eMedinewS Editorial

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Preparing for Commonwealth Games illnesses

Dear Colleague

Over one lakh people are likely to visit during the month of October to attend and participate in Commonwealth Games.

During his visit to India during Commonwealth Games, a foreigner is likely to suffer from one of the four diseases: Acute diarrhea, acute systemic febrile illness without localizing findings, skin disorders and non–diarrheal GI disorders.

Out of 100 travelers falling sick 33% will fall sick, because of fever, 40% due to acute diarrhea and the rest due to other two illnesses.

It has been estimated that out of 100 patients presenting with acute systemic febrile illness, 32 will suffer from dengue, 13 from malaria, 3 from typhoid, 5 from viral disorders and rest 45 may have no demonstrable cause. Out of 100 people developing diarrhea, 60 would be due to E. coli bacteria.

The most commonly encountered skin diseases would be insect bites, animal bites, allergic rash or reaction.

Among 100 patients suffering from non-diarrheal GI illness, 59% will be related to worm infestation, 18% to acid peptic disease and remaining to jaundice, piles or constipation.

In today’s issue, we will talk about other diseases with special reference to Typhoid.

Salient features about Typhoid

  1. Typhoid is a severe systemic illness.
  2. It presents with SUSTAINED fever with abdominal or respiratory symptoms.
  3. Abdominal symptoms usually appear in the second week; the first week is characterized by rise in fever. Liver and spleen usually becomes palpable in third week.
  4. If not treated, 15% would die. Even with treatment, the mortality is 1.5%.
  5. Blood cultures becomes positive in 40–80% cases. Blood culture should be taken as early as possible during the illness using blood or clot or bone marrow.
  6. Low hemoglobin in a patient with fever may signify typhoid or malaria.
  7. About 86% of patients with typhoid will have high SGOT and SGPT.
  8. Patients may have features suggestive of acute hepatitis (Typhoid hepatitis). In acute viral hepatitis, jaundice appears when fever disappears. Whereas, in typhoid, jaundice and fever persist together. In typhoid, fever is often more than 40°C with high SGOT/ SGPT levels, which are usually lower than 400.
  9. Multi–drug resistance cases of typhoid are on the rise. In one study, 26% of MDR cases were resistant to five drugs.
  10. Drugs like ofloxacin should be reserved as anti–TB drugs and not used for typhoid.
  11. The drug of choice for typhoid is either one or two of the three - ciprofloxacin, ceftraxione / cefixime and/or azithromycin.
  12. The drugs that are highly effective, as they have good penetration inside cells, are ciprofloxacin or azithromycin.
  13. Norfloxacin is poorly absorbable and not to be used.
  14. Resistance to azithromycin is not reported so far.
  15. If the blood culture is positive and all drugs are sensitive, then ciprofloxacin should always be given.
  16. If the culture report is not available and one is not sure about drug sensitivity then azithromycin should always be used.
  17. When two drugs need to be given, one of them should be ceftriaxone / cefixime.
  18. In routine clinical practice in the private sector, it is better to use two drugs than a single anti–typhoid medicine.
  19. The regimes, therefore, are ciprofloxacin with ceftriaxone / cefixime or ceftriaxone / cefixime with azithromycin.
  20. The standard approach is that for any febrile illness one should give antibiotics minimum for three days after the fever subsides and for at least 7 days after fever subsides in cases of severe illness or resistance cases or relapse.
  21. The usual clinical practice is to give two antibiotics, one of them for 14 days and the other for 7–10 days. Azythromycin is given 1 g on Day 1 and 500 mg daily for 10 days. One can also give 1 g daily for five days.
  22. Ceftriaxone is given 2 g morning and evening or 2 g morning and 1 g evening for 14 days. On the 7th day, one may substitute it with oral cefixime 200 mg twice daily.
  23. If cefixime is the initial drug selected for treatment, it should be given in doses of 200 mg twice daily for 14 days.
  24. Ciprofloxacin should be given 750 mg twice daily for 14 days.
  25. If the regime is ciprofloxacin and cefixime, then ciprofloxacin can be given 14 days and cefixime for 10 days.
  26. If the patient is toxic or has high persistent fever, not responding to paracetamol, one may give 8–16 mg of IV dexamethasone daily for 24 to 48 hours.
  27. About 1–6% of typhoid fever cases will relapse 2-3 weeks after the fever resolves. The treatment is to give medications to which the bacteria is sensitive for a longer duration of time.
  28. Presence of the organism in stool 12 months after the illness is called chronic carrier state. The treatment of choice is ciprofloxacin 750 mg twice a day for 4 weeks.
  29. In typhoid, after sublingual nimesulide, fever may rapidly fall and even go below normal.

    (Excerpts from IMSA CME organised on Sunday at Moolchand Medcity)

Dr KK Aggarwal
Padma Shri Awardee and Chief Editor