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Chowdhury AR, Mukherjee D, Chatterjee R, Chakravortty D. Defying the odds: Determinants of the antimicrobial response of Salmonella Typhi and their interplay. Mol Microbiol 2024; 121:213-229. [PMID: 38071466 DOI: 10.1111/mmi.15209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 11/12/2023] [Accepted: 11/27/2023] [Indexed: 02/12/2024]
Abstract
Salmonella Typhi, the invasive serovar of S. enterica subspecies enterica, causes typhoid fever in healthy human hosts. The emergence of antibiotic-resistant strains has consistently challenged the successful treatment of typhoid fever with conventional antibiotics. Antimicrobial resistance (AMR) in Salmonella is acquired either by mutations in the genomic DNA or by acquiring extrachromosomal DNA via horizontal gene transfer. In addition, Salmonella can form a subpopulation of antibiotic persistent (AP) cells that can survive at high concentrations of antibiotics. These have reduced the effectiveness of the first and second lines of antibiotics used to treat Salmonella infection. The recurrent and chronic carriage of S. Typhi in human hosts further complicates the treatment process, as a remarkable shift in the immune response from pro-inflammatory Th1 to anti-inflammatory Th2 is observed. Recent studies have also highlighted the overlap between AP, persistent infection (PI) and AMR. These incidents have revealed several areas of research. In this review, we have put forward a timeline for the evolution of antibiotic resistance in Salmonella and discussed the different mechanisms of the same availed by the pathogen at the genotypic and phenotypic levels. Further, we have presented a detailed discussion on Salmonella antibiotic persistence (AP), PI, the host and bacterial virulence factors that can influence PI, and how both AP and PI can lead to AMR.
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Affiliation(s)
- Atish Roy Chowdhury
- Department of Microbiology and Cell Biology, Division of Biological Sciences, Indian Institute of Science, Bangalore, India
| | - Debapriya Mukherjee
- Department of Microbiology and Cell Biology, Division of Biological Sciences, Indian Institute of Science, Bangalore, India
| | - Ritika Chatterjee
- Department of Microbiology and Cell Biology, Division of Biological Sciences, Indian Institute of Science, Bangalore, India
| | - Dipshikha Chakravortty
- Department of Microbiology and Cell Biology, Division of Biological Sciences, Indian Institute of Science, Bangalore, India
- School of Biology, Indian Institute of Science Education and Research, Thiruvananthapuram, India
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Nabarro LE, McCann N, Herdman MT, Dugan C, Ladhani S, Patel D, Morris-Jones S, Balasegaram S, Heyderman RS, Brown M, Parry CM, Godbole G. British Infection Association Guidelines for the Diagnosis and Management of Enteric Fever in England. J Infect 2022; 84:469-489. [PMID: 35038438 DOI: 10.1016/j.jinf.2022.01.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 12/10/2021] [Accepted: 01/05/2022] [Indexed: 11/25/2022]
Abstract
Enteric fever (EF) is an infection caused by the bacteria called Salmonella Typhi or Paratyphi. Infection is acquired through swallowing contaminated food or water. Most EF in England occurs in people returning from South Asia and other places where EF is common; catching EF in England is rare. The main symptom is fever, but stomach pain, diarrhoea, muscle aches, rash and other symptoms may occur. EF is diagnosed by culturing the bacteria from blood and/or stool in a microbiology laboratory. EF usually responds well to antibiotic treatment. Depending on how unwell the individual is, antibiotics may be administered by mouth or by injection. Over the past several years, there has been an overall increase in resistance to antibiotics used to treat enteric fever, in all endemic areas. Additionally, since 2016, there has been an ongoing outbreak of drug-resistant EF in Pakistan. This infection is called extensively drug-resistant, or XDR, EF and only responds to a limited number of antibiotics. Occasionally individuals develop complications of EF including confusion, bleeding, a hole in the gut or an infection of the bones or elsewhere. Some people may continue to carry the bacteria in their stool for a longtime following treatment for the initial illness. These people may need treatment with a longer course of antibiotics to eradicate infection. Travellers can reduce their risk of acquiring EF by following safe food and water practices and by receiving the vaccine at least a few weeks before travel. These guidelines aim to help doctors do the correct tests and treat patients for enteric fever in England but may also be useful to doctors and public health professionals in other similar countries.
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Affiliation(s)
- L E Nabarro
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; United Kingdom Health Security Agency, UK; St George's University Hospitals NHS Foundation Trust, London, UK; British Infection Association, UK
| | - N McCann
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - C Dugan
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | - S Ladhani
- United Kingdom Health Security Agency, UK; Paediatric Infectious Diseases Research Group, St George's University, London, UK
| | - D Patel
- National Travel Health Network and Centre (NaTHNaC), UK
| | - S Morris-Jones
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - R S Heyderman
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; Research Department of Infection, Division of Infection and Immunity, University College London, London, UK
| | - M Brown
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK
| | - C M Parry
- Liverpool School of Tropical Medicine, Liverpool, UK; Alder Hey Hospital and Liverpool University Hospitals, Liverpool, UK; Centre for Tropical Medicine and Global Health, University of Oxford, UK
| | - G Godbole
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; United Kingdom Health Security Agency, UK; British Infection Association, UK.
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Srinivasan M, Sindhu KN, Giri S, Kumar N, Mohan VR, Grassly NC, Kang G. Salmonella Typhi Shedding and Household Transmission by Children With Blood Culture-Confirmed Typhoid Fever in Vellore, South India. J Infect Dis 2021; 224:S593-S600. [PMID: 35238362 PMCID: PMC8892528 DOI: 10.1093/infdis/jiab409] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Children suffer the highest burden of the typhoid fever, with a considerable proportion shedding Salmonella Typhi in stool, potentially resulting in transmission of S Typhi. METHODS We enrolled 70 children with blood culture-confirmed typhoid fever (index cases), from 63 households, during community-based fever surveillance in India. The index cases and their household contacts were followed up with stool samples at multiple time points over 3 weeks and 1 week, respectively. S Typhi was detected using quantitative real-time polymerase chain reaction. RESULTS Fifteen of 70 (21.4%) children with culture-confirmed typhoid fever shed S Typhi in stool after onset of fever. Ten of 15 children shed S Typhi for a median of 11.5 (range, 3-61) days from the day of completion of antibiotics. Of 172 household contacts from 56 of the 63 index case households, 12 (7%) contacts in 11 (19.6%) households had S Typhi in stool. Five of the 12 contacts who were shedding S Typhi were asymptomatic, whereas 7 reported recent fever. CONCLUSIONS One in 5 children with typhoid fever shed S Typhi, with shedding persisting even after antibiotics. One in 5 households had at least 1 contact of the child shedding S Typhi, highlighting potential concurrent typhoid infections in households in settings with poor water and sanitation.
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Affiliation(s)
- Manikandan Srinivasan
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore,India
| | | | - Sidhartha Giri
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore,India
- Indian Council of Medical Research – Regional Medical Research Centre, Bhubaneswar, Odisha,India
| | - Nirmal Kumar
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore,India
| | | | - Nicholas C Grassly
- Department of Infectious Disease Epidemiology, Imperial College, London,United Kingdom
| | - Gagandeep Kang
- The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Vellore,India
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Giri A, Karkey A, Dongol S, Arjyal A, Maharjan A, Veeraraghavan B, Paudyal B, Dolecek C, Gajurel D, Phuong DNT, Thanh DP, Qamar F, Kang G, Hien HV, John J, Lawson K, Wolbers M, Hossain MS, Sharifuzzaman M, Luangasanatip N, Maharjan N, Olliaro P, Rupali P, Shakya R, Shakoor S, Rijal S, Qureshi S, Baker S, Joshi S, Ahmed T, Darton T, Bao TN, Lubell Y, Kestelyn E, Thwaites G, Parry CM, Basnyat B. Azithromycin and cefixime combination versus azithromycin alone for the out-patient treatment of clinically suspected or confirmed uncomplicated typhoid fever in South Asia: a randomised controlled trial protocol. Wellcome Open Res 2021; 6:207. [PMID: 35097222 PMCID: PMC8772527 DOI: 10.12688/wellcomeopenres.16801.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Typhoid and paratyphoid fever (enteric fever) is a common cause of non-specific febrile infection in adults and children presenting to health care facilities in low resource settings such as the South Asia. A 7-day course of a single oral antimicrobial such as ciprofloxacin, cefixime, or azithromycin is commonly used for its treatment. Increasing antimicrobial resistance threatens the effectiveness of these treatment choices. We hypothesize that combined treatment with azithromycin (active mainly intracellularly) and cefixime (active mainly extracellularly) will be a better option for the treatment of clinically suspected and culture-confirmed typhoid fever in South Asia. Methods: This is a phase IV, international multi-center, multi-country, comparative participant-and observer-blind, 1:1 randomised clinical trial. Patients with suspected uncomplicated typhoid fever will be randomized to one of the two interventions: Arm A: azithromycin 20mg/kg/day oral dose once daily (maximum 1gm/day) and cefixime 20mg/kg/day oral dose in two divided doses (maximum 400mg bd) for 7 days, Arm B: azithromycin 20mg/kg/day oral dose once daily (max 1gm/day) for 7 days AND cefixime-matched placebo for 7 days. We will recruit 1500 patients across sites in Bangladesh, India, Nepal, and Pakistan. We will assess whether treatment outcomes are better with the combination after one week of treatment and at one- and three-months follow-up. Discussion: Combined treatment may limit the emergence of resistance if one of the components is active against resistant sub-populations not covered by the other antimicrobial activity. If the combined treatment is better than the single antimicrobial treatment, this will be an important result for patients across South Asia and other typhoid endemic areas. Clinicaltrials.gov registration: NCT04349826 (16/04/2020)
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Affiliation(s)
- Abhishek Giri
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sabina Dongol
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Amit Arjyal
- Patan Academy of Health Sciences, Lalitpur, Bagmati, 44700, Nepal
| | - Archana Maharjan
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | | | - Buddhi Paudyal
- Patan Academy of Health Sciences, Lalitpur, Bagmati, 44700, Nepal
| | - Christiane Dolecek
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Duy Pham Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Farah Qamar
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Gagandeep Kang
- Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Ho Van Hien
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Jacob John
- Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Katrina Lawson
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Marcel Wolbers
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Md. Shabab Hossain
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | - M Sharifuzzaman
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | | | - Nhukesh Maharjan
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Piero Olliaro
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Ronas Shakya
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Sadia Shakoor
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Samita Rijal
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Sonia Qureshi
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Stephen Baker
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Subi Joshi
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | - Thomas Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, South Yorkshire, UK
| | - Tran Nguyen Bao
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, 10400, Thailand
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Christopher M. Parry
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Buddha Basnyat
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Giri A, Karkey A, Dongol S, Arjyal A, Maharjan A, Veeraraghavan B, Paudyal B, Dolecek C, Gajurel D, Phuong DNT, Thanh DP, Qamar F, Kang G, Hien HV, John J, Lawson K, Wolbers M, Hossain MS, Sharifuzzaman M, Luangasanatip N, Maharjan N, Olliaro P, Rupali P, Shakya R, Shakoor S, Rijal S, Qureshi S, Baker S, Joshi S, Ahmed T, Darton T, Bao TN, Lubell Y, Kestelyn E, Thwaites G, Parry CM, Basnyat B. Azithromycin and cefixime combination versus azithromycin alone for the out-patient treatment of clinically suspected or confirmed uncomplicated typhoid fever in South Asia: a randomised controlled trial protocol. Wellcome Open Res 2021; 6:207. [PMID: 35097222 PMCID: PMC8772527 DOI: 10.12688/wellcomeopenres.16801.1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 12/27/2023] Open
Abstract
Background: Typhoid and paratyphoid fever (enteric fever) is a common cause of non-specific febrile infection in adults and children presenting to health care facilities in low resource settings such as the South Asia. A 7-day course of a single oral antimicrobial such as ciprofloxacin, cefixime, or azithromycin is commonly used for its treatment. Increasing antimicrobial resistance threatens the effectiveness of these treatment choices. We hypothesize that combined treatment with azithromycin (active mainly intracellularly) and cefixime (active mainly extracellularly) will be a better option for the treatment of clinically suspected and culture-confirmed typhoid fever in South Asia. Methods: This is a phase IV, international multi-center, multi-country, comparative participant-and observer-blind, 1:1 randomised clinical trial. Patients with suspected uncomplicated typhoid fever will be randomized to one of the two interventions: Arm A: azithromycin 20mg/kg/day oral dose once daily (maximum 1gm/day) and cefixime 20mg/kg/day oral dose in two divided doses (maximum 400mg bd) for 7 days, Arm B: azithromycin 20mg/kg/day oral dose once daily (max 1gm/day) for 7 days AND cefixime-matched placebo for 7 days. We will recruit 1500 patients across sites in Bangladesh, India, Nepal, and Pakistan. We will assess whether treatment outcomes are better with the combination after one week of treatment and at one- and three-months follow-up. Discussion: Combined treatment may limit the emergence of resistance if one of the components is active against resistant sub-populations not covered by the other antimicrobial activity. If the combined treatment is better than the single antimicrobial treatment, this will be an important result for patients across South Asia and other typhoid endemic areas. Clinicaltrials.gov registration: NCT04349826 (16/04/2020).
