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Candellone A, Badino P, Girolami F, Cerquetella M, Nebbia P, Aresu L, Zoppi S, Bergero D, Odore R. Concomitant Campylobacteriosis in a Puppy and in Its Caregiver: A One Health Perspective Paradigm in Human-Pet Relationship. Vet Sci 2023; 10:vetsci10040244. [PMID: 37104398 PMCID: PMC10146306 DOI: 10.3390/vetsci10040244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 03/21/2023] [Accepted: 03/23/2023] [Indexed: 04/28/2023] Open
Abstract
We report a case of laboratory-confirmed Campylobacter (C). jejuni and C. upsaliensis symptomatic infection in a puppy, a French Bouledogue, female, 6 months of age, fed a raw, unbalanced, poultry-based diet (RPD), (48.1 CP, 33% EE, 0.3% Ca, 0.5% Phos, 0.5 Ca/P, on a dry-matter basis), and in its owner. Soon after adoption, the pet and the caregiver showed severe gastrointestinal signs and needed hospitalization. Fecal PCR assays, selective cultures, and antibiotic susceptibility testing were performed, and multi-drug resistant C. jejuni and C. upsaliensis were isolated from the feces of both. The same bacteria were also identified by FISH in the dog colonic biopsies collected during endoscopy. The puppy was prescribed a complete commercial diet for growing dogs, (30.00% CP, 21.00% EE, 1.2% Ca; 1% Phos; as fed) and treated with ciprofloxacin. The dog and the man healed uneventfully and tested negative for further fecal PCR analyses. This report focuses on dog nutritional management and explores the potential routes of exposure, with emphasis on emerging outbreaks related to current pet food fads. Our data support the One Health approach, where veterinarians, physicians, and owners are challenged to build effective stewardship to prevent the spread of zoonoses.
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Affiliation(s)
- Alessia Candellone
- Department of Veterinary Sciences, University of Turin, 10095 Grugliasco, Italy
- NutriTO Vet srl., 10090 Rosta, Italy
| | - Paola Badino
- Department of Veterinary Sciences, University of Turin, 10095 Grugliasco, Italy
| | - Flavia Girolami
- Department of Veterinary Sciences, University of Turin, 10095 Grugliasco, Italy
| | - Matteo Cerquetella
- School of Biosciences and Veterinary Medicine, University of Camerino, 62032 Camerino, Italy
| | - Patrizia Nebbia
- Department of Veterinary Sciences, University of Turin, 10095 Grugliasco, Italy
| | - Luca Aresu
- Department of Veterinary Sciences, University of Turin, 10095 Grugliasco, Italy
| | - Simona Zoppi
- Istituto Zooprofilattico Sperimentale del Piemonte, Liguria e Valle d'Aosta, 10154 Turin, Italy
| | - Domenico Bergero
- Department of Veterinary Sciences, University of Turin, 10095 Grugliasco, Italy
| | - Rosangela Odore
- Department of Veterinary Sciences, University of Turin, 10095 Grugliasco, Italy
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Murawska M, Sypecka M, Bartosik J, Kwiecień E, Rzewuska M, Sałamaszyńska-Guz A. Should We Consider Them as a Threat? Antimicrobial Resistance, Virulence Potential and Genetic Diversity of Campylobacter spp. Isolated from Varsovian Dogs. Antibiotics (Basel) 2022; 11:antibiotics11070964. [PMID: 35884218 PMCID: PMC9311969 DOI: 10.3390/antibiotics11070964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 12/10/2022] Open
Abstract
Campylobacteriosis seems to be a growing problem worldwide. Apart from the most common sources of numerous Campylobacter species, such as poultry and other farm animals, dogs may be an underrated reservoir of this pathogen. Our goal was to establish the frequency of occurrence, antimicrobial resistance, and detection of chosen virulence factor genes in genomes of canine Campylobacter isolates. Campylobacter isolates frequency in dogs from shelters, and private origin was 13%. All of the tested virulence factor genes were found in 28 of 31 isolates. We determined high resistance levels to the ciprofloxacin and ampicillin and moderate tetracycline resistance. For C. jejuni shelter isolates, genetic diversity was also determined using PFGE. Our results indicate that dogs may be the reservoir of potentially diverse, potentially virulent, and antimicrobial-resistant Campylobacter strains.
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Affiliation(s)
- Małgorzata Murawska
- Division of Microbiology, Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Ciszewskiego 8, 02-786 Warsaw, Poland; (E.K.); (M.R.)
