Typhoid fever/salmonella

infection

MR. F. PHIRI
Definition
Typhoid fever is a systemic infectious
(enteric fever) disease caused by
salmonella typhi characterized by high
continuous fever, malaise, and rose
coloured spots.
Causative Organism

A bacteria called Salmonella typhi.

The organism is readily killed by drying,
pasteurization, and common disinfectants.
Reservoir of infection

Man is the only reservoir of infection.

Both cases and carriers are infectious as
long as the bacilli appear in stools or
urine.
Carriers may be temporary (incubatory,
convalescent) or chronic.
Convalescent carriers excrete the bacilli
for 6 to 8 weeks.
Mode of transmission

 Faecal oral route through ingestion of

contaminated water and food, especially
raw fruits and vegetables.
Source of infection

The primary sources of infection are

faeces and urine from the sick or carriers;
the secondary sources are contaminated
water, food, fomites, fingers and flies
Environmental and Social Factors

Incidence of typhoid rises during the rainy

season.
During this period, there is also an increase
in fly population.
Outside the human body, the bacilli are
found in water, ice, food, milk and soil for
varying periods of time.
Typhoid bacilli do not multiply in water;
many of them die within 48 hours to 7 days.
The bacilli may survive for over a month
in ice and ice cream, up to 70 days in soil
irrigated with sewage under moist
conditions, and about 30 days or more in
dry conditions.
The bacilli multiply and survive in food
especially milk. Vegetables grown in
sewage farms or washed in contaminated
water are a health hazard.
Social factors such as contaminated water
supply, open air defecation and urination,
low standards of food and personal
hygiene influence the disease spread.
Incubation Period

Usually 10 to 14 days.
Depending on the dose of the bacilli, it
may take as short as 3 days and as long as
21 days.
Pathogenesis

Infection occurs through ingestion of the

organism which rapidly penetrates the
intestinal mucosa and multiplies in the
lumen for a short period and stools can be
cultured and it can be positive during the
1st 4 days of the incubation period.
From the mucosa, the organisms travel to
mesenteric lymph nodes.
After a brief period of multiplication here,
the organisms enter the blood stream via
the thoracic duct (transient primary
bacteraemia) and are transported to the
liver and spleen.
After a period of further multiplication at
these sites, huge numbers of organisms
enter the blood stream, making the onset of
clinical illness (secondary bacteraemia).
During this secondary bacteraemia, which
continues for the greater part of the illness,
very few organs escape invasion but the
involvement of the gall bladder and peyer’s
patches in the lower small intestine have
clinical importance.
The gall bladder is infected via the liver
and the resultant cholecystitis is usually
sub-clinical.
The infected bile renders stool cultures
positive.
Pre-existing gall bladder disease
predisposes to chronic bile infection,
leading to chronic faecal carriage.
Invasion of the peyer’s patches occurs
either during the primary intestinal
infection or during the secondary
bacteraemia, and further seeding occurs
through infected bile.
The peyer’s patches become hyperplastic,
with infiltration of chronic inflammatory
cells.
Later necrosis of the superficial layer
leads to formation of irregular, ovoid
ulcers along the long axis of the gut, so
that stricture formation does not occur
after healing.
When an ulcer erodes into a blood vessel,
severe haemorrhage results and
transmural perforation leads to peritonitis.
Clinical Manifestations of Typhoid Fever

