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Bacteremia, Thailand by CDCdocs



      Drug-resistant                          evaluate MICs for nalidixic acid,              enrofloxacin, a veterinary fluoro-
                                              ciprofloxacin,      and   ceftriaxone.         quinolone, is used in animals in the
                                              Susceptibility was defined according           poultry, swine, and seafood industries.
       Salmonella                             to the 2005 criteria for Salmonella of         Ceftiofur, a third-generation cephalo-
       Bacteremia,                            the Clinical Laboratory Standards              sporin, is used extensively in swine
                                              Institute (CLSI, formerly NCCLS) (6).          for treatment and prevention of dis-
                                                   Isolates showed high frequencies          ease and for growth promotion. When
     To the Editor: Despite improved          of antimicrobial drug resistance               compared with previous susceptibility
public health, serious infections with        (Figure). All S. Choleraesuis isolates         patterns (5), current nontyphoidal
nontyphoidal Salmonella enterica              with ceftriaxone resistance also               Salmonella infections in humans in
remain a major clinical and public            showed high levels of resistance to            Thailand are more resistant to
health concern in Thailand and                nalidixic acid (MIC >256 µg/mL);               quinolones and cephalosporins.
worldwide (1,2). Life-threatening             most of these also had reduced sus-            Susceptibility to nalidixic acid corre-
Salmonella infections resistant to flu-       ceptibility to ciprofloxacin (MIC              lates well with reduced susceptibility
oroquinolones, extended-spectrum              >0.125 µg/mL). Of 73 nalidixic                 to ciprofloxacin. An alarming increase
cephalosporins, or both, have been            acid–resistant Salmonella isolates, 55         in ceftriaxone resistance in S.
increasingly reported (3). Use of             (75%) required a ciprofloxacin MIC             Choleraesuis may be associated with
antimicrobial drugs for disease pre-          >0.125 µg/mL, 14 (19%) required an             inappropriate cephalosporin use in
vention and growth promotion in               MIC of 0.094 µg/mL, and 4 (6%)                 swine farming. Major revisions in
food animals has been implicated in           required an MIC of 0.064 µg/mL. One            current policies for use of antimicro-
this increase in drug resistance (4).         patient with aortitis caused by ceftri-        bial drugs in food animals in Thailand
Because of extensive global travel,           axone-resistant S. Choleraesuis died           are warranted.
such increases affect the medical             of a ruptured mycotic aneurysm.
community domestically and interna-                In the food animal industry, the
                                                                                                  This study was supported by a
tionally (5). We report a pilot survey        effect of using antimicrobial drugs has
                                                                                             research grant from the National Research
of drug resistance in Salmonella spp.         long been a subject of concern (7–9).
                                                                                             Council of Thailand through Chulalong-
in Thailand.                                  Evidence from molecular epidemio-
                                                                                             korn University, Ratchadapiseksompotch
     We studied archival nontyphoidal         logic studies (9) suggests that these
                                                                                             Fund from Faculty of Medicine,
Salmonella isolates from bacteremic           concerns are genuine and that serious
                                                                                             Chulalongkorn University, and a develop-
patients at King Chulalongkorn                problems must be addressed. This
                                                                                             ment grant for new faculty/researchers,
Memorial Hospital from January 2003           concern is also supported by reports
                                                                                             Chulalongkorn University. W.K. was sup-
to October 2005 and from bacteremic           of fatal, invasive, nontyphoidal
                                                                                             ported by the Faculty Fund, Faculty of
patients in Thailand sent to the World        Salmonella infections resistant to
                                                                                             Medicine and Research Scholar Fund,
Health      Organization      National        quinolones or extended-spectrum
                                                                                             Thailand Research Fund.
Salmonella and Shigella Center in             cephalosporins (7,10). In Thailand,
Bangkok during the first half of 2005.
The isolates from these archives were
nonoverlapping and were kept frozen
at −80°C. Isolates were divided into
Salmonella serovar Choleraesuis and
other nontyphoidal Salmonella (non-
Choleraesuis) because we observed
that Choleraesuis isolates show a high-
er frequency of resistance to fluoro-
quinolones and extended-spectrum
cephalosporins than non-Choleraesuis
isolates. A standard Etest method (AB
Biodisk, Solna, Sweden) was used to           Figure. Percentage of nontyphoidal Salmonella isolates resistant to nalidixic acid (NA) and
                                              ceftriaxone (CTRX), Thailand. KCMH, King Chulalongkorn Memorial Hospital; WHO-
                                              Salm, World Health Organization Salmonella and Shigella Center. Cho, Choleraesuis;
1Presented     at the 16th European           non-Cho, non-Choleraesuis. The analysis included 10 Cho isolates from KCMH, 44 Cho
Congress of Clinical Microbiology and         isolates from WHO-Salm, 27 non-Cho isolates from KCMH, and 41 non-Cho isolates from
Infectious Diseases, April 1–4, 2006, Nice,   WHO-Salm. Two Cho isolates from WHO-Salm with intermediate MICs for ceftriaxone are
France.                                       also included.

