What is the recommended treatment for typhoid fever?

Treatment of Typhoid Fever

The recommended first-line treatment for typhoid fever is azithromycin at a dosage of 20 mg/kg/day for 7 days, especially for uncomplicated cases and in children and pregnant women due to its superior safety profile and effectiveness against resistant strains. 1

Treatment Algorithm Based on Resistance Patterns

First-line Treatment Options:

• For fully sensitive strains:

  • Azithromycin (20 mg/kg/day for 7 days)
  • Alternative options: Fluoroquinolones, chloramphenicol, amoxicillin, trimethoprim-sulfamethoxazole 1

• For multidrug-resistant strains:

  • Fluoroquinolones (e.g., ciprofloxacin) or cefixime
  • Alternative: Azithromycin 1

• For quinolone-resistant strains:

  • Azithromycin or ceftriaxone
  • Alternative: Cefixime 1

Special Considerations:

For Children and Pregnant Women:

• Avoid fluoroquinolones when possible
• Preferred options: Azithromycin or third-generation cephalosporins 1

For Immunocompromised Patients:

• Consider longer duration of therapy
• Preferred options: Ceftriaxone or azithromycin 1

Clinical Advantages of Recommended Treatments

Azithromycin has demonstrated:

• Faster fever clearance times (<4 days)
• Higher clinical cure rates compared to fluoroquinolones like ofloxacin
• Lower relapse rates (<3%) compared to ceftriaxone (<8%) 1

Ceftriaxone has shown effectiveness in shorter courses:

• 5-day regimens have demonstrated similar efficacy to traditional 14-day chloramphenicol treatment 2
• Even ultra-short courses (2-3 days) have shown promising results in uncomplicated cases 3

Monitoring and Follow-up

• If no clinical improvement is observed within 2 days of starting treatment, consider changing the antibiotic regimen 1
• Follow-up testing is not routinely recommended after symptom resolution, except for food handlers, healthcare workers, or childcare providers 1

Important Caveats and Pitfalls

1. Resistance patterns are critical: Always consider local resistance patterns when selecting treatment, as 96% of Salmonella Typhi isolates show resistance to nalidixic acid and 58% are multidrug-resistant 1

2. Vaccination is not treatment: While typhoid vaccination is recommended for travelers to endemic areas, it is not a treatment option for active infection 4, 1

3. Avoid outdated combination vaccines: Combining paratyphoid A and B antigens with typhoid vaccine increases the risk of vaccine reactions and is not recommended 4

4. Prevention remains crucial: Proper hand hygiene and careful selection of food and drink in endemic areas are essential preventive measures, as even vaccinated individuals can become infected with large inocula of S. typhi 4, 1

By following these evidence-based recommendations and considering resistance patterns, most cases of typhoid fever can be effectively treated with minimal complications.