Quinolone-resistant Campylobacter jejuni infections in Minnesota, 1992-1998. Investigation Team

What do we feed to food-production animals? A review of animal feed ingredients and their potential impacts on human health

OBJECTIVE

Animal feeding practices in the United States have changed considerably over the past century. As large-scale, concentrated production methods have become the predominant model for animal husbandry, animal feeds have been modified to include ingredients ranging from rendered animals and animal waste to antibiotics and organoarsenicals. In this article we review current U.S. animal feeding practices and etiologic agents that have been detected in animal feed. Evidence that current feeding practices may lead to adverse human health impacts is also evaluated.

DATA SOURCES

We reviewed published veterinary and human-health literature regarding animal feeding practices, etiologic agents present in feed, and human health effects along with proceedings from animal feed workshops.

DATA EXTRACTION

Data were extracted from peer-reviewed articles and books identified using PubMed, Agricola, U.S. Department of Agriculture, Food and Drug Administration, and Centers for Disease Control and Prevention databases.

DATA SYNTHESIS

Findings emphasize that current animal feeding practices can result in the presence of bacteria, antibiotic-resistant bacteria, prions, arsenicals, and dioxins in feed and animal-based food products. Despite a range of potential human health impacts that could ensue, there are significant data gaps that prevent comprehensive assessments of human health risks associated with animal feed. Limited data are collected at the federal or state level concerning the amounts of specific ingredients used in animal feed, and there are insufficient surveillance systems to monitor etiologic agents "from farm to fork."

CONCLUSIONS

Increased funding for integrated veterinary and human health surveillance systems and increased collaboration among feed professionals, animal producers, and veterinary and public health officials is necessary to effectively address these issues.

Regional and seasonal differences in incidence and antibiotic resistance of Campylobacter from a nationwide surveillance study in The Netherlands: an overview of 2000-2004

Campylobacter is the most common cause of bacterial gastroenteritis worldwide. This study describes regional and seasonal differences among culture-proven Campylobacter infections in The Netherlands in 2000-2004. Data were used from two ongoing projects in The Netherlands, covering 3 million and 8 million inhabitants, respectively, for surveillance of infectious diseases. The incidence of Campylobacter infection was highest in the south of The Netherlands (55.7/100,000 vs. an average of 39.1/100,000 in other regions). The incidence in urbanised areas was 41.9/100,000 vs. 32.4/100,000 in rural areas. High stable rates of resistance to fluoroquinolones (35%) were observed. Resistance to erythromycin increased from 1.9% (in 2001) to 2.7% (in 2004). The highest rates of resistance to erythromycin were found in the south. Resistance rates increased with increasing urbanisation, most obviously for fluoroquinolones (35.9% urban vs. 27.10% rural). An inverse relationship was observed between the incidence of infection (high in summer, low in winter) and resistance to both fluoroquinolones and macrolides. Resistance to fluoroquinolones was higher in travel-related infections (54%) than in endemic infections (33%). Differences in regional incidence and resistance rates of Campylobacter infections were found. Foreign travel appeared to be associated with higher resistance rates. Given the high fluoroquinolone resistance rate, empirical treatment of severe, microbiologically confirmed, Campylobacter infection with a fluoroquinolone should be discouraged, pending susceptibility testing.

Re-analysis of the risks attributed to ciprofloxacin-resistant Campylobacter jejuni infections

Recent publications were compared and analysed in addition to novel surveillance data to assess the hypothesis that fluoroquinolone-resistant Campylobacter infections are causing more severe disease than susceptible infections. The available data did not support this hypothesis. There was no significant difference in duration of disease between susceptible and resistant infections. However, both for resistant and susceptible infections, disease symptoms were prolonged by on average 1-2 days for Campylobacter cases acquired during foreign travel. Nevertheless, the likelihood and duration of hospitalisation were not increased for cases related to foreign travel. These observations were confirmed by a new analysis of almost 11,000 cases. We conclude that fluoroquinolone-resistant Campylobacter infections are not more severe than susceptible infections.

Campylobacter jejuni proteomics for new travellers’ diarrhoea vaccines

Travellers' diarrhoea is defined as diarrhoea that develops while a person is abroad in or shortly after return from a developing country. Different pathogens cause diarrhoea in travellers. Campylobacter jejuni is one of the most prominent agents for this illness. Diarrhoea is defined as an abnormally increased frequency or decreased consistency of stools for less than one week. Antibiotics are effective in preventing travellers' diarrhoea, but routine prophylaxis with antibiotics, should be discouraged. Vaccination is promising but no vaccine against C. jejuni is available at the moment. This article presents the ACE BioSciences strategy for the discovery of protein based vaccine candidates using a cell surface proteomics approach of C. jejuni. New targets for C. jejuni protein vaccines were identified. As proof of concept, we could demonstrate decreased colonization of C. jejuni in mice after vaccination with some of these candidates. It is likely that the proteomics based ACE-Biosciences approach will result in reliable travellers' diarrhoea protein-vaccines in the future.

Comparison of antimicrobial resistance of Campylobacter jejuni isolated from humans, chickens, raw milk, and environmental water in Québec

This study compares the occurrence of antimicrobial resistance to erythromycin, ciprofloxacin, and tetracycline among 384 Campylobacter jejuni isolates from humans (245), fresh whole retail chickens (56), raw milk (33), and environmental water (41) collected between 2000 and 2003 in Québec, Canada. Resistance to ciprofloxacin was significantly more frequent in human isolates acquired abroad than in those acquired locally (50 versus 5.9%; P < 0.001); ciprofloxacin resistance was almost absent in water, chicken, and raw milk isolates. In contrast, resistance to erythromycin was significantly more common in chicken than in locally acquired human isolates (16 versus 3.0%, respectively; P < 0.001); no erythromycin resistance was found among water, raw milk, and human isolates acquired abroad. Resistance to tetracycline was significantly more common in chicken and human isolates acquired locally (58.9 and 45.8%, respectively) than in raw milk and water isolates (9.1 and 7.3%, respectively, P < 0.001). Tetracycline resistance was also observed in 44.4% of human isolates acquired abroad. No human isolate was resistant to both ciprofloxacin and erythromycin, but one chicken isolate was resistant to all three antimicrobial agents. Our results suggest that from 2000 to 2003 in Québec, antimicrobial resistance remained stable among locally acquired C. jejuni human clinical isolates and might even have decreased. However, the high erythromycin resistance rate observed among chicken isolates is concerning because of the risk of transmission of such isolates to humans. Additional studies are needed to monitor trends in antimicrobial resistance among food, environment, and human C. jejuni isolates as well as antibiotic use in animals.

Effect of an efflux pump inhibitor on the function of the multidrug efflux pump CmeABC and antimicrobial resistance in Campylobacter

CmeABC, a multidrug efflux pump, contributes to the resistance of Campylobacter to a broad range of antimicrobials. We hypothesize that an efflux pump inhibitor (EPI) may inhibit the function of CmeABC and control antibiotic resistance in Campylobacter. In this study, we examined the effect of EPI Phe-Arg beta-naphthyl-amide dihydrochloride (MC-207,110) on the susceptibility of Campylobacter to various antimicrobials. The presence of the EPI resulted in a 2- to 2048-fold reduction in the minimum inhibitory concentration (MIC) of antimicrobials known to be substrates of the CmeABC pump in all Campylobacter strains. Both intrinsic and acquired resistance of C. jejuni to erythromycin was decreased drastically (64- to 128-fold reduction in the MIC) in the presence of the EPI while the MICs of fluoroquinolones were only slightly decreased (2- to 4-fold). Examination of 57 Campylobacter isolates from various origins further demonstrated that MC-207,110 decreased the MICs of erythromycin (2- to 512-fold) in all isolates. Compared to wild-type strains, the isogenic CmeB mutants displayed smaller magnitudes of reduction in the MICs of antimicrobials in the presence of the EPI, indicating the inhibitory effect of the EPI is primarily CmeABC-dependent. The inhibitory effect of MC-207,110 was also dose-dependent, and as little as 0.5 microg/mL of the EPI resulted in a decreased MIC for erythromycin in C. jejuni. More importantly, the presence of MC-207,110 decreased the frequency of emergence of erythromycin-resistant mutants in C. jejuni (<10(11), well below the normal frequency of approximately 10(8)). Together, these findings indicate that EPI MC-207,110 inhibits the function of CmeABC efflux pump and potentiates the activity of antibiotics against Campylobacter. Inhibition of CmeABC by EPI is a promising approach in combating antibiotic resistance of Campylobacter in humans and animal reservoirs.

Fluoroquinolone-resistant Campylobacter species and the withdrawal of fluoroquinolones from use in poultry: a public health success story

Campylobacter species cause 1.4 million infections each year in the United States. Fluoroquinolones (e.g., ciprofloxacin) are commonly used in adults with Campylobacter infection and other infections. Fluoroquinolones (e.g., enrofloxacin) are also used in veterinary medicine. Human infections with fluoroquinolone-resistant Campylobacter species have become increasingly common and are associated with consumption of poultry. These findings, along with other data, prompted the US Food and Drug Administration to propose the withdrawal of fluoroquinolone use in poultry in 2000. A lengthy legal hearing concluded with an order to withdraw enrofloxacin from use in poultry (effective in September 2005). Clinicians are likely to continue to encounter patients with fluoroquinolone-resistant Campylobacter infection and other enteric infection because of the continued circulation of fluoroquinolone-resistant Campylobacter species in poultry flocks and in persons returning from foreign travel who have acquired a fluoroquinolone-resistant enteric infection while abroad. Judicious use of fluoroquinolones and other antimicrobial agents in human and veterinary medicine is essential to preserve the efficacy of these important chemotherapeutic agents.

Evaluation of an enzyme immunoassay-based stool antigen test to detect Campylobacter jejuni and Campylobacter coli

An enzyme immunoassay-based antigen test (Ridascreen Campylobacter; R-Biopharm, Darmstadt, Germany) was evaluated for the detection of Campylobacter jejuni and Campylobacter coli in 1050 clinical stool samples as compared with culture on selective medium. After routine inoculation for Salmonella, Shigella, Yersinia, Aeromonas, Plesiomonas, and Campylobacter, the same swab specimens were used for the antigen test. The positivity rate for Campylobacter was 9.3% in culture, and the antigen test gave a sensitivity of 69%. Forty-six stool samples culture-negative for Campylobacter grew other enteropathogens; one (positive for Salmonella sp.) was positive in the antigen test. Of all the 952 Campylobacter culture-negative samples, 830 were negative in the antigen test, giving a specificity of 87%. Almost 5% of the samples showed equivocal antigen test results. If the moderate sensitivity of the antigen test was due to a low sensitivity of culture or receiving the stool samples in transportation tubes remains to be studied.

Distribution and Genetic Variability Among Campylobacter spp. Isolates from Different Animal Species and Humans in Switzerland

In Switzerland, a national database with 1028 Campylobacter isolates from poultry, pigs, cats, dogs, cattle, humans, zoo animals and water has been created. The database contains the genetic fingerprint and background information of each Campylobacter isolate. Dominant species could be identified in the different sources with a majority of Campylobacter jejuni in poultry (73%), humans (79%), cattle (95%), zoo animals (40%) and water (100%), of Campylobacter coli in pigs (72%), and of Campylobacter upsaliensis/helveticus in cats and dogs (55%). The comparison of three genotyping methods, amplified fragment length polymorphism (AFLP), pulsed field gel electrophoresis and restriction fragment length polymorphism, revealed that AFLP allows discrimination between the different Campylobacter species and is the most appropriate method to distinguish specific strains within the same species. Genotyping analysis demonstrated that the Campylobacter population is heterogeneous among the different sources and that no dominant clone is spread in the country. Genotyping and the resulting database are useful tools to trace back future Campylobacter infections.

Dissemination of antimicrobial resistant strains of Campylobacter coli and Campylobacter jejuni among cattle in Washington State and California

The purpose of this study was to investigate the genetic similarity of Campylobacter jejuni and Campylobacter coli with similar antimicrobial resistance phenotypes, isolated from cattle on different farms and at different times, in order to evaluate the possible existence of disseminated antimicrobial resistant clones. PFGE after SmaI and KpnI restriction identified 23 and 16 distinct PFGE patterns among 29 C. jejuni and 66 C. coli isolates, respectively. In C. coli, 51 (77%) of the resistant isolates demonstrated one of the four indistinguishable PFGE patterns, whereas only 24% doxycycline resistant C. jejuni shared one of the two indistinguishable PFGE patterns. The genetic mechanisms of resistance were homogeneous within and between these clonal types. Genetically indistinguishable (clonal) groups of C. coli accounted for most Campylobacter sp. with multiple antimicrobial resistance observed in this study, consistent with a role for clonal dissemination in the epidemiology of resistance in this species.

