Original Article
Emerging trends in clinical profile, lab
diagnosis, culture and sensitivity pattern of
typhoid fever in a semi
semi-urban
urban tertiary care
hospital
S Noorul Ameen1*, Lijo George2, D Rajasekaran3
1 2 3
Assistant Professor, Post Graduate, Professor and HOD, Department of General Medicine, Chettinad Hospital and Research Institute,
Rajiv Gandhi Salai, (OMR, Chennai), Kelambakkam
Kelambakkam-603 103, Kanchipuram Dist., Tamil Nadu, INDIA.
Email: mmcsmarty@yahoo.co.in
Abstract Typhoid fever is one of the common fevers endemic in our country, which is caused by Salmonella enterica serovar
typhi. The aim of the present study is to find the recent trends in clinical presentation, laboratory profile, culture and
sensitivity pattern of it as this would give more confidence in the treating physician especially regarding the selection of
antibiotics. This study was done in Chettinad Hospital and Research Institut
Institute,
e, Kelambakkam, Kancheepuram district.
About 40 cases of culture proven typhoid fever were analysed. Males and females were equally affected with mean age
of presentation being 17.4 years with maximum number of cases in <20 years group. Fever(100%) followe followed by
abdominal pain(80%) were the most common symptoms. Among the laboratory profile leucopenia which is considered
common in typhoid occurred only in 10% of the patients in our study. Instead thrombocytopenia(50%) was more
common in our patients. Among th thee antibiotics, Salmonella was most sensitive to ceftriaxone followed by conventional
antibiotics like chloramphenicol, ampicillin and cotrimoxazole but the resistance was more to fluoroquinolones.
Keywords: Antibiotic susceptibility, Ceftriaxone
Ceftriaxone, Thrombocytopenia, Typhoid fever.
*
Address for Correspondence:
Dr. Noorul Ameen. S, A108, Pelican Nest Apartments, No 48, Creek street
street, Okkium Thoraipakkam, Chennai-600097,
600097, Tamil Nadu, INDIA.
Email: mmcsmarty@yahoo.co.in
Received Date: 08/09/2016 Revised Date: 18/100/2016 Accepted Date: 10/11/2016
resistance and more enteric fever cases being caused by
Access this article online Paratyphoid A3. The risk factors include
inclu low socio-
Quick Response Code: economic status4, contaminated drinking water, poor
Website: personal hygiene and sanitation with open defecation
www.medpulse.in playing a more important role. Even though typhoid fever
has been in existence for more than 50,000 years5, its
been really difficult to completely
ompletely eradicate the disease
mainly due to the varying sensitivity pattern of the
DOI: 12 Novembe
November organism. Time and then various antibiotics were found
2016
016 to be effective against S. Typhi and paratyphi, but these
organisms have developed remarkable mechanisms to
persist in their host6. But still enteric fever is a
INTRODUCTION manageable infection mainly due to antibiotics like
Typhoid fever is an increasing global burden with chloramphenicol, third generation antibiotics, amoxicillin,
estimated prevalence of 12 million cases in 2010 all over cotrimoxazole, fluoroquinolones and azithromycin.
the world1,2 and about 130,000 deaths annually. Globally Unfortunately in the late 1980s and 1990s, the causative
ca
south-central and south-east
east Asia have the highest organism showed an increase in resistance to antibiotics
incidence exceeding 100 cases per 100,000 person years. like chloramphenicol, cotrimoxazole, ampicillin and
The scenario is further complicated by changing trends in amoxicillin7. Recently, even resistance to
incidence within the same country, increase in antibiotic fluoroquinolones and third generation cephalosporins
How to site this article: S Noorull Ameen, Lijo George, D Rajasekaran
Rajasekaran. Emerging trends in clinical profile, lab diagnosis, culture and
sensitivity pattern of typhoid fever in a semi-urban
urban tertiary care hospital
hospital. MedPulse – International Medical Journal. November 2016;
3(11): 918-921. http://www.medpulse.in (accessed 008 November 2016).
