Typhoid fever is a bacterial infection caused by Salmonella Typhi, spread through food and water contaminated with faeces. WHO estimates it causes millions of illnesses and over 100,000 deaths a year, mostly in South Asia and sub-Saharan Africa. Nurses in these regions see “typhoid” diagnoses every day, but many are wrong, and the real cases are becoming harder to treat because of drug resistance.
Symptoms
- Fever that rises gradually over several days and persists.
- Headache, tiredness, muscle aches.
- Abdominal pain, loss of appetite, constipation or diarrhoea.
- Sometimes a relatively slow pulse for the degree of fever, an enlarged spleen, or faint pink spots on the trunk (“rose spots”).
These symptoms overlap heavily with malaria, dengue, Lassa fever and other fevers. Typhoid and malaria can also occur together.
The problem with the Widal test
The Widal test, which measures antibodies, is still widely used in Nigeria, Ghana, India and elsewhere, but it is unreliable. It can be positive because of previous infection, vaccination, cross-reaction with other infections or high background levels in endemic areas, and negative early in the disease. Over-reliance on the Widal test leads to over-diagnosis, unnecessary antibiotics and missed diagnoses of the real cause of fever.
Blood culture is the standard test for diagnosis in most settings, ideally taken before antibiotics. It also allows antibiotic sensitivity testing, which matters more and more.
Drug-resistant typhoid
Typhoid has become resistant to many older antibiotics. Extensively drug-resistant (XDR) typhoid, resistant to most first- and second-line drugs, emerged in Pakistan in 2016 and has spread. Resistance to fluoroquinolones such as ciprofloxacin is widespread in South Asia. Treatment choices (commonly azithromycin for uncomplicated cases, and ceftriaxone or carbapenems for severe or resistant disease) depend on local resistance patterns and national guidelines.
Every unnecessary antibiotic course, including those given for false-positive Widal results, adds to the resistance problem. Nurses can help by questioning diagnoses based on Widal alone and encouraging blood cultures.
Complications
- Intestinal perforation: usually in the second or third week. Sudden severe abdominal pain, rigid abdomen, worsening condition, shock. A surgical emergency, and a common reason for emergency surgery in parts of West Africa.
- Gastrointestinal bleeding: blood in stool, falling haemoglobin.
- Confusion or reduced consciousness (“typhoid encephalopathy”), sepsis, myocarditis.
Nursing care
- Observations including temperature chart, pulse, BP, and early warning score.
- Fever management with paracetamol and tepid sponging, as prescribed.
- Hydration: oral fluids or IV as prescribed; fluid balance.
- Nutrition: soft, easily digested food as tolerated.
- Abdominal assessment each shift: pain, distension, bowel sounds. Report new severe pain urgently.
- Antibiotics on time, full course.
- Infection control: hand hygiene, gloves for contact with stool; safe disposal of faeces; patients should not prepare food for others until cleared.
Prevention
- Safe water and sanitation: boil or treat water; use toilets; wash hands with soap after the toilet and before preparing food.
- Food safety: eat freshly cooked hot food; wash fruit and vegetables in safe water.
- Typhoid conjugate vaccine (TCV): WHO recommends it for children from 6 months in endemic countries, and a growing number of countries in Asia and Africa have introduced it into routine or campaign immunisation. Check your national schedule.
- Chronic carriers who work in food handling need identification and treatment.
Related: Severe malaria · Cholera · Sepsis Six
Based on WHO typhoid fact sheets and position paper on typhoid vaccines, and published evidence on Widal test performance and XDR typhoid. Educational content: follow your national treatment guidelines.