Waterborne Campylobacter jejuni epidemic in a Finnish hospital for rheumatic diseases

Aetiology, source and prevention of waterborne healthcare-associated infections: a review

The purpose of this review is to discuss the scientific literature on waterborne healthcare-associated infections (HCAIs) published from 1990 to 2012. The review focuses on aquatic bacteria and describes both outbreaks and single cases in relation to patient characteristics, the settings and contaminated sources. An overview of diagnostic methods and environmental investigations is summarized in order to provide guidance for future case investigations. Lastly, on the basis of the prevention and control measures adopted, information and recommendations are given. A total of 125 reports were included, 41 describing hospitalized children. All cases were sustained by opportunistic pathogens, mainly Legionellaceae, Pseudomonadaceae and Burkholderiaceae. Hot-water distribution systems were the primary source of legionnaires’ disease, bottled water was mainly colonized by Pseudomonaceae, and Burkholderiaceae were the leading cause of distilled and sterile water contamination. The intensive care unit was the most frequently involved setting, but patient characteristics were the main risk factor, independent of the ward. As it is difficult to avoid water contamination by microbes and disinfection treatments may be insufficient to control the risk of infection, a proactive preventive plan should be put in place. Nursing staff should pay special attention to children and immunosuppressed patients in terms of tap-water exposure and also their personal hygiene, and should regularly use sterile water for rinsing/cleaning devices.

Pentavalent single-domain antibodies reduce Campylobacter jejuni motility and colonization in chickens

Campylobacter jejuni is the leading cause of bacterial foodborne illness in the world, with symptoms ranging from acute diarrhea to severe neurological disorders. Contaminated poultry meat is a major source of C. jejuni infection, and therefore, strategies to reduce this organism in poultry, are expected to reduce the incidence of Campylobacter-associated diseases. We have investigated whether oral administration of C. jejuni-specific single-domain antibodies would reduce bacterial colonization levels in chickens. Llama single-domain antibodies specific for C. jejuni were isolated from a phage display library generated from the heavy chain IgG variable domain repertoire of a llama immunized with C. jejuni flagella. Two flagella-specific single-domain antibodies were pentamerized to yield high avidity antibodies capable of multivalent binding to the target antigen. When administered orally to C. jejuni-infected two-day old chicks, the pentabodies significantly reduced C. jejuni colonization in the ceca. In vitro, the motility of the bacteria was also reduced in the presence of the flagella-specific pentabodies, suggesting the mechanism of action is through either direct interference with flagellar motility or antibody-mediated aggregation. Fluorescent microscopy and Western blot analyses revealed specific binding of the anti-flagella pentabodies to the C. jejuni flagellin.

The occurrence and prevention of foodborne disease in vulnerable people

In developed countries, such as the United Kingdom and the United States, between 15% and 20% of the population show greater susceptibility than the general population to foodborne disease. This proportion includes people with primary immunodeficiency, patients treated with radiation or with immunosuppressive drugs for cancer and diseases of the immune system, those with acquired immune-deficiency syndrome and diabetics, people suffering from liver or kidney disease or with excessive iron in the blood, pregnant women, infants, and the elderly. Malnutrition and use of antacids, particularly proton-pump inhibitors, also increase susceptibility. We review the occurrence of infection by foodborne pathogens in these groups of people and measures to prevent infection. The nature and use of low microbial diets to reduce the risk of foodborne disease in immunocompromised patients are very variable. Diets for vulnerable people in care should exclude higher-risk foods, and vulnerable people in the community should receive clear advice about food safety, in particular avoidance of higher-risk foods and substitution of safer, nutritious foods.

Published case studies of waterborne disease outbreaks--evidence of a recurrent threat

Residents of affluent nations are remarkably lucky to have high-quality, safe drinking water supplies that most residents of modem cities enjoy, particularly when considered in contrast to the toll of death and misery that unsafe drinking water causes for most of the world's population. Some may presume that drinking-water disease outbreaks are a thing of the past, but complacency can easily arise. A review of drinking water outbreaks in developed countries over the past 3 decades reveals some of the reasons why drinking water outbreaks keep occurring when society clearly has the means to prevent them. Prevention of future outbreaks does not demand perfection, only a commitment to learn from past mistakes and to act on what has been learned.

Myopericarditis in a patient with Campylobacter enteritis: a case report and literature review

Myocarditis sometimes occurs as a complication of bacterial infection, including enteric infections caused by Salmonella, Shigella and Yersinia. Only a few cases of Campylobacter-associated myocarditis are known. We describe a 47-y-old patient with myopericarditis in association with Campylobacter spp. enteritis, and review similar cases previously described in the English literature.

