Embed Size (px)
Citation preview
Pertussis Medication Summary
Pediatrics, Pertussis : Medication
Joseph J Bocka, MD
Medication Summary
The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.
Erythromycin is the antibiotic treatment of pertussis. If the patient is allergic to erythromycin, use trimethoprim sulfamethoxazole (TMP-SMZ).
Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Erythromycin (Ilosone, EES)
Erythromycin estolate is antibiotic of choice to prevent interpersonal transfer, because of enhanced absorption, particularly in young infants. Effectiveness of prophylaxis for exposed and susceptible persons not determined; recommended for household and close contacts (50 mg/kg/d PO qid for 14 d). Effective in reducing course and symptoms if started within the first 10-14 d but not proven beyond this period. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, arresting RNA-dependent protein synthesis. For treatment of staphylococcal and streptococcal infections.
Azithromycin (Zithromax)
Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected.
Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues.
Treats mild-to-moderate microbial infections.
Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. Has a long tissue half-life.
Shown to be effective for pertussis in several small studies.
Clarithromycin (Biaxin)
Semisynthetic macrolide antibiotic that reversibly binds to P site of 50S ribosomal subunit of susceptible organisms and may inhibit RNA-dependent protein synthesis by stimulating dissociation of peptidyl tRNA from ribosomes, causing bacterial growth inhibition.
Trimethoprim and Sulfamethoxazole (TMP-SMZ, Bactrim DS, Septra)
Second-line antibiotic (for erythromycin allergy or intolerability). Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Combination blocks 2 consecutive steps in bacterial biosynthesis of essential nucleic acids and proteins. In vitro, bacterial resistance develops more slowly with combination than with either drug alone.
Vaccines
Class Summary
Active immunization increases resistance to infection. Vaccines consist of microorganisms or cellular components that act as antigens. Administration of the vaccine stimulates the production of antibodies with specific protective properties.
The need for prevention of pertussis through immunization cannot be overemphasized. Children of parents who refuse pertussis immunizations are at high risk for pertussis infection relative to vaccinated children. A case-control study identified 156 laboratory-confirmed pertussis cases over an 11-year period (matched controls n=595).[2] Among the cases, 18 (12%) were pertussis vaccine refusers and among the controls 3 (0.5%) were vaccine refusers. Children of parents who refused pertussis immunizations were at an increased risk for pertussis compared with children of parents who accepted vaccinations. A secondary case-control analysis confirmed these results. The study was performed within the Kaiser Permanente of Colorado, where 11% of all pertussis cases within the Colorado Kaiser Permanente system were attributed to parental vaccine refusal. Herd immunity does not seem to completely protect unvaccinated children from pertussis.
All children younger than 7 years should receive the pertussis vaccine. In the United States, acellular pertussis vaccine is recommended and usually is combined with diphtheria and tetanus toxoids (DTaP). When possible, the same DTaP vaccine product should be used for the
first 5 doses of the pertussis immunization series. Tdap is recommended as a one-time adolescent booster or for adults requiring tetanus immunization who did not have an adolescent booster. Reduced-volume dosing is not recommended. Measurable antibody wanes after 3-5 years and is not measurable 12 years after vaccination has been completed. Vaccine may not prevent the illness entirely, but it has been shown to lessen disease severity and duration.
Adolescents and adults have been identified as the source of pertussis transmission to infants, from household contact studies and outbreak investigations. Infectious disease experts are currently investigating the most efficacious and cost-effective means of preventing disease transmission to infants, who are at highest risk of severe disease. Options include vaccination of adolescents and adults in close contact with infants, maternal vaccination to provide passive antibody protection to the infant, and vaccinating infants with acellular pertussis vaccine at birth.
In December 2005, the American Academy of Pediatrics approved recommendations from the Committee on Infectious Diseases (COID) for universal vaccination of adolescents at the 11- or 12-year visit to boost protection against pertussis. The Food and Drug Administration (FDA) has licensed 2 tetanus toxoids (Td), reduced diphtheria toxoid and acellular pertussis vaccine (Tdap) products, for use in children aged 10-18 years (Boostrix; GlaxoSmithKline Biologicals, Rixensart, Belgium) and in those aged 11-64 years (Adacel; Sanofi Pasteur, Toronto, Canada).
The latest vaccine recommendations can be found at the CDC Immunization Schedule Website.[3]
Diphtheria, Tetanus and Acellular Pertussis (DTaP) Vaccine (Tripedia, Certiva, Infanrix)
Promotes active immunity to diphtheria, tetanus, and pertussis by inducing production of specific antibodies and antitoxins.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is the mid thigh laterally.
