Department of Pharmacy Services

XDR Typhoid Advisory

Feb 2019

WHAT IS TYPHOID FEVER? WHAT IS THE CURRENT SITUATION

Typhoid fever is a serious disease caused by Salmonella Typhi that is spread by IN PAKISTAN?
contaminated food and water. Symptoms of typhoid fever include high fever, weakness,
stomach pain, headache, cough, and loss of appetite. Some people have diarrhea or Health officials in Pakistan have
constipation. In rare cases, typhoid fever can be fatal. reported an ongoing outbreak of XDR
typhoid fever that began in Hyderabad
WHY WORRY? - EMERGING RESISTANCE - A BIG CHALLENGE in November 2016 and spread to the
city of Karachi and to multiple districts,
rd
Reduced susceptibility to Fluoroquinolones and 3 Generation Cephalosporins and first, and several deaths have been reported.
the emergence of Multidrug Resistance (MDR) and now Extensively Drug Resistant During 2016-18, 8188 cases of typhoid
(XDR) bugs has complicated treatment. Apart from parenteral Carbapenems, have been reported out of which 64%
Azithromycin is the only oral/outpatient treatment option available for XDR Typhoid. It were XDR typhoid.
is highly recommended that hospitals and general practitioners must not routinely use (Ref: https://www.who.int/csr/don/27-
Azithromycin (Oral/IV) for ‘non-typhoid’ infections (e.g. URTIs) and rather use alternate december-2018-typhoid-pakistan/en/)
drugs (e.g. IV/PO Fluoroquinolones or Clarithromycin) for covering atypical organisms
as much as possible. HOW TO PREVENT?
Food, Water & Hygiene
 RESERVE AZITHROMYCIN FOR XDR TYPHOID CASES ONLY  Limit consuming raw,
unwashed/poorly
cooked/unhygienic food and water
 Frequent hand washing (especially
TREATMENT of DRUG RESISTANT TYPHOID
before meals)
Antimicrobial therapy shortens the clinical course of enteric fever and reduces the risk  Chlorine tablets to purify water
for death. and improving sanitary conditions
 For MDR Typhoid, use oral Cefixime (or IV Ceftriaxone for severe cases) in affected communities
 For XDR Typhoid, Azithromycin or Carbapenems are indicated (based on Vaccine/Role of Immunization
susceptibility testing).
Typhoid vaccines protect 50%–80% of
 Azithromycin: Adult dosage: 1,000 mg orally once then 500 mg orally daily OR 1,000 recipients and should be offered to
mg orally once daily for 7 days. Pediatric dose is 20 mg/kg orally once then 10–20 patients with increased risk of
mg/kg orally once per day (max 1,000 mg/day) for 7 days. exposure.
 Carbapenems should be used for patients with suspected severe or complicated Vi Capsular Polysaccharide Typhoid
typhoid. It includes, but not be limited to, patients with GI complications (e.g. vaccine (Typbar)
typhoid-related intestinal perforation, peritonitis, intestinal hemorrhage, hepatitis), The parenteral polysaccharide Vi
neurologic complications (e.g. Meningitis, typhoid encephalopathy, including altered vaccine is administered as a single 0.5
consciousness, delirium, confusion), or bacteremia with sepsis or shock. mL intramuscular injection (min. age
 ID (Infectious Disease) consult is highly recommended for suspected/ confirmed 6months). A booster dose is may be
XDR typhoid cases. given after 3 years
(Ref: https://www.who.int/csr/don/27-
INFORMATION FOR HEALTH CARE PROFESSIONALS december-2018-typhoid-pakistan/en/)

The XDR strain of Salmonella Typhi is resistant to most antibiotics (Ampicillin,

Chloramphenicol, TMP-Sulfamethoxazole, Ciprofloxacin and Ceftriaxone) used to treat typhoid fever. Health care
providers should:
 Obtain a complete travel history (esp. to Hyderabad, Karachi and other parts of Sindh)
 Collect stool and blood cultures from patients with suspected typhoid fever and request antimicrobial
susceptibility testing on isolates.
o Start empiric treatment and adjust as per the susceptibility reports
o Avoid using unnecessary/broad spectrum antibiotics
 Be aware that relapses can occur, often 1–3 weeks after clinical improvement.
 ID consult is highly recommended for suspected/confirmed XDR typhoid cases
 Reserve Azithromycin for XDR typhoid only and use alternate drugs for non-typhoid infections

If you need any other information contact on the following number or email:

: 3462, 3977, 3492; Email: drug.information@shifa.com.pk