XDR Typhoid Treatment in Pakistan – Latest Guidelines and Management

Typhoid fever, also known as enteric fever, remains a serious public health concern in Pakistan, particularly during monsoon seasons due to contaminated water sources and poor sanitation. In some patients, the infection may persist or show prolonged symptoms, termed extended release typhoid, which requires timely diagnosis and aggressive management to prevent complications.

In this blog, we’ll break down the key features, diagnostic tools, and the latest treatment protocols for extended typhoid, especially in the context of South Asian settings like Pakistan.

🦠 What is XDR Typhoid?

XDR Typhoid (Extensively Drug-Resistant Typhoid) is a severe form of Salmonella Typhi infection that is resistant to:

• Chloramphenicol
• Ampicillin
• Trimethoprim-sulfamethoxazole
• Fluoroquinolones (e.g. Ciprofloxacin)
• Third-generation cephalosporins (e.g. Ceftriaxone)

First identified in Pakistan in 2016, XDR Typhoid continues to pose a public health threat, especially in urban centers like Karachi, Lahore, and Hyderabad.

🚨 Common Symptoms of XDR Typhoid

System	Symptoms
Fever	Gradual onset, step-ladder pattern, may reach 40°C
Gastrointestinal	RLQ abdominal pain, constipation or diarrhea, nausea, vomiting
Systemic	Headache, fatigue, weight loss, malaise
Neuropsychiatric	Confusion, mental dullness, “typhoid state” in severe cases
Skin	Rose spots (pink macules on abdomen)
CVS	Relative bradycardia with high-grade fever

🔬 Diagnosis: How XDR Typhoid is Detected

🧪 Investigations by Week

• Week 1: Blood Culture (Gold standard)
• Week 2: Widal Test (use cautiously)
• Week 3: Stool Culture
• Week 4: Urine Culture

🔍 Additional Tests

• CBC: Leukopenia, mild anemia
• LFTs: Mild elevation of ALT/AST
• Bone Marrow Culture: Highest sensitivity in chronic cases

💉 XDR Typhoid Treatment in Pakistan (2025 Update)

✅ First-Line Treatment for XDR Typhoid

Always guided by Culture & Sensitivity (C&S) reports.

Drug	Dosage	Duration
Meropenem (Meronem)	1g IV stat, then TDS	7–10 days
Azithromycin (Azomax)	1g PO stat, then 500mg OD	5–7 days
Ceftriaxone (Oxidil)	2g IV OD	10–14 days (if still effective)

🚑 Severe Cases: ICU or Hospitalized Patients

• Hydrocortisone 100mg IV QID for shock or encephalopathy
• IV fluids to correct dehydration
• Monitor electrolytes, renal and liver function closely

🛑 Managing the Carrier State

Some patients continue to shed Salmonella Typhi in bile:

• Ciprofloxacin 500mg BD for 4 weeks
• Consider cholecystectomy if long-term carrier despite antibiotics

🌍 Prevention of XDR Typhoid in Pakistan

🔒 Public Health Measures

• Ensure clean drinking water
• Improve sewage disposal
• Safe food handling & hand hygiene
• Pasteurization of milk

💉 Vaccination

• Ty21a Oral Vaccine (Live attenuated, 4 doses)
• Vi Capsular Polysaccharide (2 years and older)

🤒 Symptomatic Management

Symptom	Treatment
Fever	Paracetamol 500mg TDS
Gastritis	Pantoprazole 40mg OD
Weakness	Multivitamin Syrup BD
Nausea	Ondansetron 4mg TDS or Metoclopramide 10mg TDS

⚠️ When to Consider an Alternative Diagnosis?

If no clinical improvement after 5 days of appropriate antibiotic therapy, reevaluate:

• Repeat cultures
• Consider other febrile illnesses (e.g., malaria, dengue, TB)