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Singh K, Vashishtha S, Chakraborty A, Kumar A, Thakur S, Kundu B. The Salmonella typhi Cell Division Activator Protein StCAP Impacts Pathogenesis by Influencing Critical Molecular Events. ACS Infect Dis 2024; 10:1990-2001. [PMID: 38815059 DOI: 10.1021/acsinfecdis.4c00001] [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: 06/01/2024]
Abstract
Conserved molecular signatures in multidrug-resistant Salmonella typhi can serve as novel therapeutic targets for mitigation of infection. In this regard, we present the S. typhi cell division activator protein (StCAP) as a conserved target across S. typhi variants. From in silico and fluorimetric assessments, we found that StCAP is a DNA-binding protein. Replacement of the identified DNA-interacting residue Arg34 of StCAP with Ala34 showed a dramatic (15-fold) increase in Kd value compared to the wild type (Kd 546 nm) as well as a decrease in thermal stability (10 °C shift). Out of the two screened molecules against the DNA-binding pocket of StCAP, eltrombopag, and nilotinib, the former displayed better binding. Eltrombopag inhibited the stand-alone S. typhi culture with an IC50 of 38 μM. The effect was much more pronounced on THP-1-derived macrophages (T1Mac) infected with S. typhi where colony formation was severely hindered with IC50 reduced further to 10 μM. Apoptotic protease activating factor1 (Apaf1), a key molecule for intrinsic apoptosis, was identified as an StCAP-interacting partner by pull-down assay against T1Mac. Further, StCAP-transfected T1Mac showed a significant increase in LC3 II (autophagy marker) expression and downregulation of caspase 3 protein. From these experiments, we conclude that StCAP provides a crucial survival advantage to S. typhi during infection, thereby making it a potent alternative therapeutic target.
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Affiliation(s)
- Kritika Singh
- Kusuma School of Biological Sciences, Indian Institute of Technology, Delhi, New Delhi 110016, India
| | - Shubham Vashishtha
- Kusuma School of Biological Sciences, Indian Institute of Technology, Delhi, New Delhi 110016, India
| | - Ankan Chakraborty
- Kusuma School of Biological Sciences, Indian Institute of Technology, Delhi, New Delhi 110016, India
| | - Ashish Kumar
- Kusuma School of Biological Sciences, Indian Institute of Technology, Delhi, New Delhi 110016, India
| | - Sheetal Thakur
- Kusuma School of Biological Sciences, Indian Institute of Technology, Delhi, New Delhi 110016, India
| | - Bishwajit Kundu
- Kusuma School of Biological Sciences, Indian Institute of Technology, Delhi, New Delhi 110016, India
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Marchant P, Vivanco E, Silva A, Nevermann J, Fuentes I, Barrera B, Otero C, Calderón IL, Gil F, Fuentes JA. β-lactam-induced OMV release promotes polymyxin tolerance in Salmonella enterica sv. Typhi. Front Microbiol 2024; 15:1389663. [PMID: 38591031 PMCID: PMC10999688 DOI: 10.3389/fmicb.2024.1389663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/13/2024] [Indexed: 04/10/2024] Open
Abstract
The rise of multidrug-resistant bacteria is a global concern, leading to a renewed reliance on older antibiotics like polymyxins as a last resort. Polymyxins, cationic cyclic peptides synthesized nonribosomally, feature a hydrophobic acyl tail and positively charged residues. Their antimicrobial mechanism involves initial interaction with Gram-negative bacterial outer-membrane components through polar and hydrophobic interactions. Outer membrane vesicles (OMVs), nano-sized proteoliposomes secreted from the outer membrane of Gram-negative bacteria, play a crucial role in tolerating harmful molecules, including cationic peptides such as polymyxins. Existing literature has documented environmental changes' impact on modulating OMV properties in Salmonella Typhimurium. However, less information exists regarding OMV production and characteristics in Salmonella Typhi. A previous study in our laboratory showed that S. Typhi ΔmrcB, a mutant associated with penicillin-binding protein (PBP, a β-lactam antibiotic target), exhibited hypervesiculation. Consequently, this study investigated the potential impact of β-lactam antibiotics on promoting polymyxin tolerance via OMVs in S. Typhi. Our results demonstrated that sub-lethal doses of β-lactams increased bacterial survival against polymyxin B in S. Typhi. This phenomenon stems from β-lactam antibiotics inducing hypervesiculation of OMVs with higher affinity for polymyxin B, capturing and diminishing its biologically effective concentration. These findings suggest that β-lactam antibiotic use may inadvertently contribute to decreased polymyxin effectivity against S. Typhi or other Gram-negative bacteria, complicating the effective treatment of infections caused by these pathogens. This study emphasizes the importance of evaluating the influence of β-lactam antibiotics on the interaction between OMVs and other antimicrobial agents.
