What is the recommended treatment for typhoid fever?

Treatment of Typhoid Fever

For typhoid fever, the first-line treatment is a fluoroquinolone (such as ciprofloxacin) for fully sensitive strains, with ceftriaxone or azithromycin as alternatives for resistant strains. 1

First-Line Treatment Options

Based on Susceptibility Patterns:

1. Fully sensitive Salmonella typhi:

   • First choice: Fluoroquinolones (ciprofloxacin, ofloxacin)
   • Alternatives: Chloramphenicol, amoxicillin, or trimethoprim-sulfamethoxazole (if fluoroquinolones unavailable and organism is sensitive) 1

2. Multidrug-resistant strains:

   • First choice: Fluoroquinolone or cefixime
   • Alternatives: Azithromycin 1

3. Quinolone-resistant strains:

   • First choice: Azithromycin or ceftriaxone
   • Alternative: Cefixime 1

Dosing Recommendations

Adults:

• Ciprofloxacin: 500 mg orally twice daily for 7-14 days 2
• Ceftriaxone: 2 g IV once daily for 7-14 days 3
• Azithromycin: 1 g orally on day 1, then 500 mg daily for 5-7 days

Children:

• Fluoroquinolones (if susceptible)
• Ceftriaxone: 50-75 mg/kg/day IV (maximum 2 g/day) 4
• Azithromycin: 20 mg/kg/day (maximum 1 g) for 5-7 days

Treatment Algorithm

1. Assess severity and resistance patterns:

   • Check local resistance patterns or recent travel history
   • Determine if patient is severely ill (high fever, altered mental status, GI bleeding, etc.)

2. Initial empiric therapy:

   • For patients from/in areas with low resistance: Ciprofloxacin
   • For patients from South/Southeast Asia or areas with known fluoroquinolone resistance: Ceftriaxone or azithromycin
   • For severely ill patients: IV ceftriaxone

3. Adjust therapy based on culture results:

   • Modify treatment according to susceptibility testing
   • For nalidixic acid-resistant strains, avoid fluoroquinolones even if reported as susceptible 1

Duration of Treatment

• Uncomplicated cases: 7-14 days
• Severe cases: 10-14 days
• Ceftriaxone: Some studies suggest a flexible duration until defervescence plus 5 additional days 4

Special Considerations

Important Caveats:

• Increasing resistance: Fluoroquinolone resistance is increasingly common, especially in South Asia, with rates of decreased ciprofloxacin susceptibility rising from 19% in 1999 to 59% in 2008 1
• Defervescence time: Expect fever to resolve in 4-8 days with appropriate therapy 5
• Relapse risk: Monitor for relapse within 1-2 months after treatment completion
• Carrier state: Some patients may become chronic carriers despite appropriate treatment

Treatment Failures:

• If no clinical improvement after 3-5 days, consider:
  1. Switching to an alternative agent based on susceptibility
  2. Extending treatment duration
  3. Investigating for complications (intestinal perforation, abscess)

Monitoring

• Daily temperature monitoring
• Clinical assessment for complications (GI bleeding, perforation)
• Follow-up blood cultures if fever persists
• Stool cultures after treatment completion to detect carrier state in high-risk individuals

Remember that antimicrobial resistance patterns for Salmonella typhi are evolving rapidly, and treatment should be guided by local susceptibility patterns whenever possible.