Typhoid and Its Most Common Drug List

Typhoid fever, also known as enteric fever, is a systemic febrile illness that is caused by the bacteria Salmonella typhi. This disease is more common in the developing world due to inaccessibility to clean drinking water and poor sanitation conditions prevailing in these countries.

According to the 2014 report of WHO, nearly 21 million cases and 222000 deaths occur due to typhoid annually across the globe. Typhoid infection spreads throughout the body and affects many organs. If left untreated, it can cause serious complications, which can turn fatal. This disease is highly contagious. Humans are the only carriers of this infection which is acquired by fecal-oral route. These bacteria are excreted out of the body of a patient along with feces and sometimes with urine.

If we consume anything that has been contaminated, we can get infected and develop typhoid fever. Children are at the highest risk of developing typhoid fever because their immune system is not very strong and is still developing. However, children with typhoid tend to develop less severe symptoms that adults. It should be noted that even if your symptoms go away completely, one might still be carrying as well as shedding the bacteria. This may lead to a recurrence of a typhoid episode or, transmission of bacteria to others.

An infected person does not start showing symptoms right away. The incubation period for symptoms to show up are usually between 1-2 weeks. For diagnosis, stool tests are performed for checking the presence of S. typhi.[1]

Symptoms of Typhoid

Here are the most common symptoms of typhoid:

• Fever, that starts low and rises daily and can become as high as 104.9° F (40.5°C)
• Abdominal pain
• Constipation
• Headache
• Loss of appetite
• Skin rashes that are flat and rose colored
• Lethargy
• Weakness
• Generalized aches and pain
• Dry cough
• Extremely swollen abdomen
• Diarrhea (uncommon)

Patients who don’t receive any treatment, may become delirious and develop typhoid state, which is a state where a person lies motionless with half closed eyes

Treatment

A typhoid fever demands prompt treatment with antibiotics. If it gets diagnosed at an early stage, the infection is more likely to be mild in nature and can be easily treated at home with an antibiotic therapy. Patients are advised to follow good hygienic practices with strict hand washing routine and abstinence from cooking food for others during the course of infection. Patients with serious infection develop severe symptoms like persistent vomiting, swollen stomach and severe diarrhea which requires admission in a hospital for treatment. Young children with typhoid fever, are usually admitted in hospital, even if they have minor infection, as a precaution. Sometimes life-threatening complications of typhoid fever, like intestinal perforation develops in patients which requires surgery.

Some people experience typhoid fever relapse when the symptoms return nearly after a week of antibiotic treatment. This time, the symptoms are milder and last for a shorter duration of time than the original illness. This requires further treatment with antibiotics.
It is also recommended to have a stool test after your symptoms disappear in order to confirm you are completely free of the bacteria. If your results come positive for the presence of bacteria, it implies that you have now become a carrier and require 28-day course of antibiotics for flushing out the bacteria. Unless and until your diagnostic tests show you are completely free of the bacteria, you should avoid handling food for others. You are also required to strictly follow good hygienic practices.

Antibiotics belonging to classes fluoroquinolones, cephalosporins, aminopenicillins and macrolides are used for treating typhoid fever. The drugs belonging to these classes for treating typhoid are:

1. Antibiotics

Antibiotics are the drugs that work by killing the bacteria or by keeping them from multiplying in our body. With proper diagnosis of strain of bacteria and corresponding treatment with antibiotics can treat the infection within 7-10 days. Until the strain is identified, broad spectrum antibiotics are used. The strain of bacteria varies with geography and in order to avoid development of multi-drug resistant strains, strain specific antibiotics should only be used.

Chloramphenicol was the drug of choice for treating typhoid till 1970s, when chloramphenicol resistant strains emerged. After that, physicians started prescribing ampicillin and trimethoprim-sulfamethoxazole, to which the bacteria developed resistance in the late 1980s. Presently, resistance to fluoroquinolones is emerging at an alarming rate in many parts of Asia. In such areas third generation cephalosporins are used. It is only a matter of time when even these drugs will become less useful for treating typhoid fever.

A. Fluoroquinolone: These are the drugs that are most useful against gram- negative bacteria and a few gram-positive bacteria. They inhibit the enzymes topoisomerase II (DNA gyrase) and topoisomerase IV, which are used by the bacteria to multiply.

Drug: ciprofloxacin
Brand name: Cipro
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Tablet
Indicated in Pregnancy: No, unless benefits outweigh risks
Alcohol Content: No
Side Effects: Diarrhea, bloody stools, change in urination, chills, confusion, dizziness, headache, hearing loss, skin rash, nausea, vomiting, and yellow eyes.