Hospital water point-of-use filtration: a complementary strategy to reduce the risk of nosocomial infection

Cholera, hepatitis and typhoid are well-recognized water-borne illnesses that take the lives of many every year in areas of uncontrollable flood, but far less attention is afforded to the allegedly safe potable water in affluent nations and the presumed healthful quality of water in communities and hospitals. Recent literature, however, points to increasing awareness of serious clinical sequelae particularly experienced by immunocompromised patients at high risk for disease and death from exposure to water-borne microbes in hospitals. This review reflects the literature indicting hospital water as an important source for nosocomial infections, examines patient populations at greatest risk, uncovers examples of failures in remedial water treatment methods and the reasons for them, and introduces point-of-use water filtration as a practical alternative or complementary component of an infection control strategy that may reduce the risk of nosocomial infections.

An outbreak of campylobacteriosis amongst directing staff and students at the Infantry Training Centre, Brecon, Wales, March 2004

A cohort study was undertaken to determine the source of an outbreak of gastrointestinal illness affecting a number of military personnel at ITC, Brecon during the period 19--30 March 2004. Of 105 soldiers on a field training exercise over the period 15--19 March 2004, 36 subsequently developed symptoms. Nine patients had Campylobacter sp identified in their stool. Water was provided from a single source. This water was used for washing, shaving, drinking and the preparation of rations. Although not statistically significant, epidemiological investigation suggests that the water may have been the vehicle of infection.

An outbreak of gastroenteritis from a non-chlorinated community water supply

STUDY OBJECTIVE

To determine the source and the extent of a community wide outbreak of gastroenteritis.

DESIGN

A matched case-control study with postal questionnaires. Subtyping of campylobacter strains by pulsed field gel electrophoresis (PFGE).

SETTING

A rural municipality with a population of 8600 in southern Finland, August 2000. Two thirds of the population receive non-chlorinated ground water from the municipal water supply.

PARTICIPANTS

Cases were randomly selected among residents of the municipality who contacted the municipal health centre because of gastroenteritis and had illness onset between 31 July and 20 August 2000. Community controls were identified from the population registry and matched according to sex, year of birth, and postal code.

MAIN RESULTS

Four hundred and sixty three persons contacted the municipal health centre because of gastroenteritis. Campylobacter jejuni was isolated from stool samples of 24 persons. One hundred and thirty seven cases and 388 controls were enrolled in the case-control study. In multivariate analysis, drinking unboiled water from the municipal supply was significantly associated with illness (odds ratio 11.1, 95% confidence interval 1.4 to 90.2). C jejuni was isolated from one tap water sample. The water isolate and all but one of the patient isolates were indistinguishable by PFGE.

CONCLUSIONS

Combining epidemiological investigation with molecular subtyping methods provided strong evidence that water was the source of the outbreak. Non-chlorinated small ground water systems may be susceptible to waterborne outbreaks and constitute a risk to rural populations.

Detection and typing of Campylobacter jejuni and Campylobacter coli and analysis of indicator organisms in three waterborne outbreaks in Finland

Waterborne outbreaks associated with contamination of drinking water by Campylobacter jejuni are rather common in the Nordic countries Sweden, Norway, and Finland, where in sparsely populated districts groundwater is commonly used without disinfection. Campylobacters, Escherichia coli, or other coliforms have rarely been detected in potential sources. We studied three waterborne outbreaks in Finland caused by C. jejuni and used sample volumes of 4,000 to 20,000 ml for analysis of campylobacters and sample volumes of 1 to 5,000 ml for analysis of coliforms and E. coli, depending on the sampling site. Multiple samples obtained from possible sources (water distribution systems and environmental water sources) and the use of large sample volumes (several liters) increased the chance of detecting the pathogen C. jejuni in water. Filtration of a large volume (1,000 to 2,000 ml) also increased the rate of detection of coliforms and E. coli. To confirm the association between drinking water contamination and illness, a combination of Penner serotyping and pulsed-field gel electrophoresis (digestion with SmaI and KpnI) was found to be useful. This combination reliably verified similarity or dissimilarity of C. jejuni isolates from patient samples, from drinking water, and from other environmental sources, thus confirming the likely reservoir of an outbreak.

