Prolonged diarrhea due to ciprofloxacin-resistant campylobacter infection

A decade of Campylobacter and Campylobacter bacteraemias in a district general hospital and the surrounding London and South East region, England

BACKGROUND

Campylobacter bacteraemia is a rare complication of the most common bacterial gastrointestinal infection but is associated with significant morbidity and mortality. There is limited data describing current trends in surveillance and antimicrobial resistance for the Campylobacter strains involved. At the Epsom and St Helier's University Hospital (ESTH), we noted a marked increase in Campylobacter bacteraemia infections in 2021.

METHODS

We extracted Campylobacter reports using the UK Health Security Agency's (UKHSA) Second Generation Surveillance System (laboratory reporting system) between 1st January 2012 and 31st December 2021. We reviewed patient records of patients with Campylobacter bacteraemia for details including presentation, past medical history, duration of hospital stay, and antibiotic use.

RESULTS

Between 2012 and 2021, ESTH reported a total of 34 cases of Campylobacter bacteraemia. In 2021, the estimated incidence was 6.8 cases per 100,000 population and in the surrounding area, the incidence was 0.4 per 100,000 population. The incidence rate of Campylobacter bacteraemia in London and the South East region was significantly lower than ESTH (RR = 0.17, p < 0.0001). Campylobacter bacteraemia cases at ESTH reported a high number of co-morbidities (average number of comorbidities = 2.3) and had a duration of stay in hospital of a median of 7 days (IQR = 4-10 days). Campylobacter jejuni was the most commonly reported species for stool and blood Campylobacter in ESTH, London, and South East England.

CONCLUSION

Campylobacter bacteraemia reports at ESTH were significantly (p < 0.001) higher than the surrounding London and South East region. While no common cause for the exceedance of Campylobacter bacteraemia has been identified, common risk factors for Campylobacter bacteraemia infection include underlying health conditions, being older, and male.

Clinical manifestations and risk factors of campylobacter gastroenteritis in children in Taiwan

BACKGROUND

Campylobacteriosis is a common cause of bacterial gastroenteritis worldwide. This study aimed to investigate the potential risk factors, clinical and laboratory manifestations of children with campylobacteriosis under five years old in Taiwan.

METHODS

This retrospective case-control study was conducted in ten major hospitals in Taiwan from 2014 to 2017. Laboratory tests and stool specimen were collected and analyzed together with questionnaire survey. Multivariate stepwise logistic regression model was used for identification of risk factors.

RESULTS

A total of 64 campylobacteriosis cases were included with a median age of 25 months. We observed a less prolonged vomiting (p = 0.047), more bloody (p < 0.001) and mucoid (p = 0.005) stools, and lower AST levels (p = 0.020) in patients with campylobacteriosis. Lower parental educational attainment (p < 0.001), direct contact with acute gastroenteritis patients (p < 0.001), as well as diarrhea in the mutually cared children (p = 0.007) were linked to campylobacteriosis. Consumption of municipal water (p < 0.001), milk (OR 0.34, 95% CI 0.118-0.979), and soft beverages (OR 0.41, 95% CI 0.192-0.888) were identified as protective factors, while consuming takeout food (p = 0.032) and seafood (p = 0.019) increased risk of campylobacteriosis.

CONCLUSIONS

Shorter vomiting duration, bloody and mucoid stool, and less elevated AST levels are manifestations suggestive of campylobacteriosis. Risk factors of campylobacteriosis were low parental educational attainment, direct contact with acute gastroenteritis patients, diarrhea in mutually cared children, takeout food and seafood intake. Potential protective factors include municipal water, milk, and soft beverage intake.

Epidemiology and Antimicrobial Resistance of Campylobacter Infections in the United States, 2005-2018

BACKGROUND

Campylobacter is the most common cause of bacterial diarrhea in the United States; resistance to macrolides and fluoroquinolones limits treatment options. We examined the epidemiology of US Campylobacter infections and changes in resistance over time.

METHODS

The Foodborne Diseases Active Surveillance Network receives information on laboratory-confirmed Campylobacter cases from 10 US sites, and the National Antimicrobial Resistance Monitoring System receives a subset of isolates from these cases for antimicrobial susceptibility testing. We estimated trends in incidence of Campylobacter infection, adjusting for sex, age, and surveillance changes attributable to culture-independent diagnostic tests. We compared percentages of isolates resistant to erythromycin or ciprofloxacin during 2005-2016 with 2017-2018 and used multivariable logistic regression to examine the association of international travel with resistance.

RESULTS

Adjusted Campylobacter incidence remained stable or decreased for all groups analyzed since 2012. Among 2449 linked records in 2017-2018, the median patient age was 40.2 years (interquartile range, 21.6-57.8 years), 54.8% of patients were male, 17.2% were hospitalized, and 0.2% died. The percentage of resistant infections increased from 24.5% in 2005-2016 to 29.7% in 2017-2018 for ciprofloxacin (P < .001) and from 2.6% to 3.3% for erythromycin (P = .04). Persons with recent international travel had higher odds than nontravelers of having isolates resistant to ciprofloxacin (adjusted odds ratio [aOR] varied from 1.7 to 10.6 by race/ethnicity) and erythromycin (aOR = 1.7; 95% confidence interval, 1.3-2.1).

CONCLUSIONS

Campylobacter incidence has remained stable or decreased, whereas resistance to antimicrobials recommended for treatment has increased. Recent international travel increased the risk of resistance.

Fluoroquinolone resistance among fecal extended spectrum βeta lactamases positive Enterobacterales isolates from children in Dar es Salaam, Tanzania

BACKGROUND

Fluoroquinolones have been, and continue to be, routinely used for treatment of many bacterial infections. In recent years, most parts of the world have reported an increasing trend of fluoroquinolone resistant (FQR) Gram-negative bacteria.

METHODS

A cross-sectional study was conducted between March 2017 and July 2018 among children admitted due to fever to referral hospitals in Dar es Salaam, Tanzania. Rectal swabs were used to screen for carriage of extended-spectrum β-lactamase-producing Enterobacterales (ESBL-PE). ESBL-PE isolates were tested for quinolone resistance by disk diffusion method. Randomly selected fluroquinolone resistant isolates were characterized by using whole genome sequencing.

RESULTS

A total of 142 ESBL-PE archived isolates were tested for fluoroquinolone resistance. Overall phenotypic resistance to ciprofloxacin, levofloxacin and moxifloxacin was found in 68% (97/142). The highest resistance rate was seen among Citrobacter spp. (100%, 5/5), followed by Klebsiella. pneumoniae (76.1%; 35/46), Escherichia coli (65.6%; 42/64) and Enterobacter spp. (31.9%; 15/47). Whole genome sequencing (WGS) was performed on 42 fluoroquinolone resistant-ESBL producing isolates and revealed that 38/42; or 90.5%, of the isolates carried one or more plasmid mediated quinolone resistance (PMQR) genes. The most frequent PMQR genes were aac(6')-lb-cr (74%; 31/42), followed by qnrB1 (40%; 17/42), oqx, qnrB6 and qnS1. Chromosomal mutations in gyrA, parC and parE were detected among 19/42 isolates, and all were in E. coli. Most of the E. coli isolates (17/20) had high MIC values of > 32 µg/ml for fluoroquinolones. In these strains, multiple chromosomal mutations were detected, and all except three strains had additional PMQR genes. Sequence types, ST131 and ST617 predominated among E. coli isolates, while ST607 was more common out of 12 sequence types detected among the K. pneumoniae. Fluoroquinolone resistance genes were mostly associated with the IncF plasmids.

CONCLUSION

The ESBL-PE isolates showed high rates of phenotypic resistance towards fluoroquinolones likely mediated by both chromosomal mutations and PMQR genes. Chromosomal mutations with or without the presence of PMQR were associated with high MIC values in these bacteria strains. We also found a diversity of PMQR genes, sequence types, virulence genes, and plasmid located antimicrobial resistance (AMR) genes towards other antimicrobial agents.

