Do patients with recurrent episodes of campylobacteriosis differ from those with a single disease event?

Clinical and microbiological findings of recurrent Campylobacter spp. gastroenteritis in a tertiary care hospital

INTRODUCTION

Campylobacter spp. is the leading cause of bacterial enteritis in industrialized countries, but the literature about its recurrence is scarce. The objective of this study is to analyze a case series of recurrent campylobacteriosis in adult and pediatric patients.

METHODS

During a two-year period, the demographic, clinical and microbiological data were collected retrospectively from patients who met the clinical criteria of recurrent Campylobacter spp. gastroenteritis. Enteropathogens were identified by a multiplex-PCR gastrointestinal pathogens panel. When Campylobacter spp. was detected, the stool sample was cultured in specific medium and tested for antibiotic susceptibility.

RESULTS

Twenty-four (2.03%) out of 1180 patients with Campylobacter spp. positive-PCR met the inclusion criteria. Thirteen patients suffered from underlying diseases, and 11 had no known risk factors but they were all pediatric patients. From the 24 patients were documented 70 episodes. One patient had two episodes of bacteremia. Coinfection/co-detection with other enteropathogens was found in 10 patients being Giardia intestinalis the most frequent. Twelve (22.6%) out of 53 isolates were resistant to macrolides. One patient had two isolates of multi-drug resistant C. coli, only susceptible to gentamicin.

CONCLUSION

The results suggest the presence of underlying diseases in most adult patients with recurrent Campylobacter spp. infections, particularly primary immunodeficiency. Most of the pediatric patients with recurrent campylobacteriosis lack of known risk factors. Concomitant detection with other enteropathogens was common. The resistance to macrolides was much higher as compared with previous reported rates.

Clinical Features, Immunological Characteristics, and Treatment Outcomes of Campylobacter spp. Infections in Patients With Common Variable Immunodeficiency

BACKGROUND

Campylobacter infection usually causes a self-limited clinical illness lasting 5 to 7 days, resolving without antimicrobial treatment in immunocompetent subjects. However, an inadequate immune response can lead to a prolonged and severe disease requiring antibiotics and more aggressive therapeutic approaches.

OBJECTIVE

To comprehensively describe Campylobacter spp. infections in patients with common variable immunodeficiency (CVID).

METHODS

A retrospective cohort of 14 CVID patients with Campylobacter infection and 95 CVID controls attending the immunology clinic at a large tertiary hospital was assessed. Immunological, clinical, and microbiological parameters were measured with median follow-up over 20 years in both cohorts. Patients were treated according to a novel algorithm for Campylobacter in antibody-deficient patients.

RESULTS

Campylobacter patients had a higher proportion of CD21lowCD38low and transitional B cells (median 38.0% vs 14.2% and 5.4% vs 3.2%) and lower long-term average CD19+ B cells (median 0.06 vs 0.18 × 109/L) and CD4+ T cells (0.41 vs 0.62 × 109/L) in comparison with the controls. Similarly, Campylobacter patients showed a decline in B cells (median 0.02 vs 0.14 × 109/L), CD4+ T cells (0.33 vs 0.59 × 109/L), CD8+ T cells (0.26 vs 0.62 × 109/L), and natural killer cells (0.08 vs 0.18 × 109/L) over time. Antimicrobial resistance, especially to macrolides and fluoroquinolones, was common. Bacterial clearance with associated clinical improvement was obtained after a median of 20 and 113 days for acute Campylobacter (resolution within 3 mo of onset) and chronic Campylobacter (>3 mo) infections, respectively. Seven received first-line treatment (azithromycin or chloramphenicol), 4 second-line (neomycin), and 3 third-line (combination of tigecycline, chloramphenicol, and ertapenem; 1 received gentamicin owing to resistance to carbapenems).

CONCLUSIONS

Our study highlights immunological and clinical characteristics of recurrent Campylobacter infections in patients with CVID. Our treatment algorithm was successful and should be evaluated in a larger cohort.

