What is the recommended treatment for typhoid fever?

Treatment of Typhoid Fever

For typhoid fever treatment, the most effective approach is to use azithromycin, ciprofloxacin (except in South Asia due to resistance), or ceftriaxone, with the specific choice guided by local resistance patterns. 1

First-Line Treatment Options

Adult Treatment

• Ciprofloxacin: 500 mg orally twice daily for 7 days 2

  • Achieves rapid fever clearance (median 4 days) 2
  • Not recommended for cases originating from South Asia due to high resistance 1
  • FDA-approved for typhoid fever caused by Salmonella typhi 3

• Azithromycin: 20 mg/kg/day as a once-daily oral dose for 7 days 4

  • Effective even in areas with high multidrug and nalidixic acid resistance 4
  • Lower relapse rates (<3%) compared to ceftriaxone (<8%) 5
  • Preferred for pregnant women due to safety profile 5

• Ceftriaxone: 50-80 mg/kg/day for 7-10 days 5

  • Recommended by WHO as first-line empiric treatment 5
  • Particularly useful for severe infections or when oral therapy isn't possible 5

Pediatric Treatment

• Ceftriaxone is preferred for children 5
• Azithromycin is a suitable alternative with good safety profile 5
• Avoid fluoroquinolones in children when possible due to risk of arthropathy 3

Treatment Selection Algorithm

1. Check local resistance patterns before selecting therapy

   • In South Asia: Avoid ciprofloxacin due to high resistance rates 1
   • In Pakistan: Be aware of extensively drug-resistant strains 6

2. Select based on patient factors:

   • For severe disease: Use ceftriaxone parenterally 5
   • For pregnant women: Use azithromycin or ceftriaxone 5
   • For children: Prefer ceftriaxone or azithromycin over fluoroquinolones 5, 3

3. Consider strain susceptibility:

   • Fully sensitive strains: Azithromycin (preferred), fluoroquinolones, chloramphenicol, amoxicillin, or trimethoprim-sulfamethoxazole 5
   • Multidrug-resistant strains: Fluoroquinolones, cefixime, or azithromycin 5
   • Quinolone-resistant strains: Azithromycin or ceftriaxone 5

Clinical Response and Follow-Up

• Fever typically clears within 4 days with appropriate treatment 5, 2
• Clinical improvement should occur within 48-72 hours of starting therapy 5
• Treatment failure should prompt reassessment and potential switch to alternative antibiotics
  • In one study, patients failing ceftriaxone therapy improved within 48 hours after switching to ciprofloxacin 7

Common Pitfalls and Caveats

• Do not undertreat: Complete the full course of antibiotics to prevent relapse
• Bacterial shedding continues for several weeks after clinical recovery (median 4-5 weeks) and may be prolonged by antibiotic treatment 5
• Asymptomatic shedding of Salmonella Typhi can persist beyond a year in some patients 5
• Antibiotic resistance is increasing globally, particularly to fluoroquinolones in South Asia 1, 6
• Avoid antimotility agents, especially if high fever or bloody diarrhea is present 5

Prevention

• Typhoid vaccination is recommended for travelers to endemic areas 5
• Proper hand hygiene and food safety practices are essential 5
• Avoid high-risk foods and beverages in endemic areas 5

Remember that treatment success depends on early diagnosis, appropriate antibiotic selection based on local resistance patterns, and completion of the full treatment course.