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Greminger S, Strahm C, Notter J, Martens B, Helfenstein S, Den Hollander J, Frischknecht M. Vertebral osteomyelitis with Campylobacter jejuni - a case report and review of the literature of a very rare disease. J Bone Jt Infect 2024; 9:59-65. [PMID: 38601004 PMCID: PMC11002916 DOI: 10.5194/jbji-9-59-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 01/02/2024] [Indexed: 04/12/2024] Open
Abstract
Infections with Campylobacter species mainly cause gastrointestinal disease and are usually self-limiting. Systemic complications such as bacteremia and osteoarticular infections are rare. Here we report a very rare case of a vertebral osteomyelitis due to C. jejuni, and we reviewed the literature for similar cases, identifying six other cases. Therapy should be guided on resistance testing if available due to emerging resistance rates, especially to fluoroquinolones. Azithromycin may be a treatment option for C. jejuni spondylodiscitis.
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Affiliation(s)
- Simone Greminger
- Medical Center Pflanzberg, Poststrasse 20, 8274 Tägerwilen, Switzerland
| | - Carol Strahm
- Division of Infectious Diseases, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
| | - Julia Notter
- Division of Infectious Diseases, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
| | - Benjamin Martens
- Center for Spine Surgery Eastern Switzerland, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
| | - Seth Florian Helfenstein
- Division of General Internal Medicine, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
| | - Jürgen Den Hollander
- Cantonal network of Radiology and Nuclear Medicine, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
| | - Manuel Frischknecht
- Division of Infectious Diseases, Cantonal Hospital St Gallen, Rorschacher Strasse 95, 9007 St Gallen, Switzerland
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Islam D, Ruamsap N, Imerbsin R, Khanijou P, Gonwong S, Wegner MD, McVeigh A, Poly FM, Crawford JM, Swierczewski BE, Kaminski RW, Laird RM. Bioactivity and efficacy of a hyperimmune bovine colostrum product- Travelan, against shigellosis in a non-Human primate model (Macaca mulatta). PLoS One 2023; 18:e0294021. [PMID: 38091314 PMCID: PMC10718440 DOI: 10.1371/journal.pone.0294021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 10/16/2023] [Indexed: 12/18/2023] Open
Abstract
Infectious diarrhea is a World Health Organization public health priority area due to the lack of effective vaccines and an accelerating global antimicrobial resistance crisis. New strategies are urgently needed such as immunoprophylactic for prevention of diarrheal diseases. Hyperimmune bovine colostrum (HBC) is an established and effective prophylactic for infectious diarrhea. The commercial HBC product, Travelan® (Immuron Ltd, Australia) targets multiple strains of enterotoxigenic Escherichia coli (ETEC) is highly effective in preventing diarrhea in human clinical studies. Although Travelan® targets ETEC, preliminary studies suggested cross-reactivity with other Gram-negative enteric pathogens including Shigella and Salmonella species. For this study we selected an invasive diarrheal/dysentery-causing enteric pathogen, Shigella, to evaluate the effectiveness of Travelan®, both in vitro and in vivo. Here we demonstrate broad cross-reactivity of Travelan® with all four Shigella spp. (S. flexneri, S. sonnei, S. dysenteriae and S. boydii) and important virulence factor Shigella antigens. Naïve juvenile rhesus macaques (NJRM) were randomized, 8 dosed with Travelan® and 4 with a placebo intragastrically twice daily over 6 days. All NJRM were challenged with S. flexneri 2a strain 2457T on the 4th day of treatment and monitored for diarrheal symptoms. All placebo-treated NJRM displayed acute dysentery symptoms within 24-36 hours of challenge. Two Travelan®-treated NJRM displayed dysentery symptoms and six animals remained healthy and symptom-free post challenge; resulting in 75% efficacy of prevention of shigellosis (p = 0.014). These results strongly indicate that Travelan® is functionally cross-reactive and an effective prophylactic for shigellosis. This has positive implications for the prophylactic use of Travelan® for protection against both ETEC and Shigella spp. diarrheal infections. Future refinement and expansion of pathogens recognized by HBC including Travelan® could revolutionize current management of gastrointestinal infections and outbreaks in travelers' including military, peacekeepers, humanitarian workers and in populations living in endemic regions of the world.
