Zmora N, Shrestha S, Neuberger A, Paran Y, Tamrakar R, Shrestha A, Madhup SK, Bedi TRS, Koju R, Schwartz E. Open label comparative trial of mono versus dual antibiotic therapy for Typhoid Fever in adults.
PLoS Negl Trop Dis 2018;
12:e0006380. [PMID:
29684022 PMCID:
PMC5912710 DOI:
10.1371/journal.pntd.0006380]
[Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 03/09/2018] [Indexed: 11/18/2022] Open
Abstract
Background
Emerging resistance to antibiotics renders therapy of Typhoid Fever (TF) increasingly challenging. The current single-drug regimens exhibit prolonged fever clearance time (FCT), imposing a great burden on both patients and health systems, and potentially contributing to the development of antibiotic resistance and the chronic carriage of the pathogens. The aim of our study was to assess the efficacy of combining third-generation cephalosporin therapy with azithromycin on the outcomes of TF in patients living in an endemic region.
Methods
An open-label, comparative trial was conducted at Dhulikhel Hospital, Nepal, between October 2012 and October 2014. Only culture-confirmed TF cases were eligible. Patients were alternately allocated to one of four study arms: hospitalized patients received either intravenous ceftriaxone or a combination of ceftriaxone and oral azithromycin, while outpatients received either oral azithromycin or a combination of oral azithromycin and cefexime. The primary outcome evaluated was FCT and the secondary outcomes included duration of bacteremia.
Results
105 blood culture-confirmed patients, of whom 51 were treated as outpatients, were eligible for the study. Of the 88 patients who met the inclusion criteria for FCT analysis 41 patients received a single-agent regimen, while 47 patients received a combined regimen. Results showed that FCT was significantly shorter for the latter (95 versus 88 hours, respectively, p = 0·004), and this effect was exhibited in both the hospitalized and the outpatient sub-groups. Repeat blood cultures, drawn on day 3, were positive for 8/47 (17%) patients after monotherapy, versus 2/51 (4%) after combination therapy (p = 0·045). No severe complications or fatalities occurred in any of the groups.
Conclusions
Combined therapy of third-generation cephalosporins and azithromycin for TF may surpass monotherapy in terms of FCT and time to elimination of bacteremia.
Trial registration
Trial registration number: NCT02224040.
Typhoid fever (TF) is a serious disease and the most common etiology of bloodstream infections in febrile patients in the Indian subcontinent. Before the advent of antibiotics its mortality rate reached up to 40%, and dropped dramatically upon their introduction. However, over the last decades multidrug-resistant strains have emerged, further posing a challenge to the treatment of TF. Here, we propose a novel treatment approach, combining azithromycin and a third-generation cephalosporin, two antibiotic agents, which act synergistically on the two niches occupied by the bacteria, the intra- and the extra-cellular compartments respectively. In our study of a rural Nepalese population with culture-confirmed TF, we have shown that dual therapy was superior to monotherapy in terms of time to defervescence and bacteremia elimination, both in outpatient and inpatient settings. We hence advocate the combination of these two antibiotics as a more effective therapeutic strategy than the current standard of care, and suggest that such approach may shorten patients’ hospital stay, and reduce both pathogen carriage rates and the development of antibiotic resistance.
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