An epidemic-associated episome?

Population structure and ongoing microevolution of the emerging multidrug-resistant Salmonella Typhimurium ST213

Salmonella enterica serovar Typhimurium ST213 is an emergent multidrug-resistant sequence type associated with the food chain, and gastrointestinal and invasive infections in North America. Here, we applied genomic and phenotypic analyses to illustrate the diversity and evolution of sequence type ST213. The population structure and evolutionary history of ST213 strains, particularly the North American isolates (NA-ST213) distinguish them from other S. Typhimurium sequence types, including European ST213 strains. NA-ST213 isolates were distributed in four co-circulating lineages with distinct multidrug resistance profiles and unique phage and CRISPR spacers patterns that could have shaped their local microevolution. Compared to the SL1344 reference strain, NA-ST213 demonstrated reduced adherence and internalization in cultured eukaryotic cell lines but exhibited more efficient replication and intracellular survival. This study underscores the relevance of studying an emergent S. Typhimurium sequence type and the events leading to its diversification beyond the well-characterized reference strains and worldwide predominant sequence types. However, it must also serve as a cautionary tale of the potential health risk the NA-ST213 may represent; particularly when there is a close relationship with pandemic sequence types such as the monophasic ST34.

Intracontinental spread of human invasive Salmonella Typhimurium pathovariants in sub-Saharan Africa

A highly invasive form of non-typhoidal Salmonella (iNTS) disease has recently been documented in many countries in sub-Saharan Africa. The most common Salmonella enterica serovar causing this disease is Typhimurium (Salmonella Typhimurium). We applied whole-genome sequence-based phylogenetic methods to define the population structure of sub-Saharan African invasive Salmonella Typhimurium isolates and compared these to global Salmonella Typhimurium populations. Notably, the vast majority of sub-Saharan invasive Salmonella Typhimurium isolates fell within two closely related, highly clustered phylogenetic lineages that we estimate emerged independently ∼52 and ∼35 years ago in close temporal association with the current HIV pandemic. Clonal replacement of isolates from lineage I by those from lineage II was potentially influenced by the use of chloramphenicol for the treatment of iNTS disease. Our analysis suggests that iNTS disease is in part an epidemic in sub-Saharan Africa caused by highly related Salmonella Typhimurium lineages that may have occupied new niches associated with a compromised human population and antibiotic treatment.

The emergence of antibiotic resistance in typhoid fever

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.

R-Plasmid Transfer to and from Escherichia coli Strains Isolated from Human Fecal Samples

Strains of Escherichia coli recently isolated from human feces were examined for the frequency with which they accept an R factor (R1) from a derepressed fi strain of E. coli K-12 and transfer it to fecal and laboratory strains. Colicins produced by some of the isolates rapidly killed the other half of the mating pair; therefore, conjugation was conducted by a membrane filtration procedure whereby this effect was minimized. The majority of fecal E. coli isolates accepted the R factor at lower frequencies than K-12 F, varying from 10 per donor cell to undetectable levels. The frequencies with which certain fecal recipients received the R-plasmid were increased when its R transconjugant was either cured of the R1-plasmid and remated with the fi strain or backcrossed into the parental strain. The former suggests the loss of an incompatibility plasmid, and the latter suggests the modification of the R1-plasmid deoxyribonucleic acid (DNA). In general, the fecal RE. coli transconjugants were less effective donors for K-12 F and heterologous fecal strains than was the fi K-12 strain, whereas the single strain of Citrobacter freundii examined was generally more competent. Passage of the R1-plasmid to strains of salmonellae reached mating frequencies of 10 per donor cell when the recipient was a Salmonella typhi previously cured of its resident R-plasmid. However, two recently isolated strains of Salmonella accepted the R1-plasmid from E. coli K-12 R or the RE. coli transconjugants at frequencies of 5 x 10 or less.

The emergence of multidrug resistance to antimicrobial agents for the treatment of typhoid fever

Resistance to chloramphenicol was reported in Salmonella Typhi in 1950 but it was not until 22 years later that the first outbreaks of chloramphenicol-resistant typhoid fever occurred. Multidrug-resistant (MDR) Salmonella Typhi emerged in the 1980s and today has an almost worldwide distribution. Genome analysis of Salmonella Typhi strain CT18, an MDR isolate from a patient admitted to The Centre for Tropical Diseases, Ho Chi Minh City, Viet Nam, in December 1993 revealed that the resistance plasmid pHCM1 is very closely related to plasmid R27 which was first isolated in 1961. There is a core region shared by the two plasmids with five regions of variation. Two of these regions contain the genes encoding resistance. The largest region is 34.955 kbp in length, is bordered by two almost identical IS10 elements and contains several integron-like structures including a truncated Tn10 element. The second region is 14.75I kbp and encodes a trimethoprim-resistance gene, dfrA14, associated with a class one integrase. Restriction enzyme analysis has shown that the variation in Salmonella Typhi plasmids, collected during the emergence of resistant Salmonella Typhi in Viet Nam, maps to five variable regions. These regions appear to be hot spots for DNA acquisition in IncHI1 plasmids.