The course of untreated typhoid fever is

divided into four individual stages, each
lasting approximately one week.
 The symptoms may be mild or severe.
Stage 1(week 1):
 Features are non specific in the first
week. The onset is insidious in adults, but
may be abrupt in children.
The early symptoms and prodrome are
severe headache, malaise, anorexia, body
pains, and epistaxis.
The temperature rises in a step ladder
fashion (remittent fever) of about 40oC by
the end of the first week.
A mild, non-productive cough
Constipation
Usually enlarged and tender spleen
causing abdominal pain
Stage 2/ Week 2:
Patient lies prostrate, looks toxic with
sustained (continuous) high temperature
of 40oC.
Patient may become confused and
disoriented with hallucinations
Slight abdominal distension and
tenderness in the right lower quadrant.
Patient becomes delirious, and sometimes
agitated hence the nick name “nervous fever”.
Rose spots (crops of 2mm – 4mm diameter,
pink papules) that fade on pressure, develop
on the upper abdomen and lower chest,
between the 7th and 12th days. They are
difficult to detect in dark-skinned individuals.
The spots are caused by bacterial
embolization and rose spot cultures may be
positive.
Relative bradycardia, a pulse lower than
anticipated in a febrile patient.
Stage 3/ Week 3:
Patient becomes more toxic and ill
Continuous high fever persists
Delirium continues
Abdominal distension becomes more
pronounced, with scanty bowel sounds.
Crackles may develop over the lung bases
Diarrhoea (6 – 8 stools in a day), green,
foul smell, comparable to pea soup.
Hepatosplenomegaly and elevation of
liver transaminases
Considerable weight loss
Widal reaction is strongly positive with
antiO and antiH antibodies.
Blood cultures are sometimes still
positive at this stage.
A number of complications can occur in the
third week:
Intestinal haemorrhage due to bleeding in
congested Peyer’s parches; this can be very
serious and usually not fatal.
Intestinal perforation in the distal ileum:
this is a very serious complication and is
frequently fatal. It may occur without
alarming symptoms until septicaemia or
diffuse peritonitis sets in.
Encephalitis
Neuropsychiatric symptoms (described as
“muttering delirium” or “coma vigil”), with
picking at beddings or imaginary objects.
Metastatic abscesses, cholecystitis,
endocarditis and osteitis
Dehydration develops and patient is still
delirious (typhoid state)/
By the end of third week, the fever starts to
reduce.
Stage 4/ Week 4:
In patients who survive:
The fever, mental state and abdominal
distention slowly improve over a few days
but intestinal complications may still
occur.
Convalescence is usually a slow process
Prognosis:

Prognosis is good with early diagnosis

and/or appropriate treatment
Management of a patient with typhoid
fever
Investigations

 History will reveal symptoms including, pea soup

diarhoear, poor water sources etc,
 Physical examination, will reveal characteristics
signs e,.g rose spots, abdominal tenderness, etc.
 Full Blood Count will show mild leucocytosis,
leucopenia and neutropenia, normocytic anaemia,
mild thrombocytopenia
 Elevated serum transaminases and mild proteinuria
 Blood and bone marrow culture will isolate
causative organism (definitive diagnosis)
 Faecal and urine cultures
Faecal cultures are usually positive in the first
week (presumptive evidence)
Urine cultures are positive less often
Serology: Widal test will be positive. Widal
reaction detects antibodies to the causative
organism but has limitations in that patients with
previous immunization to typhoid fever and
those who had other salmonella infection will
have a positive widal test
Detection of IgG and IgM antibodies from blood
samples
Drug Therapy
1. Antibiotics e.g.
Ciprofloxacin tab 500mg orally BD for 14 days.
If patient is vomiting persistently, 400mg I.V.
12 hourly for 7 days or
Amoxycillin cap 500mg orally 8 hourly for 2
weeks, or
Co-trimoxazole tab 960mg orally BD for 1
week, or
Azithromycin cap 500mg orally as a single dose
followed by 250mg daily on day 2 to day 7
2. Antipyretic drug e.g.
Paracetamol 1g tds for 5 days
3. Fluid and Electrolyte replacement therapy
according to the level of dehydration.
NURSING CARE

Objectives
1. To allay anxiety
2. To relieve pain
4. To prevent complications
5. To prevent cross infection
ENVIRONMENT

