Title

Author(s)

Retrospective review of typhoid and paratyphoid fever in a

regional hospital

Chow, Chi-wing;

Citation

Issued Date

URL

Rights

2010

http://hdl.handle.net/10722/133486

Creative Commons: Attribution 3.0 Hong Kong License

Retrospective review of typhoid and paratyphoid fever in a

regional hospital

By

Chow Chi Wing

This work is submitted to

Faculty of Medicine of The University of Hong Kong
In partial fulfillment of the requirements for
The Postgraduate Diploma in Infectious Diseases, PDipID (HK)

Date: 27 June 2010

Supervisor: Dr SSY Wong

Declaration

I, Chow Chi Wing, declare that this dissertation represents my own work
and that it has not been submitted to this or other institution in application
for a degree, diploma or any other qualifications.
I, Chow Chi Wing, also declare that I have read and understand the
guideline on What is plagiarism? published by The University of Hong
Kong (available at http://www.hku.hk/plagiarism/) and that all parts of this
work complies with the guideline.

Candidate: Chow Chi Wing

Signature:
27 June 2010
Date:

ii

Acknowledgements
The author would like to thank Dr Samson Wong for his valuable
advice and assistance in the production of the project thesis.

Abstract
Background
The aim of this retrospective study is to describe the epidemiology,
clinical characteristics, and management of typhoid and paratyphoid fever in
a regional hospital.

Objective
To

describe

the

epidemiology,

clinical

characteristics

and

management of typhoid and paratyphoid fever in a regional hospital over a

period of six years.

Method
All cases with the diagnosis of typhoid and paratyphoid fever from
the computer system between the period 2003 and 2009 were included.
There were total seventeen cases in this study. The case records during
hospitalisation were reviewed and relevant descriptive data including patient
demographics, clinical features, complication episodes, management
strategy and outcome were collected.

Results
Two cases in this study were Indonesian. Common symptoms were
abdominal pain and diarrhoea. Common complication was deranged liver
function, elevation of alanine aminotransferase (ALT). Eleven patients had
problem of elevation of alanine aminotransferase. Four cases in this study

were infected by Nalidixic acid resistant strain. All of them were managed
by antibiotic with the use of ceftriaxone.
Among the eleven patients treated with ceftriaxone, four of them
(36.4 percent) could be managed in day ward for continuation of antibiotic
administration. The clinical outcome was satisfactory in all four cases.

Conclusion

Travel history is important in management of enteric fever. Multidrug

resistant and Nalidixic acid resistant strains pose problem in clinical
management. The occurrence of Nalidixic acid resistant organism increases
the use of cephalosporin and azithromycin for treatment of typhoid and
paratyphoid fever. With the trend of patient management in day ward,
outpatient completion of course of antibiotic shortened in-patient length of
stay.

Background
Typhoid and paratyphoid fever are systemic illnesses caused by
Salmonella typhi and Salmonella paratyphi. The diseases are characterized
by fever and abdominal symptoms. In endemic areas, outbreaks cause
morbidity and mortality. The annual incidence of typhoid is estimated to be
seventeen million cases worldwide according to information from the World
Health Organization. In the United States, majority of cases occur in
travelers to other countries. The diseases are transmitted by contaminated
food and water. With the occurrence of multi-drug resistant and Nalidixic
acid resistant strains, the choice of empirical antibiotics was changed. Multidrug resistant strains caused outbreaks in India, Southeast Asia, Mexico and
Africa. Occurrence of mulit-drug resistance organism leads to the shift of
use of fluoroquinolones and cephalosporin as empirical therapy. Besides,
occurrence of Nalidixic acid resistant strain increases the use of
cephalosporin and azithromycin for treatment of typhoid and paratyphoid
fever.

Method
Between the period 2003 and 2009, patients with the diagnosis of
typhoid and paratyphoid fever from the computer system were included in
this study. Total seventeen cases were included. The case notes were
reviewed and relevant descriptive data including patient demographics,
clinical features, complication episodes, management strategy and follow up
were collected.

