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Veeraraghavan B, Pragasam AK, Ray P, Kapil A, Nagaraj S, Perumal SPB, Saigal K, Thomas M, Gupta M, Rongsen-Chandola T, Jinka DR, Shastri J, Alexander AP, Koshy RM, De A, Singh A, Evelyn Ebenezer S, Dutta S, Bavdekar A, More D, Sanghavi S, Nayakanti RR, Jacob JJ, Amladi A, Anandan S, Abirami BS, Bakthavatchalam YD, Sethuvel DPM, John J, Kang G. Evaluation of Antimicrobial Susceptibility Profile in Salmonella Typhi and Salmonella Paratyphi A: Presenting the Current Scenario in India and Strategy for Future Management. J Infect Dis 2021; 224:S502-S516. [PMID: 35238369 PMCID: PMC8892543 DOI: 10.1093/infdis/jiab144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Abstract
Background
Systematic studies to estimate the disease burden of typhoid and paratyphoid in India are limited. Therefore, a multicenter study on the Surveillance of Enteric Fever in India was carried out to estimate the incidence, clinical presentation, and antimicrobial resistance (AMR) trend. The data presented here represent the national burden of AMR in Salmonella Typhi and Salmonella Paratyphi A.
Methods
Antimicrobial susceptibility testing was performed for S. Typhi and S. Paratyphi A (n = 2373) isolates collected prospectively during a 2-year period from November 2017 to January 2020.
Results
Of 2373 Salmonella isolates, 2032 (85.6%) were identified as S. Typhi and 341 (14.4%) were S. Paratyphi A. Approximately 2% of S. Typhi were multidrug-resistant (MDR), whereas all 341 (100%) of S. Paratyphi A isolates were sensitive to the first-line antimicrobials. Among 98% of ciprofloxacin nonsusceptible isolates, resistance (minimum inhibitory concentration [MIC] >0.5 µg/mL) was higher in S. Typhi (37%) compared with S. Paratyphi A (20%). Azithromycin susceptibility was 99.9% and 100% with a mean MIC of 4.98 μg/mL for S. Typhi and 7.39 μg/mL for S. Paratyphi A respectively. Ceftriaxone was the only agent that retained 100% susceptibility. Moreover, beta-lactam/beta-lactamase inhibitors showed potent in vitro activity against the study isolates.
Conclusions
Data obtained from this systematic surveillance study confirms the declining trend of MDR Salmonella isolates from India. The higher prevalence of ciprofloxacin nonsusceptibility enforces to limit its use and adhere to the judicious usage of azithromycin and ceftriaxone for enteric fever management.
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Affiliation(s)
| | | | - Pallab Ray
- Post Graduate Institute of Medical & Educational Research, Chandigarh, India
| | - Arti Kapil
- All India Institute of Medical Sciences, Delhi, India
| | | | | | | | | | - Madhu Gupta
- Post Graduate Institute of Medical & Educational Research, Chandigarh, India
| | | | | | - Jayanthi Shastri
- Topiwala National Medical College & BYL Nair Charitable Hospital, Mumbai, India
| | | | | | - Anuradha De
- Topiwala National Medical College & BYL Nair Charitable Hospital, Mumbai, India
| | | | | | - Shanta Dutta
- ICMR-National Institute of Cholera and Enteric Diseases, Kolkata, India
| | | | - Deepak More
- Centre for Health Research & Development-Society for Applied Studies, New Delhi, India
| | | | | | | | | | | | | | | | | | - Jacob John
- Christian Medical College, Vellore, India
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Wain J, Simpson JA, Luong TDN, To SD, Pham TD, Baker S, Day NPJ, White NJ, Parry CM. Bactericidal activities and post-antibiotic effects of ofloxacin and ceftriaxone against drug-resistant Salmonella enterica serovar Typhi. J Antimicrob Chemother 2021; 76:2606-2609. [PMID: 34179968 PMCID: PMC8446916 DOI: 10.1093/jac/dkab215] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/01/2021] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The clinical response to ceftriaxone in patients with typhoid fever is significantly slower than with ofloxacin, despite infection with Salmonella enterica serovar Typhi (S. Typhi) isolates with similar susceptibilities (MIC 0.03-0.12 mg/L). The response to ofloxacin is slower if the isolate has intermediate susceptibility (MIC 0.25-1.0 mg/L). OBJECTIVES To determine the bactericidal activity and post-antibiotic effect (PAE) of ceftriaxone and ofloxacin against S. Typhi. METHODS The mean time to reach a 99.9% reduction in log10 count (bactericidal activity) and PAE of ceftriaxone and ofloxacin were determined for 18 clinical isolates of S. Typhi in time-kill experiments (MIC range for ofloxacin 0.06-1.0 mg/L and for ceftriaxone 0.03-0.12 mg/L). RESULTS The mean (SD) bactericidal activity of ofloxacin was 33.1 (15.2) min and 384.4 (60) min for ceftriaxone. After a 30 min exposure to ofloxacin, the mean (SD) duration of PAE was 154.7 (52.6) min. There was no detectable PAE after 1 h of exposure to ceftriaxone. For ofloxacin, bactericidal activity and PAE did not significantly differ between isolates with full or intermediate susceptibility provided ofloxacin concentrations were maintained at 4×MIC. CONCLUSIONS Infections with S. Typhi with intermediate ofloxacin susceptibility may respond to doses that maintain ofloxacin concentrations at 4×MIC at the site of infection. The slow bactericidal activity of ceftriaxone and absent PAE may explain the slow clinical response in typhoid.
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Affiliation(s)
- John Wain
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam.,Quadram Institute Bioscience, Norwich Research Park, Norwich, UK
| | - Julie A Simpson
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia.,Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Thi Diem Nga Luong
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam
| | - Song Diep To
- Hospital for Tropical Diseases, Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam
| | - Thanh Duy Pham
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam
| | - Stephen Baker
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK.,Department of Medicine, University of Cambridge, Cambridge, UK
| | - Nicholas P J Day
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
| | - Christopher M Parry
- Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Vo Van Kiet, District 5, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, UK
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Hess LM, Burdick B, Minard CG, Dutta A. IV Antibiotic Durations for Nontyphoidal Salmonella Bacteremia. Hosp Pediatr 2019; 9:993-997. [PMID: 31704707 DOI: 10.1542/hpeds.2019-0231] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The objective was to determine if shorter intravenous (IV) antibiotic (<7 days) for nontyphoidal Salmonella bacteremia (NTS-B) is noninferior to longer (≥7 days) in terms of 30-day emergency department (ER) or rehospitalization in healthy children. METHODS A retrospective observational study of otherwise healthy children admitted to a children's hospital in the United States from 2006 to 2017 with NTS-B was conducted. RESULTS Of 231 patients reviewed, 51 patients had NTS-B. Median IV duration for all patients was 5 days (range 2-17 days). The short-duration group (SDG) (<7 days; N = 32) had a median of 4 days (range 2-6 days) of IV antibiotics versus a median of 9 days (range 7-17 days) in the long-duration group (LDG) (≥7 days; N = 19). The hospital length of stay in the SDG was 3.5 days versus 7 days in the LDG (P < .001). The SDG was significantly noninferior to the LDG in terms of ER visits or hospital readmissions within 30 days (absolute risk difference 5.3%; 95% confidence interval -16% to -5%), with only 1 child in the LDG returning to the ER. CONCLUSIONS IV antibiotic durations for NTS-B in otherwise healthy children were variable within our study group. Shorter courses (<7 days) of IV antibiotics were noninferior to longer courses in healthy children and reduced hospital stay. ER visits and readmissions were rare, and there was no association between IV treatment duration and risk of relapse. Prospective studies are needed to study the safety of shorter courses, but given the absence of evidence favoring longer courses, shorter courses can be considered.
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Affiliation(s)
- Lauren M Hess
- Department of Pediatrics, .,Texas Children's Hospital, Houston, Texas; and.,Baylor College of Medicine, Houston, Texas
| | | | | | - Ankhi Dutta
- Department of Pediatrics.,Texas Children's Hospital, Houston, Texas; and.,Baylor College of Medicine, Houston, Texas
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Crump JA, Sjölund-Karlsson M, Gordon MA, Parry CM. Epidemiology, Clinical Presentation, Laboratory Diagnosis, Antimicrobial Resistance, and Antimicrobial Management of Invasive Salmonella Infections. Clin Microbiol Rev 2015; 28:901-37. [PMID: 26180063 PMCID: PMC4503790 DOI: 10.1128/cmr.00002-15] [Citation(s) in RCA: 623] [Impact Index Per Article: 69.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Salmonella enterica infections are common causes of bloodstream infection in low-resource areas, where they may be difficult to distinguish from other febrile illnesses and may be associated with a high case fatality ratio. Microbiologic culture of blood or bone marrow remains the mainstay of laboratory diagnosis. Antimicrobial resistance has emerged in Salmonella enterica, initially to the traditional first-line drugs chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole. Decreased fluoroquinolone susceptibility and then fluoroquinolone resistance have developed in association with chromosomal mutations in the quinolone resistance-determining region of genes encoding DNA gyrase and topoisomerase IV and also by plasmid-mediated resistance mechanisms. Resistance to extended-spectrum cephalosporins has occurred more often in nontyphoidal than in typhoidal Salmonella strains. Azithromycin is effective for the management of uncomplicated typhoid fever and may serve as an alternative oral drug in areas where fluoroquinolone resistance is common. In 2013, CLSI lowered the ciprofloxacin susceptibility breakpoints to account for accumulating clinical, microbiologic, and pharmacokinetic-pharmacodynamic data suggesting that revision was needed for contemporary invasive Salmonella infections. Newly established CLSI guidelines for azithromycin and Salmonella enterica serovar Typhi were published in CLSI document M100 in 2015.
