Abstract
BackgroundUndifferentiated febrile illness (UFI) includes typhoid and typhus fevers and generally designates fever without any localizing signs. UFI is a great therapeutic challenge in countries like Nepal because of the lack of available point-of-care, rapid diagnostic tests. Often patients are empirically treated as presumed enteric fever. Due to the development of high-level resistance to traditionally used fluoroquinolones against enteric fever, azithromycin is now commonly used to treat enteric fever/UFI. The re-emergence of susceptibility of Salmonella typhi to co-trimoxazole makes it a promising oral treatment for UFIs in general. We present a protocol of a randomized controlled trial of azithromycin versus co-trimoxazole for the treatment of UFI.Methods/designThis is a parallel-group, double-blind, 1:1, randomized controlled trial of co-trimoxazole versus azithromycin for the treatment of UFI in Nepal. Participants will be patients aged 2 to 65 years, presenting with fever without clear focus for at least 4 days, complying with other study criteria and willing to provide written informed consent. Patients will be randomized either to azithromycin 20 mg/kg/day (maximum 1000 mg/day) in a single daily dose and an identical placebo or co-trimoxazole 60 mg/kg/day (maximum 3000 mg/day) in two divided doses for 7 days. Patients will be followed up with twice-daily telephone calls for 7 days or for at least 48 h after they become afebrile, whichever is later; by home visits on days 2 and 4 of treatment; and by hospital visits on days 7, 14, 28 and 63. The endpoints will be fever clearance time, treatment failure, time to treatment failure, and adverse events. The estimated sample size is 330. The primary analysis population will be all the randomized population and subanalysis will be repeated on patients with blood culture-confirmed enteric fever and culture-negative patients.DiscussionBoth azithromycin and co-trimoxazole are available in Nepal and are extensively used in the treatment of UFI. Therefore, it is important to know the better orally administered antimicrobial to treat enteric fever and other UFIs especially against the background of fluoroquinolone-resistant enteric fever.Trial registrationClinicalTrials.gov, ID: NCT02773407. Registered on 5 May 2016.
Highlights
Undifferentiated febrile illness (UFI) includes typhoid and typhus fevers and generally designates fever without any localizing signs
Both azithromycin and co-trimoxazole are available in Nepal and are extensively used in the treatment of UFI
Its effectiveness against enteric fever is corroborated by a recent case report [19] and demonstrable low co-trimoxazole Minimum Inhibitory Concentrations (MICs) for S. typhi and S. paratyphi A [17, 20]
Summary
Undifferentiated febrile illness (UFI) includes typhoid and typhus fevers and generally designates fever without any localizing signs. Due to the development of high-level resistance to traditionally used fluoroquinolones against enteric fever, azithromycin is commonly used to treat enteric fever/UFI. The difficulty in determining the etiology of undifferentiated febrile illness (UFI), which designates fever without localizing signs, and the emergence of resistance to commonly used antimicrobials means that the appropriate management of UFIs is an ongoing clinical challenge. UFIs in industrialized countries are often attributed to a viral syndrome but in the developing world UFI may be commonly caused by enteric fever, rickettsial illness, malaria, dengue, chikungunya, etc. The common causes of UFI in Kathmandu, Nepal includes enteric (typhoid and paratyphoid) fever and murine and scrub typhus [2, 3]. The spotted fever group rickettsioses, Q fever, leptospirosis, hantavirus infection, brucellosis and dengue may cause UFI in Nepal [3]
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