Cephalosporin and ciprofloxacin resistance in Salmonella, Taiwan.

We report the prevalence and characteristics of Salmonella strains resistant to ciprofloxacin and extended-spectrum cephalosporins in Taiwan from January to May 2004. All isolates resistant to extended-spectrum cephalosporins carried [bla.sub.CMY-2], and all ciprofloxacin-resistant Salmonella enterica serotype Choleraesuis isolates related.

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Resistance to extended-spectrum cephalosporins (ESCs) or fluoroquinolones in Salmonella enterica has become a global concern (1). ESC resistance in Salmonella strains is usually due to the production of plasmid-mediated extended-spectrum [beta]-lactamases (ESBLs) or AmpC [beta]-lactamases, and among these [beta]-lactamases, the CMY-2 AmpC enzyme has been reported most often (1-3). Resistance to fluoroquinolones in Salmonella strains is usually due to the accumulation of mutations in the quinolone resistance--determining regions (QRDRs) of DNA gyrase genes (1,4,5). Resistance to both ESCs and fluoroquinolones remains extremely rare in salmonellae.

In Taiwan, increasing resistance to fluoroquinolones and the emergence of CMY-2--producing ESC-resistant strains in salmonellae have been noted (3-6). The emergence of Salmonella strains resistant to both ceftriaxone and ciprofloxacin was reported more recently in Taiwan and may pose a serious therapeutic problem (7,8). We conducted the present study to investigate the prevalence and characteristics of Salmonella strains resistant to ciprofloxacin and ESCs in Taiwan.

The Study

From January to May 2004, a total of 600 Salmonella isolates from 585 patients were obtained from 5 medical centers and 14 district hospitals throughout Taiwan; these isolates were serotyped with commercial antisera (Difco, Detroit, MI, USA). The 4 most common serotypes of Salmonella enterica (Enteritidis, Typhimurium, Stanley, and Choleraesuis) accounted for 66.8% of all isolates. Two isolates were untypeable, and the remainder were typed into 42 serotypes (data not shown), which were each represented by 1 to 23 isolates.

MICs of antimicrobial agents were determined by the agar dilution method (9). Resistance to ciprofloxacin (MIC [greater than or equal to] 4 [micro]g/mL) was seen in 50 (8.3%) isolates (Table 1); 20 (3.3%) were resistant (MICs ranging from 8 to >64 [micro]g/mL) to ceftazidime, ceftriaxone, cefotaxime, or aztreonam (Table 2); 6 isolates showed decreased susceptibilities to 1 or 2 of the 4 ESCs (MICs 0.5-2 [micro]g/mL); 10 (1.7%) isolates were resistant to both ciprofloxacin and ESCs. S. Choleraesuis had high rates of resistance to ciprofloxacin (84.4%), ESCs (17.8%), and both (17.8%). None of the 26 Salmonella isolates with resistance or decreased susceptibility to ESCs produced ESBL, according to the double-disk synergy method (10). Among the 20 ESC-resistant isolates, 10 isolates were ciprofloxacin-resistant, 4 isolates showed decreased susceptibility to ciprofloxacin (MIC 0.25-1 [micro]g/mL) and resistance to nalidixic acid, and 6 isolates were susceptible to ciprofloxacin and nalidixic acid (Table 2). All 20 ESC-resistant isolates were susceptible to cefepime (MIC <0.03 [micro]g/mL) and imipenem (MIC <1 [micro]g/mL), and 17 isolates were resistant to >1 non-[beta]-lactam agent.

All 20 ESC-resistant isolates expressed a [beta]-lactamase of pI 9.0 by isoelectric focusing (3,11); 11 of these isolates expressed an additional pI 5.4 [beta]-lactamase (Table 2). [bla.sub.CMY-2] was detected in all ESC-resistant isolates, [bla.sub.TEM-1] was detected in the 11 isolates with the pI 5.4-[beta]-lactamase by polymerase chain reaction (PCR) and sequence analyses with the primers for the entire [bla.sub.TEM]-related and [bla.sub.CMY-2]-related structural genes (2,3).

The QRDR sequences of gyrA, gyrB, parC, and parE of the 20 ESC-resistant Salmonella isolates were determined by PCR and sequence analyses (5). All 10 ciprofloxacin-resistant isolates showed 2 mutations at the Ser-83 and Asp-87 codons in gyrA and a single mutation at the Ser-80 codon in parC (Table 2). Four isolates with decreased susceptibility to ciprofloxacin had a single mutation at either the Ser-83 or the Asp-87 codon in gyrA. All 20 ESC-resistant isolates showed no mutations in the QRDRs of gyrB and parE.

