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Mylona E, Pham Thanh D, Keane JA, Dongol S, Basnyat B, Dolecek C, Voong Vinh P, Tran Vu Thieu N, Nguyen Thi Nguyen T, Karkey A, Baker S. A retrospective investigation of the population structure and geospatial distribution of Salmonella Paratyphi A in Kathmandu, Nepal. PLoS Negl Trop Dis 2024; 18:e0011864. [PMID: 38889189 PMCID: PMC11216570 DOI: 10.1371/journal.pntd.0011864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 07/01/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024] Open
Abstract
Salmonella Paratyphi A, one of the major etiologic agents of enteric fever, has increased in prevalence in recent decades in certain endemic regions in comparison to S. Typhi, the most prevalent cause of enteric fever. Despite this increase, data on the prevalence and molecular epidemiology of S. Paratyphi A remain generally scarce. Here, we analysed the whole genome sequences of 216 S. Paratyphi A isolates originating from Kathmandu, Nepal between 2005 and 2014, of which 200 were from patients with acute enteric fever and 16 from the gallbladder of people with suspected chronic carriage. By exploiting the recently developed genotyping framework for S. Paratyphi A (Paratype), we identified several genotypes circulating in Kathmandu. Notably, we observed an unusual clonal expansion of genotype 2.4.3 over a four-year period that spread geographically and systematically replaced other genotypes. This rapid genotype replacement is hypothesised to have been driven by both reduced susceptibility to fluoroquinolones and genetic changes to virulence factors, such as functional and structural genes encoding the type 3 secretion systems. Finally, we show that person-to-person is likely the most common mode of transmission and chronic carriers seem to play a limited role in maintaining disease circulation.
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Affiliation(s)
- Elli Mylona
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), University of Cambridge, Cambridge, United Kingdom
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Duy Pham Thanh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Program, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Jacqueline A. Keane
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), University of Cambridge, Cambridge, United Kingdom
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Sabina Dongol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Christiane Dolecek
- The Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Phat Voong Vinh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Program, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nga Tran Vu Thieu
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Program, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - To Nguyen Thi Nguyen
- Department of Microbiology, Monash Biomedicine Discovery Institute, Monash University, Melbourne, Victoria, Australia
| | - Abhilasha Karkey
- The Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology & Infectious Disease (CITIID), University of Cambridge, Cambridge, United Kingdom
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
- IAVI Human Immunology Laboratory, Chelsea and Westminster Hospital, London, United Kingdom
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Moja L, Zanichelli V, Mertz D, Gandra S, Cappello B, Cooke GS, Chuki P, Harbarth S, Pulcini C, Mendelson M, Tacconelli E, Ombajo LA, Chitatanga R, Zeng M, Imi M, Elias C, Ashorn P, Marata A, Paulin S, Muller A, Aidara-Kane A, Wi TE, Were WM, Tayler E, Figueras A, Da Silva CP, Van Weezenbeek C, Magrini N, Sharland M, Huttner B, Loeb M. WHO's essential medicines and AWaRe: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections. Clin Microbiol Infect 2024; 30 Suppl 2:S1-S51. [PMID: 38342438 DOI: 10.1016/j.cmi.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/26/2024] [Accepted: 02/04/2024] [Indexed: 02/13/2024]
Abstract
The WHO Model List of Essential Medicines (EML) prioritizes medicines that have significant global public health value. The EML can also deliver important messages on appropriate medicine use. Since 2017, in response to the growing challenge of antimicrobial resistance, antibiotics on the EML have been reviewed and categorized into three groups: Access, Watch, and Reserve, leading to a new categorization called AWaRe. These categories were developed taking into account the impact of different antibiotics and classes on antimicrobial resistance and the implications for their appropriate use. The 2023 AWaRe classification provides empirical guidance on 41 essential antibiotics for over 30 clinical infections targeting both the primary health care and hospital facility setting. A further 257 antibiotics not included on the EML have been allocated an AWaRe group for stewardship and monitoring purposes. This article describes the development of AWaRe, focussing on the clinical evidence base that guided the selection of Access, Watch, or Reserve antibiotics as first and second choices for each infection. The overarching objective was to offer a tool for optimizing the quality of global antibiotic prescribing and reduce inappropriate use by encouraging the use of Access antibiotics (or no antibiotics) where appropriate. This clinical evidence evaluation and subsequent EML recommendations are the basis for the AWaRe antibiotic book and related smartphone applications. By providing guidance on antibiotic prioritization, AWaRe aims to facilitate the revision of national lists of essential medicines, update national prescribing guidelines, and supervise antibiotic use. Adherence to AWaRe would extend the effectiveness of current antibiotics while helping countries expand access to these life-saving medicines for the benefit of current and future patients, health professionals, and the environment.
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Affiliation(s)
- Lorenzo Moja
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland.
| | - Veronica Zanichelli
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Dominik Mertz
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
| | - Sumanth Gandra
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine in St. Louis, Missouri, United States
| | - Bernadette Cappello
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Graham S Cooke
- Department of Infectious Diseases, Imperial College London, London, UK
| | - Pem Chuki
- Antimicrobial Stewardship Unit, Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
| | - Stephan Harbarth
- Infection Control Programme, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; World Health Organization Collaborating Centre on Infection Prevention and Control and Antimicrobial Resistance, Geneva, Switzerland
| | - Celine Pulcini
- APEMAC, and Centre régional en antibiothérapie du Grand Est AntibioEst, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Marc Mendelson
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Evelina Tacconelli
- Infectious Diseases Unit, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Loice Achieng Ombajo
- Department of Clinical Medicine and Therapeutics, University of Nairobi, Nairobi, Kenya; Center for Epidemiological Modelling and Analysis, University of Nairobi, Nairobi, Kenya
| | - Ronald Chitatanga
- Antimicrobial Resistance National Coordinating Centre, Public Health Institute of Malawi, Blantyre, Malawi
| | - Mei Zeng
- Department of Infectious Diseases, Children's Hospital of Fudan University, Shanghai, China
| | | | - Christelle Elias
- Service Hygiène et Epidémiologie, Hospices Civils de Lyon, Lyon, France; Centre International de Recherche en Infectiologie, Institut National de la Santé et de la Recherche Médicale U1111, Centre National de la Recherche Scientifique Unité Mixte de Recherche 5308, École Nationale Supérieure de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Per Ashorn
- Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University and Tampere University Hospital, Tampere, Finland
| | | | - Sarah Paulin
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | - Arno Muller
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland
| | | | - Teodora Elvira Wi
- Department of Global HIV, Hepatitis and STIs Programme, World Health Organization, Geneva, Switzerland
| | - Wilson Milton Were
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, World Health Organization, Geneva, Switzerland
| | - Elizabeth Tayler
- WHO Regional Office for the Eastern Mediterranean (EMRO), World Health Organisation, Cairo, Egypt
| | | | - Carmem Pessoa Da Silva
- Antimicrobial Resistance Division, World Health Organization, Geneva, Switzerland; Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Nicola Magrini
- NHS Clinical Governance, Romagna Health Authority, Ravenna, Italy; World Health Organization Collaborating Centre for Evidence Synthesis and Guideline Development, Bologna, Italy
| | - Mike Sharland
- Centre for Neonatal and Paediatric Infections, Institute for Infection and Immunity, St George's University of London, London, UK
| | - Benedikt Huttner
- Health Products Policy and Standards, World Health Organization, Geneva, Switzerland
| | - Mark Loeb
- Department of Medicine, McMaster University, Hamilton, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada; World Health Organization Collaborating Centre for Infectious Diseases, Research Methods and Recommendations, McMaster University, Hamilton, Canada
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Guo J, Gan W, Chen R, Zhang M, Sun Z. Au nanoparticle sensitized blue TiO 2 nanorod arrays for efficient Gatifloxacin photodegradation. RSC Adv 2023; 13:28299-28306. [PMID: 37767117 PMCID: PMC10521361 DOI: 10.1039/d3ra05552c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/20/2023] [Indexed: 09/29/2023] Open
Abstract
TiO2 nanorod arrays have been widely used in photocatalytic processes, but their poor visible light absorption and rapid carrier recombination limit their application. Both introducing oxygen vacancies and using precious metals as surface plasmon resonance (SPR) stimulators are effective strategies to enhance their photocatalytic performance. Herein, Au nanoparticle sensitized blue TiO2 nanorod arrays (Au/B-TiO2) were successfully fabricated for efficient Gatifloxacin photodegradation. The degradation efficiency of Gatifloxacin was up to 95.0%. Moreover, the corresponding reaction rate constant (Ka) was up to 0.02007 min-1. Additionally, it was suggested that Gatifloxacin could be subject to three different degradation pathways. The superior catalytic activity of Au/B-TiO2 is a result of the combined effect of the two components. Firstly, TiO2 nanorod arrays provide a larger surface area for Au deposition and act as efficient transfer channels. Secondly, the presence of oxygen vacancies in blue TiO2 nanorod arrays enhances the catalytic activity. Thirdly, Au acts as a SPR activator, providing a large number of high-energy electrons in the photocatalysis process. Lastly, the improved light capture capabilities are essential for efficient removal of Gatifloxacin. This work provides a new approach for the construction of a high-performance heterojunction photocatalyst in advanced oxidation processes.
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Affiliation(s)
- Jun Guo
- School of Electronic Engineering, Huainan Normal University Huainan 232038 P. R China
- School of Materials Science and Engineering, Anhui University Hefei 230601 P. R China
| | - Wei Gan
- School of Materials Science and Engineering, Anhui University Hefei 230601 P. R China
| | - Ruixin Chen
- School of Materials Science and Engineering, Anhui University Hefei 230601 P. R China
| | - Miao Zhang
- School of Materials Science and Engineering, Anhui University Hefei 230601 P. R China
| | - Zhaoqi Sun
- School of Materials Science and Engineering, Anhui University Hefei 230601 P. R China
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Borgonovo F, Quici M, Gidaro A, Giustivi D, Cattaneo D, Gervasoni C, Calloni M, Martini E, La Cava L, Antinori S, Cogliati C, Gori A, Foschi A. Physicochemical Characteristics of Antimicrobials and Practical Recommendations for Intravenous Administration: A Systematic Review. Antibiotics (Basel) 2023; 12:1338. [PMID: 37627758 PMCID: PMC10451375 DOI: 10.3390/antibiotics12081338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2023] [Revised: 08/11/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023] Open
Abstract
Most antimicrobial drugs need an intravenous (IV) administration to achieve maximum efficacy against target pathogens. IV administration is related to complications, such as tissue infiltration and thrombo-phlebitis. This systematic review aims to provide practical recommendations about diluent, pH, osmolarity, dosage, infusion rate, vesicant properties, and phlebitis rate of the most commonly used antimicrobial drugs evaluated in randomized controlled studies (RCT) till 31 March 2023. The authors searched for available IV antimicrobial drugs in RCT in PUBMED EMBASE®, EBSCO® CINAHL®, and the Cochrane Controlled Clinical trials. Drugs' chemical features were searched online, in drug data sheets, and in scientific papers, establishing that the drugs with a pH of <5 or >9, osmolarity >600 mOsm/L, high incidence of phlebitis reported in the literature, and vesicant drugs need the adoption of utmost caution during administration. We evaluated 931 papers; 232 studies were included. A total of 82 antimicrobials were identified. Regarding antibiotics, 37 reach the "caution" criterion, as well as seven antivirals, 10 antifungals, and three antiprotozoals. In this subgroup of antimicrobials, the correct vascular access device (VAD) selection is essential to avoid complications due to the administration through a peripheral vein. Knowing the physicochemical characteristics of antimicrobials is crucial to improve the patient's safety significantly, thus avoiding administration errors and local side effects.
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Affiliation(s)
- Fabio Borgonovo
- Department of Infectious Diseases, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, University of Milan, 20157 Milan, Italy
| | - Massimiliano Quici
- Internal Medicine Unit, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy
| | - Antonio Gidaro
- Internal Medicine Unit, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy
| | - Davide Giustivi
- Emergency Department and Vascular Access Team ASST Lodi, 26900 Lodi, Italy
| | - Dario Cattaneo
- Unit of Clinical Pharmacology, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, University of Milan, 20157 Milan, Italy
| | - Cristina Gervasoni
- Department of Infectious Diseases, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, University of Milan, 20157 Milan, Italy
| | - Maria Calloni
- Internal Medicine Unit, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy
| | - Elena Martini
- Internal Medicine Unit, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy
| | - Leyla La Cava
- Internal Medicine Unit, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy
| | - Spinello Antinori
- Department of Infectious Diseases, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, University of Milan, 20157 Milan, Italy
| | - Chiara Cogliati
- Internal Medicine Unit, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, Department of Biomedical and Clinical Sciences, University of Milan, 20157 Milan, Italy
| | - Andrea Gori
- Department of Infectious Diseases, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, University of Milan, 20157 Milan, Italy
| | - Antonella Foschi
- Department of Infectious Diseases, Luigi Sacco Hospital, ASST Fatebenefratelli-Sacco, University of Milan, 20157 Milan, Italy
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Saha T, Arisoyin AE, Bollu B, Ashok T, Babu A, Issani A, Jhaveri S, Avanthika C. Enteric Fever: Diagnostic Challenges and the Importance of Early Intervention. Cureus 2023; 15:e41831. [PMID: 37575696 PMCID: PMC10423039 DOI: 10.7759/cureus.41831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2023] [Indexed: 08/15/2023] Open
Abstract
Enteric fever is a systemic infection caused by highly virulent Salmonella enterica serovars: Typhi and Paratyphi. Diagnosis of enteric fever is challenging due to a wide variety of clinical features which overlap with other febrile illnesses. The current diagnostic methods are limited because of the suboptimal sensitivity of conventional tests like blood culture in detecting organisms and the invasive nature of bone marrow culture. It emphasizes the need to develop improved and more reliable diagnostic modalities. The rising rates of multidrug-resistant Salmonella strains call for an accurate understanding of the current management of the disease. Proper public health measures and large-scale immunization programs will help reduce the burden of the disease. A comprehensive surveillance system can help detect the chronic carrier state and is crucial in understanding antibiotic susceptibility patterns. We conducted an all-language literature search on Medline, Cochrane, Embase, and Google Scholar till May 2022. The following search words and medical subject headings (MeSH) were used: "enteric fever," "Salmonella Typhi," "multidrug-resistant Salmonella," chronic carrier state," "Salmonella detection, "and "typhoid vaccine." We reviewed the literature on clinical features, pathophysiology, new diagnostic tests, and interventions to prevent the disease. This article explores enteric fever and its various clinical features and addresses the emerging threat of multidrug resistance. It focuses on novel methods for diagnosis and prevention strategies, including vaccines and the use of surveillance systems employed across different parts of the world.
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Affiliation(s)
- Tias Saha
- Internal Medicine, Samorita General Hospital, Faridpur, BGD
- Internal Medicine, Diabetic Association Medical College, Faridpur, BGD
| | | | - Bhaswanth Bollu
- Emergency Medicine, All India Institute of Medical Sciences, New Delhi, IND
| | - Tejaswini Ashok
- Internal Medicine, Jagadguru Sri Shivarathreeshwara Medical College, Mysore, IND
| | - Athira Babu
- Pediatrics, Saudi German Hospital, Dubai, ARE
| | - Ali Issani
- Emergency Medicine, Aga Khan University, Karachi, PAK
| | - Sharan Jhaveri
- Internal Medicine, Nathiba Hargovandas Lakhmichand Municipal Medical College, Ahmedabad, IND
| | - Chaithanya Avanthika
- Pediatrics, Icahn School of Medicine at Mount Sinai, Elmhurst Hospital Center, New York, USA
- Medicine and Surgery, Karnataka Institute of Medical Sciences, Hubli, IND
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Cestero JJ, Castanheira S, González H, Zaragoza Ó, García-del Portillo F. Affinity of cefotiam for the alternative penicillin binding protein PBP3SAL used by Salmonella inside host eukaryotic cells. J Antimicrob Chemother 2022; 78:512-520. [PMID: 36512374 PMCID: PMC9890219 DOI: 10.1093/jac/dkac422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 11/20/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Following the invasion of eukaryotic cells, Salmonella enterica serovar Typhimurium replaces PBP2/PBP3, main targets of β-lactam antibiotics, with PBP2SAL/PBP3SAL, two homologue peptidoglycan synthases absent in Escherichia coli. PBP3SAL promotes pathogen cell division in acidic environments independently of PBP3 and shows low affinity for β-lactams that bind to PBP3 such as aztreonam, cefepime, cefotaxime, ceftazidime, ceftriaxone, cefuroxime and cefalotin. OBJECTIVES To find compounds with high affinity for PBP3SAL to control Salmonella intracellular infections. METHODS An S. Typhimurium ΔPBP3 mutant that divides using PBP3SAL and its parental wild-type strain, were exposed to a library of 1520 approved drugs in acidified (pH 4.6) nutrient-rich LB medium. Changes in optical density associated with cell filamentation, a read-out of blockage in cell division, were monitored. Compounds causing filamentation in the ΔPBP3 mutant but not in wild-type strain-the latter strain expressing both PBP3 and PBP3SAL in LB pH 4.6-were selected for further study. The bactericidal effect due to PBP3SAL inhibition was evaluated in vitro using a bacterial infection model of cultured fibroblasts. RESULTS The cephalosporin cefotiam exhibited higher affinity for PBP3SAL than for PBP3 in bacteria growing in acidified LB pH 4.6 medium. Cefotiam also proved to be effective against intracellular Salmonella in a PBP3SAL-dependent manner. Conversely, cefuroxime, which has higher affinity for PBP3, showed decreased effectiveness in killing intracellular Salmonella. CONCLUSIONS Antibiotics with affinity for PBP3SAL, like the cephalosporin cefotiam, have therapeutic value for treating Salmonella intracellular infections.
