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SHORT COMMUNICATION  
Year : 2012  |  Volume : 37  |  Issue : 4  |  Page : 256-258
 

Study of Clinical Profile and Antibiotic Sensitivity Pattern in Culture-positive Typhoid Fever Cases


1 Department of Community Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
2 Department of Medicine, Kasturba Medical College, Manipal University, Manipal, Karnataka, India
3 Department of Pulmonary Medicine, Medical Officer, Kasturba Medical College, Manipal University, Manipal, Karnataka, India

Date of Submission12-Nov-2009
Date of Acceptance16-Feb-2010
Date of Web Publication15-Nov-2012

Correspondence Address:
Ashwini Kumar
Department of Community Medicine, Kasturba Medical College, Manipal University, Manipal - 576 104, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-0218.103475

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   Abstract 

Background: Salmonella enteric serotype Typhi has created a significant therapeutic problem as these strains have developed resistance to the commonly used antimicrobials for the treatment of typhoid fever. Objectives: To assess the clinical profile and sensitivity patterns to anti-typhoid drugs. Materials and Methods: A retrospective analysis of 106 culture-positive typhoid cases admitted in a tertiary care hospital during the years 2005-2008. Results: Records of 106 patients were evaluated, 83 (78.3%) males and 23 (21.7%) females. Fever was present in all patients. Headache in 63 (59.4%) patients and generalized body ache in 53 (32.5%) patients were the most common symptoms, while spleenomegaly in 47 (44.3%) patients and hepatomegaly in 42 (39.6%) patients were the common presenting signs. A maximum sensitivity of 96.6% was observed with cephalosporins, whereas a resistance of 29.2% was seen with fluoroquinolones. Conclusion: A high degree of sensitivity was noted to chloramphenicol, ampicillin and sulphonamides, showing a trend of roll-back of sensitivity to conventional antibiotics.


Keywords: Antibiotic sensitivity, clinical profile, typhoid fever


How to cite this article:
Kumar A, Pandit V, Shetty S, Rao CR, Pattanshetty S, Samarasinghe CM. Study of Clinical Profile and Antibiotic Sensitivity Pattern in Culture-positive Typhoid Fever Cases. Indian J Community Med 2012;37:256-8

How to cite this URL:
Kumar A, Pandit V, Shetty S, Rao CR, Pattanshetty S, Samarasinghe CM. Study of Clinical Profile and Antibiotic Sensitivity Pattern in Culture-positive Typhoid Fever Cases. Indian J Community Med [serial online] 2012 [cited 2019 Dec 14];37:256-8. Available from: http://www.ijcm.org.in/text.asp?2012/37/4/256/103475



   Introduction Top


Typhoid fever is a systemic infection that evolved about 50,000 years ago, [1] having remarkable mechanisms for persistence in its host. [2] It occurs in all parts of the world where there is substandard water supply and sanitation. [3] The disease remains a serious public-health problem in the developing countries. [4] The advent of chloramphenicol treatment changed the perception of typhoid fever from a severe to a readily manageable infection. [5] Outbreaks of chloramphenicol-resistant typhoid was reported in 1972. In the late 1980s and 1990s, outbreaks of typhoid caused by organisms resistant to chloramphenicol, cotrimoxazole, ampicillin and amoxicillin were reported. [6] Currently, decreased susceptibility has also been reported to fluoroquinolones and third-generation cephalosporins. [7],[8],[9],[10] With this background in mind, it becomes imperative to assess the extent of drug resistance before treatment is administered. Therefore, this study aimed to study the antibiotic sensitivity pattern among typhoid fever cases in a tertiary care setting, which most often caters to referred cases unsuccessfully treated elsewhere.


   Materials and Methods Top


A retrospective record-based analysis was carried out for all the culture-proven typhoid cases admitted to a tertiary care teaching hospital in Southern Karnataka. Due permission was sought from the hospital authorities to access the records. The medical records of all patients admitted from 1 January 2005 to 31 December 2008 with a diagnosis of typhoid fever were analyzed. Only culture-positive (Bact/alert Biomeriux culture kits) typhoid fever cases were included for the study. Of the 616 clinically suspected cases reporting to the hospital, 106 individuals who were culture positive for  Salmonella More Details typhi during the study period were included in this study. Cases of typhoid fever diagnosed on the basis of only clinical examination and Widal test were excluded from the study. The mode of clinical presentation, laboratory diagnosis, complications, response to treatment and antibiotic susceptibility patterns were recorded from the case records. Data was entered and analyzed using SPSS version 11.5. Data has been summarized using percentages and proportions.


