The Implications of Extensive Drug-resistant Typhoid Fever: A Case Report

A comparable risk of extensively drug-resistant typhoid fever in the pediatric cohort during the COVID-19 pandemic

Objective

The number of extremely drug-resistant (XDR) Salmonella typhi isolates is growing in the northwest of Pakistan, where health-care facilities are already under strain due to the coronavirus disease 2019 (COVID-19) issue. In Khyber Pakhtunkhwa, Pakistan, we currently describe the first widespread appearance of an XDR Salmonella typhi epidemic during the COVID-19 pandemic. This strain of Salmonella typhi is resistant to all first- and second-line drugs and even the third-generation cephalosporin.

Methods

Salmonella species isolated from pediatric blood samples shown a high level of resistance to the various antibiotic classes evaluated between November and December 2020. Gender, age, address, and clinical symptoms were among the demographic information that was recorded. A total of 562 blood cultures from symptomatic patients have been collected by the Pathology Laboratory at a tertiary care institution of Rehman Medical Institute, Peshawar. All samples have been processed in accordance with regulatory requirements and incubated in BacT/ALERT 3D.

Results

Of the 562 blood samples, 71 included Salmonella typhi, of which 66 (92.9%) and 5 (7%) were multidrug resistant (MDR) and XDR, respectively. Ciprofloxacin (100%), chloramphenicol (100%), ceftriaxone (100%), ampicillin (100%), and cotrimoxazole (93%) were completely resistant to all isolates. Azithromycin and carbapenems were effective against every Salmonella typhi isolate that was MDR or XDR. Males (76%) were more commonly affected than females (24%), and the frequency was substantially higher in children under 15 years of age (88%) than in adults (P = 0.0016).

Conclusion

The emergence of XDR Salmonella typhi with a high level of resistance is in fact alarming. Due to the lack of viable treatment alternatives, the current situation necessitates the immediate implementation of efficient preventive measures, such as campaigns for typhoid vaccination and food and water safety.

Fatal Complications of Extensive Drug-Resistant Typhoid Fever: A Case Report

Typhoid fever is a systemic illness that often presents with fever, abdominal pain, and diarrhea. There are multiple complications associated with typhoid fever which includes intestinal perforation, gastrointestinal hemorrhage, hepatitis, and anemia. In recent years, a new extensively drug resistant (XDR) strain of Salmonella typhi (S. typhi) emerged, associated with higher incidence of complications, responding to azithromycin and carbapenems only. In this article, we report a case of a 28-year-old Pakistani male who initially presented with fever and bloody diarrhea, complicated by massive lower gastrointestinal bleed, leading to his mortality. This case, being the first reported case in Bahrain, illustrates the importance of considering hepatic manifestations and lower gastrointestinal bleeding as fatal complications of typhoid fever, especially in the setting of recent travel to Southeast Asia.

Understanding of Future Prescribers About Antimicrobial Resistance and Their Preparedness Towards Antimicrobial Stewardship Activities in Pakistan: Findings and Implications

Background: Insufficient antimicrobial-related training for physicians during their undergraduate education could have a negative impact on their prescribing. Unlike previous studies, this study not only explored the understanding and perception of Pakistani medical students about antibiotics and resistance, but also their preparedness towards antimicrobial stewardship programs.

Methods: An online cross-sectional study was undertaken with final-year medical students using a validated questionnaire from January 2021 to May 2021. Descriptive and inference statistics were applied for data analysis.

Results: Of 411 students, only 6.3% had undergone antimicrobial resistance (AMR) training. 16.1% of students believed that antibiotics are effective for viral ailments. More than half of the students agreed that AMR is a major healthcare problem in Pakistan (65.9%). Most students viewed poor infection control practices (66.9%), the use of too many broad-spectrum antibiotics (68.4%) for a longer duration (62.8%) with inadequate doses (67.9%) as the causes of AMR. The student’s preparation was insufficient in interpreting microbiological and pathological results (26.3%), selecting the correct antibiotics (22.1%), and awareness of the antibiotic spectrum (20.9%). The median preparedness score showed significant differences with sex (p = 0.049), age (p < 0.001), institute type (p = 0.014), and family income (p = 0.006).

Conclusion: Pakistani medical students showed adequate understanding of antibiotics, but lacked preparedness for several components of ASPs, including interpretation of microbiological results and spectrum of antibiotics. More steps need to be taken to prepare medical students for AMR and stewardship initiatives adequately.

The Burden of Typhoid Fever in Sub-Saharan Africa: A Perspective

While typhoid fever has largely been eliminated in high-income regions which have developed modern water, sanitation, and hygiene facilities, it remains a significant public health burden resulting in morbidity and mortality among millions of individuals in resource-constrained settings. Prevention and control efforts are needed that integrate several high-impact interventions targeting facilities and infrastructure, including those addressing improvements in sanitation, access to safe water, and planned urbanization, together with parallel efforts directed at effective strategies for use of typhoid conjugate vaccines (TCV). The use of TCVs is a critical tool with the potential of having a rapid impact on typhoid fever disease burden; their introduction will also serve as an important strategy to combat evolving antimicrobial resistance to currently available typhoid fever treatments. Well-designed epidemiological surveillance studies play a critical role in establishing the need for, and monitoring the impact of, typhoid fever control and prevention strategies implemented by public health authorities. Here, we present a perspective based on a narrative review of the impact of typhoid fever on morbidity and mortality in sub-Saharan Africa and discuss ongoing surveillance activities and the role of vaccination in prevention and control efforts.