ESC resistance was transferred from 18 of the 20 ESC-resistant Salmonella isolates to Escherichia coli C600 in the liquid mating-out assay (3,12). All transconjugants showed decreased susceptibilities to the 4 ESCs tested (MICs 16-64 [micro]g/mL) and cefoxitin (MIC 64-128 [micro]g/mL) and were susceptible to all non-[beta]-lactam agents tested. A pI 9.0 vz [beta]-lactamase and [bla.sub.CMY-2] were detected by isoelectric focusing and PCR assays, respectively, in all transconjugants. Restricted by the endonuclease EcoRI, the 18 transferred plasmids produced 9 major restriction patterns (Figure 1 and Table 2). Patterns E and I were further divided into 4 and 2 subtypes, respectively, [bla.sub.CMY-2] on the transferred plasmids was demonstrated by Southern hybridization with the [bla.sub.CMY-2] probe.

[FIGURE 1 OMITTED]

The 38 ciprofloxacin-resistant S. Choleraesuis isolates were genotyped by pulsed-field gel electrophoresis on a CHEF Mapper apparatus (Bio-Rad Laboratories, Hercules, CA, USA) according to the PulseNet protocol (13). Banding patterns generated by XbaI restriction were compared with BioNumerics software (Applied Maths, Kortrijk, Belgium). The 38 isolates showed a close relationship (Dice correlation coefficient of 90%) and had only 1 pulsotype, based on Tenover criteria (Figure 2) (14). The pulsotype was divided into 7 pulsosubtypes, among which were 1-4 band differences. Five ESC-resistant isolates displayed the same pulsosubtypes (IA or IC) as ESC-susceptible isolates (Table 1 and Figure 2).

[FIGURE 2 OMITTED]

Conclusions

We describe the prevalence of resistance to ciprofloxacin and ESCs among salmonellae isolated from January to May 2004 in Taiwan. We found widespread resistance of Salmonella isolates to both ESCs and ciprofloxacin; high prevalence of resistance to ciprofloxacin, ESCs, and both in S. Choleraesuis; and widespread prevalence of CMY-2 producing Salmonella isolates of various serotypes in Taiwan.

The prevalence of Salmonella isolates resistant to both ceftriaxone and ciprofloxacin may pose a therapeutic problem. CMY-2 is one of the AmpC enzymes, which are usually less active against cefepime and cefpirome than ESBLs (15). Accordingly, we have used cefepime to successfully treat several patients infected with CMY-2-producing and ciprofloxacin-resistant S. Choleraesuis (8). Therefore, AmpC-producing strains should be differentiated from ESBL-producing strains by phenotypic or genotypic methods when ESC-resistant Salmonella strains are isolated in the clinical microbiology laboratory (15).

The ciprofloxacin-resistant rate in S. Choleraesuis in Taiwan has been >60% since 2001; the high prevalence was mainly due to clonal spread of resistant strains (4-6). The ciprofloxacin-resistant rate in S. Choleraesuis in this report (84.4%) was higher than those reported previously ([less than or equal to] 70%) (4-6). [bla.sub.CMY-2] in Salmonella in Taiwan was first reported in 2 S. Typhimurium strains isolated in 2000 (3). The first reported S. Choleraesuis strain with [bla.sub.CMY-2] was a ciprofloxacin-resistant strain isolated in 2002 (7). All our 38 ciprofloxacin-resistant S. Choleraesuis isolates, including 8 ESC-resistant isolates, were genetically related. Moreover, we found possibly unrelated [bla.sub.CMY-2]-positive plasmids (lanes 3, 4, 7, 8, 10, and 11 in Figure 1) among closely related isolates (Figure 2). These data together suggest that the development and rapidly increasing prevalence of ESC and ciprofloxacin resistance in S. Choleraesuis in Taiwan might result from the extremely high prevalence of ciprofloxacin resistance followed by the horizontal transfer of [bla.sub.CMY-2] into ciprofloxacin-resistant epidemic strains rather than from the spread of a clone that had been resistant to ciprofloxacin and ESCs.

All our ciprofloxacin-resistant Salmonella isolates tested had mutations in the QRDRs of gyrA and par, a finding consistent with previously reported results (1,4,5). The rates of ciprofloxacin resistance in the 3 most common serotypes, Enteritidis, Typhimurium, and Stanley, remained very low (0%-0.6%). Six of 11 ciprofloxacin-resistant isolates in the group of uncommon serotypes belonged to serotype Schwarzengrund and accounted for 42.9% of all serotype Schwarzengrund isolates. Thus, the high rate (5.5%) of ciprofloxacin resistance in this group was in part due to the high prevalence of ciprofloxacin resistance in serotype Schwarzengrund.

