Typhoid (enteric fever)
Diagnose with a blood culture, not a Widal or Typhidot. Treat with azithromycin for uncomplicated typhoid, and meropenem for severe or XDR typhoid.
A 17-year-old from Karachi has had fever for 9 days, getting higher each evening, with headache, belly ache and loose stools. He took ciprofloxacin from a pharmacy for 3 days without improvement. A private lab report says "Typhidot IgM positive". Pulse 88 with a temperature of 39.4 °C.
How do you confirm typhoid, and which antibiotic?
- Look for complications firstSevere belly pain, guarding, black stools, confusion, shock. These need admission and senior review now.
- Blood culture before antibioticsThe test that confirms typhoid and shows sensitivities.
- Do not rely on Widal or TyphidotThey give false positives and false negatives.
- Ask about previous antibioticsPharmacy ciprofloxacin or cefixime is common and affects resistance and culture.
- Uncomplicated: oral azithromycinWorks against most typhoid in Pakistan, including XDR.
- Severe or complicated: IV meropenemAdmit. Usually with azithromycin.
- Paracetamol and fluidsNo NSAIDs or steroids routinely.
- Review the culture resultChange to the narrowest drug the organism is sensitive to.
- Severe belly pain, guarding or distension
- Black stools or blood per rectum
- Confusion or drowsiness
- Low BP or shock
- Persistent vomiting, cannot take oral medicines
- Pregnant
- Not improving after 5 days of treatment
| Diagnosis | Blood culture, ideally in the first week, before antibiotics |
| Uncomplicated | Oral azithromycin for 7 days. Dose in the treatment section |
| Severe or XDR suspected | IV meropenem, usually with azithromycin |
| Ciprofloxacin and ceftriaxone | Do not use empirically in Pakistan unless the culture shows sensitivity |
| Expected response | Fever usually settles within about 4–6 days of the right antibiotic |
Check every dose against a current drug reference and your hospital protocol.
On this page
What it is
Typhoid (enteric fever) is a bloodstream infection with Salmonella Typhi or Paratyphi, spread through contaminated food and water. It is common across Pakistan.
Since 2016, extensively drug-resistant (XDR) typhoid has spread from Sindh to other parts of Pakistan. XDR strains are resistant to:
- Chloramphenicol, ampicillin, co-trimoxazole (multidrug resistance)
- Ciprofloxacin and other fluoroquinolones
- Ceftriaxone and other third-generation cephalosporins
They remain sensitive to azithromycin and carbapenems (meropenem). This is why azithromycin and meropenem are the empirical choices in Pakistan.
Recognising typhoid
- Week 1Rising fever, headache, aches, belly discomfort
- Week 2High fever, very tired, belly pain, loose stools or constipation, enlarged spleen
- Week 2–3Complications: perforation, bleeding, confusion
- Week 4Slow recovery if they survive
- Fever that climbs over days (step-ladder), often worse in the evening.
- Headache, loss of appetite, belly pain, constipation or diarrhoea, dry cough.
- Relative slow pulse for the height of the fever (not always present).
- Coated tongue, tender belly, enlarged spleen or liver. Rose spots are rarely seen on brown skin.
Tests: what helps and what misleads
| Test | Use |
|---|---|
| Blood culture | The best test. Highest yield in the first week and before antibiotics. Gives sensitivities, which matter with XDR |
| Bone marrow culture | Higher yield, even after antibiotics. Specialist use |
| Stool culture | Positive later in the illness, or in carriers |
| CBC | Often normal or low white count, low platelets in severe cases |
| LFTs | Mildly raised enzymes are common |
| Widal test | Unreliable. False positives from past infection, vaccination and other infections. False negatives early. Do not diagnose typhoid on a Widal |
| Typhidot | Unreliable for diagnosis in Pakistan. Do not start or change treatment on it alone |
| Malaria test, dengue NS1, CBC | Other causes of fever |
A positive Widal or Typhidot is not a diagnosis. A fever with a positive rapid test can still be dengue, malaria, TB or another infection. Send a blood culture and treat the patient, not the report.
Who needs admission
- Eating and drinking
- Stable observations
- No severe belly pain, bleeding or confusion
- Oral azithromycin, review in 2–3 days
- Severe belly pain or guarding
- Black stools or bleeding
- Confusion, drowsiness, shock
- Persistent vomiting
- Admit, IV meropenem, senior review
Treatment
- Culture shows sensitivity to ceftriaxone or ciprofloxacin? Then these can be used. Do not use them empirically in Pakistan.
