Page 105 - Journal of Special Operations Medicine - Spring 2014

Figure 1 Rose spots on the chest of a patient with typhoid may in fact protract the length of excretion of the or-
fever due to the bacterium Salmonella typhi. Symptoms of ganism in the feces. Antimicrobials may be indicated in
typhoid fever may include a sustained fever as high as 103° infants or those with immunosuppressive illnesses who
to 104°F (39° to 40°C), weakness, stomach pains, headache, may be at risk of invasive disease. Ceftriaxone or am-
loss of appetite. In some cases, patients have a rash of flat, picillin (only if the organism isolated is susceptible) is
rose-colored spots.
indicated for invasive disease caused by nontyphoidal
Salmonella infections, with the length of treatment to
be determined by the severity and location of the illness.
Image from the CDC Public Health Image Library treatment with fluoroquinolones for invasive disease
Treatment with ceftriaxone can be empirically started in
cases of invasive Salmonella Typhi and Paratyphi disease;

should be undertaken with caution in southeast Asia and
the Indian subcontinent due to widespread drug resis-
tance. Azithromycin can be used in most instances for un-
complicated cases of these diseases; ciprofloxacin is useful
in areas where antibiotic resistance is not a concern.

After causing significant morbidity and mortality dur-
ing the American Civil War and the Spanish-American
result. Bone marrow biopsy has the greatest yield but is War, the U.S. military became very interested in vacci-
the most invasive. The Widal test is a serologic test used nating its troops against this dread disease. Dr. Fredrick
widely in the developing world to diagnose typhoid dis- F. Russell, a U.S. Army physician, modified the existing
ease but has limited value in endemic areas, as a positive vaccine created by the British bacteriologist Sir Almroth
result may actually reflect a previous infection. Newer Wright, and by 1911 the U.S. Army became the first
polymerase chain reaction and enzyme-linked immuno- army in history to be vaccinated against typhoid.
sorbent assay testing is available in only limited areas
of the developed world but likely represent improved Two different types of vaccines, both intramuscular and
diagnostic tools for the future. oral, are available for use in the United States (Table 1).
A key point to remember about both vaccines is that,
at best, the vaccines provide only 50% to 80% protec-
Treatment and Vaccination tion against Salmonella serovar Typhi infections and no
Antimicrobials are generally not necessary to treat the protection against paratyphoid infections. Neither one
patient with an uncomplicated gastroenteritis caused by of these vaccines has been approved for use by pregnant
a non–enteric fever Salmonella infection as they have women. The oral vaccine is a live vaccine, and and its
not been shown to decrease the length of the illness and use should be delayed until 72 hours have passed since

Table 1 Vaccines to prevent typhoid fever.
Age Dose, Mode of Number of
Vaccination (y) Administration Doses Dosing Interval Boosting Interval
Oral, Live, Attenuated Ty21a Vaccine (Vivotif)
2
Primary series ≥6 1 capsule, oral 4 48 hours Not applicable
Booster ≥6 1 capsule, oral 4 48 hours Every 5 years
2
Vi Capsular Polysaccharide Vaccine (Typhim Vi)
0.50mL,
Primary series ≥2 1 Not applicable Not applicable
intramuscular
0.50mL,
Booster ≥2 1 Not applicable Every 2 years
intramuscular
Notes:
1. The vaccine must be kept refrigerated (35.6°F–46.4°F, 2° C–8°C).
2. Administer with cool liquid no warmer than 98.6°F (37°C).
Source: From The Centers for Disease Control and Prevention Yellow Book, Travelers’ Health. http://wwwnc.cdc.gov/travel/yellowbook/2014
/chapter-3-infectious-diseases-related-to-travel/typhoid-and-paratyphoid-fever#4235.

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