Fiebre tifoidea: una etiología poco frecuente de síndrome febril prolongado en pediatría / Typhoid fever: a rare etiology of prolonged febrile illness in pediatrics / Febre tifoide: uma etiología rara de síndrome febril prolongada em pediatría

Introducción: Las infecciones representan la etiología más frecuente del síndrome febril prolongado (SFP). Si bien las fiebres entéricas constituyen una causa posible, en Uruguay su prevalencia ha disminuido significativamente con la mejora de las condiciones socio sanitarias. Objetivo: Comunicar el caso de un adolescente con una etiología actualmente excepcional de SFP. Caso clínico 14 años, sano, zona suburbana. Comienza 2 semanas previo al ingreso con dolor en hemiabdomen superior. Agrega cefalea holocraneana leve y vómitos ocasionales. 5 días previos al ingreso fiebre 40°C axilar, un pico diario, sin otra sintomatología. Tránsito digestivo bajo y urinario normal. Examen físico: lúcido, buen aspecto general, abdomen doloroso a la palpación profunda en epigastrio. Sin irritación peritoneal. Resto normal. Analítica: Leucocitos 5200mm3, Proteína C reactiva 71.4mg/dL, hemocultivo sin desarrollo. Ecografía abdominal, radiografía de tórax y ecocardiograma normales. Serologías para Virus Epstein Barr, Citomegalovirus, y Bartonella henselae negativas. Orina normal, urocultivo sin desarrollo. Persiste con fiebre, agrega exantema macropapular evanescente en tronco, sin otros síntomas. Al 7° día de internación nuevo hemocultivo: Salmonella Typhi sensible a ampicilina que recibe por 14 días. Buena evolución. Discusión: La fiebre tifoidea es una enfermedad infectocontagiosa, aguda, potencialmente mortal. Las condiciones socioeconómicas son determinantes en su transmisión. La sensibilidad del hemocultivo es mayor durante la primera semana de enfermedad, por lo que en ocasiones es necesario reiterarlo. Sus manifestaciones clínicas inespecíficas y la baja incidencia hacen que esta etiología no sea habitualmente sospechada en nuestro medio. Por tanto, es importante aumentar el índice de sospecha y considerar entre los diagnósticos diferenciales de SFP esta etiología.

Introduction: Infections are the most frequent etiology of prolonged febrile illness (PFI). Although enteric fevers are a possible cause, their prevalence has significantly diminished in Uruguay, due to improved socio-sanitary conditions. Objective: To communicate the case of an adolescent with a currently exceptional etiology of PFI. Clinical case: 14 years old, healthy, suburban area. Two days prior to admission the patient has pain in upper hemi abdomen. Adds mild holocranial headache and occasional vomiting. 5 days prior to admission axilary temperature of 40°C, one daily peak, without other symptoms. Normal lower digestive and urinary transit. Physical examination: lucid, good general aspect, pain at deep palpation in epigastrium. No peritoneal irritation. Rest is normal. Laboratory: leukocytes 5200 mm3, C-reactive protein 71.4mg/dL, blood culture shows no growth. Abdominal sonogram, thoracic X-ray and echocardiogram are normal. Negative serology for Epstein Barr Virus, Cytomegalovirus and Bartonella henselae. Normal urine, urine culture with no growth. Fever persists, adds evanescent macropapular exanthema in on the trunk, without other symptoms. On the 7th day in hospital a new blood culture shows Salmonella Typhi sensitive to ampicillin, which he receives for 14 days. Good evolution. Discussion: Typhoid fever is an acute, life-threatening, infectious disease. Socioeconomic conditions are determinant in its transmission. Blood culture sensitivity is greater during the first week of the disease, that is why it must occasionally be repeated. Its unspecific clinical manifestations and low incidence make this etiology not be usually suspected in our surroundings. It is therefore important to increase our suspicion and to consider it amongst differential diagnosis in PFI.

