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a g u s t u s 2 0 0 9

Lucky H Moehario, Enty* , Ariyani Kiranasari

Department of Microbiology, Faculty of Medicine, university of Indonesia, Jakarta,

Indonesia, * Department of Microbiology, Faculty of Medicine, Catholic university of

atmajaya, Indonesia

Susceptibility Patterns of Salmonella typhi and Salmonella

paratyphi A to Ciprofloxacin, Levofloxacin, Chloramphenicol,

Tetracycline, Ceftriaxone and Trimethoprim-Sulfamethoxazole

in Jakarta, 2002-2008

INTRODUCTION

Enteric fever remains a global problem

partcularly in countries with poor hygiene.

Predominant etiologies in Indonesia are

Salmonella enterica subsp. enterica sero-

var Typhi (S. typhi) and Salmonella en-

terica subsp. enterica serovar Paratyphi A

(S. paratyphi A). CDC Indonesia reported

the prevalence of Typhoid Fever was 358-

810/100,000 population in 2007, with 64%

of the disease was found in people aged

3-19 years, and mortality rate varies from

3.1-10.4% among hospitalized patients

(1). In the last two decades, the worldwide

emergence of multidrug resistant (MDR)

strains of S. typhi had been reported. These

strains were resistant to Chloramphenicol,

Trimethoprim-Sulfamethoxazole and Am-

picillin. Moreover, Nalidixic acid-resistant

strains exhibiting reduced susceptibility to

Ciprofloxacin had become endemic in Indi-

an subcontinent, Unites States, United King-

dom and also in other developed countries

in 1997, reflecting the emergence of a global

problem (2). This study described suscepti-

bility patterns of S. typhi and S. paratyphi A

to antibiotics generally used by clinicians to

treat suspected or confirmed Typhoid Fever

in the last six years in Jakarta.

MATERIAL AND METHODS

Specimens

All blood specimens received from

hospitals, private practices, or individuals

during 2002-2008 in Laboratory of Clinical

Microbiology Faculty of Medicine Univer-

sity of Indonesia (LMK-FKUI) Jakarta.

Cultures and susceptibility tests to

antibiotics

Cultures were carried out using Bac-T

Alert

(Enseval) in 2002-2006 and Bac-

tec

9050 (Becton Dickinson) in 2008.

Positive cultures were than inoculated on

appropriate media. The identification of mi-

croorganisms was determined using stan-

dard biochemical reactions and serology test

(Biofarma). Disc diffusion method was used

to assess susceptibility of microorganisms

to antibiotics, and carried out according

to Performance Standards for Antimicro-

bial Susceptibility Testing from Clinical and

Laboratory Standards Institute (CLSI) (3)

as guidelines. Antimicrobial susceptibility

results were categorized in to three groups,

Sensitive (S), Intermediate (I) and Resistant

(R) according to CLSI (3). Antibiotic discs

used were Chloramphenicol (30 µg), Ceftri-

axone (30 µg), Ciprofloxacin (5 µg), Levo-

floxacin (5 µg), Tetracycline (30 µg), and

Trimethoprim-Sulfamethoxazole.

RESULTS

A total of 35 S. typhi isolates and 6 S.

paratyphi A isolates were obtained from

blood specimens during 2002-2008. Suscep-

tibility tests to antibiotics against those iso-

lates were evaluated (Figure 1). All S. typhi

isolates were susceptible to Ciprofloxacin,

Levofloxacin, Tetracycline and Trimethop-

rim-Sulfamethoxazole. Further, more than

90% of the S. typhi isolates were also suscep-

tible to Chloramphenicol and Ceftriaxone.

Among S. paratyphi A isolates, all 6 isolates

were susceptible to all antibiotics tested.

DISCUSSION

This study showed that S. typhi and S.

paratyphi A isolated during 2002-2008 were

susceptible to drugs commonly used by

clinicians in treating patients suspected or

with Typhoid Fever. In vitro, antibiotics such

as Chloramphenicol, Trimethoprim-Sul-

famethoxazole, Tetracycline, Ciprofloxacin,

Levofloxacin and Ceftriaxone were showing

activity against the causative agents, con-

sistent with other reports, such in Sulawesi

(1). However, in several places, i.e. Mexico,

India, Vietnam, Thailand, Korea and Peru, S.

typhi had been found resistant to Chloram-

phenicol, Trimethoprim-Sulfamethoxazole

and Ampicillin, since 2002

(2)

. S. typhi strains

resistant to Ciprofloxacin and Ceftriaxone

had been reported in Pakistan since 2006

(4)

Fluoroquinolone has been widely used in the

treatment of Typhoid Fever, and superior in

term of efficacy and safety

(5)

. However, sev-

eral concerns must be taken into account be-

cause the drug is rather toxic for children, the

cost, and its potential emergence of resistance

(2)

. MDR and quinolone resistant (QDR)

strains of S. typhi have been big regional and

global issues

(2, 6, 7)

. These strains have not been

yet isolated thus far in Indonesia, while clini-

cians had reported failed empiric therapy in

Typhoid Fever cases. With high mobility of

people to and from Indonesia, it is possibe

that the MDR and QDR strains of S. typhi are

present in Indonesia. It is strongly suggested

that the diagnosis of Typhoid Fever is not only

based on clinical pictures and serology tests,

but also etiological. The availability of reliable

surveillance data and molecular mapping of

MDR and QDR S. typhi strains will benefit

patients and communities.

This study showed that Ciprofloxacin,

Levofloxacin, Tetracycline, Trimethoprim

-Sulfamethoxazole, Chloramphenicol and

Ceftriaxone still have good in vitro activ-

ity against S. typhi and S. paratyphi A. But

clinicians should be careful in interpreting

this result, because of small number of iso-

lates tested. n

Reference at editorial desk

ceftriaxone

92.6

100

chloramphenicol

94.1

100

tetracycline

100

trimethoprim-

sulfamethoxazole

100

ciprofloxacin

100

levofloxacin

100

S. typhi

Per

centag

e of

susc

eptibilit

Susceptibility of S. typhi and S.

paratyphi A isolates to antibiotics

in Jakarta during 2002-2008

S. paratyphi A

102

100

Figure 1.