                             Emerging Infectious Diseases • • Vol. 13, No. 3, March 2007                             501

    Wanla Kulwichit,* Tanittha                     9. Su LH, Chiu CH, Chu C, Ou JT.               tinued. Results of laboratory studies
   Chatsuwan,* Chudaachhara                           Antimicrobial resistance in nontyphoid      were the following: leukocyte count
                                                      Salmonella serotypes: a global challenge.
 Unhasuta,* Chaiwat Pulsrikarn,†                      Clin Infect Dis. 2004;39:546–51.            13.3/mm3 (71% polymorphonuclear
  Aroon Bangtrakulnonth,† and                     10. Helms M, Vastrup P, Gerner-Smidt P,         leukocytes, 18% bands) and normal
     Anan Chongthaleong*                              Molbak K. Excess mortality associated       hematocrit, platelet count, blood urea
*Chulalongkorn University, Bangkok,                   with     antimicrobial     drug–resistant   nitrogen and creatinine concentra-
Thailand; and †World Health Organization              Salmonella typhimurium. Emerg Infect
                                                      Dis. 2002;8:490–5.                          tions, and liver-associated enzymes.
National Salmonella and Shigella Center,
                                                                                                       A marker pen was used to track
Bangkok, Thailand
                                                  Address for correspondence: Wanla Kulwichit,    the rapid advance of erythema
                                                  Department of Medicine, Faculty of Medicine,    overnight from her anterior, inferior
                                                  Chulalongkorn University, Bangkok 10330,        chin to the top of her breasts (Figure).
 1. Aarestrup FM, Lertworapreecha M,              Thailand, email:             The infectious disease service was
    Evans MC, Bangtrakulnonth A,                                                                  consulted the next morning. When she
    Chalermchaikit T, Hendriksen RS, et al.
    Antimicrobial susceptibility and occur-                                                       was examined, her condition had
    rence of resistance genes among                                                               improved; she had normal vital signs,
    Salmonella enterica serovar Weltevreden                                                       a slightly hoarse voice, and the ability
    from different countries. J Antimicrob                                                        to swallow some saliva. She had no
    Chemother. 2003;52:715–8.
 2. Bangtrakulnonth A, Pornreongwong S,                Fulminant                                  headache or meningismus. The chest
                                                                                                  erythema was receding. Oral exami-
                                                   Supraglottitis from
    Pulsrikarn C, Sawanpanyalert P,
    Hendriksen RS, Lo Fo Wong DM, et al.                                                          nation demonstrated erythema and an
    Salmonella serovars from humans and
    other sources in Thailand, 1993–2002.
                                                       Neisseria                                  abrasion in the posterior pharynx. Her
    Emerg Infect Dis. 2004;10:131–6.                  meningitidis                                tongue was not elevated and her uvula
                                                                                                  was midline. Anterior firm edema
 3. Sun HY, Tseng SP, Hsueh PR, Hung CC,
    Hsieh SM, Teng LJ, et al. Occurrence of            To the Editor: A 68-year-old               without crepitus extended from her
    ceftriaxone resistance in ciprofloxacin-                                                      chin to the mid-neck. Results of her
    resistant Salmonella enterica serotype
                                                  Caucasian woman with non–insulin-
    Choleraesuis isolates causing recurrent       dependent diabetes mellitus, hyper-             examination were otherwise unre-
    infection. Clin Infect Dis. 2005;40:208–9.    tension, and peripheral vascular dis-           markable. The infectious disease con-