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Affiliation(s)
- Abhishek Giri
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sabina Dongol
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Amit Arjyal
- Patan Academy of Health Sciences, Lalitpur, Bagmati, 44700, Nepal
| | - Archana Maharjan
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | | | - Buddhi Paudyal
- Patan Academy of Health Sciences, Lalitpur, Bagmati, 44700, Nepal
| | - Christiane Dolecek
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Duy Pham Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Farah Qamar
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Gagandeep Kang
- Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Ho Van Hien
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Jacob John
- Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Katrina Lawson
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Marcel Wolbers
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Md. Shabab Hossain
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | - M Sharifuzzaman
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | | | - Nhukesh Maharjan
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Piero Olliaro
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Ronas Shakya
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Sadia Shakoor
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Samita Rijal
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Sonia Qureshi
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Stephen Baker
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Subi Joshi
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | - Thomas Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, South Yorkshire, UK
| | - Tran Nguyen Bao
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, 10400, Thailand
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Christopher M. Parry
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Buddha Basnyat
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Qureshi S, Naveed AB, Yousafzai MT, Ahmad K, Ansari S, Lohana H, Mukhtar A, Qamar FN. Response of extensively drug resistant Salmonella Typhi to treatment with meropenem and azithromycin, in Pakistan. PLoS Negl Trop Dis 2020; 14:e0008682. [PMID: 33057330 PMCID: PMC7561124 DOI: 10.1371/journal.pntd.0008682] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 08/05/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Salmonella Typhi is one of the leading health problems in Pakistan. With the emergence of extensively drug resistant (XDR) Salmonella Typhi, treatment options are limited. Here we report the clinical manifestations and the response to treatment of patients with XDR Typhoid fever. The patients were treated with either Meropenem or Azithromycin or a combination of both. METHODS We reviewed the records of culture confirmed XDR typhoid who visited Aga Khan University Hospital (AKUH), Karachi and Aga Khan Secondary Care Hospital, Hyderabad from April 2017 to June 2018. Symptoms developed during disease, unplanned treatment extension and complications developed while on antimicrobials was recorded. Means with standard deviation were calculated for duration of treatment, time to defervescence, and cost of treatment. RESULTS Records of 81 culture confirmed XDR typhoid patients admitted at the AKU hospitals were reviewed. Most, (n = 45; 56%) were male. Mean age of the cases was 8.03 years with range (1-40). About three quarter (n = 66) of the patients were treated as inpatient. Fever and vomiting were the most common symptoms at the time of presentation. Oral azithromycin alone (n = 22; 27%), intravenous meropenem alone (n = 20; 25%), or a combination of azithromycin and meropenem (n = 39; 48%) were the options used for treatment. Average (95% confidence interval) time to defervescence was 7.1(5.5-8.6), 6.7(4.7-8.7), and 6.7(5.5-7.9) days for each treatment option respectively whereas there were 1,0 and 3 treatment failures in each treatment option respectively. Average cost of treatment per day for azithromycin was US$5.87 whereas it was US$88.46 for meropenem. CONCLUSION Patients treated with either Azithromycin, Meropenem alone or in combination showed similar time to defervescence. Because of the lower cost of azithromycin, it is preferable in lower socio-economic areas. Background estimates for power calculation can be made for more robust clinical trials using this observational data.
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Affiliation(s)
- Sonia Qureshi
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | | | | | - Khalil Ahmad
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Sarwat Ansari
- Department of Pediatric and Child Health, Aga Khan Maternal and Child Care Centre, Hyderabad, Pakistan
| | - Heeramani Lohana
- Department of Pediatric and Child Health, Aga Khan Maternal and Child Care Centre, Hyderabad, Pakistan
| | - Aimen Mukhtar
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
| | - Farah Naz Qamar
- Department of Pediatrics and Child Health, Aga Khan University Hospital, Karachi, Pakistan
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Jin C, Gibani MM, Pennington SH, Liu X, Ardrey A, Aljayyoussi G, Moore M, Angus B, Parry CM, Biagini GA, Feasey NA, Pollard AJ. Treatment responses to Azithromycin and Ciprofloxacin in uncomplicated Salmonella Typhi infection: A comparison of Clinical and Microbiological Data from a Controlled Human Infection Model. PLoS Negl Trop Dis 2019; 13:e0007955. [PMID: 31877141 PMCID: PMC6948818 DOI: 10.1371/journal.pntd.0007955] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 01/08/2020] [Accepted: 11/26/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The treatment of enteric fever is complicated by the emergence of antimicrobial resistant Salmonella Typhi. Azithromycin is commonly used for first-line treatment of uncomplicated enteric fever, but the response to treatment may be sub-optimal in some patient groups when compared with fluoroquinolones. METHODS We performed an analysis of responses to treatment with azithromycin (500mg once-daily, 14 days) or ciprofloxacin (500mg twice-daily, 14 days) in healthy UK volunteers (18-60 years) enrolled into two Salmonella controlled human infection studies. Study A was a single-centre, open-label, randomised trial. Participants were randomised 1:1 to receive open-label oral ciprofloxacin or azithromycin, stratified by vaccine group (Vi-polysaccharide, Vi-conjugate or control Men-ACWY vaccine). Study B was an observational challenge/re-challenge study, where participants were randomised to challenge with Salmonella Typhi or Salmonella Paratyphi A. Outcome measures included fever clearance time, blood-culture clearance time and a composite measure of prolonged treatment response (persistent fever ≥38.0°C for ≥72 hours, persistently positive S. Typhi blood cultures for ≥72 hours, or change in antibiotic treatment). Both trials are registered with ClinicalTrials.gov (NCT02324751 and NCT02192008). FINDINGS In 81 participants diagnosed with S. Typhi in two studies, treatment with azithromycin was associated with prolonged bacteraemia (median 90.8 hours [95% CI: 65.9-93.8] vs. 20.1 hours [95% CI: 7.8-24.3], p<0.001) and prolonged fever clearance times <37.5°C (hazard ratio 2.4 [95%CI: 1.2-5.0]; p = 0.02). Results were consistent when studies were analysed independently and in a sub-group of participants with no history of vaccination or previous challenge. A prolonged treatment response was observed significantly more frequently in the azithromycin group (28/52 [54.9%]) compared with the ciprofloxacin group (1/29 [3.5%]; p<0.001). In participants treated with azithromycin, observed systemic plasma concentrations of azithromycin did not exceed the minimum inhibitory concentration (MIC), whilst predicted intracellular concentrations did exceed the MIC. In participants treated with ciprofloxacin, the observed systemic plasma concentrations and predicted intracellular concentrations of ciprofloxacin exceeded the MIC. INTERPRETATION Azithromycin at a dose of 500mg daily is an effective treatment for fully sensitive strains of S. Typhi but is associated with delayed treatment response and prolonged bacteraemia when compared with ciprofloxacin within the context of a human challenge model. Whilst the cellular accumulation of azithromycin is predicted to be sufficient to treat intracellular S. Typhi, systemic exposure may be sub-optimal for the elimination of extracellular circulating S. Typhi. In an era of increasing antimicrobial resistance, further studies are required to define appropriate azithromycin dosing regimens for enteric fever and to assess novel treatment strategies, including combination therapies. TRIAL REGISTRATION ClinicalTrials.gov (NCT02324751 and NCT02192008).
