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Gasperini G, Massai L, De Simone D, Raso MM, Palmieri E, Alfini R, Rossi O, Ravenscroft N, Kuttel MM, Micoli F. O-Antigen decorations in Salmonella enterica play a key role in eliciting functional immune responses against heterologous serovars in animal models. Front Cell Infect Microbiol 2024; 14:1347813. [PMID: 38487353 PMCID: PMC10937413 DOI: 10.3389/fcimb.2024.1347813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/15/2024] [Indexed: 03/17/2024] Open
Abstract
Introduction Different serovars of Salmonella enterica cause systemic diseases in humans including enteric fever, caused by S. Typhi and S. Paratyphi A, and invasive nontyphoidal salmonellosis (iNTS), caused mainly by S. Typhimurium and S. Enteritidis. No vaccines are yet available against paratyphoid fever and iNTS but different strategies, based on the immunodominant O-Antigen component of the lipopolysaccharide, are currently being tested. The O-Antigens of S. enterica serovars share structural features including the backbone comprising mannose, rhamnose and galactose as well as further modifications such as O-acetylation and glucosylation. The importance of these O-Antigen decorations for the induced immunogenicity and cross-reactivity has been poorly characterized. Methods These immunological aspects were investigated in this study using Generalized Modules for Membrane Antigens (GMMA) as delivery systems for the different O-Antigen variants. This platform allowed the rapid generation and in vivo testing of defined and controlled polysaccharide structures through genetic manipulation of the O-Antigen biosynthetic genes. Results Results from mice and rabbit immunization experiments highlighted the important role played by secondary O-Antigen decorations in the induced immunogenicity. Moreover, molecular modeling of O-Antigen conformations corroborated the likelihood of cross-protection between S. enterica serovars. Discussion Such results, if confirmed in humans, could have a great impact on the design of a simplified vaccine composition able to maximize functional immune responses against clinically relevant Salmonella enterica serovars.
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Affiliation(s)
| | - Luisa Massai
- GSK Vaccines Institute for Global Health (GVGH), Siena, Italy
| | | | | | - Elena Palmieri
- GSK Vaccines Institute for Global Health (GVGH), Siena, Italy
| | - Renzo Alfini
- GSK Vaccines Institute for Global Health (GVGH), Siena, Italy
| | - Omar Rossi
- GSK Vaccines Institute for Global Health (GVGH), Siena, Italy
| | - Neil Ravenscroft
- Department of Chemistry, University of Cape Town, Rondebosch, South Africa
| | - Michelle M. Kuttel
- Department of Computer Science, University of Cape Town, Rondebosch, South Africa
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Akshay SD, Deekshit VK, Mohan Raj J, Maiti B. Outer Membrane Proteins and Efflux Pumps Mediated Multi-Drug Resistance in Salmonella: Rising Threat to Antimicrobial Therapy. ACS Infect Dis 2023; 9:2072-2092. [PMID: 37910638 DOI: 10.1021/acsinfecdis.3c00408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
Despite colossal achievements in antibiotic therapy in recent decades, drug-resistant pathogens have remained a leading cause of death and economic loss globally. One such WHO-critical group pathogen is Salmonella. The extensive and inappropriate treatments for Salmonella infections have led from multi-drug resistance (MDR) to extensive drug resistance (XDR). The synergy between efflux-mediated systems and outer membrane proteins (OMPs) may favor MDR in Salmonella. Differential expression of the efflux system and OMPs (influx) and positional mutations are the factors that can be correlated to the development of drug resistance. Insights into the mechanism of influx and efflux of antibiotics can aid in developing a structurally stable molecule that can be proficient at escaping from the resistance loops in Salmonella. Understanding the strategic responsibilities and developing policies to address the surge of drug resistance at the national, regional, and global levels are the needs of the hour. In this Review, we attempt to aggregate all the available research findings and delineate the resistance mechanisms by dissecting the involvement of OMPs and efflux systems. Integrating major OMPs and the efflux system's differential expression and positional mutation in Salmonella may provide insight into developing strategic therapies for one health application.
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Affiliation(s)
- Sadanand Dangari Akshay
- Nitte (Deemed to be University), Nitte University Centre for Science Education and Research, Department of Bio & Nano Technology, Paneer Campus, Deralakatte, Mangalore-575018, India
| | - Vijaya Kumar Deekshit
- Nitte (Deemed to be University), Nitte University Centre for Science Education and Research, Department of Infectious Diseases & Microbial Genomics, Paneer Campus, Deralakatte, Mangalore-575018, India
| | - Juliet Mohan Raj
- Nitte (Deemed to be University), Nitte University Centre for Science Education and Research, Department of Infectious Diseases & Microbial Genomics, Paneer Campus, Deralakatte, Mangalore-575018, India
| | - Biswajit Maiti
- Nitte (Deemed to be University), Nitte University Centre for Science Education and Research, Department of Bio & Nano Technology, Paneer Campus, Deralakatte, Mangalore-575018, India
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3
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McCann N, Nabarro L, Morris-Jones S, Patel T, Godbole G, Heyderman R, Brown M. Outpatient management of uncomplicated enteric fever: A case series of 93 patients from the Hospital of Tropical Diseases, London. J Infect 2022; 85:397-404. [PMID: 35781016 DOI: 10.1016/j.jinf.2022.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 05/04/2022] [Accepted: 06/24/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVES Enteric fever is predominantly managed as an outpatient condition in endemic settings but there is little evidence to support this approach in non-endemic settings. This study aims to review the outcomes of outpatients treated for enteric fever at the Hospital of Tropical Diseases in London, UK. METHODS We conducted a retrospective analysis of all patients with confirmed enteric fever between August 2009 and September 2020. Demographic, clinical, laboratory and microbiological data were collected and compared between the inpatient and outpatient populations. Outcomes investigated were complicated enteric fever, treatment failure and relapse. RESULTS Overall, 93 patients (59% male, median age 31) were identified with blood and/or stool culture confirmed enteric fever and 49 (53%) of these were managed as outpatients. The commonest empirical treatment for outpatients was azithromycin (70%) and for inpatients was ceftriaxone (84%). Outpatients were more likely than inpatients to receive only one antibiotic (57% vs 19%, p < 0.01) and receive a shorter duration of antibiotics (median 7 vs 11 days, p <0.01). There were no cases of complicated disease or relapse in either the inpatient or outpatient groups. There was one treatment failure in the outpatient group. Azithromycin was well-tolerated with no reported side effects. CONCLUSIONS Our findings suggest that outpatient management of uncomplicated imported enteric fever is safe and effective with the use of oral azithromycin. Careful monitoring of patients is recommended as treatment failure can occur.
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Affiliation(s)
- N McCann
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK.
| | - L Nabarro
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; St George's University Hospitals NHS Foundation Trust, London, UK
| | - S Morris-Jones
- 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
| | - T Patel
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK
| | - G Godbole
- Hospital for Tropical Diseases, University College London Hospitals NHS Foundation Trust, London, UK; Gastrointestinal Pathogens and Food Safety (One Health), United Kingdom Health Security Agency, UK
| | - R 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
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Hinnu M, Putrinš M, Kogermann K, Bumann D, Tenson T. Making Antimicrobial Susceptibility Testing More Physiologically Relevant with Bicarbonate? Antimicrob Agents Chemother 2022; 66:e0241221. [PMID: 35435706 PMCID: PMC9112938 DOI: 10.1128/aac.02412-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/04/2022] [Indexed: 01/20/2023] Open
Abstract
Azithromycin is a clinically important drug for treating invasive salmonellosis despite poor activity in laboratory assays for MIC. Addition of the main buffer in blood, bicarbonate, has been proposed for more physiologically relevant and more predictive testing conditions. However, we show here that bicarbonate-triggered lowering of azithromycin MIC is entirely due to alkalization of insufficiently buffered media. In addition, bicarbonate is unlikely to be altering efflux pump activity.
