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Background Complicated typhoid fever can involve multiple organ systems, including the liver. NICE guidelines recommend baseline and follow-up liver function tests (LFTs) in severe systemic infections to guide clinical management. Anecdotal evidence suggests that LFT monitoring in complicated typhoid fever may be inconsistent in Kashmir. This audit aimed to assess compliance with NICE guidance and identify areas for improvement.Methods A prospective audit was conducted over six months in a tertiary care hospital in Kashmir. Adult patients (n=110) with blood culture-confirmed complicated typhoid fever were included. Data were collected on baseline LFTs (ALT, AST, ALP, total bilirubin, albumin), follow-up testing, and clinical actions taken on abnormal results. Compliance was compared against NICE standards, which recommend baseline LFTs for all severe cases and repeat testing in patients with abnormal results.Results Baseline LFTs were performed in 95% of patients, nearly meeting NICE standards. Follow-up LFTs in patients with abnormal liver tests were performed in 78% of cases, indicating a 22% gap. Abnormal LFTs correlated with longer hospital stays (mean 12 vs 8 days) and higher rates of complications, including intestinal perforation. Clinical action on deranged LFTs occurred in 85% of cases. Patients whose LFTs were not adequately monitored had worse outcomes, highlighting the clinical importance of guideline adherence.Conclusions Baseline LFT monitoring in complicated typhoid fever is largely compliant with NICE guidance, but follow-up testing remains suboptimal. Establishing a structured LFT monitoring protocol, clinician reminders, and staff training could improve compliance and patient outcomes. Re-audit after implementation is recommended to assess the impact of these measures.