Tetanus Toxoid, Reduced Diphtheria Toxoid, and Acellular Pertussis Vaccine (Adacel, Boostrix)
Tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine. Promotes active immunity to diphtheria, tetanus, and pertussis by inducing production of specific neutralizing antibodies and antitoxins. Indicated for active booster immunization for tetanus, diphtheria, and pertussis prevention for persons aged 10-64 y (Adacel approved for 11-64 y, Boostrix approved for 10-18 y). Preferred vaccine for adolescents scheduled for booster.
Pharmacologic Therapy
Although antimicrobial agents initiated during the paroxysmal stage do not affect the duration and severity of illness, they can hasten the eradication of Bpertussis in the respiratory tract and help to prevent spread. Antibiotics may also prevent or alleviate secondary bacterial infection.
For patients aged 1 month or older, macrolide antibiotics such as erythromycin, clarithromycin, and azithromycin, are the preferred agents.
Erythromycin and clarithromycin are not recommended in infants younger than 1 month, because their use has been associated with increased risk of infantile hypertrophic pyloric stenosis (IHPS). Azithromycin is the recommended agent for the youngest patients, although it also carries some risk of IHPS. Patients who are aged 2 months or older with hypersensitivity to macrolides may be treated with trimethoprim-sulfamethoxazole.
Prophylaxis
The effectiveness of prophylaxis for exposed, susceptible persons has not been determined; however, it is recommended for household and close contacts of the patient. Regimens include the following:
Erythromycin 50 mg/kg/day divided 4 times daily for 14 days Alternative regimen - Clarithromycin 7.5 mg/kg twice daily for 14 days (the effectiveness of
clarithromycin has not been proven but is inferred)
Asma
Medication Summary
Pharmacologic management includes the use of control agents such as inhaled corticosteroids, inhaled cromolyn or nedocromil, long-acting bronchodilators, theophylline, leukotriene modifiers, and more recent strategies such as the use of anti-immunoglobulin E (IgE) antibodies (omalizumab). Relief medications include short-acting bronchodilators, systemic corticosteroids, and ipratropium
Bronchodilators, Beta2-Agonists
Class Summary
These agents are used to treat bronchospasm in acute asthmatic episodes, and used to prevent bronchospasm associated with exercise-induced asthma or nocturnal asthma. Several studies have suggested that short-acting beta2-agonists such as albuterol may produce adverse outcomes (eg, decreased peak flow or increased risk of exacerbations) in patients homozygous for arginine (Arg/Arg) at the 16th amino acid position of beta-adrenergic receptor gene compared with patients homozygous for glycine (Gly-Gly). Similar findings are reported for long-acting beta2-agonists, such as salmeterol.
View full drug information
Albuterol sulfate (Proventil HFA, Ventolin HFA, ProAir HFA)
This beta2-agonist is the most commonly used bronchodilator that is available in multiple forms (eg, solution for nebulization, MDI, PO solution). This is most commonly used in rescue therapy for acute asthmatic symptoms. Used as needed. Prolonged use may be associated with tachyphylaxis due to beta2-receptor downregulation and receptor hyposensitivity.
View full drug information
Pirbuterol (Maxair Autohaler)
Pirbuterol is available as a breath-actuated or ordinary inhaler. The ease of administration with the breath-actuated device makes it an attractive choice in the treatment of acute symptoms in younger children who otherwise cannot use an MDI. The Autohaler delivers 200 mcg per actuation.
Nonracemic Form of the Beta2-Agonist Albuterol
Class Summary
This nonracemic form of albuterol offers a significant reduction in the adverse effects associated with racemic albuterol (eg, muscle tremors, tachycardia, hyperglycemia, hypokalemia).
View full drug information
Levalbuterol (Xopenex)
Nonracemic form of albuterol, levalbuterol (R isomer) is effective in smaller doses and is reported to have fewer adverse effects (eg, tachycardia, hyperglycemia, hypokalemia). The dose may be doubled in acute severe episodes when even a slight increase in the bronchodilator response may make a big difference in the management strategy (eg, in avoiding patient ventilation). It is available as an MDI (45 mcg per actuation) or solution for nebulized inhalation.