- Children: weight-based dosing. See the paediatric protocol.
- Pregnancy: azithromycin and meropenem are used. Involve obstetrics.
- Steroids: dexamethasone only for severe typhoid with delirium or shock, on senior advice.
Expect a slow response
- The fever usually takes about 4–6 days to settle even on the right antibiotic. Do not switch drugs on day 2 because the fever is still there.
- Not improving after 5 days: check the culture result, look for a complication or abscess, and reconsider the diagnosis (dengue, malaria, TB, liver abscess).
Complications
Sudden worsening of belly pain, guarding, distension, shock. Free air under the diaphragm on an erect chest X-ray. Call the surgeons now. Nil by mouth, IV fluids, IV meropenem and metronidazole, and surgery. See Perforation.
- GI bleeding: black stools or fresh blood. Resuscitate and call your senior.
- Typhoid encephalopathy: confusion, drowsiness, agitation.
- Hepatitis, myocarditis, pneumonia, and others.
- Relapse in a few patients weeks after recovery: culture and treat again.
- Chronic carriers (more common with gallstones) can spread infection, especially food handlers.
Prevention
- Typhoid conjugate vaccine (TCV) is part of Pakistan's routine childhood immunisation programme. Encourage it for children and catch-up for others.
- Safe water (boiled or treated), hand washing, safe food.
- Do not take antibiotics from pharmacies without a prescription. Self-medication drives resistance.
Common mistakes
- Diagnosing typhoid on a Widal or Typhidot report.
- Starting ciprofloxacin or cefixime for typhoid in Pakistan.
- Not sending a blood culture before the first antibiotic dose.
- Changing antibiotics on day 2 because the fever has not settled.
- Missing a perforation in week 2–3 because the patient is "known typhoid".
- Missing dengue or malaria because a rapid typhoid test was positive.
Frequently asked questions
What is the treatment of XDR typhoid in Pakistan?
Uncomplicated: oral azithromycin for 7 days. Severe or complicated: IV meropenem, usually with azithromycin. Treatment is adjusted to the blood culture sensitivities.
Is the Widal test reliable for typhoid?
No. It gives false positives and false negatives. Blood culture is the test that confirms typhoid.
Is Typhidot reliable?
Not for diagnosis on its own. It should not be used to start or change treatment without clinical assessment and blood culture.
How long does fever take to settle after starting antibiotics for typhoid?
Usually about 4 to 6 days. Persistent fever beyond 5 days needs review for resistance, complications or another diagnosis.
What is the best treatment for typhoid in Pakistan?
Uncomplicated typhoid is treated with oral azithromycin for 7 days, and severe or complicated typhoid with IV meropenem, because of widespread XDR typhoid. Treatment is adjusted to the blood culture result.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A 26-year-old has had fever for 6 days. Widal test is "positive". No blood culture has been sent. What is the best next step?
Answer: Send a blood culture and start azithromycin if typhoid is likely. Blood culture is the diagnostic test of choice in the first week. Widal has poor accuracy in endemic areas. With XDR typhoid in Pakistan, azithromycin is a common empirical oral choice.
- Repeat Widal in a week: Delays diagnosis.
- Treat on the Widal result alone with ceftriaxone: Widal is unreliable; culture first.
- Start ciprofloxacin: Fluoroquinolone resistance is widespread in Pakistan.
- Stool culture only: Blood culture is best in the first week.
2. On day 12 of typhoid fever a patient develops sudden severe abdominal pain, a rigid abdomen and BP 90/60. What is the most likely complication?
Answer: Typhoid ileal perforation. Ileal perforation typically occurs in the second or third week. Resuscitate, nil by mouth, broad-spectrum IV antibiotics (for example meropenem with metronidazole) and urgent surgery.
- Typhoid hepatitis: Doesn't cause a rigid abdomen.
- Normal course of typhoid: This is an emergency.
- Acute cholecystitis: Less likely; peritonism is generalised.
- Drug reaction to azithromycin: Not this picture.
3. A blood culture grows extensively drug-resistant (XDR) Salmonella Typhi. Which drugs remain effective?
Answer: Azithromycin and carbapenems. XDR typhoid in Pakistan is resistant to chloramphenicol, ampicillin, co-trimoxazole, fluoroquinolones and third-generation cephalosporins. Azithromycin and carbapenems remain options.
