Typhoid Fever
Conditions
Keywords
Uncomplicated Typhoid Fever, Azithromycin, Cefixime, treatment failure
Brief summary
Typhoid and paratyphoid (enteric) fever affects more than 11 million children and adults globally each year including 7 million in South Asia. Up to 1% of patients who get typhoid may die of the disease and, in those that survive, a prolonged period of ill health and catastrophic financial cost to the family may follow. In the last 20 years, treatment of typhoid fever with a 7-day course of a single oral antimicrobial, such as ciprofloxacin, cefixime or azithromycin, given in an out-patient setting has led to patient recovery in 4 to 6 days without the need for expensive hospitalization. Increasing antimicrobial resistance in Asia and sub-Saharan Africa, threatens the effectiveness of these treatments and increases the risk of prolonged illness and severe disease. The recent emergence of a particularly resistant typhoid strain in Pakistan, and subsequent international spread, adds urgency to this problem and Salmonella is now listed as a high (Priority 2) pathogen by world health organisation. Treatment with combinations of antimicrobials may be more effective for treating typhoid fever and mitigate the problems of resistance. This suggestion is based on expert opinion but not backed up by good quality evidence. The ACT-South Asia study aims to compare a combination of azithromycin and cefixime with azithromycin alone in the outpatient treatment of clinically suspected and confirmed uncomplicated typhoid fever. The total recruitment will be 1500 patients across sites in Bangladesh, India, Nepal and Pakistan. A placebo (sugar pill) will be used instead of cefixime in the single drug arm so that neither the patient nor the study team know which patient is receiving which treatment.Investigators will assess whether treatment outcomes are better with the combination after one week of treatment and at one and three month follow-up. Both antimicrobials are widely used and have excellent safety profiles. If the combination treatment is better than the single antibiotic treatment, this will be an important result for patients across South Asia and other typhoid endemic areas. This study will additionally investigate the financial implications for families and health system.
Interventions
DRUGAzithromycin
Azithromycin 20 mg/kg/day for 7 days
DRUGCefixime
cefixime 20-30 mg/kg/day for 7 days
DRUGPlacebo
cefixime-matched placebo for 7 days
Sponsors
University of Oxford
Medical Research Council
Department for International Development, United Kingdom
Wellcome Trust
Oxford University Clinical Research Unit, Vietnam
Study design
Allocation
RANDOMIZED
Intervention model
PARALLEL
Primary purpose
TREATMENT
Masking
QUADRUPLE (Subject, Caregiver, Investigator, Outcomes Assessor)
Masking description
Double Blind
Eligibility
Sex/Gender
ALL
Age
2 Years to 65 Years
Healthy volunteers
No
Inclusion criteria
* A history of fever at presentation for ≥ 72 hours and a documented fever (≥37.5oC (axillary) or ≥38oC (oral)) * Age ≥ 2 years (and ≥ 10kg) to 65 years * No clear focus of infection on initial clinical evaluation * Malaria rapid Diagnostic test( RDT) negative; dengue nonstructural protein(NS) 1 RDT negative; scrub typhus RDT negative; c-reactive protein(CRP) rapid test ≥10 mg/L * Able to take oral treatment * Able to attend for follow-up and can be contacted by telephone * Written fully informed consent to participate in the study including assent for children in addition to parental/legal guardian consent.
Exclusion criteria
* History of fever for \>14 days * Pregnant or positive pregnancy test or breast-feeding * Presence of clinical symptoms or signs indicating a focal infection such as pneumonia; urinary infection, meningitis, eschar * Obtundation, haemodynamic shock, visible jaundice, gastrointestinal bleeding or any signs of severe disease that may require immediate hospitalisation * Being treated for TB or HIV or severe acute malnutrition * Patients with cardiac disease * Patient requiring intravenous antibiotics for any reason * Previous history of hypersensitivity to any of the treatment options * Either of the trial drugs are contraindicated for any reason (e.g. drug interactions) * Has received azithromycin or cefixime in the last five days * Receiving another antimicrobial and responding clinically to the treatment as judged by the attending clinician.
Design outcomes
Primary
| Measure | Time frame | Description |
|---|---|---|
| Treatment Failure | Within 28 days of treatment initiation | A composite outcome of treatment failure by the 28th day after the initiation of treatment will be defined by either of the following events: 1.Clinical failure: persistence of fever on day 7 (168 h) post treatment initiation OR The need for rescue treatment as judged by the Trial Clinician OR The development of any complication (e.g., clinically significant bleeding, fall in the Glasgow Coma Scale score, perforation of the gastrointestinal tract) OR Syndromic enteric fever relapse within 28 days of initiation of treatment. 2.Microbiological failure: a positive blood-culture for S. Typhi or S. Paratyphi on day 7 of treatment regardless of the presence of fever (microbiological failure) OR blood culture-confirmed typhoid fever relapse within 28 days of initiation of treatment. |
Secondary
| Measure | Time frame | Description |
|---|---|---|
| Time from onset of treatment to treatment failure | Within 28 days of treatment initiation | The time to treatment failure will be the time from the first dose of a study drug until an event occurs defined as a treatment failure |
| Time from symptom onset to treatment failure | Within 28 days of treatment initiation | The time to treatment failure will be the time from the day of the first symptom until an event occurs defined as a treatment failure |
| Fever clearance time (FCT) in patients in each treatment arm | at least 2 days | The FCT will be the time from the first dose of a study drug until a temperature of \< 37.5°C (axillary); \< 38.0°C (oral) has been achieved |
| faecal carriage of S.Typhi or S.Paratyphi | One and three month follow-up | Positive culture of faeces sample for S.Typhi or S.Paratyphi |
| cost effectiveness of treatment | Initiation of treatment and one month follow-up visit | The incremental cost-effectiveness ratio (ICER) will comprise of the total costs per case, real outpatient and in-patient costs, total direct and indirect costs for the family and healthcare system and health outcomes converted to Disability Adjusted Life Years (DALYs). The cost per DALY averted will be compared against multipliers of the gross domestic product/capita in each of the four countries to establish the cost-effectiveness of the combination regimen. |
| Adverse event | Within 90 days | Adverse events will be graded (grade 3/4 adverse events, serious adverse events, adverse events of any grade leading to modification of study drug dose or interruption/early discontinuation); |
Countries
Nepal
Outcome results
None listed