microorganisms

Review
Understanding the Mechanism of Antimicrobial Resistance and
Pathogenesis of Salmonella enterica Serovar Typhi
Maryam Khan and Saba Shamim *

Institute of Molecular Biology and Biotechnology, The University of Lahore, Defence Road Campus,
Lahore 54000, Pakistan
* Correspondence: sabashamimgenetics@gmail.com; Tel.: +92-3218843748

Abstract: Salmonella enterica serovar Typhi (S. Typhi) is a Gram-negative pathogen that causes typhoid
fever in humans. Though many serotypes of Salmonella spp. are capable of causing disease in both
humans and animals alike, S. Typhi and S. Paratyphi are common in human hosts only. The global
burden of typhoid fever is attributable to more than 27 million cases each year and approximately
200,000 deaths worldwide, with many regions such as Africa, South and Southeast Asia being the
most affected in the world. The pathogen is able to cause disease in hosts by evading defense
systems, adhesion to epithelial cells, and survival in host cells in the presence of several virulence
factors, mediated by virulence plasmids and genes clustered in distinct regions known as Salmonella
pathogenicity islands (SPIs). These factors, coupled with plasmid-mediated antimicrobial resistance
genes, enable the bacterium to become resistant to various broad-spectrum antibiotics used in the
treatment of typhoid fever and other infections caused by Salmonella spp. The emergence of multidrug-
resistant (MDR) and extensively drug-resistant (XDR) strains in many countries of the world has
raised great concern over the rise of antibiotic resistance in pathogens such as S. Typhi. In order
to identify the key virulence factors involved in S. Typhi pathogenesis and infection, this review
delves into various mechanisms of virulence, pathogenicity, and antimicrobial resistance to reinforce
Citation: Khan, M.; Shamim, S.
Understanding the Mechanism of
efficacious disease management.
Antimicrobial Resistance and
Pathogenesis of Salmonella enterica Keywords: Salmonella; typhoid fever; antimicrobial resistance; plasmids; pathogenicity islands;
Serovar Typhi. Microorganisms 2022, multidrug-resistant; extensively drug-resistant
10, 2006. https://doi.org/10.3390/
microorganisms10102006

Academic Editors: Bijay Khajanchi

1. Introduction
and Steven Foley
Salmonella enterica serovar Typhi (S. Typhi) is a Gram-negative, rod-shaped, flagellated
Received: 20 July 2022
bacterium. The entire bacterium is covered with a capsule that is attributable to its virulence
Accepted: 26 September 2022
and evasion of phagocytosis in the host, thereby aiding in causing infection [1]. Various
Published: 11 October 2022
species of Salmonella are pervasively found in diverse environments and are capable of
Publisher’s Note: MDPI stays neutral causing infection in humans and animals alike. These intracellular pathogens can evade
with regard to jurisdictional claims in and resist immune responses in the host, which can effectively trigger virulence and cause
published maps and institutional affil- infection. Classified according to the White–Kauffmann–Le Minor scheme, approximately
iations. 1600 serotypes of Salmonella have been sorted into the subspecies enterica [2]. On a general
scale, most serotypes are basically categorized into typhoidal and nontyphoidal strains,
in which the former includes S. Typhi and S. Paratyphi A, which are common in humans
only, while the latter strains are reported to infect both humans and several species of
Copyright: © 2022 by the authors.
animals, resulting in different illnesses, such as enteric fever, sepsis, gastroenteritis, and
Licensee MDPI, Basel, Switzerland.
salmonellosis, respectively [3].
This article is an open access article
Humans are the reservoir of S. Typhi, which has limited ability to multiply outside its
distributed under the terms and
host, though it may be capable of surviving for a prolonged time in the environment [4].
conditions of the Creative Commons
Attribution (CC BY) license (https://
The mode of its transmission is largely indirect and most commonly vehicle-borne via
creativecommons.org/licenses/by/
contaminated food and water sources [5,6]. Though S. Typhi is capable of surviving for long
4.0/). periods of time in the environment, it does not multiply in food and water sources. The

Microorganisms 2022, 10, 2006. https://doi.org/10.3390/microorganisms10102006 https://www.mdpi.com/journal/microorganisms

Microorganisms 2022, 10, 2006 2 of 15

transmission of S. Typhi is classified into two patterns. Short-cycle transmission refers to

the contamination of food and water sources by shedding of the bacterium through feces in
the immediate environment or close proximity, which facilitates transmission through poor
hygiene and sanitation practices, and is generally linked to food handlers [7]. Long-cycle
transmission occurs when the broader environment (such as untreated water or sewage) is
polluted with human feces or when it is used as a raw fertilizer for crops [8]. Long-cycle
transmission pathways are difficult to trace because it is challenging to isolate S. Typhi from
the environment [9]. The entry route of S. Typhi is the mouth, where the pathogen enters
through ingesting food and water sources contaminated with fecal matter. Postinfection,
the incubation period decreases while the risk of disease increases, correlating with the
ingested dose [4,10,11]. S. Typhi is regarded as the primary cause of typhoid fever, usually
contracted via the ingestion of contaminated food and/or water [12]. It is often considered
a travel-associated disease [13,14]. In countries such as Pakistan, the causative pathogen
is the major reported cause of pediatric septicemia [15–17]. Moreover, Salmonella spp. are
globally reported to be major foodborne pathogens, accounting for <50,000 cases in Europe
alone, with more than 80 million annual cases recorded for the year 2020 [18]. Meat, eggs,
live poultry, and dairy products are recognized as great risk sources [19,20]. Moreover,
the risk of infection is associated with various factors, predominantly poor hygiene and
lack of clean water, as well as lifestyle and environmental hazards in middle- and low-
income countries, while in high-income countries, the risk factors are mainly linked to
quintessential contamination of fruit, vegetable, and meat sources [21–23].
Though there have been various advances in the practices of healthcare and medicine,
an increasing number of people have been at risk of contracting typhoid fever, which can
be a leading reason for death in serious or complicated cases. Prior to treatment with
antimicrobial drugs, the fatality risk of typhoid fever fell between 10% and 30%, which
has now reduced to less than 1%. Presently, the rise of resistant S. Typhi strains that
evade antimicrobial agents poses a significant threat to its effective treatment [24]. The
terminology “MDR” refers to “multidrug-resistant” strains, which are seemingly resistant
to several broad-spectrum and first-generation antibiotics, whereas the term “XDR” refers
to “extensively drug-resistant” strains, which are resistant to several antibiotics, such as
ampicillin, fluoroquinolones, and chloramphenicol, along with many third-generation
antibiotics, respectively [25]. According to antimicrobial resistance data (2018/2019) by
EFSA, the prevalence of MDR Salmonella spp. in humans was reported to be more than
25% [26]. Though the fatality rate is less in developed countries, typhoid fever is a disease
that still causes more than 200,000 fatalities annually worldwide [27]. There are several
predisposing factors that indicate the severity of typhoid fever, which are necessary for
the evaluation of its treatment, prevention, and mitigation. This information is critical
in managing the economy of healthcare and its resources, which are important for the
regulation of public health. Moreover, the required information and knowledge of the
current trend of disease is very important with respect to frequent transmission [28].

2. Typhoid Fever: Epidemiology, Clinical Manifestations, and Diagnosis

Typhoid fever presents itself to be a cause of global concern, with more than 27 mil-
lion cases and approximately 200,000 deaths every year globally [29,30]. While cases are
recorded all over the world, the regions contributing most to the global burden are Africa,
South and Southeast Asia, as well as the Western Pacific regions [31–33]. In Pakistan, the
provinces of Punjab and Sindh are reported to be declared the most severely affected,
among other Asian regions [34,35].
Typhoid fever is marked by potentially life-threatening fever with a multitude of
clinical signs and symptoms. In spite of many years of research, much about the disease is
still unknown [25]. Its first incidences are reported to date back to the early 19th century,
bringing it close to the time when its causative agent, S. Typhi, known as typhoid bacillus at
that time, was discovered by Dr. Karl Eberth in the 1880s [36]. It is usually characterized as
a disease that typically afflicts children, immunocompromised adults, and the elderly, while
Microorganisms 2022, 10, 2006 3 of 15