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Affiliation(s)
- Pedro Marchant
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Erika Vivanco
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Andrés Silva
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Jan Nevermann
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Ignacio Fuentes
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Boris Barrera
- Escuela de Tecnología Médica, Facultad de Salud, Universidad Santo Tomás, Santiago, Chile
| | - Carolina Otero
- Escuela de Química y Farmacia, Facultad de Medicina, Universidad Andres Bello, Santiago, Chile
| | - Iván L. Calderón
- Laboratorio de RNAs Bacterianos, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Fernando Gil
- Microbiota-Host Interactions and Clostridia Research Group, Universidad Andres Bello, Santiago, Chile
| | - Juan A. Fuentes
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
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Yemeli Piankeu AD, Fodouop SPC, Noubom M, Gomseu Djoumsie EB, Ful Kuh G, Gatsing D. Epidemiology and Performances of Typhidot Immunoassay and Widal Slide Agglutination in the Diagnosis of Typhoid Fever in Febrile Patients in Bafoussam City, Cameroon: A Cross-Sectional Comparative Study. THE CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY = JOURNAL CANADIEN DES MALADIES INFECTIEUSES ET DE LA MICROBIOLOGIE MEDICALE 2024; 2024:6635067. [PMID: 38425657 PMCID: PMC10904207 DOI: 10.1155/2024/6635067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 01/07/2024] [Accepted: 02/05/2024] [Indexed: 03/02/2024]
Abstract
Background Enteric fever is a great public health problem associated with significant illness and death in many endemic countries, and its clinical diagnosis is still daunting. The aim of this study was to determine the prevalence and risk factors of S. Typhi among febrile patients in Bafoussam and to evaluate the diagnostic performances of Widal and Typhidot tests. Methods This was a cross-sectional study among 336 participants visiting three hospitals in Bafoussam from August 1, 2021, to November 31, 2021. Widal test, Typhidot assay, and stool culture were used to screen for salmonellosis with the help of a structured questionnaire. Results The prevalence of S. Typhi and S. Paratyphi was found to be 62.85% and 37.14%, respectively. The overall prevalence of typhoid fever using stool culture was 20.86%. The significant risk factors associated with enteric fever were lack or insufficient knowledge of typhoid fever, poor hand hygiene, and anorexia. Typhidot immunoassay was more sensitive (100%) and specific (82.3%) than the Widal test. Both were analytically inferior to stool culture. Conclusions High prevalence of typhoid fever (20.86%) was observed which was largely associated with lack or insufficient knowledge of typhoid fever, poor hygiene measure, and anorexia as risk factors. The performances of the Widal and Typhidot test against a stool culture were inferior but with Typhidot better than the Widal slide agglutination.
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Affiliation(s)
- Aurelie Dahlia Yemeli Piankeu
- Department of Biochemistry, Research Unit of Microbiology and Antimicrobial Substances, Faculty of Science, University of Dschang, Dschang, Cameroon
| | | | - Michel Noubom
- Department of Microbiology-Hematology and Immunology, Faculty of Medicine and Pharmaceutical Sciences, University of Dschang, Cameroon
| | - Emmanuel Boris Gomseu Djoumsie
- Department of Biochemistry, Research Unit of Microbiology and Antimicrobial Substances, Faculty of Science, University of Dschang, Dschang, Cameroon
| | - Georges Ful Kuh
- Department of Biochemistry, Research Unit of Microbiology and Antimicrobial Substances, Faculty of Science, University of Dschang, Dschang, Cameroon
| | - Donatien Gatsing
- Department of Biochemistry, Research Unit of Microbiology and Antimicrobial Substances, Faculty of Science, University of Dschang, Dschang, Cameroon
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Kumar H, Manoharan A, Anbarasu A, Ramaiah S. Computational study of the piperidine and FtsZ interaction in Salmonella Typhi: implications for disrupting cell division machinery. J Biomol Struct Dyn 2024:1-14. [PMID: 38321931 DOI: 10.1080/07391102.2024.2314272] [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: 10/08/2022] [Accepted: 01/29/2024] [Indexed: 02/08/2024]
Abstract
FtsZ, a bacterial cell division protein, is essential for assembling the contractile Z-ring crucial in bacterial cytokinesis. Consequently, inhibiting FtsZ could impede proto-filaments, disrupting FtsZ and other associated proteins vital for cell division machinery. Conduct an in-silico drug interaction study to identify novel drug candidates that inhibit the FtsZ protein, aiming to prevent Multi-Drug Resistant (MDR) Salmonella Typhi. Data mining was performed based on piperidine compounds, which were subsequently screened for safe pharmacokinetic profiles. Compounds that met favorable drug-likeness criteria underwent virtual screening against the FtsZ drug target. Two compounds were chosen for molecular docking and molecular dynamic simulation to verify the binding affinity and stability between the target protein and the potential compounds. The 400 isoforms of piperidine analogues were curated, among