Typhoid Fever Management

Diagnostic Approach

• In febrile travelers from endemic regions, malaria must be excluded first, with a sensitivity of 40-80% in the first week of illness, and blood smear or rapid diagnostic test for malaria should be performed, as recommended by the Centers for Disease Control and Prevention and the Infectious Diseases Society of America 1
• Blood cultures should be collected immediately, as the yield is highest within the first week of illness, and multiple sets may increase yield, with up to 80% sensitivity in the first week of illness 2, 3, 1
• The Widal test is not recommended due to poor sensitivity and specificity, and newer rapid serological tests have shown mixed results and are not reliable enough for definitive diagnosis, as stated by the Infectious Diseases Society of America 1
• Stool cultures are essential for diagnosis, according to the Centers for Disease Control and Prevention 3
• Other causes of fever with similar presentations, such as malaria, dengue, and rickettsial diseases, should be considered as alternative diagnoses, with a typical incubation period for typhoid of 7-18 days (range: 3-60 days) 1, 4

Antibiotic Resistance and Treatment

• Over 70% of S. typhi isolates imported to the UK are resistant to fluoroquinolones, and the following treatment options are recommended for different strains of Salmonella Typhi:

• First-line treatment for adults is Ceftriaxone 2g IV once daily for 7-14 days, as recommended by the Infectious Diseases Society of America 2
• Azithromycin is recommended for uncomplicated typhoid fever, with a dosage of 20 mg/kg/day for 7 days, and is preferred for children and pregnant women due to its safety profile, as suggested by the World Health Organization and other guideline societies 5
• Immunocompromised patients, including HIV-infected individuals, may require longer duration of therapy, and alternative treatment options such as ceftriaxone or azithromycin, as recommended by the Infectious Diseases Society of America 2, 5

Prevention and Special Populations

• High-risk populations, including infants <3 months, adults >50 years with vascular abnormalities, and severely immunocompromised patients, may require antibiotic treatment, as recommended by the American Academy of Pediatrics and the Centers for Disease Control and Prevention 2
• HIV-infected persons with Salmonella septicemia require long-term therapy to prevent recurrence, as recommended by the Centers for Disease Control and Prevention 6
• Pregnant women should avoid fluoroquinolones when possible, and alternative options such as third-generation cephalosporins or ampicillin should be considered, as recommended by the Centers for Disease Control and Prevention and the American College of Obstetricians and Gynecologists 6, 7, 3, 8
• Typhoid vaccination is recommended for travelers to endemic areas, as suggested by the Centers for Disease Control and Prevention, the World Health Organization, and the Clinical Infectious Diseases guidelines 9, 2, 7, 1, 5, 3, 10

Infection Control and Follow-up

• Proper hand hygiene is essential to prevent transmission, especially after using the toilet and before food preparation, as recommended by the Infectious Diseases Society of America 2, 7, 1, 5, 3, 10
• Household contacts should be evaluated for asymptomatic carriage, according to the Centers for Disease Control and Prevention 6
• Follow-up testing is not routinely recommended after symptom resolution, except for food handlers, healthcare workers, or childcare providers, according to the Infectious Diseases Society of America, and asymptomatic shedding of Salmonella Typhi can persist beyond a year in some patients 2
• Consider changing the antibiotic regimen if no improvement is seen within 2 days of starting treatment, as suggested by the Centers for Disease Control and Prevention 11