the incidence of infection in infants happens to be rare but is present [37]. Most hospitals
present cases affecting children and adults within the age bracket of 5–25 years [38,39]. The
entry of S. Typhi and its subsequent invasion and attack on the host cells is accompanied
by a short period of bacteremia, which presents no clinical symptoms in the host. This
incubation period usually spans 2 weeks but can also last a month, a factor that is largely
dependent on the bacterial count in host cells. Once this incubation period has passed,
symptoms can comprise of fever, fatigue, loss of appetite, headache, myalgia, nausea, cough
(dry), and diarrhea. Occasional shedding of bacteria through stool can be possible before
the manifestation of any clinical symptoms of disease, which might include fever, abdomi-
nal discomfort and pain, rose-colored spotting on skin, and organ perforation [40]. In the
case of insufficient or lack of treatment thereof, body temperature remains elevated, while
symptoms such as nausea, increased pulse rate, headache, and persistent cough remain
apparent [12]. These symptoms can highly vary from mild to severe, where mild symptoms
are low fever, fatigue, and diarrhea, including perforations in the intestines in the case of
acute and chronic inflammation, internal bleeding, and hemorrhage during infection [12,41].
Moreover, the intestinal surface surrounding the lesions can be comparatively healthy and
unaffected compared with the affected area. Surprisingly enough, S. Typhi that can be cul-
tured is not usually found at the perforation sites, though the DNA of the bacterium is often
detected [42]. As part of the immune response, CD68+ macrophages are the most dominant
immune cells at affected sites, along with B and T cells. Therefore, these perforations may
be clinically and pathologically similar to the presensitization phase, as observed from
“Shwartzman and Koch” reactions. Moreover, neurological complications may arise in the
most severe of cases [43,44]. The clinical and pathophysiological manifestation of typhoid
fever is largely dependent upon the severity of the case in patients. In regions with a high
incidence of the disease, community-based investigations have suggested that many of the
patients suffer from atypical typhoid fever [45]. Therefore, an approximate number of 60–90%
are treated as outpatients in various hospitals. In the case of patients receiving hospital care,
sufficient care, good nutrition, careful administration of antibiotics regimen, as well as the
prevention of disease complications are the major practices that need to be followed to avoid
complications and fatality associated with the disease [16,25].
For the diagnosis of typhoid fever, the standard procedure remains to be bone marrow
culture, but it is not commonly pursued, as it is not practical to perform it in several
endemic-hit areas. Instead, blood culture is more commonly adopted as a customary
procedure for diagnosing typhoid and paratyphoid fever, which stands at an average
sensitivity of more than 6%, according to a review [46]. Therefore, the method of diagnosis
stands to be a crucial point in effective treatment and is very important to develop new,
efficient, safer, and cheaper methods for swift diagnosis, which can be essential in saving
lives in critical cases [47]. Moreover, rapid diagnostic tests could be used in combination
with clinically devised algorithms for the differentiation of febrile patients and chronic
carriers for a more directed approach toward effective management, particularly in areas
where there is a dearth of sufficient laboratory equipment and medical facilities. Many
rapid diagnostic tests such as Typhidot, Typhidot-M test, TUBEX, and Test-It have been
developed for the swift diagnosis of typhoid, paratyphoid, and enteric fever. However,
these tests are less sensitive for disease detection [48]. Other diagnostic methods that are
being developed for the detection of pathogens include antibody in lymphocyte (ALS)
supernatant, which has been reported to exhibit remarkable sensitivity and specificity levels
in various endemic-hit areas [49–51]. In addition, PCR-based methods also show promise
at a small scale, but no such method is in current use at a widespread level, due to which its
effective sensitivity and specificity cannot be deciphered accurately. Nevertheless, this can
be enhanced by the incorporation of a pre-enrichment step in the PCR-based assays [52].
However, widespread usage of molecular-biology-based methods is, therefore, limited by
restricted medical and laboratory resources, the cost of the procedures, and the time period
required to complete the procedure [53]. Future aspects of serovar detection can be based
on high-throughput methods that can be swiftly utilized for the detection of pathogenic
Microorganisms 2022, 10, 2006 4 of 15

and resistant serovars through techniques such as mass spectrometry, antigen arrays, and
next-generation sequencing (NGS) [54,55]. The use of mass spectrometry has been reported
to be used in samples for the identification of typhoid fever from paratyphoid and enteric
fever with the help of metabolites [56–58]. Moreover, information pertaining to transcription
from patients suffering from typhoid fever (acute) may be employed for the identification of
specific signatures, which can effectively aid in the detection of typhoid cases [59,60].

3. Emergence of Antimicrobial Resistance and Current Predomination Worldwide

Prior to the routine use of antibiotics for the treatment of bacterial infections, typhoid
fever presented itself to be a great challenge in terms of effective detection and treatment.
In 1947, the main antibiotic that was prescribed for treating typhoid and enteric fever was
chloramphenicol, but the later years of the decade saw the emergence of resistance in
Salmonella spp. As an outcome of increasing plasmid-mediated resistance against chlo-
ramphenicol, the majority of infections all over the world were now being caused by
chloramphenicol-resistant Salmonella spp., which culminated in sporadic epidemics world-
wide. An example would be the epidemic in Mexico, where more than 10,000 cases of
typhoid fever caused by MDR strains were reported. Though that epidemic was con-
trolled, other reports of breakouts in various countries were vastly reported in the coming
years [35]. The past few decades have seen the rise of multidrug-resistant (MDR) S. Typhi,
resistant to typical first-line antibiotics such as chloramphenicol, ampicillin, and trimetho-
prim/sulfamethoxazole, which has led to the use of fluoroquinolone antibiotics, such as
ciprofloxacin, as first-line treatment. However, fluoroquinolone resistance, particularly in
South Asia, has resulted in third-generation cephalosporins (e.g., ceftriaxone) being used
as a first-line treatment [61].
Since the emergence of these MDR strains in the 1980s [62], the world has been
observing the silent yet swift rise of these strains in terms of resistance, first with second-
generation antibiotics such as fluoroquinolones. Since then, third-generation antibiotics
such as cefoperazone, cefotaxime, and ceftriaxone, along with cephalosporins, have been
employed for the treatment of Salmonella infections [63]. However, resistance against these
antibiotics has been sporadically reported [64]. Despite the prevalence of MDR strains in
Asian countries, cases have also been reported in regions of Africa, including South Africa,
Egypt, Nigeria, and Kenya [65], as well as several countries across Europe [66]. In 2016,
the city of Hyderabad, Pakistan, reported the first case of XDR S. Typhi [67], the number of
which has escalated to more than 10,000 XDR cases in Pakistan alone, as documented by
WHO [68]. Alarmingly, several cases of XDR S. Typhi have also been reported in developed
countries such as Canada [69], Australia [70], Denmark [71], and the USA [72]. Likewise,
outbreaks have also been reported in various other countries such as Bangladesh, the
Philippines, Iraq, and India [73]. Moreover, cases of emerging antibiotic resistance have
been reported to be exacerbated by international travel, enabling the transfer of resistant
bacterial strains [74]. Furthermore, reports from early to late 2018 (January–October)
indicated the spread of S. Typhi XDR strains to be associated with international travel to
and from Pakistan, in which out of six reported cases, five were reported to originate from
the United States (USA), while the remaining one was reported from the United Kingdom
(UK). Initial reports revealed that four out of six cases were either permanent residents
or had arrived (prior to infection) in Karachi, Islamabad, and Lahore. In the other cases,
one patient was revealed to be a resident of Lahore, while the other had a travel history to
Sindh (Karachi). Evidential data suggested that all travel-related cases of XDR strains were
positively treated with effective treatment, but the route of exposure and the early onset
was unknown. Recently, a case in Canada was treated for XDR typhoid, which originated
in Pakistan, as the patient (a child) had traveled from Canada to Sindh, Pakistan, and
then to Canada back again, where subsequent diagnosis and treatment were given [69].
During times of the COVID-19 pandemic, typhoid cases have been on the increase in
Pakistan, with more than 20,000 cases being reported in June 2020 [75]. Over the past two
decades, the emergence of S. Typhi haplotype H58, also known as 4.3.1, has been reported
Microorganisms 2022, 10, 2006 5 of 15

to be dominant in Asia and Africa [76]. This genotype has been associated with decreased
S. Typhi susceptibility to fluoroquinolones [77], as well as the acquisition of IncHI1 plasmids
for resistance. Upon phylogenetic analysis, it was found that this genotype might have
originated from South Asia, but this is not well understood [78].
Conventionally, typhoid fever caused by MDR strains exhibits resistance to all first-
generation antibiotics recommended by WHO, such as ampicillin, chloramphenicol, and
sulfamethoxazole/trimethoprim. The rise of MDR and quinolone-resistant S. Typhi strains
signifies a grave health risk in Pakistan, as quinolone-resistant strains are commonly
reported in cases of typhoid and enteric fever. However, a previous study carried out
(2001–2006) at Aga Khan University, Karachi, Pakistan, revealed that the incidence of MDR
S. Typhi strains had increased from <30% to <45% [79]. The rise of quinolone-resistant
S. Typhi strains has shifted treatment options to third-generation antibiotics (cephalosporins).
In Sindh, resistance to third-generation antibiotics, including ceftriaxone, has been on the
rise since 2016. This is proven true by the ability of Salmonella serovars to transform from
MDR to XDR by acquiring a resistance plasmid, enabling resistance of the pathogen to
antibiotics [80]. Moreover, the increasing resistance in S. Typhi against azithromycin [81–83]
and meropenem has been reported in Pakistan and Indonesia [84,85].

4. Mechanisms of Antimicrobial Resistance in S. Typhi

In Salmonella spp., particularly S. Typhi, antimicrobial resistance could either be mediated
by plasmid or chromosomal DNA [86]. Usually, resistance is developed by the inactivation
of antibacterial agents and alteration of drug targets, as well as by employing various efflux
pumps [87]. Genes expressing drug degradation enzymes and/or efflux pumps may be
expressed via point mutation, or external factors of resistance may be actively mediated by
gene transfer using virulence plasmids, phages, and mobile genetic elements [88].

4.1. Virulence Plasmids and Plasmid-Mediated Antimicrobial Resistance in S. Typhi

S. Typhi typically has plasmids that contain several virulence and antimicrobial resis-
tance genes. These plasmids vary from 50 kb to 90 kb in size and carry the spv operon, which
is significantly involved in causing infection [89], as the genes of this operon are reportedly
pivotal for bacterial proliferation in host cells and supposedly enhance the virulence of the
pathogen [90]. Though most virulence plasmids are not self-transferable, some of them do
contain tra genes that enable the transfer of plasmids via conjugation [91]. Incompatible
(Inc) plasmids are responsible for encoding multiple antimicrobial resistance in S. Typhi and
are classified into IncH1, IncH2, and IncH3. Plasmids R27, pHCM1, and pAKU1 comprise
a composited transposon that can harbor multidrug resistance in MDR S. Typhi strains [92].
The H58 clade is primarily attributable to MDR and XDR outbreaks, in which XDR strains
harboring IncHI1 plasmid enable fluoroquinolone resistance to strains [93].