 4. Hsueh PR, Teng LJ, Tseng SP, Chang CF,        ease sought treatment at an emer-               sultant recommended restarting a
    Wan JH, Yan JJ, et al. Ciprofloxacin-                                                         course of vancomycin and discontinu-
    resistant Salmonella enterica Typhi-
                                                  gency department after experiencing
    murium and Choleraesuis from pigs to          2 days of pharyngitis and 1 day of              ing clindamycin.
    humans, Taiwan. Emerg Infect Dis.             fatigue and dysphagia for solid food.                A follow-up CT scan with con-
    2004;10:60–8.                                 The morning of admission she noted              trast demonstrated anterior cervical
 5. Hakanen A, Kotilainen P, Huovinen P,                                                          soft tissue edema and patent airway
    Helenius H, Siitonen A. Reduced fluoro-
                                                  dysphagia for solid food and liquids,
    quinolone susceptibility in Salmonella        dysphonia, severe anterior neck pain,           with surrounding abnormal thickness
    enterica serotypes in travelers returning     neck swelling and erythema, dyspnea,            and soft tissue density. No abscess or
    from Southeast Asia. Emerg Infect Dis.        and a temperature of 102.3°F (39°C).            clot was seen. Endoscopic examina-
    2001;7:996–1003.                                                                              tion in the ICU showed diffuse erythe-
 6. Clinical and Laboratory Standards
                                                  A computed tomographic (CT) scan
    Institute (CLSI). Performance standards       demonstrated substantial neck soft tis-         ma and generalized supraglottic
    for antimicrobial susceptibility testing;     sue edema and narrowing of the                  edema affecting mostly the epiglottis
    15th       informational       supplement.    oropharynx and hypopharynx. She                 and arytenoids. Dental examination
    CLSI/NCCLS M100-S15. Wayne (PA):                                                              demonstrated no acute pathologic fea-
    The Institute; 2005.
                                                  received single doses of intravenous
 7. Helms M, Simonsen J, Molbak K.                ampicillin/sulbactam, clindamycin,              tures. Blood cultures at our hospital
    Quinolone resistance is associated with       dexamethasone (10 mg), and methyl-              yielded no growth, and throat culture
    increased risk of invasive illness or death   prednisolone (125 mg) before being              was negative for group A streptococci.
    during infection with Salmonella serotype                                                          The patient recovered without
    Typhimurium. J Infect Dis. 2004;190:
                                                  evacuated by air to our intensive care
    1652–4.                                       unit (ICU) at Walter Reed Army                  requiring intubation (Figure). On the
 8. Phillips I, Casewell M, Cox T, de Groot       Medical Center. Intravenous ampi-               day of discharge, a blood culture from
    B, Friis C, Jones R, et al. Does the use of   cillin/sulbactam, 3 g every 6 hours,            the referring hospital’s emergency
    antibiotics in food animals pose a risk to                                                    department was reported to be posi-
    human health? A critical review of pub-
                                                  and clindamycin, 900 mg every 8
    lished data. J Antimicrob Chemother.          hours, were continued after the trans-          tive for Neisseria meningitidis,
    2004;53:28–52.                                fer. Two doses of intravenous van-              serogroup Y. Immediate family mem-
                                                  comycin, 1 g every 12 hours, were               bers and the otolaryngologists who
                                                  given before vancomycin was discon-             conducted the endoscopic examina-

502                            Emerging Infectious Diseases • • Vol. 13, No. 3, March 2007

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