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Affiliation(s)
- Dilara Islam
- US Army Medical Directorate of the Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Nattaya Ruamsap
- US Army Medical Directorate of the Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Rawiwan Imerbsin
- US Army Medical Directorate of the Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Patchariya Khanijou
- US Army Medical Directorate of the Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Siriphan Gonwong
- US Army Medical Directorate of the Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Matthew D. Wegner
- US Army Medical Directorate of the Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Annette McVeigh
- Henry M. Jackson Foundation for Military Medicine (HJF), Bethesda, Maryland, United States of America
- Naval Medical Research Command (NMRC), Silver Spring, Maryland, United States of America
| | - Frédéric M. Poly
- Naval Medical Research Command (NMRC), Silver Spring, Maryland, United States of America
| | - John M. Crawford
- US Army Medical Directorate of the Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Brett E. Swierczewski
- US Army Medical Directorate of the Armed Forces Research Institute of Medical Sciences (USAMD-AFRIMS), Bangkok, Thailand
| | - Robert W. Kaminski
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, Maryland, United States of America
| | - Renee M. Laird
- Walter Reed Army Institute of Research (WRAIR), Silver Spring, Maryland, United States of America
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Yanestria SM, Effendi MH, Tyasningsih W, Mariyono M, Ugbo EN. First report of phenotypic and genotypic (bla OXA-61) beta-lactam resistance in Campylobacter jejuni from broilers in Indonesia. Vet World 2023; 16:2210-2216. [PMID: 38152271 PMCID: PMC10750733 DOI: 10.14202/vetworld.2023.2210-2216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 10/03/2023] [Indexed: 12/29/2023] Open
Abstract
Background and Aim Campylobacter is a zoonotic bacterium that is a major source of foodborne diseases. In humans, most cases of campylobacteriosis are caused by Campylobacter jejuni. Poultry is the main reservoir of Campylobacter for humans, because Campylobacter is part of the normal flora of the digestive tract of poultry. Antimicrobial resistance to several antibiotics in Campylobacter isolated from humans and food animals has increased rapidly. Beta-lactam is an antibiotic with a high prevalence of resistance in Campylobacter. This study aimed to investigate phenotypic and genotypic (blaOXA-61) beta-lactam resistance in C. jejuni from broilers in Indonesia. Materials and Methods A total of 100 samples of broiler intestinal contents were obtained from 10 broiler farms in Pasuruan Regency, Indonesia. Campylobacter jejuni was identified using conventional and polymerase chain reaction (PCR)-based methods. Phenotypic detection of beta-lactam resistance was performed using an antimicrobial susceptibility test with antibiotic disks of aztreonam, ampicillin, and amoxicillin-clavulanic acid. Genotypic detection by PCR was performed using the blaOXA-61 gene, which encodes beta-lactamase. Results Campylobacter jejuni was identified in 23% of the samples. Phenotypically, 100% (23/23) and 73.9% (17/23) C. jejuni isolates had high resistance to aztreonam and ampicillin, respectively, but all isolates were susceptible to amoxicillin-clavulanic acid. Genotypically, all isolates carried blaOXA-61, indicated by the presence of a 372-bp PCR product. Conclusion Campylobacter jejuni is highly resistant to beta-lactams and is a serious threat to human health. Resistance to beta-lactams should be monitored because beta-lactamase genes can be transferred between bacteria. Public awareness must also be increased on the importance of using antibiotics rationally in humans and animals.
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Affiliation(s)
- Sheila Marty Yanestria
- Doctoral Program in Veterinary Science, Faculty of Veterinary Medicine, Universitas Airlangga. Jl. Dr. Ir. H. Soekarno, Kampus C Mulyorejo, Surabaya 60115, East Java, Indonesia
| | - Mustofa Helmi Effendi
- Department of Veterinary Public Health, Faculty of Veterinary Medicine, Universitas Airlangga, Jl. Dr. Ir. H. Soekarno, Kampus C Mulyorejo, Surabaya 60115, East Java, Indonesia
| | - Wiwiek Tyasningsih
- Department of Veterinary Microbiology, Faculty of Veterinary Medicine, Universitas Airlangga, Jl. Dr. Ir. H. Soekarno, Kampus C Mulyorejo, Surabaya 60115, East Java, Indonesia
| | - Mariyono Mariyono
- Bacteriology Laboratory, Balai Besar Veteriner Wates, Jl. Yogyakarta-Wates No. Km. 27, Wates, Yogyakarta 55651, Central Java, Indonesia
| | - Emmanuel Nnabuike Ugbo
- Department of Applied Microbiology, Faculty of Science, Ebonyi State University, Enugu - Abakaliki Rd, 481101, Abakaliki, Ebonyi, Nigeria
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Park M, Kim J, Feinstein J, Lang KS, Ryu S, Jeon B. Development of Fluoroquinolone Resistance through Antibiotic Tolerance in Campylobacter jejuni. Microbiol Spectr 2022; 10:e0166722. [PMID: 36066254 PMCID: PMC9602944 DOI: 10.1128/spectrum.01667-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/18/2022] [Indexed: 12/31/2022] Open
Abstract
Antibiotic tolerance not only enables bacteria to survive acute antibiotic exposures but also provides bacteria with a window of time in which to develop antibiotic resistance. The increasing prevalence of Campylobacter jejuni isolates resistant to clinically important antibiotics, particularly fluoroquinolones (FQs), is a global public health concern. Currently, little is known about antibiotic tolerance and its effects on resistance development in C. jejuni. Here, we show that exposure to ciprofloxacin or tetracycline at concentrations 10 and 100 times higher than the MIC induces antibiotic tolerance in C. jejuni, whereas gentamicin or erythromycin treatment causes cell death. Interestingly, FQ resistance rapidly develops in C. jejuni after tolerance induction by ciprofloxacin and tetracycline. Furthermore, after tolerance is induced, alkyl hydroperoxide reductase (AhpC) plays a critical role in reducing FQ resistance development by alleviating oxidative stress. Together, these results demonstrate that exposure of C. jejuni to antibiotics can induce antibiotic tolerance and that FQ-resistant (FQR) C. jejuni clones rapidly emerge after tolerance induction. This study elucidates the mechanisms underlying the high prevalence of FQR C. jejuni and provides insights into the effects of antibiotic tolerance on resistance development. IMPORTANCE Antibiotic tolerance compromises the efficacy of antibiotic treatment by extending bacterial survival and facilitating the development of mutations associated with antibiotic resistance. Despite growing public health concerns about antibiotic resistance in C. jejuni, antibiotic tolerance has not yet been investigated in this important zoonotic pathogen. Here, our results show that exposure of C. jejuni to ciprofloxacin or tetracycline leads to antibiotic tolerance development, which subsequently facilitates the emergence of FQR C. jejuni. Importantly, these antibiotics are commonly used in animal agriculture. Moreover, our study suggests that the use of non-FQ drugs in animal agriculture promotes FQ resistance development, which is crucial because antibiotic-resistant C. jejuni is primarily transmitted from animals to humans. Overall, these findings increase our understanding of the mechanisms of resistance development through the induction of antibiotic tolerance.