them potent compound ZINC000000005416 found to possess high binding affinity (-8.49 kcal/mol) and low dissociation constant (0.597 µM). The highest binding affinity shown by ZINC000000005416 was validated by hydrogen bonds, hydrophobic interaction, and salt bridges with the functional domain of the cell division regulatory protein. Docking profiles, when correlated with molecular dynamic simulation (MDS) depicted stable trajectories and compatible conformational changes in the FtsZ-ZINC000000005416 complex. The stable simulated trajectories were validated through free-energy calculations using the Molecular Mechanics-Poisson Boltzmann Surface Area (MM/PBSA) module. Low energy conformations, although the simulation trajectory confirmed the stable ZINC000000005416-FtsZ interaction, which encouraged experimental validations. This study encourages further exploration of the compound ZINC000000005416 as a drug candidate inhibiting FtsZ protein against MDR Salmonella Typhi.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Hithesh Kumar
- Department of Bio-Sciences, School of Biosciences and Technology (SBST), Vellore Institute of Technology, Vellore, India
- Medical and Biological Computing Laboratory, Department of Biotechnology, School of Biosciences and Technology (SBST), Vellore Institute of Technology, Vellore, India
| | - Anand Manoharan
- Department of Paediatrics, The CHILDS Trust Medical Research Foundation, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Anand Anbarasu
- Medical and Biological Computing Laboratory, Department of Biotechnology, School of Biosciences and Technology (SBST), Vellore Institute of Technology, Vellore, India
| | - Sudha Ramaiah
- Department of Bio-Sciences, School of Biosciences and Technology (SBST), Vellore Institute of Technology, Vellore, India
- Medical and Biological Computing Laboratory, Department of Biotechnology, School of Biosciences and Technology (SBST), Vellore Institute of Technology, Vellore, India
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Al-Windy S. Variations of blood viscosity in acute typhoid fever: A cross-sectional study. J Med Life 2023; 16:1448-1451. [PMID: 38313175 PMCID: PMC10835560 DOI: 10.25122/jml-2023-0027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 02/23/2023] [Indexed: 02/06/2024] Open
Abstract
Typhoid fever (TF) is a systemic infection caused by Salmonella Typhi (Salmonella Enterica) transmitted through contaminated water, food, or contact with infected individuals. In various infectious diseases, blood viscosity (BV) is affected by changes in hemoglobin concentrations and acute phase reactants. Inflammatory responses can lead to elevated plasma protein levels and further affect BV. This study aimed to investigate BV changes in patients with acute TF. A cross-sectional study was performed involving 55 patients with acute TF compared to 38 healthy controls. BV and inflammatory parameters were measured in both groups. TF patients showed reduced blood cells compared to healthy controls (p=0.001). Additionally, plasma total protein (TP) levels significantly increased to 10.79±1.05 g/L in TF patients compared to 7.035±1.44 g/L in healthy controls (p=0.03). Hematocrit (HCT) levels were 11.67±2.89% in TF patients and 12.84±2.02% in healthy controls (p=0.07), suggesting a trend towards increased BV in TF patients. Elevated BV is involved in the pathogenesis of different inflammatory and infectious diseases. The increased BV in TF patients may raise the risk of complications. Therefore, monitoring BV might be a crucial tool in TF patients, mainly in the high-risk group, for early detection of cardiovascular complications.
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Affiliation(s)
- Salah Al-Windy
- Department of Biology, College of Science, Baghdad University, Baghdad, Iraq
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Fathi S, Jalilzadeh N, Amini M, Shanebandi D, Baradaran B, Oroojalian F, Mokhtarzadeh A, Kesharwani P, Sahebkar A. Surface plasmon resonance-based oligonucleotide biosensor for Salmonella Typhi detection. Anal Biochem 2023; 677:115250. [PMID: 37482208 DOI: 10.1016/j.ab.2023.115250] [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] [Received: 04/06/2023] [Revised: 07/13/2023] [Accepted: 07/14/2023] [Indexed: 07/25/2023]
Abstract
Due to high mortality rates, typhoid fever still is one of the major health problems in the world, particularly in developing countries. The lack of highly specific and sensitive diagnostic tests and the great resemblance of typhoid fever symptoms to other diseases made the false-negative diagnosis a major challenge in typhoid fever management. Hence, we decided to design a Surface Plasmon Resonance (SPR) based biosensor for specific detection of Salmonella typhi through DNA hybridization. The results showed that the 10 nM of the synthetic target sequence, as well as 1 nM of PCR product, were the lowest feasible detected concentrations by the designed biosensor. This genosensor was also found to significantly distinguish the complementary sequence with the accuracy of one base mismatch sequence. The surface of the chip can be regenerated with NaOH solution and used for consecutive diagnosis. Therefore, the function of the designed biosensor indicates its high potential for Salmonella typhi detection practice.