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Affiliation(s)
- Celina Jin
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Malick M. Gibani
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
- Department of Infectious Diseases, Imperial College London, London, United Kingdom
| | - Shaun H. Pennington
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Xinxue Liu
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Alison Ardrey
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Ghaith Aljayyoussi
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Maria Moore
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Brian Angus
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Christopher M. Parry
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- School of Tropical Medicine and Global Health, Nagsaki University, Nagasaki, Japan
| | - Giancarlo A. Biagini
- Research Centre for Drugs and Diagnostics, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Nicholas A. Feasey
- Institute of Infection and Global Health, University of Liverpool, Liverpool, United Kingdom
- Malawi Liverpool Wellcome Trust Clinical research Programme, Blantyre, Malawi
| | - Andrew J. Pollard
- Oxford Vaccine Group, Department of Paediatrics, University of Oxford, and NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
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8
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Saito MK, Parry CM, Yeung S. Modelling the cost-effectiveness of a rapid diagnostic test (IgMFA) for uncomplicated typhoid fever in Cambodia. PLoS Negl Trop Dis 2018; 12:e0006961. [PMID: 30452445 PMCID: PMC6277117 DOI: 10.1371/journal.pntd.0006961] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 12/03/2018] [Accepted: 10/31/2018] [Indexed: 11/18/2022] Open
Abstract
Typhoid fever is a common cause of fever in Cambodian children but diagnosis and treatment are usually presumptive owing to the lack of quick and accurate tests at an initial consultation. This study aimed to evaluate the cost-effectiveness of using a rapid diagnostic test (RDT) for typhoid fever diagnosis, an immunoglobulin M lateral flow assay (IgMFA), in a remote health centre setting in Cambodia from a healthcare provider perspective. A cost-effectiveness analysis (CEA) with decision analytic modelling was conducted. We constructed a decision tree model comparing the IgMFA versus clinical diagnosis in a hypothetical cohort with 1000 children in each arm. The costs included direct medical costs only. The eligibility was children (≤14 years old) with fever. Time horizon was day seven from the initial consultation. The number of treatment success in typhoid fever cases was the primary health outcome. The number of correctly diagnosed typhoid fever cases (true-positives) was the intermediate health outcome. We obtained the incremental cost effectiveness ratio (ICER), expressed as the difference in costs divided by the difference in the number of treatment success between the two arms. Sensitivity analyses were conducted. The IgMFA detected 5.87 more true-positives than the clinical diagnosis (38.45 versus 32.59) per 1000 children and there were 3.61 more treatment successes (46.78 versus 43.17). The incremental cost of the IgMFA was estimated at $5700; therefore, the ICER to have one additional treatment success was estimated to be $1579. The key drivers for the ICER were the relative sensitivity of IgMFA versus clinical diagnosis, the cost of IgMFA, and the prevalence of typhoid fever or multi-drug resistant strains. The IgMFA was more costly but more effective than the clinical diagnosis in the base-case analysis. An IgMFA could be more cost-effective than the base-case if the sensitivity of IgMFA was higher or cost lower. Decision makers may use a willingness-to-pay threshold that considers the additional cost of hospitalisation for treatment failures.
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Affiliation(s)
- Mari Kajiwara Saito
- Department of Non-Communicable Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, United Kingdom
- * E-mail:
| | - Christopher M. Parry
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
- School of Tropical Medicine and Global Health, Nagasaki University, Nagasaki, Japan
| | - Shunmay Yeung
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Department of Clinical Research, Faculty of Infectious and Tropical Disease, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Zmora N, Shrestha S, Neuberger A, Paran Y, Tamrakar R, Shrestha A, Madhup SK, Bedi TRS, Koju R, Schwartz E. Open label comparative trial of mono versus dual antibiotic therapy for Typhoid Fever in adults. PLoS Negl Trop Dis 2018; 12:e0006380. [PMID: 29684022 PMCID: PMC5912710 DOI: 10.1371/journal.pntd.0006380] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 03/09/2018] [Indexed: 11/18/2022] Open
Abstract
Background Emerging resistance to antibiotics renders therapy of Typhoid Fever (TF) increasingly challenging. The current single-drug regimens exhibit prolonged fever clearance time (FCT), imposing a great burden on both patients and health systems, and potentially contributing to the development of antibiotic resistance and the chronic carriage of the pathogens. The aim of our study was to assess the efficacy of combining third-generation cephalosporin therapy with azithromycin on the outcomes of TF in patients living in an endemic region. Methods An open-label, comparative trial was conducted at Dhulikhel Hospital, Nepal, between October 2012 and October 2014. Only culture-confirmed TF cases were eligible. Patients were alternately allocated to one of four study arms: hospitalized patients received either intravenous ceftriaxone or a combination of ceftriaxone and oral azithromycin, while outpatients received either oral azithromycin or a combination of oral azithromycin and cefexime. The primary outcome evaluated was FCT and the secondary outcomes included duration of bacteremia. Results 105 blood culture-confirmed patients, of whom 51 were treated as outpatients, were eligible for the study. Of the 88 patients who met the inclusion criteria for FCT analysis 41 patients received a single-agent regimen, while 47 patients received a combined regimen. Results showed that FCT was significantly shorter for the latter (95 versus 88 hours, respectively, p = 0·004), and this effect was exhibited in both the hospitalized and the outpatient sub-groups. Repeat blood cultures, drawn on day 3, were positive for 8/47 (17%) patients after monotherapy, versus 2/51 (4%) after combination therapy (p = 0·045). No severe complications or fatalities occurred in any of the groups. Conclusions Combined therapy of third-generation cephalosporins and azithromycin for TF may surpass monotherapy in terms of FCT and time to elimination of bacteremia. Trial registration Trial registration number: NCT02224040. Typhoid fever (TF) is a serious disease and the most common etiology of bloodstream infections in febrile patients in the Indian subcontinent. Before the advent of antibiotics its mortality rate reached up to 40%, and dropped dramatically upon their introduction. However, over the last decades multidrug-resistant strains have emerged, further posing a challenge to the treatment of TF. Here, we propose a novel treatment approach, combining azithromycin and a third-generation cephalosporin, two antibiotic agents, which act synergistically on the two niches occupied by the bacteria, the intra- and the extra-cellular compartments respectively. In our study of a rural Nepalese population with culture-confirmed TF, we have shown that dual therapy was superior to monotherapy in terms of time to defervescence and bacteremia elimination, both in outpatient and inpatient settings. We hence advocate the combination of these two antibiotics as a more effective therapeutic strategy than the current standard of care, and suggest that such approach may shorten patients’ hospital stay, and reduce both pathogen carriage rates and the development of antibiotic resistance.
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Affiliation(s)
- Niv Zmora
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sudeep Shrestha
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Ami Neuberger
- Travel Medicine & Tropical Diseases and Internal Medicine B, Rambam Medical Center, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yael Paran
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Ashish Shrestha
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | | | - T. R. S. Bedi
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Rajendra Koju
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Eli Schwartz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Center for Geographic Medicine and Tropical Diseases, the Chaim Sheba Medical Center, Tel Hashomer, Israel
- * E-mail:
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Zhu XH, Tian L, Cheng ZJ, Liu WY, Li S, Yu WT, Zhang WQ, Xiang X, Sun ZY. Viral and Bacterial Etiology of Acute Diarrhea among Children under 5 Years of Age in Wuhan, China. Chin Med J (Engl) 2017; 129:1939-44. [PMID: 27503019 PMCID: PMC4989425 DOI: 10.4103/0366-6999.187852] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Acute diarrhea remains the serious problem in developing countries, especially among children under 5 years of age. Currently, only two or three common diarrhea pathogens were screened at most hospitals in China. The aim of this study was to provide a wide variety of diarrhea pathogens and their antimicrobial resistance patterns in children under 5 years of age. METHODS Totally 381 stool samples collected from Tongji Hospital between July 1, 2014 and June 30, 2015 were tested by culture and/or polymerase chain reaction for eight kinds of bacteria and five kinds of viruses. An antimicrobial sensitivity test was performed using dilution method recommended by the Clinical and Laboratory Standards Institute. RESULTS Viral infections were mainly identified in infants (0-11 months), whereas bacterial infections were more prevalent in the age of 24-59 months. About 69.8% of samples were positive for at least one pathogen, 51.7% of samples were virus positive, followed by bacteria positive cases (19.4%), and 12.6% of cases displayed co-infections with two viruses or a virus and a bacterium. Rotavirus was the most prevalent pathogen, followed closely by norovirus, while Salmonella was the most commonly isolated bacteria, followed by diarrheagenic Escherichia coli (DEC) and Campylobacter. More than 40% of Salmonella spp. and DEC isolates were resistant to first-line antibiotics (ampicillin, trimethoprim-sulfamethoxazole, and tetracycline). Around 10% of Salmonella spp. isolates were resistant to ceftriaxone and ciprofloxacin simultaneously. Campylobacter spp. displayed high resistance to ciprofloxacin but kept low resistance to azithromycin and doxycycline. CONCLUSIONS The etiology of acute diarrhea varies in children of different age groups. The high frequency of infection with viruses suggests the urgent demand for new viral vaccine development. Proper use of antibiotics in the treatment of acute diarrhea is crucial due to the high level of antibiotic resistance.
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Affiliation(s)
- Xu-Hui Zhu
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Lei Tian
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Zhong-Ju Cheng
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Wei-Yong Liu
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Song Li
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Wei-Ting Yu
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Wen-Qian Zhang
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Xu Xiang
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Zi-Yong Sun
- Department of Clinical Laboratory, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
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Nair B, Simalti A, Sharma S. Study comparing ceftriaxone with azithromycin for the treatment of uncomplicated typhoid fever in children of India. ACTA ACUST UNITED AC 2017. [DOI: 10.4103/1755-6783.205534] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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12
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Requena-Méndez A, Berrocal M, Almela M, Soriano A, Gascón J, Muñoz J. Enteric fever in Barcelona: Changing patterns of importation and antibiotic resistance. Travel Med Infect Dis 2016; 14:577-582. [PMID: 27890811 DOI: 10.1016/j.tmaid.2016.11.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 11/21/2016] [Accepted: 11/22/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Enteric fever's incidence is decreasing among residents of high-income countries, although it's rising in travelers coming from low-resource endemic settings. The study's aim is to describe epidemiological, clinical and laboratory features of patients with enteric fever. METHODS Retrospective descriptive study of enteric fever cases diagnosed at a Tropical Medicine Unit in Barcelona, 1993-2012. RESULTS Out of 40 patients, 31(77,5%) were returning travelers, and 70% of them had been in Southern Asia. In the rest of patients without an antecedent of a recent travel, the infection occurred mainly before year 2000. The more frequently reported symptoms were fever and diarrhea, lacking significant differences between S. typhi and S. paratyphi infections. Quinolones were used as empiric treatment in 47.2% of patients, 36.1% received 3rd generation cephalosporins, 2.78% azithromycin and 13.89% other combinations. Resistance to quinolones in the S. paratyphi group (66.7%) was significantly higher compared with the S. typhi group (20%) (p:0.02). 22.5% of patients had treatment failure and 23.6% patients presented complications, none of them had been previously vaccinated. CONCLUSIONS The diagnosis of enteric fever was more frequent among travelers coming from Southern-East Asia. Quinolone resistance is widely spread, particularly in S. paratyphi serotypes and should not be considered as first choice treatment anymore.