Introdução: As infecções representam a etiologia mais frequente da síndrome febril prolongada (SFP). Embora as febres entéricas sejam uma causa possível, no Uruguai sua prevalência diminuiu significativamente com a melhoria das condições sociossanitárias. Objetivo: Relatar o caso de um adolescente com etiologia atualmente excepcional de SFP. Caso clínico 14 anos, saudável, zona suburbana. Começa 2 semanas antes da admissão com dor no abdome superior. Adiciona dor de cabeça holocraniana leve e vômitos ocasionais. 5 dias antes da admissão febre 40°C axilar, pico diário, sem outros sintomas. Trânsito digestivo inferior e trânsito urinário normais. Exame físico: lúcido, bom aspecto geral, abdome doloroso à palpação profunda no epigástrio. Sem irritação peritoneal. Resto normal. Análise: Leucócitos 5200mm3, proteína C reativa 71,4mg/dL, hemocultura sem desenvolvimento. Ultrassonografia abdominal, radiografia de tórax e ecocardiograma foram normais. As sorologias para vírus Epstein Barr, Citomegalovírus e Bartonella henselae foram negativas. Urina normal, urocultura sem desenvolvimento. Persiste com febre, acrescenta erupção macropapular evanescente no tronco, sem outros sintomas. No 7º dia de internação, nova hemocultura: Salmonella Typhi sensível à ampicilina, que recebeu por 14 dias. Boa evolução. Discussão: A febre tifóide é uma doença infecciosa aguda, potencialmente fatal. As condições socioeconômicas são decisivas na sua transmissão. A sensibilidade da hemocultura é maior durante a primeira semana da doença, por isso às vezes é necessário repeti-la. Suas manifestações clínicas inespecíficas e baixa incidência fazem com que essa etiologia não seja usualmente suspeitada em nosso meio. Portanto, é importante aumentar o índice de suspeição e considerar essa etiologia entre os diagnósticos diferenciais da SFP.

Drug resistant Salmonella infections in Pakistan

From November 2016 to March 2018, Pakistan experienced an increase in cases of typhoid fever that was followed by emergence of a strain of Salmonella Typhi [Salmonella enterica] that acquired a plasmid resistant to multiple antibiotics including first-line antibiotics such as fluoroquinolones and third-generation cephalosporins

Rationale of azithromycin prescribing practices for enteric fever in India.

Purpose: The present study was performed to assess the current susceptibility pattern of blood isolates of Salmonella spp from a super specialty hospital in North India against nalidixic acid, ciprofloxacin and azithromycin and compare the in vitro and in vivo response against azithromycin. Materials and Methods: We evaluated the minimum inhibitory concentration's (MIC's) of 107 blood isolates of Salmonella spp against nalidixic acid, azithromycin and ciprofloxacin and correlated in vitro and in vivo response of azithromycin from the treatment and discharge summaries from the Hospital Information System (HIS) software. Results: Among the 107 isolates evaluated, 94 (87.8%) were nalidixic acid-resistant (NAR) Salmonella and 36 were resistant to azithromycin by MIC testing. The MIC 90 value for azithromycin was 24 μg/mL. Among the 57 treatment histories evaluated using the HIS software, 19 (33%) patients had documented clinical non-response to azithromycin which required change of therapy. Conclusions: The present study observed a higher MIC 90 values for azithromycin compared to Salmonella isolates from Western studies. There was also a documented clinical non-response against azithromycin. The in vitro and in vivo findings in this study suggest a guarded use of azithromycin for cases of enteric fever in India. The study also augments the reversal of resistance pattern in favour of chloramphenicol, ampicillin and trimethoprim - sulfamethoxazole.

Occurrence & antibiogram of Salmonella Typhi & S. Paratyphi A isolated from Rourkela, Orissa.

