Typhoid (enteric) fever

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 13 Nov 2025

Last updated: 29 May 2024

Typhoid (enteric) fever mostly occurs in low-income countries where sanitary conditions remain poor and water supplies are not treated.

Transmission occurs through consumption of contaminated food or water.

In high-income countries, enteric fever is mainly seen among travelers returning from endemic areas.

Prolonged febrile illness with normal white blood cell count in returnees from an endemic area should increase suspicion.

Definitive diagnosis depends on bacterial isolation, usually by blood culture.

Choice of antibiotic treatment depends on antibiotic resistance patterns, travel history, and disease severity.

Several vaccines are available that provide some protection against Salmonella typhi. The newer conjugated vaccines provide higher protection, though not all vaccines are available in all countries. Current vaccines do not provide protection against S paratyphi.

Definition

Typhoid fever is a fecal-oral transmissible disease caused by the bacterium Salmonella enterica, serotype typhi. A similar clinical syndrome, paratyphoid fever, is caused by Salmonella enterica, serotype paratyphi, and the terms enteric fever and typhoid infection are used to describe both diseases. Unless otherwise stated, the information presented here will relate to both diseases.

History and exam

Key diagnostic factors

high fever

Full details

Other diagnostic factors

dull frontal headache
abdominal pain
anorexia
apathetic-lethargic state
constipation
cough
diarrhea
malaise
nausea
prostration
chills
hepatomegaly
pneumonia
relative bradycardia
rigors
rose spots
splenomegaly

Full details

Risk factors

overcrowded living in endemic areas
poor sanitation/untreated water in endemic areas
poor personal hygiene in endemic areas
visiting endemic countries (e.g., Indian subcontinent, Mexico)
travel to areas with poor sanitation within endemic countries
ignoring hygiene rules while traveling in endemic countries
travel to the Indian subcontinent
longer duration of stay in endemic country
antacid/proton-pump inhibitor (PPI) treatment

Full details

Diagnostic investigations

1st investigations to order

CBC
serum aminotransferases
blood culture
stool culture
urine culture
bone marrow culture
drug susceptibility testing

Full details

Investigations to consider

rose spot culture

Full details

Algoritmo de tratamento

Inicial

suspected enteric fever

AGUDA

confirmed enteric fever

CONTÍNUA

relapse

chronic carriage

Colaboradores

Autores

Eli Schwartz, MD, DTMH

Professor

Center for Geographical Medicine and Tropical Diseases

Chaim Sheba Medical Center

Tel HaShomer Hospital

Clinical Professor of Medicine

Sackler Faculty of Medicine

Tel Aviv University

Tel Aviv

Israel

Declarações

ES is an author of a number of references cited in this topic.

Bradley A. Connor, MD

Clinical Associate Professor

Weill Medical College of Cornell University

New York Center for Travel and Tropical Medicine

New York City

Declarações

BAC declares that he has no competing interests.

Revisores

Chris Parry, MD

Senior Lecturer (Honorary Consultant)

Division of Medical Microbiology and Genitourinary Medicine

School of Infection and Host Defence

University of Liverpool

Liverpool

Declarações

CP declares that he has no competing interests.

Paul M. Southern, MD, MSc, DTM&H

Professor

Department of Pathology

University of Texas Southwestern Medical Center

Dallas

Declarações

PMS declares that he has no competing interests.

Créditos aos pareceristas

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Declarações

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Referências

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Principais artigos

World Health Organization. Typhoid vaccines position paper. Mar 2018 [internet publication].Texto completo

Crump JA, Luby SP, Mintz ED. The global burden of typhoid fever. Bull World Health Organ. 2004 May;82(5):346-53.Texto completo Resumo

Schwartz E, Shlim DR, Eaton M, et al. The effect of oral and parenteral typhoid vaccination on the rate of infection with Salmonella typhi and Salmonella paratyphi A among foreigners in Nepal. Arch Intern Med. 1990 Feb;150(2):349-51. Resumo

Ochiai RL, Wang X, von Seidlein L, et al. Salmonella paratyphi A rates, Asia. Emerg Infect Dis. 2005 Nov;11(11):1764-6.Texto completo Resumo

Centers for Disease Control and Prevention. CDC Yellow Book 2024: health information for international travel. Section 5: travel-associated infections & diseases - typhoid & paratyphoid fever. May 2023 [internet publication].Texto completo

Engels EA, Falagas ME, Lau J, et al. Typhoid fever vaccines: a meta-analysis of studies on efficacy and toxicity. BMJ. 1998 Jan 10;316(7125):110-6.Texto completo Resumo

Jackson BR, Iqbal S, Mahon B; Centers for Disease Control and Prevention (CDC). Updated recommendations for the use of typhoid vaccine - Advisory Committee on Immunization Practices, United States, 2015. MMWR Morb Mortal Wkly Rep. 2015 Mar 27;64(11):305-8.Texto completo Resumo

Frenck RW Jr, Nakhla I, Sultan Y, et al. Azithromycin versus ceftriaxone for the treatment of uncomplicated typhoid fever in children. Clin Infect Dis. 2000 Nov;31(5):1134-8.Texto completo Resumo

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Differentials
- Malaria
- Dengue
- Rickettsial infections
Mais Differentials
Guidelines
- Yellow Book 2024: health information for international travel: typhoid and paratyphoid fever
- Diagnosis and management of enteric fever in England
Mais Guidelines
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Typhoid (enteric) fever

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Algoritmo de tratamento

suspected enteric fever

confirmed enteric fever

relapse

chronic carriage

Colaboradores

Autores

Eli Schwartz, MD, DTMH

Declarações

Bradley A. Connor, MD

Declarações

Revisores

Chris Parry, MD

Declarações

Paul M. Southern, MD, MSc, DTM&H

Declarações

Créditos aos pareceristas

Declarações

Referências

Principais artigos

Artigos de referência

Uma lista completa das fontes referenciadas neste tópico está disponível para os usuários com acesso total ao BMJ Best Practice.

Differentials

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice