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Walker J, Chaguza C, Grubaugh ND, Carey M, Baker S, Khan K, Bogoch II, Pitzer VE. Assessing the global risk of typhoid outbreaks caused by extensively drug resistant Salmonella Typhi. Nat Commun 2023; 14:6502. [PMID: 37845201 PMCID: PMC10579367 DOI: 10.1038/s41467-023-42353-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 10/09/2023] [Indexed: 10/18/2023] Open
Abstract
Since its emergence in 2016, extensively drug resistant (XDR) Salmonella enterica serovar Typhi (S. Typhi) has become the dominant cause of typhoid fever in Pakistan. The establishment of sustained XDR S. Typhi transmission in other countries represents a major public health threat. We show that the annual volume of air travel from Pakistan strongly discriminates between countries that have and have not imported XDR S. Typhi in the past, and identify a significant association between air travel volume and the rate of between-country movement of the H58 haplotype of S. Typhi from fitted phylogeographic models. Applying these insights, we analyze flight itinerary data cross-referenced with model-based estimates of typhoid fever incidence to identify the countries at highest risk of importation and sustained onward transmission of XDR S. Typhi. Future outbreaks of XDR typhoid are most likely to occur in countries that can support efficient local S. Typhi transmission and have strong travel links to regions with ongoing XDR typhoid outbreaks (currently Pakistan). Public health activities to track and mitigate the spread of XDR S. Typhi should be prioritized in these countries.
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Affiliation(s)
- Joseph Walker
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA.
| | - Chrispin Chaguza
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Yale Institute for Global Health, Yale University, New Haven, CT, USA
| | - Nathan D Grubaugh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Yale Institute for Global Health, Yale University, New Haven, CT, USA
- Department of Ecology and Evolutionary Biology, Yale University, New Haven, CT, USA
| | - Megan Carey
- Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge School of Clinical Medicine, Cambridge, UK
- Department of Infection Biology, Faculty of Infectious and Tropical Diseases, London School of Hygiene & Tropical Medicine, London, UK
| | - Stephen Baker
- Cambridge Institute of Therapeutic Immunology and Infectious Disease (CITIID), University of Cambridge School of Clinical Medicine, Cambridge, UK
- Human Immunology Laboratory, International AIDS Vaccine Initiative, London, UK
| | - Kamran Khan
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- BlueDot, Toronto, ON, Canada
| | - Isaac I Bogoch
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Divisions of Infectious Diseases and General Internal Medicine, Toronto General Hospital, University Health Network, Toronto, ON, Canada
| | - Virginia E Pitzer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
- Yale Institute for Global Health, Yale University, New Haven, CT, USA
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2
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Khadka S, Shrestha B, Pokhrel A, Khadka S, Joshi RD, Banjara MR. Antimicrobial Resistance in Salmonella Typhi Isolated From a Referral Hospital of Kathmandu, Nepal. Microbiol Insights 2021; 14:11786361211056350. [PMID: 34916803 PMCID: PMC8669115 DOI: 10.1177/11786361211056350] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 10/09/2021] [Indexed: 11/16/2022] Open
Abstract
Purpose: The morbidity and mortality due to typhoid fever can be significantly reduced with the use of effective antibiotics. At present, fluoroquinolones, third generation cephalosporins, and azithromycin are widely used to treat typhoid fever. However, changing antibiotic susceptibility among Salmonella Typhi and Salmonella Paratyphi poses a particular challenge to the therapeutic management of enteric fever. The objective of this study was to assess the antibiotic susceptibility pattern of Salmonella Typhi isolates. Patients and Methods: A total of 706 blood specimens were collected from febrile patients attending the outpatient department of Kathmandu Model Hospital during June to September, 2018. The antibiotic susceptibility testing for 11 different antibiotics (nalidixic acid, ciprofloxacin, ofloxacin, levofloxacin, cefixime, ceftriaxone, cefotaxime, azithromycin, cotrimoxazole, chloramphenicol, and amoxicillin) was performed by disk diffusion method. Furthermore, minimum inhibitory concentration (MIC) values of ciprofloxacin, ofloxacin, and azithromycin were determined by agar dilution method. Mutation at gyrA ser83 associated with reduced susceptibility to fluoroquinolones was determined by PCR-RFLP. Results: Out of 706 blood samples, 6.94% (n = 49) were culture positive for Salmonella enterica (S. Typhi, n = 46). It was revealed that 97.8% S. Typhi isolates were susceptible to conventional first-line antibiotics (ampicillin, chloramphenicol, and cotrimoxazole), 97.3% to cephalosporins and 95.7% to azithromycin. S. Typhi were either resistant or intermediately susceptible to fluoroquinolones: 97.8% to ciprofloxacin, 91.3% to ofloxacin, and 89.1% to levofloxacin. The MIC of ciprofloxacin, ofloxacin, and azithromycin for S. Typhi ranged from 0.008 to 32, 0.03 to 16, and 2 to 8 μg/mL, respectively. Out of 46 S. Typhi isolates, 44 (95.65%) had gyrA ser83 mutation. Conclusion: Fluoroquinolones have poor activity against Salmonella Typhi. The trends of increasing azithromycin MIC value among S. Typhi might limit its use for the treatment of typhoid fever. Effectiveness of conventional first-line antibiotics in vitro suggests considering their clinical use after large-scale studies.
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Affiliation(s)
- Saroj Khadka
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Nepal
| | - Basudha Shrestha
- Department of Microbiology, Kathmandu Model Hospital, Kathmandu, Nepal
| | - Anil Pokhrel
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Nepal
| | - Sachin Khadka
- Department of Medicine, Kathmandu Model Hospital, Kathmandu, Nepal
| | | | - Megha Raj Banjara
- Central Department of Microbiology, Tribhuvan University, Kirtipur, Nepal
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3
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Steele AD, Carey ME, Kumar S, MacLennan CA, Ma LF, Diaz Z, Zaidi AKM. Typhoid Conjugate Vaccines and Enteric Fever Control: Where to Next? Clin Infect Dis 2021; 71:S185-S190. [PMID: 32725223 PMCID: PMC7388705 DOI: 10.1093/cid/ciaa343] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
After the unprecedented success and acceleration of the global agenda towards typhoid fever control with a strong World Health Organization recommendation and the approval of funding from Gavi, the Vaccine Alliance (Gavi), for the use of a new typhoid conjugate vaccine (TCV), we should turn our minds to the challenges that remain ahead. Despite the evidence showing the safety and clinical efficacy of TCV in endemic populations in developing countries, we should remain vigilant and explore hurdles for the full public health impact of TCV, including vaccine supply for the potential global demand, immunization strategies to optimize the effectiveness and long-term protection provided by the vaccines, potential use of TCV in outbreak settings, and scenarios for addressing chronic carriers. Finally, challenges face endemic countries with poor surveillance systems concerning awareness of the need for TCV and the extent of the issue across their populations, and how to target immunization strategies appropriately.
