Global Trends in Typhoidal Salmonellosis: A Systematic Review

Nationwide trends and features of human salmonellosis outbreaks in China

Salmonellosis is one of the most common causes of diarrhea, affecting 1/10 of the global population. Salmonellosis outbreaks (SO) pose a severe threat to the healthcare systems of developing regions. To elucidate the patterns of SO in China, we conducted a systematic review and meta-analysis encompassing 1,134 reports across 74 years, involving 89,050 patients and 270 deaths. A rising trend of SO reports has been observed since the 1970s, with most outbreaks occurring east of the Hu line, especially in coastal and populated regions. It is estimated to have an overall attack rate of 36.66% (95% CI, 33.88-39.45%), and antimicrobial resistance towards quinolone (49.51%) and beta-lactam (73.76%) remains high. Furthermore, we developed an online website, the Chinese Salmonellosis Outbreak Database (CSOD), for visual presentation and data-sharing purposes. This study indicated that healthcare-associated SO required further attention, and our study served as a foundational step in pursuing outbreak intervention and prediction.

Relative resistance of Salmonella serotypes (Typhimurium, Infantis, and Reading) to peroxyacetic acid on chicken wings

Peroxyacetic acid (PAA) is widely used as an antimicrobial in poultry processing. Recent salmonellosis outbreaks caused by Salmonella Infantis (SI) from chicken products and Salmonella Reading (SR) from turkey products have raised concerns about their enhanced resistance (compared to Salmonella Typhimurium [ST]) to commonly used antimicrobial interventions such as PAA. The objective of this research was to evaluate the efficacy of PAA against Salmonella serotypes (Typhimurium, Infantis and Reading), effect on product color and decomposition of PAA at different pH levels. Fresh chicken wings (0.45 kg) were inoculated with a cocktail (ca. 6 log CFU/mL) of nalidixic acid resistant ST, rifampicin resistant SI and kanamycin resistant SR. Inoculated chicken wings were immersed in PAA solutions (100 or 500 ppm; adjusted to either pH 8.5 or unadjusted natural pH) for either 10 s or 60 min to replicate treatments for chicken parts or whole carcasses, respectively. Treated chicken wings were rinsed in buffered peptone water (100 mL) containing sodium thiosulfate (0.1 %), serially diluted in peptone water supplemented with 200 ppm of nalidixic acid, rifampicin or kanamycin for enumeration of ST, SI, and SR respectively, and plated on APC Petrifilm. Immersion of chicken wings in 500 ppm PAA for 60 min resulted in greater microbial reductions (P ≤ 0.05) of ST, SI, SR of ca. Two log CFU/mL each, compared to 10 s treatment. Regardless of concentration and pH of PAA, increased exposure time (60 min vs. 10 s) resulted in greater reductions (P ≤ 0.05) of ST, SI, SR. ST was slightly more resistant to PAA solutions than S. Infantis and S. Reading (P ≤ 0.05) for all experimental conditions (PAA conc, pH, and exposure times). Faster decomposition of PAA (100 and 500 ppm) was observed at pH 8.5 compared to unadjusted, natural pH (P ≤ 0.05). Product color (lightness, L*) was not affected regardless of the PAA concentration, exposure time or the pH.

Camel urine as a potential source of bioactive molecules showing their efficacy against pathogens: A systematic review

Camels are highly suited for severe desert conditions and able to provide most of the natural products like urine, which has been used as alternative medicine to treat diverse infections and disorders. There is, however, a shortage and paucity of scientific reviews highlighting the antifungal, antibacterial and antiviral effects of camel urine. By better understanding its antimicrobial characteristics, our overarching aim is to provide an exhaustive overview of this valuable natural product by synthesizing and summarizing data on the efficacy of this biofluid and also describing the potential substances exhibiting antimicrobial properties. We searched three databases in order to point out relevant articles (Web of Science, Scopus and Google Scholar) until December 2022. Research articles of interest evaluating the antimicrobial effects of camel urine were selected. Overall, camel urine furnished promising antibacterial activities against gram-positive bacteria, namely Staphylococcus aureus (30 mm), Bacillus cereus (22 mm), Bacillus subtilis (25 mm) and Micrococcus luteus (21 mm), as well as gram-negative bacteria, especially Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Enterobacter cloacae, and Salmonella spp., without forgetting its efficiency on Mycobacterium tuberculosis as well. The excretion also showed its potency against H1N1 virus, vesicular stomatitis virus and middle east respiratory syndrome coronavirus. Similarly, the camel urine featured strong antifungal activity against Candida albicans, Aspergillus niger, Aspergillus flavus and dermatophytes with a minimal inhibitory concentration of 0.625 μg/ml against Trichophyton violaceum, 2.5 μg/ml against Microsporum canis and 1.25 μg/ml against Trichophyton rubrum and Trichophyton mentagrophytes. This comprehensive review will be valuable for researchers interested in investigating the potential of camel urine in the development of novel broad-spectrum key molecules targeting a wide range of drug-resistant pathogenic microorganisms.

Environmental Surveillance for Salmonella Typhi and its Association With Typhoid Fever Incidence in India and Malawi

BACKGROUND

Environmental surveillance (ES) for Salmonella Typhi potentially offers a low-cost tool to identify communities with a high burden of typhoid fever.

METHODS

We developed standardized protocols for typhoid ES, including sampling site selection, validation, characterization; grab or trap sample collection, concentration; and quantitative PCR targeting Salmonella genes (ttr, staG, and tviB) and a marker of human fecal contamination (HF183). ES was implemented over 12 months in a historically high typhoid fever incidence setting (Vellore, India) and a lower incidence setting (Blantyre, Malawi) during 2021-2022.

