Typhoid Fever-Standard Treatment Guidlines

Defination, Investigations and Treatment of Typhoid Fever

It is caused by Salmonella typhi and Salmonella paratyphi. Salmonella typhi causes a variety of illnesses including asymptomatic carrier state, gastro-enteritis and enteric fever.

Salient features of Typhoid Ferver

• The onset of fever is typically gradual, continuous (temperature upto 40º C) constitutional symptoms such as malaise, anorexia, lethargy, headache.
• Constipation or diarrhea (pea-soup stools) which may be associated with abdominal pain and tenderness.
• Hepatomegaly and splenomegaly may be observed.
• Complications such as hepatitis, meningitis, pneumonitis and myocarditis can occur after the first week.

Investigations

Diagnosis is suggested by Rising of O antibodies (Widal test) and Confirmed by isolation of organism in blood, bone marrow, urine or stool

Pharmacological treatment

• Most patients with uncomplicated enteric fever can be managed at home with oral antibiotics and antipyretics.
• Patients with persistent vomiting, diarrhea, and/or abdominal distension should be hospitalized and given supportive therapy as well as a parenteral third-generation cephalosporin or fluoroquinolone, depending on the susceptibility profile
• Therapy should be administered for at least 10 days or for 5 days after fever resolution

Dosage schedule of antibiotics in treatment of typhoid fever

Indication–Agent–Dosage—Durations

Empirical Treatment– Ceftriaxone^{a —} 1-2 g/d IV — 7–14 days

Fully Susceptible —

1. Ciprofloxacin^b (first line)–500 mg BD (PO) or 400 mg BD (IV)——5–7 days
2. Amoxicillin (second line)–1 g TDS (PO) or 2 g QID (IV)—14 days
3. Ciprofloxacin—500 mg BD (PO) or 400 mg BD (IV)— 5–7 days

Multidrug-Resistant:

1. Ceftriaxone— 2–3 g/day (IV) —-7–14 days
2. Azithromycin– 1 g/day (PO)^{c  — 5 days}
3. Ceftriaxone— 2–3 g/d (IV)–7–14 days

Nalidixic Acid– Resistant:-

High-dose ciprofloxacin—750 mg bid (PO) or 400 mg q8h (IV)—-10–14 days

^aOr another third-generation cephalosporin [e.g., cefotaxime, 2 g TDS (IV); or cefixime, 400 mg bid (PO)].

^bOr ofloxacin 400 mg bid (PO) for 2–5 days.

^cOr 1 g on day 1 followed by 500 mg/day PO for 6 days

• The 1–5% of patients who develop chronic carriage of Salmonella can be treated for 4–6 weeks with an appropriate oral antibiotic.
• Treatment with oral amoxicillin, cotrimoxazole, ciprofloxacin, or norfloxacin is 80% effective in eradicating chronic carriage of susceptible organisms.
• However, in cases of anatomic abnormality (e.g., biliary or kidney stones), eradication often requires both antibiotic therapy and surgical correction.