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Affiliation(s)
- John A Crump
- Centre for International Health, University of Otago, Dunedin, Otago, New Zealand Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Maria Sjölund-Karlsson
- Division of Foodborne, Waterborne, and Environmental Diseases, National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Melita A Gordon
- Department of Clinical Infection, Microbiology and Immunology, Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Blantyre, Malawi
| | - Christopher M Parry
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan Department of Clinical Research, London School of Hygiene and Tropical Medicine, London, United Kingdom Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
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Tatavarthy A, Luna VA, Amuso PT. How multidrug resistance in typhoid fever affects treatment options. Ann N Y Acad Sci 2014; 1323:76-90. [PMID: 25069595 DOI: 10.1111/nyas.12490] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Salmonella enterica serotype Typhi (S. Typhi) is an enteric pathogen that causes typhoid fever. The infection can be severe, with significant morbidity and mortality, requiring antimicrobial therapy. Cases of S. Typhi infection in the United States and other developed countries are often associated with travel to endemic regions. The empirical use of first-line drugs for therapy, including ampicillin, chloramphenicol, and trimethoprim/sulfamethoxazole, has resulted in transmissible multidrug resistance. With the global increase in multidrug-resistant S. Typhi, use of ciprofloxacin, with excellent oral absorption, few side effects, and cost-effectiveness, has become popular for treatment. However, decreased ciprofloxacin susceptibility due to point mutations in the S. Typhi genes gyrA and/or parC has caused treatment failures, necessitating alternative therapeutic options. S. Typhi is typically genetically homogenous, with phylogenetic and epidemiological studies showing that identical clones and diverse S. Typhi types often coexist in the same geographic region. Studies investigating point mutations have demonstrated that selective pressure from empirical use of first-line drugs and fluoroquinolones has led to the global emergence of haplotype H-58. Antibiotic resistance is subject to high selective pressure in S. Typhi and thus demands careful use of antimicrobials.
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Affiliation(s)
- Aparna Tatavarthy
- Center for Biological Defense, College of Public Health, University of South Florida, Tampa, Florida
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Abstract
A short course of antimicrobial therapy should be the aim of all treatment unless otherwise indicated. Factors allowing short treatment courses are those that depend on the host, on the infection and on the agents administered. In essence, immunodeficiencies, long-standing infections, abscesses, or infections associated with foreign bodies cannot be treated with short-course therapies. Bactericidal antibiotics are the only agents suitable for short-course therapy. Many severe infections such as primary bacteraemia and bacteraemia complicating pneumonia, acute pyelonephritis and meningitis are amendable to short-course therapy, whilst others are not. The benefits of short-duration therapy are obvious and may contribute to halting resistance, reduced costs and rational patient management.
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Affiliation(s)
- Ethan Rubinstein
- Section of Infectious Diseases, Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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Coats J, Rae N, Nathwani D. What is the evidence for the duration of antibiotic therapy in Gram-negative bacteraemia caused by urinary tract infection? A systematic review of the literature. J Glob Antimicrob Resist 2013; 1:39-42. [PMID: 27873605 DOI: 10.1016/j.jgar.2013.01.004] [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: 12/21/2012] [Accepted: 01/25/2013] [Indexed: 11/29/2022] Open
Abstract
The frequency of secondary bacteraemia is variable depending on the site of infection but is often associated with significant morbidity and mortality. The most common source of Gram-negative bacteraemia is urinary tract infection (UTI). Current guidelines on the treatment of UTI provide no clear guidance on whether the presence of bacteraemia influences the duration or choice of therapy. Here we systematically review the current evidence base for the duration of treatment of Gram-negative bacteraemia secondary to UTI. The available evidence is sparse and of variable quality to draw any firm conclusions. However, in the absence of urgently required high-quality studies, current limited evidence appears to indicate that short courses of antibiotics are as effective at obtaining clinical and bacteriological cure as longer courses.
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Affiliation(s)
- Josh Coats
- Infection Unit, Ward 42, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK
| | - Nikolas Rae
- Infection Unit, Ward 42, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK
| | - Dilip Nathwani
- Infection Unit, Ward 42, Ninewells Hospital & Medical School, Dundee DD1 9SY, UK.
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Cooke FJ, Wain J. The emergence of antibiotic resistance in typhoid fever. Travel Med Infect Dis 2012; 2:67-74. [PMID: 17291961 DOI: 10.1016/j.tmaid.2004.04.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2004] [Accepted: 04/19/2004] [Indexed: 10/26/2022]
Abstract
Typhoid fever, caused by Salmonella typhi, causes over 20 million cases annually, with at least 700,000 deaths. The main burden of disease is in developing countries, particularly the Indian Subcontinent and South East Asia. However, cases in returning travellers, immigrants and refugees in developed countries are not uncommon. Drug resistance is fast becoming a major problem in the management of this infection. Chloramphenicol resistance became established globally in the S.Typhi population after 1972 on plasmids of incompatibility group IncH. Multi-drug resistance defined as resistance to the three first-line agents used to treat typhoid fever, namely chloramphenicol, ampicillin and co-trimoxazole, and acquired on the same plasmid type, has been endemic in most of South East Asia and the Indian Subcontinent for many years. Resistance data from many endemic areas are sparse and with the increasing problem of reduced sensitivity to the fluoroquinolone antibiotics, empirical choice of antibiotics may be difficult. We review the historical aspects of the development of resistance and the current data available on the epidemiology of antibiotic resistance in S.Typhi.
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Affiliation(s)
- Fiona J Cooke
- Centre for Molecular Microbiology and Infection, Level 1, Flowers Building, Imperial College, London SW7 2AZ, UK
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Effa EE, Lassi ZS, Critchley JA, Garner P, Sinclair D, Olliaro PL, Bhutta ZA. Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). Cochrane Database Syst Rev 2011; 2011:CD004530. [PMID: 21975746 PMCID: PMC6532575 DOI: 10.1002/14651858.cd004530.pub4] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Typhoid and paratyphoid are febrile illnesses, due to a bacterial infection, which remain common in many low- and middle-income countries. The World Health Organization (WHO) currently recommends the fluoroquinolone antibiotics in areas with known resistance to the older first-line antibiotics. OBJECTIVES To evaluate fluoroquinolone antibiotics for treating children and adults with enteric fever. SEARCH STRATEGY We searched The Cochrane Infectious Disease Group Specialized Register (February 2011); Cochrane Central Register of Controlled Trials (CENTRAL), published in The Cochrane Library (2011, Issue 2); MEDLINE (1966 to February 2011); EMBASE (1974 to February 2011); and LILACS (1982 to February 2011). We also searched the metaRegister of Controlled Trials (mRCT) in February 2011. SELECTION CRITERIA Randomized controlled trials examining fluoroquinolone antibiotics, in people with blood, stool or bone marrow culture-confirmed enteric fever. DATA COLLECTION AND ANALYSIS Two authors independently assessed the trial's methodological quality and extracted data. We calculated risk ratios (RR) for dichotomous data and mean difference for continuous data with 95% confidence intervals (CI).Comparative effectiveness has been interpreted in the context of; length of treatment, dose, year of study, known levels of antibiotic resistance, or proxy measures of resistance such as the failure rate in the comparator arm. MAIN RESULTS Twenty-six studies, involving 3033 patients, are included in this review.Fluoroquinolones versus older antibiotics (chloramphenicol, co-trimoxazole, amoxicillin and ampicillin)In one study from Pakistan in 2003-04, high clinical failure rates were seen with both chloramphenicol and co-trimoxazole, although resistance was not confirmed microbiologically. A seven-day course of either ciprofloxacin or ofloxacin were found to be superior. Older studies of these comparisons failed to show a difference (six trials, 361 participants).In small studies conducted almost two decades ago, the fluoroquinolones were demonstrated to have fewer clinical failures than ampicillin and amoxicillin (two trials, 90 participants, RR 0.11, 95% CI 0.02 to 0.57).Fluoroquinolones versus current second-line options (ceftriaxone, cefalexin, and azithromycin)The two studies comparing a seven day course of oral fluoroquinolones with three days of intravenous ceftriaxone were too small to detect important differences between antibiotics should they exist (two trials, 89 participants).In Pakistan in 2003-04, no clinical or microbiological failures were seen with seven days of either ciprofloxacin, ofloxacin or cefixime (one trial, 139 participants). In Nepal in 2005, gatifloxacin reduced clinical failure and relapse compared to cefixime, despite a high prevalence of NaR in the study population (one trial, 158 participants, RR 0.04, 95% CI 0.01 to 0.31).Compared to a seven day course of azithromycin, a seven day course of ofloxacin had a higher rate of clinical failures in populations with both multi-drug resistance (MDR) and nalidixic acid resistance (NaR) enteric fever in Vietnam in 1998-2002 (two trials, 213 participants, RR 2.20, 95% CI 1.23 to 3.94). However, a more recent study from Vietnam in 2004-05, detected no difference between gatifloxacin and azithromycin with both drugs performing well (one trial, 287 participants). AUTHORS' CONCLUSIONS Generally, fluoroquinolones performed well in treating typhoid, and maybe superior to alternatives in some settings. However, we were unable to draw firm general conclusions on comparative contemporary effectiveness given that resistance changes over time, and many studies were small. Policy makers and clinicians need to consider local resistance patterns in choosing a fluoroquinolone or alternative.There is some evidence that the newest fluoroquinolone, gatifloxacin, remains effective in some regions where resistance to older fluoroquinolones has developed. However, the different fluoroquinolones have not been compared directly in trials in these settings.