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Affiliation(s)
- Mariliis Hinnu
- University of Tartu, Institute of Technology, Tartu, Estonia
- University of Basel, Biozentrum, Basel, Switzerland
| | - Marta Putrinš
- University of Tartu, Institute of Technology, Tartu, Estonia
| | | | - Dirk Bumann
- University of Basel, Biozentrum, Basel, Switzerland
| | - Tanel Tenson
- University of Tartu, Institute of Technology, Tartu, Estonia
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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] [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,Correspondence: Gagandeep Kang, FRS, The Wellcome Trust Research Laboratory, Division of Gastrointestinal Sciences, Christian Medical College, Ida Scudder road, Vellore, Tamil Nadu-632004, India. ()
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7
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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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8
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Giri A, Karkey A, Dongol S, Arjyal A, Maharjan A, Veeraraghavan B, Paudyal B, Dolecek C, Gajurel D, Phuong DNT, Thanh DP, Qamar F, Kang G, Hien HV, John J, Lawson K, Wolbers M, Hossain MS, Sharifuzzaman M, Luangasanatip N, Maharjan N, Olliaro P, Rupali P, Shakya R, Shakoor S, Rijal S, Qureshi S, Baker S, Joshi S, Ahmed T, Darton T, Bao TN, Lubell Y, Kestelyn E, Thwaites G, Parry CM, Basnyat B. Azithromycin and cefixime combination versus azithromycin alone for the out-patient treatment of clinically suspected or confirmed uncomplicated typhoid fever in South Asia: a randomised controlled trial protocol. Wellcome Open Res 2021; 6:207. [PMID: 35097222 PMCID: PMC8772527 DOI: 10.12688/wellcomeopenres.16801.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/08/2021] [Indexed: 12/27/2023] Open
Abstract
Background: Typhoid and paratyphoid fever (enteric fever) is a common cause of non-specific febrile infection in adults and children presenting to health care facilities in low resource settings such as the South Asia. A 7-day course of a single oral antimicrobial such as ciprofloxacin, cefixime, or azithromycin is commonly used for its treatment. Increasing antimicrobial resistance threatens the effectiveness of these treatment choices. We hypothesize that combined treatment with azithromycin (active mainly intracellularly) and cefixime (active mainly extracellularly) will be a better option for the treatment of clinically suspected and culture-confirmed typhoid fever in South Asia. Methods: This is a phase IV, international multi-center, multi-country, comparative participant-and observer-blind, 1:1 randomised clinical trial. Patients with suspected uncomplicated typhoid fever will be randomized to one of the two interventions: Arm A: azithromycin 20mg/kg/day oral dose once daily (maximum 1gm/day) and cefixime 20mg/kg/day oral dose in two divided doses (maximum 400mg bd) for 7 days, Arm B: azithromycin 20mg/kg/day oral dose once daily (max 1gm/day) for 7 days AND cefixime-matched placebo for 7 days. We will recruit 1500 patients across sites in Bangladesh, India, Nepal, and Pakistan. We will assess whether treatment outcomes are better with the combination after one week of treatment and at one- and three-months follow-up. Discussion: Combined treatment may limit the emergence of resistance if one of the components is active against resistant sub-populations not covered by the other antimicrobial activity. If the combined treatment is better than the single antimicrobial treatment, this will be an important result for patients across South Asia and other typhoid endemic areas. Clinicaltrials.gov registration: NCT04349826 (16/04/2020).
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Affiliation(s)
- Abhishek Giri
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sabina Dongol
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Amit Arjyal
- Patan Academy of Health Sciences, Lalitpur, Bagmati, 44700, Nepal
| | - Archana Maharjan
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | | | - Buddhi Paudyal
- Patan Academy of Health Sciences, Lalitpur, Bagmati, 44700, Nepal
| | - Christiane Dolecek
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | | | - Duy Pham Thanh
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Farah Qamar
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Gagandeep Kang
- Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Ho Van Hien
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Jacob John
- Christian Medical College, Vellore, Tamil Nadu, 632004, India
| | - Katrina Lawson
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Marcel Wolbers
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Md. Shabab Hossain
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | - M Sharifuzzaman
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | | | - Nhukesh Maharjan
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Piero Olliaro
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Ronas Shakya
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Sadia Shakoor
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Samita Rijal
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Sonia Qureshi
- Aga Khan University Hospital, Karachi, 74800, Pakistan
| | - Stephen Baker
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Subi Joshi
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
| | - Tahmeed Ahmed
- International Centre for Diarrhoeal Disease Research (icddr, b), Dhaka, Bangladesh
| | - Thomas Darton
- Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, South Yorkshire, UK
| | - Tran Nguyen Bao
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Yoel Lubell
- Mahidol Oxford Tropical Medicine Research Unit (MORU), Bangkok, 10400, Thailand
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Christopher M. Parry
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - Buddha Basnyat
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Scineces, Lalitpur, Bagmati, 44700, Nepal
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Giri A, Karkey A, Dangol S, Arjyal A, Pokharel S, Rijal S, Gajurel D, Sharma R, Lamsal K, Shrestha P, Prajapati G, Pathak S, Shrestha SR, K C RK, Pandey S, Thapa A, Shrestha N, Thapa RK, Poudyal B, Phuong DNT, Baker S, Kestelyn E, Geskus R, Thwaites G, Basnyat B. Trimethoprim-sulfamethoxazole Versus Azithromycin for the Treatment of Undifferentiated Febrile Illness in Nepal: A Double-blind, Randomized, Placebo-controlled Trial. Clin Infect Dis 2020; 73:e1478-e1486. [PMID: 32991678 PMCID: PMC8492158 DOI: 10.1093/cid/ciaa1489] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Indexed: 11/12/2022] Open
Abstract
Background Azithromycin and trimethoprim-sulfamethoxazole (SXT) are widely used to treat undifferentiated febrile illness (UFI). We hypothesized that azithromycin is superior to SXT for UFI treatment, but the drugs are noninferior to each other for culture-confirmed enteric fever treatment. Methods We conducted a double-blind, randomized, placebo-controlled trial of azithromycin (20 mg/kg/day) or SXT (trimethoprim 10 mg/kg/day plus sulfamethoxazole 50 mg/kg/day) orally for 7 days for UFI treatment in Nepal. We enrolled patients >2 years and <65 years of age presenting to 2 Kathmandu hospitals with temperature ≥38.0°C for ≥4 days without localizing signs. The primary endpoint was fever clearance time (FCT); secondary endpoints were treatment failure and adverse events. Results From June 2016 to May 2019, we randomized 326 participants (163 in each arm); 87 (26.7%) had blood culture–confirmed enteric fever. In all participants, the median FCT was 2.7 days (95% confidence interval [CI], 2.6–3.3 days) in the SXT arm and 2.1 days (95% CI, 1.6–3.2 days) in the azithromycin arm (hazard ratio [HR], 1.25 [95% CI, .99–1.58]; P = .059). The HR of treatment failures by 28 days between azithromycin and SXT was 0.62 (95% CI, .37–1.05; P = .073). Planned subgroup analysis showed that azithromycin resulted in faster FCT in those with sterile blood cultures and fewer relapses in culture-confirmed enteric fever. Nausea, vomiting, constipation, and headache were more common in the SXT arm. Conclusions Despite similar FCT and treatment failure in the 2 arms, significantly fewer complications and relapses make azithromycin a better choice for empirical treatment of UFI in Nepal. Clinical Trials Registration NCT02773407.
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Affiliation(s)
- Abhishek Giri
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sabina Dangol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Amit Arjyal
- Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sunil Pokharel
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Samita Rijal
- Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Rabi Sharma
- Civil Service Hospital, Minbhawan Kathmandu, Nepal
| | - Kamal Lamsal
- Civil Service Hospital, Minbhawan Kathmandu, Nepal
| | | | | | - Saruna Pathak
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Raj Kumar K C
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sujata Pandey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abishkar Thapa
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Nistha Shrestha
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | | | | | - Stephen Baker
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,University of Cambridge, Cambridge, United Kingdom
| | - Evelyne Kestelyn
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Ronald Geskus
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Guy Thwaites
- Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Lalitpur, Nepal.,Patan Academy of Health Sciences, Lalitpur, Nepal.,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
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Khanam F, Rajib NH, Tonks S, Khalequzzaman M, Pollard AJ, Clemens JD, Qadri F, And The Strataa Study Team. Case Report: Salmonella Enterica Serovar Paratyphi B Infection in a Febrile Ill Child during Enhanced Passive Surveillance in an Urban Slum in Mirpur, Dhaka. Am J Trop Med Hyg 2020; 103:231-233. [PMID: 32458786 PMCID: PMC7356450 DOI: 10.4269/ajtmh.19-0958] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Paratyphoid fever is one of the major causes of morbidity of febrile illnesses in endemic regions. We report a case of high-grade fever in an infant who was positive for Salmonella enterica serovar Paratyphi B (S. Paratyphi B) both in blood and stool cultures. The baby was enrolled in the passive surveillance of multicenter, multicomponent epidemiological study of enteric fever (Strategic Typhoid alliance across Africa and Asia; STRATAA) conducted in a population of 110,000 residents over 2 years in an urban slum, Dhaka, Bangladesh. This is the only patient who was positive for S. Paratyphi B in blood and stool among more than 6,000 febrile ill patients enrolled in the passive surveillance. The report shows the significance of surveillance to identify changes in the epidemiology of enteric fever.
