Editing Typhoid fever (section)

== Treatment ==
===Oral rehydration therapy===
The rediscovery of [[oral rehydration therapy]] in the 1960s provided a simple way to prevent many of the deaths of [[diarrhea]]l diseases in general.<ref>{{Cite web|url=https://www.uptodate.com/contents/oral-rehydration-therapy|title=UpToDate|website=www.uptodate.com|access-date=2020-04-21}}</ref>

===Antibiotics===
Where resistance is uncommon, the treatment of choice is a [[fluoroquinolone]] such as [[ciprofloxacin]].<ref name="BMJ2009">{{cite journal | vauthors = Parry CM, Beeching NJ | s2cid = 3264721 | title = Treatment of enteric fever | journal = BMJ | volume = 338 | pages = b1159 | date = June 2009 | pmid = 19493937 | doi = 10.1136/bmj.b1159 }}</ref><ref name="pmid21975746">{{cite journal | vauthors = Effa EE, Lassi ZS, Critchley JA, Garner P, Sinclair D, Olliaro PL, Bhutta ZA | title = Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever) | journal = The Cochrane Database of Systematic Reviews | issue = 10 | pages = CD004530 | date = October 2011 | volume = 2011 | pmid = 21975746 | pmc = 6532575 | doi = 10.1002/14651858.CD004530.pub4 | url = https://ecommons.aku.edu/cgi/viewcontent.cgi?article=1078&context=pakistan_fhs_mc_women_childhealth_paediatr }}</ref> Otherwise, a third-generation cephalosporin such as [[ceftriaxone]] or [[cefotaxime]] is the first choice.<ref>{{cite journal | vauthors = Soe GB, Overturf GD | title = Treatment of typhoid fever and other systemic salmonelloses with cefotaxime, ceftriaxone, cefoperazone, and other newer cephalosporins | journal = Reviews of Infectious Diseases | volume = 9 | issue = 4 | pages = 719–36 | year = 1987 | pmid = 3125577 | doi = 10.1093/clinids/9.4.719 | jstor = 4454162 }}</ref><ref>{{cite journal | vauthors = Wallace MR, Yousif AA, Mahroos GA, Mapes T, Threlfall EJ, Rowe B, Hyams KC | title = Ciprofloxacin versus ceftriaxone in the treatment of multiresistant typhoid fever | journal = European Journal of Clinical Microbiology & Infectious Diseases | volume = 12 | issue = 12 | pages = 907–10 | date = December 1993 | pmid = 8187784 | doi = 10.1007/BF01992163 | s2cid = 19358454 | url = https://zenodo.org/record/1232516 }}</ref><ref>{{cite journal | vauthors = Dutta P, Mitra U, Dutta S, De A, Chatterjee MK, Bhattacharya SK | title = Ceftriaxone therapy in ciprofloxacin treatment failure typhoid fever in children | journal = The Indian Journal of Medical Research | volume = 113 | pages = 210–3 | date = June 2001 | pmid = 11816954 }}</ref><ref>{{cite journal | vauthors = ((Коваленко АН)) |title=Особенности клиники, диагностики и лечения брюшного тифа у лиц молодого возраста |journal=Voen.-meditsinskii Zhurnal |volume=332 |issue=1 |pages=33–39 |year=2011|display-authors=etal}}</ref> [[Cefixime]] is a suitable oral alternative.<ref>{{cite journal | vauthors = Bhutta ZA, Khan IA, Molla AM | title = Therapy of multidrug-resistant typhoid fever with oral cefixime vs. intravenous ceftriaxone | journal = The Pediatric Infectious Disease Journal | volume = 13 | issue = 11 | pages = 990–4 | date = November 1994 | pmid = 7845753 | doi = 10.1097/00006454-199411000-00010 }}</ref><ref>{{cite journal | vauthors = Cao XT, Kneen R, Nguyen TA, Truong DL, White NJ, Parry CM | title = A comparative study of ofloxacin and cefixime for treatment of typhoid fever in children. The Dong Nai Pediatric Center Typhoid Study Group | journal = The Pediatric Infectious Disease Journal | volume = 18 | issue = 3 | pages = 245–8 | date = March 1999 | pmid = 10093945 | doi = 10.1097/00006454-199903000-00007 }}</ref>

Properly treated, typhoid fever is not fatal in most cases. Antibiotics such as [[ampicillin]], chloramphenicol, [[trimethoprim-sulfamethoxazole]], [[amoxicillin]], and ciprofloxacin have been commonly used to treat it.<ref>Baron S et al.</ref> Treatment with antibiotics reduces the case-fatality rate to about 1%.<ref>{{cite web |url=https://www.who.int/vaccine_research/diseases/diarrhoeal/en/index7.html |title=Diarrhoeal Diseases |date=February 2009 |access-date=2013-04-25 |url-status=dead |archive-url=https://web.archive.org/web/20111102190825/http://www.who.int/vaccine_research/diseases/diarrhoeal/en/index7.html |archive-date=November 2, 2011 |website= World Health Organization}}</ref>