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Affiliation(s)
- Sepideh Fathi
- Department of Biological Sciences, Faculty of Basic Sciences, Higher Education Institute of Rab-Rashid, Tabriz, Iran; Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Nazila Jalilzadeh
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mohammad Amini
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Dariush Shanebandi
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Behzad Baradaran
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fatemeh Oroojalian
- Department of Advanced Technologies, School of Medicine, North Khorasan University of Medical Sciences, Bojnurd, Iran; Natural Products and Medicinal Plants Research Center, North Khorasan University of Medical Sciences, Bojnurd, Iran
| | - Ahad Mokhtarzadeh
- Immunology Research Centre, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Prashant Kesharwani
- Department of Pharmaceutics, School of Pharmaceutical Education and Research, Jamia Hamdard, New Delhi, India; Department of Pharmacology, Saveetha Dental College, Saveetha Institute of Medical and Technical Sciences, Saveetha University, Chennai, India; University Institute of Pharma Sciences, Chandigarh University, Mohali, Punjab, India
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran; Department of Biotechnology, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran
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Sapkota J, Roberts T, Basnyat B, Baker S, Hampton LM, Dittrich S. Diagnostics for Typhoid Fever: Current Perspectives and Future Outlooks for Product Development and Access. Open Forum Infect Dis 2023; 10:S17-S20. [PMID: 37274534 PMCID: PMC10236505 DOI: 10.1093/ofid/ofad120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023] Open
Abstract
Typhoid is an enteric disease caused by Salmonella Typhi. Like many febrile illnesses, typhoid presents with nonspecific symptoms. In routine healthcare settings in low- and middle-income countries, typhoid fever is suspected and treated empirically. Though many diagnostic tests are available for typhoid diagnosis, there are currently no diagnostic tests that meet ideal requirements for sensitivity, specificity, speed, and cost-effectiveness. With introduction of typhoid conjugate vaccine, it is essential to explore the current and future typhoid approach in the context of use case and access to ensure their utilization for disease control.
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Affiliation(s)
- Jyotshna Sapkota
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland
- Department of Microbiology, Nepal Medical College, Kathmandu, Nepal
| | - Tamalee Roberts
- Lao-Oxford-Mahosot Hospital-Wellcome Trust Research Unit, Microbiology Laboratory, Mahosot Hospital, Vientiane, Lao People's Democratic Republic
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Kathmandu, Nepal
| | - Stephen Baker
- University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
- Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge Biomedical Campus, Cambridge, United Kingdom
| | | | - Sabine Dittrich
- FIND, the Global Alliance for Diagnostics, Geneva, Switzerland
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Deggendorf Institute of Technology, European Campus Rottal-Inn, Pfarrkirchen, Germany
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Nampota-Nkomba N, Nyirenda OM, Khonde L, Mapemba V, Mbewe M, Ndaferankhande JM, Msuku H, Masesa C, Misiri T, Mwakiseghile F, Patel PD, Patel P, Johnson-Mayo I, Pasetti MF, Heyderman RS, Tracy JK, Datta S, Liang Y, Neuzil KM, Gordon MA, Laurens MB. Safety and immunogenicity of a typhoid conjugate vaccine among children aged 9 months to 12 years in Malawi: a nested substudy of a double-blind, randomised controlled trial. Lancet Glob Health 2022; 10:e1326-e1335. [PMID: 35961356 PMCID: PMC9380257 DOI: 10.1016/s2214-109x(22)00275-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 05/24/2022] [Accepted: 06/06/2022] [Indexed: 12/13/2022]
Abstract
BACKGROUND Typhoid fever is a substantial public health problem in Africa, yet there are few clinical trials of typhoid conjugate vaccine (TCV). We assessed immunogenicity and safety of Typbar TCV in Malawi. METHODS This substudy was nested within a phase 3, double-blind, parallel design, randomised controlled trial of TCV in children from Ndirande Health Centre in Ndirande township, Blantyre, Malawi. To be eligible, participants had to be aged between 9 months and 12 years with no known immunosuppression or chronic health conditions, including HIV or severe malnutrition; eligible participants were enrolled into three strata of approximately 200 children (9-11 months, 1-5 years, and 6-12 years), randomly assigned (1:1) to receive TCV or control (meningococcal serogroup A conjugate vaccine [MCV-A]) intramuscularly. Serum was collected before vaccination and at 28 days and 730-1035 days after vaccination to measure anti-Vi antibodies by ELISA. Because of COVID-19, day 730 visits were extended up to 1035 days. This nested substudy evaluated reactogenicity, safety, and immunogenicity by age stratum. Safety outcomes, analysed in the intention-to-treat population, included solicited adverse events within 7 days of vaccination (assessed on 3 separate days) and unsolicited adverse events within 28 days of vaccination. This trial is registered with ClinicalTrials.gov, NCT03299426. FINDINGS Between Feb 22 and Sept 6, 2018, 664 participants were screened, and 631 participants were enrolled and randomly assigned (320 to the TCV group and 311 to the MCV-A group). 