Results
Illustrative cases
Case 1 A lady was from Indonesia and worked as domestic helper.
She presented to Accident and Emergency Department with epigastric pain.
She was admitted to Surgical Ward for assessment and observation. She had
fever. In the presence of fever and epigastric pain, Surgical Team colleague
performed ultrasound abdomen to rule out significant biliary pathology.
However, there was no lesion in liver and gallbladder on ultrasound study
and fever in this lady persisted. Laboratory result showed deranged liver
function, elevation of alanine aminotransferase ALT 254 IU/L and elevation
of alkaline phosphatase ALP 248 IU/L. There was no rise in bilirubin.
Initially, the lady was given zinacef and flagyl for empirical antibiotic cover.
Medical team was consulted for opinion as well. Subsequently, blood
culture grew Salmonella typhi. The choice of antibiotic was changed to
ceftriaxone two grams daily regimen and completed one course in day ward
after discharge. Disease was notified. The prognosis was satisfactory,
subsequent monitoring showed normal liver function, as well as repeat stool

culture showing no growth. The length of stay of this lady was twelve days
in-patient.
Case 2 - Another lady was Indonesian as well. She was come to
Hong Kong as domestic helper one month before admission to hospital. She
presented with fever, chills, diarrhoea, with blood, as well as epigastric pain.
Abdomen examination showed epigastric tenderness, without rebound or
guarding. Per rectal examination revealed blood stained stool. There were
anaemia (haemoglobin 6.7g/dL) and liver function impairment (alanine
aminotransferase 101 IU/L). Test for malaria parasite was negative.
Ultrasound study of abdomen showed mild hepatosplenomegaly. Initially
the antibiotics used were zinacef, flagyl and ampicillin. Later, blood culture
result showed Salmonella typhi and then antibiotic was changed to
ceftriaxone two grams daily regimen and the antibiotic course was
completed in day ward after discharge. In this case, the clinical picture was
complicated with gastrointestinal bleeding. Oesophogastroduodenoscopy
showed presence of duodenal ulcer. Colonoscopy showed a rectum polyp
and histology revealed it was a tubular adenoma. Clinically, there was
improvement after course of antibiotic. Haemoglobin and liver function test
showed normal after subsequent monitoring. Disease was notified. Repeat
stool culture revealed negative growth. The length of stay was eight days inpatient.
Case 3 There was a case in this study with the bone marrow
culture showing the Salmonella species. The gentleman, with aged 29 yearold, presented with problem of on and off fever for two weeks, abdominal
pain and diarrhoea. He was a carrier of Hepatitis B infection. He worked as

company manager, who needed to travel abroad, frequently between Hong

Kong and United States. Ultrasound abdomen revealed hepatosplenomegaly.
Stool and blood culture showed negative results. Test for Human
Immunodeficiency Virus also showed negative result. Bone marrow study
was offered to the patient and the culture result from bone marrow showed
presence of Salmonella paratyphi, of Nalidixic acid resistant strain. Bone
marrow is an important source of culture material. Bone marrow cultures
may be positive in as many as 50 percent of patients after days of antibiotic
use.
Case 4, Case 5, Case 6 and Case 7 - In this study, there were four
cases of Salmonella species that were Nalidixic acid resistant. All of these
patients were managed by intravenous ceftriaxone use with the treatment
period between ten and fourteen days duration. The four cases were:
Case 4 male aged 46 year-old, with history of old pulmonary
tuberculosis, presented with fever and malaise; there was no diarrhoea or
constipation, as well as no history of recent travel. Rose spot was detected
on physical examination. Blood culture showed Salmonella typhi, of
Nalidixic acid resistance strain. He was given two weeks course of
ceftriaxone.
Case 5 female aged 50 year-old, history of post radioactive iodine
therapy related hypothyroidism. She presented with fever and diarrhoea and
there was history of travel to Southeast Asia, with seafood intake. Blood
culture grew Salmonella typhi, of Nalidixic acid resistance strain. She was
given ceftriaxone therapy for a total duration of ten days.

