National Antimicrobial Resistance Monitoring System Research Articles

Establishing Statistical Equivalence of Data from Different Sampling Approaches for Assessment of Bacterial Phenotypic Antimicrobial Resistance.

ABSTRACTTo assess phenotypic bacterial antimicrobial resistance (AMR) in different strata (e.g., host populations, environmental areas, manure, or sewage effluents) for epidemiological purposes, isolates of target bacteria can be obtained from a stratum using various sample types. Also, different sample processing methods can be applied. The MIC of each target antimicrobial drug for each isolate is measured. Statistical equivalence testing of the MIC data for the isolates allows evaluation of whether different sample types or sample processing methods yield equivalent estimates of the bacterial antimicrobial susceptibility in the stratum. We demonstrate this approach on the antimicrobial susceptibility estimates for (i) nontyphoidal Salmonella spp. from ground or trimmed meat versus cecal content samples of cattle in processing plants in 2013-2014 and (ii) nontyphoidal Salmonella spp. from urine, fecal, and blood human samples in 2015 (U.S. National Antimicrobial Resistance Monitoring System data). We found that the sample types for cattle yielded nonequivalent susceptibility estimates for several antimicrobial drug classes and thus may gauge distinct subpopulations of salmonellae. The quinolone and fluoroquinolone susceptibility estimates for nontyphoidal salmonellae from human blood are nonequivalent to those from urine or feces, conjecturally due to the fluoroquinolone (ciprofloxacin) use to treat infections caused by nontyphoidal salmonellae. We also demonstrate statistical equivalence testing for comparing sample processing methods for fecal samples (culturing one versus multiple aliquots per sample) to assess AMR in fecal Escherichia coli. These methods yield equivalent results, except for tetracyclines. Importantly, statistical equivalence testing provides the MIC difference at which the data from two sample types or sample processing methods differ statistically. Data users (e.g., microbiologists and epidemiologists) may then interpret practical relevance of the difference.IMPORTANCE Bacterial antimicrobial resistance (AMR) needs to be assessed in different populations or strata for the purposes of surveillance and determination of the efficacy of interventions to halt AMR dissemination. To assess phenotypic antimicrobial susceptibility, isolates of target bacteria can be obtained from a stratum using different sample types or employing different sample processing methods in the laboratory. The MIC of each target antimicrobial drug for each of the isolates is measured, yielding the MIC distribution across the isolates from each sample type or sample processing method. We describe statistical equivalence testing for the MIC data for evaluating whether two sample types or sample processing methods yield equivalent estimates of the bacterial phenotypic antimicrobial susceptibility in the stratum. This includes estimating the MIC difference at which the data from the two approaches differ statistically. Data users (e.g., microbiologists, epidemiologists, and public health professionals) can then interpret whether that present difference is practically relevant.

Isolation and characterization of two novel groups of kanamycin-resistance ColE1-like plasmids in Salmonella enterica serotypes from food animals.

While antimicrobial resistance in Salmonella enterica is mainly attributed to large plasmids, small plasmids may also harbor antimicrobial resistance genes. Previously, three major groups of ColE1-like plasmids conferring kanamycin-resistance (KanR) in various S. enterica serotypes from diagnostic samples of human or animals were reported. In this study, over 200 KanR S. enterica isolates from slaughter samples, collected in 2010 and 2011 as a part of the animal arm of the National Antimicrobial Resistance Monitoring System, were screened for the presence of ColE1-like plasmids. Twenty-three KanR ColE1-like plasmids were successfully isolated. Restriction fragment mapping revealed five major plasmid groups with subgroups, including two new groups, X (n = 3) and Y/Y2/Y3 (n = 4), in addition to the previously identified groups A (n = 7), B (n = 6), and C/C3 (n = 3). Nearly 75% of the plasmid-carrying isolates were from turkey and included all the isolates carrying X and Y plasmids. All group X plasmids were from serotype Hadar. Serotype Senftenberg carried all the group Y plasmids and one group B plasmid. All Typhimurium isolates (n = 4) carried group A plasmids, while Newport isolates (n = 3) each carried a different plasmid group (A, B, or C). The presence of the selection bias in the NARMS strain collection prevents interpretation of findings at the population level. However, this study demonstrated that KanR ColE1-like plasmids are widely distributed among different S. enterica serotypes in the NARMS isolates and may play a role in dissemination of antimicrobial resistance genes.