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Affiliation(s)
- A Duncan Steele
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Megan E Carey
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Supriya Kumar
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Calman A MacLennan
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Lyou-Fu Ma
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Zoey Diaz
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, Washington, USA
| | - Anita K M Zaidi
- Enteric and Diarrheal Diseases, Bill & Melinda Gates Foundation, Seattle, Washington, USA
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4
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Pandey P, Lee K, Amatya B, Angelo KM, Shlim DR, Murphy H. Health problems in travellers to Nepal visiting CIWEC clinic in Kathmandu - A GeoSentinel analysis. Travel Med Infect Dis 2021; 40:101999. [PMID: 33639265 DOI: 10.1016/j.tmaid.2021.101999] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 09/21/2020] [Accepted: 02/18/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Nepal has always been a popular international travel destination. There is limited published data, however, on the spectrum of illnesses acquired by travellers to Nepal. METHODS GeoSentinel is a global data collection network of travel and tropical medicine providers that monitors travel-related morbidity. Records for ill travellers with at least one confirmed or probable diagnosis, were extracted from the GeoSentinel database for the CIWEC Clinic Kathmandu site from January 1, 2009 to December 31, 2017. RESULTS A total of 24,271 records were included. The median age was 30 years (range: 0-91); 54% were female. The top 3 system-based diagnoses in travellers were: gastrointestinal (32%), pulmonary (16%), and dermatologic (9%). Altitude illness comprised 9% of all diagnoses. There were 278 vaccine-preventable diseases, most frequently influenza A (41%) and typhoid fever (19%; S. typhi 52 and S. paratyphi 62). Of 64 vector-borne illnesses, dengue was the most frequent (64%), followed by imported malaria (14%). There was a single traveller with Japanese encephalitis. Six deaths were reported. CONCLUSIONS Travellers to Nepal face a wide spectrum of illnesses, particularly diarrhoea, respiratory disease, and altitude illness. Pre-travel consultations for travellers to Nepal should focus on prevention and treatment of diarrhoea and altitude illness, along with appropriate immunizations and travel advice.
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Affiliation(s)
- Prativa Pandey
- CIWEC Hospital and Travel Medicine Center, Lainchaur, Kathmandu, Nepal.
| | - Keun Lee
- Centers for Disease Control and Prevention, Division of Global Migration and Quarantine, Atlanta, GA, USA.
| | - Bhawana Amatya
- CIWEC Hospital and Travel Medicine Center, Lainchaur, Kathmandu, Nepal.
| | - Kristina M Angelo
- Centers for Disease Control and Prevention, Division of Global Migration and Quarantine, Atlanta, GA, USA.
| | - David R Shlim
- Jackson Hole Travel and Tropical, Jackson Hole, WY, USA.
| | - Holly Murphy
- IHA Infectious Diseases Consultants, 5333 McAuley Dr., Ypsilanti, MI, USA.
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5
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Dhimal M, Dumre SP, Sharma GN, Khanal P, Ranabhat K, Shah LP, Lal BK, Jha R, Upadhyaya BP, Acharya B, Shrestha SK, Davidson SA, Charoensinphon P, Karki KB. An outbreak investigation of scrub typhus in Nepal: confirmation of local transmission. BMC Infect Dis 2021; 21:193. [PMID: 33602136 PMCID: PMC7893900 DOI: 10.1186/s12879-021-05866-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 02/02/2021] [Indexed: 12/13/2022] Open
Abstract
Background Scrub typhus is a largely ignored tropical disease and a leading cause of undifferentiated febrile illness in the areas of tsutsugamushi triangle caused by Orientia tsutsugamushi. It is frequently diagnosed in South Asian countries, although clear epidemiological information is not available from Nepal. After the 2015 earthquake in Nepal, a sudden upsurge in scrub typhus cases was reported. The objective of this study was to investigate epidemiology of scrub typhus and its causative agents in humans, animals, and chigger mites to understand the ongoing transmission ecology. Methods Scrub typhus cases with confirmed diagnosis throughout the country were included in the analysis. Studies were concentrated in the Chitwan district, the site of a major outbreak in 2016. Additional nation-wide data from 2015 to 2017 available from the government database included to analyse the disease distribution by geographical mapping. Results From 2015 to 2017, 1239 scrub typhus cases were confirmed with the largest outbreak occurring in 2016 with 831 (67.1%) cases. The case fatality rate was 5.7% in 2015 which declined to 1.1% in 2017. A nationwide outbreak of scrub typhus was declared as the cases were detected in 52 out of the 75 districts of Nepal. Seasonal trend was observed with a peak during August and September. In addition to the human cases, the presence of O. tsutsugamushi was also confirmed in animals (rodents) and chigger mites (Leptotrombidium imphalum) from the outbreak areas of southern Nepal. Conclusion The detection of O. tsutsugamushi in humans, animals, and chigger mites from outbreak locations and wide-spread reports of scrub typhus throughout the country consecutively for 3 years confirms the ongoing transmission of O. tsutsugamushi with a firmly established ecology in Nepal. The country’s health system needs to be strengthened for systematic surveillance, early outbreak detection, and immediate actions including treatment and preventive measures. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-05866-6.
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Affiliation(s)
- Meghnath Dhimal
- Nepal Health Research Council (NHRC), Ramshah Path, Kathmandu, Nepal.
| | - Shyam Prakash Dumre
- Central Department of Microbiology, Tribhuvan University, Kathmandu, Nepal.,Institute of Tropical Medicine, Nagasaki University, Nagasaki, Japan
| | - Guna Nidhi Sharma
- Epidemiology and Disease Control Division, Department of Health Services, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal.,Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | - Pratik Khanal
- Nepal Health Research Council (NHRC), Ramshah Path, Kathmandu, Nepal.,Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
| | - Kamal Ranabhat
- Institute of Medicine, Tribhuvan University, Kathmandu, Nepal.,Department of Health Services, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | - Lalan Prasad Shah
- Department of Health Services, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | - Bibek Kumar Lal
- Epidemiology and Disease Control Division, Department of Health Services, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | - Runa Jha
- National Public Health Laboratory, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | - Bishnu Prasad Upadhyaya
- National Public Health Laboratory, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | - Bhim Acharya
- Epidemiology and Disease Control Division, Department of Health Services, Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | | | - Silas A Davidson
- Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, Thailand
| | | | - Khem B Karki
- Nepal Health Research Council (NHRC), Ramshah Path, Kathmandu, Nepal.,Institute of Medicine, Tribhuvan University, Kathmandu, Nepal
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6
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Khadka P, Thapaliya J, Thapa S. Susceptibility pattern of Salmonella enterica against commonly prescribed antibiotics, to febrile-pediatric cases, in low-income countries. BMC Pediatr 2021; 21:38. [PMID: 33446146 PMCID: PMC7809854 DOI: 10.1186/s12887-021-02497-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 01/07/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In most low-income countries, febrile-pediatric-cases are often treated empirically with accessible antibiotics without periodic epidemiological surveillance, susceptibility testing, or minimal lethal dose calculations. With this backdrop, the study was undertaken to evaluate the susceptibility trend of Salmonella enterica against the commonly prescribed antibiotics. METHODS All isolates of Salmonella enterica were identified by standard protocols of biotyping and serotyping, then tested against antibiotics by the modified Kirby disk-diffusion method. Minimum Inhibitory Concentration (MIC) of isolates was determined by the agar-dilution method and compared with disk diffusion results and on nalidixic-acid sensitive/resistant strains. RESULTS Among 1815 febrile-pediatric patients, 90(4.9%) isolates of Salmonella enterica [serovar: Salmonella Typhi 62(68.8%) and Salmonella Paratyphi A 28(31.1%)] were recovered. The incidence of infection was higher among males, age groups 5 to 9, and patients enrolling in the out-patient department (OPD). On the disk-diffusion test, most isolates were sensitive against first-line drugs i.e.cephalosporins, and macrolides. However, against quinolones, a huge percentile 93.3%, of isolates were resistant [including 58 Typhiand 26 Paratyphiserovar] while nearly 14% were resistant against fluoroquinolones. When MICs breakpoint were adjusted as follows: 4 μg/ml for azithromycin, ≥1 μg/ml for ciprofloxacin, 2 μg/ml for ofloxacin, 8 μg/ml for nalidixic acid, and 1 μg/ml for cefixime, higher sensitivity and specificity achieved. Compared to other tested antibiotics, a low rate of azithromycin resistance was observed. Nevertheless, higher resistance against fluoroquinolones was observed on NARS strain. CONCLUSION Higher susceptibility of Salmonella enterica to the conventional anti-typhoidal drugs (amoxicillin, chloramphenicol, cotrimoxazole, cephotaxime) advocates for its reconsideration. Although, the lower susceptibility against fluoroquinolones among nalidixic-acid-resistant Salmonella (NARS) strain negates its empirical use among the study age group.