Case 6 This is the 29 year-old gentleman illustrated in Case 3.

Case 7 female aged 35 year-old, history of hyperthyroidism,
received course of anti-thyroid drug, then in remission. She presented with
fever, abdominal pain and diarrhoea. There was no history of recent travel.
Blood culture grew Salmonella paratyphi A, of Nalidixic acid resistant
strain. Microbiologist was consulted and suggested two-week course of
ceftriaxone. The length of stay for this lady was seven days and she received
and completed her course of antibiotic in day ward after discharge.

Demography
Age Among these seventeen patients, two of them with age
younger than 18 (one year 16 and one year 17). Six of them were aged
between 18 and 40. Five of them were aged between 41 and 60. Four were
aged between 61 and 80. The youngest one and the elder one were aged 16
and aged 80 respectively.
Sex Ten of them were female while seven of them were male.
Race Fifteen were Chinese. Two were Indonesian.
Occupation One was a health care assistant in old-aged home.
One worked at a bakery. Two were company manager, who needed to travel
abroad, one between Hong Kong and United States and the other travelling
between Hong Kong and Mainland usually. Two were domestic helpers
from Indonesia.

Age

<18
18-40
41-60
>60

2
6
5
4

Sex

Male
Female

7
10

Race

Chinese
Indonesian

15
2

Table 1: Demographics of study population

Exposure History
Four of them gave clear history of exposure to contaminated food
and water in endemic areas.

Clinical Features
Pyrexia Five cases with fever lasting longer than one week
before attending to hospital for consultation while the rest (twelve patients)
were within one week between onset of fever and first day of admission.
Gastrointestinal

symptoms

Fourteen

patients

had

gastrointestinal symptoms, among them, seven patients with abdominal pain,

another seven patients with diarrhoea. One patient had symptom of bloody
diarrhoea.
Headache four patients had symptom of headache on initial
presentation.
Cough, malaise four patients initially presented with cough and
malaise, together with symptom of fever.

Rose spot one patient had sign of Rose spot on physical

examination.

Pyrexia
Pyrexia more than 1 week

17
5

Gastrointestinal
Abdominal pain
Diarrhoea

14
7
7

Headache

Cough, malaise

Rose spot

Travel history

Table 2: Clinical characteristics

Travel history six patients had recent travel history. Three of
them had travel to Mainland within one month. One was a company
manager, who needed frequent travel between Hong Kong and United States.
Regarding the domestic helpers, two Indonesian came from their parent
country and worked as domestic helper in Hong Kong. Their vaccination
status was not clearly documented in the case records.

Complications
There were deranged liver function (elevation of alanine
aminotransferase ALT), neuropsychiatric and haematological complications
among the patients:
Deranged liver function (elevation of alanine aminotransferase
ALT) eleven patients had problem of elevation of ALT to various

10

extent. The highest ALT level was up to six-fold of the upper limit of
normal range.
Neuropsychiatric disturbance one patient had presentation of
fever, headache and delirium. This gentleman had problem of on and off
fever for one week. He went to the Accident and Emergency Department
because of persistent fever and headache. After admission to ward, he had
problem of delirium. Lumbar puncture was performed to rule out central
nervous system infection.
Haematological one patient had problem of anaemia.
There was no case with problem of focal abscess formation or
chronic carriage.

Deranged liver function

(elevation of alanine aminotransferase
ALT)

11

Delirium

Anaemia

Table 3: Complications of enteric fever in study population

Laboratory Result
Four patients had laboratory feature of lymphopenia in this study.
Eleven patients had problem of elevation of alanine aminotransferase (ALT).

