What is the recommended treatment for typhoid?

Typhoid Fever Treatment

For typhoid fever, intravenous ceftriaxone 2g daily for 14 days is the preferred first-line treatment, especially for patients with unstable clinical condition or those returning from Asia where fluoroquinolone resistance exceeds 70%. 1

First-Line Treatment Selection

Ceftriaxone (Preferred)

• Administer ceftriaxone 2g IV daily for adults for a full 14-day course to minimize relapse risk 1
• This is particularly critical for patients returning from South Asia, where fluoroquinolone resistance rates exceed 70% 1
• Ceftriaxone demonstrates effectiveness with few adverse effects and performs comparably to azithromycin and fluoroquinolones in clinical trials 2

Azithromycin (Oral Alternative)

• Azithromycin is an appropriate oral alternative for uncomplicated disease, especially when fluoroquinolone resistance is confirmed 1
• Resistance to azithromycin remains rare in most regions 1
• Studies show azithromycin 20 mg/kg/day for 5-7 days achieves 94-97% cure rates with potentially lower relapse rates compared to ceftriaxone 3

Fluoroquinolones (Geographic Restrictions Apply)

• Avoid fluoroquinolones as first-line therapy in cases originating from South Asia due to resistance rates exceeding 70% 1, 4
• Ciprofloxacin is FDA-approved for typhoid fever 5, but clinical utility is severely limited by resistance patterns
• When considering fluoroquinolones, verify the isolate is sensitive to nalidixic acid on disc testing, as ciprofloxacin disc testing alone is unreliable 1

Critical Treatment Considerations

Resistance Pattern Assessment

• Always base antibiotic selection on local resistance patterns and travel history 4, 2
• In Pakistan specifically, both ciprofloxacin-resistant and ceftriaxone-resistant typhoid is now common 4
• 96% of isolates from Vietnam showed nalidixic acid resistance, with 58% demonstrating multidrug resistance 6

Duration and Monitoring

• Complete the full 14-day course of ceftriaxone to reduce relapse risk 1
• Complications including gastrointestinal bleeding, intestinal perforation, and typhoid encephalopathy occur in 10-15% of patients, particularly when illness duration exceeds 2 weeks before treatment 1

Common Pitfalls to Avoid

Diagnostic Timing

• Obtain blood cultures within the first week of symptom onset when sensitivity is highest (40-80%) 1
• Do not rely on the Widal serological test, which lacks adequate sensitivity and specificity 1

Vaccination Misconceptions

• Previous typhoid vaccination provides incomplete protection and does not eliminate the need for treatment 1
• Vaccination does not protect against paratyphoid fever 1

Antibiotic Selection Errors

• Do not assume fluoroquinolone susceptibility based solely on ciprofloxacin disc testing without confirming nalidixic acid sensitivity 1
• Avoid using older fluoroquinolones (ciprofloxacin, ofloxacin) as empiric therapy for patients from endemic regions where resistance is widespread 4