Enteric fever, caused by Salmonella enterica serovars typhi and paratyphi A (S. typhi and S. paratyphi A) is a major public health problem in many developing countries, including India. It is one of the leading causes for morbidity and mortality. Incidence of typhoid fever in India is about 214.2 per 100,000 persons /year [1]. S. typhiis the most common etiologic agent and there is an increasing number of cases due to S. paratyphi A [2, 3].

This has been attributed to the use of Vi polysaccharide vaccine or monovalent vaccine which provides protection against typhoid fever only [3]. Knowing the proportion of disease due to S. typhi and S. paratyphi A is significant, as these serovars may have subtle differences in their modes of transmission, clinical course and may necessitate differing control measures.

However, there remains no single test that has proven to be sufficiently sensitive, specific, and practical for use in developing countries. In actual practice, most of the infections by Salmonella enterica serotype Typhi are diagnosed clinically without proper laboratory evidence and consequently treated presumptively with antibiotics [4].Though blood cultureisthe gold standardin diagnosis of enteric fever, excessive antibiotic use has reduced the isolation rate to 40-60 percent [3]. Obtaining accurate data on disease burden in developing countries is difficult because the diagnosis of enteric fever is often a clinical one, without blood culture conurbation, and most of the patients are treated as outpatients [4].

The last two decades have seen the emergence of multi-drug resistance against the conventional anti-typhoidal drugs (ampicillin, cotrimoxazole and chloramphenicol) among the Salmonella sp. From 2000, there have been reports of high levels of chloramphenicol susceptibility from many parts of India and the Salmonella strains have regained susceptibility to this drug due to less use [5]. Antibiogram showed 2% of the strains to be sensitive to all the drugs tested and 12% were MDR and showed the presence of plasmids [6-8]. World wide the emergence of multidrug resistant S. Typhiand S. Paratyphi Astrains has been shown to be geographically heterogeneous, stressing the importance of continuing surveillance of antimicrobial resistance among Salmonella isolates [2].

To confirm the diagnosis blood culture, Widal test and Typhoid test was done as per standard protocols. The treatment administered and its duration was also recorded along with the patient’s outcome. The results was recorded and analysed. They were analysed as to those that were diagnosed clinically and those that were confirmed with laboratory support. The clinical profile of typhoid and paratyphoid fever was analysed. The antimicrobial susceptibility pattern of Salmonella species isolated was analysed.

Statistical methods: Enteric fever, common symptoms and sign and blood culture was considered as primary outcome variables. Descriptive analysis was carried out by mean and standard deviation for quantitative variables, frequency and proportion for categorical variables.

Non-normally distributed quantitative variables were summarized by median and interquartile range (IQR). Data wasrepresented using appropriate diagrams like bar diagram, pie diagram and box plots. Proportions and categorical data were analysed byChi-square test and t-test.

Ethical consideration and permission: The ethical clearance was obtained from institutional review board and informed consent was taken from each of the participant.

Our study included a total of 200 clinically suspected cases of enteric fever during the study period. Out of 200 patients included, 121 casesof clinically suspected entericfever were found to beeither blood culture positive or serology positive forenteric fever. Out of 121 cases, 76 (62.81%) participants were males and 45 (37.19%) were females. Male to female ratio was 1.7: 1. The youngest patient was 13 years of age and 65years was the oldest patient’s age. 68(56.2%) cases were in the age group of 13y-30years, 44(36.4%) cases were in the age group 31-50years and only 9 (7.4 %) cases were of above 50 years. The mean age was 30.55±12.65 years.

All the 121 cases presented with fever. 63 (52%) had low grade and 58 (48%) had high grade fever. Mean duration of fever was 11.61±7.4 days. 75 patients (62%) had headache; 75 (62%) had chills, 59 (49%) had arthralgias and myalgias; 49 (40%) cases had abdominal pain, 58 (48%) had vomiting,

The clinical signs included bradycardia in 67 (55%) individuals, 25 (21%) had abdominal tenderness; 32 (26%) had splenomegaly, 14 (11.5%) hepatomegaly. None had other complications like meningitis or epistaxis, perforation or gastrointestinal haemorrhage.

No deaths were reported (Table 2). Among the study population, 23 patients (19%) patients were treated with oral antibiotic. Most of them were treated with azithromycin (17), 4 patients were treated with cotrimoxazole and 1 each received ciprofloxacin and cefixime.(Table 3)

Blood culture was done in 80 patients, S.typhi was isolated in 6 cases, S. paratyphi A in 28 cases, 44 had no growth after one week of incubation and 2 samples grew skin commensals. Blood culture not done in 41 cases (Table 4). All the isolates were sensitive to ceftriaxone.

Out of 107 in whom cases Widaltest was done, 42 were positive for typhoid fever; 37 were had a significant titre for paratyphoid fever. In 28 cases, Widal test was negative. Out of 121 cases of enteric fever, after combining the clinical and laboratory criteria, 58 cases were found to have typhoid fever while 53 cases were found to have paratyphoid fever, while 10 were diagnosed purely based on clinical criteria of enteric fever (Table 5).

Typhoid fever continues to be a public health problem especially in the tropics. There is a dearth of available epidemiological data to project the actual situation in India [3].

Our study included 121 cases of clinically suspected enteric fever were found to beeither blood culture positive or serology positive forenteric fever. Male to female ratio was 1.7: 1. The mean age was 30.55±12.65 years. In the study by Chowta M N et al[11] observed similar proportion of females and male patients in their study.

Average age of presentation was 23.9 years which was slightly lesser compared to the current study. Gupta, S., et al[12] in a total of 81 culture positive patientsalso had similar proportion of males 62.2% and females as ours. However, averageage of patients was 18.2 (range 2-45) years which was less compared to the current study.

Out of 121 cases, 53 were paratyphoid, 58 were typhoid fever, 10 were diagnosed based on clinical criteria of enteric fever.

In the study by Gupta, S., et al[12] widal test results (single titres) were positive (defined as S typhi O antigens ≥ 160 and S typhi H antigen or S paratyphi H antigen ≥ 160) in 35/81 (43.2%) of patients.

Widal was positive in 21/54 (38.8%) patients presenting in the first week of fever, while those presenting in second week or after had positive test in 14/27 (51%) cases. Mushtaq S., et al[14]did Widal test for 129 patients, obtained after mean duration of 4 days in hospital. WIDAL test was considered diagnostic for typhoid fever if titres of more than 1:160 or demonstration of four-fold rise in antibody titre[10].

The clinical profile included bradycardia, abdominal tenderness, splenomegaly and hepatomegaly but did not show any serious complications in our study. The results of blood culture and widal test correlated well in the study.

The prevalence, presentation and sensitivity of the typhoid may differ with different geographical area. Variation can be observed at the same site and also variation in place within countries and regions.

This contributes to the rate in a certain geographical area and also determines the susceptibility pattern of different antibiotics in salmonella species.

Authors acknowledge the technical support in data entry, analysis and manuscript editing by “Evidencian Research Associates.”