Food and Water-borne

Diseases
JOCELYN T. SAGURIT, MD, FPCP, DPSMID
BATAAN GENERAL HOSPITAL AND MEDICAL CENTER
Outline
• Acute Infectious Diarrhea Management in Children and Adults
• Acute bloody diarrhea
• Cholera
• Typhoid Fever
 Philippine Clinical
Practice Guidelines-
Management of
ACUTE INFECTIOUS
DIARRHEA in
Children and Adults
• Acute watery diarrhea ranks seventh among the top leading causes
of morbidity
• Diarrheal disease is the second leading cause of death in children
under five years old, and was responsible for the deaths of
370,000 children in 2019. (WHO)
• Food and water-borne disease is the most common cause of diarrhea
• ACUTE DIARRHEA- the passage of 3 or more loose, watery or bloody
stools in a 24-hour period, with a duration of less than 14 days
• The patient should not have received antibiotics within the last three months and
should not have been previously hospitalized

• ACUTE INFECTIOUS DIARRHEA- suspected if a patient has acute

diarrhea accompanied by any of the following: nausea, vomiting,
abdominal pain and fever
Pre-treatment clinical evaluations recommended for
immunocompetent persons presenting with acute
infectious diarrhea
• EXTENSIVE CLINICAL HISTORY- this includes questions on
consumption of raw, ill-prepared, or rotten foods, intake of
contaminated food or water, and history of travel should be obtained

• COMPLETE PHYSICAL EXAMINATION- to assess disease severity,

degree of dehydration, presence of complications and presence of
comorbid conditions
 Clinical use of diagnostics tests in children
and adults with acute infectious diarrhea

• Diagnostic tests should be based on the assessment of the patient’s

clinical status
• Routine stool examination is not indicated in acute watery diarrhea,
except in cases where parasitism is suspected or in the the presence
of bloody diarrhea
 Clinical use of diagnostics tests in children
and adults with acute infectious diarrhea

• Stool cultures are indicated only for the following:

• 1. severe cases
• 2. high risk of transmission of enteric pathogens
• 3. high risk of complications
• 4. for epidemiologic purposes

• The yield of stool culture is highest when requested within 3 days of

symptom onset and before administration of antibiotics
 Clinical parameters indicative of dehydration in
children with acute infectious diarrhea
• Abnormal vital signs (tachycardia, tachypnea)
• Depressed level of consciousness
• Depressed fontanels
• Sunken eyes
• Decreased or absent tears
• Poor skin turgor
• Prolonged capillary refill time
• Abnormal respiratory pattern
• Decreased urine output
Clinical manifestation of dehydration in children
according to severity
 Clinical parameters indicative of dehydration in
adults with acute infectious diarrhea
• Fatigue
• Thirst
• Sunken eyes
• Orthostatic hypotension, tachycardia, tacypnea
• Lethargy
• Dry oral mucosa
• Muscle weakness
• Poor skin turgor
• Prolonged capillary refill time
• Cold, clammy skin
Clinical manifestation of dehydration in
adults according to severity
Clinical and laboratory parameters indicative of
dehydration in adults with acute infectious
diarrhea

• Increased urine specific gravity (≥ 1.010)

• Increased urine osmolality (>800 mosm/kg)
• Increased serum osmolality (≥ 295 mosm/kg)
• Increased BUN/creatinine ratio (>20)
• Metabolic acidosis (pH <7.35, HCO3 < 22 mmol/L)
 Laboratory tests to assess the presence of
complications of acute infectious diarrhea
• Complications such as acute kidney injury, electrolyte imbalances
and hemolytic- uremic syndrome can occur in children and adults
with acute infectious diarrhea
• The following laboratory tests may be requested for patients
suspected to have complications:
• Complete blood count
• Urinalysis
• Serum electrolytes (Na, K, Cl)
• BUN and creatinine
• Serum bicarbonate or total CO2 (if available)
• ABG (optional)
What is the role of colonoscopy in the evaluation
of acute infectious diarrhea in children and
adults?

