What is the recommended management for enteric fever?

Management of Enteric Fever

For enteric fever treatment, azithromycin is recommended as first-line therapy for children ≥3 months and adults, particularly in areas with fluoroquinolone resistance, while ceftriaxone is preferred for infants <3 months or when fluoroquinolone resistance is suspected. 1

Diagnostic Approach

• Obtain blood, stool, and urine cultures before initiating antimicrobial therapy to guide treatment decisions 2, 1
• Patients with clinical features of sepsis should receive immediate empiric broad-spectrum antimicrobial therapy after culture collection 2
• Consider enteric fever in febrile patients with or without diarrhea who have:
  • History of travel to endemic areas
  • Consumed foods prepared by people with recent endemic exposure
  • Laboratory exposure to Salmonella Typhi or Paratyphi 2

Antimicrobial Treatment Algorithm

First-line Treatment Options:

1. For adults and children ≥3 months:

   • Azithromycin (preferred in areas with fluoroquinolone resistance) 2, 1
   • Clinical evidence shows lower risk of clinical failure (OR 0.48) and shorter hospital stay (-1.04 days) with azithromycin compared to fluoroquinolones 2, 3

2. For infants <3 months:

   • Ceftriaxone 2, 1

3. For fully susceptible S. typhi (based on susceptibility testing):

   • Fluoroquinolone (ciprofloxacin 500mg twice daily for 10-14 days or ofloxacin 400mg twice daily for 7-14 days) 1, 4
   • Short-course (7-day) ciprofloxacin regimens have shown 96% cure rates in susceptible strains 5

Treatment Based on Resistance Patterns:

1. For multidrug-resistant strains:

   • Fluoroquinolone or cefixime (with azithromycin as an alternative) 2, 1

2. For quinolone-resistant strains:

   • Azithromycin or ceftriaxone (with cefixime as an alternative) 2, 1
   • Studies show azithromycin is superior to ofloxacin for nalidixic acid-resistant strains, with shorter fever clearance time and better fecal clearance 6

Critical Considerations

• Early treatment is crucial - patients treated early have better outcomes than those treated later 2, 1

• Antimicrobial choice should be guided by:

  • Local antimicrobial susceptibility patterns
  • Travel history
  • Patient age
  • Severity of illness 2, 1

• Critically ill patients should receive prompt parenteral therapy with ceftriaxone 1

• Treatment duration should typically be 10-14 days for fluoroquinolones 1

• Monitor for:

  • Fever clearance
  • Clinical improvement
  • Potential complications 1

Pitfalls and Caveats

• Avoid delaying antimicrobial therapy when infection is strongly suspected in critically ill patients 1
• Fluoroquinolone resistance is increasing globally, particularly in South Asia, limiting ciprofloxacin effectiveness 2, 7
• Cefixime may not perform as well as fluoroquinolones or ceftriaxone for treating enteric fever 8
• Reassess fluid and electrolyte balance, nutritional status, and optimal dose/duration of antimicrobial therapy in patients with persistent symptoms 1
• Extensively drug-resistant strains have emerged in Pakistan, requiring careful consideration of local resistance patterns 8

Early and appropriate antimicrobial therapy significantly reduces morbidity and mortality compared to supportive treatment alone or inadequate dosing 1.