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Affiliation(s)
- Myungseo Park
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Saint Paul, Minnesota, USA
| | - Jinshil Kim
- Department of Food and Animal Biotechnology, Research Institute for Agriculture and Life Sciences, Seoul National University, Seoul, Republic of Korea
- Department of Agricultural Biotechnology, Seoul National University, Seoul, Republic of Korea
- Center for Food and Bioconvergence, Seoul National University, Seoul, Republic of Korea
| | - Jill Feinstein
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Saint Paul, Minnesota, USA
| | - Kevin S. Lang
- Department of Veterinary and Biomedical Sciences, College of Veterinary Medicine, University of Minnesota, Saint Paul, Minnesota, USA
| | - Sangryeol Ryu
- Department of Food and Animal Biotechnology, Research Institute for Agriculture and Life Sciences, Seoul National University, Seoul, Republic of Korea
- Department of Agricultural Biotechnology, Seoul National University, Seoul, Republic of Korea
- Center for Food and Bioconvergence, Seoul National University, Seoul, Republic of Korea
| | - Byeonghwa Jeon
- Division of Environmental Health Sciences, School of Public Health, University of Minnesota, Saint Paul, Minnesota, USA
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Doxycycline as an antimalarial: Impact on travellers' diarrhoea and doxycycline resistance among various stool bacteria - Prospective study and literature review. Travel Med Infect Dis 2022; 49:102403. [PMID: 35872253 DOI: 10.1016/j.tmaid.2022.102403] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 06/18/2022] [Accepted: 07/17/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Antibiotics predispose travellers to acquire multidrug-resistant bacteria, such as extended-spectrum beta-lactamase-producing Enterobacterales (ESBL-PE). Although widely used in antimalarial prophylaxis, doxycycline has scarcely been studied in this respect. METHODS We explored the impact of doxycycline on rates of traveller's diarrhoea (TD), ESBL-PE acquisition and, particularly, doxycycline co-resistance among travel-acquired ESBL-PE in a sample of 412 visitors to low- and middle-income countries. We reviewed the literature on traveller studies of doxycycline/tetracycline resistance among stool pathogens and the impact of doxycycline on TD rates, ESBL-PE acquisition, and doxycycline/tetracycline resistance. RESULTS The TD rates were similar for doxycycline users (32/46; 69.6%) and non-users (256/366; 69.9%). Of the 90 travel-acquired ESBL-PE isolates, 84.4% were co-resistant to doxycycline: 100% (11/11) among users and 82.3% (65/79) among non-users. The literature on doxycycline's effect on TD was not conclusive nor did it support a recent decline in doxycycline resistance. Although doxycycline did not increase ESBL-PE acquisition, doxycycline-resistance among stool pathogens proved more frequent for users than non-users. CONCLUSIONS Our prospective data and the literature review together suggest the following: 1) doxycycline does not prevent TD; 2) doxycycline use favours acquisition of doxy/tetracycline-co-resistant intestinal bacteria; 3) although doxycycline does not predispose to travel-related ESBL-PE acquisition per se, it selects ESBL-PE strains co-resistant to doxycycline; 4) doxycycline resistance rates are high among stool bacteria in general with no evidence of any tendency to decrease.
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Simms AJ, Kobayashi T, Schwartzhoff PV, Sekar P. Prosthetic hip infection due to Campylobacter jejuni. BMJ Case Rep 2022; 15:e248240. [PMID: 35272991 PMCID: PMC8915350 DOI: 10.1136/bcr-2021-248240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2022] [Indexed: 11/03/2022] Open
Abstract
A woman in her 60s with a left hip prosthesis was presented with left hip pain and fever. She had an elevated white blood cell count and inflammatory markers. Synovial fluid Gram stain demonstrated curved Gram-negative rods identified as Campylobacter jejuni The patient initially refused surgery and after 3 months underwent one-stage exchange after which she was treated with 12 weeks of levofloxacin. Her inflammatory markers normalised and she was clinically doing well at her 6-month follow-up. C. jejuni is a rare cause of prosthetic joint infection and should be included in the differential diagnosis when a patient has risk factors even without significant preceding gastrointestinal symptoms. Per most recent Infectious Diseases Society of America guidelines, treatment after one-stage revision includes 4-6 weeks of intravenous antimicrobials followed by possible oral suppression therapy, while the European guidelines recommend 12 weeks of orally bioavailable antibiotics.
