Table 2 Open in new tab Recommendations...

Region of travel

AMR pattern

Uncomplicated typhoid fever (oral drugs)

Complicated typhoid fever (may need IV preparations)

South Asia⁷^,¹¹

India

Decreasing MDR (resistance to chloramphenicol, co-trimoxazole and ampicillin) resistance, high level resistance to fluoroquinolones, negligible resistance to ceftriaxone. Few reports of azithromycin resistance, re-emerging sensitivity to older drugs

First line: Azithromycin^a
Alternative: Cefixime
Chloramphenicol
Co-trimoxazole

Ceftriaxone or
Cefotaxime
Azithromycin

Pakistan

Variable MDR resistance, high level fluoroquinolone resistance, moderate incidence of ceftriaxone resistance with/without XDR strain

Azithromycin

Carbapenems: Ertapenem
Meropenem

Nepal

Variable MDR resistance, high level resistance to fluoroquinolones, negligible resistance to ceftriaxone

Azithromycin

Ceftriaxone

Bangladesh

Variable MDR resistance, high level resistance to fluoroquinolones, negligible resistance to ceftriaxone. Few reports of azithromycin resistance

Azithromycin

Ceftriaxone

South East Asia⁷^,¹⁴^,⁹⁴

Vietnam, Myanmar and Cambodia

Variable MDR and fluoroquinolone resistance, susceptible to cephalosporins

Cefixime Azithromycin

Ceftriaxone Cefotaxime
Ertapenem

Indonesia, Malaysia, Papua New Guinea, Laos

Decreased ciprofloxacin susceptibility (DCS), susceptible to other groups of antimicrobials

Azithromycin Cefixime
Ciprofloxacin^b

Ceftriaxone
Cefotaxime

Africa¹⁶

Ghana

High incidence of MDR with susceptibility to other drugs

Ciprofloxacin Cefixime
Azithromycin

Ciprofloxacin
Ceftriaxone
Cefotaxime

South Africa, Kenya, Tanzania, Congo, Nigeria

MDR with DCS

Cefixime Ciprofloxacin^b
Azithromycin

Ceftriaxone
Cefotaxime

Burkina Faso

Susceptible

Ciprofloxacin Ofloxacin
Ampicillin
Co-trimoxazole Chloramphenicol

Ciprofloxacin

South and Central America⁹⁵^,⁹⁶

El Salvador
Mexico

No MDR reported, possible DCS

Co-trimoxazole
Ampicillin
Ciprofloxacin

Ciprofloxacin
Ceftriaxone

Table 2

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Recommendations for empirical therapy in returning travellers with suspected typhoid fever

Region of travel		AMR pattern	Uncomplicated typhoid fever (oral drugs)	Complicated typhoid fever (may need IV preparations)
South Asia⁷^,¹¹	India	Decreasing MDR (resistance to chloramphenicol, co-trimoxazole and ampicillin) resistance, high level resistance to fluoroquinolones, negligible resistance to ceftriaxone. Few reports of azithromycin resistance, re-emerging sensitivity to older drugs	First line: Azithromycin^a Alternative: Cefixime Chloramphenicol Co-trimoxazole	Ceftriaxone or Cefotaxime Azithromycin
	Pakistan	Variable MDR resistance, high level fluoroquinolone resistance, moderate incidence of ceftriaxone resistance with/without XDR strain	Azithromycin	Carbapenems: Ertapenem Meropenem
	Nepal	Variable MDR resistance, high level resistance to fluoroquinolones, negligible resistance to ceftriaxone	Azithromycin	Ceftriaxone
	Bangladesh	Variable MDR resistance, high level resistance to fluoroquinolones, negligible resistance to ceftriaxone. Few reports of azithromycin resistance	Azithromycin	Ceftriaxone
South East Asia⁷^,¹⁴^,⁹⁴	Vietnam, Myanmar and Cambodia	Variable MDR and fluoroquinolone resistance, susceptible to cephalosporins	Cefixime Azithromycin	Ceftriaxone Cefotaxime Ertapenem
	Indonesia, Malaysia, Papua New Guinea, Laos	Decreased ciprofloxacin susceptibility (DCS), susceptible to other groups of antimicrobials	Azithromycin Cefixime Ciprofloxacin^b	Ceftriaxone Cefotaxime
Africa¹⁶	Ghana	High incidence of MDR with susceptibility to other drugs	Ciprofloxacin Cefixime Azithromycin	Ciprofloxacin Ceftriaxone Cefotaxime
	South Africa, Kenya, Tanzania, Congo, Nigeria	MDR with DCS	Cefixime Ciprofloxacin^b Azithromycin	Ceftriaxone Cefotaxime
	Burkina Faso	Susceptible	Ciprofloxacin Ofloxacin Ampicillin Co-trimoxazole Chloramphenicol	Ciprofloxacin
South and Central America⁹⁵^,⁹⁶	El Salvador Mexico	No MDR reported, possible DCS	Co-trimoxazole Ampicillin Ciprofloxacin	Ciprofloxacin Ceftriaxone