- Correspondence: (M.M.); (A.S.-G.)
| | - Monika Sypecka
- Translational Platform for Regenerative Medicine, Mossakowski Medical Research Institute, Polish Academy of Sciences, Pawińskiego 5, 02-106 Warsaw, Poland;
| | - Justyna Bartosik
- Division of Parasitology and Invasive Diseases, Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Ciszewskiego 8, 02-786 Warsaw, Poland;
| | - Ewelina Kwiecień
- Division of Microbiology, Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Ciszewskiego 8, 02-786 Warsaw, Poland; (E.K.); (M.R.)
| | - Magdalena Rzewuska
- Division of Microbiology, Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Ciszewskiego 8, 02-786 Warsaw, Poland; (E.K.); (M.R.)
| | - Agnieszka Sałamaszyńska-Guz
- Division of Microbiology, Department of Preclinical Sciences, Institute of Veterinary Medicine, Warsaw University of Life Sciences, Ciszewskiego 8, 02-786 Warsaw, Poland; (E.K.); (M.R.)
- Correspondence: (M.M.); (A.S.-G.)
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Igwaran A, I. Okoh A. Campylobacteriosis Agents in Meat Carcasses Collected from Two District Municipalities in the Eastern Cape Province, South Africa. Foods 2020; 9:E203. [PMID: 32079101 PMCID: PMC7074574 DOI: 10.3390/foods9020203] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Revised: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 01/12/2023] Open
Abstract
Raw meats are sometimes contaminated with Campylobacter species from animal faeces, and meats have repeatedly been implicated in foodborne infections. This study evaluated the prevalence, virulence genes, antimicrobial susceptibility patterns, and resistance gene determinants in Campylobacter species isolated from retailed meat carcasses. A total of 248 raw meat samples were collected from butcheries, supermarkets, and open markets; processed for enrichment in Bolton broth; and incubated at 42 °C for 48 h in 10% CO2. Thereafter, the broths were streaked on modified charcoal cefoperazone deoxycholate agar (mCCDA) plates and incubated at the same conditions and for the same amount of time. After incubation, colonies were isolated and confirmed by Polymerase chain reaction using specific oligonucleotide sequences used for the identification of the genus Campylobacter, species, and their virulence markers. The patterns of antimicrobial resistance profiles of the identified isolates were studied by disk diffusion method against 12 antibiotics, and relevant resistance genes were assessed by PCR. From culture, 845 presumptive Campylobacter isolates were obtained, of which 240 (28.4%) were identified as genus Campylobacter. These were then characterised into four species, of which C. coli had the highest prevalence rate (22.08%), followed by C. jejuni (16.66%) and C. fetus (3.73%). The virulence genes detected included iam (43.14%), cadF (37.25%), cdtB (23.53%), flgR (18.63%), and flaA (1.96%), and some of the isolates co-harboured two to four virulence genes. Of the 12 antibiotics tested, the highest phenotypic resistance displayed by Campylobacter isolates was against clindamycin (100%), and the lowest level of resistance was observed against imipenem (23.33%). The frequency of resistance genes detected included catll (91.78%), tetA (68.82%), gyra (61.76%), ampC (55%), aac(3)-IIa (aacC2)a (40.98%), tetM (38.71%), ermB (18.29%), tetB (12.90%), and tetK (2.15%). There is a high incidence of Campylobacter species in meat carcasses, suggesting these to be a reservoir of campylobacteriosis agents in this community, and as such, consumption of undercooked meats in this community is a potential health risk to consumers.
