eMedicine Specialties > Ophthalmology > Infectious Disease

Typhoid Fever: Treatment & Medication

Author: Theodore Curtis, MD, Assistant Professor of Ophthalmology, University of Colorado; Consulting Staff, Rocky Mountain Lions Eye Institute
Coauthor(s): David T Wheeler, MD, Associate Professor, Departments of Ophthalmology and Pediatrics, Oregon Health & Science University
Contributor Information and Disclosures

Updated: Sep 29, 2006

Treatment

Medical Care

  • Chloramphenicol was the initial drug of choice (DOC) but is not commonly used because of widespread resistance, high relapse rates, and risk of bone marrow toxicity.
  • The current DOC for adults is an oral fluoroquinolone, most commonly oral ciprofloxacin. This drug combines a lower documented resistance rate with excellent penetration into macrophages and the biliary system, which may reduce relapse rates and chronic carrier states. Alternative antibiotics can be used if sensitivities are known or suspected resistance is low. However, there has been a sharp increase in strains resistant to fluoroquinolones, trimethoprim/sulfamethoxazole, and ampicillin.
  • The current DOC for children and pregnant women is parenteral ceftriaxone.
  • Patients in shock or with altered mental status may benefit from parenteral corticosteroid administration.
  • Supportive care often is required, including intravenous fluids and occasionally transfusion. The use of antipyretics has been discouraged due to risk of shock, but a recent study of 29 children demonstrated no complications with acetaminophen or ibuprofen.
  • Nearly all ophthalmic complications are managed medically, including infection, uveitis, serous retinal detachment, and other presumed sequelae of inflammation.

Surgical Care

  • Prompt surgical intervention for severe intestinal bleeding or bowel perforation has been shown to reduce mortality substantially.
  • A role may exist for cholecystectomy in treatment of the long-term carrier state with underlying biliary disease.
  • Surgical drainage of lid or orbital abscesses occasionally is required. Postoperative topical antibiotic coverage should contain chloramphenicol 1% or ciprofloxacin 0.3%, the only ophthalmic ointments with activity against S typhi.

Consultations

Infectious disease, general surgery, and gastroenterology

Diet

Initially nothing by mouth (NPO), advance as tolerated

Medication

Other antibiotics in addition to those listed as DOC depend on assessment of resistance risk and/or known sensitivities. These include trimethoprim-sulfamethoxazole, ampicillin, amoxicillin, azithromycin, and third-generation cephalosporins. Chloramphenicol ophthalmic is useful topically but no longer recommended as systemic therapy due to widespread resistance, recurrence risk, and bone marrow toxicity.

Antibiotics

Therapy must be comprehensive and cover all likely pathogens in the context of the clinical setting.


Ciprofloxacin (Cipro, Ciloxan)

DOC for nonpregnant adults unless sensitivities of the organism are known or suspected resistance.

Adult

500 mg PO bid for 10-14 d

Pediatric

Not established

Several, including antacids and vitamin A analogs; consult prescribing information

Absolute: Documented hypersensitivity; tendon pain
Relative: Childhood; pregnancy; breastfeeding; disease involving GI, renal, or hepatic function; elderly or dehydrated patients; CNS disease

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Prolonged use can result in overgrowth of nonsusceptible bacteria; discontinue at the first sign of hypersensitivity


Ceftriaxone (Rocephin)

DOC for children and pregnant women.

Adult

1-2 g IV qd for 5-7 d

Pediatric

50-80 mg/kg IM qd for 5-7 d

Aminoglycosides, loop diuretics, macrolides, tetracycline, others

Absolute: Cephalosporin hypersensitivity
Relative: Breastfeeding; coagulopathy; colitis; GI disease; penicillin hypersensitivity

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

May cause nonspecific GI complaints, eosinophilia, leukopenia, rash, urticaria, and seizures; bacterial overgrowth of nonsusceptible organisms can result from prolonged use


Ciprofloxacin ophthalmic (Ciloxan)

Inhibits bacterial growth by inhibiting DNA gyrase. Available as 0.3% solution or ointment.

Adult

Apply 1 gtt or 1-cm ribbon to inferior cul-de-sac of affected eye(s); frequency of topical use is dictated by clinical setting

Pediatric

<2 years: Not established (ointment)
>2 years: Administer as in adults

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

A white crystalline precipitate located in superficial portion of corneal defect may occur (onset starts in 1-7 d); precipitate usually is cleared within 2 wk and does not adversely affect clinical course or outcome; do not use in ocular infections that may become systemic; superinfections may occur with prolonged or repeated antibiotic therapy


Chloramphenicol ophthalmic (AK-Chlor, Chloromycetin, Chloroptic)

Binds to 50 S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria. Available as solution (0.5%) or ointment (1%).