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Affiliation(s)
- Andrew Joseph Simms
- Internal Medicine, Infectious Diseases, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Takaaki Kobayashi
- Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Patrick V Schwartzhoff
- Internal Medicine, Carver College of Medicine, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Poorani Sekar
- Internal Medicine, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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7
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Kantele A, Lääveri T. Extended-spectrum beta-lactamase-producing strains among diarrhoeagenic Escherichia coli-prospective traveller study with literature review. J Travel Med 2022; 29:6217594. [PMID: 33834207 PMCID: PMC8763120 DOI: 10.1093/jtm/taab042] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 01/27/2020] [Accepted: 01/29/2020] [Indexed: 01/25/2023]
Abstract
BACKGROUND Antibiotics are no longer the primary approach for treating all travellers' diarrhoea (TD): most cases resolve without antibiotics and using them predisposes to colonization by multidrug-resistant bacteria. Data are accumulating on increasing resistance among TD pathogens, yet research into the most common agents, diarrhoeagenic Escherichia coli (DEC), remains limited. METHODS A total of 413 travellers to the (sub)tropics were analyzed for travel-acquired diarrhoeal pathogens and ESBL-PE. To identify ESBL-producing DEC, ESBL-producing E. coli (ESBL-EC) isolates were subjected to multiplex qPCR for various DEC pathotypes: enteroaggregative (EAEC), enteropathogenic (EPEC), enterotoxigenic (ETEC), enteroinvasive (EIEC) and enterohaemorrhagic (EHEC) E. coli.For a literature review, we screened studies among travellers and locals in low- and middle-income countries (LMICs) on the frequency of ESBL-producing DEC, and among travellers, also DEC with resistance to ciprofloxacin, azithromycin, and rifamycin derivatives. RESULTS Our rate of ESBL-EC among all DEC findings was 2.7% (13/475); among EAEC 5.7% (10/175), EPEC 1.1% (2/180), ETEC 1.3% (1/80) and EHEC (0/35) or EIEC 0% (0/5). The literature search yielded three studies reporting ESBL-EC frequency and thirteen exploring resistance to TD antibiotics among travel-acquired DEC. For EAEC and ETEC, the ESBL-EC rates were 10-13% and 14-15%, resistance to fluoroquinolones 0-42% and 0-40%, azithromycin 0-29% and 0-61%, and rifaximin 0% and 0-20%. The highest rates were from the most recent collections. Proportions of ESBL-producing DEC also appear to be increasing among locals in LMICs and even carbapenemase-producing DEC were reported. CONCLUSION ESBL producers are no longer rare among DEC, and the overall resistance to various antibiotics is increasing. The data predict decreasing efficacy of antibiotic treatment, threatening its benefits, for disadvantages still prevail when efficacy is lost.
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Affiliation(s)
- Anu Kantele
- To whom correspondence should be addressed. Professor Anu Kantele, Meilahti Vaccine Research Center MeVac, University of Helsinki and Helsinki University Hospital, Biomedicum 1, Haartmaninkatu 8, FI-00029 HUS, Finland; Tel: +358-50-309-7640;
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Abstract
Acute bacterial gastroenteritis is among the most common infections worldwide, with millions of infections annually in the United States. Much of the illness is foodborne, occurring as both sporadic cases and large multistate outbreaks. Pathogen evolution through genetic exchange of virulence traits and antibiotic resistance determinants poses challenges for empiric therapy. Culture-independent diagnostic tests in clinical laboratories afford rapid diagnosis and expanded identification of pathogens. However, cultures remain important to generate sensitivity data and strain archiving for outbreak investigations. Most infections are self-limited, permitting judicious selection of antibiotic use in more severe forms of illness.
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Affiliation(s)
- James M Fleckenstein
- Department of Medicine, Division of Infectious Diseases, Washington University in Saint Louis, School of Medicine, Campus Box 8051, 660 South Euclid Avenue, Saint Louis, MO 63110, USA; Infectious Disease Section, Medicine Service, Veterans Affairs Saint Louis Health Care System, 915 North Grand Boulevard, Saint Louis, MO 63106, USA.
| | - F Matthew Kuhlmann
- Department of Medicine, Division of Infectious Diseases, Washington University in Saint Louis, School of Medicine, Campus Box 8051, 660 South Euclid Avenue, Saint Louis, MO 63110, USA
| | - Alaullah Sheikh
- Department of Medicine, Division of Infectious Diseases, Washington University in Saint Louis, School of Medicine, Campus Box 8051, 660 South Euclid Avenue, Saint Louis, MO 63110, USA
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The worldwide trend of Campylobacter spp., infection from duck-related isolates and associated phenotypic and genotypic antibiotic resistance, since 1985: identifying opportunities and challenges for prevention and control. Poult Sci 2021; 100:101213. [PMID: 34237548 PMCID: PMC8267597 DOI: 10.1016/j.psj.2021.101213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2020] [Revised: 04/05/2021] [Accepted: 04/11/2021] [Indexed: 12/26/2022] Open
Abstract
Campylobacter, a leading cause of foodborne diseases, is well recognized worldwide. Poultry and poultry products are considered as major sites for Campylobacter infection in humans. The extensive uses of antibiotics mostly as growth promoters and for therapeutic purposes have led to the emergence of antibiotic-resistant strains of foodborne pathogens including Campylobacter. A key tenet of this paper is the need for reviewing the previous studies conducted around the globe on the prevalence and antimicrobial resistance of Campylobacter spp. isolates in duck to better understand the sources and trends of infection. Based on published data, the prevalence of Campylobacter spp. in duck and duck-related samples ranged from 0% to 100% and was largely influenced by the isolation method. Among Campylobacter spp., C. jejuni was the predominant cause of campylobacteriosis, followed by C. coli. Campylobacter spp. from ducks were mostly resistant to fluoroquinolones and tetracycline and a lesser extent to gentamicin, chloramphenicol, and erythromycin. Some studies showed that ducks may pose a risk for acquiring campylobacteriosis because they had genotypes quite similar to human isolates detected previously. A continued monitoring approach is needed, at national and international levels, with enhanced surveillance and reporting of trends, as well as harmonization of surveillance systems toward a one-health approach to monitoring antimicrobial resistance in animal production particularly if increased resistance rates are being demonstrated.