Background & objectives: Almost round-the-year occurrence of Salmonella Typhi and Salmonella Paratyphi A has been noticed in Rourkela since last 13 and five years respectively. The incidence of infection along with the antibiogram of these two serotypes in this area were carried out. Methods: The study was carried out at Ispat General Hospital, Rourkela, India, between January 2005 and December 2008 with 5340 blood samples collected from patients with suspected enteric fever and pyrexia of unknown origin. Isolation, identification and antibiogram of the causative organisms were performed according to standard bacteriological procedures. Results: A total of 298 Salmonella isolates showed an overall per cent positivity of 5.58. Multidrug resistance was found in 11.96 per cent and 15.62 per cent isolates of S. Typhi and S. Paratyphi A respectively. Less than 2 per cent isolates of Salmonella showed resistance to ciprofloxacin. A resistance of 3.0 to 6.25 per cent against third generation cephalosporins was observed among the salmonella isolates. Interpretation & conclusion: A round-the-year occurrence of Salmonella spp. in Rourkela might have been due to the presence of a considerable number of carriers in the locality, poor sanitation in nearby slum areas, and inadequate and contaminated community water supply at times. Higher degree of susceptibility among S. Typhi isolates against various antibiotics was encouraging, but increasing trend of resistance observed among S. Paratyphi A isolates was a matter of concern.

Evaluation of the current trend of nalidixic acid susceptibility in typhoidal Salmonellae; a marker of therapeutic failure for the fluoroquinolones

Typhoid is a major health problem faced by the developing countries like Pakistan. More than 20 million cases are reported annually worldwide. Currently fluoroquinolones are the drugs of choice to treat typhoid fever. In vivo resistance to fluoroquinolones leading to therapeutic failure is developing rapidly and is becoming a major concern for the clinicians. The objective of this study was to determine the sensitivity pattern of Nalidixic acid over the last four years. A descriptive cross sectional study was carried out at the Microbiology Department of the Army Medical College, National University of Sciences and Technology, Rawalpindi from January 2006 to December 2009. All the isolates were dealt with standard microbiological procedures. The antimicrobial sensitivity of Nalidixic acid and Ciprofloxacin was determined using Kirby-Bauer disc diffusion method as per the guidelines of Clinical and Laboratory Standard Institute [CLSI]. Out of 240 isolates, 111 were Salmonella typhi and 129 were Salmonella paratyphi A. The resistance of the typhoidal Salmonella to Nalidixic acid has reached significant levels and it seems only a matter of time when hundred percent resistance will be encountered. All isolates were sensitive to Ciprofloxacin on disc diffusion method. Resistance to Nalidixic acid predicting therapeutic failure with fluoroquinolones is on a steady rise

An increase in enteric fever cases due to Salmonella Paratyphi A in & around Chandigarh.

BACKGROUND & OBJECTIVE: Enteric fever is a major public health problem in India. It is classically caused by Salmonella enterica serotype Typhi. Salmonella enterica serotype Paratyphi A which had been reported less frequently from cases of enteric fever has shown an increasing trend since 1996 in India. There is also variation in the antimicrobial susceptibility of Salmonella Paratyphi A from different parts of the country. An attempt is therefore made to study the rate of isolation and antimicrobial susceptibility pattern of Salmonella Paratyphi A from cases of enteric fever coming to a tertiary care hospital at Chandigarh. METHODS: The blood samples of patients suspected of having enteric fever and admitted to Government Medical College and Hospital, Chandigarh, from January 2006 to April 2007 (11,240) were processed by conventional methods. Antimicrobial susceptibility was tested by Kirby-Bauer disc diffusion method. The minimum inhibitory concentration to two antibiotics- ciprofloxacin and chloramphenicol was determined by agar dilution technique. Simultaneously, retrospective analysis was done from January 2003-December 2005 to study any difference in the incidence and antimicrobial susceptibility pattern of Salmonella Paratyphi A among enteric fever patients. RESULTS: Of 305 total isolates, 231 were S. Typhi and 84 S. Paratyphi A rise. The number of Salmonella Paratyphi A cases rose from 27 in 2006 (34.18%) to 13 (40.63%) in four months of 2007. All were sensitive to ciprofloxacin and cefotaxime but MIC to ciprofloxacin was raised (0.125-0.5 microg/ml). Resistance to nalidixic acid was 92.5 per cent. Chloramphenicol sensitivity re-emerged with 90 per cent isolates sensitive to it while sensitivity to ampicillin dropped (72.5%) as compared to previous years. Only one isolate was multi-drug resistant. INTERPRETATION & CONCLUSION: The present study conferencing Salmonella Paratyphi A as the rapidly emerging pathogen of enteric fever. With increasing resistance to fluoroquinolones and possibility of re-emergence of sensitivity to chloramphenicol, the policy of empirical treatment of enteric fever needs to be rationalized.