Inferring the interaction structure of resistance to antimicrobials

The growth of antimicrobial resistance presents a significant threat to human and animal health. Of particular concern is multi-drug resistance, as this increases the chances an infection will be untreatable by any antibiotic. In order to understand multi-drug resistance, it is essential to understand the association between drug resistances. Pairwise associations characterize the connectivity between resistances and are useful in making decisions about courses of treatment, or the design of drug cocktails. Higher-order associations, interactions, which tie together groups of drugs can suggest commonalities in resistance mechanism and lead to their identification. To capture interactions, we apply log-linear models of contingency tables to analyze publically available data on the resistance of Escheresia coli isolated from chicken and turkey meat by the National Antimicrobial Resistance Monitoring System. Standard large sample and conditional exact testing approaches for assessing significance of parameters in these models breakdown due to structured patterns inherent to antimicrobial resistance. To address this, we adopt a Bayesian approach which reveals that E. coli resistance associations can be broken into two subnetworks. The first subnetwork is characterized by a hierarchy of β-lactams which is consistent across the chicken and turkey datasets. Tier one in this hierarchy is a near equivalency between amoxicillin-clavulanic acid, ceftriaxone and cefoxitin. Susceptibility to tier one then implies susceptibility to ceftiofur. The second subnetwork is characterized by more complex interactions between a variety of drug classes that vary between the chicken and turkey datasets.

CRISPR Typing and Antibiotic Resistance Correlates with Polyphyletic Distribution in Human Isolates of Salmonella Kentucky.

Although infrequently associated with reported salmonellosis in humans, Salmonella enterica, subsp. enterica serovar Kentucky (ser. Kentucky) is the most common nonclinical, nonhuman serovar reported in the United States. The goal of this study was to use Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR)-multi-virulence-locus sequence typing (MVLST) to subtype a collection of human clinical isolates of ser. Kentucky submitted to the Pennsylvania Department of Health and to determine the extent of antibiotic resistance in these strains. This analysis highlighted the polyphyletic nature of ser. Kentucky, and separated our isolates into two groups, Group I and Group II, which were equally represented in our collection. Furthermore, antimicrobial susceptibility testing on all isolates using a National Antimicrobial Resistance Monitoring System (NARMS) panel of antibiotics demonstrated that resistance profiles could be divided into two groups. Group I isolates were resistant to cephems and penicillins, whereas Group II isolates were resistant to quinolones, gentamicin, and sulfisoxazole. Collectively, 50% of isolates were resistant to three or more classes of antibiotics and 30% were resistant to five or more classes. The correlation of antibiotic resistance with the two different lineages may reflect adaptation within two distinct reservoirs of ser. Kentucky, with differential exposure to antimicrobials.

Use of whole-genome sequencing for Campylobacter surveillance from NARMS retail poultry in the United States in 2015

Whole genome sequencing (WGS) has become a rapid and affordable tool for public health surveillance and outbreak detection. In this study, we used the Illuminia MiSeq® to sequence 589 Campylobacter isolates obtained in 2015 from retail poultry meats as part of the National Antimicrobial Resistance Monitoring System (NARMS). WGS data were used to identify the Campylobacter species and to compare the concordance between resistance genotypes and phenotypes. WGS accurately identified 386 C. jejuni and 203 C. coli using gyrA sequence information. Ten resistance genes, including tetO, blaOXA-61, aph(2″)-Ic, aph(2″)-If, aph(2″)-Ig, aph(3’)-III, ant(6)-1a, aadE, aph(3”)-VIIa, and Inu(C), plus mutations in housekeeping genes (gyrA at position 86, 23S rRNA at position 2074 and 2075), were identified by WGS analysis. Overall, there was a high concordance between phenotypic resistance to a given drug and the presence of known resistance genes. Concordance between both resistance and susceptible phenotypes and genotype was 100% for ciprofloxacin, nalidixic acid, gentamicin, azithromycin, and florfenicol. A few discrepancies were observed for tetracycline, clindamycin, and telithromycin. The concordance between resistance phenotype and genotype ranged from 67.9% to 100%; whereas, the concordance between susceptible phenotype and genotype ranged from 98.0% to 99.6%. Our study demonstrates that WGS can correctly identify Campylobacter species and predict antimicrobial resistance with a high degree of accuracy.

Prevalence and Antimicrobial Resistance of Enterococci Isolated from Retail Meats in the United States, 2002 to 2014.