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Affiliation(s)
- Emmanuel E Effa
- University of Calabar Teaching HospitalInternal MedicinePMB 1278CalabarNigeria
| | - Zohra S Lassi
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiPakistan74800
| | - Julia A Critchley
- Newcastle UniversityInstitute of Health and SocietyWilliam Leech BuildingThe Medical SchoolNewcastleUKNE2 4HH
| | - Paul Garner
- Liverpool School of Tropical MedicineInternational Health GroupPembroke PlaceLiverpoolUKL3 5QA
| | - David Sinclair
- Liverpool School of Tropical MedicineInternational Health GroupPembroke PlaceLiverpoolUKL3 5QA
| | - Piero L Olliaro
- World Health OrganizationUNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR)1211 Geneva 27GenevaSwitzerland
| | - Zulfiqar A Bhutta
- Aga Khan University HospitalDivision of Women and Child HealthStadium RoadPO Box 3500KarachiPakistan74800
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Thaver D, Zaidi AK, Critchley JA, Azmatullah A, Madni SA, Bhutta ZA. Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). Cochrane Database Syst Rev 2008:CD004530. [PMID: 18843659 DOI: 10.1002/14651858.cd004530.pub3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fluoroquinolones are recommended as first-line therapy for typhoid and paratyphoid fever (enteric fever), but how they compare with other antibiotics and different fluoroquinolones is unclear. OBJECTIVES To evaluate fluoroquinolone antibiotics for treating enteric fever in children and adults compared with other antibiotics, different fluoroquinolones, and different durations of fluoroquinolone treatment. SEARCH STRATEGY In November 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 4), MEDLINE, EMBASE, LILACS, mRCT, conference proceedings, and reference lists. SELECTION CRITERIA Randomized controlled trials of fluoroquinolones in people with blood or bone marrow culture-confirmed enteric fever. DATA COLLECTION AND ANALYSIS Two authors independently assessed the trials' methodological quality and extracted data. We calculated odds ratios (OR) for dichotomous data with 95% confidence intervals (CI). We analysed trials with greater than 60% children separately from trials of mostly adults. MAIN RESULTS Of 38 included trials, 22 had unclear allocation concealment and 34 did not use blinding. Four trials included exclusively children, seven had both adults and children, and three studied outpatients. ADULTS Among primary outcomes (clinical failure, microbiological failure, and relapse), compared with chloramphenicol, fluoroquinolones were not statistically significantly different for clinical failure (594 participants) or microbiological failure (378 participants), but they reduced clinical relapse (OR 0.14, 95% CI 0.04 to 0.50; 467 participants, 6 trials). We detected no statistically significant difference versus co-trimoxazole (82 participants, 2 trials) or azithromycin (152 participants, 2 trials). Fluoroquinolones reduced clinical failure compared with ceftriaxone (OR 0.08, 95% CI 0.01 to 0.45; 120 participants, 3 trials), but not microbiological failure or relapse. Versus cefixime, fluoroquinolones reduced clinical failure (OR 0.05, 95% CI 0.01 to 0.24; 238 participants; 2 trials) and relapse (OR 0.18, 95% CI 0.03 to 0.91; 218 participants, 2 trials). CHILDREN In children with high proportions of nalidixic acid-resistant strains, older fluoroquinolones increased clinical failures compared with azithromycin (OR 2.67, 95% CI 1.16 to 6.11; 125 participants, 1 trial), with no differences using newer fluoroquinolones (285 participants, 1 trial). Fluoroquinolones and cefixime were not statistically significantly different (82 participants, 1 trial). Trials comparing different durations of fluoroquinolone treatment were not statistically significantly different (889 participants, 9 trials). Norfloxacin had more clinical failures than other fluoroquinolones (417 participants, 5 trials). AUTHORS' CONCLUSIONS Trials were small and methodological quality varied. In adults, fluoroquinolones may be better for reducing clinical relapse rates compared to chloramphenicol. Data are limited for other comparisons, particularly in children.
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Affiliation(s)
- Durrane Thaver
- Department of Paediatrics & Child Health, Aga Khan University Hospital, Stadium Road, PO Box 3500, Karachi, Pakistan, 74800.
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Dolecek C, Tran TPL, Nguyen NR, Le TP, Ha V, Phung QT, Doan CD, Nguyen TBB, Duong TL, Luong BH, Nguyen TB, Nguyen TAH, Pham ND, Mai NL, Phan VBB, Vo AH, Nguyen VMH, Tran TTN, Tran TC, Schultsz C, Dunstan SJ, Stepniewska K, Campbell JI, To SD, Basnyat B, Nguyen VVC, Nguyen VS, Nguyen TC, Tran TH, Farrar J. A multi-center randomised controlled trial of gatifloxacin versus azithromycin for the treatment of uncomplicated typhoid fever in children and adults in Vietnam. PLoS One 2008; 3:e2188. [PMID: 18493312 PMCID: PMC2374894 DOI: 10.1371/journal.pone.0002188] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2007] [Accepted: 03/27/2008] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Drug resistant typhoid fever is a major clinical problem globally. Many of the first line antibiotics, including the older generation fluoroquinolones, ciprofloxacin and ofloxacin, are failing. OBJECTIVES We performed a randomised controlled trial to compare the efficacy and safety of gatifloxacin (10 mg/kg/day) versus azithromycin (20 mg/kg/day) as a once daily oral dose for 7 days for the treatment of uncomplicated typhoid fever in children and adults in Vietnam. METHODS An open-label multi-centre randomised trial with pre-specified per protocol analysis and intention to treat analysis was conducted. The primary outcome was fever clearance time, the secondary outcome was overall treatment failure (clinical or microbiological failure, development of typhoid fever-related complications, relapse or faecal carriage of S. typhi). PRINCIPAL FINDINGS We enrolled 358 children and adults with suspected typhoid fever. There was no death in the study. 287 patients had blood culture confirmed typhoid fever, 145 patients received gatifloxacin and 142 patients received azithromycin. The median FCT was 106 hours in both treatment arms (95% Confidence Interval [CI]; 94-118 hours for gatifloxacin versus 88-112 hours for azithromycin), (logrank test p = 0.984, HR [95% CI] = 1.0 [0.80-1.26]). Overall treatment failure occurred in 13/145 (9%) patients in the gatifloxacin group and 13/140 (9.3%) patients in the azithromycin group, (logrank test p = 0.854, HR [95% CI] = 0.93 [0.43-2.0]). 96% (254/263) of the Salmonella enterica serovar Typhi isolates were resistant to nalidixic acid and 58% (153/263) were multidrug resistant. CONCLUSIONS Both antibiotics showed an excellent efficacy and safety profile. Both gatifloxacin and azithromycin can be recommended for the treatment of typhoid fever particularly in regions with high rates of multidrug and nalidixic acid resistance. The cost of a 7-day treatment course of gatifloxacin is approximately one third of the cost of azithromycin in Vietnam. TRIAL REGISTRATION Controlled-Trials.com ISRCTN67946944.
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Affiliation(s)
- Christiane Dolecek
- Oxford University Clinical Research Unit, The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam.
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13
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Rubinstein E. Short antibiotic treatment courses or how short is short? Int J Antimicrob Agents 2007; 30 Suppl 1:S76-9. [PMID: 17826038 DOI: 10.1016/j.ijantimicag.2007.06.017] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2007] [Accepted: 06/07/2007] [Indexed: 11/28/2022]
Abstract
Antibiotic therapy in recent years has become more intense and more frequent. Resistance acquisition by community and hospital strains is however also increasing. One of the methods to halt the increase in resistance may be shorter courses of antibiotics, if their clinical efficacy is not impaired. Shorter courses of antibiotic therapy have been very successful in typhoid fever: 3 days; in meningococcal meningitis: a single dose to 3 days' course; ventilator-associated pneumonia: 8 days; and possibly ICU-associated infections: 3-5 days. On the contrary, IV catheter-associated infections require full treatment courses (14 days). More studies are needed in various infectious entities with various agents to be able to better define the optimal duration of therapy.