Comparison of disk diffusion and agar dilution methods for erythromycin and ciprofloxacin susceptibility testing of Campylobacter jejuni subsp. jejuni

Disk diffusion was a reliable, easy, and inexpensive method for testing the susceptibility of Campylobacter jejuni to erythromycin (215 susceptible and 45 resistant isolates) and to ciprofloxacin (154 susceptible, two intermediate, and 124 resistant isolates) using, respectively, an erythromycin disk and ciprofloxacin and nalidixic acid disks.

Prevalence, Molecular Characterization and Antimicrobial Resistance of Thermophilic Campylobacter Isolates from Cattle, Hens, Broilers and Broiler Meat in South-eastern Italy

Eleven cattle farms, 8 layer farms, 7 broiler farms and 30 broiler meat samples were investigated in south-eastern Italy throughout 2003 to evaluate the prevalence, the molecular type and antimicrobial resistance of thermophilic Campylobacters. A total of 398 samples were analysed. One Campylobacter isolate for each positive faecal swab and three isolates per positive broiler meat sample were selected for further analysis. Multiplex PCR was performed for species-level identification and PCR-RFLP of the flagellin A gene for genotyping. Resistance to 14 antimicrobials was studied in 188 Campylobacter isolates. Prevalence of campylobacters was high both on farms (100%) and in food samples (73%). On 4/11 cattle farms and on 10/15 poultry farms more than one species was isolated. The presence of more than one genotype was found on 8/11 cattle farms, on 10/15 poultry farms and in 8/22 Campylobacter-positive food samples. High rates of resistance to quinolone were observed: 9/31 (29%) C. jejuni bovine isolates, 4/22 (18%) C. jejuni poultry isolates, and 14/26 (54%) C. coli poultry isolates. Resistance to sulphamethoxazole-trimethoprim was also observed frequently: 18/26 (69%) of the avian C. coli strains, 25/31 (80%) of the C. jejuni strains isolated from poultry and 15/22 (68%) of those isolated from cattle were resistant. There was a significant difference between the rate of resistance to macrolides of C. coli and C. jejuni isolated in poultry, which amounted to 23% and 3%, respectively. This study provided data on the prevalence and antimicrobial resistance of thermophilic campylobacters in south-eastern Italy and confirmed that flaA-typing is an efficient tool to study the epidemiology of Campylobacter strains in short-term investigations.

Antibiotic-resistant Campylobacter: could efflux pump inhibitors control infection?

Campylobacter is the most common cause of bacterial gastroenteritis in the world. Poultry is the main reservoir of human infections. The widespread use of antibiotics in agriculture and veterinary medicine has resulted in the emergence of an increasing number of antibiotic-resistant Campylobacter strains that can be transmitted to humans through the food chain. Of particular concern to public health is the prevalence of resistance to macrolides and fluoroquinolones that are used in the treatment of life-threatening campylobacteriosis. The CmeABC efflux system has been shown to contribute to the intrinsic and acquired resistance to these antibiotics. In addition, by mediating resistance to bile, it is essential for colonization of the chicken gut in vivo. Inhibition of CmeABC may provide an effective means of reversing antibiotic resistance and decreasing the transmission of Campylobacter via the food chain. This would positively impact on public health by decreasing the morbidity, mortality and increased healthcare costs associated with the treatment of antibiotic-resistant Campylobacter.

Tracking Oxytetracyline Mobility Across Environmental Interfaces by Second Harmonic Generation

This work examines the binding behavior of the antibiotic oxytetracycline (OTC) to mineral oxide/water interfaces in the presence and absence of organic functional groups using the interface-specific technique second harmonic generation (SHG). Studies show that OTC binding to fused quartz, methyl ester, carboxylic acid, and alkyl interfaces is fully reversible and highly dependent on solution pH, with appreciable adsorption occurring only at pH 8. Relative surface coverage at pH 8 is highest for the polar organic-functionalized surfaces, and surface saturation occurs for the methyl ester-functionalized fused quartz/water interface at 2 x 10(-5) M. Adsorption isotherm measurements indicate that the binding process is controlled by hydrogen bonding and hydrophobic interactions, with free energies of adsorption on the order of -40 kJ/mol for all interfaces studied. The results indicate that OTC transport in the environment will depend heavily on soil pH and composition and have implications for the development of bacterial antibiotic resistance.

Temporal prevalence of antimicrobial resistance in Campylobacter spp. from beef cattle in Alberta feedlots

Antimicrobial resistance (AMR) was temporally assessed in campylobacters isolated from beef cattle (7,738 fecal samples from 2,622 animals) in four commercial feedlots in Alberta. All calves were administered chlortetracycline and oxytetracycline in feed, and a majority of the animals (93%) were injected with long-acting oxytetracycline upon arrival at the feedlot. Fecal samples from individual animals were collected upon arrival (i.e., entry sample), 69 days (standard deviation [SD] = 3 days) after arrival (i.e., interim sample), and 189 days (SD = 33 days) after arrival (i.e., exit sample) at the feedlot. In total, 1,586 Campylobacter isolates consisting of Campylobacter coli (n = 154), Campylobacter fetus (n = 994), Campylobacter jejuni (n = 431), Campylobacter hyointestinalis (n = 4), and Campylobacter lanienae (n = 3) were recovered and characterized. The administration of antimicrobials did not decrease carriage rates of campylobacters, and minimal resistance (< or =4%) to azithromycin, ciprofloxacin, enrofloxacin, gentamicin, and meropenem was observed. In contrast, substantive increases in the prevalence of isolates resistant to tetracycline and doxycycline (56 to 89%) for C. coli, C. fetus, and C. jejuni, as well as in the number of animals (7 to 42%) from which resistant isolates were recovered, were observed during the feedlot period. Increased resistance to erythromycin (total isolates and carriages rates) was also observed in isolates of C. coli over the three isolation times. The majority of C. fetus isolates recovered were resistant to nalidixic acid, but this was independent of when they were isolated. A relatively limited number of multidrug-resistant isolates were recovered and consisted primarily of C. coli resistant to tetracyclines and erythromycin (10% of isolates). Over the course of the feedlot period, considerable increases in antimicrobial resistance were observed in C. coli, C. fetus, and C. jejuni, but with the exception of erythromycin resistance in C. coli, the administration of antimicrobial agents to beef cattle was found to have a minimal impact on resistance to macrolides and fluoroquinolones, the two classes of antimicrobials used to treat campylobacteriosis in humans. However, the widespread use of antimicrobial agents in beef production and the possible horizontal transfer of mobile genetic elements with antimicrobial resistance determinants among Campylobacter and other bacterial taxa emphasize the need to monitor AMR development in bacteria from beef cattle.