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Affiliation(s)
- Priyatam Khadka
- Medical Microbiology, Tri-Chandra Multiple Campus, Kathmandu, Nepal.
| | - Januka Thapaliya
- Medical Microbiology, Tri-Chandra Multiple Campus, Kathmandu, Nepal
| | - Shovana Thapa
- International Friendship Children's Hospital, Kathmandu, Nepal
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7
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Abstract
Enteric fever is a common but serious disease that affects mostly children and adolescents in the developing countries. Salmonella enterica serovar Typhi remains responsible for most of the disease episodes; however, S. Paratyphi A has also been reported as an emerging infectious agent of concern. The control measures for the disease must encompass early diagnosis, surveillance and vaccine to protect against the disease. Sanitation and hygiene play a major role in reducing the burden of enteric diseases as well. The current status of diagnostics, the surveillance practices in the recent past and the vaccine development efforts have been taken into account for suggesting effective prevention and control measures. However, the challenges in all these aspects persist and cause hindrance in the implementation of the available tools. Hence, an integrative approach and a comprehensive policy framework are required to be in place for the prevention, control and elimination of typhoid fevers.
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Affiliation(s)
- Bratati Mukhopadhyay
- Policy Center for Biomedical Research, Translational Health Science & Technology Institute, Faridabad, Haryana, India
| | - Dipika Sur
- Policy Center for Biomedical Research, Translational Health Science & Technology Institute, Faridabad, Haryana, India
| | - Sanjukta Sen Gupta
- Policy Center for Biomedical Research, Translational Health Science & Technology Institute, Faridabad, Haryana, India
| | - N K Ganguly
- Policy Center for Biomedical Research, Translational Health Science & Technology Institute, Faridabad, Haryana, India
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8
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Lo NC, Gupta R, Stanaway JD, Garrett DO, Bogoch II, Luby SP, Andrews JR. Comparison of Strategies and Incidence Thresholds for Vi Conjugate Vaccines Against Typhoid Fever: A Cost-effectiveness Modeling Study. J Infect Dis 2019; 218:S232-S242. [PMID: 29444257 PMCID: PMC6226717 DOI: 10.1093/infdis/jix598] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Typhoid fever remains a major public health problem globally. While new Vi conjugate vaccines hold promise for averting disease, the optimal programmatic delivery remains unclear. We aimed to identify the strategies and associated epidemiologic conditions under which Vi conjugate vaccines would be cost-effective. Methods We developed a dynamic, age-structured transmission and cost-effectiveness model that simulated multiple vaccination strategies with a typhoid Vi conjugate vaccine from a societal perspective. We simulated 10-year vaccination programs with (1) routine immunization of infants (aged <1 year) through the Expanded Program on Immunization (EPI) and (2) routine immunization of infants through the EPI plus a 1-time catch-up campaign in school-aged children (aged 5–14 years). In the base case analysis, we assumed a 0.5% case-fatality rate for all cases of clinically symptomatic typhoid fever and defined strategies as highly cost-effective by using the definition of a low-income country (defined as a country with a gross domestic product of $1045 per capita). We defined incidence as the true number of clinically symptomatic people in the population per year. Results Vi conjugate typhoid vaccines were highly cost-effective when administered by routine immunization activities through the EPI in settings with an annual incidence of >50 cases/100000 (95% uncertainty interval, 40–75 cases) and when administered through the EPI plus a catch-up campaign in settings with an annual incidence of >130 cases/100000 (95% uncertainty interval, 50–395 cases). The incidence threshold was sensitive to the typhoid-related case-fatality rate, carrier contribution to transmission, vaccine characteristics, and country-specific economic threshold for cost-effectiveness. Conclusions Typhoid Vi conjugate vaccines would be highly cost-effective in low-income countries in settings of moderate typhoid incidence (50 cases/100000 annually). These results were sensitive to case-fatality rates, underscoring the need to consider factors contributing to typhoid mortality (eg, healthcare access and antimicrobial resistance) in the global vaccination strategy.
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Affiliation(s)
- Nathan C Lo
- Division of Infectious Diseases and Geographic Medicine, California.,Division of Epidemiology, Stanford University School of Medicine, California
| | - Ribhav Gupta
- Division of Infectious Diseases and Geographic Medicine, California
| | - Jeffrey D Stanaway
- Institute for Health Metrics and Evaluation, University of Washington, Seattle
| | | | - Isaac I Bogoch
- Department of Medicine, University of Toronto, Washington, D. C.,Division of Internal Medicine, Toronto General Hospital, University Health Network, Toronto, Canada.,Division of Infectious Diseases, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Stephen P Luby
- Division of Infectious Diseases and Geographic Medicine, California
| | - Jason R Andrews
- Division of Infectious Diseases and Geographic Medicine, California
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Abstract
Background & objectives Although febrile illnesses are a frequent cause of consultation and hospitalization in low- and middle-income countries (LMICs), research has mainly focused on acute febrile illnesses (AFIs). In contrast, there are limited data on the causes of persistent febrile illnesses (PFIs) in LMIC. Lack of clarity on the differential diagnosis of PFIs in the rural tropics leads to the absence of diagnostic guidance tools. Methods In this study, a review of the potential causes of persistent fever defined as fever of more than seven days was done in Nepal, with a focus on nine pathogen-specific conditions. The current knowledge on their burden, distribution and diagnosis was summarized. Results Limited data were found on the incidence and public health burden of leptospirosis, murine typhus and brucellosis due to the absence of diagnostic tools outside reference laboratories and the overlap of signs and symptoms with other febrile conditions. The incidence of malaria and visceral leishmaniasis (VL) was found to be decreasing in Nepal, with some changes of the geographical areas at risk. Interpretation & conclusions This review indicates a need for more research on the causes of PFIs in Nepal and in the region and for the development of clinical guidance tailored to current local epidemiology. Guidance tools should include specific clinical features (e.g. eschar), results of rapid diagnostic tests (e.g. malaria, VL), appropriate indications for more sophisticated tests (e.g. abdominal ultrasound, polymerase chain reaction) and recommendations for adequate use of empirical treatment.