Long-Acting Beta2-Agonists
Class Summary
Long-acting bronchodilators (LABA) are not used for the treatment of acute bronchospasm. They are used for the preventive treatment of nocturnal asthma or exercise-induced asthmatic symptoms, for example.
Currently, 2 LABA are available in the United States: salmeterol (Serevent) and formoterol (Foradil). Salmeterol and formoterol are available as combination products with inhaled corticosteroids in the United States (Advair, Symbicort, Dulera).
LABA may increase the chance of severe asthma episodes and death when those episodes occur. Most cases have occurred in patients with severe and/or acutely deteriorating asthma; they have also occurred in a few patients with less severe asthma.
LABAs are not considered first-line medications to treat asthma. LABAs should not be used as isolated medications and should be added to the asthma treatment plan only if other medicines do not control asthma, including the use of low- or medium-dose corticosteroids. If used as isolated medication, LABAs should be prescribed by a subspecialist (ie, pulmonologist, allergist).
View full drug information
Salmeterol (Serevent Diskus)
This long-acting preparation of a beta2-agonist is used primarily to treat nocturnal or exercise-induced symptoms. It has no anti-inflammatory action and is not indicated in the treatment of acute bronchospastic episodes. It may be used as an adjunct to inhaled corticosteroids to reduce the potential adverse effects of the steroids. The medication is delivered via a Diskus DPI.
View full drug information
Formoterol (Foradil Aerolizer)
Formoterol relieves bronchospasm by relaxing the smooth muscles of the bronchioles in conditions associated with asthma.
Methylxanthines
Class Summary
These agents are used for long-term control and prevention of symptoms, especially nocturnal symptoms.
View full drug information
Theophylline (Theo-24, Theochron, Uniphyl)
Theophylline is available in short-acting and long-acting formulations. Because of the need to monitor serum concentrations, this agent is used infrequently. The dose and frequency depend on the particular product selected.
Inhaled Corticosteroids
Class Summary
Steroids are the most potent anti-inflammatory agents. Inhaled forms are topically active, poorly absorbed, and least likely to cause adverse effects. They are used for long-term control of symptoms and for the suppression, control, and reversal of inflammation. Inhaled forms reduce the need for systemic corticosteroids.
Inhaled steroids block late asthmatic response to allergens; reduce airway hyperresponsiveness; inhibit cytokine production, adhesion protein activation, and inflammatory cell migration and activation; and reverse beta2-receptor downregulation and subsensitivity (in acute asthmatic episodes with LABA use).
View full drug information
Ciclesonide (Alvesco)
Ciclesonide is an aerosol inhaled corticosteroid indicated for maintenance treatment of asthma as prophylactic therapy in adult and adolescent patients aged 12 y and older. Not indicated for relief of acute bronchospasm.
Corticosteroids have wide range of effects on multiple cell types (eg, mast cells, eosinophils, neutrophils, macrophages, lymphocytes) and mediators (eg, histamines, eicosanoids, leukotrienes, cytokines) involved in inflammation.
Individual patients experience variable time to onset and degree of symptom relief. Maximum benefit may not be achieved for 4 wk or longer after initiation of therapy.
After asthma stability is achieved, it is best to titrate to lowest effective dosage to reduce the possibility of adverse effects. For patients who do not adequately respond to the starting dose after 4 wk of therapy, higher doses may provide additional asthma control.
View full drug information
Beclomethasone (QVAR)
Beclomethasone inhibits bronchoconstriction mechanisms; causes direct smooth muscle relaxation; and may decrease the number and activity of inflammatory cells, which, in turn, decreases airway hyperresponsiveness. It is available as 40 mcg/actuation or 80 mcg/actuation.
View full drug information
Fluticasone (Flovent Diskus, Flovent HFA)
Fluticasone has extremely potent vasoconstrictive and anti-inflammatory activity. It has a weak hypothalamic-pituitary adrenocortical axis inhibitory potency when applied topically. It is available as an MDI aerosolized product (HFA) or DPI (Diskus).
View full drug information
Budesonide inhaled (Pulmicort Flexhaler or Respules)
Budesonide has extremely potent vasoconstrictive and anti-inflammatory activity. It has a weak hypothalamic-pituitary adrenocortical axis inhibitory potency when applied topically. It is available as a DPI in 90 mcg/actuation (delivers about 80 mcg/actuation) or 180 mcg/actuation
(delivers about 160 mcg/actuation). A nebulized susp (ie, Respules) is also available for young children.
