What is the recommended treatment for a patient with suspected typhoid ileitis?

Treatment of Typhoid Ileitis

Surgery is mandatory for typhoid intestinal perforation, combined with broad-spectrum antibiotics covering Gram-negative bacteria and anaerobes. 1

Immediate Surgical Management

When perforation occurs, operative intervention is the definitive treatment. 1 The diagnosis is typically based on findings of peritonitis in a patient with a history of prolonged febrile illness, as blood and bone marrow cultures are often unavailable in resource-limited settings where typhoid perforation is most common. 1

Surgical Options

Multiple surgical procedures can be performed based on the extent of disease: 1

• Simple excision and closure of small perforations (reported in up to 88.2% of cases)
• Primary closure with single or double-layer technique
• Resection and primary anastomosis
• Limited right hemicolectomy
• Stoma creation for severe cases

Double-layer closure significantly reduces mortality compared to single-layer closure (mortality 19% vs 40%), primarily by decreasing late (>24 hours) postoperative deaths. 2, 3 A prospective series using two-layer closure achieved an 8% mortality rate compared to 31% with single-layer technique. 3

Antibiotic Therapy

Perioperative Antibiotic Regimen

Broad-spectrum antibiotic coverage is essential and significantly reduces mortality. 2, 3 The combination of chloramphenicol, gentamicin, and metronidazole reduced mortality from 40% to 19% compared to chloramphenicol alone, primarily by decreasing late mortality. 2, 3

Recommended perioperative regimen: 2, 3

• Chloramphenicol PLUS
• Gentamicin PLUS
• Metronidazole

This triple-antibiotic approach provides coverage against Gram-negative bacteria, anaerobes, and resistant Salmonella typhi strains. 2, 3

Treatment of Uncomplicated Typhoid (Without Perforation)

For patients with suspected enteric fever presenting with sepsis but without perforation: 1, 4

First-line empiric therapy (after obtaining blood, stool, and urine cultures): 1, 4

• Ceftriaxone 50-80 mg/kg/day IV (maximum 2g/day) for severe cases requiring hospitalization 4
• Azithromycin 20 mg/kg/day orally (maximum 1g/day) for 7 days for less severe cases 4

Avoid fluoroquinolones (ciprofloxacin) for empiric therapy in cases originating from South Asia due to >70% resistance rates. 1, 4, 5 Ciprofloxacin should only be used if the isolate is confirmed sensitive to both ciprofloxacin AND nalidixic acid on disc testing. 1

Critical Supportive Care Measures

Aggressive Fluid Resuscitation

Intraoperative fluid administration >10 ml/kg significantly reduces early mortality (mortality 14% vs 43% with <10 ml/kg), primarily by preventing early (<24 hours) postoperative deaths. 2 This represents one of the most impactful low-cost interventions available. 3

Administer isotonic intravenous fluids (lactated Ringer's or normal saline) for: 1

• Severe dehydration
• Shock or altered mental status
• Peritonitis with perforation

Additional Supportive Measures

• Correct electrolyte abnormalities and anemia 1
• Provide thromboprophylaxis with low molecular weight heparin 1
• Monitor for complications: gastrointestinal bleeding, intestinal perforation, and typhoid encephalopathy occur in 10-15% of patients, particularly if illness duration exceeds 2 weeks 1

Common Pitfalls to Avoid

Do not delay surgery when perforation is suspected. Persistent septicemia after laparotomy most likely indicates resistant Salmonella typhi infection requiring second-line antibiotic therapy. 6 The mortality rate for typhoid perforation ranges from 4.6% to 39%, with extremes of age, generalized peritonitis, lower white blood cell count, increased number of perforations, and postoperative enterocutaneous fistula all worsening prognosis. 1, 3

Do not use single-layer closure or narrow-spectrum antibiotics (chloramphenicol alone), as these approaches are associated with significantly higher mortality rates. 2, 3

Do not rely on ciprofloxacin empirically without susceptibility testing, especially for infections acquired in Asia, where resistance is now the norm. 1, 4, 5 Ceftriaxone-resistant typhoid is also emerging in Pakistan. 5