Characterisation of burden of illness measures associated with human (Fluoro)quinolone-resistant Campylobacter spp. infections - a scoping review

Campylobacter spp. are one of the most common causes of bacterial gastroenteritis in Canada and worldwide. Fluoroquinolones are often used to treat complicated human campylobacteriosis and strains of Campylobacter spp. resistant to these drugs are emerging along the food chain. A scoping review was conducted to summarise how human (fluoro)quinolone-resistant (FQR; quinolones including fluoroquinolones) Campylobacter spp. infections are characterised in the literature by describing how burden of illness (BOI) associated with FQR is measured and reported, describing the variability in reporting of study characteristics, and providing a narrative review of literature that compare BOI measures of FQR Campylobacter spp. infections to those with susceptible infections. The review identified 26 studies that yielded many case reports, a lack of recent literature and a lack of Canadian data. Studies reported 26 different BOI measures and the most common were hospitalisation, diarrhoea, fever and duration of illness. There were mixed results as BOI measures reported in literature were inconsistently defined and there were limited comparisons between resistant and susceptible infections. This presents a challenge when attempting to assess the magnitude of the BOI due to FQR Campylobacter spp., highlighting the need for more research in this area.

Resistance to Antibiotics in Thermophilic Campylobacters

Campylobacter jejuni (C. jejuni) is one of the most frequent causes of bacterial enterocolitis globally. The disease in human is usually self-limiting, but when complications arise antibiotic therapy is required at a time when resistance to antibiotics is increasing worldwide. Mechanisms of antibiotic resistance in bacteria are diverse depending on antibiotic type and usage and include: enzymatic destruction or drug inactivation; alteration of the target enzyme; alteration of cell membrane permeability; alteration of ribosome structure and alteration of the metabolic pathway(s). Resistance of Campylobacter spp. to antibiotics, especially fluoroquinolones is now a major public health problem in developed and developing countries. In this review the mechanisms of resistance to fluoroquinolones, macrolides, tetracycline, aminoglycoside and the role of integrons in resistance of Campylobacter (especially at the molecular level) are discussed, as well as the mechanisms of resistance to β-lactam antibiotics, sulphonamides and trimethoprim. Multiple drug resistance is an increasing problem for treatment of campylobacter infections and emergence of resistant strains and resistance are important One Health issues.

Antimicrobial Resistance and Genetic Diversity of Campylobacter spp. Isolated from Broiler Chicken at Three Levels of the Poultry Production Chain in Costa Rica

ABSTRACT

Campylobacter spp. are considered the most common bacterial cause of human gastroenteritis, one of the four main causes of diarrheal disease worldwide, and they are one of the main foodborne pathogens causing hospitalizations and deaths. Here, 148 strains of Campylobacter spp. isolated from poultry at farms, processing plants, and retail stores in Costa Rica were examined for resistance to six antibiotics. An agar dilution test was used to determine the MIC and susceptibility profiles against doxycycline, ciprofloxacin, nalidixic acid, enrofloxacin, chloramphenicol, and erythromycin. In addition, a pulsed-field gel electrophoresis analysis was carried out to determine the genotype relatedness of a representative subset of the isolates. Approximately 136 (92%) of the 148 analyzed isolates showed resistance to the tested drugs. Nalidixic acid, ciprofloxacin, and enrofloxacin were the antibiotics for which resistance occurred most frequently (91.2, 85.8, and 85.8%, respectively), followed by doxycycline (25.0%), chloramphenicol (5.4%), and erythromycin (2.7%). The profile conferring only resistance to quinolones was the most frequently found, and only 2.0% of the isolates showed resistance to quinolones and macrolides simultaneously. Results showed a high frequency of resistant Campylobacter spp. strains and evidenced the distribution, selection, and circulation of resistant strains along the poultry chain from farms to consumers. Cross-contamination and resistance seem to play important roles in the dissemination of these strains at specific points of the poultry chain, even when control measures are being taken. The establishment of effective surveillance and control strategies represents an essential tool for foodborne diseases mitigation. The rational use of antibiotics, especially those still showing efficacy, should be a priority in both human and veterinary medicine to contain the progress of this phenomenon and its consequences.

HIGHLIGHTS

Waterborne Isolates of Campylobacter jejuni Are Able to Develop Aerotolerance, Survive Exposure to Low Temperature, and Interact With Acanthamoeba polyphaga

Campylobacter jejuni is regarded as the leading cause of bacterial gastroenteritis around the world. Even though it is generally considered to be a sensitive microaerobic pathogen, it is able to survive in the environment outside of the intestinal tract of the host. This study aimed to assess the impact of selected environmental parameters on the survival of 14 C. jejuni isolates of different origins, including 12 water isolates. The isolates were tested for their antibiotic resistance, their ability to survive at low temperature (7°C), develop aerotolerance, and to interact with the potential protozoan host Acanthamoeba polyphaga. The antibiotic susceptibility was determined by standard disk diffusion according to EUCAST. Out of the 14 isolates, 8 were resistant to ciprofloxacin (CIP) and 5 to tetracycline (TET), while only one isolate was resistant to erythromycin (ERY). Five isolates were resistant to two different antibiotic classes. Tetracycline resistance was only observed in isolates isolated from wastewater and a clinical sample. Further, the isolates were tested for their survival at 7°C under both aerobic and microaerobic conditions using standard culture methods. The results showed that under microaerobic conditions, all isolates maintained their cultivability for 4 weeks without a significant decrease in the numbers of bacteria and variation between the isolates. However, significant differences were observed under aerobic conditions (AC). The incubation led to a decrease in the number of cultivable cells, with complete loss of cultivability after 2 weeks (one water isolate), 3 weeks (7 isolates), or 4 weeks of incubation (6 isolates). Further, all isolates were studied for their ability to develop aerotolerance by repetitive subcultivation under microaerobic and subsequently AC. Surprisingly, all isolates were able to adapt and grow under AC. As the last step, 5 isolates were selected to evaluate a potential protective effect provided by A. polyphaga. The cocultivation of isolates with the amoeba resulted in the survival of about 40% of cells treated with an otherwise lethal dose of gentamicin. In summary, C. jejuni is able to adapt and survive in a potentially detrimental environment for a prolonged period of time, which emphasizes the role of the environmental transmission route in the spread of campylobacteriosis.

A cross-sectional study of the prevalence factors associated with fluoroquinolone resistant Campylobacter jejuni in broiler flocks in Canada

Campylobacter infections in humans are usually self-limiting; however, antibiotic intervention may be necessary in the case of severe infection. Fluoroquinolones are often the drug of choice for treatment of campylobacteriosis; however, resistance to these drugs can develop rapidly, complicating treatment protocols. Increasing resistance to fluoroquinolones in human infections has coincided with approval of use of fluoroquinolones in animals, therefore, isolation of fluoroquinolone resistant (FQr) Campylobacter in broiler flocks is concerning. This cross-sectional study utilized data collected from 2013-2018 by the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) on-farm surveillance program to investigate prevalence factors associated with the isolation of FQr C. jejuni from broiler faecal samples. Mixed effects logistic regression models accounting for clustering of flocks within hatcheries, with and without a fixed effect for the presence of flock level tetracycline resistance were used to assess prevalence factors among 536 C. jejuni isolates from 158 flocks. Both models indicated that the type of bird used (Ross versus Cobb or mixed), the use of virginiamycin as a feed additive, the use of traps to control rodent populations in the barn, and the total number of birds in the barn were significant prevalence factors for increased FQr C. jejuni in a flock. In the model where flock level tetracycline resistance was included as a fixed effect, the odds of FQr C. jejuni increased by 16 (95% CI: 3.74, 68), and the magnitude of the effect of each of the identified prevalence factors was larger. Both models indicated that methods of disinfection of water lines between production cycles is important, with the use of chlorine being protective in the model where tetracycline resistance was included as a fixed effect, and the use of hydrogen peroxide being a risk factor in the model where tetracycline resistance was not included as a fixed effect. The use of hot water to wash the barn between production cycles was also a significant protective factor in the model where tetracycline resistance was not included as a fixed effect. These results indicate that biosecurity and sanitation procedures play a role in the dissemination of FQr C. jejuni in broiler flocks. Future analysis should seek to understand the effect of different disinfectant products on the isolation of FQr C. jejuni. Gaining a better understanding of the management of these critical practices may allow for the reduction of this enteric pathogen in broiler flocks in Canada.