View full drug information
Mometasone furoate inhalation powder (Asmanex Twisthaler)
Mometasone is a corticosteroid for inhalation. It is indicated for asthma as prophylactic therapy.
Systemic Corticosteroids
Class Summary
These agents are used for short courses (3-10 d) to gain prompt control of inadequately controlled acute asthmatic episodes. They are also used for long-term prevention of symptoms in severe persistent asthma as well as for suppression, control, and reversal of inflammation. Frequent and repetitive use of beta2-agonists has been associated with beta2-receptor subsensitivity and downregulation; these processes are reversed with corticosteroids.
Higher-dose corticosteroids have no advantage in severe asthma exacerbations, and intravenous administration has no advantage over oral therapy, provided that GI transit time or absorption is not impaired. The usual regimen is to continue frequent multiple daily dosing until the FEV1 or peak expiratory flow (PEF) is 50% of the predicted or personal best values; then, the dose is changed to twice daily. This usually occurs within 48 hours.
View full drug information
Prednisone (Deltasone, Orasone) and prednisolone (Pediapred, Prelone, Orapred)
An immunosuppressant for the treatment of autoimmune disorders, prednisone may decrease inflammation by reversing increased capillary permeability and suppressing polymorphonuclear neutrophil (PMN) activity.
View full drug information
Methylprednisolone (Solu-Medrol)
Methylprednisolone may decrease inflammation by reversing increased capillary permeability and suppressing PMN activity.
Leukotriene Modifiers
Class Summary
Knowledge that leukotrienes cause bronchospasm, increased vascular permeability, mucosal edema, and inflammatory cell infiltration has led to the concept of modifying their action by using pharmacologic agents. These are either 5-lipoxygenase inhibitors or leukotriene-receptor antagonists.
View full drug information
Zafirlukast (Accolate)
Zafirlukast is a selective competitive inhibitor of LTD4 and LTE4 receptors.
View full drug information
Montelukast (Singulair)
The last agent introduced in its class, montelukast has the advantages that it is chewable, it has a once-a-day dosing, and it has no significant adverse effects.
Monoclonal Antibodies
Class Summary
These agents bind selectively to human IgE on the surface of mast cells and basophils.
View full drug information
Omalizumab (Xolair)
Omalizumab is a recombinant, DNA-derived, humanized IgG monoclonal antibody that binds selectively to human IgE on surface of mast cells and basophils. It reduces mediator release,
which promotes allergic response. It is indicated for moderate-to-severe persistent asthma in patients who react to perennial allergens in whom symptoms are not controlled by inhaled corticosteroids.
Combination Inhaled Steroids/Long-Acting Beta2-Agonists
Class Summary
These combinations may decrease asthma exacerbations when inhaled short-acting beta2-agonists and corticosteroids have failed. Refer to previous discussion in the LABAs section regarding increased risk of severe asthma episodes and death with LABAs. In a recent study, use of combination therapy using fluticasone propionate and salmeterol prolonged time to first severe asthma exacerbation.[54]
Budesonide is an inhaled corticosteroid that alters level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators involved in the asthmatic response. Available as MDI in 2 strengths; each actuation delivers formoterol 4.5 mcg with either 80 mcg or 160 mcg.
View full drug information
Budesonide/formoterol (Symbicort)
Formoterol relieves bronchospasm by relaxing the smooth muscles of the bronchioles in conditions associated with asthma. Budesonide is an inhaled corticosteroid that alters the level of inflammation in airways by inhibiting multiple types of inflammatory cells and decreasing production of cytokines and other mediators involved in the asthmatic response. This combination is available as an MDI in 2 strengths; each actuation delivers formoterol 4.5-mcg with either 80-mcg or 160-mcg of budesonide.
View full drug information
Mometasone and formoterol (Dulera)
This is a combination corticosteroid and LABA metered-dose inhaler. Mometasone elicits local anti-inflammatory effects in the respiratory tract with minimal systemic absorption. Formoterol elicits bronchial smooth muscle relaxation.
This combination is indicated for prevention and maintenance of asthma symptoms in patients inadequately controlled with other asthma controller medications (eg, low-dose to medium-
dose inhaled corticosteroids) or whose disease severity clearly warrants initiation of treatment with 2 maintenance therapies, including a LABA. Available in 2 strengths; each actuation delivers mometasone/formoterol 100 mcg/5 mcg or 200 mcg/5 mcg.