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Affiliation(s)
- Kanika Deshpande Koirala
- Department of Medicine, B.P. Koirala Institute of Health Science, Dharan, Nepal; Epidemiology and Control of Neglected Tropical Diseases Unit, Institute of Tropical Medicine, Antwerp, Belgium; Institute of Global Health, University of Geneva, Geneva, Switzerland
| | - François Chappuis
- Institute of Global Health, University of Geneva; Division of Tropical & Humanitarian Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Kristien Verdonck
- Epidemiology and Control of Neglected Tropical Diseases Unit, Institute of Tropical Medicine, Antwerp, Belgium
| | - Suman Rijal
- Department of Medicine, B.P. Koirala Institute of Health Science, Dharan, Nepal
| | - Marleen Boelaert
- Epidemiology and Control of Neglected Tropical Diseases Unit, Institute of Tropical Medicine, Antwerp, Belgium
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10
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Abstract
Antimicrobial resistance (AMR) is a global problem to animal and public health. It has drawn the attention of public health experts, stakeholders, and medical science due to the substantial economic loss that it causes to individuals and nation as a whole. Various cross-sectional studies and some national surveys in developing countries have shown increase in the burden of antimicrobial resistance. Nepal is one of the major contributors to the growing burden of AMR due to widespread irrational use of antibiotics along with poor health care systems poor infection control and prevention measures. This review was conducted to summarize the situation of AMR in Nepal, determinants of AMR, current government intervention strategies and the way forward to reduce the AMR burden in Nepal. Available cross sectional reports warn that bacterial pathogens are becoming highly resistant to most first- and some second-line antibiotics. The irrational and injudicious use of high doses of antibiotics for therapy and sub-optimal doses as growth promoters are leading causes of AMR in Nepal. Establishment of a surveillance programme and a national plan for containment of AMR, following the National Antibiotics Treatment Guideline 2014 and generation of awareness among veterinarians, technicians, and medical physicians on prudent use of antimicrobial drugs in Nepal could reduce the burden of AMR. In addition, there is a need to develop a national laboratory strategic plan to provide guidance and governance to national laboratories.
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Affiliation(s)
- Krishna Prasad Acharya
- Ministry of Land Management, Agriculture and Co-operatives (MoLMAC), Gandaki, Nepal.,Regional Veterinary Laboratory, Pokhara, Nepal
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11
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Joshi S, Adhikary R, Beena HB, Bhavana MV, Bhalwar R. Trends in antibiotic susceptibility of enteric fever isolates from South India, 2002–2013. Med J Armed Forces India 2019; 75:81-85. [DOI: 10.1016/j.mjafi.2018.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 08/07/2018] [Indexed: 10/28/2022] Open
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12
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Petersiel N, Shresta S, Tamrakar R, Koju R, Madhup S, Shresta A, Bedi TRS, Zmora N, Paran Y, Schwartz E, Neuberger A. The epidemiology of typhoid fever in the Dhulikhel area, Nepal: A prospective cohort study. PLoS One 2018; 13:e0204479. [PMID: 30261024 PMCID: PMC6160059 DOI: 10.1371/journal.pone.0204479] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Accepted: 09/11/2018] [Indexed: 11/25/2022] Open
Abstract
Introduction Typhoid fever (TF) continues to cause considerable morbidity and mortality in Nepal, but only limited epidemiologic data is available about TF outside Kathmandu. Methods As part of an interventional trial, we performed a prospective cohort study of bacteremic TF patients in Dhulikhel Hospital between October 2012 and October 2014. Demographic, epidemiological, clinical, and microbiologic data were recorded. Results 116 bacteremic typhoid patients were included in the study. Most were young, healthy, adults (mean age 27.9±12 years), 41.4% of whom were female. More than 70% of patients were employed in non-manual services or were university students. Salmonella Typhi accounted for 64/115 (55.7%) of all isolates, while Salmonella Paratyphi accounted for 51/115 (44.3%), of which 42 were Paratyphi A and 9 Paratyphi B. A significant proportion of TF cases occurred also during the dry season (48/116, 41.6%). The clinical presentation of Salmonella Typhi and Paratyphi infections was similar, except for a greater proportion of arthralgia in patients with Salmonella Typhi. Most Salmonella Typhi and Paratyphi isolates were resistant to nalidixic acid and susceptible to older antibiotics. One Salmonella Paratyphi isolate was resistant to ceftriaxone. Conclusions TF remains common in the Dhulikhel area, even among those with a high level of education. Public health measures aimed at reducing the incidence of TF in the Dhulikhel area are warranted. The relative burden of TF caused by Salmonella Paratyphi is rising; a vaccine with activity against Salmonella Paratyphi is needed. Since Salmonella Paratyphi B was more prevalent in this cohort than in large cohorts of patients from Kathmandu, it is likely that there are significant regional variations in the epidemiology of TF outside Kathmandu.
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Affiliation(s)
- Neta Petersiel
- Unit of Infectious Diseases–Tropical Diseases & Travel Medicine, Internal Medicine B, Rambam Medical Center, Haifa, Israel
- * E-mail:
| | - Sudeep Shresta
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | | | - Rajendra Koju
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Surendra Madhup
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Ashish Shresta
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - TRS Bedi
- Dhulikhel Hospital, Kathmandu University Hospital, Dhulikhel, Nepal
| | - Niv Zmora
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yael Paran
- Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eli Schwartz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- The Center for Geographic Medicine and Tropical Diseases, the Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - Ami Neuberger
- Unit of Infectious Diseases–Tropical Diseases & Travel Medicine, Internal Medicine B, Rambam Medical Center, Haifa, Israel
- Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
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13
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Dahal RH, Chaudhary DK. Microbial Infections and Antimicrobial Resistance in Nepal: Current Trends and Recommendations. Open Microbiol J 2018; 12:230-242. [PMID: 30197696 PMCID: PMC6110072 DOI: 10.2174/1874285801812010230] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 06/25/2018] [Accepted: 07/03/2018] [Indexed: 11/22/2022] Open
Abstract
Antimicrobial resistance is a life threatening challenges to the world. Most of the well-known antibiotics are currently ineffective to several microbial diseases. Ampicillin, metronidazole, amoxicillin, cotrimoxazole, chloramphenicol, ciprofloxacin, nalidixic acid, gentamicin, and ceftazidime are common antibiotics whose resistance pattern has been elevated in recent years. The rise and dissemination of resistant bacteria has contributed in increasing cases of antimicrobial resistance. Multi-drug Resistant (MDR) organism such as Staphylococcus aureus, Pseudomionas aeruginosa, Escherchia coli, and Mycobacterium tuberculosis are principal problems for public health and stakeholders. Globally, issues of antimicrobial resistance are major concern. In the context of Nepal, insufficient surveillance system, lack of appropriate policy, and poor publications regarding the use of antibiotics and its resistance pattern has misled to depict exact scenario of antimicrobial resistance. This mini-review presents current trends of antibiotic use and its resistance pattern in Nepal. In addition, global progression of antibiotic discovery and its resistance has been covered as well. Furthermore, use of antibiotics and possible ways on improvement of effectiveness have been discussed.