Current and future developments in travelers' diarrhea therapy

Diarrhea continues to be the leading health problem among international travelers to developing tropical and semi-tropical regions. Despite more than 50 years of research providing information about the etiology and pathogenesis of the disease, the rate of illness and consequences remain unchanged. An estimated 40% of travelers to developing nations will become ill with diarrhea. Although travelers' diarrhea is considered a self-limited disease, novel and effective approaches to disease prevention and treatment have been realized in recent years. Also, recent evidence has identified a potential for long-term complications of the illness, including postinfectious irritable bowel syndrome. With the advent of poorly absorbed (<0.4%) rifaximin, a treatment option for the common watery diarrhea syndrome equivalent to previously used absorbed antibacterial drugs has emerged. Rifaximin with an excellent safety profile and limited potential to induce coliform resistance, prevents most of the diarrhea that would otherwise occur. With further studies in different settings, new consideration should be given to the routine use of chemoprophylaxis for travelers to high-risk countries. Antibacterial drugs will continue to be the optimal treatment for travelers' diarrhea subjects for the most part caused by bacterial enteropathogens and shorten the duration of diarrhea by 1-2 days compared with no active drug treatment.

Effect of conventional and organic production practices on the prevalence and antimicrobial resistance of Campylobacter spp. in poultry

Intestinal tracts of broilers and turkeys from 10 conventional broiler farms and 10 conventional turkey farms, where antimicrobials were routinely used, and from 5 organic broiler farms and 5 organic turkey farms, where antimicrobials had never been used, were collected and cultured for Campylobacter species. A total of 694 Campylobacter isolates from the conventional and organic poultry operations were tested for antimicrobial resistance to nine antimicrobial agents by the agar dilution method. Although Campylobacter species were highly prevalent in both the conventional and organic poultry operations, the antimicrobial resistance rates were significantly different between the organic operations and the conventional operations. Less than 2% of Campylobacter strains isolated from organically raised poultry were resistant to fluoroquinolones, while 46% and 67% of Campylobacter isolates from conventionally raised broilers and conventionally raised turkeys, respectively, were resistant to these antimicrobials. In addition, a high frequency of resistance to erythromycin (80%), clindamycin (64%), kanamycin (76%), and ampicillin (31%) was observed among Campylobacter isolates from conventionally raised turkeys. None of the Campylobacter isolates obtained in this study was resistant to gentamicin, while a large number of the isolates from both conventional and organic poultry operations were resistant to tetracycline. Multidrug resistance was observed mainly among Campylobacter strains isolated from the conventional turkey operation (81%). Findings from this study clearly indicate the influence of conventional and organic poultry production practices on antimicrobial resistance of Campylobacter on poultry farms.

Low-Level Fluoroquinolone Resistance among Campylobacter jejuni Isolates in Australia

BACKGROUND

Ciprofloxacin-resistant Campylobacter jejuni isolates obtained from infected patients in Australia have not been detected in studies of isolates from specific geographic areas. The Australian government has prohibited the use of fluoroquinolone in food-producing animals. To assess the impact of this policy, we have examined the antimicrobial susceptibility of isolates from 5 Australian states.

METHODS

We conducted a period-prevalence survey of the susceptibility of C. jejuni isolates to 10 antimicrobial agents. C. jejuni isolates obtained from 585 patients from 5 Australian states (Queensland, South Australia, Tasmania, Victoria, and Western Australia) were identified by means of notifiable disease databases and were systematically selected from September 2001 to August 2002.

RESULTS

Among locally acquired infections, only 2% of isolates (range, 0%-8% in different states) were resistant to ciprofloxacin. The locally acquired isolates also exhibited resistance to sulfisoxazole (55%), ampicillin (46%), roxithromycin (38%), tetracycline (7%), nalidixic acid (6%), chloramphenicol (3%), erythromycin (3%), gentamicin (2%), and kanamycin (0.2%). Treatment with antimicrobial agents in the 4 weeks before onset was not associated with ciprofloxacin resistance.

CONCLUSIONS

The very low level of ciprofloxacin resistance in C. jejuni isolates likely reflects the success of Australia's policy of restricting use of fluoroquinolones in food-producing animals.

Dissemination of fluoroquinolone-resistant Campylobacter spp. within an integrated commercial poultry production system

While characterizing the intestinal bacterial community of broiler chickens, we detected epsilon-proteobacterial DNA in the ilea of 3-day-old commercial broiler chicks (J. Lu, U. Idris, B. Harmon, C. Hofacre, J. J. Maurer, and M. D. Lee, Appl. Environ. Microbiol. 69:6816-6824, 2003). The sequences exhibited high levels of similarity to Campylobacter jejuni and Campylobacter coli sequences, suggesting that chickens can carry Campylobacter at a very young age. Campylobacter sp. was detected by PCR in all samples collected from the ilea of chicks that were 3 to 49 days old; however, it was detected only in the cecal contents of chickens that were at least 21 days old. In order to determine whether the presence of Campylobacter DNA in young chicks was due to ingestion of the bacteria in food or water, we obtained commercial broiler hatching eggs, which were incubated in a research facility until the chicks hatched. DNA sequencing of the amplicons resulting from Campylobacter-specific 16S PCR performed with the ileal, cecal, and yolk contents of the day-of-hatching chicks revealed that Campylobacter DNA was present before the chicks consumed food or water. The 16S rRNA sequences exhibited 99% similarity to C. jejuni and C. coli sequences and 95 to 98% similarity to sequences of other thermophilic Campylobacter species, such as C. lari and C. upsaliensis. The presence of C. coli DNA was detected by specific PCR in the samples from chicks obtained from a commercial hatchery; however, no Campylobacter was detected by culturing. In order to determine whether the same strains of bacteria were present in multiple levels of the integrator, we cultured Campylobacter sp. from a flock of broiler breeders and their 6-week-old progeny that resided on a commercial broiler farm. The broiler breeders had been given fluoroquinolone antibiotics, and we sought to determine whether the same fluoroquinolone-resistant strain was present in their progeny. The isolates were typed by pulsed-field gel electrophoresis, which confirmed that the parental and progeny flocks contained the same strain of fluoroquinolone-resistant C. coli. These data indicate that resistant C. coli can be present in multiple levels of an integrated poultry system and demonstrated that molecular techniques or more sensitive culture methods may be necessary to detect early colonization by Campylobacter in broiler chicks.

