Typhoid fever
Typhoid fever is an intestinal infection caused by the bacterium Salmonella Typhi. It enters the body in water and food contaminated by the faeces of someone…
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Medicines commonly prescribed for Typhoid fever
For informational purposes only. Always consult a doctor before using any medicine.
Dosage form: INJECTABLE, 1 g sodium ceftriaxoneActive substance: ceftriaxoneManufacturer: Laboratorios Normon S.A.Prescription requiredDosage form: TABLET, 500 mgActive substance: azithromycinManufacturer: Aristo Pharma Iberia S.L.Prescription requiredDosage form: TABLET, 500 mgActive substance: ciprofloxacinManufacturer: Laboratorios Alter S.A.Prescription required
Typhoid fever is an intestinal infection caused by the bacterium Salmonella Typhi. It enters the body in water and food contaminated by the faeces of someone who is ill or carrying it, which is why it is fairly described as a disease of dirty hands and dirty water. In Europe it is almost always an imported infection: the people who get it are those returning from a trip, most often from South Asia. It is treated with antibiotics and, when treatment starts in time, ends in full recovery — but delay is not safe, because untreated typhoid leads to serious complications.
A fork in the road first, so that you do not read the wrong page. If you were bitten by a tick, a flea or a louse and then developed a fever and a rash, what you want is typhus — a different disease with a confusingly similar name. Typhoid fever is not spread by bites: only by water and food.
Where and how it is caught
The source is human only: someone who is ill, or a carrier who feels nothing at all. Animals do not spread typhoid. The bacterium leaves in the faeces and reaches water and food wherever the water supply, the sewerage or ordinary kitchen hygiene breaks down.
The usual routes while travelling:
- tap water, ice in drinks, water used for brushing teeth;
- raw vegetables, herbs and salads washed in local water;
- fruit that somebody else peeled;
- street-stall food, particularly anything that has stood and cooled;
- unpasteurised milk, soft cheese and ice cream made from it;
- shellfish and other seafood from contaminated water.
Most cases are linked to South Asia — India, Pakistan, Bangladesh, Nepal — and the infection also occurs in South-East Asia, Africa, and Central and South America. It can be picked up in a perfectly respectable hotel: a very small number of bacteria is enough to cause illness. One to three weeks usually pass between infection and the first signs, sometimes as many as six, so the connection with the trip is not always obvious.
Paratyphoid fever deserves a separate mention: it is caused by related salmonellae, runs a similar though usually milder course, and is approached in the same way.
How the illness unfolds
The main thing to know in advance is that typhoid does not begin like food poisoning. There is usually neither vomiting nor diarrhoea in the first days, and that is exactly why it gets missed.
- A stepwise fever. The temperature does not jump straight up: it climbs day after day — a little higher today than yesterday — and by the end of the first week reaches 39–40 °C and stays there.
- A severe, constant headache, exhaustion, aching all over, complete loss of appetite.
- A dry cough — common, and misleading, because it resembles a cold.
- Abdominal pain and bloating, with discomfort low on the right.
- Constipation rather than diarrhoea. In adults, during the first week the bowels open less often than usual or not at all. Diarrhoea does occur, but it is more a feature of children and tends to come later, in the second or third week. The expectation that a gut infection must start with diarrhoea is what misleads people most here.
- Rose spots — a few pale pink marks on the chest and abdomen. There are not many, they blanch under pressure, they last a couple of days and they are easily missed, especially on brown and black skin.
- A slower pulse than the fever would lead you to expect, which a doctor will notice.
Left untreated, by the second or third week the person becomes slow, indifferent and confused. The practical conclusion is simple: if a fever after a trip to a risk area lasts more than three days and keeps climbing, that is not "a cold picked up on the plane" and you should see a doctor the same day.
What it gets mistaken for in a returning traveller
Fever after the tropics is a situation where what matters is less a first-glance diagnosis than a proper order of exclusion. The doctor will be thinking about several things at once:
- malaria — ruled out first and urgently, because it can kill within days and also starts as a fever with no obvious cause;
- dengue — high fever, severe pain behind the eyes and in the muscles, a rash;
- hepatitis A — spread by the same water and food, but producing jaundice and dark urine;
- paratyphoid fever — practically indistinguishable by symptoms; the culture tells them apart;
- ordinary food poisoning — starts abruptly with vomiting and diarrhoea and settles by itself within a few days. Typhoid neither starts that way nor settles by itself.
So do tell the doctor where you have been, when you came back and what you ate and drank there, even if the trip was a month ago and you are sure it is something else. It is one sentence, and it changes the whole direction of the work-up.