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Affiliation(s)
- Juan J Cestero
- Laboratory of Intracellular Bacterial Pathogens, National Center for Biotechnology (CNB-CSIC), Madrid, Spain
| | - Sónia Castanheira
- Laboratory of Intracellular Bacterial Pathogens, National Center for Biotechnology (CNB-CSIC), Madrid, Spain
| | - Henar González
- Laboratory of Intracellular Bacterial Pathogens, National Center for Biotechnology (CNB-CSIC), Madrid, Spain
| | - Óscar Zaragoza
- Mycology Reference Laboratory, National Center for Microbiology, Instituto de Salud Carlos III, Madrid, Spain
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Kuehn R, Stoesser N, Eyre D, Darton TC, Basnyat B, Parry CM. Treatment of enteric fever (typhoid and paratyphoid fever) with cephalosporins. Cochrane Database Syst Rev 2022; 11:CD010452. [PMID: 36420914 PMCID: PMC9686137 DOI: 10.1002/14651858.cd010452.pub2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Typhoid and paratyphoid (enteric fever) are febrile bacterial illnesses common in many low- and middle-income countries. The World Health Organization (WHO) currently recommends treatment with azithromycin, ciprofloxacin, or ceftriaxone due to widespread resistance to older, first-line antimicrobials. Resistance patterns vary in different locations and are changing over time. Fluoroquinolone resistance in South Asia often precludes the use of ciprofloxacin. Extensively drug-resistant strains of enteric fever have emerged in Pakistan. In some areas of the world, susceptibility to old first-line antimicrobials, such as chloramphenicol, has re-appeared. A Cochrane Review of the use of fluoroquinolones and azithromycin in the treatment of enteric fever has previously been undertaken, but the use of cephalosporins has not been systematically investigated and the optimal choice of drug and duration of treatment are uncertain. OBJECTIVES To evaluate the effectiveness of cephalosporins for treating enteric fever in children and adults compared to other antimicrobials. SEARCH METHODS We searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, the WHO ICTRP and ClinicalTrials.gov up to 24 November 2021. We also searched reference lists of included trials, contacted researchers working in the field, and contacted relevant organizations. SELECTION CRITERIA We included randomized controlled trials (RCTs) in adults and children with enteric fever that compared a cephalosporin to another antimicrobial, a different cephalosporin, or a different treatment duration of the intervention cephalosporin. Enteric fever was diagnosed on the basis of blood culture, bone marrow culture, or molecular tests. DATA COLLECTION AND ANALYSIS We used standard Cochrane methods. Our primary outcomes were clinical failure, microbiological failure and relapse. Our secondary outcomes were time to defervescence, duration of hospital admission, convalescent faecal carriage, and adverse effects. We used the GRADE approach to assess certainty of evidence for each outcome. MAIN RESULTS We included 27 RCTs with 2231 total participants published between 1986 and 2016 across Africa, Asia, Europe, the Middle East and the Caribbean, with comparisons between cephalosporins and other antimicrobials used for the treatment of enteric fever in children and adults. The main comparisons are between antimicrobials in most common clinical use, namely cephalosporins compared to a fluoroquinolone and cephalosporins compared to azithromycin. Cephalosporin (cefixime) versus fluoroquinolones Clinical failure, microbiological failure and relapse may be increased in patients treated with cefixime compared to fluoroquinolones in three small trials published over 14 years ago: clinical failure (risk ratio (RR) 13.39, 95% confidence interval (CI) 3.24 to 55.39; 2 trials, 240 participants; low-certainty evidence); microbiological failure (RR 4.07, 95% CI 0.46 to 36.41; 2 trials, 240 participants; low-certainty evidence); relapse (RR 4.45, 95% CI 1.11 to 17.84; 2 trials, 220 participants; low-certainty evidence). Time to defervescence in participants treated with cefixime may be longer compared to participants treated with fluoroquinolones (mean difference (MD) 1.74 days, 95% CI 0.50 to 2.98, 3 trials, 425 participants; low-certainty evidence). Cephalosporin (ceftriaxone) versus azithromycin Ceftriaxone may result in a decrease in clinical failure compared to azithromycin, and it is unclear whether ceftriaxone has an effect on microbiological failure compared to azithromycin in two small trials published over 18 years ago and in one more recent trial, all conducted in participants under 18 years of age: clinical failure (RR 0.42, 95% CI 0.11 to 1.57; 3 trials, 196 participants; low-certainty evidence); microbiological failure (RR 1.95, 95% CI 0.36 to 10.64, 3 trials, 196 participants; very low-certainty evidence). It is unclear whether ceftriaxone increases or decreases relapse compared to azithromycin (RR 10.05, 95% CI 1.93 to 52.38; 3 trials, 185 participants; very low-certainty evidence). Time to defervescence in participants treated with ceftriaxone may be shorter compared to participants treated with azithromycin (mean difference of -0.52 days, 95% CI -0.91 to -0.12; 3 trials, 196 participants; low-certainty evidence). Cephalosporin (ceftriaxone) versus fluoroquinolones It is unclear whether ceftriaxone has an effect on clinical failure, microbiological failure, relapse, and time to defervescence compared to fluoroquinolones in three trials published over 28 years ago and two more recent trials: clinical failure (RR 3.77, 95% CI 0.72 to 19.81; 4 trials, 359 participants; very low-certainty evidence); microbiological failure (RR 1.65, 95% CI 0.40 to 6.83; 3 trials, 316 participants; very low-certainty evidence); relapse (RR 0.95, 95% CI 0.31 to 2.92; 3 trials, 297 participants; very low-certainty evidence) and time to defervescence (MD 2.73 days, 95% CI -0.37 to 5.84; 3 trials, 285 participants; very low-certainty evidence). It is unclear whether ceftriaxone decreases convalescent faecal carriage compared to the fluoroquinolone gatifloxacin (RR 0.18, 95% CI 0.01 to 3.72; 1 trial, 73 participants; very low-certainty evidence) and length of hospital stay may be longer in participants treated with ceftriaxone compared to participants treated with the fluoroquinolone ofloxacin (mean of 12 days (range 7 to 23 days) in the ceftriaxone group compared to a mean of 9 days (range 6 to 13 days) in the ofloxacin group; 1 trial, 47 participants; low-certainty evidence). AUTHORS' CONCLUSIONS Based on very low- to low-certainty evidence, ceftriaxone is an effective treatment for adults and children with enteric fever, with few adverse effects. Trials suggest that there may be no difference in the performance of ceftriaxone compared with azithromycin, fluoroquinolones, or chloramphenicol. Cefixime can also be used for treatment of enteric fever but may not perform as well as fluoroquinolones. We are unable to draw firm general conclusions on comparative contemporary effectiveness given that most trials were small and conducted over 20 years previously. Clinicians need to take into account current, local resistance patterns in addition to route of administration when choosing an antimicrobial.
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Affiliation(s)
- Rebecca Kuehn
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Nicole Stoesser
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - David Eyre
- Big Data Institute, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Thomas C Darton
- Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Buddha Basnyat
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Clinical Research Unit/Patan Academy of Health Science, Nepal International Clinic, Kathmandu, Nepal
| | - Christopher Martin Parry
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Saluja T, Rai GK, Chaudhary S, Kanodia P, Giri BR, Kim DR, Yang JS, Park IY, Kyung SE, Vemula S, Reddy E J, Kim B, Gupta BP, Jo SK, Ryu JH, Park HK, Shin JH, Lee Y, Kim H, Kim JH, Mojares ZR, Wartel TA, Sahastrabuddhe S. Immune non-interference and safety study of Vi-DT typhoid conjugate vaccine with a measles, mumps and rubella containing vaccine in 9-15 months old Nepalese infants. Vaccine 2022; 40:5828-5834. [PMID: 36064672 DOI: 10.1016/j.vaccine.2022.08.034] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 07/06/2022] [Accepted: 08/15/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Typhoid fever is a common disease in developing countries especially in the Indian subcontinent and Africa. The available typhoid conjugate vaccines (TCV) have been found to be highly immunogenic in infants and children less than 2 years of age. Many countries are planning to adopt TCV in their routine EPI programs around 9 months of age when measles containing vaccines are given. Therefore, Vi-DT TCV was tested in 9-15 months aged healthy infants in Nepal to demonstrate non-interference with a measles containing vaccine. METHODS This was a randomized, open label, phase III study to assess the immune non-interference, safety, and reactogenicity of Vi-DT typhoid conjugate vaccine when given concomitantly with measles, mumps and rubella (MMR) vaccine. A total of 360 participants aged 9-15 months were enrolled and randomized equally into Vi-DT + MMR (180 participants) or MMR alone (180 participants) group and were evaluated for immunogenicity and safety 28 days post vaccination. RESULTS Using the immunogenicity set, difference between proportions (95% CI) of the Vi-DT + MMR group vs MMR alone group were -2.73% (-8.85, 3.38), -3.19% (-11.25, 4.88) and 2.91% (-3.36, 9.18) for sero-positivity rate of anti-measles, anti-mumps and anti- rubella, respectively. Only the lower bound of the range in difference of the proportions for sero-positivity rate of anti-mumps did not satisfy the non-inferiority criteria as it was above the -10% limit, which may not be of clinical significance. These results were confirmed in the per protocol set. There were no safety concerns reported from the study and both Vi-DT + MMR and MMR alone groups were comparable in terms of solicited and unsolicited adverse events . CONCLUSIONS Results indicated that there is non-interference of MMR vaccine with Vi-DT and Vi-DT conjugate vaccine could be considered as an addition to the EPI schedule among children at risk of contracting typhoid.
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Affiliation(s)
- Tarun Saluja
- International Vaccine Institute, Seoul, Republic of Korea.
| | | | | | | | | | - Deok Ryun Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | - Jae Seung Yang
- International Vaccine Institute, Seoul, Republic of Korea
| | - Il-Yeon Park
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Sridhar Vemula
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Bomi Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Sue Kyoung Jo
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | | | | | - Hun Kim
- SK bioscience, Seoul, Republic of Korea
| | - Jerome H Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - T Anh Wartel
- International Vaccine Institute, Seoul, Republic of Korea
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9
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Nabarro LE, McCann N, Herdman MT, Dugan C, Ladhani S, Patel D, Morris-Jones S, Balasegaram S, Heyderman RS, Brown M, Parry CM, Godbole G. British Infection Association Guidelines for the Diagnosis and Management of Enteric Fever in England. J Infect 2022; 84:469-489. [PMID: 35038438 DOI: 10.1016/j.jinf.2022.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/10/2021] [Accepted: 01/05/2022] [Indexed: 11/25/2022]
Abstract
Enteric fever (EF) is an infection caused by the bacteria called Salmonella Typhi or Paratyphi. Infection is acquired through swallowing contaminated food or water. Most EF in England occurs in people returning from South Asia and other places where EF is common; catching EF in England is rare. The main symptom is fever, but stomach pain, diarrhoea, muscle aches, rash and other symptoms may occur. EF is diagnosed by culturing the bacteria from blood and/or stool in a microbiology laboratory. EF usually responds well to antibiotic treatment. Depending on how unwell the individual is, antibiotics may be administered by mouth or by injection. Over the past several years, there has been an overall increase in resistance to antibiotics used to treat enteric fever, in all endemic areas. Additionally, since 2016, there has been an ongoing outbreak of drug-resistant EF in Pakistan. This infection is called extensively drug-resistant, or XDR, EF and only responds to a limited number of antibiotics. Occasionally individuals develop complications of EF including confusion, bleeding, a hole in the gut or an infection of the bones or elsewhere. Some people may continue to carry the bacteria in their stool for a longtime following treatment for the initial illness. These people may need treatment with a longer course of antibiotics to eradicate infection. Travellers can reduce their risk of acquiring EF by following safe food and water practices and by receiving the vaccine at least a few weeks before travel. These guidelines aim to help doctors do the correct tests and treat patients for enteric fever in England but may also be useful to doctors and public health professionals in other similar countries.
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Affiliation(s)
- L E Nabarro
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; United Kingdom Health Security Agency, UK; St George's University Hospitals NHS Foundation Trust, London, UK; British Infection Association, UK
| | - N McCann
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - C Dugan
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Ladhani
- United Kingdom Health Security Agency, UK; Paediatric Infectious Diseases Research Group, St George's University, London, UK
| | - D Patel
- National Travel Health Network and Centre (NaTHNaC), UK
| | - S Morris-Jones
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - R S Heyderman
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; Research Department of Infection, Division of Infection and Immunity, University College London, London, UK
| | - M Brown
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - C M Parry
- Liverpool School of Tropical Medicine, Liverpool, UK; Alder Hey Hospital and Liverpool University Hospitals, Liverpool, UK; Centre for Tropical Medicine and Global Health, University of Oxford, UK
| | - G Godbole
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; United Kingdom Health Security Agency, UK; British Infection Association, UK.
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10
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Giri A, Karkey A, Dongol S, Arjyal A, Maharjan A, Veeraraghavan B, Paudyal B, Dolecek C, Gajurel D, Phuong DNT, Thanh DP, Qamar F, Kang G, Hien HV, John J, Lawson K, Wolbers M, Hossain MS, Sharifuzzaman M, Luangasanatip N, Maharjan N, Olliaro P, Rupali P, Shakya R, Shakoor S, Rijal S, Qureshi S, Baker S, Joshi S, Ahmed T, Darton T, Bao TN, Lubell Y, Kestelyn E, Thwaites G, Parry CM, Basnyat B. Azithromycin and cefixime combination versus azithromycin alone for the out-patient treatment of clinically suspected or confirmed uncomplicated typhoid fever in South Asia: a randomised controlled trial protocol. Wellcome Open Res 2021; 6:207. [PMID: 35097222 PMCID: PMC8772527 DOI: 10.12688/wellcomeopenres.16801.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Typhoid and paratyphoid fever (enteric fever) is a common cause of non-specific febrile infection in adults and children presenting to health care facilities in low resource settings such as the South Asia. A 7-day course of a single oral antimicrobial such as ciprofloxacin, cefixime, or azithromycin is commonly used for its treatment. Increasing antimicrobial resistance threatens the effectiveness of these treatment choices. We hypothesize that combined treatment with azithromycin (active mainly intracellularly) and cefixime (active mainly extracellularly) will be a better option for the treatment of clinically suspected and culture-confirmed typhoid fever in South Asia. Methods: This is a phase IV, international multi-center, multi-country, comparative participant-and observer-blind, 1:1 randomised clinical trial. Patients with suspected uncomplicated typhoid fever will be randomized to one of the two interventions: Arm A: azithromycin 20mg/kg/day oral dose once daily (maximum 1gm/day) and cefixime 20mg/kg/day oral dose in two divided doses (maximum 400mg bd) for 7 days, Arm B: azithromycin 20mg/kg/day oral dose once daily (max 1gm/day) for 7 days AND cefixime-matched placebo for 7 days. We will recruit 1500 patients across sites in Bangladesh, India, Nepal, and Pakistan. We will assess whether treatment outcomes are better with the combination after one week of treatment and at one- and three-months follow-up. Discussion: Combined treatment may limit the emergence of resistance if one of the components is active against resistant sub-populations not covered by the other antimicrobial activity. If the combined treatment is better than the single antimicrobial treatment, this will be an important result for patients across South Asia and other typhoid endemic areas. Clinicaltrials.gov registration: NCT04349826 (16/04/2020)
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Affiliation(s)
- Abhishek Giri
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sabina Dongol
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Amit Arjyal
- Patan Academy of Health Sciences, Lalitpur, Bagmati, 44700, Nepal
| | - Archana Maharjan
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | | | - Buddhi Paudyal
- Patan Academy of Health Sciences, Lalitpur, Bagmati, 44700, Nepal
| | - Christiane Dolecek
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Duy Pham Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Farah Qamar
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Gagandeep Kang
- Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Ho Van Hien
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Jacob John
- Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Katrina Lawson
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Marcel Wolbers
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Md. Shabab Hossain
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | - M Sharifuzzaman
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | | | - Nhukesh Maharjan
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Piero Olliaro
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Ronas Shakya
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Sadia Shakoor
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Samita Rijal
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Sonia Qureshi
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Stephen Baker
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Subi Joshi
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | - Thomas Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, South Yorkshire, UK
| | - Tran Nguyen Bao
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, 10400, Thailand
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Christopher M. Parry
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Buddha Basnyat
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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11
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Giri A, Karkey A, Dongol S, Arjyal A, Maharjan A, Veeraraghavan B, Paudyal B, Dolecek C, Gajurel D, Phuong DNT, Thanh DP, Qamar F, Kang G, Hien HV, John J, Lawson K, Wolbers M, Hossain MS, Sharifuzzaman M, Luangasanatip N, Maharjan N, Olliaro P, Rupali P, Shakya R, Shakoor S, Rijal S, Qureshi S, Baker S, Joshi S, Ahmed T, Darton T, Bao TN, Lubell Y, Kestelyn E, Thwaites G, Parry CM, Basnyat B. Azithromycin and cefixime combination versus azithromycin alone for the out-patient treatment of clinically suspected or confirmed uncomplicated typhoid fever in South Asia: a randomised controlled trial protocol. Wellcome Open Res 2021; 6:207. [PMID: 35097222 PMCID: PMC8772527 DOI: 10.12688/wellcomeopenres.16801.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 12/27/2023] Open
Abstract
Background: Typhoid and paratyphoid fever (enteric fever) is a common cause of non-specific febrile infection in adults and children presenting to health care facilities in low resource settings such as the South Asia. A 7-day course of a single oral antimicrobial such as ciprofloxacin, cefixime, or azithromycin is commonly used for its treatment. Increasing antimicrobial resistance threatens the effectiveness of these treatment choices. We hypothesize that combined treatment with azithromycin (active mainly intracellularly) and cefixime (active mainly extracellularly) will be a better option for the treatment of clinically suspected and culture-confirmed typhoid fever in South Asia. Methods: This is a phase IV, international multi-center, multi-country, comparative participant-and observer-blind, 1:1 randomised clinical trial. Patients with suspected uncomplicated typhoid fever will be randomized to one of the two interventions: Arm A: azithromycin 20mg/kg/day oral dose once daily (maximum 1gm/day) and cefixime 20mg/kg/day oral dose in two divided doses (maximum 400mg bd) for 7 days, Arm B: azithromycin 20mg/kg/day oral dose once daily (max 1gm/day) for 7 days AND cefixime-matched placebo for 7 days. We will recruit 1500 patients across sites in Bangladesh, India, Nepal, and Pakistan. We will assess whether treatment outcomes are better with the combination after one week of treatment and at one- and three-months follow-up. Discussion: Combined treatment may limit the emergence of resistance if one of the components is active against resistant sub-populations not covered by the other antimicrobial activity. If the combined treatment is better than the single antimicrobial treatment, this will be an important result for patients across South Asia and other typhoid endemic areas. Clinicaltrials.gov registration: NCT04349826 (16/04/2020).
