Which patients with typhoid fever should be hospitalized?

Hospitalization Criteria for Typhoid Fever

Patients with typhoid fever should be hospitalized if they have clinical instability (sepsis, fever ≥38.5°C with severe illness), signs of complications (intestinal perforation, gastrointestinal bleeding, encephalopathy, septic shock), or inability to tolerate oral therapy. 1, 2

Immediate Hospitalization Indicators

Severe Clinical Presentations

• Septic shock or hemodynamic instability requires immediate hospitalization and intensive care 1, 3
• Fever ≥38.5°C in travelers from endemic areas with documented severe illness warrants admission for IV antibiotic therapy 1, 2
• Altered mental status or encephalopathy indicates severe disease requiring inpatient monitoring 1, 3
• Respiratory distress or acute respiratory distress syndrome necessitates ICU-level care 3

Complications Requiring Surgical Evaluation

• Signs of intestinal perforation (acute abdominal pain, peritoneal signs, pneumoperitoneum on imaging) demand urgent hospitalization and surgical consultation 4, 5, 6, 7
• Gastrointestinal bleeding requires inpatient management 4, 1
• Abdominal distension with severe tenderness suggesting peritonitis warrants admission 5, 7

The perforation-surgery interval significantly impacts mortality, with 86.5% of patients presenting more than 72 hours after perforation having worse outcomes 7. Complications occur in 10-15% of patients, typically after 2 weeks of untreated illness 4, 1.

Risk Stratification for Admission

High-Risk Patient Populations

• Immunocompromised patients (HIV-positive, chronic liver disease) require hospitalization due to increased risk of severe disease and mortality 1, 8
• Patients with leukopenia have 3.88 times higher odds of intestinal perforation and should be admitted 6
• Male patients have 4.39 times higher risk of perforation compared to females 6
• Patients with inadequate prior antibiotic treatment have 4.58 times increased perforation risk 6

Clinical Deterioration Markers

• Dehydration or electrolyte imbalance requiring IV fluid resuscitation 4
• Inability to tolerate oral medications due to severe vomiting 1, 8
• Duration of illness >2 weeks without treatment, as complications are more likely 4
• Short duration of symptoms with severe presentation (paradoxically associated with higher perforation risk) 6

Outpatient Management Criteria

Patients may be managed as outpatients only if ALL of the following are present:

• Hemodynamically stable with fever <38.5°C 1, 2
• Able to tolerate oral medications and maintain hydration 4
• No signs of complications (no peritoneal signs, no altered mental status, no respiratory distress) 1, 2
• Reliable follow-up available within 24-48 hours 4
• No high-risk features (immunocompromised, leukopenia, severe abdominal pain) 1, 6

For outpatients, oral azithromycin 500 mg daily for 7-14 days is first-line for cases from South/Southeast Asia due to high fluoroquinolone resistance 2. Expected fever clearance is 4-5 days with appropriate therapy 2.

Critical Monitoring During Hospitalization

Laboratory Surveillance

• Blood cultures (2-3 specimens of 20 mL each) should be obtained before antibiotics, as bacteremia is low (0.3 CFU/mL) 2
• Complete blood count to monitor for leukopenia (perforation risk marker) 6
• Liver function tests and ammonia levels if hepatic involvement suspected 8

Imaging Considerations

• Chest and abdominal radiographs detect pneumoperitoneum in 74.7% of perforation cases 7
• Ultrasound shows free peritoneal fluid in 85.7% of perforations 7
• CT abdomen for equivocal cases showing mesenteric lymphadenopathy and bowel wall thickening 8

Treatment Escalation

• IV ceftriaxone should be started immediately for hospitalized patients after culture collection 4, 1, 2
• High-dose dexamethasone may be considered as adjunct therapy in severe cases with septic shock, though data in children are limited 3
• Surgical consultation within 72 hours if perforation suspected, as delayed operation increases mortality 7

The mortality rate for typhoid perforation is 23.1%, significantly associated with delayed presentation, shock on admission, HIV positivity, multiple perforations, and postoperative complications 7. Overall typhoid mortality is 1% but increases substantially in elderly patients and those with complications 4.