11

WBC (10^9/L)

Lymphocyte

(4.0-11.0)

(10^9/L)(1.0-3.8)

Case 1

3.5

1.1

Case 2

8.9

1.7

Case 3

7.7

2.0

Case 4

6.4

2.4

Case 5

8.4

0.6

Case 6

10.0

1.4

Case 7

7.0

0.9

Case 8

8.7

1.2

Case 9

7.4

0.4

Case 10

13.2

1.0

Case 11

2.7

1.2

Case 12

6.0

2.4

Case 13

5.7

0.9

Case 14

13.7

2.3

Case 15

4.3

1.5

Case 16

7.5

1.8

Case 17

4.8

2.3

Table 4: White blood cell and lymphocyte count in study population

12

ALT(IU/L)(<41)
Case 1

15

Case 2

16

Case 3

155

Case 4

109

Case 5

72

Case 6

117

Case 7

20

Case 8

Case 9

32

Case 10

79

Case 11

45

Case 12

93

Case 13

127

Case 14

34

Case 15

169

Case 16

254

Case 17

101

Table 5: Alanine aminotransferase (ALT) in study population

13

Laboratory diagnosis
There were thirteen cases of typhoid fever and four cases of
paratyphoid fever in this study.
Culture of organism nine out of seventeen cases had positive
culture from blood. There was one patient with the diagnosis showed up by
bone marrow culture. One case had positive Salmonella typhi in stool.

Site

Number of cases

Culture from blood

Culture from stool

Culture from bone marrow

Table 6: Number of culture positive cases from different sites

14

Nalidixic acid resistant strain there were four cases.

Organism

Site of

Sensitivity pattern

culture
Case 1

Salmonella

blood

Amp R, Chl S, Cot S

blood

Nal R, Amp S, Chl S, Cot S, Cip S,

typhi
Case 2

Salmonella
typhi

Case 3

Case 4

Cef S

Salmonella

bone

Nal R, Amp S, Chl S, Cot S, Cip S,

paratyphi

marrow

Cef S

Salmonella

blood

Nal R, Amp S, Chl S, Cot S, Cip S,

paratyphi A

Cef S

Table 7: Antibiotic sensitivity pattern of four cases infected by

Nalidixic acid resistant strains in study.
Chloramphenical(Chl),
Ciprofloxacin(Cip),

Cotrimoxazole(Cot),

Ceftriaxone(Cef),

Ampicillin(Amp),

Nalidixic

acid(Nal),

Resistant(R), Sensitive(S)

Serology Test six cases was suggested by the Serological test.

Three patients had paired sera Widal agglutination test showing four-fold
rise. Three patients had single Widal agglutination test showing rise in
antibody titer of the following results: i) Salmonella typhi H 1:2560, ii)
Salmonella paratyphi BH1:640, and iii) Salmonella typhiH1:640.

15

Management
Antibiotic treatment is essential in treatment of typhoid and
paratyphoid fever:
Choice of antibiotic Among the seventeen patients, different
antibiotics was used. Eleven patients were given ceftriaxone, four given
fluoroquinolone, one given septrin (trimethoprim-sulfamethoxazole), as
well as one given the combination of ceftriaxone and azithromycin.
Duration and Dose of antibiotic treatment Sixteen patients
were received antibiotic treatment between ten and fourteen days duration.
One patient was received combination of cephalosporin and macrolide for a
period of one week. Regarding the dosage of third generation cephalosporin,
ceftriaxone, dosage regimens of one gram daily or two grams daily were
given in individual cases.
Length of stay Four patients had in-patient stay longer than
fourteen days. Five patients had length of stay (LOS) between eight and
fourteen days. Eight patients had LOS shorter than eight days.
Outpatient administration of antibiotic Among the eleven
patients receiving ceftriaxone, four of them (36.4 percent) could be
managed in day ward for continuation of antibiotic. The length of in-patient
stay of these four patients were 6 days, 7 days, 13 days and 8 days. In 2009,
there were three patients receiving treatment in day ward. For the one with
the length of stay of thirteen days, the patient was admitted to surgical ward
for management of fever and abdominal pain. Initial focus was on problem
of biliary system. Later blood culture revealed Salmonella species and she
was taken over to medical ward for further care of her enteric fever problem.