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Affiliation(s)
- Abhishek Giri
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sabina Dongol
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Amit Arjyal
- Patan Academy of Health Sciences, Lalitpur, Bagmati, 44700, Nepal
| | - Archana Maharjan
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | | | - Buddhi Paudyal
- Patan Academy of Health Sciences, Lalitpur, Bagmati, 44700, Nepal
| | - Christiane Dolecek
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Duy Pham Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Farah Qamar
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Gagandeep Kang
- Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Ho Van Hien
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Jacob John
- Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Katrina Lawson
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Marcel Wolbers
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Md. Shabab Hossain
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | - M Sharifuzzaman
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | | | - Nhukesh Maharjan
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Piero Olliaro
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Ronas Shakya
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Sadia Shakoor
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Samita Rijal
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Sonia Qureshi
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Stephen Baker
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Subi Joshi
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | - Thomas Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, South Yorkshire, UK
| | - Tran Nguyen Bao
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, 10400, Thailand
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Christopher M. Parry
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Buddha Basnyat
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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12
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Mylona E, Voong Vinh P, Qureshi S, Karkey A, Dongol S, Ha Thanh T, Walson J, Ballell L, Fernández Álvaro E, Qamar F, Baker S. Tebipenem as an oral alternative for the treatment of typhoid caused by XDR Salmonella Typhi. J Antimicrob Chemother 2021; 76:3197-3200. [PMID: 34534310 PMCID: PMC8598285 DOI: 10.1093/jac/dkab326] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/05/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Antimicrobial therapy is essential for the treatment of enteric fever, the infection caused by Salmonella serovars Typhi and Paratyphi A. However, an increase in resistance to key antimicrobials and the emergence of MDR and XDR in Salmonella Typhi poses a major threat for efficacious outpatient treatments. OBJECTIVES We recently identified tebipenem, an oral carbapenem licensed for use for respiratory tract infections in Japan, as a potential alternative treatment for MDR/XDR Shigella spp. Here, we aimed to test the in vitro antibacterial efficacy of this drug against MDR and XDR typhoidal Salmonella. METHODS We determined the in vitro activity of tebipenem in time-kill assays against a collection of non-XDR and XDR Salmonella Typhi and Salmonella Paratyphi A (non-XDR) isolated in Nepal and Bangladesh. We also tested the efficacy of tebipenem in combination with other antimicrobials. RESULTS We found that both XDR and non-XDR Salmonella Typhi and Salmonella Paratyphi A are susceptible to tebipenem, exhibiting low MICs, and were killed within 8-24 h at 2-4×MIC. Additionally, tebipenem demonstrated synergy with two other antimicrobials and could efficiently induce bacterial killing. CONCLUSIONS Salmonella Paratyphi A and XDR Salmonella Typhi display in vitro susceptibility to the oral carbapenem tebipenem, while synergistic activity with other antimicrobials may limit the emergence of resistance. The broad-spectrum activity of this drug against MDR/XDR organisms renders tebipenem a good candidate for clinical trials.
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Affiliation(s)
- Elli Mylona
- University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK.,Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
| | - Phat Voong Vinh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Abhilasha Karkey
- Nepal Academy of Health Sciences, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Sabina Dongol
- Nepal Academy of Health Sciences, Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Tuyen Ha Thanh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Judd Walson
- Division of Allergy and Infectious Disease, Center for Emerging and Re-emerging Infectious Diseases, University of Washington School of Medicine, Seattle, WA, USA
| | | | | | | | - Stephen Baker
- University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK.,Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, UK
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13
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Paul M, Harbarth S, Huttner A, Thwaites GE, Theuretzbacher U, Bonten MJM, Leibovici L. Investigator-initiated Randomized Controlled Trials in Infectious Diseases: Better Value for Money for Registration Trials of New Antimicrobials. Clin Infect Dis 2021; 72:1259-1264. [PMID: 32619238 DOI: 10.1093/cid/ciaa930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Indexed: 12/19/2022] Open
Abstract
Randomized controlled trials (RCTs) conducted by the industry are expensive, especially trials conducted for registration of new drugs for multidrug-resistant (MDR) bacteria. Lower-cost investigator-initiated trials have recently been successful in recruiting patients with severe infections caused by MDR bacteria. In this viewpoint, we contrast the aims, methods, and resulting costs of industry-led and investigator-initiated trials and ask whether contemporary registration trial costs are justified. Contract research organizations, delivering and monitoring industry-sponsored trials at a significant cost, have little incentive to make trials more efficient or less expensive. The value of universal monitoring of all trial data is questionable. We propose that clinical trial networks play a more influential role in RCT design and planning, lead adaptive risk-based trial monitoring, and work with the industry to maximize efficient recruitment and lower costs in registration trials for the approval of new antimicrobials.
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Affiliation(s)
- Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Stephan Harbarth
- Division of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.,Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Angela Huttner
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Guy E Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Beilison Hospital Petah-Tikva, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Ramat-Aviv, Israel
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14
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Manesh A, Meltzer E, Jin C, Britto C, Deodhar D, Radha S, Schwartz E, Rupali P. Typhoid and paratyphoid fever: a clinical seminar. J Travel Med 2021; 28:6129661. [PMID: 33550411 DOI: 10.1093/jtm/taab012] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Revised: 01/07/2021] [Indexed: 01/06/2023]
Abstract
Rationale for review: Enteric fever (EF) caused by Salmonella enterica subspecies enterica serovar Typhi (Salmonella Typhi) and S. Paratyphi (Salmonella Paratyphi) remains an important cause of infectious morbidity and mortality in many low-income countries and, therefore, still poses a major infectious risk for travellers to endemic countries. Main findings: Although the global burden of EF has decreased over the past two decades, prevalence of EF remains high in Asia and Africa, with the highest prevalence reported from the Indian subcontinent. These statistics are mirrored by data on travel-related EF. Widespread and increasing antimicrobial resistance has narrowed treatment options for travel-related EF. Ceftriaxone- and azithromycin-based therapies are commonly used, even with the emergence of extremely drug-resistant typhoid in Pakistan. Preventive measures among locals and travellers include provision of safe food and water and vaccination. Food and water precautions offer limited protection, and the efficacy of Salmonella Typhi vaccines is only moderate signifying the need for travellers to be extra cautious. Recommendations: Improvement in the diagnosis of typhoid with high degree of clinical suspicion, better diagnostic assays, early and accurate detection of resistance, therapy with appropriate drugs, improvements in hygiene and sanitation with provision of safe drinking water in endemic areas and vaccination among travellers as well as in the endemic population are keys to controlling typhoid. While typhoid vaccines are recommended for travellers to high-risk areas, moderate efficacy and inability to protect against Salmonella Paratyphi are limitations to bear in mind. Improved Salmonella Typhi vaccines and vaccines against Salmonella Paratyphi A are required.
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Affiliation(s)
- Abi Manesh
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Eyal Meltzer
- Department of Medicine `C', Center for Geographic Medicine, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Celina Jin
- Oxford Vaccine Group, Department of Pediatrics, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Carl Britto
- Oxford Vaccine Group, Department of Pediatrics, NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - Divya Deodhar
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Sneha Radha
- Department of Infectious Diseases, Christian Medical College, Vellore, India
| | - Eli Schwartz
- Department of Medicine `C', Center for Geographic Medicine, Sheba Medical Center, Tel-Hashomer, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Priscilla Rupali
- Department of Infectious Diseases, Christian Medical College, Vellore, India
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15
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Henderson A, Bursle E, Stewart A, Harris PNA, Paterson D, Chatfield MD, Paul M, Dickstein Y, Rodriguez-Baño J, Turnidge JD, Kahlmeter G. A systematic review of antimicrobial susceptibility testing as a tool in clinical trials assessing antimicrobials against infections due to gram-negative pathogens. Clin Microbiol Infect 2021; 27:1746-1753. [PMID: 33813125 DOI: 10.1016/j.cmi.2021.03.019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/03/2021] [Accepted: 03/06/2021] [Indexed: 02/01/2023]
Abstract
BACKGROUND Antimicrobial susceptibility testing (AST) is the standard of care for treating bacterial infections. In randomized clinical trials of new antimicrobials, AST might not be performed or reported in real time. OBJECTIVES To determine local, real-time laboratory AST performance, its usage in the trial flow, quality control (QC) of the local testing, central AST performance and the effect of using AST categorization on the trials' primary outcomes. DATA SOURCES We systematically searched PubMed, Embase, PsychINFO and Web of Science. ELIGIBILITY CRITERIA We included registered randomized controlled trials published in journals between January 2015 and December 2019. PARTICIPANTS AND INTERVENTIONS We included trials comparing different antibiotics for the treatment of infections caused predominantly by Gram-negative bacteria. METHODS Primary outcomes for different trial populations were extracted and differences between trial arms were compared for patients with infections caused by susceptible versus non-susceptible bacteria. Results are described narratively. RESULTS Of 32 randomized trials, 25 trials reported that local AST was performed, 1312 reported the local laboratory AST methods, no trial reported QC, but post-hoc referral for AST at a reference laboratory was common. Patients' outcomes were superior when patients with infections due to susceptible and non-susceptible pathogens were compared post hoc (median difference 14%, interquartile range 8%-24%) in trials allowing this comparison (seven antimicrobials), except for colistin, where 14-day mortality was 9% higher when patients were treated with colistin for colistin-susceptible versus colistin-resistant carbapenem-resistant Acinetobacter baumannii. When excluding patients with pathogens that were non-susceptible to either antimicrobial in the trials, the difference in the primary outcome between the trial arms was reduced in five out of six trials. CONCLUSIONS Trials should perform AST to guide patient inclusion or exclusion from the study and consider the impact of the central laboratory susceptibility results on the study outcomes when using post-hoc reference testing.
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Affiliation(s)
- Andrew Henderson
- Princess Alexandra Hospital, Brisbane, QLD, Australia; University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, QLD, Australia.
| | - Evan Bursle
- Princess Alexandra Hospital, Brisbane, QLD, Australia; University of Queensland, QLD, Australia; Sullivan and Nicolaides Pathology, Brisbane, QLD, Australia
| | - Adam Stewart
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, QLD, Australia; Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Patrick N A Harris
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, QLD, Australia; Pathology Queensland, Brisbane, QLD, Australia
| | - David Paterson
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, QLD, Australia
| | - Mark D Chatfield
- University of Queensland, Faculty of Medicine, UQ Centre for Clinical Research, QLD, Australia
| | - Mical Paul
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Yaakov Dickstein
- Infectious Diseases Institute, Rambam Health Care Campus, Haifa, Israel; Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Jesus Rodriguez-Baño
- Hospital Universitario Virgen Macarena, Sevilla, Spain; Servicio de Enfermedades Infecciosas, Hospital Universitario Virgen Macarena, Sevilla, Spain; Departamento de Medicina, Universidad de Sevilla and Instituto de Biomedicina de Seville, Sevilla, Spain
| | - John D Turnidge
- University of Adelaide, Adelaide, SA, Australia; European Committee on Antimicrobial Susceptibility Testing (EUCAST), Adelaide, Australia
| | - Gunnar Kahlmeter
- European Committee on Antimicrobial Susceptibility Testing (EUCAST), Adelaide, Australia; European Committee on Antimicrobial Susceptibility Testing (EUCAST), Vaxjo, Sweden
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16
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Acharya KP, Phuyal S, Chand R, Kaphle K. Current scenario of and future perspective for scientific research in Nepal. Heliyon 2021; 7:e05751. [PMID: 33458438 PMCID: PMC7797519 DOI: 10.1016/j.heliyon.2020.e05751] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 08/16/2020] [Accepted: 12/14/2020] [Indexed: 11/19/2022] Open
Abstract
Scientific research can act as the 'bedrock for development' which can provide a solid foundation for the overall socioeconomic transformation in a country through invention and innovation. The inclusion of seven groups of Nepalese monuments in the United Nations Educational, Scientific and Cultural Organization (UNESCO)'s world heritage sites provides evidence of the richness in architecture and civil engineering in the country, which also show how Nepal was influenced by arts and religious philosophy. The government of Nepal (GoN) has established different scientific departments, universities, and research institutions, and has tried to emphasize the application of science and research for the development of the nation. These institutions, however, have inadequate resources, exist in a poor academic and research environment and are subject to overt political influence. Despite these various problems, a variety of pioneer research and development activities have been conducted, which show positive rays of hope. This review presents history, current situation, progress and future perspective for scientific research and development in Nepal.
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Affiliation(s)
- Krishna Prasad Acharya
- Animal Quarantine Office (AQO)-Kathmandu, Department of Livestock Services (DLS), Kathmandu, Nepal
| | - Sarita Phuyal
- Central Referral Veterinary Hospital, Department of Livestock Services (DLS), Kathmandu, Nepal
| | - Rakesh Chand
- Center for One Health Research & Promotion (COHRP), Kathmandu, Nepal
- Department of Veterinary Medicine, University of Cambridge, Madingley Road Cambridge, CB3 0ES, UK
| | - Krishna Kaphle
- Institute of Agriculture and Animal Science (IAAS), Tribhuvan University (TU), Rupandehi, Nepal
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17
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Capeding MR, Sil A, Tadesse BT, Saluja T, Teshome S, Alberto E, Kim DR, Park EL, Park JY, Yang JS, Chinaworapong S, Park J, Jo SK, Chon Y, Yang SY, Ryu JH, Cheong I, Shim KY, Lee Y, Kim H, Lynch JA, Kim JH, Excler JL, Wartel TA, Sahastrabuddhe S. Safety and immunogenicity of Vi-DT conjugate vaccine among 6-23-month-old children: Phase II, randomized, dose-scheduling, observer-blind Study. EClinicalMedicine 2020; 27:100540. [PMID: 33150320 PMCID: PMC7599314 DOI: 10.1016/j.eclinm.2020.100540] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/13/2020] [Accepted: 08/21/2020] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND Typhoid causes significant mortality among young children in resource-limited settings. Conjugate typhoid vaccines could significantly reduce typhoid-related child deaths, but only one WHO-prequalified typhoid conjugate vaccine exists for young children. To address this gap, we investigated the safety, immunogenicity and dose-scheduling of Vi-DT typhoid conjugate vaccine among children aged 6-23 months. METHODS In this single center, observer blind, phase II trial, participants were randomly assigned (2:2:1) to receive one or two doses of Vi-DT or comparator vaccine. Anti-Vi IgG titer and geometric mean titers (GMT) were determined at 0, 4, 24 and 28 weeks. Data were analyzed using per-protocol and immunogenicity (a subset of intention-to-treat analysis) sets. The trial is registered with ClinicalTrials.gov (NCT03527355). FINDINGS Between April and July 2018, 285 children were randomized; 114 received one or two doses of Vi-DT while 57 received comparator. 277 completed the study follow-up per protocol; 112 and 110 from single- and two-dose Vi-DT schedules, respectively and 55 from the placebo group were included in the per protocol analysis. Safety profile is satisfactory. Thirteen serious adverse events were reported during the 28-week follow-up, none of which were related to Vi-DT. The seroconversion rate four weeks after the first dose was 100% (95% CI 98·3-100) in Vi-DT recipients and 7·0% (95% CI 2·8-16·7) in comparator recipients (p<0·0001). Similarly, the seroconversion rate 4 weeks after the second dose was 98·2% (95% CI 93· 6-99·5) and 21·8% (95% CI 13·0-34·4) among Vi-DT and comparator groups, respectively (p<0·0001). Anti-Vi IgG GMT was significantly higher in Vi-DT than in control group at all post-vaccination visits (p<0·0001). INTERPRETATION Both single and two doses of Vi-DT vaccine are safe, well tolerated, and immunogenic for infants and toddlers in a moderately endemic setting.
