Management of typhoid
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"Typhoid Fever"[MeSH Terms] AND treatment
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WHO typhoid fever clinical management antimicrobial treatment guideline ceftriaxone azithromycin
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https://www.cdc.gov/yellow-book/hcp/travel-associated-infect…
Management of typhoid (enteric fever)
Typhoid fever is a potentially serious systemic infection caused by Salmonella Typhi (and clinically similar S. Paratyphi). Management should be clinician-directed because antimicrobial resistance and local travel exposure determine the correct antibiotic.
1. Confirm diagnosis and assess severity
- Obtain blood cultures before antibiotics, if this does not delay treatment. Ask for antimicrobial susceptibility testing.
- Stool culture may also help, but is often negative early in illness.
- Do not rely on the Widal test alone to diagnose or guide therapy.
- Assess travel and exposure history, particularly travel to Pakistan, Iraq, South Asia, or areas with known drug resistance.
- Check for complications: dehydration, shock, altered mental state, gastrointestinal bleeding, abdominal guarding/distension, hepatitis, or sepsis.
Blood culture remains the diagnostic mainstay, though sensitivity is limited; bone marrow culture is more sensitive when available. Harrison's Principles of Internal Medicine, 22nd ed., p. 1734.
2. Supportive care
- Oral fluids and nutrition where tolerated. Use IV fluids if dehydrated, vomiting, hypotensive, or unable to drink.
- Paracetamol/acetaminophen for fever and discomfort.
- Monitor temperature, pulse, blood pressure, hydration, urine output, abdominal signs, and mental status.
- Avoid antimotility drugs if there is significant diarrhea, abdominal pain, or possible ileus.
3. Antibiotic treatment
Start empiric treatment if clinical suspicion is high, ideally after cultures are collected. Then narrow or change treatment based on culture susceptibility.
| Clinical setting | Usual empiric approach |
|---|---|
| Uncomplicated illness, able to take oral drugs | Azithromycin is commonly used, especially where fluoroquinolone resistance is likely |
| Moderate to severe illness, vomiting, hospitalized | IV ceftriaxone is commonly used where susceptibility is expected |
| Exposure linked to Pakistan or Iraq, or suspected XDR typhoid | Uncomplicated: azithromycin. Severe/complicated: a carbapenem such as meropenem, guided by an infectious-diseases specialist and susceptibility results |
| Fluoroquinolone-susceptible isolate | Ciprofloxacin may be considered only when susceptibility is documented and local resistance risk is low |
Do not use ciprofloxacin empirically in many endemic settings because reduced fluoroquinolone susceptibility is common. Traditional agents such as chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole should be used only when susceptibility is confirmed.
For uncomplicated disease, expert sources commonly use at least about 7 days of effective therapy, but exact agent, route, dose, and duration depend on age, pregnancy status, severity, site of acquisition, renal/hepatic function, and susceptibility result. Yamada's Textbook of Gastroenterology, 7th ed., p. 2477-2480.
The current CDC enteric-fever guidance recommends azithromycin or ceftriaxone for many travelers, but azithromycin for uncomplicated and a carbapenem for complicated illness after travel to Pakistan or Iraq.
4. Indications for hospital admission
Admit patients with:
- Persistent vomiting or inability to maintain hydration
- Shock, sepsis, severe dehydration, or marked weakness
- Confusion, delirium, stupor, or encephalopathy
- Gastrointestinal hemorrhage, severe abdominal pain, guarding, distension, or suspected perforation
- Significant comorbidity, immunocompromise, pregnancy, or inability to ensure follow-up
- Failure to improve on outpatient treatment
5. Management of complications
- Sepsis/shock: IV fluids, cultures, IV antibiotics, close monitoring, and critical-care support if necessary.
- Intestinal bleeding: resuscitation, blood products if indicated, surgical and gastroenterology input.
- Ileal perforation/peritonitis: urgent surgical review plus broad IV antimicrobial coverage. Perforation requires surgery. Yamada's Textbook of Gastroenterology, 7th ed., p. 2488.
- Severe typhoid with shock or encephalopathy: manage in hospital/ICU. Some specialist references support high-dose dexamethasone in severe disease with delirium, coma, or shock, under specialist supervision.
6. Follow-up
- Fever may persist for 3 to 5 days after effective antibiotics begin. The daily maximum temperature should generally fall.
- If fever does not improve by day 5, reassess for resistance, wrong diagnosis, inadequate source control, abscess, osteomyelitis, or another focal infection.
