Morbidity and Mortality Associated with Typhoid Fever Among Hospitalized Patients in Hyderabad District, Pakistan, 2017-2018: Retrospective Record Review (Preprint)

Abstract

BACKGROUND Hyderabad, Pakistan, was the first city to witness an outbreak of extensively drug-resistant (XDR) typhoid fever. The outbreak strain is resistant to ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, fluoroquinolones, and third-generation cephalosporin, greatly limiting treatment options. However, despite over 5,000 documented cases, information on mortality and morbidity has been limited. OBJECTIVE This study was carried out to assess the morbidity and mortality associated with XDR and non-XDR Typhi infections in Pakistan. METHODS We reviewed medical records of culture-confirmed typhoid cases in five hospitals in Hyderabad from October 1, 2016, to September 30, 2018. Data were obtained on age, gender, the onset of fever, physical examination, serological and microbiological test results, treatment before and during hospitalization, duration of hospitalization, complications, and deaths. RESULTS A total of 1,452 culture-confirmed typhoid cases including 947 (66%) XDR and 505 (34%) non-XDR cases were identified. Overall, one or more complications were reported in 360 (38%) of XDR and in 89 (18%) of non-XDR typhoid patients (P < 0.001). Ileal perforation was the most commonly reported complication in both XDR (210; 23%) and non-XDR patients (71; 14%) (p<0.001). Overall, mortality was documented in 17 (1.8%) patients with XDR Typhi infections and 3 (0.6%) patients with non-XDR Typhi infections (p<0.061). CONCLUSIONS As this first XDR typhoid outbreak continued to spread, the increased duration of illness before hospitalization and increased rate of complications have important implications for clinical care and medical costs and heighten the importance of prevention and control measures.