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Two Outbreaks of Multidrug-Resistant Salmonella Serotype Typhimurium DT104 Infections Linked to Raw-Milk Cheese in Northern California
Sara H. Cody, MD;
Sharon L. Abbott, MS;
Anthony A. Marfin, MD, MPH;
Beth Schulz, MPH;
Philip Wagner;
Keith Robbins;
Janet C. Mohle-Boetani, MD;
Duc J. Vugia, MD, MPH
JAMA. 1999;281:1805-1810.
Context 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.
Design 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.
Setting and Participants 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.
Main Outcome Measures 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.
Conclusion Raw-milk products pose a risk for multidrug-resistant Salmonella Typhimurium DT104 infections.
Author Affiliations: Division of Communicable Disease Control, California Department of Health Services, Berkeley (Drs Cody, Mohle-Boetani, and Vugia and Ms Abbott); Epidemic Intelligence Service, Epidemiology Program Office (Dr Cody), and the Foodborne and Diarrheal Diseases Branch (Mr Robbins), Centers for Disease Control and Prevention, Atlanta, Ga; Public Health Department, Santa Clara Valley Health and Hospital System, San Jose, Calif (Drs Cody and Marfin); San Mateo County Department of Health, San Mateo, Calif (Ms Schulz); and the Milk and Dairy Branch, California Department of Food and Agriculture, Sacramento (Mr Wagner). Dr Cody is now with the Santa Clara County Department of Public Health, San Jose, Calif.
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