Clinical outcomes in typhoid fever: adverse impact of infection with nalidixic acid-resistant Salmonella typhiReportar como inadecuado

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BMC Infectious Diseases

, 5:37

First Online: 18 May 2005Received: 23 October 2004Accepted: 18 May 2005


BackgroundWidespread use of fluoroquinolones has resulted in emergence of Salmonella typhi strains with decreased susceptibility to fluoroquinolones. These strains are identifiable by their nalidixic acid-resistance. We studied the impact of infection with nalidixic acid-resistant S. typhi NARST on clinical outcomes in patients with bacteriologically-confirmed typhoid fever.

MethodsClinical and laboratory features, fever clearance time and complications were prospectively studied in patients with blood culture-proven typhoid fever, treated at a tertiary care hospital in north India, during the period from November 2001 to October 2003. Susceptibility to amoxycillin, co-trimoxazole, chloramphenicol, ciprofloxacin and ceftriaxone were tested by disc diffusion method. Minimum inhibitory concentrations MIC of ciprofloxacin and ceftriaxone were determined by E-test method.

ResultsDuring a two-year period, 60 patients age mean ± SD: 15 ± 9 years; males: 40 67% were studied. All isolates were sensitive to ciprofloxacin and ceftriaxone by disc diffusion and MIC breakpoints. However, 11 patients had clinical failure of fluoroquinolone therapy. Infections with NARST isolates 47 78% were significantly associated with longer duration of fever at presentation median IQR 10 7-15 vs. 4 3-6 days; P = 0.000, higher frequency of hepatomegaly 57% vs. 15%; P = 0.021, higher levels of aspartate aminotransferase 121 66–235 vs. 73 44–119 IU-L; P = 0.033, and increased MIC of ciprofloxacin 0.37 ± 0.21 vs. 0.17 ± 0.14 μg-mL; P = 0.005, as compared to infections with nalidixic acid-susceptible isolates. All 11 patients with complications were infected with NARST isolates. Total duration of illness was significantly longer in patients who developed complications than in patients who did not 22 14.8–32 vs. 12 9.3–20.3 days; P = 0.011. Duration of prior antibiotic intake had a strong positive correlation with the duration of fever at presentation r = 0.61; P = 0.000 as well as the total duration of illness r = 0.53; P = 0.000.

ConclusionTyphoid fever caused by NARST infection is associated with poor clinical outcomes, probably due to delay in initiating appropriate antibiotic therapy. Fluoroquinolone breakpoints for S. typhi need to be redefined and fluoroquinolones should no longer be used as first-line therapy, if the prevalence of NARST is high.

Electronic supplementary materialThe online version of this article doi:10.1186-1471-2334-5-37 contains supplementary material, which is available to authorized users.

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Autor: Tamilarasu Kadhiravan - Naveet Wig - Arti Kapil - SK Kabra - K Renuka - Anoop Misra


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