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Affiliation(s)
- Aboi Igwaran
- SAMRC Microbial Water Quality Monitoring Centre, University of Fort Hare, Alice 5700, South Africa
- Applied and Environmental Microbiology Research Group (AEMREG), Department of Biochemistry and Microbiology, University of Fort Hare, Private Bag X1314, Alice 5700, South Africa
| | - Anthony I. Okoh
- SAMRC Microbial Water Quality Monitoring Centre, University of Fort Hare, Alice 5700, South Africa
- Applied and Environmental Microbiology Research Group (AEMREG), Department of Biochemistry and Microbiology, University of Fort Hare, Private Bag X1314, Alice 5700, South Africa
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Selwet M. The Prevalence of Virulence Genes and Multidrug Resistance in Thermophilic Campylobacter Spp. Isolated from Dogs. Open Life Sci 2019; 14:681-687. [PMID: 33817207 PMCID: PMC7874824 DOI: 10.1515/biol-2019-0077] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 12/16/2019] [Indexed: 11/25/2022] Open
Abstract
The aim of the study was to determine the role of dogs as a potential reservoir of Campylobacter spp. At the next stage of the research the frequency of occurrence of selected virulence genes, i.e. cadF, flaA and iam as well as genes responsible for the formation the cytolethal distending toxin (CDT), i.e. cdtA, cdtB and cdtC was determined. The isolates obtained in the research were tested for their resistance to selected antibiotics: ciprofloxacin (CIP), enrofloxacin (EF), erythromycin (E) and tetracycline (TE). Campylobacter spp. was found in 63 (12.6%) out of a total number of 500 isolates. 61 (12.2%) isolates were identified as C. jejuni. The number of C. jejuni isolates found in the younger animals was smaller (p <0.05) than in the older ones. The frequency of occurrence of virulence genes and the genes responsible for the formation of CDT was significantly (p <0.05) higher in the older dogs. A comparison of the effect of antibiotics showed that the isolates obtained from both age groups exhibited low resistance to erythrosine (13.5% in the group aged under 1 year and 8.6% in the group aged over 1 year). Both groups exhibited the highest resistance to ciprofloxacin and enrofloxacin.
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Affiliation(s)
- Marek Selwet
- Department of General and Environmental Microbiology, Poznań University of Life Sciences, ul. Szydłowska 28, 60-637 Poznań, Poland
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Lluque A, Riveros M, Prada A, Ochoa TJ, Ruiz J. Virulence and Antimicrobial Resistance in Campylobacter spp. from a Peruvian Pediatric Cohort. SCIENTIFICA 2017; 2017:7848926. [PMID: 29130018 PMCID: PMC5654289 DOI: 10.1155/2017/7848926] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/10/2017] [Accepted: 08/29/2017] [Indexed: 06/07/2023]
Abstract
The presence of virulence factors (VFs) and mechanisms of quinolones and macrolide resistance was analyzed in Campylobacter spp. from a pediatric cohort study in Lima. In 149 isolates (39 Campylobacter jejuni and 24 Campylobacter coli from diarrheic cases; 57 C. jejuni and 29 C. coli from controls), the presence of the cdtABC and cadF genes and iam marker was established. Nalidixic acid, ciprofloxacin, erythromycin, and azithromycin susceptibilities were established in 115 isolates and tetracycline-susceptibility was established in 100 isolates. The presence of mutations in the gyrA, parC, and 23S rRNA genes was determined. The cadF gene and all genes from the cdtABC operon were significantly more frequent among C. jejuni (P < 0.0001); the iam marker was more frequent in C. coli (P < 0.0001). No differences were observed in VFs between cases and controls. Almost all isolates were tetracycline-resistant; nalidixic acid and ciprofloxacin resistance reached levels of 90.4% and 88.7%, respectively. Resistance to macrolides was 13% (C. jejuni 4.3%; C. coli 26.1%). Resistance to ciprofloxacin was related to GyrA Thr86 substitutions, while 13 of 15 macrolide-resistant isolates possessed a 23S rRNA mutation (A2075G). Differences in the presence of VFs and alarming levels of resistance to tested antimicrobial agents were observed among C. jejuni and C. coli.
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Affiliation(s)
- Angela Lluque
- Instituto de Medicina Tropical, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Maribel Riveros
- Instituto de Medicina Tropical, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Ana Prada
- Instituto de Medicina Tropical, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Theresa J. Ochoa
- Instituto de Medicina Tropical, Universidad Peruana Cayetano Heredia, Lima, Peru
- Department of Epidemiology, School of Public Health, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Joaquim Ruiz
- ISGlobal, Barcelona Ctr. Int. Health Res. (CRESIB), Hospital Clínic, Universitat de Barcelona, Barcelona, Spain
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Denis M, Nagard B, Rose V, Bourgoin K, Cutimbo M, Kerouanton A. No Clear Differences between Organic or Conventional Pig Farms in the Genetic Diversity or Virulence of Campylobacter coli Isolates. Front Microbiol 2017; 8:1016. [PMID: 28694791 PMCID: PMC5483432 DOI: 10.3389/fmicb.2017.01016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Accepted: 05/22/2017] [Indexed: 12/11/2022] Open
Abstract
To evaluate the impact of pig farm management on the genetic diversity and on the virulence of Campylobacter coli, we characterized isolates from 19 organic pig farms (62 isolates) and from 24 conventional pig farms (58 isolates). The 120 C. coli isolates were typed using pulsed field gel electrophoresis (PFGE) and multilocus sequence typing (MLST) and the presence of nine virulence genes was screened using real-time PCR. The capacity of adhesion and invasion of 61 isolates (32 from organic and 29 from conventional farms) were then tested on human intestinal Caco-2 cells. A total of 59 PFGE types and of 50 sequence types (STs) were identified. Twelve PFGE types and nine STs, accounting for 34 and 41.6% of the isolates, respectively, were common between the two production systems with ST854 dominating (18.3% of the isolates). Twenty-nine PFGE types and 25 STs were only found in isolates from organic farms, and 18 PFGE types and 16 STs from conventional farms. No significant differences were found in diversity despite the differences in rearing systems, except at the locus level for the glnA, gltA, and uncA genes. All isolates, regardless of their origin, carried the ceuE, iam, ciaB, and flaA genes and more than 95% of the isolates carried the cadF and cdtABC genes. No significant differences were found in pathogenicity between the two farming systems. The pathogenicity of the C. coli isolates was low compared to C. jejuni control strains tested. The plasmid gene virb11 was detected in only 13 isolates from organic farms; these isolates showed greater invasion capacity than those without this gene. Our study indicates that pig farm management does not significantly affect the diversity and the virulence of Campylobacter coli isolated from pigs. The common genotypes between conventional and organic farms may indicate that some genotypes are adapted to pigs.
