Paeds · infectious-diseases
Enteric fever and invasive bacterial enteritis
Also known as Typhoid fever · Paratyphoid fever · Enteric (typhoid) fever · Invasive bacterial gastroenteritis · Bacillary dysentery (shigellosis) · Shiga-toxin producing E. coli (STEC) colitis and haemolytic uraemic syndrome
A fellowship approach to enteric fever (Salmonella Typhi and Paratyphi) and invasive bacterial enteritis (Shigella, Campylobacter, invasive non-typhoidal Salmonella, Shiga-toxin producing E. coli) in children: separating invasive disease from non-invasive watery diarrhoea, the stepwise fever of typhoid, blood and stool diagnostics, culture-guided and XDR-aware antibiotics, the special danger of haemolytic uraemic syndrome, and typhoid conjugate vaccine prevention — across ANZ, the UK, the US and Canada.
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Target exams
Red flags
- Stepwise rising fever for 4-7 days with abdominal pain, relative bradycardia and constipation in a returned traveller or endemic setting — think enteric fever and draw blood culture before antibiotics
- Sudden severe abdominal pain, rigid abdomen, peritonism or melaena/haematemesis in weeks 3-4 of suspected typhoid — intestinal perforation or haemorrhage, a surgical emergency
- Bloody diarrhoea followed by oliguria, pallor, petechiae or altered consciousness 5-10 days later — Shiga-toxin producing E. coli with evolving haemolytic uraemic syndrome
- High-volume bloody mucoid stool with high fever, tenesmus and abdominal pain in a young child or during a childcare outbreak — invasive shigellosis needing antibiotics
- A sick febrile infant, or any child with malaria, malnutrition, HIV or sickle cell disease, and diarrhoea with bacteraemia — invasive non-typhoidal Salmonella can be rapidly fatal
- Persistent fever after 5-7 days of apparently correct therapy, or relapse after completion — reassess for resistance, complication, deep focus or carrier state
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics — fever in the returned traveller and invasive enteric infection
- Infectious diseases and immunisation — enteric fever and bacterial dysentery
- Learning Goal 8 — Infectious disease: diagnosis and management of enteric fever and invasive bacterial enteritis including XDR typhoid
- Learning Goal 13 — Acute and emergency care: recognition and resuscitation of the septic child with invasive enteric disease and haemolytic uraemic syndrome
- Renewed curriculum for first-year trainees from 2027 — Learning goal 6: febrile illness including enteric fever
- Infectious Diseases — enteric fever, XDR Salmonella Typhi, shigellosis, STEC and HUS
- Written Exam: the differential of stepwise fever, blood-versus-stool diagnostics, and culture-guided antibiotic choice
- Pharmacology / Public Health — typhoid conjugate vaccine, antimicrobial stewardship and notifiable disease duties
- Long Cases — prolonged fever in a returned traveller; XDR typhoid; HUS following bloody diarrhoea
- Short Cases — the child with dysentery; recognition of perforation and sepsis
- Communication stations — explaining blood culture before antibiotics, antibiotic stewardship, and vaccine prevention
- Level 2 — Infection, immunology and allergy: recognises enteric fever and invasive bacterial enteritis
- Level 3 — Safeguarding and public health: notifiable disease notification, contact tracing and outbreak response
- General Paediatrics: distinguishes invasive from non-invasive diarrhoea and escalates red flags
- Foundation of Practice (FOP) — enteric fever, shigellosis, STEC and haemolytic uraemic syndrome
- Applied Knowledge in Practice (AKP) — diagnosis, complications and management of invasive enteric infection in children
- TAS — antimicrobial resistance, vaccine prevention and global child health
- History — travel, food and water exposure, immunisation, and the timeline of fever and stool
- Communication — counselling on blood culture, antibiotic choice and convalescence
- Patient Management — stepwise investigation and risk-stratified treatment of the febrile child
- General Pediatrics Content Outline — Domain 4: Acute and chronic illness — enteric fever and dysentery
- General Pediatrics Content Outline — Domain 8: Infectious diseases — invasive bacterial enteritis, XDR organisms and HUS
- Medical Knowledge — typhoid conjugate vaccine, culture-guided therapy and antimicrobial stewardship
- Patient Care 1: resuscitation of the child with invasive enteric disease, sepsis and HUS
- Medical Knowledge 2: diagnostic decision making — blood versus stool diagnostics, XDR patterns
- Systems-Based Practice 4: notifiable disease reporting, public health and vaccine programmes
- Medical Expert — enteric fever, shigellosis and STEC-HUS; culture-guided and resistance-aware therapy
- Infectious Diseases and Immunity (10-15%) — invasive bacterial enteritis
- Health Advocate — typhoid conjugate vaccination, travel medicine and safe water advocacy
Overview & Definition