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Chau TT, Campbell JI, Galindo CM, Van Minh Hoang N, Diep TS, Nga TTT, Van Vinh Chau N, Tuan PQ, Page AL, Ochiai RL, Schultsz C, Wain J, Bhutta ZA, Parry CM, Bhattacharya SK, Dutta S, Agtini M, Dong B, Honghui Y, Anh DD, Canh DG, Naheed A, Albert MJ, Phetsouvanh R, Newton PN, Basnyat B, Arjyal A, La TTP, Rang NN, Phuong LT, Van Be Bay P, von Seidlein L, Dougan G, Clemens JD, Vinh H, Hien TT, Chinh NT, Acosta CJ, Farrar J, Dolecek C. Antimicrobial drug resistance of Salmonella enterica serovar typhi in asia and molecular mechanism of reduced susceptibility to the fluoroquinolones. Antimicrob Agents Chemother 2007; 51:4315-23. [PMID: 17908946 PMCID: PMC2167998 DOI: 10.1128/aac.00294-07] [Citation(s) in RCA: 152] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
This study describes the pattern and extent of drug resistance in 1,774 strains of Salmonella enterica serovar Typhi isolated across Asia between 1993 and 2005 and characterizes the molecular mechanisms underlying the reduced susceptibilities to fluoroquinolones of these strains. For 1,393 serovar Typhi strains collected in southern Vietnam, the proportion of multidrug resistance has remained high since 1993 (50% in 2004) and there was a dramatic increase in nalidixic acid resistance between 1993 (4%) and 2005 (97%). In a cross-sectional sample of 381 serovar Typhi strains from 8 Asian countries, Bangladesh, China, India, Indonesia, Laos, Nepal, Pakistan, and central Vietnam, collected in 2002 to 2004, various rates of multidrug resistance (16 to 37%) and nalidixic acid resistance (5 to 51%) were found. The eight Asian countries involved in this study are home to approximately 80% of the world's typhoid fever cases. These results document the scale of drug resistance across Asia. The Ser83-->Phe substitution in GyrA was the predominant alteration in serovar Typhi strains from Vietnam (117/127 isolates; 92.1%). No mutations in gyrB, parC, or parE were detected in 55 of these strains. In vitro time-kill experiments showed a reduction in the efficacy of ofloxacin against strains harboring a single-amino-acid substitution at codon 83 or 87 of GyrA; this effect was more marked against a strain with a double substitution. The 8-methoxy fluoroquinolone gatifloxacin showed rapid killing of serovar Typhi harboring both the single- and double-amino-acid substitutions.
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Affiliation(s)
- Tran Thuy Chau
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, 190 Ben Ham Tu, Ho Chi Minh City, Vietnam
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15
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Phongmany S, Phetsouvanh R, Sisouphone S, Darasavath C, Vongphachane P, Rattanavong O, Mayxay M, Ramsay AC, Blacksell SD, Thammavong C, Syhavong B, White NJ, Newton PN. A randomized comparison of oral chloramphenicol versus ofloxacin in the treatment of uncomplicated typhoid fever in Laos. Trans R Soc Trop Med Hyg 2005; 99:451-8. [PMID: 15837357 DOI: 10.1016/j.trstmh.2004.08.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2004] [Revised: 08/02/2004] [Accepted: 08/05/2004] [Indexed: 11/30/2022] Open
Abstract
We conducted a randomized open trial of oral chloramphenicol (50mg/kg/day in four divided doses for 14 days) versus ofloxacin (15 mg/kg/day in two divided doses for 3 days) in 50 adults with culture-confirmed uncomplicated typhoid fever in Vientiane, Laos. Patients had been ill for a median (range) of 8 (2-30) days. All Salmonella enterica serotype typhi isolates were nalidixic acid-sensitive, four (8%) were chloramphenicol-resistant and three (6%) were multidrug-resistant. Median (range) fever clearance times were 90 (24-224) hours in the chloramphenicol group and 54 (6-93) hours in the ofloxacin group (P<0.001). One patient in the chloramphenicol group developed an ileal perforation. Three days ofloxacin was more effective than 14 days chloramphenicol for the in-patient treatment of typhoid fever, irrespective of antibiotic susceptibility, and was of similar cost.
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16
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Vinh H, Duong NM, Phuong LT, Truong NT, Bay PVB, Wain J, Diep TS, Ho VA, White NJ, Day NPJ, Parry CM. Comparative trial of short-course ofloxacin for uncomplicated typhoid fever in Vietnamese children. ACTA ACUST UNITED AC 2005; 25:17-22. [PMID: 15814044 DOI: 10.1179/146532805x23308] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
An open, randomised comparison of 2 or 3 days of oral ofloxacin (10 mg/kg/day) for uncomplicated typhoid fever was conducted in 235 Vietnamese children. Multi-drug-resistant Salmonella typhi was isolated from 182/202 (90%) children and 5/166 (3%) tested isolates were nalidixic acid-resistant (Na(R)). Eighty-nine of 116 children randomised to 2 days and 107/119 randomised to 3 days were blood culture-positive and eligible for analysis. There were 12 (13.5%) failures in the 2-day group (six clinical failures, four blood culture-positive post treatment, two relapses) compared with eight (7.5%) failures in the 3-day group (four clinical failures, one blood culture-positive post treatment, three relapses) (OR 1.9, 95% CI 0.7-5.5,p = 0.17). There were no significant differences in the mean (95% confidence interval) fever clearance times (h) [92 (82-102) vs 101 (93-110), p = 0.18] or duration of hospitalisation (d) [7.6 (7.2-8.1) vs 8.0 (7.6-8.4), p = 0.19] between the two groups. There was one failure in the four eligible children infected with an Na(R) isolate of S. typhi. No adverse events were attributable to the ofloxacin. These results extend previous observations on the efficacy of short courses of ofloxacin for children with uncomplicated multi-drug-resistant typhoid fever.
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Affiliation(s)
- Ha Vinh
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
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17
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Thaver D, Zaidi AK, Critchley J, Madni SA, Bhutta ZA. Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). Cochrane Database Syst Rev 2005:CD004530. [PMID: 15846718 DOI: 10.1002/14651858.cd004530.pub2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Fluoroquinolones are recommended as first-line therapy for typhoid and paratyphoid fever, but how they compare with other cheaper antibiotics and different fluoroquinolones is unclear. OBJECTIVES To evaluate fluoroquinolone antibiotics for treating enteric fever in children and adults compared with other antibiotics, different fluoroquinolones, and different treatment durations of the same fluoroquinolone. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register (August 2004), CENTRAL (The Cochrane Library Issue 3, 2004), MEDLINE (1966 to August 2004), EMBASE (1974 to August 2004), LILACS (1982 to August 2004), conference proceedings, reference lists, and contacted researchers. SELECTION CRITERIA Randomized controlled trials of fluoroquinolones in people with blood or bone marrow culture-confirmed enteric fever. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed the methodological quality of trials and extracted data. We calculated the odds ratio (OR) for dichotomous data with 95% confidence intervals. We analysed norfloxacin separately. MAIN RESULTS Thirty-three trials met the inclusion criteria; 22 had unclear allocation concealment, and 29 were not blinded. Three trials exclusively included children, and two studied outpatients. The main analysis examined clinical failure, microbiological failure, and relapse. Compared with chloramphenicol, fluoroquinolones were not statistically significantly different for clinical (544 participants) or microbiological failure (378 participants) in adults; they reduced clinically diagnosed relapse in adults (OR 0.14, 0.04 to 0.50; 467 participants, 6 trials), but this was not statistically significant in participants with blood culture-confirmed relapse (121 participants, 2 trials). Compared with co-trimoxazole, we detected no statistically significant difference (82 participants, 2 trials). Among adults, fluoroquinolones reduced clinical failure compared with ceftriaxone (OR 0.08, 0.01 to 0.45; 120 participants, 3 trials), but showed no difference for microbiological failure or relapse. We detected no statistically significant difference between fluoroquinolones and cefixime (80 participants, 1 trial) or azithromycin (152 participants, 2 trials). In trials of hospitalized children, fluoroquinolones were not statistically significantly different from ceftriaxone (60 participants, 1 trial, involving norfloxacin) or cefixime (82 participants, 1 trial). Norfloxacin had more clinical failures than other fluoroquinolones (417 participants, 5 trials). Trials comparing different durations of fluoroquinolone treatment showed no statistically significant differences (693 participants, 8 trials). AUTHORS' CONCLUSIONS Many trials were small, and methodological quality varied widely. Although enteric fever most commonly affects children, trials in this group were particularly sparse. Insufficient data in all comparisons preclude any firm conclusions to be made regarding superiority of fluoroquinolones over first-line antibiotics in children and adults.
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18
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Parry CM. The treatment of multidrug-resistant and nalidixic acid-resistant typhoid fever in Viet Nam. Trans R Soc Trop Med Hyg 2004; 98:413-22. [PMID: 15138078 DOI: 10.1016/j.trstmh.2003.10.014] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2003] [Accepted: 10/01/2003] [Indexed: 11/18/2022] Open
Abstract
Multidrug-resistant (MDR) Salmonella Typhi (resistant to chloramphenicol, ampicillin, and trimethoprim-sulphamethoxazole) and isolates with reduced susceptibility to fluoroquinolones (indicated by resistance to nalidixic acid, NaR) have caused epidemics and become endemic in southern Viet Nam during the 1990s. Short courses of ofloxacin have proved acceptable for treating MDR/NaS isolates of S. Typhi (ofloxacin MIC90 = 0.06 mg/l) causing uncomplicated disease. Ofloxacin (10-15 mg/kg/d) given for 2, 3, or 5 d cured >90% of patients with an average fever clearance time (FCT) of 4 d. Less than 3% of patients relapsed or had a positive post-treatment stool culture. In contrast, the response of NaR isolates (ofloxacin MIC90 = 0.5 mg/l) to such regimens is poor. For example, ofloxacin (20 mg/kg/d) given for 7 d cured only 75% of patients, with an FCT of 7 d, and 19% of patients had positive post-treatment faecal cultures. Currently available alternatives for NaR infections include ceftriaxone, cefixime, and azithromycin. These antimicrobials are reasonably effective but expensive. New, effective, and affordable regimens are needed to treat these NaR infections. Short courses of the new generation fluoroquinolones or combinations of the available antimicrobials are possible options.