Bacteria of the genus Enterococcus are important human pathogens that are frequently resistant to a number of clinically important antibiotics. They are also used as markers of animal fecal contamination of human foods and are employed as sentinel organisms for tracking trends in resistance to antimicrobials with Gram-positive activity. As part of the National Antimicrobial Resistance Monitoring System (NARMS), we evaluated several retail meat commodities for the presence of enterococci from 2002 to 2014, and we found 92.0% to be contaminated. The majority of isolates were either Enterococcus faecalis (64.0%) or Enterococcus faecium (28.6%), and the antimicrobial resistance of each isolate was assessed by broth microdilution. The resistance prevalences for several drugs, including erythromycin and gentamicin, were significantly higher among poultry isolates, compared to retail beef or pork isolates. None of the isolates was resistant to the clinically important human drug vancomycin, only 1 isolate was resistant to linezolid, and resistance to tigecycline was below 1%. In contrast, a majority of both E. faecalis (67.5%) and E. faecium (53.7%) isolates were resistant to tetracycline. Overall, the robust NARMS testing system employed consistent sampling practices and methods throughout the testing period, with the only significant trend in resistance prevalence being decreased E. faecium resistance to penicillin. These data provide excellent baseline levels of resistance that can be used to measure future changes in resistance prevalence that may result from alterations in the use of antimicrobials in food animal production.IMPORTANCE Enterococci, including E. faecalis and E. faecium, are present in the guts of food-producing animals and are used as a measure of fecal contamination of meat. We used the large consistent sampling methods of NARMS to assess the prevalence of Enterococcus strains isolated from retail meats, and we found over 90% of meats to be contaminated with enterococci. We also assessed the resistance of the Enterococcus strains, commonly used as a measure of resistance to agents with Gram-positive activity, in foods. Resistance prevalence was over 25% for some antimicrobials and sample sources but was less than 1% for several of the most important therapeutic agents used in human medicine.

Results of the national surveillance of antimicrobial resistance of Enterobacteriaceae and Gram negative bacilli in health care-associated infections in Colombia, 2012-2014.

The Colombian National Antimicrobial Resistance Monitoring System for the surveillance of healthcare-associated infections was set up to meet this problem in the third quarter of 2012. To describe resistance profiles and laboratory-based surveillance based on the information collected by the System. We conducted a retrospective and descriptive study of the information notified to the Colombian Public Health Surveillance System (Sivigila), and in the Whonet databases covering the period from July 2012 to December 2014 provided by the primary data-generating units in the country, as well as laboratory surveillance results from 1,642 phenotypic and genotypic tests on carbapenemase isolates (927 from Enterobacteriaceae, 614 from Pseudomonas spp. and 101 from Acinetobacter spp.). There was a significant increase in Escherichia coli resistance to third-generation cephalosporins (reaching 26.3% in ICUs and 22.5% in other hospital wards), and Klebsiella pneumoniae resistance to ertapenem also increased (reaching 14.6% in ICUs). Acinetobacter baumannii carbapenem resistance exceeded 50% in ICUs whereas Pseudomonas aeruginosa had lower carbapenem resistance (38.8%). KPC (n = 574) and NDM (n=57) were the most frequently occurring carbapenemases in Enterobacteriaceae, VIM (n=229) and KPC (n=114) in P. aeruginosa, and OXA-23 in A. baumannii (n=87); several carbapenemase combinations were identified, KPC + VIM being the most common in Pseudomonas spp. and Enterobacteriaceae. The data from the surveillance of healthcare-associated infections revealed significant carbapenem resistance profiles and antimicrobial resistance mechanisms circulating in Colombian healthcare institutions.

In Vitro Activity of Neomycin, Streptomycin, Paromomycin and Apramycin against Carbapenem-Resistant Enterobacteriaceae Clinical Strains.

We determined the in vitro susceptibility of four aminoglycosides, which are not of the 4,6-disubstituted deoxystreptamine (DOS) subclass against a collection of carbapenem-resistant Enterobacteriaceae (CRE). CRE clinical strains (n = 134) were collected from multiple hospitals in China and carried blaNDM (blaNDM−1, blaNDM−5 or blaNDM−7; n = 66), blaKPC−2 (n = 62) or blaIMP−4 (n = 7; including one carrying blaNDM−1 and blaIMP−4). MICs of neomycin, paromomycin, streptomycin and apramycin as well as three 4,6-disubstituted DOS aminoglycosides (amikacin, gentamicin and tobramycin) were determined using the broth microdilution with breakpoints defined by the Clinical Laboratory Standards Institute (for amikacin, gentamicin and tobramycin), US Food and Drug Administration (streptomycin), the National Antimicrobial Resistance Monitoring System (apramycin) or la Société Française de Microbiologie (neomycin and paromomycin). Apramycin-resistant strains were subjected to whole genome sequencing using Illumina X10 platform. Among CRE strains, 65.7, 64.9, 79.1, and 95.5% were susceptible to neomycin (MIC50/MIC90, 8/256 μg/ml), paromomycin (4/>256 μg/ml), streptomycin (16/256 μg/ml) and apramycin (4/8 μg/ml), respectively, while only 55.2, 28.4, and 35.1% were susceptible to amikacin (32/>256 μg/ml), gentamicin (128/>256 μg/ml) and tobramycin (64/>256 μg/ml), respectively. Six CRE strains including five Escherichia coli of different sequence types and one Klebsiella pneumoniae were resistant to apramycin and the apramycin-resistant gene aac(3)-IVa was detected in all of these strains. In conclusion, neomycin, paromomycin, streptomycin and apramycin retain activity against most CRE strains. Although none of these non-4,6-disubstituted DOS aminoglycosides are suitable for intravenous use in human at present, these agents warrant further investigations to be used against CRE infections.

