Approach to managing typhoid and paratyphoid fevers
Typhoid and paratyphoid fevers always require antibiotic treatment, unlike nontyphoidal Salmonella enteritis, which often requires supportive management only. Antibiotic choice depends on whether the patient is well enough to be treated in the community and, for patients who require hospital admission, the likely country of acquisition.
Patients with gastrointestinal symptoms may require supportive management in addition to antibiotic therapy; rehydration is the mainstay of therapy.
Some S. Typhi and S. Paratyphi isolates have high resistance rates to antimicrobials, which limits treatment options. Extensively drug-resistant (XDR) strains of S. Typhi that are resistant to third-generation cephalosporins (eg ceftriaxone, cefotaxime) are increasing in prevalence in parts of Asia, particularly in Pakistan. The prevalence of multidrug-resistant (MDR) strains of S. Typhi that are resistant to amoxicillin, trimethoprim+sulfamethoxazole and ciprofloxacin is increasing in both Asia and AfricaMarchello, 2020. Azithromycin resistance in S. Typhi has emerged recently in Bangladesh but remains rare in returned travellersNabarro, 2022.
Azithromycin, ceftriaxone, cefotaxime or meropenem may be indicated for empirical or directed therapy, depending on travel location and clinical factors. Ciprofloxacin should only be considered for directed therapy once susceptibility is confirmed. Aminoglycosides (such as gentamicin and tobramycin) are not clinically effective and must not be usedAustralian Commission on Safety and Quality in Health Care (ACSQHC), 2021.
Clinical response to treatment may be delayed for several days, even for infections caused by susceptible bacteria.
Typhoid and paratyphoid fevers are notifiable conditions. In addition to starting antibiotic therapy, refer patients with confirmed infection to the local public health authority1 so that public health management (eg follow-up testing) can be implemented. See also, the Australian public health guidelines for the management of typhoid and paratyphoid fevers.
Some patients with typhoid or paratyphoid fever become long-term carriers (ie continue shedding the organism in stool for more than 1 year) – seek expert advice for management.