Int J Entric Pathog. 2014 January; 1(2): 76-8. Published Online 2014 January 1. Case Report
First CTX-M type ß–lactamase-Producing and Ciprofloxacin Resistant Salmonella Infection Acquired by a Child in IRANFarzaneh Firoozeh 1, Fereshteh Shahcheraghi 2,*, Taghi Zahraei-Salehi 3, Mohammad Mehdi Aslani 2, Reihaneh Banisaeed 31 Department of Microbiology and Immunology, School of Medicine, Kashan University of Medical Sciences, Kashan, IR Iran 2 Department of Microbiology and Microbiology Research Center, Pasteur Institute, Tehran, IR Iran 3 Department of Microbiology, Faculty of Veterinary Medicine, University of Tehran, Tehran, IR Iran* Corresponding author: Fereshteh Shahcheraghi, Department of Microbiology and Microbiology Research Center, Pasteur Institute, Tehran, IR Iran. Tel: +98-2166405535, Fax: +98- 2166405535, E-mail: [email protected] Received: August 23, 2013; Revised: August 25, 2013; Accepted: August 31, 2013
The frequency of multidrug-resistance (MDR) among Salmonella isolates has increased dramatically. Here we report the first case of CTX-M type ß–lactamase producing ciprofloxacin-resistant Salmonella infection as a child in Iran. Antimicrobial resistance profile was determined according to the Clinical and Laboratory Standards Institute. A double disk synergy test was used in the production of extended-spectrum β-lactamases (ESBLs). PCR assays were carried out to detect blaTEM, blaSHV and blaCTX-M beta lactamase genes. The presence of class 1 integrons was investigated by PCR assays. The Salmonella Enteritidis isolate from the child was ciprofloxacin and extended-spectrum cephalosporins resistant and found to carry the blaCTX-M beta-lactamase gene and class 1 integrons, suggests that antimicrobial resistance determinants may be located on the same genetic unit of the class 1 integrons identified here. Resistance to ciprofloxacin and extended- spectrum cephalosporins, the drugs of choice for treating invasive salmonellosis, especially in children is a public health problem.
Keywords: Ciprofloxacin; blaCTX-M; Extended Spectrum β-lactamase; Multidrug Resistance; Salmonella Enteritidis 1. Introduction
pain, fulminant diarrhea, nausea, vomiting and fever ad- Salmonella enterica is a common cause of the food borne mitted to the pediatric infection diseases' ward due to gastroenteritis. Though non-typhoidal salmonellosis is gastroenteritis. The stool and blood specimens for culture self-limiting, but antibiotic therapy can be life saving in were sent to the Microbiology Laboratory in Pasteur Insti- children, elderly, and immune compromised personals tute of Iran. Direct microscopic examination of the stool with systemic infections (1). Fluoroquinolones and third- specimens showed leukocytes. Culture of the stool was generation cephalosporins are major antibiotics used for performed, and on the 3rd day of hospitalization identi- treatment of invasive salmonellosis (2). Increasing occur- fied as Salmonella species, was isolated from the two con- rence of antimicrobial resistant Salmonella strains have secutive stool cultures. The identification of the isolated complicated the treatment process. In particular, detec- as Salmonella enterica was confirmed by conventional tion of fluoroquinolon and expanded spectrum cepha- standard biochemical and serological tests (4). The iso- losporin's resistant Salmonella strains is a newly emerg- late from the child was serotyped by multiplex PCR assays ing threat in many countries (3). In this study, we report and confirmed using commercial antisera as described a ciprofloxacin and expanded spectrum cephalosporin's previously and found to be Salmonella enterica serotype resistant Salmonella Enteritidis isolated from a child with Enteritidis (5). The antimicrobial resistance of Salmonella severe gastroenteritis. Resistance to the drugs of choice Enteritidis isolate to twenty-one antimicrobial agents for severe salmonellosis, especially in children is of major was determined by agar disk diffusion, and the mini- clinical concern. This is the first report of emerging CTX- mum inhibitory concentrations (MICs) of ciprofloxacin M type ß–lactamase-producing ciprofloxacin resistant and ceftriaxone were evaluated by the broth-microdilu- Salmonella isolated from a human clinical specimens.
tion methods' accordance with the standards of the Clini- cal and Laboratory Standards Institute. The strain was 2. Case Report
found to be resistant to ampicillin, streptomycin, oxytet- racycline, doxycycline, trimethoprim-sulfamethoxazole, In April 2010, a one-year-old boy with acute abdominal chloramphenicol, cephalothin, ceftazidime, ceftriaxone, Implication for health policy/practice/research/medical education:
In the present study, we described the first report of ciprofloxacin resistant Salmonella infection acquired by a child in Iran.