305 participants in the TCV group and 297 participants in the MCV-A group were vaccinated. Among TCV recipients, anti-Vi IgG geometric mean titres increased more than 500 times from 4·2 ELISA units (EU)/mL (95% CI 4·0-4·4) at baseline to 2383·7 EU/mL (2087·2-2722·3) at day 28, then decreased to 48·0 EU/mL (39·9-57·8) at day 730-1035, remaining more than 11 times higher than baseline. Among MCV-A recipients, anti-Vi IgG titres remained unchanged: 4·3 EU/mL (4·0-4·5) at baseline, 4·4 EU/mL (4·0-4·7) on day 28, and 4·6 EU/mL (4·2-5·0) on day 730-1035. TCV and MCV-A recipients had similar solicited local (eight [3%] of 304, 95% CI 1·3-5·1 and three [1%] of 293, 0·4-3·0) and systemic (27 [9%] of 304, 6·2-12·6 and 27 [9%] of 293, 6·4-13·1) reactogenicity. Related unsolicited adverse events occurred similarly in TCV and MCV-A recipients in eight (3%) of 304 (1·3-5·1) and eight (3%) of 293 (1·4-5·3). INTERPRETATION This study provides evidence of TCV safety, tolerability, and immunogenicity up to 730-1035 days in Malawian children aged 9 months to 12 years. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
| | - Osward M Nyirenda
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Lameck Khonde
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Victoria Mapemba
- Blantyre Malaria Project, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Maurice Mbewe
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - John M Ndaferankhande
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Harrison Msuku
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Clemens Masesa
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Theresa Misiri
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Felistas Mwakiseghile
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Priyanka D Patel
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Pratiksha Patel
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Ifayet Johnson-Mayo
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Marcela F Pasetti
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Robert S Heyderman
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; Department of Infection, Division of Infectious Diseases, University College London, London, UK
| | - J Kathleen Tracy
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Shrimati Datta
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yuanyuan Liang
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Kathleen M Neuzil
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Melita A Gordon
- Malawi-Liverpool-Wellcome Trust Clinical Research Programme, Kamuzu University of Health Sciences, Blantyre, Malawi; University of Liverpool, Liverpool, UK
| | - Matthew B Laurens
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD, USA.
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Teferi MY, El-Khatib Z, Alemayehu EA, Adane HT, Andualem AT, Hailesilassie YA, Kebede AS, Asamoah BO, Boltena MT, Shargie MB. Prevalence and antimicrobial susceptibility level of typhoid fever in Ethiopia: A systematic review and meta-analysis. Prev Med Rep 2022; 25:101670. [PMID: 34976707 PMCID: PMC8686025 DOI: 10.1016/j.pmedr.2021.101670] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 11/10/2021] [Accepted: 12/12/2021] [Indexed: 11/24/2022] Open
Abstract
Typhoid fever continues to be a health challenge in low-and middle-income countries where access to clean water and sanitation infrastructure is scarce. The non-confirmatory diagnostic method continues to hinder effective diagnosis and treatment, ensuring in a high antimicrobial resistance. This systematic review and meta-analysis aimed to estimate the pooled prevalence and antimicrobial susceptibility level of typhoid fever in Ethiopia. The review was designed based on the condition-context-population review approach. Fifteen eligible articles were identified from PubMed, Google Scholar, and Science Direct databases. Risk of bias and quality of studies were assessed using the Joanna Briggs Institute's appraisal criteria. Heterogeneity was assessed using Cochran's Q test and I2 statistics. The review protocol was registered in PROSPERO (registration number CRD42021224478). The estimated pooled prevalence of typhoid fever from blood and stool culture diagnosis was 3% (95% CI: 2%-4%, p < 0.01) (I2 = 82.25) and Widal test examination 33% (95% CI: 22%-44%) (I2 = 99.14). The sub-group analyses identified a lower detection of typhoid fever of 2% (95% CI: 1%-3%) among febrile patients compared to typhoid suspected cases of 6% (95% CI: 2%-9%). The stool culture test identified was twofold higher, value of 4% (95% CI: 2%-7%) salmonella S. Typhi infection than blood culture test of 2% (95% CI: 1%-4%). The antimicrobial susceptibility of salmonella S. Typhi for antibiotics was 94%, 80% and 65% for ceftriaxone, ciprofloxacin, and gentamycin respectively. Low susceptibility of salmonella S. Typhi isolates against nalidixic acid 22% (95% CI: 2%-46%) and chloramphenicol 11% (95% CI: 2%-20%) were observed. The diagnosis of typhoid fever was under or overestimated depending on the diagnostic modality. The Widal test which identified as nonreliable has long been used in Ethiopia for the diagnosis of salmonella S. Typhi causing high diagnosis uncertainties. Antimicrobial susceptibility of salmonella S. Typhi was low for most nationally recommended antibiotics. Ethiopian Food and Drug Authority must strengthen its continued monitoring and enhanced national antimicrobial surveillance system using the best available state-of-the-art technology and or tools to inform the rising resistance of salmonella S. Typhi towards the prescription of standard antibiotics. Finally, it is crucial to develop an evidence-based clinical decision-making support system for the diagnosis, empiric treatment and prevention of antimicrobial resistance.
