Treatment Guidelines of Typhoid and Paratyphoid (Enteric fever) in Adults 1. Introduction and Scope - Library
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Treatment Guidelines of Typhoid and
Paratyphoid (Enteric fever) in Adults Trust ref: B8/2009
1. Introduction and Scope
Enteric fever is caused by Salmonella enterica serovars Typhi (typhoid) and Paratyphi
(paratyphoid), which can be a serious life threatening infection. The mortality rate untreated is
10%. The causative organisms are acquired by ingestion of contaminated food or water and are
widespread in subtropical or tropical areas and resource-poor countries with poor hygiene.
Nationally there are around 500 cases of enteric fever notified per year to Public Health England.
In Leicester we see around 10-15 cases per year. The majority of Leicester cases are imported
in returning travellers, however outbreaks and isolated cases from food-borne contamination do
occur in the UK.
This guideline covers the management of Typhoid and Paratyphoid in adults.
• The overarching Fever in the Returning Traveller guideline can be found here [click]
• The Diagnosis and Management of Enteric (Typhoid) Fever in Children and Young
People guideline can be found here [click]
2. Clinical guidance
History details:
Enteric fever typically presents within 2-3 weeks of exposure but partial treatment may delay
onset of symptoms.
• Where has the patient been and for how long? When did they return?
• Did they have any illness or antibiotics when away?
• Are household contacts or travel companions unwell?
Presenting symptoms:
Are often non-specific but fever is almost invariably present. Other prominent features include
malaise, headache, cough, diarrhoea, constipation and abdominal pain.
Presenting signs:
• Fever - often higher than 38 oC and unremitting (lasting more than 3 days),
• Relative bradycardia,
• Hypotension,
• Confusion,
• Meningism,
• Splenomegaly and rose spots on the abdomen (rare).
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. Please
see the Fever in Returning Travellers guideline (http://bit.ly/UHLFeverInTraveller).
Treatment Guidelines of Typhoid and Paratyphoid (Enteric fever) in Adults Page 1 of 5
V4 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B8/2009 Next review: December 2021
NB: Paper copies of guideline may not be most recent version. The definitive version is held on InsiteInvestigations required on admission: FBC and differential count, clotting, malarial parasite
screen, U&E, LFT, bone profile, CRP, glucose, blood cultures (three sets, label with high risk
labels and send in biohazard bag), HIV test, stool MC&S, CXR. Urine MC&S should be sent and
discussed with microbiology to ensure that the sample is cultured irrespective of the results
obtained on the automated cell count machine.
Diagnosis: Typhoid/paratyphoid can be diagnosed from blood, stool and urine cultures. There is
no useful serological test.
Other features: low to normal white cell count, raised CRP, abnormal liver function tests (raised
ALT)
If suspected enteric fever call Infectious Diseases Unit to arrange admission (ext 6269 or 6951)
and seek advice from Infectious Diseases SpR/consultant on call through switchboard.
Immediate treatment and management:
1. Ensure blood cultures (three sets, with high risk labels and in a biohazard bag) and other
investigations as listed above are obtained. Blood cultures can be taken even if the
patient is currently afebrile
2. Supportive treatment with i.v. fluids if needed
3. Patient should be nursed in isolation with standard precautions
4. Admit all patients with suspected enteric fever to the Infectious Diseases Unit.
5. Patients with suspected or confirmed enteric fever should be reported to Consultant in
Communicable Diseases at the local Public Health England unit (contact via switchboard)
Antimicrobial treatment:
Antibiotics should be avoided unless the patient is clinically unstable. If this is the case then
please contact the ID SpR/consultant on call to discuss treatment options.
Antimicrobial treatment for confirmed enteric fever:
• First line: Oral azithromycin 1 g on the first day and then 500 mg daily thereafter
• Second line, if the patient is unable to have treatment orally: IV meropenem 1 g every 8-
hours
Steroid treatment for severe disease:
Adjunctive corticosteroid treatment may be added in cases of severe disease, such as septic
shock, obtundation or coma.
These patients should be discussed with Infectious Diseases and Critical Care to determine
management and whether patient should be transferred to IDU or ITU.
Monitoring treatment:
1. Review treatment within 72-hours and adjust treatment according to antimicrobial
susceptibilities with advice from microbiology or Infectious Diseases.