View full drug information
Salmeterol/fluticasone inhaled (Advair)
This is a combination corticosteroid and LABA metered-dose inhaler. Fluticasone inhibits bronchoconstriction mechanisms, produces direct smooth muscle relaxation, and may decrease number and activity of inflammatory cells, in turn decreasing airway hyper-responsiveness. It also has vasoconstrictive activity. Salmeterol relaxes the smooth muscles of the bronchioles in conditions associated with bronchitis, emphysema, asthma, or bronchiectasis and can relieve bronchospasms. Its effect may also facilitate expectoration. Adverse effects are more likely to occur when administered at high or more frequent doses than recommended. Two delivery mechanisms are available (ie, powder for inhalation [Diskus], metered-dose inhaler [MDI]). Diskus is available as a combination of salmeterol 50 mcg with fluticasone 100 mcg, 250 mcg, or 500 mcg. The MDI is available as 21 mcg salmeterol with fluticasone 45 mcg, 115 mcg, or 230 mcg.
Anticholinergic Agents
Class Summary
These agents may be added to beta2-agonist therapy for treatment of acute exacerbations.
Ipratropium (Atrovent)
Chemically related to atropine, protropium has antisecretory properties and, when applied locally, inhibits secretions from serous and seromucous glands lining the nasal mucosa. The MDI delivers 17 mcg/actuation. Solution for inhalation contains 500 mcg/2.5 mL (ie, 0.02% solution for nebulization).
Kejang demam
Medication Summary
Patients presenting in status epilepticus can be treated with routine seizure medications, including benzodiazepines, phenytoin, and phenobarbital. For further discussion on the treatment of seizures, see Pediatrics, Status Epilepticus.
Antipyretics
Class Summary
Antipyretics should be used in patients who appear uncomfortable secondary to fever. Antipyretics do not appear to prevent recurrence of febrile seizures.
View full drug information
Acetaminophen (Tylenol)
Reduces fever by acting directly on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.
View full drug information
Ibuprofen (Advil, Motrin)
One of the few NSAIDs indicated for reduction of fever. Inhibits the formation of prostaglandins.
Anticonvulsant agents
Class Summary
Prophylactic treatment with an anticonvulsant agent may be considered for subsequent fever episodes.
View full drug information
Diazepam (Valium, Diastat)
Can decrease number of subsequent febrile seizures when given with each febrile episode. Modulates postsynaptic effects of GABA-A transmission, resulting in an increase in presynaptic inhibition. Appears to act on part of the limbic system, the thalamus, and hypothalamus, to induce a calming effect. Also has been found to be an effective adjunct for the relief of skeletal muscle spasm caused by upper motor neuron disorders.
Rapidly distributes to other body fat stores. Twenty minutes after initial IV infusion, serum concentration drops to 20% of Cmax.
Individualize dosage and increase cautiously to avoid adverse effects. Available as IV, PO, and PR dosage forms.
View full drug information
Lorazepam (Ativan)
Sedative hypnotic with short onset of effects and relatively long half-life.
By increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter in the brain, may depress all levels of CNS, including limbic and reticular formation.
Important to monitor patient's blood pressure after administering dose. Adjust as necessary.
Tphioid
Future directions
Researchers in Cameroon report that a compound derived from the seeds of Turraeanthus africanus, an African folk remedy for typhoid fever, is active against S typhi in vitro.[51] Perhaps they are on their way to creating an addition to the shrinking arsenal of effective antimicrobials.
View full drug information
Chloramphenicol (Chloromycetin)
Binds to 50S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria. Since its introduction in 1948, has proven to be remarkably effective for enteric fever worldwide. For sensitive strains, still most widely used antibiotic to treat typhoid fever. In the 1960s, S typh i strains with plasmid-mediated resistance to chloramphenicol began to appear and later became widespread in
many endemic countries of the Americas and Southeast Asia, highlighting need for alternative agents.
Produces rapid improvement in patient's general condition, followed by defervescence in 3-5 d. Reduced preantibiotic-era case-fatality rates from 10%-15% to 1%-4%. Cures approximately 90% of patients. Administered PO unless patient is nauseous or experiencing diarrhea; in such cases, IV route should be used initially. IM route should be avoided because it may result in unsatisfactory blood levels, delaying defervescence.
View full drug information
Amoxicillin (Trimox, Amoxil, Biomox)
Interferes with synthesis of cell wall mucopeptides during active multiplication, resulting in bactericidal activity against susceptible bacteria. At least as effective as chloramphenicol in rapidity of defervescence and relapse rate. Convalescence carriage occurs less commonly than with other agents when organisms are fully susceptible. Usually given PO with a daily dose of 75-100 mg/kg tid for 14 d.
