From the Guidelines
The recommended treatment for typhoid fever is intravenous ceftriaxone, which is now preferred as a first-line agent, especially in patients returned from Asia where there are increasing reports of fluoroquinolone resistant isolates. This is based on the evidence from the study published in the Journal of Infection in 2009 1, which highlights the increasing resistance of Salmonella Typhi to fluoroquinolones. The study notes that more than 70% of isolates of S. typhi and S. paratyphi imported into the UK are resistant to fluoroquinolones, but all isolates reported to the HPA in 2006 were sensitive to ceftriaxone.
Some key points to consider in the treatment of typhoid fever include:
- The use of ciprofloxacin discs to determine Salmonella typhi and Salmonella paratyphi sensitivity is unreliable, and only if the organism is also sensitive on disc testing to nalidixic acid should the isolate be considered sensitive to fluoroquinolones 1.
- Azithromycin is a suitable oral alternative for uncomplicated disease if fluoroquinolone resistance is confirmed, with resistance being currently rare in the UK 1.
- Cefixime, when used as an alternative oral first-line agent, has reported treatment failure rates of 4-37.6% 1.
- Treatment should be continued for 14 days to reduce the risk of relapse, with relapse rates for fluoroquinolones reported as ceftriaxone <8% and azithromycin <3% 1.
- The addition of steroids may be helpful in severe cases 1.
It is essential to note that the choice of antibiotic should ideally be guided by local resistance patterns, as drug-resistant typhoid is increasingly common worldwide. Patients should complete the full course of antibiotics even if symptoms improve, maintain good hydration, and follow up with healthcare providers to ensure complete recovery. Proper hand hygiene and food safety practices are essential during recovery to prevent transmission to others.
From the FDA Drug Label
Typhoid Fever (Enteric Fever) caused by Salmonella typhi. The recommended treatment for typhoid (Salmonella Typhi infection) is ciprofloxacin (PO), as it is effective against Salmonella typhi.
- The efficacy of ciprofloxacin in the eradication of the chronic typhoid carrier state has not been demonstrated. 2
From the Research
Typhoid Treatment Options
- The recommended treatment for typhoid fever (Salmonella Typhi infection) includes antibiotics such as azithromycin, ciprofloxacin, and ceftriaxone 3, 4, 5, 6, 7.
- A 7-day course of a single oral antimicrobial such as ciprofloxacin, cefixime, or azithromycin is commonly used for the treatment of uncomplicated typhoid fever 3.
- However, increasing antimicrobial resistance threatens the effectiveness of these treatment choices, and alternative treatments such as combined therapy with azithromycin and cefixime are being explored 3.
Comparison of Treatment Options
- Azithromycin and ciprofloxacin have been shown to be similarly effective in the treatment of typhoid fever, including cases caused by multidrug-resistant strains 4.
- Ceftriaxone has been found to be effective in the treatment of enteric fever, with few adverse effects, and may be a suitable alternative to azithromycin and fluoroquinolones 6.
- A study comparing ciprofloxacin, azithromycin, and cefixime for the treatment of uncomplicated typhoid fever found that azithromycin had a higher clinical cure rate and shorter fever clearance time compared to the other two antibiotics 7.
Considerations for Treatment
- The choice of antibiotic should take into account current, local resistance patterns, as well as the route of administration 6.
- Combined therapy with azithromycin and cefixime may be a better option for the treatment of clinically suspected and culture-confirmed typhoid fever in areas with high levels of antimicrobial resistance 3.
- A 7-day course of azithromycin can be successfully used in uncomplicated typhoid fever due to isolates of multidrug-resistant S. enterica serovar Typhi 7.