Bayesian hierarchical model of ceftriaxone resistance proportions among Salmonella serotype Heidelberg infections

The National Antimicrobial Resistance Monitoring System (NARMS) at the Centers for Disease Control and Prevention tracks resistance among Salmonella infections. The annual number of Salmonella isolates of a particular serotype from states may be small, making direct estimation of resistance proportions unreliable. We developed a Bayesian hierarchical model to improve estimation by borrowing strength from relevant sampling units. We illustrate the models with different specifications of spatio-temporal interaction using 2004–2013 NARMS data for ceftriaxone-resistant Salmonella serotype Heidelberg. Our results show that Bayesian estimates of resistance proportions were smoother than observed values, and the difference between predicted and observed proportions was inversely related to the number of submitted isolates. The model with interaction allowed for tracking of annual changes in resistance proportions at the state level. We demonstrated that Bayesian hierarchical models provide a useful tool to examine spatio-temporal patterns of small sample size such as those found in NARMS.

Potential Information Loss Due to Categorization of Minimum Inhibitory Concentration Frequency Distributions.

A bacterial isolate's susceptibility to antimicrobial is expressed as the lowest drug concentration inhibiting its visible growth, termed minimum inhibitory concentration (MIC). The susceptibilities of isolates from a host population at a particular time vary, with isolates with specific MICs present at different frequencies. Currently, for either clinical or monitoring purposes, an isolate is most often categorized as Susceptible, Intermediate, or Resistant to the antimicrobial by comparing its MIC to a breakpoint value. Such data categorizations are known in statistics to cause information loss compared to analyzing the underlying frequency distributions. The U.S. National Antimicrobial Resistance Monitoring System (NARMS) includes foodborne bacteria at the food animal processing and retail product points. The breakpoints used to interpret the MIC values for foodborne bacteria are those relevant to clinical treatments by the antimicrobials in humans in whom the isolates were to cause infection. However, conceptually different objectives arise when inference is sought concerning changes in susceptibility/resistance across isolates of a bacterial species in host populations among different sampling points or times. For the NARMS 1996-2013 data for animal processing and retail, we determined the fraction of comparisons of susceptibility/resistance to 44 antimicrobial drugs of twelve classes of a bacterial species in a given animal host or product population where there was a significant change in the MIC frequency distributions between consecutive years or the two sampling points, while the categorization-based analyses concluded no change. The categorization-based analyses missed significant changes in 54% of the year-to-year comparisons and in 71% of the slaughter-to-retail within-year comparisons. Hence, analyses using the breakpoint-based categorizations of the MIC data may miss significant developments in the resistance distributions between the sampling points or times. Methods considering the MIC frequency distributions in their entirety may be superior for epidemiological analyses of resistance dynamics in populations.

National Antimicrobial Resistance Monitoring System: Two Decades of Advancing Public Health Through Integrated Surveillance of Antimicrobial Resistance.

Drug-resistant bacterial infections pose a serious and growing public health threat globally. In this review, we describe the role of the National Antimicrobial Resistance Monitoring System (NARMS) in providing data that help address the resistance problem and show how such a program can have broad positive impacts on public health. NARMS was formed two decades ago to help assess the consequences to human health arising from the use of antimicrobial drugs in food animal production in the United States. A collaboration among the Centers for Disease Control and Prevention, the U.S. Food and Drug Administration, the United States Department of Agriculture, and state and local health departments, NARMS uses an integrated “One Health” approach to monitor antimicrobial resistance in enteric bacteria from humans, retail meat, and food animals. NARMS has adapted to changing needs and threats by expanding surveillance catchment areas, examining new isolate sources, adding bacteria, adjusting sampling schemes, and modifying antimicrobial agents tested. NARMS data are not only essential for ensuring that antimicrobial drugs approved for food animals are used in ways that are safe for human health but they also help address broader food safety priorities. NARMS surveillance, applied research studies, and outbreak isolate testing provide data on the emergence of drug-resistant enteric bacteria; genetic mechanisms underlying resistance; movement of bacterial populations among humans, food, and food animals; and sources and outcomes of resistant and susceptible infections. These data can be used to guide and evaluate the impact of science-based policies, regulatory actions, antimicrobial stewardship initiatives, and other public health efforts aimed at preserving drug effectiveness, improving patient outcomes, and preventing infections. Many improvements have been made to NARMS over time and the program will continue to adapt to address emerging resistance threats, changes in clinical diagnostic practices, and new technologies, such as whole genome sequencing.