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Key Words
- AHRI, Armauer Hansen Research Institute
- AMR, Antimicrobial Resistance
- AMS, Antimicrobial Susceptibility
- Antimicrobial resistance
- Antimicrobial susceptibility
- Ethiopia
- JBI, The Joanna Briggs Institute
- LMICs, Low- and Middle-Income Countries
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-analyses
- PROSPERO, International Prospective Registry of Systematic Reviews
- SSA, Sub-Saharan Africa
- Systematic review and Meta-analysis
- Typhoid fever
- WHO, The World Health Organization
- XDR, Extensive Drug Resistance
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Affiliation(s)
| | - Ziad El-Khatib
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- World Health Programme, Université du Québec en Abitibi-Témiscamingue (UQAT), Québec, Canada
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10
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Gong Y, Li J, Zhu D, Wang S, Xu Y, Li Y, Wang Y, Song Y, Liu W, Tian Y. Case Report: Near-Fatal Intestinal Hemorrhage and Acute Acalculous Cholecystitis due to Vi-Negative and Fluoroquinolone-Insensitive Salmonella enterica Serovar Typhi Infection: A Rare Entity. Front Med (Lausanne) 2021; 8:666643. [PMID: 34447758 PMCID: PMC8383206 DOI: 10.3389/fmed.2021.666643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/14/2021] [Indexed: 11/13/2022] Open
Abstract
Typhoid fever is usually a mild clinical disease. Typhoid fever with massive intestinal hemorrhage is rare in the antibiotic era. Acute acalculous cholecystitis (AAC) is also rare in adults. Here, we describe the first adult case of typhoid fever with both complications due to Vi-negative and fluoroquinolone-insensitive Salmonella enterica serovar Typhi (S. Typhi) infection. We aim to alert physicians to this rare condition.
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Affiliation(s)
- Yuehua Gong
- Yantai Center for Disease Control and Prevention, Yantai, China
| | - Jianlin Li
- Department of Radiology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai, China
| | - Dongnan Zhu
- Yantai Center for Disease Control and Prevention, Yantai, China
| | - Songsong Wang
- Yantai Center for Disease Control and Prevention, Yantai, China
| | - Yingchun Xu
- Yantai Center for Disease Control and Prevention, Yantai, China
| | - Yan Li
- Yantai Center for Disease Control and Prevention, Yantai, China
| | - Yanqing Wang
- Yantai Center for Disease Control and Prevention, Yantai, China
| | - Yan Song
- Yantai Center for Disease Control and Prevention, Yantai, China
| | - Wenjuan Liu
- Yantai Center for Disease Control and Prevention, Yantai, China
| | - Yunlong Tian
- Yantai Center for Disease Control and Prevention, Yantai, China
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11
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Marchant P, Carreño A, Vivanco E, Silva A, Nevermann J, Otero C, Araya E, Gil F, Calderón IL, Fuentes JA. "One for All": Functional Transfer of OMV-Mediated Polymyxin B Resistance From Salmonella enterica sv. Typhi Δ tolR and Δ degS to Susceptible Bacteria. Front Microbiol 2021; 12:672467. [PMID: 34025627 PMCID: PMC8131662 DOI: 10.3389/fmicb.2021.672467] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Accepted: 04/12/2021] [Indexed: 12/22/2022] Open
Abstract
The appearance of multi-resistant strains has contributed to reintroducing polymyxin as the last-line therapy. Although polymyxin resistance is based on bacterial envelope changes, other resistance mechanisms are being reported. Outer membrane vesicles (OMVs) are nanosized proteoliposomes secreted from the outer membrane of Gram-negative bacteria. In some bacteria, OMVs have shown to provide resistance to diverse antimicrobial agents either by sequestering and/or expelling the harmful agent from the bacterial envelope. Nevertheless, the participation of OMVs in polymyxin resistance has not yet been explored in S. Typhi, and neither OMVs derived from hypervesiculating mutants. In this work, we explored whether OMVs produced by the hypervesiculating strains Salmonella Typhi ΔrfaE (LPS synthesis), ΔtolR (bacterial envelope) and ΔdegS (misfolded proteins and σ E activation) exhibit protective properties against polymyxin B. We found that the OMVs extracted from S. Typhi ΔtolR and ΔdegS protect S. Typhi WT from polymyxin B in a concentration-depending manner. By contrast, the protective effect exerted by OMVs from S. Typhi WT and S. Typhi ΔrfaE is much lower. This effect is achieved by the sequestration of polymyxin B, as assessed by the more positive Zeta potential of OMVs with polymyxin B and the diminished antibiotic's availability when coincubated with OMVs. We also found that S. Typhi ΔtolR exhibited an increased MIC of polymyxin B. Finally, we determined that S. Typhi ΔtolR and S. Typhi ΔdegS, at a lesser level, can functionally and transiently transfer the OMV-mediated polymyxin B resistance to susceptible bacteria in cocultures. This work shows that mutants in genes related to OMVs biogenesis can release vesicles with improved abilities to protect bacteria against membrane-active agents. Since mutations affecting OMV biogenesis can involve the bacterial envelope, mutants with increased resistance to membrane-acting agents that, in turn, produce protective OMVs with a high vesiculation rate (e.g., S. Typhi ΔtolR) can arise. Such mutants can functionally transfer the resistance to surrounding bacteria via OMVs, diminishing the effective concentration of the antimicrobial agent and potentially favoring the selection of spontaneous resistant strains in the environment. This phenomenon might be considered the source for the emergence of polymyxin resistance in an entire bacterial community.
