eMedicine Specialties > Pediatrics: General Medicine > Infectious Disease

Campylobacter Infections

Jocelyn Y Ang, MD, Assistant Professor, Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Michigan and Wayne State University
Sharon Nachman, MD, Chief of Pediatric Infectious Diseases, Associate Professor, Department of Pediatrics, Division of Infectious Diseases, State University of New York at Stony Brook

Updated: Oct 5, 2009

Introduction

Background

The family Campylobacteraceae includes 2 genera: Campylobacter and Arcobacter. The genus Campylobacter includes 18 species and subspecies; 11 of these are considered pathogenic to humans and cause enteric and extraintestinal illnesses. The major pathogens are Campylobacter jejuni and Campylobacter fetus.

Scanning electron microscope image of Campylobacter jejuni, illustrating its corkscrew appearance and bipolar flagella. Source: Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, Virginia.

• Enteric
  • C jejuni subspecies jejuni
  • C jejuni subspecies doylei
  • Campylobacter coli
  • Campylobacter upsaliensis
  • Campylobacter lari
  • C fetus subspecies fetus
  • Campylobacter hyointestinalis
  • Campylobacter concisus
• Extraintestinal
  • C jejuni subspecies jejuni
  • C upsaliensis
  • C lari
  • C fetus subspecies fetus
  • C concisus
  • Campylobacter sputorum
  • Campylobacter curvus
  • Campylobacter rectus

Campylobacter pylori has been reclassified as Helicobacter pylori and is not addressed in this article (see Helicobacter Pylori Infection).

Campylobacter pathogens are small, curved, motile, microaerophilic, gram-negative rods. They vary in width from 0.2-0.9 mm and vary in length from 0.5-5.0 mm. They exhibit rapid, darting motility in corkscrew fashion using a single flagellum or 2 flagella (monotrichous, amphitrichous). They also possess a lipopolysaccharide endotoxin.

Campylobacteriosis infects humans and animals. The animal reservoir is the gastrointestinal tract of dogs, cats, and other pets that can carry the organism. Transmission of C jejuni to humans occurs by ingestion of contaminated food or water, including unpasteurized milk and undercooked poultry, or by direct contact with fecal material from infected animals or persons. The 2 types of illnesses associated with Campylobacter infections in humans are intestinal infection and extraintestinal infection. The prototype for intestinal infection is C jejuni, and the prototype for extraintestinal infection is C fetus.

Pathophysiology

Factors responsible for the diseases caused by C jejuni are not well known. Based on clinical illness, researchers have postulated the following mechanisms:¹

• Adherence and production of heat-labile enterotoxins, inducing secretory diarrhea
• Invasion and proliferation within the intestinal epithelium, leading to cell damage and inflammatory response
• Translocation of the organism into the intestinal mucosa and proliferation in the lamina propria and mesenteric lymph nodes, leading to extraintestinal infections such as meningitis, cholecystitis, urinary tract infection, and mesenteric adenitis

Information on the pathogenesis of Campylobacter infections other than C jejuni is scarce. Bacteremia is more common with C fetus infection. A surface protein in C fetus inhibits the C3b binding responsible for both the serum and phagocytic resistance of the organism, making the organism resistant to the bactericidal effects of human serum. After oral ingestion, C fetus may colonize the intestinal tract, resulting in portal bacteremia. In immunocompetent hosts, the organism is phagocytosed by the reticuloendothelial cells in the liver, preventing further spread. However, in patients that have predisposing factors that might serve as a local site of infection such as a gravid uterus, bacteremia can lead to severe complications. Infants may be affected hematogenously or by ascending infection during amnionitis and premature rupture of membranes.

Frequency

United States

In the United States, 2 million symptomatic enteric Campylobacter infections are estimated per year (1% of the US population per year).² Incidence in the rural population is 5-6 times higher because of increased consumption of raw milk. In 2008, according to the Foodborne Diseases Active Surveillance Network (FoodNet) of the Centers for Diseases Control and Prevention (CDC), which collects data on the incidence of infection with foodborne pathogens, the estimated overall incidence rate of laboratory-confirmed Campylobacter infections in the United States was 12.7 cases per 100,000 population; this was not a significant change when compared to the previous 3 years.³ The incidence varies by site and is highest in California. Among all age groups, the highest incidence occurred among children younger than 4 years, whereas the highest rate of hospitalization was in persons older than 50 years.

International

In developing and developed countries, continuous increase in the number of C jejuni has been seen, with incidence rates as high as 73 cases per 100,000 population reported.⁴ Campylobacter gastroenteritis is especially common during the first 5 years of life.^5,6 Isolation rates in children with acute diarrhea range from 10-46%,^5,7 and are higher in winter than other seasons.⁷

Mortality/Morbidity

The vast majority of patients fully recover from C jejuni infection within 5 days (range, 2-10 d), either spontaneously or after appropriate antimicrobial therapy. Infection with C fetus is a concern in immunocompromised patients, pregnant women, and neonates. Previously healthy patients usually recover without complications.

Race

Campylobacter infection has no race predilection.