Clinically Important Resistance among Salmonella enterica Serotype Typhi Isolates—United States, 2003–2015

Background Salmonella Typhi (Typhi) causes typhoid fever, accounting for an estimated 5,700 illnesses and 623 hospitalizations per year in the United States. Most infections are acquired during travel to regions outside the United States where typhoid fever is prevalent and antimicrobial resistance is a problem. Fluoroquinolones (e.g., ciprofloxacin) are considered the treatment of choice for susceptible Typhi infections due to their superior ability to concentrate intracellularly and in bile, however, nonsusceptibility has been associated with treatment failure or delayed response. Azithromycin and ceftriaxone are treatment options. We describe antimicrobial susceptibility among Typhi isolates in the United States and the implications for management.MethodsThe National Antimicrobial Resistance Monitoring System at CDC conducts susceptibility testing on all Typhi isolates submitted by public health laboratories. We used broth microdilution to determine minimum inhibitory concentrations (MICs) to agents representing 9 antimicrobial classes and categorized isolates according to criteria from the Clinical and Laboratory Standards Institute. We defined ciprofloxacin nonsusceptibility as MIC ≥0.12 μg/mL, ciprofloxacin resistance as MIC ≥1, azithromycin resistance as MIC ≥32, and ceftriaxone resistance as MIC ≥4.ResultsFrom 2003–2015, isolates were tested from 4,550 patients; 2,760 (61%) were ciprofloxacin nonsusceptible, 4% were ciprofloxacin resistant. One isolate was azithromycin resistant and none were ceftriaxone resistant. Ciprofloxacin nonsusceptibility increased from 39% in 2003 to 66% in 2015; resistance increased from 0.3% to 8%. Median age of patients was 23 years (range 1–99 years), 53% were male, most were from the Northeast (33%) or the West (29%), and 74% had an isolate from blood.ConclusionTwo thirds of Typhi isolates exhibited ciprofloxacin nonsusceptibility, which has increased over the last decade, and full resistance is increasing. Clinicians should be aware of high rates of fluoroquinolone nonsusceptibility when selecting empiric therapy and should tailor antimicrobial treatment to susceptibility results when feasible. Azithromycin and ceftriaxone remain important treatment options.Disclosures All authors: No reported disclosures.

Retail Meat as a Potential Transmission Source of Community-Acquired Urinary Tract Infection

Background Escherichia coli causes approximately 80% of community-acquired UTI (CA-UTI), but the sources of these uropathogenic E. coli infections are not well established. Recent studies have suggested that food, especially poultry, may serve as a source of UPEC. Here we prospectively examined E. coli isolates from patients with CA-UTI and retail meat concurrently available from the same geographic region to determine the frequency of shared genotypes.MethodsBetween September 2016 and May 2017, we collected urine samples from patients with UTI examined at a university-affiliated healthcare center. During the same time, we recovered E.coli from retail meat products (chicken breast, ground turkey, ground beef, and pork chops) collected as part of the National Antimicrobial Resistance Monitoring System (NARMS) FDA retail meat sampling program in Northern California. Urine samples and buffered peptone water containing meat samples were cultured on MacConkey agar. Lactose-positive and indole-positive colonies were presumptively identified as E coli. Bacterial DNA was extracted by a freeze-boil method. E. coli isolates were genotyped by multilocus sequence typing (MLST).ResultsOf 1020 urine samples, E. coli was isolated from 210 (21%). Five pandemic MLST genotypes (ST95, ST127, ST69, ST73, and ST131) accounted for 126 (60%) isolates. Of 200 meat samples, E. coli was isolated from 76 (38%). E. coli was isolated from 29 (73%) of 40 ground turkey samples, 34 (43%) of 80 chicken breast, 7 (18%) of 40 ground beef, and 6 (15%) of 40 pork chop. ST69 and ST131 were isolated from 3 chicken samples. Other genotypes of E. coli isolates from meat samples and CA-UTI included ST10 (3), ST38 (2), ST88 (1), ST117 (5), ST906 (1), and ST1844 (1). Eleven (32%) of 34 chicken samples contained UPEC strains, compared with 4 (14%) of 29 ground turkey samples, and 1 (17%) of 6 pork chop samples; no beef samples contained UPEC strains.ConclusionOverall, we found that nearly one-quarter of retail poultry products that we tested contained UPEC strains with the same MLST genotypes found in CA-UTI patients. Foodborne transmission may account for a substantial proportion of CA-UTI. Additional studies are needed to demonstrate transmission of these genotypes from poultry to patients and to target possible prevention measures.Disclosures All authors: No reported disclosures.