Activities of telithromycin, erythromycin, fluoroquinolones, and doxycycline against Campylobacter strains isolated from Finnish subjects

The in vitro susceptibilities of 478 Campylobacter jejuni and Campylobacter coli strains isolated from Finnish subjects during 2002 to 2004 were determined. Susceptibility to erythromycin remained high, and telithromycin did not offer any advantage over erythromycin. Reduced susceptibilities to fluoroquinolones and doxycycline were detected almost exclusively among isolates of foreign origin.

The epidemiology of antibiotic resistance in Campylobacter

Antibiotic resistance, particularly with the fluoroquinolones and macrolide antibiotics, has now emerged globally with thermophilic campylobacters, including Campylobacter jejuni and C. coli, giving rise to concerns about how these organisms have acquired such resistance characteristics, as well as consequences for human and animal treatment. This review examines (i) the clinical epidemiology of antibiotic resistance in human and animal thermophilic campylobacters, (ii) an update on resistance rates globally, (iii) surveillance of antimicrobial resistance in campylobacters originating from animals, particularly poultry, (iv) the role of the environment in the acquisition and transmission of antibiotic-resistant campylobacters, as well as (v) issues of biocide resistance in campylobacters.

Fitness of antimicrobial-resistant Campylobacter and Salmonella

Campylobacter and Salmonella are the most commonly reported bacterial causes of human foodborne infections, and increasing proportions of these pathogens become resistant to medically important antimicrobial agents, imposing a burden on public health. Acquisition of resistance to antibiotics affects the adaptation and evolution of Salmonella and Campylobacter in various environments. Many resistance-conferring mutations entail a biological fitness cost, while others (e.g. fluoroquinolone resistance in Campylobacter) have no cost or even enhanced fitness. In Salmonella, the fitness disadvantage due to antimicrobial resistance can be restored by acquired compensatory mutations, which occur both in vitro and in vivo. The compensated or even enhanced fitness associated with antibiotic resistance may facilitate the spread and persistence of antimicrobial-resistant Salmonella and Campylobacter in the absence of selection pressure, creating a significant barrier for controlling antibiotic-resistant foodborne pathogens.

Genetic mechanisms contributing to reduced tetracycline susceptibility of Campylobacter isolated from organic and conventional dairy farms in the midwestern and northeastern United States

Campylobacter is one of the most common causes of gastroenteritis and can be acquired through contact with farm animals or the consumption of raw milk. Because of concerns over the role of food-producing animals in the dissemination of antimicrobial resistance to humans, we evaluated the prevalence of antimicrobial resistance in Campylobacter isolates from dairy farms and the genetic mechanism conferring the observed resistance. Evaluation of antimicrobial resistance was completed on 912 isolates from conventional and 304 isolates from organic dairy farms to eight drugs (azithromycin, chloramphenicol, ciprofloxacin, clindamycin, erythromycin, gentamicin, nalidixic acid, and tetracycline) with microbroth dilution. Resistance to seven of eight drugs was very low and did not differ by farm type. However, tetracycline resistance was common in Campylobacter isolated from both organic and conventional dairy farms, with 48 and 58% of isolates affected, respectively. By multiplex PCR, we determined that tetracycline resistance was highly associated with the carriage of tetO in Campylobacter isolates (X2 = 124, P < 0.01, kappa = 0.86).

Antimicrobial resistance in Campylobacter jejuni from humans and broilers in Norway

In this study comprising isolates from 2001 to 2003, resistance was considerably more widespread among Campylobacter jejuni from humans infected abroad than infected within Norway. The discrepancy was particularly notable for fluoroquinolone resistance (67.4% vs. 6.5%). This is probably a reflection of a low resistance prevalence in Norwegian broiler isolates (1.2% fluoroquinolone resistant).

Resistance to antibiotics: are we in the post-antibiotic era?

Serious infections caused by bacteria that have become resistant to commonly used antibiotics have become a major global healthcare problem in the 21st century. They not only are more severe and require longer and more complex treatments, but they are also significantly more expensive to diagnose and to treat. Antibiotic resistance, initially a problem of the hospital setting associated with an increased number of hospital-acquired infections usually in critically ill and immunosuppressed patients, has now extended into the community causing severe infections difficult to diagnose and treat. The molecular mechanisms by which bacteria have become resistant to antibiotics are diverse and complex. Bacteria have developed resistance to all different classes of antibiotics discovered to date. The most frequent type of resistance is acquired and transmitted horizontally via the conjugation of a plasmid. In recent times new mechanisms of resistance have resulted in the simultaneous development of resistance to several antibiotic classes creating very dangerous multidrug-resistant (MDR) bacterial strains, some also known as "superbugs". The indiscriminate and inappropriate use of antibiotics in outpatient clinics, hospitalized patients and in the food industry is the single largest factor leading to antibiotic resistance. In recent years, the number of new antibiotics licensed for human use in different parts of the world has been lower than in the recent past. In addition, there has been less innovation in the field of antimicrobial discovery research and development. The pharmaceutical industry, large academic institutions or the government are not investing the necessary resources to produce the next generation of newer safe and effective antimicrobial drugs. In many cases, large pharmaceutical companies have terminated their anti-infective research programs altogether due to economic reasons. The potential negative consequences of all these events are relevant because they put society at risk for the spread of potentially serious MDR bacterial infections.

Antimicrobial resistance of Escherichia coli isolates from broiler chickens and humans

BACKGROUND

Antimicrobial usage is considered the most important factor promoting the emergence, selection and dissemination of antimicrobial-resistant microorganisms in both veterinary and human medicine. The aim of this study was to investigate the prevalence and genetic basis of tetracycline resistance in faecal Escherichia coli isolates from healthy broiler chickens and compare these data with isolates obtained from hospitalized patients in Jamaica.