 Patient must be nursed in a clean environment, and in

Isolation to prevent the spread of the disease.
 There should be no bed pan or urinal lying around in Patient’s
room. Used bedpans and urinals must be emptied
immediately after use and disinfected.
 Room must be mopped and dump dusted with a disinfectant,
and there must be nothing in the room – that would attract
flies e.g. left over foods or any colour or effective smell.
 Visitors must be restricted or prevent from entering this
environment for fear of contracting the infection.
 If possible, the environment must have running water and
soap for washing hands.
 The room must be well ventilated to allow free air movement.
PSYCHOLOGICAL CARE

 Explain the condition to patient and his relatives ie, its cause,
predisposing factors, mode of transmission, treatment and
complications if the case is not well managed.
 Explain that the disease is curable, but the most important
thing is to adhere to treatment and observe personal hygiene.
 Explain to patient friends and his relatives why patients has
been quarantined, tell them about the nature of the disease
and why its important for him to be quarantined
 Explain every procedure that is done on him to allay anxiety
and gain his co.operation.
 Allow patient and his relatives to ask questions and answer
them politely.
OBSERVATIONS.

 Observe patient for fever which a common symptom in

this condition. Observe patient especially the 1st two-
three days of starting treatment to see if patient is
responding to treatment.
 Observe and pulse rate 4-6 hrly, if BP is low, it may be an
indication of intestinal bleeding. IF BP is low commence
a drip of IV fluids especially N/Saline and inform the
doctor.
 Observe patient for abdominal pains and signs of shock
and take precautions to prevent it or manage it.
 Observe for nasal bleeding.
 Observe for general condition of patient in case he may be
going into a stupor or coma.
NUTRITION

 Frequent feeds are needed because of gastro-intestinal bleeding

or other gastro-intestinal disruption.
 Sometimes IV feeds are recommended and given until the
patient can digest food.
 Avoid hard foods as they may irritate the mucosa lining of the
intestinal lumen, preferably give fluid diet.
 Avoid spicy foods because they will worsen the abdominal
pains due to irritants contained in the spicies.
 Give high protein and vitamin diet to help in repair of damaged
body cells.
 Serve meals in small amounts to stimulate the appetite since
patient has loss of appetite, and observe as he eats in case he
has developed sore throat. If he has sore throat give frequent
sips of milk to sooth the throat.
ELIMINATION

Observe patient’s elimination patterns and

the consistence of the waste matter because
the patient may constipation or sometimes
diarrhea. Record the observations.
Observe the urination pattern and
encourage him to be voiding not to avoid
urinating for fear of pain on urination.
Observe the colour and smell of urine in
case of infection.
HYGIENE

 All health personnel and relatives attending to this patient

must strictly observe hygiene. Everytime after attending
to this patient, they must always remember to wash their
hands and even before they leave the patient’s room.
 Patient himself should be taught that he must always
wash hands after visiting the toilet and before eating
anything.
 Fruits must be washed before eating them
 Left over foods must always be well covered and be re-
boiled before eating it.
 Drinking water must always be treated either by boiling
or chlorinating it and kept in a clean container with a
tightly closed lid.
 Relatives and friends must not be allowed to sit on patient’s
bed, and must wash their hands before leaving patient’s room.
 Gloves must always be warm when attending to this patient.
 Patient must have daily baths to promote blood circulation
and self esteem.
 If patient has long finger nails, the nurse must see to it that
they are cut short to prevent labouring of micro organism.
 Linen must be changed frequently especially when soiled,
then disinfected and sent to the laundly separated with a label.
 Patient must have oral toilet or mouth washes to prevent
halitosis which may promote appetite.
MEDICATION:

Give prescribed antibiotics and observe

for effects of the drug(s) side effects and
general condition if responding to
treatment or not.
Give the right drug, at the right time to
the right patient and the right dose.
Observe patient and make sure he has
swallowed the drug if given orally.
IEC

