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Campylobacter

Infection caused by gram-negative , spiral-shaped microaerophobic bacteria of the family Campylobacteraceae ( CDC ) 
Campylobacteriosis is the disease caused by the infection with Campylobacter.

Campylobacter belong to a distinct group of specialized bacteria designated rRNA superfamily VI of class Proteobacteria Gram negative rods slender motile , non spore forming First isolated in 1906 from aborting sheep in UK Currently there are 17 species and 6 sub-species assigned to the genus Campylobacter C.jejuni ( 90 % ) and C.coli- most common bacterial cause of human gastroenteritis and are the most common cause of food-borne diarrhoea in many industrialized countries

How common –One of the most widespread infectious disease of the last century Responsible for a great majority of deaths in children due to diarrhoea in Sub-Saharan Africa Prevalence has increased in both developed and developing world in the last decade Campylobacter jejuni is a major cause of gastroenteritis worldwide Campylobacter is becoming more common in older men.

Transmission/ Incubation –Transmission- Oral route
Most cases sporadic and associated with- 
○ consuming raw or uncooked meat ( particularly poultry )
○ unpasteurized milk
○ untreated water
○ owning domestic pets with diarrhoea
○ drinking milk contaminated by birds ( occasionally )
○ Animal to human → close contact ↑es risk of infection
contact with animals particularly farm animals like cows and chickens , domestic cats and dogs
○ Human-to-human → may occur ( uncommon ) from infected individuals or from convalescent carriers – especially young children ( epidemics can happen in nurseries , paediatric wards )
it is Zoonosis → disease transmitted to humans from animals or animal products Incubation period- usually 3-4 day but can be up to 8 to 9 days Low infective dose ie as low as 500 organisms can cause illness for eg one drop of juice from raw chicken meat can cause infection C.jejuni account for majority of cases ( > 90 % ) 
All Campylobacter species can normally be present in the GI tract of domestic and wild animals and birds Peak incidence in summer months ( about 8 weeks earlier than salmonelliosis ) in industrialized countries the infection is often seasonal whereas in developing countries it does not show seasonability Bimodal age distribution -> greatest incidence in infants and young adults Infection generally mild but can be fatal in very young , old and immunocompromised.

Pathogenesis –Pathogenesis is not fully understood Can produce both inflammatory and non-inflammatory diarrhoea How it causes diarrhoea -> remains unclear but involves
○ attachment to intestinal mucosa
○ motility by means of flagella
 and other factors as 
○ iron acquisition ○ invasion of enterocytes ○ possible toxin production Immunity is acquired following one or more infection → duration is not known Antibodies –> serum and secretory antibodies to Campylobacter , flagella , enterotoxin , lipopolysaccharide and other surface antigens are produced
○ appear within 10 days
○ peak in 2-3 weeks the decline rapidly

Antibodies to OMP and LPS can cross react with myelin components –> can lead to Guillain-Barre or Miller Fisher syndromes
 Few cases ( for eg immunocompromised ) bacteria translocate from intestinal lumen –> bacteremia. 
○ severe dysentery like illness – inflammatory infiltrates into lamina propria and crypt abscesses in rectal , colonic and terminal ileum can be seen.

history-How long Blood in stools Recent fever Nausea and vomiting Food history ? chicken Milk – unpasteurized Water ? untreated Travel Close contact Immune status

Chicken is considered to be the most common source of infection.

Presentation-Illness may start with abdominal pain and diarrhoea Onset of symptoms usually happens 24-72 hours after ingestion and may take longer in those who have taken a low dose Prodromal -> 
○ influenza like fever generalized aching sometimes with rigors and sweats
○ 24 hrs before illness Main illness – profuse diarrhoea which is watery and may be bloody ( in 1/3rd cases )
○ nausea common but vomiting less pronounced
○ it is an inflammatory enteritis that is found initially in the small bowel but later affects the colon and the rectum
○ abdominal pain is intense
○ nausea is common but only about 15 %
○ fever , weight loss and cramps Usually self limiting 5-8 days ( average 6 days ) but may last longer occasionally Can be difficult to distinguish from salmonella or shigella
○ abdominal pain tends to be ↑↑ severe in Campylobacter
○ suspected appendicitis – usual reason for admission ( abdominal pain mimics appendicitis ) Illness usually less severe in developed countries Enterocolitis , toxic megacolon may occur in severe cases.