Antimicrobial resistance patterns and molecular resistance markers of Campylobacter jejuni isolates from human diarrheal cases

The aim of this study is to characterize the antimicrobial resistance of Campylobacter jejuni recovered from diarrheal patients in Belgium, focusing on the genetic diversity of resistant strains and underlying molecular mechanisms of resistance among Campylobacter jejuni resistant strains isolated from diarrheal patients in Belgium. Susceptibility profile of 199 clinical C. jejuni isolates was determined by minimum inhibitory concentrations against six commonly-used antibiotics (ciprofloxacin, nalidixic acid, tetracycline, streptomycin, gentamicin, and erythromycin). High rates of resistance were observed against nalidixic acid (56.3%), ciprofloxacin (55.8%) and tetracycline (49.7%); these rates were similar to those obtained from different national reports in broilers intended for human consumption. Alternatively, lower resistance rates to streptomycin (4.5%) and erythromycin (2%), and absolute sensitivity to gentamicin were observed. C. jejuni isolates resistant to tetracycline or quinolones (ciprofloxacin and/or nalidixic acid) were screened for the presence of the tetO gene and the C257T mutation in the quinolone resistance determining region (QRDR) of the gyrase gene gyrA, respectively. Interestingly, some of the isolates that displayed phenotypic resistance to these antimicrobials lacked the corresponding genetic determinants. Among erythromycin-resistant isolates, a diverse array of potential molecular resistance mechanisms was investigated, including the presence of ermB and mutations in the 23S rRNA gene, the rplD and rplV ribosomal genes, and the regulatory region of the cmeABC operon. Two of the four erythromycin-resistant isolates harboured the A2075G transition mutation in the 23S rRNA gene; one of these isolates exhibited further mutations in rplD, rplV and in the cmeABC regulatory region. This study expands the current understanding of how different genetic determinants and particular clones shape the epidemiology of antimicrobial resistance in C. jejuni in Belgium. It also reveals many questions in need of further investigation, such as the role of other undetermined molecular mechanisms that may potentially contribute to the antimicrobial resistance of Campylobacter.

Antimicrobial Resistance of Human Campylobacter Species Infections in Saskatchewan, Canada (1999-2006): A Historical Provincial Collection of All Reported Cases

To describe a historical baseline of antimicrobial resistance (AMR) profiles for human clinical Campylobacter species isolates obtained by laboratory surveillance in the province of Saskatchewan from 1999 to 2006; to determine if there were differences in resistance between Campylobacter jejuni and Campylobacter coli; and to determine if there were changes in the annual resistance levels in the two species. One thousand three hundred seventy-eight Campylobacter isolates were subjected to antimicrobial susceptibility testing using the E-test method. Annual resistance levels in C. jejuni and C. coli were compared using logistic regression models. One thousand two hundred (87.1%) isolates were C. jejuni and 129 (9.4%) were C. coli. Resistance in C. jejuni isolates included ciprofloxacin (CIP: 9.4%), erythromycin (ERY: 0.5%), and tetracycline (33.3%). CIP resistance in C. jejuni was higher in 1999 (15.5%, odds ratio [OR] = 3.96, p = 0.01), 2000 (12.7%, OR = 3.10, p = 0.01), 2005 (10.2%, OR = 2.47, p = 0.05), and 2006 (13.0%, OR = 3.22, p = 0.01) compared with 2004 (4.4%). C. coli had significantly higher CIP resistance (15.5%, OR = 1.78, p = 0.03), ERY resistance (13.2%, OR = 60.12, p < 0.01), multidrug resistance (2.3%, OR = 36.29, p < 0.01), and CIP-ERY resistance (3.1%, OR = 50.23, p < 0.01) compared with C. jejuni. This represents the first and most current report of AMR of the collective human Campylobacter isolates from a province in Canada and provides a baseline against which current and future resistance patterns can be compared. Fluoroquinolone resistance in C. jejuni isolates fluctuated from 1999 to 2006, including an increased prevalence in 2005-2006, while macrolide/lincosamide resistance remained very low. Human clinical C. jejuni isolates from Saskatchewan demonstrated resistance to multiple antimicrobials but had significantly less fluoroquinolone and macrolide resistance than C. coli isolates.

Outbreak of Fluoroquinolone-Resistant Campylobacter jejuni Infections Associated with Raw Milk Consumption from a Herdshare Dairy - Colorado, 2016

In August 2016, a local public health agency (LPHA) notified the Colorado Department of Public Health and Environment (CDPHE) of two culture-confirmed cases of Campylobacter infection among persons who consumed raw (unpasteurized) milk from the same herdshare dairy. In Colorado, the sale of raw milk is illegal; however, herdshare programs, in which a member can purchase a share of a herd of cows or goats, are legal and are not regulated by state or local authorities. In coordination with LPHAs, CDPHE conducted an outbreak investigation that identified 12 confirmed and five probable cases of Campylobacter jejuni infection. Pulsed-field gel electrophoresis (PFGE) patterns for the 10 cases with available isolates were identical using the enzyme Sma. In addition, two milk samples (one from the dairy and one obtained from an ill shareholder) also tested positive for the outbreak strain. Five C. jejuni isolates sent to CDC for antimicrobial susceptibility testing were resistant to ciprofloxacin, tetracycline, and nalidixic acid (1). Although shareholders were notified of the outbreak and cautioned against drinking the milk on multiple occasions, milk distribution was not discontinued. Although its distribution is legal through herdshare programs, drinking raw milk is inherently risky (2). The role of public health in implementing control measures associated with a product that is known to be unsafe remains undefined.

Antimicrobial Resistance in Campylobacter Species: Mechanisms and Genomic Epidemiology

The Campylobacter genus is a large and diverse group of Gram-negative bacteria that are known to colonize humans and other mammals, birds, reptiles, and shellfish. While it is now recognized that several emerging Campylobacter species can be associated with human disease, two species, C. jejuni and C. coli, are responsible for the vast majority of bacterial gastroenteritis in humans worldwide. Infection with C. jejuni, in particular, has also been associated with a number of extragastrointestinal manifestations and autoimmune conditions, most notably Guillain-Barré syndrome. The antimicrobial drugs of choice for the treatment of severe Campylobacter infection include macrolides, such as erythromycin, clarithromycin, or azithromycin. Fluoroquinolones, such as ciprofloxacin, are also commonly used for empirical treatment of undiagnosed diarrheal disease. However, resistance to these and other classes of antimicrobial drugs is increasing and is a major public health problem. The US Centers for Disease Control and Prevention estimates that over 300,000 infections per year are caused by drug-resistant Campylobacter. In this chapter, we discuss the taxonomy of the Campylobacter genus, the clinical and global epidemiological aspects of Campylobacter infection, with an emphasis on C. jejuni and C. coli, and issues related to the treatment of infection and antimicrobial resistance mechanisms. We further discuss the use of next-generation sequencing for the detection and surveillance of antimicrobial resistance genes.

