- Primary pathogens (Salmonella enterica serovar Typhi · Salmonella Paratyphi A, B, C)
- Resistance context (MDR (ampicillin, chloramphenicol, TMP-SMX) · fluoroquinolone-nonsusceptible · XDR (resistant to cephalosporins) in South Asia and travel-associated cases)
First-line therapy
Ceftriaxone • i.v. • 50–75 mg/kg/day • 1×/day
Max 2000 mg/day · Duration: 7–10 days · First-line for most non-XDR cases; step down to oral when clinically stable
Enter weight on Kids to calculate doses
Cefixime • p.o. • 15–20 mg/kg/day • 2×/day
Max 400 mg/day · Duration: 10–14 days · IAP/WHO: 15–20 mg/kg/day divided · after i.v. therapy or mild susceptible disease
- • Cefixime: oral step-down when blood culture confirms susceptibility to third-generation cephalosporins and child is afebrile, tolerating oral intake — treat ≥7 days after defervescence or 10–14 days total (IAP, WHO).
- • Meropenem: XDR Salmonella Typhi (resistant to ceftriaxone/cefixime); severe or complicated typhoid (encephalopathy, intestinal perforation, hemorrhage, shock) — especially travel to Pakistan, Iraq, or endemic South Asia (CDC, WHO).
- • Travel to Pakistan/Iraq or no travel history with community XDR risk: empiric azithromycin for uncomplicated illness; carbapenem for complicated — do not rely on ceftriaxone alone (CDC Yellow Book 2024).
- • Add or switch to azithromycin if no improvement on carbapenem monotherapy in XDR disease — consider combination per ID specialist (CDC case series).
- • Fluoroquinolones: only if susceptible on culture; not routine first-line in children due to resistance and safety concerns (WHO, AAP).
Enter weight on Kids to calculate doses
Clinical notes
- • Obtain blood cultures (and stool culture when appropriate) before starting antibiotics whenever possible — do not delay treatment in critically ill children (WHO, CDC, AAP).
- • Modify therapy when susceptibility results are available; MDR Typhi is resistant to ampicillin, chloramphenicol, and TMP-SMX; XDR Typhi is resistant to cephalosporins and fluoroquinolones (CDC, WHO).
- • XDR management: uncomplicated — oral azithromycin 20 mg/kg/day; complicated — i.v. meropenem ± azithromycin; consult infectious diseases; notify public health (CDC MMWR, Pakistan NIH advisory).
- • Hospital admission: severe or complicated disease; persistent vomiting; dehydration or shock; infants and young children; suspected intestinal perforation or hemorrhage; inability to take oral therapy; no clinical improvement by day 5–7 of appropriate therapy (WHO, IAP).
- • Supportive care with rehydration, antipyretics, and nutrition; typhoid vaccine for prevention in endemic/travel settings — does not replace treatment (WHO, CDC).
- • CDC Yellow Book — Typhoid and paratyphoid fever (2024)
- • CDC MMWR — Extensively drug-resistant Salmonella Typhi (2019)
- • WHO — Typhoid fever treatment guidelines (2022)
+ 4 more
- • IAP — Management of enteric fever in children (2006)
- • AAP Red Book — Salmonella infections (Typhi) (2024)
- • ESPGHAN / ESPID — Enteric fever principles (2014)
- • NICE — Fever in under 5s (severe illness assessment) (2021)