What is the recommended treatment and dosage for a child with typhoid?

Treatment of Typhoid Fever in Children

The recommended first-line treatment for a child with typhoid fever is ceftriaxone at a dose of 75-80 mg/kg/day (maximum 2g/day) given intravenously or intramuscularly for 5-7 days. 1, 2

Antibiotic Options and Dosing

First-line Treatment:

• Ceftriaxone:
  • Dosage: 75-80 mg/kg/day IV/IM (maximum 2g/day)
  • Frequency: Once daily or divided into two doses
  • Duration: 5-7 days, or until defervescence plus 5 additional days 1
  • Advantages: High cure rate, low relapse rate, once-daily dosing possible

Alternative Options:

1. Ciprofloxacin (for children where fluoroquinolones are deemed appropriate):

   • Dosage: 20 mg/kg/day divided into two doses (maximum 500 mg twice daily)
   • Duration: 7-10 days 3
   • Note: Despite concerns about safety in children, fluoroquinolones have shown efficacy in multidrug-resistant typhoid 4

2. Cefixime (oral option):

   • Dosage: 20 mg/kg/day divided into two doses
   • Duration: 7-14 days 4, 5
   • Note: Less effective than fluoroquinolones but provides a useful oral alternative 4

3. Azithromycin:

   • Dosage: 20 mg/kg/day (maximum 1000 mg/day)
   • Duration: 5 days
   • Note: Effective with low relapse rates, good oral option 6

Treatment Algorithm

1. Assess severity:

   • Uncomplicated typhoid: Alert, no severe symptoms, able to take oral medications
   • Complicated typhoid: Altered mental status, severe dehydration, GI bleeding, perforation, shock

2. Initial treatment:

   • For uncomplicated cases where oral therapy is appropriate:

     • Cefixime 20 mg/kg/day in two divided doses OR
     • Azithromycin 20 mg/kg/day once daily

   • For moderate to severe cases requiring parenteral therapy:

     • Ceftriaxone 75-80 mg/kg/day IV/IM once daily

3. Monitor response:

   • Expect defervescence in 4-8 days
   • If no improvement after 5 days, consider alternative antibiotics or complications

4. Duration of therapy:

   • Continue until 5 days after defervescence (typically 7-10 days total)
   • For complicated cases, longer duration may be necessary

Clinical Considerations

• Blood cultures should be obtained before initiating antibiotics when possible
• Supportive care with hydration and antipyretics is essential
• Monitor for complications such as intestinal perforation, GI bleeding, or encephalopathy
• Multidrug-resistant typhoid is increasingly common, making ceftriaxone a reliable first choice

Special Situations

• For children with severe penicillin/cephalosporin allergies, azithromycin is the preferred alternative
• In areas with high fluoroquinolone resistance, ceftriaxone remains the most reliable option
• For children who have improved on IV therapy, consider switching to oral therapy (cefixime or azithromycin) to complete the course

The evidence strongly supports ceftriaxone as the most effective treatment for children with typhoid fever, with high cure rates and low relapse rates compared to other antibiotics 1, 2.