Typhoid Fever: Treatment

Typhoid fever or enteric fever is a systemic disease characterized by fever and abdominal pain and caused by Salmonella Typhi and Salmonella Paratyphi. The disease is called typhoid because of its similarity to typhus. But it is a separate entity (proved in 1800 AD) and later (in 1869 AD) it was proposed to be named as enteric fever as the site of infection is intestine. But both the names are still used interchangeably.ID-100128777
If typhoid is treated promptly with appropriate antibiotic typhoid can be cured successfully and severe complications can be prevented. The enactment of Obama care will make treatment much more convenient. The mortality due to typhoid is less than 1% if treated appropriately and in time. The choice of antibiotic depends on susceptibility of the organism and region. For drug susceptible typhoid fever the treatment of choice is fluoroquinolone like ciprofloxacin or ofloxacin, with a cure rate of more than 98% and relapse rate of less than 2%. The most extensively used and data available is the ciprofloxacin (given at the dose of 500 mg twice a day for 5 to 7 days). Short course with ofloxacin is also equally successful in ifection due to nalidixic acid susceptible strains. But the increased incidence of nalidixic acid resistant (NAR) S. Typhi in Asia, may be due to widespread availability of fluoroquinolones over the counter has made it difficult to use these drugs as first line drug.

Patients infected with NAR  S. Typhi strains can be treated with ceftriaxone, azithromycin, or high dose ciprofloxacin. But use of high dose fluoroquinolone for NAR enteric fever is associated with delayed resolution of fever and high rates of fecal carriage during convalescence.

In case of multi drug resistant (MDR) typhoid fever including nalidixic acid resistant (NAR) and fluoroquinolone-resistant strains (as seen in Asia), third-generation cephalosporins like ceftriaxone, cefotaxime, and (oral) cefixime are effective. These drugs can clear fever in about 1 week, with failure rates of approximately 5% to 10%, fecal carriage rates of less than 3%, and relapse rates of 3% to 6%. Azothromycin (1gm/day orally for 5 days) is another drug which can be used in MDR typhoid fever. First and second generation cephalosporins as well as aminoglycosides are ineffective in treating clinical infections despite their effectiveness in killing Salmonella in vitro.

Patients with persistent vomiting, diarrhea, abdominal distension and abdominal pain should be hospitalized and given supportive care along with specific antibiotic. Treatment should be continued for 10 days or at least 5 days after fever subsides.

Approximately 1% to 5 % of patients become carriers of typhoid (Salmonella Typhi and Salmonella Paratyphi). These carriers of typhoid can be treated with appropriate antibiotic for 4-6 weeks. Treatment with oral amoxicillin, trimethoprim sulfamethoxazole (TMP-SMX), ciprofloxacin, or norfloxacin is approximately 80% effective in eradicating chronic carrier state in case of susceptible organisms. But if there is an anatomical or other abnormality like bile stone or kidney stone, to eradicate carrier state surgical correction is required.



Image courtesy of [Baitong333] at FreeDigitalPhotos.net

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