• Colonoscopy is NOT warranted in the initial evaluation of acute

infectious diarrhea
Treatment: Children
What are the criteria for admission among children
presenting with acute infectious diarrhea?
• Based on clinical history: unable to tolerate fluids, suspected
electrolyte abnormalities, or conditions for safe follow-up and home
management are not met
• Based on physical findings: altered consciousness, abdominal
distension, respiratory distress, or hypothermia (temperature <36C)
• Co-existing infections such as pneumonia, meningitis/encephalitis, or
sepsis
• Moderate to severe malnutrition
• Suspected surgical condition
Recommended management for children
according to level of dehydration
Protocol for mild and
moderate dehydration
Protocol for mild and
moderate dehydration
Treatment protocol for
severe dehydration
Treatment protocol for
severe dehydration
 How should dehydration among children
with acute infectious diarrhea be managed?
• Frequency of monitoring
• Check the child from time to time during rehydration to ensure that ORS is
being taken satisfactorily and that signs of dehydration are not worsening.
• Evaluate the child’s hydration status at least hourly
• For breastfed infants, breastfeeding should be continued in addition
to hydration therapy
• Carbonated, sweetened, caffeinated and sports drinks are not
recommended for fluid replacement
 What are the indications for empiric antibiotic
treatment in children with acute infectious diarrhea?

• Primary management of acute infectious diarrhea in children is still

rehydration therapy
• Routine empiric antibiotic therapy is not recommended
• Antimicrobials may be recommended for the following conditions:
• Suspected cholera
• Bloody diarrhea
• Diarrhea associated with other acute infections (e.g. pneumonia, meningitis,
etc)
What are the recommended antimicrobials
for acute infectious diarrhea in children?
What are the recommended antimicrobials
for acute infectious diarrhea in children?
 Should zinc and racecadotril be given in
children with acute infectious diarrhea?
• Zinc supplementation (20 mg/day for 10-14 days) should be
given routinely as adjunctive therapy for acute infectious diarrhea
in children > 6 months old to shorten the duration of diarrhea
and reduce frequency of stools
• Zinc supplementation is NOT routinely given as adjunctive therapy
for acute infectious diarrhea in children < 6 months old as it may
cause diarrhea to persist.
 Should zinc and racecadotril be given in
children with acute infectious diarrhea?

• Racecadotril (1.5mg/kg/dose) 3x a day during the first 3 days of

watery diarrhea may be given to infants and children as adjunctive
therapy to shorten the duration of diarrhea
• Loperamide is NOT recommended for children with acute infectious
gastroenteritis due to serious adverse events.
 Role of anti-emetics in the management of
vomiting in children with acute infectious
diarrhea

• Anti- emetics are NOT recommended in children presenting with

vomiting with acute infectious diarrhea due to safety issues
 Role of probiotics in the management of
acute infectious diarrhea in children
• Probiotics are recommended as adjunctive therapy throughout the
duration of diarrhea. Probiotics have been shown to reduce symptom
severity and duration of diarrhea
• Probiotics may be extended for 7 more days after completion of
antibiotics
• The following probiotics may be used:
• Saccharomyces boulardii 250-750 mg/day for 5-7 days
• Lactobacillus rhamnosus GG ≥ 1010 CFU/day for 5-7 days
• Lactobacillus reuteri DSM 17938 108 to 4 x 108 CFU/day for 5-7 days
• There is insufficient evidence to recommend Bacillus clausii
 Recommended diet for children with acute
infectious diarrhea
• Breastfeeding should be continued in breastfed infants
• In general, feeding should be continued. However, if feeding is not
tolerated, early refeeding may be started as soon as the child is able.
Resumption of age-appropriate usual diet is recommended during or
immediately after rehydration process is completed.
• If diarrhea persists for > 7 days or if patients are hospitalized due to
severe diarrhea, lactose-free diet may be given to children who are
predominantly bottle-fed to reduce treatment failure and decrease
the duration of diarrhea
 Recommended diet for children with acute
infectious diarrhea

• No change from age- appropriate diet is recommended

• Diluted lactose milk is NOT recommended
• Restrictive diet such as BRAT (banana, rice, apple, tea) diet is not
recommended because of the risk of malnutrition from its
inadequate nutritional value
 Recommended management for complications
of acute infectious diarrhea in children