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Affiliation(s)
- Pedro Marchant
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Alexander Carreño
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Eduardo Vivanco
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Andrés Silva
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Jan Nevermann
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Carolina Otero
- Escuela de Química y Farmacia, Facultad de Medicina, Universidad Andres Bello, Santiago, Chile
| | - Eyleen Araya
- Departamento de Ciencias Químicas, Facultad de Ciencias Exactas, Universidad Andres Bello, Santiago, Chile
| | - Fernando Gil
- Microbiota-Host Interactions and Clostridia Research Group, Universidad Andres Bello, Santiago, Chile.,ANID-Millennium Science Initiative Program-Millennium Nucleus in the Biology of the Intestinal Microbiota, Santiago, Chile
| | - Iván L Calderón
- Laboratorio de RNAs Bacterianos, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
| | - Juan A Fuentes
- Laboratorio de Genética y Patogénesis Bacteriana, Departamento de Ciencias Biológicas, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
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12
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Garsow AV, Campbell E, Closs G, Kowalcyk BB. Food Safety Challenges in Refugee Camps: What Do We Know? J Food Prot 2021; 84:876-884. [PMID: 33411925 DOI: 10.4315/jfp-20-316] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Accepted: 12/23/2020] [Indexed: 01/21/2023]
Abstract
ABSTRACT Refugee camps provide basic necessities such as food, water, shelter, and medical treatment for displaced persons. Unsanitary conditions in refugee camps due to overcrowding, poor sanitation systems, lack of clean water, and minimal ways to cook and store food can lead to an increased risk of foodborne illness. This article reviews the limited literature on the epidemiology of foodborne illness in refugee camps, effective risk mitigation strategies, and opportunities for future research. Eleven relevant articles were identified, suggesting that research in this area is limited. Identified research focused on three pathogens-Vibrio cholerae, Salmonella, and hepatitis E virus-that can cause serious diseases such as cholera, salmonellosis, typhoid fever, and hepatitis E. Storage and handling of clean water for personal hygiene and food preparation were critical components for ensuring food safety. Knowledge pertaining to best practices for hygiene and food preparation also were identified as important. Gaps in current research include determination of the prevalence of pathogens in food sold in refugee camps and development of culturally relevant food safety supply chain quality management systems. More research that focuses on burden and attribution of foodborne illness and food safety interventions in refugee camps is necessary. HIGHLIGHTS
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Affiliation(s)
| | - Emily Campbell
- Department of Food Science and Technology.,(ORCID: https://orcid.org/0000-0002-7562-5035 [E.C.])
| | - Gary Closs
- Department of Food Science and Technology
| | - Barbara B Kowalcyk
- Department of Food Science and Technology.,Translational Data Analytics Institute, The Ohio State University, Columbus, Ohio 43210, USA
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13
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Masuet-Aumatell C, Atouguia J. Typhoid fever infection - Antibiotic resistance and vaccination strategies: A narrative review. Travel Med Infect Dis 2020; 40:101946. [PMID: 33301931 DOI: 10.1016/j.tmaid.2020.101946] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 12/01/2020] [Accepted: 12/03/2020] [Indexed: 02/07/2023]
Abstract
Typhoid fever is a bacterial infection caused by the Gram-negative bacterium Salmonella enterica subspecies enterica serovar Typhi (S. Typhi), prevalent in many low- and middle-income countries. In high-income territories, typhoid fever is predominantly travel-related, consequent to travel in typhoid-endemic regions; however, data show that the level of typhoid vaccination in travellers is low. Successful management of typhoid fever using antibiotics is becoming increasingly difficult due to drug resistance; emerging resistance has spread geographically due to factors such as increasing travel connectivity, affecting those in endemic regions and travellers alike. This review provides an overview of: the epidemiology and diagnosis of typhoid fever; the emergence of drug-resistant typhoid strains in the endemic setting; drug resistance observed in travellers; vaccines currently available to prevent typhoid fever; vaccine recommendations for people living in typhoid-endemic regions; strategies for the introduction of typhoid vaccines and stakeholders in vaccination programmes; and travel recommendations for a selection of destinations with a medium or high incidence of typhoid fever.
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Affiliation(s)
- Cristina Masuet-Aumatell
- Preventive Medicine Department, Bellvitge Biomedical Research Institute (IDIBELL), University Hospital of Bellvitge, Faculty of Medicine, University of Barcelona, Feixa Llarga s/n, L'Hospitalet de Llobregat, 08907, Barcelona, Catalonia, Spain.
| | - Jorge Atouguia
- Instituto Higiene e Medicina Tropical, Universidade Nova de Lisboa, Rua da Junquiera, 100, Lisbon, Portugal.
