The frightening disease burden of blood culture proven XDR Typhoidal isolates in pediatric population in a tertiary care hospital in Islamabad; Time to implement a holistic approach countrywide


  • Samia Khawaja Pakistan Institute of Medical Sciences, Islamabad Pakistan
  • Umme Farwa Pakistan Institute of Medical Sciences, Islamabad Pakistan
  • Soffia Khursheed Pakistan Institute of Medical Sciences, Islamabad Pakistan
  • Mehreen Mushtaq Pakistan Institute of Medical Sciences, Islamabad Pakistan
  • Muhammad Moaaz Ali Pakistan Institute of Medical Sciences, Islamabad Pakistan
  • Muhammad Shafiq Pakistan Institute of Medical Sciences, Islamabad Pakistan



Background: Typhoid fever is a deadly enteric bacterial infection and millions of people all over the globe are endangered of acquiring it. Since the first outbreak of XDR typhoid in Pakistan in 2016, the ever-rising resistance of typhoid has become a major threat faced by the pediatric population of Pakistan. There is a dearth of available data in children harboring this extensively drug resistant pathogen countrywide. The objective of this study is to highlight the alarmingly increasing prevalence of XDR S. typhi in pediatric population in Federal territory in Pakistan.

Material and Methods: This Cross-sectional study was conducted at Microbiology Lab, Children Hospital, PIMS from June 2022 to May 2023. Blood culture samples of children (with strong clinical suspicion of typhoid) ranging one till 12 years (both genders).

Result: Out of a total of 245 typhoid suspected blood culture samples, 153 (62%) samples yielded growth of typhoidal Salmonella isolates with 109 (71 %) isolates proved as XDR Salmonella Typhi ,35 (23%) as MDR Salmonella Typhi and the rest 09 cases (6 %) were Salmonella paratyphi A. There was a male predominance of 96(63%) and the rest 57(37%) were females. Age range most commonly affected was 5-8 years followed by 9-12 yrs. There was 100% susceptibility to Meropenem in XDR typhoid cases and 99% XDR cases were susceptible to Azithromycin.

Conclusion: We concluded that there is widespread existence of MDR/ XDR S.typhi in pediatric population in federal territory as well as all over Pakistan but there is scarcity of documented data nationwide. Hence, our study signifies that a holistic approach should be implemented along with continuous ongoing surveillance to combat this frightening MDR/ XDR disease burden in this particular population.

Key Words: Salmonella Typhi, Extensively Drug Resistant (XDR), Typhoidal isolates


Radhakrishnan A, Als D, Mintz ED, Crump JA, Stanaway J, Breiman RF, Bhutta ZA. Introductory article on global burden and epidemiology of typhoid fever. Am J Trop Med Hyg. 2018; 99(3_Suppl): 4-9. DOI:

World Health Organization, 2018. Typhoid. Geneva, Switzerland: WHO. Available at: // ization/diseases/typhoid/en/. Accessed April 4, 2020

Dougan G, Baker S. Salmonella enterica serovar typhi and the pathogenesis of typhoid fever. Annu Rev Microbiol. 2014. 68: 317–36. DOI:

Typhoid. Available online at: newsroom/fact-sheets/detail/typhoid (accessed September 9, 2021).

Stanaway JD, Reiner RC, Blacker B F, et al. The global burden of typhoid and paratyphoid fevers: A systematic analysis for the Global Burden of Disease Study 2017. Lancet Infect Dis. 2019; 19 (4): 369–81. DOI:

Rasheed MK, Hasan SS, Babar ZUD, Ahmed SI. Extensively drug-resistant typhoid fever in Pakistan. Lancet Infect Dis. 2019; 19 (3): 242-3. DOI:

Akram J, Khan AS, Khan HA, GilaniSA, Akram SJ, Ahmad FJ, et al. Extensively Drug- Resistant (XDR) Typhoid: Evolution, prevention, and its management. Biomed Res Int. 2020; 2020: 6432580. DOI:

WHO, Typhoid fever – Islamic Republic of Pakistan, 2018, Available from: 2018-typhoid-pakistan/en/

Yousafzai MT, Irfan S, Thobani RS, Kazi AM, Hotwani A, Memon AM, et al. Burden of culture confirmed enteric fever cases in Karachi, Pakistan: Surveillance for enteric fever in Asia Project (SEAP), 2016–2019. Clin Infect Dis. 2020; 71(S3): S214–21. DOI:

Ministry of National Health Services, Regulation & Coordination Government of Pakistan ‘. National Institute of Health, Islamabad, Pakistan. Field Epidemiology & Disease Surveillance Division.