Without treatment, some patients develop sustained fever, bradycardia, hepatosplenomegaly, abdominal symptoms, and occasionally pneumonia. In white-skinned patients, pink spots, which fade on pressure, appear on the skin of the trunk in up to 20% of cases. In the third week, untreated cases may develop gastrointestinal and cerebral complications, which may prove fatal in 10–20% of cases. The highest case fatality rates are reported in children under 4. Around 2–5% of those who contract typhoid fever become chronic carriers, as bacteria persist in the [[biliary tract]] after symptoms have resolved.<ref>{{Cite web|url=https://www.who.int/ith/diseases/typhoidfever/en/|title=WHO {{!}} Typhoid fever|website=www.who.int|access-date=2017-08-10|url-status=dead|archive-url=https://web.archive.org/web/20170727173454/http://www.who.int/ith/diseases/typhoidfever/en/|archive-date=2017-07-27}}</ref>

=== Surgery ===
Surgery is usually indicated if [[intestinal perforation]] occurs. One study found a 30-day mortality rate of 9% (8/88), and surgical site infections at 67% (59/88), with the disease burden borne predominantly by low-resource countries.<ref name=GlobalSurg2>{{cite journal | vauthors = Anyomih TK, Drake TM, Glasbey J, Fitzgerald JE, Ots R, et al | title = Management and Outcomes Following Surgery for Gastrointestinal Typhoid: An International, Prospective, Multicentre Cohort Study | journal = World Journal of Surgery | volume = 42 | issue = 10 | pages = 3179–3188 | date = October 2018 | pmid = 29725797 | pmc = 6132852 | doi = 10.1007/s00268-018-4624-8 | collaboration = GlobalSurg Collaborative }}</ref>

For surgical treatment, most surgeons prefer simple closure of the perforation with drainage of the [[peritoneum]]. Small bowel [[Surgery#Resection|resection]] is indicated for patients with multiple perforations. If antibiotic treatment fails to eradicate the [[hepatobiliary]] carriage, the [[gallbladder]] should be resected. [[Cholecystectomy]] is sometimes successful, especially in patients with [[gallstone]]s, but is not always successful in eradicating the carrier state because of persisting [[hepatic]] infection.<ref>{{cite journal | vauthors = Waddington CS, Darton TC, Pollard AJ | title = The challenge of enteric fever | journal = The Journal of Infection | volume = 68 | pages = S38-50 | date = January 2014 | pmid = 24119827 | doi = 10.1016/j.jinf.2013.09.013 | url= | series = Hot Topics in Infection and Immunity in Children - Papers from the 10th annual IIC meeting, Oxford, UK, 2012 | issue = Suppl 1 }}</ref><ref name="G Gonzalez-Escobedo, JM Marshall, JS Gunn 2010"/>

=== Resistance ===
As [[Antimicrobial resistance|resistance]] to ampicillin, chloramphenicol, trimethoprim-sulfamethoxazole, and [[streptomycin]] is now common, these agents are no longer used as first-line treatment of typhoid fever.<ref>{{Cite web|url=https://wwwnc.cdc.gov/travel/notices/watch/xdr-typhoid-fever-pakistan|title=Extensively Drug-Resistant Typhoid Fever in Pakistan – Watch – Level 1, Practice Usual Precautions – Travel Health Notices {{!}} Travelers' Health {{!}} CDC|website=wwwnc.cdc.gov|access-date=2020-04-21}}</ref> Typhoid resistant to these agents is known as multidrug-resistant typhoid.<ref>{{cite journal | vauthors = Zaki SA, Karande S | title = Multidrug-resistant typhoid fever: a review | journal = Journal of Infection in Developing Countries | volume = 5 | issue = 05 | pages = 324–37 | date = May 2011 | pmid = 21628808 | doi = 10.3855/jidc.1405 | doi-access = free }}</ref>

Ciprofloxacin resistance is an increasing problem, especially in the [[Indian subcontinent]] and [[Southeast Asia]]. Many centres are shifting from ciprofloxacin to [[ceftriaxone]] as the first line for treating suspected typhoid originating in South America, India, Pakistan, Bangladesh, Thailand, or Vietnam. Also, it has been suggested that [[azithromycin]] is better at treating resistant typhoid than both fluoroquinolone drugs and ceftriaxone.<ref name="pmid21975746" /> Azithromycin can be taken by mouth and is less expensive than ceftriaxone, which is given by injection.<ref>{{cite journal | vauthors = Gibani MM, Britto C, Pollard AJ | title = Typhoid and paratyphoid fever: a call to action | journal = Current Opinion in Infectious Diseases | volume = 31 | issue = 5 | pages = 440–448 | date = October 2018 | pmid = 30138141 | pmc = 6319573 | doi = 10.1097/QCO.0000000000000479 }}</ref>

A separate problem exists with laboratory testing for reduced susceptibility to ciprofloxacin; current recommendations are that isolates should be tested simultaneously against ciprofloxacin (CIP) and against [[nalidixic acid]] (NAL), that isolates sensitive to both CIP and NAL should be reported as "sensitive to ciprofloxacin", and that isolates sensitive to CIP but not to NAL should be reported as "reduced sensitivity to ciprofloxacin". But an analysis of 271 isolates found that around 18% of isolates with reduced susceptibility to [[fluoroquinolones]], the class to which CIP belongs ([[Minimum inhibitory concentration|MIC]] 0.125–1.0&nbsp;mg/L), would not be detected by this method.<ref>{{cite journal | vauthors = Cooke FJ, Wain J, Threlfall EJ | title = Fluoroquinolone resistance in Salmonella Typhi | journal = BMJ | volume = 333 | issue = 7563 | pages = 353–4 | date = August 2006 | pmid = 16902221 | pmc = 1539082 | doi = 10.1136/bmj.333.7563.353-b }}</ref>