A Case of Multidrug-Resistant Salmonella enterica Serovar Typhi Treated with a Bench to Bedside Approach

We report a relapsed case of a 25 year-old man with multi-drug resistant Salmonella serovar Typhi (MDRST) bacteremia who had recently returned from travel in India. Due to unresponsiveness to ciprofloxacin and ceftriaxone, we examined the strain's resistance to quinolones and extended-spectrum beta-lactamases (ESBLs). The strain had a single gyrA mutation at codon 83 (Ser83Phe), which explains its decreased susceptibility to fluoroquinolone and resistance to nalidixic acid. In the screening tests of ESBLs, TEM-1 was positive, which is beta-lactamase but not ESBL. The patient was finally successfully treated with meropenem and aztreonam. In the presence of clinical unresponsiveness despite favorable sensitivity tests, further laboratory evaluations are needed, which should include studies of genes related to antibiotic resistance and ESBLs. In addition, further prospective trials should be done about the possible inclusion of antibiotics not yet mentioned in the current guidelines. With MDRST on the rise worldwide, the most optimal and effective line of antibiotic defense needs to be devised.

Relato de caso de febre tifóide no Município de Maringá, Estado do Paraná / Report on typhoid fever case in Maringá, State of Paraná

A febre tifóide é doença bacteriana aguda causada por Salmonella enterica sorotipo typhi, que é adquirida pela ingestão de água ou alimento contaminado. O objetivo do presente trabalho é descrever um caso de febre tifóide ocorrido em Maringá, após três anos sem notificação da doença no Estado do Paraná.

Typhoid fever is an acute bacterial disease caused by Salmonella enterica serotype typhi, which is acquired by consumption of contaminated food or water. This paper had the aim of describing a case of typhoid fever that occurred in Maringá, State of Paraná, after three years without any notifications of the disease.

Nalidixic acid-resistant Salmonella enterica serotype typhi infection presenting with sub-intestinal obstruction and mesenteric adenitis

Nalidixic acid-resistant Salmonella typhi NARST infections increase minimal inhibitory concentrations of fluoroquinolones, due to chromosomal mutations in the gene encoding DNA gyrase, and can lead to a delayed treatment response. This in turn alters the course of the disease allowing for a protracted period of illness and the occurrence of complications. In this case report, we present a patient from the Indian sub-continent, who was diagnosed with NARST complicated by sub-intestinal obstruction, her diagnosis, treatment, and subsequent recovery

Intracranial haemorrhage in typhoid fever

Intracranial haemorrhage in typhoid fever is very rare. We report another case of non-traumatic intracranial hemorrhage in a 6-year-old boy suffering from typhoid fever, unconsciousness, seizure and non-coherent speech. Investigations revealed severe thrombocytopenia and prolonged prothrombin time. CT scan of brain showed intraparenchymal haemorrhage in frontal regions bilaterally with perilesional oedema, subarachnoid bleed and extension into the lateral ventricles. No aneurysm or arterio-venous malformation was seen on MR angiography. The patient recovered without any neurological deficit

Efficacy of azithromycin in the treatment of childhood typhoid Fever.

