Ceftriaxone-resistant Salmonella enterica serotype Typhi in a pregnant traveller returning from Karachi, Pakistan to Denmark, 2019.

We describe a ceftriaxone-resistant Salmonella Typhi bacteraemia in a pregnant woman returning from a family visit in Pakistan. Whole genome sequencing confirmed similarity to a Pakistani outbreak clone. Pregnancy and unawareness of this outbreak delayed appropriate antibiotic therapy. Concurrently, we detected faecal carriage of a carbapenemase-producing Escherichia coli. Awareness of the ongoing outbreak should affect empiric treatment of typhoid fever and hygiene precautions in travellers returning from Pakistan. Meropenem may be warranted in severe cases.

Emphysematous osteomyelitis caused by Salmonella typhi in beta thalassemia major.

There have been various cases of salmonella osteomyelitis reported in sickle cell anemia. We present a case of emphysematous osteomyelitis caused by Salmonella typhi in a 29-year-old beta thalassemia major patient. Diagnosis of emphysematous osteomyelitis was confirmed by computed tomography and magnetic resonance imaging, and culture of pus drained during surgical debridement confirmed the causative microorganism, Salmonella typhi. Antimicrobials were given according to microbiological sensitivity for a period of 8 weeks. Our patient also received hyperbaric oxygen therapy. At the end of therapy, he was afebrile and laboratory parameters normalized with a residual joint deformity which developed within 3 months.

Epidemiological Profile and Antimicrobial Resistance Pattern of Enteric Fever in a Tertiary Care Hospital of North India - a Seven Year Ambispective Study.

INTRODUCTION: Enteric-fever is a major public-health problem in developing countries emerging as multidrug-resistant, Nalidixic-acid resistant and extremely drug-resistant Salmonella (Pakistan, 2016), has intensified the use of WHO watch/reserve group antimicrobials such as azithromycin and meropenem. METHODS: This ambispective-study was conducted on 782 non-repeat blood-culture isolates of S. Typhi, S. Paratyphi A and S. Paratyphi B obtained from 29,184 blood cultures received at a 1000-bedded tertiary-care hospital of North-India from 2011-2017. Identification and antibiograms were obtained by Vitek-2 compact and Kirby-Bauer's disc diffusion with resistance to ampicillin, chloramphenicol and cotrimoxazole being labeled as multidrug-resistant. Decreased ciprofloxacin-susceptibility and ciprofloxacin-resistance were defined as MIC 0.125-0.5 and >1 µg/ml. RESULTS: S. Typhi and S. Paratyphi A in a ratio of 3.9:1 were seen between July-September predominantly distributed between 6-45 year age group. Resistance to co-trimoxazole, chloramphenicol, ceftriaxone and azithromycin was 6.1%, 13.8%, 16.1 and 5.78% respectively. Multidrug-resistant S. typhi and S. paratyphi A were 2.73% and 1.91% respectively. CONCLUSION: Enteric-fever is a major public-health problem in India. Emergence of multidrug-resistant, Nalidixic-acid resistant and extremely-drug resistant Salmonella mandates ongoing surveillance for targeted empirical therapy and containment of spread. Repeated epidemics call for water, sanitation, hygiene and vaccination strategies to sustain herd-immunity.

Epidemiological Characteristics and Clinical Treatment Outcome of Typhoid Fever in Ningbo, China, 2005-2014: Pulsed-Field Gel Electorophoresis Results Revealing Great Proportion of Common Transmission Sources.

We aimed to describe the molecular epidemiological characteristics and clinical treatment outcome of typhoid fever in Ningbo, China during 2005-2014. Eighty-eight Salmonella Typhi isolates were obtained from 307 hospitalized patients. Three prevalent pulsed-field gel electrophoresis (PFGE) patterns of 54 isolates from 3 outbreaks were identified. Overall, there were 64 (72.7%) isolates from clustered cases and 24 (27.3%) isolates from sporadic cases. Resistance to nalidixic acid (NAL) (n = 47; 53.4%) and ampicillin (AMP) (n = 40; 45.4%) and rare resistance to tetracycline (TET) (n = 2; 2.3%) and gentamicin (GEN) (n = 2; 2.3%) were observed. No isolates resistant to cefotaxime (CTX), chloramphenicol (CL), ciprofloxacin (CIP), and trimethoprim-sulfamethoxazole (SXT) were found. The occurrence of reduced sensitivity to CIP was 52.3% (n = 46). The medians of fever clearance time in cases with and without complications were 7 (interquartile range (IQR): 4-10) and 5 (IQR: 3-7) days (P = 0.001), respectively, when patients were treated with CIP or levofloxacin (LEV) and/or third-generation cephalosporins (CEP). Rates of serious complications were at low levels: peritonitis (2.3%), intestinal hemorrhage (6.8%), and intestinal perforation (1.1%). The present study revealed a long-term clustering trend with respect to PFGE patterns, occasional outbreaks, and the rapid spread of AMP resistance and decreased CIP susceptibility among S. Typhi isolates in recent years.

