Synopsis
Recognise typhoid and paratyphoid after travel or food exposure, secure cultures before treatment when safe, manage severity and resistance intelligently, and complete exclusion, clearance and notification duties.
- Enteric fever is systemic infection caused by Salmonella enterica serovars Typhi or Paratyphi, usually acquired through food or water contaminated by human faeces.
- Think of sustained fever with headache, malaise and abdominal symptoms after travel to South Asia or another endemic region; diarrhoea, constipation or no bowel disturbance are all possible.
- Blood culture is the first-line diagnostic test and should be obtained before antimicrobials whenever this does not delay treatment of a severely unwell patient.
- Send stool culture as an additional investigation, but a negative stool result does not exclude acute disease; bone-marrow culture is more sensitive but is reserved for specialist diagnostic difficulty.
- For uncomplicated disease without an extensively drug-resistant exposure, oral azithromycin 500 mg once daily for seven days is a current UK specialist-supported empirical option.
- Complicated infection ordinarily requires intravenous ceftriaxone 2 g once daily; suspected complicated extensively drug-resistant disease may require meropenem plus azithromycin pending susceptibility.
- Do not choose ciprofloxacin empirically because fluoroquinolone non-susceptibility is common; use it only when the isolate is fully susceptible and the specialist plan supports it.
- Typhoid and paratyphoid are notifiable diseases in England. Notify on clinical suspicion and cooperate with the health protection team on exclusion, contact assessment and clearance cultures.
Key red flags
Hypotension, altered consciousness, rising lactate, oliguria or respiratory compromise indicates severe infection and requires immediate sepsis care.
Sudden worsening abdominal pain, guarding, rigidity, free air or unexplained deterioration suggests terminal ileal perforation and needs urgent surgical assessment.
Melaena, haematochezia, haematemesis, falling haemoglobin or circulatory instability can represent enteric-fever intestinal haemorrhage.
Travel from Pakistan, Iraq or another setting with extensively drug-resistant strains changes empirical therapy and demands immediate specialist microbiology advice.
Fever after tropical travel still requires urgent malaria films; identifying enteric fever does not safely exclude malaria or another concurrent infection.
Pregnancy, infancy, advanced age, immunosuppression and inability to take oral treatment lower the threshold for admission and intravenous therapy.
Fever usually rises over several days with headache, marked malaise, anorexia, dry cough or myalgia; the patient may look disproportionately unwell despite few focal signs.
Confusion, delirium, reduced consciousness, seizure or focal neurology may accompany severe disease and should prompt glucose measurement, sepsis care and assessment for meningitis or cerebral malaria.
Investigation priorities
Confirm bacteraemia, identify Typhi or Paratyphi and generate the susceptibility profile that controls definitive therapy.
Management branches
Sustained fever or compatible systemic illness follows residence in or travel to an endemic setting.
- Perform ABCDE, establish dates and exact locations, review antibiotics and vaccination, and assess for bleeding, peritonism, encephalopathy and shock.
- Take blood-culture sets before antimicrobials if this can be done immediately; add stool culture, severity bloods and urgent malaria testing without allowing sampling to delay resuscitation.
- Notify suspected typhoid or paratyphoid according to national arrangements and contact the health protection team early for risk-group, household and occupational advice.
- Ask microbiology or infection specialists to select empirical treatment from severity, likely geography and current resistance data, then narrow when organism and susceptibility are known.
The patient has no shock, organ dysfunction, gastrointestinal complication or absorption problem and reliable follow-up is possible.
- For disease without an extensively drug-resistant exposure, use oral azithromycin 500 mg once daily for seven days as a supported empirical regimen, checking interactions and pregnancy.
- Review within 48 to 72 hours because fever may resolve slowly; confirm adherence, culture result and susceptibility rather than changing treatment for fever alone in a stable improving patient.