What is the recommended management for typhoid?

Management of Typhoid Fever

Azithromycin is the first-line treatment for typhoid fever, particularly in areas with high fluoroquinolone resistance, with a dose of 500 mg once daily for 7-14 days in adults and 20 mg/kg/day (maximum 1g/day) for 7-14 days in children. 1, 2, 3

First-Line Treatment Options

• Azithromycin demonstrates superior outcomes with lower risk of clinical failure and shorter hospital stays compared to fluoroquinolones for uncomplicated typhoid fever 1, 2
• Azithromycin has a lower risk of relapse (OR 0.09) compared to ceftriaxone and is particularly effective against quinolone-resistant strains 2, 3
• For fully susceptible S. typhi strains, fluoroquinolones (except in South Asia due to resistance) may be considered, but azithromycin remains a strong alternative 1, 2

Treatment Algorithm Based on Resistance Patterns

• For uncomplicated typhoid fever: Azithromycin 500 mg once daily for 7-14 days (adults) or 20 mg/kg/day (maximum 1g/day) for 7-14 days (children) 1, 3
• For severe cases requiring parenteral therapy: Ceftriaxone 1-2g IV/IM daily for adults or 50-80 mg/kg/day for children (maximum 2g/day) for 5-7 days 1, 3
• Once clinical improvement occurs with IV therapy, transition to oral azithromycin may be considered 1, 3
• For multidrug-resistant strains: Azithromycin or ceftriaxone 1
• For quinolone-resistant strains: Azithromycin is the preferred first-line therapy 1, 2

Diagnostic Approach

• Blood cultures should be obtained before starting antibiotics when possible, as they have the highest yield within the first week of symptom onset 1, 3
• Stool and urine cultures become positive after the first week of illness 3
• Do not rely solely on clinical presentation for diagnosis; obtain cultures whenever possible 3

Monitoring and Expected Response

• Monitor for clinical response, with expected fever clearance within 4-5 days of appropriate therapy 1, 2
• Watch for potential drug interactions with azithromycin 1, 2
• Common adverse effects of azithromycin include gastrointestinal symptoms: nausea, vomiting, abdominal pain, and diarrhea 1, 2
• Complications of typhoid fever occur in 10-15% of patients and are more likely if duration of illness exceeds 2 weeks 1, 3

Complications Management

• In severe cases with intestinal perforation, surgical intervention is recommended 1
• Simple excision and closure of small perforations has been reported in up to 88.2% of cases with intestinal perforation 1
• For patients with clinical features of sepsis, broad-spectrum antimicrobial therapy should be started after collection of blood, stool, and urine cultures 2

Prevention

• Typhoid vaccination is recommended for travelers to areas that have a recognized risk of exposure to S. typhi, people with intimate exposure to a documented typhoid carrier, and laboratory personnel routinely exposed to S. typhi cultures 4
• Two typhoid vaccines are available in the United States: an oral live-attenuated Ty21a vaccine and a parenteral Vi-polysaccharide vaccine 4
• Typhoid vaccination provides incomplete protection and does not protect against paratyphoid 1, 2
• Hand hygiene and appropriate food safety practices are essential preventive measures 1

Pitfalls to Avoid

• Do not use ciprofloxacin empirically for cases originating from South Asia due to high resistance rates 2, 3, 5
• Do not discontinue treatment prematurely; complete the full course of antibiotics to prevent relapse 1
• Do not delay surgical intervention in cases with intestinal perforation 1
• Be aware that increasing resistance to fluoroquinolones has been observed, particularly among travelers to South and Southeast Asia 1, 2