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Infectious Diseases

Typhoid Fever (Enteric Fever)

A systemic bacterial infection caused by Salmonella enterica serovar Typhi (S. Typhi) or Paratyphi A, B, C. Spread via faecal-oral route through contaminated food and water.

Also known as: Enteric Fever

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Referral and warning signs

When to refer

Refer to Hospital (HC3/4/H) for initiation of treatment, confirmation of diagnosis, and management. URGENT referral needed if: Severe illness (high fever, prostration, delirium), Signs of complications (severe abdominal pain/distension, GI bleeding, signs of peritonitis, shock).

Red flags

  • Severe abdominal pain or rigidity.
  • Hematochezia or Melena (GI bleeding).
  • Signs of shock.
  • Altered mental status / Delirium / Coma.
  • Persistent high fever despite treatment.

Signs and symptoms

  • Insidious/gradual onset (typically 10-15 days incubation).
  • First Week: Stepwise rising fever, headache, malaise, chills, anorexia, cough (often dry), constipation (more common than diarrhoea initially), abdominal pain/tenderness.
  • Second Week: Sustained high fever, relative bradycardia (pulse rate lower than expected for fever), marked fatigue/prostration, abdominal distension, splenomegaly (tender), 'Rose spots' (faint salmon-coloured macules on trunk - transient, often missed), diarrhoea ('pea soup' type) may develop.
  • Third Week (if untreated): Complications develop. Delirium, stupor ('typhoid state'), intestinal haemorrhage, intestinal perforation, continued fever.
  • Fourth Week: Gradual improvement if survives, or death from complications.

Risk factors

  • Consumption of contaminated food or water.
  • Poor sanitation and hygiene.
  • Close contact with an infected person or chronic carrier.
  • Travel to endemic areas.

Diagnosis

Clinical assessment

Suspicion based on gradual onset sustained fever, headache, abdominal pain, relative bradycardia, splenomegaly in endemic setting. Rose spots highly suggestive but uncommon/transient.

Differential diagnosis

  • Malaria (severe).
  • Brucellosis.
  • Tuberculosis (disseminated).
  • Rickettsial infections (Typhus).
  • Amoebiasis.
  • Leptospirosis.
  • Viral Hepatitis.
  • Lymphoma.
  • Other causes of fever/sepsis.

Investigations

  • Blood Culture: Gold standard for diagnosis. Highest yield in first 1-2 weeks of illness. Obtain before antibiotics.
  • Stool Culture: Positive later in illness (week 2-3) and in carriers.
  • Urine Culture: May be positive later.
  • Bone Marrow Culture: Highest sensitivity but invasive.
  • Rapid Diagnostic Tests (Serology - e.g., Tubex, Typhidot): Detect antibodies (IgM/IgG). Limited sensitivity/specificity, especially in endemic areas (background antibodies). May support diagnosis in right clinical context but should NOT replace culture. Positive IgM suggests recent infection.
  • Widal Test: Agglutination test. NOT recommended for diagnosis of individual cases due to very poor sensitivity/specificity, cross-reactivity, difficulty in interpretation (especially single titre).
  • FBC: May show anaemia, leucopenia (or normal/mildly elevated WBC).

Diagnostic criteria

Definitive: Isolation of S. Typhi/Paratyphi from blood, stool, urine, or bone marrow. Presumptive: Compatible clinical picture + Positive RDT (IgM) / Supporting evidence.

Management

Non-pharmacological management

  • Adequate hydration (oral or IV fluids).
  • Nutritional support.
  • Fever control (paracetamol).
  • Monitor for complications.

Pharmacological treatment

  • Antibiotic Therapy: (Start based on clinical suspicion/positive RDT, adjust based on culture/sensitivity if available). (LOC: HC3+)
  • - First line (Fluoroquinolones - check local resistance): Ciprofloxacin 500mg PO Q12H for 10-14 days. (Child: 10-15mg/kg Q12H). (Resistance increasing).
  • - Alternative (Third-gen Cephalosporins): Ceftriaxone 1-2g IV/IM OD for 10-14 days (especially for severe/complicated cases or quinolone resistance). (Child: 50-75mg/kg OD). (LOC: HC4)
  • - Alternative: Azithromycin 500mg-1g PO OD for 7-14 days.
  • - Alternative (if susceptible): Chloramphenicol 500mg PO/IV Q6H for 14 days (Child: 25mg/kg/dose). (Risk of aplastic anaemia). (LOC: HC3/4)
  • - Alternative (if susceptible/pregnancy): Amoxicillin 1g PO Q8H for 14 days (Child: 15-25mg/kg/dose). (LOC: HC3)
  • Severe Typhoid (delirium, shock, obtundation): Consider adding Dexamethasone IV/PO for first 48h (specialist advice).
  • Management of Complications:
  • - Intestinal Perforation/Haemorrhage: Requires urgent surgical intervention, blood transfusion, broad-spectrum antibiotics covering anaerobes.

Monitoring

Monitor fever resolution (usually within 3-5 days of effective antibiotics). Monitor for complications (bleeding, perforation). Monitor clinical improvement.

Complications

  • Intestinal Haemorrhage (lower GI bleed).
  • Intestinal Perforation -> Peritonitis.
  • Toxic myocarditis.
  • Encephalopathy / Delirium / Coma ('typhoid state').
  • Cholecystitis.
  • Osteomyelitis / Septic arthritis.
  • Pneumonia.
  • Relapse (common if treatment inadequate).
  • Chronic carrier state (gallbladder colonization).

Prevention

  • Access to safe drinking water.
  • Improved sanitation and sewage disposal.
  • Proper food hygiene practices (handwashing, thorough cooking).
  • Identification and treatment of chronic carriers.
  • Vaccination: Typhoid vaccines (injectable Vi polysaccharide, oral Ty21a) available, offer moderate protection, recommended for travellers/high-risk groups.

Patient education

  • Explanation of the infection and faecal-oral transmission.
  • Importance of completing the full antibiotic course.
  • Need for adequate hydration and nutrition.
  • Personal hygiene measures (handwashing after toilet, before eating).
  • Food and water safety precautions.
  • Importance of follow-up stool cultures (if required to confirm clearance/detect carrier state).

Uganda-specific notes

Typhoid fever is endemic. Diagnosis often relies on clinical suspicion and RDTs (Tubex/Typhidot) due to limited culture access; interpret RDTs cautiously. Widal test highly unreliable. Fluoroquinolone resistance is a growing concern, Ceftriaxone or Azithromycin often used.

References

  • Uganda Clinical Guidelines (UCG) 2023

    Chapter 2, Section 2.1.9

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