title: Two outbreaks of multidrug-resistant Salmonella serotype typhimurium DT104 infections linked to raw-milk cheese in Northern California.
abstract: BACKGROUND
  Salmonella serotype Typhimurium definitive type 104 (DT104), with resistance to 5 drugs (ampicillin, chloramphenicol, streptomycin, sulfonamides, and tetracycline), has emerged as the most common multidrug-resistant Salmonella strain in the United States. However, illnesses resulting from this strain have not been associated definitively with a source in this country.
  
  
  OBJECTIVE
  To determine the source of 2 outbreaks of Salmonella Typhimurium DT104.
  
  
  METHODS
  Matched case-control study conducted between March 24 and April 5, 1997 (outbreak 1), enhanced surveillance for new cases dating from February 1, 1997 (outbreak 2), and environmental and laboratory investigations.
  
  
  METHODS
  The case-control study included residents of 2 adjacent counties in northern California infected with the outbreak strain of Salmonella Typhimurium var Copenhagen and age-matched controls. For enhanced surveillance, a case was defined as Salmonella Typhimurium infection in a person exposed to fresh Mexican-style cheese.
  
  
  METHODS
  Risk factors for infection and source of implicated food.
  
  
  RESULTS
  Outbreak 1 peaked in February 1997; 31 patients were confirmed by culture as having Salmonella Typhimurium var Copenhagen infection, isolates of which showed indistinguishable pulsed-field gel electrophoresis (PFGE) patterns. The outbreak strain was phage type DT104 with the 5-drug resistance pattern. Sixteen cases and 25 controls were enrolled in the case-control study; 15 of 16 Salmonella Typhimurium var Copenhagen cases compared with 14 of 24 matched controls reported eating unpasteurized Mexican-style cheese, (matched odds ratio, 7.9; 95% confidence interval, 1.1-354.9). Enhanced surveillance uncovered outbreak 2, which peaked in April 1997 and was caused by a non-Copenhagen variant of Salmonella Typhimurium. During outbreak 2, Salmonella Typhimurium was isolated from 79 persons who ate fresh Mexican-style cheese from street vendors and from cheese samples and raw milk. The PFGE pattern of the milk isolate matched 1 of the 3 patterns recovered from patients; all strains were phage type DT104b with the 5-drug resistance pattern.
  
  
  CONCLUSIONS
  Raw-milk products pose a risk for multidrug-resistant Salmonella Typhimurium DT104 infections.
authors.affiliation: Division of Communicable Disease Control, California Department of Health Services, Berkeley, USA. codysar@wpgate.hhs.co.santa-clara.ca.us
authors.forename: S H
authors.initials: SH
authors.lastname: Cody
authors.forename: S L
authors.initials: SL
authors.lastname: Abbott
authors.forename: A A
authors.initials: AA
authors.lastname: Marfin
authors.forename: B
authors.initials: B
authors.lastname: Schulz
authors.forename: P
authors.initials: P
authors.lastname: Wagner
authors.forename: K
authors.initials: K
authors.lastname: Robbins
authors.forename: J C
authors.initials: JC
authors.lastname: Mohle-Boetani
authors.forename: D J
authors.initials: DJ
authors.lastname: Vugia
mesh_terms: D000293:Adolescent; D000328:Adult; D000668:Ampicillin Resistance; D000818:Animals; D002140:California / Q000453:epidemiology; D016022:Case-Control Studies; D002611:Cheese / Q000382:microbiology* / Q000506:poisoning; D002648:Child; D002675:Child, Preschool; D002702:Chloramphenicol Resistance; D004196:Disease Outbreaks; D004352:Drug Resistance, Microbial; D018432:Drug Resistance, Multiple; D016521:Electrophoresis, Gel, Pulsed-Field; D004812:Epidemiologic Methods; D005260:Female; D005511:Food Handling; D006630:Hispanic or Latino; D006801:Humans; D007223:Infant; D016013:Likelihood Functions; D008297:Male; D008875:Middle Aged; D008892:Milk / Q000382:microbiology* / Q000506:poisoning; D012478:Salmonella Food Poisoning / Q000453:epidemiology* / Q000209:etiology; D012486:Salmonella typhimurium / Q000145:classification / Q000187:drug effects / Q000302:isolation & purification; D012703:Serotyping; D013242:Sterilization; D013307:Streptomycin / Q000494:pharmacology; D013449:Sulfonamides / Q000494:pharmacology; D013753:Tetracycline Resistance
chemical_list: D013449:Sulfonamides; D013307:Streptomycin