127: Enteric Fever in a Multicultural Canadian Tertiary Care Pediatric Setting: A 28 Year Review

Enteric fever, caused by Salmonella typhi and paratyphi, is estimated to cause 16 million cases and 600,000 deaths per year. After influenza, it is the 2nd most common cause of vaccine-preventable fever related admission following international travel. Although public health measures have effectively eliminated domestic acquisition, enteric fever continues to occur in Canada mainly as a result of travel. To describe the epidemiology, microbiology, clinical presentation, management, and outcomes of patients with enteric fever diagnosed or treated at a large tertiary care paediatric centre over a 28-year period. We performed a retrospective chart review of all patients seen under age 18 years with blood or stool cultures that were positive for S. typhi or S. paratyphi over the study period. We identified 126 children with positive cultures for S. typhi or S. paratyphi between January 1985 and December 2013. Of these, relapse was microbiologically confirmed in four cases and all recovered. Most cases occurred in children who visited friends and relatives abroad, with 80% reporting a travel history to India, Pakistan, or Bangladesh. Of the patients for whom vaccination history was available, only 4.7% received a typhoid vaccine. There was significant resistance to ampicillin and ciprofloxacin but all isolates were sensitive to 3rd generation cephalosporins. Over the last 13 years, there has been a 154% increase in the number of cases overall compared to the previous 15 year period and the proportion of cases originating from South Asia has increased from 66% to 85%. In many cases there was also evidence of a delay in diagnosis and treatment. The median number of physician visits prior to diagnosis was 3 (IQR 2–4, maximum 8) and the median duration between first physician contact and initiation of appropriate antibiotics was four days (IQR 2–7, maximum 27 days). Enteric fever remains a major, preventable global infectious disease, and this review highlights the unique aspects of prevention, recognition, and management in a resource-rich, multicultural setting. Children who travel to endemic areas to visit friends and relatives abroad should be targeted for prevention through counselling and vaccination. Upon return, clinicians must keep enteric fever on their differential for any child returning with fever from the Indian subcontinent, particularly since symptoms are nonspecific. Based on changing resistance patterns, we recommend that third generation cephalosporins be used as empiric therapy until culture and antibiotic susceptibility testing results are available.

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