Multiresistant Salmonella and Other Infections
in Adopted Infants from India
Since January 1981, multiresistant Salmonella serotypes have
been
isolated from 33 infants adopted by U.S. parents from one nursery
in
Calcutta, India. Shigella, Campylobacter, and Plasmodium vivax have
also been isolated from some of these infants. Persons in 31
states
have adopted infants from this nursery, although 3
states--Minnesota,
Oregon, and Washington--have received 86 (49%) of the 176 infants
sent
for adoption. Most ill infants have had diarrhea and various
levels
of malnutrition that have required only supportive measures.
However,
7 of the 33 infants have required hospitalization--3 for diarrhea
and
dehydration, 3 for malnutrition and P. vivax malaria, and 1 for
Salmonella meningitis. There have been no deaths. Four secondary
cases of gastroenteritis occurred among household contacts in 4
families (involving 3 children and 1 mother). Four different
Salmonella spp., S. typhimurium, S. alachua, S. mbandaka, and S.
bareilly, have been isolated from the adopted infants. All
Salmonella
isolates have been resistant to ampicillin, chloramphenicol,
kanamycin, gentamicin, and trimethoprim-sulfamethoxazole.
Resistance
to tetracycline, cephalothin, and cephamandole has been variable.
All
Salmonella isolates are sensitive to cefotaxime and moxalactam.
The foundling nursery in Calcutta receives babies shortly after
birth and sends infants to the United States between the first and
second month of life. Most of these infants are born prematurely
or
are severely underweight and at high risk of developing infectious
complications while in the nursery. Despite control efforts, the
nursery has had an ongoing problem with Salmonella infections for
at
least 1 year. A particularly severe outbreak of neonatal
salmonellosis associated with a high mortality rate was recognized
in
May 1981. In September 1981, the nursery began to separate infants
into cohorts by age and health status. This appeared to be
successful
in limiting the spread of infection but did not eliminate
Salmonella
from the nursery. The adoption agency in the United States
provides
information to each set of parents about health problems they may
encounter with their newly adopted child.
Reported by N Boucneau, International Mission of Hope; J Allard,
PhD,
State Epidemiologist, Washington State Dept of Social and Health
Svcs;
J Korlath, M Osterholm, PhD, AG Dean, MD, State Epidemiologist,
Minnesota State Dept of Health; P Williams, DVM, JA Googins, MD,
State
Epidemiologist, Oregon Dept of Human Resources; K Powell, MD, Dept
of
Pediatrics, Strong Memorial Hospital, R Rothenberg, MD, State
Epidemiologist, New York State Dept of Health; Enteric Diseases Br,
Div of Bacterial Diseases, Antimicrobial and Infection Mechanisms
Br,
Hospital Infection Program, Center for Infectious Diseases, Field
Services Div, Epidemiology Program Office, CDC.
Editorial Note
Editorial Note: Outbreaks due to similarly multiresistant strains
of
S. typhimurium have been reported from India since 1976 (1,2).
Like
Salmonella wein, these resistant strains have caused prolonged
outbreaks of enteritis in pediatric wards (2). Multiresistant S.
alachua isolates have been reported from Calcutta since 1971 and
have
frequently been associated with neonatal meningitis in that city
(3,4). S. mbandaka was a rare serotype worldwide and virtually
unheard of in the United States until 1977. Since that year the
number of isolates has been steadily increasing: 1978 (2), 1979
(14),
1980 (40), 1981 (103). None of these S. mbandaka isolates were
known
to be related to adopted infants from Calcutta. Outbreaks of S.
mbandaka gastroenteritis have occurred in the United States, but
specific vehicles have not been identified. Since S. alachua and
S.
mbandaka are rare in the United States, it may be useful to
investigate isolates of these serotypes to determine whether they
are
related to adopted infants from India.
Resistant strains of Salmonella are not new to the United
States.
In 1975, 21% of all Salmonella and 49% of S. typhimurium strains
submitted to CDC were resistant to 2 or more antimicrobials (5).
The
multiresistant Salmonella strains from India are of particular
concern
when associated with infants who are malnourished. If these
strains
are associated with extraintestinal illness, they can be a problem,
since they are resistant to drugs of proven efficacy for
extraintestinal salmonellosis--chloramphenicol, ampicillin,
gentamicin, and trimethoprim-sulfamethoxazole. Infants with
extraintestinal infection could be treated with a third generation
cephalosporin pending the results of sensitivity tests of their
infections.
Secondary spread of Salmonella, when the patient with the index
case is an infant, has been reported, and Leeder (6) found 31% of
household contacts infected in a study in Michigan. Enteric
isolation
should reduce this problem and should be vigorously enforced to
prevent the nosocomial spread of these strains.
Few clinical data are available concerning the use of
third-generation cephalosporins in the treatment of extraintestinal
salmonellosis. However, the minimal inhibitory concentration for
several of these newer cephalosporins is quite low, and central
nervous system penetration is sufficient so that they should be
effective even in treating meningitis. Moxalactam has been most
extensively studied and has been shown to be effective in the
treatment of meningitis caused by other gram-negative organisms
(7).
References
Ahuja S, Mago ML, Singh H, Saxena SN. Multiple drug resistance
pattern of Salmonella strains in India during 1976. Indian J
Med
Res 1979;70:702-9.
Rowe B, Frost JA, Threlfall EJ, Ward LR. Spread of a
multiresistant clone of Salmonella typhimurium phage type
66/122
in South-East Asia and the Middle East. Lancet 1980;1:1070-1.
Chaudhuri AB, Ghosal SP, Dutta N. Salmonella alachua infection
in
early infancy. Indian J Pathol Microbiol 1978;21:45-52.
Bhat MB, Sharma KB. Genetic studies on the co-existence of
col-plasmid(s) and R-plasmid(s) in S. wien and S. alachua.
Indian
J Med Res 1980;71:22-8.
Ryder RW, Blake PB, Murlin AC, et al. Increase in antibiotic
resistance among isolates of Salmonella in the United States,
1967-1975. J Infect Dis 1980;142:485-91.
Leeder FS. An epidemic of Salmonella panama infections in
infants. Ann NY Acad Sci 1956;66:54-66.
Schaad UB, McCracken GH, Threlkeld N, Thomas ML. Clinical
evaluation of a new broad-spectrum oxa-beta-lactam antibiotic,
moxalactam, in neonates and infants. J. Pediatr
1981;98:129-36.
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