Identification of Plasmid-Mediated Quinolone Resistance in Salmonella Isolated from Swine Ceca and Retail Pork Chops in the United States

Fluoroquinolones are important antimicrobial drugs used to treat human Salmonella infections, and resistance is rare in the United States for isolates from human and animal sources. Recently, a number of Salmonella isolates from swine cecal contents and retail pork products from National Antimicrobial Resistance Monitoring System (NARMS) surveillance exhibited decreased susceptibility to ciprofloxacin. We identified two qnrB19 quinolone resistance plasmids that are predominantly responsible for this phenomenon and found them distributed among several Salmonella serotypes isolated throughout the United States.

Increasing Campylobacter Infections, Outbreaks, and Antimicrobial Resistance in the United States, 2004-2012.

Campylobacteriosis, a leading cause of foodborne illness in the United States, was not nationally notifiable until 2015. Data describing national patterns and trends are limited. We describe the epidemiology of Campylobacter infections in the United States during 2004-2012. We summarized laboratory-confirmed campylobacteriosis data from the Nationally Notifiable Disease Surveillance System, National Outbreak Reporting System, National Antimicrobial Resistance Monitoring System, and Foodborne Diseases Active Surveillance Network. During 2004-2012, 303520 culture-confirmed campylobacteriosis cases were reported. Average annual incidence rate (IR) was 11.4 cases/100000 persons, with substantial variation by state (range, 3.1-47.6 cases/100000 persons). IRs among patients aged 0-4 years were more than double overall IRs. IRs were highest among males in all age groups. IRs in western states and rural counties were higher (16.2/100000 and 14.2/100000, respectively) than southern states and metropolitan counties (6.8/100000 and 11.0/100000, respectively). Annual IRs increased 21% from 10.5/100000 during 2004-2006 to 12.7/100000 during 2010-2012, with the greatest increases among persons aged >60 years (40%) and in southern states (32%). The annual median number of Campylobacter outbreaks increased from 28 in 2004-2006 to 56 in 2010-2012; in total, 347 were reported. Antimicrobial susceptibility testing of isolates from 4793 domestic and 1070 travel-associated infections revealed that, comparing 2004-2009 to 2010-2012, ciprofloxacin resistance increased among domestic infections (12.8% vs 16.1%). During 2004-2012, incidence of campylobacteriosis, outbreaks, and clinically significant antimicrobial resistance increased. Marked demographic and geographic differences exist. Our findings underscore the importance of national surveillance and understanding of risk factors to guide and target control measures.

Comparative Analysis of Extended-Spectrum-β-Lactamase CTX-M-65-Producing Salmonella enterica Serovar Infantis Isolates from Humans, Food Animals, and Retail Chickens in the United States.

We sequenced the genomes of 10 Salmonella enterica serovar Infantis isolates containing blaCTX-M-65 obtained from chicken, cattle, and human sources collected between 2012 and 2015 in the United States through routine National Antimicrobial Resistance Monitoring System (NARMS) surveillance and product sampling programs. We also completely assembled the plasmids from four of the isolates. All isolates had a D87Y mutation in the gyrA gene and harbored between 7 and 10 resistance genes [aph(4)-Ia, aac(3)-IVa, aph(3')-Ic, blaCTX-M-65, fosA3, floR, dfrA14, sul1, tetA, aadA1] located in two distinct sites of a megaplasmid (∼316 to 323 kb) similar to that described in a blaCTX-M-65-positive S Infantis isolate from a patient in Italy. High-quality single nucleotide polymorphism (hqSNP) analysis revealed that all U.S. isolates were closely related, separated by only 1 to 38 pairwise high-quality SNPs, indicating a high likelihood that strains from humans, chickens, and cattle recently evolved from a common ancestor. The U.S. isolates were genetically similar to the blaCTX-M-65-positive S Infantis isolate from Italy, with a separation of 34 to 47 SNPs. This is the first report of the blaCTX-M-65 gene and the pESI (plasmid for emerging S Infantis)-like megaplasmid from S Infantis in the United States, and it illustrates the importance of applying a global One Health human and animal perspective to combat antimicrobial resistance.