RESULTS

S. Typhi prevalence in ES samples was higher in Vellore compared with Blantyre; 39/520 (7.5%; 95% confidence interval [CI], 4.4%-12.4%) vs 11/533 (2.1%; 95% CI, 1.1%-4.0%) in grab and 79/517 (15.3%; 95% CI, 9.8%-23.0%) vs 23/594 (3.9%; 95% CI, 1.9%-7.9%) in trap samples. Detection was clustered by ES site and correlated with site catchment population in Vellore but not Blantyre. Incidence of culture-confirmed typhoid in local hospitals was low during the study and zero some months in Vellore despite S. Typhi detection in ES.

CONCLUSIONS

ES describes the prevalence and distribution of S. Typhi even in the absence of typhoid cases and could inform vaccine introduction. Expanded implementation and comparison with clinical and serological surveillance will further establish its public health utility.

β-lactam-induced OMV release promotes polymyxin tolerance in Salmonella enterica sv. Typhi

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.

Sensing of trans-cleavage activity of CRISPR/Cas12a for detection of Salmonella

Salmonella typhimurium (S. typhi) a predominant foodborne pathogen, significantly impacting global public health. Therefore, timely diagnosis is imperative to safeguard overall human health. To address this, we developed a novel CRISPR/Cas12a-mediated electrochemical detection system (biosensor) for targeting the SifA gene of S. typhi. To construct the biosensor, we utilized a screen-printed gold electrode (SPGE) as an electrochemical transducer and CRISPR/Cas12a for detection of SifA gene of S. typhi. The developed electrochemical biosensor exhibited an exceptional detection limit of 0.634 ± 0.029 pM, which was determined through differential pulse voltammetry (DPV) by utilizing a potentiostat. We compared the fabricated biosensor with gold standard RT-PCR and the visual detection limit of SifA was found to be 10 μM (in spiked buffer samples). The lower detection limit of fabricated biosensor provides an upper edge over the RT-PCR. Further, the fabricated biosensor also has the potential to serve as a rapid, stable, efficient, and early detection tool for S. typhi, offering promising advancements in diagnostic realms.

Can Salmonella typhi Cause Acute Appendicitis?

Salmonella typhi, commonly known for causing typhoid fever, is recognized as a bacterium responsible for a wide range of gastrointestinal and systemic infections. While its systemic manifestations have been well-documented, its association with localized gastrointestinal complications, such as appendicitis, remains relatively rare and less explored. This case report presents a compelling clinical case of a 55-year-old patient who presented with symptoms of gastrointestinal distress and was diagnosed with S. typhi-induced appendicitis. The patient's history, clinical presentation, laboratory investigations, radiological findings, management, and outcomes are thoroughly discussed. The report also touches upon the broader context of appendicitis etiology and highlights the significance of prompt diagnosis and intervention in cases of Salmonella-induced appendicitis.

Controlling the bacterial load of Salmonella Typhi in an experimental mouse model by a lytic Salmonella phage STWB21: a phage therapy approach

BACKGROUND

Salmonella enterica serotype Typhi is one of the major pathogens causing typhoid fever and a public health burden worldwide. Recently, the increasing number of multidrug-resistant strains of Salmonella spp. has made this utmost necessary to consider bacteriophages as a potential alternative to antibiotics for S. Typhi infection treatment. Salmonella phage STWB21, isolated from environmental water, has earlier been reported to be effective as a safe biocontrol agent by our group. In this study, we evaluated the efficacy of phage STWB21 in reducing the burden of salmonellosis in a mammalian host by inhibiting Salmonella Typhi invasion into the liver and spleen tissue.

RESULTS

Phage treatment significantly improved the survival percentage of infected mice. This study also demonstrated that oral administration of phage treatment could be beneficial in both preventive and therapeutic treatment of salmonellosis caused by S. Typhi. Altogether the result showed that the phage treatment could control tissue inflammation in mice before and after Salmonella infection.

CONCLUSIONS

To the best of our knowledge, this is the first report of phage therapy in a mouse model against a clinically isolated Salmonella Typhi strain that includes direct visualization of histopathology and ultrathin section microscopy images from the liver and spleen sections.

Aortic Endograft Infection: Diagnosis and Management

Aortic endograft infection (AEI) is a rare but life-threatening complication of endovascular aneurysm repair (EVAR). The clinical features of AEI range from generalized weakness and mild fever to fatal aortic rupture or sepsis. The diagnosis of AEI usually depends on clinical manifestations, laboratory tests, and imaging studies. Management of Aortic Graft Infection Collaboration (MAGIC) criteria are often used to diagnose AEI. Surgical removal of the infected endograft, restoration of aortic blood flow, and antimicrobial therapy are the main components of AEI treatment. After removing an infected endograft, in situ aortic reconstruction is often performed instead of an extra-anatomic bypass. Various biological and prosthetic aortic grafts have been used in aortic reconstruction to avoid reinfection, rupture, or occlusion. Each type of graft has its own merits and disadvantages. In patients with an unacceptably high surgical risk and no evidence of an aortic fistula, conservative treatment can be an alternative. Treatment results are determined by bacterial virulence, patient status, including the presence of an aortic fistula, and hospital factors. Considering the severity of this condition, the best strategy is prevention. When encountering a patient with AEI, current practice emphasizes a multidisciplinary team approach to achieve an optimal outcome.