Use of ciprofloxacin in developing countries

BACKGROUND

The demographic and subsequent economic pressures in developing nations have contributed to the increasing levels of antibiotic resistance among both commensal flora and pathogenic bacteria. As empirical options are diminishing daily, the role of ciprofloxacin in pediatric infections is becoming increasingly significant.

OBJECTIVE

The levels of resistance among various enteric pathogens are described, and the efficacy and safety of ciprofloxacin in treating infections such as shigellosis, cholera and Escherichia coli gastroenteritis are discussed. The findings of a large study of invasive salmonellosis in children in rural Africa are briefly presented, including the role of ciprofloxacin in multiresistant invasive disease. In addition the role of ciprofloxacin as a chemoprophylactic agent in the control of meningococcal disease is discussed.

RESULTS

The efficacy and safety of ciprofloxacin in children were found to be similar to those observed in adults for gastrointestinal infectious diseases. Overall the data presented confirm that ciprofloxacin is a safe and efficacious agent for use in children in the developing world.

CONCLUSION

Ciprofloxacin has been shown to be safe and efficacious in children in developing countries. Subsequently a priority for both the pharmaceutical industry and regulatory authorities in developing nations is to prevent fluoroquinolone misuse and development of antibiotic resistance.

Seasonal incidence of and antibiotic resistance among Aeromonas species isolated from domestic wastewater before and after treatment in stabilization ponds

The efficiency of stabilization pond treatment of domestic wastewater in removing culturable cells of motile Aeromonas and its influence on the incidence of resistance to seven antibiotics were investigated in this study. Removal efficiency was higher (P < 0.001) in the warm months (98.8%) than in the cold months (97%). Among the 264 isolates, 163 were Aeromonas caviae, 24 were A. hydrophila, and 54 were A. sobria. Twenty-three isolates could not be identified to the species level. In the influent, A. caviae dominated in both cold and warm months. In the water samples originating from the influent, A. sobria was present at higher percentages in the warm period. All the isolates were resistant to amoxicillin and most of them (73%) exhibited resistance to cephalothin. Of the three species tested, A. sobria was more susceptible to antibiotics than either A. caviae or A. hydrophila. The most striking difference among the species was seen in resistance to cephalothin. There were 91 % of A. caviae strains and 96% of A. hydrophila isolates that were resistant to cephalothin. However, only 9% of A. sobria strains exhibited resistance to this drug. The high incidence of resistance in raw sewage was connected with a high proportion of A. caviae, whereas in the water samples collected from the effluent during the warm months, a high proportion of A. sobria decreased the total amount of multiple-resistant bacteria. Results demonstrated the need for identification to the species level.

Occurrence of drug-resistant bacteria in communal well water around Port Harcourt, Nigeria

A total of 108 raw water samples was collected from 36 wells at nine shanty settlements around Port Harcourt, Nigeria, over a period of 7 months. Samples were analysed for their bacteriological quality. Selected bacterial strains isolated from the samples were tested for their susceptibility to ten commonly used antibiotics. The organisms isolated include Pseudomonas spp., Klebsiella spp., Staphylococcus spp., Proteus spp., Enterococcus faecalis, Aeromonas spp., Escherichia coli, Chromobacterium spp., Flavobacterium spp., and Serratia spp. Out of 300 strains tested, 23 (6.9%) were susceptible to all the antibiotics, 277 (92.3%) were resistant to at least one antibiotic and 232 (77.3%) were resistant to two or more antibiotics. The epidemiological significance of these results is discussed.

Antibiotic exposure and resistance in mixed bacterial populations

Antibiotic use is often blamed for increases in the prevalence of infections due to antibiotic-resistance bacteria. This paper clarifies the effects of antibiotic exposure on bacterial antibiotic resistance by developing models that describe the growth of competing bacterial strains whose antibiotic sensitivities differ. The analysis generalizes logistic growth models to include first-order growth parameters that are arbitrary functions of antibiotic levels. It derives closed-form solutions for population size, composition, and average antibiotic sensitivities as functions of antibiotic exposure. Strategies to minimize the bacterial population size are analyzed in the context of the model. These heuristic models explore in formal terms the population dynamics thought to underlie resistance development.