Health care utilizations and costs of Campylobacter enteritis in Germany: A claims data analysis

OBJECTIVE

The number of reported cases of Campylobacter enteritis (CE) remains on a high level in many parts of the world. The aim of this study was to analyze the health care utilizations and direct and indirect costs of CE and sequelae of patients insured by a large health insurance with 26 million members in Germany.

METHODS

Claims data of insurants with at least one CE diagnosis in 2017 (n = 13,150) were provided, of which 9,945 were included in the analysis of health care utilizations and costs. If medical services were not diagnosis-linked, CE-associated costs were estimated in comparison to up to three healthy controls per CE patient. Indirect costs were calculated by multiplying the work incapacities by the average labor costs. Total costs of CE in Germany were extrapolated by including all officially reported CE cases in 2017 using Monte Carlo simulations.

RESULTS

Insurants showed a lower rate of 56 CE diagnoses per 100,000 than German surveillance data for 2017, but with a similar age, gender and regional distribution. Of those CE cases, 6.3% developed post-infectious reactive arthritis, Guillain-Barré syndrome (GBS), inflammatory bowel disease (IBD) and/or irritable bowel syndrome (IBS). Health care utilizations differed depending on CE severity, age and gender. Average CE-specific costs per patient receiving outpatient care were € 524 (95% CI 495-560) over a 12-month period, whereas costs per hospitalized CE case amounted to € 2,830 (2,769-2,905). The analyzed partial costs of sequelae ranged between € 221 (IBS) and € 22,721 (GBS) per patient per 12 months. Total costs of CE and sequelae extrapolated to Germany 2017 ranged between € 74.25 and € 95.19 million, of which 10-30% were due to sequelae.

CONCLUSION

CE is associated with a substantial economic burden in Germany, also due to care-intensive long-lasting sequelae. However, uncertainties remain as to the causal relationship of IBD and IBS after CE.

Renal Abscess and Recurrent Bacteremia Caused by Campylobacter Infection in an Adult With Common Variable Immunodeficiency

Campylobacter bacteremia and extraintestinal manifestations are extremely rare, occurring more frequently in immunocompromised patients. We report a rare clinical case of a 46-year-old female with common variable immunodeficiency (CVID) presenting with a previously undescribed extraintestinal complication - renal abscess - and recurrent bacteremia caused by Campylobacter, which was a therapeutic challenge and required the use of secondary prophylactic antibiotic treatment to prevent recurrence.

Bacteraemia, antimicrobial susceptibility and treatment among Campylobacter-associated hospitalisations in the Australian Capital Territory: a review

BACKGROUND

Campylobacter spp. cause mostly self-limiting enterocolitis, although a significant proportion of cases require hospitalisation highlighting potential for severe disease. Among people admitted, blood culture specimens are frequently collected and antibiotic treatment is initiated. We sought to understand clinical and host factors associated with bacteraemia, antibiotic treatment and isolate non-susceptibility among Campylobacter-associated hospitalisations.

METHODS

Using linked hospital microbiology and administrative data we identified and reviewed Campylobacter-associated hospitalisations between 2004 and 2013. We calculated population-level incidence for Campylobacter bacteraemia and used logistic regression to examine factors associated with bacteraemia, antibiotic treatment and isolate non-susceptibility among Campylobacter-associated hospitalisations.

RESULTS

Among 685 Campylobacter-associated hospitalisations, we identified 25 admissions for bacteraemia, an estimated incidence of 0.71 cases per 100,000 population per year. Around half of hospitalisations (333/685) had blood culturing performed. Factors associated with bacteraemia included underlying liver disease (aOR 48.89, 95% CI 7.03-340.22, p < 0.001), Haematology unit admission (aOR 14.67, 95% CI 2.99-72.07, p = 0.001) and age 70-79 years (aOR 4.93, 95% CI 1.57-15.49). Approximately one-third (219/685) of admissions received antibiotics with treatment rates increasing significantly over time (p < 0.05). Factors associated with antibiotic treatment included Gastroenterology unit admission (aOR 3.75, 95% CI 1.95-7.20, p < 0.001), having blood cultures taken (aOR 2.76, 95% CI 1.79-4.26, p < 0.001) and age 40-49 years (aOR 2.34, 95% CI 1.14-4.79, p = 0.02). Non-susceptibility of isolates to standard antimicrobials increased significantly over time (p = 0.01) and was associated with overseas travel (aOR 11.80 95% CI 3.18-43.83, p < 0.001) and negatively associated with tachycardia (aOR 0.48, 95%CI 0.26-0.88, p = 0.02), suggesting a healthy traveller effect.

