title: A nosocomial outbreak of fluoroquinolone-resistant salmonella infection.
abstract: BACKGROUND
  Infection with fluoroquinolone-resistant strains of salmonella is rare, as is nosocomial salmonella infection. We describe the first recognized outbreak of fluoroquinolone-resistant salmonella infections in the United States, which occurred in two nursing homes and one hospital in Oregon.
  
  
  METHODS
  We interviewed medical staff and reviewed patients' charts and death certificates. In Nursing Home A we conducted a case-control study. Patients were defined as residents of the nursing home from whom fluoroquinolone-resistant Salmonella enterica serotype Schwarzengrund was isolated between February 1996 and December 1998. Controls were residents with similar medical conditions whose cultures did not yield salmonella. We compared isolates using pulsed-field gel electrophoresis and sequence analysis. We reviewed pharmacy records to compare the use of fluoroquinolone among several nursing homes.
  
  
  RESULTS
  Eleven patients with fluoroquinolone-resistant salmonellosis were identified at two nursing homes. The index patient had been hospitalized in the Philippines and had probably acquired the infection there. Transmission was probably direct (from patient to patient) or through contact with contaminated surfaces. Treatment with fluoroquinolones during the six months before a culture was obtained was associated with a significant risk of salmonella infection (4 of 5 patients had taken fluoroquinolones, as compared with 2 of 13 controls; odds ratio, 22.0; 95 percent confidence interval, 1.06 to 1177). The patients were not significantly more likely than the controls to have taken other antibiotics. More fluoroquinolones were used at Nursing Home A than at similar nursing homes in Oregon. The isolates from the outbreak had similar patterns on pulsed-field gel electrophoresis and the same gyrA mutations. The isolates from the outbreak were also similar to the only previous isolate of fluoroquinolone-resistant salmonella in the United States, which came from a patient in New York who had been transferred from a hospital in the Philippines.
  
  
  CONCLUSIONS
  We describe a prolonged nosocomial outbreak of infection with fluoroquinolone-resistant S. enterica serotype Schwarzengrund. More such outbreaks are likely in institutional settings, particularly those in which there is heavy use of antimicrobial agents.
authors.affiliation: Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA. sco2@cdc.gov
authors.forename: S J
authors.initials: SJ
authors.lastname: Olsen
authors.forename: E E
authors.initials: EE
authors.lastname: DeBess
authors.forename: T E
authors.initials: TE
authors.lastname: McGivern
authors.forename: N
authors.initials: N
authors.lastname: Marano
authors.forename: T
authors.initials: T
authors.lastname: Eby
authors.forename: S
authors.initials: S
authors.lastname: Mauvais
authors.forename: V K
authors.initials: VK
authors.lastname: Balan
authors.forename: G
authors.initials: G
authors.lastname: Zirnstein
authors.forename: P R
authors.initials: PR
authors.lastname: Cieslak
authors.forename: F J
authors.initials: FJ
authors.lastname: Angulo
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000890:Anti-Infective Agents / Q000494:pharmacology / Q000627:therapeutic use*; D016022:Case-Control Studies; D003428:Cross Infection / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission; D004196:Disease Outbreaks; D018562:Disease Transmission, Infectious; D004352:Drug Resistance, Microbial; D004363:Drug Utilization / Q000706:statistics & numerical data; D016521:Electrophoresis, Gel, Pulsed-Field; D005260:Female; D024841:Fluoroquinolones; D006761:Hospitals; D006801:Humans; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D009735:Nursing Homes; D009922:Oregon / Q000453:epidemiology; D012307:Risk Factors; D012480:Salmonella Infections / Q000453:epidemiology* / Q000382:microbiology / Q000635:transmission; D019779:Salmonella enterica / Q000145:classification / Q000187:drug effects / Q000302:isolation & purification
chemical_list: D000890:Anti-Infective Agents; D024841:Fluoroquinolones