Typhoid fever
ICD-10 A01.0 · ICD-11 1A07

Treatment of Severe or Complicated Enteric Fever with Extensive Drug Resistance

This protocol addresses patients with severe or complicated enteric fever caused by an extensively drug-resistant (XDR) organism — one that is resistant to multiple standard antibiotic classes — who cannot be managed with oral therapy alone and require urgent inpatient parenteral treatment.

Clinical Scenario

Patients presenting with severe illness, an inability to tolerate oral treatment due to vomiting and/or severe diarrhoea, or intestinal and extra-intestinal complications of enteric fever typically require hospitalisation and parenteral antimicrobial therapy.

The infecting organism is extensively drug resistant: resistant to chloramphenicol, amoxicillin, cotrimoxazole, ciprofloxacin, and ceftriaxone. This resistance profile substantially limits the available treatment options.

Treatment Approach (partial overview)

Management centres on parenteral antimicrobial therapy selected for the XDR resistance profile, with transition to an appropriate oral regimen once the patient has clinically improved; patients with certain severe complications may require concurrent or additional targeted interventions.

Partial overview — full regimen, dosing, and decision algorithm available below
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References

Severe enteric fever, patients unable to tolerate oral treatment due to vomiting and/or severe diarrhoea, and/or patients with intestinal/extra-intestinal complications typically require hospitalisation and parenteral antimicrobial treatment.

Extensively drug resistant: resistant to chloramphenicol, amoxicillin, cotrimoxazole, ciprofloxacin and ceftriaxone.

Treatment options for extensively drug-resistant enteric fever are limited to azithromycin (for uncomplicated disease) and meropenem (for severe disease).

Once patients have clinically improved, treatment can be completed with appropriate oral antibiotics (e.g. oral ciprofloxacin or azithromycin, depending on the antimicrobial susceptibility profile).

Data are limited, but concurrent treatment with high-dose dexamethasone should be considered for patients with severe enteric fever with delirium, obtundation, coma or shock.

In patients with severe enteric fever with intestinal perforation and peritonitis, surgical intervention is recommended.

Intestinal bleeding, perforations or ulcerations are life-threatening and may require immediate fluid resuscitation, surgical interventions and broad-spectrum antimicrobial coverage for polymicrobial peritonitis.

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