Drug: ofloxacin
Brand name: Floxin
The U.S. FDA Status: Discontinued
Dosage Form: Tablet
Indicated in Pregnancy: No, unless benefits outweigh risks
Alcohol Content: No
Side Effects: Abdominal pain, anxiety, black stools, chills, confusion, cough, depression, fast heartbeat,flushed skin, headache and increased thirst

Drug: levofloxacin
Brand name: Levaquin
The U.S. FDA Status: Approved
Availability: Prescription
Dosage Form: Tablet
Indicated in Pregnancy: No, unless benefits outweigh risks
Alcohol Content: No
Side Effects: Diarrhea, insomnia, abdominal pain, confusion, redness, skin rash, mood swings and burning sensations

B. Cephalosporins (third generation): These are powerful antibiotics that prevent the replication of bacteria in the human body. These drugs combine and block synthesis of bacterial cell wall, thereby inhibiting bacterial growth. Only injectable formulations are available.

Drug: ceftriaxone
Brand name: Ceftriaxone
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Injectable
Indicated in Pregnancy: No, unless benefits outweigh risks
Alcohol Content: No
Side Effects: Chest pain, chills, cough, sore throat, unusual bruising, fatigue and mouth ulcers

Drug: cefotaxime sodium
Brand name: Cefotaxime
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Injectable
Indicated in Pregnancy: Yes, under strict supervision
Alcohol Content: No
Side Effects: Hives, difficulty breathing, swelling of face, nausea, diarrhea and pain, redness, swelling and bleeding at the site of injection

Drug: cefoperazone
Brand name: Cefobid
The U.S. FDA Status: Discontinued
Dosage Form: Injectable
Indicated in Pregnancy: Yes, under strict supervision
Alcohol Content: No
Side Effects: Skin rashes, nausea, vomiting, diarrhea, pain after infection and aplastic anemia

C. Macrolides: By inhibiting protein synthesis in bacteria, macrolides prevent bacterial growth in the body.

Drug: azithromycin
Brand name: Zithromax
The U.S. FDA Status: Approved
Availability: Prescription
Dosage Form: Injectable
Indicated in Pregnancy: Yes, under strict supervision
Alcohol Content: No
Side Effects: Diarrhea, abdominal pain, loose stools, nausea, vomiting, blistering of skin, swelling, abdominal pain and body aches

D. Aminopenicillins: Transpeptidase is an enzyme that is required by the bacteria for cell wall synthesis. By inhibiting this enzyme, bacterial cell wall synthesis is inhibited, thereby preventing bacterial multiplication.

Drug: ampicillin sodium
Brand name: Ampicillin Sodium
The U.S. FDA Status: Approved
Availability: Prescription only
Dosage Form: Injectable
Indicated in Pregnancy: No, unless benefits outweigh risks
Alcohol Content: No
Side Effects: Skin rash, eosinophilia, swelling, fever, vomiting, anorexia and pain at site of injection

E. Cotrimoxazole: A fixed dose combination of two antibiotics, trimethoprim and sulphamethoxazole is called cotrimoxazole. These are generally given together because they enhance each other’s action in killing the bacteria. These drugs interfere with the synthesis of folic acid in the bacteria, which is required for DNA synthesis, thus preventing bacterial cells from multiplying.

Drug: sulphamethoxazole and trimethoprim
Brand name: Bactrim
The U.S. FDA Status: Approved
Availability: Prescription
Dosage Form: Tablet
Indicated in Pregnancy: No
Alcohol Content: No
Side Effects: Abdominal pain, black stools, chills, diarrhea, headache, itching, nausea, wheezing and sore throat

F. Chloramphenicol: It prevents bacterial protein synthesis and inhibits bacterial cell multiplication. As the bacteria causing typhoid fever has developed resistance against chloramphenicol, this drug is now seldom used.

Drug: chloramphenicol sodium succinate
Brand name: Chloarmphenicol sodium succinate
The U.S. FDA Status: Approved
Availability: Prescription
Dosage Form: Injectable
Indicated in Pregnancy: No, unless benefits outweigh risks
Alcohol Content: No
Side Effects: Pale skin, sore throat, unusual bleeding, fatigue, confusion, eye pain, skin rash and numbness in hands and feet

TYPHOID VACCINES:

These vaccines are used for preventing typhoid fever in healthy individuals. They cannot be given to a person who is already suffering from typhoid. WHO recommends that children residing in areas where typhoid fever is common should be vaccinated compulsorily. For others, the organization recommends vaccination for people and children who are at risk.^[2]

There are two vaccines available for protecting against typhoid. These are:

1. Oral vaccine containing live, attenuated mutant strain of Salmonella typhi Ty21a bacteria, which is available as enteric coated capsules. The time frame for which the vaccine provides protection is not clear and varies with dose and the number of subsequent exposures to the bacteria.

2. Injectable Vi capsular polysaccharide vaccine (ViCPS vaccine) which is available as an intramuscular vaccine and induces protection after 7 days of administration. In areas which are at high risk of typhoid outbreak, the vaccine provides immunity for nearly 3 years. Re-vaccination is recommended after 3 years.^[3]

OTC Drugs Available

Although typhoid requires prompt treatment with antibiotics for properly treating the disease, there are a few drugs that can be given for managing fever and abdominal pain, which should only be taking after consulting with a physician. These are: