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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

  1. 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.

  2. 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.

  3. Chaudhuri AB, Ghosal SP, Dutta N. Salmonella alachua infection in early infancy. Indian J Pathol Microbiol 1978;21:45-52.

  4. 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.

  5. 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.

  6. Leeder FS. An epidemic of Salmonella panama infections in infants. Ann NY Acad Sci 1956;66:54-66.

  7. 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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