2. Switch to oral medication treatment as soon as clinically appropriate.
3. Monitor temperature, FBC, LFT and CRP for response
4. Fever should diminish within 5-7 days. If not responding to treatment, consider pyogenic
collection or metastatic infection (including osteomyelitis, aortitis, and infective endocarditis)
and ask for Infectious Diseases advice
Treatment Guidelines of Typhoid and Paratyphoid (Enteric fever) in Adults Page 2 of 5
V4 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B8/2009 Next review: December 2021
NB: Paper copies of guideline may not be most recent version. The definitive version is held on InsiteDuration of treatment:
Duration of treatment is dependent upon the antibiotic regimen and the presence of any
complications. Infectious Diseases or microbiology will advise on the duration required.
Follow up:
• Up to 5-10% can have a relapse of infection. This usually occurs within 3 weeks (it can be
up to 3 months). Advice should be sought from Infectious Diseases.
• Having enteric fever does not induce immunity therefore advise patient to have typhoid
vaccine before their next travel to an at-risk country.
Chronic carriage:
5% can have chronic carriage. This is generally defined as persistent culture of Salmonella
enterica serovar 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.
These patients should be investigated for underlying abnormalities e.g. cholelithiasis or other
biliary tract abnormalities. Chronic carriage may occur in the urine and is associated with
schistosomiasis or urinary tract abnormalities
Eradication is difficult requiring at least 28 days of appropriate therapy which should be guided
by antimicrobial susceptibilities. Discuss with 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 Public Health
England, East Midlands Unit, who can be contacted via switchboard.
The public health department conduct surveillance questionnaires to help elucidate source,
identify people who are at risk of infection (e.g. co- travellers) and ensure clearance for specific
at risk groups (e.g. food handlers).
3. Education and Training
No additional education and training required within this guideline.
4. Monitoring compliance
What will be measured to How will compliance be Monitoring Reporting
Frequency
monitor compliance monitored Lead arrangements
Adherence to antimicrobial Annual Trust wide Antimicrobial Annually To CMG
therapy prescribing audit pharmacists boards
5. Key Words
Typhoid, Salmonella, typhi, paratyphi, enteric fever
Treatment Guidelines of Typhoid and Paratyphoid (Enteric fever) in Adults Page 3 of 5
V4 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B8/2009 Next review: December 2021
NB: Paper copies of guideline may not be most recent version. The definitive version is held on Insite6. References and Further Information
1. Butler T. Treatment of typhoid fever in the 21st century: promises and shortcomings. CMI
2011;17(7): 959-962
2. Clark et al. Enteric fever in a UK regional infectious disease unit : A 10 year retrospective
review J infect 2010; 60:91-98
3. Public health England website: Public Health Operational Guidelines for Typhoid and
Paratyphoid. http://www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/1317132464189
4. Effa E et al. Fluoroquinolones for treating typhoid and paratyphoid fever. The Cochrane
Library, 2012 issue 1.
5. Zaki1 SA et al. Multidrug-resistant typhoid fever: a review. J Infect Dev Ctries 2011;
5(5):324-337.
CONTACT AND REVIEW DETAILS
Guideline Lead (Name and Title) Executive Lead
Dr Helena White (ID Consultant) Medical Director
Contributing Authors Ratified by
Dr Ryan Hamilton (Antimicrobial Pharmacist) AWP 13 November 2018
Dr David Bell (ID Consultant) PGC 21 December 2018
Details of Changes made during review:
• Formatting changed
• Diagnostic guidance updated
• Empirical treatment updated
Treatment Guidelines of Typhoid and Paratyphoid (Enteric fever) in Adults Page 4 of 5
V4 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B8/2009 Next review: December 2021
NB: Paper copies of guideline may not be most recent version. The definitive version is held on InsiteReview Record
Date Issue No. Reviewed By Description of change (if any)
9.13 2 S.Alleyne • Use of biohazard bags
• 1 and 2 line agents and duration of treatment dependent
st nd
on agent
• Removed use of effective antimicrobials
• Discussed Urinary carriage
• Consider vaccination
• Contact number of Leicester HPU
27.7.15 3 R Hamilton & C • Meropenem dosing regimen rationalised
•
®
Ashton Septrin generic name given
5.1.17 4 H A White • Update PHE telephone number
R Hamilton • Simplification of discussion on antimicrobials and follow-up
D Bell • Addition of corticosteroids for severe disease
• Formatting changes
Treatment Guidelines of Typhoid and Paratyphoid (Enteric fever) in Adults Page 5 of 5
V4 Approved by Policy and Guideline Committee on 21 December 2018 Trust Ref: B8/2009 Next review: December 2021
NB: Paper copies of guideline may not be most recent version. The definitive version is held on InsiteYou can also read