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Affiliation(s)
- Ana Requena-Méndez
- Barcelona Institute for Global Health, ISGlobal-CRESIB, Universitat de Barcelona, Spain.
| | - Monica Berrocal
- Barcelona Institute for Global Health, ISGlobal-CRESIB, Universitat de Barcelona, Spain
| | - Manuel Almela
- Department of Microbiology (CDB), Hospital Clínic, Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clinic, Barcelona, Spain
| | - Joaquim Gascón
- Barcelona Institute for Global Health, ISGlobal-CRESIB, Universitat de Barcelona, Spain
| | - José Muñoz
- Barcelona Institute for Global Health, ISGlobal-CRESIB, Universitat de Barcelona, Spain
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13
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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: 662] [Impact Index Per Article: 73.6] [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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14
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Yombi JC, Martins L, Vandercam B, Rodriguez-Villalobos H, Robert A. Clinical features and outcome of typhoid fever and invasive non-typhoidal salmonellosis in a tertiary hospital in Belgium: analysis and review of the literature. Acta Clin Belg 2015; 70:265-71. [PMID: 25819116 DOI: 10.1179/2295333715y.0000000016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Typhoid fever (TF) occurs rarely in industrialized countries because of advances in health care and improvement of drinking water. Conversely, non-typhoid salmonellosis (NTS) remains widespread, because of food contamination or asymptomatic carriage. Non-typhoid salmonellosis can be severe when becoming invasive non-typhoid salmonellosis (iNTS). Although established prognostic indicators of the two pathologies are different, direct comparisons between iNTS and TF in the literature remain scarce. The purpose of this study was to analyse and compare demographic, clinical features and outcome of hospitalized patients with TF and iNTS. METHODS Demographic, clinical features and outcome were retrospectively analysed in a series of patients hospitalized between 2007 and 2012. RESULTS A total of 33 patients were enrolled, including 13 with established TF and 20 with iNTS. No differences between TF and iNTS patients were observed in incidence of fever, abdominal cramps, diarrhoea, headache, nausea and vomiting and duration of antibiotic therapy (≤ 7 days in both groups). Although the clinical outcome of TF patients was identical to that of iNTS patients, including incidence of complications, length of hospitalization and mortality (1/13 (7.7%) vs 2/20 (10%), P = 0.43), comorbidities were less frequent in the TF group than in the iNTS group (2/13 vs 15/20, P = 0.003). CONCLUSION The clinical profile and outcome of TF patients are similar to those with iNTS. Although comorbidities are more often associated with iNTS, the results of our study suggest that clinical management of these two diseases should remain similar.
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15
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Abstract
Gastroenteritis due to enteric pathogens is generally a self-limiting disease for which antimicrobial treatment is not required. However, treatment should be considered for cases of severe or prolonged diarrhea, extraintestinal isolation of bacteria, or diarrhea in immunocompromised hosts, the elderly, and infants. Various resistance trends and current issues concerning antimicrobial susceptibility testing of enteric pathogens are reviewed in this article, including Campylobacter, Salmonella, Shigella, Vibrio, Aeromonas, Plesiomonas, and Clostridium difficile. Updated interpretive criteria from breakpoint-setting organizations are reviewed, along with explanations for recent changes in antimicrobial breakpoints.
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Affiliation(s)
- Romney M Humphries
- Pathology & Laboratory Medicine, University of California Los Angeles, 10833 Le Conte Avenue, Brentwood Annex, Los Angeles, CA 90095, USA
| | - Audrey N Schuetz
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College/NewYork-Presbyterian Hospital, 525 East 68th Street, Starr 737C, New York, NY 10065, USA.
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Clinically and microbiologically derived azithromycin susceptibility breakpoints for Salmonella enterica serovars Typhi and Paratyphi A. Antimicrob Agents Chemother 2015; 59:2756-64. [PMID: 25733500 PMCID: PMC4394775 DOI: 10.1128/aac.04729-14] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2014] [Accepted: 02/15/2015] [Indexed: 11/20/2022] Open
Abstract
Azithromycin is an effective treatment for uncomplicated infections with Salmonella enterica serovar Typhi and serovar Paratyphi A (enteric fever), but there are no clinically validated MIC and disk zone size interpretative guidelines. We studied individual patient data from three randomized controlled trials (RCTs) of antimicrobial treatment in enteric fever in Vietnam, with azithromycin used in one treatment arm, to determine the relationship between azithromycin treatment response and the azithromycin MIC of the infecting isolate. We additionally compared the azithromycin MIC and the disk susceptibility zone sizes of 1,640 S. Typhi and S. Paratyphi A clinical isolates collected from seven Asian countries. In the RCTs, 214 patients who were treated with azithromycin at a dose of 10 to 20 mg/ml for 5 to 7 days were analyzed. Treatment was successful in 195 of 214 (91%) patients, with no significant difference in response (cure rate, fever clearance time) with MICs ranging from 4 to 16 μg/ml. The proportion of Asian enteric fever isolates with an MIC of ≤ 16 μg/ml was 1,452/1,460 (99.5%; 95% confidence interval [CI], 98.9 to 99.7) for S. Typhi and 207/240 (86.3%; 95% CI, 81.2 to 90.3) (P < 0.001) for S. Paratyphi A. A zone size of ≥ 13 mm to a 5-μg azithromycin disk identified S. Typhi isolates with an MIC of ≤ 16 μg/ml with a sensitivity of 99.7%. An azithromycin MIC of ≤ 16 μg/ml or disk inhibition zone size of ≥ 13 mm enabled the detection of susceptible S. Typhi isolates that respond to azithromycin treatment. Further work is needed to define the response to treatment in S. Typhi isolates with an azithromycin MIC of >16 μg/ml and to determine MIC and disk breakpoints for S. Paratyphi A.
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Hassing RJ, Goessens WHF, van Pelt W, Mevius DJ, Stricker BH, Molhoek N, Verbon A, van Genderen PJJ. Salmonella subtypes with increased MICs for azithromycin in travelers returned to The Netherlands. Emerg Infect Dis 2014; 20:705-8. [PMID: 24655478 PMCID: PMC3966360 DOI: 10.3201/eid2004.131536] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Antimicrobial susceptibility was analyzed for 354 typhoidal Salmonella isolates collected during 1999-2012 in the Netherlands. In 16.1% of all isolates and in 23.8% of all isolates that showed increased MICs for ciprofloxacin, the MIC for azithromycin was increased. This resistance may complicate empirical treatment of enteric fever.
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Kobayashi T, Hayakawa K, Mawatari M, Mezaki K, Takeshita N, Kutsuna S, Fujiya Y, Kanagawa S, Ohmagari N, Kato Y, Morita M. Case report: failure under azithromycin treatment in a case of bacteremia due to Salmonella enterica Paratyphi A. BMC Infect Dis 2014; 14:404. [PMID: 25041573 PMCID: PMC4223471 DOI: 10.1186/1471-2334-14-404] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 07/03/2014] [Indexed: 12/03/2022] Open
Abstract
Background Limited information is available regarding the clinical efficacy of azithromycin for the treatment of enteric fever due to fluoroquinolone-resistant Salmonella Typhi and Salmonella Paratyphi among travelers returning to their home countries. Case presentation We report a case of a 52-year-old Japanese man who returned from India, who developed a fever of 39°C with no accompanying symptoms 10 days after returning to Japan from a 1-month business trip to Delhi, India. His blood culture results were positive for Salmonella Paratyphi A. He was treated with 14 days of ceftriaxone, after which he remained afebrile for 18 days before his body temperature again rose to 39°C with no apparent symptoms. He was then empirically given 500 mg of azithromycin, but experienced clinical and microbiological failure of azithromycin treatment for enteric fever due to Salmonella Paratyphi A. However, the minimum inhibitory concentration (MIC) of azithromycin was not elevated (8 mg/L). He was again given ceftriaxone for 14 days with no signs of recurrence during the follow-up. Conclusion There are limited data available for the treatment of enteric fever using azithromycin in travelers from developed countries who are not immune to the disease, and thus, careful follow-up is necessary. In our case, the low azithromycin dose might have contributed the treatment failure. Additional clinical data are needed to determine the rate of success, MIC, and contributing factors for success and/or failure of azithromycin treatment for both Salmonella Typhi and Salmonella Paratyphi infections.
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Affiliation(s)
- Tetsuro Kobayashi
- Disease Control and Prevention Center, National Center for Global Health and Medicine, Shinjuku-ku Toyama 1-21-1, 162-8655 Tokyo, Japan.
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Balaji V, Sharma A, Ranjan P, Kapil A. Revised ciprofloxacin breakpoints for Salmonella Typhi: Its implications in India. Indian J Med Microbiol 2014; 32:161-3. [DOI: 10.4103/0255-0857.129804] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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20
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Fernando S, Molland JG, Gottlieb T. Failure of oral antibiotic therapy, including azithromycin, in the treatment of a recurrent breast abscess caused by Salmonella enterica serotype Paratyphi A. Pathog Glob Health 2013. [PMID: 23182142 DOI: 10.1179/2047773212y.0000000010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
We report a case of recurrent, multifocal Salmonella enterica serotype Paratyphi A breast abscesses, resistant to ciprofloxacin, which relapsed despite surgery, aspiration and multiple courses of antibiotics, including co-trimoxazole and azithromycin. The patient was cured after a prolonged course of intravenous ceftriaxone.
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Comeau JL, Tran TH, Moore DL, Phi CM, Quach C. Salmonella enterica serotype Typhi infections in a Canadian pediatric hospital: a retrospective case series. CMAJ Open 2013; 1:E56-61. [PMID: 25077103 PMCID: PMC4006666 DOI: 10.9778/cmajo.20120012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In developed countries, typhoid fever generally occurs in travellers or recent immigrants from endemic areas. Our aim was to describe the epidemiology of Salmonella enterica serotype Typhi infections among children presenting to a pediatric teaching hospital in Montréal, Quebec. METHODS We included all patients less than 18 years of age who presented to the Montreal Children's Hospital between 1991 and 2011 with a laboratory-confirmed diagnosis of typhoid fever (Salmonella enterica ser. Typhi isolated from blood or stool) in a retrospective case series. RESULTS During the study period, we identified 39 cases of typhoid fever (mean age of patient 7.5 yr). Four (10.3%) of these cases occurred in newly arrived immigrants shortly after their arrival in Canada (median 15.5 d). Most cases (76.9%) occurred in children who had visited friends and relatives in their home country. None of the travellers had received a vaccination against typhoid fever before their departure. All cases presented with high fever (mean temperature 40.4°C) that lasted for a mean of 15.8 days. Common accompanying symptoms included anorexia, abdominal pain, vomiting and diarrhea. All 39 isolates of S. enterica ser. Typhi were susceptible to third-generation cephalosporins, and 7 were resistant to ciprofloxacin. Ampicillin resistance occurred in 10 (25.6%) of the isolates. No deaths occurred among the study participants. INTERPRETATION Most cases of typhoid fever occurred in children who had travelled to endemic areas to visit friends and relatives. Thus, there is a role for increased awareness on the part of family physicians and pediatricians caring for these children to discuss travel-related infections during regularly scheduled appointments, because parents might not consult travel clinics or discuss their travel plans before travelling back to their home country.
