Typhoid Fever Treatment Guidelines

First-Line Treatment Options

The preferred initial treatment for typhoid fever is intravenous ceftriaxone, especially for patients with unstable clinical condition or those returning from Asia where fluoroquinolone resistance exceeds 70% 1
The typical dosage of intravenous ceftriaxone is 2g IV daily for adults, and the duration of treatment is 14 days to reduce the risk of relapse 1
Azithromycin is a suitable oral alternative for uncomplicated disease, especially when fluoroquinolone resistance is confirmed, with resistance to azithromycin being currently rare in many regions 1

In regions like South Asia, fluoroquinolones should be avoided as first-line therapy due to high resistance rates, with more than 70% of isolates imported to the UK being resistant 1
When testing isolates for antibiotic sensitivity, ciprofloxacin disc testing alone is unreliable, and the organism should also be sensitive to nalidixic acid on disc testing to be considered truly sensitive to fluoroquinolones 1

Complications such as gastrointestinal bleeding, intestinal perforation, and typhoid encephalopathy occur in 10-15% of patients, and are more likely if the duration of illness is more than 2 weeks 1
Previous vaccination provides incomplete protection against typhoid fever and does not protect against paratyphoid 1

Blood cultures have the highest yield within the first week of symptom onset, with a sensitivity of 40-80%, while stool and urine cultures become positive after the first week, with sensitivities of 35-65% and 0-58%, respectively 1
Bone marrow cultures have higher sensitivity than blood cultures, and the serological Widal test lacks sensitivity and specificity, and is not recommended 1

The Centers for Disease Control and Prevention recommends typhoid vaccination for travelers to areas with recognized risk of exposure to S. typhi, particularly in developing countries in Latin America, Asia, and Africa 2, 3
Careful selection of food and drink remains important even after vaccination, as vaccines are not 100% effective 3, 4