Copyright 2014, Alborz University of Medical Sciences.; Published by Safnek. This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
cefixime, cefotaxime, aztreonam, ciprofloxacin, and nor- selection of ciprofloxacin resistance genes that trans- floxacin. Ciprofloxacin and ceftriaxone minimum inhibi- ferred into the human. It is probable that ciprofloxacin tory concentrations (MICs) values were 4 μg/mL and 128 and extended spectrum β-lactam resistant Salmonella μg/mL, respectively. The isolate was investigated for ESBL strain identified here are transmitted to a child via con- production using the double disk synergy test according to published methods (3). The genes responsible for the Quinolone resistance in gram-negative bacteria is ESBL phenotype (blaTEM, blaSHV, blaCTX-M) were identi- commonly due to mutations in quinolone target genes, fied by PCR assay using primers and conditions reported DNA gyrase (gyrA) and topoisomerase IV (parC) and/or previously (3). By PCR assays the Salmonella Enteritidis regulatory genes of outer membrane proteins or efflux isolate was found to carry class 1 integrons (Figure 1). PCR pumps (8). Plasmid mediated quinolone/fluoroquinolon amplification conditions and primers described previ- resistance determinants qnrA, qnrB1-8, qnrS1-2 have since been described (9). In most studies was shown that qnr genes were accompanied by genes encoding extended- Figure 1. PCR amplification of Class 1 Integrons intI and Sul1 Genes in
spectrum β-lactamases and often embedded in complex Salmonella Enteritidis Isolated From an one-year-old Boy.
sul1 type integrons (ESBLs). Here, the ciprofloxacin-resis- tant Salmonella Enteritidis strain, found to carry sul1-asso- ciated class-1 integrons and the blaCTX-M beta-lactamase gene. Thus, the fluoroquinolon and extended-spectrum cephalosporins resistance determinants may be locat- ed on the same genetic unit of the class 1 integrons de- It is obvious that the use of antimicrobials will result in the selection of resistance strains. Accordingly, efforts must be made to reduce the use of certain antibiotics in animals, to delay the transmission of antibiotic-resistant Salmonella strains to human via food products.
Authors’ Contribution
(A) Lane M: 1 kbp DNA ladder as the molecular size marker; lane 1: PCR mix with no template; lane 2: positive control; lane 3: the intI gene was All authors have participated equally in the study.
detected in Salmonella isolate from child. (B) Lane M: 1 kbp DNA ladder as the molecular size marker; lane 1: PCR mix with no template; lane 2: Financial Disclosure
positive control; lane 3: the sul1 gene was detected in Salmonella isolate Funding/Support
3. Discussion
Fluoroquinolones and extended-spectrum cephalospo- rins are commonly used to treat Salmonella infections. References
Bacterial resistance to these important drugs has dra- 1. Rayamajhi N, Kang SG, Kang ML, Lee HS, Park KY, Yoo HS. Assess- matically increased. Animals and animal products are ment of antibiotic resistance phenotype and integrons in Sal- significant sources of resistant bacteria for the human monella enterica serovar Typhimurium isolated from swine. J Vet Med Sci. 2008;70(10):1133-7.
2. Firoozeh F, Zahraei-Salehi T, Shahcheraghi F, Karimi V, Aslani MM. In this study, we have isolated a ciprofloxacin-resistant Characterization of class I integrons among Salmonella enterica Salmonella Enteritidis from clinical specimens of a child serovar Enteritidis isolated from humans and poultry. FEMS Im- with invasive salmonellosis. Previous study has reported munol Med Microbiol. 2012;64(2):237-43.
ciprofloxacin-resistant in Salmonella strains isolated 3. Ranjbar R, Giammanco GM, Aleo A, Plano MR, Naghoni A, Owlia P, et al. Characterization of the first extended-spectrum beta- from poultry in our country (7). The enrofloxacin is main lactamase-producing nontyphoidal Salmonella strains isolated prescribed fluoroquinolon in treatment of bacterial in Tehran, Iran. Foodborne Pathog Dis. 2010;7(1):91-5.
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environment of quinolone resistance gene qnrB2 in a com- 6. Fey PD, Safranek TJ, Rupp ME, Dunne EF, Ribot E, Iwen PC, et al. plex sul1-type integron in the newly described Salmonella Ceftriaxone-resistant salmonella infection acquired by a child enterica serovar Keurmassar. Antimicrob Agents Chemother. from cattle. N Engl J Med. 2000;342(17):1242-9.
7. Morshed R, Peighambari SM. Drug resistance, plasmid profile 9. Nordmann P, Poirel L. Emergence of plasmid-mediated resis- and random amplified polymorphic DNA analysis of Iranian tance to quinolones in Enterobacteriaceae. J Antimicrob Chemoth- isolates of Salmonella enteritidis. New Microbiol. 2010;33(1):47-56.
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