When urgent help is needed
Serious complications usually appear in the third week, and almost always where treatment started late or never started at all. The bacterium damages the wall of the bowel, and that wall can bleed or burst.
Call an ambulance (in Europe the single number is 112) if there is:
- sudden sharp abdominal pain that keeps getting worse, with a hard belly that hurts at the slightest movement — this is how a perforated bowel presents;
- black, tarry stools, or dark red blood in them;
- vomiting of blood, or vomit that looks like coffee grounds;
- confusion, delirium, or heavy drowsiness the person is hard to rouse from;
- sudden pallor, cold sweat, a fast weak pulse;
- signs of dehydration: no urine for many hours, going dizzy on standing.
Do not drive yourself and do not send the patient to hospital alone. Take along all the medicines they are taking, and tell the medical staff which country they have returned from.
How the diagnosis is confirmed and how it is treated
The diagnosis is confirmed by culture: chiefly of blood, and also of stool and urine, and occasionally of bone marrow. The sample is taken before the first dose of antibiotic where possible, but if the person is seriously ill, treatment starts without waiting for the result. Rapid finger-prick tests are unreliable and cannot be relied on alone.
Typhoid is treated with antibiotics, and there is an important detail here. Resistance is increasing year on year, particularly in South Asia, where strains insensitive to several drugs at once are widespread. That is why the particular antibiotic is chosen by a doctor, taking account of the country the person travelled from, and changed later if the culture indicates it. For the same reason it is a poor idea to start treatment yourself with whatever is in the medicine cupboard: after that the culture stops showing anything, and resistance is only fed.
What to expect from treatment:
- the fever does not break at once — it usually persists for about another five days after the antibiotic is started, and that is not a sign the drug is failing;
- the course must be finished, even once you feel entirely well;
- something to bring the temperature down, plenty to drink, light food in small amounts;
- medicines that stop diarrhoea are not used in this infection: they do not help and they are not safe;
- severe cases are treated in hospital, with intravenous fluids and antibiotics.
Vaccination and the rules for water and food while travelling
There is a vaccine to have before travelling to a risk area, either as an injection or as capsules taken by mouth. It is worth seeing a doctor in good time, some weeks before the flight, so that protection has a chance to build; a booster is needed after a few years, and the interval depends on the type of vaccine. It is generally recommended from early childhood onwards, but the exact indications and schedules differ from country to country, so this is a question for a doctor before the trip.
The protection the vaccine gives is not complete. It lowers the risk appreciably but does not remove it, and a vaccinated person can still fall ill. That is precisely why care with water and food is still needed: the vaccine does not replace it.
- drink bottled or boiled water, and brush your teeth with it too;
- go without ice in your drinks;
- eat freshly cooked hot dishes rather than food that has stood uncovered and gone cold;
- fruit and vegetables only if you peeled them yourself;
- avoid salads, raw or lightly cooked seafood, unpasteurised milk and everything made from it;
- wash your hands with soap after the toilet and before eating, and use sanitiser where there is no water;
- if you are ill, or suspect you might be, do not cook for other people.
After the illness: relapse and carriage
Most treated people recover completely. But two things are worth knowing in advance.
Relapse. Sometimes the symptoms return one or two weeks after the course finishes. The illness is usually milder than the first time, but treatment has to be repeated, so if the fever comes back you should see a doctor again rather than wait.
Carriage. In a small proportion of people the bacterium stays in the body after recovery, most often settling in the gallbladder. The person is well and feels nothing, yet for months and sometimes years they shed the organism and can infect the household, especially if they cook for the family. That is why two things matter: finishing the course, and having follow-up stool cultures after treatment. Until the results come back clear, they should not prepare food for others, and hands need washing with particular care.
In catering, in healthcare and in work with young children, people return to their post only after negative results, and the same applies to a child going back to nursery. The exact rules and timescales belong to each country. Carriage itself can be treated: a long course of antibiotics is prescribed and, if there are gallstones, removing the gallbladder is sometimes discussed.
Online consultation
An online consultation is useful both before a trip and after it. Before departure the doctor goes through the itinerary, says whether the vaccine is needed and what else is worth arranging in advance, and explains the water and food rules for that particular country. On your return they assess the fever and the other symptoms, say which tests to have first and how urgently, read any results you already have, and help you make sense of the treatment and the follow-up cultures. If what you describe sounds like an emergency, the doctor will say plainly that you need to be seen in person and how quickly.
This material is for information only and does not replace medical advice.
Consult with a doctor about Typhoid fever
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Online doctors for Typhoid fever
Discuss your symptoms and possible next steps for Typhoid fever with a doctor online.