Dietary protocatechuic acid ameliorates ileal mucosal barrier injury and inflammatory response and improves intestinal microbiota composition in Yellow chickens challenged with Salmonella typhimurium

Salmonella typhimurium (ST) is a common foodborne pathogen that severely affects the health of humans and livestock. Protocatechuic acid (PCA) has been shown to possess anti-inflammatory and anti-bacterial functions. Chickens were used to investigate the effect of PCA on the gut health infected with ST. A total of one hundred eighty, 1-d-old birds were randomly allocated into 3 treatments, each with 6 replicates per treatment and 10 chicks per replicate. Broiler chicks in the control and ST treatment were fed a basal diet, and birds in the PCA+ST treatment received the basal diet with 600 mg/kg PCA. On d 14 and 16 of the trial, broilers in ST and PCA+ST treatments received an oral dose of ST, while broilers in CON received an equal amount of PBS. The data were analyzed by the one-way ANOVA. Dietary PCA increased (P < 0.05) final body weight, average daily gain, and feed to gain ratio in ST-challenged Yellow broilers. Protocatechuic acid significantly alleviated ST-induced intestinal mucosal injury reflected in the decreased (P < 0.05) plasma activity of diamine oxidase and ileal apoptosis, with increased (P < 0.05) ileal villus height and villus height/crypt depth. Protocatechuic acid treatment significantly decreased (P < 0.05) ST-induced proinflammatory cytokine (Interleukin-1β, Interleukin-6, Tumor necrosis factor-α, and Interferon-β) content in ileum. Meanwhile, PCA treatment significantly increased (P < 0.05) the transcript abundances of claudin 1 (CLDN1), zonula occludens-1 (ZO-1), and mucin 2 (MUC2) in ileum, all related to the intestinal barrier in ST-challenged Yellow broilers. Additionally, PCA also increased (P < 0.05) the diversity and richness of the cecal microflora as reflected by reduced (P < 0.05) abundance of Bacteroidota, Proteobacteria and Escherichia-Shigella, and increased (P < 0.05) abundance of Firmicutes and Lactobacillus in ST-challenged Yellow broilers. These findings indicate that PCA relieves ST-induced loss weight, intestinal barrier injury, inflammatory response, and improves intestinal microbiota composition in Yellow broilers.

Outbreak of Paratyphoid Fever Caused by Contaminated Street-Vended Food at Qingyang Town, China, 2016

In 2016, an outbreak of paratyphoid fever occurred in 40 cases at Qingyang town, in China. A case-control study was carried out to determine the source of this outbreak. Case-control study was conducted to identify the risk factors of this outbreak. The cases were identified as patients with isolation of S. Paratyphi, controls were confirmed cases' healthy classmates, colleagues or neighbors and matched by age (±5 y) and gender. Pulsed-field gel electrophoresis was performed to source tracking. Totally, 40 cases were reported: 24 cases were students, and 20 (20/24) of them were Qingyang High School students. For the case-control study, consuming Chinese egg pancakes was detected as a risk factor (OR_1:1 = 5.000; 95% CI: 1.710-14.640), and hand-washing before meals was protective behavior compared with seldom hand-washing (OR_1:1 = 23.256; 95% CI: 2.451-200.000). S. Paratyphi was cultured from a well water sample used for washing contents of the pancakes. Isolates from well water and paratyphoid cases showed the same PFGE patterns. Contaminated well water and Chinese egg pancakes were likely source and vehicle of this outbreak. Health education, especially handwashing, and food safety supervision should be promoted particularly in schools.

Hotspots sequences of gyrA, gyrB, parC, and parE genes encoded for fluoroquinolones resistance from local Salmonella Typhi strains in Jakarta

Background

Infection of Salmonella enterica subsp. enterica serovar Typhi is the primary etiology of typhoid fever globally and is common in many developing countries, especially those with dense populations and poor environmental sanitation. Antibiotic fluoroquinolones were used for the treatment in the 1980s due to the resistance to the first-line antibiotics. However, many cases of treatment failure of fluoroquinolones in typhoidal patients have been reported from numerous countries in Asia, Europe, Africa, and America. Mutations in quinolone resistance determining regions (QRDR) genes, gyrA, gyrB, parC, and parE, are found in fluoroquinolone-resistant Salmonella Typhi. Contrast reports came from the S. Typhi isolates in Indonesia, mainly Jakarta and the surroundings, obtained from patients with typhoid fever, with good sensitivity to the fluoroquinolones, i.e., nalidixic acid, ciprofloxacin, moxifloxacin, and levofloxacin. The present study, therefore, aimed to identify the hotspot sequences of gyrA, gyrB, parC, and parE genes of the local S. Typhi strains based on their susceptibility to fluoroquinolones from patients with typhoid fever in Jakarta and its satellite cities.

Results

A total of 28 isolates were identified as S. Typhi. All isolates were susceptible to nalidixic acid, levofloxacin, and moxifloxacin. Twenty-seven isolates (96.4%) were susceptible to ciprofloxacin, with one isolate (3.6%) being intermediate. The hotspot sequences of gyrA, gyrB, parC, and parE genes from all isolates were identical to the fluoroquinolone-sensitive reference sequence Salmonella enterica subsp. enterica serovar Typhi Ty2 (NCBI GenBank AE014613.1), including the isolate with intermediate susceptibility. The mutation was not found, and amino acid deduced from all hotspots in susceptible and intermediate isolates showed no replacement in all reported codons.

Conclusions

This study showed that the local S. Typhi strains from Jakarta and surroundings were susceptible to fluoroquinolones (nalidixic acid, ciprofloxacin, levofloxacin, and moxifloxacin), and the hotspot sequences of the gyrA, gyrB, parC, and parE genes were all identical to the reference sequence. Thus, the hotspot sequences of the gyrA, gyrB, parC, and parE genes seemingly were conserved in Jakarta’s local S. Typhi strains and could be considered wild type. The phenotypic susceptibility was consistent with the genotypic characteristic without non-synonymous mutations associated with drug resistance.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12866-022-02666-z.

Effectiveness of typhoid conjugate vaccine in Zimbabwe used in response to an outbreak among children and young adults: A matched case control study

BACKGROUND

Zimbabwe suffers from regular outbreaks of typhoid fever (TF), worse since 2017. Most cases were in Harare and a vaccination campaign with Typhoid Conjugate Vaccine (TCV) was conducted in March 2019. The vaccine effectiveness (VE) was assessed against culture-confirmed S. Typhi in children six months to 15 years and in individuals six months to 45 years in Harare.