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Affiliation(s)
- Ram H Dahal
- Department of Microbiology, Tri-Chandra Multiple Campus, Tribhuvan University, Katmhandu, Nepal
| | - Dhiraj K Chaudhary
- Department of Soil Science, Prithu Technical College, Institute of Agriculture and Animal Science, Tribhuvan University, Lamahi, Dang, Nepal
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14
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Abstract
Many infectious/communicable diseases (IDs) are endemic in Nepal. Until a decade and half ago, IDs were the major cause of both morbidity and mortality accounting 70% for both. However, as a result of various preventive measures implemented by both the state and non-state actors, the overall IDs have shown a changing (declining) trend. The most impressive decline has been seen in the intestinal helminth infection. Though the overall burden of IDs is decreasing, several newer infectious diseases (emerging infections) namely, dengue fever, scrub typhus, influenza (H5N1 and H1N1), and others are posing a great public health problem. On the other hand, though sporadic, outbreaks of endemic diseases together with HIV-TB coinfection and infection with drug resistance microbes during recent years have constituted a serious public health as well as medical problem. On the contrary, with the decline of IDs, noninfectious diseases (noncommunicable disease, NCD) namely, diabetes, cancer (and cancer therapy), and others are on the rise particularly in urban areas. Hence, currently Nepal is trapped in "double burden" of diseases. Risk of opportunistic infection has increased in immunocompromised person with NCD. To address the present situation, the multi-sectoral plan and strategies developed must be implemented effectively.
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Affiliation(s)
- Rameshwar Adhikari
- Research Center for Applied Science and Technology (RECAST), Tribhuvan University, Kathmandu, Nepal
| | - Santosh Thapa
- Department of Microbiology, Immunology and Genetics, Graduate School of Biomedical Sciences, University of North Texas Health Science Center, Fort Worth, Texas USA
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15
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Pandya KD, Palomo-Caturla I, Walker JA, K Sandilya V, Zhong Z, Alugupalli KR. An Unmutated IgM Response to the Vi Polysaccharide of Salmonella Typhi Contributes to Protective Immunity in a Murine Model of Typhoid. J Immunol 2018; 200:4078-4084. [PMID: 29743315 DOI: 10.4049/jimmunol.1701348] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 04/16/2018] [Indexed: 11/19/2022]
Abstract
T cell-dependent B cell responses typically develop in germinal centers. Abs generated during such responses are isotype switched and have a high affinity to the Ag because of somatic hypermutation of Ab genes. B cell responses to purified polysaccharides are T cell independent and do not result in the formation of bona fide germinal centers, and the dominant Ab isotype produced during such responses is IgM with very few or no somatic mutations. Activation-induced cytidine deaminase (AID) is required for both somatic hypermutation and Ig isotype switching in humans and mice. To test the extent to which unmutated polysaccharide-specific IgM confers protective immunity, we immunized wildtype and AID-/- mice with either heat-killed Salmonella enterica serovar Typhi (S. Typhi) or purified Vi polysaccharide (ViPS). We found that wildtype and AID-/- mice immunized with heat-killed S. Typhi generated similar anti-ViPS IgM responses. As expected, wildtype, but not AID-/- mice generated ViPS-specific IgG. However, the differences in the Ab-dependent killing of S. Typhi mediated by the classical pathway of complement activation were not statistically significant. In ViPS-immunized wildtype and AID-/- mice, the ViPS-specific IgM levels and S. Typhi bactericidal Ab titers at 7 but not at 28 d postimmunization were also comparable. To test the protective immunity conferred by these immunizations, mice were challenged with a chimeric S. Typhimurium strain expressing ViPS. Compared with their naive counterparts, immunized wildtype and AID-/- mice exhibited significantly reduced bacterial burden regardless of the route of infection. These data indicate that an unmutated IgM response to ViPS contributes to protective immunity to S. Typhi.
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Affiliation(s)
- Kalgi D Pandya
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107; and
| | - Isabel Palomo-Caturla
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107; and
| | - Justin A Walker
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107; and
| | - Vijay K Sandilya
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107; and
| | - Zhijiu Zhong
- Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107
| | - Kishore R Alugupalli
- Department of Microbiology and Immunology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA 19107; and .,Sidney Kimmel Cancer Center, Thomas Jefferson University, Philadelphia, PA 19107
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16
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Khanal PR, Satyal D, Bhetwal A, Maharjan A, Shakya S, Tandukar S, Parajuli NP. Renaissance of Conventional First-Line Antibiotics in Salmonella enterica Clinical Isolates: Assessment of MICs for Therapeutic Antimicrobials in Enteric Fever Cases from Nepal. Biomed Res Int 2017; 2017:2868143. [PMID: 29018810 DOI: 10.1155/2017/2868143] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Accepted: 08/02/2017] [Indexed: 11/18/2022]
Abstract
Enteric fever caused by Salmonella enterica is a life-threatening systemic illness of gastrointestinal tract especially in tropical countries. Antimicrobial therapy is generally indicated but resistance towards commonly used antibiotics has limited their therapeutic usefulness. Therefore, we aimed to determine the antimicrobial susceptibility pattern by minimum inhibitory concentration method of common therapeutic regimens against Salmonella enterica from enteric fever clinical cases. Salmonella enterica clinical isolates recovered from the patients with suspected enteric fever whose blood samples were submitted to microbiology laboratory of Manmohan Memorial Community Hospital, Kathmandu, from March 2016 to August 2016, were studied. These isolates were subjected to antimicrobial susceptibility testing against common therapeutic antimicrobials by Kirby-Bauer disk diffusion method. The minimum inhibitory concentration of ciprofloxacin, azithromycin, chloramphenicol, and cefixime was determined by Agar dilution method based on the latest CLSI protocol. A total of 88 isolates of Salmonella enterica were recovered from blood samples of enteric fever cases. Out of them, 74 (84.09%) were Salmonella Typhi and 14 (15.91%) were Salmonella Paratyphi A. On Kirby-Bauer disk diffusion antimicrobial susceptibility testing, entire isolates were susceptible to cotrimoxazole, cefixime, ceftriaxone, azithromycin, and chloramphenicol. Sixty-four (72.7%) Salmonella enterica isolates were nalidixic acid resistant and nonsusceptible to ciprofloxacin and levofloxacin. On MIC determination, four Salmonella isolates were ciprofloxacin resistant with MIC 1 µg/ml and two isolates were ciprofloxacin intermediate with MIC 0.5 µg/ml. The MIC range of azithromycin was from 0.125 µg/ml to 2.0 µg/ml, whereas that for chloramphenicol was 2.0 µg/ml–8.0 µg/ml and for cefixime was 0.0075–0.5 µg/ml, respectively. Despite global surge of antimicrobial resistance among Salmonella enterica clinical isolates, the level of drug resistance in our study was not so high. However, higher level of NARST strains limits therapeutic use of fluoroquinolones and necessitates the routine monitoring of such resistance determinants in order to effectively and rationally manage enteric fever cases.