• Acute kidney injury (AKI) is a serious and potentially life-threatening

complication. It is best to refer the patient immediately to a specialist
at the first sign of AKI
• ORS is safe and effective therapy for nearly all children with
hyponatremia
• Hospital treatment and close monitoring are recommended for
patients suspected to have hyponatremia. Referral to a specialist is
advised.
Treatment: Adult
 Who should be admitted among adults
presenting with acute infectious diarrhea?
• Presence of any of the following clinical history and physical findings
warrant admission:
• Poor tolerance to oral rehydration
• Moderate to severe dehydration
• Acute kidney injury
• Electrolyte abnormalities
• Unstable comorbid conditions (e.g. uncontrolled diabetes, congestive heart failure,
unstable coronary artery disease, chronic kidney disease, chronic liver disease,
immunocompromised conditions)
• Frail or elderly (≥ 60 years old) patients
• Poor nutritional status
• Patients with unique social circumstances (living alone, residence far from a hospital)
How should dehydration in adults be
managed?
 How should dehydration in adults be
managed?

Algorithm for initial

assessment of dehydration
for adult patients
Algorithm for fluid resuscitation of adult
patients
Algorithm for maintenance and replacement
therapy
 How should dehydration in adults be
managed?

• Sports drinks and soda are NOT recommended to replace losses

• For calculations of maintenance fluid rate, it is suggested to use the
actual or estimated body weight. However, the ideal body weight
should be used for overweight or obese patients.
• Elderly patients and those at risk of fluid overload (patients with heart
failure or kidney disease) should be referred to a specialist for
individualized fluid management.
 How should dehydration in adults be
managed?
• Recommendations for the type of fluid:
• PLRS, a chloride-restrictive IVF, is the fluid of choice for hydration and fluid
resuscitation of patients with diarrhea. If PLRS is not available, plain normal
saline solution may still be used
• During initial resuscitation, hourly monitoring of vital signs, mental status,
peripheral perfusion, and urine output must be done. The subsequent
frequency of monitoring should be based on the clinician’s judgment.
• The routine use of albumin, hydroxyethyl starch (HES) dextran or gelatin for
fluid resuscitation of dehydrated patients is not recommended
 Indications for empiric antimicrobial treatment
in adults with acute infectious diarrhea
• Empiric antimicrobial treatment is recommended for patients with
moderate to severe dehydration plus any of the following clinical
features:
• Fever alone
• Fever and bloody stools
• Symptoms persisting for 3 days
• The following antimicrobials are recommended as empiric treatment:
• Azithromycin 1g single dose OR
ciprofloxacin 500 mg BID for 3-5 days
• Once the suspected organism is confirmed, antimicrobial therapy may
be modified accordingly
Recommended antimicrobials for the following
etiologies of acute infectious diarrhea in adults
Recommended antimicrobials for the following
etiologies of acute infectious diarrhea in adults
Common etiologic agents for acute bloody
diarrhea
Common etiologic agents for acute bloody
diarrhea
• Loperamide is NOT recommended for adults with acute infectious
diarrhea due to unfavorable risk-benefit profile

• Racecadotril (100 mg 3x a day) may be given to decrease the

frequency and duration of diarrhea

• There is insufficient evidence to recommend the use of probiotics in

adults with acute diarrhea
 Recommended management for complications
of acute infectious diarrhea in adults
• Acute kidney injury is a serious and potentially life-threatening
complication. it is best to refer the patient immediately to a specialist
at the first sign of AKI
• Hospital treatment and close monitoring is recommended for
patients with severe hyponatremia, severe hypernatremia, or
symptomatic patients regardless of the degree of sodium imbalance.
The approach to therapy depends on the patients’ risk stratification.
Referral to a specialist is advised
• Hospital treatment and close monitoring is recommended for
patients with severe hypokalemia, severe hyperkalemia, or
symptomatic patients regardless of the degree of potassium
imbalance. Referral to a specialist is advised.
Prevention
 Interventions that are effective in the
prevention of acute infectious diarrhea
• Hand hygiene
• Water safety interventions
• Proper food handling
• Proper excreta disposal
• Vaccines
• Supplements
• Breastfeeding
 Hand hygiene