METHODS

A matched case-control study was conducted in three urban suburbs of Harare targeted by the TCV vaccination campaign. Suspected TF cases were enrolled prospectively in four health facilities and were matched to facility (1:1) and community (1:5) controls.

FINDINGS

Of 504 suspected cases from July 2019 to March 2020, 148 laboratory-confirmed TF cases and 153 controls confirmed-negative were identified. One hundred and five (47 aged six months to 15 years) cases were age, sex, and residence matched with 105 facility-based controls while 96 cases were matched 1:5 by age, sex, and immediate-neighbour with 229 community controls. The adjusted VE against confirmed TF was 75% (95%CI: 1-94, p = 0.049) compared to facility controls, and 84% (95%CI: 57-94, p < 0.001) compared to community controls in individuals six months to 15 years. The adjusted VE against confirmed TF was 46% (95%CI: 26-77, p = 0.153) compared to facility controls, and 67% (95%CI: 35-83, p = 0.002) compared to community controls six months to 45 years old.

INTERPRETATION

This study confirms that one vaccine dose of TCV is effective to control TF in children between six months and 15 years old in an African setting.

Epidemiological Investigation of Salmonella enterica Isolates in Children with Diarrhea in Chengdu, China

Background: Children with the immature intestinal immune system are prone to Salmonella infection through the fecal-oral route causing diarrhea. Non-typhoid Salmonella (NTS) is difficult to treat and eliminate due to its zoonosis. Salmonella typhi, including typhoid and paratyphoid A, B, and C, only infect humans and cause invasive infectious diseases. Salmonella typhi infection is serious and requires antibiotic treatment. The bacterial resistance caused by conventional antibacterial drugs brings great difficulties to treatment. Objectives: This study aimed to investigate the epidemiology of S. enterica in children with diarrhea in Chengdu, China. Methods: Fresh stool specimens or rectal swabs from 6656 children aged 1 day to 13 years with diarrhea were collected, cultured, identified, and tested for antimicrobial susceptibility. Analytical Profile index 20E was used for biochemical identification, and the Kirby-Bauer method was used for the bacterial sensitivity test. The whole process was conducted in accordance with the fourth edition of the National Clinical Examination procedures, and the drug sensitivity test was conducted in accordance with the Clinical and Laboratory Standards Institute 2020 guidelines. Results: A total of 649 Salmonella strains were isolated from 6656 children with suspected Salmonella infection, among which the isolation rates of NTS and S. typhi were 8.92% and 0.83%, respectively. The infection rate of S. typhimurium was the highest every year (74.88%). Salmonella infections are on the rise, especially typhimurium, Dublin, Typhi, and London. Paratyphi is unstable, presenting a phenomenon of transition and replacement (the male to female ratio:1.12:1). The infection rate was the lowest within 1 day and 6 months (P < 0.05). Salmonella mainly infected children under 3 years of age, and the positive rate was reported as 88.29%. Within June-September, the infection rate of Salmonella was the highest, with a positive rate of 72.73%. The isolated 649 Salmonella strains had good susceptibility to cefotaxime and ciprofloxacin (87.67% and 79.20%, respectively), almost no susceptibility to ampicillin, and a drug resistance rate of 92.91%. Conclusions: The typhoid and paratyphoid vaccines should be considered together, and vaccines should focus on children under 3 years of age. Antibiotics should be rationally selected according to the drug sensitivity test and disease condition.

Whole Genome Sequencing Analysis of Salmonella enterica Serovar Typhi: History and Current Approaches

In recent years, the advance in whole-genome sequencing technology has changed the study of infectious diseases. The emergence of genome sequencing has improved the understanding of infectious diseases, which has revamped many fields, such as molecular microbiology, epidemiology, infection control, and vaccine production. In this review we discuss the findings of Salmonella enterica serovar Typhi genomes, publicly accessible from the initial complete genome to the recent update of Salmonella enterica serovar Typhi genomes, which has greatly improved Salmonella enterica serovar Typhi and other pathogen genomic research. Significant information on genetic changes, evolution, antimicrobial resistance, virulence, pathogenesis, and investigation from the genome sequencing of S. Typhi is also addressed. This review will gather information on the variation of the Salmonella enterica serovar Typhi genomes and hopefully facilitate our understanding of their genome evolution, dynamics of adaptation, and pathogenesis for the development of the typhoid point-of-care diagnostics, medications, and vaccines.

Salmonella Paratyphi B; Public Health and Parental Choice: When to Treat Asymptomatic Carriers of Infection?

BACKGROUND

Salmonella Paratyphi B (Paratyphoid B) is a rare infection and a notifiable disease in England. Disease is typically mild, and chronic carriage in children has been described in endemic countries. Almost all cases in England are imported, with very few cases of community transmission reported.

METHODS

The aim of this work was to describe an unusual cluster of Paratyphoid B cases transmitted within England, examining clinical, epidemiologic and microbiologic data. Detailed phylogenetic analysis is presented to corroborate public health epidemiologic links between cases.

RESULTS

One child had recently returned from an endemic area and had mild gastrointestinal symptoms. One year later, 2 other children with no travel history developed invasive disease requiring hospitalization. Epidemiologic links confirmed person-to-person spread between these three cases. All isolates of S. Paratyphi B (n = 93) received by the Gastrointestinal Bacteria Reference Unit between 2014 and 2019 were typed using whole genome sequencing. Three cases of Paratyphoid B were identified in the same geographical location over a 2-year period. S. Paratyphi B strains isolated from the stool and blood of the three cases were closely linked (0-5 single-nucleotide polymorphisms) using whole genome sequencing.