MedPulse – International Medical Journal, ISSN: 2348
2348-2516, EISSN: 2348-1897, Volume 3, Issue 11, November 2016
201 pp 918-921
have been increasing8-11. With this backgro
background, we have Research Institute, Chennai. These cases included 20
tried to find the clinical profile and drug sensitivity males and 20 females with 24 patients in the age group of
pattern among culture proven typhoid fever cases in a less than 20 years, 14 patients in 20-39
20 years and only 2
tertiary care setting in a semiurban hospital and to our patients above 40 years. The clinical features (FIGURE.2)
surprise we have found an increasing sensitivity to older included fever in all the 40 cases. The next common
antibiotics like chloramphenicol,
hloramphenicol, cotrimoxazole, manifestation was abdominal pain in 32 (80%) of the
ampicillin and amoxicillin, in addition to ceftriaxone patients, diarrhoea in 18 (45%), vomiting in 15 (37.5%),
which is a relatively newer drug. headache in 9 (22.5%),
5%), constipation in 5 (12.5%) and rash
in 1 (2.5%). Out of 40 patients, 9 of them had
MATERIALS AND METHODS hypotension at least once during the hospital stay and all
The study was conducted in Chettinad Hospital and of them responded to intravenous fluids and none
Research Institute, Department of General Medicine. required ionotropic support. Hepatomegaly was present in
Study Design: Retrospective study 20 patients,
atients, splenomegaly in 14, mesenteric
Study Period: April 2013- June 2015. lymphadenopathy in 3 patients. Haematological profile
Inclusion Criteria showed leucopenia in only 4 patients, leucocytosis in 2.
1. All cases of culture proven enteric fever cases. Interesting findings were thrombocytopenia in 20 patients
2. All patients who are willing to participate in the with severe thrombocytopenia (< 50000) in 2 patients,
pat
study. basopenia in 9 patients, but eosinopenia in only 2 patient.
Exclusion Criteria:
Patients not willing to participate in the study. <20 YRS
AGE
Methodology 5 20-39 YRS
All cases of culture proven cases of typhoid fever were
>=40 YRS
studied during the study period. All cases were analysed
for their clinical presentation both history and clinical 35
50
examination, laboratory profile, culture and sensitivity
pattern off common antibiotics used in the treatment of
enteric fever.
RESULTS Figure 1: Age distribution
A total of 40 cases were studied during the period from
April 2013 to June 2015 in Chettinad Hospital and
CLINICAL PRESENTATION
100.00%
90.00%
80.00%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Figure 2: Clinical presentation of typhoid fever cases
Copyright © 2016, Statperson Publications, MedPulse – International Medical Journal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 3, Issue 11
1 November 2016
S Noorul Ameen
Ameen, Lijo George, D Rajasekaran
HEMATOLOGICAL PROFILE
EOSINOPENIA
BASOPENIA
THROMBOCYTOPENIA
LEUCOCYTOSIS
LEUCOPENIA
0.00% 20.00% 40.00% 60.00% 80.00% 100.00%
Figure 3: Hematological profile of typhoid fever cases
Further the antibiotic sensitivity was also studied and the constipation was considered a prominent symptom in
following pattern was noted. Most of the cases were typhoid fever, in our study only 12.5% of patients had
sensitive to the 3rd generation cephalophorin, Ceftriaxone. constipation. The typical rose spots of typhoid fever
Old drugs such as cotrimoxazole and chloramphenicol occurred only in one patient and it occurred on the
were sensitive
tive in 33 and 29 of the patients respectively. seventh day of illness. The occurrence of mesenteric
The resistance was very high among the commonly used adenopathy was 77% in one study15 whereas in our study
drugs such as ciprofloxacin and ofloxacin but sensitivity was found in only 7.5% (3 patients). Thrombocytopenia
was high for ampicillin interestingly. The sensitivity was
as noticed in 50% of patients compared with about 40%
pattern is shown in Table 1 in a study done by Ali Hassan Abro et al16. In our study
there was only 12.5% of multidrug resistant cases who
Table 1: Sensitivity pattern of common antibiotics used in had resistance to first line drugs such as ampicillin,
treatment of typhoid fever
chloramphenicol and cotrimoxazole which wh is in
Sensitive No. of Resistant No. of
Drugs accordance with other studies on enteric fever17,18.