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Affiliation(s)
- Jeannette L. Comeau
- Infectious Diseases Division, Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montréal, Que
- Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montréal, Que
| | - Thai Hoa Tran
- Infectious Diseases Division, Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montréal, Que
| | - Dorothy L. Moore
- Infectious Diseases Division, Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montréal, Que
| | - Chi-Minh Phi
- Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montréal, Que
| | - Caroline Quach
- Infectious Diseases Division, Department of Pediatrics, Montreal Children’s Hospital, McGill University, Montréal, Que
- Department of Microbiology, Montreal Children’s Hospital, McGill University, Montréal, Que
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Vlieghe ER, Phe T, De Smet B, Veng CH, Kham C, Bertrand S, Vanhoof R, Lynen L, Peetermans WE, Jacobs JA. Azithromycin and ciprofloxacin resistance in Salmonella bloodstream infections in Cambodian adults. PLoS Negl Trop Dis 2012; 6:e1933. [PMID: 23272255 PMCID: PMC3521708 DOI: 10.1371/journal.pntd.0001933] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2012] [Accepted: 10/17/2012] [Indexed: 02/07/2023] Open
Abstract
Background Salmonella enterica is a frequent cause of bloodstream infection (BSI) in Asia but few data are available from Cambodia. We describe Salmonella BSI isolates recovered from patients presenting at Sihanouk Hospital Centre of Hope, Phnom Penh, Cambodia (July 2007–December 2010). Methodology Blood was cultured as part of a microbiological prospective surveillance study. Identification of Salmonella isolates was performed by conventional methods and serotyping. Antibiotic susceptibilities were assessed using disk diffusion, MicroScan and E-test macromethod. Clonal relationships were assessed by Pulsed Field Gel Electrophoresis; PCR and sequencing for detection of mutations in Gyrase and Topoisomerase IV and presence of qnr genes. Principal Findings Seventy-two Salmonella isolates grew from 58 patients (mean age 34.2 years, range 8–71). Twenty isolates were identified as Salmonella Typhi, 2 as Salmonella Paratyphi A, 37 as Salmonella Choleraesuis and 13 as other non-typhoid Salmonella spp. Infection with human immunodeficiency virus (HIV) was present in 21 of 24 (87.5%) patients with S. Choleraesuis BSI. Five patients (8.7%) had at least one recurrent infection, all with S. Choleraesuis; five patients died. Overall, multi drug resistance (i.e., co-resistance to ampicillin, sulphamethoxazole-trimethoprim and chloramphenicol) was high (42/59 isolates, 71.2%). S. Typhi displayed high rates of decreased ciprofloxacin susceptibility (18/20 isolates, 90.0%), while azithromycin resistance was very common in S. Choleraesuis (17/24 isolates, 70.8%). Two S. Choleraesuis isolates were extended spectrum beta-lactamase producer. Conclusions and Significance Resistance rates in Salmonella spp. in Cambodia are alarming, in particular for azithromycin and ciprofloxacin. This warrants nationwide surveillance and revision of treatment guidelines. Salmonella enterica is a bacterium that causes important morbidity and mortality worldwide, especially in tropical low-resource settings. Over the past two decades, increasing rates of resistance for the commonly available oral antibiotics have been reported in Salmonella spp., especially from South(east) Asia. As microbiology laboratories are extremely scarce in Cambodia, data on the presence and resistance of Salmonella spp. in this country are limited. The authors describe the different types and antibiotic resistance of 72 Salmonella isolates from blood cultures sampled in 58 adult Cambodian patients with fever. The most common serovars were Salmonella Typhi and Salmonella Choleraesuis. The latter serovar causes illness in pigs, and may occasionally infect humans through contact with contaminated animals or environments, especially those with decreased immunity. The authors noted resistance for the first line oral antibiotics in nearly three quarters of all Salmonella isolates. In addition, 90% of all S. Typhi had decreased susceptibility for ciprofloxacin, while around 70% of S. Choleraesuis showed resistance to azithromycin. These results seriously limit the treatment options for typhoid fever and other invasive Salmonella infections and warrant nationwide surveillance of antibiotic resistance. This is the first report to describe such high rates of azithromycin resistance in Salmonella enterica.
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Affiliation(s)
- Erika R. Vlieghe
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp (ITM), Antwerp, Belgium
- * E-mail: (ERV); (JAJ)
| | - Thong Phe
- Sihanouk Hospital Centre of Hope (SHCH), Phnom Penh, Cambodia
| | - Birgit De Smet
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp (ITM), Antwerp, Belgium
| | - Chhun H. Veng
- Sihanouk Hospital Centre of Hope (SHCH), Phnom Penh, Cambodia
| | - Chun Kham
- Sihanouk Hospital Centre of Hope (SHCH), Phnom Penh, Cambodia
| | - Sophie Bertrand
- Belgian Reference Center for Salmonella, Scientific Institute of Public Health (IPH), Brussels, Belgium
| | - Raymond Vanhoof
- Belgian Reference Center for Salmonella, Scientific Institute of Public Health (IPH), Brussels, Belgium
| | - Lut Lynen
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp (ITM), Antwerp, Belgium
| | | | - Jan A. Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp (ITM), Antwerp, Belgium
- * E-mail: (ERV); (JAJ)
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Forehand CC, Cribb J, May JR. Examination of the Relationship Between Antimicrobials and Thrombocytosis. Ann Pharmacother 2012; 46:1425-9. [DOI: 10.1345/aph.1r080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Objective: To evaluate whether there is a relationship between antimicrobial therapy and the development of thrombocytosis. Data Sources: Literature was accessed through EMBASE (1977-June 2012) and MEDLINE (1977-June 2012) using the terms thrombocytosis and antimicrobial. In addition, reference citations from publications identified were reviewed. Study Selection and Data Extraction: All English-language publications identified were evaluated. For case reports, the Naranjo probability scale was used to calculate the likelihood of the drug causing the reaction. Data Synthesis: Thrombocytosis occurring during antimicrobial therapy is well documented, with several case reports and clinical trial observations. However, a direct causal relationship is not yet supported by the available literature. Platelets are welt known to be an acute phase reactant, with an elevated count occurring after acute conditions such as blood loss, inflammation, or infection. Thrombocytosis during antimicrobial therapy may be the result of an infectious process and not an adverse drug event. Conclusions: Based on the current available literature, a definitive link cannot be established between antimicrobial therapy and occurrence of thrombocytosis.
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Affiliation(s)
- Christy C Forehand
- Georgia Health Sciences Health System and College of Pharmacy, University of Georgia, Augusta, GA
| | - Jennifer Cribb
- Tuscaloosa Veterans Affairs Medical Center, Tuscaloosa, AL
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Chandey M, Multani AS. A comparative study of efficacy and safety of azithromycin and ofloxacin in uncomplicated typhoid Fever: a randomised, open labelled study. J Clin Diagn Res 2012; 6:1736-9. [PMID: 23373040 DOI: 10.7860/jcdr/2012/4702.2631] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2012] [Accepted: 08/08/2012] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To compare the efficacy and safety of azithromycin with ofloxacin in patients with uncomplicated typhoid fever. MATERIAL AND METHODS Forty adult patients with bacteriologically or serologically diagnosed, uncomplicated typhoid fever were included from Medicine out-patient department at Government medical college, Amritsar, India. They were randomized into 2 groups of 20 patients each. Group I: patients received ofloxacin 200mg orally twice daily for 7 days. Group II: Patients received Azithromycin orally 1 gm on day 1 and then 500 mg daily from day 2 to day 6. The following parameters were noted a) fever clearance time b) cure rate c) adverse drug reaction d) recurrence of symptoms, if any, during 4 weeks follow up. RESULTS Nineteen out of 20 patients from group I were cured with mean fever clearance time of 3.68 days while all 20 patients from group II were cured with mean fever clearance time of 3.65 days. No significant side effects were noted in any of the patients. No relapse was recorded in the present study in a follow up period of 4 weeks in both study groups. CONCLUSION Both ofloxacin and Azithromycin are almost equally efficacious and safe in treatment of typhoid fever with no major adverse effect. Azithromycin is an effective alternative in conditions where ofloxacin is contraindicated i.e., children, pregnant women and quinolone resistant cases of typhoid fever.
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Affiliation(s)
- Manish Chandey
- Assistant Professor, Department of Medicine, Sri Guru Ram Das Institute of Medical Sciences and Research , Amritsar, Punjab, India
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Rai S, Jain S, Prasad KN, Ghoshal U, Dhole TN. Rationale of azithromycin prescribing practices for enteric fever in India. Indian J Med Microbiol 2012; 30:30-3. [PMID: 22361757 DOI: 10.4103/0255-0857.93017] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
PURPOSE The present study was performed to assess the current susceptibility pattern of blood isolates of Salmonella spp from a super specialty hospital in North India against nalidixic acid, ciprofloxacin and azithromycin and compare the in vitro and in vivo response against azithromycin. MATERIALS AND METHODS We evaluated the minimum inhibitory concentration's (MIC's) of 107 blood isolates of Salmonella spp against nalidixic acid, azithromycin and ciprofloxacin and correlated in vitro and in vivo response of azithromycin from the treatment and discharge summaries from the Hospital Information System (HIS) software. RESULTS Among the 107 isolates evaluated, 94 (87.8%) were nalidixic acid-resistant (NAR) Salmonella and 36 were resistant to azithromycin by MIC testing. The MIC 90 value for azithromycin was 24 μg/mL. Among the 57 treatment histories evaluated using the HIS software, 19 (33%) patients had documented clinical non-response to azithromycin which required change of therapy. CONCLUSIONS The present study observed a higher MIC 90 values for azithromycin compared to Salmonella isolates from Western studies. There was also a documented clinical non-response against azithromycin. The in vitro and in vivo findings in this study suggest a guarded use of azithromycin for cases of enteric fever in India. The study also augments the reversal of resistance pattern in favour of chloramphenicol, ampicillin and trimethoprim - sulfamethoxazole.
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Affiliation(s)
- S Rai
- Department of Microbiology, UCMS and GTB Hospital, Dilshad Garden, Delhi - 110 095, India.