National Antimicrobial Resistance Monitoring System: Two Decades of Advancing Public Health Through Integrated Surveillance of Antimicrobial Resistance

Drug-resistant bacterial infections pose a serious and growing public health threat globally. In this review, we describe the role of the National Antimicrobial Resistance Monitoring System (NARMS) in providing data that help address the resistance problem and show how such a program can have broad positive impacts on public health. NARMS was formed two decades ago to help assess the consequences to human health arising from the use of antimicrobial drugs in food animal production in the United States. A collaboration among the Centers for Disease Control and Prevention, the U.S. Food and Drug Administration, the United States Department of Agriculture, and state and local health departments, NARMS uses an integrated "One Health" approach to monitor antimicrobial resistance in enteric bacteria from humans, retail meat, and food animals. NARMS has adapted to changing needs and threats by expanding surveillance catchment areas, examining new isolate sources, adding bacteria, adjusting sampling schemes, and modifying antimicrobial agents tested. NARMS data are not only essential for ensuring that antimicrobial drugs approved for food animals are used in ways that are safe for human health but they also help address broader food safety priorities. NARMS surveillance, applied research studies, and outbreak isolate testing provide data on the emergence of drug-resistant enteric bacteria; genetic mechanisms underlying resistance; movement of bacterial populations among humans, food, and food animals; and sources and outcomes of resistant and susceptible infections. These data can be used to guide and evaluate the impact of science-based policies, regulatory actions, antimicrobial stewardship initiatives, and other public health efforts aimed at preserving drug effectiveness, improving patient outcomes, and preventing infections. Many improvements have been made to NARMS over time and the program will continue to adapt to address emerging resistance threats, changes in clinical diagnostic practices, and new technologies, such as whole genome sequencing.

Quantitative Risk Assessment of Antimicrobial-Resistant Foodborne Infections in Humans Due to Recombinant Bovine Somatotropin Usage in Dairy Cows

Recombinant bovine somatotropin (rbST) is a production-enhancing technology that allows the dairy industry to produce milk more efficiently. Concern has been raised that cows supplemented with rbST are at an increased risk of developing clinical mastitis, which would potentially increase the use of antimicrobial agents and increase human illnesses associated with antimicrobial-resistant bacterial pathogens delivered through the dairy beef supply. The purpose of this study was to conduct a quantitative risk assessment to estimate the potential increased risk of human infection with antimicrobial-resistant bacteria and subsequent adverse health outcomes as a result of rbST usage in dairy cattle. The quantitative risk assessment included the following steps: (i) release of antimicrobial-resistant organisms from the farm, (ii) exposure of humans via consumption of contaminated beef products, and (iii) consequence of the antimicrobial-resistant infection. The model focused on ceftiofur (parenteral and intramammary) and oxytetracycline (parenteral) treatment of clinical mastitis in dairy cattle and tracked the bacteria Campylobacter spp., Salmonella enterica subsp. enterica, and Escherichia coli in the gastrointestinal tract of the cow. Parameter estimates were developed to be maximum risk to overestimate the risk to humans. The excess number of cows in the U.S. dairy herd that were predicted to carry resistant bacteria at slaughter due to rbST administration was negligible. The total number of excess human illnesses caused by resistant bacteria due to rbST administration was also predicted to be negligible with all risks considerably less than one event per 1 billion people at risk per year for all bacteria. The results indicate a high probability that the use of rbST according to label instructions presents a negligible risk for increasing the number of human illnesses and subsequent adverse outcomes associated with antimicrobial-resistant Campylobacter, Salmonella, or E. coli .

Virulence and Genomic Feature of Multidrug Resistant Campylobacter jejuni Isolated from Broiler Chicken

The aim of this study was to reveal the molecular mechanism involved in multidrug resistance and virulence of Campylobacter jejuni isolated from broiler chickens. The virulence of six multidrug resistant C. jejuni was determined by in vitro and in vivo methods. The de novo whole genome sequencing technology and molecular biology methods were used to analyze the genomic features associated with the multidrug resistance and virulence of a selected isolate (C. jejuni 1655). The comparative genomic analyses revealed a large number of single nucleotide polymorphisms, deletions, rearrangements, and inversions in C. jejuni 1655 compared to reference C. jejuni genomes. The co-emergence of Thr-86-Ile mutation in gyrA gene, A2075G mutation in 23S rRNA gene, tetO, aphA and aadE genes and pTet plasmid in C. jejuni 1655 contributed its multidrug resistance to fluoroquinolones, macrolides, tetracycline, and aminoglycosides. The combination of multiple virulence genes may work together to confer the relative higher virulence in C. jejuni 1655. The co-existence of mobile gene elements (e.g., pTet) and CRISPR-Cas system in C. jejuni 1655 may play an important role in the gene transfer and immune defense. The present study provides basic information of phenotypic and genomic features of C. jejuni 1655, a strain recently isolated from a chicken displaying multidrug resistance and relatively high level of virulence.

Emerging Infections Program as Surveillance for Antimicrobial Drug Resistance

Across the United States, antimicrobial drug-resistant infections affect a diverse population, and effective interventions require concerted efforts across various public health and clinical programs. Since its onset in 1994, the Centers for Disease Control and Prevention Emerging Infections Program has provided robust and timely data on antimicrobial drug-resistant infections that have been used to inform public health action across a spectrum of partners with regard to many highly visible antimicrobial drug-resistance threats. These data span several activities within the Program, including respiratory bacterial infections, health care-associated infections, and some aspects of foodborne diseases. These data have contributed to estimates of national burden, identified populations at risk, and determined microbiological causes of infection and their outcomes, all of which have been used to inform national policy and guidelines to prevent antimicrobial drug-resistant infections.

Clinical implications of reduced susceptibility to fluoroquinolones in paediatric Shigella sonnei and Shigella flexneri infections

Objectives

We aimed to quantify the impact of fluoroquinolone resistance on the clinical outcome of paediatric shigellosis patients treated with fluoroquinolones in southern Vietnam. Such information is important to inform therapeutic management for infections caused by this increasingly drug-resistant pathogen, responsible for high morbidity and mortality in young children globally.

Methods

Clinical information and bacterial isolates were derived from a randomized controlled trial comparing gatifloxacin with ciprofloxacin for the treatment of paediatric shigellosis. Time–kill experiments were performed to evaluate the impact of MIC on the in vitro growth of Shigella and Cox regression modelling was used to compare clinical outcome between treatments and Shigella species.

Results

Shigella flexneri patients treated with gatifloxacin had significantly worse outcomes than those treated with ciprofloxacin. However, the MICs of fluoroquinolones were not significantly associated with poorer outcome. The presence of S83L and A87T mutations in the gyrA gene significantly increased MICs of fluoroquinolones. Finally, elevated MICs and the presence of the qnrS gene allowed Shigella to replicate efficiently in vitro in high concentrations of ciprofloxacin.

Conclusions

We found that below the CLSI breakpoint, there was no association between MIC and clinical outcome in paediatric shigellosis infections. However, S. flexneri patients had worse clinical outcomes when treated with gatifloxacin in this study regardless of MIC. Additionally, Shigella harbouring the qnrS gene are able to replicate efficiently in high concentrations of ciprofloxacin and we hypothesize that such strains possess a competitive advantage against fluoroquinolone-susceptible strains due to enhanced shedding and transmission.