Patients (%) Patients (%)
Tetracycline 37 (92.5) 3 (7.5)
Nalidixic acid resistance was found in 87.5% of the cases.
Ceftriaxone 35 (87.5) 5 (12.5) This trend has also been substanciated by other studies
Cotrimoxazole 33 (82.5) 7 (17.5) which showed about 78.3%19 and 78%17 of Nalidixic acid
Ampicillin 33 (82.5) 7 (17.5) resistance. This is mainly
nly due to indiscriminate use of
Chloramphenicol 29 (72.5) 11 (27.5) ciprofloxacin as the first line drug in treatment of
Cefotaxim 7 (17.5) 33 (82.5) Salmonella typhi cases. Eventhough there had been more
Ciprofloxacin 5 (12.5) 35 (87.5) multidrug resistant cases of enteric fever in 1980s and
Ofloxacin 3 (7.5) 37 (92.5) 90s, change in antibiotic preference for typhoid has
Amikacin 2 (5) 38 (95) changedd the trend of increased susceptibility to
conventional antibiotics such as chloramphenicol,
Out of 40 patients, 38 cases were treated with parenteral
ampiciilin and cotrimoxazole. Most importantly the
ceftriaxone for 14 days. The remaining cases were treated
proportion of ceftriaxone sensitive cases was more in our
with amikacin and ampicillin. Among the 38 patients
study which shows that it could be considered the first
firs
treated with ceftriaxone, fever subsided by 4 days in 24
line treatment in inpatient cases of enteric fever. The
patients (60%).
response to this drug has been good with defervescense of
fever in about 4 days in 60% of cases treated with
DISCUSSION ceftriaxone.
Typhoid fever is a common health problem in India and
Southeast Asia. This infection iff not treated adequately
can lead onto a mortality of about 30% but with
CONCLUSION
Enteric is a common endemic fever in India. Eventhough
appropriate antibiotic treatment the mortality reduces to
the incidence
ence has gone down recently due to improved
0.5%12. In our study the incidence of typhoid fever was
sanitation and heathcare facilities, still it is a major
higher in age group <20 years as in previous researches13.
burden to the society. It mainly affects children and
The common clinical manifestations were fever,
young adults. Community based studies on risk factors,
abdominal pain, vomiting and diarrhoea which is in
clinical presentation and especially culture and
a sensitivity
accordance with the previous study14. Eventhough
pattern are necessary for improved care for these cases. In
MedPulse – International Medical Journal, ISSN: 2348-2516,
2516, EISSN: 2348
2348-1897, Volume 3, Issue 11, November 2016 Page 920
MedPulse – International Medical Journal, ISSN: 2348-2516, EISSN: 2348-1897, Volume 3, Issue 11, November 2016 pp 918-921
our locality, the interesting finding was association of 9. Mehta G, Randhawa VS, Mohapatra NP: Intermediate
many cases with thrombocytopenia and constipation susceptibility to ciprofloxacin in Salmonella typhistrains
in India: Eur J Clin Microbiol Infect Dis. 2001;20:760–1.
which was more common in many studies was less
10. Harish BN, Madhulika U, Parija SC: Isolated high-level
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improved susceptibility to conventional antibiotics like subsp.enterica serotype Paratyphi A: J Med
chloramphenicol, cotrimoxazole, ampicillin and newer Microbiol. 2004;53:819.
antibiotics like ceftriaxone with increased resistance to 11. Saha SK, Talukder SY, Islam M, Saha S: A highly
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Bangladesh: Pediatr Infect Dis J. 1999;18:387.
12. Cooke FJ, Wain J: The emergence of antibiotic resistance
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Source of Support: None Declared
Conflict of Interest: None Declared
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