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 blaCMY-2, and all ciprofloxacin-resistant Salmonella enterica serotype Choleraesuis isolates were genetically related.


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.
All 20 ESC-resistant isolates expressed a β-lactamase of pI 9.0 by isoelectric focusing (3,11); 11 of these isolates expressed an additional pI 5.4 β-lactamase (Table 2). bla CMY-2 was detected in all ESC-resistant isolates. bla TEM-1 was detected in the 11 isolates with the pI 5.4 β-lactamase by polymerase chain reaction (PCR) and sequence analyses with the primers for the entire bla TEM -related and bla 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 ciprofloxacinresistant 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 ESCresistant 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 µg/mL) and cefoxitin (MIC 64-128 µg/mL) and were susceptible to all non-β-lactam agents tested. A pI 9.0 vz β-lactamase and bla 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 CMY-2 on the transferred plasmids was demonstrated by Southern hybridization with the bla CMY-2 probe.
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).

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)(5)(6). The ciprofloxacin-resistant rate in S. Choleraesuis in this report (84.4%) was higher than those reported previously (<70%) (4)(5)(6). bla 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 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 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 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 ciprofloxacinresistant 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.