Global Epidemiology of Campylobacter Infection

Campylobacter jejuni infection is one of the most widespread infectious diseases of the last century. The incidence and prevalence of campylobacteriosis have increased in both developed and developing countries over the last 10 years. The dramatic increase in North America, Europe, and Australia is alarming, and data from parts of Africa, Asia, and the Middle East indicate that campylobacteriosis is endemic in these areas, especially in children. In addition to C. jejuni, there is increasing recognition of the clinical importance of emerging Campylobacter species, including Campylobacter concisus and Campylobacter ureolyticus. Poultry is a major reservoir and source of transmission of campylobacteriosis to humans. Other risk factors include consumption of animal products and water, contact with animals, and international travel. Strategic implementation of multifaceted biocontrol measures to reduce the transmission of this group of pathogens is paramount for public health. Overall, campylobacteriosis is still one of the most important infectious diseases that is likely to challenge global health in the years to come. This review provides a comprehensive overview of the global epidemiology, transmission, and clinical relevance of Campylobacter infection.

Comparison of epidemiologically linked Campylobacter jejuni isolated from human and poultry sources

Campylobacter jejuni is responsible for most foodborne bacterial infections worldwide including Australia. The aim of this study was to investigate a combination of typing methods in the characterization of C. jejuni isolated from clinical diarrhoeal samples (n = 20) and chicken meat (n = 26) in order to identify the source of infection and rank isolates based on their relative risk to humans. Sequencing of the flaA short variable region demonstrated that 86% of clinical isolates had genotypes that were also found in chicken meat. A polymerase chain reaction binary typing system identified 27 different codes based on the presence or absence of genes that have been reported to be associated with various aspects of C. jejuni pathogenicity, indicating that not all isolates may be of equal risk to human health. The lipooligosaccharide (LOS) of the C. jejuni isolates was classified into six classes (A, B, C, E, F, H) with 10·4% remaining unclassified. The majority (72·7%) of clinical isolates possessed sialylated LOS classes. Sialylated LOS classes were also detected in chicken isolates (80·7%). Antimicrobial tests indicated a low level of resistance, with no phenotypic resistance found to most antibiotics tested. A combination of typing approaches was useful to assign isolates to a source of infection and assess their risk to humans.

Antimicrobial resistance among Campylobacter isolates obtained from retail chicken meat and offal products in Japan

A rapid increase in antimicrobial resistance in Campylobacter has been posing a serious concern for human health. In this study, we aimed to demonstrate the overall trend in antimicrobial resistance among Campylobacter isolates obtained from chicken meat and offal products collected from a wide geographic area throughout Japan. Resistance to Enrofloxacin was most frequently observed, with significantly higher rate of resistance among isolates obtained from offal (55.6%) than from meat (27.3%) samples (p = 0.05). These results highlight need for a better understanding of the characteristics of Campylobacter isolates obtained from chicken meat and offal products.

Analysis of resistance to antimicrobials and presence of virulence/stress response genes in Campylobacter isolates from patients with severe diarrhoea

Campylobacter infections are a major cause of diarrhoea world-wide and two of the antimicrobials used for their control (erythromycin and ciprofloxacin) have been losing efficacy in recent years. In a sample of 174 genotyped isolates from the stools of patients with severe diarrhoea in Qatar, collected between 2005 and 2012, 63.2% showed resistance to ciprofloxacin, 8.6% to erythromycin, 0.57% to chloramphenicol and all were sensitive to gentamycin. While 33.9% of isolates were sensitive to all four antimicrobials, 59.8% were resistant to at least one, 6.3% were resistant to two and none showed resistance to three antimicrobials. There was no host sex- or age-dependence among isolates resistant to ciprofloxacin and erythromycin and no significant variation was found with the region of origin of the patients. All isolates were screened for the presence of 3 virulence factors (ciaB, cadF and cdtB) and two stress-response factors (htrB and clpP), all of which were present in more than 50% of the isolates. Host sex-, age- and region of origin-dependent variations in prevalence were found for some of these factors. Data analysis for the combination of virulence factors and their effect on antimicrobial resistance indicated that the prevalence of resistance to both erythromycin and ciprofloxacin was higher in isolates harbouring ciaB but not clpP. Prevalence of resistance to ciprofloxacin was similar in clpP positive and negative isolates also possessing htrB, while for htrB-negative isolates prevalence was higher in the absence of clpP. These results are discussed and their implications are highlighted.

Ciprofloxacin-resistant Campylobacter in broiler chicken in Canada

This case study outlines the patterns of ciprofloxacin resistance in Campylobacter isolated from retail chicken meat in Canada. Campylobacter is the third most common cause of foodborne enteric illness in Canada; it usually causes a self-limited illness, but in some cases antimicrobials may be indicated. Ciprofloxacin (a fluoroquinolone) is an antimicrobial used to treat a number of infections in humans; other fluoroquinolones are used both therapeutically and prophylactically in livestock animals, including broiler chickens. The Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) has been testing retail chicken meat samples across Canada for the presence of Campylobacter and for resistant strains since 2003. At the end of 2010, CIPARS documented that retail chicken meat samples in Canada contaminated with Campylobacter ranged from 36% in the Maritimes to 42% in British Columbia. Furthermore, levels of ciprofloxacin-resistant Campylobacter varied across the country, with higher percentages in British Columbia (17% in 2010) and Saskatchewan (11%), in comparison with lower percentages in Ontario (5%), Québec (2%, and the Maritimes (4%). In 2011 and 2012, resistance declined in British Columbia and Saskatchewan, but began to rise in Québec and Ontario. Recently, the Canadian poultry industry developed a policy to eliminate the preventive use of third generation cephalosporins and fluoroquinolones in broiler chickens (meat chickens) and broiler breeder chickens (chickens that produce the eggs that will become the broilers). CIPARS will continue to monitor trends in antimicrobial use and resistance following this industry intervention. By following good food preparation and hygiene practices, Canadians can reduce the risks of developing a Campylobacter infection (resistant or susceptible) from retail chicken.

Association of multicellular behaviour and drug resistance in Salmonella enterica serovars isolated from animals and humans in Ethiopia

AIMS

To determine the association between multicellular behaviour, integron status and antibiotic resistance among 87 Ethiopian Salmonella enterica isolates of animal and human origin.

METHODS AND RESULTS

Isolates were characterized for their biofilm forming ability, antimicrobial susceptibility and the presence and characteristics of a class 1 integron and Salmonella genomic island 1 (SGI1). The majority of isolates grown at environmental temperatures (20°C) exhibited robust biofilm formation (72·4%) and displayed RDAR colony morphology on Congo red agar plates. The presence of a class 1 integron correlated with the extent of drug resistance and ability to exhibit multicellular behaviour.

CONCLUSIONS

Although cellulose production and RDAR morphology correlated with increased multicellular behaviour, neither was required for biofilm formation. Contrary to previous reports, colony morphology was generally consistent within a serovar. No integrons were detected in isolates deficient for multicellular behaviour, indicating a potential role of bacterial community formation in transfer of genetic elements among environmental isolates.

SIGNIFICANCE AND IMPACT OF STUDY

Infection by Salm. enterica is a major public health problem worldwide. The dominance of multidrug resistance and multicellular behaviour in Salmonella isolates of Ethiopian origin highlights a need for integrated surveillance and further detailed phenotypic and molecular studies of isolates from this region.

Antimicrobial resistance and antimicrobial use associated with laboratory-confirmed cases of Campylobacter infection in two health units in Ontario

AIM

A population-based study was conducted over a two-year period in the Perth District (PD) and Wellington-Dufferin-Guelph (WDG) health units in Ontario to document antimicrobial resistance and antimicrobial use associated with clinical cases of laboratory-confirmed campylobacteriosis.

METHODS

Etest (bioMérieux SA, France) was used to determine the minimum inhibitory concentration of amoxicillin/clavulanic acid, ampicillin, chloramphenicol, ciprofloxacin (CIP), clindamycin, erythromycin (ERY), gentamicin, nalidixic acid and tetracycline. Data regarding antimicrobial use were collected from 250 cases.