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Abstract
Emergence of multidrug resistance and decreased ciprofloxacin susceptibility (DCS) in Salmonella enterica serovar Typhi in South Asia have rendered older drugs, including ampicillin, chloramphenicol, trimethoprim-sulphamethoxazole, ciprofloxacin, and ofloxacin, ineffective or suboptimal for typhoid fever. Ideally, treatment should be safe and available for adults and children in shortened courses of 5 days, cause defervescence within 1 week, render blood and stool cultures sterile, and prevent relapse. In this review of 20 prospective clinical trials that enrolled more than 1600 culture-proven patients, azithromycin meets these criteria better than other drugs. Among fluoroquinolones, which are more effective than cephalosporins, gatifloxacin appears to be more effective than ciprofloxacin and ofloxacin for patients infected with bacteria showing DCS. Ceftriaxone continues to be useful as a back-up choice, and chloramphenicol, despite its toxicity for bone marrow and history of plasmid-mediated resistance, is making a comeback in developing countries that show their bacteria to be susceptible to it.
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Affiliation(s)
- T Butler
- Department of Microbiology and Immunology, Ross University School of Medicine, North Brunswick, NJ 08902, USA.
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Effa EE, Bukirwa H. WITHDRAWN: Azithromycin for treating uncomplicated typhoid and paratyphoid fever (enteric fever). Cochrane Database Syst Rev 2011; 2011:CD006083. [PMID: 21975751 PMCID: PMC6532635 DOI: 10.1002/14651858.cd006083.pub3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Review status: Current question - no update intended. Azithromycin treatments are included in the review: Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). (Thaver D, Zaidi AKM, Critchley JA, Azmatullah A, Madni SA, Bhutta ZA. Fluoroquinolones for treating typhoid and paratyphoid fever (enteric fever). Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004530. DOI: 10.1002/14651858.CD004530.pub3.) This latter review is being updated, and will be published in late 2011.Enteric fever (typhoid and paratyphoid fever) is potentially fatal. Infection with drug-resistant strains of the causative organism Salmonella enterica serovar Typhi or Paratyphi increases morbidity and mortality. Azithromycin may have better outcomes in people with uncomplicated forms of the disease. OBJECTIVES To compare azithromycin with other antibiotics for treating uncomplicated enteric fever. SEARCH STRATEGY In August 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, LILACS, and mRCT. We also searched conference proceedings, reference lists, and contacted researchers and a pharmaceutical company. SELECTION CRITERIA Randomized controlled trials comparing azithromycin with other antibiotics for treating children and adults with uncomplicated enteric fever confirmed by cultures of S. Typhi or Paratyphi in blood and/or stool. DATA COLLECTION AND ANALYSIS Both authors independently extracted data and assessed the risk of bias. Dichotomous data were presented and compared using the odds ratio, and continuous data were reported as arithmetic means with standard deviations and were combined using the mean difference (MD). Both were presented with 95% confidence intervals (CI). MAIN RESULTS Seven trials involving 773 participants met the inclusion criteria. The trials used adequate methods to generate the allocation sequence and conceal allocation, and were open label. Three trials exclusively included adults, two included children, and two included both adults and children; all were hospital inpatients. One trial evaluated azithromycin against chloramphenicol and did not demonstrate a difference for any outcome (77 participants, 1 trial). When compared with fluoroquinolones in four trials, azithromycin significantly reduced clinical failure (OR 0.48, 95% CI 0.26 to 0.89; 564 participants, 4 trials) and duration of hospital stay (MD -1.04 days, 95% CI -1.73 to -0.34 days; 213 participants, 2 trials); all four trials included people with multiple-drug-resistant or nalidixic acid-resistant strains of S. Typhi or S. Paratyphi. We detected no statistically significant difference in the other outcomes. Compared with ceftriaxone, azithromycin significantly reduced relapse (OR 0.09, 95% CI 0.01 to 0.70; 132 participants, 2 trials) and not other outcome measures. Few adverse events were reported, and most were mild and self limiting. AUTHORS' CONCLUSIONS Azithromycin appears better than fluoroquinolone drugs in populations that included participants with drug-resistant strains. Azithromycin may perform better than ceftriaxone.
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Affiliation(s)
- Emmanuel E Effa
- University of Calabar Teaching HospitalInternal MedicinePMB 1278CalabarCross River StateNigeria
| | - Hasifa Bukirwa
- Makerere University Medical SchoolMulago Hospital ComplexPO Box 24943KampalaUganda
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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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Maragkoudakis S, Poulidaki SR, Papadomanolaki E, Alevraki G, Papadogianni M, Oikonomou N, Fanourgiakis P. Empiric antimicrobial therapy and infectious diarrhea. Do we need local guidelines? Eur J Intern Med 2011; 22:e60-2. [PMID: 21925045 DOI: 10.1016/j.ejim.2011.06.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Revised: 05/31/2011] [Accepted: 06/01/2011] [Indexed: 11/16/2022]
Abstract
BACKGROUND In the management of acute diarrhea, administration of antibiotics may be indicated. Appropriate antimicrobial therapy can shorten illness, reduce morbidity and can be life-saving in invasive infections. Emergence of microbial strains resistant to commonly used antibiotics means that treatment failures may become common. Because of changing patterns of resistance, knowledge of recent local patterns of susceptibility can guide the initial choice of antibiotics. METHODS A retrospective study was conducted to investigate the epidemiology of infective gastroenteritis in patients over 14years old in the region of Chania (Crete). We reviewed all positive stool cultures and susceptibilities of the pathogens recovered from patients with symptoms of acute diarrhea, from 2003 until October 2010. RESULTS Out of 194 positive stool cultures, we observed 139 cases of Salmonella enterica and 48 cases of Campylobacter jejuni. During the last 3years of observation there was an increased incidence of C. jejuni, especially after the tap water outbreak that occurred in our region in 2009. DISCUSSION In the vast majority of acute diarrhea in adults, antibiotics are of no benefit and overprescription may confer to side effects, costs and emergence of resistance. Antibiotics are initiated in cases of febrile diarrheas especially those believed to have moderate to severe disease. Considering the increased incidence of C. jejuni and the resistance of the great majority of isolated strains to quinolones as well as the sensitivity of Salmonella spp. to azithromycin, administration of azithromycin empirically for acute diarrhea, when indicated, could be appropriate in our region.
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Affiliation(s)
- S Maragkoudakis
- 1st Department of Internal Medicine, General Hospital of Chania, Greece
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McGregor A, Wing JLK, Pollock E, Armstrong-James D, Morris-Jones S, Brown M. Management of quinolone-resistant typhoid osteomyelitis. Br J Hosp Med (Lond) 2011; 72:468-9. [DOI: 10.12968/hmed.2011.72.8.468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Alastair McGregor
- Infectious Diseases and Microbiology, Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London NW1 2BU,
| | | | | | | | - Stephen Morris-Jones
- Department of Microbiology, University College London Hospitals NHS Foundation Trust, London and
| | - Michael Brown
- Infectious Diseases and General Medicine, Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, and Department of Clinical Research, London School of Hygiene and Tropical Medicine, London
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Abstract
Enteric fever is a major public health problem in developing countries. Ciprofloxacin resistance has now become a norm in the Indian subcontinent. Novel molecular substitutions may become frequent in future owing to selective pressures exerted by the irrational use of ciprofloxacin in human and veterinary therapeutics, in a population endemic with nalidixic acid-resistant strains. The therapeutics of ciprofloxacin-resistant enteric fever narrows down to third- and fourth-generation cephalosporins, azithromycin, tigecycline and penems. The first-line antimicrobials ampicillin, chloramphenicol and co-trimoxazole need to be rolled back. Antimicrobial surveillance coupled with molecular analysis of fluoroquinolone resistance is warranted for reconfirming novel and established molecular patterns for therapeutic reappraisal and for novel-drug targets. This review explores the antimicrobial resistance and its molecular mechanisms, as well as novel drugs in the therapy of enteric fever.
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Affiliation(s)
- Malini Rajinder Capoor
- Department of Microbiology, Vardhman Mahaveer Medical College and Safdarjung Hospital, New Delhi, India
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Antimicrobial susceptibility to azithromycin among Salmonella enterica isolates from the United States. Antimicrob Agents Chemother 2011; 55:3985-9. [PMID: 21690279 DOI: 10.1128/aac.00590-11] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Due to emerging resistance to traditional antimicrobial agents, such as ampicillin, trimethoprim-sulfamethoxazole, and chloramphenicol, azithromycin is increasingly used for the treatment of invasive Salmonella infections. In the present study, 696 isolates of non-Typhi Salmonella collected from humans, food animals, and retail meats in the United States were investigated for antimicrobial susceptibility to azithromycin. Seventy-two Salmonella enterica serotype Typhi isolates from humans were also tested. For each isolate, MICs of azithromycin and 15 other antimicrobial agents were determined by broth microdilution. Among the non-Typhi Salmonella isolates, azithromycin MICs among human isolates ranged from 1 to 32 μg/ml, whereas the MICs among the animal and retail meat isolates ranged from 2 to 16 μg/ml and 4 to 16 μg/ml, respectively. Among Salmonella serotype Typhi isolates, the azithromycin MICs ranged from 4 to 16 μg/ml. The highest MIC observed in the present study was 32 μg/ml, and it was detected in three human isolates belonging to serotypes Kentucky, Montevideo, and Paratyphi A. Based on our findings, we propose an epidemiological cutoff value (ECOFF) for wild-type Salmonella of ≤16 μg/ml of azithromycin. The susceptibility data provided could be used in combination with clinical outcome data to determine tentative clinical breakpoints for azithromycin and Salmonella enterica.
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Gaborieau V, Weill FX, Marchou B. Salmonella enterica serovar Typhi de sensibilité diminuée à la ciprofloxacine. Med Mal Infect 2010; 40:691-5. [DOI: 10.1016/j.medmal.2010.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2009] [Revised: 04/09/2010] [Accepted: 06/07/2010] [Indexed: 10/19/2022]
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Abstract
Recent reports indicate that nalidixic acid susceptibility correlates well with the clinical outcome of patients with Salmonella Typhi infection treated with quinolones. We report a case of enteric fever caused by S Typhi in which the isolate was resistant to nalidixic acid, but showed in vitro susceptibility to ciprofloxacin. Following treatment with ciprofloxacin, the clinical outcome was not satisfactory and the patient had a relapse. However, after using a higher dose of ciprofloxacin, the patient was cured. We recommend that all Salmonella systemic infections resistant to nalidixic acid with in vitro but decreased susceptibility to fluoroquinolones be treated with other antibiotics like third-generation cephalosporins or azithromycin. These patients should be closely followed up and observed for further relapse.
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Affiliation(s)
- Ali Mohammed Somily
- Department of Pathology-Microbiology, King Saud College of Medicine, Riyadh, Saudi Arabia.