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Affiliation(s)
- Farhana Khanam
- icddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Nazmul Hasan Rajib
- icddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Susan Tonks
- Oxford Vaccine Group, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Md Khalequzzaman
- icddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Andrew J Pollard
- Oxford Vaccine Group, University of Oxford, and the NIHR Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - John D Clemens
- icddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
| | - Firdausi Qadri
- icddr,b, (International Centre for Diarrhoeal Disease Research, Bangladesh), Dhaka, Bangladesh
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A prospective study of bloodstream infections among febrile adolescents and adults attending Yangon General Hospital, Yangon, Myanmar. PLoS Negl Trop Dis 2020; 14:e0008268. [PMID: 32352959 PMCID: PMC7217485 DOI: 10.1371/journal.pntd.0008268] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 05/12/2020] [Accepted: 04/03/2020] [Indexed: 11/20/2022] Open
Abstract
Data on causes of community-onset bloodstream infection in Myanmar are scarce. We aimed to identify etiological agents of bloodstream infections and patterns of antimicrobial resistance among febrile adolescents and adults attending Yangon General Hospital (YGH), Yangon, Myanmar. We recruited patients ≥12 years old with fever ≥38°C who attended YGH from 5 October 2015 through 4 October 2016. A standardized clinical history and physical examination was performed. Provisional diagnoses and vital status at discharge was recorded. Blood was collected for culture, bloodstream isolates were identified, and antimicrobial susceptibility testing was performed. Using whole-genome sequencing, we identified antimicrobial resistance mechanisms of Enterobacteriaceae and sequence types of Enterobacteriaceae and Streptococcus agalactiae. Among 947 participants, 90 (9.5%) had bloodstream infections (BSI) of which 82 (91.1%) were of community-onset. Of 91 pathogens isolated from 90 positive blood cultures, we identified 43 (47.3%) Salmonella enterica including 33 (76.7%) serovar Typhi and 10 (23.3%) serovar Paratyphi A; 20 (22.0%) Escherichia coli; 7 (7.7%) Klebsiella pneumoniae; 6 (6.6%), Staphylococcus aureus; 4 (4.4%) yeasts; and 1 (1.1%) each of Burkholderia pseudomallei and Streptococcus agalactiae. Of 70 Enterobacteriaceae, 62 (88.6%) were fluoroquinolone-resistant. Among 27 E. coli and K. pneumoniae, 18 (66.6%) were extended-spectrum beta-lactamase (ESBL)-producers, and 1 (3.7%) each were AmpC beta-lactamase- and carbapenemase-producers. Fluoroquinolone resistance was associated predominantly with mutations in the quinolone resistance-determining region. blaCTX-M-15 expression was common among ESBL-producers. Methicillin-resistant S. aureus was not detected. Fluoroquinolone-resistant, but not multiple drug-resistant, typhoidal S. enterica was the leading cause of community-onset BSI at a tertiary hospital in Yangon, Myanmar. Fluoroquinolone and extended-spectrum cephalosporin resistance was common among other Enterobactericeae. Our findings inform empiric management of severe febrile illness in Yangon and indicate that measures to prevent and control enteric fever are warranted. We suggest ongoing monitoring and efforts to mitigate antimicrobial resistance among community-onset pathogens.
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12
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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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Patil N, Mule P. Sensitivity Pattern Of Salmonella typhi And Paratyphi A Isolates To Chloramphenicol And Other Anti-Typhoid Drugs: An In Vitro Study. Infect Drug Resist 2019; 12:3217-3225. [PMID: 31686872 PMCID: PMC6800285 DOI: 10.2147/idr.s204618] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 06/07/2019] [Indexed: 11/23/2022] Open
Abstract
Purpose To investigate the antimicrobial sensitivity pattern of commonly prescribed antimicrobials (chloramphenicol, cefixime, ofloxacin, azithromycin, and ceftriaxone) against Salmonella enterica isolates. Methods Blood culture positive isolates of S. typhi and S. paratyphi A (N = 251) received at Metropolis Healthcare Limited (Mumbai, India) from four zones of India (North, South, West, and East) between April and August 2018 were tested for antimicrobial susceptibility by E-test method. Based on the minimum inhibitory concentration (MIC), the organism was categorized as sensitive, intermediate, and resistant against the respective antibiotics as per Clinical and Laboratory Standards Institute criteria 2018. Results Out of 251 Salmonella isolates, 192 (76.5%) were S. typhi and 59 (23.5%) were S. paratyphi A. All 251 (100%) Salmonella isolates were sensitive to cefixime, ceftriaxone, and azithromycin; 237/251 (94.4%) isolates to chloramphenicol and only 9/251 (3.6%) isolates were sensitive to ofloxacin. Based on average MIC and MIC breakpoints, Salmonella isolates were found to be sensitive to chloramphenicol (MIC: 3.89±6.94 µg/mL), cefixime (MIC: 0.13±0.11 µg/mL), azithromycin (MIC: 3.32±2.19 µg/mL), and ceftriaxone (MIC: 0.11±0.18 µg/mL) and resistant to ofloxacin (MIC: 2.95±6.06 µg/mL). More than 20% of Salmonella isolates had MICs of chloramphenicol as 1.5 µg/mL (27.85% isolates) and 2 µg/mL (29.53% isolates). Conclusion Our study confirms the re‑emergence of susceptibility of Salmonella isolates to chloramphenicol. Further, the concern about fluoroquinolone-decreased susceptibility as indicated by the intermediate susceptibility or resistance was reiterated in this study. Though cefixime, azithromycin, and ceftriaxone showed susceptibility, the possibility of antibiotic resistance with the irrational use of these antibiotics cannot be deterred. This study thus emphasizes the need for continuous evaluation and judicious use of antimicrobials, considering the ever-changing landscape.
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Affiliation(s)
- Niranjan Patil
- Microbiology and Molecular Biology Department, Metropolis Healthcare Limited, Mumbai, India
| | - Prashant Mule
- Microbiology and Molecular Biology Department, Metropolis Healthcare Limited, Mumbai, India
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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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Graphene Oxide-PES-Based Mixed Matrix Membranes for Controllable Antibacterial Activity against Salmonella typhi and Water Treatment. INT J POLYM SCI 2018. [DOI: 10.1155/2018/7842148] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The present work is focused on preparation, characterization, and antibacterial activity evaluation of graphene oxide/polyethersulfone mixed matrix filtration membranes. Graphene oxide (GO) was synthesized via improved Hummer’s method and characterized by XRD, FTIR, and SEM. FT-IR spectra showed the presence of carboxylic acid and hydroxyl groups on GO nanosheets. Different concentrations of the synthesized GO at 0.25, 0.5, and 1.0 wt. % were incorporated in polyethersulfone (PES) matrix via phase inversion method to fabricate GO-PES membranes. Increasing porosity and formation of wider, finger-like channels were observed with increased GO concentrations relative to pristine membranes as evident from scanning electron microscopy (SEM) micrographs of the fabricated membranes. However, membranes prepared with 1 wt. % GO appear to contain aggregation and narrowing of pore morphology. GO-incorporated membranes demonstrated enhanced flux, water-retaining capacities, and wettability as compared to pristine PES membranes. Shake flask and colony counting methods were employed to carry out antibacterial testing of synthesized GO and fabricated GO-PES membranes against Salmonella typhi (S. typhi)—a gram-negative bacteria present in water that is known as causative agent of typhoid. Synthesized GO showed significant reduction up to 70.8% in S. typhi cell count. In the case of fabricated membranes, variable concentrations of GO are observed to significantly influence the percentage viability of S. typhi, with reduction percentages observed at 41, 60, and 69% for 0.25, 0.5, and 1.0 wt. % GO-incorporated membranes relative to 17% in the case of pristine PES membranes. The results indicate a good potential for applying GO/PES composite membranes for water filtration application.
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Typhoid fever: issues in laboratory detection, treatment options & concerns in management in developing countries. Future Sci OA 2018; 4:FSO312. [PMID: 30057789 PMCID: PMC6060388 DOI: 10.4155/fsoa-2018-0003] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 04/26/2018] [Indexed: 11/17/2022] Open
Abstract
Multidrug-resistant Salmonella enterica subsp. enterica serovar Typhi (resistant to ampicillin, chloramphenicol and cotrimoxazole), was significantly reduced with the increased usage of fluoroquinolones and azithromycin. This has led to declining multidrug resistance rates in India with increasing ciprofloxacin nonsusceptibility rates and clinical failures due to azithromycin. However, for the available agents such as ceftriaxone, azithromycin and fluoroquinolones, the dose and duration for treatment is undefined. The ongoing clinical trials for typhoid management are expected to recommend the defined dose and duration for better clinical outcome. We made an attempt to summarize the issues in laboratory detection, treatment options and responses, and the concerns in clinical practice seen in the developing countries. Typhoid fever is an important cause of mortality in developing countries and is a major public health concern. Cephalosporins or azithromycin are the drugs of choice for treating infection caused by the reduced fluoroquinolone susceptibility of S. Typhi. Emergence of cephalosporin resistance in S. Typhi and azithromycin-associated clinical and microbiological failure is of significant concern in developing countries. An approach of cephalosporin–azithromycin combination therapy has been suggested, which could be a potential alternative in treating uncomplicated S. Typhi infection in endemic areas. This review summarizes the field so far.