   Results Top


Among the 106 individuals who were culture positive for Salmonella typhi, majority [83 (78.3%)] were males and 23 (21.7%) were females. Majority of the patients were (55.7%) in the age group of 15-30 years, and were students (39.6%). The mean age of the patients was 28.8 years (SD 1.32). People engaged in skilled and semiskilled occupation constituted 46%, while housewives [9 (8.5%)] and children [4 (3.8%)] formed the rest of the study population in addition to students. The average duration of hospital stay was 8.7 days. Fever was present in all the patients. Headache, vomiting, abdominal pain and diarrhea were the common associated symptoms seen in 63 (59.4%), 30 (28.3%), 21 (19.8%) and 29 (27.4%) patients, respectively. Splenomegaly was seen in 47 (44.3%), hepatomegaly was present in 42 (39.6%) while hepatosplenomegaly was seen in 23 (21.7%). Abdominal tenderness was another common presenting sign [23 (21.7%)]. Widal was concomitantly positive in 73 (68.9%) cases. Liver enzymes (alanine aminotransferase, aspartate aminotransferase and alkaline phosphatase) were raised in 52 (49.1%) patients. Complications were very few. Only one patient each had gastrointestinal bleed, gastrointestinal perforation, myocarditis and encephalitis as complications. The outcome was favorable, with 92.5% patients recovering from the illness. Relapse of the disease was seen among two (1.9%) cases, while five patients (4.7%) were discharged against medical advice. Antibiotic sensitivity for cephalosporins was 96.2% while antibiotic resistance was 29.2% with fluoroquinolones. Sensitivity to chloramphenicol was 92.5%, ampicillin 85% and sulphonamides 82.1%, as described in [Table 1]. Majority [50 (47.6%)] of the typhoid cases were treated with ceftriaxone. Another five (4.8%) cases were treated with quinolones. A combination of ceftriaxone and quinolones were given for 32 cases (30.5%). Rest of the patients were treated with a combination of antibiotics, including beta lactams, quinolones, aminoglycosides and sulphonamides. The overall outcome of the patients was good; 99 (92.5%) patients recovered without any complications.
Table 1: Antibiotic sensitivity pattern among culture-positive typhoid fever cases (n=106)

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   Discussion Top


The clinical profile of enteric fever in our study was similar to that reported in other studies. [11],[12],[13],[14] Fever was always present, and was often associated with headache. Diarrhea and vomiting were frequently encountered, but constipation (7.5%) was not very common. Splenomegaly, hepatomegaly and abdominal tenderness were the common signs. Hepatic dysfunction in the form of raised liver enzymes was seen in 49.1% of our patients. Rasool et al. also reported a high incidence of liver dysfunction (54.2%). [15]

The antibiotic sensitivity pattern in the patients showed a high level of resistance to fluoroquinolones at 29.2%. Decreasing susceptibility of Salmonella typhi to ciprofloxacin has been well documented in several studies, [3],[16],[17],[18] and is indicative of the effects of indiscriminate use of this group of antibiotics. Sensitivity to cephalosporins in the current study was high, as reported in other studies. [11],[16],[17],[18] The change in the resistance patterns of chloramphenicol, ampicillin and cotrimoxazole is noteworthy. [18] The following resistance pattern of serotype Typhi strains was observed from Kolkata: chloramphenicol, 13%; ampicillin, 13%; amoxicillin-clavulanic acid, 0%; cotrimoxazole, 15%; ciprofloxacin, 10%; ofloxacin, 2%; and ceftriaxone, 0%. A significant decrease over the years in resistance to chloramphenicol, ampicillin and cotrimoxazole was noticed (P<0.0001). [18] Sensitivity to the conventional antibiotics, especially chloramphenicol is high (92.5%). Similar findings were reported in other studies. [18],[19] Our study thus confirms a roll-back sensitivity of Salmonella typhi to chloramphenicol.

Our findings indicate a remarkable reversal in the resistance pattern of serotype Salmonella typhi. Similar trends have been noted in several other studies. [13],[18],[19],[20] The emergence of isolates resistant to ciprofloxacin suggests that if irrational and indiscriminate use persists, it is probably only a matter of time before the organisms develop widespread resistance to fluoroquinolones. Therefore, chloramphenicol and other antimicrobials like ampicillin, sulphonamides and aminoglycosides may still be used in the treatment of typhoid fever, as the organism is sensitive to these drugs. There is an urgent need to keep the possible emergence of untreatable strains to a minimum by the administration of appropriate antibiotics as indicated by the sensitivity tests.


   Conclusion Top


A high degree of sensitivity was noted to conventional antibiotics, stressing the need for rational use of antibiotics after appropriate and timely antibiotic sensitivity and resistance testing.


