Management

Seek expert advice:

• azithromycin is increasingly used for the empirical treatment of enteric fever

Notes:

• for many decades, antibiotics such as chloramphenicol, ampicillin, and cotrimoxazole were used for treating enteric fever
  • emergence of multiple-drug-resistant (MDR) Salmonella strains, which are resistant to chloramphenicol, ampicillin, and cotrimoxazole, has changed treatment options (2)
    • second-line antibiotics like the fluoroquinolones (ciprofloxacin, ofloxacin, perfloxacin), third-generation cephalosporins (ceftriaxone, cefotaxime, cefixime), and azithromycin are often now used for treating MDR typhoid fever
      • infections with isolates susceptible to nalidixic acid (prototype fluoroquinolone) respond extremely well to fluoroquinolones
      • the extensive use of fluoroquinolones has since led to the emergence of intermediate and fully fluoroquinolone resistant strains
        
        
    • a systematic review concluded that (1):
      • azithromycin appears better than fluoroquinolone drugs in populations that included participants with drug-resistant strains
      • azithromycin may perform better than ceftriaxone
        
        
    • azithromycin is increasingly used for the empirical treatment of enteric fever
      • but widespread use of this drug in many parts of South Asia today may rapidly lead to development of resistance, highlighting the importance of good microbiological surveillance
      • some authors have advocated the addition of doxycycline for suspected enteric fever cases in regions of South Asia with high incidence of Rickettsia spp

Reference:

• 1. Effa EE, Bukirwa H. Azithromycin for treating uncomplicated typhoid and paratyphoid fever (enteric fever).Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006083
• 2. Gibbani MM et al. Typhoid and paratyphoid fever: a call to action.Curr Opin Infect Dis. 2018 Oct;31(5):440-44