Outpatient management of uncomplicated enteric fever: A case series of 93 patients from the Hospital of Tropical Diseases, London

OBJECTIVES

Enteric fever is predominantly managed as an outpatient condition in endemic settings but there is little evidence to support this approach in non-endemic settings. This study aims to review the outcomes of outpatients treated for enteric fever at the Hospital of Tropical Diseases in London, UK.

METHODS

We conducted a retrospective analysis of all patients with confirmed enteric fever between August 2009 and September 2020. Demographic, clinical, laboratory and microbiological data were collected and compared between the inpatient and outpatient populations. Outcomes investigated were complicated enteric fever, treatment failure and relapse.

RESULTS

Overall, 93 patients (59% male, median age 31) were identified with blood and/or stool culture confirmed enteric fever and 49 (53%) of these were managed as outpatients. The commonest empirical treatment for outpatients was azithromycin (70%) and for inpatients was ceftriaxone (84%). Outpatients were more likely than inpatients to receive only one antibiotic (57% vs 19%, p < 0.01) and receive a shorter duration of antibiotics (median 7 vs 11 days, p <0.01). There were no cases of complicated disease or relapse in either the inpatient or outpatient groups. There was one treatment failure in the outpatient group. Azithromycin was well-tolerated with no reported side effects.

CONCLUSIONS

Our findings suggest that outpatient management of uncomplicated imported enteric fever is safe and effective with the use of oral azithromycin. Careful monitoring of patients is recommended as treatment failure can occur.

British Infection Association Guidelines for the Diagnosis and Management of Enteric Fever in England

Enteric fever (EF) is an infection caused by the bacteria called Salmonella Typhi or Paratyphi. Infection is acquired through swallowing contaminated food or water. Most EF in England occurs in people returning from South Asia and other places where EF is common; catching EF in England is rare. The main symptom is fever, but stomach pain, diarrhoea, muscle aches, rash and other symptoms may occur. EF is diagnosed by culturing the bacteria from blood and/or stool in a microbiology laboratory. EF usually responds well to antibiotic treatment. Depending on how unwell the individual is, antibiotics may be administered by mouth or by injection. Over the past several years, there has been an overall increase in resistance to antibiotics used to treat enteric fever, in all endemic areas. Additionally, since 2016, there has been an ongoing outbreak of drug-resistant EF in Pakistan. This infection is called extensively drug-resistant, or XDR, EF and only responds to a limited number of antibiotics. Occasionally individuals develop complications of EF including confusion, bleeding, a hole in the gut or an infection of the bones or elsewhere. Some people may continue to carry the bacteria in their stool for a longtime following treatment for the initial illness. These people may need treatment with a longer course of antibiotics to eradicate infection. Travellers can reduce their risk of acquiring EF by following safe food and water practices and by receiving the vaccine at least a few weeks before travel. These guidelines aim to help doctors do the correct tests and treat patients for enteric fever in England but may also be useful to doctors and public health professionals in other similar countries.

Comparison of patient-controlled sedation with either methohexitone or propofol

We studied 42 patients undergoing oral surgery under local anaesthesia with i.v. sedation, allocated randomly to receive either methohexitone (group M) or propofol (group P) for patient-controlled sedation (PCS). Group M patients self-administered 2.5-mg (0.5 ml) bolus doses of methohexitone and group P, 5-mg (0.5 ml) doses of propofol, without a lockout. The 0.5-ml bolus dose was delivered over 7.2 s for both drugs. The procedure was completed satisfactorily in all patients. Patients in both groups achieved their desired levels of sedation. No patient lost verbal contact. Group M patients had higher heart rates during the procedure. The lowest SpO2 values recorded were 92% and 95% for group P and group M, respectively. Immediately after operation patients in group M reported that they felt more sleepy than those in group P (P < 0.01) but there were no differences at subsequent times. The results of the psychomotor tests were comparable for the two groups after operation, except for the "posting box task" at 15 min after operation when the mean decrement (compared with preoperative performance) was -3% for group P and -13% for group M (P < 0.05). More patients in group P complained of pain in their hand. We conclude that methohexitone is a suitable alternative drug to propofol for PCS.

Smoking and stress: cigarettes and marihuana

In a sample of 88 undergraduates, smoking cigarettes and marihuana was associated with more recent stressful events, while smoking cigarettes was associated with higher scores on Type A personality.

Effectiveness and sequelae of very low-dose suxamethonium for nasal intubation

We have studied the effectiveness and sequelae of low-dose suxamethonium in 60 day-case oral surgery patients requiring nasal intubation. Anaesthesia was induced with propofol and alfentanil; 60 patients were allocated randomly to three groups of 20 patients and received no suxamethonium, suxamethonium 0.25 mg kg-1 or 0.5 mg kg-1. All patients received i.v. fentanyl and diclofenac 100 mg rectally for analgesia. Good intubating conditions were produced in all 20 patients receiving suxamethonium 0.25 mg kg-1, in 19 patients receiving suxamethonium 0.5 mg kg-1 and in 11 patients not receiving a neuromuscular blocker. The incidence of postoperative myalgia after suxamethonium 0.25 mg kg-1 (20%) did not differ significantly from the incidence after propofol and alfentanil alone (28%).