Clinical response and outcome of infection with Salmonella enterica serotype Typhi with decreased susceptibility to fluoroquinolones: a United States foodnet multicenter retrospective cohort study

Abstract

Patients with typhoid fever due to Salmonella enterica serotype Typhi strains for which fluoroquinolones MICs are elevated yet that are classified as susceptible by the current interpretive criteria of the Clinical and Laboratory Standards Institute may not respond adequately to fluoroquinolone therapy. Patients from seven U.S. states with invasive Salmonella serotype Typhi infection between 1999 and 2002 were enrolled in a multicenter retrospective cohort study. Patients infected with Salmonella serotype Typhi isolates with ciprofloxacin MICs of 0.12 to 1 microg/ml (decreased ciprofloxacin susceptibility but not resistant to ciprofloxacin [DCS]) were compared with patients infected with isolates with ciprofloxacin MICs <0.12 microg/ml for fever clearance time and treatment failure. Of 71 patients, 30 (43%) were female and 24 (34%) were infected with Salmonella serotype Typhi with DCS; the median age was 14 years (range, 1 to 51 years). Twenty-one (88%) of 24 isolates with DCS were resistant to nalidixic acid. The median antimicrobial-related fever clearance times in the DCS and non-DCS groups were 92 h (range, 21 to 373 h) and 72 h (range, 19 to 264 h) (P = 0.010), respectively, and the fluoroquinolone-related fever clearance times in the DCS and non-DCS groups were 90 h (range, 9 to 373 h) and 64 h (range, 34 to 204 h) (P = 0.153), respectively. Four (17%) of 24 patients in the DCS group and 2 (4%) of 46 patients in the non-DCS group (relative risk, 2.5; 95% confidence interval, 1.2 to 5.1) experienced treatment failure. Associations persisted after adjustment for potential confounders. We demonstrate that patients infected with Salmonella serotype Typhi isolates with DCS show evidence of a longer time to fever clearance and more frequent treatment failure. Nalidixic acid screening does not detect all isolates with DCS.

FIG. 1.

Time to fever clearance from time of administration of the first hospital dose of antimicrobial among hospitalized typhoid fever patients, FoodNet sites, 1999 to 2002. Solid line, patients infected with isolates without DCS; dashed line, patients infected with isolates with DCS. Fever was defined as a temperature of ≥99.5°F or ≥37.5°C. The estimated median fever clearance times were 157 h (95% CI, 93 to 232 h) for the group of patients infected with isolates with DCS and 86 h (95% CI, 64 to 107 h) for the group of patients infected with isolates without DCS.

FIG. 2.

Time to fever clearance from time of administration of the first hospital dose of a fluoroquinolone antimicrobial among hospitalized typhoid fever patients, FoodNet sites, 1999 to 2002. Solid line, patients infected with isolates without DCS; dashed line, patients infected with isolates with DCS. Fever was defined as a temperature of ≥99.5°F or ≥37.5°C. The estimated median fever clearance times were 142 h (95% CI, 85 to 204 h) for the group of patients infected with isolates with DCS and 72 h (95% CI, 55 to 130 h) for the group of patients infected with isolates without DCS.