CONCLUSIONS

Campylobacter infections result in considerable hospital burden. Among those admitted to hospital, an interplay of factors involving clinical presentation, presence of underlying comorbidities, complications and increasing age influence how a case is investigated and managed.

Recurrent Campylobacter Enteritis in Patients with Hypogammaglobulinemia: Review of the Literature

Recurrent Campylobacter enteritis is a well-recorded complication of primary hypogammaglobulinemia but has only rarely been reported with other types of immunodeficiency, and no cases have been reported after rituximab-associated secondary hypogammaglobulinemia. We therefore reviewed our local microbiology laboratory databases and conducted a literature search, to provide a detailed characterization of the immunodeficiency states associated with recurrent Campylobacter enteritis. Published cases had primary hypogammaglobulinemia, most frequently in the setting of common variable immunodeficiency, x-linked agammaglobulinemia, and Good syndrome. No cases were identified in the literature after rituximab or secondary hypogammaglobulinemia. We report a 73-year-old patient with recurrent Campylobacter enteritis and hypogammaglobulinemia in the setting of non-Hodgkin lymphoma, chemotherapy, and maintenance rituximab. Physicians should be aware of the association of recurrent Campylobacter enteritis and immunodeficiency, most commonly in primary hypogammaglobulinemia. Rituximab alone may not be sufficiently immunosuppressive for recurrent campylobacteriosis to occur; additional factors, including hematological malignancy and its treatment, appear necessary. Patients with recurrent Campylobacter enteritis and those starting rituximab should be investigated for hypogammaglobulinemia and B-lymphopenia.

Potential Use of Fosfomycin-Tromethamine for Treatment of Recurrent Campylobacter Species Enteritis

We report 2 cases of recurrent Campylobacter coli enteritis caused by macrolide- and fluoroquinolone-resistant strains in 2 patients with hypogammaglobulinemia, successfully treated with a prolonged course of fosfomycin-tromethamine with no side effects. Fosfomycin-tromethamine may be a feasible alternative therapy for recurrent enteritis caused by Campylobacter species resistant to first-line drugs.

An exploratory analysis of individuals with multiple episodes of different reportable diseases, Montreal, 1990-2012

OBJECTIVES

Studies of public health reporting have only examined multiple episodes of the same communicable disease within an individual. We aimed to characterize Montreal residents with multiple reportable disease episodes from 1990 to 2012, while accounting for all types of reportable diseases.

STUDY DESIGN

Retrospective cohort study.

METHODS

We performed an exploratory analysis using descriptive statistics, contingency tables, and logistic regression.

RESULTS

There were 157,839 individuals with at least one disease report and a total of 179,455 disease reports. The 9.8% of subjects with more than one episode accounted for 20.7% of all reported episodes. Among subjects with four or fewer episodes, 54.0% were women, while 74.3% of subjects with five or more episodes were men. Subjects with multiple episodes were more likely to be reported for sexually transmitted infections than were persons with a single episode [difference of proportions: 10.4% (95% CI: 10.0%-10.9%)] and to reside in the neighbourhood encompassing Montreal's gay village.

CONCLUSIONS

Individuals with multiple communicable disease reports place a large burden on public health officials. These results may help guide investigation and prevention efforts to reduce the number of excess episodes.

