Management

Typhoid diagnosed and treated early has a very low mortality. It is a safe policy to treat a critically ill patient who might have typhoid as if they do. The general principles of management for enteric fevers are similar to those for other Gram-negative infections, with rehydration and supportive care. However, there are some specific features.

Ciprofloxacin and other quinolone drugs have been demonstrated to be effective in large clinical trials. Resistance to the traditional choices of chloramphenicol or trimethoprim-sulfamethoxazole (co-trimoxazole) is common in Asia, and increasing elsewhere. The third-generation cephalosporins, including cefotaxime and ceftriaxone, are also effective. Therefore, although chloramphenicol is still a first-line agent for the treatment of sensitive strains, quinolones or third-generation cephalosporins are now often required.

Steroid therapy has been shown to improve outcome in some severely ill patients with typhoid. High-dose dexamethasone (3 mg/kg followed by 1 mg/kg every 6 h) reduces mortality where there is reduced consciousness or shock (Hoffman^efal 1984).

Typhoid leads to inflammation in Peyer's patches. This leads to sloughing, particularly in the third week of the clinical disease. The result can be either severe gastrointestinal hemorrhage or perforation, with high mortality. The onset of hemorrhage is usually obvious, with a rapid rise in pulse and a drop in blood pressure. Bowel perforation may be difficult to diagnose early, as patients with typhoid already have a tender distended abdomen with scanty bowel sounds. The use of steroids can further complicate diagnosis. Where the patient deteriorates rapidly, abdominal free fluid and gas under the diaphragm should be actively sought.

The bowel in severe typhoid may be very friable. In the absence of perforation the management of gastrointestinal hemorrhage should be conservative. Early simple surgical intervention has replaced conservative management for bowel perforation.

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