title: Gatifloxacin versus chloramphenicol for uncomplicated enteric fever: an open-label, randomised, controlled trial.
abstract: BACKGROUND
  We aimed to investigate whether gatifloxacin, a new generation and affordable fluoroquinolone, is better than chloramphenicol for the treatment of uncomplicated enteric fever in children and adults.
  
  
  METHODS
  We did an open-label randomised superiority trial at Patan Hospital, Kathmandu, Nepal, to investigate whether gatifloxacin is more effective than chloramphenicol for treating uncomplicated enteric fever. Children and adults clinically diagnosed with enteric fever received either gatifloxacin (10 mg/kg) once a day for 7 days, or chloramphenicol (75 mg/kg per day) in four divided doses for 14 days. Patients were randomly allocated treatment (1:1) in blocks of 50, without stratification. Allocations were placed in sealed envelopes opened by the study physician once a patient was enrolled into the trial. Masking was not possible because of the different formulations and ways of giving the two drugs. The primary outcome measure was treatment failure, which consisted of at least one of the following: persistent fever at day 10, need for rescue treatment, microbiological failure, relapse until day 31, and enteric-fever-related complications. The primary outcome was assessed in all patients randomly allocated treatment and reported separately for culture-positive patients and for all patients. Secondary outcome measures were fever clearance time, late relapse, and faecal carriage. The trial is registered on controlled-trials.com, number ISRCTN 53258327.
  
  
  RESULTS
  844 patients with a median age of 16 (IQR 9-22) years were enrolled in the trial and randomly allocated a treatment. 352 patients had blood-culture-confirmed enteric fever: 175 were treated with chloramphenicol and 177 with gatifloxacin. 14 patients had treatment failure in the chloramphenicol group, compared with 12 in the gatifloxacin group (hazard ratio [HR] of time to failure 0·86, 95% CI 0·40-1·86, p=0·70). The median time to fever clearance was 3·95 days (95% CI 3·68-4·68) in the chloramphenicol group and 3·90 days (3·58-4·27) in the gatifloxacin group (HR 1·06, 0·86-1·32, p=0·59). At 1 month only, three of 148 patients were stool-culture positive in the chloramphenicol group and none in the gatifloxacin group. At the end of 3 months only one person had a positive stool culture in the chloramphenicol group. There were no other positive stool cultures even at the end of 6 months. Late relapses were noted in three of 175 patients in the culture-confirmed chloramphenicol group and two of 177 in the gatifloxacin group. There were no culture-positive relapses after day 62. 99 patients (24%) experienced 168 adverse events in the chloramphenicol group and 59 (14%) experienced 73 events in the gatifloxacin group.
  
  
  CONCLUSIONS
  Although no more efficacious than chloramphenicol, gatifloxacin should be the preferred treatment for enteric fever in developing countries because of its shorter treatment duration and fewer adverse events.
  
  
  BACKGROUND
  Wellcome Trust.
authors.affiliation: Oxford University Clinical Research Unit-Patan Academy of Health Sciences, Kathmandu, Nepal.
authors.forename: Amit
authors.initials: A
authors.lastname: Arjyal
authors.forename: Buddha
authors.initials: B
authors.lastname: Basnyat
authors.forename: Samir
authors.initials: S
authors.lastname: Koirala
authors.forename: Abhilasha
authors.initials: A
authors.lastname: Karkey
authors.forename: Sabina
authors.initials: S
authors.lastname: Dongol
authors.forename: Krishna Kumar
authors.initials: KK
authors.lastname: Agrawaal
authors.forename: Nikki
authors.initials: N
authors.lastname: Shakya
authors.forename: Kabina
authors.initials: K
authors.lastname: Shrestha
authors.forename: Manish
authors.initials: M
authors.lastname: Sharma
authors.forename: Sanju
authors.initials: S
authors.lastname: Lama
authors.forename: Kasturi
authors.initials: K
authors.lastname: Shrestha
authors.forename: Nely Shrestha
authors.initials: NS
authors.lastname: Khatri
authors.forename: Umesh
authors.initials: U
authors.lastname: Shrestha
authors.forename: James I
authors.initials: JI
authors.lastname: Campbell
authors.forename: Stephen
authors.initials: S
authors.lastname: Baker
authors.forename: Jeremy
authors.initials: J
authors.lastname: Farrar
authors.forename: Marcel
authors.initials: M
authors.lastname: Wolbers
authors.forename: Christiane
authors.initials: C
authors.lastname: Dolecek
mesh_terms: D000293:Adolescent; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D002648:Child; D002675:Child, Preschool; D002701:Chloramphenicol / Q000008:administration & dosage*; D005243:Feces / Q000382:microbiology; D024841:Fluoroquinolones / Q000008:administration & dosage*; D000077734:Gatifloxacin; D006801:Humans; D053208:Kaplan-Meier Estimate; D008826:Microbial Sensitivity Tests; D009390:Nepal; D016016:Proportional Hazards Models; D019779:Salmonella enterica / Q000187:drug effects / Q000302:isolation & purification; D013997:Time Factors; D017211:Treatment Failure; D014435:Typhoid Fever / Q000097:blood / Q000188:drug therapy* / Q000382:microbiology; D055815:Young Adult
chemical_list: D000900:Anti-Bacterial Agents; D024841:Fluoroquinolones; D002701:Chloramphenicol; D000077734:Gatifloxacin