Treatment Response in Enteric Fever in an Era of Increasing Antimicrobial Resistance: An Individual Patient Data Analysis of 2092 Participants Enrolled into 4 Randomized, Controlled Trials in Nepal.

BACKGROUND.: Enteric fever, caused by Salmonella Typhi and Salmonella Paratyphi A, is the leading cause of bacterial febrile disease in South Asia. METHODS.: Individual data from 2092 patients with enteric fever randomized into 4 trials in Kathmandu, Nepal, were pooled. All trials compared gatifloxacin with 1 of the following comparator drugs: cefixime, chloramphenicol, ofloxacin, or ceftriaxone. Treatment outcomes were evaluated according to antimicrobial if S. Typhi/Paratyphi were isolated from blood. We additionally investigated the impact of changing bacterial antimicrobial susceptibility on outcome. RESULTS.: Overall, 855 (41%) patients had either S. Typhi (n = 581, 28%) or S. Paratyphi A (n = 274, 13%) cultured from blood. There were 139 (6.6%) treatment failures with 1 death. Except for the last trial with ceftriaxone, the fluoroquinolone gatifloxacin was associated with equivalent or better fever clearance times and lower treatment failure rates in comparison to all other antimicrobials. However, we additionally found that the minimum inhibitory concentrations (MICs) against fluoroquinolones have risen significantly since 2005 and were associated with increasing fever clearance times. Notably, all organisms were susceptible to ceftriaxone throughout the study period (2005-2014), and the MICs against azithromycin declined, confirming the utility of these alternative drugs for enteric fever treatment. CONCLUSION.: The World Health Organization and local government health ministries in South Asia still recommend fluoroquinolones for enteric fever. This policy should change based on the evidence provided here. Rapid diagnostics are urgently required given the large numbers of suspected enteric fever patients with a negative culture.

A case of clinical and microbiological failure of azithromycin therapy in Salmonella enterica serotype Typhi despite low azithromycin MIC.

Typhoid fever remains a serious problem in many developing countries. Due to resistance to multiple first line drugs, azithromycin has evolved as an important drug in the treatment of typhoid. While therapy with azithromycin is highly effective, no clinically validated mean inhibitory concentration (MIC) break points or disc diffusion cutoff guidelines are available so far. We describe an Indian adult with clinical and microbiological failure to azithromycin despite low azithromycin MIC.

Typhoid fever: case report and literature review. / Fiebre tifoidea: reporte de caso y revisión de la literatura.

Typhoid fever remains a major health problem worldwide, in contrast to Chile, where this disease is an isolated finding. Clinical presentation is varied, mainly presenting with fever, malaise, abdominal discomfort, and nonspecific symptoms often confused with other causes of febrile syndrome. We report a six-year-old, male patient presenting with fever of two weeks associated with gastrointestinal symptoms, malaise, hepatomegaly and elevated liver enzymes. Differential diagnoses were considered and a Widal reaction and two blood cultures were requested; both came back positive, confirming the diagnosis of typhoid fever caused by Salmonella typhi. Prior to diagnosis confirmation, empirical treatment was initiated with ceftriaxone and metronidazole, with partial response; then drug therapy was adjusted according to ciprofloxacin susceptibility testing with a favorable clinical response. We discuss diagnostic methods and treatment of enteric fever with special emphasis on typhoid fever.