Antimicrobial Resistance Patterns of Enterococcus Isolated from Feedlot Cattle after Feeding Direct-Fed Microbials in Diets with and Without Tylosin

ObjectivesThe purpose of this study was to determine the antimicrobial resistance patterns of Enterococcus isolated from feedlot cattle supplemented with either a direct-fed microbials (DFM; L. salivarius, L28) or tylosin as part of their finishing diet.Materials and MethodsL. salivarius L28 was used in this study, a newly isolated DFM. Three treatments based on conventional high concentrate diets were fed to finishing cattle for harvest: base (no DFM, tylosin or monensin), MonPro (DFM at a feeding rate of 107 cfu/head/d, with monensin, but no tylosin), and a control (tylosin and monensin). A total of 36 composite fecal samples, from 3 animals per pen, were collected after 56 d of feeding. Samples were weighed, enriched and plated onto KF Streptococcus Agar supplemented with 1% TTC solution. Three typical isolates from each plate were randomly selected and streaked onto 5% sheep blood agar for antimicrobial resistance analysis using Sensititre susceptibility MIC plates, following the National Antimicrobial Resistance Monitoring System (NARMS) protocol. The data was analyzed using a Chi-Squared test to compare resistance patterns across treatment group with a significant value of p < 0.05.ResultsEnterococcus was isolated from 100% (n = 36) of fecal samples collected. After 56 d of feeding, 100% (n = 36) of the control group isolates were resistant to at least 1 antibiotic, and 66% (n = 24) were multi-drug resistant (MDR) to 3 or more antibiotics. Isolates from the base treatment group on d 56 exhibited 97% (n = 35) resistance to 1 drug and 28% (n = 10) were MDR. Ninety-4 percent (n = 34) of isolates in the MonPro group showed resistance on d 56, and 47% (n = 17) of isolates were MDR. The percent of isolates with MDR differed significantly between treatments (p = 0.004). Specific antibiotics of concern are listed in Table 1.ConclusionWhile the enterococci isolated in this study, in all 3 treatments, had resistance to at least 1 antibiotic, there were differences in the MDR. The most MDR was observed in the control groups. MDR in the isolates collected from cattle fed the base diet was similar to the isolates from cattle fed the MonPro diet. A total of 10 and 17 of the isolates were MDR, respectively. The supplementation of L28 instead of the tylosin resulted in fewer MDR enterococci. These results indicate that supplementation with a DFM, such as L28, may be effective in mitigating the presence of multi-drug resistnace in feedlot cattle.

Antibiotic Resistance of Salmonella Enterica Isolated from Whole-Muscle Beef Cuts and Beef Carcasses in Mexico

ObjectivesA substantial number of cattle are raised in Mexico and imported into the U.S., however due to lax regulations, protocols for use of antibiotics in animals are not always properly followed. The objective of this study was to determine and compare the antibiotic susceptibility profiles of Salmonella enterica recovered along the beef production chain in Southeastern Mexico.Materials and MethodsA total of 120 Salmonella enterica isolates were recovered from whole-muscle beef cuts samples (n = 60) and beef cattle carcasses at harvest (n = 60) in 2 cities in the Yucatan Peninsula of Mexico (Cancun and Merida). All Salmonella isolates were recovered using standard microbiological methods in a previous study. A frozen stock cultures of each isolate was streaked onto blood agar plates and incubated at 37°C for 18 h. Susceptibility profiles were determined using the Sensititre (Trek Diagnostic Systems, Westlake, OH) automated antimicrobial susceptibility system with the National Antimicrobial Resistance Monitoring System (NARMS) Gram Negative plate format CMV3AGNF. The minimum inhibitory concentration (MIC) for each of the 14 antimicrobials tested was interpreted using the Clinical and Laboratory Standards Institute (CLSI) standards for microdilution broth methods and NARMS breakpoints. Fourteen antimicrobials were tested: amoxicillin/clavulanic acid 2:1 ratio (AUG2), ampicillin (AMP), azithromycin (AZI), cefoxitin (FOX), ceftiofur (TIF), ceftriaxone (AXO), ciprofloxacin (CIP), chloramphenicol (CHL), gentamycin (GEN), nalidixic acid (NAL), streptomycin (STR), sulfisoxazole (FIS), tetracycline (TET), trimethoprim/sulfamethohazole (SXT). Statistical analyses were performed using the GraphPad Prism software to determine statistical differences among the antibiotics tested.ResultsOverall, 68 (56.7%) S. enterica isolates exhibited resistance to at least one or more antibiotic. Furthermore, the isolates displayed 19 different resistance phenotypes. Among the whole-muscle beef cuts isolates, 61.7% (37/60) were considered resistant, most commonly to TET (21.6%), followed by multidrug-resistance (MDR) phenotypes to AMP-CHL-STR-TET-SXT (10.8%) and AMP-CHL-TET-SXT (8.1%). Among carcass isolates, 51.7% (31/60) were deemed resistant, most frequently to NAL (18.4) and TET (15.8%). Additionally, the most common MDR phenotypes among carcass isolates were the phenotype CHL-STR-TET-SXT (10.5%) and the phenotype CHL-NAL-STR-TET-SXT (7.9%). No significant differences were found between the resistance patterns across multiple antibiotics (p-value > 0.05).ConclusionIn Mexico, antimicrobial resistance, and in particular, multidrug-resistance may be of concern due to the high prevalence of Salmonella along the beef production chain. An initial investigation like the one presented here contributes to a broader global understanding of the potential exposure to drug-resistant Salmonella through food, thus providing insight into the need for control strategies to avoid the spreading of antibiotic resistant Salmonella in Mexico.

