Extensively drug-resistant typhoid — DTM&H MCQ
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Correct answer: A — Oral azithromycin with susceptibility-guided follow-up
The correct answer is A, oral azithromycin with susceptibility-guided follow-up. This isolate is extensively drug resistant (XDR), a pattern well described in Sindh province, Pakistan, where Salmonella Typhi has acquired resistance to first-line agents including ceftriaxone and fluoroquinolones. The British Infection Association guidelines for enteric fever in England specifically address this scenario, recommending oral azithromycin for uncomplicated enteric fever, with meropenem reserved for severe or complicated disease from XDR regions. As she is clinically stable, apyrexial danger signs absent, and tolerating oral intake, oral azithromycin is appropriate rather than parenteral carbapenem therapy, but ongoing susceptibility data must guide any step-up if response is inadequate. Azithromycin resistance remains rare in these XDR strains, making it the reliable oral option here. Why the other options are wrong: C. Oral ciprofloxacin for 7 days: The isolate is explicitly reported as ciprofloxacin resistant, so a fluoroquinolone will fail clinically despite in vitro reporting nuances; fluoroquinolone resistance is near-universal in Pakistani XDR strains. D. Intramuscular benzathine penicillin: Salmonella Typhi is not treated with penicillins, and this agent has no role in enteric fever; it is used for conditions such as syphilis and streptococcal prophylaxis. E. Doxycycline and rifampicin for 6 weeks: This regimen is used for brucellosis, not typhoid, and has no evidence base or guideline support for Salmonella Typhi treatment. B. Praziquantel after a fatty meal: Praziquantel is an antihelminthic used for schistosomiasis and other trematode or cestode infections; it has no antibacterial activity and is irrelevant to enteric fever. Key point: In a stable patient with XDR typhoid from Sindh, Pakistan, resistant to ceftriaxone and ciprofloxacin, oral azithromycin (reserving meropenem for severe or complicated disease) is the guideline-recommended first-line treatment.
Reference: British Infection Association, Guidelines for the diagnosis and management of enteric fever in England, Journal of Infection, 2022 (https://www.britishinfection.org/application/files/6816/5461/2016/EFpublished__guidance_13042022.pdf)