Gastrointestinal and Hepatobiliary Complications of Extensively Drug-Resistant Typhoid at a Tertiary Care Hospital in Pakistan

Introduction: Typhoid fever is a major health problem in developing countries. Extensively drug-resistant (XDR) typhoid is an emerging threat to world health. The objectives of this study were to report our blood culture proven patients having XDR typhoid and compare the rate of gastrointestinal (GI) and hepatobiliary manifestations and complications of antimicrobial sensitive and resistant strains. Materials and methods: This prospective observational study was carried out at a tertiary care hospital in Pakistan, from January 2019 till August 2020 on all consecutive blood culture proven patients of Salmonella typhi. A total of 57 cases of Salmonella were identified, of which 10 were nonresistant, seven multi drug-resistant (MDR), 39 extensively drug-resistant (XDR), and one was extended-spectrum beta lactamase (ESBL) positive. Alarmingly, one of the S. typhi isolate in addition to the first line drugs, was also resistant to azithromycin. Patients were treated with antibiotics according to antimicrobial susceptibility of the Salmonella in accordance with the World Health Organization (WHO) and Medical Microbiology and Infectious Diseases Society of Pakistan (MMIDSP) guidelines and GI and hepatobiliary complications were recorded. Results: Overall rate of complications was low. Some 10% (1/10) with nonresistant typhoid, 14% (1/7) with MDR, and 15% (6/39) of our patients with XDR typhoid fever had abdominal tenderness (p=0.95). None of the patients had GI bleeding, abdominal abscess, or peritonitis. Some 20% (2/10) patients with nonresistant typhoid, 29% (2/7) with MDR, and 18% (7/39) with XDR typhoid developed acute hepatitis, with greater than three times elevation of liver transaminases. There was no statistically significant difference in the occurrence of hepatitis between these groups (p=0.98). Interestingly, one of our patients with XDR typhoid also developed cholestatic hepatitis. Conclusion: There is no significant difference in GI and hepatobiliary complications amongst antimicrobial sensitive and resistant strains of typhoid. However, emergence of resistant strains calls for focus on prevention and judicious use of antimicrobials.