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Zmora N, Shrestha S, Neuberger A, Paran Y, Tamrakar R, Shrestha A, Madhup SK, Bedi TRS, Koju R, Schwartz E. Open label comparative trial of mono versus dual antibiotic therapy for Typhoid Fever in adults. PLoS Negl Trop Dis 2018; 12:e0006380. [PMID: 29684022 PMCID: PMC5912710 DOI: 10.1371/journal.pntd.0006380] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 03/09/2018] [Indexed: 11/18/2022] Open
Abstract
Background Emerging resistance to antibiotics renders therapy of Typhoid Fever (TF) increasingly challenging. The current single-drug regimens exhibit prolonged fever clearance time (FCT), imposing a great burden on both patients and health systems, and potentially contributing to the development of antibiotic resistance and the chronic carriage of the pathogens. The aim of our study was to assess the efficacy of combining third-generation cephalosporin therapy with azithromycin on the outcomes of TF in patients living in an endemic region. Methods An open-label, comparative trial was conducted at Dhulikhel Hospital, Nepal, between October 2012 and October 2014. Only culture-confirmed TF cases were eligible. Patients were alternately allocated to one of four study arms: hospitalized patients received either intravenous ceftriaxone or a combination of ceftriaxone and oral azithromycin, while outpatients received either oral azithromycin or a combination of oral azithromycin and cefexime. The primary outcome evaluated was FCT and the secondary outcomes included duration of bacteremia. Results 105 blood culture-confirmed patients, of whom 51 were treated as outpatients, were eligible for the study. Of the 88 patients who met the inclusion criteria for FCT analysis 41 patients received a single-agent regimen, while 47 patients received a combined regimen. Results showed that FCT was significantly shorter for the latter (95 versus 88 hours, respectively, p = 0·004), and this effect was exhibited in both the hospitalized and the outpatient sub-groups. Repeat blood cultures, drawn on day 3, were positive for 8/47 (17%) patients after monotherapy, versus 2/51 (4%) after combination therapy (p = 0·045). No severe complications or fatalities occurred in any of the groups. Conclusions Combined therapy of third-generation cephalosporins and azithromycin for TF may surpass monotherapy in terms of FCT and time to elimination of bacteremia. Trial registration Trial registration number: NCT02224040. Typhoid fever (TF) is a serious disease and the most common etiology of bloodstream infections in febrile patients in the Indian subcontinent. Before the advent of antibiotics its mortality rate reached up to 40%, and dropped dramatically upon their introduction. However, over the last decades multidrug-resistant strains have emerged, further posing a challenge to the treatment of TF. Here, we propose a novel treatment approach, combining azithromycin and a third-generation cephalosporin, two antibiotic agents, which act synergistically on the two niches occupied by the bacteria, the intra- and the extra-cellular compartments respectively. In our study of a rural Nepalese population with culture-confirmed TF, we have shown that dual therapy was superior to monotherapy in terms of time to defervescence and bacteremia elimination, both in outpatient and inpatient settings. We hence advocate the combination of these two antibiotics as a more effective therapeutic strategy than the current standard of care, and suggest that such approach may shorten patients’ hospital stay, and reduce both pathogen carriage rates and the development of antibiotic resistance.
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Affiliation(s)
- Niv Zmora
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sudeep Shrestha
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Ami Neuberger
- Travel Medicine & Tropical Diseases and Internal Medicine B, Rambam Medical Center, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Yael Paran
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | | | - Ashish Shrestha
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | | | - T. R. S. Bedi
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Rajendra Koju
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Eli Schwartz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Center for Geographic Medicine and Tropical Diseases, the Chaim Sheba Medical Center, Tel Hashomer, Israel
- * E-mail:
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Bandyopadhyay R, Balaji V, Yadav B, Jasmine S, Sathyendra S, Rupali P. Effectiveness of treatment regimens for Typhoid fever in the nalidixic acid-resistant S. typhi (NARST) era in South India. Trop Doct 2018; 48:182-188. [PMID: 29495943 DOI: 10.1177/0049475518758884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The epidemiology of typhoid fever in South Asia has changed. Multi-drug resistant (MDR) Salmonella typhi ( S. typhi) is now frequently resistant to nalidixic acid and thus labelled NARST. Treatment failure with the use of fluoroquinolones has been widely noted, forcing clinicians to adopt alternative treatment strategies. In this observational study, we looked at various treatment regimens and correlated clinical and microbiological outcomes. In 146 hospitalised adults, the median minimum inhibitory concentration (MIC) for ciprofloxacin was 0.38 µg/mL with a median fever clearance time (FCT) of eight days (range = 2-35 days). Of the regimens used, gatifloxacin and azithromycin had a shorter FCT of six days compared to ceftriaxone (ten days; P < 0.001). Though mortality and relapse in our cohort was low, NARST seemed to correlate with mortality ( P = 0.006). Gatifloxacin or azithromycin clearly emerge as the drugs of choice for treatment of typhoid in South India.
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Affiliation(s)
- Rini Bandyopadhyay
- 1 Assistant Professor, Christian Medical College, Vellore, Tamil Nadu, India
| | - Veeraghavan Balaji
- 2 Professor of Microbiology, Christian Medical College, Vellore, Tamil Nadu, India
| | - Bijesh Yadav
- 3 Consultant statistician, Department of Biostatistics, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sudha Jasmine
- 4 Associate Professor, Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Sowmya Sathyendra
- 5 Professor, Department of Medicine, Christian Medical College, Vellore, Tamil Nadu, India
| | - Priscilla Rupali
- 6 Professor and Head, Department of Infectious Diseases, Christian Medical College, Vellore, Tamil Nadu, India
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Abstract
PURPOSE OF REVIEW Increasing antimicrobial resistance in Salmonella Typhi is a serious public health concern, especially in industrializing countries. Here we review recent clinical and laboratory data concerning the evolution of antimicrobial resistance, with particular reference to the emergence resistance against fluoroquinolones, third generation cephalosporins, and azithromycin. RECENT FINDINGS The last 40 years have witnessed the sequential emergence of resistance to all first-line antimicrobials used in the treatment of S. Typhi infections. Multidrug resistance (MDR), defined by resistance to chloramphenicol, amoxicillin, and co-trimoxazole, emerged in the 1990s, followed rapidly by reduced susceptibility to fluoroquinolones. In the current decade, high-level fluoroquinolone resistance has emerged in south Asia and threatens to spread worldwide. Increasing reliance is now being placed on the activity of third generation cephalosporins and azithromycin, but resistance against these agents is developing. Carbapenems and tigecycline may be alternatives, although clinical data are sparse, and in some settings reversion to chloramphenicol and co-trimoxazole susceptibility is occurring. Therefore, older drugs may yet have a role in the treatment of S. Typhi infections. SUMMARY Good surveillance, improved diagnostics, more prudent use of antimicrobials, and effective vaccines will all be critical to reducing the burden of disease caused by S. Typhi.
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Pokharel S, Basnyat B, Arjyal A, Mahat SP, Kc RK, Bhuju A, Poudyal B, Kestelyn E, Shrestha R, Phuong DNT, Thapa R, Karki M, Dongol S, Karkey A, Wolbers M, Baker S, Thwaites G. Co-trimoxazole versus azithromycin for the treatment of undifferentiated febrile illness in Nepal: study protocol for a randomized controlled trial. Trials 2017; 18:450. [PMID: 28969659 PMCID: PMC5625657 DOI: 10.1186/s13063-017-2199-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 09/19/2017] [Indexed: 11/18/2022] Open
Abstract
Background Undifferentiated febrile illness (UFI) includes typhoid and typhus fevers and generally designates fever without any localizing signs. UFI is a great therapeutic challenge in countries like Nepal because of the lack of available point-of-care, rapid diagnostic tests. Often patients are empirically treated as presumed enteric fever. Due to the development of high-level resistance to traditionally used fluoroquinolones against enteric fever, azithromycin is now commonly used to treat enteric fever/UFI. The re-emergence of susceptibility of Salmonella typhi to co-trimoxazole makes it a promising oral treatment for UFIs in general. We present a protocol of a randomized controlled trial of azithromycin versus co-trimoxazole for the treatment of UFI. Methods/design This is a parallel-group, double-blind, 1:1, randomized controlled trial of co-trimoxazole versus azithromycin for the treatment of UFI in Nepal. Participants will be patients aged 2 to 65 years, presenting with fever without clear focus for at least 4 days, complying with other study criteria and willing to provide written informed consent. Patients will be randomized either to azithromycin 20 mg/kg/day (maximum 1000 mg/day) in a single daily dose and an identical placebo or co-trimoxazole 60 mg/kg/day (maximum 3000 mg/day) in two divided doses for 7 days. Patients will be followed up with twice-daily telephone calls for 7 days or for at least 48 h after they become afebrile, whichever is later; by home visits on days 2 and 4 of treatment; and by hospital visits on days 7, 14, 28 and 63. The endpoints will be fever clearance time, treatment failure, time to treatment failure, and adverse events. The estimated sample size is 330. The primary analysis population will be all the randomized population and subanalysis will be repeated on patients with blood culture-confirmed enteric fever and culture-negative patients. Discussion Both azithromycin and co-trimoxazole are available in Nepal and are extensively used in the treatment of UFI. Therefore, it is important to know the better orally administered antimicrobial to treat enteric fever and other UFIs especially against the background of fluoroquinolone-resistant enteric fever. Trial registration ClinicalTrials.gov, ID: NCT02773407. Registered on 5 May 2016. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2199-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sunil Pokharel
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Buddha Basnyat
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal. .,Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.