Table 1. Resistance to ciprofloxacin, extended-spectrum
cephalosporins, and both in Salmonella enterica serotypes,
by region and pulsotype, Taiwan, January-May 2004

                        No. of resistant S. enterica
                     isolates/no. of total isolates (%)

Resistance and
region *            Enteritidis   Typhimurium    Stanley

Ciprofloxacin       1/161 (0.6)    0/142 (0)     0/53 (0)
resistance
  Northern           0/96 (0)      0/38 (0)      0/14 (0)
  Central           1/32 (3.1)     0/34 (0)      0/14 (0)
  Southern           0/25 (0)      0/60 (0)      0/24 (0)
  Eastern             0/8 (0)      0/10 (0)      0/1 (0)
ESC resistance       0/161 (0)     0/142 (0)    3/53 (5.7)
  Northern           0/96 (0)      0/38 (0)     1/14 (7.1)
  Central            0/32 (0)      0/34 (0)     1/14 (7.1)
  Southern           0/25 (0)      0/60 (0)     1/24 (4.2)
  Eastern             0/8 (0)      0/10 (0)      0/1 (0)
Ciprofloxacin and    0/161 (0)     0/142 (0)     0/53 (0)
ESC resistance
  Northern           0/96 (0)      0/38 (0)      0/14 (0)
  Central            0/32 (0)      0/34 (0)      0/14 (0)
  Southern           0/25 (0)      0/60 (0)      0/24 (0)
  Eastern             0/8 (0)      0/10 (0)      0/1 (0)

                          No. of resistant S. enterica
                       isolates/no. of total isolates (%)

                                     Uncommon
Resistance and                      serotypes         All
region *            Choleraesuis    ([dagger])     serotypes

Ciprofloxacin       38/45 (84.4)   11/199 (5.5)   50/600 (8.3)
resistance
  Northern          13/16 (81.3)    6/88 (6.8)    19/252 (7.5)
  Central            6/8 (75.0)    4/37 (10.8)    11/125 (8.8)
  Southern          18/20 (90.0)    1/65 (1.5)    19/194 (9.8)
  Eastern            1/1 (100)       0/9 (0)       1/29 (3.4)
ESC resistance      8/45 (17.8)    9/199 (4.5)    20/600 (3.3)
  Northern           1/16 (6.3)     7/88 (8.0)    9/252 (3.6)
  Central             0/8 (0)       1/37 (2.7)    2/125 (0.8)
  Southern          7/20 (35.0)     1/65 (1.5)    9/194 (4.6)
  Eastern             0/1 (0)        0/9 (0)        0/29 (0)
Ciprofloxacin and   8/45 (17.8)    2/199 (1.0)    10/600 (1.7)
ESC resistance
  Northern           1/16 (6.3)     1/88 (1.1)    2/252 (0.8)
  Central             0/8 (0)       1/37 (2.7)    1/125 (0.8)
  Southern          7/20 (35.0)      0/65 (0)     7/194 (3.6)
  Eastern             0/1 (0)        0/9 (0)        0/29 (0)

                              Pulsotypes of
Resistance and            Choleraesuis isolates
region *                     (no of isolates)

Ciprofloxacin
resistance
  Northern                 A (11), D (1), E (1)
  Central                      A (5), C (1)
  Southern          A (14), B (1), C (1), F (1), G (1)
  Eastern                         A (1)
ESC resistance
  Northern
  Central
  Southern
  Eastern
Ciprofloxacin and
ESC resistance
  Northern                        E (1)
  Central
  Southern              A (4), C (1), F (1), G (1)
  Eastern

* ESC, extended-spectrum cephalosporin.

([dagger]) Includes 197 isolates of 42 uncommon serotypes and 2
untypeable isolates.

Table 2. Characteristics of 20 Salmonella isolates resistant to
extended-spectrum cephalosporins

                                                          gyrA at
                                                          position
                                                         ([dagger])

               Specimen                 Resistance        83 (TCC
Serotype         type      pl (s)        pattern *         [Ser])

Albany          Urine       9.0       Am ESC Fx Cm Na        --
                                     Sxt Tc ([dagger])

Cairo           Stool     9.0, 5.4    Am ESC Fx Cm Na    TTC (Phe)
                                       Gm Km Sxt Tc
                                        ([dagger])

                Urine       9.0       Am ESC Fx Cm Cp    TTC (Phe)
                                         Na Sxt Tc