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Affiliation(s)
| | - Arijit Sil
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Tarun Saluja
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Edison Alberto
- Research Institute for Tropical Medicine, Manila, The Philippines
| | - Deok Ryun Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Ju Yeon Park
- International Vaccine Institute, Seoul, Republic of Korea
| | - Jae Seung Yang
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Jiwook Park
- International Vaccine Institute, Seoul, Republic of Korea
| | - Sue-Kyoung Jo
- International Vaccine Institute, Seoul, Republic of Korea
| | - Yun Chon
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | | | | | | | - Hun Kim
- SK bioscience, Seoul, Republic of Korea
| | - Julia A Lynch
- International Vaccine Institute, Seoul, Republic of Korea
| | - Jerome H Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - T Anh Wartel
- International Vaccine Institute, Seoul, Republic of Korea
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18
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Giri A, Karkey A, Dangol S, Arjyal A, Pokharel S, Rijal S, Gajurel D, Sharma R, Lamsal K, Shrestha P, Prajapati G, Pathak S, Shrestha SR, K C RK, Pandey S, Thapa A, Shrestha N, Thapa RK, Poudyal B, Phuong DNT, Baker S, Kestelyn E, Geskus R, Thwaites G, Basnyat B. Trimethoprim-sulfamethoxazole Versus Azithromycin for the Treatment of Undifferentiated Febrile Illness in Nepal: A Double-blind, Randomized, Placebo-controlled Trial. Clin Infect Dis 2020; 73:e1478-e1486. [PMID: 32991678 PMCID: PMC8492158 DOI: 10.1093/cid/ciaa1489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Indexed: 11/12/2022] Open
Abstract
Background Azithromycin and trimethoprim-sulfamethoxazole (SXT) are widely used to treat undifferentiated febrile illness (UFI). We hypothesized that azithromycin is superior to SXT for UFI treatment, but the drugs are noninferior to each other for culture-confirmed enteric fever treatment. Methods We conducted a double-blind, randomized, placebo-controlled trial of azithromycin (20 mg/kg/day) or SXT (trimethoprim 10 mg/kg/day plus sulfamethoxazole 50 mg/kg/day) orally for 7 days for UFI treatment in Nepal. We enrolled patients >2 years and <65 years of age presenting to 2 Kathmandu hospitals with temperature ≥38.0°C for ≥4 days without localizing signs. The primary endpoint was fever clearance time (FCT); secondary endpoints were treatment failure and adverse events. Results From June 2016 to May 2019, we randomized 326 participants (163 in each arm); 87 (26.7%) had blood culture–confirmed enteric fever. In all participants, the median FCT was 2.7 days (95% confidence interval [CI], 2.6–3.3 days) in the SXT arm and 2.1 days (95% CI, 1.6–3.2 days) in the azithromycin arm (hazard ratio [HR], 1.25 [95% CI, .99–1.58]; P = .059). The HR of treatment failures by 28 days between azithromycin and SXT was 0.62 (95% CI, .37–1.05; P = .073). Planned subgroup analysis showed that azithromycin resulted in faster FCT in those with sterile blood cultures and fewer relapses in culture-confirmed enteric fever. Nausea, vomiting, constipation, and headache were more common in the SXT arm. Conclusions Despite similar FCT and treatment failure in the 2 arms, significantly fewer complications and relapses make azithromycin a better choice for empirical treatment of UFI in Nepal. Clinical Trials Registration NCT02773407.
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Affiliation(s)
- Abhishek Giri
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sabina Dangol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Amit Arjyal
- Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sunil Pokharel
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Samita Rijal
- Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Rabi Sharma
- Civil Service Hospital, Minbhawan Kathmandu, Nepal
| | - Kamal Lamsal
- Civil Service Hospital, Minbhawan Kathmandu, Nepal
| | | | | | - Saruna Pathak
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Raj Kumar K C
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sujata Pandey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abishkar Thapa
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Nistha Shrestha
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | | | | | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,University of Cambridge, Cambridge, United Kingdom
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Ronald Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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19
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Gandra S, Alvarez-Uria G, Turner P, Joshi J, Limmathurotsakul D, van Doorn HR. Antimicrobial Resistance Surveillance in Low- and Middle-Income Countries: Progress and Challenges in Eight South Asian and Southeast Asian Countries. Clin Microbiol Rev 2020; 33:e00048-19. [PMID: 32522747 PMCID: PMC7289787 DOI: 10.1128/cmr.00048-19] [Citation(s) in RCA: 94] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Antimicrobial resistance (AMR) is a serious global health threat and is predicted to cause significant health and economic impacts, particularly in low- and middle-income countries (LMICs). AMR surveillance is critical in LMICs due to high burden of bacterial infections; however, conducting AMR surveillance in resource-limited settings is constrained by poorly functioning health systems, scarce financial resources, and lack of skilled personnel. In 2015, the United Nations World Health Assembly endorsed the World Health Organization's Global Action Plan to tackle AMR; thus, several countries are striving to improve their AMR surveillance capacity, including making significant investments and establishing and expanding surveillance networks. Initial data generated from AMR surveillance networks in LMICs suggest the high prevalence of resistance, but these data exhibit several shortcomings, such as a lack of representativeness, lack of standardized laboratory practices, and underutilization of microbiology services. Despite significant progress, AMR surveillance networks in LMICs face several challenges in expansion and sustainability due to limited financial resources and technical capacity. This review summarizes the existing health infrastructure affecting the establishment of AMR surveillance programs, the burden of bacterial infections demonstrating the need for AMR surveillance, and current progress and challenges in AMR surveillance efforts in eight South and Southeast Asian countries.
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Affiliation(s)
- Sumanth Gandra
- Division of Infectious Diseases, Department of Internal Medicine, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Gerardo Alvarez-Uria
- Department of Infectious Diseases, Rural Development Trust Hospital, Bathalapalli, Anantapur, Andhra Pradesh, India
| | - Paul Turner
- Cambodia Oxford Medical Research Unit, Angkor Hospital for Children, Siem Reap, Cambodia
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Jyoti Joshi
- Center for Disease Dynamics, Economics and Policy, New Delhi, India
| | - Direk Limmathurotsakul
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - H Rogier van Doorn
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit, National Hospital for Tropical Diseases, Hanoi, Vietnam
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20
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Debellut F, Hendrix N, Pitzer VE, Neuzil KM, Constenla D, Bar-Zeev N, Marfin A, Pecenka C. Forecasting Demand for the Typhoid Conjugate Vaccine in Low- and Middle-income Countries. Clin Infect Dis 2020; 68:S154-S160. [PMID: 30845321 PMCID: PMC6405267 DOI: 10.1093/cid/ciy1076] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The World Health Organization (WHO) released a position paper in March 2018 calling for integration of a novel typhoid conjugate vaccine (TCV) into routine immunization along with catch-up campaigns for children up to age 15. Gavi, the Vaccine Alliance, has committed funding to help resource-constrained countries introduce this vaccine. In this article, the Typhoid Vaccine Acceleration Consortium forecasts demand if WHO recommendations are followed. METHODS We built a model of global TCV introductions between 2020 and 2040 to estimate the demand of the vaccine for 133 countries. We estimated each country's year of introduction by examining its estimated incidence of typhoid fever, its history of introducing new vaccines, and any knowledge we have of its engagement with typhoid prevention, including intention to apply for Gavi funding. Our model predicted use in routine infant vaccination as well as campaigns targeting varying proportions of the unvaccinated population up to 15 years of age. RESULTS Between 2020 and 2025, demand will predominantly come from African countries, many receiving Gavi support. After that, Asian countries generate most demand until 2030, when campaigns are estimated to end. Demand will then track the birth cohort of participating countries, suggesting an annual routine demand between 90 and 100 million doses. Peak demand is likely to occur between 2023 and 2026, approaching 300 million annual doses if campaign implementation is high. CONCLUSIONS In our analysis, target population for catch-up campaigns is the main driver of uncertainty. At peak demand, there is some risk of exceeding presently estimated peak production capacity. Therefore, it will be important to carefully coordinate introductions, especially when accompanied by campaigns targeting large proportions of the eligible population.
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Affiliation(s)
| | - Nathaniel Hendrix
- The Comparative Health Outcomes, Policy, and Economics (CHOICE) Institute, University of Washington, Seattle
| | - Virginia E Pitzer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Kathleen M Neuzil
- Center for Vaccine Development and Global Health at the University of Maryland School of Medicine, Baltimore, MD
| | - Dagna Constenla
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Naor Bar-Zeev
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Anthony Marfin
- Center for Vaccine Innovation and Access, PATH, Seattle, Washington
| | - Clint Pecenka
- Center for Vaccine Innovation and Access, PATH, Seattle, Washington
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21
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Castanheira S, López-Escarpa D, Pucciarelli MG, Cestero JJ, Baquero F, García-Del Portillo F. An alternative penicillin-binding protein involved in Salmonella relapses following ceftriaxone therapy. EBioMedicine 2020; 55:102771. [PMID: 32344200 PMCID: PMC7186495 DOI: 10.1016/j.ebiom.2020.102771] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 04/09/2020] [Accepted: 04/14/2020] [Indexed: 11/17/2022] Open
Abstract
Background Salmonella causes intracellular infections in humans. Besides quinolones, third generation cephalosporins are first line drugs used for salmonellosis therapy. An unresolved anomaly of this practice involves high relapse rates associated to quinolone- or cephalosporin-susceptible Salmonella isolates in patients that are discharged clinically following initial recovery. Reduced drug accessibility to intracellular locations has been hypothesized to impair pathogen eradication although supporting evidence is lacking in vivo. Here, we uncover a novel penicillin-binding protein as the first Salmonella factor likely contributing to relapse following beta-lactam, mainly ceftriaxone, therapy. Methods We used Salmonella enterica serovar Typhimurium mutants lacking the alternative penicillin-binding proteins PBP2SAL or PBP3SAL. Affinity of PBP2SAL and PBP3SAL for beta-lactam antibiotics was tested. Relapse after ceftriaxone therapy was analysed in the murine typhoid model. Findings S. Typhimurium does not express PBP2SAL or PBP3SAL in the Mueller-Hinton medium used for susceptibility testing. The pathogen produces these PBPs in response to acidic pH and nutrient limitation, conditions found in phagosomes of mammalian cells. PBP3SAL has low affinity for beta-lactams, even at acidic pH. In vitro susceptibility to ceftriaxone at low pH is strongly reduced. S. Typhimurium lacking PBP3SAL was unable to cause relapse in mice following ceftriaxone therapy. Interpretation The reduced capacity of ceftriaxone to clear S. Typhimurium in vivo is favoured by a switch in beta-lactam targets. This switch, involving production of the less-susceptible PBP3SAL, remains invisible for standard procedures used in clinical therapy. We conclude that eradication of salmonellosis will be possible only upon targeting of PBP3SAL with novel drugs.
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Affiliation(s)
- Sónia Castanheira
- Laboratory de Intracellular Bacterial Pathogens. National Centre for Biotechnology (CNB)-CSIC, Darwin 3, E-28049 Madrid, Spain
| | - David López-Escarpa
- Laboratory de Intracellular Bacterial Pathogens. National Centre for Biotechnology (CNB)-CSIC, Darwin 3, E-28049 Madrid, Spain
| | - M Graciela Pucciarelli
- Laboratory de Intracellular Bacterial Pathogens. National Centre for Biotechnology (CNB)-CSIC, Darwin 3, E-28049 Madrid, Spain; Department of Molecular Biology, University Autónoma of Madrid, Centre of Molecular Biology 'Severo Ochoa' (CBMSO)-CSIC, E-28049 Madrid, Spain
| | - Juan J Cestero
- Laboratory de Intracellular Bacterial Pathogens. National Centre for Biotechnology (CNB)-CSIC, Darwin 3, E-28049 Madrid, Spain
| | - Fernando Baquero
- Department of Microbiology, Ramón y Cajal University Hospital, IRYCIS, Madrid, Spain
| | - Francisco García-Del Portillo
- Laboratory de Intracellular Bacterial Pathogens. National Centre for Biotechnology (CNB)-CSIC, Darwin 3, E-28049 Madrid, Spain.
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22
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O'Reilly PJ, Pant D, Shakya M, Basnyat B, Pollard AJ. Progress in the overall understanding of typhoid fever: implications for vaccine development. Expert Rev Vaccines 2020; 19:367-382. [PMID: 32238006 DOI: 10.1080/14760584.2020.1750375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Typhoid fever continues to have a substantial impact on human health, especially in Asia and sub-Saharan Africa. Access to safe water, and adequate sanitation and hygiene remain the cornerstone of prevention, but these are not widely available in many impoverished settings. The emergence of antibiotic resistance affects typhoid treatment and adds urgency to typhoid control efforts. Vaccines provide opportunities to prevent and control typhoid fever in endemic settings. AREAS COVERED Literature search was performed looking for evidence concerning the global burden of typhoid and strategies for the prevention and treatment of typhoid fever. Cost of illness, available typhoid and paratyphoid vaccines and cost-effectiveness were also reviewed. The objective was to provide a critical overview of typhoid fever, in order to assess the current understanding and potential future directions for typhoid treatment and control. EXPERT COMMENTARY Our understanding of typhoid burden and methods of prevention has grown over recent years. However, typhoid fever still has a significant impact on health in low and middle-income countries. Introduction of typhoid conjugate vaccines to the immunization schedule is expected to make a major contribution to control of typhoid fever in endemic countries, although vaccination alone is unlikely to eliminate the disease.
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Affiliation(s)
- Peter J O'Reilly
- Oxford Vaccine Group, Department of Pediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre , Oxford, UK
| | - Dikshya Pant
- Department of Paediatrics, Patan Academy of Health Sciences, Patan Hospital , Kathmandu, Nepal
| | - Mila Shakya
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences , Kathmandu, Nepal
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences , Kathmandu, Nepal
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Pediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre , Oxford, UK
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23
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Jin C, Gibani MM, Pennington SH, Liu X, Ardrey A, Aljayyoussi G, Moore M, Angus B, Parry CM, Biagini GA, Feasey NA, Pollard AJ. Treatment responses to Azithromycin and Ciprofloxacin in uncomplicated Salmonella Typhi infection: A comparison of Clinical and Microbiological Data from a Controlled Human Infection Model. PLoS Negl Trop Dis 2019; 13:e0007955. [PMID: 31877141 PMCID: PMC6948818 DOI: 10.1371/journal.pntd.0007955] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 01/08/2020] [Accepted: 11/26/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The treatment of enteric fever is complicated by the emergence of antimicrobial resistant Salmonella Typhi. Azithromycin is commonly used for first-line treatment of uncomplicated enteric fever, but the response to treatment may be sub-optimal in some patient groups when compared with fluoroquinolones. METHODS We performed an analysis of responses to treatment with azithromycin (500mg once-daily, 14 days) or ciprofloxacin (500mg twice-daily, 14 days) in healthy UK volunteers (18-60 years) enrolled into two Salmonella controlled human infection studies. Study A was a single-centre, open-label, randomised trial. Participants were randomised 1:1 to receive open-label oral ciprofloxacin or azithromycin, stratified by vaccine group (Vi-polysaccharide, Vi-conjugate or control Men-ACWY vaccine). Study B was an observational challenge/re-challenge study, where participants were randomised to challenge with Salmonella Typhi or Salmonella Paratyphi A. Outcome measures included fever clearance time, blood-culture clearance time and a composite measure of prolonged treatment response (persistent fever ≥38.0°C for ≥72 hours, persistently positive S. Typhi blood cultures for ≥72 hours, or change in antibiotic treatment). Both trials are registered with ClinicalTrials.gov (NCT02324751 and NCT02192008). FINDINGS In 81 participants diagnosed with S. Typhi in two studies, treatment with azithromycin was associated with prolonged bacteraemia (median 90.8 hours [95% CI: 65.9-93.8] vs. 20.1 hours [95% CI: 7.8-24.3], p<0.001) and prolonged fever clearance times <37.5°C (hazard ratio 2.4 [95%CI: 1.2-5.0]; p = 0.02). Results were consistent when studies were analysed independently and in a sub-group of participants with no history of vaccination or previous challenge. A prolonged treatment response was observed significantly more frequently in the azithromycin group (28/52 [54.9%]) compared with the ciprofloxacin group (1/29 [3.5%]; p<0.001). In participants treated with azithromycin, observed systemic plasma concentrations of azithromycin did not exceed the minimum inhibitory concentration (MIC), whilst predicted intracellular concentrations did exceed the MIC. In participants treated with ciprofloxacin, the observed systemic plasma concentrations and predicted intracellular concentrations of ciprofloxacin exceeded the MIC. INTERPRETATION Azithromycin at a dose of 500mg daily is an effective treatment for fully sensitive strains of S. Typhi but is associated with delayed treatment response and prolonged bacteraemia when compared with ciprofloxacin within the context of a human challenge model. Whilst the cellular accumulation of azithromycin is predicted to be sufficient to treat intracellular S. Typhi, systemic exposure may be sub-optimal for the elimination of extracellular circulating S. Typhi. In an era of increasing antimicrobial resistance, further studies are required to define appropriate azithromycin dosing regimens for enteric fever and to assess novel treatment strategies, including combination therapies. TRIAL REGISTRATION ClinicalTrials.gov (NCT02324751 and NCT02192008).
