Typhoid (enteric) fever

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

Last reviewed: 5 Aug 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 tests

1st tests to order

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

Full details

Tests to consider

rose spot culture

Full details

Treatment algorithm

INITIAL

suspected enteric fever

ACUTE

confirmed enteric fever

ONGOING

relapse

chronic carriage

Contributors

Authors

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

Disclosures

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

Disclosures

BAC declares that he has no competing interests.

Peer reviewers

Chris Parry, MD

Senior Lecturer (Honorary Consultant)

Division of Medical Microbiology and Genitourinary Medicine

School of Infection and Host Defence

University of Liverpool

Liverpool

Disclosures

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

Disclosures

PMS declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

World Health Organization. Typhoid vaccines position paper. Mar 2018 [internet publication].Full text

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

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. Abstract

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

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].Full text

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.Full text Abstract

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.Full text Abstract

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.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

suspected enteric fever

confirmed enteric fever

relapse

chronic carriage

Contributors

Authors

Eli Schwartz, MD, DTMH

Disclosures

Bradley A. Connor, MD

Disclosures

Peer reviewers

Chris Parry, MD

Disclosures

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

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of 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