4.2. Antimicrobial-Resistance-Associated Genes in S. Typhi

The resistance to antibiotics in Gram-negative bacteria is primarily attributed to the
production of β-lactamases (ESBLs). TEM, SHV, and CTX-M are the main types of ESBLs
in Salmonella spp., which confer resistance to penicillin and cephalosporin [94]. These
enzymes are primarily antimicrobial degrading enzymes, which do so by cleaving the
β-lactam ring. In S. Typhi, the presence of these genes has been attributed to the genetic
transfer of resistance genes from other Gram-negative bacterial species and also selection
pressure driven by the misinformed use of broad-spectrum antibiotics [95]. Tetracycline-
resistant genes (tetA, tetB, tetG) are responsible for encoding resistance against tetracycline
by activating the efflux pump responsible for transporting the drug out of the cell, thereby
reducing its concentration. Genes conferring resistance against quinolones (qnrA, qnrB,
qnrC, qnrS) encode for pentapeptide proteins, which offer bonding and protection to DNA
gyrase and other enzymes. The cat1 and cat2 genes mediate resistance to chloramphenicol
by inactivating it through the action of the acetyltransferase enzyme. Genetic elements
identifying the mobile gene cassettes that carry multidrug-resistant genes are known as
Microorganisms 2022, 10, 2006 6 of 15

integrons. In S. Typhi, the presence of integrons (class 1 and 2) equalizes the distribution of
antimicrobial resistance, in which class 1 is more dominantly found [96–98].

5. Pathogenesis of S. Typhi
The infectious dose of S. Typhi in humans has been observed to be more than 10,000 cells
in order to cause active infection, but this figure is subject to change in terms of various
host and environmental factors. Enteropathogenic pathogens weaken the gut epithelia by
exploiting tight junction (TJ) components for invading gut cells or tissues or promoting
signaling responses that augment their invasion [99,100]. S. Typhi invasion of the gut
epithelia is reported to increase TJ permeability [101]. Furthermore, there have been studies
that suggest a lower count of the bacterium [102,103]. The pathogen tends to attack the
mucosal lining of the intestines via the action of microfold cells (M cells), thereby helping to
form an undetectable bacterial load in the absence of clinical signs and symptoms, resulting
in general bacteremia. Therefore, the bacterium is able to invade the host system but does
not necessarily trigger the onset of a rapid immune host response. This is a vital aspect
of S. Typhi infection, in which the main inflammatory response is lacking in the host and
is different from the infection caused by nontyphoid serovars of Salmonella spp. [104]. It
has been found that the ability of gut mucosal penetration correlates with the ability of the
bacterial species to invade nonphagocytic cells by expression of a type III secretion system
(T3SS), known as T3SS-1. When Salmonella spp. reach the small intestine, the expression
of SP-1 is induced by several stimuli, such as elevated osmolarity and iron concentration,
neutral pH, and decreased O2 levels [105]. T3SS-1 enables the injection of bacterial effector
proteins directly into the host cells, promoting actin polymerization and ruffling membrane
rearrangements, thereby leading to bacterial internalization. This mechanism is known as the
trigger mechanism and is widely dependent on host cells [106]. Postinfection, the incubation
phase of the pathogen may not always be demonstrated by a symptomatic phase.
The understanding of the pathogenesis, replication, and transmission of a particular
pathogen is very crucial for its diagnosis, treatment, and prevention. This aspect is now
elucidated better due to the breakthrough advances in genomics and molecular biology,
which aid greatly in deciphering the behavior of a pathogen as well as its mode of trans-
mission. The pathogenesis and the response of the host against Salmonella infection are
dependent upon the attachment and ability of the pathogen to invade the host’s epithelial
cells, after which it can effectively disseminate to surrounding sites via the action of phago-
cytic cells. The final stage of the infection comprises the survival, replication, as well as
transfer of the pathogen from one host to another, thereby initiating active transmission
among susceptible hosts. S. Typhi enters the human host through contaminated sources
of food and water and tends to pass through the stomach into the epithelial cells of the
gut. The first challenge of Salmonella colonization is stomach acidity, and certain situations
in which it either is reduced (by the usage of antacids, proton pump inhibitors) or the
intestinal integrity is compromised (surgery, antibiotic use, inflammatory bowel disease)
elevate the chances of Salmonella infection in the host. This is mediated by the adaptive acid
response of Salmonella spp. upon acid exposure in vitro, which probably facilitates survival
and movement into the small intestine. As in the case with most pathogens, attachment
of bacterial cells is pertinent prior to their invasion in the host, which is dependent upon
the adhesion molecules of the bacterium, which then interact with the host receptors. This
interaction is not elucidated well but is assumed to be facilitated by fimbrial adhesion
present in the outer region of the bacterial cell. It has been reported that S. Typhi pos-
sesses 12 fimbriae regulating operons of chaperone class, but none of these are particularly
unique to S. Typhi [107]. This diversity may be attributable to the selective response by the
host [108]. For instance, type IV-B pilus operon (pil) is expressed in S. Typhi, which enables
wild-type (pil+) S. Typhi strains to mediate adherence to host intestinal cells [109]. The
evasion of intestinal epithelial cells by Salmonella spp. is mediated by endocytosis, which
involves rearrangement of the cytoskeleton, disrupting the epithelial cell border as well
as the reconfiguration of membrane ruffles. Under conditions similar to human intestinal
Microorganisms 2022, 10, 2006 7 of 15

cells, many efficiently adhering species of Salmonella are activated for the invasion of host
cells. These species are regulated partly by the pathogenicity island (SPI-1) of Salmonella
and its encoded regulatory and effector proteins, which altogether cause alterations within
the host cells, thereby easing pathogenesis. The induction of SPI-1 by ancestral strains of
S. enterica undoubtedly enables the efficient adherence and invasion of epithelial cells,
which allows for the colonization of a new host environment [110].
S. Typhi is able to cause systemic infection in human hosts. This infection is often
restricted to eventually generating a secretory immune response in the human intestine
and its epithelium, where immune cells, particularly neutrophils, are secreted [111–113].
Moreover, it also enables the secretion of interleukin-8 (IL-8) along with other chemoat-
tractants commonly induced by the presence of pathogens in the intestinal epithelium,
which then direct the migration of neutrophils into the affected region [114]. In the absence
of migration to and the presence of neutrophils in the gut region, S. Typhi may be able to
invade and attack more invasively than before, though previously, this theory was not
supported by enough evidence. Nevertheless, it has long been reported that S. Typhi does,
however, stimulate the secretion of interleukin-6 (IL-6) in epithelial cells [115]. Though it
has been established worldwide that S. Typhi causes a more aggressive form of the disease
when compared with S. Paratyphi, these data may differ, as a study conducted in Nepal
suggested that both pathogenic serovars caused similar clinical symptoms, thus causing
equal or comparably identical forms of the disease in the tested subjects [116]. Around 5%
of acutely infected patients tend to become chronic carriers of the pathogen when there is a
lack of efficacious antimicrobial treatment. Chronic carriage comes with its own risks and
adds to the burden of disease by mediating its persistence, thereby complicating treatment
and mitigation practices [117]. Therefore, efforts to control the spread of disease in the
future must be circled around identifying and treating chronic carriage of pathogens [118].

6. Pathogenicity and Its Role in S. Typhi Virulence

6.1. Salmonella Pathogenicity Islands (SPIs)
The capability of S. Typhi infection is dependent on virulence genes, which are ul-
timately located in Salmonella pathogenicity islands (SPIs), which are distinct genetic
components (acquired from other pathogenic bacteria via horizontal gene transfer) found
on chromosomal regions of pathogenic bacteria [119]. These SPIs carry a base composition
distinct from the core genome, which is why they are often associated with mobile genetic
elements and tRNA. Recent research has elucidated about 15 SPIs in S. Typhi. Several
virulence factors known for adhesion, invasion, and toxins are found to be clustered in
the SPIs [120]. Virulence genes have also been reported to be associated with SPIs, in
which they serve various functions such as pathogen survival, bacterial multiplication, and
evasion of host immune responses, respectively. SPI-1 to SPI-10 and SPI-15 to SPI-17 are all
reported SPIs for S. Typhi (Table 1). Among these, SPI-1 and SPI-2 are the most commonly
studied and primarily contribute to pathogenicity, as they encode the type III secretion
system of proteins. This system of proteins is directly involved in the host–pathogen
interaction during pathogenesis, which makes it pivotal to be encoded on SPIs [121]. The
host macrophages and their interaction with Salmonella lead to the altered expression of a
number of genes comprising pro- and anti-inflammatory mediators as well as adhesion
receptors [122]. Some other genes that are regulated are those that encode proteins involved
in cellular death [123,124]. Some particular serovars different from S. Typhi are reported
to facilitate the induction of sudden and acute macrophagic death in a very short span of
time (approximately 30 min) postinfection [125], which is regulated by the effector protein
SipB of SPI-1, contingent on the cellular protein of the host cell (caspase-1) [126,127]. This
protein is significant in mediating apoptosis through proinflammatory mediators, which
is a counter-attack measure on the part of the host cells in case of a systemic infection in
the host [128]. This proinflammatory action and the eventual recruiting of the phagocytic
immune cells may contribute to bacterial dissemination. Host cell cytotoxicity promoted
Microorganisms 2022, 10, 2006 8 of 15

by Salmonella-induced caspase-1 might take place independently or in association with the

activation of caspase-2, which acts as an initiator of caspase-1 [129].

Table 1. Description of major Salmonella pathogenicity islands (SPIs) and their associated effector proteins.