• Hand hygiene should be promoted in all settings and on all occasions

to reduce transmission of microbes that cause acute infectious
diarrhea
• Handwashing with soap and water is the best method to reduce the number
of microbes
• If soap and water are not available, alcohol-based hand sanitizers (containing
at least 60% alcohol) may be used. Hand sanitizers, moist hand wipes or
towelettes are not recommended when hands are visibly dirty or greasy
• All efforts should be made to provide access to clean water, soap and
hand drying materials
 Water safety interventions

• Drinking water should be clean and safe. Recommended methods to

ensure clean and safe water include boiling, chemical disinfection,
and filtration with ultraviolet radiation
 Proper food handling
• There is no standard recommended screening test for food handlers
in the Philippines
• No person shall be employed in any food establishment without a
health certificate issued by the city or municipal health officer in
accordance with Food Establishments Code on Sanitation of the
Philippines
• Food industry workers need to notify their employers if they have any
of the following conditions: hepatitis A, diarrhea, vomiting, fever,
sore throat, skin rash or other skin lesions, and discharge from the
ears, eyes or nose
 Proper excreta disposal
• Safe stool disposal and hand hygiene are key behaviors to prevent
infectious diarrhea
• The following are approved excreta disposal facilities based on the
Code on Sanitation of the Philippines
• Flush toilet connected to a community sewer, Imhoff tank, septic tank,
digester tank or chemical tank
• Ventilated improved pit (VIP) latrine, sanitary pit in rural areas, pit type or
“antipolo” toilet
• Any disposal device approved by the Secretary of Health or his duly
authorized representative
• Open defecation threatens public health and safety and is
UNACCEPTABLE
 Vaccines

• Killed oral cholera vaccine may be given to children and adults living
in endemic areas and during outbreaks to prevent acute infectious
diarrhea caused by cholera
• Universal immunization of infants against rotavirus is recommended.
Rotavirus vaccines are effective in preventing rotavirus diarrhea and
rotavirus diarrhea-associated hospitalization
 Supplements
• The following probiotic strains may be given to children and adults to
prevent acute infectious diarrhea or its recurrence
• Bifidobacterium lactis
• Lactobacillus rhamnosus GG
Lactobacillus reuteri
• Zinc supplementation is recommended to prevent acute infectious
diarrhea among children 6 months to 12 years old. It should NOT be
given to children < 6 months old
• Vitamin A supplementation may be given to children ≥ 6 months to
reduce the incidence of acute infectious diarrhea. The recommended
doses are:
• 100,000 IU every 4-6 months for infants 6-12 months old
• 200,000 IU every 4-6 months for children > 12 months old
 Breastfeeding

• Exclusive breastfeeding is recommended during the first 6 months

of life to prevent diarrhea. Breastfeeding also reduced the incidence
of hospitalization and mortality from diarrhea.
• All healthcare providers should promote breastfeeding
 When is an outbreak suspected?
• Cases of A-I-D in excess of what would normally be expected in a
defined community, geographical area or season, and lasting a few
days, weeks or several years (WHO)
• A single case of communicable disease that has been absent from a
population or caused by an agent not previously recognized in the
community or the emergence of a previously known disease (CDC)
 How is it managed?
• Suspected cases of outbreaks should be reported immediately to
disease reporting unit or disease surveillance coordinators
• Collection of demographic data and specimen is mandatory. Stool
samples via rectal swab or bulk stool should be sent to designated
laboratories for analysis and confirmation. Water and food samples
may be collected, to determine the source of outbreak
• Response to outbreak should involve epidemiologic investigation and
formation of hypotheses, treatment of cases, implementation of
control and prevention measures, and risk communication
Cholera
 Cholera

• An acute diarrheal illness caused by infection of the intestine with

the toxigenic bacterium Vibrio cholerae serogroup O1 and O139
• Approx 1.3 to 4 M get cholera worldwide and 21,000 to 143,000 die
from it
• 1 out of 10 people who get sick with cholera will develop severe
symptoms
 Vibrio cholerae O1 or O139

• Causes widespread epidemics of cholera

• V. cholerae O1 has 2 biotypes – Classical and El
Tor
• Each biotype has distinct serotypes- Inaba, Ogawa
and Hikojima
• El Tor biotype remains asymptomatic or have
only mild illness
• Classical biotype of V. cholerae O1 have
become quite rare and are limited to parts of
Bangladesh and India
 Where is cholera found?

