Enteric (typhoid) fever: diagnosis, resistance and the third week

Manage now— do this, in order

• Obtain blood cultures before the first antibiotic dose — the only investigation that produces an organism and a susceptibility profile; yield is about 80% in the first week and destroyed by a single dose. Take 10–15 mL per bottle in an adult, 1–3 mL in a small child, from separate sites. Prompt appropriate therapy reduces mortality from 10–30% to under 1%.Not available at your setup — Blood culture.
• Uncomplicated disease suitable for oral therapy (including decreased-ciprofloxacin-susceptibility, fluoroquinolone-resistant and ESBL strains): azithromycin 500 mg (some use 1 g) orally once daily for 7 days; child 20 mg/kg once daily, max 1 g/day.Doctor / Nurse
• Admitted, vomiting or moderately unwell: ceftriaxone 2 g IV once daily (or 1 g 12-hourly) for 10–14 days; child 75 mg/kg IV once daily, max 2 g/day. Severe or complicated disease (delirium, shock, bleeding, perforation): ceftriaxone 2 g IV once daily with organ support for at least 14 days, adding azithromycin or escalating if response is poor.Doctor / Nurse
• Suspected or confirmed XDR strain (Pakistan or Iraq, XDR contact, or no defervescence by day 5–7 of ceftriaxone): azithromycin 500 mg orally once daily or meropenem 1–2 g IV 8-hourly for 10–14 days (child azithromycin 20 mg/kg daily max 1 g, meropenem 20 mg/kg/dose 8-hourly max 1 g/dose). Ciprofloxacin only for a confirmed fully susceptible isolate — where decreased susceptibility is prevalent, including most of South Asia, fluoroquinolones must not be used empirically. Add metronidazole 500 mg IV 8-hourly (child 7.5 mg/kg/dose) to the cephalosporin if there is perforation or peritonitis.Doctor / Nurse
• Rehydrate and support: most patients arrive several litres depleted — oral rehydration where tolerated, IV crystalloid otherwise; in shock 500 mL over 15 minutes in an adult (10 mL/kg over 15–30 minutes in a child), reassessing after each bolus, to 20–30 mL/kg before considering vasopressor support — more cautiously if myocarditis is suspected. Correct hyponatraemia and hypokalaemia; treat hypoglycaemia in children with 10% dextrose 2 mL/kg IV. Paracetamol 1 g 6-hourly (max 4 g daily) in adults, 15 mg/kg 6-hourly (max 60 mg/kg/day) in children. Exclude malaria in parallel, always.
• High-dose dexamethasone only for the severe subgroup with delirium, obtundation, stupor, coma or shock: 3 mg/kg IV over 30 minutes, then 1 mg/kg IV 6-hourly for eight doses, given alongside — and never delaying — the antibiotic. Do not give corticosteroids in uncomplicated enteric fever, where they may increase relapse.Doctor / Nurse
• Suspected perforation is a surgical emergency: resuscitate, keep nil by mouth, pass a nasogastric tube for decompression, add metronidazole to broaden cover, give analgesia and arrange surgery — antibiotics alone do not treat a perforated bowel, and delay to laparotomy is the principal determinant of death. A negative erect chest radiograph does not exclude perforation, and ultrasound cannot.
• Intestinal haemorrhage: resuscitate with crystalloid and blood, transfusing to a haemoglobin threshold of approximately 70 g/L (80 g/L with ischaemic heart disease), correct coagulopathy, and stop all NSAIDs and anticoagulants — most bleeding stops with antibiotics, transfusion and time.Doctor / NurseNot available at your setup — Blood & blood products.
• Never give NSAIDs or aspirin (the ileum is ulcerated — they promote bleeding and mask perforation), and never antimotility agents, enemas, purgatives or laxatives. Do not change the antibiotic on day two — temperature may remain elevated for up to five days after correct therapy begins; persistence at day 5–7 means a resistant organism, an undrained focus, a missed perforation, drug fever or a wrong diagnosis. Infection control: hand washing with soap and water (alcohol gel alone is inadequate against enteric organisms), a dedicated toilet, notification — and arrange follow-up, since relapse occurs in up to 10% and about 5% become chronic carriers.