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Affiliation(s)
- Christopher M Parry
- Oxford University Wellcome Trust Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam.
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19
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Randall LP, Cooles SW, Piddock LJV, Woodward MJ. Mutant prevention concentrations of ciprofloxacin and enrofloxacin for Salmonella enterica. J Antimicrob Chemother 2004; 54:688-91. [PMID: 15243029 DOI: 10.1093/jac/dkh360] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To determine the mutant prevention concentrations (MPCs) of ciprofloxacin and enrofloxacin against four strains of Salmonella enterica serovar Enteritidis and four strains of S. Typhimurium including one fully susceptible, one multiply resistant (MAR), one GyrA mutant and one GyrA/MAR mutant. Further, to examine mutants arising after exposure to sub-MPC concentrations of the antibiotics for susceptibility to ciprofloxacin and enrofloxacin, and cyclohexane tolerance. METHODS MICs were determined using the agar dilution method of the BSAC. The MPC was recorded as the lowest concentration of antibiotic to inhibit growth from an inoculum of 10(10) cfu. RESULTS The MPCs and resulting MPC/MIC ratios of enrofloxacin were generally two- to four-fold higher than for ciprofloxacin. At 24 h for both antibiotics, MPCs were lowest for the fully susceptible strains (0.25-0.5 mg/L), similar for the MAR (1-4 mg/L) and GyrA (2-4 mg/L) mutants and highest for the GyrA/MAR mutants (1-8 mg/L). MPC/MIC ratios at 24 h were 2-16 for all strains except those for the MAR strains without mutation in gyrA where the ratios were 8-64. CONCLUSIONS The ability to eradicate Salmonella in vivo depends on many factors such as antibiotic susceptibility of the strain, dose and route of administration. It is suggested that these MPC values will be useful when considering dosing strategies. In view of the high MPC/MIC ratio, MAR strains with wild-type gyrA, although susceptible to ciprofloxacin (MICs 0.06-0.13 mg/L), may give rise to treatment failures.
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Affiliation(s)
- L P Randall
- Veterinary Laboratories Agency (Weybridge), New Haw, Addlestone, Surrey, UK.
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20
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Piersma D, Overbosch D, Petit P, van Genderen PJJ. Protracted fever after a journey to India and Nepal: a case of persistent Salmonella paratyphi infection. J Travel Med 2004; 11:257-9. [PMID: 15541231 DOI: 10.2310/7060.2004.19012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Djura Piersma
- Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands
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21
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Wain J, Diem Nga LT, Kidgell C, James K, Fortune S, Song Diep T, Ali T, O Gaora P, Parry C, Parkhill J, Farrar J, White NJ, Dougan G. Molecular analysis of incHI1 antimicrobial resistance plasmids from Salmonella serovar Typhi strains associated with typhoid fever. Antimicrob Agents Chemother 2003; 47:2732-9. [PMID: 12936967 PMCID: PMC182646 DOI: 10.1128/aac.47.9.2732-2739.2003] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The first outbreak of multidrug-resistant (MDR) typhoid fever in Vietnam was in 1993, and by 1995 nearly 90% of cases were MDR. Plasmid HCM1, sequenced in full, is an incHI1 plasmid from Salmonella enterica serovar Typhi strain CT18, isolated in Vietnam in 1993. Restriction analysis shows that pHCM1 shares a restriction fragment length polymorphism (RFLP) pattern with plasmids isolated from the first outbreak and 10 of 17 MDR plasmids isolated from sporadic cases occurring at the same time in Vietnam. A core region of pHCM1 has significant DNA sequence similarity to plasmid R27, isolated in 1961 from S. enterica in the United Kingdom. There are five regions of DNA in pHCM1 which are not present in R27. Two of these are putative acquisition regions; the largest is 34.955 kbp in length and includes sequences of several antibiotic resistance genes and several insertion sequences. The borders of this region are defined by two identical IS10 left elements, associated with an inversion of DNA or with a truncated Tn10 element. The second, smaller region is 14.751 kbp and carries a trimethoprim resistance gene dfr14A cassette associated with a class 1 integrase. In 1993 to 1994, restriction analysis revealed some variations in the structures of Salmonella serovar Typhi MDR plasmids which were mapped to the two putative acquisition regions and three smaller variable regions. In 1996 a single RFLP type, RFLP7, was found to carry the dfrA7 and sul-1 genes, which were not present on R27 or pHCM1. This plasmid type appears to have a selective advantage over other plasmids with the same resistance phenotype.
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Affiliation(s)
- John Wain
- Wellcome Trust Clinical Research Unit, Department of Biological Sciences, Imperial College, London.
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22
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Abstract
Typhoid fever, a systemic infection caused by Salmonella enterica serotype typhi, remains an important worldwide cause of morbidity and mortality. Endemic cases in the United States are unusual, with most following foreign travel to the Indian subcontinent, Africa, Asia, or Latin America. The classic findings of typhoid fever include rose spots, relative bradycardia, and stepwise fevers, but unfortunately these signs are frequently absent. Gastrointestinal manifestations may include diffuse abdominal pain, bleeding, perforation, cholecystitis, and cholangitis. The diagnosis should be suspected after collection of the appropriate clinical and travel history with confirmation by blood or bone marrow culture. Novel methods are in development to establish the diagnosis when cultures are negative or unavailable. Multidrug resistance has increased worldwide, and decisions on antimicrobial therapy must take such resistance into account. The empiric treatment of choice is a fluoroquinolone drug; ceftriaxone and azithromycin are alternatives. Preventive strategies include good sanitation and food handling practices along with vaccination of selected groups.
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Affiliation(s)
- Nancy F Crum
- Division of Infectious Diseases, Clinical Investigation Department (KCA), Naval Medical Center San Diego, 34800 Bob Wilson Drive, Suite 5, San Diego, CA 92134-1005.
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23
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Crump JA, Barrett TJ, Nelson JT, Angulo FJ. Reevaluating fluoroquinolone breakpoints for Salmonella enterica serotype Typhi and for non-Typhi salmonellae. Clin Infect Dis 2003; 37:75-81. [PMID: 12830411 DOI: 10.1086/375602] [Citation(s) in RCA: 162] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2003] [Accepted: 03/20/2003] [Indexed: 11/03/2022] Open
Abstract
Salmonella enterica infections cause considerable morbidity and mortality worldwide. Antimicrobial therapy may be life-saving for patients with extraintestinal infections with S. enterica serotype Typhi or non-Typhi salmonellae. Because antimicrobial resistance to several classes of traditional first-line drugs has emerged in the past several decades, the quinolone antimicrobial agents, particularly the fluoroquinolones, have become the drugs of choice. Recently, resistance to nalidixic acid has emerged among both Typhi and non-Typhi Salmonella serotypes. Such Salmonella isolates typically also have decreased susceptibility to fluoroquinolones, although minimum inhibitory concentrations of the fluoroquinolones usually are within the susceptible range of the interpretive criteria of the NCCLS. A growing body of clinical and microbiological evidence indicates that such nalidixic acid-resistant S. enterica infections also exhibit a decreased clinical response to fluoroquinolones. In this article, we recommend that laboratories test extraintestinal Salmonella isolates for nalidixic acid resistance, we recommend that short-course fluoroquinolone therapy be avoided for infection with nalidixic acid-resistant extraintestinal salmonellae, and we summarize existing data and data needs that would contribute to reevaluation of the current NCCLS fluoroquinolone breakpoints for salmonellae.
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Affiliation(s)
- John A Crump
- Foodborne and Diarrheal Diseases Branch, Div. of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, MS A-38, Centers for Disease Control and Prevention, 1600 Clifton Rd., Atlanta, GA 30333, USA.
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25
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Piddock LJV. Fluoroquinolone resistance in Salmonella serovars isolated from humans and food animals. FEMS Microbiol Rev 2002; 26:3-16. [PMID: 12007640 DOI: 10.1111/j.1574-6976.2002.tb00596.x] [Citation(s) in RCA: 131] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Quinolone-resistant Salmonella enterica usually contain a mutation in gyrA within the region encoding the quinolone resistance determining region of the A subunit of DNA gyrase. These mutations confer substitutions analogous to Escherichia coli Ser83-->Phe and Asp87-->Gly or Tyr, or a novel mutation resulting in Ala119-->Glu or Val. Mutations in gyrB are rare, and no mutations in parC or parE have been described. Quinolone-resistant Salmonella can also be cross-resistant to other agents including chloramphenicol and tetracycline. Increased efflux has been demonstrated and for some strains this has been associated with increased expression of acrB. Mutation in soxR has also been shown for one isolate. Detection of low level resistance (minimum inhibitory concentrations <0.5 microg ml(-1)) to fluoroquinolones is proving an increasing problem in the treatment of invasive Salmonella infections.