RESULTS

Of the 250 cases, 165 (65.7%) reported staying home or being hospitalized due to campylobacteriosis. Fifty-four per cent of cases (135 of 249) reported taking antimicrobials to treat campylobacteriosis. In 115 cases (51.1%), fecal culture results were not used for treatment decisions because they were not available before the initiation of antimicrobial treatment and/or they were not available before the cessation of symptoms. Of the 250 cases, 124 (49.6%) had available Campylobacter isolates, of which 66 (53.2%) were resistant to at least one of the antimicrobials tested. No resistance to ampicillin, chloramphenicol or gentamicin was found in these isolates. Six isolates (4.8%) were resistant to CIP. Two isolates (1.6%) were resistant to ERY; however, no isolates were resistant to both CIP and ERY.

CONCLUSION

Prudent use practices should be promoted among physicians to reduce the use of antimicrobials for the treatment of gastroenteritis in general and campylobacteriosis in particular, as well as to minimize the future development of resistance to these antimicrobials in Campylobacter species.

Heterogeneity of Campylobacter species isolated from serial stool specimens of Egyptian children using pulsed field gel electrophoresis

BACKGROUND

The genus Campylobacter spp. is a common cause of human acute bacterial enteritis and travellers' diarrhoea worldwide.

OBJECTIVE

To determine whether multiple serial isolations of Campylobacter spp., when obtained from a single child, represented the same or a different organism.

METHODS

In a birth cohort study conducted in Egypt, numerous children showed serial isolations of Campylobacter spp. Of these, 13 children were selected from different households based on the successive isolation of six or more Campylobacter isolates from stool samples.

RESULTS

Eighty isolates were recovered and identified as either Campylobacter coli (n = 25) or Campylobacter jejuni (n = 55). Pulsed-field gel electrophoresis (PFGE) revealed the presence of 38 unique C. jejuni and 24 C. coli profiles at a similarity level of ≥ 90%. Although no serially-identical isolates were detected in six children, others demonstrated at least one identical couple of isolates; all identified serially between one to six weeks. Two children demonstrated > 80% similar couples of isolates that appeared seven months apart. PFGE could be a useful tool for differentiating reinfection, relapse and convalescent excretion phases.

CONCLUSION

Our data suggest that Campylobacter infection in children is a complex process; children are exposed to multiple species in endemic environments and strains of the same bacterium appear to be shed serially between one to six weeks after the first exposure. Isolates that persisted for longer periods were relatively less similar, as shown from the results of this study.

Burden of illness and factors associated with duration of illness in clinical campylobacteriosis

A population-based study investigated the burden of illness, including the duration of illness associated with laboratory-confirmed cases of campylobacteriosis in two health unit areas. Questionnaire data were collected for 250 cases. The median duration of illness was 8 days and 66% of cases reported symptoms of moderate severity or greater. A Cox proportional hazards model identified antimicrobial use factors associated with a significantly increased rate of symptom resolution (shorter duration of illness): macrolides for less than the recommended number of days, ciprofloxacin for at least 3 days, and antimicrobials not recommended for campylobacteriosis. The impact of antimicrobial use was consistent regardless of when, during the course of illness, the antimicrobial use began. The effectiveness of ciprofloxacin in these results may be due to the low prevalence of resistance to ciprofloxacin in isolates from this study. The effect of antimicrobials not recommended for campylobacteriosis should be further investigated.

Resistance mechanisms in Campylobacter jejuni

Campylobacter jejuni is a major cause of food-borne gastroenteritis worldwide. While mortality is low, morbidity imparted by post-infectious sequelae such as Guillain-Barré syndrome, Reiter syndrome/reactive arthritis and irritable bowel syndrome is significant. In addition, the economic cost is high due to lost productivity. Food animals, particularly poultry, are the main reservoirs of C. jejuni. The over-use of antibiotics in the human population and in animal husbandry has led to an increase in antibiotic-resistant infections, particularly with fluoroquinolones. This is problematic because C. jejuni gastroenteritis is clinically indistinguishable from that caused by other bacterial pathogens, and such illnesses are usually treated empirically with fluoroquinolones. Since C. jejuni is naturally transformable, acquisition of additional genes imparting antibiotic resistance is likely. Therefore, an understanding of the antibiotic resistance mechanisms in C. jejuni is needed to provide proper therapy both to the veterinary and human populations.

Increasing antimicrobial resistance of campylobacter jejuni isolated from paediatric diarrhea cases in a tertiary care hospital of new delhi, India

INTRODUCTION

The resistance to the clinically important antimicrobial agents, particularly the fluoroquinolones and the macrolides, is increasing among the Campylobacter isolates. Only limited data is available regarding the changing antimicrobial resistance pattern in the Indian scenario.

METHODOLOGY

Three hundred fifty cases (ages ≤12years) of acute diarrhoea, who were admitted to a tertiary-care hospital, were investigated for Campylobacter spp. The antimicrobial susceptibilities of all the C. jejuni isolates were assessed by the disk diffusion method according to the CLSI guidelines.

RESULTS

A total of 36 isolates of C. jejuni were tested for their antimicrobial susceptibilities. A high degree of resistance to the fluoroquinolones (100% to Nalidixic acid and 86.66% to Ciprofloxacin) was detected in the Campylobacter isolates. The frequency of resistance against Tetracycline was 33.33% and that against Erythromycin was 22.2%. Fifteen (41.66%) isolates were multiresistant, being resistant to 3 or more antimicrobial agents.

CONCLUSIONS

An increased resistance to the quinolones and the macrolides and multidrug resistance warrant a reconsideration of their use as the drugs of choice in patients with severe gastroenteritis when Campylobacter is the presumed cause.

Impacts of culture-independent diagnostic practices on public health surveillance for bacterial enteric pathogens

For decades, culture has been the mainstay of diagnostic testing for bacterial enteric pathogens. This paradigm is changing as clinical laboratories adopt culture-independent methods, such as antigen-based tests and nucleic acid-based assays. Public health surveillance for enteric infections addresses 4 interrelated but distinct objectives: case investigation for localized disease control; assessment of disease burden and trends to prioritize and assess impact of population-based control measures; outbreak detection; and microbiologic characterization to improve understanding of pathogens, their virulence mechanisms, and epidemiology. We summarize the challenges and opportunities that culture-independent tests present and suggest strategies, such as validation studies and development of culture-independent tests compatible with subtyping, that could be adopted to ensure that surveillance remains robust. Many of these approaches will require time and resources to implement, but they will be necessary to maintain a strong surveillance system. Public health practitioners must clearly explain the value of surveillance, especially how outbreak detection benefits the public, and collaborate with all stakeholders to develop solutions.

Bacteremia caused by antimicrobial resistant Campylobacter species at a medical center in Taiwan, 1998-2008

OBJECTIVES

This study was intended to delineate the clinical and microbiological characteristics of patients with bacteremia caused by Campylobacter species.

METHODS

Twenty-four patients with Campylobacter bacteremia were treated at the National Taiwan University Hospital from 1998 to 2008. All isolates from the 24 patients were confirmed to the species level by multiplex PCR (cadF, hipO and asp gene) and 16S RNA gene sequencing.

RESULTS

Bacteremia was caused by Campylobacter coli in 15 (62.5%) patients, Campylobacter fetus in 6 (25%), and Campylobacter jejuni in 3 (12.5%). Of the 24 patients, 16 were male. The major underlying conditions included chronic renal insufficiency (41.7%), liver cirrhosis (37.5%), malignancy (33.3%), and previous abdominal surgery (33.3%). The most common infections were intra-abdominal infection (54.2%), followed by primary bacteremia (41.7%), and cellulitis (4.2%). The mean Pittsburgh bacteremia score was 2.5 (range, 0-9). During the bacteremic episodes, six (25%) patients developed septic shock. Third-generation cephalosporins were administered to 12 (50%) patients as empirical therapy. All-cause mortality was 4.2% at 14 days and 12.5% at 30 days. The majority of the isolates were resistant to third-generation cephalosporins and quinolones, with minimum inhibitory concentration (MIC(90)) values of 32 mg/L for cefotaxime, 128 mg/L for ceftriaxone, and 32 mg/L for both ciprofloxacin and levofloxacin. All isolates possessed a parC mutation (Arg-139-Gln) and 15 exhibited an additional gyrA mutation (Thr-86-Ile). Among these isolates, 20.8% were susceptible to erythromycin (MIC≤0.5 mg/L).

