What is the recommended treatment for typhoid?

Recommended Treatment for Typhoid Fever

The preferred initial treatment for typhoid fever is intravenous ceftriaxone at a dosage of 2g IV daily for adults for 14 days, especially for patients with unstable clinical condition or those returning from Asia where fluoroquinolone resistance exceeds 70%. 1

First-Line Treatment Options

Intravenous Treatment

• Ceftriaxone (2g IV daily for adults) for 14 days is the recommended first-line treatment for typhoid fever, particularly for patients with severe illness or those returning from regions with high fluoroquinolone resistance 1
• The extended 14-day treatment duration is important to reduce the risk of relapse 1

Oral Treatment Options

• Azithromycin is a suitable oral alternative for uncomplicated disease, especially when fluoroquinolone resistance is confirmed 1
• Azithromycin resistance remains relatively rare in many regions, making it an effective choice 1
• Ciprofloxacin is FDA-approved for typhoid fever but should not be used for cases originating from South Asia due to high resistance rates 2, 3

Treatment Selection Based on Geographic Resistance Patterns

• In South Asia, fluoroquinolones should be avoided as first-line therapy due to high resistance rates (>70% of isolates imported to the UK) 1
• Ciprofloxacin-resistant and ceftriaxone-resistant typhoid is common in Pakistan, requiring careful antibiotic selection 3
• When testing isolates for antibiotic sensitivity, ciprofloxacin disc testing alone is unreliable; the organism should also be sensitive to nalidixic acid on disc testing to be considered truly sensitive to fluoroquinolones 1

Treatment Duration and Monitoring

• Standard treatment duration is 14 days for ceftriaxone to prevent relapse 1
• Blood cultures have the highest yield within the first week of symptom onset (sensitivity 40-80%) 1
• Bone marrow cultures have higher sensitivity than blood cultures and may be considered in difficult cases 1

Complications and Special Considerations

• Complications such as gastrointestinal bleeding, intestinal perforation, and typhoid encephalopathy occur in 10-15% of patients, especially if illness duration exceeds 2 weeks 1
• Previous vaccination provides incomplete protection against typhoid fever and does not protect against paratyphoid 1
• Children and adolescents with uncomplicated typhoid fever may be effectively treated with azithromycin at 20mg/kg/day (maximum 1g/day) 4

Treatment Algorithm Based on Clinical Presentation and Geography

1. Severe illness or patient from high-resistance region (especially South Asia):

   • Intravenous ceftriaxone 2g daily (adults) for 14 days 1

2. Uncomplicated illness in regions with low fluoroquinolone resistance:

   • Oral azithromycin 20mg/kg/day (maximum 1g/day) for 7 days 1, 4
   • OR ciprofloxacin (if not from South Asia) 2, 3

3. For confirmed multidrug-resistant strains:

   • Ceftriaxone or azithromycin based on susceptibility testing 1, 5

Common Pitfalls to Avoid

• Relying on ciprofloxacin for patients returning from South Asia (resistance exceeds 70%) 1, 3
• Using inadequate treatment duration (less than 14 days for ceftriaxone), which increases relapse risk 1
• Depending on the Widal serological test, which lacks sensitivity and specificity 1
• Assuming that previous typhoid vaccination provides complete protection 1