Journal of Travel Medicine
Background: Extensively drug resistant (XDR) typhoid fever is a threat to travelers to Pakistan. We describe a multicontinental case series of travel-acquired XDR typhoid fever to demonstrate the global spread of the problem, and encourage preventive interventions as well as appropriate empiric antimicrobial use.
Methods: Cases were extracted from the GeoSentinel database, microbiologic laboratory records of 2 large hospitals in Toronto, Canada, and by invitation to TropNet sites. All isolates were confirmed XDR Salmonella enterica serovar Typhi (Salmonella Typhi), with resistance to ampicillin, ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole.
Results: Seventeen cases were identified in Canada (10), USA (2), Spain (2), Italy (1), Australia (1), and Norway (1). Patients under 18 years represented 71% (12/17) of cases, and all patients travelled to Pakistan to visit friends or relatives. Only 1 patient is known to have been vaccinated. Predominant symptoms were fever, abdominal pain, vomiting and diarrhea. Antimicrobial therapy was started on day 1 of presentation in 75% (12/16) of patients, and transition to a carbapenem or azithromycin occurred a median of 2 days after blood culture was drawn. Antimicrobial susceptibilities were consistent with the XDR Salmonella Typhi phenotype, and whole genome sequencing on 3 isolates confirmed their belonging to the XDR variant of the H58 clade.
Conclusions: XDR typhoid fever is a particular risk for travelers to Pakistan, and empiric use of a carbapenem or azithromycin should be considered. Pre-travel typhoid vaccination and counseling are necessary and urgent interventions, especially for VFR travelers. Ongoing sentinel surveillance of XDR typhoid fever is needed to understand changing epidemiology.
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Journal of Travel Medicine
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Abstract
Background: Extensively drug resistant (XDR) typhoid fever is a threat to travelers to Pakistan. We describe a multicontinental case series of travel-acquired XDR typhoid fever to demonstrate the global spread of the problem, and encourage preventive interventions as well as appropriate empiric antimicrobial use.
Methods: Cases were extracted from the GeoSentinel database, microbiologic laboratory records of 2 large hospitals in Toronto, Canada, and by invitation to TropNet sites. All isolates were confirmed XDR Salmonella enterica serovar Typhi (Salmonella Typhi), with resistance to ampicillin, ceftriaxone, ciprofloxacin, and trimethoprim-sulfamethoxazole.
Results: Seventeen cases were identified in Canada (10), USA (2), Spain (2), Italy (1), Australia (1), and Norway (1). Patients under 18 years represented 71% (12/17) of cases, and all patients travelled to Pakistan to visit friends or relatives. Only 1 patient is known to have been vaccinated. Predominant symptoms were fever, abdominal pain, vomiting and diarrhea. Antimicrobial therapy was started on day 1 of presentation in 75% (12/16) of patients, and transition to a carbapenem or azithromycin occurred a median of 2 days after blood culture was drawn. Antimicrobial susceptibilities were consistent with the XDR Salmonella Typhi phenotype, and whole genome sequencing on 3 isolates confirmed their belonging to the XDR variant of the H58 clade.
Conclusions: XDR typhoid fever is a particular risk for travelers to Pakistan, and empiric use of a carbapenem or azithromycin should be considered. Pre-travel typhoid vaccination and counseling are necessary and urgent interventions, especially for VFR travelers. Ongoing sentinel surveillance of XDR typhoid fever is needed to understand changing epidemiology.