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Affiliation(s)
- Laura J V Piddock
- Antimicrobial Agents Research Group, Division of Infection and Immunity, University of Birmingham, Birmingham, B15 2TT, UK.
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Vinh H, Wain J, Chinh MT, Tam CT, Trang PT, Nga D, Echeverria P, Diep TS, White NJ, Parry CM. Treatment of bacillary dysentery in Vietnamese children: two doses of ofloxacin versus 5-days nalidixic acid. Trans R Soc Trop Med Hyg 2000; 94:323-6. [PMID: 10975012 DOI: 10.1016/s0035-9203(00)90343-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Nalidixic acid (NA: 55 mg/kg daily for 5 days) is the recommended treatment for uncomplicated bacillary dysentery in areas where multidrug-resistant Shigella are prevalent. An open randomized comparison of this NA regimen with 2 doses of ofloxacin (total 15 mg/kg) was conducted in 1995/96 in 135 Vietnamese children with fever and bloody diarrhoea. Sixty-six children with a bacterial pathogen isolated were eligible for analysis. Of the 63 Shigella isolates, 39 (62%) were resistant to multiple antibiotics. Resolution times for fever and diarrhoea were similar in the 2 groups, but excretion time of stool pathogen was significantly longer in the NA recipients [median (range) days 1 (1-9) vs 1 (1-2), P = 0.001]. There were 9 (25%) treatment failures in the NA regimen and 3 (10%) in the ofloxacin group; P = 0.1. Two patients had NA-resistant Shigella flexneri. One of these isolates was selected during NA treatment. From a clinical and public health standpoint a 2-dose regimen of ofloxacin is preferable to nalidixic acid in the treatment of bacillary dysentery.
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Affiliation(s)
- H Vinh
- Centre for Tropical Diseases, Ho Chi Minh City, Vietnam
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27
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Mirza S, Kariuki S, Mamun KZ, Beeching NJ, Hart CA. Analysis of plasmid and chromosomal DNA of multidrug-resistant Salmonella enterica serovar typhi from Asia. J Clin Microbiol 2000; 38:1449-52. [PMID: 10747124 PMCID: PMC86462 DOI: 10.1128/jcm.38.4.1449-1452.2000] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/1999] [Accepted: 01/23/2000] [Indexed: 11/20/2022] Open
Abstract
Molecular analysis of chromosomal DNA from 193 multidrug-resistant (MDR) Salmonella enterica serovar Typhi isolates from 1990 to 1995 from Pakistan, Kuwait, Malaysia, Bangladesh, and India produced a total of five major different pulsed-field gel electrophoresis (PFGE) patterns. Even within a particular country MDR S. enterica serovar Typhi DNA was found to be in different PFGE groups. Similar self-transferable 98-MDa plasmids belonging to either incompatibility group incHI1 or incHI1/FIIA were implicated in the MDR phenotype in S. enterica serovar Typhi isolates from all the locations except Quetta, Pakistan, where the majority were of incFIA. A total of five different PFGE genotypes with six different plasmids, based on incompatibility and restriction endonuclease analysis groups, were found among these MDR S. enterica serovar Typhi isolates.
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Affiliation(s)
- S Mirza
- Departments of Medical Microbiology and Genitourinary Medicine, University of Liverpool, Liverpool L69 3GA, United Kingdom
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Konadu EY, Lin FY, Hó VA, Thuy NT, Van Bay P, Thanh TC, Khiem HB, Trach DD, Karpas AB, Li J, Bryla DA, Robbins JB, Szu SC. Phase 1 and phase 2 studies of Salmonella enterica serovar paratyphi A O-specific polysaccharide-tetanus toxoid conjugates in adults, teenagers, and 2- to 4-year-old children in Vietnam. Infect Immun 2000; 68:1529-34. [PMID: 10678970 PMCID: PMC97311 DOI: 10.1128/iai.68.3.1529-1534.2000] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/1999] [Accepted: 11/26/1999] [Indexed: 11/20/2022] Open
Abstract
Salmonella enterica serovar Paratyphi A O-specific polysaccharide (O-SP) was activated with 1-cyano-4-dimethylaminopyridinium tetrafluoroborate (CDAP) and bound to tetanus toxoid (TT) with adipic acid dihydrazide as a linker (SPA-TT(1)) or directly (SPA-TT(2)). In mice, these two conjugates elicited high levels of immunoglobulin G (IgG) anti-lipopolysaccharide (LPS) in serum with bactericidal activity (E. Konadu, J. Shiloach, D. A. Bryla, J. B. Robbins, and S. C. Szu, Infect. Immun. 64:2709-2715, 1996). The safety and immunogenicity of the two conjugates were then evaluated sequentially in Vietnamese adults, teenagers, and 2- to 4-year-old children. None of the vaccinees experienced significant side effects, and all had preexisting LPS antibodies. At 4 weeks after injection, there were significant increases of the geometric mean IgG and IgM anti-LPS levels in the adults and teenagers: both conjugates elicited a greater than fourfold rise in the IgG anti-LPS level in serum in >/=80% of the volunteers. SPA-TT(2) elicited slightly higher, though not statistically significantly, levels of IgG anti-LPS than did SPA-TT(1) in these age groups. Accordingly, only SPA-TT(2) was evaluated in the 2- to 4-year-old children. On a random basis, one or two injections were administered 6 weeks apart to the children. No significant side effects were observed, and the levels of preexisting anti-LPS in serum were similar in children of all ages. A significant rise in the IgG anti-LPS titer was elicited by the first injection (P = 0.0001); a second injection did not elicit a booster response. Representative sera from all groups had bactericidal activity that could be adsorbed by S. enterica serovar Paratyphi A LPS.
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Affiliation(s)
- E Y Konadu
- National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland 20892-2720, USA
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Alghasham AA, Nahata MC. Clinical use of fluoroquinolones in children. Ann Pharmacother 2000; 34:347-59; quiz 413-4. [PMID: 10917383 DOI: 10.1345/aph.18146] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE To review the pharmacokinetics, efficacy, and safety of fluoroquinolones in children. DATA SOURCES A MEDLINE search (January 1966-March 1998) was conducted for relevant literature. STUDY SELECTION AND DATA EXTRACTION Data from compassionate use and published studies were reviewed for the assessment of pharmacokinetics, efficacy, and safety of fluoroquinolones in children. DATA SYNTHESIS Fluoroquinolones have a broad spectrum coverage of gram-positive and gram-negative bacteria, including Pseudomonas aeruginosa and intracellular organisms. Fluoroquinolones are well absorbed from the gastrointestinal tract, have excellent tissue penetration, low protein binding, and long elimination half-lives. These antibiotics are effective in treating various infections and are well tolerated in adults. However, the use of fluoroquinolones in children has been restricted due to potential cartilage damage that occurred in research with immature animals. Fluoroquinolones have been used in children on a compassionate basis. Ciprofloxacin is the most frequently used fluoroquinolone in children, most often in the treatment of pulmonary infection in cystic fibrosis as well as salmonellosis and shigellosis. Other uses include chronic suppurative otitis media, meningitis, septicemia, and urinary tract infection. Safety data of fluoroquinolones in children appear to be similar to those in adults. Fluoroquinolones are associated with tendinitis and reversible arthralgia in adults and children. However, direct association between fluoroquinolones and arthropathy remains uncertain. CONCLUSIONS Fluoroquinolones have been found to be effective in treating certain infections in children. Additional research is needed to define the optimal dosage regimens in pediatric patients. Although fluoroquinolones appear to be well tolerated, further investigations are needed to determine the risk of arthropathy in children. However, their use in children should not be withheld when the benefits outweigh the risks.
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Affiliation(s)
- A A Alghasham
- College of Medicine and King Khalid University Hospital, Riyadh, Saudi Arabia
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Connerton P, Wain J, Hien TT, Ali T, Parry C, Chinh NT, Vinh H, Ho VA, Diep TS, Day NP, White NJ, Dougan G, Farrar JJ. Epidemic typhoid in vietnam: molecular typing of multiple-antibiotic-resistant Salmonella enterica serotype typhi from four outbreaks. J Clin Microbiol 2000; 38:895-7. [PMID: 10655411 PMCID: PMC86238 DOI: 10.1128/jcm.38.2.895-897.2000] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Multidrug-resistant Salmonella enterica serotype Typhi isolates from four outbreaks of typhoid fever in southern Vietnam between 1993 and 1997 were compared. Pulsed-field gel electrophoresis, bacteriophage and plasmid typing, and antibiotic susceptibilities showed that independent outbreaks of multidrug-resistant typhoid fever in southern Vietnam are caused by single bacterial strains. However, different outbreaks do not derive from the clonal expansion of a single multidrug-resistant serotype Typhi strain.