Co-infection With Dengue Virus and Extensively Drug-Resistant Salmonella typhi

In South Asia, infectious diseases are associated with significant morbidity and mortality. Malaria, typhoid, and dengue are the most common infectious diseases, and patients may be co-infected with these diseases, resulting in diagnostic and treatment dilemmas.

Dengue is caused by the Arboviridae family of viruses and is transmitted by Aedes aegypti. Dengue virus has four serotypes and the symptoms of dengue fever mimic those of other infectious diseases such as malaria, chikungunya, Zika virus disease, influenza A, enteric fever, and coronavirus disease 2019, which are also prevalent in areas of frequent dengue fever outbreak. Dengue fever is characterized by fever, severe myalgia, retro-orbital pain, skin rashes, and bone pain, which is why dengue fever is also referred to as breakbone fever. Patients with secondary dengue virus infection more commonly present with abdominal pain when compared with those with primary dengue virus infection.

Salmonella typhi causes enteric fever, which is a human infection with no animal reservoir, but the symptoms of enteric fever closely resemble those of dengue fever. Concurrent infections with multiple organisms are especially difficult to diagnose.

In this report, we present the case of a 15-year-old boy from Peshawar, Pakistan, who was co-infected with the dengue virus and extensively drug-resistant Salmonella typhi. To the best of our knowledge, this is the first reported case of co-infection with dengue virus and extensively drug-resistant Salmonella typhi. 

Traditional Widal Agglutination Test Versus Rapid Immunochromatographic Test in the Diagnosis of Enteric Fever: A Prospective Study From South India

Introduction Early diagnosis and treatment are crucial to reducing the morbidity of patients with enteric fever/typhoid fever. Among the available diagnostic tests, the blood culture is considered a gold standard. However, in most of the developing and resource-limited settings, the diagnosis is made utilizing the traditional Widal test and rapid immunochromatographic test (ICT). This study was aimed to compare the diagnostic value and efficacy of ICT and traditional Widal test in the diagnosis of typhoid fever. Methods A prospective study was conducted, and 40 patients were included in the study. The Widal test and Salmonella enterica serovar Typhi IgM/IgG immunochromatographic test were performed for all the patients. The Widal is a tube agglutination test, and the rapid ICT utilizes the principle of enzyme-linked immunosorbent assay (ELISA). All the samples were also tested for the presence of antibodies (IgG and IgM) against the S. enterica serovar Typhi and the titers against 'O' and 'H' antigens of S. enterica serovar Typhi. An antibody titer of 1:80 or more against the 'O' and 'H' antigen was considered positive. Results In the ICT, 24 samples (60%) tested positive for the IgM antibodies, and only 15 samples tested positive and for IgG antibodies. In the Widal test, 27 samples (67.6%) returned positive for antibodies against the S. enterica serovar Typhi 'O' antigen. The sensitivity (90% vs 72.73%), specificity (81.25% vs 64%), and accuracy (82.12% vs 64.87%) for the Widal test were found to be more when compared to the ICT. Conclusion The results indicate that the traditional Widal agglutination test is superior to the rapid ICT in the diagnosis of enteric fever. However, both these tests cannot be considered as gold standards for the diagnosis owing to their low positive predictive values.

A Case Report of Extensively Drug Resistant Typhoid in Karachi, Pakistan: A Major Health Concern to Curb the Outbreak

The disease burden of extensively drug resistant typhoid in developing countries is a major emerging issue that cannot be ignored. Since its emergence from multidrug strains, the majority of typhoid cases in Karachi, Pakistan, have been extensively drug resistant, mostly infecting younger patients. In the study, the authors analysed one such case in an adolescent male and discussed how, by the implementation of national health policies, the spread of these infectious diseases could be prevented and the overall burden on the healthcare system decreased in areas with already limited resources.

Molecular investigation of antibiotic resistant bacterial strains isolated from wastewater streams in Pakistan

Antibiotic resistance is a global public health issue and it is even more daunting in developing countries. The main objective of present study was to investigate molecular responses of antibiotic-resistant bacteria. The 48 bacterial strains, which were previously isolated and identified were subjected to disc diffusion and MIC (minimum inhibitory concentration) determination, followed by investigating the production of the three beta-lactamases (ESBLs (Extended-spectrum Beta-lactamases), MBLs (Metallo Beta-lactamases), AmpCs) and exploring prevalence of the two antibiotic-resistant genes (ARGs); blaTEM and qnrS. Higher MIC values were observed for penicillin(s) than that for fluoroquinolones (ampicillin > amoxicillin > ofloxacin > ciprofloxacin > levofloxacin). Resistance rates were high (58-89%) for all of the tested beta-lactams. Among the tested strains, 5 were ESBL producers (4 Aeromonas spp. and 1 Escherichia sp.), 2 were MBL producers (1 Stenotrophomonas sp. and 1 Citrobacter sp.) and 3 were AmpC producers (2 Pseudomonas spp. and 1 Morganella sp.). The ARGs qnrS2 and blaTEM were detected in Aeromonas spp. and Escherichia sp. The results highlighted the role of Aeromonas as a vector. The study reports bacteria of multidrug resistance nature in the wastewater environment of Pakistan, which harbor ARGs of clinical relevance and could present a public health concern.