Campylobacter infection in a cohort of rural children in Moramanga, Madagascar

Background

Campylobacter infection is the most common cause of bacterial gastroenteritis in developing countries, including Madagascar. Reports of pathogenicity have not been consistent and repeated exposures over time seem to lead to the development of protective immunity in developing areas. We conducted this study to support evidence for these hypotheses by exploring the association between infection and age, the reoccurrence of infection and the pathogenicity of Campylobacter.

Methods

We carried out a community-based longitudinal study of children under the age of 24 months in two rural villages in Moramanga, Madagascar. Children were visited twice a week and a stool specimen was collected in cases of diarrhoea. Stools specimens were collected bimonthly from all children enrolled, regardless of symptoms. Children were followed-up until the age of 36 months.

Results

Between January 2010 and May 31^st 2012, 508 children were included in the cohort. We detected 319 episodes of Campylobacter infection in total, and 43.3% (n = 220) of the children had at least one episode of intestinal Campylobacter infection. The rate of Campylobacter isolation from stool specimens was 9.3%. The annual incidence rate for symptomatic Campylobacter infection was 0.05 episodes/child. The probability of Campylobacter infection was highest between the ages of six and 23 months. Taking children under six months of age as the reference group, the age-specific odds ratio for the association was 5.0 (95% CI: 2.9-8.6) for children aged six to 11 months, 5.7 (95% CI: 3.3-10.0) for children aged 12 to 17 months and 3.3 (95% CI: 1.8-5.8) for children aged 18 to 23 months. A second episode of infection occurred 63 days after the first episode in children with primary infections, and after 137 days in children with multiple infections (p < 0.01). First episodes of Campylobacter infection were associated with diarrhoea (odds ratio = 16.1; 95% CI: 1.8-140.8).

Conclusion

Our findings suggest that protective immunity to Campylobacter may be acquired over time, following repeated exposures. However, Campylobacter infection prevention measures should be reinforced in the first year of life, as this age seems to be associated with the highest risk of diarrhoea during Campylobacter infection.

Campylobacteriosis in returning travellers and potential secondary transmission of exotic strains

SUMMARY

Multilocus sequence types (STs) were determined for 232 and 737 Campylobacter jejuni/coli isolates from Dutch travellers and domestically acquired cases, respectively. Putative risk factors for travel-related campylobacteriosis, and for domestically acquired campylobacteriosis caused by exotic STs (putatively carried by returning travellers), were investigated. Travelling to Asia, Africa, Latin America and the Caribbean, and Southern Europe significantly increased the risk of acquiring campylobacteriosis compared to travelling within Western Europe. Besides eating chicken, using antacids, and having chronic enteropathies, we identified eating vegetable salad outside Europe, drinking bottled water in high-risk destinations, and handling/eating undercooked pork as possible risk factors for travel-related campylobacteriosis. Factors associated with domestically acquired campylobacteriosis caused by exotic STs involved predominantly person-to-person contacts around popular holiday periods. We concluded that putative determinants of travel-related campylobacteriosis differ from those of domestically acquired infections and that returning travellers may carry several exotic strains that might subsequently spread to domestic populations even through limited person-to-person transmission.

Campylobacteriosis in urban versus rural areas: a case-case study integrated with molecular typing to validate risk factors and to attribute sources of infection