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Affiliation(s)
- Martine Denis
- ANSES, Hygiene and Quality of Poultry and Pig Products Unit, Bretagne-Loire UniversityPloufragan, France
| | - Bérengère Nagard
- ANSES, Hygiene and Quality of Poultry and Pig Products Unit, Bretagne-Loire UniversityPloufragan, France
| | - Valérie Rose
- ANSES, Hygiene and Quality of Poultry and Pig Products Unit, Bretagne-Loire UniversityPloufragan, France
| | - Kévin Bourgoin
- ANSES, Hygiene and Quality of Poultry and Pig Products Unit, Bretagne-Loire UniversityPloufragan, France
| | - Mélina Cutimbo
- ANSES, Hygiene and Quality of Poultry and Pig Products Unit, Bretagne-Loire UniversityPloufragan, France
| | - Annaëlle Kerouanton
- ANSES, Hygiene and Quality of Poultry and Pig Products Unit, Bretagne-Loire UniversityPloufragan, France
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Selwet M, Galbas M, Słomski R, Cłapa T, Porzucek F. Monitoring of Virulence Genes, Drug-Resistance in Campylobacter coli Isolated from Golden Retrievers. Pol J Microbiol 2016; 65:237-240. [DOI: 10.5604/17331331.1204486] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2015] [Indexed: 11/13/2022] Open
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Ghorbanalizadgan M, Bakhshi B, Kazemnejad Lili A, Najar-Peerayeh S, Nikmanesh B. A molecular survey of Campylobacter jejuni and Campylobacter coli virulence and diversity. IRANIAN BIOMEDICAL JOURNAL 2015; 18:158-64. [PMID: 24842142 PMCID: PMC4048480 DOI: 10.6091/ibj.1359.2014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background: The aim of this study was to determine the prevalence of virulence-associated genes and enterobacterial repetitive intergenic consensus PCR (ERIC-PCR) analysis of Campylobacter spp. isolated from children with diarrhea in Iran. Methods: A total of 200 stool specimens were obtained from children under 5 years during July 2012 to July 2013. Detection of C. jejuni and C. coli was performed by standard biochemical and molecular methods. The presence of virulence-associated genes and genetic diversity of isolates was examined using PCR and ERIC-PCR analyses. Results: A total of 12 (6%) Campylobacter spp. were isolated from patients including 10 (4.5%) C. jejuni and 2 (1.5%) C.coli. The flaA, cadF and ciaB genes were present in 100% of isolates, while no plasmid of virB11 gene was present in their genome. The prevalence of invasion-associated marker was 100% among C. coli and was not detected in C. jejuni isolates. The distribution of both pldA and the genes associated with cytolethal distending toxin (CDT) was 58.3% in C. jejuni isolates. Seven distinct ERIC-PCR profiles were distinguished in three clusters using ERIC-PCR analysis. Genotyping analysis showed a relative correlation with geographic location of patients and virulence gene content of isolates. Conclusion: To our knowledge, this is the first molecular survey of Campylobacter spp. in Iran concerning genotyping and virulence gene content of both C. jejuni and C. coli. ERIC-PCR revealed appropriate discriminatory power for clustering C. jejuni isolates with identical virulence gene content. However, more studies are needed to clearly understand the pathogenesis properties of specific genotypes.
