Case Series of Imported Enteric Fever at a Referral Center in Tokyo, Japan: Antibiotic Susceptibility and Risk Factors for Relapse

Takashi Matono Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.

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Yasuyuki Kato Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.

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Masatomo Morita Department of Bacteriology I, National Institute of Infectious Diseases, Toyama, Shinjuku-ku, Tokyo, Japan.

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Hidemasa Izumiya Department of Bacteriology I, National Institute of Infectious Diseases, Toyama, Shinjuku-ku, Tokyo, Japan.

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Kei Yamamoto Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.

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Satoshi Kutsuna Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.

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Nozomi Takeshita Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.

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Kayoko Hayakawa Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.

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Kazuhisa Mezaki Microbiology Laboratory, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.

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Maho Kawamura Department of Microbiology, Tokyo Metropolitan Institute of Public Health, Hyakunincho, Shinjuku-ku, Tokyo, Japan.

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Noriko Konishi Department of Microbiology, Tokyo Metropolitan Institute of Public Health, Hyakunincho, Shinjuku-ku, Tokyo, Japan.

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Yasutaka Mizuno Department of Infectious Diseases, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan.

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Shuzo Kanagawa Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.

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Norio Ohmagari Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan.

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Owing to the increase in Salmonella strains with decreased fluoroquinolone susceptibility in the endemic areas, we have been treating enteric fever with intravenous ceftriaxone empirically since 2007. In this study, we reevaluated our treatment protocol. This retrospective cohort study was conducted at a single institute in Tokyo, Japan, between January 2006 and December 2013. Enteric fever was defined as isolation of Salmonella Typhi or Salmonella Paratyphi A, B, and C from the blood and/or stool of patients with fever. Of the 35 patients with imported enteric fever, 28 (80%) had returned from south Asia. Ciprofloxacin-susceptible strains were detected in only 12% of the cases. The isolates showed excellent susceptibility to ampicillin (91%), chloramphenicol (94%), ceftriaxone (97%), and azithromycin (97%). One case of Salmonella Paratyphi B was excluded, and of the remaining 34 patients, 56% were treated with ceftriaxone alone, 26% with ceftriaxone then fluoroquinolone, and 9% with levofloxacin alone. The overall relapse rate was 6.1%; however, among those receiving ceftriaxone monotherapy, the relapse rate was 11% (N = 2). The relapse group was characterized by longer times to treatment initiation (P = 0.035) and defervescence (> 7 days) after treatment initiation (P = 0.022). In such cases, we recommend that ceftriaxone treatment be continued for > 4 days after defervescence or be changed to fluoroquinolone if the strains are found to be susceptible to prevent relapse. Furthermore, ampicillin and chloramphenicol, which are no longer prescribed, may be reconsidered as treatment options in Asia.

Author Notes

* Address correspondence to Yasuyuki Kato, Disease Control and Prevention Center, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo 162-8655, Japan. E-mail: ykato@hosp.ncgm.go.jp

Financial support: This work is supported by a grant from the Ministry of Health, Labor, and Welfare (H24-shinkou-ippan-013).

Authors' addresses: Takashi Matono and Yasuyuki Kato, Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan, E-mails: sincedec2012@gmail.com and ykato@hosp.ncgm.go.jp. Masatomo Morita and Hidemasa Izumiya, Department of Bacteriology I, National Institute of Infectious Diseases, Toyama, Shinjuku-ku, Tokyo, Japan, E-mails: mmorita@niid.go.jp and izumiya@nih.go.jp. Kei Yamamoto, Satoshi Kutsuna, Nozomi Takeshita, and Kayoko Hayakawa, Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan, E-mails: nicepoko@gmail.com, sonare.since1192@gmail.com, nozomitake@gmail.com, and kayokohayakawa@gmail.com. Kazuhisa Mezaki, Microbiology Laboratory, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, Japan, E-mail: kmezaki@hosp.ncgm.go.jp. Maho Kawamura and Noriko Konishi, Department of Microbiology, Tokyo Metropolitan Institute of Public Health, Hyakunincho, Shinjuku-ku, Tokyo, Japan, E-mails: Maho_Kawamura@member.metro.tokyo.jp and Noriko_Konishi@member.metro.tokyo.jp. Yasutaka Mizuno, Department of Infectious Diseases, Tokyo Medical University, Shinjuku-ku, Tokyo, Japan, E-mail: mizuno@tokyo-med.ac.jp. Shuzo Kanagawa and Norio Ohmagari, Disease Control and Prevention Center, National Center for Global Health and Medicine, Toyama, Shinjuku-ku, Tokyo, E-mails: skanagaw@hosp.ncgm.go.jp and nohmagari@hosp.ncgm.go.jp.

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