Extensively Drug-Resistant Typhoidal Salmonellae: Are These Bugs Swarming Into Suburban and Rural Areas of Pakistan?

Background Typhoid is a serious public health concern with increasing antibiotic resistance. Early suspicion and choice of susceptible antibiotics are key to avoiding the morbidity and mortality associated with this disease. We have carried out this study to assess the antibiotic sensitivity of typhoidal salmonellae in Kharian, Pakistan. Materials and methods This cross-sectional study was carried out at Combined Military Hospital, Kharian, Pakistan, from January 2019 to September 2020. Blood culture specimens from patients clinically suspected of enteric fever were tested through the BacT/ALERT 3D automated blood culture system. Positive microbial growth was further identified by colony morphology, appropriate staining, biochemical testing, and Salmonella-specific grouping sera. Salmonella typhi and Salmonella paratyphi A-C were further analyzed for antimicrobial susceptibility using agar disc diffusion testing by the modified Kirby-Bauer technique. The Clinical and Laboratory Standards Institute (CLSI) guidelines (2018-2020) document M-100 was followed for antibiotic selection and assigning the sensitivity status of the isolates. Meropenem and azithromycin were additionally tested keeping in view the possibility of encountering isolates with extensive antimicrobial resistance. Results A total of 315 blood culture samples were received during the study period. Of these, 239 (75.9%) reported negative and 76 (24.1%) were positive. The mean age was 22.37 ± 12.39 years. There were 41 (53.9%) males and 35 (46.1%) females. Salmonella enterica (combined Salmonella typhi and Salmonella paratyphi A) was 100% sensitive to azithromycin, meropenem, and imipenem. Ampicillin and chloramphenicol have 28.9% sensitivity each. Ceftriaxone, co-trimoxazole, and ciprofloxacin revealed 64.5%, 23.7%, and 11.8% sensitivity, respectively. Among them, 11.84% of the isolates were pan-sensitive, 35.5% of the cultures were multidrug-resistant (MDR), and 35.5% of the cultures were extensively drug-resistant (XDR). Conclusion The study demonstrates that polyresistant typhoidal salmonellae are no more confined to a couple of outbreaks in large cities of Pakistan. It is the tip of the iceberg, and the balance has tilted toward difficult-to-treat typhoid and paratyphoid fevers all across the country owing to significant resistance to the commonly used antityphoid antibiotics (cephalosporins and fluoroquinolones). Azithromycin and carbapenems are offering the last line of defense against the rampant Salmonella typhi and Salmonella paratyphi.