Extensively Drug-Resistant Typhoid Fever in Pakistan

Warning - Level 3, Avoid Nonessential Travel
Alert - Level 2, Practice Enhanced Precautions
Watch - Level 1, Practice Usual Precautions

Key Points

  • An outbreak of extensively drug-resistant (XDR) typhoid fever in Pakistan is ongoing. Extensively drug-resistant infections do not respond to most antibiotics.
  • Cases of XDR typhoid fever have been reported among people in North America, Europe, East Asian, and the South Pacific who traveled to Pakistan.
  • All travelers to Pakistan are at risk of getting XDR typhoid fever. 
  • If you are going to South Asia, including Pakistan, protect yourself by getting a typhoid fever vaccination before your trip and taking extra care to follow safe food and water guidelines.
What is typhoid fever?

Typhoid fever is a serious disease caused by Salmonella Typhi (Typhi) bacteria. The bacteria spread through contaminated food and water and person-to-person contact. 

Symptoms of typhoid fever include high fever, weakness, stomach pain, headache, constipation or diarrhea, cough, and loss of appetite. Typhoid fever can be fatal without appropriate antibiotic treatment.

What is the current situation?

In 2016, a large outbreak of extensively drug-resistant (XDR) Salmonella Typhi infections began in Sindh province, Pakistan, and spread throughout the country. The strains (kinds) of Typhi linked to the outbreak do not respond to most antibiotics used to treat typhoid fever. Some people linked to the outbreak have died. Several countries (including the United States) have reported XDR typhoid fever among people who traveled to and returned from Pakistan.

In the United States, public health officials have increased efforts to quickly interview and test samples from patients who may have typhoid fever.

What can travelers do to prevent typhoid fever?

Get the typhoid vaccine

CDC recommends that all travelers (even short-term travelers) to Pakistan and South Asia be vaccinated against typhoid fever before travel.  Visit a doctor or travel clinic to discuss options. Two typhoid fever vaccines have been approved for use in the United States.

  • An injectable vaccine (approved for people aged 2 and older): given as a shot at least 2 weeks before travel
  • An oral vaccine (approved for people aged 6 and older): a total of four capsules taken by mouth (one every other day), finishing at least one week before travel

Because the maker of the oral vaccine temporarily stopped its production in December 2020, it may not be available to travelers. If the oral vaccine is not available, travelers aged 2 and older should get the injectable vaccine. 

Always practice safe eating and drinking habits

The bacteria that cause typhoid fever are most often spread through contaminated food and water and person to person contact. Because typhoid fever vaccines are not 100% effective, travelers should always practice safe eating and drinking habits to help prevent infection.

  • Follow safe food and water guidelines.
  • Wash your hands often, especially before eating.
  • Avoid eating food prepared by anyone who is sick or has recently been sick.

If you get sick during or after travel

If you travel abroad and get sick while traveling, seek medical care. If you get sick after returning to the United States, seek medical care and tell your health care provider where and when you traveled. Do not prepare food for other people. Learn more about typhoid fever at CDC’s typhoid fever page for travelers.

Information for Healthcare Professionals: Management Recommendations

XDR Typhi strains have demonstrated resistance to

  • Fluoroquinolones, including ciprofloxacin
  • Ampicillin
  • Ceftriaxone
  • Chloramphenicol
  • Trimethoprim-sulfamethoxazole

The Pakistan XDR typhoid fever outbreak strain remains susceptible to azithromycin and carbapenems.

Azithromycin is effective for uncomplicated typhoid fever (bacteremia without secondary complications) and should be used for patients with suspected uncomplicated typhoid fever who have traveled to Pakistan.

  • Adult dosage: usually 1 g orally once, then 500 mg orally daily for 5–7 days, or 1 g orally once daily for 5–7 days
  • Pediatric dosage: 20 mg/kg orally once, then 10–20 mg/kg orally once daily (maximum 1,000 mg per day) for 5–7 days

Carbapenems should be used to treat suspected severe or complicated typhoid fever in patients who recently traveled to Pakistan.

  • Findings associated with complicated typhoid fever could include gastrointestinal complications (e.g., intestinal perforation, peritonitis, intestinal hemorrhage, hepatitis), neurologic complications (such as encephalopathy, including altered consciousness, delirium, confusion), or bacteremia with sepsis or shock.
  • Patients who do not improve on a carbapenem alone may benefit from the addition of a second antibiotic, such as azithromycin. When managing patients with suspected severe or complicated typhoid fever, consider consulting an infectious disease specialist.

Obtain a 30-day international travel history from all patients with suspected or confirmed typhoid fever. Obtain stool and blood cultures from patients with suspected typhoid fever and request antimicrobial susceptibility testing on isolates. Adjust treatment based on culture and sensitivity results.

Even with proper treatment, relapses can occur, often 1–3 weeks after clinical improvement.

Report all cases of confirmed typhoid fever to the appropriate state or local health department. Clinical laboratories should submit all Salmonella Typhi isolates to their state or local public health laboratory for submission to the CDC.

Traveler Information

Clinician Information

This notice was originally posted September 30, 2019.