SPIs Protein Function

SipA Promote membrane ruffling and Salmonella invasion by
SipC directly interacting with actin cytoskeleton
Promote membrane ruffling and Salmonella invasion by
SopE
directly interacting with actin cytoskeleton by inducing
SopE2
membrane ruffling after injection into epithelial cells
SipB Nucleates actin and translocates other effector proteins
SPI-1 IaeP Involved in post-translational modification of T3SS
SopA
Recruit immune cells and secrete fluid in intestinal lumen
SopC
Inhibits cellular apoptosis
AvrA
Inhibits macrophage degradation
SicA
Serve as a chaperone
SicP
SsaB Disrupts Golgi apparatus
SpiC Disrupts vesicular transport
SsaE
Serve as a chaperone
SscA
SPI-2 SsPH2
Rearrange cytoskeletal system
SseJ
SrFT Cellular apoptosis
PipB
Target pathogen-induced filaments
SopD2
MgtC
Ensure adaptation in nutrition-scarce environment
MgtB
SPI-3
MisL Ensures attachment to epithelial cells
MarT Activates MIS L protein
SPI-4 SicE Ensures attachment to epithelial cells
SPI-5 SsrAB Serves key role in developing infection
SPI-6 Invasion proteins Ensure invasion of pathogen into host cells
SPI-7 Produces Vi antigen
SPI-8 Contributes to putative virulence
Contribute to toxin production and invasion of pathogen
SPI-9 T1SS and RTX
into host cells
SPI-10 Production of sef fimbriae
SPI-11 Function not clear
SPI-12 Function not clear
SPI-13 Function not clear
SPI-14 Function not clear
SPI-15 Serves a vague role to effector proteins attached to T3SS
SPI-16 Encodes genes for tRNA arg and lipopolysaccharides
SPI-17 Encodes genes for tRNA arg and lipopolysaccharides
Microorganisms 2022, 10, 2006 9 of 15

Proteins associated with initial adhesion and survival during systemic infection are
encoded by SPI-3, a conserved SPI, allowing S. Typhi and other Salmonella spp. to persist in
environments where nutrition is scarce [130]. SPI-4 ensures intracellular survival in host
macrophages and also supposedly carries a type I toxin secretion system [131]. SPI-5 is
associated with encoding effector proteins (sopB gene) for both types of type III secretion
systems [132]. SPI-7 encodes for Vi antigen, while genes for putative virulence factors and
resistance to bacteriocins are encoded by SPI-8 [130]. SPI-9 is responsible for encoding the
type I secretion system and its proteins, whereas SPI-10 encodes for fimbriae virulence factors,
such as sef fimbriae. SPI-11 to SPI-14 are not reportedly found in S. Typhi, while SPI-15 serves
a vague role with effector proteins attached to secretion systems. Genes and proteins for tRNA
and lipopolysaccharide are encoded by SPI-16 and SPI-17, respectively [133].

6.2. Vi Antigen
Vi capsular polysaccharide (Vi) is a significant virulence factor of S. Typhi and is
encoded by the B locus and is essential for the biosynthesis of the capsular part of the
antigen. In the case of this capsule being present, S. Typhi is comparatively more invasive
and lethal in attacking host cells in serum than other serovars of Salmonella [134]. The
capsular part of the Vi antigen exhibits potential immunomodulatory properties that
contribute to pathogenesis, disease progression, inhibition of bactericidal activity, reduction
in the host immune response, and limitation of the complement deposition. This important
aspect is why the Vi capsule has been considered to be contained as an integral part of
traditional and conjugate typhoid vaccines. Apart from Salmonella spp., other significant
bacterial pathogens also express the Vi antigen, such as Citrobacter spp. [135]. Moreover,
the genome of S. Typhi contains various pseudogenes that have been observed to depict the
inhibition of the host and its immune responses by the pathogen in an identical process
previously reported in other similar pathogens [136]. S. Typhi is also reported to contain
more than 300 genes that are only specific to this serovar. This genetic specificity is
identified by the findings of an additional exotoxin known as the typhoid toxin, which
has a significant role in driving the pathogenesis of enteric fever caused by S. Typhi and
Paratyphi A. Therefore, it is important to characterize virulence factors that may serve
a vital role in the pathogenesis of infection, which could then be investigated for the
development of vaccines [53].

7. Conclusions
While regional outbreaks can be unprecedented, travelers arriving in Pakistan and
other affected countries appear to be at high risk of MDR and XDR typhoid infection; conse-
quently, a sufficient amount of health strategies and prevention steps are recommended and
advised by the CDC to be taken for efficient and safe travels. Vaccines for use against ty-
phoid have been reported since the development and widespread usage of heat-inactivated
whole-cell vaccines in the latter half of the 19th century. However, it was not until now
that the efficacy has been reported to be limited. Vi-polysaccharide vaccine, along with
a live attenuated vaccine, provides 60–80% of protection, but one of its major downsides
is that it requires readministration every 24–36 and 60 months, respectively. Moreover,
none of the vaccines are recommended for use in children less than 24 months, which
makes typhoid vaccination arduous to be incorporated into their vaccination programs,
especially in underprivileged countries. Furthermore, new drugs could be designed to
curb the resistance to antibiotics, along with proper monitoring of drug use, prescription,
and awareness of usage, which could eventually decrease the global burden of S. Typhi
infection and the occurrence of MDR and XDR strains.

Author Contributions: Conceptualization, M.K. and S.S.; methodology, M.K. and S.S.; validation, S.S.;
investigation, M.K.; resources, M.K. and S.S.; writing—original draft preparation, M.K.; writing—review
and editing, S.S.; supervision, S.S.; project administration, S.S. All authors have read and agreed to the
published version of the manuscript.
Microorganisms 2022, 10, 2006 10 of 15

Funding: This research received no external funding.

Data Availability Statement: Not applicable.
Acknowledgments: The authors gratefully acknowledge Abdul Rehman (University of the Punjab)
for his insightful wisdom and comments that greatly improved the manuscript.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Lindberg, A.A. Polyosides (encapsulated bacteria). Comptes Rendus Acad. Sci. III 1999, 322, 925–932. [CrossRef]
2. Elnekave, E.; Hong, S.L.; Lim, S.; Johnson, T.J.; Perez, A.; Alvarez, J. Comparing serotyping with whole-genome sequencing for
subtyping of non-typhoidal Salmonella enterica: A large-scale analysis of 37 serotypes with a public health impact in the USA.
Microb. Genom. 2020, 6, e000425. [CrossRef] [PubMed]
3. Gangathraprabhu, B.; Kannan, S.; Santhanam, G.; Suryadevara, N.; Maruthamuthu, M. A review on the origin of multidrug-
resistant Salmonella and perspective of tailored phoP gene towards avirulence. Microb. Pathog. 2020, 147, 104352. [CrossRef]
[PubMed]
4. Crump, J.A. Progress in typhoid fever epidemiology. Clin. Infect. Dis. 2019, 68, S4–S9. [CrossRef]
5. Luby, S.P.; Faizan, M.K.; Fisher-Hoch, S.P.; Syed, A.; Mintz, E.D.; Bhutta, Z.A.; McCormick, J.B. Risk factors for typhoid fever in an
endemic setting, Karachi, Pakistan. Epidemiol. Infect. 1998, 120, 129–138. [CrossRef]
6. Li, Q. Mechanisms for the invasion and dissemination of Salmonella. Can. J. Infect. Dis. Med. Microbiol. 2022, 2022, 2655801.
[CrossRef]
7. Gauld, J.S.; Olgemoeller, F.; Heinz, E.; Nkhata, R.; Bilima, S.; Wailan, A.M.; Kennedy, N.; Mallewa, J.; Gordon, M.A.; Read, J.M.; et al.
Spatial and genomic data to characterize endemic typhoid transmission. Clin. Infect. Dis. 2022, 74, 1993–2000. [CrossRef]
8. Gauld, J.S.; Bilima, S.; Diggle, P.J.; Feasey, N.A.; Read, J.M. Rainfall anomalies and typhoid fever in Blantyre, Malawi. Epidemiol.
Infect. 2022, 150, E122. [CrossRef]
9. Nair, S.; Patel, V.; Hickey, T.; Maguire, C.; Greig, D.R.; Lee, W.; Godbole, G.; Grant, K.; Chattaway, M.A. Real-time PCR assay for
differentiation of typhoidal and nontyphoidal Salmonella. J. Clin. Microbiol. 2019, 57, e00167-19. [CrossRef]
10. Mermin, J.H.; Villar, R.; Carpenter, J.; Roberts, L.; Samaridden, A.; Gasanova, L.; Lomakina, S.; Bopp, C.; Hutwagner, L.; Mead, P.; et al.
A massive epidemic of multidrug-resistant typhoid fever in Tajikistan associated with consumption of municipal water. J. Infect.
Dis. 1999, 179, 1416–1422. [CrossRef]
11. Karkey, A.; Thompson, C.N.; Tran Vu Thieu, N.; Dongol, S.; Le Thi Phuong, T.; Voong Vinh, P.; Arjyal, A.; Martin, L.B.; Rondini, S.;
Farrar, J.J.; et al. Differential epidemiology of Salmonella Typhi and Paratyphi A in Kathmandu, Nepal: A matched case control
investigation in a highly endemic enteric fever setting. PLoS Negl. Trop. Dis. 2013, 7, e2391. [CrossRef] [PubMed]
12. Parry, C.M.; Hien, T.T.; Dougan, G.; White, N.J.; Farrar, J.J. Typhoid fever. N. Engl. J. Med. 2002, 347, 1770–1782. [CrossRef]
[PubMed]
13. Connor, B.A.; Schwartz, E. Typhoid and paratyphoid fever in travellers. Lancet Infect. Dis. 2005, 5, 623–628. [CrossRef]
14. Masuet-Aumatell, C.; Atouguia, J. Typhoid fever infection—Antibiotic resistance and vaccination strategies: A narrative review.
Travel Med. Infect. Dis. 2021, 40, 101946–101960. [CrossRef] [PubMed]
15. Crump, J.A.; Mintz, E.D. Global trends in typhoid and paratyphoid Fever. Clin. Infect. Dis. 2010, 50, 241–246. [CrossRef]
[PubMed]
16. Wain, J.; Hendriksen, R.S.; Mikoleit, M.L.; Keddy, K.H.; Ochiai, R.L. Typhoid fever. Lancet 2015, 385, 1136–1145. [CrossRef]
17. Rudd, K.E.; Johnson, S.C.; Agesa, K.M.; Shackelford, K.A.; Tsoi, D.; Kievlan, D.R.; Colombara, D.V.; Ikuta, K.S.; Kissoon, N.; Finfer, S.; et al.
Global, regional, and national sepsis incidence and mortality, 1990–2017: Analysis for the Global Burden of Disease Study. Lancet 2020, 395,
200–211. [CrossRef]
18. Mukherjee, N.; Nolan, V.G.; Dunn, J.R.; Banerjee, P. Sources of human infection by Salmonella enterica serotype Javiana:
A systematic review. PLoS ONE 2019, 14, e0222108. [CrossRef]
19. Wu, G.; Liu, L.; Qi, Y.; Sun, Y.; Yang, N.; Xu, G.; Zhou, H.; Li, X. Splenic gene expression profiling in white leghorn layer inoculated
with the Salmonella enterica serovar enteritidis. Anim. Genet. 2015, 46, 617–626. [CrossRef]
20. EFSA; ECDC. The European Union One Health 2020 Zoonoses Report. EFSA J. 2021, 19, e6971–e7295.
21. Galgallo, D.A.; Roka, Z.G.; Boru, W.G.; Abill, K.; Ransom, J. Investigation of a Typhoid fever epidemic in Moyale Sub-County,
Keny-2015. J. Health Popul. Nutr. 2018, 37, 14–18. [CrossRef] [PubMed]
22. Carstens, C.K.; Salazar, J.K.; Darkoh, C. Multistate outbreaks of foodborne illness in the united states associated with fresh
produce from 2010 to 2017. Front. Microbiol. 2019, 10, 2667. [CrossRef] [PubMed]
23. Gong, B.; Li, H.; Feng, Y.; Zeng, S.; Zhuo, Z.; Luo, J.; Chen, X.; Li, X. Prevalence, serotype distribution and antimicrobial resistance
of non-typhoidal Salmonella in hospitalized patients in Conghua District of Guangzhou, China. Front. Cell Infect. Microbiol. 2022,
12, 805384. [CrossRef] [PubMed]
24. Saha, S.; Islam, M.S.; Sajib, M.S.I.; Saha, S.; Uddin, M.J.; Hooda, Y.; Hasan, M.; Amin, M.R.; Hanif, M.; Shahidullah, M.; et al.
Epidemiology of typhoid and paratyphoid: Implications for vaccine policy. Clin. Infect. Dis. 2019, 68, S117–S123. [CrossRef]
[PubMed]
Microorganisms 2022, 10, 2006 11 of 15

