Yonsei Med J.  2009 Feb;50(1):147-151. 10.3349/ymj.2009.50.1.147.

A Case of Multidrug-Resistant Salmonella enterica Serovar Typhi Treated with a Bench to Bedside Approach

• Yoon HJ
• Cho SH
• Kim SH

• KMID: 1782981
• DOI: http://doi.org/10.3349/ymj.2009.50.1.147

Abstract

We report a relapsed case of a 25 year-old man with multi-drug resistant Salmonella serovar Typhi (MDRST) bacteremia who had recently returned from travel in India. Due to unresponsiveness to ciprofloxacin and ceftriaxone, we examined the strain's resistance to quinolones and extended-spectrum beta-lactamases (ESBLs). The strain had a single gyrA mutation at codon 83 (Ser83Phe), which explains its decreased susceptibility to fluoroquinolone and resistance to nalidixic acid. In the screening tests of ESBLs, TEM-1 was positive, which is beta-lactamase but not ESBL. The patient was finally successfully treated with meropenem and aztreonam. In the presence of clinical unresponsiveness despite favorable sensitivity tests, further laboratory evaluations are needed, which should include studies of genes related to antibiotic resistance and ESBLs. In addition, further prospective trials should be done about the possible inclusion of antibiotics not yet mentioned in the current guidelines. With MDRST on the rise worldwide, the most optimal and effective line of antibiotic defense needs to be devised.

Keyword

Salmonella enterica serovar Typhi; multi-drug resistance; treatment

MeSH Terms

Adult
Anti-Bacterial Agents/*administration & dosage
Aztreonam/*administration & dosage
Bacteremia/drug therapy/microbiology
Drug Resistance, Bacterial/genetics
Drug Resistance, Multiple/genetics
Drug Therapy, Combination
Humans
Male
Salmonella typhi/*drug effects/genetics
Thienamycins/*administration & dosage
Typhoid Fever/*drug therapy

Reference

1. Edelman R, Levine MM. Summary of an international workshop on typhoid fever. Rev Infect Dis. 1986. 8:329–349.

2. Giraud E, Brisabois A, Martel JL, Chaslus-Dancla E. Comparative studies of mutations in animal isolates and experimental in vitro- and in vivo-selected mutants of Salmonella spp. suggest a counterselection of highly fluoroquinolone-resistant strains in the field. Antimicrob Agents Chemother. 1999. 43:2131–2137.

3. Bhutta ZA. Current concepts in the diagnosis and treatment of typhoid fever. BMJ. 2006. 333:78–82.

4. Olarte J, Galindo E. Salmonella typhi resistant to chloramphenicol, ampicillin, and other antimicrobial agents: strains isolated during an extensive typhoid fever epidemic in Mexico. Antimicrob Agents Chemother. 1973. 4:597–601.

5. Brown JD, Duong Hong M, Rhodes ER. Chloramphenicol-resistant Salmonella typhi in Saigon. JAMA. 1975. 231:162–166.

6. Lee K, Yong D, Yum JH, Lim YS, Chong Y, Lee BK. Abstract. 43rd Interscience Conference on Antimicrobial Agents and Chemotherapy. 2003. Abstract C2-865.

7. Lee K, Yong D, Yum JH, Lim YS, Kim HS, Lee BK, et al. Emergence of multidrug-resistant Salmonella enterica serovar Typhi in Korea. Antimicrob Agents Chemother. 2004. 48:4130–4135.

8. Shin YH, Yoo JS, Kim KS, Chung DJ, Oh KS, Lee JK, et al. In vitro antimicrobial susceptibility of Salmonella typhi, Salmonella typhimurium and Salmonella enteritidis isolated in Korea, 1997. J Korean Soc Chemother. 1998. l6:205–214.

9. Hanson ND, Thomson KS, Moland ES, Sanders CC, Berthold G, Penn RG. Molecular characterization of a multiply resistant Klebsiella pneumoniae encoding ESBLs and a plasmid-mediated AmpC. J Antimicrob Chemother. 1999. 44:377–380.

10. Rasheed JK, Jay C, Metchock B, Berkowitz F, Weigel L, Crellin J, et al. Evolution of extended-spectrum β-lactam resistance (SHV-8) in a strain of Escherichia coli during multiple episodes of bacteremia. Antimicrob Agents Chemother. 1997. 41:647–653.

