Background & objectives: Clinical non response to ciprofloxacin therapy in enteric fever is increasingly being encountered in endemic areas possibly due to the increase in the levels of resistance to ciprofloxacin in Salmonella typhi. The antimicrobial susceptibility tests for S. typhi performed by the disc diffusion method using NCCLS breakpoints fail to detect the increasing MIC of ciprofloxacin, leading to the inappropriate treatment of enteric fever with ciprofloxacin. We explored the possibility of testing S. typhi strains for their susceptibility to nalidixic acid by disc diffusion method as a marker for high MIC to ciprofloxacin.
Methods: Isolates (94) of S. typhi were tested for in vitro susceptibility to nalidixic acid (30 micrograms) and ciprofloxacin (5 micrograms) by disc diffusion method using NCCLS guidelines. The MIC of these strains to ciprofloxacin was also determined by E-test.
Results: Of the 94 strains tested, 56 were NARST (nalidixic acid resistant S. typhi) and 34 were NASST (nalidixic acid sensitive S. typhi). MIC of ciprofloxacin in the NASST strains varied from 0.002-0.125 microgram/ml while that for NARST strains varied from 0.023-0.38 microgram/ml, which is about 10-folds higher than that of NASST strains.
Interpretation & conclusion: Our study shows that resistance to nalidixic acid is associated with a high MIC to ciprofloxacin in S. typhi. These strains would have been interpreted as ciprofloxacin sensitive by routine antimicrobial susceptibility testing by disc diffusion method. Hence screening of S. typhi isolates by the nalidixic acid susceptibility test may be incorporated in a clinical bacteriology laboratory to alert the treating physicians of the possibility of the failure to ciprofloxacin therapy in patients with enteric fever.