Slide 1:Original article Enteric Fever in Mumbai – Clinical Profile, Sensitivity Patterns and Response to Antimicrobials S. Jog, R. Soman, T Singhal, C. Rodrigues, A Mehta, FD Dastur JAPI


Slide 2:Abstract Aims : To study the clinical profile, haematological features of culture proven typhoid cases, the antimicrobial susceptibility pattern of the isolates, time to defervescence with the treatment received. Material and Methods : Retrospective chart review of all cases of culture proven enteric fever carried out at a tertiary care private hospital in Mumbai over the period January 2003 to September 2005. .


Slide 3:Results : Culture positivity seen in 52.6%. Sixty one percent were Salmonella typhi, while 39% were Salmonella paratyphi A . An absolute eosinopenia was seen in 76.9% of the patients. 46.2% received antibiotics before admission Conclusions : A high culture positivity despite prior or ongoing antibiotic treatment was seen. Absolute eosinophil count of 0% could be an important marker of typhoid. High prevalence of nalidixic acid resistance, a marker of resistance to fluoroquinolones was observed. Combination treatment was not found to be superior to treatment with single antibiotic.


Slide 4:INTRODUCTION Systemic illness caused by Salmonella enterica serotype typhi or paratyphi A/B. Blood culture is the ‘gold standard’ for diagnosis and also gives information about antibiotic sensitivity of the isolate; however the cost of cultures, lack of “culture of cultures” and administration of prior antibiotics are impediments in this diagnostic approach AIMS AND OBJECTIVES The primary aim to study the sensitivity patterns of S. enteritica and response to antimicrobial therapy. The secondary aims were to study the clinical and laboratory profile of patients with culture proven enteric fever.


Slide 5:MATERIAL AND METHODS The records of all patients discharged from hospital between January 2003 and September 2005 with a diagnosis of enteric fever, typhoid fever or paratyphoid fever were assessed for suitability for inclusion in our study. Only culture proven cases of enteric fever were included in the study. They were used to calculate the culture positivity. Two sample t test was used to compare continuous variable and chi square test was used to compare categorical variables. A p value of < 0.05 was considered singnificant.


Slide 6:RESULTS 119 (52.6%) were culture proven cases of enteric fever and were included in the analyses. Seventy-four of the 119 study patients were male and 45 were female. The age ranged from 7 months to 66 years, the mean age being 21.7 years. All patients had fever prior to admission; the median duration of fever prior to admission was 7 days, High-grade fever seen in 66.3% and chills in 57.9%. Vomiting, abdominal pain and loose stools in 42%, 33.6% and 31% patients respectivel. Constipation in 2. None relative bradycardia. Hepatosplenomegaly was seen in 12.6%. Only hepatomegaly was seen in 15.9% only splenomegaly was seen in 7.5% patients. Seven patients gave history of enteric fever in the past. Only 1 of these 7 was culture proven,


Slide 7:WBC count with the normal limit 85% Leucopenia (WBC count 11000/cumm only 4 patients. Absolute eosinopenia (0% eosinophils) was seen in 76.9%. patients. The mean platelet 2,04,800/ cumm. Thrombocytopenia seen in 25.9%. Hyperbilirubinemia (> 1 mg/dl) in 28.7%). ALT was elevated (> 60 IU/ml) in 43% patients.


Slide 8:All the Salmonella paratyphi A were isolated from blood cultures. The cultures were sent after a mean period of 11 days after the onset of fever. Widal test results were available for 64 of 119 patients. Widal test was positive (define as S. Typhi O antigen > 120 & either S Typhi or S. paratyphi H antigen titers > 120) in 24 of 64 patients. The mean duration of fever at which Widal test was positive was 10.7 days. Fifty-five patients(46.2%) received antibiotics before being admitted to the hospital.


Slide 9:The mean duration of receipt of antimicrobials after hospitalization was 11 days. Defervescence defined as time period in days from the day of onset of the antibiotic treatment in the hospital to the disappearance of fever was calculated for various patient groups. The mean time to defervescence in the group of patients who had received antibiotics prior to admission was 4.5 days. days while in the patients who did not receive prior antibiotics was 5 days.


Slide 10:DISCUSSION Very prolonged fever lasting more than 90 days, seen in 2 of our patients was unusual for enteric. Relative bradycardia and constipation considered to be salient features of enteric were not seen/very infrequently seen in our study. Conversely, absolute eosinopenia, (seen in 77% of our patients) can be used as a pointer of enteric when a complete blood count is done in a patient with fever. 46.2% patients in our study received antibiotics either single or in combination for as long as 10 days before being admitted to the hospital.


Slide 11:The high yield from blood cultures despite antibiotics could have been as a result from processing of the blood cultures by the BACTEC method, (soybean casein digest broth, yeast extract, animal tissue digest, sucrose, hemin, menadione, pyridoxal hydrochloride, sodium bicarbonate and sodium polyanethol sulphonate as a culture medium optimised with cationic exchange resin). However results of our study advocate that blood cultures should be sent in suspected enteric fever even if the patient is on antimicrobials. The mean fever clearance time with ceftriaxone used as single therapy observed in our study was 4.2 days. No change in the time to defervescence with ceftriaxone over the years was seen in our study.


Slide 12:Surprisingly, receipt of antibiotic therapy prior to admission was found to have no significant impact on the time to defervescence. Study suggest that combination therapy may not be superior to single drug therapy, as we did not observe any significant difference in the time to defervescence in those patients who received ceftriaxone alone or in combination with azithromycin.


Slide 13:Limitations Patients were receiving various antimicrobials singly or in combination for varying periods prior to hospitalization, which could impact the time to defervescence. Conclusions Importance of absolute eosinopenia as a diagnostic marker of typhoid. High culture positivity despite receipt of prior antibiotics. High prevalence of nalidixic acid resistance (79%), Return of susceptibility to chloramphenicol (96%), 100% sensitivity to ceftriaxone and non superiority of combination therapy versus single agent therapy.


Slide 14:THANK YOU..