CONCLUSIONS

This case series highlights the potential public health risks of paratyphoid B and the range of pediatric complications associated with this illness, especially in younger children. Although rare, chronic carriage of Paratyphoid B can lead to transmission in nonendemic areas and should be considered in all children presenting with signs of enteric fever even where there is no history of foreign travel.

Performance of Immunodiagnostic Tests for Typhoid Fever: A Systematic Review and Meta-Analysis

Typhoid fever, also known as typhoid, is a life-threatening bacterial infection that remains a global health concern. The infection is associated with a significant morbidity and mortality rate, resulting in an urgent need for specific and rapid detection tests to aid prevention and management of the disease. The present review aims to assess the specificity and sensitivity of the available literature on the immunodiagnostics of typhoid fever. A literature search was conducted using three databases (PubMed, ProQuest and Scopus) and manual searches through the references of identified full texts to retrieve relevant literature published between 1 January 2011 and 31 December 2020. Of the 577 studies identified in our search, 12 were included in further analysis. Lipopolysaccharides (LPS) and hemolysin E (HlyE) were the most frequently studied antigens. The specimens examined in these studies included serum and saliva. Using blood culture as the gold standard, anti-LPS IgA gave the highest sensitivity of 96% (95% CI: 93–99) and specificity of 96% (95% CI: 93–99) for distinguishing between typhoid cases and healthy controls, whereas the combination of anti-LPS and anti-flagellin total IgGAM gave the highest sensitivity of 93% (95% CI: 86–99) and specificity of 95% (95% CI: 89–100) for distinguishing typhoid cases and other febrile infections. A comparably high sensitivity of 92% (95% CI: 86–98) and specificity of 89% (95% CI: 78–100) were shown in testing based on detection of the combination of anti-LPS (IgA and IgM) and anti-HlyE IgG as well as a slightly lower sensitivity of 91% (95% CI: 74–100) in the case of anti-50kDa IgA. Anti-50kDa IgM had the lowest sensitivity of 36% (95% CI: 6–65) against both healthy and febrile controls. The development of a rapid diagnostic test targeting antibodies against lipopolysaccharides combined with flagellin appeared to be a suitable approach for the rapid detection test of typhoid fever. Saliva is added benefit for rapid typhoid diagnosis since it is less invasive. As a result, further studies could be done to develop additional approaches for adopting such samples.

ROLE OF MACROPHAGE MIGRATION INHIBITORY FACTOR, CLUSTER OF DIFFERENTIATION 19 AND INTERLEUKIN 23 IN INDIVIDUALS INFECTED WITH Salmonella typhi

Salmonella enterica serovar typhi (S.typhi) is one of the most important gram negative bacteria that cause enteric fever and stimulate the immune response in infected patients. This study aimed to compare the humoral and cellular immune responses in patients infected with S.typhi. For this, the concentration of three immunological markers viz., Macrophage migration inhibitory factor (MIF), Cluster of Differentiation 19 (CD19), and Interleukin 23 (IL-23) were measured by the Enzyme-Linked Immunosorbent Assay in the serum of 54 S.typhi infected patients, and 31 healthy individuals. The results demonstrated a significant increase (P =<0.05) in the serum concentration of MIF in patients infected with acute infection of S. typhi compared with healthy individuals but there were no significant differences in chronic infection. While there was a significant increase (P =<0.05) in serum concentration of CD19 and IL-23 in patients infected with acute and chronic infection of S.typhi as compared with healthy individuals. In conclusion, macrophage migration inhibitory factor plays a vital role in patients infected with acute infection of S. typhi and has no synergism with T-cell and B-cell in acute and chronic infection.

Glycyrrhizin Attenuates Salmonella Typhimurium-Induced Tissue Injury, Inflammatory Response, and Intestinal Dysbiosis in C57BL/6 Mice

Salmonellae are one of the most important foodborne pathogens, which threaten the health of humans and animals severely. Glycyrrhizin (GL) has been proven to exhibit anti-inflammatory and tissue-protective properties. Here, we investigated the effects of GL on tissue injury, inflammatory response, and intestinal dysbiosis in Salmonella Typhimurium-infected mice. Results showed that GL or gentamicin (GM) significantly (P < 0.05) alleviated ST-induced splenomegaly indicated by the decreased spleen index, injury of liver and jejunum indicated by the decreased hepatocytic apoptosis, and the increased jejunal villous height. GL significantly (P < 0.05) increased secretion of inflammatory cytokines (IFN-γ, IL-12p70, IL-6, and IL-10) in spleen and IL-12p40 mRNA expression in liver. Meanwhile, GL or GM pre-infection treatments significantly (P < 0.05) decreased ST-induced pro-inflammatory cytokine (IFN-γ, TNF-α, and IL-6) expression in both spleen and liver and increased (P < 0.05) anti-inflammatory cytokine IL-10 secretion in spleen. Furthermore, GL or GM pre-infection treatment also regulates the diversities and compositions of intestinal microbiota and decreased the negative connection among the intestinal microbes in ST-infected mice. The above findings indicate that GL alleviates ST-induced splenomegaly, hepatocytic apoptosis, injury of jejunum and liver, inflammatory response of liver and spleen, and intestinal dysbacteriosis in mice.