Yousafzai MT, Qamar FN, Shakoor S, Saleem K, Lohana H, Karim S. Ceftriaxone-resistant Salmonella Typhi outbreak in Hyderabad city of Sindh, Pakistan: High Time for the introduction of typhoid conjugate vaccine. Clin Infect Dis. 2019; 68: S16–S21. DOI:

Saeed N, Usman M, Khan EA. An overview of extensively drug-resistant Salmonella Typhi from a tertiary care hospital in Pakistan. Cureus. 2019; 11: e5663. DOI:

Chatham-Stephens K, Medalla F, Hughes M, Appiah GD, Aubert RD, Caidi H, et al. Emergence of extensively drug-resistant Salmonella Typhi infections among travelers to or from Pakistan - United States, 2016-2018. MMWR Morb Mortal Wkly Rep. 2019; 68(1): 11–3. DOI:

Andrews JR, Qamar FN, Charles RC, Ryan ET. Extensively drug-resistant typhoid—are conjugate vaccines arriving just in time? N Engl J Med. 2018; 379: 1493–5. DOI:

World Health Organization. Typhoid vaccines: WHO position paper, March 2018- recommendations. Vaccine 2019; 37: 214–6.


Iftikhar A, Bari A, Jabeen U, Bano I. Spectrum of complications in childhood Enteric Fever as reported in a Tertiary Care Hospital. Pak J Med Sci. 2018; 34(5): 1115-9. DOI:

Memon H, Saeed F, Iqbal M, Saboohi E, Hanif S, Mallick AHH. Association of extensively drug-resistant salmonella infection in children with typhoid fever. Pak J Med Sci. 2022; 38(7): 1864-9.


Herekar F, Sarfaraz S, Imran M, Ghouri N, Shahid S, Mahesar M. Clinical spectrum and outcomes of patients with different resistance patterns of Salmonella enterica. Pak J Med Sci. 2022; 38(2): 356-61. DOI:

Shahid S, Mahesar M, Ghouri N, Noreen S. A review of clinical profile, complications and antibiotic susceptibility pattern of extensively drug-resistant (XDR) Salmonella Typhi isolates in children in Karachi. BMC Infect Dis. 2021; 21(1): 900.


Khan M. A plausible explanation for male dominance in typhoid ileal perforation. Clin Exper Gastroenterol. 2012; 5: 213-7. DOI: https://doi/org/10.2147/CEG.S36569

Fatima M, Kumar S, Hussain M, Memon NM, Vighio A, Syed MA, et al. Morbidity and mortality associated with typhoid fever among hospitalized patients in Hyderabad District, Pakistan, 2017-2018: Retrospective record review. JMIR Public Health Surveill. 2021; 7(5): e27268.


Ahdi SG, Batool A, Siddique AW, Waqas A, Gul R, Saleem F. The menace of drug resistant Salmonella Typhi in children: Experience from a tertiary care hospital in Pakistan. Pak Pediatr J. 2022; 46(3): 260-7.

Aslam A, Kharal AS, Aslam M, Raza A. Trends of antimicrobial resistance in typhoidal strains of salmonella in a Tertiary Care Hospital in Pakistan. Cureus. 2021; 13(1): e12664. DOI:

Hussain A, Satti L, Hanif F, Zehra NM, Nadeem S, Bangash TM, et al. Typhoidal Salmonella strains in Pakistan: an impending threat of extensively drug-resistant Salmonella Typhi. Eur J Clin Microbiol Infect Dis. 2019; 38(11): 2145–9.


Qamar FN, Yousafzai MT, Dehraj IF, Shakoor S, Shakoor S, Irfan S, et al. Antimicrobial resistance in typhoidal salmonella: Surveillance for Enteric Fever in Asia Project, 2016–2019. Clin Infect Dis 2020; 71 (Suppl3): S276–84.


Ahmad M, Shah N, Siddiqui MA. Frequency and Antibiotics sensitivity pattern of culture-positive Salmonella Typhi in Children. J Coll Physicians Surg Pak 2023; 33(03): 303-7. DOI: