What is the recommended treatment for enteric fever?

Treatment of Enteric Fever

For patients with enteric fever, empiric treatment with a fluoroquinolone (such as ciprofloxacin 500mg twice daily for 10-14 days) or azithromycin is recommended, with the choice depending on local antimicrobial susceptibility patterns and travel history. 1

First-line Treatment Options

Antibiotic Selection Based on Susceptibility

• For fully susceptible S. typhi strains:

  • Fluoroquinolones: Ciprofloxacin 500mg twice daily for 10-14 days or ofloxacin 400mg twice daily for 7-14 days 1
  • FDA has approved ciprofloxacin specifically for typhoid fever (enteric fever) caused by Salmonella typhi 2

• For multidrug-resistant strains:

  • Fluoroquinolone or cefixime, with azithromycin as an alternative 1

• For quinolone-resistant strains:

  • Azithromycin or ceftriaxone, with cefixime as an alternative 1

Age-specific Recommendations

• Age <3 months: Third-generation cephalosporin (e.g., ceftriaxone) 1
• Age ≥3 months: Azithromycin, depending on local susceptibility patterns 1

Treatment Duration

• Standard treatment duration for ciprofloxacin is 10-14 days 1
• Evidence suggests that a 10-day regimen of ciprofloxacin 500mg twice daily is as effective as a 14-day regimen for treating enteric fever, including cases with multidrug-resistant strains 3

Clinical Considerations

Diagnostic Approach

• Blood, stool, and urine cultures should be obtained before initiating antimicrobial therapy 1
• Do not delay treatment in critically ill patients while awaiting culture results 1

Monitoring and Follow-up

• Monitor for defervescence, which typically occurs within 4-5 days of starting appropriate treatment 4, 3
• Reassess fluid and electrolyte balance, nutritional status, and optimal dose and duration of antimicrobial therapy in patients with persistent symptoms 1

Important Caveats

Resistance Patterns

• Ciprofloxacin resistance has become increasingly common in the Indian subcontinent 5
• In areas with high fluoroquinolone resistance, third- and fourth-generation cephalosporins, azithromycin, or carbapenems may be necessary 5, 6

Treatment Efficacy Considerations

• Early treatment is critical as patients treated early in their clinical course have better outcomes than those treated later 1
• While ceftriaxone is an effective alternative, it may have a longer time to defervescence compared to fluoroquinolones 6
• Cefixime may be less effective than fluoroquinolones, with potentially higher rates of clinical failure, microbiological failure, and relapse 6

Emerging Resistance

• Extensively drug-resistant strains have emerged in some regions, particularly Pakistan 6
• Local antimicrobial susceptibility patterns should guide empiric therapy choices 1, 6

Treatment Algorithm

1. Assess local resistance patterns and patient travel history
2. Obtain cultures before starting antibiotics when possible
3. Select empiric therapy:
   • If local fluoroquinolone resistance is low: Ciprofloxacin 500mg twice daily for 10-14 days
   • If local fluoroquinolone resistance is high: Azithromycin or ceftriaxone
   • For children <3 months: Third-generation cephalosporin
4. Adjust therapy based on culture results and clinical response
5. Monitor for clinical improvement and defervescence
6. Complete full course of antibiotics even after symptom resolution