• Cholera bacterium is usually found in water or in foods that have

been contaminated by feces from a person infected with cholera
bacteria.
• Cholera is most likely to occur and spread in places with inadequate
water treatment, poor sanitation and inadequate hygiene
• V cholerae can also live in brackish rivers and coastal water- shellfish
eaten raw have been a source of infection- the bacteria attaches to
the chitin-containing shells of crabs, shrimps and other shellfish
 Transmission
• By drinking water or eating food contaminated with cholera bacteria
• In epidemic, the source of the contamination is usually the feces of an
infected person that contaminates water or food
• It can spread rapidly in areas with inadequate treatment of sewage
and drinking water
• Occasionally spread through eating raw or undercooked shellfish that
are contaminated
• Infection is not likely to spread directly from one person to another
casual contact with an infected person is not a risk factor for
becoming ill
 Symptoms of cholera
• Infection is often mild or without symptoms, but can be severe.
• 1 in 10 people who get sick with cholera will develop severe symptoms
• Profuse watery diarrhea rice-water stools
• Vomiting
• thirst
• leg cramps
• Restlessness or irritability
• Rapid loss of body fluids leads to dehydration and shock
• Rapid heart rate
• Loss of skin elasticity
• Dry mucous membranes
• Low blood pressure
• Without treatment, death can occur within hours

• Usually takes 2-3 days for symptoms to appear after a person ingests cholera bacteria,
(ranges from a few hours to 5 days)
 Risk factors for poor outcome

• Individuals with achlorhydria (the absence of hydrochloric acid in

digestive stomach juices)
• Blood type O
• Chronic medical conditions
• Those without ready access to rehydration therapy and medical
services
 Diagnosis

• Isolation and identification of V. cholerae serogroup O1 or O139 by

culture remains the GOLD STANDARD for laboratory diagnosis of
cholera
• Cary Blair media is ideal for transport and the selective media
THIOSULFATE-CITRATE-BILE SALTS (TCBS) AGAR is ideal for isolation
and identification
 Rapid Tests
• In areas with limited or no laboratory testing,
the Crystal VC dipstick rapid test can provide
an early warning to public health officials that
an outbreak of cholera is occurring
X
 SUSPECTED CHOLERA CASE (WHO)

• In areas where a cholera outbreak has not been declared: any 2

patient 2 years or older presenting with acute watery diarrhea and
severe dehydration or dying from acute watery diarrhea
• In areas where a cholera outbreak is declared: any person presenting
with or dying from acute watery diarrhea
 CONFIRMED CHOLERA (WHO)

• A suspected case with Vibrio cholerae O1 and O139 confirmed by

culture or PCR and in countries where cholera is not present or has
been eliminated, the Vibrio cholerae O1 or O139 strain is
demonstrated to be toxigenic
Treatment
 Rehydration therapy

• With timely rehydration therapy, more than 99% of cholera patients

will survive
• REHYDRATION is the most important treatment for cholera
• Includes:
• 1. adequate volumes of a solution of oral rehydration salts;
• 2. IV fluids when necessary;
• 3. electrolytes
Fluid Replacement or Treatment
Recommendations
Fluid Replacement or Treatment
Recommendations
 Oral Rehydration
• Give ORS immediately to dehydrated patients who can sit up and
drink
• A rough estimate of oral rehydration rate for older children and adults
is 100 ml of ORS every 5 minutes until the patient stabilizes
• The approximate amount of ORS (in ml) needed over 4 hours can also
be calculated by multiplying the patient’s weight in kg by 75
• Patients should continue to eat normal diet or resume a normal diet
once vomiting stops
• For infants, encourage the mother to continue breastfeeding
 Treatment

