence is related to Vi antigen and invasin protein
  
*Virulence is related to Vi antigen and invasin protein
   
 
===Epidemiology===
  
===Epidemiology===
   
−
*Fecal-oral transmission acquired from contraminated food, milk, or water
 +
*Fecal-oral transmission acquired from contaminated food, milk, or water
 
*Less than 5% of infected people become chronic carriers, with bacteria remaining in the gallbladder despite adequate antibiotic treatment
  
*Less than 5% of infected people become chronic carriers, with bacteria remaining in the gallbladder despite adequate antibiotic treatment
   
 
===Pathophysiology===
  
===Pathophysiology===
   
−
*Induction of pH-shock proteins and other adaptions allow ingested bacteria to pass through the stomch and into the small intestine
 +
*Induction of pH-shock proteins and other adaptions allow ingested bacteria to pass through the stomach and into the small intestine
−
*There, they penetrate the intestinal mucosa followed by mononuclear cells, which transport them to lypmh nodes
 +
*There, they penetrate the intestinal mucosa followed by mononuclear cells, which transport them to lymph nodes
 
*They multiple within the reticuloendothelial system during the incubation period
  
*They multiple within the reticuloendothelial system during the incubation period
 
*After a threshold is reached, they disseminate to blood
  
*After a threshold is reached, they disseminate to blood
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*Most commonly presents as [[fever in the returned traveller]]
  
*Most commonly presents as [[fever in the returned traveller]]
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*Incubation period 5 to 21 days
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*Incubation period [[Usual incubation period::5 to 21 days]]
  +
*Symptoms progress over weeks
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*Prominent symptoms include high [[Causes::fever]], [[Causes::headache]], [[Causes::diarrhea]] or [[Causes::constipation]], [[Causes::relative bradycardia]], [[Causes::splenomegaly]], and [[Causes::leukopenia]]
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**First week: [[Causes::fever]], [[Causes::chills]], [[Causes::bacteremia]], [[Causes::relative bradycardia]], [[Causes::headache]]
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*If untreated for several weeks, a blanchable [[Causes::papular rash]] ("rose spots") may appear
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**Second week: [[Causes::abdominal pain]], and a blanchable [[Causes::papular rash]] ("rose spots") may appear
  +
**Third week: can progress to gastrointestinal perforation, hepatosplenomegaly, GI bleed, secondary bacteremia
  +
*[[Causes::Constipation]] is more common in adults, while [[Causes::diarrhea]] is more common in children and people with [[HIV]]
  +
*CBC shows [[Causes::leukopenia]] and [[Causes::anemia]]
 
*Extraintestinal manifestations are myriad
  
*Extraintestinal manifestations are myriad
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**[[Meningoencephalopathy]], [[abscess]] or [[empyema]], and others
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**[[Myelitis]], [[psychosis]], [[ataxia]], [[parkinsonism]]
  +
**[[Meningoencephalopathy]]
  +
**[[Abscess]] or [[empyema]]
 
**[[Endocarditis]], [[myocarditis]], and [[pericarditis]]
  
**[[Endocarditis]], [[myocarditis]], and [[pericarditis]]
 
**[[Pneumonia]]
  
**[[Pneumonia]]
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==Diagnosis==
  
==Diagnosis==
   
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*Blood cultures (large volume, like x4), stool cultures, bone marrow
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*Blood cultures (large volume, like x4), stool cultures, bone marrow biopsy (most sensitive)
−
*Biopsy (most sensitive)
  
   
 
==Management==
  
==Management==
   
−
*Treatment with third-generation cephalosporins like [[Is treated by::ceftriaxone]]
 +
*Treatment with third-generation cephalosporins like [[Is treated by::ceftriaxone]], stepped down to oral when improving and susceptibility data are available
  +
**Alternatives are [[Is treated by::azithromycin]], followed by [[ampicillin]], [[TMP-SMX]], [[chloramphenicol]]
−
*Avoid fluoroquinolones due to high resistance rate
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**Avoid [[fluoroquinolones]] due to high resistance rate
−  
  +
*Duration 10 to 14 days
  +
**Can take 4 to 6 days to defervesce, even with treatment
  +
*Monitor for relapse 2 to 3 weeks after treatment ends
  +
{| class="wikitable"
  +
!Antibiotic
  +
!Dose
  +
!Duration
  +
|-
  +
|[[azithromycin]]
  +
|1 g p.o. once followed by 500 mg p.o. daily, or
  +
1 g p.o. daily
  +
|5 to 7 days
  +
|-
  +
|[[ciprofloxacin]]
  +
|500 mg p.o. twice daily
  +
| rowspan="2" |7 to 10 days
  +
|-
  +
|[[ofloxacin]]
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|400 mg p.o. twice daily
  +
|-
  +
|[[ceftriaxone]]
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|2 g IV daily
  +
| rowspan="6" |10 to 14 days
  +
|-
  +
|[[cefotaxime]]
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|1 to 2 g IV every 6 to 8 hours
  +
|-
  +
|[[cefixime]]
  +
|200 mg p.o. twice daily
  +
|-
  +
|[[meropenem]]
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|1 to 2 IV every 8 hours
  +
|-
  +
|[[TMP-SMX]]
  +
|1 DS tablet p.o. twice daily
  +
|-
  +
|[[amoxicillin]]
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|1 g p.o. three times daily
  +
|-
  +
|[[chlormaphenicol]]
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|500 tp 750 mg p.o. four times daily
  +
|14 to 21 days
  +
|}
 
[[Category:Gram-negative bacilli]]
  
[[Category:Gram-negative bacilli]]
 
[[Category:Returned travellers]]
  
[[Category:Returned travellers]]

Latest revision as of 10:59, 13 May 2024

Background

Microbiology

  • Caused by Salmonella enterica subspecies enterica serotypes Typhi and Paratyphi
  • Virulence is related to Vi antigen and invasin protein

Epidemiology

  • Fecal-oral transmission acquired from contaminated food, milk, or water
  • Less than 5% of infected people become chronic carriers, with bacteria remaining in the gallbladder despite adequate antibiotic treatment

Pathophysiology

  • Induction of pH-shock proteins and other adaptions allow ingested bacteria to pass through the stomach and into the small intestine
  • There, they penetrate the intestinal mucosa followed by mononuclear cells, which transport them to lymph nodes
  • They multiple within the reticuloendothelial system during the incubation period
  • After a threshold is reached, they disseminate to blood

Clinical Manifestations

Diagnosis

  • Blood cultures (large volume, like x4), stool cultures, bone marrow biopsy (most sensitive)

Management

  • Treatment with third-generation cephalosporins like ceftriaxone, stepped down to oral when improving and susceptibility data are available
  • Duration 10 to 14 days
    • Can take 4 to 6 days to defervesce, even with treatment
  • Monitor for relapse 2 to 3 weeks after treatment ends
Antibiotic Dose Duration
azithromycin 1 g p.o. once followed by 500 mg p.o. daily, or

1 g p.o. daily

5 to 7 days
ciprofloxacin 500 mg p.o. twice daily 7 to 10 days
ofloxacin 400 mg p.o. twice daily
ceftriaxone 2 g IV daily 10 to 14 days
cefotaxime 1 to 2 g IV every 6 to 8 hours
cefixime 200 mg p.o. twice daily
meropenem 1 to 2 IV every 8 hours
TMP-SMX 1 DS tablet p.o. twice daily
amoxicillin 1 g p.o. three times daily
chlormaphenicol 500 tp 750 mg p.o. four times daily 14 to 21 days
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