Once the sensitivities are known: a systematic review of antibiotic choice in typhoid fever

Typhoid fever is primarily a disease of the developing world, which can also be seen in travellers returning to developed countries. Treatment guidelines vary between countries and are complicated by evolving resistance patterns. Currently nalidixic acid-resistant (NaR) and multidrug resistant (MDR) isolates are common. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines were adhered to in this review. Data were identified through an electronic search of PubMed/MEDLINE and Scopus databases. Pre-defined inclusion/exclusion criteria determined the final selection of seven open-label, well-powered randomised controlled trials.\ud \ud Overall, no definite recommendation can be made due to the small number of large, well-powered comparative trials conducted on typhoid. Broadly, the results of this systematic review suggest that quinolones and azithromycin are equally effective in treating fully-sensitive Salmonella enterica serotype Typhi, while azithromycin is favoured over quinolones in the presence of nalidixic acid resistance. Quinolones are favoured over oral cephalosporins in all typhoid resistance types. Gatifloxacin is highly efficacious even in a population with high nalidixic acid resistance and chloramphenicol is as effective as either azithromycin or gatifloxacin in patients who do not have MDR typhoid. However, caution is recommended with the use of chloramphenicol, as there should be careful monitoring for evidence of serious toxicity. There is a need for further comparative trials, involving ceftriaxone, ciprofloxacin and azithromycin