• Reassess patient after 1 hour of therapy and then every 1 to 2 hours

until rehydration is complete
• During initial stages of therapy, while still dehydrated, adults can
consume as much as 1000 ml of ORS per hour, if necessary, and
children as much as 20 ml/kg body weight per hour.
 Antibiotic Treatment: Summary
Recommendations
1.Oral or intravenous hydration is the primary treatment for cholera.
2.In conjunction with hydration, treatment with antibiotics is
patients. It is also recommended for patients who have severe or
some dehydration and continue to pass a large volume of stool
treatment. Antibiotic treatment is also recommended for all
patients with comorbidities (e.g., severe acute malnutrition, HIV
infection).
3.Antibiotics are given as soon as the patient can tolerate oral
antibiotic should be informed by local antibiotic susceptibility
doxycycline is recommended as first-line treatment for adults
(including pregnant women) and children. If resistance to
azithromycin and ciprofloxacin are alternative options.
 Antibiotic Treatment: Summary
Recommendations
4. During an epidemic or outbreak, antibiotic susceptibility should be monitored
through regular testing of sample isolates from various geographic areas.
5. None of the guidelines recommend antibiotics as prophylaxis for cholera
prevention, and all emphasize that antibiotics should be used in conjunction with
aggressive hydration.
6. Education of healthcare workers, assurance of adequate supplies, and
monitoring of practices are all important for appropriate dispensation of antibiotic
dispensation of antibiotic
 Zinc Treatment

• Supplementation of 20 mg zinc per day in children 6 months or older

should be started immediately
• Zinc significantly reduced the duration and severity of diarrhea in
children suffering from cholera
 Prevention

• All feces (human waste) from sick persons should be thrown away
carefully to ensure it does not contaminate anything nearby
• People caring for cholera patients must wash their hands thoroughly
after touching anything that might be contaminated with patient’s
feces
 Infection control for cholera in health care
settings
• Healthcare providers should take precautions to prevent the spread of cholera in clinical settings:
• Chemoprophylaxis with antibiotics is not indicated for healthcare providers
• All staff should be trained on cholera prevention and infection control measures, such as handwashing and safe
handwashing and safe disposal of human waste
• Handwashing with soap and clean water or 0.05% chlorine should be done before and after each patient contact
after each patient contact
• If soap and water are not available, use an alcohol-based hand sanitizer with at least 60% alcohol, or if neither are available, 0.05%
chlorine solution
• Several chlorine solutions can be used for surface disinfection (solution calculations are based on using unscented
household bleach with 5–6 % active chlorine):
• 2% chlorine
• Made by mixing 3 parts water and 2 parts bleach (or 400 ml of bleach in 1 litre of water)
• Used for disinfecting vomit, feces, and corpses
• 0.2% chlorine
• Made by mixing 9 parts water and 1 part bleach (or 40 ml of bleach in 1 litre of water)
• Used for cleaning floors, boots, personal protective equipment (gloves, aprons, goggles), bedding, latrines, dishes
• 0.05% chlorine
• Made by mixing 9 parts water and 1 part 0.5% chlorine solution (or 10 ml of bleach in 1 litre of water)
• Used for bathing soiled patients, handwashing, laundry
 Vaccines

• The World Health Organization (WHO) recommends cholera vaccination in

these circumstances:
• In areas where local transmission of cholera occurs
• During humanitarian crises with a high risk of cholera
• During cholera outbreaks
TYPHOID FEVER
• Typhoid fever is still a major problem with a reported global burden
estimate of 26.9 million cases in 2010 with a case fatality rate of 1%.
• In the Philippines, there were 2025 cases of typhoid and paratyphoid
fever in 2010
 Clinical Manifestations
• Any individual who lives in or who has history of travel from tropical
and subtropical areas
• Who presents with fever of ≥ 5 days of fever- documented at > 38 ℃
WITH any of the following symptoms:
• Headache
• Diarrhea
• Body malaise/weakness
• Abdominal distention/pain
• Gastrointestinal bleeding
• Changes in orientation/confusion
• Should be considered a SUSPECTED typhoid fever case
 Candidates for Hospital Admission
• 1. Complicated Typhoid Fever
• Patients who are unable to take oral fluids due to persistent vomiting
• Those who are at risk to develop severe form of typhoid fever with unstable
vital signs, severe dehydration, spontaneous bleeding, persistent abdominal
pain, difficulty in breathing, neurologic manifestations and patients showing
signs of complications (myocarditis, DIC, HUS, severe pneumonia)
• 2. Typhoid fever in pregnancy
• 3. Social Circumstances
• Unavailability of caregiver; long distance travel and unavailability of medicines
in the locality
Laboratory Tests to Confirm the Diagnosis of
Typhoid Fever
• Direct Detection Methods
• Culture and isolation
• PCR
• Indirect Methods
• Antibody detection
• Tubex
• Typhidot
• TyphiRapid
 Recommended antibiotics for
Uncomplicated Typhoid Fever
Antibiotics Duration of Treatment
Amoxicillin 500 mg/cap 2 caps q6h 14 days
Chloramphenicol 500 mg 2 caps q6h 14 days
TMP-SMX 800/160 mg 1 tab q12h 14 days
Cefixime 200 mg 1 tab q12h 7 days
Azithromycin 500 mg 1-2 tab q 24h 7 days
Ciprofloxacin 500 mg 1 tab q 12h 7 days
Ofloxacin 400 mg 1 tab q12h 7 days
Remarks
Compliance issues due to pill burden
Compliance issues due to pill burden
Risk of bone marrow suppression
Increased drug pressure and risk for Stevens-
Johnson’s Syndrome
Higher cost; inaccessibility
Higher cost; increased drug pressure; risk of QT
prolongation
Collateral damage to tuberculosis and MRSA;
risk of QT prolongation
Collateral damage to tuberculosis and MRSA;
risk of QT prolongation
 Recommended Antibiotics for Complicated
Typhoid Fever
First-line treatment Step down antibiotics Duration of treatment