A note on antibiotic resistance in the bacterial flora of raw sewage and sewage-polluted River Tigris in Mosul, Iraq

Polluted water samples collected from the River Tigris in the vicinity of a raw sewage outfall were examined for the incidence of antibiotic resistance among coliform bacteria on three occasions during 1983. Eighty percent or more of the coliform bacteria were resistant to one or more antibiotics. At the same time, raw sewage samples were examined for the incidence of antibiotic-resistant bacteria, and Escherichia coli, Pseudomonas spp. and Staphylococcus spp. were selected for sensitivity testing. Collectively, more than 90% of the 480 strains of the three organisms were resistant to one or more antibiotics. The minimal inhibitory concentration (MIC) of ampicillin for twenty-nine strains including coliforms, E. coli, Klebsiella sp., Serratia sp., Ps. aeruginosa, Pseudomonas sp., Micrococcus sp., Staph. aureus, Streptococcus faecalis and Bacillus sp. from raw sewage and polluted River Tigris water was determined and that for Ps. aeruginosa was 250 micrograms/ml. The high incidence of antibiotic-resistant bacteria in natural waters could be related to the widespread use of antibiotics in this locality.

R-plasmid transfer in Salmonella spp. isolated from wastewater and sewage-contaminated surface waters

A total of 865 Salmonella isolates from wastewaters and sewage-contaminated natural waters were tested for antimicrobial resistance by using NR10 medium and incubation at 43 degrees C. Of the strains, 12.7% were resistant to one or more of the compounds tested, and 30% transferred resistance to an Escherichia coli recipient. The highest minimal inhibitory concentrations were ca. 1,000 micrograms/ml. Transfer frequencies ranged from 10(-3) to 10(-7).

Enteropathogen carriage by healthy individuals living in an area with poor sanitation

Faecal carriage of bacterial enteropathogens (enteropathogenic Escherichia coli (EPEC), shigellae and salmonellae) was studied in 265 individuals: 65 infants 3-6 months of age (50 bottle-fed and 15 breast-fed), 100 school-age children 8-10 years of age and 100 adults 21-50 years of age. All were apparently healthy, did not have gastrointestinal symptoms, had not received antibiotics in the preceding fortnight and were not malnourished. Enteropathogens were isolated from the faeces of 24 individuals (9.1%). Cultures were positive for enteropathogens in 20% of the infants (both breast- and bottle-fed), 8% of school-age children and 3% of the adults. EPEC was the most frequent isolate. Twelve different serotypes were detected. The highest recoveries were E. coli 026:K60 and 044 . K74. Shigella was detected only in school-age children (2%) and salmonella only in adults (1%). Campylobacter jejuni and Yersinia enterocolitica were studied only in the school-age children: there was one isolate of each of them. Most enteropathogens isolated were susceptible to the majority of the antibiotics tested. Only four E. coli strains, isolated from bottle-fed infants, could be considered multi-resistant. Two of the strains wer E. coli 044:K74 and 020a020c:K61. The remainder were E. coli 0111:K58 and wee capable of transferring some of their antibiotic resistance traits to a recipient strain.

Effect of UV light disinfection on antibiotic-resistant coliforms in wastewater effluents

Total coliforms and total coliforms resistant to streptomycin, tetracycline, or chloramphenicol were isolated from filtered activated sludge effluents before and after UV light irradiation. Although the UV irradiation effectively disinfected the wastewater effluent, the percentage of the total surviving coliform population resistant to tetracycline or chloramphenicol was significantly higher than the percentage of the total coliform population resistant to those antibiotics before UV irradiation. This finding was attributed to the mechanism of R-factor-mediated resistance to tetracycline. No significant difference was noted for the percentage of the surviving total coliform population resistant to streptomycin before or after UV irradiation. Multiple drug resistance patterns of 300 total coliform isolates revealed that 82% were resistant to two or more antibiotics. Furthermore, 46% of these isolates were capable of transferring antibiotic resistance to a sensitive strain of Escherichia coli.