Robust immunity induced by multi-epitope DnaK peptides, potential vaccine candidates against Salmonella: An in vitro study

Enteric fever is a common yet serious issue, most troublesome in underdeveloped and developing nations affecting all age group primarily children. Pitfalls of existing vaccines along with rapidly rising Multi-Drug-Resistant Salmonella strains necessitate the need for the development of new vaccine candidates having potential to provide complete protection. Several vaccine strategies are being pursued to stimulate protective immunity against typhoid, including conjugate vaccines for the elicitation of cellular and humoral responses as both arms of immunity are essential for complete protection. Bacterial HSPs are highly immunogenic to produce humoral and cellular immune responses. In this study, we are reporting in vitro immunostimulatory activity of immunodominant multi-epitope protective antigenic DnaK peptides identified earlier by immunoinformatics approach. Remarkable increase in antibody titer, lymphocyte proliferation, cytokines and NO level with individual /mixture of DnaK peptides as compared to control demonstrate immunogenic potential of these peptides that effectively augments both humoral and cellular immune responses. None of the peptides cause any hemolysis in human RBCs. Overall; our findings strongly elucidate the immune-stimulatory potential of DnaK peptides to be explored as potent vaccine candidates against multiple pathogens.

"One for All": Functional Transfer of OMV-Mediated Polymyxin B Resistance From Salmonella enterica sv. Typhi ΔtolR and ΔdegS to Susceptible Bacteria

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.

Simple differentiation of Salmonella Typhi, Paratyphi and Choleraesuis from Salmonella species using the eazyplex TyphiTyper LAMP assay

Introduction. Identification of typhoidal Salmonella (TS) serovars and their discrimination from non-typhoidal Salmonella (NTS) is conventionally performed by seroagglutination. This method is labour-intensive, requires technical experience and can be inconclusive in some cases. Molecular assays may be reliable alternative diagnostic tools.

Aim. This study was designed to evaluate the eazyplex TyphiTyper based on loop-mediated isothermal amplification (LAMP) for fast identification of TS and S. Choleraesuis in culture.

Methodology. A total of 121 Salmonella strains and 33 isolates of other Enterobacterales species were tested by the eazyplex TyphiTyper. Simulated and clinical blood cultures (BCs) were used to examine the performance of the assay for diagnosis of systemic infection. Sample preparation took about 5 min and the test running time was 20 min. Amplification was measured by real-time fluorescence detection.

Results. All TS and S. Choleraesuis strains were correctly identified. The most common NTS S. Typhimurium (n=34) and S. Enteritidis (n=15) were detected as Salmonella species without any false positive result for TS targets. Cross-reactions of NTS with TS were only rarely observed. Direct testing of positive BCs gave correct results. Sensitivities and specificities of the assay were as follows: 100 and 99.3 % for S. Typhi, 100 and 98.7 % for S. Paratyphi A, 100 and 97.3 % for S. Paratyphi B, 100 and 100 % for S. Paratyphi C, 100 and 100 % for S. Choleraesuis, and 100 and 100 % for Salmonella species, respectively.

Conclusion. The eazyplex TyphiTyper is very easy to perform and allows the rapid identification of TS and S. Choleraesuis isolates.

Proteomic analysis of the antimicrobial effects of sublethal concentrations of thymol on Salmonella enterica serovar Typhimurium

Salmonella enterica serovar Typhimurium is an important foodborne pathogen that causes serious and extensive food contamination as well as disease and death worldwide. Considering the increasing severity of antibiotic resistance, antibiotic alternatives are urgently needed. As a natural biocide and a component of some essential oils from herbs, thymol is capable of killing various bacteria through a potentially unique mechanism, although the targets of thymol have not been completely elucidated. In this study, the variation in the whole proteome of Salmonella after thymol stress was evaluated using the SWATH multiplex technique. The strain Salmonella Typhimurium CVCC541 was treated with a sublethal concentration (75 μg/mL) of thymol, which rapidly increased the permeability of bacterial membranes at the tested concentration. Thymol destroyed the integrity of the bacterial membrane, as observed by transmission electron microscopy. The proteomes of the treated and untreated cells were characterized after an 8-h treatment. The proteomic analysis of thymol-treated cells indicated that 144 proteins exhibited upregulation or downregulation compared with the control cells, particularly those involved in cellular structure and metabolism. The results of this study showed that thymol may play an antimicrobial role in altering the membrane permeability, virulence change, and antioxidant response of Salmonella Typhimurium. The results of the present study provide an improved understanding of the proteomic response of Salmonella Typhimurium to thymol stress, including the identification of promising targets for the future exploration of innovative approaches to control Salmonella Typhimurium.

Integrating Typhoid Fever Within the Sustainable Development Goals: Pragmatism or Utopia?

Several decades following the first estimates of the global burden of typhoidal salmonellosis (infections caused by Salmonella Typhi and Salmonella Paratyphi), this disorder remains a major cause of morbidity worldwide with an estimated 17 million cases annually. The risk factors for typhoid include poverty, poor living conditions with unsafe water and lack of adequate sanitation, and unsafe foods-all reasons for the disease burden being highest among such populations including urban slums. A recent review of typhoid trends globally and in specific countries suggests that the relative contributions of these risk factors to disease burden reduction as well as persistence have varied. There is also the risk of periodic outbreaks related to introduction of relatively virulent drug-resistant strains or movements of vulnerable populations, including those in conflict zones. Most countries of the world are now aligning their health and multisectoral strategies to address the Sustainable Development Goals (SDGs) and targets, which were agreed upon by all countries of the world in September 2015. Though neglected so far, there are huge opportunities for mainstreaming typhoid prevention and control strategies within the SDGs. This article reviews some of the approaches that may help elevate typhoid to a higher level of awareness in public health programs and policy and to ensure that investments in major public health preventive measures are made part of the universal health coverage agenda.

Drug-resistant enteric fever worldwide, 1990 to 2018: a systematic review and meta-analysis

BACKGROUND

Antimicrobial resistance (AMR) is an increasing threat to global health. There are > 14 million cases of enteric fever every year and > 135,000 deaths. The disease is primarily controlled by antimicrobial treatment, but this is becoming increasingly difficult due to AMR. Our objectives were to assess the prevalence and geographic distribution of AMR in Salmonella enterica serovars Typhi and Paratyphi A infections globally, to evaluate the extent of the problem, and to facilitate the creation of geospatial maps of AMR prevalence to help targeted public health intervention.

