What is the recommended treatment for enteric fever?

Treatment of Enteric Fever

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

Antibiotic Selection Algorithm

First-line options (based on susceptibility):

1. Fluoroquinolones (if susceptible):

   • Adults: Ciprofloxacin 500mg twice daily for 10-14 days 1, 2
   • Children: Not first choice due to risk of arthropathy 2

2. Azithromycin:

   • Particularly important in areas with fluoroquinolone resistance
   • Recommended for children ≥3 months 3, 1

3. Third-generation cephalosporins:

   • Ceftriaxone: For infants <3 months or when fluoroquinolone resistance is suspected 3, 1
   • Cefixime: Alternative option, though may be less effective than fluoroquinolones 4

For specific resistance patterns:

• Multidrug-resistant strains: Fluoroquinolone (if susceptible) or cefixime, with azithromycin as alternative 1
• Quinolone-resistant strains: Azithromycin or ceftriaxone 1
• Extensively drug-resistant strains: Treatment should be guided by susceptibility testing 5

Clinical Considerations

Timing and Diagnostic Approach

• Blood, stool, and urine cultures should be obtained before initiating antimicrobial therapy 3, 1
• Patients with clinical features of sepsis should receive immediate empiric broad-spectrum antimicrobial therapy after culture collection 3, 1

Treatment Duration and Monitoring

• Standard treatment duration: 10-14 days for fluoroquinolones 1
• Monitor for:
  • Fever clearance (typically occurs within 4-7 days of appropriate treatment) 6
  • Clinical improvement
  • Potential complications

Special Populations

• Infants <3 months: Third-generation cephalosporin (e.g., ceftriaxone) is recommended 3, 1
• Children ≥3 months: Azithromycin is preferred, depending on local susceptibility patterns 3, 1
• Critically ill patients: Consider parenteral therapy with ceftriaxone 1, 7

Evidence Quality and Considerations

Recent evidence suggests increasing resistance to traditional first-line agents for enteric fever, particularly in South Asia 4, 8. A 2022 Cochrane review found that ceftriaxone is an effective treatment with few adverse effects, though comparative effectiveness with other agents is difficult to determine due to small trial sizes and changing resistance patterns 4.

The emergence of extensively drug-resistant (XDR) strains in Pakistan since 2016 has complicated treatment decisions 5. These strains respond to only a limited number of antibiotics, highlighting the importance of susceptibility testing.

Common Pitfalls to Avoid

1. Failing to obtain cultures before starting antibiotics: This can make it difficult to tailor therapy based on susceptibility results
2. Not considering local resistance patterns: Treatment should be guided by regional resistance data
3. Inadequate treatment duration: Shorter courses may lead to relapse
4. Delaying treatment in critically ill patients: Prompt empiric therapy is essential for patients with sepsis features
5. Using chloramphenicol as first-line therapy: While historically important, it's now reserved for specific situations due to potential toxicity and resistance 9, 7

Remember that early and appropriate antimicrobial therapy significantly reduces morbidity and mortality in enteric fever compared to supportive treatment alone or inadequate dosing 1.