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Affiliation(s)
- P Connerton
- The Department of Biochemistry, Imperial College of Science, Technology and Medicine, London SW7 2AZ, United Kingdom
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Levine MM, Ferreccio C, Abrego P, Martin OS, Ortiz E, Cryz S. Duration of efficacy of Ty21a, attenuated Salmonella typhi live oral vaccine. Vaccine 1999; 17 Suppl 2:S22-7. [PMID: 10506405 DOI: 10.1016/s0264-410x(99)00231-5] [Citation(s) in RCA: 179] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Currently, two different formulations of Ty21a live oral typhoid vaccine are commercialized. The enteric-coated capsule formulation was licensed based on results of three years of follow-up of a randomized, placebo-controlled, double-blind field trial in Area Occidente, Santiago, Chile, which demonstrated that three doses of this formulation, given on an every other day immunization schedule, conferred the best protection among several options evaluated. Subsequently, a liquid formulation (lyophilized vaccine organisms reconstituted with buffer and water into a vaccine cocktail) was commercialized after it was shown to provide superior protection than enteric-coated capsules over three years of follow-up in a randomized, placebo-controlled field trial in Area Sur Oriente and Area Norte, Santiago. Surveillance in the Area Occidente trial was continued for four additional years (i.e., total seven years of follow-up) and in the Area Sur Oriente/Area Norte trial for two additional years (i.e., a total of five years of follow-up). These additional surveillance data, which were analyzed to ascertain the longevity of protection conferred by these formulations of Ty21a, revealed that three doses of Ty21a in enteric-coated capsules (every other day schedule) conferred 67% protection over three years and 62% protection over seven years of follow-up, whereas three doses of liquid formulation (every other day schedule) elicited 77% protection over three years and 78% over five years of follow-up. Based on its excellent clinical acceptability, ease of oral administration, proven practicality in school-based mass immunization, and long-term efficacy enduring at least seven years, it is proposed that school-based immunization with Ty21a be utilized as a control measure in areas where the incidence of typhoid fever is high and Salmonella typhi are antibiotic-resistant.
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Affiliation(s)
- M M Levine
- Center for Vaccine Development, University of Maryland School of Medicine, 685 W. Baltimore St., Baltimore MD 21201, USA
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Cao XT, Kneen R, Nguyen TA, Truong DL, White NJ, Parry CM. A comparative study of ofloxacin and cefixime for treatment of typhoid fever in children. The Dong Nai Pediatric Center Typhoid Study Group. Pediatr Infect Dis J 1999; 18:245-8. [PMID: 10093945 DOI: 10.1097/00006454-199903000-00007] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Despite concerns about safety in children, fluoroquinolone antibiotics have become the treatment of choice in patients with multidrug-resistant typhoid fever in Vietnam. However, quinolone-resistant strains of Salmonella typhi have recently been reported from Vietnam; and if quinolone resistance becomes established, alternative oral treatment options will be needed. OBJECTIVE Cefixime, an orally administered third generation cephalosporin, was compared with ofloxacin for the treatment of uncomplicated typhoid fever in children. METHODS In an open trial children with suspected typhoid fever were randomized to receive either ofloxacin (10 mg/kg/day in two divided doses) for 5 days or cefixime (20 mg/kg/day in two divided doses) for 7 days. RESULTS S. typhi was isolated from 82 patients (44 in the cefixime group, 38 in the ofloxacin group) and 70 (85%) of the isolates were multidrug-resistant. Median (95% confidence interval, range) fever clearance times were 4.4 (4 to 5.2, 0.2 to 9.9) days for ofloxacin recipients and 8.5 (4.2 to 9, 1.8 to 15.2) days for cefixime-treated patients (P < 0.0001). There were 11 treatment failures (10 acute and one relapse) in the cefixime group and 1 acute treatment failure in the ofloxacin group (mean difference, 22%; 95% confidence interval, 9 to 36%). CONCLUSION Short course treatment with cefixime may provide a useful alternative treatment in cases of uncomplicated typhoid fever in children, but it is less effective than short course treatment with ofloxacin.
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Affiliation(s)
- X T Cao
- Dong Nai Pediatric Centre, Bien Hoa City, Dong Nai Province, Vietnam
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Thomsen LL, Paerregaard A. Treatment with ciprofloxacin in children with typhoid fever. SCANDINAVIAN JOURNAL OF INFECTIOUS DISEASES 1998; 30:355-7. [PMID: 9817514 DOI: 10.1080/00365549850160639] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
We investigated the use, treatment results and safety of ciprofloxacin in the treatment of childhood typhoid and paratyphoid infections in an industrialized country. The study was retrospective, and the material consisted of children admitted to Hvidovre or Glostrup University Hospitals from 1991 to 1995, and treated with ciprofloxacin for a culture proven diagnosis of typhoid fever. 21 children were included, 18 had positive cultures for Salmonella typhi and 3 had positive cultures for S. paratyphi A. All isolates were fully susceptible to ciprofloxacin. The median duration of treatment was 10 d, median oral dose was 24 mg/kg/d and the median intravenous dose was 15 mg/kg/d. Within 4 d after start of treatment all subjects had a normal body temperature. No subjects had clinical or microbiological relapse and all stool cultures after end of treatment were negative. Adverse events were rare, but in 2 children a transient limb/ataxia or a period of confusion were recorded. Both children recovered within a few days without sequelae. We conclude that ciprofloxacin was effective and well tolerated for treatment of typhoid fever in children. The few adverse events that were recorded left no permanent sequelae, and were likely to be caused by the disease itself.
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Affiliation(s)
- L L Thomsen
- University Clinic of Paediatrics, Glostrup, Denmark
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Hoa NT, Diep TS, Wain J, Parry CM, Hien TT, Smith MD, Walsh AL, White NJ. Community-acquired septicaemia in southern Viet Nam: the importance of multidrug-resistant Salmonella typhi. Trans R Soc Trop Med Hyg 1998; 92:503-8. [PMID: 9861362 DOI: 10.1016/s0035-9203(98)90891-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
In a prospective study conducted between mid 1993 and 1994, 437 adults and children were admitted with community-acquired septicaemia to an infectious diseases hospital in southern Viet Nam. Gram-negative aerobes accounted for 90% of isolates and were predominantly Salmonella typhi (67%), Sal. para-typhi A (3%), Escherichia coli (10%), and Klebsiella spp. (5%). Other Salmonella spp. (1%), Pseudomonas aeruginosa (1%), Neisseria meningitidis (0.5%) and Haemophilus influenzae (0.2%) were uncommon. Staphylococcus aureus (5.5%) and Streptococcus pneumoniae (2%) were the most common Gram-positive isolates. Patients with enteric fever were younger (median age 16 years, range 1-63) than the other patients (median age 43 years, range 1-88) (P < 0.001) and had a lower mortality rate (0.3% vs. 23%; relative risk 69.5, 95% confidence interval 9.5-507.8; P < 0.0001). Over 70% of the Sal. typhi isolated were multi-drug-resistant, and 4% were resistant to nalidixic acid. Multidrug-resistant Sal. typhi is a major cause of community-acquired septicaemia in Viet Nam.
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Affiliation(s)
- N T Hoa
- Centre for Tropical Diseases, Cho Quan Hospital, Ho Chi Minh City, Viet Nam
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Salam MA, Dhar U, Khan WA, Bennish ML. Randomised comparison of ciprofloxacin suspension and pivmecillinam for childhood shigellosis. Lancet 1998; 352:522-7. [PMID: 9716056 DOI: 10.1016/s0140-6736(97)11457-x] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Infections caused by multiply resistant Shigella species are a major cause of childhood morbidity and mortality in Third World countries. The fluoroquinolone agent ciprofloxacin is active in vitro against these strains of bacteria, but has not been routinely used to treat acute childhood infections because of concern that quinolones may cause arthropathy in children. We undertook a randomised double-blind study to test the effects of ciprofloxacin treatment in children with shigella dysentery. METHODS We compared the efficacy and toxic effects of ciprofloxacin suspension (10 mg/kg every 12 h for 5 days, maximum individual dose 500 mg) with those of pivmecillinam tablets (15-20 mg/kg every 8 h for 5 days, maximum individual dose 300 mg). We enrolled 143 children aged 2-15 years with dysentery of 72 h or less duration. Patients stayed in hospital for 6 days, and were followed up 7, 30, and 180 days after hospital discharge. Joint symptoms and function were assessed daily for 6 days. Clinical success was defined as the absence of frank dysentery on day 3, and on day 5 no bloody-mucoid stools, one or no watery stool, six or fewer total stools, and no fever. If no shigella were isolated from faecal samples on day 3 or thereafter, treatment was judged bacteriologically successful. FINDINGS 13 patients were excluded since they did not meet eligibility criteria; 10 withdrew before day 5. Thus 120 patients (60 in each group) completed the study. Treatment was clinically successful in 48 (80%) of 60 patients who received ciprofloxacin and in 39 (65%) of 60 patients who received pivmecillinam (p=0.10). Treatment was bacteriologically successful in all of the patients receiving ciprofloxacin, and in 54 (90%) of the patients receiving pivmecillinam (p=0.03). Joint pain after treatment began in 13 (18%) of 71 patients who received ciprofloxacin and 16 (22%) of 72 patients who received pivmecillinam (p>0.2), and no patient had signs of arthritis. INTERPRETATION In our trial, ciprofloxacin suspension and pivmecillinam had the same clinical efficacy. Ciprofloxacin had greater bacteriological efficacy and was not associated with the development of arthropathy. We conclude that ciprofloxacin is an effective and safe drug for use in multiply resistant childhood shigellosis.
