infectious diseases
Typhoid Fever
Treatment of Typhoid Fever
Ceftriaxone Sometimes a fluoroquinolone orazithromycin Antibiotic resistance is common and increasing, particularly in endemic areas, so susceptibility testing should guide drug selection. In general, preferred antibiotics include Ceftriaxone1 g IM or IV every 12 hours (25 to 37.5 mg/kg in children) for 14 days Various fluoroquinolones (eg,ciprofloxacin500 mg orally 2 times a day for 10 to 14 days,levofloxacin500 mg orally or IV once a day for 14 days,moxifloxacin400 mg orally or IV once a day for 14 days) Chloramphenicol500 mg orally or IV every 6 hours is still widely used, but resistance is increasing. Fluoroquinolones may be used in children, but caution is required. For fluoroquinolone-resistant strains,azithromycin1 g orally on day 1, then 500 mg once a day for 6 days can be tried. Resistance rates to alternative therapies (eg,amoxicillin,trimethoprim/sulfamethoxazole [TMP/SMX]) are high, so use of these drugs depends on in vitro sensitivity. Corticosteroids may be added to antibiotics to treat severe toxicity. Defervescence and clinical improvement usually follow.Prednisone20 to 40 mg orally once a day (or equivalent) for the first 3 days of treatment usually suffices. Higher doses of corticosteroids (dexamethasone3 mg/kg IV initially, followed by 1 mg/kg IV every 6 hours for 48 hours total) are used in patients with marked delirium, coma, or shock. Nutrition should be maintained with frequent feedings. While febrile, patients are usually kept on bed rest. Salicylates (which may cause hypothermia and hypotension), as well as laxatives and enemas, should be avoided. Diarrhea may be minimized with a clear liquid diet; parenteral nutrition may be needed temporarily. Fluid and electrolyte therapy and blood replacement may be needed. Intestinal perforation and associated peritonitis call for surgical intervention and broader gram-negative and anti–Bacteroides fragiliscoverage. Relapses are treated the same as the initial illness, although duration of antibiotic therapy seldom needs to be>5 days. Patients must be reported to the local health department and prohibited from handling food until proven free of the organism. Typhoid bacilli may be isolated for as long as 3 to 12 months after the acute illness in people who do not become carriers. Thereafter, 3 stool cultures at monthly intervals must be negative to exclude a carrier state. Carriers with normal biliary tracts should be given antibiotics. The cure rate is about 80% withamoxicillin, TMP/SMX, orciprofloxacingiven for 4 to 6 weeks. In some carriers with gallbladder disease, eradication has been achieved with TMP/SMX andrifampin. In other cases, cholecystectomy with 1 to 2 days of preoperative antibiotics and 2 to 3 days of postoperative antibiotics is effective. However, cholecystectomy does not ensure elimination of the carrier state, probably because of residual foci of infection elsewhere in the hepatobiliary tree. 