What is the recommended treatment for typhoid fever in a ward setting?

Treatment of Typhoid Fever in a Ward Setting

Azithromycin is the recommended first-line treatment for typhoid fever in a ward setting, with a dose of 500 mg once daily for 7-14 days for adults or 20 mg/kg/day (maximum 1g/day) for children. 1

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 3
• The mean fever clearance time for patients treated with azithromycin (5.8 days) is shorter than that for patients treated with cefixime (7.1 days) and ciprofloxacin (8.2 days) 2

Treatment Algorithm Based on Resistance Patterns

• For fully susceptible S. typhi, fluoroquinolones (ofloxacin or ciprofloxacin) remain effective, but azithromycin is still a strong alternative 1
• For multidrug-resistant strains (resistant to ampicillin, chloramphenicol, and cotrimoxazole), azithromycin or ceftriaxone is recommended 1
• For quinolone-resistant strains, azithromycin is the preferred first-line therapy 1, 3
• Avoid using ciprofloxacin empirically for cases originating from South Asia due to high resistance rates 3, 4

Alternative Treatment Options for Severe Cases

• Ceftriaxone is recommended for severe cases requiring parenteral therapy at a dose of 1-2g IV/IM daily for adults or 50-80 mg/kg/day for children (maximum 2g/day) for 5-7 days 1, 5
• Once clinical improvement occurs with IV therapy, transition to oral azithromycin may be considered 1
• For patients with clinical features of sepsis, broad-spectrum antimicrobial therapy should be started after collection of blood, stool, and urine cultures 3

Diagnostic Recommendations

• Blood cultures should be obtained before starting antibiotics when possible, as they have the highest yield within the first week of symptom onset 1, 5
• Stool and urine cultures become positive after the first week of illness 5
• Do not rely solely on clinical presentation for diagnosis; obtain cultures whenever possible 5

Monitoring and Expected Response

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

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
• Other complications to monitor for include gastrointestinal bleeding and typhoid encephalopathy 5

Important Clinical Considerations

• 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 6, 3
• Resistance to nalidixic acid, a quinolone, is a marker for decreased susceptibility to ciprofloxacin and increased from 19% in 1999 to 59% in 2008 6

Prevention in Ward Settings

• Personal hygiene, particularly hand hygiene before and after all patient contacts, will minimize risk for transmitting enteric pathogens to patients 6
• Healthcare personnel who contract an acute diarrheal illness accompanied by fever, cramps, or bloody stools should be excluded from patient care until the illness has been evaluated and treated 6