RESULTS

Eighty-two E. coli strains isolated from faecal samples of broiler chickens and urine and wound specimens of hospitalized patients were analyzed by agar disc diffusion to determine their susceptibility patterns to 11 antimicrobial agents. Tetracycline resistance determinants were investigated by plasmid profiling, transformations, and amplification of plasmid-borne resistance genes. Tetracycline resistance occurred at a frequency of 82.4% in avian isolates compared to 43.8% in human isolates. In addition, among avian isolates there was a trend towards higher resistance frequencies to kanamycin and nalidixic acid (p < 0.05), while a greater percentage of human isolates were resistant to chloramphenicol and gentamicin (p < 0.05). Multiple drug resistance was found in isolates from both sources and was usually associated with tetracycline resistance. Tetracycline-resistant isolates from both avian and human sources contained one or several plasmids, which were transmissible by transformation of chemically-competent E. coli. Tetracycline resistance was mediated by efflux genes tetB and/or tetD.

CONCLUSION

The present study highlights the prevalence of multiple drug resistant E. coli among healthy broiler chickens in Jamaica, possibly associated with expression of tetracycline resistance. While there did not appear to be a common source for multiple drug resistance in the strains from avian or human origin, the genes encoding resistance are similar. These results suggest that genes are disseminated in the environment and warrant further investigation of the possibility for avian sources acting as reservoirs for tetracycline resistance.

Antimicrobial-resistant bacteria in the community setting

Over the past decade, antimicrobial resistance has emerged as a major public-health crisis. Common bacterial pathogens in the community such as Streptococcus pneumoniae have become progressively more resistant to traditional antibiotics. Salmonella strains are beginning to show resistance to crucial fluoroquinolone drugs. Community outbreaks caused by a resistant form of Staphylococcus aureus, known as community-associated meticillin (formerly methicillin)-resistant Staphylococcus aureus, have caused serious morbidity and even deaths in previously healthy children and adults. To decrease the spread of such antimicrobial-resistant pathogens in the community, a greater understanding of their means of emergence and survival is needed.

Resistance to three antimicrobial agents of Campylobacter isolated from organically- and intensively-reared chickens purchased from retail outlets

Resistance rates to three antimicrobials (ciprofloxacin, erythromycin and nalidixic acid) in Campylobacter isolated from organically- and intensively-reared chickens purchased from supermarkets and butcher's shops in London were determined. Significant differences in the minimum inhibitory concentrations (MICs) of nalidixic acid were found, with the highest values in unpackaged intensively-reared chickens and the lowest values in organically-reared chickens. Using pre-set breakpoints, all isolates from all groups of chickens were identified as resistant to erythromycin and nalidixic acid. All isolates from the organically-reared group were susceptible to ciprofloxacin. Of the supermarket intensively-reared chickens, 8.7% harboured resistant isolates, all on the external parts, indicating post-slaughtering contamination. The highest percentage (26.7%) was in chickens from butcher shops, mostly in the chicken cavities, suggesting a link to treatment on the farm.

Comparison of Campylobacter isolated from humans and food-producing animals in Japan

AIMS

To compare the antimicrobial resistance, serotypes and flagellin gene types of Campylobacter isolated from humans and food-producing animals and thereby facilitate elucidation of the origin of Campylobacter causing human infection in Japan.

METHODS AND RESULTS

The MIC values of ampicillin, dihydrostreptomycin, gentamicin, erythromycin, oxytetracycline, nalidixic acid and enrofloxacin for Campylobacter isolated from humans (134 isolates), cattle (38 isolates), pigs (69 isolates), layers (84 isolates) and broilers (51 isolates) were compared. The MIC(90) values of ampicillin for Campylobacter jejuni isolates from poultry were higher than those from humans and cattle. Campylobacter coli that was resistant to dihydrostreptomycin and erythromycin was observed at a higher frequency in humans and pigs than in poultry. The restriction fragment profiles of flaA of human, bovine and broiler isolates were analysed by clustering, and the isolates were classified into five clusters. Cluster I contained only human and bovine isolates. Clusters III, IV and V contained human, bovine and broiler isolates.

CONCLUSIONS

Campylobacter isolates from humans included isolates that exhibited characteristics identical to those of the bovine, porcine and poultry isolates.

SIGNIFICANCE AND IMPACT OF THE STUDY

In addition to poultry, cattle and pigs are believed to be sources of campylobacteriosis in Japan.

The Dynamics of Antimicrobial-Resistant Campylobacter jejuni on Japanese Broiler Farms

We investigated for dynamics of Campylobacter clones on 2 different managerial broiler farms. Campylobacter isolates were differentiated by resistance typing and molecular typing methods. On farm I, the same C. jejuni clones resistant to fluoroquinolone and oxytetracycline were isolated after one and half years again and another susceptible clone was invaded. The susceptible clone was isolated again after half year. Broiler flocks on the farm may be repeatedly infected with a few C. jejuni clones. On farm II, new clones including antimicrobial resistant one, were often invaded. The change of predominant C. jejuni clone in each flock on both the farms was observed, in the absence of antimicrobial selective pressure.

Safety and Tolerability of the Antibacterial Rifaximin in the Treatment of Travellers??? Diarrhoea

Although travellers' diarrhoea can sometimes be associated with postinfectious complications, the condition is typically self-limiting. The infectious-diarrhoea guidelines subcommittees of the Infectious Disease Society of America and the American College of Gastroenterology recommend empirical antibacterial therapy for travellers' diarrhoea. Because therapy is directed largely at relieving symptoms and minimising inconvenience, the chosen antibacterial should ideally be both efficacious and pose a low risk of adverse effects. This review discusses the safety and tolerability of rifaximin in the treatment of travellers' diarrhoea, with a focus on data from controlled clinical trials. Data were obtained from a MEDLINE search using the key word 'rifaximin' with no date limits and from the rifaximin New Drug Application submitted to the US FDA for approval to market rifaximin in the US.Currently, the antibacterials considered as standard treatment for travellers' diarrhoea are systemically absorbed, carry defined risks of adverse effects, and have many uses other than the treatment of enteric disease. The minimally absorbed (<0.4%) oral antibacterial rifaximin constitutes a non-systemic approach to antidiarrhoeal therapy that should overcome some of the limitations of current antibacterials used for travellers' diarrhoea. Rifaximin is differentiated from these, and most other antibacterials, by having a tolerability profile comparable with that of placebo and minimal potential for drug interactions. To date, clinically relevant resistance to rifaximin has not been observed. As the first nonabsorbable antibacterial to be marketed for travellers' diarrhoea, rifaximin should help to change the management paradigm for travellers' diarrhoea and other gastrointestinal illnesses from a systemic approach to a predictably safer, non-systemic approach.

