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Indian Journal of Medical Sciences, Vol. 60, No. 9, September, 2006, pp. 389-390 Letter To Editor Quinolone-resistant typhoid fever Gogia A, Agarwal PK, Khosla P, Jain S, Jain KP Department of Medicine, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi Correspondence Address:J-6/27 Rajouri Garden, New Delhi - 110 027 Email: atulgogs@rediffmail.com Code Number: ms06058 Sir, An estimated 600,000 deaths from enteric fever occur annually throughout the world.[1] Multi-drug resistant typhoid fever is being increasingly reported from all over the world, including India. In India, S. typhi drug resistance has been reported since 1960, followed by the first outbreak of multi-drug resistant S. typhi (MDRST) in Calicut.[2],[3] Since then, MDRST has appeared throughout the world, especially in South America, the Indian subcontinent, Africa and south east Asia.[4] A 19-year-old girl was admitted with complaints of moderate-grade fever of 3 weeks duration along with weakness, nausea and retching. She was evaluated and found to have normal hematological and biochemical parameters. Widal test done showed a titer of 1:160 for O antigen of Salmonella typhi. Blood culture was not done initially. Ultrasound abdomen showed mild splenomegaly. She was put on oral ofloxacin 10 mg/kg/day for 10 days without any response. Later, a blood culture done grew Salmonella typhi resistant to ciprofloxacin and ofloxacin (MIC> 32 mcg/ml), while it was sensitive to ampicillin, chloramphenicol, co-triamoxazole, ceftriaxone and cefixime. She was started on injectable ceftriaxone in the dose of 80 mg/kg/day for 5 days, which was then increased to 100 mg/kg/day for the next 4 days, although the fever spike decreased but did not touch the baseline. Oral co-triamoxazole was added and patient improved clinically in the next 2-3 days with remission of fever. The antibiotics were continued for another 1 week after defervescence. Enteric fever continues to be a major public health problem, especially in the developing countries of the tropics. The sensitivity pattern of S. typhi is changing and there is re-emergence of sensitivity to chloramphenicol but rising resistance to ciprofloxacin.[4] The emergence of antibiotic-resistant strains of bacteria is closely linked to the irrational use of antibiotics in treating human infections, especially ciprofloxacin.[4] Ampicillin, chloramphenicol and co-triamoxazole had been the first line drugs for treating typhoid fever, but with emerging resistance in the 70s and 80s, they fell in disuse. There is a change in the antibiogram of S. typhi now with re-emergence of sensitivity to chloramphenicol, ampicillin and co-triamoxazole with resistance to quinolones. This changing pattern has been supported by studies by Lakshmi et al.[5] There have been reports in literature of resistance to nalidixic acid, ciprofloxacin but not to ofloxacin. Our case report is the first to show resistance of S. typhi to both ciprofloxacin and ofloxacin, the other aspect being that it was sensitive to ampicillin, chloramphenicol and co-triamoxazole. Our case highlights the fact that S. typhi is showing a reduced susceptibility to quinolones. The resistance to quinolones may be primary or acquired due to inappropriate antimicrobial use and also due to inappropriate dosage of the antibiotics. In our case, it is remotely possible that the patient might have developed secondary quinolone resistance due to use of ofloxacin prior to the culture report; but either ways, it is important that laboratories test S. typhi for reduced susceptibility to fluoroquinolones. This also highlights the fact that with increasing resistance to fluoroquinolones and the possibility of re-emergence of sensitivity to chloramphenicol among salmonellae, the policy of empirical treatment of enteric fever needs to be rationalized. The changing trend in the antibiogram of S. typhi probably demands reconsideration of chloramphenicol and co-triamoxazole in typhoid fever instead of fluoroquinolones to prevent the emergence of multi-drug resistance. References
Copyright 2006 - Indian Journal of Medical Sciences |
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