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Affiliation(s)
- Celina Jin
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Malick M. Gibani
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Shaun H. Pennington
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Alison Ardrey
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Ghaith Aljayyoussi
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Maria Moore
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Brian Angus
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Christopher M. Parry
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- School of Tropical Medicine and Global Health, Nagsaki University, Nagasaki, Japan
| | - Giancarlo A. Biagini
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nicholas A. Feasey
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Malawi Liverpool Wellcome Trust Clinical research Programme, Blantyre, Malawi
| | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
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Pitzer VE, Meiring J, Martineau FP, Watson CH, Kang G, Basnyat B, Baker S. The Invisible Burden: Diagnosing and Combatting Typhoid Fever in Asia and Africa. Clin Infect Dis 2019; 69:S395-S401. [PMID: 31612938 PMCID: PMC6792124 DOI: 10.1093/cid/ciz611] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Measuring the burden of typhoid fever and developing effective strategies to reduce it require a surveillance infrastructure that is currently lacking in many endemic countries. Recent efforts and partnerships between local and international researchers have helped to provide new data on the incidence and control of typhoid in parts of Asia and Africa. Here, we highlight examples from India, Nepal, Vietnam, Fiji, Sierra Leone, and Malawi that summarize past and present experiences with the diagnosis, treatment, and prevention of typhoid fever in different locations with endemic disease. While there is no validated road map for the elimination of typhoid, the lessons learned in studying the epidemiology and control of typhoid in these settings can provide insights to guide future disease control efforts.
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Affiliation(s)
- Virginia E Pitzer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, Connecticut
| | - James Meiring
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and the National Institute for Health Research Oxford Biomedical Research Centre, United Kingdom
| | | | - Conall H Watson
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, United Kingdom
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Gagandeep Kang
- Translational Health Sciences Technology Institute, Faridabad, Haryana, India
| | - Buddha Basnyat
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Stephen Baker
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Department of Medicine, University of Cambridge, United Kingdom
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25
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Blohmke CJ, Muller J, Gibani MM, Dobinson H, Shrestha S, Perinparajah S, Jin C, Hughes H, Blackwell L, Dongol S, Karkey A, Schreiber F, Pickard D, Basnyat B, Dougan G, Baker S, Pollard AJ, Darton TC. Diagnostic host gene signature for distinguishing enteric fever from other febrile diseases. EMBO Mol Med 2019; 11:e10431. [PMID: 31468702 PMCID: PMC6783646 DOI: 10.15252/emmm.201910431] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 07/30/2019] [Accepted: 08/09/2019] [Indexed: 12/19/2022] Open
Abstract
Misdiagnosis of enteric fever is a major global health problem, resulting in patient mismanagement, antimicrobial misuse and inaccurate disease burden estimates. Applying a machine learning algorithm to host gene expression profiles, we identified a diagnostic signature, which could distinguish culture-confirmed enteric fever cases from other febrile illnesses (area under receiver operating characteristic curve > 95%). Applying this signature to a culture-negative suspected enteric fever cohort in Nepal identified a further 12.6% as likely true cases. Our analysis highlights the power of data-driven approaches to identify host response patterns for the diagnosis of febrile illnesses. Expression signatures were validated using qPCR, highlighting their utility as PCR-based diagnostics for use in endemic settings.
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Affiliation(s)
- Christoph J Blohmke
- Department of PaediatricsCentre for Clinical Vaccinology and Tropical MedicineOxford Vaccine GroupOxfordUK
- Oxford National Institute of Health Research Biomedical CentreUniversity of OxfordOxfordUK
| | | | - Malick M Gibani
- Department of PaediatricsCentre for Clinical Vaccinology and Tropical MedicineOxford Vaccine GroupOxfordUK
- Oxford National Institute of Health Research Biomedical CentreUniversity of OxfordOxfordUK
| | - Hazel Dobinson
- Department of PaediatricsCentre for Clinical Vaccinology and Tropical MedicineOxford Vaccine GroupOxfordUK
- Oxford National Institute of Health Research Biomedical CentreUniversity of OxfordOxfordUK
| | - Sonu Shrestha
- Department of PaediatricsCentre for Clinical Vaccinology and Tropical MedicineOxford Vaccine GroupOxfordUK
- Oxford National Institute of Health Research Biomedical CentreUniversity of OxfordOxfordUK
| | - Soumya Perinparajah
- Department of PaediatricsCentre for Clinical Vaccinology and Tropical MedicineOxford Vaccine GroupOxfordUK
- Oxford National Institute of Health Research Biomedical CentreUniversity of OxfordOxfordUK
| | - Celina Jin
- Department of PaediatricsCentre for Clinical Vaccinology and Tropical MedicineOxford Vaccine GroupOxfordUK
- Oxford National Institute of Health Research Biomedical CentreUniversity of OxfordOxfordUK
| | - Harri Hughes
- Department of PaediatricsCentre for Clinical Vaccinology and Tropical MedicineOxford Vaccine GroupOxfordUK
- Oxford National Institute of Health Research Biomedical CentreUniversity of OxfordOxfordUK
| | - Luke Blackwell
- Department of PaediatricsCentre for Clinical Vaccinology and Tropical MedicineOxford Vaccine GroupOxfordUK
- Oxford National Institute of Health Research Biomedical CentreUniversity of OxfordOxfordUK
| | - Sabina Dongol
- Patan Academy of Healthy SciencesOxford University Clinical Research UnitKathmanduNepal
| | - Abhilasha Karkey
- Patan Academy of Healthy SciencesOxford University Clinical Research UnitKathmanduNepal
| | | | - Derek Pickard
- Infection Genomics ProgramThe Wellcome Trust Sanger InstituteHinxtonUK
| | - Buddha Basnyat
- Patan Academy of Healthy SciencesOxford University Clinical Research UnitKathmanduNepal
| | - Gordon Dougan
- Infection Genomics ProgramThe Wellcome Trust Sanger InstituteHinxtonUK
| | - Stephen Baker
- The Hospital for Tropical DiseasesWellcome Trust Major Overseas ProgrammeOxford University Clinical Research UnitHo Chi Minh CityVietnam
| | - Andrew J Pollard
- Department of PaediatricsCentre for Clinical Vaccinology and Tropical MedicineOxford Vaccine GroupOxfordUK
- Oxford National Institute of Health Research Biomedical CentreUniversity of OxfordOxfordUK
| | - Thomas C Darton
- Department of PaediatricsCentre for Clinical Vaccinology and Tropical MedicineOxford Vaccine GroupOxfordUK
- Oxford National Institute of Health Research Biomedical CentreUniversity of OxfordOxfordUK
- The Hospital for Tropical DiseasesWellcome Trust Major Overseas ProgrammeOxford University Clinical Research UnitHo Chi Minh CityVietnam
- Department of Infection, Immunity and Cardiovascular DiseaseUniversity of SheffieldSheffieldUK
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26
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Capeding MR, Alberto E, Sil A, Saluja T, Teshome S, Kim DR, Park JY, Yang JS, Chinaworapong S, Park J, Jo SK, Chon Y, Yang SY, Ham DS, Ryu JH, Lynch J, Kim JH, Kim H, Excler JL, Wartel TA, Sahastrabuddhe S. Immunogenicity, safety and reactogenicity of a Phase II trial of Vi-DT typhoid conjugate vaccine in healthy Filipino infants and toddlers: A preliminary report. Vaccine 2019; 38:4476-4483. [PMID: 31585725 PMCID: PMC7273193 DOI: 10.1016/j.vaccine.2019.09.074] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 09/20/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Typhoid fever remains an important public health problem in developing countries and is endemic in many parts of Asia and Africa where the incidence of disease typically peaks in school-aged children. Age restrictions and other limitations of existing oral live-attenuated typhoid and parenteral Vi polysaccharide vaccines have triggered the development of Vi conjugate vaccines with improved immunological properties, use in younger age range, and longer durability of protection. We present the safety, reactogenicity, and immunogenicity data from a Phase II study after a single dose of Vi polysaccharide conjugated to diphtheria toxoid (Vi-DT) conducted in 6-23-month old Filipino children. METHODS This is a randomized, observer-blinded Phase II study to assess the immunogenicity, safety and reactogenicity of Vi-DT compared to placebo, conducted in Muntinlupa City, The Philippines. Participants aged 6-23 months were enrolled and randomized to Vi-DT (25 µg) or placebo (0.9% sodium chloride) and evaluated for immunogenicity and overall safety 28 days post vaccination. RESULTS A total of 285 participants were enrolled and age-stratified: 6 to < 9 months, 9-12 months, and 13-23 months. Seventy-six (76) participants received Vi-DT and 19 received placebo per each strata. All participants seroconverted after a single dose of Vi-DT versus 7% of placebo recipients. Anti-Vi IgG GMT was 444.38 [95% CI (400.28; 493.34)] after a single dose of Vi-DT; there was no change in GMT after placebo administration, 0.41 [95% CI (0.33; 0.51), p < 0.0001]. A similar pattern of immunogenicity was reported across all age strata. The vaccine reported to be safe and well tolerated. CONCLUSIONS Vi-DT vaccine was immunogenic, safe, and well tolerated in children aged 6-23 months. ClinicalTrials.gov registration number: NCT03527355.
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Affiliation(s)
| | - Edison Alberto
- Research Institute for Tropical Medicine, Manila, Philippines
| | - Arijit Sil
- International Vaccine Institute, Seoul, Republic of Korea
| | - Tarun Saluja
- International Vaccine Institute, Seoul, Republic of Korea.
| | - Samuel Teshome
- International Vaccine Institute, Seoul, Republic of Korea
| | - Deok Ryun Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | - Ju Yeon Park
- International Vaccine Institute, Seoul, Republic of Korea
| | - Jae Seung Yang
- International Vaccine Institute, Seoul, Republic of Korea
| | | | - Jiwook Park
- International Vaccine Institute, Seoul, Republic of Korea
| | - Sue-Kyoung Jo
- International Vaccine Institute, Seoul, Republic of Korea
| | - Yun Chon
- International Vaccine Institute, Seoul, Republic of Korea
| | | | | | | | - Julia Lynch
- International Vaccine Institute, Seoul, Republic of Korea
| | - Jerome H Kim
- International Vaccine Institute, Seoul, Republic of Korea
| | - Hun Kim
- SK Bioscience, Seoul, Republic of Korea
| | | | - T Anh Wartel
- International Vaccine Institute, Seoul, Republic of Korea
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27
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Andrews JR, Vaidya K, Bern C, Tamrakar D, Wen S, Madhup S, Shrestha R, Karmacharya B, Amatya B, Koju R, Adhikari SR, Hohmann E, Ryan ET, Bogoch II. High Rates of Enteric Fever Diagnosis and Lower Burden of Culture-Confirmed Disease in Peri-urban and Rural Nepal. J Infect Dis 2019; 218:S214-S221. [PMID: 28961918 PMCID: PMC6226739 DOI: 10.1093/infdis/jix221] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background In South Asia, data on enteric fever are sparse outside of urban areas. We characterized enteric fever diagnosis patterns and the burden of culture-confirmed cases in peri-urban and rural Nepal. Methods We used national reports to estimate enteric fever diagnosis rates over 20 years (1994-2014) and conducted a prospective study of patients presenting with a >72-hour history of fever to 4 peri-urban and rural healthcare facilities (during August 2013-June 2016). We compared clinical characteristics of patients with culture-confirmed Salmonella Typhi or Paratyphi infection to those of patients without enteric fever. We used generalized additive models with logistic link functions to evaluate associations of age and population density with culture positivity. Results National rates of enteric fever diagnosis were high, reaching 18.8 cases per 1000 during 2009-2014. We enrolled 4309 participants with acute febrile illness. Among those with a provisional clinical diagnosis, 55% (1334 of 2412) received a diagnosis of enteric fever; however, only 4.1% of these had culture-confirmed typhoidal Salmonella infection. Culture positivity was highest among young adults and was strongly associated with higher population density (P < .001). Conclusions Enteric fever diagnosis rates were very high throughout Nepal, but in rural settings, few patients had culture-confirmed disease. Expanded surveillance may inform local enteric fever treatment and prevention strategies.
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Affiliation(s)
| | - Krista Vaidya
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel
| | - Caryn Bern
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California
| | - Dipesh Tamrakar
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel
| | - Shawn Wen
- D-Lab, Massachusetts Institute of Technology, Cambridge
| | - Surendra Madhup
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel
| | - Rajeev Shrestha
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel
| | | | - Bibush Amatya
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel
| | - Rajendra Koju
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel
| | | | - Elizabeth Hohmann
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
| | - Edward T Ryan
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts
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28
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Abstract
Purpose of review Enteric fever remains a major global-health concern, estimated to be responsible for between 11.9 and 26.9 million cases annually. Long-term prevention of enteric fever will require improved access to safe drinking water combined with investment in sanitation and hygiene interventions. In the short-to-medium term, new control strategies for typhoid fever have arrived in the form of typhoid Vi-conjugate vaccines (TCVs), offering hope that disease control can be achieved in the near future. Recent findings The diagnosis of enteric fever is complicated by its nonspecific clinical presentation, coupled with the low sensitivity of commonly used diagnostics. Investment in diagnostics has the potential to improve management, to refine estimates of disease burden and to facilitate vaccine impact studies. A new generation of reliable, diagnostic tests is needed that are simultaneously accessible, cost-effective, sensitive, and specific. The emergence and global dissemination of multidrug-resistant, fluoroquinolone-resistant, and extensively drug-resistant (XDR) strains of Salmonella Typhi emphasizes the importance of continued surveillance and appropriate antibiotic stewardship, integrated into a global strategy to address antimicrobial resistance (AMR). Current empirical treatment guidelines are out of date and should be updated to respond to local trends in AMR, so as to guide treatment choices in the absence of robust diagnostics and laboratory facilities. In September 2017, the WHO Strategic Advisory Group of Experts (SAGE) immunization recommended the programmatic use of TCVs in high burden countries. Ongoing and future studies should aim to study the impact of these vaccines in a diverse range of setting and to support the deployment of TCVs in high-burden countries. Summary The advent of new generation TCVs offers us a practical and affordable public-health tool that – for the first time – can be integrated into routine childhood immunization programmes. In this review, we advocate for the deployment of TCVs in line with WHO recommendations, to improve child health and limit the spread of antibiotic-resistant S. Typhi.