| | - Amit Arjyal
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Saruna Pathak Mahat
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Raj Kumar Kc
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abhusani Bhuju
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Buddhi Poudyal
- Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Evelyne Kestelyn
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Ritu Shrestha
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | | | - Rajkumar Thapa
- Patan Hospital, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Manan Karki
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Sabina Dongol
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit Nepal, Patan Academy of Health Sciences, Lalitpur, Nepal
| | - Marcel Wolbers
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Stephen Baker
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
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Dolecek C. Typhoid Fever and Other Enteric Fevers. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00115-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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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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Gatifloxacin versus ceftriaxone for uncomplicated enteric fever in Nepal: an open-label, two-centre, randomised controlled trial. THE LANCET. INFECTIOUS DISEASES 2016; 16:535-545. [PMID: 26809813 PMCID: PMC4835582 DOI: 10.1016/s1473-3099(15)00530-7] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/02/2015] [Accepted: 12/08/2015] [Indexed: 12/16/2022]
Abstract
Background Because treatment with third-generation cephalosporins is associated with slow clinical improvement and high relapse burden for enteric fever, whereas the fluoroquinolone gatifloxacin is associated with rapid fever clearance and low relapse burden, we postulated that gatifloxacin would be superior to the cephalosporin ceftriaxone in treating enteric fever. Methods We did an open-label, randomised, controlled, superiority trial at two hospitals in the Kathmandu valley, Nepal. Eligible participants were children (aged 2–13 years) and adult (aged 14–45 years) with criteria for suspected enteric fever (body temperature ≥38·0°C for ≥4 days without a focus of infection). We randomly assigned eligible patients (1:1) without stratification to 7 days of either oral gatifloxacin (10 mg/kg per day) or intravenous ceftriaxone (60 mg/kg up to 2 g per day for patients aged 2–13 years, or 2 g per day for patients aged ≥14 years). The randomisation list was computer-generated using blocks of four and six. The primary outcome was a composite of treatment failure, defined as the occurrence of at least one of the following: fever clearance time of more than 7 days after treatment initiation; the need for rescue treatment on day 8; microbiological failure (ie, blood cultures positive for Salmonella enterica serotype Typhi, or Paratyphi A, B, or C) on day 8; or relapse or disease-related complications within 28 days of treatment initiation. We did the analyses in the modified intention-to-treat population, and subpopulations with either confirmed blood-culture positivity, or blood-culture negativity. The trial was powered to detect an increase of 20% in the risk of failure. This trial was registered at ClinicalTrials.gov, number NCT01421693, and is now closed. Findings Between Sept 18, 2011, and July 14, 2014, we screened 725 patients for eligibility. On July 14, 2014, the trial was stopped early by the data safety and monitoring board because S Typhi strains with high-level resistance to ciprofloxacin and gatifloxacin had emerged. At this point, 239 were in the modified intention-to-treat population (120 assigned to gatifloxacin, 119 to ceftriaxone). 18 (15%) patients who received gatifloxacin had treatment failure, compared with 19 (16%) who received ceftriaxone (hazard ratio [HR] 1·04 [95% CI 0·55–1·98]; p=0·91). In the culture-confirmed population, 16 (26%) of 62 patients who received gatifloxacin failed treatment, compared with four (7%) of 54 who received ceftriaxone (HR 0·24 [95% CI 0·08–0·73]; p=0·01). Treatment failure was associated with the emergence of S Typhi exhibiting resistance against fluoroquinolones, requiring the trial to be stopped. By contrast, in patients with a negative blood culture, only two (3%) of 58 who received gatifloxacin failed treatment versus 15 (23%) of 65 who received ceftriaxone (HR 7·50 [95% CI 1·71–32·80]; p=0·01). A similar number of non-serious adverse events occurred in each treatment group, and no serious events were reported. Interpretation Our results suggest that fluoroquinolones should no longer be used for treatment of enteric fever in Nepal. Additionally, under our study conditions, ceftriaxone was suboptimum in a high proportion of patients with culture-negative enteric fever. Since antimicrobials, specifically fluoroquinolones, are one of the only routinely used control measures for enteric fever, the assessment of novel diagnostics, new treatment options, and use of existing vaccines and development of next-generation vaccines are now a high priority. Funding Wellcome Trust and Li Ka Shing Foundation.
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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: 640] [Impact Index Per Article: 71.1] [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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25
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Dave J, Sefton A. Enteric fever and its impact on returning travellers. Int Health 2015; 7:163-8. [DOI: 10.1093/inthealth/ihv018] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 02/26/2015] [Indexed: 11/14/2022] Open
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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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Shrestha P, Arjyal A. Conducting randomized controlled trials for the treatment of enteric Fever. Clin Infect Dis 2014; 59:1503-4. [PMID: 25097084 PMCID: PMC4207420 DOI: 10.1093/cid/ciu636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Poojan Shrestha
- Patan Academy of Health Sciences, Oxford University Clinical Research Unit, Lalitpur, Nepal
| | - Amit Arjyal
- Patan Academy of Health Sciences, Oxford University Clinical Research Unit, Lalitpur, Nepal
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Limpitikul W, Henpraserttae N, Saksawad R, Laoprasopwattana K. Typhoid outbreak in Songkhla, Thailand 2009-2011: clinical outcomes, susceptibility patterns, and reliability of serology tests. PLoS One 2014; 9:e111768. [PMID: 25375784 PMCID: PMC4222948 DOI: 10.1371/journal.pone.0111768] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 09/30/2014] [Indexed: 12/04/2022] Open
Abstract
Objective To determine the clinical manifestations and outcomes, the reliability of Salmonella enterica serotype Typhi (S ser. Typhi) IgM and IgG rapid tests, and the susceptibility patterns and the response to treatment during the 2009–2011 typhoid outbreak in Songkhla province in Thailand. Method The medical records of children aged <15 years with S ser. Typhi bacteremia were analysed. The efficacy of the typhoid IgM and IgG rapid tests and susceptibility of the S ser. Typhi to the current main antibiotics used for typhoid (amoxicillin, ampicillin, cefotaxime, ceftriaxone, co-trimoxazole, and ciprofloxacin), were evaluated. Results S ser. Typhi bacteremia was found in 368 patients, and all isolated strains were susceptible to all 6 antimicrobials tested. Most of the patients were treated with ciprofloxacin for 7–14 days. The median time (IQR) of fever before treatment and duration of fever after treatment were 5 (4, 7) days and 4 (3, 5) days, respectively. Complications of ascites, lower respiratory symptoms, anemia (Hct <30%), and ileal perforation were found in 7, 7, 22, and 1 patients, respectively. None of the patients had recurrent infection or died. The sensitivities of the typhoid IgM and IgG tests were 58.3% and 25.6% respectively, and specificities were 74.1% and 50.5%, respectively. Conclusion Most of the patients were diagnosed at an early stage and treated with a good outcome. All S ser. Typhi strains were susceptible to standard first line antibiotic typhoid treatment. The typhoid IgM and IgG rapid tests had low sensitivity and moderate specificity.
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Affiliation(s)
| | - Narong Henpraserttae
- Bureau of Epidemiology, Department of Disease Control, Ministry of Public Health in Songkhla, Songkhla, Thailand
| | - Rachanee Saksawad
- Department of Pediatrics, Hat Yai Education Center, Hat Yai Hospital, Hat Yai, Songkhla, Thailand
| | - Kamolwish Laoprasopwattana
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
- * E-mail:
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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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Gaubert A, Kauss T, Marchivie M, Ba BB, Lembege M, Fawaz F, Boiron JM, Lafarge X, Lindegardh N, Fabre JL, White NJ, Olliaro PL, Millet P, Grislain L, Gaudin K. Preliminary pharmaceutical development of antimalarial-antibiotic cotherapy as a pre-referral paediatric treatment of fever in malaria endemic areas. Int J Pharm 2014; 468:55-63. [PMID: 24726300 PMCID: PMC4045394 DOI: 10.1016/j.ijpharm.2014.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2014] [Accepted: 04/08/2014] [Indexed: 11/19/2022]
Abstract
Artemether (AM) plus azithromycin (AZ) rectal co-formulations were studied to provide pre-referral treatment for children with severe febrile illnesses in malaria-endemic areas. The target profile required that such product should be cheap, easy to administer by non-medically qualified persons, rapidly effective against both malaria and bacterial infections. Analytical and pharmacotechnical development, followed by in vitro and in vivo evaluation, were conducted for various AMAZ coformulations. Of the formulations tested, stability was highest for dry solid forms and bioavailability for hard gelatin capsules; AM release from AMAZ rectodispersible tablet was suboptimal due to a modification of its micro-crystalline structure.