METHODS

We performed a systematic review of the literature by searching seven databases for studies published between 1990 and 2018. We recategorised isolates to allow the analysis of fluoroquinolone resistance trends over the study period. The prevalence of multidrug resistance (MDR) and fluoroquinolone non-susceptibility (FQNS) in individual studies was illustrated by forest plots, and a random effects meta-analysis was performed, stratified by Global Burden of Disease (GBD) region and 5-year time period. Heterogeneity was assessed using the I2 statistics. We present a descriptive analysis of ceftriaxone and azithromycin resistance.

FINDINGS

We identified 4557 articles, of which 384, comprising 124,347 isolates (94,616 S. Typhi and 29,731 S. Paratyphi A) met the pre-specified inclusion criteria. The majority (276/384; 72%) of studies were from South Asia; 40 (10%) articles were identified from Sub-Saharan Africa. With the exception of MDR S. Typhi in South Asia, which declined between 1990 and 2018, and MDR S. Paratyphi A, which remained at low levels, resistance trends worsened for all antimicrobials in all regions. We identified several data gaps in Africa and the Middle East. Incomplete reporting of antimicrobial susceptibility testing (AST) and lack of quality assurance were identified.

INTERPRETATION

Drug-resistant enteric fever is widespread in low- and middle-income countries, and the situation is worsening. It is essential that public health and clinical measures, which include improvements in water quality and sanitation, the deployment of S. Typhi vaccination, and an informed choice of treatment are implemented. However, there is no licenced vaccine for S. Paratyphi A. The standardised reporting of AST data and rollout of external quality control assessment are urgently needed to facilitate evidence-based policy and practice.

TRIAL REGISTRATION

PROSPERO CRD42018029432.

Surgical Infections in Low- and Middle-Income Countries: A Global Assessment of the Burden and Management Needs

Background: The burden of surgical infections in low- and middle-income countries (LMICs) remains poorly defined compared with high-income countries. Although there are common infections necessitating surgery prevalent across the world, such as appendicitis and peptic ulcer disease, other conditions are more localized geographically. To date, comprehensive assessment of the burden of surgically treatable infections or sequelae of surgical infections in LMICs is lacking. Methods: We reviewed the literature to define the burden of surgical infections in LMICs and characterize the needs and challenges of addressing this issue. Results: Surgical infections comprise a broad range of diseases including intra-abdominal, skin and soft tissue, and healthcare-associated infections and other infectious processes. Treatment of surgical infections requires a functional surgical ecosystem, microbiology services, and appropriate and effective antimicrobial therapy. Systems must be developed and maintained to evaluate screening, prevention, and treatment strategies. Solutions and interventions are proposed focusing on reducing the burden of disease, improving surveillance, strengthening antibiotic stewardship, and enhancing the management of surgical infections. Conclusions: Surgical infections constitute a large burden of disease globally. Challenges to management in LMICs include a shortage of trained personnel and material resources. The increasing rate of antimicrobial drug resistance, likely related to antibiotic misuse, adds to the challenges. Development of surveillance, infection prevention, and antimicrobial stewardship programs are initial steps forward. Education is critical and should begin early in training, be an active process, and be sustained through regular programs.

Antioxidant activity of dichloromethane fraction of Dichrocephala integrifolia in Salmonella typhi-infected rats

OBJECTIVE

Infectious diseases such as typhoid fever lead to the formation of free radicals which can damage the body. Many medicinal plants have antioxidant molecules that neutralize free radicals. The present work evaluated the antioxidant activity and histopathological effects of the dichloromethane fraction of Dichrocephala integrifolia in Salmonella typhi-infected rats.

METHODS

The S. typhi-infected rats concurrently received daily doses of D. integrifolia extract at doses of 25, 50 and 100 mg/kg body weight or ciprofloxacin (5 mg/kg body weight) for 15 days. Body temperature was measured daily during infection and treatment periods. At the end of treatment period, the animals were sacrificed and biological responses including hematological parameters, superoxide dismutase and catalase activities, and glutathione, malondialdehyde and nitric oxide concentrations were evaluated.

RESULTS

The elevated body temperature induced by infection was significantly decreased in animals treated with 25, 50 or 100 mg/kg of the extract. Platelet levels decreased slightly in infected rats, while treatment with the dichloromethane fraction of D. integrifolia significantly increased platelet levels; this response was greater than that elicited by ciprofloxacin. The doses of 50 and 100 mg/kg of the dichloromethane fraction of D. integrifolia notably decreased monocyte and neutrophil values. Activity of superoxide dismutase and catalase and levels of glutathione in the tissues of treated animals were increased significantly (P < 0.01), while malondialdehyde and nitric oxide levels were significantly decreased (P < 0.01), following treatment with the dichloromethane fraction of D. integrifolia.

CONCLUSION

The results of this study show that the dichloromethane fraction of D. integrifolia has protective effects against a series of pathological conditions initiated by oxidation and tissue damage in the course of a S. typhi infection.

Aptamer-based fluorometric determination of Salmonella Typhimurium using Fe3O4 magnetic separation and CdTe quantum dots

Based on the high sensitivity and stable fluorescence of CdTe quantum dots (QDs) in conjunction with a specific DNA aptamer, the authors describe an aptamer-based fluorescence assay for the determination of Salmonella Typhimurium. The fluorescence detection and quantification of S. Typhimurium is based on a magnetic separation system, a combination of aptamer-coated Fe₃O₄ magnetic particles (Apt-MNPs) and QD-labeled ssDNA2 (complementary strand of the aptamer). Apt-MNPs are employed for the specific capture of S. Typhimurium. CdTe QD-labeled ssDNA2 was used as a signaling probe. Simply, the as-prepared CdTe QD-labeled ssDNA2 was first incubated with the Apt-MNPs to form the aptamer-ssDNA2 duplex. After the addition of S. Typhimurium, they could specifically bind the DNA aptamer, leading to cleavage of the aptamer-ssDNA2 duplex, accompanied by the release of CdTe QD-labeled DNA. Thus, an increased fluorescence signal can be achieved after magnetic removal of the Apt-MNPs. The fluorescence of CdTe QDs (λexc/em = 327/612 nm) increases linearly in the concentration range of 10 to 10¹⁰ cfu•mL^-1, and the limit of detection is determined to be 1 cfu•mL^-1. The detection process can be performed within 2 h and is successfully applied to the analysis of spiked food samples with good recoveries from 90% to 105%.