An intervention study was carried out in Paediatric wards for a period of one year from January 2003 to December 2003 to determine the efficacy and safety of azithromycin in the treatment of uncomplicated childhood typhoid fever. A total of 50 cases were enrolled in the study. The inclusion criteria of the cases were: documented fever for more than 7 days plus two or more of the following clinical features: toxic appearance, abdominal tenderness, hepatomegaly, splenomegaly, diarrhoea, constipation and coated tongue plus positive Widal test and/or blood culture positivity. Patients who had complication like gastrointestinal tract (GIT) haemorrhage; intestinal perforation and/or shock were excluded from the study. Data were collected in a structured questionnaire. Azithromycin was given at a dose of 10mg/kg /day for a period of 07 days. The time to defervescence was 3.82+/-1.49 days. The minimum defervescence time was 02 days and maximum was 07 days. Clinical cure rate was 94%. No serious adverse effect was noted related to azithromycin therapy except nausea, vomiting, and jaundice. Prior treatment with antibiotics did not affect defervescence time (P>0.05). Pre-treatment febrile period has got positive and linear correlation with clinical response (r = +0.593). It was found that once daily administration of oral azithromycin for seven days in the treatment of uncomplicated typhoid fever was effective and reasonably safe.

Antimicrobial susceptibility patterns of Salmonella enterica serotype typhi in eastern Nepal.

The aim of the present study was to evaluate antimicrobial susceptibility patterns with special reference to multidrug resistance, susceptibility to ciprofloxacin, and bacteriophage typing of Salmonella enterica serotype Typhi isolated from blood sent for culture in a tertiary-care teaching hospital in eastern Nepal during January 2000-December 2004. In total, 132 strains of S. enterica Typhi, isolated from 2,568 blood culture samples collected from cases of suspected enteric fever, were tested for susceptibility to commonly-used antimicrobials by the disc-diffusion method. There were 35 multidrug-resistant strains. None of the isolates were resistant to ciprofloxacin. Of 52 isolates tested for minimum inhibitory concentration (MIC) of ciprofloxacin, 36 (69.23%) showed reduced susceptibility (MIC >0.25 mg/L). Of 112 strains tested for nalidixic acid susceptibility, 86 (76%) were resistant. Strains with reduced susceptibility to ciprofloxacin and resistance to nalidixic acid could be correlated. The commonest phage type was El. Nalidixic acid susceptibility could be a useful screening test for the detection of decreased susceptibility of S. Typhi to ciprofloxacin, a drug which is commonly used even for minor ailments in this area.

Open study on efficacy and tolerability of ciprofloxacin XR compared with ciprofloxacin BID in the treatment of typhoid fever.

AIM: To compare the efficacy and tolerability of ciproflaxin extended-release and ciproflaxin intermediate release in the treatment of typhoid fever. METHODS: A prospective, open labelled, clinical trial, comparing the safety and efficacy of extended-release ciprofloxacin 1000 mg once daily (Ciprofloxacin XR) and ciprofloxacin intermediate release 500 mg two times daily (Ciprofloxacin bid) was performed in adult with typhoid fever. Diagnosis for typhoid fever was based on Widal serology test, blood culture and Polymerase Chain Reaction (PCR) for Salmonella typhi. A two-sided student t-test and chi-square or Fisher's exact test were used for the analysis of clinical responses. RESULTS: Good clinical responses were obtained in 32 subjects (14 with Intermediate release ciprofloxacin and 18 with Extended-release ciprofloxacin) and there were no failure case (0%). Day to reach defervescence in Ciprofloxacin BID (mean 3.28 days) was similar to Ciprofloxacin XR group (mean 3.72 days) with p=0.43. Mild side effects were noted in 7.1% of subjects who received Ciprofloxacin BID compared by 22.2% in subjects who received Ciprofloxacin XR, with p=0.29. There were no moderate or severe side effects on both drugs. CONCLUSION: Clinical outcomes were similar for the two treatments and both treatments were well tolerated. Once daily ciprofloxacin XR was safe, effective, and non-inferior to twice-daily ciprofloxacin IR in the treatment of typhoid fever.