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Affiliation(s)
- Alexandra Gaubert
- Université de Bordeaux, EA 4575 Analytical and Pharmaceutical Developments Applied to Neglected Diseases and Counterfeits, Bordeaux, France
| | - Tina Kauss
- Université de Bordeaux, EA 4575 Analytical and Pharmaceutical Developments Applied to Neglected Diseases and Counterfeits, Bordeaux, France.
| | - Mathieu Marchivie
- Université de Bordeaux, FRE 3396 CNRS Pharmacochimie, Bordeaux, France
| | - Boubakar B Ba
- Université de Bordeaux, EA 4575 Analytical and Pharmaceutical Developments Applied to Neglected Diseases and Counterfeits, Bordeaux, France
| | - Martine Lembege
- Université de Bordeaux, Laboratory of Organic and Therapeutic Chemistry, Pharmacochimie, Bordeaux, France
| | - Fawaz Fawaz
- Université de Bordeaux, EA 4575 Analytical and Pharmaceutical Developments Applied to Neglected Diseases and Counterfeits, Bordeaux, France
| | - Jean-Michel Boiron
- EFS (Etablissement Français du Sang) Aquitaine Limousin, Bordeaux, France
| | - Xavier Lafarge
- EFS (Etablissement Français du Sang) Aquitaine Limousin, Bordeaux, France
| | | | - Jean-Louis Fabre
- OTECI (Office Technique d'Etude et de Coopération Internationale), Paris, France
| | - Nicholas J White
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand; Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, UK
| | - Piero L Olliaro
- Centre for Tropical Medicine, Nuffield Department of Medicine, University of Oxford, UK; UNICEF/UNDP/WB/WHO Special Program for Research & Training in Tropical Diseases (TDR), Geneva, Switzerland
| | - Pascal Millet
- Université de Bordeaux, EA 4575 Analytical and Pharmaceutical Developments Applied to Neglected Diseases and Counterfeits, Bordeaux, France
| | | | - Karen Gaudin
- Université de Bordeaux, EA 4575 Analytical and Pharmaceutical Developments Applied to Neglected Diseases and Counterfeits, Bordeaux, France
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Teh CSJ, Chua KH, Thong KL. Paratyphoid fever: splicing the global analyses. Int J Med Sci 2014; 11:732-41. [PMID: 24904229 PMCID: PMC4045793 DOI: 10.7150/ijms.7768] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 03/05/2014] [Indexed: 11/24/2022] Open
Abstract
The incidence of enteric fever caused by Salmonella enterica serovar Paratyphi A (S. Paratyphi A) is increasing in many parts of the world. Although there is no major outbreak of paratyphoid fever in recent years, S. Paratyphi A infection still remains a public health problem in many tropical countries. Therefore, surveillance studies play an important role in monitoring infections and the emergence of multidrug resistance, especially in endemic countries such as India, Nepal, Pakistan and China. In China, enteric fever was caused predominantly by S. Paratyphi A rather than by Salmonella enterica serovar Typhi (S. Typhi). Sometimes, S. Paratyphi A infection can evolve into a carrier state which increases the risk of transmission for travellers. Hence, paratyphoid fever is usually classified as a "travel-associated" disease. To date, diagnosis of paratyphoid fever based on the clinical presentation is not satisfactory as it resembles other febrile illnesses, and could not be distinguished from S. Typhi infection. With the availability of Whole Genome Sequencing technology, the genomes of S. Paratyphi A could be studied in-depth and more specific targets for detection will be revealed. Hence, detection of S. Paratyphi A with Polymerase Chain Reaction (PCR) method appears to be a more reliable approach compared to the Widal test. On the other hand, due to increasing incidence of S. Paratyphi A infections worldwide, the need to produce a paratyphoid vaccine is essential and urgent. Hence various vaccine projects that involve clinical trials have been carried out. Overall, this review provides the insights of S. Paratyphi A, including the bacteriology, epidemiology, management and antibiotic susceptibility, diagnoses and vaccine development.
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Affiliation(s)
- Cindy Shuan Ju Teh
- 1. Department of Medical Microbiology, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur
| | - Kek Heng Chua
- 2. Department of Biomedical Science, Faculty of Medicine, University of Malaya, 50603 Kuala Lumpur
| | - Kwai Lin Thong
- 3. Institute of Biological Sciences, Faculty of Science, University of Malaya, 50603 Kuala Lumpur
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Akhtar S, Sarker MR, Jabeen K, Sattar A, Qamar A, Fasih N. Antimicrobial resistance in Salmonella enterica serovar typhi and paratyphi in South Asia-current status, issues and prospects. Crit Rev Microbiol 2014; 41:536-45. [PMID: 24645636 DOI: 10.3109/1040841x.2014.880662] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The human race owes a debt of gratitude to antimicrobial agents, penicillin and its successors that have saved people from tremendous pain and suffering in the last several decades. Unfortunately, this consideration is no more true, as millions of people are prone to the challenging threat of emergence of antimicrobial resistance worldwide and the menace is more distressing in developing countries. Comparable with other bacterial species, Salmonella enterica serovar Typhi (S. typhi) and Paratyphi (S. paratyphi) have been evolving multidrug resistance (MDR) against a wide array of antibiotics, including chloramphenicol, ampicillin and co-trimoxazole, and globally affecting 21 million people with 220,000 deaths each year. S. typhi and S. paratyphi infections are also endemic in South Asia and a series of antibiotics used to treat these infections, have been losing efficacy against enteric fever. Currently, quinolones are regarded as a choice to treat MDR Salmonella in these regions. Travel-related cases of enteric fever, especially from South Asian countries are the harbinger of the magnitude of MDR Salmonella in that region. Conclusively, the MDR will continue to grow and the available antimicrobial agents would become obsolete. Therefore, a radical and aggressive approach in terms of rational use of antibiotics during treating infections is essentially needed.
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Affiliation(s)
- Saeed Akhtar
- a Department of Food Science and Technology , Bahauddin Zakariya University Multan , Multan , Pakistan
| | - Mahfuzur R Sarker
- b Department of Microbiology , Oregon State University , Corvallis , OR , USA
| | - Kausar Jabeen
- c Department of Pathology and Microbiology , Agha Khan University Karachi , Karachi , Pakistan , and
| | - Ahsan Sattar
- d Department of Microbiology , Institute of Pure and Applied Biology, Bahauddin Zakariya University , Multan , Pakistan
| | - Aftab Qamar
- a Department of Food Science and Technology , Bahauddin Zakariya University Multan , Multan , Pakistan
| | - Naima Fasih
- c Department of Pathology and Microbiology , Agha Khan University Karachi , Karachi , Pakistan , and
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Invasive Salmonellosis by the Very Rare Salmonella choleraesuis in a Returning Traveler on a Tumor Necrosis Factor- α Inhibitor. Case Rep Med 2014; 2014:934657. [PMID: 24715927 PMCID: PMC3970466 DOI: 10.1155/2014/934657] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 01/03/2014] [Indexed: 11/18/2022] Open
Abstract
Salmonella choleraesuis is one of the least commonly reported nontyphoidal salmonellae in the United States, accounting for only 0.08% and ranking lower than 20th place among all human source salmonellosis reported to the CDC in 2009. In the state of Connecticut, only 12 cases have been reported since 1998 and our case is the only case since 2008. We report a case of invasive Salmonellosis caused by Salmonella choleraesuis in a patient on an antitumor necrosis factor-α agent (adalimumab) who recently returned from a trip to the Dominican Republic.
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Koirala S, Basnyat B, Arjyal A, Shilpakar O, Shrestha K, Shrestha R, Shrestha UM, Agrawal K, Koirala KD, Thapa SD, Karkey A, Dongol S, Giri A, Shakya M, Pathak KR, Campbell J, Baker S, Farrar J, Wolbers M, Dolecek C. Gatifloxacin versus ofloxacin for the treatment of uncomplicated enteric fever in Nepal: an open-label, randomized, controlled trial. PLoS Negl Trop Dis 2013; 7:e2523. [PMID: 24282626 PMCID: PMC3837022 DOI: 10.1371/journal.pntd.0002523] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 09/25/2013] [Indexed: 11/29/2022] Open
Abstract
Background Fluoroquinolones are the most commonly used group of antimicrobials for the treatment of enteric fever, but no direct comparison between two fluoroquinolones has been performed in a large randomised trial. An open-label randomized trial was conducted to investigate whether gatifloxacin is more effective than ofloxacin in the treatment of uncomplicated enteric fever caused by nalidixic acid-resistant Salmonella enterica serovars Typhi and Paratyphi A. Methodology and Principal Findings Adults and children clinically diagnosed with uncomplicated enteric fever were enrolled in the study to receive gatifloxacin (10 mg/kg/day) in a single dose or ofloxacin (20 mg/kg/day) in two divided doses for 7 days. Patients were followed for six months. The primary outcome was treatment failure in patients infected with nalidixic acid resistant isolates. 627 patients with a median age of 17 (IQR 9–23) years were randomised. Of the 218 patients with culture confirmed enteric fever, 170 patients were infected with nalidixic acid-resistant isolates. In the ofloxacin group, 6 out of 83 patients had treatment failure compared to 5 out of 87 in the gatifloxacin group (hazard ratio [HR] of time to failure 0.81, 95% CI 0.25 to 2.65, p = 0.73). The median time to fever clearance was 4.70 days (IQR 2.98–5.90) in the ofloxacin group versus 3.31 days (IQR 2.29–4.75) in the gatifloxacin group (HR = 1.59, 95% CI 1.16 to 2.18, p = 0.004). The results in all blood culture-confirmed patients and all randomized patients were comparable. Conclusion Gatifloxacin was not superior to ofloxacin in preventing failure, but use of gatifloxacin did result in more prompt fever clearance time compared to ofloxacin. Trial registration: ISRCTN 63006567 (www.controlled-trials.com). Enteric fever, which comprises of typhoid and paratyphoid fevers, is common in many developing countries. It is also sometimes seen in the Western world in returning travellers. This present study of uncomplicated enteric fever in an outpatient setting in a hospital in Kathmandu, Nepal compared the newer gatifloxacin with the widely-used ofloxacin (two drugs of the fluroquinolone class) in the treatment of this illness. Although fluroquinolones are commonly considered the main group of drugs in the treatment of enteric fever, there have not been comparisons of efficacy between two drugs in this same class in the treatment of enteric fever. Furthermore, certain strains of enteric fever organism called nalidixic-acid resistant strains are proving very difficult to treat in both the local population and the Western travellers. The study focused primarily on the efficacy of the 2 drugs against these particular strains. The results revealed that both drugs were effective but gatifloxacin decreased the patient's fever more rapidly than ofloxacin. Dysglycemia was noted in a 35-year-old woman taking gatifloxacin who did not disclose a pre-existing diagnosis of diabetes at time of enrollment, but not in any other healthy child or young adult.
