Enteric Fever: Indian Academy of Pediatrics Guidelines
Written By : MD Bureau
Medically Reviewed By : Dr. Kamal Kant Kohli
Published On 2022-07-19 05:30 GMT | Update On 2022-07-19 08:55 GMT
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Enteric fever is acute generalized infection of the reticuloendothelial system with predilection for intestinal lymphoid tissue and gallbladder. The term includes typhoid fever caused by Salmonella typhi (around 80% of all cases worldwide) and paratyphoid fever caused by Salmonella paratyphi A or B (20% of all cases). The bacterium is gram negative and non lactose fermenting.
The Indian Academy of Pediatrics (IAP) has released Standard Treatment Guidelines 2022 for Enteric Fever. The lead author for these guidelines on Enteric Fever is Dr Tapisha Gupta along with co-author Dr Bhaskar Shenoy, Dr Darshan Chauhan. The guidelines come Under the Auspices of the IAP Action Plan 2022, and the members of the IAP Standard Treatment Guidelines Committee include Chairperson Remesh Kumar R, IAP Coordinator Vineet Saxena, National Coordinators SS Kamath, Vinod H Ratageri, Member Secretaries Krishna Mohan R, Vishnu Mohan PT and Members Santanu Deb, Surender Singh Bisht, Prashant Kariya, Narmada Ashok, Pawan Kalyan.
Following are the major recommendations of guidelines:
Diagnosis
Mainly clinical: The most common cause of fever without focus. • Infant to children up to 5 years: Fever, vomiting, and diarrhea.
• Older children: Fever in increasing trend (step ladder pattern) over 5–7 days, anorexia, abdominal pain, cough followed by toxic look, lethargy, tender abdomen, soft splenomegaly, hepatomegaly, and relative bradycardia.
| TABLE 1: Choice of empirical therapy for typhoid fever. | ||
| Patient's condition | First-line choice | Second-line choice |
| Severe illness Indoor patient Any complications | Ceftriaxone | Cefotaxime (concomitant hepatitis) Aztreonam (penicillin allergy) |
| Outpatient department | Cefixime | Azithromycin (penicillin allergy) |
| TABLE 2: Drug dosage guideline. | ||
| Drug | Dose (mg/kg/day) | Maximum dose (per day) |
| Ceftriaxone | 100 | 4 g |
| Cefotaxime | 150–200 | 8 g |
| Cefixime | 20 | 1,200 mg |
| Azithromycin | 20 | 1 g |
| Aztreonam | 50–100 | 8 g |
Drug dosage guideline is presented in Table 2.
Duration of Treatment
Treat for at least 7 days after defervescence or a total of 14 days, whichever is later. Azithromycin is used for a total of 7 days.Steroids are indicated only in severe illness. If the patient presents with shock, coma, or in altered sensorium, dexamethasone in the dose of 3 mg/kg followed by 1 mg/kg every 6 hours for 2 days may be given. Prolonged use of steroids can increase the relapse rate and cause adverse effects, hence use judiciously.
Delayed Defervescence : If by day 7 of antibiotics, defervescence has not occurred but child looks less toxic, there is increase in duration between fever spikes or quick response to antipyretics, same antibiotics can be continued till day 10.
Clinical Failure:
No defervescence and child looks toxic with increase in fever spikes after 7 days of starting optimal treatment is clinical failure. In such a scenario, rule out:Complications such as abscess formation and infection-associated hemophagocytic lymphohistiocytosis (HLH);Co Infections such as malaria and hepatitis A; Drug fever or thrombophlebitis;If the child was culture negative, review the diagnosis with careful history, physical examination, and repeat investigations.
Special Therapeutic Concerns
1. Culture positive report empowers the clinician, gives confidence even in late defervescence and prevents unnecessary use of azithromycin which must be kept as a reserve drug.
2.Quinolones are contraindicated in pediatric age group and should not be used for treatment of enteric fever.
3. Aminoglycosides like amikacin have no role in management as their site of action is extracellular while Salmonella is an intracellular organism.
4. In the era of antimicrobial resistance (AMR), it is very important that laboratories give drug sensitivity reports with minimum inhibitory concentrations (MICs) and its interpretation. In enteric fever, MIC ≤1 for ceftriaxone is associated with excellent clinical outcome. Rising ceftriaxone MICs are being reported from India. MIC breakpoints for resistance to ceftriaxone are [≥4 as per Clinical and Laboratory Standards Institute (CLSI)] and [>2 as per European Committee on Antimicrobial Susceptibility Testing (EUCAST)]. Azithromycin is the drug of choice in ceftriaxone resistant isolates. If such a child is hemodynamically unstable or the disease is severe, then meropenem may be used.
Relapse
Even after adequate treatment, enteric fever has a relapse rate of 5–20%. Recurrence of fever 2–3 weeks after its initial resolution is called relapse. It is usually milder. Treatment of relapse is with the same drug used for initial therapy. Relapse can be differentiated from reinfection only by molecular typing.
Carrier State
It is defined as an asymptomatic person who sheds Salmonella in stool or urine beyond 3 months of an episode of enteric fever. It is uncommon in pediatric age group hence post illness screening for S. typhi carriage is not recommended. If detected treat with trimethoprim-sulfamethoxazole (10 mg/kg/day for 6–12 weeks) or high dose amoxicillin (75–100 mg/kg/day for 4–6 weeks) to decrease the risk to close contact.
Reference:
Feigin RD, Cherry JD, Kaplan SL. Feigin and Cherry's Textbook of Pediatric Infectious Diseases, 6th edition. Amsterdam, Netherlands: Elsevier; 2009. pp. 1567-82.
Shah NS, Rao S. Antimicrobial therapy in enteric fever. In: Shah NS, Rao S (Eds). IAP Specialty Series on Pediatric Endocrinology, 2nd edition. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2013.
Sukumaran TU. Enteric fever in children. In: Parthasarathy A (Ed). Textbook of Pediatric Infectious Disease. New Delhi: Jaypee Brothers Medical Publishers (P) Ltd.; 2019.
Wijedoru L, Mallett S, Parry CM. Rapid diagnostic tests for typhoid and paratyphoid fever. Cochrane Database Syst Rev. 2017;5(5): CD008892.
The guidelines can be accessed on the official site of IAP: https://iapindia.org/standard-treatment-guidelines/
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