5-Year Impact Factor: 0.9
Volume 34, 12 Issues, 2024
  Letter to the Editor     July 2024  

Extensively Drug-Resistant Salmonella Typhi: A National Disaster

By Sajid Ali Shah, Shahan Ahmed


  1. Department of Paediatrics, Combined Military Hospital, Mardan, Pakistan
doi: 10.29271/jcpsp.2024.07.864


A lot of work has been done on extensively drug-resistant Salmonella typhi, (XDR S. Typhi)1 however, strict and practical steps are now needed to address this disaster. Not only do we need to formulate national guidelines, but we also need to implement them strictly at all levels. Almost all the children we see with typhoid fever are XDR S. Typhi. We need to fight this disaster at multiple levels.

  1. First, diagnosing the typhoid fever is challenging. The gold standard is blood or bone marrow culture.2 However, in routine practice, most patients with fever are advised widal or typhidot test. This has resulted in over diagnosis of typhoid fever and unnecessary treatment.3 Second, the favourite drugs for typhoid treatment have been fluoroquinolones and third-generation cephalosporins. This irrational use of these drugs has led to drug resistance and the emergence of XDR S. Typhi. Third, widal and typhidot tests have been banned as diagnostic tests for typhoid fever in the Army medical set-up. The same should be implemented in all the civilian medical settings. All laboratories, whether civilian or govern-ment, should be held responsible for implementing the new guidelines.
  2. The only oral drug available for XDR typhoid is azithro-mycin. However, its use has increased significantly after the COVID-19 pandemic, despite a lack of evidence to support its use for this purpose. This trend must be strictly curbed at the national level.4 In our hospital, we only reviewed a one-month record of azithromycin prescriptions and found that up to 50 adults and 34 children had been prescribed azithromycin in a primary care setting. In most of the cases, azithromycin was either prescribed unne-cessarily, or when other alternative antibiotics were available. This highlights the need for antibiotic stewardship awareness and implementation.
  3. Several effective vaccines are available for typhoid prevention. The effectiveness of these vaccines against drug-resistant typhoid fever has been established. The World Health Organisation recom-mends typhoid vaccines for children above the age of six months. These vaccines have been tried in multiple countries and have been found to provide protection against typhoid for three years after the first dose. This is where the lawmakers can play a role. They can include these vaccines in our routine immunisation programme. The Global Alliance for Vaccines and Immunisation (GAVI) has already committed millions of dollars for these vaccine introductions in fund-eligible countries.5

The  authors  declared  no  conflict  of  interest.

SAS: Concept and design and critical review of the manuscript.
SA: Data collection and drafting.
Both authors approved the final version of the manuscript to be published.


  1. Carey ME, McCann NS, Gibani MM. Typhoid fever control in the 21st century: Where are we now? Curr Opin Infect Dis 2022; 35(5):424-30. doi: 10.1097/QCO.000000000000 0879.
  2. Prakash P, Mishra OP, Singh AK, Gulati AK, Nath G. Evaluation of nested PCR in diagnosis of typhoid fever. J Clin Microbiol 2005; 43(1):431-2. doi: 10.1128/JCM.43.1.431- 432.2005.
  3. Nepal TN, Dorji T, Tsheten T, Tenzin K, Pelzom D, Gurung MS, et al. Relying on Widal test alone could lead to over diagnosis of typhoid fever: Findings from a records review of febrile patients at Damphu Hospital, Bhutan, 2011-2012. Bhutan Health J 2018; 4(1):50-4. doi:10.47811/bhj.57.
  4. Saeed U, Uppal SR, Piracha ZZ, Uppal R. Azithromycin treatment for SARS-CoV-2-related COVID-19 pandemic could worsen extensively drug resistant (XDR) typhoid: A risk of losing the last bullet against Salmonella enterica serovar typhi. Jundishapur J Microbio 2021; 14(1):e113874. doi: 10.5812/jjm.113874.
  5. Nampota-Nkomba N, Carey ME, Jamka LP, Fecteau N, Neuzil KM. Using typhoid conjugate vaccines to prevent disease, promote health equity, and counter drug-resistant typhoid fever. Open Forum Infect Dis 2023; 10(Suppl 1):S6-12. doi: 10.1093/ofid/ofad022.