Extensively drug-resistant typhoid — DTM&H MCQ

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HardTropical bacterial infectionsExtensively drug-resistant typhoidDTM&H

A 21-year-old man returns from visiting relatives in Pakistan with 8 days of fever, abdominal pain and relative bradycardia. Blood culture grows Salmonella Typhi; he is toxic with ileus and local alerts report extensively drug-resistant strains. What is the most appropriate treatment?

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Correct answer: B — Meropenem pending susceptibility results

The correct answer is B, meropenem pending susceptibility results. This patient has severe, complicated enteric fever (toxic, with ileus) acquired in Pakistan, a region with well documented extensively drug-resistant (XDR) Salmonella Typhi that is resistant to ampicillin, chloramphenicol, co-trimoxazole, fluoroquinolones and third-generation cephalosporins. British Infection Association guidance recommends empirical treatment with a carbapenem (meropenem, usually combined with azithromycin) for suspected or confirmed enteric fever in patients returning from Pakistan, given the near-universal fluoroquinolone resistance and the spread of XDR ceftriaxone-resistant clones. In a toxic patient with ileus, a bactericidal intravenous agent with reliable activity while culture and sensitivity results are awaited is essential, and meropenem meets this need until de-escalation is possible. Why the other options are wrong: D. Ciprofloxacin as empiric monotherapy: fluoroquinolone resistance is now near-universal among Pakistan-acquired S. Typhi isolates, so ciprofloxacin would very likely fail and delay effective therapy in a severely unwell patient. E. Oral amoxicillin for 5 days: amoxicillin (an aminopenicillin) is a first-line agent to which MDR and XDR strains are already resistant, and oral therapy is inappropriate with ileus impairing absorption. C. Metronidazole followed by paromomycin: these target amoebiasis and protozoal or anaerobic infection, not Salmonella Typhi, and have no role in enteric fever. A. Doxycycline for suspected rickettsiosis: there is no clinical picture (rash, eschar, exposure history) supporting rickettsial disease here; the blood culture has already confirmed S. Typhi as the pathogen. Key point: Severe enteric fever after travel to Pakistan should prompt empirical carbapenem (plus azithromycin) therapy because of endemic XDR S. Typhi resistant to fluoroquinolones and third-generation cephalosporins.

Reference: Nabarro LE, McCann N, Herdman MT, et al. British Infection Association guidelines for the diagnosis and management of enteric fever in England. Journal of Infection, 2022;84:469-489. https://www.britishinfection.org/application/files/6816/5461/2016/EFpublished__guidance_13042022.pdf