25. Bhan, M.K.; Bahl, R.; Bhatnagar, S. Typhoid and paratyphoid fever. Lancet 2005, 366, 749–762. [CrossRef]
26. Lozano-León, A.; García-Omil, C.; Rodríguez-Souto, R.R.; Lamas, A.; Garrido-Maestu, A. An evaluation of the pathogenic
potential, and the antimicrobial resistance, of Salmonella strains isolated from mussels. Microorganisms 2022, 10, 126. [CrossRef]
27. Crump, J.A.; Luby, S.P.; Mintz, E.D. The global burden of typhoid fever. Bull. World Health Organ. 2004, 82, 346–353.
28. Dougan, G.; Baker, S. Salmonella enterica serovar Typhi and the pathogenesis of typhoid fever. Annu. Rev. Microbiol. 2014, 68,
317–336. [CrossRef]
29. Bano-Zaidi, M.; Aguyano-Romero, M.; Campos, F.D.; Colome-Ruiz, J.; Gonzalez, M.E.; Piste, I.M.; Magaña, C.P.; Gamboa, M.
Typhoid fever outbreak with severe complications in Yucatan, Mexico. Lancet Glob. Health 2018, 6, e1062–e1063. [CrossRef]
30. IHME. Global Burden of Disease Collaborative Network. GBD 2020 Cause and Risk Summaries: Typhoid Fever—Level 4 Cause.
Seattle, United States: Institute for Health Metrics and Evaluation (IHME). 2020. Available online: http://www.healthdata.org/
results/gbd_summaries/2019/typhoid-fever-level-4-cause (accessed on 1 July 2022).
31. Radhakrishnan, A.; Als, D.; Mintz, E.D.; Crump, J.A.; Stanaway, J.; Breiman, R.F.; Bhutta, Z.A. Introductory article on global
burden and epidemiology of typhoid fever. Am. J. Trop. Med. Hyg. 2018, 99, 4–9. [CrossRef]
32. Kim, S.; Bansal, J. A rare case of typhoid fever in the United States associated with travel to Mexico. Cureus 2022, 14, e22316.
[CrossRef] [PubMed]
33. Khanam, F.; Ross, A.G.; Nigel, A.; McMillan, J.; Qadri, F. Toward typhoid fever elimination. Int. J. Infect. Dis. 2022, 119, 41–43.
[CrossRef] [PubMed]
34. Rasheed, M.K.; Hasan, S.S.; Babar, Z.U.D.; Ahmed, S.I. Extensively drug-resistant typhoid fever in Pakistan. Lancet Infect. Dis.
2019, 19, 242–243. [CrossRef]
35. Akram, J.; Khan, A.S.; Khan, H.A.; Gilani, S.A.; Akram, S.J.; Ahmad, F.J.; Mehboob, R. Extensively drug-resistant (XDR) typhoid:
Evolution, prevention, and its management. BioMed Res. Int. 2020, 2020, 6432580. [CrossRef]
36. Kaljee, L.M.; Pach, A.; Garrett, D.; Bajracharya, D.; Karki, K.; Khan, I. Social and economic burden associated with typhoid fever
in Kathmandu and surrounding areas: A qualitative study. J. Infect. Dis. 2018, 218, S243–S249. [CrossRef] [PubMed]
37. Marks, F.; Adu-Sarkodie, Y.; Hünger, F.; Sarpong, N.; Ekuban, S.; Agyekum, A.; Nkrumah, B.; Schwarz, N.G.; Favorov, M.O.;
Meyer, C.G.; et al. Typhoid fever among children. Ghana Emerg. Infect. Dis. 2010, 16, 1796–1797. [CrossRef]
38. Karkey, A.; Arjyal, A.; Anders, K.L.; Boni, M.F.; Dongol, S.; Koirala, S.; My, P.V.; Nga, T.V.; Clements, A.C.; Holt, K.E.; et al. The burden
and characteristics of enteric fever at a healthcare facility in a densely populated area of Kathmandu. PLoS ONE 2010, 5, e13988.
[CrossRef]
39. Mogasale, V.; Maskery, B.; Ochiai, R.L.; Lee, J.S.; Mogasale, V.V.; Ramani, E.; Kim, Y.E.; Park, J.K.; Wierzba, T.F. Burden of typhoid
fever in low income and middle-income countries: A systematic, literature-based update with risk-factor adjustment. Lancet Glob.
Health 2014, 2, e570–e580. [CrossRef]
40. Dobinson, H.C.; Gibani, M.M.; Jones, C.; Thomaides-Brears, H.B.; Voysey, M.; Darton, T.C.; Waddington, C.S.; Campbell, D.;
Milligan, I.; Zhou, L.; et al. Evaluation of the clinical and microbiological response to Salmonella paratyphi a infection in the first
paratyphoid human challenge model. Clin. Infect. Dis. 2017, 64, 1066–1073. [CrossRef]
41. Neil, K.P.; Sodha, S.V.; Lukwago, L.; O-Tipo, S.; Mikoleit, M.; Simington, S.M.; Mukobi, P.; Balinandi, S.; Majalija, S.; Ayers, J.; et al.
A large outbreak of typhoid fever associated with a high rate of intestinal perforation in Kasese District, Uganda, 2008–2009. Clin.
Infect. Dis. 2012, 54, 1091–1099. [CrossRef]
42. Nguyen, Q.C.; Everest, P.; Tran, T.K.; House, D.; Murch, S.; Parry, C.; Connerton, P.; Phan, V.B.; To, S.D.; Mastroeni, P.; et al.
A clinical, microbiological, and pathological study of intestinal perforation associated with typhoid fever. Clin. Infect. Dis. 2004,
39, 61–67.
43. Khan, M.I.; Soofi, S.B.; Ochiai, R.L.; Khan, M.J.; Sahito, S.M.; Habib, M.A.; Puri, M.K.; Von Seidlein, L.; Park, J.K.; You, Y.A.; et al.
Epidemiology, clinical presentation, and patterns of drug resistance of Salmonella Typhi in Karachi, Pakistan. J. Infect. Dev. Ctries.
2012, 6, 704–714. [CrossRef] [PubMed]
44. Lutterloh, E.; Likaka, A.; Sejvar, J.; Manda, R.; Naiene, J.; Monroe, S.S. Multidrug-resistant typhoid fever with neurologic findings
on the Malawi-Mozambique border. Clin. Infect. Dis. 2012, 54, 1100–1106. [CrossRef] [PubMed]
45. Thompson, C.N.; Blacksell, S.D.; Paris, D.H.; Arjyal, A.; Karkey, A.; Dongol, S.; Giri, A.; Dolecek, C.; Day, N.; Baker, S.; et al.
Undifferentiated febrile illness in Kathmandu, Nepal. Am. J. Trop. Med. Hyg. 2015, 92, 875–878. [CrossRef]
46. Mogasale, V.; Ramani, E.; Mogasale, V.V.; Park, J. What proportion of Salmonella Typhi cases are detected by blood culture?
A systematic literature review. Ann. Clin. Microbiol. Antimicrob. 2016, 15, 32–39. [CrossRef] [PubMed]
47. Andrews, J.R.; Ryan, E.T. Diagnostics for invasive Salmonella infections: Current challenges and future directions. Vaccine 2015, 33,
C8–C15. [CrossRef] [PubMed]
48. Wijedoru, L.; Mallett, S.; Parry, C. Rapid diagnostic tests for typhoid and paratyphoid (Enteric) fever. Cochrane Database Syst. Rev.
2017, 5, 1–121. [CrossRef] [PubMed]
49. Khanam, F.; Sheikh, A.; Sayeed, M.A.; Bhuiyan, M.S.; Choudhury, F.K.; Salma, U.; Pervin, S.; Sultana, T.; Ahmed, D.; Goswami, D.; et al.
Evaluation of a typhoid/paratyphoid diagnostic assay (TPTest) detecting anti-Salmonella IgA in secretions of peripheral blood
lymphocytes in patients in Dhaka, Bangladesh. PLoS Negl Trop. Dis. 2013, 7, e2316. [CrossRef]
50. Islam, K.; Sayeed, M.A.; Hossen, E.; Khanam, F.; Charles, R.C.; Andrews, J.; Ryan, E.T.; Qadri, F. Comparison of the performance
of the TPTest, Tubex, Typhidot and Widal immunodiagnostic assays and blood cultures in detecting patients with typhoid fever
in Bangladesh, including using a bayesian latent class modeling approach. PLoS Negl. Trop. Dis. 2016, 10, e0004558. [CrossRef]
Microorganisms 2022, 10, 2006 12 of 15

