LETTERS TO THE EDITOR
Microbes, Infection and Chemotherapy ISSN: 2789 - 4274 https://doi.org/10.54034/mic.e1331
Typhoid fever in Pakistan: a recurring challenge?
Vitorino Modesto dos Santos1,*, Lister A. Modesto dos Santos2,#, Laura Campos-Modesto3,**, Julia Campos-Modesto4
1Armed Forces Hospital and Catholic University, Brasília-DF, Brazil. and Catholic University, Brasília-DF, Brazil
2General Surgery of the IAMSPE, São Paulo-SP, Brazil.
3Medical Course at the University Center of Brasília (Uniceub), Brasília-DF, Brazil.
4Medical Course of Catholic University, Brasília-DF, Brazil
Corresponding author: E-mail:vitorinomodesto@gmail.com
Orcid ID: *https://orcid.org/0000-0002-7033-6074, #https://orcid.org/0000-0003-4647-4044, **https://orcid.org/0000-0002-9401-2277
Submitted: january 08, 2022
Reviewed: january 12, 2022
Approved: january 14, 2022
Dear Editor
In Pakistan, as in Brazil, the water- and food-borne infections constitute important and unsolved public health problems causing high rate of morbidity and mortality; and recent manuscripts have stressed the role of infection by Salmonella enterica subspecies (1,2). During the current COVID-19 pandemic the routine attention to endemic infections has lowered in the whole world, hampering the prevention and control of these entities (1). Additional concerns are about the low rate of successful anti-typhoid fever (TF) vaccination programs and the elevated number of antibiotic resistance occurrences in developing countries (1). Early adequate antimicrobial therapy is needed to avoid complications and mortality (2). The resistance to ampicillin, chloramphenicol and cotrimoxazole is generalized, and multidrug-resistant (MDR) S. Typhi is evolving to extensively drug-resistant (XDR), that is MDR plus resistance to fluoroquinolones and thirdgeneration cephalosporins (1). Therefore, it is useful to remark on some major aspects of this novel scenery.
Pakistan is one of five countries declared as endemic for TF (2). Transmission involves all age ranges, predominantly affecting children, and the yearly global incidence of TF is over 18 million cases with more than 200,000 deaths (1). Besides, approximately 1,000 cases per 100,000 children have been reported annually, and patients infected by MDR and XDR S. Typhi were confirmed in public hospitals (1,2). Uncontrolled over the counter antibiotic sales, and suboptimal dose of antimicrobials, contribute to the diagnosis delay and to increased resistant bacteria (1). Saleem et al. undertook a cross-sectional study (from 2019 to 2020) on the sensitivity of S. Typhi in 149 children aged 3-12 years and with TF. Resistance to ampicillin, cotrimoxazole, chloramphenicol and ceftriaxone was over 80%, while sensitivity for meropenem, azithromycin, and ciprofloxacin achieved 100%, 93.3% and 53.7%, respectively (2). Rose spots, high fever of gradual onset, and temperature-pulse dissociation (Faget sign) were emphasized as classical signs of TF; as well as usual manifestations in children including vomiting, diarrhea, anemia, thrombocytopenia and hepatosplenomegaly (2). Worthy of note is a complete resistance to fluoroquinolones (including gatifloxacin after 2010) which is associated to prolonged fever and treatment failures of patients with TF. The conclusive comments included the need for constant monitoring of antimicrobials sensitivity, with corrective measures to avoid the irrational use of fluoroquinolones (2).
In Brazil, 1,127 cases of TF with 8 deaths were reported from 2010 to 2019, affecting 28.7% patients with 20 to 34-year-old, 58.2% males, 70.2% from the North region, and 81.5 % from urban areas (3). Main symptoms were fever (92.9%), headache (70.2%), abdominal pain (63.3%), diarrhea (62.4%), and asthenia (59.0%). Infections were due to consumption of untreated water (25.0%) and contaminated foods (14.2%). Although a reduction in cases of TF was observed in the period analyzed, there may have been some reduction in the suspicion, notification, or diagnostic investigation (3).
In the present setting, one can barely estimate the deleterious burden of the ongoing COVID-19 pandemic on neglected infectious diseases, as is the case of TF in low-income areas such as slum districts of Karachi (1).
Key words:
Antibiotic resistance, Pakistan, Salmonella Typhi, Typhoid fever.
Conflict of interest
The authors had full freedom of manuscript preparation and there are no potential conflicts of interest to disclaim.
Funding Sources
There was no grant support.
Ethical Statement
In writing the manuscript, the authors followed the policy of the Committee on Publication Ethics (COPE).
References
1. Mohsin S, Taylor-Robinson AW. Persistence of first-line antibiotic resistant typhoid fever among Pakistani children: a growing concern for regional antimicrobial stewardship. Microbes Infect Chemother. 2022;2:e1301. https://doi.org/10.54034/mic.e1301.
2. Saleem S, Parkash A, Jalil M, Mubashir F. Sensitivity pattern of Salmonella typhi from blood culture in paediatric population. Liaquat Nat J Prim Care. 2021;3(2):77-81. https://doi.org/10.37184/lnjpc.2707-3521.3.24.
3. Brazil Ministry of Health. Health Surveillance Secretariat. Epidemiological Report - Neglected tropical diseases. Epidemiol. Bull. 2021; March 3 (Special number): 27-28. https://www.gov.br/saude/pt-br/doençasnegligenciadas.
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