   Acknowledgments Top


The authors gratefully acknowledge all the co-operation extended by The Heads of Department of General Medicine and Community Medicine, Kasturba Medical College, Manipal, as well as the Medical Superintendent, Kasturba Hospital, Manipal University, Karnataka.

 
   References Top

1.Kidgell C, Reichard U, Wain J, Linz B, Torpdahl M, Dougan G, et al. Salmonella typhi, the causative agent of typhoid fever, is approximately 50,000 years old. Infect Genet Evol 2002;2:39-45.  Back to cited text no. 1
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2.Merrell DS, Falkow S. Frontal and stealth attack strategies in microbial pathogenesis. Nature 2004;430:250-6.  Back to cited text no. 2
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3.Ivanoff B, Levine MM, Lambert PH. Vaccination against typhoid fever: Present status. Bull World Health Organ 1994;72:957-71.  Back to cited text no. 3
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4.Crump JA, Luby SP, Mintz ED. The global burden of typhoid fever. Bull World Health Organ 2004;82:346-53.  Back to cited text no. 4
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5.Woodward TE, Smadel JE, Ley HL Jr, Green R, Manikar DS. Preliminary report on the beneficial effect of chloromycetin in the treatment of typhoid fever. Ann Intern Med 1948;29:131-4.  Back to cited text no. 5
    
6.Mirza SH, Beeching NJ, Hart CA. Multi-drug resistant typhoid: A global problem. J Med Microbiol 1996;44:317-9.  Back to cited text no. 6
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7.Rowe B, Ward LR, Threlfall EJ. Multidrug-resistant Salmonella typhi: A worldwide epidemic. Clin Infect Dis 1997;24 Suppl 1:S106-9.  Back to cited text no. 7
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8.Mehta G, Randhawa VS, Mohapatra NP. Intermediate susceptibility to ciprofloxacin in Salmonella typhi strains in India. Eur J Clin Microbiol Infect Dis 2001;20:760-1.  Back to cited text no. 8
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9.Harish BN, Madhulika U, Parija SC. Isolated high-level ciprofloxacin resistance in Salmonella enterica subsp. enterica serotype Paratyphi A. J Med Microbiol 2004;53:819.  Back to cited text no. 9
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11.Chowta MN, Chowta NK. Study of clinical profile and antibiotic response in typhoid fever. Indian J Med Microbiol 2005;23:125-7.  Back to cited text no. 11
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12.Parry CM, Hien TT, Dougan G, White NJ, Farrar JJ. Typhoid fever. N Engl J Med 2002;347:1770-82.  Back to cited text no. 12
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13.Kadhiravan T, Wig N, Kapil A, Kabra SK, Renuka K, Misra A. Clinical outcomes in typhoid fever: Adverse impact of infection with nalidixic acid-resistant Salmonella typhi. BMC Infect Dis 2005;5:37.  Back to cited text no. 13
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14.Jog S, Soman R, Singhal T, Rodrigues C, Mehta A, Dastur FD. Enteric fever in Mumbai-clinical profile, sensitivity patterns and response to antimicrobials. J Assoc Physicians India 2008;56:237-40.  Back to cited text no. 14
    
15.Rasoolinejad M, Esmallpoor N, Mogbel A. Salmonella hepatitis (analysis of hepatic involvement in 107 patients with typhoid fever). Acta Med Iranica 2003;41:161-3.  Back to cited text no. 15
    
16.Kumar R, Gupta N, Shalini. Multidrug-resistant typhoid fever. Indian J Pediatr 2007;74:39-42.  Back to cited text no. 16
    
17.Saharan G, Gupta A, Gupta BK, Sharma BP, Kochar DK, Purohit VP. Evaluation of antibiotic sensitivity pattern in cases of enteric fever in north west Rajasthan. J Indian Med Assoc 2008;106:528-30, 532.  Back to cited text no. 17
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18.Dutta S, Sur D, Manna B, Bhattacharya SK, Deen JL, Clemens JD. Rollback of Salmonella enterica serotype typhi resistance to chloramphenicol and other antimicrobials in Kolkata, India. Antimicrob Agents Chemother 2005;49:1662-3.  Back to cited text no. 18
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19.Gupta V, Kaur J, Kaistha N. Re-emerging chloramphenicol sensitivity and emerging low level ciprofloxacin resistance among Salmonella enterica serotype typhi isolates in North India. Trop Doct 2009;39:28-30.  Back to cited text no. 19
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20.Willke A, Ergonul O, Bayar B. Widal test in diagnosis of typhoid fever in Turkey. Clin Diagn Lab Immunol 2002;9:938-41.  Back to cited text no. 20
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    Materials and Me...
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