51. Darton, T.C.; Jones, C.; Dongol, S.; Voysey, M.; Blohmke, C.J.; Shrestha, R.; Karkey, A.; Shakya, M.; Arjyal, A.; Waddington, C.S.; et al.
Assessment and translation of the antibody-in-lymphocyte supernatant (als) assay to improve the diagnosis of enteric fever in
two controlled human infection models and an endemic area of Nepal. Front. Microbiol. 2017, 8, 2031. [CrossRef]
52. Zhou, L.; Pollard, A.J. A fast and highly sensitive blood culture PCR method for clinical detection of Salmonella enterica serovar
Typhi. Ann. Clin. Microbiol. Antimicrob. 2010, 9, 14–21. [CrossRef] [PubMed]
53. Shakya, M.; Neuzil, K.M.; Pollard, A.J. Prospects of future typhoid and paratyphoid vaccines in endemic countries. J. Infect. Dis.
2021, 224, S770–S774. [CrossRef]
54. Kuhns, M.; Zautner, A.E.; Rabsch, W.; Zimmermann, O.; Weig, M.; Bader, O.; Groß, U. Rapid discrimination of Salmonella enterica
serovar typhi from other serovars by MALDI-TOF mass spectrometry. PLoS ONE 2012, 7, e40004. [CrossRef] [PubMed]
55. Liang, L.; Juarez, S.; Nga, T.V.; Dunstan, S.; Nakajima-Sasaki, R.; Davies, D.H.; McSorley, S.; Baker, S.; Felgner, P.L. Immune profiling
with a Salmonella Typhi antigen microarray identifies new diagnostic biomarkers of human typhoid. Sci. Rep. 2013, 3, 1043. [CrossRef]
[PubMed]
56. Näsström, E.; Thieu, N.T.V.; Dongol, S.; Karkey, A.; Vinh, P.V.; Thanh, T.H.; Johansson, A.; Arjyal, A.; Thwaites, G.; Dolecek, C.; et al.
Salmonella Typhi and Salmonella Paratyphi A elaborate distinct systemic metabolite signatures during enteric fever. Elife 2014, 3, e03100.
[CrossRef]
57. Näsström, E.; Parry, C.M.; Thieu, N.T.V.; Maude, R.R.; de Jong, H.K.; Fukushima, M.; Rzhepishevska, O.; Marks, F.; Panzner, U.;
Im, J.; et al. Reproducible diagnostic metabolites in plasma from typhoid fever patients in Asia and Africa. Elife 2017, 6, e15651.
[CrossRef]
58. Näsström, E.; Jonsson, P.; Johansson, A.; Dongol, S.; Karkey, A.; Basnyat, B.; Tran Vu Thieu, N.; Trinh Van, T.; Thwaites, G.E.;
Antti, H.; et al. Diagnostic metabolite biomarkers of chronic typhoid carriage. PLoS Negl. Trop. Dis. 2018, 12, e0006215. [CrossRef]
59. Thompson, L.J.; Dunstan, S.J.; Dolecek, C.; Perkins, T.; House, D.; Dougan, G.; Nguyen, T.H.; Tran, T.P.; Doan, C.D.; Le, T.P.; et al.
Transcriptional response in the peripheral blood of patients infected with Salmonella enterica serovar Typhi. Proc. Natl. Acad. Sci.
USA 2009, 106, 22433–22438. [CrossRef]
60. Blohmke, C.J.; Darton, T.C.; Jones, C.; Suarez, N.M.; Waddington, C.S.; Angus, B.; Zhou, L.; Hill, J.; Clare, S.; Kane, L.; et al.
Interferon-driven alterations of the host’s amino acid metabolism in the pathogenesis of typhoid fever. J. Exp. Med. 2016, 213,
1061–1077. [CrossRef]
61. Cuypers, W.L.; Jacobs, J.; Wong, V.; Klemm, E.J.; Deborggraeve, S.; Van Puyvelde, S. Fluoroquinolone resistance in Salmonella:
Insights by whole-genome sequencing. Microb Genom. 2018, 4, e000195. [CrossRef]
62. Ochiai, R.L.; Acosta, C.J.; Danovaro-Holliday, M.C.; Baiqing, D.; Bhattacharya, S.K.; Agtini, M.D.; Bhutta, Z.A.; Canh, D.G.; Ali,
M.; Shin, S.; et al. A study of typhoid fever in five Asian countries: Disease burden and implications for controls. Bull. World
Health Organ. 2008, 86, 260–268. [CrossRef] [PubMed]
63. Shin, D.; Groisman, E.A. Signal-dependent binding of the response regulators PhoP and PmrA to their target promoters in vivo.
J. Biol. Chem. 2005, 280, 4089–4094. [CrossRef] [PubMed]
64. Crump, J.A.; Sjolund-Karlsson, M.; Gordon, M.A.; Parry, C.M. Epidemiology, clinical presentation, laboratory diagnosis,
antimicrobial resistance, and antimicrobial management of invasive Salmonella infections. Clin. Microbiol. Rev. 2015, 28, 901–937.
[CrossRef]
65. Lynch, M.F.; Blanton, E.M.; Bulens, S.; Polyak, C.; Vojdani, J.; Stevenson, J.; Medalla, F.; Barzilay, E.; Joyce, K.; Barrett, T.; et al.
Typhoid fever in the United States, 1999–2006. J. Am. Med. Assoc. 2009, 302, 859–865. [CrossRef]
66. Mengo, D.M.; Kariuki, S.; Muigai, A.W.T.; Revathi, G.N. Trends in Salmonella enterica serovar typhi in Nairobi, Kenya from 2004 to
2006. J. Infect. Dev. Ctries. 2010, 813, 393–396. [CrossRef]
67. Qamar, F.N.; Yousafzai, M.T.; Khalid, M.; Kazi, A.M.; Lohana, H.; Karim, S.; Khan, A.; Hotwani, A.; Qureshi, S.; Kabir, F.; et al.
Outbreak investigation of ceftriaxone resistant Salmonella enterica serotype Typhi and its risk factors among the general population
in Hyderabad, Pakistan: A matched case-control study. Lancet Infect. Dis. 2018, 18, 1368–1376. [CrossRef]
68. World Health Organization. Drug resistant Salmonella infections in Pakistan: Update. Wkly. Epidemiol Monit. 2019, 12, 34.
69. Wong, W.; Al, H.; Patel, S.; Yau, Y.; Eshaghi, A.; Zittermann, S.; Tattum, L.; Morris, S.K. The first Canadian pediatric case of
extensively drug-resistant Salmonella Typhi originating from an outbreak in Pakistan and its implication for empiric antimicrobial
choices. IDCases 2019, 15, e00492. [CrossRef]
70. Howard-Jones, A.; Kesson, A.M.; Outhred, A.C.; Britton, P.N. First reported case of extensively drug-resistant typhoid in Australia.
Med. J. Aust. 2019, 211, 286–286.e1. [CrossRef]
71. Engsbro, A.L.; Jespersen, H.S.R.; Goldschmidt, M.I.; Mollerup, S.; Worning, P.; Pedersen, M.S.; Westh, H.; Schneider, U.V.
Ceftriaxone resistant Salmonella enterica serotype Typhi in a pregnant traveller returning from Karachi, Pakistan to Denmark. Euro
Surveill. 2019, 24, 1900289. [CrossRef]
72. Chatham-Stephens, K.; Medalla, F.; Hughes, M.; Appiah, G.D.; Aubert, R.D.; Caidi, H.; Angelo, K.M.; Walker, A.T.; Hatley, N.;
Masani, S.; et al. Emergence of extensively drug-resistant Salmonella Typhi infections among travelers to or from Pakistan—United
States, 2016–2018. Morb. Mortal. Wkly. Rep. 2019, 68, 11–13. [CrossRef] [PubMed]
73. Dyson, Z.A.; Klemm, E.J.; Palmer, S.; Dougan, G. Antibiotic resistance and typhoid. Clin. Infect. Dis. 2019, 68, S165–S170.
[CrossRef] [PubMed]
74. Bokhary, H.; Pangesti, K.N.A.; Rashid, H.; Abd-El-Ghany, M.; Hill-Cawthorne, G.A. Travel-related antimicrobial resistance:
A systematic review. Trop. Med. Infect. Dis. 2021, 6, 11. [CrossRef] [PubMed]
Microorganisms 2022, 10, 2006 13 of 15