- Gentamicin: Not effective for typhoid.
- Chloramphenicol and co-trimoxazole: Resistant in XDR strains.
- Ciprofloxacin and ceftriaxone: XDR strains are resistant to both.
- Amoxicillin: Resistant.
4. Since 2016, an outbreak of extensively drug-resistant (XDR) typhoid has spread in Sindh. Which public health measures are most important for control?
Answer: TCV, WASH, rational antibiotics. XDR Salmonella Typhi (resistant to chloramphenicol, ampicillin, co-trimoxazole, fluoroquinolones and third-generation cephalosporins) emerged in Hyderabad and spread across Sindh and beyond; treatment options are azithromycin (uncomplicated) and carbapenems (complicated). Control: TCV (single dose, from 6 months — campaigns in Sindh, then added to Pakistan’s routine EPI at 9 months; Pakistan was the first country to introduce TCV into routine immunisation), WASH (safe chlorinated water, sewage separation from water pipes, latrines), food hygiene, identifying chronic carriers, antimicrobial stewardship (avoid unnecessary antibiotics), and surveillance with blood cultures and sensitivity testing.
- Ciprofloxacin for fevers: Giving ciprofloxacin for fevers worsens resistance.
- Vaccinate over-60s: Children, not people over 60, carry most of the burden.
- Azithromycin prophylaxis for all: Mass azithromycin prophylaxis would drive resistance to the last oral option.
5. A 9-year-old in Hyderabad (Sindh) has fever for 8 days, relative bradycardia and blood cultures growing Salmonella Typhi resistant to ceftriaxone and fluoroquinolones. Which is the oral option for this XDR strain?
Answer: Azithromycin. XDR typhoid, emerging from Hyderabad (Sindh) since 2016, is resistant to chloramphenicol, ampicillin, co-trimoxazole, fluoroquinolones and third-generation cephalosporins. Treatment: azithromycin for uncomplicated disease; meropenem (± azithromycin) for complicated/severe illness. Prevention: typhoid conjugate vaccine (TCV) in the EPI schedule at 9 months, safe water and hygiene.
- Ciprofloxacin: XDR strains are resistant to fluoroquinolones.
- Co-trimoxazole: XDR strains are resistant to co-trimoxazole.
- Chloramphenicol: XDR strains are resistant to chloramphenicol.
6. A man with 10 days of step-ladder fever has a pulse of 80/min at 39.5 °C, a coated tongue and a low white cell count. What is the most likely diagnosis?
Answer: Typhoid fever. Typhoid (Salmonella Typhi) gives a slowly rising fever, a pulse slower than expected for the temperature (relative bradycardia), leukopenia, abdominal pain, rose spots and splenomegaly. Blood culture is best in week 1; Widal is unreliable. Complications in week 3 include bowel perforation and bleeding from Peyer's patches.
- Dengue fever: Sudden high fever, aches, low platelets; pulse usually fast.
- Falciparum malaria: Paroxysms of fever with rigors; check smears.
- Acute pyelonephritis: Loin pain, dysuria, high white count.
- Bacterial lobar pneumonia: Cough, rusty sputum, high white count.
7. Which test best confirms enteric (typhoid) fever during the first week of illness?
Answer: Blood culture. In the first week, Salmonella Typhi circulates in the blood, so blood culture is the test of choice (positive in 60–80%). Stool and urine cultures become positive in the second and third weeks. The Widal test is unreliable, especially in endemic areas like Pakistan. Bone marrow culture is the most sensitive but is reserved for difficult cases.
- Widal test: Antibodies take time to rise and give many false positives in endemic areas.
- Stool culture: Usually positive from the second week.
- Urine culture: Usually positive from the third week.
- Typhidot IgM: A rapid antibody test with limited specificity; it cannot confirm the diagnosis.
References and dose sources
- CDC: Typhoid fever clinical care
- WHO fact sheet: Typhoid
- Azithromycin dosing: Drugs.com: Azithromycin dosage (see also our azithromycin dose page)
- Paracetamol dosing: Drugs.com: Acetaminophen (paracetamol) dosage (see also our paracetamol dose page)
- Meropenem dosing: Drugs.com: Meropenem dosage (see also our meropenem dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.