Treatment Guidelines of

Enteric Fever
(typhoid and paratyphoid)
in Adults

APPROVED BY:
TRUST REFERENCE:

B8/2009

Date (approved):

July 2008

MOST RECENT REVIEW:

July 2008

NEXT REVIEW:

July 2009

ORGINATOR (Author):

I.Stephenson

RATIFIED BY:

UHL Antimicrobial Working Party July 2008

Treatment Guidelines of Enteric fever (typhoid and paratyphoid) in adults

Introduction
Typhoid is caused by Salmonella typhi and is a serious life threatening infection. Paratyphoid, caused
by S. paratyphi, is similar to typhoid but generally milder. The causative organisms are acquired by
ingestion of contaminated food or water and are widespread in subtropical or tropical areas and
developing countries with poor hygiene. The majority of Leicester cases are imported in returning
travellers, however outbreaks and isolated cases from food-borne contamination do occur in the UK.

Clinical guidance
History details: Where has the patient been and for how long? Did they have any illness or
antibiotics when away? When did they return? Are household contacts or travel companions unwell?
Typhoid typically presents 5-21 days of infection but partial treatment may delay onset of symptoms.
Presenting symptoms: are often non-specific and may include malaise, fever and rigors. Prominent
features include headache, cough, diarrhoea, constipation and abdominal pain.
Presenting signs: fever (often high >38OC and unremitting), relative bradycardia, hypotension,
confusion, meningism, splenomegaly and rose spots on the abdomen.
Severe infection and complications: intestinal bleeding and perforation with peritonitis may occur if
untreated and bacteraemic seeding can cause cerebral, bone, splenic or pulmonary infections

Differential diagnosis: returning travellers may have more than one imported infection: malaria,
hepatitis, systemic sepsis, pneumonia, meningitis, viral illness e.g. dengue, HIV

Investigations required on admission: FBC and differential count, clotting, thick and thin films for
malaria parasite count, U&E, LFT, Bone, CRP, glucose, blood cultures (with high risk labels),
MSU, stool MC&S, CXR
Diagnosis: Blood cultures are positive in up to 80% cases. Stool cultures are positive in up to 40%
cases. There is no serological test.
Other features: low to normal white cell count, raised CRP, abnormal liver function tests (raised ALT)
Do not start empirical treatment without obtaining blood cultures. Blood cultures can be taken
even if patient currently afebrile.

If suspected enteric fever call ID unit to arrange admission (ext 6269 or 6952) and seek advice from
ID SpR/consultant on call.

Treatment Guidelines of Enteric Fever

Author: I.Stephenson
Written June 2008
Contact: I.Stephenson
Last Reviewed July 2008
Trust Ref: TBC
Next Review July 2009
NB: Paper copies of guideline may not be most recent version. The definitive version is held on the INsite Documents at http://dms.xuhl-tr.nhs.uk

Treatment
Do not start empirical treatment without obtaining blood cultures. Blood cultures can be taken
even if patient currently afebrile.
Typhoid is usually treated with a single agent antibiotic and fluoroquinolones have therapeutic
advantages to beta-lactam therapy for uncomplicated typhoid when organisms are fully susceptible.
However, treatment is complicated by emergence and spread of resistance to antibiotics traditionally
used such as amoxicillin, septrin and quinolones particularly in south east Asia. Therefore it is
important to obtain appropriate specimens before treatment so that antimicrobial susceptibilities can
be determined to guide treatment.
Immediate treatment and management:
1. Ensure blood cultures (with high risk labels) and investigations are obtained
2. Supportive treatment with i.v. fluids if needed
3. Patient should be nursed in isolation with standard precautions
4. Transfer to Infectious Diseases Unit. Admit all patients with suspected enteric fever
5. Patients with suspected or confirmed enteric fever should be reported to Consultant in
Communicable Diseases at the local Health Protection Agency (contact details below)
6. First line antimicrobial treatment: i.v. ceftriaxone 2g once daily
a. For patients with cephalosporin allergy use: Azithromycin 1g orally once, followed by
500mg od daily.
b. If patient unable to tolerate oral antibiotics: imipenem 500mg q.d.s i.v
Monitoring treatment:
1. Adjust antimicrobial treatment according to antimicrobial susceptibilities with advice from ID or
microbiology
2. Effective antimicrobials may include:
a. Ciprofloxacin 500mg bd
b. Azithromycin 500mg od
c. Amoxicillin 1g tds
d. Cotrimoxazole 480 mg bd
3. Monitor temperature, FBC, LFT and CRP for response
4. If non-responding to treatment consider pyogenic collection and ask for ID advice
Duration of treatment:
1. Duration of treatment should be 10-14 days depending on clinical response
Follow up:
1. Arrange outpatient follow-up with Infectious Diseases Unit at 3 weeks
2. Relapse of infection can occur within 3 weeks in some patients: in these cases repeat
antimicrobial treatment for 21 days is advised
Chronic carriage:
Chronic carriage is recognised in some patients and is generally defined as persistent culture of S
typhi in stool at least 12 months after acute infection. These patients do not have symptomatic
disease, but by excreting organisms they pose an infective risk to others. Eradication is difficult
requiring at least 28 days of appropriate therapy which should be guided by antimicrobial
susceptibilities. Discuss ID or microbiology for advice. Cholecystectomy could be considered.

Public Health involvement

Suspected enteric fever is a notifiable public health infection.
All confirmed cases of enteric fever must be reported to the Consultant in Communicable Diseases at the local
Health Protection Agency who can be contacted on 0116 2631400
Treatment Guidelines of Enteric Fever
Author: I.Stephenson
Written June 2008
Contact: I.Stephenson
Last Reviewed July 2008
Trust Ref: TBC
Next Review July 2009
NB: Paper copies of guideline may not be most recent version. The definitive version is held on the INsite Documents at http://dms.xuhl-tr.nhs.uk