75. Haqqi, A.; Khurram, M.; Din, M.S.U.; Aftab, M.N.; Ali, M.; Ahmed, H.; Afzal, M.S. COVID-19 and Salmonella Typhi co-epidemics
in Pakistan: A real problem. J. Med. Virol. 2020, 93, 184–186. [CrossRef] [PubMed]
76. Pragasam, A.K.; Pickard, D.; Wong, V.; Dougan, G.; Kang, G.; Thompson, A.; John, J.; Balaji, V.; Mutreja, A. Phylogenetic analysis
indicates a longer term presence of the globally distributed H58 haplotype of Salmonella Typhi in Southern India. Clin. Infect. Dis.
2020, 71, 1856–1863. [CrossRef] [PubMed]
77. Park, S.E.; Pham, D.T.; Boinett, C.; Wong, V.K.; Pak, G.D.; Panzner, U.; Espinoza, L.; von Kalckreuth, V.; Im, J.; Schütt-Gerowitt, H.; et al.
The phylogeography and incidence of multi-drug resistant typhoid fever in sub-Saharan Africa. Nat. Commun. 2018, 9, 5094–6003.
[CrossRef]
78. Shin, E.; Park, J.; Jeong, H.J.; Park, A.K.; Na, K.; Lee, H.; Chun, J.H.; Hwang, K.J.; Kim, C.J.; Kim, J. Emerging high-level
ciprofloxacin-resistant Salmonella enterica serovar typhi haplotype H58 in travelers returning to the Republic of Korea from India.
PLOS Negl. Trop. Dis. 2021, 15, e0009170. [CrossRef]
79. Britto, C.D.; Wong, V.K.; Dougan, G.; Pollard, A.J. A systematic review of antimicrobial resistance in Salmonella enterica serovar
Typhi, the etiological agent of typhoid. PLoS Negl. Trop. Dis. 2018, 12, e0006779. [CrossRef]
80. Saeed, M.; Rasool, M.H.; Rasheed, F.; Saqalein, M.; Nisar, M.A.; Imran, A.A.; Tariq, S.; Amir, A.; Ikram, A.; Khurshid, M.
Extended-spectrum beta-lactamases producing extensively drug-resistant Salmonella Typhi in Punjab, Pakistan. J. Infect. Dev.
Ctries. 2020, 14, 169–176. [CrossRef]
81. Shaikh, A.; Tahir, A. Antimicrobial resistance trends of typhoidal Salmonellae in southern Pakistan. RMJ 2019, 44, 7–10.
82. Jain, S.; Das Chugh, T. Antimicrobial resistance among blood culture isolates of Salmonella enterica in New Delhi. J. Infect. Dev.
Ctries. 2013, 7, 788–795. [CrossRef] [PubMed]
83. Saha, S.; Sajib, M.S.I.; Garrett, D.; Qamar, F.N. Antimicrobial resistance in typhoidal Salmonella: Around the World in 3 Days. Clin.
Infect. Dis. 2020, 71, S91–S95. [CrossRef] [PubMed]
84. Laghari, G.S.; Hussain, Z.; Hussain, S.Z.M.; Kumar, H.; Uddin, S.M.M.; Haq, A. Antimicrobial susceptibility patterns of Salmonella
species in southern Pakistan. Cureus 2019, 11, e4379. [CrossRef] [PubMed]
85. Marchello, C.S.; Carr, S.D.; Crump, J.A. A systematic review on antimicrobial resistance among Salmonella Typhi worldwide. Am.
J. Trop. Med. Hyg. 2020, 103, 2518–2527. [CrossRef]
86. Boerlin, P.; Reid-Smith, R.J. Antimicrobial resistance: Its emergence and transmission. Anim. Health Res. Rev. 2008, 9, 115–126.
[CrossRef]
87. Tracz, D.M.; Boyd, D.A.; Bryden, L.; Hizon, R.; Giercke, S.; Caeseele, P.V.; Mulvey, M.R. Increase in ampC promoter strength due
to mutations and deletion of the attenuator in a clinical isolate of cefoxitin-resistant Escherichia coli as determined by RT-PCR.
J. Antimicrob. Chemother. 2005, 55, 768–772. [CrossRef]
88. Carattoli, A. Plasmids and the spread of resistance. Int. J. Med. Microbiol. 2013, 303, 298–304. [CrossRef]
89. Lobato-Márquez, D.; Molina-García, L.; Moreno-Córdoba, I.; García-del Portillo, F.; Díaz-Orejas, R. Stabilization of the virulence
plasmid pSLT of Salmonella Typhimurium by three maintenance systems and its evaluation by using a new stability test. Front.
Mol. Biosci. 2016, 3, 66. [CrossRef]
90. Guiney, D.G.; Fierer, J. The role of the spv genes in Salmonella pathogenesis. Front. Microbiol. 2011, 2, 129. [CrossRef]
91. Ahmer, B.M.M.; Tran, M.; Heffron, F. The virulence plasmid of Salmonella typhimurium is self-transmissible. J Bacteriol. 1999, 181,
1364–1368. [CrossRef]
92. Gabant, P.; Chahdi, A.O.; Couturier, M. Nucleotide sequence and replication 845 characteristics of RepHI1B: A replicon specific to
the IncHI1 plasmids. Plasmid 1994, 846, 111–120. [CrossRef]
93. Klemm, E.J.; Shakoor, S.; Page, A.J.; Qamar, F.N.; Judge, K.; Saeed, D.K.; Wong, V.K.; Dallman, T.J.; Nair, S.; Baker, S.; et al.
Emergence of an Extensively Drug-Resistant Salmonella enterica Serovar Typhi clone harboring a promiscuous plasmid encoding
resistance to fluoroquinolones and third-generation cephalosporins. MBio 2018, 9, e00105-18. [CrossRef] [PubMed]
94. Al-Gallas, N.; Belghouthi, K.; Barratt, N.A.; Ghedira, K.; Hotzel, H.; Tomaso, H.; El-Adawy, H.; Neubauer, H.; Laouini, D.;
Zarrouk, S.; et al. Identification and characterization of multidrug-resistant ESBL-producing Salmonella enterica serovars Kentucky
and Typhimurium isolated in Tunisia CTX-M-61/TEM-34, a novel cefotaxime-hydrolysing β-lactamase of Salmonella. J. Appl.
Microbiol. 2022, 132, 279–289. [CrossRef] [PubMed]
95. Riyaaz, A.A.A.; Perera, V.; Sivakumaran, S.; de Silva, N. Typhoid fever due to extended spectrum β- lactamase-producing
Salmonella enterica serovar Typhi: A case report and literature review. Case Rep. Infect. Dis. 2018, 2018, 4610246.
96. Abdel Aziz, S.A.; Abdel Latef, K.G.; Shany, A.S.S.; Rouby, S.R. Molecular detection of integrin and antimicrobial substances genes
in multidrug resistant Salmonella isolated from poultry, calves and human in Beni-Suef governorate, Egypt. Beni-Suef Univ. J. Basic
Appl. Sci. 2018, 7, 535–542.
97. Odoch, T.; Sekse, C.; Abee-Lund, T.M.; Hansen, H.H.C.; Kankya, C.; Wasteson, Y. Diversity and antimicrobial resistance genotypes
in non-typhoidal Salmonella isolates from poultry farms in Uganda. Int. J. Environ. Res. Public Health 2018, 15, 324. [CrossRef]
[PubMed]
98. Kim, C.; Latif, I.; Neupane, D.P.; Lee, G.Y.; Kwon, R.S.; Batool, A.; Ahmed, Q.; Qamar, M.U.; Song, J. The molecular basis of
extensively drug-resistant Salmonella Typhi isolates from pediatric septicemia patients. PLoS ONE 2021, 16, e0257744. [CrossRef]
[PubMed]
99. Awad, W.; Hess, C.; Hess, M. Enteric pathogens and their toxin-induced disruption of the intestinal barrier through alteration of
tight junctions in chickens. Toxins 2017, 9, 60. [CrossRef]
Microorganisms 2022, 10, 2006 14 of 15