Adult

Apply 1 gtt or 1-cm ribbon to inferior cul-de-sac of affected eye(s) or at site of skin incision; frequency of topical use is dictated by clinical setting

Pediatric

Not established; however, can be administered as in adults

Administered concurrently with barbiturates, chloramphenicol serum levels may decrease, while barbiturate levels may increase, causing toxicity; manifestations of hypoglycemia may occur with sulfonylureas; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants; may increase serum hydantoin levels, possibly resulting in toxicity; chloramphenicol levels may be increased or decreased

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Bone marrow toxicity, including aplastic anemia and death, have been reported following topical application of chloramphenicol; overgrowth of nonsusceptible bacterial may occur with prolonged use; medication may retard corneal would healing


Azithromycin (Zithromax)

Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected. Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues. Treats mild-to-moderate microbial infections.

Adult

Day 1: 500 mg PO
Days 2-5: 250 mg PO qd
Alternatively, 1 g PO once

Pediatric

<6 months: Not established
>6 months:
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg PO qd; not to exceed 250 mg/d

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Pregnancy

B - Usually safe but benefits must outweigh the risks.

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients

Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.


Prednisolone ophthalmic (Pred Forte)

Indicated for treatment of inflammation of the conjunctiva, cornea, and anterior segment. Available as 1% and 0.12% solution.

Adult

1 gtt applied to inferior cul-de-sac of affected eye(s); frequency is dictated by clinical setting

Pediatric

Not established; however, can be administered as in adults

Documented hypersensitivity; viral diseases or mycobacterial infections of conjunctiva or cornea

Pregnancy

C - Safety for use during pregnancy has not been established.

Precautions

Elevation of intraocular pressure leading to glaucoma and optic nerve damage, posterior subcapsular cataracts, delayed wound healing, and increased susceptibility to ocular infection may occur with prolonged use; fungal and viral infections should be specifically ruled out in persistent corneal ulceration; monitor intraocular pressure in patients receiving medication for more than 10 d

More on Typhoid Fever

Overview: Typhoid Fever
Differential Diagnoses & Workup: Typhoid Fever
Treatment & Medication: Typhoid Fever
Follow-up: Typhoid Fever
References
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References

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  9. Jong EC. Travel immunizations. Med Clin North Am. Jul 1999;83(4):903-22, vi. [Medline].

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  15. World Health Organization. Background document: the diagnosis, treatment, and prevention of typhoid fever. Geneva, Switzerland: 2003.

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Further Reading

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Keywords

enteric fever, Salmonella typhi

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Contributor Information and Disclosures

Author

Theodore Curtis, MD, Assistant Professor of Ophthalmology, University of Colorado; Consulting Staff, Rocky Mountain Lions Eye Institute
Theodore Curtis, MD is a member of the following medical societies: American Academy of Ophthalmology and American Association for Pediatric Ophthalmology and Strabismus
Disclosure: Nothing to disclose.

Coauthor(s)

David T Wheeler, MD, Associate Professor, Departments of Ophthalmology and Pediatrics, Oregon Health & Science University
David T Wheeler, MD is a member of the following medical societies: American Academy of Ophthalmology, American Association for Pediatric Ophthalmology and Strabismus, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Medical Editor

Richard W Allinson, MD, Associate Professor, Department of Ophthalmology, Texas A&M University Health Science Center, Scott and White Clinic
Disclosure: Nothing to disclose.

Pharmacy Editor

Simon K Law, MD, PharmD, Assistant Professor of Ophthalmology, Jules Stein Eye Institute; Chief of Section of Ophthalmology Surgical Services, Department of Veterans Affairs Healthcare Center, West Los Angeles
Simon K Law, MD, PharmD is a member of the following medical societies: American Academy of Ophthalmology, American Glaucoma Society, and Association for Research in Vision and Ophthalmology
Disclosure: Nothing to disclose.

Managing Editor

R Christopher Walton, MD, Professor, Director of Uveitis and Ocular Inflammatory Diseases Service, Assistant Department of Ophthalmology, Assistant Dean for Graduate Medical Education and Continuing Education, University of Tennessee College of Medicine; Consulting Staff, Regional Medical Center, Memphis Veterans Affairs Medical Center, St Jude Children's Research Hospital
R Christopher Walton, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Healthcare Executives, American Uveitis Society, Association for Research in Vision and Ophthalmology, and Retina Society
Disclosure: Nothing to disclose.

CME Editor

Lance L Brown, OD, MD, Ophthalmologist, Affiliated With Freeman Hospital and St John's Hospital, Regional Eye Center, Joplin, Missouri
Disclosure: Nothing to disclose.

Chief Editor

Hampton Roy Sr, MD, Associate Clinical Professor, Department of Ophthalmology, University of Arkansas for Medical Sciences
Hampton Roy Sr, MD is a member of the following medical societies: American Academy of Ophthalmology, American College of Surgeons, and Pan-American Association of Ophthalmology
Disclosure: Nothing to disclose.

 
 
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