A nine-year-old boy returns from visiting family in Pakistan with a fever that has risen a little each day for six days. He is constipated, his abdomen is vaguely tender, and his pulse is slower than you would expect for 39.5 degrees. His aunt mentions that typhoid is "going around" the village. Ask the question that organises the whole encounter — is this an organism invading the bloodstream from the gut, or one staying in the lumen? — and you are doing enteric-fever medicine. [1]
Enteric fever is the systemic, bacteraemic illness caused by Salmonella enterica serotypes Typhi (typhoid fever) and Paratyphi A, B and C (paratyphoid fever). After invading the intestinal mucosa, the organism survives in macrophages, spreads through the reticuloendothelial system, and re-enters the blood to produce a sustained, stepwise fever with abdominal and systemic features. It is a human-restricted infection transmitted by the faecal-oral route, and it has no animal reservoir. [1]
Invasive bacterial enteritis is the broader family of bacterial intestinal infections in which the organism — or its toxin — penetrates the mucosa or enters the bloodstream, producing colitis, dysentery or systemic upset. The members most relevant to children are Shigella species (bacillary dysentery), Campylobacter jejuni (invasive colitis and a cause of Guillain-Barré syndrome), invasive non-typhoidal Salmonella (a major cause of bacteraemia in African infants and in immunocompromised children everywhere), and the Shiga-toxin producing Escherichia coli (STEC, also called enterohaemorrhagic E. coli, EHEC), whose toxin drives haemolytic uraemic syndrome. [12]
The clinical reason this grouping matters is that invasive disease behaves differently from the common, self-limiting non-invasive watery diarrhoea caused by rotavirus, norovirus, enterotoxigenic E. coli and Giardia. Non-invasive disease is treated with oral rehydration and usually needs no antibiotic and no cultures. Invasive disease can cause sepsis, perforation, haemolysis and renal failure, demands blood and stool diagnostics, and usually needs a targeted antibiotic chosen in the light of local resistance. Holding these two frames at once is the core skill of this topic. [10]
References15ShowHide
- [1]Wain J, Hendriksen RS, Mikoleit ML, et al. Typhoid fever Lancet (London, England), 2015.PMID 25458731
- [2]Crump JA, Luby SP, Mintz ED The global burden of typhoid fever Bulletin of the World Health Organization, 2004.PMID 15298225
- [3]Kuehn R, Stoesser N, Eyre D, Darton TC, Parry CM Treatment of enteric fever (typhoid and paratyphoid fever) with cephalosporins Cochrane Database of Systematic Reviews, 2022.PMID 36420914
- [4]Parry CM, Qamar FN, Rijal S, McCann N What should we be recommending for the treatment of enteric fever? Open Forum Infectious Diseases, 2023.PMID 37274536
- [5]Jin C, Gibani MM, Moore M, et al. Efficacy and immunogenicity of a Vi-tetanus toxoid conjugate vaccine in the prevention of typhoid fever using a controlled human infection model of Salmonella Typhi: a randomised controlled, phase 2b trial Lancet (London, England), 2017.PMID 28965718
- [6]Patel PD, Liang Y, Meiring JE, et al. Efficacy of typhoid conjugate vaccine: final analysis of a 4-year, phase 3, randomised controlled trial in Malawian children Lancet (London, England), 2024.PMID 38281499
- [7]Yousafzai MT, Karim S, Qureshi S, et al. Effectiveness of typhoid conjugate vaccine against culture-confirmed Salmonella enterica serotype Typhi in an extensively drug-resistant outbreak setting of Hyderabad, Pakistan: a cohort study The Lancet Global Health, 2021.PMID 34297962
- [8]Carey ME, Dyson ZA, Ingle DJ, et al. Global diversity and antimicrobial resistance of typhoid fever pathogens: insights from a meta-analysis of 13,000 Salmonella Typhi genomes eLife, 2023.PMID 37697804
- [9]da Silva KE, Tanmoy AM, Pragasam AK, et al. The international and intercontinental spread and expansion of antimicrobial-resistant Salmonella Typhi: a genomic epidemiology study The Lancet Microbe, 2022.PMID 35750070
- [10]Kotloff KL, Nataro JP, Blackwelder WC, et al. Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a prospective, case-control study Lancet (London, England), 2013.PMID 23680352
- [11]Liu J, Platts-Mills JA, Juma J, et al. Use of quantitative molecular diagnostic methods to identify causes of diarrhoea in children: a reanalysis of the GEMS case-control study Lancet (London, England), 2016.PMID 27673470
- [12]Nataro JP, Kaper JB Diarrheagenic Escherichia coli Clinical Microbiology Reviews, 1998.PMID 9457432
- [13]Christopher PR, David KV, John SM, Sankarapandian V Antibiotic therapy for Shigella dysentery Cochrane Database of Systematic Reviews, 2010.PMID 20687081
- [14]Bhutta ZA International travel and the risk of extensively drug-resistant typhoid: issues and potential solutions Clinical Infectious Diseases, 2021.PMID 32609356
- [15]Moore SR, Lima NL, Soares AM, Oriá RB, Pinkerton RC, Barrett LJ, Guerrant RL, Lima AA Prolonged episodes of acute diarrhea reduce growth and increase risk of persistent diarrhea in children Gastroenterology, 2010.PMID 20638937