What is the recommended treatment for typhoid?

Recommended Treatment for Typhoid Fever

For the treatment of typhoid fever, intravenous ceftriaxone is the preferred first-line agent, particularly for patients returning from Asia where fluoroquinolone resistance is common. 1

First-Line Treatment Options

For Hospitalized Patients or Severe Cases:

• Intravenous ceftriaxone: The preferred initial treatment, especially for patients with unstable clinical condition or those returning from Asia where fluoroquinolone resistance exceeds 70% 1
• Dosage: Not specifically stated in guidelines, but typically 2g IV daily for adults 1
• Duration: 14 days to reduce risk of relapse 1

For Uncomplicated Cases (Outpatient Treatment):

• Azithromycin: Suitable oral alternative for uncomplicated disease, especially when fluoroquinolone resistance is confirmed 1
• Dosage: 20mg/kg/day oral dose once daily (maximum 1g/day) for 7 days 2
• Advantage: Resistance to azithromycin is currently rare in the UK and many regions 1

Treatment Selection Based on Resistance Patterns

Regional Considerations:

• South Asia: Avoid fluoroquinolones as first-line therapy due to high resistance rates (>70% of isolates imported to the UK are resistant) 1, 3
• Pakistan: Both ciprofloxacin-resistant and ceftriaxone-resistant typhoid is common 3
• Other regions: Treatment should be guided by local resistance patterns 3

Resistance Testing:

• When testing isolates for antibiotic sensitivity, ciprofloxacin disc testing alone is unreliable 1
• The organism should also be sensitive to nalidixic acid on disc testing to be considered truly sensitive to fluoroquinolones 1

Alternative Treatment Options

• Ciprofloxacin: Only for confirmed sensitive isolates 4, 3

  • Dosage: 500mg orally twice daily for 7-10 days 5, 6
  • Note: FDA-approved for typhoid fever caused by Salmonella typhi 4
  • Caution: Not recommended for patients returning from South Asia due to high resistance rates 3

• Combination therapy: Azithromycin plus cefixime is being investigated as a potential treatment option to combat resistance 2

Treatment Duration and Monitoring

• Standard treatment duration: 14 days to reduce risk of relapse 1
• Relapse rates: <8% for ceftriaxone and <3% for azithromycin 1
• For ciprofloxacin (when appropriate): 10 days of treatment (500mg twice daily) has been shown to be as effective as 14 days at the same dosage 6

Complications and Special Considerations

• Complications such as gastrointestinal bleeding, intestinal perforation, and typhoid encephalopathy occur in 10-15% of patients 1
• These complications are more likely if the duration of illness is >2 weeks 1
• In severe cases, addition of steroids may be helpful 1
• Previous vaccination provides incomplete protection against typhoid fever and does not protect against paratyphoid 1

Diagnostic Considerations

• Blood cultures have the highest yield within the first week of symptom onset (40-80% sensitivity) 1
• Stool and urine cultures become positive after the first week (sensitivity: stool 35-65%, urine 0-58%) 1
• Bone marrow cultures have higher sensitivity than blood cultures 1
• The serological Widal test lacks sensitivity and specificity and is not recommended 1

Remember that appropriate treatment should be initiated promptly when typhoid fever is strongly suspected, especially in patients with unstable clinical conditions, while awaiting culture results 1.