Recognition and Management of Drug-Resistant Typhoid Fever

Kevin Chatham-Stephens, MD, MPH


October 08, 2018

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Hello. I am Dr Kevin Chatham-Stephens, a medical epidemiologist with the Enteric Diseases Epidemiology Branch at CDC. As part of the CDC Expert Commentary Series on Medscape, I would like to tell you about drug-resistant typhoid fever.

Antimicrobial resistance is one of the biggest public health challenges of our time. Recently, drug-resistant typhoid fever has become an increasing concern. Patients with typhoid fever, which is caused by Salmonella Typhi bacteria, typically have high fever, headache, cough, abdominal pain, and constipation or diarrhea. There are 300-400 culture-confirmed cases of typhoid fever in the United States annually, mostly among international travelers.

The first known outbreak of extensively drug-resistant (XDR) typhoid fever is occurring in Pakistan. The S Typhi strain causing this outbreak is resistant to multiple antibiotics, including chloramphenicol, ampicillin, trimethoprim-sulfamethoxazole, and fluoroquinolones (ciprofloxacin and ceftriaxone). The outbreak strain is susceptible to carbapenems and azithromycin. In addition to the patients in Pakistan, one patient in the United Kingdom and two patients in the United States have been diagnosed with XDR typhoid fever after returning from Pakistan.

Vaccination can help prevent typhoid fever. CDC recommends vaccination for people traveling to places where typhoid fever is endemic, such as South Asia, especially India and Pakistan. Two typhoid fever vaccines are available in the United States. The oral live attenuated vaccine (brand name Vivotif®) consists of four capsules, with one capsule taken every other day over the course of a week. This vaccine can be given to patients at least 6 years old and should be completed at least 1 week before traveling. A booster series is recommended every 5 years as needed.

The Vi capsular polysaccharide vaccine (brand name Typhim Vi®) is given intramuscularly at least 2 weeks before traveling. This vaccine can be given to patients at least 2 years old, and a booster dose is recommended every 2 years as needed.

In addition to vaccination, be sure to advise your patients to select food and water carefully while traveling internationally; practical advice can be found on the CDC Travelers' Health website. Tell your patients to seek medical care, even while abroad, if they have symptoms consistent with typhoid fever, such as feeling very ill with fever, fatigue, headache, and abdominal pain. If you suspect that your patient has typhoid fever, obtain a complete travel history, order blood or stool cultures and antimicrobial susceptibility testing, and consider getting an infectious diseases consultation. If S Typhi is isolated, notify your local or state health department.

And carefully consider treatment options for patients with typhoid fever. For patients who have traveled to Pakistan, azithromycin should be used for suspected uncomplicated typhoid fever, but carbapenems should be used for patients with suspected severe or complicated typhoid fever. When culture and sensitivity results are available, adjust the treatment regimen accordingly. Because fluoroquinolone (including ciprofloxacin) resistance is very high among typhoid fever patients in the United States, especially those who have traveled to South Asia, avoid empiric treatment with fluoroquinolones.

For more information, please visit CDC's typhoid fever website.

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