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Bacterial, viral and parasitic pathogens analysed by qPCR: Findings from a prospective study of travellers' diarrhoea. Travel Med Infect Dis 2020; 40:101957. [PMID: 33359433 DOI: 10.1016/j.tmaid.2020.101957] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 12/19/2020] [Accepted: 12/21/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The diagnostics of travellers' diarrhoea (TD) has been revolutionised by multiplex qPCR assays. While mostly of bacterial aetiology, viruses and parasites account for the disease among 10-20% of travellers. Despite this, prospective studies applying qPCR assays remain scarce that cover not only bacteria, such as the various diarrhoeagenic Escherichia coli (DEC), but also viral and parasitic pathogens. METHOD We analysed by qPCR pre- and post-travel stool samples of 146 Finnish travellers for bacterial, viral and parasitic pathogens: enteropathogenic (EPEC), enteroaggregative (EAEC), enterotoxigenic (ETEC), enterohaemorrhagic (EHEC), and enteroinvasive (EIEC) E. coli; Shigella, Campylobacter, Salmonella, Yersinia and Vibrio cholerae; norovirus G1 and G2, rotavirus, enteroviruses, and sapovirus; and Giardia lamblia, Entamoeba histolytica, and Cryptosporidium. Symptoms and medication data during travel were collected by questionnaires. RESULTS We detected bacterial pathogens in 102/146 samples (69.9%; EAEC, EPEC, ETEC most common), viral ones in 13 (8.9%; norovirus most common), and parasitic ones in one (0.7%; Giardia). Noroviruses were associated with severe symptoms (23.5% versus non-severe 4.9%). In the TD group, 41.7% (5/12) of those with viral pathogens (vs. 13.3%; 11/83 without) took antibiotics. CONCLUSION Viral pathogens, particularly noroviruses, prevail in severe TD. The symptoms of viral disease are often severe and lead to unwarranted use of antibiotics.
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Wysok B, Wojtacka J, Hänninen ML, Kivistö R. Antimicrobial Resistance and Virulence-Associated Markers in Campylobacter Strains From Diarrheic and Non-diarrheic Humans in Poland. Front Microbiol 2020; 11:1799. [PMID: 32849410 PMCID: PMC7417443 DOI: 10.3389/fmicb.2020.01799] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 07/09/2020] [Indexed: 12/19/2022] Open
Abstract
Campylobacteriosis is one of the most common causes of bacterial gastroenteritis. However, the clinical course of the illness varies in symptoms and severity. The aim of this study was to characterize Campylobacter jejuni (34 isolates) and C. coli (9 isolates) from persons with diarrheal and non-diarrheal stools at the time of examination and fecal sampling, in Poland by using whole-genome sequencing (WGS). Multilocus sequence typing (MLST) analysis revealed a high diversity with a total of 20 sequence types (STs) among 26 Campylobacter isolates from diarrheic and 13 STs among 17 isolates from non-diarrheic persons. ST-50 and ST-257 were most common in both groups. The phenotypic resistance rate was 74.4% for ciprofloxacin, 67.4% for sulfamethoxazole/trimethoprim, 58.1% for amoxicillin, 48.8% for tetracycline, and 46.5% for ceftriaxone. Only single isolates were resistant to erythromycin, gentamicin, and amoxicillin/clavulanic acid. Overall genotypic resistance toward amoxicillin, fluoroquinolones, tetracyclines, and aminoglycosides was predicted to occur in 93.1, 67.4, 48.8, and 11.6% of the isolates, respectively. None of the isolates showed the presence of the erm(B) gene or mutation in 23S rRNA. Neither was variation found in the important target region in L4 and L22 ribosomal proteins. In regard to the CmeABC efflux pump, a set of variable mutations affecting the regulatory region was noted. All Campylobacter isolates possessed genes associated with adhesion (cadF, jlpA, porA, and pebA) and invasion (ciaB, pldA, and flaC). The type IV secretion system (T4SS) was found in isolates from both diarrheic (15.4%, CI 95%: 6.1–33.5%) and non-diarrheic (23.5%, CI 95%: 9.6–47.3%) persons. The rates of the presence of cytolethal distending toxin cdtABC gene cluster and type VI secretion system (T6SS) were higher in Campylobacter isolates obtained from persons with diarrhea (96.2%, CI 95%: 81.7–99.3% and 26.9%, CI 95%: 13.7–46.1%) compared to isolates from non-diarrheic persons (76.5%, CI 95%: 52.7–90.4% and 11.8%, CI 95%: 3.3–34.3%). The lack of statistically significant differences between two groups in tested virulence factors suggests that individual susceptibility of the host might play more determining role in the disease outcome than characteristics of the infecting strain.
