Extended-Spectrum Beta-Lactamase-Producing Salmonella Enteritidis in Trinidad and Tobago.

To the Editor: Salmonella Enteritidis, a predominantly localized pathogen of the human gastrointestinal tract, can become invasive in very young, very old, malnourished, and immunocompromised patients. In recent years, S. Enteritidis has emerged as a major intestinal pathogen in Trinidad and Tobago (population 1.2 million); in 1997, S. Enteritidis caused 79 (66%) of 119 culture-confirmed salmonella infections, in contrast to 18 (18%) of 99, 48 (47%) of 102, and 107 (61%) of 178 in 1994, 1995, and 1996, respectively. Increased incidence of S. Enteritidis infections has been reported worldwide (1.2). Of 216 human S. Enteritidis isolates tested for antimicrobial susceptibility between 1994 and 1996 in Trinidad, none were resistant to cephalosporins, aminoglycosides, ampicillin, trimethoprim-sulphamethoxazole, chloramphenicol, and norfloxacin/ciprofloxacin by the Kirby-Bauer disk diffusion method, which uses the National Committee for Clinical Laboratory Standards (NCCLS) breakpoints (3).

Here we report an unusual isolate of S. Enteritidis resistant to all penicillins and cephalosporins--including third-generation cephalosporins, gentamicin, tobramicin, and trimethoprimsulphamethoxazole--by the Kirby-Bauer disk diffusion method. Amoxicillin-clavulanate and piperacillin-tazobactam disks gave zone sizes of 15 mm and 19 mm, respectively, which are classified as intermediate in the NCCLS guidelines. This isolate was recovered from the blood culture of a febrile, nonneutropenic patient with multiple myeloma on two occasions 24 hours apart in March 1998. The isolate was sensitive only to ofloxacin and imipenem. Admitted to the hospital with compressed fracture of the spine for physiotherapy in December 1997, the patient had several febrile episodes and received several courses of multiple empirically prescribed antibiotics (cefotaxime, gentamicin, and piperacillin). The patient had not traveled abroad during the previous 6 months.

Because cephalosporin resistance in salmonellae has not been reported before in the Caribbean, we investigated the mechanism behind this third-generation cephalosporin resistance further. Using amoxicillin-clavulanate in combination with ceftazidime, cefiriaxone, and aztreonam, we performed the double disk synergy test to determine whether this strain was an extended-spectrum betalactamase producer as described elsewhere (3); augmentation of the zone at the junction of amoxicillin-clavulanate and aztreonam/cefiriaxone/cefiazidime zones confirmed that indeed it was.

In the past few years, third-generation cephalosporin resistance in S. Enteritidis has been described in Europe (4), the United States (5), Turkey (6), India (7.8), and Argentina (0). Few reports exist of extended-spectrum beta-lactamasemediated third-generation cephalosporin resistance in Salmonella spp. To our knowledge, this is the first report of this type of resistance among S. Enteritidis in the Caribbean. This patient was treated with ciprofloxacin for 1 week; subsequent blood cultures were negative.

This unusual isolate highlights the need to establish an antimicrobial resistance surveillance network for Salmonella isolates, including S. Enteritidis, to monitor the trends and new types of resistance mechanisms in the Caribbean. An epidemiologic study of S. Enteritidis infections is being planned to describe the extent of the problem and to define risk factors and vehicles of human infections in three Caribbean countries, including Trinidad and Tobago.

References

(1.) Centers for Disease Control and Prevention. Salmonella surveillance annual tabulation summary, 1993-1995. Atlanta: U.S. Department of Health and Human Services; 1997.

(2.) Communicable Disease Surveillance Center. Salmonella in humans: PHLS salmonella data set, England and Wales, 1981-1996. London: The Center; 1997.

(3.) National Committee for Clinical Laboratory Standards. Performance standards for the antimicrobial disk susceptibility tests for bacteria that grow aerobically. Approved standard M7 - A4. Villanova (PA): The Committee; 1997.

(4.) Fantin B, Pangon B, Potel G, Caron F, Vallee E, Vallois JM, et al. Activity of sulbactam in combination with ceftriaxone in vitro and in experimental endocarditis caused by Escherichia coli producing SHV-2-like beta-lactamases. Antimicrob Agents Chemother 1990:34;581-6.

(5.) Morosini MI, Blasquez J, Negri MC, Canton R, Loza E, Baquero F. Characterization of a nosocomial outbreak involving all epidemic plasmid encoding for TEM-27 in Salmonella enteritidis. J Infect Dis 1996;174:1015-20.

(6.) Herikstad H, Hayes PS, Hogan J, Floyd P, Snyder L, Augulo FJ. Ceftriaxone resistant Salmonella in the United States. Pediatr Infect Dis J 1997; 16:904-5.

(7.) Vahaboglu H, Hall LM, Mulazimoglu L, Dodanli S, Yildirim I, Livermore DM. Resistance extended spectrum cephalosporins caused by PER-1 beta lactamase, in Salmonella typhimurium in Istanbul, Turkey. J Med Microbiol 1995;43:294-9.

(8.) Kumar A, Nath G, Bhatia BD, Bhargava V, Loiwal V. An outbreak of multidrug resistant Salmonella typhimurium in a nursery. Indian Pediatr 1995;(3)980:881-5.

(9.) Wattal C, Kaul V, Chigh TD, Kler N, Bhandari SK. An outbreak of multi drug resistant Salmonella typhimurium in Delhi (India). Indian J Med Res 1994;100:266-7.

(10.) Rossi A, Lopardo H, Woloj M, Picanet A, Marino M, Galds M, et al. Non-typhoid Salmonella spp. resistant to cefotaxime. J Antimicrob Chemother 1995;36:697-702.

B.P. Cherian,(*) Nicole Singh,(*) W. Charles,(*) and P. Prabhakar(*)([dagger])

(*) Port of Spain General Hospital, Port of Spain, Trinidad; and ([dagger]) Caribbean Epidemiology Center (CAREC), Port of Spain, Trinidad