{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,15]],"date-time":"2026-08-15T16:29:01Z","timestamp":1786811341079,"version":"build-2736575974"},"reference-count":32,"publisher":"SAGE Publications","license":[{"start":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T00:00:00Z","timestamp":1785542400000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"},{"start":{"date-parts":[[2026,8,1]],"date-time":"2026-08-01T00:00:00Z","timestamp":1785542400000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/journals.sagepub.com\/page\/policies\/text-and-data-mining-license"}],"content-domain":{"domain":["journals.sagepub.com"],"crossmark-restriction":true},"short-container-title":["Therapeutic Advances in Infection"],"published-print":{"date-parts":[[2026,8]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Extensively drug-resistant (XDR) typhoid fever is a major public health concern in Pakistan, with limited treatment options and rising morbidity. There is a limited amount of evidence available on the role of the environmental factors that may impact the severity of the disease in adults.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Objectives<\/jats:title>\n                    <jats:p>To evaluate clinical outcomes, antimicrobial resistance patterns, and environmental factors associated with disease severity among adults with XDR typhoid fever in Northern Punjab, Pakistan.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Design<\/jats:title>\n                    <jats:p>Prospective observational study.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>\n                      A prospective observational study was conducted from January 2024 to January 2025 at a tertiary care hospital in Northern Punjab. The enrollment occurred among adult patients (18- 60 years) with blood culture-confirmed XDR\n                      <jats:italic toggle=\"yes\">Salmonella enterica<\/jats:italic>\n                      serovar Typhi infection using consecutive sampling. Clinical characteristics, susceptibility to antimicrobials, and environmental exposure were recorded. Severity of the disease was defined based on clinically significant complications and adverse outcomes. The chi-square test and Fisher exact test were used to analyze the associations, followed by multivariable logistic regression analysis to adjust for potential confounders.\n                    <\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Among 110 patients, meropenem (98.2%) and azithromycin (96.4%) showed the highest antimicrobial susceptibility. Contaminated drinking water, poor sanitation, street food and season of diagnosis were also significantly associated with severe disease (p&lt;0.05).<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusion<\/jats:title>\n                    <jats:p>XDR typhoid fever in Northern Punjab was characterized by extensive antimicrobial resistance, while poor sanitation, contaminated drinking water, street food consumption, and season of diagnosis were significantly associated with severe disease. There is an immediate need to strengthen water, sanitation, antibiotic stewardship, and vaccination strategies.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Registration<\/jats:title>\n                    <jats:p>Not applicable.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1177\/20499361261474659","type":"journal-article","created":{"date-parts":[[2026,8,13]],"date-time":"2026-08-13T18:36:42Z","timestamp":1786646202000},"update-policy":"https:\/\/doi.org\/10.1177\/sage-journals-update-policy","source":"Crossref","is-referenced-by-count":0,"title":["Clinical outcomes, environmental exposure factors, and antibiotic resistance patterns of extensively drug-resistant (XDR) typhoid fever in Pakistan: A prospective observational study"],"prefix":"10.1177","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0005-5414-1356","authenticated-orcid":false,"given":"Hamna","family":"Khalid","sequence":"first","affiliation":[{"name":"Department of Medicine, Wah Medical College"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdul Rehman","family":"Shahid","sequence":"additional","affiliation":[{"name":"Department of Medicine, Wah Medical College"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eman","family":"Ahmad","sequence":"additional","affiliation":[{"name":"Department of Medicine, POF Hospital"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Noshaba","family":"Razaq","sequence":"additional","affiliation":[{"name":"Department of Medicine, Wah Medical College"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fatima Binte","family":"Muhammad","sequence":"additional","affiliation":[{"name":"Department of Medicine, Wah Medical College"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Laiba Irfan","family":"Ghauri","sequence":"additional","affiliation":[{"name":"Department of Medicine, Wah Medical College"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sehrish","family":"Khan","sequence":"additional","affiliation":[{"name":"Department of Medicine, Wah Medical College"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Muhammad Dawood","family":"Nazir","sequence":"additional","affiliation":[{"name":"Department of Medicine, Wah Medical College"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-7391-4709","authenticated-orcid":false,"given":"Noof K.","family":"Binashikhbubkr","sequence":"additional","affiliation":[{"name":"Hadhramout University"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"179","published-online":{"date-parts":[[2026,8,13]]},"reference":[{"issue":"1","key":"e_1_3_9_2_2","first-page":"1","article-title":"Community engagement: the missing piece in solving the puzzle of XDR typhoid spread in Pakistan","volume":"46","author":"Shahzadi A","year":"2025","unstructured":"Shahzadi A, Ashiq Z. Community engagement: the missing piece in solving the puzzle of XDR typhoid spread in Pakistan. J Public Health Policy 2025; 46(1): 1\u20138. https:\/\/doi.org\/10.1057\/s41271-025-00568-8","journal-title":"J Public Health Policy"},{"issue":"2","key":"e_1_3_9_3_2","first-page":"S1","volume":"10","author":"Chen J","year":"2023","unstructured":"Chen J, Long JE, Vannice K, et al. Taking on typhoid: eliminating typhoid fever as a global health problem. Open Forum Infect Dis 2023; 10(Suppl 2): S1\u2013S10. https:\/\/doi.org\/10.1093\/ofid\/ofad055","journal-title":"Taking on typhoid: eliminating typhoid fever as a global health problem. Open Forum Infect Dis"},{"issue":"3","key":"e_1_3_9_4_2","first-page":"taab012","article-title":"Typhoid and paratyphoid fever: a clinical seminar","volume":"28","author":"Manesh A","year":"2021","unstructured":"Manesh A, Meltzer E, Jin C, et al. Typhoid and paratyphoid fever: a clinical seminar. Typhoid and paratyphoid fever: a clinical seminar. J Travel Med 2021; 28(3): taab012. https:\/\/doi.org\/10.1093\/jtm\/taab012","journal-title":"Typhoid and paratyphoid fever: a clinical seminar. J Travel Med"},{"key":"e_1_3_9_5_2","doi-asserted-by":"publisher","DOI":"10.3855\/jidc.13539"},{"key":"e_1_3_9_6_2","first-page":"16","article-title":"Prevalence of multidrug-resistant Salmonella Typhi isolated from blood samples","author":"Mina SA","year":"2023","unstructured":"Mina SA, Hasan MZ, Hossain AZ, et al. Prevalence of multidrug-resistant Salmonella Typhi isolated from blood samples. 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