Bacterial Diseases Then the Initial Episode but May Be Severe
Bacterial diseases then the initial episode but may be severe, even fatal. Manifestations may last as long as three weeks during a relapse. Second and third relapses have been described. Diagnosis. The diagnosis of typhoid fever can often be suspected on the basis of the clinical picture. Definitive diagnosis is established by isolation of the organism from blood, feces, urine, or, occasionally, sputum or purulent exudates. A fourfold or greater increase in agglutinin titer, especially against the 0 antigens of s. Tryphosa and in the absence of recent immunization provides confirmatory evidence of infection. Since in the early stages the patient frequently appears ill, is highly febrile, has a leukopenia and no localizing signs, the differential diagnostic possibilities include many diseases.
Prominent among these are systemic infections with other salmonellae, disseminated tuberculosis, malaria, brucellosis, shigellosis, murine typhus fever, tularemia, Rocky Mountain spotted fever, acute bronchitis, influenza, and pneumonia caused by viruses or Mycoplasma pneumonia. Certain non-microbial diseases associated with fever and abdominal complaints, such as Hodgkin's disease, may also be confused with typhoid fever. Herpes labialis is _rare in typhoid fever, and its presence should lead to a consideration of other diagnoses. Prognosis. The fatality rate prior to effective antimicrobial therapy varied among different socioeconomic and age groups but was around 10 percent.
Death was usually associated with pro-found toxemia, intestinal perforation, intestinal hemorrhage, or intercurrent pneumonia. The fatality rate since the introduction of chlorate-phenicol is 1 or 2 percent when facilities are available for appropriate supportive care. Treatment. Chloramphenicol has been employed successfully in the management of typhoid fever since -1948 and is still the antimicrobial agent of choice. It is given orally in doses of approximately 50 mg. per kilogram per day in four divided doses until the temperature is normal; thereafter, the dose may be reduced to 30 mg. per kilogram per day. Chloramphenicol therapy should be continued for a total of two weeks. Response to treatment is not rapid. Patients usually show subjective improvement after one or two days, but the temperature does not. return to normal until three to five days after the beginning of therapy.
Hemorrhage and perforation may develop during chloramphenicol therapy, even in afebrile patients. Treatment of relapse is the same as for the initial episode. Chloramphenicol therapy does not alter the incidence of chronic carriers after typhoid fever. • Chloramphenicol may result in suppression of agglutinin response in patients treated during the early phase of typhoid fever. Ampicillin is also effective in the treatment of typhoid fever, but the response appears to be slower with ampicillin than with chloramphenicol.
If ampicillin is used in the treatment of typhoid fever, it should be administered intramuscularly in a dose for adults of 1 gram every six or eight hours until the patient is afebrile, and should then be continued orally for a total of two weeks of therapy. Occasional patients with typhoid fever. without evidence of suppurative complications show no evidence of clinical response to chloramphenicol or ampicillin after six to eight days of therapy, although blood cultures may become negative. For these patients, and patients with severe toxemia during typhoid, the use of prednisone or drugs with similar activity should be considered.
Prednisone should be given in a dose of 60 mg. per -day in four divided doses for the first day, 40 mg. during the second day, and 20 mg. on the third day; corticosteroid therapy should be discontinued after the third day. In patients treated with prednisone, the temperature returns to normal or occasionally deer-eases to hypothermic levels within hours, and the toxic state rapidly ameliorates. Prednisone should be administered only in conjunction with appropriate antimicrobial therapy, and under these conditions, it does not increase the risk of complications. Perforation, although previously managed by surgical means, is now usually treated conservatively without surgical intervention.
When perforation occurs, chloramphenicol should be continued, and additional antimicrobial drugs should be administered to control the multiplication of intestinal flora in the peritoneal space. Trans-fusion is required for large hemorrhages. Patients with typhoid fever are unusually sensitive to the antipyretic effect of salicylates and may develop profound hypothermia after small doses. Tepid sponge baths are effective in lowering the temperature and should be used instead of saliency. Laxatives and enemas should not be used because of the danger of inciting intestinal perforation or hemorrhage. Treatment of Carriers. Cholecystectomy results in termination of the chronic enteric carrier state in about S5 percent of cases.
Ampicillin in a total dose of 6_ grams per day given orally in four equal doses for a period of six weeks combined with probenecid will apparently terminate the carrier state in most patients without gall-stones and with normal gallbladder function as indicated by cholecystogram. Ampicillin occasion-ally terminates the carrier state in persons with evidence of gallbladder disease or gallstones, but the proportion of apparent cures is less than 25 percent. Penicillin G in doses of 12 million units or more daily combined with probenecid for 14 days has also been successful in terminating the carrier state in some persons.
Chloramphenicol has not been shown to be effective in the treatment of the chronic carrier state and should not be used in this situation. Prophylaxis. Typhoid vaccine is effective in reducing the incidence of disease among properly immunized persons. Immunization should be considered for inhabitants of areas where the incidence of the disease is high, for travelers to