Campylobacter jejuni Infections: update on emerging issues and trends

Infection with Campylobacter jejuni is one of the most common causes of gastroenteritis worldwide; it occurs more frequently than do infections caused by Salmonella species, Shigella species, or Escherichia coli O157:H7. In developed countries, the incidence of Campylobacter jejuni infections peaks during infancy and again during early adulthood. Most infections are acquired by the consumption and handling of poultry. A typical case is characterized by diarrhea, fever, and abdominal cramps. Obtaining cultures of the organism from stool samples remains the best way to diagnose this infection. An alarming recent trend is the rapid emergence of antimicrobial agent--resistant Campylobacter strains all over the world. Use of antibiotics in animals used for food has accelerated this trend. It is fortunate that complications of C. jejuni infections are rare, and most patients do not require antibiotics. Guillain-Barré syndrome is now recognized as a post-infectious complication of C. jejuni infection, but its incidence is <1 per 1000 infections. Careful food preparation and cooking practices may prevent some Campylobacter infections.

Effect of low-osmolality nutrient media on growth and culturability of Campylobacter species

The growth and culturability of Campylobacter jejuni NCTC 11351 and other campylobacters were examined in media having different osmolalities at a range of temperatures (4, 25, and 42 degreesC). The medium osmolalities used ranged from the osmolality of full-strength nutrient medium (modified campylobacter broth having an osmolality of around 254 mosmol) down to 96 mosmol. The following two methods were used to produce media having different osmolalities: dilution of the nutrient medium with distilled water and reformulation of the medium such that the concentrations of various osmolytes were altered while the nutrient content of the medium was unchanged. The results obtained with the two experimental methods were similar, indicating that there was an osmotic threshold effect, such that none of the campylobacters examined (C. jejuni NCTC 11351 and ATCC 33291, Campylobacter lari, and Campylobacter coli) grew in media having osmolalities around 130 mosmol and at temperatures below at 42 degreesC. Conversely, growth occurred in media having osmolalities of around 175 mosmol and above. Osmolar concentrations can be expressed in terms of osmolarity or osmolality. Osmolality is easier to evaluate, is the more commonly used term, and was used in the current study. In nutrient media having low osmolalities (i.e., 130 mosmol and below), the number of CFUs per milliliter declined rapidly regardless of the temperature, and no cells were recovered after 24 h. However, at nongrowth temperatures (25 and 4 degreesC) in higher-osmolality media (175 mosmol and above) a significant population was recovered throughout the experiment (up to 96 h). In low-osmolality nutrient media, the cellular morphology was principally coccoid, while in the early stages of growth in full-strength media the morphology was predominantly rodlike. We propose that the formation of coccoid cells in these experiments was the result of osmotic stress in low-osmolality media. This osmotic effect was apparent regardless of the osmolyte used to reformulate the medium (NaCl, KCl, Na2SO4, NH4Cl, and glucose were used).

Water as a reservoir for Campylobacter jejuni infection in cows studied by serotyping and pulsed-field gel electrophoresis (PFGE)

The occurrence of campylobacters was studied in the faecal samples of a dairy herd with about 20 animals and in the lake which was their source of drinking water during the grazing period from June to September. Of the total of 141 faecal samples studied, 0-21% were found to be positive for C. jejuni at various sampling times throughout the year. More cows were found to be campylobacter-positive in summer or in autumn after the grazing period than after the winter, when the animals were inside and their drinking water source was municipal chlorinated tap water. C. jejuni was isolated from most of the lake water samples. Serotyping with heat stable antigens and molecular typing with PFGE using SacII- and SmaI-digested DNA revealed that an animal that was permanently infected with C. jejuni sero-/PFGE-type PEN 0:6, 25/I/ND most probably contaminated the lake water in summer 1987. This was the only sero/PFGE-type isolated from the lake water in summer and autumn 1987 and in spring 1988. This sero/PFGE-type was also isolated from four other cows in autumn 1987, suggesting that lake water was the source of the infection. This study is first to employ molecular methods to assess the possible role of contaminated drinking water in the transmission of campylobacter infection within a dairy herd.

Survival of Escherichia coli and Campylobacter jejuni in untreated and filtered lake water

The survival of Campylobacter jejuni and Escherichia coli in lake water was studied using viable counts. Escherichia coli survived better than C. jejuni in all the test conditions studied. Both the species survived better in filtered than in untreated water. This suggests that predation and/or competition for nutrients affect the survival of both the species in an aquatic environment. Campylobacter jejuni survived less well in filtered autoclaved water and in 0.9% NaCl than in filtered water without autoclaving. The lack of some essential nutrients, which may be degraded by autoclaving, might explain these results.