Abstract
BackgroundTyphoid fever remains a significant cause of morbidity and mortality in Asia and Africa. The emergence of azithromycin resistance in South Asia is concerning, as azithromycin is one of the last effective oral drugs for treating typhoid.ObjectivesTo describe the molecular mechanism and phylogenetics of azithromycin-resistant (AzithR) Salmonella Typhi isolates from Patan Hospital, Kathmandu, Nepal.MethodsWhole-genome sequences of three AzithR S. Typhi isolates (MIC >256 mg/L) were analysed and compared with a global collection to investigate the azithromycin resistance mechanism and phylogenetic structure. Clinical information is reported for one of the three patients infected with AzithR S. Typhi.ResultsThe three AzithR isolates belonged to the H58 lineage and were genetically identical; they were distantly related to contemporaneous S. Typhi from Nepal and AzithR S. Typhi recently described in Bangladesh. Azithromycin resistance was mediated by a non-synonymous mutation in the acrB gene (R717L). The three AzithR isolates showed reduced susceptibility to ciprofloxacin (double mutation in the gyrA: S83F and D87G), and were susceptible to ampicillin, chloramphenicol and co-trimoxazole. Clinical information from one patient suggested non-response to azithromycin treatment.ConclusionsThis is the first molecular description of AzithR S. Typhi in Nepal. These organisms showed no phylogenetic link to AzithR S. Typhi in Bangladesh. Our data suggest that increasing use of azithromycin may pose a strong selective pressure driving the emergence of AzithR S. Typhi in South Asia. Further investigations are needed to evaluate treatment responses to azithromycin, predict evolutionary trajectories, and track the transmission of these organisms.
Highlights
Typhoid fever is a life-threatening systemic infection predominantly caused by Salmonella enterica serovar Typhi
Third-generation cephalosporins have since been used for typhoid treatment, but the emergence of extensively-drug resistant (XDR; Multi-drug resistance (MDR) plus resistance to fluoroquinolones and third-generation cephalosporins) S
Typhoid fever is frequently managed in the outpatient department (OPD) of the hospital and blood culture is routinely performed when enteric fever is suspected.[6]
Summary
Typhoid fever is a life-threatening systemic infection predominantly caused by Salmonella enterica serovar Typhi The disease has been controlled in developed countries, it continues to cause significant morbidity and mortality in resource-poor settings in Asia and Africa. Typhi has continually evolved resistance to antimicrobials used for its treatment, posing a constant clinical challenge and likely exacerbating disease burden.[1] Multi-drug resistance (MDR; resistance to chloramphenicol, ampicillin, trimethoprim/sulfamethoxazole) first evolved in S. Third-generation cephalosporins have since been used for typhoid treatment, but the emergence of extensively-drug resistant (XDR; MDR plus resistance to fluoroquinolones and third-generation cephalosporins) S. Typhoid fever remains a significant cause of morbidity and mortality in Asia and Africa. The emergence of azithromycin resistance in South Asia is concerning, as azithromycin is one of the last effective oral drugs for treating typhoid
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