The exact mechanism by which eosinopenia develops is unclear, but our findings suggest that it can be a useful diagnostic clue.[25] LFT values were significantly increased in patients with S Typhi, although not high enough to qualify as “typhoid hepatitis,” which has been previously described.[29, 30] It should be noted, though, that in cases of markedly elevated

LFT values, the clinician should also look for water-borne co-transmission of hepatitis viruses, namely hepatitis A and E.[30] In the present case series, we report a high rate of nalidixic acid resistance (76%). In 2006, the overall rate of NARST was 54% and it was 65% for India for the period 1999 to 2006.[14] On the basis of these results, third-generation cephalosporins should now be considered the antibiotics of choice for the initial Tanespimycin cell line empiric treatment of typhoid that requires parenteral therapy, especially when there is a history of travel to India, Pakistan, or Bangladesh.[7-10] The recommended duration of treatment is 10 to 14 days,[1, 7] and one of our patients who had been treated with ceftriaxone for 8 days developed Salmonella osteomyelitis. In our study,

S Typhi isolates were not tested for susceptibility to the newer macrolides. The use of macrolides in endemic areas is limited, because of their high cost and low availability. It should be noted, though, that azithromycin is a promising option for oral treatment

of typhoid in this website returning travelers, as no resistance has been reported yet and the cure rate is >90%.[9, 15, 31] A very recent randomized study showed that combination therapy of ceftriaxone with azithromycin, compared to ceftriaxone alone, significantly decreased the time to defervescence and the length of hospital stay, in a group of Israeli travelers to Nepal who had acquired Salmonella Paratyphi.[32] None of our VFR travelers had been vaccinated or formally educated about preventive measures prior to travel. Safe food and water practices are of utmost importance; however, the evidence on pre-travel vaccination is quite controversial.[33-35] In the study by Lynch and colleagues,[14] only 5% of all US travelers found to have typhoid Interleukin-2 receptor fever, over a 10-year period, had actually received the vaccine. On the contrary, in a large nation-wide study, 62% of the Israeli travelers who acquired typhoid fever had received vaccination within 3 years.[21] However, the same study[21] showed that the incidence of enteric fever in Israeli travelers to Nepal declined, compared to the prevaccination era. A single case-control study of travelers to India estimated the efficacy of the Ty21a vaccine to be only 23%.[34] Nevertheless, in that study, only three doses of the oral vaccine were used, which may, in part, explain its low efficacy.