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Affiliation(s)
- Beata Wysok
- Department of Veterinary Public Health, Faculty of Veterinary Medicine, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Joanna Wojtacka
- Department of Veterinary Public Health, Faculty of Veterinary Medicine, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland
| | - Marja-Liisa Hänninen
- Department of Food Hygiene and Environmental Health, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
| | - Rauni Kivistö
- Department of Food Hygiene and Environmental Health, Faculty of Veterinary Medicine, University of Helsinki, Helsinki, Finland
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12
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A One Health approach to prevention, treatment, and control of campylobacteriosis. Curr Opin Infect Dis 2020; 32:453-460. [PMID: 31305492 DOI: 10.1097/qco.0000000000000570] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW To review recent findings regarding the control and treatment of campylobacteriosis. RECENT FINDINGS The application of improved diagnostics has led to an upward shift in the attributable burden of Campylobacter infections, in both the United States and Europe as well as in resource-poor settings. Increased focus has brought a fundamental feature of campylobacteriosis -- the ability to cause relapsing disease back into focus, and expanding data on antimicrobial resistance has lead from a switch in first-line therapy for severe diarrhea from quinolones to azithromycin in most contexts, even as evidence of expanding macrolide resistance emerges. SUMMARY Campylobacter spp. infection is a common infection worldwide. Antibiotic-resistant Campylobacter spp. has become an emerging threat with the increase in industrial poultry production, as well as the broad use of antibiotics in both animals and humans.
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Frost I, Van Boeckel TP, Pires J, Craig J, Laxminarayan R. Global geographic trends in antimicrobial resistance: the role of international travel. J Travel Med 2019; 26:5496989. [PMID: 31115466 DOI: 10.1093/jtm/taz036] [Citation(s) in RCA: 147] [Impact Index Per Article: 29.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 05/03/2019] [Accepted: 05/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Rising antimicrobial resistance (AMR) is a threat to modern medicine, and increasing international mobility facilitates the spread of AMR. Infections with resistant organisms have higher morbidity and mortality, are costlier to treat, result in longer hospital stays and place a greater burden on health systems than infections caused by susceptible organisms. Here we review the role of travel in the international dissemination of AMR and consider actions at the levels of travelers, travel medicine practitioners and policymakers that would mitigate this threat. RESULTS Resistant pathogens do not recognize international borders; travelers to areas with high AMR prevalence are likely to be exposed to resistant bacteria and return to their home countries colonized. Medical tourists go between health facilities with drastically different rates of AMR, potentially transmitting highly resistant strains.Drug-resistant bacteria have been found in every continent; however, differences between countries in the prevalence of AMR depend on multiple factors. These include levels of antibiotic consumption (including inappropriate use), access to clean water, adequate sanitation, vaccination coverage, the availability of quality healthcare and access to high-quality medical products. CONCLUSIONS Travelers to areas with high levels of AMR should have vaccines up to date, be aware of ways of treating and preventing travelers' diarrhea (other than antibiotic use) and be informed on safe sexual practices. The healthcare systems of low- and middle-income countries require investment to reduce the transmission of resistant strains by improving access to clean water, sanitation facilities and vaccines. Efforts are needed to curb inappropriate antibiotic use worldwide. In addition, more surveillance is needed to understand the role of the movement of humans, livestock and food products in resistance transmission. The travel medicine community has a key role to play in advocating for the recognition of AMR as a priority on the international health agenda. KEY POLICY RECOMMENDATIONS AMR is a threat to modern medicine, and international travel plays a key role in the spread of highly resistant strains. It is essential that this is addressed at multiple levels. Individual travelers can reduce antibiotic consumption and the likelihood of infection. Travelers should have up-to-date vaccines and be informed on methods of preventing and treating travelers' diarrhea, other than use of antibiotics and on safe sexual practices, such as condom use. Healthcare facilities need to be aware of the travel history of patients to provide appropriate treatment to those who are at high risk of exposure and to prevent further spread. Internationally, in countries without reliable and universal access to clean water, sanitation and hygiene, investment is needed to reduce the emergence and spread of resistance and ensure the antimicrobials available are of assured quality. High-income countries must ensure their use of antimicrobials is appropriate to reduce selection for AMR. Surveillance across all countries is needed to monitor and respond to this emerging threat.
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Affiliation(s)
- Isabel Frost
- Center for Disease Dynamics, Economics & Policy, New Delhi, India.,Amity Institute of Public Health, Amity University, Noida, India
| | - Thomas P Van Boeckel
- Center for Disease Dynamics, Economics & Policy, New Delhi, India.,Swiss Federal Institute of Technology Zurich, Department of Earth Systems Science, Institute for Integrative Biology, ETH Zurich, Zurich, Switzerland
| | - João Pires
- Swiss Federal Institute of Technology Zurich, Department of Earth Systems Science, Institute for Integrative Biology, ETH Zurich, Zurich, Switzerland
| | - Jessica Craig
- Center for Disease Dynamics, Economics & Policy, New Delhi, India
| | - Ramanan Laxminarayan
- Center for Disease Dynamics, Economics & Policy, New Delhi, India.,Princeton Environmental Institute, Princeton University, New Jersey, USA
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Eckbo EJ, Yansouni CP, Pernica JM, Goldfarb DM. New Tools to Test Stool: Managing Travelers' Diarrhea in the Era of Molecular Diagnostics. Infect Dis Clin North Am 2019; 33:197-212. [PMID: 30712762 DOI: 10.1016/j.idc.2018.10.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Travelers' diarrhea affects up to 60% of visitors to tropical and subtropical regions. Although symptoms are generally self-limited, some infections are associated with significant morbidity and occasional mortality. Newer molecular diagnostic techniques allow for highly sensitive, specific, and expeditious testing of a wide range of potential pathogens. Identification of the causative pathogen of travelers' diarrhea allows for targeted therapy and management and a reduction in empiric broad-spectrum coverage.
