What is the recommended management for enteric fever ulcers?

Management of Enteric Fever Ulcers

For patients with enteric fever ulcers, the recommended management includes intravenous ceftriaxone as first-line therapy, followed by appropriate oral antibiotics based on susceptibility testing, along with supportive care and monitoring for complications such as gastrointestinal bleeding and perforation. 1

Diagnosis and Initial Assessment

• Enteric fever is caused by Salmonella Typhi and Salmonella Paratyphi A/B/C
• Blood cultures have the highest yield within the first week of symptom onset (40-80% sensitivity)
• Stool and urine cultures become positive after the first week (stool 35-65%, urine 0-58%)
• Bone marrow cultures have higher sensitivity than blood cultures for diagnosis 1
• Newer rapid serological tests (Typhidot, Typhidot-M, Tubex) show mixed results and are not recommended as sole diagnostic tools 1

Antimicrobial Therapy

First-line Treatment

• Intravenous ceftriaxone is the preferred first-line agent, especially for patients from Asia where >70% of isolates are resistant to fluoroquinolones 1
• Treatment should be started empirically when enteric fever is strongly suspected, especially if the patient is clinically unstable 1
• For patients with clinical features of sepsis who are suspected of having enteric fever, broad-spectrum antimicrobial therapy should be initiated after blood, stool, and urine cultures are collected 1

Second-line/Oral Step-down Options

• Azithromycin is a suitable oral alternative for uncomplicated disease when fluoroquinolone resistance is confirmed 1, 2
• Azithromycin appears better than fluoroquinolone drugs in populations with drug-resistant strains and may perform better than ceftriaxone for preventing relapse 2
• Treatment should be continued for 14 days to reduce risk of relapse 1

Considerations for Antibiotic Selection

• Antimicrobial therapy should be narrowed when susceptibility testing results become available 1
• If an isolate is unavailable, antimicrobial choice may be tailored to susceptibility patterns from the setting where acquisition occurred 1
• Fluoroquinolones should only be used if the isolate is sensitive to both ciprofloxacin and nalidixic acid 1

Management of Complications

Gastrointestinal Bleeding and Perforation

• Complications such as gastrointestinal bleeding, intestinal perforation, and typhoid encephalopathy occur in 10-15% of patients 1
• These complications are more likely if the duration of illness is >2 weeks 1
• For patients with bleeding ulcers, intravenous PPI administration should be given for 72-96 hours before starting standard triple therapy for H. pylori (if present) 1
• Surgical consultation should be sought for patients with signs of perforation or for whom endoscopic therapy has failed 1
• Addition of steroids may be helpful in severe cases 1

Supportive Care

• Ensure adequate fluid and electrolyte balance
• Monitor for signs of perforation (acute abdomen, free air on imaging)
• For severe dehydration, intravenous rehydration should be continued until pulse, perfusion, and mental status normalize 1
• Reduced osmolarity oral rehydration solution is recommended as first-line therapy for mild to moderate dehydration 1

Monitoring and Follow-up

• Monitor for clinical improvement (fever clearance typically occurs within 4 days with appropriate therapy) 1
• Test for H. pylori if ulcers are present and provide eradication therapy if positive 1
• Monitor for relapse, which occurs in <8% with ceftriaxone and <3% with azithromycin 1

Common Pitfalls and Caveats

• Vaccination provides incomplete protection against typhoid fever and does not protect against paratyphoid 1
• The serological Widal test lacks sensitivity and specificity and is not recommended 1
• When testing isolates for antibiotic sensitivity, ciprofloxacin disc testing alone is unreliable; the isolate should also be tested for nalidixic acid sensitivity 1
• Low-dose azithromycin may lead to treatment failure, so appropriate dosing is essential 3
• Resistance patterns vary by geographic region and are changing over time, with increasing minimum inhibitory concentrations to quinolones and ceftriaxone reported 4, 5

By following this evidence-based approach to managing enteric fever ulcers, clinicians can optimize outcomes and reduce the risk of complications in affected patients.