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17
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Alvarez MI, Glover LC, Luo P, Wang L, Theusch E, Oehlers SH, Walton EM, Tram TTB, Kuang YL, Rotter JI, McClean CM, Chinh NT, Medina MW, Tobin DM, Dunstan SJ, Ko DC. Human genetic variation in VAC14 regulates Salmonella invasion and typhoid fever through modulation of cholesterol. Proc Natl Acad Sci U S A 2017; 114:E7746-55. [PMID: 28827342 DOI: 10.1073/pnas.1706070114] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Risk, severity, and outcome of infection depend on the interplay of pathogen virulence and host susceptibility. Systematic identification of genetic susceptibility to infection is being undertaken through genome-wide association studies, but how to expeditiously move from genetic differences to functional mechanisms is unclear. Here, we use genetic association of molecular, cellular, and human disease traits and experimental validation to demonstrate that genetic variation affects expression of VAC14, a phosphoinositide-regulating protein, to influence susceptibility to Salmonella enterica serovar Typhi (S Typhi) infection. Decreased VAC14 expression increased plasma membrane cholesterol, facilitating Salmonella docking and invasion. This increased susceptibility at the cellular level manifests as increased susceptibility to typhoid fever in a Vietnamese population. Furthermore, treating zebrafish with a cholesterol-lowering agent, ezetimibe, reduced susceptibility to S Typhi. Thus, coupling multiple genetic association studies with mechanistic dissection revealed how VAC14 regulates Salmonella invasion and typhoid fever susceptibility and may open doors to new prophylactic/therapeutic approaches.
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18
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Saad NJ, Bowles CC, Grenfell BT, Basnyat B, Arjyal A, Dongol S, Karkey A, Baker S, Pitzer VE. The impact of migration and antimicrobial resistance on the transmission dynamics of typhoid fever in Kathmandu, Nepal: A mathematical modelling study. PLoS Negl Trop Dis 2017; 11:e0005547. [PMID: 28475605 PMCID: PMC5435358 DOI: 10.1371/journal.pntd.0005547] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 05/17/2017] [Accepted: 04/03/2017] [Indexed: 11/21/2022] Open
Abstract
Background A substantial proportion of the global burden of typhoid fever occurs in South Asia. Kathmandu, Nepal experienced a substantial increase in the number of typhoid fever cases (caused by Salmonella Typhi) between 2000 and 2003, which subsequently declined but to a higher endemic level than in 2000. This epidemic of S. Typhi coincided with an increase in organisms with reduced susceptibility against fluoroquinolones, the emergence of S. Typhi H58, and an increase in the migratory population in Kathmandu. Methods We devised a mathematical model to investigate the potential epidemic drivers of typhoid in Kathmandu and fit this model to weekly data of S. Typhi cases between April 1997 and June 2011 and the age distribution of S. Typhi cases. We used this model to determine if the typhoid epidemic in Kathmandu was driven by heightened migration, the emergence of organisms with reduced susceptibility against fluoroquinolones or a combination of these factors. Results Models allowing for the migration of susceptible individuals into Kathmandu alone or in combination with the emergence of S. Typhi with reduced susceptibility against fluoroquinolones provided a good fit for the data. The emergence of organisms with reduced susceptibility against fluoroquinolones organisms alone, either through an increase in disease duration or increased transmission, did not fully explain the pattern of S. Typhi infections. Conclusions Our analysis is consistent with the hypothesis that the increase in typhoid fever in Kathmandu was associated with the migration of susceptible individuals into the city and aided by the emergence of reduced susceptibility against fluoroquinolones. These data support identifying and targeting migrant populations with typhoid immunization programmes to prevent transmission and disease. Typhoid fever is endemic in Nepal, with Kathmandu coined “the typhoid capital of the world”. We developed a mathematical model to assess the importance of migration and antimicrobial resistance on the transmission of typhoid fever in Kathmandu, Nepal from April 1997 to June 2011. During this period, the burden of typhoid fever increased markedly from January 2000 to December 2003, after which the epidemic declined, but to a higher endemic level than in 2000. Our findings are consistent with the hypothesis that migration of susceptible individuals into Kathmandu played an important role in the epidemic, and may have been further aided by the emergence of typhoid fever with reduced susceptibility against fluoroquinolones. This study showed that identifying and targeting migrant populations with control efforts could be an important avenue to prevent typhoid transmission and disease.
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Affiliation(s)
- Neil J. Saad
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, Connecticut, United States of America
- * E-mail: (NJS); (VEP)
| | - Cayley C. Bowles
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, California, United States of America
| | - Bryan T. Grenfell
- Department of Ecology and Evolutionary Biology, Princeton University, Princeton, New Jersey, United States of America
- Fogarty International Center, Bethesda, Maryland, United States of America
| | - Buddha Basnyat
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
| | - Amit Arjyal
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Sabina Dongol
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit, Patan Academy of Health Sciences, Kathmandu, Nepal
| | - Stephen Baker
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, United Kingdom
- The Hospital for Tropical Diseases, Wellcome Trust Major Overseas Programme, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | - Virginia E. Pitzer
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, Yale University, New Haven, Connecticut, United States of America
- Fogarty International Center, Bethesda, Maryland, United States of America
- * E-mail: (NJS); (VEP)
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19
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Adhikari A, Rauniyar R, Raut PP, Manandhar KD, Gupta BP. Evaluation of sensitivity and specificity of ELISA against Widal test for typhoid diagnosis in endemic population of Kathmandu. BMC Infect Dis 2015; 15:523. [PMID: 26573629 PMCID: PMC4647669 DOI: 10.1186/s12879-015-1248-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Accepted: 10/28/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Widal test, which has poor predictive outcomes in predominant typhoid population, is not standard enough to predict accurate diagnosis. This study aims to compare the diagnostic accuracy of Widal test to ELISA using blood culture as gold standard. METHODS The blood samples were collected in Capital Hospital, Kathmandu, Nepal from febrile patients having ≥48 h fever in 3 years study period for blood culture, Widal test and IgG-IgM ELISA. RESULTS Amongst 1371 febrile cases, 237 were Salmonella typhi positive to blood culture and 71.4 % typhoid fever patient were of 46-60 years old with male to female ratio of 2:1. Blood culture confirmed patients had ≥1:40 anti-TH and anti-TO titre in 45.56 % (n = 108) and 43.88 % (n = 104) patients respectively. The sensitivity and specificity of IgG (0.96 and 0.95) and IgM (0.95 and 0.94) at 95 % confidence level were significant compared to Widal anti-TH (0.72 and 0.58) and TO (0.80 and 0.51) test (p value, 0.038) at titre level ≥1:200. Further the PPV of Widal TH and TO (0.38 and 0.23) was low compared to IgG and IgM ELISA (0.78 and 0.77) (p value, 0.045). CONCLUSION Widal test is not sensitive enough for an endemic setting like Nepal and thus should be either replaced with more accurate test like ELISA or follow an alternative diagnostic methodology.
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Affiliation(s)
- Anurag Adhikari
- Asian Institute of Technology & Management, Lalitpur, Nepal. .,Everest Institute of Virology and Immunology, Kathmandu, Nepal.
| | | | | | - Krishna Das Manandhar
- Central Department of Biotechnology, Tribhuvan University, Kirtipur, Kathmandu, Nepal. .,Everest Institute of Virology and Immunology, Kathmandu, Nepal.
| | - Birendra Prasad Gupta
- Central Department of Biotechnology, Tribhuvan University, Kirtipur, Kathmandu, Nepal. .,Everest Institute of Virology and Immunology, Kathmandu, Nepal.