Preventing antibiotic resistance: the next step

There is universal agreement that the emergence of antibiotic-resistant bacteria is a significant health problem, leading to preventable morbidity and mortality. Kaiser Permanente (KP) has made great strides in improving the antibiotic-prescribing behavior of its physicians, thereby limiting the emergence of antibiotic resistance in the clinical setting. This, however, is only a beginning. Greater than 70% of the antibiotics used in the United States are for nontherapeutic purposes in animal feed. The resulting emergence of resistant bacteria that cause human disease is described. I propose a campaign throughout KP to broaden our prevention efforts by phasing out meat, dairy, poultry, and fish products raised using antibiotic feed additives.

Ciprofloxacin resistance and its molecular mechanism in Campylobacter spp. isolated in Kuwait

Campylobacter spp. are an important cause of diarrhea in Kuwait. Because susceptibility data for ciprofloxacin and erythromycin, the two recommended drugs for treatment, are not available for this part of the world, 64 Campylobacter spp. isolates obtained from human diarrheal stools in Kuwait during 2000--2003 were studied for susceptibility to these antimicrobials by E-test. The utility of a simple mismatch amplification mutation assay (MAMA) PCR to detect base substitution in the gyrA gene mediating resistance to ciprofloxacin was also explored. Approximately, 53% (34/64) of the isolates were resistant to ciprofloxacin (MIC, 4-64 microg/ml) and 5% (3/64) to erythromycin (MIC>256 microg/ml). MAMA PCR showed a Thr-86-to-Ile mutation in gyrA gene of 23/26 ciprofloxacin-resistant C. jejuni, and in all resistant C. coli. Sequencing of PCR product showed that two resistant strains of C. coli studied had Thr-86-to-Ile (ACT--> ATT) gyrA mutation and three resistant strains of C. jejuni studied had Thr-86-to-Ile (ACA--> ATA) gyrA mutation. In addition, all the three C. jejuni strains had silent mutations. Thus, ciprofloxacin is of limited use for treatment in Kuwait and MAMA PCR is a useful assay to study gyrA mutation. Because Kuwait has a large expatriate population of workers, it can be a focus of spread of antimicrobial resistance.

Poorly Absorbed Antibiotics for the Treatment of Traveler' Diarrhea

This article describes the use of poorly absorbed antibiotics for the treatment of traveler's diarrhea. Poorly absorbed oral antibiotics can deliver high concentrations of drug to the site of enteric infection with minimal risk of systemic adverse effects, toxicity, and drug interactions. Compared with systemically absorbed oral antibiotics, poorly absorbed oral antibiotics may be less associated with the pressure that leads to the development of bacterial resistance, because they do not affect bacteria outside the gastrointestinal tract. In clinical studies, poorly absorbed oral antibiotics, including aztreonam, bicozamycin, and rifaximin, were more effective than and as well tolerated as placebo; in particular, rifaximin was as effective as oral ciprofloxacin in reducing the duration of illness in traveler's diarrhea. More research is warranted to delineate the effects of poorly absorbed antibiotics in invasive infection and to assess the potential for the development of bacterial resistance.

Emergence of Fluoroquinolone Resistance in Campylobacter jejuni in Chickens Exposed to Enrofloxacin Treatment at the Inherent Dosage Licensed in Japan

The objective of the present study was to determine whether selection of fluoroquinolone resistance could be easily induced in Campylobacter jejuni-colonized chickens by treatment with enrofloxacin of representative fluoroquinolones at the inherent dosage licensed in Japan (50 ppm in drinking water for 3 days). In the case of isolates from chickens of study 1, an increase in the population of susceptible isolates appeared after the cessation of treatment and maintained throughout the experiments. On the contrary, our results of study 2 demonstrated that administration of enrofloxacin generated a rapid increase of fluoroquinolone resistance in C. jejuni showing the mutation of Asp-90-Asn in the gyrA gene. Present results indicate that the enrofloxacin treatment for broilers at the inherent dosage is able to select fluoroquinolone resistance in C. jejuni. We conclude that whatever enrofloxacin dosage is used, an emergence of fluoroquinolone resistant of C. jejuni occurs.

Prevalence and antimicrobial resistance of Campylobacter in antimicrobial-free and conventional pig production systems

The objectives of this study were to determine and compare the prevalence and antimicrobial resistance of Campylobacter species in swine reared in conventional and antimicrobial-free (ABF) production systems. Campylobacter coli was the predominant species, with 1,459 isolates (99%) in the study. We found significantly higher prevalence of C. coli on the ABF farms (77.3%) than on the conventional farms (27.6%) among pigs at the nursery stage (P < 0.001). At slaughter, we found significantly higher prevalence at the postevisceration than at the preevisceration stage (P < 0.001) in both production systems. The 1,459 C. coli isolates were tested with the agar dilution method for their susceptibility to six antimicrobials: chloramphenicol, ciprofloxacin, erythromycin, gentamicin, nalidixic acid, and tetracycline. Resistance was most prevalent against tetracycline (66.2% of isolates) followed by erythromycin (53.6% of isolates). Frequency of resistance to these two antimicrobials was significantly higher among conventional herds (83.4% for tetracycline and 77% for erythromycin) than among ABF herds (56.2% for tetracycline and 34.5% for erythromycin). Resistance to ciprofloxacin at the MIC (> 4 mg/liter) was also found on farms in both systems. Multidrug-resistant C. coli strains were detected in both the conventional (7%) and ABF (4%) herds. This is the first report of ciprofloxacin-resistant strains of C. coli in ABF pigs in the United States. These findings highlight the high prevalence of antimicrobial-resistant C. coli in both conventional and ABF pig production systems and have significant implications for the persistence of antimicrobial-resistant Campylobacter in the pig production environment regardless of levels of antimicrobial use.