La fiebre tifoidea continúa siendo un importante problema de salud a nivel mundial, en contraste con Chile donde esta patología es un hallazgo aislado. Las formas clínicas son variadas, se presenta principalmente con fiebre, compromiso del estado general, manifestaciones abdominales y síntomas inespecíficos, confundiéndose con otras causas de síndrome febril. Se presenta el caso clínico de un varón de seis años con fiebre de dos semanas de evolución, asociado a síntomas digestivos, compromiso del estado general, hepatomegalia y aumento de enzimas hepáticas. Para el diagnóstico diferencial, se solicitaron: una reacción de Widal y dos hemocultivos. Ambos con resultados positivos, confirmando el diagnóstico de fiebre tifoidea por Salmonella typhi. Previo a esto el paciente fue tratado empíricamente con ceftriaxona y metronidazol, con respuesta parcial; luego se ajustó el manejo, según antibiograma, a ciprofloxacino y la evolución fue satisfactoria. Se discuten métodos, diagnóstico y tratamiento de fiebre entérica con especial énfasis en fiebre tifoidea.

A novel ciprofloxacin-resistant subclade of H58 Salmonella Typhi is associated with fluoroquinolone treatment failure.

The interplay between bacterial antimicrobial susceptibility, phylogenetics and patient outcome is poorly understood. During a typhoid clinical treatment trial in Nepal, we observed several treatment failures and isolated highly fluoroquinolone-resistant Salmonella Typhi (S. Typhi). Seventy-eight S. Typhi isolates were genome sequenced and clinical observations, treatment failures and fever clearance times (FCTs) were stratified by lineage. Most fluoroquinolone-resistant S. Typhi belonged to a specific H58 subclade. Treatment failure with S. Typhi-H58 was significantly less frequent with ceftriaxone (3/31; 9.7%) than gatifloxacin (15/34; 44.1%)(Hazard Ratio 0.19, p=0.002). Further, for gatifloxacin-treated patients, those infected with fluoroquinolone-resistant organisms had significantly higher median FCTs (8.2 days) than those infected with susceptible (2.96) or intermediately resistant organisms (4.01)(pS. Typhi clade internationally, but there are no data regarding disease outcome with this organism. We report an emergent new subclade of S. Typhi-H58 that is associated with fluoroquinolone treatment failure.

Antibacterial effect of roselle extracts (Hibiscus sabadariffa), sodium hypochlorite and acetic acid against multidrug-resistant Salmonella strains isolated from tomatoes.

UNLABELLED: Antibiotic-resistant Salmonella strains were isolated from saladette and red round type tomatoes, and an analysis done of the antibacterial activity of roselle calyx extracts against any of the identified strains. One hundred saladette tomato samples and 100 red round tomato samples were collected from public markets. Each sample consisted of four whole tomatoes. Salmonella was isolated from the samples by conventional culture procedure. Susceptibility to 16 antibiotics was tested for the isolated Salmonella strains by standard test. The antibacterial effect of four roselle calyx extracts (water, methanol, acetone and ethyl acetate), sodium hypochlorite and acetic acid against antibiotic-resistant Salmonella isolates was evaluated on contaminated tomatoes. Twenty-four Salmonella strains were isolated from 12% of each tomato type. Identified Salmonella serotypes were Typhimurium and Typhi. All isolated strains exhibited resistance to at least three antibiotics and some to as many as 12. Over contaminated tomatoes, the roselle calyx extracts produced a greater reduction (2-2·6 log) in antibiotic-resistant Salmonella strain concentration than sodium hypochlorite and acetic acid. SIGNIFICANCE AND IMPACT OF THE STUDY: The presence of multidrug-resistant Salmonella in vegetables is a significant public health concern. Multidrug-resistant Salmonella strains were isolated from raw tomatoes purchased in public markets in Mexico and challenged with roselle Hibiscus sabdariffa calyx extracts, sodium hypochlorite and acetic acid. On tomatoes, the extracts caused a greater reduction in the concentration of antibiotic-resistant Salmonella strains than sodium hypochlorite and acetic acid. Roselle calyx extracts are a potentially useful addition to disinfection procedures of raw tomatoes in the field, processing plants, restaurants and homes.

Absence of multidrug resistance in Salmonella enterica serotypes Typhi and Paratyphi A isolates with intermediate susceptibility to ciprofloxacin.

