Synopsis
Recognise enteric fever after travel, obtain cultures before antimicrobial exposure, treat according to severity and resistance and coordinate notification, exclusion and clearance with UK health protection.
- Suspect enteric fever in a returning traveller with sustained fever, headache, malaise and abdominal symptoms, even when diarrhoea is absent.
- Ask exact countries, dates, urban or rural exposure, food and water, visiting friends and relatives, vaccination and every antibiotic taken abroad.
- Obtain multiple blood-culture sets before antibiotics; blood culture is the practical first-line diagnostic test early in illness.
- Send stool culture as well, but a negative early stool result does not exclude systemic enteric fever.
- Bone-marrow culture is the most sensitive culture method and may remain positive after antibiotics, but its invasiveness limits routine use.
- Start intravenous ceftriaxone for severe susceptible-pattern disease while seeking urgent specialist resistance advice; XDR exposure may require a carbapenem.
- Azithromycin is used for selected uncomplicated susceptible disease, while ciprofloxacin is used only when the isolate is fully susceptible.
- Notify suspected typhoid or paratyphoid promptly and follow health-protection instructions for contacts, exclusion and microbiological clearance.
Key red flags
Peritonism, sudden worsening abdominal pain or free air suggests ileal perforation requiring emergency surgery.
Haematemesis, melaena, haematochezia or falling haemoglobin can reflect ulceration and major intestinal bleeding.
Confusion, reduced consciousness, shock, oliguria or rising lactate marks severe systemic disease.
Travel to Pakistan or another setting with extensively drug-resistant typhoid materially changes empirical antimicrobial choice.
Persistent fever after five to seven days of active treatment suggests resistance, complication, inadequate exposure or an alternative diagnosis.
Food handling, healthcare, social care and contact with vulnerable people create immediate public-health exclusion and clearance implications.
Delirium, encephalopathy, meningism or reduced consciousness indicates complicated illness and mandates urgent hospital treatment.
Increasing right-lower-quadrant pain, guarding, bleeding or ileus during the second or third week suggests ileal ulceration.
Visiting friends and relatives, unsafe food or water and antibiotic purchase abroad define probability and likely resistance more accurately than vaccination history alone.
Investigation priorities
Recover S Typhi or Paratyphi and determine susceptibility before antimicrobial exposure.
Management branches
A traveller has sustained fever and an exposure pattern compatible with typhoid or paratyphoid.
- Use immediate travel and malaria assessment, examine for shock, encephalopathy, bleeding and peritonism and begin enteric isolation precautions.
- Obtain several blood-culture sets, stool culture, full blood count, renal and liver profile before antibiotics when this causes no dangerous delay.
- Tell microbiology the countries, dates and any overseas antibiotics so culture handling and resistance risk are interpreted correctly.
- Notify the local health-protection team on suspicion rather than waiting for final serovar confirmation.
The patient is stable, can absorb tablets, has no complication and resistance risk is addressed.
- Use azithromycin 500 mg orally once daily for seven days when selected for susceptible uncomplicated infection by local or specialist guidance.
- Use ciprofloxacin only if the isolate is fully susceptible; do not rely on travel region or historical fluoroquinolone use.
- Review fever curve and clinical condition daily; fever may resolve gradually, but deterioration or persistent fever triggers repeat cultures and complication search.