Concurrent quantitation of total campylobacter and total ciprofloxacin-resistant campylobacter loads in rinses from retail raw chicken carcasses from 2001 to 2003 by direct plating at 42 degrees C

This is the first report on the use of a normally lethal dose of ciprofloxacin in a Campylobacter agar medium to kill all ciprofloxacin-sensitive Campylobacter spp. but allow the selective isolation and quantitation of naturally occurring presumptive ciprofloxacin-resistant Campylobacter CFU in rinses from retail raw chicken carcasses (RTCC). Thermophilic-group total Campylobacter CFU and total ciprofloxacin-resistant Campylobacter CFU (irrespective of species) were concurrently quantified in rinses from RTCC by direct plating of centrifuged pellets from 10 or 50 ml out of 400-ml rinse subsamples concurrently on Campylobacter agar and ciprofloxacin-containing Campylobacter agar at 42 degrees C (detection limit = 0.90 log(10) CFU/carcass). For 2001, 2002, and 2003, countable Campylobacter CFU were recovered from 85%, 96%, and 57% of RTCC, while countable ciprofloxacin-resistant Campylobacter CFU were recovered from 60%, 59%, and 17.5% of RTCC, respectively. Total Campylobacter CFU loads in RTCC rinses ranged from 0.90 to 4.52, 0.90 to 4.58, and 0.90 to 4.48 log(10) CFU/carcass in 2001, 2002, and 2003, respectively. Total ciprofloxacin-resistant Campylobacter CFU loads in RTCC rinses ranged from 0.90 to 4.06, 0.90 to 3.95, and 0.90 to 3.04 log(10) CFU/carcass in 2001, 2002, and 2003, respectively. Overall, total Campylobacter loads of 0.90 to 2.0, 2 to 3, 3 to 4, 4 to 5 log(10) CFU/carcass, respectively, were recovered from 16%, 32%, 26%, and 5% of RTCC tested over the 2-year sampling period. For the same period, total ciprofloxacin-resistant Campylobacter loads of 0.90 to 2.0, 2 to 3, 3 to 4, and 4 to 5 log(10) CFU/carcass, respectively, were recovered from 24%, 11%, 7%, and 0.2% of RTCC tested. There was a steady decline in total Campylobacter and total ciprofloxacin-resistant Campylobacter loads in RTCC rinses from 2001/2002 to 2003.

Human health consequences of antimicrobial drug-resistant Salmonella and other foodborne pathogens

There are several clinical and public health consequences associated with antimicrobial drug resistance in non-Typhi Salmonella species and other foodborne pathogens. If bacteria acquire resistance to clinically important antimicrobial drugs, early empirical treatment may fail, and there will be limitations in the choices of treatment after the establishment of microbial diagnosis. Drug-resistant gastrointestinal pathogens preferentially cause illness in persons receiving antimicrobial drugs for any medical condition. Consequently, emerging resistance in foodborne pathogens may result in increased burdens of illness and outbreaks in settings where patients are treated with antimicrobial drugs. Finally, resistance may be associated with increased virulence, and several epidemiological studies have demonstrated that infections with drug-resistant non-Typhi Salmonella serotypes and Campylobacter species are associated with excess mortality and morbidity. Mitigation of drug resistance in foodborne bacteria is likely to be of benefit for human health.

Role of efflux pumps and topoisomerase mutations in fluoroquinolone resistance in Campylobacter jejuni and Campylobacter coli

Point mutations in the topoisomerase (DNA gyrase A) gene are known to be associated with fluoroquinolone resistance in Campylobacter. Recent studies have shown that an efflux pump encoded by cmeABC is also involved in decreased susceptibilities to fluoroquinolones, as well as other antimicrobials. Genome analysis suggests that Campylobacter jejuni contains at least nine other putative efflux pumps. Using insertional inactivation and site-directed mutagenesis, we investigated the potential contributions of these pumps to susceptibilities to chloramphenicol, ciprofloxacin, erythromycin, and tetracycline in C. jejuni and Campylobacter coli. Insertional inactivation of cmeB resulted in 4- to 256-fold decreases in the MICs of chloramphenicol, ciprofloxacin, erythromycin, and tetracycline, with erythromycin being the most significantly affected. In contrast, inactivation of all other putative efflux pumps had no effect on susceptibility to any of the four antimicrobials tested. Mutation of gyrA at codon 86 (Thr-Ile) caused 128- and 64-fold increases in the MICs of ciprofloxacin and nalidixic acid, respectively. The replacement of the mutated gyrA with a wild-type gyrA allele resulted in a 32-fold decrease in the ciprofloxacin MIC and no change in the nalidixic acid MIC. Our findings indicate that CmeABC is the only efflux pump among those tested that influences antimicrobial resistance in Campylobacter and that a point mutation (Thr-86-Ile) in gyrA directly causes fluoroquinolone resistance in Campylobacter. These two mechanisms work synergistically in acquiring and maintaining fluoroquinolone resistance in Campylobacter species.

pVir and bloody diarrhea in Campylobacter jejuni enteritis

The plasmid pVir may play a role in the virulence of Campylobacter jejuni, a leading cause of bacterial gastroenteritis. The pVir plasmid was identified in 17% of 104 C. jejuni clinical isolates studied and was significantly associated with the occurrence of blood in patient stool, a marker of invasive infection. The pVir plasmid was not associated with greater occurrence of diarrhea, fever, pain, vomiting, or need for patient hospitalization. Isolates containing pVir were also associated with the presence of a tetracycline-resistance plasmid, but pVir did not transfer with tetracycline-resistance plasmids to recipient strains of C. jejuni. The association of pVir and bloody stool suggests that pVir may be clinically relevant in C. jejuni infections.

CmeR functions as a transcriptional repressor for the multidrug efflux pump CmeABC in Campylobacter jejuni

CmeABC, a resistance-nodulation-division (RND) type of efflux pump, contributes to Campylobacter resistance to a broad spectrum of antimicrobial agents and is also essential for Campylobacter colonization of the animal intestinal tract by mediation of bile resistance. As one of the main systems for Campylobacter adaptation to different environments, CmeABC is likely subject to control by regulatory elements. We describe the identification of a transcriptional repressor for CmeABC. Insertional mutagenesis of cmeR, an open reading frame immediately upstream of the cmeABC operon, resulted in overexpression of cmeABC, as determined by transcriptional fusion (P(cmeABC-lacZ)) and immunoblotting with CmeABC-specific antibodies. Overexpression of the efflux pump was correlated with a moderate increase in the level of resistance of the cmeR mutant to several antimicrobials. In vitro, recombinant CmeR bound specifically to the promoter region of cmeABC, precisely, to the inverted repeat sequences in the cmeABC promoter. A single nucleotide deletion between the two half sites of the inverted repeat reduced the level of CmeR binding to the promoter sequence and resulted in overexpression of cmeABC. Together, these findings indicate that cmeR encodes a transcriptional repressor that directly interacts with the cmeABC promoter and modulates the expression of cmeABC. Mutation either in CmeR or in the inverted repeat impedes the repression and leads to enhanced production of the MDR efflux pump.