Shigella species from Addis Ababa: frequency of isolation and in vitro drug sensitivity

One hundred and five shigella isolates from Addis Ababa were studied to determine serogroup frequency and in vitro antibacterial drug sensitivity. About 70% of the isolates were Shigella flexneri followed by Sh. dysenteriae (15%), Sh. boydii (10%) and Sh. sonnei (5%). All or most of the strains were susceptible to cephalothin, gentamicin, kanamycin, polymyxin B and trimethoprim-sulphamethoxazole. Frequencies of susceptibility to ampicillin, carbenicillin and chloramphenicol were, respectively, 79, 80 and 75%. Only 37, 23 and 58% were susceptible to streptomycin, sulphadiazine and tetracycline, respectively. Resistance to one or more drugs was detected in 85% while 72% were multiply resistant. There were 24 different resistance patterns, varying from resistance to one drug to resistance to seven drugs. The findings have been compared with reports from other countries. This study and several others cited support the view that trimethoprim-sulphamethoxazole is the best alternative drug for treatment of shigellosis particularly in regions with multiple drug-resistant strains.

R factors in coliform-fecal coliform sewage flora of the prairies and Northwest Territories of Canada

Coliform and fecal coliform populations found in the raw sewages and final sewage effluents of the prairie provinces and the Northwest Territories were examined for antibiotic resistance and the possession of R factors. It was determined that 8.91% of the total coliform and 10.80% of the fecal coliform populations carried R factors. The following numbers of combinations of R determinants were found: 39 in the Escherichia coli population, 6 in the Citrobacter population, 20 in the Enterobacter populations, 10 in the Klebsiella populations, and 11 in the Aeromonas populations. The maximum number of R determinants transferable simultaneously was seven; organisms with R factors containing determinants for chloramphenicol usually contained determinants for ampicillin. Of the coliform and fecal coliform populations, 2 to 4% were resistant to chloramphenicol in some provinces, and from 17 to 30% of the populations were resistant to three or more antibiotics. It was calculated that coliforms containing R factors in the raw sewage reached population levels of 1.5 X 10(7)/100 ml, and fecal coliforms containing R factors reached population levels of 8.6 X 10(5) ml. Final effluent discharges to the receiving environment contained R factor-containing coliform and fecal coliform populations of 3.1 X 10(4)/100 ml and 5.8 X 10(2)/100 ml, respectively. The incidence of bacteria containing R factors in sewage appears to be increasing with time, and their removal from sewage before discharge to the receiving environment is desirable. Consideration of data on bacteria with R factors should be made in future water quality deliberations and in discharge regulations.

Incidence of R factors in coliform, fecal coliform, and Salmonella populations of the Red River in Canada

Coliforms, fecal coliforms, and Salmonella were isolated from the Red River, Manitoba, Canada, and identified. These organisms were then examined for resistance to 12 antibiotics. Some fecal coliforms were resistant to all 12 antibiotics, and 18% of the Salmonella isolates were resistant to one or more antibiotics. A total of 52.9% of the fecal coliforms resistant to three or more antibiotics were able to transfer single or multiple resistance (R) determinants to the Salmonella recipient, and 40.7% could transfer R determinants to the Escherichia coli recipient. Of the resistant Salmonella, 57% transferred one or two determinants to the Salmonella recipient, and 39% transferred one or two determinants to the E. coli recipient. It was calculated that populations of fecal coliforms containing R factors were as high as 1,400 per 100 ml and that an accidental intake of a few milliliters of water could lead to transient or permanent colonization of the digestive tract. Consideration of data on bacteria with R factors should be made in future water quality deliberations and in discharge regulations.

Plasmid-determined resistance to serum bactericidal activity: a major outer membrane protein, the traT gene product, is responsible for plasmid-specified serum resistance in Escherichia coli

Resistance to the bactericidal activity of serum appears to be an important virulence property of invasive bacteria. The conjugative multiple-antibiotic-resistance plasmid R6-5 was found to confer upon Escherichia coli host bacteria increased resistance against rabbit serum. Gene-cloning techniques were used to localize the serum resistance determinant of R6-5 to a segment of the plasmid that encodes conjugal transfer functions, and a pACYC184 hybrid plasmid, designated pKT107, that contains this segment was constructed. The generation and analysis of deletion and insertion mutant derivatives of the pKT107 plasmid that no longer specify serum resistance permitted precise localization of the serum-resistance cistron on the R6-5 map and demonstrated that this locus is coincident with that of traT, one of the two surface exclusion genes of R6-5. Examination of the proteins synthesized in E. coli minicells of pKT107 and its serum-sensitive mutant derivative plasmids confirmed that the serum-resistance gene product of R6-5 is the traT protein and showed that this protein is a major structural component (about 21,000 copies per cell) of the bacterial outer membrane.