- Relapse can occur 1 to 3 weeks after apparent recovery and requires reassessment and further directed therapy.
- A small proportion become chronic stool carriers. Food handlers, healthcare workers, children in daycare, and others subject to public-health rules may need follow-up cultures and clearance before returning. The CDC guidance estimates chronic carriage in about 1% to 4% of treated patients.
7. Prevent transmission and future infection
- Strict handwashing with soap after toileting and before preparing food.
- Do not prepare food for others while symptomatic, and follow local public-health advice.
- Use safe drinking water and thoroughly cooked food.
- Typhoid vaccination is recommended for travelers to risk areas, but it does not replace food and water precautions.
Important resistance update
Resistance patterns are changing, including extensively drug-resistant S. Typhi and emerging resistance to ceftriaxone and azithromycin. Treatment should therefore be culture- and susceptibility-guided, not based on an old standard regimen.
A recent systematic review of randomized trials on azithromycin versus other antibiotics is indexed as PMID 39623850, but regimen selection must still reflect local resistance data.
Treatment of migrain headeach
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American Headache Society migraine acute preventive treatment guideline CGRP 2025
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Treatment of migraine headache
Treatment has two parts: treating the current attack and preventing frequent attacks.
1. Treat an acute migraine attack
Treat early in the headache, rest in a dark quiet room, drink fluids, and avoid known triggers.
For mild to moderate attacks
- Paracetamol/acetaminophen
- NSAID such as ibuprofen, naproxen, or diclofenac, if safe for you
- Add an anti-nausea medicine such as metoclopramide or prochlorperazine if nausea/vomiting is prominent
For moderate to severe attacks, or when simple painkillers fail
- A triptan, for example sumatriptan, rizatriptan, or zolmitriptan, is a common migraine-specific option.
- Newer non-vasoconstricting options include CGRP receptor antagonists, such as ubrogepant or rimegepant, or lasmiditan, where available.
Triptans should generally be avoided in people with coronary artery disease, previous stroke/TIA, peripheral vascular disease, uncontrolled hypertension, hemiplegic migraine, or certain complicated migraine syndromes. They should not be combined with an ergot medication within 24 hours.
Do not routinely use opioids, codeine, tramadol, butalbital-containing medicines, or frequent combination analgesics. They are less effective for migraine and can lead to medication-overuse headache. Tintinalli's Emergency Medicine, p. 1330-1336.
2. Avoid medication-overuse headache
Limit acute medicines:
- Triptans, opioids, combination analgesics: ideally no more than 10 days/month
- Paracetamol or NSAIDs: ideally no more than 15 days/month
If you need acute treatment more often, discuss preventive treatment with a clinician.
3. Preventive treatment
Consider prevention when attacks are frequent, disabling, prolonged, poorly responsive to acute medicines, or acute medicines are needed too often.
Common options, selected according to other health conditions:
- Beta-blockers: propranolol, metoprolol
- Antiseizure medicines: topiramate, valproate
- Antidepressants: amitriptyline, venlafaxine
- CGRP-targeting treatments: erenumab, fremanezumab, galcanezumab, eptinezumab; oral options include atogepant or rimegepant
- OnabotulinumtoxinA (Botox): mainly for chronic migraine
CGRP-targeting treatments are now recognized by the American Headache Society as a first-line preventive option, with selection based on access, medical history, preference, and pregnancy plans. See the AHS preventive-therapy position.
4. Non-drug prevention
- Keep regular sleep, meals, hydration, and exercise.
- Keep a headache diary to identify triggers and track treatment response.
- Reduce excess caffeine and avoid abrupt caffeine withdrawal.
- Consider cognitive behavioral therapy, relaxation training, mindfulness, or biofeedback.
- Address anxiety, depression, sleep apnea, or neck pain if present.
A 2025 systematic review found supportive evidence for behavioral approaches in migraine prevention (PMID 39968795).
Seek urgent medical care now if
- Sudden, explosive “worst-ever” headache
- New headache with weakness, numbness, speech difficulty, fainting, seizure, or persistent visual loss
- Fever, stiff neck, confusion, rash, or severe vomiting
- Headache after head injury
- New severe headache during pregnancy/postpartum
- New headache after age 50, or with cancer/immunosuppression
- A usual migraine that is substantially different or not settling
If this is your first severe headache or the diagnosis of migraine has not been confirmed, it should be assessed by a clinician before self-treating.
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