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14
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Jeon HJ, Im J, Haselbeck A, Holm M, Rakotozandrindrainy R, Bassiahi AS, Panzner U, Mogeni OD, Seo HJ, Lunguya O, Jacobs J, Okeke IN, Terferi M, Owusu-Dabo E, Dougan G, Carey M, Steele AD, Kim JH, Clemens JD, Andrews JR, Park SE, Baker S, Marks F. How Can the Typhoid Fever Surveillance in Africa and the Severe Typhoid Fever in Africa Programs Contribute to the Introduction of Typhoid Conjugate Vaccines? Clin Infect Dis 2020; 69:S417-S421. [PMID: 31665772 PMCID: PMC6821306 DOI: 10.1093/cid/ciz629] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background The World Health Organization now recommends the use of typhoid conjugate vaccines
(TCVs) in typhoid-endemic countries, and Gavi, the Vaccine Alliance, added TCVs into the
portfolio of subsidized vaccines. Data from the Severe Typhoid Fever in Africa (SETA)
program were used to contribute to TCV introduction decision-making processes,
exemplified for Ghana and Madagascar. Methods Data collected from both countries were evaluated, and barriers to and benefits of
introduction scenarios are discussed. No standardized methodological framework was
applied. Results The Ghanaian healthcare system differs from its Malagasy counterpart: Ghana features a
functioning insurance system, antimicrobials are available nationwide, and several sites
in Ghana deploy blood culture–based typhoid diagnosis. A higher incidence of
antimicrobial-resistant Salmonella Typhi is reported in Ghana, which
has not been identified as an issue in Madagascar. The Malagasy people have a low
expectation of provided healthcare and experience frequent unavailability of medicines,
resulting in limited healthcare-seeking behavior and extended consequences of untreated
disease. Conclusions For Ghana, high typhoid fever incidence coupled with spatiotemporal heterogeneity was
observed. A phased TCV introduction through an initial mass campaign in high-risk areas
followed by inclusion into routine national immunizations prior to expansion to other
areas of the country can be considered. For Madagascar, a national mass campaign
followed by routine introduction would be the introduction scenario of choice as it
would protect the population, reduce transmission, and prevent an often-deadly disease
in a setting characterized by lack of access to healthcare infrastructure. New,
easy-to-use diagnostic tools, potentially including environmental surveillance, should
be explored and improved to facilitate identification of high-risk areas.
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Affiliation(s)
- Hyon Jin Jeon
- International Vaccine Institute, Seoul, Republic of Korea.,University of Antananarivo, Madagascar
| | - Justin Im
- University of Antananarivo, Madagascar
| | | | | | | | | | | | | | | | - Octavie Lunguya
- Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp
| | - Jan Jacobs
- Department of Microbiology and Immunology, Katholieke Universiteit Leuven, Leuven, Belgium.,Faculty of Pharmacy, University of Ibadan, Nigeria
| | - Iruka N Okeke
- Armauer Hansen Research Institute, ALERT Campus, Addis Ababa, Ethiopia
| | - Mekonnen Terferi
- School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana
| | | | - Gordon Dougan
- International Vaccine Institute, Seoul, Republic of Korea
| | - Megan Carey
- Bill & Melinda Gates Foundation, Seattle, Washington
| | | | | | - John D Clemens
- icddr,b, Dhaka, Bangladesh.,Fielding School of Public Health, University of California, Los Angeles.,Korea University School of Medicine, Seoul
| | | | - Se Eun Park
- University of Antananarivo, Madagascar.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Stephen Baker
- International Vaccine Institute, Seoul, Republic of Korea.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Florian Marks
- International Vaccine Institute, Seoul, Republic of Korea.,University of Antananarivo, Madagascar
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15
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Extensively Drug-Resistant (XDR) Typhoid: Evolution, Prevention, and Its Management. BIOMED RESEARCH INTERNATIONAL 2020; 2020:6432580. [PMID: 32462008 PMCID: PMC7212280 DOI: 10.1155/2020/6432580] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 01/09/2020] [Accepted: 02/04/2020] [Indexed: 11/25/2022]
Abstract
Typhoid fever is the result of a human host-restricted Salmonella enteric serotype typhi infection that causes enteric fever. Around 21 million people contract typhoid annually, with Pakistan's inhabitants at most risk amongst Asian countries where typhoid remains prevalent. Decades of indiscriminate antibiotic usage has driven the evolution of multidrug-resistant strains and more recently, extensively drug-resistant (XDR) strains of Salmonella enteric serotype typhi. Current reports of extensively drug-resistant typhoid fever outbreak in Pakistan are not only a major concern for Pakistan but also for health authorities worldwide: intercontinental transmission, spread, and replacement of native strains in neighboring countries and a major impediment to Pakistani health care management. The WHO records that there are 5274 cases of extensively drug-resistant (XDR) typhoid fever out of a total of 8188 total cases of typhoid fever reported in Pakistan. The last remaining feasible oral antibiotic that XDR typhoid remains susceptible to is azithromycin; this is a cause of major concern. Additionally, several cases of XDR typhoid fever have also been reported in patients travelling from Pakistan to the USA, UK, and Canada. This review article attempts to raise the issue of XDR typhoid with respect to its epidemiology, prevention, management, and future outlook and stresses a better understanding of antimicrobial stewardship and general surveillance of the disease. Although progress is being made to combat XDR typhoid locally, efficient, unified efforts on a national and international scale are required to contain the XDR outbreak before it is no longer manageable and leads us back to the preantibiotic era.
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