BACKGROUND: We describe the antimicrobial susceptibility pattern of 64 blood stream isolates of Salmonella enterica serotypes Typhi and Paratyphi A studied from January 2013 to December 2014 at a tertiary care centre in North India. METHODS: Isolates were identified by standard biochemical reactions and confirmed by slide agglutination using specific antisera. Antimicrobial susceptibility testing was performed by Kirby-Bauer disc diffusion method and by E-test. RESULTS: In this study, 92% (46/50) of Salmonella Typhi and all Paratyphi A (n=14) isolates were susceptible to ampicillin, chloramphenicol and cotrimoxazole. Eighty percent of Typhi (40/50) and 64% (9/14) of Paratyphi A were intermediately susceptible to ciprofloxacin. Nineteen percent (12/64) of isolates were resistant to ciprofloxacin. No resistance to ceftriaxone and azithromycin was detected. CONCLUSIONS: Our study adds to the current knowledge of world-wide reports of multidrug resistance in S. Typhi.

Synthesis of silver nanoparticles using A. indicum leaf extract and their antibacterial activity.

Green synthesis of silver nanoparticles has been achieved using environmentally acceptable plant extract. It is observed that Abutilon indicum leaf extract can reduce silver ions into silver nanoparticles within 15 min of reaction time. The formation and stability of the reduced silver nanoparticles in the colloidal solution were monitored by UV-Vis spectrophotometer analysis. The mean particle diameter of silver nanoparticles was calculated from the XRD pattern. FT-IR spectra of the leaf extract after the development of nanoparticles are determined to allow identification of possible functional groups responsible for the conversion of metal ions to metal nanoparticles. The AgNPs thus obtained showed highly potent antibacterial activity toward Gram-positive (Staphyloccocus aureus and Bacillus subtilis) and Gram-negative (Salmonella typhi and Escherichia coli) microorganisms.

Septic arthritis of the hip in a Cambodian child caused by multidrug-resistant Salmonella enterica serovar Typhi with intermediate susceptibility to ciprofloxacin treated with ceftriaxone and azithromycin.

Septic arthritis is a rare complication of typhoid fever. A 12-year-old boy without pre-existing disease attended a paediatric hospital in Cambodia with fever and left hip pain. A hip synovial fluid aspirate grew multidrug-resistant Salmonella enterica ser. Typhi with intermediate susceptibility to ciprofloxacin. Arthrotomy, 2 weeks of intravenous ceftriaxone and 4 weeks of oral azithromycin led to resolution of symptoms. The optimum management of septic arthritis in drug-resistant typhoid is undefined.

Fever of unknown origin attributable to haematocolpos infected with Salmonella enterica Serotypetyphi resistant to nalidixic acid: a case report.

The prevalence of nalidixic acid-resistant Salmonella Typhi (NARST) infection is increasing worldwide. We are reporting an unusual case of infected haematocolpos presenting as urinary obstruction in a patient with fever of unknown origin (FUO). This case report highlights the importance of quinolone-resistant typhoid fever in the differential diagnosis of any acute febrile illness in countries, like India, where Salmonella infection is endemic.

Antimicrobial susceptibility of Salmonella enterica serovars in a tertiary care hospital in southern India.

BACKGROUND & OBJECTIVES: Salmonella enterica serovars Typhi and Paratyphi are predominantly known to cause enteric fever. Multidrug resistance in S. Tphi and S. Paratyphi has emerged as a cause of concern. This study was done to evaluate status in antimicrobial susceptibility patterns of Salmonella enterica serovar Typhi (S. Typhi) and S. Paratyphi obtained from blood culture in a tertiary care hospital in south India. METHODS: Blood isolates of Salmonella species over a two year period between May 2009 and June 2011 were studied. A total of 322 isolates of Salmonella species were tested for antimicrobial susceptibility by Kirby-Bauer disc diffusion method. The MIC of ciprofloxacin was obtained by E-test, and azithromycin MIC was confirmed by agar dilution method for a limited number of isolates. RESULTS: Of the total of 322 isolates studied, 186 (57.8%) were S. Typhi, 134 (41.6%) were S. Paratyphi A, and two were S. Paratyphi B. Of these, 44(13.66%) were resistant to ciprofloxacin (MIC <0.50 µg/ml) and 296 (91.9%) were nalidixic acid resistant. Of these 296 nalidixic acid resistant isolates, 278 (94%) were susceptible to ciprofloxacin by MIC criteria (<0.5 µg/ml). Of the 262 isolates tested for azithromycin sensitivity, only 120 (46%) were susceptible, whereas 81 (31%) were resistant and 55 (21%) showed intermediate susceptibility. Of the isolates, 322 (90%) were susceptible to ampicillin and (95%) were susceptible to co-trimoxazole. However, all the isolates were susceptible to chloramphenicol and ceftriaxone. INTERPRETATION & CONCLUSIONS: Nalidixic acid resistance screening is not a reliable surrogate indicator of ciprofloxacin resistance. Ciprofloxacin MIC should to be routinely done. Azithromycin resistance appears to be emerging. However, isolates showed a high degree of susceptibility to ampicillin, co-trimoxazole and chloramphenicol. Thus, antibiotics like ampicillin and co-trimoxazole may once again be useful for the management of enteric fever in southern India.

