Typhoid fever — DTM&H MCQ

Correct answer: B — IV ceftriaxone 2 g daily

The correct answer is B, IV ceftriaxone 2 g daily. This presentation (stepwise fever over two weeks, headache, abdominal discomfort, constipation, relative bradycardia, and rose spots) is classic enteric fever, and travel from Nepal places this within the Indian subcontinent, where Salmonella Typhi and Paratyphi A are now largely fluoroquinolone-resistant. UK guidance therefore states that ciprofloxacin should not be used empirically for infections acquired in this region, and that intravenous ceftriaxone is the empirical treatment of choice until susceptibilities are known. Ceftriaxone gives reliable coverage against multidrug-resistant and fluoroquinolone-resistant strains circulating across South Asia, and IV therapy is appropriate given the systemic, potentially bacteraemic nature of enteric fever pending culture results. Why the other options are wrong: A. Oral ciprofloxacin 500 mg twice daily: Fluoroquinolone resistance is now widespread among Typhi and Paratyphi A strains from the Indian subcontinent, so ciprofloxacin cannot be relied upon empirically and risks clinical failure. D. Oral azithromycin 500 mg daily: This is a reasonable alternative for uncomplicated disease when oral therapy is tolerated, but it is not the first-line empirical choice recommended ahead of ceftriaxone, particularly if there is any suggestion of systemic or complicated illness. C. Oral chloramphenicol 500 mg four times daily: Historic first-line agent now largely abandoned due to high rates of resistance and significant toxicity (bone marrow suppression), making it unsuitable as empirical therapy. E. Oral amoxicillin 500 mg three times daily: Amoxicillin resistance emerged decades ago as part of the original multidrug-resistant Typhi phenotype, so it cannot be relied upon empirically without confirmed susceptibility. Key point: For enteric fever acquired on the Indian subcontinent, empirical fluoroquinolones are contraindicated due to resistance, and IV ceftriaxone is the treatment of choice pending susceptibility results.

Reference: UKHSA, Enteric fevers: migrant health guide, GOV.UK (updated 2025): 'typhoid and paratyphoid A infections acquired in India and Pakistan are generally resistant to ciprofloxacin as well, and intravenous ceftriaxone is the empirical treatment of choice for such cases until susceptibilities are known.' https://www.gov.uk/guidance/enteric-fevers-migrant-health-guide