What is the recommended treatment for an admitted patient with typhoid fever?

Treatment of Typhoid Fever in Admitted Patients

For admitted patients with typhoid fever, intravenous ceftriaxone is the first-line treatment of choice due to its high efficacy and lower resistance rates compared to fluoroquinolones. 1

First-Line Treatment Options

• Ceftriaxone:

  • Dosage: 50-80 mg/kg/day IV for 7-10 days 1
  • Highly effective with all isolates reported to be sensitive to it 1
  • Particularly useful for severe infections or when oral therapy isn't possible
  • Fever clearance time typically occurs within 48-72 hours of starting appropriate therapy 1

• Azithromycin:

  • Suitable alternative with lower risk of clinical failure compared to fluoroquinolones 1
  • Lower relapse rates (<3%) compared to ceftriaxone (<8%) 1
  • Preferred option for children and pregnant women due to its safety profile 1

Treatment Selection Based on Resistance Patterns

Strain	Recommended Treatment	Alternative Options
Fully sensitive	Azithromycin	Fluoroquinolones, chloramphenicol, amoxicillin, trimethoprim-sulfamethoxazole
Multidrug-resistant	Ceftriaxone	Azithromycin
Quinolone-resistant	Azithromycin or ceftriaxone	Cefixime

Important Clinical Considerations

1. Duration of Treatment:

   • Treatment should continue for 14 days to reduce the risk of relapse 1
   • Early discontinuation of treatment can lead to relapse 1

2. Antimicrobial Resistance Concerns:

   • More than 70% of Salmonella typhi isolates are resistant to fluoroquinolones 1
   • Ciprofloxacin should only be used if susceptibility is confirmed 1, 2
   • Cefixime has reported treatment failure rates of 4-37.6%, making it less reliable than ceftriaxone 1, 3

3. Monitoring Response:

   • Clinical improvement typically occurs within 48-72 hours of starting appropriate therapy 1
   • Consider changing antibiotics if no clinical response after 3-5 days
   • Additional antibiotics may be needed in approximately 10% of patients due to clinical non-response 3

Special Populations

• Pregnant women: Ceftriaxone is considered a safe alternative during pregnancy 1
• Children: Azithromycin is preferred due to its safety profile 1

Common Pitfalls to Avoid

1. Using fluoroquinolones as first-line therapy in areas with high resistance rates

   • Fluoroquinolone resistance is particularly high in South and Southeast Asia 1
   • Using ciprofloxacin discs alone to determine Salmonella typhi sensitivity is unreliable 1

2. Inadequate treatment duration

   • Stopping treatment early increases relapse risk 1

3. Relying on the Widal test for diagnosis

   • Lacks sensitivity and specificity; not recommended for diagnosis 1

4. Using antimotility agents in patients with high fever or blood in stool 1

Typhoid fever treatment should be guided by local resistance patterns, with ceftriaxone being the safest empiric choice for admitted patients given the widespread fluoroquinolone resistance. Complete the full course of antibiotics to prevent relapse and monitor closely for clinical response.