Decreased ciprofloxacin susceptibility in Salmonella Typhi and Paratyphi infections in ill-returned travellers: the impact on clinical outcome and future treatment options.

The emergence of decreased ciprofloxacin susceptibility (DCS) in Salmonella enterica serovar Typhi and serovar Paratyphi A, B or C limits treatment options. We studied the impact of DCS isolates on the fate of travellers returning with enteric fever and possible alternative treatment options. We evaluated the clinical features, susceptibility data and efficacy of empirical treatment in patients with positive blood cultures of a DCS isolate compared to patients infected with a ciprofloxacin-susceptible (CS) isolate in the period from January 2002 to August 2008. In addition, the pharmacokinetic and pharmacodynamic parameters of ciprofloxacin, levofloxacin and gatifloxacin were determined to assess if increasing the dose would result in adequate unbound fraction of the drug 24-h area under the concentration-time curve/minimum inhibitory concentration (ƒAUC(0-24)/MIC) ratio. Patients with DCS more often returned from the Indian subcontinent and had a longer fever clearance time and length of hospital stay compared to patients in whom the initial empirical therapy was adequate. The mean ƒAUC(0-24)/MIC was 41.3 ± 18.8 in the patients with DCS and 585.4 ± 219 in patients with a CS isolate. For DCS isolates, the mean ƒAUC0-24/MIC for levofloxacin was 60.5 ± 28.7 and for gatifloxacin, it was 97.9 ± 28.0. Increasing the dose to an adequate ƒAUC(0-24)/MIC ratio will lead to conceivably toxic drug levels in 50% of the patients treated with ciprofloxacin. Emerging DCS isolates has led to the failure of empirical treatment in ill-returned travellers. We demonstrated that, in some cases, an adequate ƒAUC(0-24)/MIC ratio could be achieved by increasing the dose of ciprofloxacin or by the use of alternative fluoroquinolones.

Enteric fever in Karachi: current antibiotic susceptibility of Salmonellae isolates.

OBJECTIVE: To determine the current sensitivity and resistance profile of Salmonellae (S.) isolates in a laboratory setting. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Dr. Essa`s Laboratory and Diagnostic Centre, Karachi, Pakistan, from November 2008 - October 2010. METHODOLOGY: Isolates from blood culture specimens of 481 bacteraemic patients were identified using conventional biochemical tests. Salmonellae was confirmed with specific antisera and their antibiograms determined by Kirby-Bauer Disc Diffusion method using 12 relevant antibiotics. Inclusions of the study were bacteraemia documented in all blood samples positive for S. typhi, S. paratyphi-A and B. Exclusions were all samples other than blood and blood samples negative for S. typhi and S. paratyphi-A and B during the same period. Multidrug resistance (MDR) of isolates was defined as the isolates showing resistance to all conventional anti-typhoid medicines i.e., Chloramphenicol, Ampicillin and Co-trimoxazole. RESULTS: Specimens (n=217) yielded 131 Salmonellae typhi (60.36%), 71 S. paratyphi-A (32.71%), and 15 S. paratyphi-B (6.9%); these were sensitive to the Quinolones [Enoxacin: 94.96% (n=91), Ciprofloxacin, 96.47% (n=182), Ofloxacin: 95.74% (n=203)], and Cephalosporins [Cefixime: 96.62% (n=202), Cefotaxime: 99.17% (n=206), Ceftriaxone: 98.79% (n=208)]. Resistance to Amoxicillin was 96.48% (n=128) and 29.91% (n=78) to Co-trimoxazole. About 62.64% (n=136) of the isolates were MDR strains. CONCLUSION: Ciprofloxacin is currently a suitable empirical choice in presumed enteric fever cases, but culture and sensitivity analysis should be encouraged and results incorporated in prescription strategy. Increasing frequency of S. paratyphi-A isolates possibly suggests incomplete coverage employing monovalent vaccine.