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In vitro activity of azithromycin against nontyphoidal Salmonella enterica. Antimicrob Agents Chemother 2010; 54:3498-501. [PMID: 20498312 DOI: 10.1128/aac.01678-09] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The in vitro activity of azithromycin against 1,237 nontyphoidal Salmonella enterica isolates collected from Finnish patients between 2003 and 2008 was investigated. Only 24 (1.9%) of the isolates tested and 15 (5.1%) of the 294 isolates with reduced fluoroquinolone susceptibility had azithromycin MICs of >or=32 microg/ml. These data show that azithromycin has good in vitro activity against nontyphoidal S. enterica, and thus, it may be a good candidate for clinical treatment studies of salmonellosis.
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Macrólidos y cetólidos. Enferm Infecc Microbiol Clin 2009; 27:412-8. [DOI: 10.1016/j.eimc.2009.06.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 06/04/2009] [Accepted: 06/10/2009] [Indexed: 11/24/2022]
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Thaver D, Zaidi AKM, Critchley J, Azmatullah A, Madni SA, Bhutta ZA. A comparison of fluoroquinolones versus other antibiotics for treating enteric fever: meta-analysis. BMJ 2009; 338:b1865. [PMID: 19493939 PMCID: PMC2690620 DOI: 10.1136/bmj.b1865] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To review evidence supporting use of fluoroquinolones as first line agents over other antibiotics for treating typhoid and paratyphoid fever (enteric fever). DESIGN Meta-analysis of randomised controlled trials. DATA SOURCES Cochrane Infectious Diseases Group specialised register, CENTRAL (issue 4, 2007), Medline (1966-2007), Embase (1974-2007), LILACS (1982-2007), selected conferences, reference lists, and ongoing trial register (November 2007). Review methods Trials comparing fluoroquinolones with chloramphenicol, cephalosporins, or azithromycin in culture-proven enteric fever were included. Two reviewers extracted data and assessed methodological quality. Odds ratios with 95% confidence intervals were estimated. Trials recruiting over 60% children were analysed separately from trials on adults. Primary outcomes studied were clinical failure, microbiological failure, and relapse. RESULTS Twenty trials were included. Trials were small and often of limited methodological quality. Only 10 trials concealed allocation and only three were blinded. In trials on adults, fluoroquinolones were not significantly different from chloramphenicol for clinical failure (594 participants) or microbiological failure (n=378), but reduced clinical relapse (odds ratio 0.14 (95% confidence interval 0.04 to 0.50), n=467, 6 trials). Azithromycin and fluoroquinolones were comparable (n=152, 2 trials). Compared with ceftriaxone, fluoroquinolones reduced clinical failure (0.08 (0.01 to 0.45), n=120, 3 trials) but not microbiological failure or relapse. Compared with cefixime, fluoroquinolones reduced clinical failure (0.05 (0.01 to 0.24), n=238, 2 trials) and relapse (0.18 (0.03 to 0.91), n=218, 2 trials). In trials on children infected with nalidixic acid resistant strains, older fluoroquinolones (ofloxacin) produced more clinical failures than azithromycin (2.67 (1.16 to 6.11), n=125, 1 trial), but there were no differences with newer fluoroquinolones (gatifloxacin, n=285, 1 trial). Fluoroquinolones and cefixime were not significantly different (n=82, 1 trial). CONCLUSIONS In adults, fluoroquinolones may be better than chloramphenicol for preventing clinical relapse. Data were limited for other comparisons, particularly for children.
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Affiliation(s)
- Durrane Thaver
- Department of Paediatrics and Child Health, The Aga Khan University, PO Box 3500, Karachi 74800, Pakistan
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Capoor MR, Nair D, Posti J, Singhal S, Deb M, Aggarwal P, Pillai P. Minimum inhibitory concentration of carbapenems and tigecycline against Salmonella spp. J Med Microbiol 2009; 58:337-341. [PMID: 19208884 DOI: 10.1099/jmm.0.47853-0] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Antimicrobial resistance in Salmonella spp. is of grave concern, more so in quinolone-resistant and extended-spectrum beta-lactamase (ESBL)-producing isolates that cause complicated infections. The MIC of azithromycin, ciprofloxacin, cefixime, cefepime, ceftriaxone, gatifloxacin, imipenem, levofloxacin, meropenem and ofloxacin (E-test strip) and tigecycline and faropenem (agar dilution) against 210 Salmonella spp. was determined. MIC(90) (defined as the antimicrobial concentration that inhibited growth of 90 % of the strains) of the carbapenems (imipenem and meropenem) for Salmonella Typhi and Salmonella Paratyphi A was 0.064 microg ml(-1). MIC(90) of faropenem was 0.25 microg ml(-1) for S. Typhi, S. Paratyphi A and Salmonella Typhimurium. The MIC(90) of azithromycin for all Salmonella spp. ranged from 8 to 16 microg ml(-1). Tigecycline showed an MIC(90) of 2 microg ml(-1) for S. Typhi, 1 microg ml(-1) for S. Paratyphi A and 4 microg ml(-1) for S. Typhimurium. We concluded that tigecycline and the carbapenems are likely to have roles in the final stage of treatment of quinolone-resistant and ESBL-producing multidrug-resistant salmonellae.
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Affiliation(s)
- Malini R Capoor
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Deepthi Nair
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Jitendra Posti
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Smita Singhal
- New Drug Discovery, Ranbaxy Research Laboratories, Gurgaon, India
| | - Monorama Deb
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Pushpa Aggarwal
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Parukutty Pillai
- Department of Microbiology, Majeedia Hospital, Hamdard University, New Delhi, India
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Nguyen S, Baclet N, Huleux T, Pasquet A, Legout L, Dubreuil L, Yazdanpanah Y, Senneville E. [Pneumonia in a traveller coming back from Asia]. Med Mal Infect 2008; 38:667-70. [PMID: 18951744 DOI: 10.1016/j.medmal.2008.09.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2007] [Revised: 11/13/2007] [Accepted: 09/17/2008] [Indexed: 10/21/2022]
Abstract
A case of Salmonella paratyphi A infection was diagnosed late in a patient treated for febrile pneumonia after his returning from India. This case was remarkable in two aspects: first, it illustrated the reemergence of S.paratyphi A infections in people having traveled to India, with increasing fluoroquinolone resistance, and second the difficulty of diagnosing this disease, since the patient was initially treated for pneumonia and flu-like syndrome. Salmonella typhi or paratyphi infections should be evoked in case of persistent fever in patients having traveled to endemic areas, even if digestive signs are absent. Furthermore, choosing an empiric antibiotic treatment with fluoroquinolones could lead to treatment failure if the patient traveled in a country where fluoroquinolone resistance is high, as in Asia and especially in India.
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Affiliation(s)
- S Nguyen
- Service universitaire des maladies infectieuses et du voyageur, centre hospitalier de Tourcoing, 135, rue du Président-Coty, 59208 Tourcoing, France.
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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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Effa EE, Bukirwa H. Azithromycin for treating uncomplicated typhoid and paratyphoid fever (enteric fever). Cochrane Database Syst Rev 2008:CD006083. [PMID: 18843701 DOI: 10.1002/14651858.cd006083.pub2] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Enteric fever (typhoid and paratyphoid fever) is potentially fatal. Infection with drug-resistant strains of the causative organism Salmonella enterica serovar Typhi or Paratyphi increases morbidity and mortality. Azithromycin may have better outcomes in people with uncomplicated forms of the disease. OBJECTIVES To compare azithromycin with other antibiotics for treating uncomplicated enteric fever. SEARCH STRATEGY In August 2008, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2008, Issue 3), MEDLINE, EMBASE, LILACS, and mRCT. We also searched conference proceedings, reference lists, and contacted researchers and a pharmaceutical company. SELECTION CRITERIA Randomized controlled trials comparing azithromycin with other antibiotics for treating children and adults with uncomplicated enteric fever confirmed by cultures of S. Typhi or Paratyphi in blood and/or stool. DATA COLLECTION AND ANALYSIS Both authors independently extracted data and assessed the risk of bias. Dichotomous data were presented and compared using the odds ratio, and continuous data were reported as arithmetic means with standard deviations and were combined using the mean difference (MD). Both were presented with 95% confidence intervals (CI). MAIN RESULTS Seven trials involving 773 participants met the inclusion criteria. The trials used adequate methods to generate the allocation sequence and conceal allocation, and were open label. Three trials exclusively included adults, two included children, and two included both adults and children; all were hospital inpatients. One trial evaluated azithromycin against chloramphenicol and did not demonstrate a difference for any outcome (77 participants, 1 trial). When compared with fluoroquinolones in four trials, azithromycin significantly reduced clinical failure (OR 0.48, 95% CI 0.26 to 0.89; 564 participants, 4 trials) and duration of hospital stay (MD -1.04 days, 95% CI -1.73 to -0.34 days; 213 participants, 2 trials); all four trials included people with multiple-drug-resistant or nalidixic acid-resistant strains of S. Typhi or S. Paratyphi. We detected no statistically significant difference in the other outcomes. Compared with ceftriaxone, azithromycin significantly reduced relapse (OR 0.09, 95% CI 0.01 to 0.70; 132 participants, 2 trials) and not other outcome measures. Few adverse events were reported, and most were mild and self limiting. AUTHORS' CONCLUSIONS Azithromycin appears better than fluoroquinolone drugs in populations that included participants with drug-resistant strains. Azithromycin may perform better than ceftriaxone.
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Affiliation(s)
- Emmanuel E Effa
- Internal Medicine, University of Calabar Teaching Hospital, PMB 1278, Calabar, Cross River State, Nigeria.
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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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Capoor MR, Rawat D, Nair D, Hasan AS, Deb M, Aggarwal P, Pillai P. In vitro activity of azithromycin, newer quinolones and cephalosporins in ciprofloxacin-resistant Salmonella causing enteric fever. J Med Microbiol 2007; 56:1490-1494. [DOI: 10.1099/jmm.0.47353-0] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
The therapeutic alternatives available for use against ciprofloxacin-resistant enteric fever isolates in an endemic area are limited. The antibiotics currently available are the quinolones, third-generation cephalosporins and conventional first-line drugs. In this study, the MICs of various newer drugs were determined for 31 ciprofloxacin-resistant enteric fever isolates (26 Salmonella enterica serovar Typhi and 5 S. enterica serovar Paratyphi A). MICs for ciprofloxacin, ofloxacin, gatifloxacin, levofloxacin, cefotaxime, cefixime, cefepime and azithromycin were determined using Etest strips and the agar dilution method. By Etest, all of the ciprofloxacin-resistant isolates had ciprofloxacin MICs ≥32 μg ml−1. S. Typhi showed MIC90 values of 0.50, 0.25 and 0.38 μg ml−1 for cefixime, cefotaxime and cefepime, respectively. For the cephalosporins, a negligible difference in MIC90 and MIC50 values for S. Typhi and S. Paratyphi A was observed. A single isolate of S. Typhi showed a high azithromycin MIC of 64 μg ml−1. The MIC90 value for azithromycin in S. Typhi and S. Paratyphi was 24 μg ml−1. Gatifloxacin demonstrated lower resistance (80.8 %) compared with the other quinolones (92–100 %) in S. Typhi. The rise in MIC levels of these antimicrobials is a matter for serious concern.
