Azithromycin Treatment for SARS-CoV-2-related COVID-19 Pandemic Could Worsen Extensively Drug Resistant (XDR) Typhoid: A Risk of Losing the Last Bullet Against Salmonella enterica Serovar Typhi

Principal Investigator (PI):   Dr Rizwan Uppal

Author Names:  Rizwan Uppal, Umar Saeed, Sara Rizwan Uppal, Zahra Zahid Piracha, Azhar Rasheed, Zubair Aftab, Hafsah Zaheer

Corresponding Author & Co-PI:  Dr. Umar Saeed

The research conducted at Microbiology department of IDC, revealed SARS-CoV-2 and COVID-19 impact on Extensively Drug Resistant (XDR) Typhoid in Pakistan. It was demonstrated that frequent usage of Azithromycin among COVID-19 patients may give rise to drug-resistant strains. Furthermore, novel therapeutic options against multiple drug-resistant bacteria were also proposed. The study is published in well reputed Jundishapur Journal of Microbiology.

Letter to Editor

Viral infections are increasing day by day (1-3). Severe acute respiratory syndrome (SARS) coronavirus 2 (SARS-CoV-2) pandemic has resulted in the negligence of diseases such as diabetes, heart diseases, and many more. Among these neglected diseases is extensively drug resistant (XDR) typhoid fever. Intensive care units in hospitals are hotspots for antimicrobial resistance (4). Although antibiotics do not inhibit SARS-CoV-2 replication, yet viral respiratory infections may lead to bacterial pneumonia (4). Hydroxychloroquine and azithromycin have been frequently used for COVID-19 ailment based upon small uncontrolled studies, which showed preliminary effective results. Azithromycin is commonly used to potentially treat or prevent co-infection with SARS-CoV-2. It has been reported that azithromycin may have antiviral properties against RNA viruses such as Zika, rhinovirus, and SARS-CoV-2 (4-7).
In Pakistan, since 2016, there have been several out-breaks of antimicrobial resistant strains of Salmonella enterica serovar Typhi belonging to the H58 haplotype that cause XDR typhoid fever (8). The H58 strains are resistant to chloramphenicol, ampicillin, and trimethoprim- sulfamethoxazole antibiotics (9). Salmonella enterica serovar Typhi has shown resistance to fluoroquinolones and ceftriaxone (10), while orally only azithromycin antibiotic has shown significant responses for the treatment of XDR typhoid. In Pakistan, azithromycin has been given to treat COVID-19 patients while neglecting the prevalence of XDR typhoid fever. This might bring havoc in the near future if XDR becomes resistant against azithromycin. Of note, XDR typhoid fever has been extensively misdiagnosed before due to serological tests such as Widal and


Authors’ Contribution

RU and US conceived the study. RU is the principal investigator (PI) of the study. US wrote the manuscript and analyzed the data and Co-PI of this study. SRU and ZZP assisted in manuscript writing and data analysis.

Conflict of Interests

The authors have no conflicts of in-

Ethical Approval

The manuscript was approved by the ethical board of IDC for publication.


No funding was allotted for this study.