Highly resistant Salmonella enterica serovar Typhi with a novel gyrA mutation raises questions about the long-term efficacy of older fluoroquinolones for treating typhoid fever.

As a consequence of multidrug resistance, clinicians are highly dependent on fluoroquinolones for treating the serious systemic infection typhoid fever. While reduced susceptibility to fluoroquinolones, which lessens clinical efficacy, is becoming ubiquitous, comprehensive resistance is exceptional. Here we report ofloxacin treatment failure in typhoidal patient infected with a novel, highly fluoroquinolone-resistant isolate of Salmonella enterica serovar Typhi. The isolation of this organism has serious implications for the long-term efficacy of ciprofloxacin and ofloxacin for typhoid treatment.

In vitro susceptibility of typhoidal Salmonellae against newer antimicrobial agents: a search for alternate treatment options.

OBJECTIVES: To determine the minimum inhibitory concentrations (MICs) of ceftriaxone, azithromycin, pefloxacin, cefipime and imipenem for Salmonella Typhi (S. Typhi) and Paratyphi. METHODS: One hundred and fifty four isolates of Salmonella Typhi and S. Paratyphi A, B and C growing in blood culture were selected. MICs of ceftriaxone, azithromycin, pefloxacin, cefipime and imipenem were performed by agar dilution method as recommended by clinical laboratory standard institutes. RESULTS: MIC90 of azithromycin and pefloxacin was 8 microg/ml, cefipime was 0.06 microg/ml and imipenem was 0.5 microg/ml. None of the strains were found to be resistant to ceftriaxone but 3 isolates showed higher MIC value of 2 microg/ml. CONCLUSION: Azithromycin appears a suitable alternate for the treatment of typhoid in the community. Imipenem and cefipime are good options in complicated cases to be treated in hospital settings. Pefloxacin cannot be used as MICs are higher. Presence of isolates with higher MIC of ceftriaxone is serious and stresses upon continuous laboratory surveillance to guide clinicians appropriately.

The influence of reduced susceptibility to fluoroquinolones in Salmonella enterica serovar Typhi on the clinical response to ofloxacin therapy.

BACKGROUND: Infection with Salmonella enterica serovar Typhi (S. Typhi) with reduced susceptibility to fluoroquinolones has been associated with fluoroquinolone treatment failure. We studied the relationship between ofloxacin treatment response and the ofloxacin minimum inhibitory concentration (MIC) of the infecting isolate. Individual patient data from seven randomised controlled trials of antimicrobial treatment in enteric fever conducted in Vietnam in which ofloxacin was used in at least one of the treatment arms was studied. Data from 540 patients randomised to ofloxacin treatment was analysed to identify an MIC of the infecting organism associated with treatment failure. PRINCIPAL FINDINGS: The proportion of patients failing ofloxacin treatment was significantly higher in patients infected with S. Typhi isolates with an MIC≥0.25 µg/mL compared with those infections with an MIC of ≤0.125 µg/mL (p<0.001). Treatment success was 96% when the ofloxacin MIC was ≤0.125 µg/mL, 73% when the MIC was between 0.25 and 0.50 µg/mL and 53% when the MIC was 1.00 µg/mL. This was despite a longer duration of treatment at a higher dosage in patients infected with isolates with an MIC≥0.25 µg/mL compared with those infections with an MIC of ≤0.125 µg/mL. SIGNIFICANCE: There is a clear relationship between ofloxacin susceptibility and clinical outcome in ofloxacin treated patients with enteric fever. An ofloxacin MIC of ≥0.25 µg/mL, or the presence of nalidixic acid resistance, can be used to define S. Typhi infections in which the response to ofloxacin may be impaired.

Enteric fever in a 6-year-old traveler caused by Salmonella enterica serotypes Typhi and Paratyphi A: laboratory detection strategies and treatment options.

We report the first pediatric case of enteric fever caused by Salmonella enterica serotypes Typhi and Paratyphi A. Mixed infections are infrequently reported, potentially because detection of two different Salmonella serotypes in blood cultures is technically challenging. We suggest laboratory strategies to aid in the recognition of mixed infections.