In the light of the author's experience with chloramphenicol therapy of typhoid fever in 122 children, the following conclusions appear to be valid:I. Prolonged chloramphenicol therapy is unnecessary, undesirable and sometimes even harmful. The course of therapy should be limited to the period of fever and continued for just one or two days after the temperature has become normal. This view is based upon the following considerations:A. The finding that relapses were just as frequent on longer courses as on shorter ones.B. Prolonged courses of chloramphenicol expose the patient more intensely to the hazard of severe and sometimes fatal gastrointestinal disturbances.C. Prolonged courses may expose the patient more seriously to severe and sometimes fatal bone marrow depressions.D. This conclusion is of special importance where the availability of the drug and the expense involved are factors to be taken carefully into consideration.II. Except in hypertoxic forms of typhoid, chloramphenicol therapy should be instituted as early as possible and should not be delayed for any reason. This view is based upon the following considerations:A. On the one hand, when chloramphenicol is started early, during the first week of illness, the relapse rate is higher in comparison to the relapse rate when therapy is started later.B. On the other hand, complications and mortality rates are considerably higher when therapy is postponed to the second week or later.C. Weighing these two hazards against each other, it appears that the latter outweighs the former and that it would certainly be wiser to take the risk of a relapse than of a severe complication or a fatality and therefore therapy should be started in every case as early as diagnostic considerations permit.III. In hypertoxic forms of typhoid, chloramphenicol therapy should be withheld at the beginning, trying supportive therapy, including blood transfusions. Later chloramphenicol may be started but with small doses only, perhaps 12.5 mg./kg./day. If no deterioration in the general condition takes place it may then be increased, say 3 to 4 days later, to 25 mg./kg./day and 3 to 4 days later again, to 50 mg./kg./day, provided the general condition of the patient does not deteriorate.IV. If in spite of special care in instituting chloramphenicol therapy in hypertoxic forms of typhoid an intestinal perforation-like syndrome develops, chloramphenicol therapy should be stopped immediately and general supportive measures instituted as soon as possible. The same applies when the intestinal perforation-like syndrome develops suddenly in a patient not previously severely toxic.V. Gastrointestinal disturbances during chloramphenicol therapy should be taken seriously, and any degree of severity in such disturbances warrants the immediate cessation of chloramphenicol with the immediate institution of corrective measures to combat the electrolyte disturbances which might have resulted.
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