CONCLUSION

Bacteremia caused by antimicrobial resistant Campylobacter species is alarming although the mortality rate is low.

Burden and transmission of zoonotic foodborne disease in a rural community in Mexico

BACKGROUND

The foodborne transmission and human health impact of Salmonella and Campylobacter infections have rarely been evaluated at the population level in highly endemic settings.

METHODS

A prospective 15-month cohort study of 127 infants and 119 elderly people was combined with animal and food surveillance to determine the incidence and severity of Salmonella and Campylobacter gastroenteritis in a comparatively prosperous rural community in Mexico.

RESULTS

Salmonella and Campylobacter were isolated in up to 75% and 57%, respectively, of raw retail meat and in up to 4.5% of ready-to-eat foods. Rates of acute gastroenteritis of any etiology in infants and elderly people were, respectively, 2.1 and 0.7 episodes per person per year. The annual incidence density rate of Salmonella gastroenteritis was 17.8 per 100 infants and 7.9 per 100 elderly people; the rate of Campylobacter gastroenteritis was 11.7 per 100 infants and 0 per 100 elderly people. Pulsed-field gel electrophoresis analysis yielded multiple clusters of human, meat, and/or animal Salmonella and Campylobacter isolates with indistinguishable patterns. On average, gastroenteritis episodes with these pathogens lasted 3 days in infants and 2 days in elderly people. Medical attention was sought in 44% of diarrheal episodes in infants and in 26% of diarrheal episodes in elderly people; none required hospitalization. Infants with multidrug-resistant Salmonella gastroenteritis had a higher frequency of bloody stools and medical visits (50% vs 11%; odds ratio, 8.5; P = .04) than those with more susceptible strains.

CONCLUSIONS

In this relatively advantaged Mexican rural community, the human health impact of a food chain heavily contaminated with Salmonella and Campylobacter was of low magnitude.

A nationwide study of Campylobacter jejuni and Campylobacter coli bacteremia in Finland over a 10-year period, 1998-2007, with special reference to clinical characteristics and antimicrobial susceptibility

BACKGROUND

Campylobacter bacteremia is an uncommon condition, usually diagnosed in elderly and immunocompromised patients.

METHODS

Blood culture isolates and clinical information were collected for patients with diagnoses of Campylobacter jejuni or Campylobacter coli bacteremia in Finland from 1998 through 2007. Bacterial species were identified by means of polymerase chain reaction analysis, and minimal inhibitory concentrations for ciprofloxacin, clindamycin, doxycycline, erythromycin, gentamicin, meropenem, and metronidazole were determined with an agar dilution method. Medical records and mortality data within 1 year after the bacteremic episode were reviewed.

RESULTS

The study included 76 patients (median age, 46 years), for whom bacterial isolates (C. jejuni in 73, C. coli in 3) and clinical information were available. Most patients (70%) had no significant underlying diseases. The majority (82%) of the isolates were susceptible for all antimicrobial agents tested. However, antimicrobial therapy seemed to have only a limited effect, because no differences could be detected between patients with appropriate empirical antimicrobial treatment and those with delayed appropriate, inappropriate, or no antimicrobial therapy, either in the duration of hospitalization (median, 4 days for both groups) or in attributable mortality. The outcome of the infection was severe in 4 patients infected with C. jejuni; 2 died within 30 days, spondylodiscitis developed in 1, and Guillain-Barré syndrome developed in 1.

CONCLUSIONS

C. jejuni and C. coli bacteremia occurred mainly in moderately young individuals without severe underlying diseases. The bacterial isolates were predominantly susceptible to antimicrobial agents, and the outcome of the disease was typically good, regardless of appropriate or inappropriate antimicrobial treatment given in the hospital.

Lack of correlation between the 257C-to-T mutation in the gyrA gene and clinical severity of Campylobacter jejuni infection in a region of high incidence of ciprofloxacin resistance

BACKGROUND

Fluoroquinolone resistance is increasingly detected in Campylobacter jejuni worldwide. Despite the fact that a point mutation in the gyrA gene has been linked with increased fitness in animals, the association of resistant organisms with more severe infections in man remains controversial.

METHODS

Erythromycin and quinolone susceptibility of 147 C. jejuni strains isolated from individual patients with diarrhoea in southwest Hungary were investigated and the molecular background of fluoroquinolone resistance was determined. Hospitalization and the presence of macroscopic blood in the stool were correlated with the presence of 257C-to-T mutation of the gyrA gene causing resistance to fluoroquinolones.

RESULTS

Isolates showed an extensive genetic heterogeneity by macrorestriction analysis of the chromosome. While all strains retained susceptibility to erythromycin, 68% were non-susceptible to ciprofloxacin. The mutation causing a Thr-86-to-Ile replacement in the gyrA gene was present in 98% of non-susceptible isolates. Infection caused by isolates containing this mutation did not show any significant association with either hospitalization or with the development of bloody diarrhoea.

CONCLUSIONS

Our findings indicate that in a region with high-level ciprofloxacin resistance in C. jejuni, non-susceptibility to this antibiotic did not correlate with the severity of infection.

Impact of erythromycin resistance on the virulence properties and fitness of Campylobacter jejuni

Epidemiological studies of macrolide resistance in Campylobacter jejuni demonstrated that infections with macrolide-resistant C. jejuni could be associated with an increased risk of adverse events, development of invasive illness or death compared to macrolide-susceptible isolates. In this study, an in vitro induction experiment was conducted using susceptible C. jejuni strain and erythromycin as a selecting agent to obtain Ery-resistant mutant with 23S rRNA gene mutation (A2074C). Changes in the virulence characteristics and fitness between the susceptible parent strain and Ery-resistant mutant were examined. Ery-resistant mutant demonstrated slightly more resistance to bile in the bile tolerance assay compared to the susceptible strain but with no statistical significant difference. However Ery-resistant mutant apparently demonstrated reduced adhesion and invasion characteristics to intestinal epithelial cells, murine macrophage and short time intracellular survivability within macrophage compared to the susceptible strain. Co-inoculation of the two strains in the mice resulted in low colonization level of the resistant strain compared to the susceptible strain. Competition experiments resulted in mutant that grew significantly slower than the susceptible parent strain and the mutation imposed a fitness cost in Ery-resistant mutant. Taken together these findings demonstrated the increment of the virulence characteristics of Ery-susceptible strain rather than Ery-resistant strain. The adverse events previously observed in the epidemiological studies for macrolide-resistant strains infection, we suggested this maybe attributed to the resistivity of the resistant strains to the treatment and consequently prolonged the symptoms and compromised the disease in patients.

Update on human Campylobacter jejuni infections

PURPOSE OF REVIEW

The present review will update the reader to the clinical, epidemiological and immunologic advances in the field of human campylobacteriosis.

RECENT FINDINGS

New advances in human campylobacteriosis include an increased appreciation of the role of Campylobacter jejuni in postinfectious sequelae, a broadened understanding of Campylobacter-associated disease burden and the interplay between host immunity and bacterial factors. Antibiotic management has also become more complex: C. jejuni has undergone a rapid increase in resistance to the fluoroquinolone antibiotics and concurrently, postinfectious irritable bowel syndrome has been associated with a longer duration of untreated infection. In anticipation of new candidate C. jejuni vaccines, progress in understanding human immune responses to infection has been made via human experimental infections. These tightly controlled studies have also increased our understanding of the natural history of campylobacteriosis as well as observations of recrudescent infection following treatment with C. jejuni-sensitive antibiotics.

