Multidrug-Resistant Salmonella Serotype Anatum in Travelers and Seafood from Asia, United States

A multidrug-resistant Salmonella enterica serotype Anatum strain reported in Taiwan was isolated in the United States from patients and from seafood imported from Asia. Isolates harbored 11 resistance determinants, including quinolone and inducible cephalosporin resistance genes. Most patients had traveled to Asia. These findings underscore the need for global One Health resistance surveillance.

We found 43 isolates genetically related to MDR Salmonella Anatum from Taiwan in the National Center for Biotechnology Information Pathogen Detection Isolates Browser (http://www.ncbi.nlm.nih. gov/pathogens). We analyzed genome assemblies for resistance determinants and plasmids by using databases adapted from ResFinder and PlasmidFinder (Center for Genomic Epidemiology, https://cge.cbs. dtu.dk). To assess strain relatedness, we constructed a core genome multilocus sequence typing (cgMLST) phylogenetic tree and pairwise matrix of allele differences by using BioNumerics version 7.6 (Applied Maths, http://www.applied-maths.com). We contacted US health departments to obtain patient information and isolates for susceptibility testing by broth microdilution (Appendix Table 1, http://wwwnc. cdc.gov/EID/article/26/5/19-0992-App1.pdf).
The 7 patients from the United States were 19-71 (median 48) years of age; 3 were women and 4 men. Among 5 patients with data on race, 3 were Asian and 2 white. All patients reported illness, including diarrhea (7/7), abdominal pain (4/7), nausea (2/7), and fever (1/7). None were hospitalized or died. Four became ill <3 days after returning from travel to the Philippines; 1 visited Japan before the Philippines. Two additional patients reported travel before illness onset; 1 traveled to the Philippines and the other to Taiwan and Mexico, but travel and illness onset dates were unavailable.
One patient had never travelled internationally. Her isolate was indistinguishable from 1 from a patient who traveled to Asia and differed by only 2 alleles from an isolate from shrimp imported from the Philippines. Before illness onset, she ate at several restaurants and had shrimp at an Asian restaurant and sushi bar.
In patient isolates from the United States, bla DHA-1 appeared to be carried in a complex integron, with the regulatory ampR gene positioned upstream and qnrB4 downstream. Six isolates had IncC plasmids similar to pR16.0676_90k (GenBank accession no. CP029802) (1), which likely carried all 11 resistance genes, but long-read sequencing is required for confirmation. Isolate PNUSAS038936 lacked the IncC plasmid replicon but appeared to have an IS26-mediated integration of the entire resistance region from the plasmid (≈60 kb) into the chromosome.
The emergence and spread of Salmonella carrying bla DHA-1 has both clinical and public health implications. Unlike most plasmid-mediated AmpC β-lactamase genes, bla DHA-1 is inducible (2,3), which can complicate detection and treatment. Isolates can appear susceptible to third-generation cephalosporins in vitro, but treatment may fail if AmpC induction occurs (3,4). The cooccurrence of bla DHA-1 ; the plasmid-mediated quinolone resistance gene qnrB4; and in the isolates from the Philippines, mph(A), a macrolide-resistance gene, is worrisome because third-generation cephalosporins (e.g., ceftriaxone), fluoroquinolones (e.g., ciprofloxacin), and the macrolide azithromycin are recommended for Salmonella infections requiring treatment (5,6). In addition, the presence of mcr-1.1, which confers resistance to colistin, a drug of last resort for treating MDR gram-negative bacterial infections, is concerning.
Our findings underscore the need for global, One Health surveillance. Most infections likely were acquired during travel in Asia. International travel, particularly to Asia, has been associated with acquisition of Salmonella with clinically important resistance (7,8). Resistance also can be disseminated via food and animals. Imported food likely was the source of infection for 1 patient without international travel. Among imported foods tested by the US Food and Drug Administration, seafood from Asia is a frequently reported source of antimicrobial-resistant Salmonella (9,10). Given the extent of international travel and trade, data sharing among human health, animal health, and food production sectors and across geographic borders is essential to detect MDR strains and inform strategies and interventions to prevent spread.

Acknowledgments
We thank state and local health departments in California, Colorado, Hawaii, and Virginia for sequencing and submitting the human Salmonella isolates described in this report and for collecting and sharing public health investigation information for patients with us. At the US Food and Drug Administration, we acknowledge the Office of Regulatory Affairs for collecting and testing the seafood samples and sequencing isolates; the GenomeTrakr program in the Center for Food Safety and Applied Nutrition for processing and submitting isolate data to the National Center for Biotechnology Information (NCBI); and National Antimicrobial Resistance Monitoring System colleagues at the Center for Veterinary Medicine for telling us about the isolates. We also thank PulseNet for processing and submitting human isolate data to NCBI, and NCBI staff for making the Pathogen Detection Isolates Browser publicly available. A lthough leptospirosis, a bacterial zoonosis, is responsible for ≈1 million cases per year worldwide, estimates of its incidence in Africa are limited by a lack of quality-assured studies (1). Humans become infected through mucosal membranes or skin breaks by direct contact with reservoir animals or exposure to urine-contaminated soil or water. We describe an outbreak of leptospirosis in prison inmates in Cape Town, South Africa, and identification of probable animal sources and environmental routes of infection.
In September 2015, the South Africa Department of Correctional Services requested the National Institute for Communicable Diseases to assist with investigation and management of leptospirosis infections in 2 inmates at a maximum-security prison in Cape Town. The National Health Laboratory Service Animal Ethics Committee clearance 131/11 granted approval for rodent trapping and testing; ethical clearance certificate no. M160667 from the Human Research Ethics Committee (Medical) of the University of the Witwatersrand covered the outbreak investigation.
Case-patient 1, a 52-year-old man, was admitted to a hospital in Cape Town. He had jaundice, overwhelming sepsis, disseminated intravascular Leptospirosis is a neglected zoonotic disease. In 2015, leptospirosis was diagnosed in 2 prison inmates in South Africa. Using real-time PCR and DNA sequencing, we identified Leptospira interrogans serogroup Icterohaemorrhagiae in rodents and water samples within the prison. Leptospirosis might be frequently underdiagnosed in South Africa.