Campylobacter infection is a leading cause of bacterial gastroenteritis worldwide, and most clinical cases appear as isolated, sporadic infections for which the source is rarely apparent. From July 2005 to December 2007 we conducted a prospective case-case study of sporadic, domestically-acquired Campylobacter enteritis in rural versus urban areas and a prevalence study of Campylobacter in animal and environmental sources in the Eastern Townships, Quebec. Isolates were typed using Multilocus Sequence Typing (MLST) to reinforce the case-case findings and to assign a source probability estimate for each human isolate. The risk of human campylobacteriosis was 1.89-fold higher in rural than urban areas. Unconditional multivariate logistic regression analysis identified two independent risk factors associated with human Campylobacter infections acquired in rural area: occupational exposure to animals (OR = 10.6, 95% CI: 1.2–91, p = 0.032), and household water coming from a private well (OR = 8.3, 95% CI: 3.4–20.4, p<0.0001). A total of 851 C. jejuni isolates (178 human, 257 chicken, 87 bovine, 266 water, 63 wild bird) were typed using MLST. Among human isolates, the incidence rates of clonal complexes (CC) CC-21, CC-45, and CC-61 were higher in rural than urban areas. MLST-based source attribution analysis indicated that 64.5% of human C. jejuni isolates were attributable to chicken, followed by cattle (25.8%), water (7.4%), and wild birds (2.3%). Chicken was the attributable source for the majority of cases, independent of residential area, sex and age. The increased incidence in rural compared to urban areas was associated with occupational exposure to animals, particularly cattle among those aged 15–34 years, and with consumption of private well water. Both bovine and water exposure appeared to contribute to the seasonal variation in campylobacteriosis. These results provide a basis for developing public education and preventive programs targeting the risk factors identified.

The second study of infectious intestinal disease (IID2): increased rates of recurrent diarrhoea in individuals aged 65 years and above

Background

Infectious intestinal disease (IID) is a major health and economic burden in high-income countries. In the UK, there are an estimated 17 million IID cases annually, of which 6 million are caused by the 12 most common pathogens. Host factors that influence risk of IID are not well understood.

Methods

We analyzed data from the IID2 Study, a UK cohort that measured IID incidence, to investigate factors associated with recurrent IID. We calculated rates of IID by age group, sex, previous episodes experienced, and socioecomic indicators. We used Cox models to investigate factors associated with recurrent illness.

Results

The rate of IID was five times higher among infants than those aged 65 years and above (hazard ratio, HR = 5.0, 95% CI: 3.1 – 8.0). However, the association between previous IID and a subsequent IID episode was stronger in the elderly. Among those aged 65 years and above, each additional IID episode increased the rate of subsequent IID three-fold (HR = 3.1, 95% CI: 2.5 – 3.7). Among infants, the corresponding increase was 1.7-fold (HR = 1.7, 95% CI: 1.3 – 2.3).

Conclusions

Elderly populations have a high propensity for recurrent IID. More detailed studies are needed to identify vulnerable subgroups and susceptibility factors, and inform adequate control policies among the elderly.

Environmental and demographic risk factors for campylobacteriosis: do various geographical scales tell the same story?

BACKGROUND

Campylobacter is a common cause of bacterial gastro-enteritis characterized by multiple environmental sources and transmission pathways. Ecological studies can be used to reveal important regional characteristics linked to campylobacteriosis risk, but their results can be influenced by the choice of geographical units of analysis. This study was undertaken to compare the associations between the incidence of campylobacteriosis in Quebec, Canada and various environmental characteristics using seven different sets of geographical units.

METHODS

For each set of geographical unit, a conditional autoregressive model was used to model the incidence of reported cases of campylobacteriosis according to environmental (poultry density, ruminant density, slaughterhouse presence, temperature, and precipitation) and demographic (population density, level of education) characteristics. Models were compared in terms of number of significant predictors, differences in direction and magnitude of predictors, and fit of the models.

RESULTS

In general, the number of significant predictors was reduced as the aggregation level increased. More aggregated scales tend to show larger but less precise estimates for all variables, with the exception of slaughterhouse presence. Regional characteristics associated with an increased regional risk of campylobacteriosis, for at least some geographical units, were high ruminant density, high poultry density, high population density, and presence of a large poultry slaughterhouse, whereas a reduction in risk was associated with a lower percentage of people with diplomas, a lower level of precipitation, and warmer temperature. Two clusters of elevated residual risk were observed, with different location and size depending on the geographical unit used.

CONCLUSIONS

Overall, our results suggest that the use of municipality or census consolidated subdivision were the most optimal scales for studying environmental determinants of campylobacteriosis at a regional level. This study highlights the need for careful selection and analysis of geographical units when using ecological study designs.