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Journal of Clinical Microbiology, March 2005, p. 1037-1044, Vol. 43, No. 3
0095-1137/05/$08.00+0     doi:10.1128/JCM.43.3.1037-1044.2005
Copyright © 2005, American Society for Microbiology. All Rights Reserved.

Nosocomial Outbreak Caused by Salmonella enterica Serotype Livingstone Producing CTX-M-27 Extended-Spectrum ß-Lactamase in a Neonatal Unit in Sousse, Tunisia

Laboratoire de Microbiologie-Immunologie,¹ Laboratoire d'Hygiène, Hôpital Farhat Hached, Sousse, Tunisia,³ Centre National de Référence des Salmonella, Unité de Biodiversité des Bactéries Pathogènes Emergentes, Institut Pasteur, INSERM U 389, Paris, France²

Received 6 July 2004/ Returned for modification 10 August 2004/ Accepted 17 October 2004

In this study, we report an outbreak of Salmonella enterica serotype Livingstone resistant to extended-spectrum cephalosporins that occurred in a neonatal ward of the maternity department of Farhat Hached Hospital, Sousse, Tunisia, in 2002. A total of 16 isolates were recovered from 16 babies hospitalized in the ward during the period 1 to 16 July. All these babies developed diarrhea, and three of them developed septicemia. All the isolates demonstrated resistance to ceftriaxone and ceftazidime due to the production of an extended-spectrum ß-lactamase (ESBL). The isolates were also resistant to aminoglycosides (kanamycin, tobramycin, netilmicin, gentamicin, and amikacin) and sulfamethoxazole-trimethoprim. DNA profiles were determined by pulsed-field gel electrophoresis using the XbaI and SpeI endonucleases and by ribotyping with PstI digestion. They yielded the same patterns, showing that the outbreak was caused by a single clone. The ESBL was identified as CTX-M-27 by sequencing of PCR products and by isoelectric focusing. The ESBL resistance was transferred by a 40-kb conjugative plasmid. The mobile insertion sequence ISEcp1 was found to be located upstream of bla_CTX-M-27 in the same position as that known for a bla_CTX-M-14 sequence. A new gene named dfrA21, encoding resistance to trimethoprim and carried by a 90-kb plasmid, was characterized. The dfrA21 gene was inserted as a single resistance cassette in a class I integron. The babies were treated with colistin, and all except two recovered. The outbreak came to an end when appropriate actions were taken: patient isolation, hand washing, and disinfection of the ward.

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