• H Joshua Posen, Waison Wong, Daniel S Farrar, Aaron Campigotto, Tiffany Chan, Kevin R Barker, HagmannStefan H FSHFDivision of Pediatric Infectious Diseases, Steven and Alexandra Cohen Children's Medical Center/Northwell Health, New Hyde Park, NY, USA.Department of Pediatrics, Donald and Barbara Zucker School of Medicine/Hofstra Northwell, New Hemp, Edward T Ryan, Regina C LaRocque, Ashlee M Earl, Colin J Worby, Francesco Castelli, Victoria Pérez Fumadó, Philip N Britton, Michael Libman, Davidson H Hamer, and Shaun K Morris.
• Department of Paediatrics, Division of Infectious Diseases, Hospital for Sick Children, Toronto, ON, Canada.
• J Travel Med. 2023 Feb 18; 30 (1).

BackgroundExtensively drug-resistant (XDR) typhoid fever is a threat to travelers to Pakistan. We describe a multicontinental case series of travel-acquired XDR typhoid fever to demonstrate the global spread of the problem and encourage preventive interventions as well as appropriate empiric antimicrobial use.MethodsCases were extracted from the GeoSentinel database, microbiologic laboratory records of two large hospitals in Toronto, Canada, and by invitation to TropNet sites. All isolates were confirmed XDR Salmonella enterica serovar Typhi (Salmonella typhi), with resistance to ampicillin, ceftriaxone, ciprofloxacin and trimethoprim-sulfamethoxazole.ResultsSeventeen cases were identified in Canada (10), USA (2), Spain (2), Italy (1), Australia (1) and Norway (1). Patients under 18 years represented 71% (12/17) of cases, and all patients travelled to Pakistan to visit friends or relatives. Only one patient is known to have been vaccinated. Predominant symptoms were fever, abdominal pain, vomiting and diarrhoea. Antimicrobial therapy was started on Day 1 of presentation in 75% (12/16) of patients, and transition to a carbapenem or azithromycin occurred a median of 2 days after blood culture was drawn. Antimicrobial susceptibilities were consistent with the XDR S. typhi phenotype, and whole genome sequencing on three isolates confirmed their belonging to the XDR variant of the H58 clade.ConclusionsXDR typhoid fever is a particular risk for travelers to Pakistan, and empiric use of a carbapenem or azithromycin should be considered. Pre-travel typhoid vaccination and counseling are necessary and urgent interventions, especially for visiting friends and relatives travelers. Ongoing sentinel surveillance of XDR typhoid fever is needed to understand changing epidemiology.© International Society of Travel Medicine 2022. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

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