Third-Generation Cephalosporin Resistance in Shigella sonnei, Argentina

Marcela Radice,* Cristina González,† Pablo Power,* María del Carmen Vidal,† and Gabriel Gutkind*
*Universidad de Buenos Aires, Buenos Aires, Argentina, and †Hospital SAMIC Obera, Misiones, Argentina

Shigellosis is an important public health problem, especially in developing countries. Antibiotic treatment of bacterial dysentery, aimed at resolving diarrhea or reducing its duration, is especially indicated whenever malnutrition is involved. First-line drugs include ampicillin and trimethoprim-sulfamethoxazole (TMP-SMX); however, multidrug-resistant (i.e., resistant to ampicillin, TMP-SMX, and chloramphenicol) Shigella isolates are ubiquitous (1-3). When epidemiologic data indicate a rise in resistance, fluoroquinolones may be used in adults and oral third-generation cephalosporins in children. Except for a single strain in Calcutta (4), Shigella have not obtained any extended-spectrum beta-lactamase (ESBL)(4), even though multidrug-resistance plasmids were described in this genus as early as the late 1950s (5,6).

A new family of ESBLs, displaying greater affinity for cefotaxime than ceftazidime (CTX-M), has appeared in various countries. In Argentina, CTX-M-2 is the most prevalent ESBL (7) and has been reported in several enterobacteria (8-10). Although very common in nosocomial pathogens, it has also been recovered from other enteric microorganisms (11). We describe our analysis of the first Shigella sonnei isolate resistant to cefotaxime (CTX) but not to ceftazidime.

The Study

The isolate was from stool samples from a 6-month-old girl, seen in the outpatient clinic of Hospital SAMIC Oberá in northern Argentina. The child had vomiting and laboratory-confirmed bloody diarrhea approximately 20 days after a 1-week hospital stay for diarrhea and primary malnutrition. During the hospital stay, she received gentamicin for 1 week, but no bacterial enteropathogen was isolated.

The child lived in Oberá, a subtropical area in Misiones that has no running water. In this region, Shigella spp. is three times more prevalent than Salmonella spp. and other enteropathogens as the cause of pediatric diarrhea, and S. sonnei resistance to ampicillin and TMP-SMX is approximately 43% and 74%, respectively.

S. sonnei was isolated on eosin-methylene blue agar plates. The isolate did not produce gas and was hydrogen sulfide-negative and nonmotile. In triple sugar iron agar, it was negative for citrate, phenylalanine deaminase, and indol production. It was methyl-red positive, Voges-Proskauer negative, ornithine decarboxylase positive, arginine dihydrolase negative, lysine decarboxylase negative, and urease (Christensen) negative. (All media were from Britania, Argentina.) Confirmatory serotyping was carried out with antisera from the Instituto Nacional de Microbiología Dr. Carlos Malbran.

Confirmatory susceptibility tests followed conventional methods (12,13). Briefly, MICs were determined by the agar dilution method, using Mueller-Hinton agar (Britania) and inoculums of 10⁴ CFU per spot; plates were incubated 18 hours at 35°C. Escherichia coli ATCC 25922 and E. coli ATCC 35218 were included as quality controls. Antibiotics tested were ampicillin, ampicillin + clavulanate (CLA), cefoxitin, cefotaxime (CTX), CTX+ CLA (CTX/CLA), ceftazidime, and ceftazidime + CLA (ceftazidime/CLA); a fixed concentration of 4µg/mL lithium CLA was used when combined with beta-lactam drugs. Antimicrobial drugs were provided by Argentia, Argentina (Ampicillin, CTX), Sigma Chemical Co., St. Louis, USA (ceftazidime), Roemmers, Argentina (CLA) and Merck Sharp & Dohme, Argentina (cefoxitin). MICs were as follows: ampicillin, >1,024 µg/mL; ampicillin + CLA 16 µg/mL; cefoxitin, 2 µg/mL; CTX, 16 µg/mL; CTX/CLA, < 0.063 µg/mL; ceftazidime, 1 µg/mL; ceftazidime/CLA, < 0.063 µg/mL.

Resistance to gentamicin, amikacin, and TMP-SMX was detected by agar diffusion (13); quality controls also included E. faecalis ATCC 29212.

Conclusions

The presence of an ESBL was confirmed by microbiologic and biochemical tests using different third-generation cephalosporins as substrates for the enzymes present in bacterial sonicates and an iodometric detection system (9). A microbiologic confirmation test for ESBLs was performed according to recommendations of the National Committee for Clinical Laboratory Standards for E. coli and Klebsiella spp. (13). After isoelectric focusing (9), crude bacterial extracts rendered two bands that hydrolyzed 500 µg/mL ampicillin (isoelectric points 5.4 and 8.2), the latter also active on 1,000 µg/mL ceftriaxone. As this enzyme was likely CTX-M-2 (the band comigrated with authentic CTX-M-2 samples) and the first probably corresponded to TEM-1 (or another related enzyme), plasmid DNA obtained by the method of Birnboin and Doly (14) was used as the template for polymerase chain reaction amplification, with specific primers for CTX-M-2 (bla_CTX-M-2 I: 5'-TTAATGATGACTCAGAGCATTC-3'; bla_CTX-M-2 II: 5'-GATACCTCGCTCCATTTATTG-3') and TEM-1 (bla_TEM-1 I: 5'-ATAAAATTCTTGAAGACGAAA-3'; bla _TEM-1 II 5'-GACAGTTACCAATGCTTAATCA-3'). Two fragments of 0.9 kbp and 1.2 kbp were obtained; they showed 100% agreement with theoretical and experimentally obtained fragments from bona fide CTX-M-2 and TEM-1 producing strains, respectively (8,10).

