Because of the high incidence of MDRTF in endemic areas and isolation of an increasing number of MDRST strains in the developed world, conventional antibiotics such as Cm, Am and TMP-SMX can no longer be considered as the first line drugs in typhoid fever.
Pediatricians are then faced today with a serious clinical dilemma. "Should every child with suspected typhoid fever be treated as a case of MDRTF?" The reasons for this dilemma are that: (1) no clinical sign or symptom is pathognomonic of MDRTF; (2) the incidence of MDRTF in each community is unknown and (3) a higher incidence of life-threatening complications in MDRTF has been observed emphasizing the need for im mediate institution of effective antibiotic therapy. A few relevant factors that can resolve the issue to some extent are the epidemiological background of the case, the presence of any serious complication at presentation and the response to therapy received previously. Whenever the clinical situation permits, specific antimicrobial therapy should be instituted after completion of appropriate cultures and susceptibility studies. Although there can be no firm guidelines and each case should be assessed individually, the clinical indications to start empirical therapy for MDRTF are : (1) a seriously ill child presenting with a life-threatening complication of typhoid fever; (2) rapid clinical deterioration or development of a complication during conventional antibiotic therapy; (3) a child with typhoid fever in a developed country who has recently traveled to an endemic area, or with a history of close contact with people returning recently from these areas; and (4) a child with uncomplicated typhoid fever who fails to respond to an adequate trial of conventional antibiotics.
Fluoroquinolones and third generation cephalosporins are the available therapeutic alternatives tor treatment of MDRTF in children. No controlled study unequivocally establishes superiority of one group of antimicrobials over the other. Most of the clinical experience with these agents has been through uncontrolled antibiotic trials. The choice of antibiotic in various trials has been primarily dictated by cost, availability and the route of administration. Patterns of in vitro susceptibility of MDRST to fluoroquinolones and third generation cephalosporins accurately predict their in vivo efficacy. Use of drugs such as cephalexin, aminoglycosides, furazolidine and second generation cephalosporins, alone or in combination, may not prove to be effective in the treatment of MDRTF, even if the drug is reported to be effective in vitro. In order to evaluate the efficacy of fluoroquinolones and third generation cephalosporins in the treatment of MDRTF, it is worthwhile to compare them with chloramphenicol, once considered the "gold standard" in the treatment of typhoid fever. Ciprofloxacin and ceftriaxone seem to be the most effective therapeutic choices for treatment of MDRTF. Follow up studies on children with MDRTF are needed to know the rates of relapse and carrier state, and for assessing long term complications arising out of ciprofloxacin therapy.
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