CS310649-A May 12, 2020

Typhoid and paratyphoid fever are systemic, life-threatening illnesses caused 

by Salmonella serotypes Typhi and Paratyphi, respectively. Symptoms of 

typhoid and paratyphoid fever include high fever, weakness, stomach pain, 

headache, diarrhea or constipation, cough, and loss of appetite. Typhoid 

and paratyphoid fever are transmitted commonly through consumption of 

contaminated food or water. Following safe food and water practices is the 

best way to help prevent typhoid and paratyphoid fever; vaccination can 

also help prevent typhoid fever.

Typhoid fever and 

antimicrobial resistance

Antimicrobial resistance 

in typhoid fever has been 

increasing. 

The first known outbreak 

of a strain of extensively 

drug-resistant (XDR) typhoid 

fever in Pakistan resulted in 

over 10,000 cases from 2016–

2019, including 30 cases in 

the United States. 

This XDR strain is resistant 

to most antibiotics used to 

treat typhoid fever, including 

ciprofloxacin and ceftriaxone. 

The strain remains susceptible 

to azithromycin and 

carbapenems.

As treatment options become 

more limited, counseling 

patients on prevention 

measures becomes 

increasingly important. These 

measures include receiving 

pre-travel vaccination, 

washing hands frequently, 

and taking food and water 

precautions during travel.

Who’s at higher risk?

Travelers to eastern and southern Asia (especially Pakistan, 

India, and Bangladesh), Africa, the Caribbean, Central and 

South America, and the Middle East are at increased risk for 

typhoid and paratyphoid fever. 

Travelers visiting friends and relatives are at additional risk, 

because they may not seek health consultation or typhoid 

vaccination before travel and may be less careful with food 

and water during travel. 

Although the risk of illness with typhoid or paratyphoid fever 

increases with the duration of stay, travelers have acquired 

typhoid fever even during visits of less than a week to 

countries where the disease is endemic (such as Pakistan, 

India, and Bangladesh).

How common are typhoid and paratyphoid fever?

An estimated 11–21 million cases of typhoid fever and 5 million cases of paratyphoid fever occur 

worldwide each year, causing an estimated 215,000 deaths. 

About 425 cases of typhoid fever and 125 cases of paratyphoid fever are diagnosed in the United 

States annually, mostly among international travelers to places where the diseases are endemic.

Typhoid and Paratyphoid Fever: 

Information for Healthcare Professionals
Diagnosis

Blood culture is the mainstay of diagnosis. Early suspicion can ensure that cultures are sent 

to the laboratory for diagnosis and resistance testing, and that appropriate antimicrobial treatment 

is started quickly. 

If you suspect your patient has typhoid or paratyphoid fever:

• Obtain a complete travel history.

• Collect stool and blood cultures, and request antimicrobial susceptibility testing.

• Consider getting an infectious diseases consultation. 

Learn more at www.cdc.gov/typhoid-fever and www.cdc.gov/travel.

Report all cases of confirmed typhoid or paratyphoid fever to the appropriate local or state 

health departments.

Treatment 

Carefully consider empiric treatment options. Most typhoid and paratyphoid fever infections 

diagnosed in the United States, especially among patients who traveled to South Asia, are caused 

by strains not susceptible to fluoroquinolones. Therefore, fluoroquinolones should not be used 

for empiric treatment. Azithromycin is recommended for suspected uncomplicated disease and 

third-generation cephalosporins for severe or complicated disease. Patients who traveled to 

Pakistan should initially be treated with azithromycin for suspected uncomplicated typhoid fever 

and carbapenems for severe or complicated typhoid fever. Treatment regimens should be adjusted 

when culture and sensitivity results are available. 

Prevention 

Vaccination can help prevent typhoid fever. CDC recommends vaccination for people traveling 

to places where typhoid fever is endemic, such as South Asia, especially Pakistan, India, or 

Bangladesh. 

Two typhoid fever vaccines are available in the United States:

• Oral vaccine — can be given to people at least 6 years old. 

It consists of four pills taken every other day and should be 

finished at least 1 week before travel.

• Injectable vaccine — can be given to people at least 2 years 

old and should be given at least 2 weeks before travel. 

Both vaccines protect 50%– 80% of those vaccinated. The 

injectable vaccine requires a booster every 2 years, and the 

oral vaccine requires a booster every 5 years. There is not a 

vaccine for paratyphoid fever. 

Advise your patients to select food and water carefully while traveling internationally.

Drinking water should be bottled, boiled, or treated (e.g., using chlorine) to remove germs. 

Travelers should avoid consuming salads; uncooked vegetables; raw, unpeeled fruits; and 

unpasteurized fruit juices. Foods should be fully cooked and consumed hot.

Tell your patients to seek medical care, even while abroad, if they have a fever and feel very ill.