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Affiliation(s)
- Eric J Eckbo
- Department of Pathology and Laboratory Medicine, Division of Medical Microbiology, University of British Columbia, Vancouver General Hospital, 899 West 12th Avenue, Vancouver, British Columbia V5Z 1M9, Canada
| | - Cédric P Yansouni
- J.D. MacLean Centre for Tropical Diseases, McGill University Health Centre, 1001 Boulevard Decarie, Montreal, Quebec H4A 3J1, Canada
| | - Jeffrey M Pernica
- Department of Pediatrics, Division of Infectious Diseases, McMaster University, Hamilton Health Sciences Centre, 1280 Main Street West, Hamilton, Ontario L8S 4K1, Canada
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, Division of Medical Microbiology, University of British Columbia, Vancouver, British Columbia, Canada; Department of Pediatrics, Division of Infectious Diseases, University of British Columbia, Vancouver, British Columbia, Canada.
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Bodhidatta L, Anuras S, Sornsakrin S, Suksawad U, Serichantalergs O, Srijan A, Sethabutr O, Mason CJ. Epidemiology and etiology of Traveler's diarrhea in Bangkok, Thailand, a case-control study. TROPICAL DISEASES TRAVEL MEDICINE AND VACCINES 2019; 5:9. [PMID: 31183159 PMCID: PMC6555966 DOI: 10.1186/s40794-019-0085-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 05/09/2019] [Indexed: 11/24/2022]
Abstract
Background Traveler’s diarrhea (TD) is a common health problem among visitors from developed to developing countries. Although global and regional estimates of pathogen distribution are available, the etiology of diarrhea among non-military travelers to Thailand is largely unknown. Methods A prospective TD case-control study was conducted among adult travelers from developed countries at a prominent hospital in Bangkok, Thailand during 2001–2003. Stool samples were collected from acute TD cases and non-diarrheal controls and analyzed for bacterial, viral, and protozoan pathogens by microbiology, ELISA or PCR methods. Calculation of adjusted odd ratios for risk factors was performed by logistic regression using STATA statistical software. Results Stool samples were collected and analyzed from 389 TD cases and 400 non-diarrhea controls. At least one pathogen was detected in 227 (58%) cases and 124 (31%) controls. Plesiomonas (14%), Vibrio (14%), Campylobacter (14%), and norovirus (12%) were the most frequently isolated pathogens among cases and significantly associated with diarrhea at p = 0.006, p < 0.001, p < 0.001, p < 0.001, respectively. Shigella (3%) and ETEC (8%), detected in lower prevalence, also showed significant association with TD at p < 0.001 and p = 0.002, respectively. Travelers from East Asian countries had an increased risk of Vibrio infection (Crude odds ratio: 3.1, p-value = 0.001); travelers from the United States, Canada, and Europe had an increased risk of Campylobacter infection (Crude odds ratio: 2.6, p-value = 0.001); and travelers from Australia and New Zealand had an increased risk of Salmonella infection (Crude odds ratio: 3.2, p-value = 0.009). Conclusions Etiology of TD in Thailand is mainly of bacterial origin. Plesiomonas, Vibrio, and norovirus are underappreciated diarrheagenic pathogens. In our study, the origin of the traveler plays an important role in diarrhea etiology. Understanding variations in TD severity and etiology among travelers from different regions warrants further study. Electronic supplementary material The online version of this article (10.1186/s40794-019-0085-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ladaporn Bodhidatta
- 1Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, 10400 Thailand
| | - Sinn Anuras
- 2Bumrungrad International Hospital, Bangkok, 10110 Thailand
| | - Siriporn Sornsakrin
- 1Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, 10400 Thailand
| | - Umaporn Suksawad
- 1Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, 10400 Thailand
| | - Oralak Serichantalergs
- 1Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, 10400 Thailand
| | - Apichai Srijan
- 1Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, 10400 Thailand
| | - Orntipa Sethabutr
- 1Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, 10400 Thailand
| | - Carl J Mason
- 1Department of Enteric Diseases, Armed Forces Research Institute of Medical Sciences (AFRIMS), Bangkok, 10400 Thailand.,3Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD 20817 USA
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Schiaffino F, Colston JM, Paredes-Olortegui M, François R, Pisanic N, Burga R, Peñataro-Yori P, Kosek MN. Antibiotic Resistance of Campylobacter Species in a Pediatric Cohort Study. Antimicrob Agents Chemother 2019; 63:e01911-18. [PMID: 30420482 PMCID: PMC6355604 DOI: 10.1128/aac.01911-18] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 11/06/2018] [Indexed: 12/22/2022] Open
Abstract