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Affiliation(s)
- Samir Koirala
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Sciences, Patan Hospital, Patan, Nepal
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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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Decreased ciprofloxacin susceptibility in Salmonella Typhi and Paratyphi infections in ill-returned travellers: the impact on clinical outcome and future treatment options. Eur J Clin Microbiol Infect Dis 2013; 32:1295-301. [PMID: 23609512 DOI: 10.1007/s10096-013-1878-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Accepted: 04/02/2013] [Indexed: 10/26/2022]
Abstract
The emergence of decreased ciprofloxacin susceptibility (DCS) in Salmonella enterica serovar Typhi and serovar Paratyphi A, B or C limits treatment options. We studied the impact of DCS isolates on the fate of travellers returning with enteric fever and possible alternative treatment options. We evaluated the clinical features, susceptibility data and efficacy of empirical treatment in patients with positive blood cultures of a DCS isolate compared to patients infected with a ciprofloxacin-susceptible (CS) isolate in the period from January 2002 to August 2008. In addition, the pharmacokinetic and pharmacodynamic parameters of ciprofloxacin, levofloxacin and gatifloxacin were determined to assess if increasing the dose would result in adequate unbound fraction of the drug 24-h area under the concentration-time curve/minimum inhibitory concentration (ƒAUC(0-24)/MIC) ratio. Patients with DCS more often returned from the Indian subcontinent and had a longer fever clearance time and length of hospital stay compared to patients in whom the initial empirical therapy was adequate. The mean ƒAUC(0-24)/MIC was 41.3 ± 18.8 in the patients with DCS and 585.4 ± 219 in patients with a CS isolate. For DCS isolates, the mean ƒAUC0-24/MIC for levofloxacin was 60.5 ± 28.7 and for gatifloxacin, it was 97.9 ± 28.0. Increasing the dose to an adequate ƒAUC(0-24)/MIC ratio will lead to conceivably toxic drug levels in 50% of the patients treated with ciprofloxacin. Emerging DCS isolates has led to the failure of empirical treatment in ill-returned travellers. We demonstrated that, in some cases, an adequate ƒAUC(0-24)/MIC ratio could be achieved by increasing the dose of ciprofloxacin or by the use of alternative fluoroquinolones.
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Immune profiling with a Salmonella Typhi antigen microarray identifies new diagnostic biomarkers of human typhoid. Sci Rep 2013; 3:1043. [PMID: 23304434 PMCID: PMC3540400 DOI: 10.1038/srep01043] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/07/2012] [Indexed: 11/08/2022] Open
Abstract
Current serological diagnostic assays for typhoid fever are based on detecting antibodies against Salmonella LPS or flagellum, resulting in a high false-positive rate. Here we used a protein microarray containing 2,724 Salmonella enterica serovar Typhi antigens (>63% of proteome) and identified antibodies against 16 IgG antigens and 77 IgM antigens that were differentially reactive among acute typhoid patients and healthy controls. The IgG target antigens produced a sensitivity of 97% and specificity of 80%, whereas the IgM target antigens produced 97% and 91% sensitivity and specificity, respectively. Our analyses indicated certain features such as membrane association, secretion, and protein expression were significant enriching features of the reactive antigens. About 72% of the serodiagnostic antigens were within the top 25% of the ranked antigen list using a Naïve bayes classifier. These data provide an important resource for improved diagnostics, therapeutics and vaccine development against an important human pathogen.
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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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Emary K, Moore CE, Chanpheaktra N, An KP, Chheng K, Sona S, Duy PT, Nga TVT, Wuthiekanun V, Amornchai P, Kumar V, Wijedoru L, Stoesser NE, Carter MJ, Baker S, Day NP, Parry CM. Enteric fever in Cambodian children is dominated by multidrug-resistant H58 Salmonella enterica serovar Typhi with intermediate susceptibility to ciprofloxacin. Trans R Soc Trop Med Hyg 2012; 106:718-24. [DOI: 10.1016/j.trstmh.2012.08.007] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2012] [Accepted: 08/07/2012] [Indexed: 11/15/2022] Open
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Pradhan R, Shrestha U, Gautam SC, Thorson S, Shrestha K, Yadav BK, Kelly DF, Adhikari N, Pollard AJ, Murdoch DR. Bloodstream infection among children presenting to a general hospital outpatient clinic in urban Nepal. PLoS One 2012; 7:e47531. [PMID: 23115652 PMCID: PMC3480362 DOI: 10.1371/journal.pone.0047531] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2012] [Accepted: 09/13/2012] [Indexed: 11/18/2022] Open
Abstract
Background There are limited data on the etiology and characteristics of bloodstream infections in children presenting in hospital outpatient settings in South Asia. Previous studies in Nepal have highlighted the importance of murine typhus as a cause of febrile illness in adults and enteric fever as a leading bacterial cause of fever among children admitted to hospital. Methods We prospectively studied a total of 1084 febrile children aged between 2 months and 14 years presenting to a general hospital outpatient department in Kathmandu Valley, Nepal, over two study periods (summer and winter). Blood from all patients was tested by conventional culture and by real-time PCR for Rickettsia typhi. Results Putative etiological agents for fever were identified in 164 (15%) patients. Salmonella enterica serovar Typhi (S. Typhi) was identified in 107 (10%), S. enterica serovar Paratyphi A (S. Paratyphi) in 30 (3%), Streptococcus pneumoniae in 6 (0.6%), S. enterica serovar Typhimurium in 2 (0.2%), Haemophilus influenzae type b in 1 (0.1%), and Escherichia coli in 1 (0.1%) patient. S. Typhi was the most common organism isolated from blood during both summer and winter. Twenty-two (2%) patients were PCR positive for R. typhi. No significant demographic, clinical and laboratory features distinguished culture positive enteric fever and murine typhus. Conclusions Salmonella infections are the leading cause of bloodstream infection among pediatric outpatients with fever in Kathmandu Valley. Extension of immunization programs against invasive bacterial disease to include the agents of enteric fever and pneumococcus could improve the health of children in Nepal.
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Affiliation(s)
- Rahul Pradhan
- Pediatric Research Unit, Pediatric Department, Patan Academy of Health Sciences, Lalitpur, Nepal.
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Palomino JC, Martin A. Is repositioning of drugs a viable alternative in the treatment of tuberculosis? J Antimicrob Chemother 2012; 68:275-83. [DOI: 10.1093/jac/dks405] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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Humphries RM, Fang FC, Aarestrup FM, Hindler JA. In vitro susceptibility testing of fluoroquinolone activity against Salmonella: recent changes to CLSI standards. Clin Infect Dis 2012; 55:1107-13. [PMID: 22752519 DOI: 10.1093/cid/cis600] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Fluoroquinolone (FQ) resistance in Salmonella enterica is a significant clinical concern. Recognition of resistance by the clinical laboratory is complicated by the multiple FQ resistance mechanisms found in Salmonella. The Clinical Laboratory Standards Institute (CLSI) recently addressed this issue by revising the ciprofloxacin break points for Salmonella species. It is critical for clinicians and laboratory workers to be aware of the multiple technical issues surrounding these revised break points. In this article, we review FQ resistance mechanisms in Salmonella, their clinical significance, and data supporting the revised ciprofloxacin break points. We encourage clinical laboratories to adopt the revised CLSI ciprofloxacin break points for all Salmonella isolates in which susceptibility testing is indicated and discuss the technical issues for laboratories using commercial antimicrobial susceptibility systems.
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Affiliation(s)
- Romney M Humphries
- Department of Pathology and Laboratory Medicine, David Geffen School of Medicine at UCLA, Los Angeles California, USA.
