The diagnostic void: how typhoid-by-default drives antimicrobial resistance in Ethiopia

The empirical diagnosis of typhoid-by-default represents a severe failure in Ethiopia's management of febrile illnesses. This practice of diagnosing undifferentiated fever as typhoid without confirmation drives antimicrobial resistance (AMR) through a unique diagnostic ecosystem shaped by historical precedent, systemic constraints, community demand, and reliance on the outdated Widal test. This diagnostic void promotes empirical use of broad-spectrum antibiotics, selecting for resistant Salmonella enterica serotype Typhi, while contributing to the spread of AMR in commensal organisms and other pathogens. This practice contributes to a broader AMR crisis that extends beyond enteric fever, compromising the treatment of urinary, respiratory, and other common infections. The result is a self-perpetuating cycle of multisystem treatment failures, excess mortality, and economic loss. In this Personal View, we discuss the steps required to break this cycle: eliminating the Widal test, implementing validated diagnostic algorithms for febrile presentation, expanding diagnostic access, introducing typhoid vaccines, and establishing antimicrobial stewardship programmes. Addressing this issue is an urgent public health priority for both national and global AMR containment.