Assessment –Blood pressure Pulse Temperature CRT Abdominal examination Urine- dehydration Consider baseline bloods
○ FBC -leukocytosis ( neutrophilia ) Blood culture- febrile , young , immunocompromised.

Diagnosis -No gold standard or common method for the isolation of all Campylobacter species from clinical samples Diarrhoea stool specimen- isolation of bacteria
Sample should be collected before initiation of antibiotic therapy ( if used )
It should also be transported without significant delay as the organism is fastidious and a delay in transport will affect the viability of Campylobacter spp ( ideally within 2 hours ) if this is not possible check with the local microbiology unit about an appropriate transport medium Gram-stained smear or Microscopy Culture Serology- if present with reactive arthritis or GB syndrome.

management –Usually self limiting and no specific treatment required Reassure and provide written information

Admission –Vomiting , bloody diarrhoea or both ( tend to have a longer illness ) Shock or severe dehydration Overall condition worsening Pain in RLQ – suspected appendicitis Older age > 60 Diarrhoea > 10 days duration Comorbidities -
○ immunodeficiency
○ inflammatory bowel dis
○ valvular heart condition
○ diabetes
○ renal impairment
○ rheumatoid disease
○ SLE Serious complication suspected eg Gullain-Barre syndrome

Antibiotics-Antibiotics should be used in severe or complicated cases only It has been reported that there has been a worldwide increase in the incidence of both human and veterinary isolates of Campylobacter resistant to ciprofloxacin ( Campylobacter isolates resistant to fluoroquinolone ( FQ ) and tetracycline are highly prevalent in many countries Luangtongkum et al )
 macrolides -azithromycin are the current drugs of choice when antibiotic resistance is indicated ( CDC )
 Several reports mention rapid emergence of antibiotic resistance in particularly against fluoroquinolones as they have been used as growth promoters in food animals and the veterinary industry is accelerating Resistance against several strains of Campylobacter has been reported worldwide
 NICE document -Summary of antimicrobial prescribing guidance – managing common infections recommends that ‘ antibiotic therapy is not usually indicated unless patient is systemically unwell. If systemically unwell and Campylobacter suspected consider Clarithromycin 250 mg to 500 mg bd for 5 to 7 days , if treated early within 3 days ‘
 Consider microbiology advice if in doubt agent to use or indication related issues A study from Peru has shown low resistance for amoxicillin and clavulanic acid in children ( this has also been noted in earlier studies from Spain ) No vaccine is currently available.

Complications –Reactive arthritis
○ typically affects the ankles , knees and wrists
○ affects 1-2 % of patients
○ can be severe but self limiting Irritable bowel syndrome Guillain- Barre syndrome
○ peripheral polyneuropathy
○ can cause serious and potential paralysis Miller Fisher syndrome- a clinical variant of GBS Bactermia and septicaemia

Campylobacter is also known to be associated with various infections and conditions as

○ infections as septic thrombophlebitis , neonatal sepsis , pneumonia , blood stream infections
○ gastrointestinal conditions as inflammatory bowel disease , Barrett’s oesophagus and colorectal cancer , coeliac disease , cholecystitis
○ periodontal disease
○ cardiovascular conditions as endocarditis , myocarditis , pericarditis , myopericarditis , atrial fibrillation and aortitis with aortic dissection
 Death is rare ( in the developed world )
In a study of patients between 1989 and 2010 with Campylobacter only 82
 deaths ( 0.008 % ) were reported
This is also in line with the WHO description about the disease which says that death from Campylobacteriosis is rare and usually confined to very young children or elderly patients , or to those who have other comorbidities as AIDS

Patient information

ABHB Wales http://www.wales.nhs.uk/sitesplus/documents/866/PIU1036%283%29%28ABUHB%29%28Active%29%28OCT%2017%29.pdf

Government of Western Australiahttps://healthywa.wa.gov.au/Articles/A_E/Campylobacter-infection