Chester         Stool       9.0          Am ESC Fx           --

Choleraesuis    Wound     9.0, 5.4    Am ESC Fx Cm Cp    TTC (Phe)
                                      Na Gm Km Sxt Tc

                Blood     9.0, 5.4    Am ESC Fx Cm Cp    TTC (Phe)
                                         Na Gm Tc

                Blood     9.0, 5.4    Am ESC Fx Cm Cp    TTC (Phe)
                                      Na Gm Km Sxt Tc

                Blood     9.0, 5.4    Am ESC Fx Cm Cp    TTC (Phe)
                                       Na Gm Km Sxt
                Joint     9.0, 5.4    Am ESC Fx Cm Cp    TTC (Phe)
                fluid                 Na Gm Km Sxt Tc

Kaduna          Tissue    9.0, 5.4    Am ESC Fx Cm Cp    TTC (Phe)
                                         Na Sxt Tc
Saintpaul       Stool       9.0        Am ESC Fx Gm          --

Stanley         Stool     9.0, 5.4       Am ESC Fx           --
                                         Cm Sxt Tc

                Stool       9.0          Am ESC Fx           --
                                         Cm Sxt Tc

                           gyrA at
                           position
                          ([dagger])

                                                         Isolate
                                                       (restriction
                                         parC at        pattern of
                                       position 80     transferred
                                       (AGC [Ser])   [bla.sub.CMY-2]+
               Specimen    87 (GAC      ([double         plasmid)
Serotype         type       [Asp])      dagger])       ([section])

Albany          Urine     AAC (Asn)        --          SA04.028 (C)

Cairo           Stool         --           --         NC04.001 (H1),
                                                      NC04.002 (H1),
                                                      NC04.003 (H1)

                Urine     GGC (Gly)     AAC (Arg)     NC04.004 (H2)

Chester         Stool         --           --          NG04.016 (G)

Choleraesuis    Wound     AAC (Asn)     ATC (Ile)      NL04.050 (B)

                Blood     AAC (Asn)     ATC (Ile)      SB04.003 (A)

                Blood     AAC (Asn)     ATC (Ile)     SE04.005 (F),
                                                         SG04.060

                Blood     AAC (Asn)     ATC (Ile)     SG04.039 (E1),
                                                         SG04.086

                Joint     AAC (Asn)     ATC (Ile)     SG04.042 (E2),

                fluid                                 SG04.047 (E4)

Kaduna          Tissue    AAC (Asn)     ATC (Ile)      CE04.015 (I)

Saintpaul       Stool         --           --         NG04.011 (G),
                                                       NG04.018 (G)

Stanley         Stool         --           --          CG04.039 (D)

                Stool         --           --         NB04.022 (A),
                                                      SE04.006 (E3)

* Am, ampicillin; ESC, extended-spectrum cephalosporins, Fx,
cefoxitin, Cm, chloramphenicol, Cp, ciprofloxacin; Na, nalidixic acid;
Gm, gentamicin, Km, kanamycin, Sxt, trimethoprim-sulfamethoxazole; Tc,
tetracycline.

([dagger]) The S. Albany isolate and the 3 S. Cairo isolates showed
decreased susceptibilities to ciprofloxacin (MIC 0.25-1 [micro]g/mL).

([double dagger]) Nucleotide and amino acid changes at the QRDRs of
gyrA and parC. --, no alterations in the genes.

([section]) For each isolate, the first letter indicates region (C,
central region; N, northern region, S, southern region), and the
second letter represents hospital. Isolates NC04.001, NC04.002, and
NC04.003 were from the same patients; all other isolates were from
different patients.

This work was partly supported by a research grant NSC93-2320-B-006-016 from the National Science Council, Taiwan.

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Jing-Jou Yan, * Chien-Shun Chiou, ([dagger]) Tsai-Ling Yang Lauderdale, ([double dagger]) Shu-Huei Tsai, * and Jiunn-Jong Wu *

* National Cheng Kung University College of Medicine, Tainan, Taiwan; ([dagger]) Center for Disease Control, Taichung City, Taiwan; and ([double dagger]) National Health Research Institutes, Taipei, Taiwan

Dr. Yan is an associate professor, Department of Pathology, National Cheng Kung University College of Medicine, Tainan, Taiwan. His major research interests are the epidemiology and mechanisms of antimicrobial resistance, especially [beta]-lactamases in gram-negative bacteria.

Address for correspondence: Jiunn-Jong Wu, Department of Medical Laboratory Science and Biotechnology, College of Medicine, National Cheng Kung University, No. 1 University Rd, Tainan, Taiwan 70101; fax: [phone]: email: [e-mail]