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Koirala KD, Thanh DP, Thapa SD, Arjyal A, Karkey A, Dongol S, Shrestha UM, Farrar JJ, Basnyat B, Baker S. Highly resistant Salmonella enterica serovar Typhi with a novel gyrA mutation raises questions about the long-term efficacy of older fluoroquinolones for treating typhoid fever. Antimicrob Agents Chemother 2012; 56:2761-2. [PMID: 22371897 PMCID: PMC3346606 DOI: 10.1128/aac.06414-11] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2011] [Accepted: 02/16/2012] [Indexed: 01/17/2023] Open
Abstract
As a consequence of multidrug resistance, clinicians are highly dependent on fluoroquinolones for treating the serious systemic infection typhoid fever. While reduced susceptibility to fluoroquinolones, which lessens clinical efficacy, is becoming ubiquitous, comprehensive resistance is exceptional. Here we report ofloxacin treatment failure in typhoidal patient infected with a novel, highly fluoroquinolone-resistant isolate of Salmonella enterica serovar Typhi. The isolation of this organism has serious implications for the long-term efficacy of ciprofloxacin and ofloxacin for typhoid treatment.
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Affiliation(s)
| | - Duy Pham Thanh
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Sudeep Dhoj Thapa
- Oxford University Clinical Research Unit—Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Amit Arjyal
- Oxford University Clinical Research Unit—Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit—Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Sabina Dongol
- Oxford University Clinical Research Unit—Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Upendra Man Shrestha
- Oxford University Clinical Research Unit—Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Jeremy J. Farrar
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Diseases, University of Oxford, Oxford, United Kingdom
| | - Buddha Basnyat
- Oxford University Clinical Research Unit—Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Stephen Baker
- Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Diseases, University of Oxford, Oxford, United Kingdom
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Abstract
Infections with Salmonella are an important public health problem worldwide. On a global scale, it has been appraised that Salmonella is responsible for an estimated 3 billion human infections each year. The World Health Organization (WHO) has estimated that annually typhoid fever accounts for 21.7 million illnesses (217,000 deaths) and paratyphoid fever accounts for 5.4 million of these cases. Infants, children, and adolescents in south-central and South-eastern Asia experience the greatest burden of illness. In cases of enteric fever, including infections with S. Typhi and S. Paratyphi A and B, it is often necessary to commence treatment before the results of laboratory sensitivity tests are available. Hence, it is important to be aware of options and possible problems before beginning treatment. Ciprofloxacin has become the first-line drug of choice since the widespread emergence and spread of strains resistant to chloramphenicol, ampicillin, and trimethoprim. There is increase in the occurrence of strains resistant to ciprofloxacin. Reports of typhoidal salmonellae with increasing minimum inhibitory concentration (MIC) and resistance to newer quinolones raise the fear of potential treatment failures and necessitate the need for new, alternative antimicrobials. Extended-spectrum cephalosporins and azithromycin are the options available for the treatment of enteric fever. The emergence of broad spectrum β-lactamases in typhoidal salmonellae constitutes a new challenge. Already there are rare reports of azithromycin resistance in typhoidal salmonellae leading to treatment failure. This review is based on published research from our centre and literature from elsewhere in the world. This brief review tries to summarize the history and recent trends in antimicrobial resistance in typhoidal salmonellae.
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Affiliation(s)
- B N Harish
- Department of Microbiology, Institute of National Importance, Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry - 605 006, 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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47
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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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48
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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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49
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Ashley EA, Lubell Y, White NJ, Turner P. Antimicrobial susceptibility of bacterial isolates from community acquired infections in Sub-Saharan Africa and Asian low and middle income countries. Trop Med Int Health 2011; 16:1167-79. [PMID: 21707879 PMCID: PMC3469739 DOI: 10.1111/j.1365-3156.2011.02822.x] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Antimicrobial resistance has arisen across the globe in both nosocomial and community settings as a consequence of widespread antibiotic consumption. Poor availability of laboratory diagnosis means that resistance frequently goes unrecognised and may only be detected as clinical treatment failure. In this review, we provide an overview of the reported susceptibility of common community acquired bacterial pathogens in Sub-Saharan Africa and Asia to the antibiotics that are most widely used in these areas. METHODS We reviewed the literature for reports of the susceptibility of prevalent pathogens in the community in SSA and Asia to a range of commonly prescribed antibiotics. Inclusion criteria required that isolates were collected since 2004 and that they were obtained from either normally sterile sites or urine. The data were aggregated by region and by age group. RESULTS Eighty-three studies were identified since 2004 which reported the antimicrobial susceptibilities of common bacterial pathogens. Different methods were used to assess in-vitro susceptibility in the different studies. The quality of testing (evidenced by resistance profiles) also varied considerably. For Streptococcus pneumoniae and Neisseria meningitidis most drugs maintained relatively high efficacy, apart from co-trimoxazole to which there were high levels of resistance in most of the pathogens surveyed. CONCLUSIONS Compared with the enormous infectious disease burden and widespread use of antibiotics there are relatively few reliable data on antimicrobial susceptibility from tropical Asia and Africa upon which to draw firm conclusions, although it is evident that many commonly used antibiotics face considerable resistance in prevalent bacterial pathogens. This is likely to exacerbate morbidity and mortality. Investment in improved antimicrobial susceptibility testing and surveillance systems is likely to be a highly cost-effective strategy and should be complemented by centralized and readily accessible information resources.
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Affiliation(s)
- Elizabeth A Ashley
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkok, Thailand
- Imperial College NHS TrustLondon, UK
| | - Yoel Lubell
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkok, Thailand
- Centre for Tropical Medicine, University of OxfordOxford, UK
| | - Nicholas J White
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkok, Thailand
- Centre for Tropical Medicine, University of OxfordOxford, UK
| | - Paul Turner
- Mahidol-Oxford Tropical Medicine Research Unit, Mahidol UniversityBangkok, Thailand
- Centre for Tropical Medicine, University of OxfordOxford, UK
- Shoklo Malaria Research UnitMae Sot, Thailand
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50
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Vinh H, Anh VTC, Anh ND, Campbell JI, Hoang NVM, Nga TVT, Nhu NTK, Minh PV, Thuy CT, Duy PT, Phuong LT, Loan HT, Chinh MT, Thao NTT, Tham NTH, Mong BL, Bay PVB, Day JN, Dolecek C, Lan NPH, Diep TS, Farrar JJ, Chau NVV, Wolbers M, Baker S. A multi-center randomized trial to assess the efficacy of gatifloxacin versus ciprofloxacin for the treatment of shigellosis in Vietnamese children. PLoS Negl Trop Dis 2011; 5:e1264. [PMID: 21829747 PMCID: PMC3149021 DOI: 10.1371/journal.pntd.0001264] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2011] [Accepted: 06/17/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The bacterial genus Shigella is the leading cause of dysentery. There have been significant increases in the proportion of Shigella isolated that demonstrate resistance to nalidixic acid. While nalidixic acid is no longer considered as a therapeutic agent for shigellosis, the fluoroquinolone ciprofloxacin is the current recommendation of the World Health Organization. Resistance to nalidixic acid is a marker of reduced susceptibility to older generation fluoroquinolones, such as ciprofloxacin. We aimed to assess the efficacy of gatifloxacin versus ciprofloxacin in the treatment of uncomplicated shigellosis in children. METHODOLOGY/PRINCIPAL FINDINGS We conducted a randomized, open-label, controlled trial with two parallel arms at two hospitals in southern Vietnam. The study was designed as a superiority trial and children with dysentery meeting the inclusion criteria were invited to participate. Participants received either gatifloxacin (10 mg/kg/day) in a single daily dose for 3 days or ciprofloxacin (30 mg/kg/day) in two divided doses for 3 days. The primary outcome measure was treatment failure; secondary outcome measures were time to the cessation of individual symptoms. Four hundred and ninety four patients were randomized to receive either gatifloxacin (n=249) or ciprofloxacin (n=245), of which 107 had a positive Shigella stool culture. We could not demonstrate superiority of gatifloxacin and observed similar clinical failure rate in both groups (gatifloxacin; 12.0% and ciprofloxacin; 11.0%, p=0.72). The median (inter-quartile range) time from illness onset to cessation of all symptoms was 95 (66-126) hours for gatifloxacin recipients and 93 (68-120) hours for the ciprofloxacin recipients (Hazard Ratio [95%CI]=0.98 [0.82-1.17], p=0.83). CONCLUSIONS We conclude that in Vietnam, where nalidixic acid resistant Shigellae are highly prevalent, ciprofloxacin and gatifloxacin are similarly effective for the treatment of acute shigellosis.
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Affiliation(s)
- Ha Vinh
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Vo Thi Cuc Anh
- Huu Nghi Hospital, Cao Lanh, Dong Thap Province, Vietnam
| | - Nguyen Duc Anh
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - James I. Campbell
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| | - Nguyen Van Minh Hoang
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Tran Vu Thieu Nga
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Nguyen Thi Khanh Nhu
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Pham Van Minh
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Cao Thu Thuy
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Pham Thanh Duy
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Le Thi Phuong
- Huu Nghi Hospital, Cao Lanh, Dong Thap Province, Vietnam
| | - Ha Thi Loan
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Mai Thu Chinh
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | | | - Bui Li Mong
- Huu Nghi Hospital, Cao Lanh, Dong Thap Province, Vietnam
| | | | - Jeremy N. Day
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| | - Christiane Dolecek
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| | | | - To Song Diep
- The Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Jeremy J. Farrar
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| | | | - Marcel Wolbers
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
| | - Stephen Baker
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
- Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, United Kingdom
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