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29
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Lima NCB, Tanmoy AM, Westeel E, de Almeida LGP, Rajoharison A, Islam M, Endtz HP, Saha SK, de Vasconcelos ATR, Komurian-Pradel F. Analysis of isolates from Bangladesh highlights multiple ways to carry resistance genes in Salmonella Typhi. BMC Genomics 2019; 20:530. [PMID: 31253105 PMCID: PMC6599262 DOI: 10.1186/s12864-019-5916-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Accepted: 06/20/2019] [Indexed: 12/12/2022] Open
Abstract
Background Typhoid fever, caused by Salmonella Typhi, follows a fecal-oral transmission route and is a major global public health concern, especially in developing countries like Bangladesh. Increasing emergence of antimicrobial resistance (AMR) is a serious issue; the list of treatments for typhoid fever is ever-decreasing. In addition to IncHI1-type plasmids, Salmonella genomic island (SGI) 11 has been reported to carry AMR genes. Although reports suggest a recent reduction in multidrug resistance (MDR) in the Indian subcontinent, the corresponding genomic changes in the background are unknown. Results Here, we assembled and annotated complete closed chromosomes and plasmids for 73 S. Typhi isolates using short-length Illumina reads. S. Typhi had an open pan-genome, and the core genome was smaller than previously reported. Considering AMR genes, we identified five variants of SGI11, including the previously reported reference sequence. Five plasmids were identified, including the new plasmids pK91 and pK43; pK43and pHCM2 were not related to AMR. The pHCM1, pPRJEB21992 and pK91 plasmids carried AMR genes and, along with the SGI11 variants, were responsible for resistance phenotypes. pK91 also contained qnr genes, conferred high ciprofloxacin resistance and was related to the H58-sublineage Bdq, which shows the same phenotype. The presence of plasmids (pHCM1 and pK91) and SGI11 were linked to two H58-lineages, Ia and Bd. Loss of plasmids and integration of resistance genes in genomic islands could contribute to the fitness advantage of lineage Ia isolates. Conclusions Such events may explain why lineage Ia is globally widespread, while the Bd lineage is locally restricted. Further studies are required to understand how these S. Typhi AMR elements spread and generate new variants. Preventive measures such as vaccination programs should also be considered in endemic countries; such initiatives could potentially reduce the spread of AMR. Electronic supplementary material The online version of this article (10.1186/s12864-019-5916-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nicholas Costa Barroso Lima
- Departamento de Bioquímica e Biologia Molecular, Universidade Federal do Ceará, Fortaleza, Ceará, Brazil.,Laboratório Nacional de Computação Científica, Petrópolis, Brazil
| | - Arif M Tanmoy
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands.,Fondation Mérieux - Laboratoire des Pathogènes Emergents, Lyon, France.,Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, 1207, Bangladesh
| | - Emilie Westeel
- Fondation Mérieux - Laboratoire des Pathogènes Emergents, Lyon, France
| | | | - Alain Rajoharison
- Fondation Mérieux - Laboratoire des Pathogènes Emergents, Lyon, France
| | - Maksuda Islam
- Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, 1207, Bangladesh
| | - Hubert P Endtz
- Department of Medical Microbiology & Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands.,Fondation Mérieux - Laboratoire des Pathogènes Emergents, Lyon, France
| | - Samir K Saha
- Child Health Research Foundation, Department of Microbiology, Dhaka Shishu Hospital, Dhaka, 1207, Bangladesh.,Bangladesh Institute of Child Health, Dhaka Shishu Hospital, Dhaka, 1207, Bangladesh
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30
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Sharma T, Sharma C, Sankhyan A, Bedi SP, Bhatnagar S, Khanna N, Gautam V, Sethi S, Vrati S, Tiwari A. Serodiagnostic evaluation of recombinant CdtB of S. Typhi as a potential candidate for acute typhoid. Immunol Res 2019; 66:503-512. [PMID: 29931558 DOI: 10.1007/s12026-018-9009-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Typhoid fever caused by human restricted Salmonella typhi presents a considerable health burden on developing South-Asian nations like India. The suboptimal sensitivity and specificity associated with culture-based isolation of etiological agent and the extensively used surface antigen-based serological assays often lead to misdiagnosis and inappropriate antimicrobial treatment. The increasing reports of the emergence of resistant strains and undefined disease burden signify the critical need for an inexpensive, reliable, easy-to-use, and highly sensitive diagnostic test for typhoid fever. Utilizing S. typhi-specific and immunogenic antigens in sero-diagnostic assays could lead to precise diagnosis of acute typhoid and prompt treatment. In this study, we report cloning, expression, and purification of recombinant Cytolethal distending toxin subunit B (CdtB) of S. typhi, which is reported to be highly specific, immunogenic, and expressed only upon S. typhi infection. We further evaluated the purified recombinant CdtB for its diagnostic potential in an IgM-based indirect ELISA format using 33 human samples. Twenty-one serum samples from blood culture confirmed cases (n = 21) of typhoid and 12 samples from healthy controls (n = 12) were tested. The assay showed sensitivity of 100% and specificity of 83.3% respectively with positive and negative predictive values of 91.3 and 100% respectively. Efficient detection of specific IgM antibodies indicates that CdtB could be highly valuable in sero-diagnosis of acute typhoid and rapid screening of clinical samples.
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Affiliation(s)
- Tarang Sharma
- Centre for Bio-design & Diagnostics, Translational Health Science and Technology Institute, Faridabad, Haryana, India
| | - Chandresh Sharma
- Centre for Bio-design & Diagnostics, Translational Health Science and Technology Institute, Faridabad, Haryana, India
| | - Anurag Sankhyan
- Centre for Bio-design & Diagnostics, Translational Health Science and Technology Institute, Faridabad, Haryana, India.,Central Research Institute, Kasauli, Himachal Pradesh, India
| | - Sanjiv Pal Bedi
- Department of Experimental Medicine & Biotechnology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Shinjini Bhatnagar
- Paediatric Biology Centre, Translational Health Science and Technology Institute, Faridabad, Haryana, India
| | - Navin Khanna
- International Centre for Genetic Engineering & Biotechnology, New Delhi, India
| | - Vikas Gautam
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Sethi
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sudhanshu Vrati
- Regional Centre for Biotechnology, Faridabad, Haryana, India
| | - Ashutosh Tiwari
- Centre for Bio-design & Diagnostics, Translational Health Science and Technology Institute, Faridabad, Haryana, India. .,Department of Experimental Medicine & Biotechnology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
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31
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Parry CM, Ribeiro I, Walia K, Rupali P, Baker S, Basnyat B. Multidrug resistant enteric fever in South Asia: unmet medical needs and opportunities. BMJ 2019; 364:k5322. [PMID: 30670452 PMCID: PMC6340381 DOI: 10.1136/bmj.k5322] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Investments in newer diagnostics and antimicrobial treatments are critical to improve management of enteric fever in South Asia, say Christopher Parry and colleagues
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Affiliation(s)
- Christopher M Parry
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
- School of Tropical Medicine and Global Health, Nagasaki University, Japan
| | - Isabela Ribeiro
- Dynamic Portfolio Unit, Drugs for Neglected Diseases initiative, Geneva, Switzerland
| | - Kamini Walia
- Department of Medical Microbiology, Institute of Medical Education and Research, Chandigarh, India
| | - Priscilla Rupali
- Department of Medicine, Christian Medical College, Vellore, India
| | - Stephen Baker
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Buddha Basnyat
- Centre for Tropical Medicine and Global Health, Oxford University, Oxford, UK
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
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32
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Thapa A, Mittal N, Kayastha G, Basnyat B. Typhoid fever with isolated left lateral rectus palsy. BMJ Case Rep 2018; 2018:bcr-2018-225746. [PMID: 30181402 DOI: 10.1136/bcr-2018-225746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 17-year-old young woman presented to Patan Hospital, Kathmandu, Nepal, with high-grade fever and headache for 4 days and non-projectile vomiting for 1 day. She also had blurred vision with dizziness on and off. There was no abnormal physical finding. Enteric fever was suspected, and she was empirically started on azithromycin (20 mg/kg) for 7 days. She became afebrile after 2 days and was followed up in 7 days with diplopia since 5 days. At this time, the blood culture was positive for Salmonella serovar typhi. On examination, there was isolated left lateral rectus palsy which accounted for her diplopia. Methylprednisolone (1 mg/kg) was prescribed which was tapered over 1 month and gradually her diplopia subsided. We hypothesise that vasculitic change in the blood vessel supplying the left abducens nerve could be causing the diplopia.
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Affiliation(s)
- Abishkar Thapa
- Oxford University Clinical Research Unit, Patan Hospital, Lalitpur, Province - 3, Nepal
| | - Nancy Mittal
- Oxford University Clinical Research Unit, Patan Hospital, Lalitpur, Province - 3, Nepal
| | - Gyan Kayastha
- Medicine, Patan Academy of Health Sciences, Kathmandu, Province - 3, Nepal
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Hospital, Lalitpur, Province - 3, Nepal
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Andrews JR, Baker S, Marks F, Alsan M, Garrett D, Gellin BG, Saha SK, Qamar FN, Yousafzai MT, Bogoch II, Antillon M, Pitzer VE, Kim JH, John J, Gauld J, Mogasale V, Ryan ET, Luby SP, Lo NC. Typhoid conjugate vaccines: a new tool in the fight against antimicrobial resistance. THE LANCET. INFECTIOUS DISEASES 2018; 19:e26-e30. [PMID: 30170987 DOI: 10.1016/s1473-3099(18)30350-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 05/10/2018] [Accepted: 05/17/2018] [Indexed: 10/28/2022]
Abstract
Typhoid fever is an acute systemic infectious disease responsible for an estimated 12-20 million illnesses and over 150 000 deaths annually. In March, 2018, a new recommendation was issued by WHO for the programmatic use of typhoid conjugate vaccines in endemic countries. Health economic analyses of typhoid vaccines have informed funding decisions and national policies regarding vaccine rollout. However, by focusing only on averted typhoid cases and their associated costs, traditional cost-effectiveness analyses might underestimate crucial benefits of typhoid vaccination programmes, because the potential effect of typhoid vaccines on the treatment of patients with non-specific acute febrile illnesses is not considered. For every true case of typhoid fever, three to 25 patients without typhoid disease are treated with antimicrobials unnecessarily, conservatively amounting to more than 50 million prescriptions per year. Antimicrobials for suspected typhoid might therefore be an important selective pressure for the emergence and spread of antimicrobial resistance globally. We propose that large-scale, more aggressive typhoid vaccination programmes-including catch-up campaigns in children up to 15 years of age, and vaccination in lower incidence settings-have the potential to reduce the overuse of antimicrobials and thereby reduce antimicrobial resistance in many bacterial pathogens. Funding bodies and national governments must therefore consider the potential for broad reductions in antimicrobial use and resistance in decisions related to the rollout of typhoid conjugate vaccines.
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Affiliation(s)
- Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA.
| | - Stephen Baker
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Florian Marks
- Department of Medicine, University of Cambridge, Cambridge, UK; Epidemiology Unit, International Vaccine Institute, Seoul, South Korea
| | - Marcella Alsan
- Center for Health Policy and the Center for Primary Care and Outcomes Research, Stanford University, Stanford, CA, USA
| | | | | | - Samir K Saha
- Department of Microbiology, Bangladesh Institute of Child Health, Dhaka Shishu Hospital, Dhaka, Bangladesh
| | - Farah Naz Qamar
- Department of Paediatrics and Child Health, Aga Khan University, Karachi, Pakistan
| | | | - Isaac I Bogoch
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Marina Antillon
- Center for Health Economics Research and Modeling Infectious Diseases, University of Antwerp, Belgium
| | - Virginia E Pitzer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
| | - Jong-Hoon Kim
- Epidemiology Unit, International Vaccine Institute, Seoul, South Korea
| | - Jacob John
- Department of Community Health, Christian Medical College, Vellore, Tamil Nadu, India
| | | | - Vittal Mogasale
- Policy and Economic Research Department, Development and Delivery Unit, International Vaccine Institute, Seoul, South Korea
| | - Edward T Ryan
- Division of Infectious Diseases, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Nathan C Lo
- Division of Infectious Diseases and Geographic Medicine, Stanford University School of Medicine, Stanford, CA, USA
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Cuypers WL, Jacobs J, Wong V, Klemm EJ, Deborggraeve S, Van Puyvelde S. Fluoroquinolone resistance in Salmonella: insights by whole-genome sequencing. Microb Genom 2018; 4. [PMID: 29975627 PMCID: PMC6113872 DOI: 10.1099/mgen.0.000195] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
Fluoroquinolone (FQ)-resistant Salmonella spp. were listed by the WHO in 2017 as priority pathogens for which new antibiotics were urgently needed. The overall global burden of Salmonella infections is high, but differs per region. Whereas typhoid fever is most prevalent in South and South-East Asia, non-typhoidal salmonellosis is prevalent across the globe and associated with a mild gastroenteritis. By contrast, invasive non-typhoidal Salmonella cause bloodstream infections associated with high mortality, particularly in sub-Saharan Africa. Most Salmonella strains from clinical sources are resistant to first-line antibiotics, with FQs now being the antibiotic of choice for treatment of invasive Salmonella infections. However, FQ resistance is increasingly being reported in Salmonella, and multiple molecular mechanisms are already described. Whole-genome sequencing (WGS) is becoming more frequently used to analyse bacterial genomes for antibiotic-resistance markers, and to understand the phylogeny of bacteria in relation to their antibiotic-resistance profiles. This mini-review provides an overview of FQ resistance in Salmonella, guided by WGS studies that demonstrate that WGS is a valuable tool for global surveillance.
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Affiliation(s)
- Wim L Cuypers
- 1Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium.,2Department of Mathematics and Computer Science, University of Antwerp, Antwerpen, Belgium
| | - Jan Jacobs
- 3Department of Clinical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium.,4Department of Microbiology and Immunology, Katholieke Universiteit Leuven (KU Leuven), Leuven, Belgium
| | - Vanessa Wong
- 5Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK.,6Wellcome Trust Sanger Institute, Hinxton, UK
| | | | - Stijn Deborggraeve
- 1Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Sandra Van Puyvelde
- 6Wellcome Trust Sanger Institute, Hinxton, UK.,1Department of Biomedical Sciences, Institute of Tropical Medicine, Antwerpen, Belgium
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Typhoid fever: issues in laboratory detection, treatment options & concerns in management in developing countries. Future Sci OA 2018; 4:FSO312. [PMID: 30057789 PMCID: PMC6060388 DOI: 10.4155/fsoa-2018-0003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/26/2018] [Indexed: 11/17/2022] Open
Abstract
Multidrug-resistant Salmonella enterica subsp. enterica serovar Typhi (resistant to ampicillin, chloramphenicol and cotrimoxazole), was significantly reduced with the increased usage of fluoroquinolones and azithromycin. This has led to declining multidrug resistance rates in India with increasing ciprofloxacin nonsusceptibility rates and clinical failures due to azithromycin. However, for the available agents such as ceftriaxone, azithromycin and fluoroquinolones, the dose and duration for treatment is undefined. The ongoing clinical trials for typhoid management are expected to recommend the defined dose and duration for better clinical outcome. We made an attempt to summarize the issues in laboratory detection, treatment options and responses, and the concerns in clinical practice seen in the developing countries. Typhoid fever is an important cause of mortality in developing countries and is a major public health concern. Cephalosporins or azithromycin are the drugs of choice for treating infection caused by the reduced fluoroquinolone susceptibility of S. Typhi. Emergence of cephalosporin resistance in S. Typhi and azithromycin-associated clinical and microbiological failure is of significant concern in developing countries. An approach of cephalosporin–azithromycin combination therapy has been suggested, which could be a potential alternative in treating uncomplicated S. Typhi infection in endemic areas. This review summarizes the field so far.
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Zmora N, Shrestha S, Neuberger A, Paran Y, Tamrakar R, Shrestha A, Madhup SK, Bedi TRS, Koju R, Schwartz E. Open label comparative trial of mono versus dual antibiotic therapy for Typhoid Fever in adults. PLoS Negl Trop Dis 2018; 12:e0006380. [PMID: 29684022 PMCID: PMC5912710 DOI: 10.1371/journal.pntd.0006380] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 03/09/2018] [Indexed: 11/18/2022] Open
Abstract
Background Emerging resistance to antibiotics renders therapy of Typhoid Fever (TF) increasingly challenging. The current single-drug regimens exhibit prolonged fever clearance time (FCT), imposing a great burden on both patients and health systems, and potentially contributing to the development of antibiotic resistance and the chronic carriage of the pathogens. The aim of our study was to assess the efficacy of combining third-generation cephalosporin therapy with azithromycin on the outcomes of TF in patients living in an endemic region. Methods An open-label, comparative trial was conducted at Dhulikhel Hospital, Nepal, between October 2012 and October 2014. Only culture-confirmed TF cases were eligible. Patients were alternately allocated to one of four study arms: hospitalized patients received either intravenous ceftriaxone or a combination of ceftriaxone and oral azithromycin, while outpatients received either oral azithromycin or a combination of oral azithromycin and cefexime. The primary outcome evaluated was FCT and the secondary outcomes included duration of bacteremia. Results 105 blood culture-confirmed patients, of whom 51 were treated as outpatients, were eligible for the study. Of the 88 patients who met the inclusion criteria for FCT analysis 41 patients received a single-agent regimen, while 47 patients received a combined regimen. Results showed that FCT was significantly shorter for the latter (95 versus 88 hours, respectively, p = 0·004), and this effect was exhibited in both the hospitalized and the outpatient sub-groups. Repeat blood cultures, drawn on day 3, were positive for 8/47 (17%) patients after monotherapy, versus 2/51 (4%) after combination therapy (p = 0·045). No severe complications or fatalities occurred in any of the groups. Conclusions Combined therapy of third-generation cephalosporins and azithromycin for TF may surpass monotherapy in terms of FCT and time to elimination of bacteremia. Trial registration Trial registration number: NCT02224040. Typhoid fever (TF) is a serious disease and the most common etiology of bloodstream infections in febrile patients in the Indian subcontinent. Before the advent of antibiotics its mortality rate reached up to 40%, and dropped dramatically upon their introduction. However, over the last decades multidrug-resistant strains have emerged, further posing a challenge to the treatment of TF. Here, we propose a novel treatment approach, combining azithromycin and a third-generation cephalosporin, two antibiotic agents, which act synergistically on the two niches occupied by the bacteria, the intra- and the extra-cellular compartments respectively. In our study of a rural Nepalese population with culture-confirmed TF, we have shown that dual therapy was superior to monotherapy in terms of time to defervescence and bacteremia elimination, both in outpatient and inpatient settings. We hence advocate the combination of these two antibiotics as a more effective therapeutic strategy than the current standard of care, and suggest that such approach may shorten patients’ hospital stay, and reduce both pathogen carriage rates and the development of antibiotic resistance.
