Complicated enteric fever (encephalopathy, shock, perforation, GI bleeding) needs IV ceftriaxone (or azithromycin combination), blood cultures before antibiotics, and early surgical review for perforation. Fluoroquinolone resistance is high in India.
At the bedside
Timed steps- 1
Cultures
DiagnoseBlood culture (best in week 1, ~40-80% sensitive); bone marrow culture more sensitive; Widal is unreliable.
- 2
Uncomplicated
TreatAzithromycin 500 mg-1 g daily for 7 days or cefixime orally; fluoroquinolones only if susceptible.
- 3
Severe
TreatCeftriaxone 2 g IV daily (some use 2 g 12-hourly or 4 g/day in severe cases) for 10-14 days ± azithromycin; adjust to susceptibility. XDR typhoid (travel from Pakistan): meropenem + azithromycin.
- 4
Week 2-3
ComplicationsPerforation (abdominal pain, guarding, free gas): resuscitate, add anaerobic cover, urgent laparotomy. GI bleed: transfusion, endoscopy. Encephalopathy/shock: consider high-dose dexamethasone (3 mg/kg then 1 mg/kg 6-hourly × 8 doses).
Complicated enteric fever
Ceftriaxone
- Dose
- 2 g once daily for 10-14 days
Enteric fever
Step 1 of ~4
Blood cultures
Based on Parry CM, Hien TT, Dougan G, White NJ, Farrar JJ. Educational use; follow local protocol.
Evidence
- Parry 2002 NEJM review: clinical features, diagnosis, complications, dexamethasone in severe typhoid (Hoffman 1984).
- ICMR 2019: regimen choices and resistance data for India.
🇮🇳 India notes
- Fluoroquinolone non-susceptibility in Salmonella Typhi is very high in India; ceftriaxone MICs are rising. Typhoid conjugate vaccine is being introduced.
References
Test yourself
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Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.