Antimicrobial resistance in Salmonella that caused foodborne disease outbreaks: United States, 2003–2012

Although most non-typhoidal Salmonella illnesses are self-limiting, antimicrobial treatment is critical for invasive infections. To describe resistance in Salmonella that caused foodborne outbreaks in the United States, we linked outbreaks submitted to the Foodborne Disease Outbreak Surveillance System to isolate susceptibility data in the National Antimicrobial Resistance Monitoring System. Resistant outbreaks were defined as those linked to one or more isolates with resistance to at least one antimicrobial drug. Multidrug resistant (MDR) outbreaks had at least one isolate resistant to three or more antimicrobial classes. Twenty-one per cent (37/176) of linked outbreaks were resistant. In outbreaks attributed to a single food group, 73% (16/22) of resistant outbreaks and 46% (31/68) of non-resistant outbreaks were attributed to foods from land animals (P < 0·05). MDR Salmonella with clinically important resistance caused 29% (14/48) of outbreaks from land animals and 8% (3/40) of outbreaks from plant products (P < 0·01). In our study, resistant Salmonella infections were more common in outbreaks attributed to foods from land animals than outbreaks from foods from plants or aquatic animals. Antimicrobial susceptibility data on isolates from foodborne Salmonella outbreaks can help determine which foods are associated with resistant infections.

Ceftriaxone-Resistant Nontyphoidal Salmonella from Humans, Retail Meats, and Food Animals in the United States, 1996-2013.

Ceftriaxone resistance in Salmonella is a serious public health threat. Ceftriaxone is commonly used to treat severe Salmonella infections, especially in children. Identifying the sources and drivers of ceftriaxone resistance among nontyphoidal Salmonella is crucial. The National Antimicrobial Resistance Monitoring System (NARMS) tracks antimicrobial resistance in foodborne and other enteric bacteria from humans, retail meats, and food animals. We examined NARMS data reported during 1996-2013 to characterize ceftriaxone-resistant Salmonella infections in humans. We used Spearman rank correlation to examine the relationships between the annual percentage of ceftriaxone resistance among Salmonella isolates from humans with isolates from retail meats and food animals. A total of 978 (2.9%) of 34,100 nontyphoidal Salmonella isolates from humans were resistant to ceftriaxone. Many (40%) ceftriaxone-resistant isolates were from children younger than 18 years. Most ceftriaxone-resistant isolates were one of three serotypes: Newport (40%), Typhimurium (26%), or Heidelberg (12%). All were resistant to other antimicrobials, and resistance varied by serotype. We found statistically significant correlations in ceftriaxone resistance between human and ground beef Newport isolates (r = 0.83), between human and cattle Typhimurium isolates (r = 0.57), between human and chicken Heidelberg isolates (r = 0.65), and between human and turkey Heidelberg isolates (r = 0.67). Ceftriaxone resistance among Salmonella Newport, Typhimurium, and Heidelberg isolates from humans strongly correlates with ceftriaxone resistance in isolates from ground beef, cattle, and poultry, respectively. These findings support other lines of evidence that food animals are important reservoirs of ceftriaxone-resistant Salmonella that cause human illness in the United States.