Ceftriaxone 2-3g IV q24h Cefixime 200 mg 1 tab q12h 14 days

Azithromycin 1g IV q 24h Azithromycin 500 mg 1 tab q24h 7 days

Ciprofloxacin 400 mg IV q12h Ciprofloxacin 500-750 mg q12h 14 days

Ofloxacin 400 mg IV q12h Ofloxacin 400 mg 1 tab q12h 14 days

*stepping down to an oral antibiotic may be done if patient is afebrile for 48 hrs and is able to tolerate oral
medications
**if intestinal perforation is suspected, surgical evaluation and coverage for anaerobes must be considered
 Recommended antibiotics for typhoid fever
in pregnant patients

First-line treatment Step down antibiotics Duration of treatment

Ampicillin 1-2g IV q6h Amoxicillin 1g q6h 10-14 days
Ceftriaxone 2-3g IV q24h Cefixime 200 mg 1 tab q12h 7 days
 Multi-drug resistant typhoid fever (MDRTF)
• Typhoid fever caused by Salmonella typhi strains which are resistant
to the first-line recommended drugs for treatment namely
chloramphenicol, ampicillin and TMP-SMX.

• MDRTF should be suspected in the following situations:

• Failure to respond after 5 to 7 days treatment with a 1st-line antibiotic
• Household contact with a documented case or during an epidemic of MDRTF
• Clinical deterioration
• Development of complications
 Empiric treatment for suspected MDRTF

Antibiotic Duration of treatment

Cefixime 200 mg 1 tab q12h 7 days
Ciprofloxacin 500 mg 1 tab q12h 7 days
Ofloxacin 400 mg 1 tab q12h 7days
Azithromycin 500 mg 1-2 tab q24h 7 days
 Chronic carrier

• An asymptomatic patient who continues to have positive stool or

rectal swab cultures for S. typhi a year following recovery from acute
illness
 Treatment for Chronic carriers

Antibiotic Duration of treatment

TMP-SMX 800/160mg 1 tab q12h 6-12 weeks
Amoxicillin 100 mg/kg/day 6-12 weeks
Ampicillin 100 mg/kg/day 6-12 weeks
Norfloxacin 400 mg 1 tab q12h 4 weeks
Ciprofloxacin 750 mg 1tab q12h 4 weeks
 Typhoid vaccines

• INDICATION
• Travelers to endemic areas
• Persons with intimate exposure to a documented typhoid fever carrier
• Laboratory workers routinely exposed to cultures of Salmonella serotype
Typhi or specimens containing this organism
Schedule for typhoid fever vaccine
 Take home message
• Assess the severity of dehydration of the patient
• Fluid and electrolyte replacement are very important in the
management of food and water-borne diseases.
• Antibiotic therapy is warranted in only few cases.
• Hand hygiene, proper food preparation and safe water are very
important in the prevention of FWBD.