Region of travel		AMR pattern	Uncomplicated typhoid fever (oral drugs)	Complicated typhoid fever (may need IV preparations)
South Asia⁷^,¹¹	India	Decreasing MDR (resistance to chloramphenicol, co-trimoxazole and ampicillin) resistance, high level resistance to fluoroquinolones, negligible resistance to ceftriaxone. Few reports of azithromycin resistance, re-emerging sensitivity to older drugs	First line: Azithromycin^a Alternative: Cefixime Chloramphenicol Co-trimoxazole	Ceftriaxone or Cefotaxime Azithromycin
	Pakistan	Variable MDR resistance, high level fluoroquinolone resistance, moderate incidence of ceftriaxone resistance with/without XDR strain	Azithromycin	Carbapenems: Ertapenem Meropenem
	Nepal	Variable MDR resistance, high level resistance to fluoroquinolones, negligible resistance to ceftriaxone	Azithromycin	Ceftriaxone
	Bangladesh	Variable MDR resistance, high level resistance to fluoroquinolones, negligible resistance to ceftriaxone. Few reports of azithromycin resistance	Azithromycin	Ceftriaxone
South East Asia⁷^,¹⁴^,⁹⁴	Vietnam, Myanmar and Cambodia	Variable MDR and fluoroquinolone resistance, susceptible to cephalosporins	Cefixime Azithromycin	Ceftriaxone Cefotaxime Ertapenem
	Indonesia, Malaysia, Papua New Guinea, Laos	Decreased ciprofloxacin susceptibility (DCS), susceptible to other groups of antimicrobials	Azithromycin Cefixime Ciprofloxacin^b	Ceftriaxone Cefotaxime
Africa¹⁶	Ghana	High incidence of MDR with susceptibility to other drugs	Ciprofloxacin Cefixime Azithromycin	Ciprofloxacin Ceftriaxone Cefotaxime
	South Africa, Kenya, Tanzania, Congo, Nigeria	MDR with DCS	Cefixime Ciprofloxacin^b Azithromycin	Ceftriaxone Cefotaxime
	Burkina Faso	Susceptible	Ciprofloxacin Ofloxacin Ampicillin Co-trimoxazole Chloramphenicol	Ciprofloxacin
South and Central America⁹⁵^,⁹⁶	El Salvador Mexico	No MDR reported, possible DCS	Co-trimoxazole Ampicillin Ciprofloxacin	Ciprofloxacin Ceftriaxone

^aIn regions with rising MIC to AZT noted – Cotrimoxazole or high dose Amoxicillin can be considered for oral therapy

^bIn regions where no fluroquinolone resistance is noted, treatment can start with ciprofloxacin/ofloxacin. Gatifloxacin was shown to have reduced fever clearance time and treatment failures when compared to cefixime

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