16

Day ward completion of course of antibiotic shortened in-patient length of

stay.
Follow up of stool result After appropriate treatment, all
seventeen cases had follow up stool study within three months. All results
were negative.

17

Discussion
Epidemiology
Typhoid and paratyphoid fever are systemic diseases characterized
by sustained fever and abdominal symptoms. In United States,
approximately 300 clinical cases reported per year1 and most of the cases
are travellers returned from endemic areas. Despite the recommendation of
vaccination, many travellers are not fully compliance to the vaccination
programme. In developing and developed countries, enteric fever still
causes morbidity and mortality. The annual incidence of typhoid is
estimated to be 17 million cases worldwide according to information from
the World Health Organization. The disease is transmitted by contaminated
food and water.

Microbiology
Typhoid and paratyphoid fever are caused by Salmonella Typhi or
Salmonella Paratyphi A, B or C. There are over 2000 different antigenic
types

of

Salmonella.

Salmonellae

are

typical

members

of

the

Enterobacteriaceae. They are Gram-negative bailli. Salmonella enterica

express two sets of antigens, which can be demonstrated by serotyping. The
two sets of antigens are O antigen and H antigen. Certain serotypes of
Salmonella enterica express a surface polysaccharide. One of the examples
is the Vi antigen of Salmonella Typhi.2

Pathogenesis

18

The development of typhoid fever depends on the specific organism

involved and the number of organism ingested. In general, the greater the
number of organism ingested, the greater chance to have the disease.
Subsequently, gastrointestinal infection and then systemic spread and
persistence are resulted. The organisms Salmonella typhi enter the gastric
acid barrier and then pass to the small intestine. They enter the submucosal
region, proliferate and then result in hypertrophy of the Peyers patches
through recruitment of mononuclear cell and lymphocyte. Hypertrophy and
the resulting necrosis account for the clinical manifestation of occurrence of
abdominal pain and ileal perforation. Dissemination of organism
dissemination of the organism from Peyers patch to the reticuloendothelial
system then occurs. Replication occurs within the reticuloendothelial system,
accounting for the clinical manifestation of clinical sepsis and
hepatosplenomegaly. Later, the organisms reside within the monocytederived or tissue macrophages in the liver, spleen and bone marrow. This is
an important source of diagnosis from culture.3,4

Clinical presentation, complication

Patients with typhoid and paratyphoid fever usually have nonspecific symptoms like fever, abdominal pain, malaise, cough, etc. Classic
presentation of typhoid fever includes three phases fever, bacteremia
phase; then proceed to occurrence of abdominal pain and rose spot;
subsequently, the presence of hepatosplenomegaly, intestinal haemorrhage
and perforation. Patients will develop febrile illness 5 to 21 days after
ingestion of the organism, via contaminated food or water. Depending of the

19

host immune status, gastric acidity, as well as infectious load of organism,

clinical manifestation may vary person to person.
In the study, common symptoms include fever, abdominal pain and
diarrhoea. There were two patients with clinical sign of hepatosplenomegaly.
One patient had the sign of Rose spot on the trunk. Reviewing all seventeen
cases, there was no pulse temperature dissociation in the temperature chart.
Important point was that the initial presentation could be very non-specific.
Patients had the symptoms of fever, malaise and cough on initial
presentation. That led the physicians thinking about alternative diagnosis.
For example, four patients had the symptoms of fever and cough on initial
presentation. The physician in-charge put chest infection as the working
diagnosis after initial assessment. Later the culture result came back and
management strategy was changed. Another example was that one patient
presented with the clinical picture suspecting central nervous system
infection with fever, headache and delirium. The investigation was targeted
to rule out central nervous system infection and lumbar puncture was
performed.
Apart from surgical cause for fever and abdominal pain, physician
should have the differential diagnosis of enteric fever in mind while taking
care of patient with travel or with history of contaminated food and water
exposure. Prompt recognization of symptom and sign from patients would
lead to a clear clinical picture for management.
Other non-specific symptoms include cough and malaise. Four
patients (23.5 percent) had symptom of cough and malaise together with
fever in this study. Several features could be observed. Physician managed