Myositis associated with Salmonella paratyphi A bacteremia appears to be common

Background

Fever and severe myalgia in a tropical country like India bring to mind leptospirosis, rickettsioses, dengue, and other viral fevers. Enteric fever is widely prevalent in Asia, but myositis has not been previously described in Salmonella paratyphi A bacteremia.

Materials and Methods

Retrospectively, we recruited patients with enteric fever admitted to our treating unit over a 6-month period. Demography, historical, clinical, and laboratory data were obtained. Data of culture-positive S. paratyphi A patients were analyzed and were compared with those patients with culture-negative enteric fever.

Results

Forty-three cases were found in total with 19 of S. paratyphi A bacteremia. Elevations in creatine kinase (CK) ranged from one-and-half to six times normal. Forty-seven percent had thrombocytopenia and alanine transaminase elevations, while aspartate transaminase elevations were seen in 17 patients, which corresponded to those with elevated CK levels.

Conclusions

Myositis associated with S. typhi and S. paratyphi is very rare and is more often due to non-typhoidal Salmonellae. Elevated creatine kinase was seen in most of our patients with S. paratyphi A bacteremia. Such myositis has not been described previously and hence, myalgia with fever in a tropical country could be a harbinger of paratyphoid fever.

Implementation of Interventions for the Control of Typhoid Fever in Low- and Middle-Income Countries

Past research has focused on typhoid fever surveillance with little attention to implementation methods or effectiveness of control interventions. This study purposefully sampled key informants working in public health in Chile, India, Pakistan, Bangladesh, Thailand, Vietnam, South Africa, and Nigeria to 1) scope typhoid-relevant interventions implemented between 1990 and 2015 and 2) explore contextual factors perceived to be associated with their implementation, based on the Consolidated Framework for Implementation Research (CFIR). We used a mixed methods design and collected quantitative data (CFIR questionnaire) and qualitative data (interviews with 34 public health experts). Interview data were analyzed using a deductive qualitative content analysis and summary descriptive statistics are provided for the CFIR data. Despite relatively few typhoid-specific interventions reportedly implemented in these countries, interventions for diarrheal disease control and regulations for food safety and food handlers were common. Most countries implemented agricultural and sewage treatment practices, yet few addressed the control of antibiotic medication. Several contextual factors were perceived to have influenced the implementation of typhoid interventions, either as enablers (e.g., economic development) or barriers (e.g., limited resources and habitual behaviors). Consolidated Framework for Implementation Research factors rated as important in the implementation of typhoid interventions were remarkably consistent across countries. The findings provide a snapshot of typhoid-relevant interventions implemented over 25 years and highlight factors associated with implementation success from the perspective of a sample of key informants. These findings can inform systematic investigations of the implementation of typhoid control interventions and contribute to a better understanding of the direct effects of implementation efforts.

Introductory Article on Global Burden and Epidemiology of Typhoid Fever

This article is the introduction to a 12-paper supplement on global trends in typhoid fever. The Tackling Typhoid (T2) project was initiated in 2015 to synthesize the existing body of literature on typhoidal salmonellae and study national and regional typhoid fever trends. In addition to a global systematic review, eight case studies were undertaken to examine typhoid and paratyphoid fever trends in endemic countries alongside changes in relevant contextual factors. Incidence variations exist both within and between regions with large subnational differences as well, suggesting that public health changes impacting typhoid and paratyphoid fevers in one setting may not have similar impacts in another. This supplement also brings to light the lack of national typhoid fever surveillance systems, inconsistencies in diagnostics, and the lack of typhoid fever associated morbidity and mortality data in many countries, making it difficult to accurately quantify and track burden of disease. To better understand typhoid fever there is a need for more high-quality data from resource-poor settings. The implementation of typhoid surveillance systems alongside the transition to blood-culture confirmation of cases, where possible, would aid in the improvement of data quality in low-income settings. The following supplement includes the results of our global systematic review, eight-country case study articles, a qualitative article informed by semistructured interviews, and a conclusion article on potential ways forward for typhoid control.

Typhoid Fever: Way Forward

The Tackling Typhoid supplement shows that typhoid fever continues to be a problem globally despite socioeconomic gains in certain settings. Morbidity remains high in many endemic countries, notably in sub-Saharan Africa and South Asia. In addition, antimicrobial resistance is a growing issue that poses a challenge for clinical management. The findings from this supplement revealed that outside of high-income countries, there were few reliable population-based estimates of typhoid and paratyphoid fever derived from surveillance systems. This indicates the need for monitoring systems that can also characterize the effectiveness of interventions, particularly in low- and middle-income settings. The country case studies indicated that gains in economic conditions, education, and environmental health may be associated with reductions in typhoid fever burden. Over the study period, the effect is mainly notable in countries with higher baseline levels of economic development, female literacy, and investments in public sanitation. High burden countries must continue to invest in strategies at the local level to address environmental factors such as access to safe drinking water and improved public sanitation that are known to interrupt transmission or diminish the risk of acquiring typhoid. Developing more effective vaccines and incorporating appropriate immunization strategies that target populations with the greatest risk could potentially alleviate disease burden.