View full drug information
Trimethoprim and sulfamethoxazole (Bactrim DS, Septra)
Inhibits bacterial growth by inhibiting synthesis of dihydrofolic acid. Antibacterial activity of TMP-SMZ includes common urinary tract pathogens, except Pseudomonas aeruginosa. As effective as chloramphenicol in defervescence and relapse rate. Trimethoprim alone has been effective in small groups of patients.
View full drug information
Ciprofloxacin (Cipro)
Fluoroquinolone with activity against pseudomonads, streptococci, MRSA, Staphylococcus epidermidis, and most gram-negative organisms but no activity against anaerobes. Inhibits bacterial DNA synthesis and, consequently, growth. Continue treatment for at least 2 d (7-14 d typical) after signs and symptoms have disappeared. Proven to be highly effective for typhoid and paratyphoid fevers. Defervescence occurs in 3-5 d, and convalescent carriage and relapses are rare. Other quinolones (eg, ofloxacin, norfloxacin, pefloxacin) usually are effective. If
vomiting or diarrhea is present, should be given IV. Fluoroquinolones are highly effective against multiresistant strains and have intracellular antibacterial activity.
Not currently recommended for use in children and pregnant women because of observed potential for causing cartilage damage in growing animals. However, arthropathy has not been reported in children following use of nalidixic acid (an earlier quinolone known to produce similar joint damage in young animals) or in children with cystic fibrosis, despite high-dose treatment.
View full drug information
Cefotaxime (Claforan)
Arrests bacterial cell wall synthesis, which inhibits bacterial growth. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms. Excellent in vitro activity against S typhi and other salmonellae and has acceptable efficacy in typhoid fever. Only IV formulations are available. Recently, emergence of domestically acquired ceftriaxone-resistant Salmonella infections has been described.
View full drug information
Azithromycin (Zithromax)
Treats mild to moderate microbial infections. Administered PO at 10 mg/kg/d (not exceeding 500 mg), appears to be effective to treat uncomplicated typhoid fever in children 4-17 y. Confirmation of these results could provide an alternative for treatment of typhoid fever in children in developing countries, where medical resources are scarce.
View full drug information
Ceftriaxone (Rocephin)
Third-generation cephalosporin with broad-spectrum gram-negative activity against gram-positive organisms; Excellent in vitro activity against S typhi and other salmonellae.
View full drug information
Cefoperazone (Cefobid)
Discontinued in the United States. Third-generation cephalosporin with gram-negative spectrum. Lower efficacy against gram-positive organisms.
View full drug information
Ofloxacin (Floxin)
A pyridine carboxylic acid derivative with broad-spectrum bactericidal effect.
View full drug information
Levofloxacin (Levaquin)
For pseudomonal infections and infections due to multidrug-resistant gram-negative organisms.
Corticosteroids
Class Summary
Dexamethasone may decrease the likelihood of mortality in severe typhoid fever cases complicated by delirium, obtundation, stupor, coma, or shock if bacterial meningitis has been definitively ruled out by cerebrospinal fluid studies. To date, the most systematic trial of this has been a randomized controlled study in patients aged 3-56 years with severe typhoid fever who were receiving chloramphenicol therapy. This study compared outcomes in 18 patients given placebo with outcomes in 20 patients given dexamethasone 3 mg/kg IV over 30 minutes followed by dexamethasone 1 mg/kg every 6 hours for 8 doses. The fatality rate in the dexamethasone arm was 10% versus 55.6% in the placebo arm (P =.003).[52]
Nonetheless, this point is still debated. A 2003 WHO statement endorsed the use of steroids as described above, but reviews by eminent authors in the New England Journal of Medicine (2002)[6] and the British Medical Journal (2006)[53] do not refer to steroids at all. A 1991 trial compared patients treated with 12 doses of dexamethasone 400 mg or 100 mg to a retrospective cohort in whom steroids were not administered. This trial found no difference in outcomes among the groups.[54]
The data are sparse, but the authors of this article agree with the WHO that dexamethasone should be used in cases of severe typhoid fever.
View full drug information
Dexamethasone (Decadron)
Prompt administration of high-dose dexamethasone reduces mortality in patients with severe typhoid fever without increasing incidence of complications, carrier states, or relapse among survivors.
Proceed to Follow-up
