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CORRESPONDENCE
Year : 2008  |  Volume : 26  |  Issue : 1  |  Page : 91
 

Ciprofloxacin breakpoints in enteric fever - time to revise our susceptibility criteria


P.D. Hinduja National Hospital and Medical Research Center, Mahim, Mumbai - 400 016, India

Date of Submission09-Feb-2007
Date of Acceptance01-May-2007

Correspondence Address:
C Rodrigues
P.D. Hinduja National Hospital and Medical Research Center, Mahim, Mumbai - 400 016
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0255-0857.38874

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How to cite this article:
Rodrigues C, Kumar N J, Lalwani J, Mehta A. Ciprofloxacin breakpoints in enteric fever - time to revise our susceptibility criteria. Indian J Med Microbiol 2008;26:91

How to cite this URL:
Rodrigues C, Kumar N J, Lalwani J, Mehta A. Ciprofloxacin breakpoints in enteric fever - time to revise our susceptibility criteria. Indian J Med Microbiol [serial online] 2008 [cited 2019 Sep 16];26:91. Available from: http://www.ijmm.org/text.asp?2008/26/1/91/38874


Dear editor,

Apart from its considerable morbidity and absenteeism, enteric fever today consumes vast resources in developing nations. Most laboratories in India follow the Enterobacteriaceae CLSI guidelines for ciprofloxacin with an MIC of ≤1 mg/mL and zone diameter of ≥21 mm being considered as susceptible for  Salmonella More Details .

In Mumbai, resistance to nalidixic acid in Salmonella typhi has steadily increased from 0% in 1992 to 82% in 2000 and 86% in 2002. [1],[2] However, in vitro susceptibility to ciprofloxacin may be seen on the basis of breakpoints that were established more than a decade ago. Clinical failure and increasing MIC to ciprofloxacin in salmonellae has prompted most clinicians to reconsider its use despite apparent in vitro susceptibility. Yet we need to re-iterate that ciprofloxacin, when susceptible, is still an ideal choice for treatment of enteric fever in the subcontinent.

In an attempt to address this issue, we analysed a total of 96 nalidixic acid-resistant (no zone of inhibition on disc diffusion) blood culture isolates in the year 2005 - 44 of S. typhi and 52 S. paratyphi A [Table - 1].

Two criteria were considered: (1) Keeping the current CLSI (January 2006) recommended guidelines for MIC of Enterobacteriaceae in mind, based on a regression analysis of log MIC vs. zone diameter, to accommodate a susceptible MIC of ≤1 g/mL, the zone diameter for 'susceptible' was increased to ≥27 mm from 21 mm with a corresponding increase in the zone diameter for resistant isolates from ≤15 mm to ≤21 mm for resistant MIC of ≥4 g/mL. (2) Keeping pharmacokinetic and pharmacodynamic principles for gram-negative bacteria in mind (AUC/MIC >125), with a 750 mg twice daily dose of ciprofloxacin, the attainable AUC is 31.06 μg.h/mL, allowing a maximum MIC of <0.25 g/mL to be regarded as susceptible.

In our analysis, all the isolates of S. paratyphi A had a MIC ≥1 g/mL, making ciprofloxacin no longer an option available for therapy for this organism. However, there were 12 S. typhi isolates with an MIC of <0.25 g/mL, 9 of them with a zone diameter of >30 mm. Thus for a PK/PD breakpoint, we suggest that the MIC of ciprofloxacin be lowered to ≤0.25 μg/mL and the resistant zone diameter breakpoint be increased to ≤28 mm and the susceptible one to ≥30 mm. Either way, we believe that the zone diameters must increase for S. typhi and S. paratyphi A .

 
 ~ References Top

1.Rodrigues C, Mehta A, Joshi VR. Salmonella typhi in the past decade: Learning to live with the resistance. Clin Infect Dis 2002;34:126.  Back to cited text no. 1  [PUBMED]  [FULLTEXT]
2.Rodrigues C, Mehta A, Shenai S. Enteric fever in Mumbai, India: The good news and the bad news. Clin Infect Dis 2003;36:535.  Back to cited text no. 2    



 
 
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