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20
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Abstract
We report a case of isolated urinary Salmonella enterica serotype Typhi in an HIV-positive man who has sex with men. He was clinically well and blood and stool cultures were negative, indicating that this may have been a sexually acquired urinary tract infection.
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21
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Eliakim-Raz N, Lador A, Leibovici-Weissman Y, Elbaz M, Paul M, Leibovici L. Efficacy and safety of chloramphenicol: joining the revival of old antibiotics? Systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother 2015; 70:979-96. [PMID: 25583746 DOI: 10.1093/jac/dku530] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Chloramphenicol is an old broad-spectrum antibiotic. We assessed its efficacy and safety. METHODS This was a systematic review and meta-analysis. Electronic databases were searched to identify randomized controlled trials (RCTs) that assessed patients, of any age, with systemic bacterial infections that can cause sepsis and compared chloramphenicol alone versus other antibiotics. No restrictions on the date of publication, language or publication status were applied. The primary outcome assessed was overall mortality. RESULTS Sixty-six RCTs fulfilled the inclusion criteria, and these included 9711 patients. We found a higher mortality with chloramphenicol for respiratory tract infections [risk ratio (RR) 1.40, 95% CI 1.00-1.97] and meningitis (RR 1.27, 95% CI 1.00-1.60), both without heterogeneity. The point estimate was similar for enteric fever, without statistical significance. No statistically significant difference was found between chloramphenicol and other antibiotics regarding treatment failure, except for enteric fever (RR 1.46, 95% CI 1.07-2.00, without heterogeneity). This difference derived mainly from studies comparing chloramphenicol with fluoroquinolones (RR 1.85, 95% CI 1.07-3.2). There were no statistically significant differences between chloramphenicol and other antibiotics in terms of adverse events, including haematological events, except for anaemia, which occurred more frequently with chloramphenicol (RR 2.80, 95% CI 1.65-4.75, I(2) =0%), and gastrointestinal side effects, which were less frequent with chloramphenicol (RR 0.67, 95% CI 0.46-0.99, I(2) =0%). Many of the studies included were sponsored by pharmaceutical companies marketing the comparator drug to chloramphenicol, and this might have influenced the results. CONCLUSIONS Chloramphenicol cannot be recommended as a first-line treatment for respiratory tract infections, meningitis or enteric fever as alternatives are probably more effective. Chloramphenicol is as safe as treatment alternatives for short antibiotic courses. RCTs are needed to test this treatment against MDR organisms when better alternatives do not exist.
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Affiliation(s)
- Noa Eliakim-Raz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel
| | - Adi Lador
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Yaara Leibovici-Weissman
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel Department of Medicine D, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel
| | - Michal Elbaz
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Mical Paul
- Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel Unit of Infectious Diseases, Rambam Hospital, Haifa, Israel
| | - Leonard Leibovici
- Department of Medicine E, Rabin Medical Center, Beilinson Hospital, Petah-Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
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22
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Dunstan SJ, Hue NT, Han B, Li Z, Tram TTB, Sim KS, Parry CM, Chinh NT, Vinh H, Lan NPH, Thieu NTV, Vinh PV, Koirala S, Dongol S, Arjyal A, Karkey A, Shilpakar O, Dolecek C, Foo JN, Phuong LT, Lanh MN, Do T, Aung T, Hon DN, Teo YY, Hibberd ML, Anders KL, Okada Y, Raychaudhuri S, Simmons CP, Baker S, de Bakker PIW, Basnyat B, Hien TT, Farrar JJ, Khor CC. Variation at HLA-DRB1 is associated with resistance to enteric fever. Nat Genet 2014; 46:1333-6. [PMID: 25383971 PMCID: PMC5099079 DOI: 10.1038/ng.3143] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2014] [Accepted: 10/15/2014] [Indexed: 12/18/2022]
Abstract
Enteric fever affects more than 25 million people annually and results from systemic infection with Salmonella enterica serovar Typhi or Paratyphi pathovars A, B or C(1). We conducted a genome-wide association study of 432 individuals with blood culture-confirmed enteric fever and 2,011 controls from Vietnam. We observed strong association at rs7765379 (odds ratio (OR) for the minor allele = 0.18, P = 4.5 × 10(-10)), a marker mapping to the HLA class II region, in proximity to HLA-DQB1 and HLA-DRB1. We replicated this association in 595 enteric fever cases and 386 controls from Nepal and also in a second independent collection of 151 cases and 668 controls from Vietnam. Imputation-based fine-mapping across the extended MHC region showed that the classical HLA-DRB1*04:05 allele (OR = 0.14, P = 2.60 × 10(-11)) could entirely explain the association at rs7765379, thus implicating HLA-DRB1 as a major contributor to resistance against enteric fever, presumably through antigen presentation.
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Affiliation(s)
- Sarah J Dunstan
- 1] Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. [2] Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK. [3] Nossal Institute of Global Health, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Nguyen Thi Hue
- 1] Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. [2] Faculty of Biology, University of Science, Vietnam National University, Ho Chi Minh City, Vietnam
| | - Buhm Han
- 1] Asan Institute for Life Sciences, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea. [2] Department of Medicine, Division of Genetics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. [3] Program in Medical and Population Genetics, Broad Institute, Cambridge, Massachusetts, USA. [4] Partners Center for Personalized Genetic Medicine, Boston, Massachusetts, USA
| | - Zheng Li
- Genome Institute of Singapore, Singapore
| | - Trinh Thi Bich Tram
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Christopher M Parry
- 1] Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. [2] Liverpool School of Tropical Medicine, Liverpool, UK
| | | | - Ha Vinh
- Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | | | - Nga Tran Vu Thieu
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Phat Voong Vinh
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Samir Koirala
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Sciences, Patan Hospital, Patan, Nepal
| | - Sabina Dongol
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Sciences, Patan Hospital, Patan, Nepal
| | - Amit Arjyal
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Sciences, Patan Hospital, Patan, Nepal
| | - Abhilasha Karkey
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Sciences, Patan Hospital, Patan, Nepal
| | - Olita Shilpakar
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Sciences, Patan Hospital, Patan, Nepal
| | - Christiane Dolecek
- 1] Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. [2] Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| | | | | | | | - Tan Do
- Vietnam National Institute of Ophthalmology, Hanoi, Vietnam
| | - Tin Aung
- Singapore Eye Research Institute, Singapore
| | - Do Nu Hon
- Vietnam National Institute of Ophthalmology, Hanoi, Vietnam
| | - Yik Ying Teo
- 1] Department of Statistics and Applied Probability, National University of Singapore, Singapore. [2] Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | - Martin L Hibberd
- 1] Genome Institute of Singapore, Singapore. [2] London School of Tropical Medicine and Hygiene, London, UK
| | - Katherine L Anders
- 1] Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. [2] Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| | - Yukinori Okada
- 1] Department of Human Genetics and Disease Diversity, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan. [2] Laboratory for Statistical Analysis, RIKEN Center for Integrative Medical Sciences, Yokohama, Japan
| | - Soumya Raychaudhuri
- 1] Department of Medicine, Division of Genetics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. [2] Program in Medical and Population Genetics, Broad Institute, Cambridge, Massachusetts, USA. [3] Partners Center for Personalized Genetic Medicine, Boston, Massachusetts, USA. [4] Department of Medicine, Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, Massachusetts, USA. [5] Faculty of Medical and Human Sciences, University of Manchester, Manchester, UK
