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CORRESPONDENCE
Year : 2018  |  Volume : 31  |  Issue : 6  |  Page : 380

Risk factors and antimicrobial susceptibility pattern in patients with culture-positive typhoid


Department of Microbiology, Government Medical College and Hospital, Sector 32, Chandigarh, India

Date of Web Publication17-Jul-2019

Correspondence Address:
Varsha Gupta
Department of Microbiology, Government Medical College and Hospital, Sector 32, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-258X.262899


How to cite this article:
Gupta V, Singhal L, Goel A, Gupta M, Chander J. Risk factors and antimicrobial susceptibility pattern in patients with culture-positive typhoid. Natl Med J India 2018;31:380

How to cite this URL:
Gupta V, Singhal L, Goel A, Gupta M, Chander J. Risk factors and antimicrobial susceptibility pattern in patients with culture-positive typhoid. Natl Med J India [serial online] 2018 [cited 2019 Oct 20];31:380. Available from: http://www.nmji.in/text.asp?2018/31/6/380/262899



Enteric fever is an endemic disease in developing countries such as India with Salmonella enterica var Typhi (S. typhi) and S. enterica var Paratyphi A (S. paratyphi A) being the major causative agents. Many risk factors have been studied such as poor sanitation, poor personal hygiene, large household size, close location to water bodies and travel to endemic areas. In addition, climatic factors such as rainfall, temperature and seasonal variations also affect the distribution of typhoid fever.[1] In recent years, changes in the epidemiology and drug susceptibility profile have been noted by various workers.[2] Re-emergence of susceptibility to conventional first-line antibiotics and reduced susceptibility to ciprofloxacin have been reported.[2] Moreover, resistance of S. typhi to third-generation cephalosporins, though low at present (1%) is emerging. Carbapenems and tigecycline may be alternatives, although clinical data are sparse. Few cases of extended-spectrum β-lactamase (ESBL) production in S. typhi have been reported from Asia.[3]

A total of 20 non-repeat S. typhi isolates, obtained from blood culture of patients suspected of having enteric fever between July 2016 and June 2017 were studied. Information related to clinical presentation, risk factors and demography were recorded. Salmonella isolates were identified biochemically and confirmed by serotyping. Antibiotic susceptibility was determined by the disk-diffusion method according to the Clinical and Laboratory Standards Institute guidelines.[4] Nalidixic acid-resistant isolates were studied further. Screening for ESBL production was done by the double disc synergy method.[5]

Of the 20 cases (11 males and 9 females), 75% were children (<14 years). Cases were reported throughout the year, with the majority (11, 55%) reported between March and May. Only 4 cases were reported between September and November; whereas, between June–August and December–February, only 3 and 2 patients, respectively, were diagnosed. All isolates were susceptible to firstline antibiotics, i.e. chloramphenicol, ampicillin and cotrimoxazole. This reversal may be due to either the emergence of de novo susceptible strains or loss of high molecular weight self-transferable plasmid encoding chloramphenicol, ampicillin and cotrimoxazole resistance.[6],[7],[8] We observed 95% resistance to ciprofloxacin, which can be attributed to the overuse of ciprofloxacin for treating enteric fever and other acute febrile illnesses. A concordance of 100% between susceptibility pattern of pefloxacin and ciprofloxacin was observed. We found no resistance to azithromycin and third-generation cephalosporins, which should be reserved for multidrug-resistant cases. None of the isolates was found to produce ESBLs. With the emerging resistance, the spread of ESBL-producing strains may limit therapeutic options with carbapenems and tigecycline as the last resort.

To conclude, the incidence of typhoid fever is influenced by climatic conditions. Enteric fever should be considered in cases of fever with thrombocytopenia, which may be a rare presentation. There is increasing resistance to fluoroquinolones, sensitivity to cephalosporins and re-emergence of sensitivity to ampicillin, chloramphenicol and cotrimoxazole in northern India. This re- emphasizes the necessity of continuous surveillance of antibiograms of Salmonella isolates to rationalize treatment protocols.

Conflicts of interest. None declared



 
  References Top

1.
Rasul F, Sughra K, Mushtaq A, Zeeshan N, Mehmood S, Rashid U. Surveillance report on typhoid fever epidemiology and risk factor assessment in district Gujrat, Punjab, Pakistan. Bio med Res 2017;28:6921-6.  Back to cited text no. 1
    
2.
Singhal L, Gupta PK, Kale P, Gautam V, Ray P. Trends in antimicrobial susceptibility of Salmonella typhi from North India (2001-2012). Indian J Med Microbiol 2014; 32:149-52.  Back to cited text no. 2
    
3.
González-LópezJJ, Piedra-Carrasco N, Salvador F, Rodríguez V, Sánchez-Montalvá A, Planes AM, et al. ESBL-producing Salmonella enterica serovar typhi in traveler returning from Guatemala to Spain. Emerg Infect Dis 2014;20:1918-20.  Back to cited text no. 3
    
4.
Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; 27th Informational Supplement. [Document M100-S27]. Wayne, PA:CLSI; 2017.  Back to cited text no. 4
    
5.
Ramachandran A, Shanthi M, Sekar U. Detection of blaCTX-M extended spectrum beta-lactamase producing Salmonella enterica serotype Typhi in a tertiary care centre. J Clin Diagn Res 2017;11:DC21-4.  Back to cited text no. 5
    
6.
Dutta S, Sur D, Manna B, Bhattacharya SK, Deen JL, Clemens JD, et al. Rollback of Salmonella enterica serotype typhi resistance to chloramphenicol and other antimicrobials in Kolkata, India. Antimicrob Agents Chemother 2005;49:1662-3.  Back to cited text no. 6
    
7.
Gupta V, Singla N, Bansal N, Kaistha N, Chander J. Trends in the antibiotic resistance patterns of enteric fever isolates: A three year report from a tertiary care centre. Malays J Med Sci 2013;20:71-5.  Back to cited text no. 7
    
8.
Choudhary A, Gopalakrishnan R, Nambi PS, Ramasubramanian V, Ghafur KA, Thirunarayan MA, et al. Antimicrobial susceptibility of Salmonella enterica serovars in a tertiary care hospital in Southern India. Indian J Med Res 2013;137:800-2.  Back to cited text no. 8
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