What is the recommended treatment regimen for enteric fever in an inpatient (IPD) setting?

Treatment of Enteric Fever in Inpatient (IPD) Setting

For patients with enteric fever requiring inpatient treatment, ceftriaxone 50-80 mg/kg/day (maximum 2g/day) intravenously for 5-7 days is the recommended first-line therapy. 1, 2, 3

First-Line Treatment Options

• Ceftriaxone 50-80 mg/kg/day (maximum 2g/day) intravenously in divided doses for 5-7 days is the preferred initial treatment for hospitalized patients with enteric fever 1, 2
• For adults, ceftriaxone 1-2g every 12-24 hours is appropriate based on severity 4
• Blood cultures should be obtained before initiating antibiotics whenever possible 1, 5
• For patients with clinical features of sepsis, broad-spectrum antimicrobial therapy should be started immediately after blood culture collection 4, 5

Alternative Treatment Options

• Azithromycin 20 mg/kg/day (maximum 1g/day) can be used when IV therapy is not required or as step-down therapy 1
• In areas with known susceptibility, fluoroquinolones (ciprofloxacin or ofloxacin) may be considered, but resistance is increasingly common globally 1, 5
• For severe cases with sepsis, broader coverage may be needed initially until culture results are available 4, 5

Treatment Based on Resistance Patterns

• Over 70% of S. typhi isolates in many regions are now resistant to fluoroquinolones, making ceftriaxone a better empiric choice 1, 6
• Antimicrobial therapy should be modified when susceptibility testing results become available 4
• For extensively drug-resistant (XDR) strains, consult infectious disease specialists for guidance 7

Treatment Duration and Monitoring

• Most patients with uncomplicated enteric fever should receive 5-7 days of appropriate antibiotics 1, 2, 3
• Patients treated initially with parenteral antibiotics should be transferred to an oral regimen once clinical improvement occurs and temperature has been normal for 24 hours 1
• Monitor for clinical response, with expected fever clearance within 4-5 days of appropriate therapy 1, 2
• Mean time to defervescence with ceftriaxone therapy is approximately 4 days in responsive cases 2

Step-Down Therapy

• Once clinical improvement occurs, patients can be switched to oral therapy to complete the treatment course 1
• Options for oral step-down therapy include:
  • Azithromycin 20 mg/kg/day (maximum 1g/day) 1
  • Cefixime 8 mg/kg/day (for children) or 400 mg daily (for adults) 1
  • Fluoroquinolones (if susceptibility is confirmed) 1, 6

Special Considerations

• For patients with persistent or recurrent signs of peritoneal irritation, failure of bowel function to return to normal, continued fever or leukocytosis, consider CT imaging to identify persistent or new intra-abdominal infection 4
• Rehydration therapy is crucial, with isotonic intravenous fluids recommended for severe dehydration 4
• In comparative studies, ceftriaxone has shown significant reduction in time to become afebrile, faster resolution of clinical signs and symptoms, and shorter hospital stays compared to older agents like chloramphenicol 3

Common Pitfalls to Avoid

• Avoid using fluoroquinolones empirically for cases originating from South Asia due to high resistance rates 1, 6
• Do not rely solely on clinical presentation for diagnosis; obtain cultures whenever possible 1, 7
• Avoid premature discontinuation of antibiotics before complete resolution of symptoms 1
• Consider local resistance patterns when selecting empiric therapy, as these vary geographically and change over time 1, 6

In comparative studies, short-course treatment with ceftriaxone has demonstrated excellent efficacy with cure rates above 90% and low relapse rates, making it the preferred inpatient treatment option for enteric fever 2, 3, 6.