Double enteric infection (‘la fièvre typhoïde intriquée’). An account of an epidemic

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Abstract
1. A double enteric infection is defined as the simultaneous infection of an individual or group of individuals with two organisms of the enteric group. The literature of the previously recorded cases and epidemics, in which the diagnosis of double enteric infection has been established by cultural methods, is reviewed.2. An account is given of a double enteric outbreak of seventy–six cases which occurred amongst British troops and police at Acre, Palestine, in 1948. The infection is thought to have been due to contamination of the water supply with sewage during the civil disturbances. The diagnosis was established bacteriologi–cally in seventy-four cases (93.3%);Salm. typhi was isolated in forty–three cases, Salm. paratyphi B in three, and both Salm. typhi and Salm. paratyphi B from twenty–eight cases. There were three fatal cases in the epidemic (mortality rate = 3·94%).3. The morbidity rate from enteric fever among the infantry unit was 60%, and among the Palestine police, 17%. The possible reasons for this difference is discussed, and the conclusion drawn that it was probably due to the Palestine policemen being older men, with longer overseas service and more 'seasoned' to life in subtropical conditions.4. Thirteen cases were treated with polymyxin B (15 mg. 4-hourly for 4-day periods); with this small dose no beneficial therapeutic effects were observed, and ten cases showed evidence of renal damage while under treatment.5. The bacteriology, epidemiology and clinical aspects of double enteric infections are discussed. The diagnosis of a double enteric infection may be established with the greatest certainty by blood culture. Such infections are usually water-borne or milk-borne, and tend to occur when there has been a severe breach of hygiene, e.g. in the contamination of a water supply by sewage. The claim that the prognosis in instances of double enteric infection is worse than with single infections is not supported by the experiences at Acre where the three fatal cases occurred in cases infected with Salm. typhi alone.