The objective of this study was to determine the phenotypic patterns of antibiotic resistance and the epidemiology of drug-resistant Campylobacter spp. from a low-resource setting. A birth cohort of 303 patients was followed until 5 years of age. Stool samples from asymptomatic children (n = 10,008) and those with diarrhea (n = 3,175) were cultured for Campylobacter Disk diffusion for ciprofloxacin (CIP), nalidixic acid (NAL), erythromycin (ERY), azithromycin (AZM), tetracycline (TE), gentamicin (GM), ampicillin (AMP), amoxicillin and clavulanic acid (AMC), ceftriaxone (CRO), chloramphenicol (C), and trimethoprim-sulfamethoxazole (TMS) was determined. Antibiotic resistances in Campylobacter jejuni and non-C. jejuni isolates from surveillance and diarrhea samples were compared, and the association between personal macrolide exposure and subsequent occurrence of a macrolide-resistant Campylobacter spp. was assessed. Of 917 Campylobacter isolates, 77.4% of C. jejuni isolates and 79.8% of non-C. jejuni isolates were resistant to ciprofloxacin, while 4.9% of C. jejuni isolates and 24.8% of non-C. jejuni isolates were not susceptible to azithromycin. Of the 303 children, 33.1% had been diagnosed with a Campylobacter strain nonsusceptible to both azithromycin and ciprofloxacin. Personal macrolide exposure did not affect the risk of macrolide-resistant Campylobacter Amoxicillin and clavulanic acid (94.0%) was one of the antibiotics with the highest rates of susceptibility. There is a high incidence of quinolone- and macrolide-resistant Campylobacter infections in infants under 24 months of age. Given the lack of association between personal exposure to macrolides and a subsequent Campylobacter infection resistant to macrolides, there is a need to evaluate the source of multidrug-resistant (MDR) Campylobacter This study provides compelling evidence to propose amoxicillin/clavulanic acid as a treatment for campylobacteriosis.
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Affiliation(s)
- Francesca Schiaffino
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Faculty of Science and Philosophy, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Josh M Colston
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | | | - Ruthly François
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nora Pisanic
- Department of Environmental Health and Engineering, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rosa Burga
- U.S. Naval Medical Research Unit 6 (NAMRU-6), Iquitos, Loreto, Peru
| | - Pablo Peñataro-Yori
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Asociación Benéfica Prisma, Iquitos, Loreto, Peru
| | - Margaret N Kosek
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Asociación Benéfica Prisma, Iquitos, Loreto, Peru
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Diptyanusa A, Ngamprasertchai T, Piyaphanee W. A review of antibiotic prophylaxis for traveler's diarrhea: past to present. TROPICAL DISEASES TRAVEL MEDICINE AND VACCINES 2018; 4:14. [PMID: 30455974 PMCID: PMC6223076 DOI: 10.1186/s40794-018-0074-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 10/22/2018] [Indexed: 01/17/2023]
Abstract
As there is rapid increase in international travel to tropical and subtropical countries, there will likely be more people exposed to diarrheal pathogens in these moderate to high risk areas and subsequent increased concern for traveler’s diarrhea. The disease may appear as a mild clinical syndrome, yet a more debilitating presentation can lead to itinerary changes and hospitalization. As bacterial etiologies are the most common causative agents of TD, the use of antibiotic prophylaxis to prevent TD has been reported among travelers for several years. The most common type of antibiotic used for TD has changed over 50 years, depending on many influencing factors. The use of antibiotic prophylaxis for TD prevention in travelers is still controversial, mainly because of difficulties balancing the risks and benefits. Many factors, such as emerging drug resistance, side effects, cost and risk behavior need to be considered. This article aims to review antibiotic prophylaxis from the 1950s to 2000s, to describe the trend and reasons for different antibiotic use in each decade. We conclude that prophylactic antibiotics should be restricted to some high-risk travelers or short-term critical trips.
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Affiliation(s)
- Ajib Diptyanusa
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400 Thailand
| | - Thundon Ngamprasertchai
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400 Thailand
| | - Watcharapong Piyaphanee
- Department of Clinical Tropical Medicine, Faculty of Tropical Medicine, Mahidol University, 420/6 Ratchawithi Road, Ratchathewi, Bangkok, 10400 Thailand
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Antibiotic resistance, molecular characterizations, and clinical manifestations of Campylobacteriosis at a military medical center in Hawaii from 2012-2016: a retrospective analysis. Sci Rep 2018; 8:11736. [PMID: 30082843 PMCID: PMC6078982 DOI: 10.1038/s41598-018-29461-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 06/28/2018] [Indexed: 01/20/2023] Open
Abstract
Hawaii has one of the highest incidences of Campylobacteriosis in the United States, but there remains little published data on circulating strains or antimicrobial resistance. We characterized 110 clinical Campylobacter isolates (106 C. jejuni, 4 C. coli) processed at Tripler Army Medical Center in Honolulu, HI from 2012–2016. Twenty-five percent of C. jejuni isolates exhibited fluoroquinolone (FQ) resistance, compared with 16% for tetracycline (TET), and 0% for macrolides. Two of the four C. coli isolates were resistant to FQ, TET, and macrolides. C. jejuni isolates further underwent multilocus sequence typing, pulsed-field gel electrophoresis, and molecular capsular typing. Nineteen capsule types were observed, with two capsule types (HS2 and HS9) being associated with FQ resistance (p < 0.001 and p = 0.006, respectively). HS2 FQ-resistant isolates associated with clonal complex 21, possibly indicating clonal spread in FQ resistance. Macrolides should be considered for treatment of suspect cases due to lack of observed resistance.
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