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Affiliation(s)
- Malini R. Capoor
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Deepti Rawat
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Deepthi Nair
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Azra S. Hasan
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Monorama Deb
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Pushpa Aggarwal
- Department of Microbiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Parukutty Pillai
- Department of Microbiology, Majeedia Hospital, Hamdard University, New Delhi, India
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Kitchen LW, Vaughn DW. Role of U.S. military research programs in the development of U.S.-licensed vaccines for naturally occurring infectious diseases. Vaccine 2007; 25:7017-30. [PMID: 17728025 DOI: 10.1016/j.vaccine.2007.07.030] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2006] [Revised: 05/16/2007] [Accepted: 07/19/2007] [Indexed: 11/30/2022]
Abstract
U.S. military physicians and researchers have collaborated in the development of eight U.S.-licensed vaccines since 1934, when product efficacy requirements were added to product safety requirements mandated in 1902. These vaccines include influenza (1945), rubella (1969), adenovirus types 4 and 7 (1980), meningococcus A, C, Y, W-135 (1981), hepatitis B (1981), oral typhoid (1989), Japanese encephalitis (1992), and hepatitis A (1995). Current efforts include new adenovirus and Japanese encephalitis vaccines, and vaccines to prevent dengue, diarrhea due to enterotoxigenic E. coli, Campylobacter, and Shigella, malaria, hemorrhagic fever with renal syndrome, scrub typhus, meningococcus type B, and HIV infection. All vaccines currently administered to U.S. military forces must be licensed by the U.S. Food and Drug Administration (FDA).
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Affiliation(s)
- Lynn W Kitchen
- Military Infectious Diseases Research Program, U.S. Army Medical Research and Materiel Command, Fort Detrick, MD 21702-5012, USA.
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Farrar J. A Personal Perspective on Clinical Research in Enteric Fever. Clin Infect Dis 2007; 45 Suppl 1:S9-14. [PMID: 17582579 DOI: 10.1086/518139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
With the global spread of enteric fever, the emergence of Salmonella enterica serovar Paratyphi as a major pathogen (particularly in Asia), the spread of drug resistance, and the global increase in the incidence of non-Typhi salmonella, particularly in patients coinfected with human immunodeficiency virus, there is now more than ever a need for clinical research in enteric fever. The work of Ted Woodward 60 years ago remains relevant today, and his holistic approach to clinical research inspired many of us to follow in his footsteps. There remains healthy discussion among clinicians about the best treatment for enteric fever, and pragmatic, well-designed, randomized controlled trials are required to provide clear evidence. Vaccines and public health measures will have the greatest impact on the overall burden of disease; however, while we wait for these measures, prompt diagnosis and early treatment with the best available and affordable drug will help patients, reduce transmission within the community, and potentially help to contain the spread of drug resistance. Better integration of clinical medicine with epidemiology, public health, vaccine development, and modern laboratory science will help to yield tangible benefits for the vast number of people who have this disease.
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Affiliation(s)
- Jeremy Farrar
- The Hospital for Tropical Diseases, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.
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Parry CM, Ho VA, Phuong LT, Bay PVB, Lanh MN, Tung LT, Tham NTH, Wain J, Hien TT, Farrar JJ. Randomized controlled comparison of ofloxacin, azithromycin, and an ofloxacin-azithromycin combination for treatment of multidrug-resistant and nalidixic acid-resistant typhoid fever. Antimicrob Agents Chemother 2006; 51:819-25. [PMID: 17145784 PMCID: PMC1803150 DOI: 10.1128/aac.00447-06] [Citation(s) in RCA: 106] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Isolates of Salmonella enterica serovar Typhi that are multidrug resistant (MDR, resistant to chloramphenicol, ampicillin, and trimethoprim-sulfamethoxazole) and have reduced susceptibility to fluoroquinolones (nalidixic acid resistant, Na(r)) are common in Asia. The optimum treatment for infections caused by such isolates is not established. This study compared different antimicrobial regimens for the treatment of MDR/Na(r) typhoid fever. Vietnamese children and adults with uncomplicated typhoid fever were entered into an open randomized controlled trial. Ofloxacin (20 mg/kg of body weight/day for 7 days), azithromycin (10 mg/kg/day for 7 days), and ofloxacin (15 mg/kg/day for 7 days) combined with azithromycin (10 mg/kg/day for the first 3 days) were compared. Of the 241 enrolled patients, 187 were eligible for analysis (186 S. enterica serovar Typhi, 1 Salmonella enterica serovar Paratyphi A). Eighty-seven percent (163/187) of the patients were children; of the S. enterica serovar Typhi isolates, 88% (165/187) were MDR and 93% (173/187) were Na(r). The clinical cure rate was 64% (40/63) with ofloxacin, 76% (47/62) with ofloxacin-azithromycin, and 82% (51/62) with azithromycin (P = 0.053). The mean (95% confidence interval [CI]) fever clearance time for patients treated with azithromycin (5.8 days [5.1 to 6.5 days]) was shorter than that for patients treated with ofloxacin-azithromycin (7.1 days [6.2 to 8.1 days]) and ofloxacin (8.2 days [7.2 to 9.2 days]) (P < 0.001). Positive fecal carriage immediately posttreatment was detected in 19.4% (12/62) of patients treated with ofloxacin, 6.5% (4/62) of those treated with the combination, and 1.6% (1/62) of those treated with azithromycin (P = 0.006). Both antibiotics were well tolerated. Uncomplicated typhoid fever due to isolates of MDR S. enterica serovar Typhi with reduced susceptibility to fluoroquinolones (Na(r)) can be successfully treated with a 7-day course of azithromycin.
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Abstract
Enteric fever--a more inclusive term for typhoid fever and paratyphoid fever--is a systemic infection caused by Salmonella enterica, including S enterica serotype Typhi (S typhi) and serotype Paratyphi (S paratyphi). In developed countries there have been two major changes in the pattern of the disease: a marked decline in its incidence and its characterisation as a predominantly travel-associated disease. The risk to travellers appears to vary by geographic region visited, with travel to the Indian subcontinent accounting for the greatest travel risk. Although the most common cause of enteric fever is S typhi, the incidence of disease caused by S paratyphi among travellers may be more important, since the available vaccines only protect against S typhi. Descriptions of the clinical presentation in travellers are scarce but severe complications and death are rare, probably due to rapid access to readily available medical care. Drug resistance reflects the situation in endemic countries, and shows a steady increase in multidrug-resistance patterns. Currently, the recommendation for first-line therapy is ceftriaxone and, where isolates have been found to be quinolone sensitive, fluoroquinolones can still be given. Preventive measures are educating travellers about hygiene precautions and vaccination. With an increase in multidrug-resistant strains, a more effective vaccine for S typhi and S paratyphi is urgently needed.
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Affiliation(s)
- Bradley A Connor
- Weill Medical College of Cornell University, and the New York Center for Travel and Tropical Medicine, New York, NY, USA
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Abstract
Typhoid fever is estimated to have caused 21.6 million illnesses and 216,500 deaths globally in 2000, affecting all ages. There is also one case of paratyphoid fever for every four of typhoid. The global emergence of multidrug-resistant strains and of strains with reduced susceptibility to fluoroquinolones is of great concern. We discuss the occurrence of poor clinical response to fluoroquinolones despite disc sensitivity. Developments are being made in our understanding of the molecular pathogenesis, and genomic and proteomic studies reveal the possibility of new targets for diagnosis and treatment. Further, we review guidelines for use of diagnostic tests and for selection of antimicrobials in varying clinical situations. The importance of safe water, sanitation, and immunisation in the presence of increasing antibiotic resistance is paramount. Routine immunisation of school-age children with Vi or Ty21a vaccine is recommended for countries endemic for typhoid. Vi vaccine should be used for 2-5 year-old children in highly endemic settings.
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Affiliation(s)
- M K Bhan
- All India Institute of Medical Sciences, New Delhi 110029, India.
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Huang DB, DuPont HL. Problem pathogens: extra-intestinal complications of Salmonella enterica serotype Typhi infection. THE LANCET. INFECTIOUS DISEASES 2005; 5:341-8. [PMID: 15919620 DOI: 10.1016/s1473-3099(05)70138-9] [Citation(s) in RCA: 110] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Typhoid fever, caused by Salmonella enterica seroptype Typhi (S typhi), has an estimated worldwide prevalence of 12-33 million cases. The pathogenesis of this disease depends on the ingested inoculum size of S typhi, the virulence of the strain, the host's immune response and previous exposure, and local protective factors. Numerous extra-intestinal complications can occur with S typhi infection, including the involvement of the central nervous system (3-35%), cardiovascular system (1-5%), pulmonary system (1-86%), bone and joints (< or =1%), hepatobiliary system (1-26%), genitourinary system (<1%), and others. Due to an increase in multidrug-resistant S typhi, fluoroquinolones and third-generation cephalosporins have been increasingly used for typhoid fever and its complications. We describe the epidemiology, clinical manifestations, pathogenesis, and treatment of extra-intestinal S typhi infections.
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Affiliation(s)
- David B Huang
- Center for Infectious Diseases, Baylor College of Medicine, Houston, Texas 77030, USA.
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Murray BE, Anderson KE, Arnold K, Bartlett JG, Carpenter CC, Falkow S, Hartman JT, Lehman T, Reid TW, Ryburn FM, Sack RB, Struelens MJ, Young LS, Greenough WB. Destroying the Life and Career of a Valued Physician-Scientist Who Tried to Protect Us from Plague: Was It Really Necessary? Clin Infect Dis 2005; 40:1644-8. [PMID: 15889363 DOI: 10.1086/431348] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Accepted: 04/26/2005] [Indexed: 11/03/2022] Open
Abstract
Thomas Campbell Butler, at 63 years of age, is completing the first year of a 2-year sentence in federal prison, following an investigation and trial that was initiated after he voluntarily reported that he believed vials containing Yersinia pestis were missing from his laboratory at Texas Tech University. We take this opportunity to remind the infectious diseases community of the plight of our esteemed colleague, whose career and family have, as a result of his efforts to protect us from infection by this organism, paid a price from which they will never recover.
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Affiliation(s)
- Barbara E Murray
- Division of Infectious Diseases, Department of Internal Medicine, University of Texas Medical School, Houston, TX 77030, USA.
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