MEMO: Drug-resistant Salmonella enterica serotype Typhi (XDR S. Typhi)     

TO:  Health Care Professionals in Niagara

FROM: Dr. Andrea Feller, MD, MS, FAAP FACPM, Associate Medical Officer of Health

REFERENCE: Drug-resistant Salmonella enterica serotype Typhi (XDR S. Typhi)   

DATE:  May 28, 2019

Background

• There is an ongoing outbreak of extensively drug-resistant Salmonella enterica serotype Typhi (XDR S. Typhi) in Pakistan
• To date, there are no laboratory confirmed cases in Niagara
• Currently, there are a total of nine cases reported in returning travelers in Ontario as of May 6, 2019
• The strain associated with this outbreak is only susceptible to azithromycin and carbapenems

Recommendations

All suspect and confirmed cases of typhoid fever must be reported to Niagara Region Public Health Infectious Disease program as soon as possible.

Inquire about travel to Pakistan and other areas in South Asia in patients with symptoms compatible with typhoid fever.

• Fever
• Weakness
• Abdominal pain
• Headache
• Diarrhea or constipation
• Cough
• Rash with flat rose - coloured spots
• Loss of appetite

Note: Patients who have received the typhoid fever vaccine may still become ill, as the vaccine is 50-80% effective.

Lab testing

• Blood cultures and stool samples should be collected for bacterial culture and submitted for routine testing, including travel history on the requisition
• In addition to routine susceptibility testing, all S.Typhi isolates from Pakistan should be tested for carbapenem and azithromycin susceptibility
• All isolates of S. Typhi should be forwarded to the Public Health Ontario lab for confirmation

Patients with suspected typhoid fever and a travel history to Pakistan should be empirically treated with azithromycin or carbapenems based on clinical presentation pending full antimicrobial susceptibility testing results.  Do not use fluoroquinolones or ceftriaxone empirically for these patients. 

Prevention

• Advise patients who are planning to travel abroad to obtain a travel medicine consultation as early as possible before their trip, including an assessment of the need for typhoid vaccine
• Counsel on following safe food and water practices and proper hand hygiene
• Patients who are visiting friends and relatives (VFR) are at higher risk compared to business travelers and tourists and should be counselled accordingly

For more information, contact the Infectious Disease program at 1-888-505-6074 or 905-688-8248 ext. 7330, Monday to Friday 8:30 a.m.to 4:30 p.m., after hours 905-984-3690.