Potential for in vivo acquisition of R plasmids by one strain of Vibrio cholerae biotype El tor

The feces of five patients admitted to a hospital during an outbreak of cholera in Melbourne, Australia, in November 1972, were examined for the presence of tetracycline-resistant coliforms and tetracycline-resistant strains of Vibrio cholerae. Despite the abundance of tetracycline-resistant coliforms able to transfer this resistance to other strains of Escherichia coli, no tetracycline-resistant strains of V. cholerae were detected. In vitro transfer experiments using the V. cholerae strain responsible for the outbreak as recipient revealed that it was a particularly poor host for most R plasmids.

Microbial development of drug resistance: mechanisms and clinical significance

Bacteria have demonstrated a disconcerting ability to develop resistance to antimicrobial agents nearly as quickly as new compounds become available. During the past two decades the molecular bases of several types of resistance have been elucidated. Mechanisms of resistance include the transference of genetic material either through conjugation (involving direct contact between microorganisms), or indirectly through transduction (involving bacteriophages). In addition to this "infectious" drug resistance, genetic mutations which permit the utilization of new metabolic pathways, and the production of enzymes which can inactivate the antimicrobic have been described. One particularly complex problem has been the ability of many Enterobacteriaceae to develop resistance to multiple antimicrobials simultaneously. The possible effect of such an occurrence is illustrated by the recent epidemic of multiply resistant Salmonella typhi in Mexico. Because the typhoid bacilli shared an identical resistance pattern to an epidemic Shigella dysenteriae type 1 the in vivo interspecies transmission of resistance has been postulated. Understanding the various mechanisms of resistance development should allow more rational use of antimicrobial agents.

Antimicrobial resistance and R factors in Salmonella isolated in California (1971-1972)

The antimicrobial resistance of 2,246 strains of Salmonella isolated from humans in California was determined. Resistance to one or more of the 12 antimicrobial agents tested was found in 32% of the isolates. Salmonella typhimurium strains represented 31% of the serotypes isolated; 49% of these strains were resistant. Fifty-one percent of S. heidelberg, 42.5% of S. newport, and 40% of S. saint paul strains were resistant. Seventy-seven percent of all resistant serotypes were resistant to two or more of the antimicrobial agents tested. R factors were demonstrated in 70% of the multiply resistant strains. Resistance of the Salmonella strains to one or more of the 12 antimicrobials tested and the frequency of resistance to tetracycline and ampicillin were significantly greater than resistance reported in other studies performed in this country. Chloramphenicol resistance was encountered in 33 (1.5%) of the Salmonella isolates; 19 of these were S. typhi demonstrating a pattern of resistance to streptomycin, sulfisoxazole, tetracycline, and chloramphenicol and carrying an R factor capable of transferring the complete pattern of resistance.

Salmonella typhi resistant to chloramphenicol, ampicillin, and other antimicrobial agents: strains isolated during an extensive typhoid fever epidemic in Mexico

During 1972 a large epidemic, in excess of 10,000 cases, of typhoid fever occurred in Mexico City, Pachuca, and other communities of Mexico. The main characteristic of the epidemic, in addition to the large number of persons affected, was the prevalence of a strain of Salmonella typhi which was highly resistant to chloramphenicol both in vivo and in vitro, and which belonged to a single phage type, Vi degraded approaching type A. Of 493 strains of S. typhi studied during the outbreak, 452 (91.7%) were resistant to chloramphenicol (CM), tetracycline (TC), streptomycin (SM), and sulfonamides (SU). The epidemic strain owes its resistance to an R factor which is easily transferable to Escherichia coli K-12 and which appears to be stable. In the third month of the outbreak, a strain of S. typhi resistant to CM, TC, SM, SU, ampicillin (AM), and kanamycin (KM) was isolated from a patient with severe typhoid fever. During the following 9 months, six additional strains of S. typhi resistant to AM, CM, TC, SM, and SU were also isolated. Transfer experiments to E. coli K-12 indicate that these strains are infected with two different R factors, one causing CM, TC, SM, and SU resistance and the other causing AM or AM and KM resistance. The frequency of transfer of the resistance in overnight crosses was in the order of 10(-4) for CM, TC, SM, and SU and 10(-6) for AM or AM, and KM. The appearance of these strains resistant both to chloramphenicol and ampicillin was a cause for concern for the clinicians; fortunately, they have remained an infrequent cause of disease.