Treatment of Enteric Fever in India
Azithromycin is the recommended first-line treatment for enteric fever in India due to high fluoroquinolone resistance, with ceftriaxone as the preferred parenteral option for severe cases. 1, 2
First-Line Treatment Options
- Azithromycin 20 mg/kg/day (maximum 1g/day) orally for 7 days is recommended as first-line therapy for uncomplicated enteric fever in India, where fluoroquinolone resistance is prevalent 1, 3, 2
- Azithromycin demonstrates superior outcomes with lower risk of clinical failure (OR 0.48) and shorter hospital stays compared to fluoroquinolones 1, 2
- Azithromycin also shows significantly lower risk of relapse (OR 0.09) compared to ceftriaxone 3, 2
- Recent studies from India have shown 100% susceptibility of Nalidixic acid resistant Salmonella (NARS) to azithromycin, making it a reliable choice 4
Treatment for Severe Cases
- For severe cases requiring hospitalization, ceftriaxone 50-80 mg/kg/day (maximum 2g/day) intravenously for 5-7 days is recommended 1, 3
- In a 2019 study from north India, ceftriaxone was the most commonly used antibiotic for hospitalized children with enteric fever, with a mean duration of treatment being six days 5
- An alarming increase in resistance to ceftriaxone has been documented among NARS in Mumbai, with 11.6% of isolates showing resistance 4
Alternative Treatment Options
- For patients with clinical features of sepsis, broad-spectrum antimicrobial therapy should be started immediately after blood, stool, and urine culture collection 6
- In outpatient settings in India, cefixime is commonly prescribed for enteric fever, as observed in a 2019 study 5
- Ciprofloxacin, once a mainstay of treatment, is no longer recommended as empiric therapy in India due to high resistance rates 7
Treatment Based on Resistance Patterns
- Ciprofloxacin resistance has become the norm in the Indian subcontinent 7
- Multidrug resistance (MDR) to traditional first-line drugs (ampicillin, chloramphenicol, and co-trimoxazole) is common in India, with one study showing MDR in 39% of S. typhi isolates 8
- Treatment should be modified based on antimicrobial susceptibility testing results when available 6
Special Considerations
- Blood cultures should be obtained before starting antibiotics when possible 1, 3
- Clinical non-response to initial therapy occurs in approximately 10% of patients in India, necessitating a change in antibiotics 5
- Complications of enteric fever (gastrointestinal bleeding, intestinal perforation, encephalopathy) are more common if duration of illness exceeds 2 weeks 2
- Severe complications may require intensive care management, as reported in a case from Punjab, India 9
Treatment Algorithm for Enteric Fever in India
- For uncomplicated cases: Azithromycin 20 mg/kg/day (maximum 1g/day) orally for 7 days 1, 3, 2
- For severe cases or those unable to take oral medications: Ceftriaxone 50-80 mg/kg/day (maximum 2g/day) IV for 5-7 days 1, 3
- For clinical non-response to initial therapy: Consider switching to an alternative agent based on local susceptibility patterns or using combination therapy 5
- For patients with sepsis: Initiate broad-spectrum antibiotics immediately after obtaining cultures 6
Common Pitfalls to Avoid
- Avoid empiric use of fluoroquinolones like ciprofloxacin due to high resistance rates in India 7
- Do not rely solely on clinical presentation for diagnosis; obtain cultures whenever possible 3
- Avoid delaying treatment in severe cases; initiate parenteral therapy promptly 9
- Do not continue ineffective therapy; reassess if fever persists beyond 5-6 days of appropriate treatment 5