100. Paradis, T.; Bègue, H.; Basmaciyan, L.; Dalle, F.; Bon, F. Tight junctions as a key for pathogens invasion in intestinal epithelial cells.
Int. J. Mol. Sci. 2021, 22, 2506. [CrossRef]
101. Tafazoli, F.; Magnusson, K.-E.; Zheng, L. Disruption of epithelial barrier integrity by Salmonella enterica serovar Typhimurium
requires geranylgeranylated proteins. Am. Soc. Microbiol. 2003, 71, 872–881. [CrossRef]
102. Glynn, J.R.; Hornick, R.B.; Levine, M.M.; Bradley, D.J. Infecting dose and severity of typhoid: Analysis of volunteer data and
examination of the influence of the definition of illness used. Epidemiol. Infect. 1995, 115, 23–30. [CrossRef] [PubMed]
103. Waddington, C.S.; Darton, T.C.; Jones, C.; Haworth, K.; Peters, A.; John, T.; Thompson, B.A.; Kerridge, S.A.; Kingsley, R.A.; Zhou, L.; et al.
An outpatient, ambulant design, controlled human infection model using escalating doses of Salmonella Typhi challenge delivered in
sodium bicarbonate solution. Clin. Infect. Dis. 2014, 58, 1230–1240. [CrossRef] [PubMed]
104. Snyder, M.J.; Hornick, R.B.; McCrumb, F.R.; Morse, L.J.; Woodward, T.E. Asymptomatic typhoidal bacteremia in volunteers.
Antimicrob. Agents Chemotherap. 1963, 161, 604–607.
105. Lou, L.; Zhang, P.; Piao, R.; Wang, Y. Salmonella Pathogenicity Island 1 (SPI-1) and its complex regulatory network. Front. Cell
Infect. Microbiol. 2019, 9, 270–281. [CrossRef] [PubMed]
106. Barilleau, E.; Védrine, M.; Koczerka, M.; Burlaud-Gaillard, J.; Kempf, F.; Grépinet, O.; Virlogeux-Payant, I.; Velge, P.; Wiedemann, A.
Investigation of the invasion mechanism mediated by the outer membrane protein PagN of Salmonella Typhimurium. BMC
Microbiol. 2021, 21, 153–170. [CrossRef] [PubMed]
107. Townsend, S.M.; Kramer, N.E.; Edwards, R.; Baker, S.; Hamlin, N.; Simmonds, M.; Stevens, K.; Maloy, S.; Parkhill, J.; Dougan, G.; et al.
Salmonella enterica serovar Typhi possesses a unique repertoire of fimbrial gene sequences. Infect. Immun. 2001, 69, 2894–2901. [CrossRef]
108. Nicholson, T.L.; Bäumler, A.J. Salmonella enterica serotype Typhimurium elicits cross-immunity against a Salmonella enterica
serotype enteritidis strain expressing LP fimbriae from the lac promoter. Infect Immun. 2001, 69, 204–212. [CrossRef]
109. Zhang, X.L.; Tsui, I.S.; Yip, C.M.; Fung, A.W.; Wong, D.K.; Dai, X.; Yang, Y.; Hackett, J.; Morris, C. Salmonella enterica serovar Typhi
uses type IVB pili to enter human intestinal epithelial cells. Infect Immun. 2000, 68, 3067–3073. [CrossRef]
110. Kingsley, R.A.; Bäumler, A.J. Host adaptation and the emergence of infectious disease: The Salmonella paradigm. Mol. Microbiol.
2000, 36, 1006–1014. [CrossRef]
111. Graham, S.M.; Molyneux, E.M.; Walsh, A.L.; Cheesbrough, J.S.; Molyneux, M.E.; Hart, C.A. Nontyphoidal Salmonella infections of
children in tropical Africa. Pediatr. Infect. Dis. J. 2000, 19, 1189–1196. [CrossRef]
112. Fleckenstein, J.M.; Kopecko, D.J. Breaching the mucosal barrier by stealth: An emerging pathogenic mechanism for enteroadherent
bacterial pathogens. J. Clin. Investig. 2001, 107, 27–30. [CrossRef] [PubMed]
113. Ohl, M.E.; Miller, S.I. Salmonella: A model for bacterial pathogenesis. Annu. Rev. Med. 2001, 52, 259–274. [CrossRef] [PubMed]
114. Gewirtz, A.T.; Simon Jr, P.O.; Schmitt, C.K.; Taylor, L.J.; Hagedorn, C.H.; O’Brien, A.D.; Neish, A.S.; Madara, J.L. Salmonella
typhimurium translocates flagellin across intestinal epithelia, inducing a proinflammatory response. J. Clin. Investig. 2001, 107,
99–109. [CrossRef] [PubMed]
115. Weinstein, D.L.; O’Neill, B.L.; Metcalf, E.S. Salmonella typhi stimulation of human intestinal epithelial cells induces secretion of
epithelial cell-derived interleukin 6. Infect Immun. 1997, 65, 395–404. [CrossRef]
116. Maskey, A.P.; Day, J.N.; Phung, Q.T.; Thwaites, G.E.; Campbell, J.I.; Zimmerman, M.; Farrar, J.J.; Basnyat, B. Salmonella enterica
serovar Paratyphi A and S. enterica serovar Typhi cause indistinguishable clinical syndromes in Kathmandu, Nepal. Clin. Infect.
Dis. 2006, 42, 1247–1253. [PubMed]
117. Baker, S.; Holt, K.E.; Clements, A.C.; Karkey, A.; Arjyal, A.; Boni, M.F.; Dongol, S.; Hammond, N.; Koirala, S.; Duy, P.T.; et al.
Combined high-resolution genotyping and geospatial analysis reveals modes of endemic urban typhoid fever transmission. Open
Biol. 2011, 1, 110008–110020. [CrossRef]
118. Gibani, M.M.; Britto, C.; Pollard, A.J. Typhoid and paratyphoid fever: A call to action. Curr. Opin. Infect. Dis. 2018, 31, 440–448.
[CrossRef]
119. Liaquat, S.; Sarwar, Y.; Ali, A.; Haque, A.; Farooq, M.; Martinez-Ballesteros, I.; Laorden, L.; Garaizar, J.; Bikandi, J. Virulotyping of
Salmonella enterica serovar Typhi isolates from Pakistan: Absence of complete SPI10 in Vi negative isolates. PLoS Negl. Trop. Dis.
2018, 12, e0006839. [CrossRef]
120. Kaur, J.; Jain, S.K. Role of antigens and virulence factors of Salmonella enterica serovar Typhi in its pathogenesis. Microbiol. Res.
2012, 167, 199–210. [CrossRef]
121. Moest, T.P.; Meresse, S. Salmonella T3SSs: Successful mission of the secret(ion) agents. Curr. Opin. Microbiol. 2013, 16, 38–44.
[CrossRef]
122. Weinstein, D.L.; O’Neill, B.L.; Hone, D.M.; Metcalf, E.S. Differential early interactions between Salmonella enterica serovar Typhi
and two other pathogenic Salmonella serovars with intestinal epithelial cells. Infect. Immun. 1998, 66, 2310–2318. [CrossRef]
[PubMed]
123. Eckmann, L.; Smith, J.R.; Housley, M.P.; Dwinell, M.B.; Kagnoff, M.F. Analysis by high density cDNA arrays of altered gene
expression in human intestinal epithelial cells in response to infection with the invasive enteric bacteria Salmonella. J. Biol. Chem.
2000, 275, 14084–14094. [CrossRef] [PubMed]
124. Rosenberger, C.M.; Scott, M.G.; Gold, M.R.; Hancock, R.E.; Finlay, B.B. Salmonella Typhimurium infection and lipopolysaccharide
stimulation induce similar changes in macrophage gene expression. J. Immunol. 2000, 164, 5894–5904. [CrossRef] [PubMed]
125. Navarre, W.W.; Zychlinsky, A. Pathogen-induced apoptosis of macrophages: A common end for different pathogenic strategies.
Cell Microbiol. 2000, 2, 265–273. [CrossRef]
Microorganisms 2022, 10, 2006 15 of 15

126. Brennan, M.A.; Cookson, B.T. Salmonella induces macrophage death by caspase-1-dependent necrosis. Mol. Microbiol. 2000, 38,
31–40. [CrossRef]
127. Boise, L.H.; Collins, C.M. Salmonella-induced cell death: Apoptosis, necrosis or programmed cell death? Trends. Microbiol. 2001, 9,
64–67. [CrossRef]
128. Monack, D.M.; Hersh, D.; Ghori, N.; Bouley, D.; Zychlinsky, A.; Falkow, S. Salmonella exploits caspase-1 to colonize Peyer’s
patches in a murine typhoid model. J. Exp. Med. 2000, 192, 249–258. [CrossRef] [PubMed]
129. House, D.; Bishop, A.; Parry, C.; Dougan, G.; Wain, J. Typhoid fever: Pathogenesis and disease. Curr. Opin. Infect. Dis. 2001, 14,
573–578. [CrossRef]
130. Saxena, M.K.; Kumar, R.; Saxena, A.; Singh, Y. Virulence system of Salmonella with special reference to Salmonella enterica.
In Salmonella—A Re-Emerging Pathogen; Mascellino, M.T., Ed.; IntechOpen: London, UK, 2018; pp. 41–53.
131. Aphons, J.A.M.; van Asten, J.; van Dijk, E. Distribution of “classic” virulence factors among Salmonella spp. FEMS Immunol. Med.
Microbiol. 2005, 44, 251–259.
132. Riquelme, S.; Varas, M.; Valenzuela, C.; Velozo, P.; Chahin, N.; Aguilera, P.; Sabag, A.; Labra, B.; Álvarez, S.A.; Chávez, F.P.; et al.
Relevant genes linked to virulence are required for Salmonella Typhimurium to survive intracellularly in the social amoeba
dictyosteliumdiscoideum. Front. Microbiol. 2016, 7, 1305–1314. [CrossRef]
133. Fowoyo, P.T. The mechanisms of virulence and antimicrobial resistance in Salmonella enterica serovar Typhi: A systematic review.
Afr. J. Bio. Sci. 2020, 2, 13–26.
134. Hart, P.J.; O’Shaughnessy, C.M.; Siggins, M.K.; Bobat, S.; Kingsley, R.A.; Goulding, D.A.; Crump, J.A.; Reyburn, H.; Micoli, F.;
Dougan, G.; et al. Differential killing of Salmonella enterica Serovar Typhi by antibodies targeting Vi and lipopolysaccharide
O:9 antigen. PLoS ONE 2016, 11, e0145945.
135. Raffatellu, M.; Chessa, D.; Wilson, R.P.; Dusold, R.; Rubino, S.; Bäumler, A.J. The Vi capsular antigen of Salmonella enterica serotype
Typhi reduces toll-like receptor-dependent Interleukin-8 expression in the intestinal mucosa. Infect. Immun. 2005, 73, 3367–3374.
[CrossRef] [PubMed]
136. Parkhill, J.; Dougan, G.; James, K.D.; Thomson, N.R.; Pickard, D.; Wain, J.; Churcher, C.; Mungall, K.L.; Bentley, S.D.; Holden,
M.T.; et al. Complete genome sequence of a multiple drug resistant Salmonella enterica serovar Typhi CT18. Nature 2001, 413,
848–852. [CrossRef] [PubMed]