11. Pitout JD, Hossain A, Hanson ND. Phenotypic and molecular detection of CTX-M-β-lactamases produced by Escherichia coli and Klebsiella spp. J Clin Microbiol. 2004. 42:5715–5721.

12. Pérez-Pérez FJ, Hanson ND. Detection of plasmidmediated AmpC β-lactamase genes in clinical isolates by using multiplex PCR. J Clin Microbiol. 2002. 40:2153–2162.

13. Gupta B, Kumar R, Khurana S. Multi drug resistant Salmonella Typhi in Ludhiana (Punjab). Indian J Pathol Microbiol. 1993. 36:5–7.

14. Gautam V, Gupta NK, Chaudhary U, Arora DR. Sensitivity pattern of Salmonella serotypes in Northern India. Braz J Infect Dis. 2002. 6:281–287.

15. Jones RN, Rhomberg PR, Varnam DJ, Mathai D. A comparison of the antimicrobial activity of meropenem and selected broad-spectrum antimicrobials tested against multi-drug resistant Gram-negative bacilli including bacteraemic Salmonella spp.: initial studies for the MYSTIC programme in India. Int J Antimicrob Agents. 2002. 20:426–431.

16. Pokharel BM, Koirala J, Dahal RK, Mishra SK, Khadga PK, Tuladhar NR. Multidrug-resistant and extended-spectrum beta-lactamase (ESBL)-producing Salmonella enterica (serotypes Typhi and Paratyphi A) from blood isolates in Nepal: surveillance of resistance and a search for newer alternatives. Int J Infect Dis. 2006. 10:434–438.

17. Jean SS, Lee YT, Guo SM, Hsueh PR. Recurrent infections caused by cefotaxime- and ciprofloxacin-resistant Salmonella enterica serotype choleraesuis teated successfully with imipenem. J Infect. 2005. 51:e163–e165.

18. Mathai D, Rhomberg PR, Biedenbach DJ, Jones RN. The India Antimicrobial Resistance Study Group. Evaluation of the in vitro activity of six broad-spectrum β-lactam antimicrobial agents tested against recent clinical isolates from India: a survey of ten medical center laboratories. Diagn Microbiol Infect Dis. 2002. 44:367–377.

19. Piddock LJ, Johnson MM, Webber MA. Activity of faropenem and imipenem for ciprofloxacin-resistant bacteria. J Antimicrob Chemother. 2003. 52:500–502.

20. Adinolfi LE, Utili R, Dilillo M, Tripodi MF, Attanasio V, Ruggiero G. Intracellular activity of cefamandole and aztreonam against phagocytosed Escherichia coli and Staphylococcus aureus. J Antimicrob Chemother. 1989. 24:927–935.

21. Pruul H, Lewis G, McDonald PJ. Enhanced susceptibility of gram-negative bacteria to phagocytic killing by human polymorphonuclear leucocytes after brief exposure to aztreonam. J Antimicrob Chemother. 1998. 22:675–686.

22. Bonina L, Carbone M, Matera G, Teti G, Joysey HS, Hormaeche CE, et al. Beta-lactam antibiotics (aztreonam, ampicillin, cefazolin and ceftazidime) in the control and eradication of Salmonella typhimurium in naturally resistant and susceptible mice. J Antimicrob Chemother. 1990. 25:813–823.

23. Gotuzzo E, Echevarría J, Carrillo C, Sánchez J, Grados P, Maguiña C, et al. Randomized comparison of aztreonam and chloramphenicol in treatment of typhoid fever. Antimicrob Agents Chemother. 1994. 38:558–562.

24. Paradelis AG, Delidou K, Stavrakis AO, Crassaris LG. Comparative in vitro activity of aztreonam and other antimicrobial agents against Salmonella species. Drugs Exp Clin Res. 1985. 11:163–167.

25. Girgis NI, Sultan Y, Hammad O, Farid Z. Comparison of the efficacy, safety and cost of cefixime, ceftriaxone and aztreonam in the treatment of multidrug-resistant Salmonella typhi septicemia in children. Pediatr Infect Dis J. 1995. 14:603–605.

26. Hooper DC. Mechanisms of fluoroquinolone resistance. Drug Resist Updat. 1999. 2:38–55.

27. Paterson DL. Resistance in gram-negative bacteria: enterrobacteriaceae. Am J Med. 2006. 119:6 Suppl 1. S20–S28. discussion S62-70.