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Affiliation(s)
- M A Salam
- International Centre for Diarrhoeal Disease Research, Bangladesh, Dhaka
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Nguyen TC, Solomon T, Mai XT, Nguyen TL, Nguyen TT, Wain J, To SD, Smith MD, Day NP, Le TP, Parry C, White NJ. Short courses of ofloxacin for the treatment of enteric fever. Trans R Soc Trop Med Hyg 1997; 91:347-9. [PMID: 9231214 DOI: 10.1016/s0035-9203(97)90102-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Typhoid fever continues to be a major public health problem in tropical countries, exacerbated in recent years by the spread of multi-drug resistant strains of Salmonella typhi. Short treatment courses of fluoroquinolones are effective, and have the advantage of reduced cost and increased compliance, but the optimal length of treatment is unknown. In an open, randomized comparison, 107 adults with uncomplicated enteric fever (95 of whom had positive blood cultures for S. typhi and 5 for S. paratyphi) were treated with oral ofloxacin, 15 mg/kg/d for 2 d or 10 mg/kg/d for 3 d. Mean fever clearance times were the same in the 2 treatment groups (97 h). There were 7 treatment failures, one in the 2 d group and 6 in the 3 d group (P = 0.07). Three of the 5 patients infected with nalidixic acid resistant strains of S. typhi had treatment failures, compared with 4 of 90 with nalidixic acid sensitive isolates (P < 0.0001; relative risk 13.5, 95% confidence interval 4.1-43%). Treatment with ofloxacin for 2 or 3 d is equally effective in adults with uncomplicated enteric fever caused by nalidixic acid sensitive strains of S. typhi. The epidemiology and management of nalidixic acid resistent typhoid needs further investigation.
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Affiliation(s)
- T C Nguyen
- Centre for Tropical Diseases, Cho Quan Hospital, Ho Chi Minh City, Viet Nam
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Bethell DB, Day NP, Dung NM, McMullin C, Loan HT, Tam DT, Minh LT, Linh NT, Dung NQ, Vinh H, MacGowan AP, White LO, White NJ. Pharmacokinetics of oral and intravenous ofloxacin in children with multidrug-resistant typhoid fever. Antimicrob Agents Chemother 1996; 40:2167-72. [PMID: 8878600 PMCID: PMC163492 DOI: 10.1128/aac.40.9.2167] [Citation(s) in RCA: 26] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
The pharmacokinetics of oral and intravenous ofloxacin (7.5 mg.kg of body weight-1 given over 30 min) were studied in an open crossover study of 17 Vietnamese children, aged between 5 and 14 years, with acute uncomplicated typhoid fever. Following oral administration, the median (95% confidence interval [CI]) time to peak concentration of ofloxacin in serum (Cmax) was 1.7 h (1.4 to 1.9 h) and the mean (95% CI) Cmax was 5.5 mg.liter-1 (4.7 to 6.3 mg.liter-1) compared with a Cmax of 8.7 mg.liter-1 (7.6 to 9.7 mg.liter-1) following the intravenous infusion. The median (95% CI) total apparent volume of distribution following the first intravenous dose, 1.35 liter.kg-1 (1.17 to 1.73 liter.kg-1), was significantly larger than that following the second dose, 0.99 liter.kg-1 (0.86 to 1.17 liter.kg-1; P < 0.0005), although the estimates for systemic clearance were similar: 0.255 liter.kg-1 h-1 (0.147 to 0.325 liter.kg-1 h-1) compared with 0.172 liter.kg-1 h-1 (0.127 to 0.292 liter.kg-1 h-1; P = 0.14). The mean residence times (95% CI) following intravenous and oral administration were similar: 5.24 h (4.84 to 6.58 h) and 6.24 h (5.32 to 7.85 h), respectively. The mean (95% CI) oral bioavailability was 91% (74 to 109%). The peak concentrations in serum were 10 to 100 times higher than the maximum MICs for ofloxacin against multidrug-resistant Salmonella typhi isolated in this area. Although the systemic clearance values were higher than those reported previously for adults, these data overall suggest that weight-or area-adjusted dose regimens for the treatment of typhoid in older children should be the same as those for adults.
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Affiliation(s)
- D B Bethell
- Centre for Tropical Diseases, Ho Chi Minh City, Vietnam
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White NJ, Dung NM, Vinh H, Bethell D, Hien TT. Fluoroquinolone antibiotics in children with multidrug resistant typhoid. Lancet 1996; 348:547. [PMID: 8757168 DOI: 10.1016/s0140-6736(05)64703-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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39
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Krop LC. Ofloxacin: Why the Increased Popularity? J Pharm Technol 1996. [DOI: 10.1177/875512259601200306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: To provide a rationale for the increasing use of ofloxacin as a substitute for ciprofloxacin, and to review the appropriate use of these agents. Data Source: A MEDLINE search was conducted to identify relevant literature. References in those articles were reviewed for additional published information. Study Selection: Published review articles and clinical trials on ofloxacin were reviewed, with particular emphasis on pharmacoeconomics, pharmacodynamics, and studies evaluating the safety and efficacy of ofloxacin. Data Synthesis: Ofloxacin is a broad-spectrum antimicrobial agent that has in vitro activity similar to that of ciprofloxacin. Ciprofloxacin exhibits lower minimum inhibitory concentrations for Pseudomonas aeruginosa, and ofloxacin is more active against Chlamydia trachomatis and gram-positive aerobic organisms. Both agents have limited anaerobic activity. Unlike ciprofloxacin, ofloxacin is 100% bioavailable, exhibits a greater area under the concentration curve, contributing to its bactericidal activity, and is eliminated primarily by the kidney. Both ciprofloxacin and ofloxacin have long half-lives, allowing twice-daily dosing. However, because a decrease in renal function often accompanies increasing age, ofloxacin can be administered once daily in the elderly. Both agents have a large volume of distribution and exhibit excellent tissue and cell penetration. Several clinical studies have demonstrated ofloxacin's effectiveness in treating a variety of systemic infections caused by susceptible organisms, including P. aeruginosa. Adverse effects are infrequent with both fluoroquinolones, and if they occur such effects are usually gastrointestinal in nature. Ofloxacin has a much lower incidence of drug interactions, in particular with theophylline and caffeine. Ofloxacin is less expensive than ciprofloxacin. Conclusions: Overall, the activity of ofloxacin is similar to that of ciprofloxacin and the two agents are therapeutically equivalent. The data presented warrant routine therapeutic substitution of ofloxacin for ciprofloxacin. Ciprofloxacin should be reserved for instances in which specific prescribing criteria are met.
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Bethell DB, Hien TT, Phi LT, Day NP, Vinh H, Duong NM, Len NV, Chuong LV, White NJ. Effects on growth of single short courses of fluoroquinolones. Arch Dis Child 1996; 74:44-6. [PMID: 8660045 PMCID: PMC1511581 DOI: 10.1136/adc.74.1.44] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The aim of the study was to document the effects of short courses of fluoroquinolones given during an outbreak of multidrug resistant typhoid fever in southern Viet Nam on the growth of children over a period of two years. In a prospective cohort study, 326 Vietnamese children aged between 1 and 14 years were followed up for two years after receiving either ciprofloxacin (70 mg/kg given over 7 d) (n = 173) or ofloxacin (45-50 mg/kg given over 3-5 d) (n = 153) for suspected typhoid fever. Growth velocity and weight for height were compared with an age matched control group of children from the same locality (n = 223) who had not contracted typhoid or received any fluoroquinolones. In the ofloxacin and ciprofloxacin treated patients there was no evidence of acute joint toxicity, nor of any joint symptoms attributable to either of the fluoroquinolones. There was no difference in expected weight for height measurements between the three groups of children over the two year period. During the first year, height velocity in ciprofloxacin treated children was greater than in either ofloxacin treated children or untreated controls. Height velocity in the latter two groups was not significantly different. After two years height velocity was similar in the three groups. The results support the use of short course fluoroquinolone treatment in childhood typhoid, especially when caused by strains resistant to other antibiotics.
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Affiliation(s)
- D B Bethell
- Centre for Tropical Diseases, Ho Chi Minh City, Viet Nam
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Mirza SH, Beeching NJ, Hart CA. The prevalence and clinical features of multi-drug resistant Salmonella typhi infections in Baluchistan, Pakistan. ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY 1995; 89:515-9. [PMID: 7495365 DOI: 10.1080/00034983.1995.11812984] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Between January and July 1994, a prospective study of bacteraemia in 692 patients with fever without localizing signs was undertaken at the Quetta Military Hospital in Baluchistan, Pakistan. Salmonella spp. were isolated from 76 (11%) of the patients; 62 had S. typhi and 14 had S. paratyphi A. Significantly more isolations of S. typhi were made in the hot dry months of May and June than in the earlier months. Although multi-drug resistance (to chloramphenicol ampicillin and cotrimoxazole) was detected in 43 (69%) of the S. typhi isolates, it was not found in any of the S. paratyphi A. Defervescence of patients with chloramphenicol-sensitive S. typhi took 7-10 days of chloramphenicol therapy. In contrast, most (91%) of the patients infected with multi-drug resistant S. typhi who were treated with fluoroquinolones achieved defervescence in 1-3 days; the remainder took 4-6 days.
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Affiliation(s)
- S H Mirza
- Combined Military Hospital, Quetta, Pakistan
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