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Affiliation(s)
- Mahdi Ghorbanalizadgan
- Dept. of Bacteriology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Bita Bakhshi
- Dept. of Bacteriology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | | | - Shahin Najar-Peerayeh
- Dept. of Bacteriology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Bahram Nikmanesh
- Children’s Hospital Medical Center, Tehran university of Medical Sciences, Tehran, Iran
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Prevalence of Campylobacter jejuni and Campylobacter coli species in cats and dogs from Bydgoszcz (Poland) region. Pol J Vet Sci 2013; 16:115-20. [PMID: 23691584 DOI: 10.2478/pjvs-2013-0016] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The aim of this study was to investigate the role of cats and dogs as a potential reservoir of Campylobacter spp. Rectal swabs from 83 dogs and 71 cats were examined. Samples were obtained from the animals aged between 2 weeks and 24 months living in shelters, private households, farms and from veterinary clinics located in Bydgoszcz region during routine check-up. Campylobacter spp. were isolated from 4.81% dogs and 9.86% cats, respectively. C. jejuni was predominant in this study. All strains were isolated in autumn and winter from the animals living in farms and private houses. All the animals positive for Campylobacter prevalence had access to small water basins, accidental source of food and had contact with wild birds, poultry or their feaces. Isolates characterization revealed high prevalence of Campylobacter virulence genes-flaA, cadF and cdtB. 91% of isolated strains were susceptible to erythromycin. 81% among isolated strains were susceptible to azithromycin, 64% to tetracycline and 36% to ciprofloxacin. For 2 C. jejuni strains isolated from cats Random Amplified Polymorphic DNA (RAPD) profiling indicated 80% homology between them.
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Quetz JDS, Lima IFN, Havt A, Prata MMG, Cavalcante PA, Medeiros PHQS, Cid DAC, Moraes ML, Rey LC, Soares AM, Mota RMS, Weigl BH, Guerrant RL, Lima AAM. Campylobacter jejuni infection and virulence-associated genes in children with moderate to severe diarrhoea admitted to emergency rooms in northeastern Brazil. J Med Microbiol 2011; 61:507-513. [PMID: 22174372 DOI: 10.1099/jmm.0.040600-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Campylobacter is an important cause of foodborne gastroenteritis. We determined the occurrence of Campylobacter jejuni and Campylobacter coli, using culture-based methods and PCRs targeting virulence-associated genes (VAGs) among children aged ≤14 years who were treated for diarrhoea at emergency rooms in northeastern Brazil. Genomic DNA was extracted directly from stool samples collected from 366 children. A questionnaire was also applied to qualify the clinical conditions presented by each child at the time of admission. C. jejuni and C. coli were detected in 16.4 % (60/366) and 1.4 % (5/366) of the diarrhoeal samples, respectively, by PCR, a much higher proportion than that detected by conventional methods. C. jejuni VAGs were detected in the following proportions of hipO-positive samples: ciaB, 95 % (57/60); dnaJ, 86.7 % (52/60); racR, 98.3 % (59/60); flaA, 80 % (48/60); pldA, 45 % (27/60); cdtABC, 95 % (57/60); and pVir 0 % (0/60). Particular symptoms, such as blood in faeces, vomiting, fever, and/or abdominal pain, were not associated with detection of C. jejuni nor were they associated with any particular VAG or combination of VAGs (P>0.05). C. jejuni and its VAGs were detected in a substantial proportion of the children admitted. Further efforts shall be directed towards elucidating whether these genetic factors or their expressed proteins play a role in Campylobacter pathogenesis.
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Affiliation(s)
- Josiane da S Quetz
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
| | - Ila F N Lima
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
| | - Alexandre Havt
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
| | - Mara M G Prata
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
| | - Paloma A Cavalcante
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
| | - Pedro H Q S Medeiros
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
| | - David A C Cid
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
| | - Milena L Moraes
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
| | - Luís Carlos Rey
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
| | - Alberto M Soares
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
| | - Rosa M S Mota
- Science Center/Unit of Statistics, Federal University of Ceara, Fortaleza, CE 60455-760, Brazil
| | - Bernhard H Weigl
- Program for Appropriate Technology in Health (PATH), Seattle, Washington, WA 98107, USA
| | - Richard L Guerrant
- Center for Global Health, University of Virginia, Charlottesville, VA 22908, USA
| | - Aldo A M Lima
- Institute of Biomedicine for Brazilian Semi-Arid/Clinical Research Unit, Federal University of Ceara, Fortaleza, CE 60430-270, Brazil
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