 Explain to the patient the cause and predisposing

factors of typhoid fever.
 Talk about preventive measures – hand washing
before eating and after use of the toilet, covering left
over foods and re-boiling it before eating, washing
fruits before eating them.
 Proper disposal of human faeces and urine.
 Proper disposal of human faeces and urine, covering
pit latrines etc.
 Boil drinking water
 Keep surroundings clean and dry to keep flies away
which may spread infection
 Proper handling of soiled linen – handle with gloves and
sluice it separately and disinfect before washing it, and
this linen to be kept and washed separately from other
linen.
 Educate patient on restriction of visitors into the
environment
 Educate patient on other risk factors like over use of anti-
acids, this should be avoided.
 Educate the community where this patient comes from
on causes, signs and symptoms, complications and how
to prevent the disease eg by observing hand washing
after toilet and before eating. Tell them to avoid visiting
patients with such an illness.
Prevention and control of typhoid fever

There generally three lines of defence

against typhoid fever:
1. Control of Reservoir/cases
Early diagnosis: early symptoms are non-
specific. Culture of blood and stools are
important investigations in the diagnosis
of cases
Notification: this should be done
following the notification procedure
Isolation: since typhoid fever is infectious
and has a prolonged course, enteric
precautions should be observed. Patients
should be admitted to a health facility and
isolated until three bacteriologically
negative stools and urine reports are
obtained on three separate days.
Treatment: appropriate and effective
treatment should be administered.
Disinfection: stool and urine are the sole
sources of infection. They should be
received in closed containers and
disinfected using the recommended
disinfectant. All soiled clothes and linen
should be soaked in a recommended
disinfectant. Hand washing should be
observed by all who get in contact with
the patient and contaminated items.
Follow up: follow up examination of
stools and urine should be done for S.
typhi 3 to 4 months after discharge of the
patient, and again after 12 months to
prevent the development of the carrier
state.
Carriers
Identification: carriers are identified by
cultural and serological examinations.
Duodenal drainage establishes the
presence of salmonella in the biliary tract
in carriers.
Treatment: the carrier should be given an
intensive course of effective drug therapy.
Surveillance: carriers should be kept under
surveillance. They should be prevented
from handling food, milk or water for
others.
Information, Education and
Communication: regarding hand washing
with soap after defecation or urination and
before preparing food, use of toilets/pit
latrines, control of fly population, terminal
disinfection of all contaminated articles.
2. Control of Sanitation
Protection and purification of water
supplies, Improvement of basic sanitation,
Promotion of food hygiene are essential
measures to interrupt transmission of
typhoid fever.
3. Mass Immunization with Typhoid
Vaccine
Those living in endemic areas
Household contacts
Groups at risk of infection such as school
children and hospital staff
Travelers proceeding to endemic areas,
Complications of typhoid fever

1. Intestinal haemorrhage: This occurs

when the sloughs overlaying the peyer’s
patches separate during the late second or
early 3rd week of the illness.
Signs and Symptoms
Sharp fall in body temperature and blood
pressure, and sudden tachycardia.
Passage of bright red blood per rectum
but may be absent in the presence of
paralytic ileus.
Management: Sedation and blood
transfusion
2. Intestinal perforation: also occur when
the sloughs overlaying the peyer’s patches
separate during the late second or early 3rd
week of the illness.
Signs and Symptoms
Recognition of perforation is difficult.
Usually pain and tenderness worsens
Pulse rate rises
Body temperature falls suddenly
Discovery of free fluid in the abdomen
Demonstration of gas under the
diaphragm
3. Complications in the liver, gallbladder
and pancreas
Hepatitis
Cholangitis
Cholecystitis
Pancreatitis
4. Cardiorespiratory complications
Toxic myocarditis (tachycardia, weak
pulse and heart sounds, hypotension, ECG
abnormalities
Mild bronchitis
Bronch-pneumonia and lobar
consolidation
5. Complications in the nervous system
Toxic confusional state (disorientation,
delirium and restlessness)
Facial twitching or convulsions
Paranoid psychosis or catatonia
Meningitis
Encephalomyelitis
6. Hematological and renal complications
Subclinical disseminated intravascular
coagulation
Hemolysis
Immune complex glomerulonephritis
Nephritic syndrome

7. Musculoskeletal complications
Arthritis
Osteomyelitis