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Affiliation(s)
- Niv Zmora
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sudeep Shrestha
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Ami Neuberger
- Travel Medicine & Tropical Diseases and Internal Medicine B, Rambam Medical Center, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yael Paran
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Ashish Shrestha
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | | | - T. R. S. Bedi
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Rajendra Koju
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Eli Schwartz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Center for Geographic Medicine and Tropical Diseases, the Chaim Sheba Medical Center, Tel Hashomer, Israel
- * E-mail:
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Adhikari S, Paudyal B, Sigdel KR, Basnyat B. Meningitis due to scrub typhus: the importance of a differential diagnosis in an endemic area. BMJ Case Rep 2018; 2018:bcr-2018-224499. [PMID: 29654106 DOI: 10.1136/bcr-2018-224499] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A patient with fever and neck stiffness was treated as partially treated bacterial meningitis based on history, examination and cerebrospinal fluid analysis. After initial improvement with ceftriaxone, vancomycin and dexamethasone, symptoms recurred. Fever resolved promptly after treatment was started with doxycycline, when scrub typhus immunoglobulin M test came positive. Meningitis is a well-known complication of scrub typhus. However, scrub typhus is seldom considered in the differential diagnosis of meningitis in the Indian subcontinent. Early diagnosis and prompt institution of doxycycline therapy may lead to early cure of scrub typhus even when features of meningitis supervene. However, ceftriaxone which is commonly used to treat bacterial meningitis is suboptimal in the treatmenwgt36t of scrub typhus.
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Affiliation(s)
- Sudeep Adhikari
- Department of Internal Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Buddhi Paudyal
- Department of Internal Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Keshav Raj Sigdel
- Department of Internal Medicine, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Hospital, Kathmandu, Nepal
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Basnyat B. Typhoid versus typhus fever in post-earthquake Nepal. LANCET GLOBAL HEALTH 2018; 4:e516-7. [PMID: 27443773 DOI: 10.1016/s2214-109x(16)30094-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 05/05/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Buddha Basnyat
- Nepal International Clinic, Lal Durbar, GPO Box 3596, Kathmandu, Nepal; Oxford University Clinical Research Unit-Patan Academy of Health Sciences, Kathmandu, Nepal; Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, Oxford University, Oxford, UK; Global Antibiotic Resistance Partnership-Nepal, Kathmandu, Nepal.
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Thompson CN, Karkey A, Dongol S, Arjyal A, Wolbers M, Darton T, Farrar JJ, Thwaites GE, Dolecek C, Basnyat B, Baker S. Treatment Response in Enteric Fever in an Era of Increasing Antimicrobial Resistance: An Individual Patient Data Analysis of 2092 Participants Enrolled into 4 Randomized, Controlled Trials in Nepal. Clin Infect Dis 2018; 64:1522-1531. [PMID: 28329181 PMCID: PMC5434338 DOI: 10.1093/cid/cix185] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 02/25/2017] [Indexed: 12/16/2022] Open
Abstract
Background. Enteric fever, caused by Salmonella Typhi and Salmonella Paratyphi A, is the leading cause of bacterial febrile disease in South Asia. Methods. Individual data from 2092 patients with enteric fever randomized into 4 trials in Kathmandu, Nepal, were pooled. All trials compared gatifloxacin with 1 of the following comparator drugs: cefixime, chloramphenicol, ofloxacin, or ceftriaxone. Treatment outcomes were evaluated according to antimicrobial if S. Typhi/Paratyphi were isolated from blood. We additionally investigated the impact of changing bacterial antimicrobial susceptibility on outcome. Results. Overall, 855 (41%) patients had either S. Typhi (n = 581, 28%) or S. Paratyphi A (n = 274, 13%) cultured from blood. There were 139 (6.6%) treatment failures with 1 death. Except for the last trial with ceftriaxone, the fluoroquinolone gatifloxacin was associated with equivalent or better fever clearance times and lower treatment failure rates in comparison to all other antimicrobials. However, we additionally found that the minimum inhibitory concentrations (MICs) against fluoroquinolones have risen significantly since 2005 and were associated with increasing fever clearance times. Notably, all organisms were susceptible to ceftriaxone throughout the study period (2005-2014), and the MICs against azithromycin declined, confirming the utility of these alternative drugs for enteric fever treatment. Conclusion. The World Health Organization and local government health ministries in South Asia still recommend fluoroquinolones for enteric fever. This policy should change based on the evidence provided here. Rapid diagnostics are urgently required given the large numbers of suspected enteric fever patients with a negative culture.
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Affiliation(s)
- Corinne N Thompson
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, University of Oxford, United Kingdom
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, and
| | - Sabina Dongol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, and
| | - Amit Arjyal
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, and
| | - Marcel Wolbers
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, University of Oxford, United Kingdom
| | - Thomas Darton
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Jeremy J Farrar
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, University of Oxford, United Kingdom
| | - Guy E Thwaites
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, University of Oxford, United Kingdom
| | - Christiane Dolecek
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, University of Oxford, United Kingdom
- Mahidol Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand ; and
| | - Buddha Basnyat
- Centre for Tropical Medicine and Global Health, University of Oxford, United Kingdom
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, and
- Global Antibiotic Resistance Partnership, Nepal
| | - Stephen Baker
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, University of Oxford, United Kingdom
- Department of Medicine, University of Cambridge, United Kingdom
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Zellweger RM, Basnyat B, Shrestha P, Prajapati KG, Dongol S, Sharma PK, Koirala S, Darton TC, Dolecek C, Thompson CN, Thwaites GE, Baker SG, Karkey A. A 23-year retrospective investigation of Salmonella Typhi and Salmonella Paratyphi isolated in a tertiary Kathmandu hospital. PLoS Negl Trop Dis 2017; 11:e0006051. [PMID: 29176850 PMCID: PMC5720835 DOI: 10.1371/journal.pntd.0006051] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Revised: 12/07/2017] [Accepted: 10/19/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Salmonella serovars Typhi (S. Typhi) and Paratyphi A (S. Paratyphi A), the causative agents of enteric fever, have been routinely isolated organisms from the blood of febrile patients in the Kathmandu Valley since the early 1990s. Susceptibility against commonly used antimicrobials for treating enteric fever has gradually changed throughout South Asia since this time, posing serious treatment challenges. Here, we aimed to longitudinally describe trends in the isolation of Salmonella enterica and assess changes in their antimicrobial susceptibility in Kathmandu over a 23-year period. METHODS We conducted a retrospective analysis of standardised microbiological data from April 1992 to December 2014 at a single healthcare facility in Kathmandu, examining time trends of Salmonella-associated bacteraemia and the corresponding antimicrobial susceptibility profiles of the isolated organisms. RESULTS Over 23 years there were 30,353 positive blood cultures. Salmonella enterica accounted for 65.4% (19,857/30,353) of all the bacteria positive blood cultures. S. Typhi and S. Paratyphi A were the dominant serovars, constituting 68.5% (13,592/19,857) and 30.5% (6,057/19,857) of all isolated Salmonellae. We observed (i) a peak in the number of Salmonella-positive cultures in 2002, a year of heavy rainfall and flooding in the Kathmandu Valley, followed by a decline toward pre-flood baseline by 2014, (ii) an increase in the proportion of S. Paratyphi in all Salmonella-positive cultures between 1992 and 2014, (iii) a decrease in the prevalence of MDR for both S. Typhi and S. Paratyphi, and (iv) a recent increase in fluoroquinolone non-susceptibility in both S. Typhi and S. Paratyphi isolates. CONCLUSIONS Our work describes significant changes in the epidemiology of Salmonella enterica in the Kathmandu Valley during the last quarter of a century. We highlight the need to examine current treatment protocols for enteric fever and suggest a change from fluoroquinolone monotherapy to combination therapies of macrolides or cephalosporins along with older first-line antimicrobials that have regained their efficacy.
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Affiliation(s)
- Raphaël M. Zellweger
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
- Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
- Global Antibiotic Resistance Partnership, Centre for Disease Dynamics Economics and Policy, Washington DC, Unites States of America
| | - Poojan Shrestha
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | | | - Sabina Dongol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Paban K. Sharma
- Patan Academy of Health Sciences, Patan Hospital, Kathmandu, Nepal
| | - Samir Koirala
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Thomas C. Darton
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Christiane Dolecek
- Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Corinne N. Thompson
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy E. Thwaites
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Stephen G. Baker
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
- The Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
- Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
- Global Antibiotic Resistance Partnership, Centre for Disease Dynamics Economics and Policy, Washington DC, Unites States of America
- * E-mail:
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Matono T, Morita M, Yahara K, Lee KI, Izumiya H, Kaku M, Ohnishi M. Emergence of Resistance Mutations in Salmonella enterica Serovar Typhi Against Fluoroquinolones. Open Forum Infect Dis 2017; 4:ofx230. [PMID: 29255729 PMCID: PMC5726467 DOI: 10.1093/ofid/ofx230] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/18/2017] [Indexed: 12/24/2022] Open
Abstract
Background Little is known about the evolutionary process and emergence time of resistance mutations to fluoroquinolone in Salmonella enterica serovar Typhi. Methods We analyzed S. Typhi isolates collected from returned travelers between 2001 and 2016. Based on ciprofloxacin susceptibility, isolates were categorized as highly resistant (minimum inhibitory concentration [MIC] ≥ 4 μg/mL [CIPHR]), resistant (MIC = 1–2 μg/mL [CIPR]), intermediate susceptible (MIC = 0.12–0.5 μg/mL [CIPI]), and susceptible (MIC ≤ 0.06 μg/mL [CIPS]). Results A total of 107 isolates (33 CIPHR, 14 CIPR, 30 CIPI, and 30 CIPS) were analyzed by whole-genome sequencing; 2461 single nucleotide polymorphisms (SNPs) were identified. CIPS had no mutations in the gyrA or parC genes, while each CIPI had 1 of 3 single mutations in gyrA (encoding Ser83Phe [63.3%], Ser83Tyr [33.3%], or Asp87Asn [3.3%]). CIPHR had the same 3 mutations: 2 SNPs in gyrA (encoding Ser83Phe and Asp87Asn) and a third in parC (encoding Ser80Ile). CIPHR shared a common ancestor with CIPR and CIPI isolates harboring a single mutation in gyrA encoding Ser83Phe, suggesting that CIPHR emerged 16 to 23 years ago. Conclusions Three SNPs—2 in gyrA and 1 in parC—are present in S. Typhi strains highly resistant to fluoroquinolone, which were found to have evolved in 1993–2000, approximately 10 years after the beginning of the ciprofloxacin era. Highly resistant strains with survival advantages arose from strains harboring a single mutation in gyrA encoding Ser83Phe. Judicious use of fluoroquinolones is warranted to prevent acceleration of such resistance mechanisms in the future.
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Affiliation(s)
- Takashi Matono
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan.,Department of Infection Control and Laboratory Diagnostics, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Masatomo Morita
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan
| | - Koji Yahara
- Department of Bacteriology II, National Institute of Infectious Diseases, Tokyo, Japan
| | - Ken-Ichi Lee
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan
| | - Hidemasa Izumiya
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan
| | - Mitsuo Kaku
- Department of Infection Control and Laboratory Diagnostics, Internal Medicine, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Makoto Ohnishi
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan
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Darton TC, Jones C, Dongol S, Voysey M, Blohmke CJ, Shrestha R, Karkey A, Shakya M, Arjyal A, Waddington CS, Gibani M, Carter MJ, Basnyat B, Baker S, Pollard AJ. Assessment and Translation of the Antibody-in-Lymphocyte Supernatant (ALS) Assay to Improve the Diagnosis of Enteric Fever in Two Controlled Human Infection Models and an Endemic Area of Nepal. Front Microbiol 2017; 8:2031. [PMID: 29109704 PMCID: PMC5660281 DOI: 10.3389/fmicb.2017.02031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Accepted: 10/04/2017] [Indexed: 11/17/2022] Open
Abstract
New diagnostic tests for enteric fever are urgently needed to assist with timely antimicrobial treatment of patients and to measure the efficacy of prevention measures such as vaccination. In a novel translational approach, here we use two recently developed controlled human infection models (CHIM) of enteric fever to evaluate an antibody-in-lymphocyte supernatant (ALS) assay, which can detect recent IgA antibody production by circulating B cells in ex vivo mononuclear cell culture. We calculated the discriminative ability of the ALS assay to distinguish diagnosed cases in the two CHIM studies in Oxford, prior to evaluating blood culture-confirmed diagnoses of patients presenting with fever to hospital in an endemic areas of Kathmandu, Nepal. Antibody responses to membrane preparations and lipopolysaccharide provided good sensitivity (>90%) for diagnosing systemic infection after oral challenge with Salmonella Typhi or S. Paratyphi A. Assay specificity was moderate (~60%) due to imperfect sensitivity of blood culture as the reference standard and likely unrecognized subclinical infection. These findings were augmented through the translation of the assay into the endemic setting in Nepal. Anti-MP IgA responses again exhibited good sensitivity (86%) but poor specificity (51%) for detecting blood culture-confirmed enteric fever cases (ROC AUC 0.79, 95%CI 0.70–0.88). Patients with anti-MP IgA ALS titers in the upper quartile exhibited a clinical syndrome synonymous with enteric fever. While better reference standards are need to assess enteric fever diagnostics, routine use of this ALS assay could be used to rule out infection and has the potential to double the laboratory detection rate of enteric fever in this setting over blood culture alone.
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Affiliation(s)
- Thomas C Darton
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom.,Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, United Kingdom
| | - Claire Jones
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Sabina Dongol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Merryn Voysey
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Christoph J Blohmke
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Rajendra Shrestha
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Abhilasha Karkey
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Mila Shakya
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Amit Arjyal
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Claire S Waddington
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Malick Gibani
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Michael J Carter
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom.,Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Stephen Baker
- Wellcome Trust Major Overseas Programme, Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Andrew J Pollard
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, University of Oxford, National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
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Sherchan JB, Morita M, Matono T, Izumiya H, Ohnishi M, Sherchand JB, Tandukar S, Laghu U, Nagamatsu M, Kato Y, Ohmagari N, Hayakawa K. Molecular and Clinical Epidemiology of Salmonella Paratyphi A Isolated from Patients with Bacteremia in Nepal. Am J Trop Med Hyg 2017; 97:1706-1709. [PMID: 29016327 DOI: 10.4269/ajtmh.17-0227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Little is known about the epidemiology of typhoid and paratyphoid fever in Nepal. We aimed to elucidate the molecular and clinical epidemiology of Salmonella Paratyphi A in Nepal. Isolates were collected from 23 cases of bacteremia due to S. Paratyphi A between December 2014 and October 2015. Thirteen patients (57%) were male, and the median age was 21 years. None of the patients had an underlying chronic disease. All S. Paratyphi A isolates were sensitive to ampicillin, trimethoprim/sulfamethoxazole, ceftriaxone, and chloramphenicol. All isolates were resistant to nalidixic acid and were categorized as intermediately susceptible to levofloxacin. Phylogenetic analysis revealed close relatedness among the isolates, including several clonal groups, suggesting local spread. Patients with bacteremia due to S. Paratyphi A in Kathmandu, Nepal, were relatively young and nondebilitated. Improving control of S. Paratyphi infections should focus on effective infection control measures and selection of empirical therapy based on current resistance patterns.