SUMMARY

As one of the most common agents of bacterial gastroenteritis and a major health burden for both developing world and industrialized nations, Campylobacter infections remain a high priority for research efforts to improve prevention and management. Priorities for the future include vaccine development, pathogen-specific immunity and identification of risk factors for postinfectious sequelae.

Antimicrobial resistance profiles of Campylobacter from humans, retail chicken meat, and cattle feces

We determined the antimicrobial resistance profiles of Campylobacter isolates from cases of sporadic human infection (n = 119), retail chicken meat (n = 105), and cattle feces (n = 105). Ampicillin and tetracycline resistance was highest in human isolates (32% and 29%, respectively) and retail chicken isolates (25% and 25%, respectively), whereas nalidixic acid resistance was highest in cattle fecal isolates (20%). We found that the antimicrobial resistance profiles were more similar in human and chicken meat isolates than those observed when comparing human and cattle fecal isolates. When we analyzed the distribution of minimum inhibitory concentrations for each antibiotic, in each host, the distribution was similar between human and chicken meat isolates, whereas cattle fecal isolates remained highly distinct from the other two hosts. This study suggests that chicken may be a major source of human Campylobacter infection and that the antimicrobial resistances found in the Campylobacter from this source will therefore also be prevalent in clinical isolates.

Prevalence and antimicrobial resistance in Campylobacter spp. isolated from retail chicken in two health units in Ontario

Campylobacter is an important enteric pathogen of humans and can cause diarrhea, fever, and abdominal pain. Campylobacter infections have frequently been associated with the handling and consumption of raw and undercooked poultry. Antimicrobial resistance among Campylobacter strains is of concern in the treatment of campylobacteriosis in vulnerable populations. A 2-year multidisciplinary study was conducted in the Perth and Wellington-Dufferin-Guelph public health units in Ontario, Canada, to investigate the prevalence and antimicrobial resistance of Campylobacter spp. in retail chicken. Retail chicken samples were collected from randomly selected stores in these health units. Resulting Campylobacter isolates were tested for susceptibility to amoxicillin-clavulanic acid (AMC), ampicillin (AMP), chloramphenicol (CHL), ciprofloxacin (CIP), clindamycin (CLI), erythromycin (ERY), gentamicin (GEN), nalidixic acid (NAL), tetracycline (TCY), and trimethoprim-sulfamethoxazole (SXT) using the E test. The prevalence of Campylobacter in 1,256 retail chicken samples was 59.6%. Of these positive samples, 9% contained Campylobacter coli, 1% contained Campylobacter lari, and 90% contained Campylobacter jejuni. Of the chicken isolates that were resistant to one or more antimicrobial agents, 301 isolates (40%) were resistant to one agent, 374 (50%) were resistant to two, 39 (5%) were resistant to three, 20 (3%) were resistant to four, and 6 (1%) were resistant to five. Nine isolates (1%) were susceptible to all antimicrobial agents tested. All isolates were susceptible to AMC, CHL, and GEN. Less than 10% of isolates were resistant to NAL, CIP, CLI, ERY, and AMP. Resistance to TCY was common (56%). No isolates had a resistance pattern that included all three antimicrobials important in the treatment of human campylobacteriosis (CIP, ERY, and TCY); however, 24 isolates (3.2%) were resistant to at least two of these antimicrobials.

Review article: rifaximin, a minimally absorbed oral antibacterial, for the treatment of travellers' diarrhoea

BACKGROUND

Travellers' diarrhoea, a common problem worldwide with significant medical impact, is generally treated with anti-diarrhoeal agents and fluid replacement. Systemic antibiotics are also used in selected cases, but these may be associated with adverse effects, bacterial resistance and drug-drug interactions.

AIM

To review the clinical evidence supporting the efficacy and safety of the minimally absorbed oral antibiotic rifaximin in travellers' diarrhoea.

METHODS

PubMed and the Cochrane Register of Controlled Clinical Trials (to January 2010) and International Society of Travel Medicine congress abstracts (2003-2009) were searched to identify relevant publications.

RESULTS

A total of 10 publications were included in the analysis. When administered three times daily for 3 days, rifaximin is superior to placebo or loperamide; it is at least as effective as ciprofloxacin in reducing duration of illness and restoring wellbeing in patients with travellers' diarrhoea, both with and without identification of a pathogen, as well as in diarrhoea caused by Escherichia coli infection. Rifaximin demonstrates only minimal potential for development of bacterial resistance and for cytochrome P450-mediated drug-drug interactions, and its tolerability profile is similar to that of placebo.

CONCLUSION

When antibiotic therapy is warranted in uncomplicated travellers' diarrhoea, rifaximin may be considered as a first-line treatment option because of its favourable efficacy, tolerability and safety profiles.

Implications of the One Health Paradigm for Clinical Microbiology

Clinical microbiologists have a new and unique opportunity to increase our value to health care by broadening how we think about disease processes and asking ourselves what we can do to help resolve a disease, assist in tracking a cause, or even predict an outbreak before it occurs. Human health, animal health (both wildlife and domestic animals), and environmental health are forever bound together. The convergence of people, animals, and the environment defines the parameters of One Health and directs attention to the impact this overlap has on public health, disease detection, and control. One Health (sometimes referred to as One Medicine) is a concept that promotes, improves, and defends the health and well-being of all species through the integration of the sciences of human medicine, veterinary medicine, and environmental studies. As microbiologists, we need to be aware of this One Health concept and how it can positively impact our profession by allowing us to be more productive members of the health care team. There are several things we can do to get started. We can review organism pathogenicity and evaluate and question test results that may signal an unusual event or process that led to a disease. We can be alert to the epidemiologic potential of organism isolates from patients as they may apply to infection control or community epidemiology. We can become familiar with the zoonotic diseases and recognize the etiologic agents associated with wild and domestic animals and apply that knowledge to our diagnostic skills. As we further understand the "big picture" of One Health, we can ask strategic questions that can lead us to provide further technical assistance to facilitate earlier interventions that lead to positive patient outcomes and ultimately healthier populations. In human medicine, we generally work with one species of animal. Veterinarians work with all the rest. It is time to communicate with and learn from our veterinary clinical microbiology colleagues and begin to understand the critical nature of the human, animal, and environment interface. This is our opportunity to be at the front of this line and not stand on the sidelines watching.

Phenotypic and Genotypic Antimicrobial Resistance Profiles of Campylobacter jejuni Isolated from Cattle, Sheep, and Free-Range Poultry Faeces

Minimum inhibitory concentrations (MIC) of 13 antimicrobial agents were determined by broth microdilution for 72 Campylobacter jejuni strains from livestock. Twenty-three (31.9%) isolates were fully susceptible; all isolates were susceptible to erythromycin, chloramphenicol, streptomycin, gentamicin, sulfamethoxazole, and meropenem, and all but one to kanamycin. Resistance to quinolones was highest (52.8%), reaching similar values among poultry, dairy cattle, and sheep, but lower in beef cattle. Resistance to tetracyclines (48.6%) was mainly associated to dairy cattle and β-lactams (26.4%) to poultry. Multidrug resistance was mainly detected in dairy cattle (28.6%) and poultry (21.0%), whereas beef cattle had the highest percentage of fully susceptible isolates. Two real-time PCR assays to detect point mutations associated to quinolone (C257T in the gyrA gene) and macrolide (A2075G in the 23S rRNA genes) resistance were developed and validated on these strains. The analysis of a further set of 88 isolates by real-time PCR confirmed the absence of macrolide resistance and demonstrated the reproducibility and processability of the assay.