What is the treatment for typhoid fever with symptoms of green colored stool, abdominal pain, and a Total Leukocyte Count (TLC) of 23,000?

Treatment of Typhoid Fever with Severe Presentation

This patient requires immediate empiric broad-spectrum antibiotic therapy with IV ceftriaxone after obtaining blood, stool, and urine cultures, given the concerning presentation of abdominal pain, positive typhoid test, and markedly elevated leukocyte count (23,000) suggesting severe disease or possible complications. 1, 2

Immediate Management

Urgent Assessment for Complications

• The elevated TLC of 23,000 is highly concerning as it suggests either severe systemic infection or a potential complication such as intestinal perforation, which occurs in 10-15% of typhoid cases and carries mortality rates of 4.6-39% 3, 1
• Typhoid intestinal perforation typically presents with abdominal pain and fever, most commonly occurring in the third week of disease but can occur as early as 24 hours 3
• Immediate surgical consultation is warranted if there are signs of peritonitis, as surgery is recommended for typhoid intestinal perforation 3

Empiric Antibiotic Therapy

• Start IV ceftriaxone 50-80 mg/kg/day (maximum 2g/day) immediately after obtaining blood, stool, and urine cultures for patients with severe disease, fever, abdominal pain, and suspected complications 1, 4, 2
• Blood cultures should be drawn in 2-3 specimens prior to antibiotics, as they have the highest yield within the first week of symptoms (sensitivity 40-80%) 1
• Do not use ciprofloxacin empirically if the patient is from or has traveled to South/Southeast Asia (including India) due to high fluoroquinolone resistance rates 1, 4

Treatment Based on Severity and Geographic Origin

For Severe/Complicated Cases

• IV ceftriaxone is the first-line treatment for severe typhoid with relapse rates <8% 1, 2
• Continue IV therapy until clinically improved and afebrile for 24 hours, then transition to oral therapy 4
• Consider adding steroids in severe typhoid fever to improve outcomes 1, 2

For Uncomplicated Cases (After Ruling Out Complications)

• Azithromycin 500 mg once daily (or 20 mg/kg/day, maximum 1g/day) for 7-14 days is first-line for cases from South/Southeast Asia, with superior efficacy, lower clinical failure rates (OR 0.48), and lower relapse rates (OR 0.09, <3%) compared to fluoroquinolones 1, 4, 2
• Fluoroquinolones (ciprofloxacin or ofloxacin) can only be used if susceptibility is confirmed and the patient is from regions with low resistance 1, 2

Treatment Duration and Monitoring

• Continue treatment for 14 days total to reduce relapse risk 1, 2
• Expected fever clearance is 4-5 days with appropriate therapy 1, 4
• If fever persists beyond 4-5 days, consider treatment failure due to resistance and switch to alternative therapy (e.g., from ceftriaxone to azithromycin or vice versa) 5

Critical Pitfalls to Avoid

• Do not delay surgical evaluation in patients with severe abdominal pain and elevated leukocyte count, as typhoid perforation requires surgical intervention (primary closure, excision and closure, or resection and anastomosis) 3
• Do not rely on Widal test alone for diagnosis; blood culture is the gold standard 1
• Do not use ciprofloxacin disc testing alone to determine fluoroquinolone susceptibility; the organism must also be sensitive to nalidixic acid 2
• Green-colored stool is not specific for typhoid and may represent bile-stained diarrhea, but combined with positive typhoid test and severe symptoms, warrants aggressive management 3

Specific Considerations for This Case

• The markedly elevated TLC (23,000) is atypical for uncomplicated typhoid, which usually presents with leukopenia or normal counts 5
• This elevation strongly suggests either:
  • Intestinal perforation with peritonitis (requiring emergency surgery) 3
  • Severe systemic infection 1
  • Secondary bacterial infection 3
• Obtain imaging (ultrasound or CT if available) to evaluate for free air, ascites, mesenteric lymphadenitis, or other complications 5, 6