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Affiliation(s)
- Jatan Bahadur Sherchan
- Department of Clinical Microbiology, Kathmandu University School of Medical Sciences, Dhulikhel, Nepal
| | - Masatomo Morita
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan
| | - Takashi Matono
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan
| | - Hidemasa Izumiya
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan
| | - Makoto Ohnishi
- Department of Bacteriology I, National Institute of Infectious Diseases, Tokyo, Japan
| | - Jeevan B Sherchand
- Public Health Research Laboratory, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Sarmila Tandukar
- Public Health Research Laboratory, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Ujjwal Laghu
- Public Health Research Laboratory, Institute of Medicine, Tribhuvan University Teaching Hospital, Kathmandu, Nepal
| | - Maki Nagamatsu
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Yasuyuki Kato
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Norio Ohmagari
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
| | - Kayoko Hayakawa
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Tokyo, Japan
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44
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Pokharel S, Basnyat B, Arjyal A, Mahat SP, Kc RK, Bhuju A, Poudyal B, Kestelyn E, Shrestha R, Phuong DNT, Thapa R, Karki M, Dongol S, Karkey A, Wolbers M, Baker S, Thwaites G. Co-trimoxazole versus azithromycin for the treatment of undifferentiated febrile illness in Nepal: study protocol for a randomized controlled trial. Trials 2017; 18:450. [PMID: 28969659 PMCID: PMC5625657 DOI: 10.1186/s13063-017-2199-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 09/19/2017] [Indexed: 11/18/2022] Open
Abstract
Background Undifferentiated febrile illness (UFI) includes typhoid and typhus fevers and generally designates fever without any localizing signs. UFI is a great therapeutic challenge in countries like Nepal because of the lack of available point-of-care, rapid diagnostic tests. Often patients are empirically treated as presumed enteric fever. Due to the development of high-level resistance to traditionally used fluoroquinolones against enteric fever, azithromycin is now commonly used to treat enteric fever/UFI. The re-emergence of susceptibility of Salmonella typhi to co-trimoxazole makes it a promising oral treatment for UFIs in general. We present a protocol of a randomized controlled trial of azithromycin versus co-trimoxazole for the treatment of UFI. Methods/design This is a parallel-group, double-blind, 1:1, randomized controlled trial of co-trimoxazole versus azithromycin for the treatment of UFI in Nepal. Participants will be patients aged 2 to 65 years, presenting with fever without clear focus for at least 4 days, complying with other study criteria and willing to provide written informed consent. Patients will be randomized either to azithromycin 20 mg/kg/day (maximum 1000 mg/day) in a single daily dose and an identical placebo or co-trimoxazole 60 mg/kg/day (maximum 3000 mg/day) in two divided doses for 7 days. Patients will be followed up with twice-daily telephone calls for 7 days or for at least 48 h after they become afebrile, whichever is later; by home visits on days 2 and 4 of treatment; and by hospital visits on days 7, 14, 28 and 63. The endpoints will be fever clearance time, treatment failure, time to treatment failure, and adverse events. The estimated sample size is 330. The primary analysis population will be all the randomized population and subanalysis will be repeated on patients with blood culture-confirmed enteric fever and culture-negative patients. Discussion Both azithromycin and co-trimoxazole are available in Nepal and are extensively used in the treatment of UFI. Therefore, it is important to know the better orally administered antimicrobial to treat enteric fever and other UFIs especially against the background of fluoroquinolone-resistant enteric fever. Trial registration ClinicalTrials.gov, ID: NCT02773407. Registered on 5 May 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2199-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sunil Pokharel
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Buddha Basnyat
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal. .,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Amit Arjyal
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Saruna Pathak Mahat
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Raj Kumar Kc
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abhusani Bhuju
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Buddhi Poudyal
- Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Evelyne Kestelyn
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ritu Shrestha
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Rajkumar Thapa
- Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Manan Karki
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sabina Dongol
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Marcel Wolbers
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Stephen Baker
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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45
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Darton TC, Baker S, Randall A, Dongol S, Karkey A, Voysey M, Carter MJ, Jones C, Trappl K, Pablo J, Hung C, Teng A, Shandling A, Le T, Walker C, Molina D, Andrews J, Arjyal A, Basnyat B, Pollard AJ, Blohmke CJ. Identification of Novel Serodiagnostic Signatures of Typhoid Fever Using a Salmonella Proteome Array. Front Microbiol 2017; 8:1794. [PMID: 28970824 PMCID: PMC5609549 DOI: 10.3389/fmicb.2017.01794] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 09/05/2017] [Indexed: 11/26/2022] Open
Abstract
Current diagnostic tests for typhoid fever, the disease caused by Salmonella Typhi, are poor. We aimed to identify serodiagnostic signatures of typhoid fever by assessing microarray signals to 4,445 S. Typhi antigens in sera from 41 participants challenged with oral S. Typhi. We found broad, heterogeneous antibody responses with increasing IgM/IgA signals at diagnosis. In down-selected 250-antigen arrays we validated responses in a second challenge cohort (n = 30), and selected diagnostic signatures using machine learning and multivariable modeling. In four models containing responses to antigens including flagellin, OmpA, HlyE, sipC, and LPS, multi-antigen signatures discriminated typhoid (n = 100) from other febrile bacteremia (n = 52) in Nepal. These models contained combinatorial IgM, IgA, and IgG responses to 5 antigens (ROC AUC, 0.67 and 0.71) or 3 antigens (0.87), although IgA responses to LPS also performed well (0.88). Using a novel systematic approach we have identified and validated optimal serological diagnostic signatures of typhoid fever.
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Affiliation(s)
- Thomas C Darton
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, and the Oxford National Institutes for Health Research Biomedical Research Centre, University of OxfordOxford, United Kingdom.,The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research UnitHo Chi Minh City, Vietnam.,Department of Infection, Immunity and Cardiovascular Disease, The University of SheffieldSheffield, United Kingdom
| | - Stephen Baker
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research UnitHo Chi Minh City, Vietnam
| | - Arlo Randall
- Antigen Discovery Incorporated, IrvineCA, United States
| | - Sabina Dongol
- Oxford University Clinical Research Unit, Patan Academy of Health SciencesKathmandu, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health SciencesKathmandu, Nepal
| | - Merryn Voysey
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, and the Oxford National Institutes for Health Research Biomedical Research Centre, University of OxfordOxford, United Kingdom.,Nuffield Department of Primary Care Health Sciences, University of OxfordOxford, United Kingdom
| | - Michael J Carter
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, and the Oxford National Institutes for Health Research Biomedical Research Centre, University of OxfordOxford, United Kingdom
| | - Claire Jones
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, and the Oxford National Institutes for Health Research Biomedical Research Centre, University of OxfordOxford, United Kingdom
| | - Krista Trappl
- Antigen Discovery Incorporated, IrvineCA, United States
| | - Jozelyn Pablo
- Antigen Discovery Incorporated, IrvineCA, United States
| | - Chris Hung
- Antigen Discovery Incorporated, IrvineCA, United States
| | - Andy Teng
- Antigen Discovery Incorporated, IrvineCA, United States
| | | | - Tim Le
- Antigen Discovery Incorporated, IrvineCA, United States
| | | | | | - Jason Andrews
- Division of Infectious Diseases and Geographic Medicine, Stanford University, StanfordCA, United States
| | - Amit Arjyal
- Nuffield Department of Primary Care Health Sciences, University of OxfordOxford, United Kingdom
| | - Buddha Basnyat
- Nuffield Department of Primary Care Health Sciences, University of OxfordOxford, United Kingdom
| | - Andrew J Pollard
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, and the Oxford National Institutes for Health Research Biomedical Research Centre, University of OxfordOxford, United Kingdom
| | - Christoph J Blohmke
- Oxford Vaccine Group, Centre for Clinical Vaccinology and Tropical Medicine, Department of Paediatrics, and the Oxford National Institutes for Health Research Biomedical Research Centre, University of OxfordOxford, United Kingdom
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46
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Tran Vu Thieu N, Trinh Van T, Tran Tuan A, Klemm EJ, Nguyen Ngoc Minh C, Voong Vinh P, Pham Thanh D, Ho Ngoc Dan T, Pham Duc T, Langat P, Martin LB, Galan J, Liang L, Felgner PL, Davies DH, de Jong HK, Maude RR, Fukushima M, Wijedoru L, Ghose A, Samad R, Dondorp AM, Faiz A, Darton TC, Pollard AJ, Thwaites GE, Dougan G, Parry CM, Baker S. An evaluation of purified Salmonella Typhi protein antigens for the serological diagnosis of acute typhoid fever. J Infect 2017; 75:104-114. [PMID: 28551371 PMCID: PMC5522525 DOI: 10.1016/j.jinf.2017.05.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Revised: 05/15/2017] [Accepted: 05/16/2017] [Indexed: 12/14/2022]
Abstract
Objectives The diagnosis of typhoid fever is a challenge. Aiming to develop a typhoid diagnostic we measured antibody responses against Salmonella Typhi (S. Typhi) protein antigens and the Vi polysaccharide in a cohort of Bangladeshi febrile patients. Methods IgM against 12 purified antigens and the Vi polysaccharide was measured by ELISA in plasma from patients with confirmed typhoid fever (n = 32), other confirmed infections (n = 17), and healthy controls (n = 40). ELISAs with the most specific antigens were performed on plasma from 243 patients with undiagnosed febrile disease. Results IgM against the S. Typhi protein antigens correlated with each other (rho > 0.8), but not against Vi (rho < 0.6). Typhoid patients exhibited higher IgM against 11/12 protein antigens and Vi than healthy controls and those with other infections. Vi, PilL, and CdtB exhibited the greatest sensitivity and specificity. Specificity and sensitivity was improved when Vi was combined with a protein antigen, generating sensitivities and specificities of 0.80 and >0.85, respectively. Applying a dynamic cut-off to patients with undiagnosed febrile disease suggested that 34–58% had an IgM response indicative of typhoid. Conclusions We evaluated the diagnostic potential of several S. Typhi antigens; our assays give good sensitivity and specificity, but require further assessment in differing patient populations.
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Affiliation(s)
- Nga Tran Vu Thieu
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Tan Trinh Van
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Anh Tran Tuan
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Elizabeth J Klemm
- The Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, United Kingdom
| | - Chau Nguyen Ngoc Minh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Phat Voong Vinh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Duy Pham Thanh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Thanh Ho Ngoc Dan
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Trung Pham Duc
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam
| | - Pinky Langat
- The Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, United Kingdom
| | - Laura B Martin
- Sclavo Berhing Vaccines Institute for Global Health, Siena, Italy
| | - Jorge Galan
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, CT, USA
| | - Li Liang
- Department of Medicine, Division of Infectious Diseases, University of California, Irvine, CA, USA
| | - Philip L Felgner
- Department of Medicine, Division of Infectious Diseases, University of California, Irvine, CA, USA
| | - D Huw Davies
- Department of Medicine, Division of Infectious Diseases, University of California, Irvine, CA, USA
| | - Hanna K de Jong
- Department of Internal Medicine, Division of Infectious Diseases and Center for Infection and Immunity Amsterdam (CINIMA), Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Rapeephan R Maude
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Masako Fukushima
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Lalith Wijedoru
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | | | - Rasheda Samad
- Chittagong Medical College Hospital, Chittagong, Bangladesh
| | - Arjen M Dondorp
- Mahidol-Oxford Tropical Medicine Research Unit (MORU), Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Malaria Research Group and Dev Care Foundation, Bangladesh
| | - Abul Faiz
- Malaria Research Group and Dev Care Foundation, Bangladesh
| | - Thomas C Darton
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Sheffield Teaching Hospitals NHS Trust Foundation and the University of Sheffield, Sheffield, United Kingdom
| | - Andrew J Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Guy E Thwaites
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Gordon Dougan
- The Wellcome Trust Sanger Institute, Hinxton, Cambridgeshire, United Kingdom; The Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Christopher M Parry
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Stephen Baker
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Viet Nam; Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom; The Department of Medicine, University of Cambridge, Cambridge, United Kingdom.
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47
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Karki M, Pandit S, Baker S, Basnyat B. Cotrimoxazole treats fluoroquinolone-resistant Salmonella typhi H58 infection. BMJ Case Rep 2016; 2016:bcr-2016-217223. [PMID: 27797841 DOI: 10.1136/bcr-2016-217223] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A woman aged 20 years presented with fever and no localising signs. She was treated with cotrimoxazole and the subsequent blood culture was positive for Salmonella typhi (S. typhi), which was resistant to fluoroquinolones but susceptible to cotrimoxazole. Genotyping identified an FQ-R subclade of H58 S. typhi Fever clearance time was 4 days after starting the antibiotics, and no relapses were noted on 2 months of follow-up. This inexpensive, well-known and easily available antimicrobial could be suitably redeployed for fluoroquinolone-resistant enteric fever in South Asia.
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Affiliation(s)
- Manan Karki
- Oxford University Clinical Research Unit, Patan Hospital, Kathmandu, Nepal
| | - Sarbagya Pandit
- Oxford University Clinical Research Unit, Patan Hospital, Kathmandu, Nepal
| | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Hospital, Kathmandu, Nepal
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48
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Gupta PK, Gupta J. Former first-line antibiotics for treatment of enteric fever. THE LANCET. INFECTIOUS DISEASES 2016; 16:892-893. [PMID: 27477979 DOI: 10.1016/s1473-3099(16)30143-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 05/24/2016] [Indexed: 06/06/2023]
Affiliation(s)
- Puneet Kumar Gupta
- Department of Microbiology, Dr Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh, 176001, India.
| | - Jyoti Gupta
- Department of Psychiatry, Dr Rajendra Prasad Government Medical College, Kangra at Tanda, Himachal Pradesh, 176001, India
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49
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Ryan ET. Troubling news from Asia about treating enteric fever: a coming storm. THE LANCET. INFECTIOUS DISEASES 2016; 16:508-509. [DOI: 10.1016/s1473-3099(15)00542-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 12/11/2015] [Indexed: 11/29/2022]
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50
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Pham Thanh D, Karkey A, Dongol S, Ho Thi N, Thompson CN, Rabaa MA, Arjyal A, Holt KE, Wong V, Tran Vu Thieu N, Voong Vinh P, Ha Thanh T, Pradhan A, Shrestha SK, Gajurel D, Pickard D, Parry CM, Dougan G, Wolbers M, Dolecek C, Thwaites GE, Basnyat B, Baker S. A novel ciprofloxacin-resistant subclade of H58 Salmonella Typhi is associated with fluoroquinolone treatment failure. eLife 2016; 5:e14003. [PMID: 26974227 PMCID: PMC4805543 DOI: 10.7554/elife.14003] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/19/2016] [Indexed: 01/22/2023] Open
Abstract
The interplay between bacterial antimicrobial susceptibility, phylogenetics and patient outcome is poorly understood. During a typhoid clinical treatment trial in Nepal, we observed several treatment failures and isolated highly fluoroquinolone-resistant Salmonella Typhi (S. Typhi). Seventy-eight S. Typhi isolates were genome sequenced and clinical observations, treatment failures and fever clearance times (FCTs) were stratified by lineage. Most fluoroquinolone-resistant S. Typhi belonged to a specific H58 subclade. Treatment failure with S. Typhi-H58 was significantly less frequent with ceftriaxone (3/31; 9.7%) than gatifloxacin (15/34; 44.1%)(Hazard Ratio 0.19, p=0.002). Further, for gatifloxacin-treated patients, those infected with fluoroquinolone-resistant organisms had significantly higher median FCTs (8.2 days) than those infected with susceptible (2.96) or intermediately resistant organisms (4.01)(p<0.001). H58 is the dominant S. Typhi clade internationally, but there are no data regarding disease outcome with this organism. We report an emergent new subclade of S. Typhi-H58 that is associated with fluoroquinolone treatment failure. Clinical trial registration: ISRCTN63006567. DOI:http://dx.doi.org/10.7554/eLife.14003.001 People who ingest a type of bacteria called Salmonella Typhi can develop the symptoms of typhoid fever. This disease is common in low-income settings in Asia and Africa, and causes a high rate of death in people who are not treated with antimicrobial drugs. During a study in Nepal, Thanh et al. tried to evaluate which of two antimicrobials was better for treating typhoid fever. One of the drugs – called gatifloxacin – did not work in some of the patients. To understand why this treatment failed, Thanh et al. decoded the entire DNA sequences of all the Salmonella Typhi bacteria isolated during the study. Comparing this genetic data to the clinical data of the patients identified a new variant of Salmonella Typhi. These bacteria have a specific combination of genetic mutations that render them resistant to the family of drugs that gatifloxacin belongs to – the fluoroquinolones. Patients infected with the variant bacteria and treated with gatifloxacin were highly likely to completely fail treatment and have longer-lasting fevers. On further investigation Thanh et al. found these organisms were likely recently introduced into Nepal from India. Fluoroquinolones are amongst the most effective and common antimicrobials used to treat typhoid fever and other bacterial infections. However, the presence of bacteria that are resistant to these compounds in South Asia means that they should no longer be the first choice of drug to treat typhoid fever in this location. DOI:http://dx.doi.org/10.7554/eLife.14003.002
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Affiliation(s)
- Duy Pham Thanh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Sabina Dongol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Nhan Ho Thi
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Corinne N Thompson
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom.,The London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Maia A Rabaa
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Amit Arjyal
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Kathryn E Holt
- Department of Biochemistry and Molecular Biology, Bio21 Molecular Science and Biotechnology Institute, The University of Melbourne, Melbourne, Australia
| | - Vanessa Wong
- The Wellcome Trust Sanger Institute, Cambridge, United Kingdom
| | - Nga Tran Vu Thieu
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Phat Voong Vinh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Tuyen Ha Thanh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | | | | | - Derek Pickard
- The Wellcome Trust Sanger Institute, Cambridge, United Kingdom
| | - Christopher M Parry
- The London School of Hygiene and Tropical Medicine, London, United Kingdom.,School of Tropical Medicine and Global Health, Department of Clinical Research, Nagasaki University, Nagasaki, Japan
| | - Gordon Dougan
- The Wellcome Trust Sanger Institute, Cambridge, United Kingdom
| | - Marcel Wolbers
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Christiane Dolecek
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom.,Department of Zoology, University of Oxford, Oxford, United Kingdom
| | - Guy E Thwaites
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Stephen Baker
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Oxford University, Oxford, United Kingdom.,The London School of Hygiene and Tropical Medicine, London, United Kingdom
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