No resistant Shigella was isolated from the other 124 pediatric patients admitted that month for nonsurgical (85 patients) or surgical reasons (29) nor was a nosocomial outbreak caused by a third-generation cephalosporin-resistant enterobacteria detected. The patient recovered. The isolated microorganism was not the likely cause for the patient's first hospitalization as it could not be isolated at that time. Likely alternatives for its acquisition are 1) intestinal selection or acquisition of a resistant enterobacterium and in vivo transference to a freshly acquired Shigella or 2) direct acquisition of the resistant strain from contaminated water (not sustained, as no other resistant Shigella was obtained from the same community in the following year).

These findings, which may portend the spread of serious resistance in Shigella throughout Argentina and beyond, suggest the need for susceptibility testing of all Shigella spp. whenever financially feasible.

This work was supported, in part, by grant TB 39 from Universidad de Buenos Aires to Gabriel Gutkind, who is a member of Carrera del Investigador Científico, CONICET (Argentina).

Dr. Radice is a teaching assistant and researcher at the Universidad de Buenos Aires. Her main area of research is bacterial resistance to beta-lactam antibiotics mediated by beta-lactamases, especially in enterobacteria.

Address for correspondence: Gabriel O. Gutkind, Cátedra de Microbiología, Facultad de Farmacia y Bioquímica, Universidad de Buenos Aires, Junín 954, 1113-Buenos Aires, Argentina; fax: +54 11 4 964 8274; e-mail: ggutkind@ffyb.uba.ar

References

1. Mates A, Eyny D, Philo S. Antimicrobial resistance trends in Shigella serogroups isolated in Israel, 1990-1995. Eur J Clin Microbiol Infect Dis 2000;19:108-11.
2. Prats G, Mirelis B, Llovet T, Muñoz C, Miro E, Navarro F. Antibiotics resistance trends in enteropathogenic bacteria isolated in 1985-1987 and 1995-1998 in Barcelona. Antimicrob Agents Chemother 2000;44:1140-5.
3. Replogle ML, Fleming DW, Cieslak PR. Emergence of antimicrobial-resistant shigellosis in Oregon. Clin Infect Dis 2000;30:515-9.
4. Ahamed J, Kundu M. Molecular characterization of the SHV-11 b-lactamase of Shigella dysenteriae. Antimicrob Agents Chemother 1999;43:2081-3.
5. Watanabe T, Fukasawa T. Episome-mediated transfer of drug resistance in Enterobacteriaeceae. J Bacteriol 1960;81:669-78.
6. Akiba T, Koyama T, Isshiki Y, Kimura S, Fukushima T. Studies on the mechanism of development of multiple drug-resistant Shigella strains. Nihon Iji Shimpo 1960;1866:45-50.
7. Radice M. Mecanismos de resistencia a antibióticos b-lactámicos: Análisis de las b-lactamasas de espectro expandido en Escherichia coli [dissertation]. Buenos Aires: University of Buenos Aires; 1998.
8. Bauernfeind A, Casellas JM, Goldberg M, Holley M, Jungwirth R, Mangold P, et al. A new plasmidic cefotaximase from patients infected with Salmonella typhimurium. Infection 1992;20:158-63.
9. Rossi A, Lopardo H, Woloj M, Picandet AM, Mariño M, Galas M, et al. Non-typhoid Salmonella spp. resistant to cefotaxime. J Antimicrob Chemother 1995;36:697-702.
10. Power P, Radice M, Barberis C, de Mier C, Mollerach M, Maltagliatti M, et al. Cefotaxime-hydrolysing b-lactamases in Morganella morganii. Eur J Clin Microbiol Infect Dis 1999;18:743-7.
11. Rossi A, Galas M, Binztein N, Rivas M, Caffer MI, Corso A, et al. Unusual multiresistant Vibrio cholerae O1 El Tor in Argentina. Lancet 1993;342:1172-3.
12. National Committee for Clinical Laboratory Standards. Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically. Approved Standard M7-A4, 4th edition, Vol. 19, No. 1. Wayne (PA): NCCLS; 1999.
13. National Committee for Clinical Laboratory Standards. Zone diameter interpretative standards and equivalent minimum inhibitory concentration (MIC) breakpoints for Enterobacteriaceae. Approved Standard M-2-A6, 6th edition, Vol. 19, No. 1. Wayne (PA): NCCLS; 1999.
14. Birnboin HC, Doly J. A rapid alkaline extraction procedure for screening recombinant plasmid DNA. Nucleic Acids Res 1979;7:1513.

Home | Top of Page | Current Issue | Expedited | Upcoming Issue | Past Issue | EID Search | Contact Us

CDC Home | Search | Health Topics A-Z

This page last reviewed June 23, 2001

Emerging Infectious Diseases Journal
National Center for Infectious Diseases
Centers for Disease Control and Prevention