Information from Food Safety Agency in the USA https://www.fsis.usda.gov/shared/PDF/Campylobacter_Questions_and_Answers.pdf

INFORMATION FOR CLINICIANS

A good read for primary care health professionals from Victoria State Government https://www2.health.vic.gov.au/public-health/infectious-diseases/disease-information-advice/campylobacter

 

 

References

  1. Campylobacter Fact sheet updated Dec 2016 WHO Media centre
  2. Campylobacter Centers for Disease Control and Prevention CDC 24/7 :Savings Lives , Protecting People
  3. Identification of Campylobacter species UK Standards for Microbiology Investigations Public Health England
  4. Case studies in infectious diseases Peter M Lydard et al Garland Publishing Inc March 2009
  5. Medical Microbiology Edited by David Greenwood et al Churchill Livingstone July 2012
  6. Infection Microbiology and Management Barbara A Bannister et al Wiley-Blackwell Dec 2009
  7. First Consult Campylobacter infections Alejandro Perez et al September 2011
  8. Diagnosis and Management of Foodborne Illness Am Fam Physician sep 1;92(5):358-365
  9. Manson’s Tropical Diseases – Jeremy Farrar, Patrick Manson Saunders Oct 2013
  10. The management of infective gastroenteritis in adults a consensus statement by an expert panel convened bt the British Society for the study of infection Journal of Infection November 1996 Volume 33,Issue 3, Pages 143-152
  11. Kaakoush, Nadeem O et al. “Global Epidemiology of Campylobacter Infection.” Clinical microbiology reviews vol. 28,3 (2015): 687-720. doi:10.1128/CMR.00006-15 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4462680/
  12. Nichols GLRichardson JFSheppard SK, et al
    Campylobacter epidemiology: a descriptive study reviewing 1 million cases in England and Wales between 1989 and 2011
  13. Igwaran, Aboi, and Anthony Ifeanyi Okoh. “Human campylobacteriosis: A public health concern of global importance.” Heliyon vol. 5,11 e02814. 14 Nov. 2019, doi:10.1016/j.heliyon.2019.e02814 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6861584/
  14. Travel-Related Infectious Diseases Centre for Disease Control and Prevention Chapter 4 https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/campylobacteriosis
  15. Carron M, Chang YM, Momanyi K, Akoko J, Kiiru J, et al. (2018) Campylobacter, a zoonotic pathogen of global importance: Prevalence and risk factors in the fast-evolving chicken meat system of Nairobi, Kenya. PLOS Neglected Tropical Diseases 12(8): e0006658. https://doi.org/10.1371/journal.pntd.0006658
  16. Evidence for Multiple-Antibiotic Resistance in Campylobacter jejuni Not Mediated by CmeB or CmeF Lilian PumbweLuke P. RandallMartin J. WoodwardLaura J. V. Piddock
  17. Antibiotic Resistance of Campylobacter Species in a Pediatric Cohort Study
    Francesca SchiaffinoJosh M. ColstonMaribel Paredes-OlorteguiRuthly FrançoisNora PisanicRosa BurgaPablo Peñataro-YoriMargaret N. Kosek 
  18. CDC Campylobacter antibiotic resistance via https://www.cdc.gov/campylobacter/campy-antibiotic-resistance.html
  19. Luangtongkum, Taradon et al. “Antibiotic resistance in Campylobacter: emergence, transmission and persistence.” Future microbiology vol. 4,2 (2009): 189-200. doi:10.2217/17460913.4.2.189
  20. Alfredson DA, Korolik V. Antibiotic resistance and resistance mechanisms in Campylobacter jejuni and Campylobacter coli. FEMS Microbiol Lett. 2007;277(2):123‐132. doi:10.1111/j.1574-6968.2007.00935.x ( Abstract )
  21. Campylobacter WHO Key Facts via https://www.who.int/news-room/fact-sheets/detail/campylobacter
  22. Van Vliet, A.. and Ketley, J.. (2001), Pathogenesis of enteric Campylobacter infection. Journal of Applied Microbiology, 90: 45S-56S. doi:10.1046/j.1365-2672.2001.01353.x

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