20

the case as chest infection only. Investigation focused on ruling out

pulmonary tuberculosis infection. One patient with the sign of Rose spot
was detected by review examination by senior doctor. Patients with enteric
fever syndrome usually present with non-specific symptom and sign.
Particular attention to this diagnosis should be paid in the assessment.
One patient in this study had problem of gastrointestinal
haemorrhage. There was no case with problem of intestinal perforation
requiring surgical intervention in this study.

Diagnosis
Diagnosis of typhoid fever is based on the culture of organism from
materials. Blood culture is positive in 40-80% of patients. Stool culture is
positive in 30% of patients.5 Bone marrow culture is more sensitive. It may
be positive in as many as 50% of patients with prior antibiotic use.3
Serological test Widal test is neither specific nor sensitive. Its clinical use
and significance are doubtful.

Treatment
Typhoid fever is managed by appropriate antibiotic therapy. The
optimal choice of antibiotic and duration of antibiotic are unknown.6-8
However, the principle of prescription should base upon local resistance
pattern, clinical setting, whether oral treatment is feasible, as well as
availability of resource. It is better to choose single antibiotic agent for
treatment. Multi-drug resistant and Nalidixic acid resistant strains pose
problem in clinical management. Multidrug resistant Salmonella typhi is, by

21

definition,

resistant

to

the

original

first

line

agents

including

chloramphenicol, ampicillin and trimethoprim-sulfamethoxazole. Multidrug

resistant strains caused outbreaks in India, Southeast Asia, Mexico and
Africa.9 In old day, enteric fever was managed with antibiotics of choice
including ampicillin, trimethoprim-sulfamethoxazole and chloramphenicol.
Resistance pattern leads to the shift of use of fluoroquinolones and
cephalosporin as empirical therapy. Besides, the emergence of Nalidixic
acid resistant organism also invites management difficulty. Nalidixic acid
resistant organisms have decreased susceptibility to fluoroquinolones. There
strains had been found in up to 70 to 90 percent of isolates in India, Nepal as
well as Vietnam.10-12 These strains were less effective managed by short
courses of fluoroquinolones use, compared with Nalidixic acid sensitive
strain.
Chloramphenicol, ampicillin and trimethoprim-sulfamethoxazole
remain the main choice in countries where the organism is still susceptible
to the above antibiotics and where fluoroquinolones are not available or
affordable. The above antibiotics are not expensive; however, patients need
to comply with the frequency of use and the longer duration, two to three
weeks of treatment period.
Nalidixic acid resistant organisms with decreased susceptibility to
fluoroquinolones cause problem in some parts of Asia. Unfortunately,
quinolone-resistant strains are often multidrug resistant. Hence, the choice
of antibiotic is shifted towards use of third generation cephalosporin and
azithromycin. Examples of third generation cephalosporins include
ceftriaxone, cefixime, cefoperazone and cefotaxime. In randomized