| | - Cameron P Simmons
- 1] Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. [2] Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK. [3] Department of Microbiology and Immunology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Stephen Baker
- 1] Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. [2] Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK. [3] London School of Tropical Medicine and Hygiene, London, UK
| | - Paul I W de Bakker
- 1] Department of Medical Genetics, Center for Molecular Medicine, University Medical Center Utrecht, Utrecht, the Netherlands. [2] Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Buddha Basnyat
- Oxford University Clinical Research Unit-Nepal, Patan Academy of Health Sciences, Patan Hospital, Patan, Nepal
| | - Tran Tinh Hien
- Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam
| | - Jeremy J Farrar
- 1] Oxford University Clinical Research Unit, Hospital for Tropical Diseases, Ho Chi Minh City, Vietnam. [2] Centre for Tropical Medicine, Nuffield Department of Clinical Medicine, Oxford University, Oxford, UK
| | - Chiea Chuen Khor
- 1] Genome Institute of Singapore, Singapore. [2] Singapore Eye Research Institute, Singapore. [3] Saw Swee Hock School of Public Health, National University of Singapore, Singapore. [4] Department of Paediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore. [5] Department of Ophthalmology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Zhou Z, McCann A, Weill FX, Blin C, Nair S, Wain J, Dougan G, Achtman M. Transient Darwinian selection in Salmonella enterica serovar Paratyphi A during 450 years of global spread of enteric fever. Proc Natl Acad Sci U S A 2014; 111:12199-204. [PMID: 25092320 DOI: 10.1073/pnas.1411012111] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Multiple epidemic diseases have been designated as emerging or reemerging because the numbers of clinical cases have increased. Emerging diseases are often suspected to be driven by increased virulence or fitness, possibly associated with the gain of novel genes or mutations. However, the time period over which humans have been afflicted by such diseases is only known for very few bacterial pathogens, and the evidence for recently increased virulence or fitness is scanty. Has Darwinian (diversifying) selection at the genomic level recently driven microevolution within bacterial pathogens of humans? Salmonella enterica serovar Paratyphi A is a major cause of enteric fever, with a microbiological history dating to 1898. We identified seven modern lineages among 149 genomes on the basis of 4,584 SNPs in the core genome and estimated that Paratyphi A originated 450 y ago. During that time period, the effective population size has undergone expansion, reduction, and recent expansion. Mutations, some of which inactivate genes, have occurred continuously over the history of Paratyphi A, as has the gain or loss of accessory genes. We also identified 273 mutations that were under Darwinian selection. However, most genetic changes are transient, continuously being removed by purifying selection, and the genome of Paratyphi A has not changed dramatically over centuries. We conclude that Darwinian selection is not responsible for increased frequency of enteric fever and suggest that environmental changes may be more important for the frequency of disease.
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Thandassery RB, Sharma M, Abdelmola A, Derbala MFM, Al Kaabi SR. Uncommon gastrointestinal complications of enteric fever in a non-endemic country. Qatar Med J 2014; 2014:46-9. [PMID: 25320692 PMCID: PMC4197373 DOI: 10.5339/qmj.2014.7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 06/05/2014] [Indexed: 11/21/2022] Open
Abstract
Enteric fever is a systemic illness with varying presentation. It is an important infectious disease in developing countries and also in industrialized countries where many migrants reside. Enteric fever can result in complications in different organ systems and delay in identification and prompt treatment can be fatal. The important gastrointestinal complications of enteric fever include hepatitis, intestinal ulcers, bleeding and bowel perforation. We report three relatively uncommon complications of enteric fever in Qatar, a non-endemic country, ileal ulcer presenting with hematochezia; duodenal ulcer with polyserositis, cholestatic hepatitis and bone marrow suppression; enteric fever related peritonitis.
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Affiliation(s)
- Ragesh Babu Thandassery
- Department of Gastroenterology and Hepatology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Manik Sharma
- Department of Gastroenterology and Hepatology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Abdellatif Abdelmola
- Department of Gastroenterology and Hepatology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Moutaz F M Derbala
- Department of Gastroenterology and Hepatology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Saad Rashid Al Kaabi
- Department of Gastroenterology and Hepatology, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar
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25
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Jaradat ZW, Abedel Hafiz L, Ababneh MM, Ababneh QO, Al Mousa W, Al-Nabulsi A, Osaili TM, Holley R. Comparative analysis of virulence and resistance profiles of Salmonella Enteritidis isolates from poultry meat and foodborne outbreaks in northern Jordan. Virulence 2014; 5:601-10. [PMID: 24780883 DOI: 10.4161/viru.29002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This study was conducted to isolate Salmonella Enteritidis from poultry samples and compare their virulence and antibiotic resistance profiles to S. Enteritidis isolated from outbreaks in northern Jordan. Two hundred presumptive isolates were obtained from 302 raw poultry samples and were subjected to further analysis and confirmation. A phylogenic tree based on 16S rRNA sequencing was constructed and selected isolates representing each cluster were further studied for their virulence in normal adult Swiss white mice. The most virulent strains were isolated from poultry samples and had an LD 50 of 1.55 × 10 (5) CFU, while some of the outbreak isolates were avirulent in mice. Antibiotic resistance profiling revealed that the isolates were resistant to seven of eight antibiotics screened with each isolate resistant to multiple antibiotics (from two to six). Of the poultry isolates, 100%, 88.9%, 77.8%, 66.7%, and 50% showed resistance to nalidixic acid, ciprofloxacin, ampicillin, cephalothin, and cefoperazone, respectively. Two outbreak isolates were sensitive to all tested antibiotics, while 71.4% were resistant to cefoperazone and only 28.6% showed resistance to nalidixic acid. Salmonella outbreak isolates were genetically related to poultry isolates as inferred from the 16S rRNA sequencing, yet were phenotypically different. Although outbreak strains were similar to poultry isolates, when tested in the mouse model, some of the outbreak isolates were highly virulent while others were avirulent. This might be due to a variation in susceptibility of the mouse to different S. Enteritidis isolates.
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Affiliation(s)
- Ziad W Jaradat
- Department of Biotechnology and Genetic Engineering; Jordan University of Science and Technology; Irbid, Jordan
| | - Leena Abedel Hafiz
- Department of Biotechnology and Genetic Engineering; Jordan University of Science and Technology; Irbid, Jordan
| | - Mustafa M Ababneh
- Department of Basic Veterinary Medical Sciences; Jordan University of Science and Technology; Irbid, Jordan
| | - Qotaibah O Ababneh
- Department of Biotechnology and Genetic Engineering; Jordan University of Science and Technology; Irbid, Jordan; Department of Biochemistry and Biophysics; Texas A&M University; College Station, TX USA
| | - Waseem Al Mousa
- Department of Biotechnology and Genetic Engineering; Jordan University of Science and Technology; Irbid, Jordan
| | - Anas Al-Nabulsi
- Department of Nutrition and Food Technology; Jordan University of Science and Technology; Irbid, Jordan
| | - Tareq M Osaili
- Department of Nutrition and Food Technology; Jordan University of Science and Technology; Irbid, Jordan
| | - Richard Holley
- Department of Food Science; University of Manitoba; Winnipeg, MB Canada
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