22

controlled trial, third generation cephalosporins, ceftriaxone and cefixime,

were studied for treatment of typhoid fever. The fever clearance time,
relapse rate and faecal carriage rate were analyzed. The fever clearance time
averaged one week and the rate of treatment failure was five to ten
percent.13-16 The relapse rate was three to six percent. The faecal carriage
rate was less than three percent.
Regarding the dose of cephalosporin, ceftriaxone, 2 to 3 gram once
daily regimen parenterally or cefixime (20 to 30mg/kg per day orally in two
divided doses) for 7 to 14 days is recommended.17 Review the eleven
patients receiving the treatment of ceftriaxone, nine of them received the
recommended dose of ceftriaxone. While two of them, the dose was
suboptimal according to the recommendation. Following the clinical
response of patients receiving suboptimal dosage, both had satisfactory
clinical response. There was no clinical relapse and follow up stool culture
showed negative result.
Four patients in this study received fluoroquinolones therapy. There
was strong evidence that fluoroquinolones were effective drugs for the
treatment of typhoid fever. In randomized controlled trials, for patients
infected by quinolone-susceptible Salmonella typhi, fluoroquinolones have
proved safe in all age groups and was rapidly effective after short course of
treatment. The average fever clearance time was less than four days. The
cure rate exceeded 96 percent. Less than two percent of patients received
fluoroquinolones had persistent faecal carriage or relapse.13,14,18-20

23

In Asia, the production of generic fluoroquinolones reduces the price

of fluoroquinolones considerably. Unfortunately, resistance to firstgeneration fluoroquinolones is widespread in many parts of Asia.
Azithromycin recommended dose for treatment of typhoid fever
10 to 20mg/kg to 1 gram maximum once daily for duration of five to seven
days.21,22 Azithromycin can achieve very good intracellular concentration
and its use for treatment of typhoid fever is in a rising trend because of the
occurrence of fluoroquinolone resistance strains.

Prevention
In order to prevent typhoid and paratyphoid fever, prevention
measures should be implemented strictly. Public health intervention
stressing on personal and environmental hygiene, as well as proper
sanitation system are essences for successful management. The public
should be taught about proper hand washing and safe food-handling practice.
Keeping food storage environment clean handle and store raw and
cooked food separately. Regularly clean the refrigerator. Excluding typhoid
carrier from handling food and from providing care to patients is also
important.
Vaccine There are live oral S typhi vaccine strain TY21a and
parenteral Vi polysaccharide vaccine. They are neither completely effective
against S typhi and neither providing protection against paratyphoid fever.
For travelers to high risk areas, typhoid vaccination may provide protection
at very little risk. Prevention of enteric fever requires implementing
immunization for young children in endemic areas.

24

One vaccine is produced by conjugating the Vi capsular polysaccharide of S

typhi to a nontoxic recombinant Pseudomonas aeruginosa exotoxin A. It
was tested for safety, immunogenicity and efficacy in a randomized
controlled trial in Vietnam. It showed greater than ninety percent efficacy. 23

Conclusion
Two cases were Indonesian in this study. They came to Hong Kong
as domestic helper.
Common symptoms were abdominal pain and diarrhoea. Common
complication was deranged liver function. Eleven patients had problem of
deranged liver function, elevation of alanine aminotransferase.
Four cases in this study were infected by Nalidixic acid resistant
strain. All of them were managed by antibiotic with use of ceftriaxone.
Among the eleven patients treated with ceftriaxone, four of them (36.4
percent) could be managed in day ward for continuation of antibiotic
administration. The clinical outcome was satisfactory in all four cases.
Travel history is an important piece of information for management
of typhoid and paratyphoid fever because getting information from the areas,
where there are multi-drug resistant and Nalidixic acid resistant strains,
guides the use of antibiotic in a proper way.
Nowadays, antibiotic use reduces morbidity and mortality of typhoid
and paratyphoid fever. Although severe complications, e.g. intestinal
perforation, are less common, prompt recognization of the diagnosis and
watching out for complication reduce the morbidity and mortality.

25

Regarding the treatment, in this study, four cases (23.5 percent) were
infected by Nalidixic acid resistant strain. Two of them had travel history to
endemic area. The occurrence of Nalidixic acid resistant organism increases
the use of cephalosporin and azithromycin for treatment of typhoid and
paratyphoid fever.
With the trend of utilization of day ward for more clinical procedure
and treatment, the length of stay for patients receiving parenteral antibiotic
treatment is shortened as they can complete the course of treatment in day
ward setting.

26

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