Sex

In England and Wales, incidence was higher in males from birth until age 17 years and in females aged 20-36 years.⁸

Age

Individuals of any age can be infected with C jejuni enteritis. The rate of infection differs between developed and developing countries. In developed countries, the peak attack rates are in infants younger than 1 year; a second, broader peak attack rate occurs in persons aged 20-29 years.⁹ In developing countries, symptomatic infection chiefly affects children younger than 5 years and declines with age.^10,11 This is likely due to the development of protective immunity secondary to a high level of exposure to the organism early in life.

In contrast to the age-specific distribution of Campylobacter enteritis, the highest rate of bacteremia occurs in patients aged 69 years and older.¹² Roughly 30% of isolates are C jejuni, 9% are C coli, and 53% are C fetus.

Clinical

History

Clinical manifestations of all Campylobacter species infections that cause enteric illness overlap and appear identical. These manifestations include the following:

• Diarrhea
  • Mild episodes of diarrhea subside within 7 days in 60-70% of cases, last for 2 weeks in 20-30%, and persist longer than 2 weeks in 5-10% of cases. In one third to one half of patients, initial symptoms include periumbilical cramping, intense abdominal pain that mimics appendicitis, malaise, myalgias, headache, and vomiting.
  • Watery secretory diarrhea consists of more than 10 stools per day and is frequently seen in younger children. Dehydration occurs in approximately 10% of these children.
  • Inflammatory diarrhea symptoms are indistinguishable from those caused by Shigella organisms, Escherichia coli, and Salmonella species. They are characterized by malaise, fever, abdominal cramps, tenesmus, bloody stools, and fecal leukocytes on light microscopy.
  • Rarely, in young adults and adolescents, inflammatory diarrhea can be severe and can be confused with Crohn disease and ulcerative colitis. Toxic megacolon with massive bleeding may occasionally occur. In asymptomatic neonates, C jejuni has been isolated from blood-streaked formed stools or hematochezia.
• Extraintestinal infections
  • Bacteremia with C jejuni is uncommon and is most frequently found in patients with immunodeficiency,¹³ patients with chronic illness,¹² and patients at extremes of ages. Bloodstream infections and systemic infections by C fetus are rare. The 3 patterns of bacteremia are as follows:
    • Transient bacteremia in a normal host with acute Campylobacter enteritis: These patients usually completely recover without treatment.
    • Secondary bacteremia or deep focus of infection such as meningitis, pneumonia, endocarditis, and thrombophlebitis in a normal host: Bacteremia usually originates from the intestinal tract and responds to antimicrobial therapy. 
    • Chronic bacteremia with relapses that can persist for several months occurring in an immunocompromised host: In these patients, bacteremia can also arise from an infected indwelling catheter. Many such patients do not have acute enteritis.
  • Localized extraintestinal infections are uncommon manifestations and include cholecystitis, arthritis, urinary tract infection, pancreatitis, osteomyelitis, and meningitis.^14,15 These manifestations may be the initial presentation of C jejuni infection or may occur simultaneously with bacteremia. They frequently are seen in patients who are immunocompromised or who are at extremes of age. Appropriate treatment is necessary.
• Because of the affinity of C fetus for the genital tract (and by the tropism for fetal tissue), C fetus,^16,17 and rarely C jejuni,^17,18 are associated with perinatal infection. Abortion or stillbirth and premature labor have been described. Infants are often premature and develop signs and symptoms suggestive of sepsis, including fever, cough, respiratory distress, vomiting, diarrhea, cyanosis, convulsions, and jaundice. Infection typically progresses to meningitis, which may be rapidly fatal or may result in serious neurologic sequelae. The source of the organism in these cases has been the mother.

Physical

• The abdomen is frequently tender upon palpation, especially the right lower quadrant.
• Rarely, splenomegaly may be present.

Causes

• Individuals at increased risk for Campylobacter enteritis include the following:
  • Those with occupational exposure to cattle, sheep, and other farm animals
  • Laboratory workers
  • Those in contact with the excreta of infected persons
  • Homosexual men
• The following underlying conditions increase risk for Campylobacter bacteremia, suggesting the importance of both humoral and cell-mediated immunity:^12,13,19
  • Hypogammaglobulinemia
  • Human immunodeficiency virus (HIV) infection
  • Kwashiorkor
  • Pregnancy
  • Malignancy
  • Extremes of age
  • Alcoholism
  • Diabetes mellitus
  • Postsplenectomy status
  • Human leukocyte antigen B27 (HLA-B27) - Increases risk for immunoreactive complications, such as reactive arthritis or Reiter syndrome

Differential Diagnoses

Other Problems to Be Considered

• Other bacterial causes of inflammatory diarrhea
  • Shigella organism
  • Enteroinvasive E coli
  • E coli O157:H7
  • Salmonella species
  • Yersinia enterocolitica
  • Aeromonas species 
  • Vibrio parahaemolyticus
• Inflammatory bowel disease
• Pseudomembranous enterocolitis secondary to Clostridium difficile infection
• Intussusception in infants
• Acute abdomen 
• Acute appendicitis

Workup

Laboratory Studies

• Microbiologic studies in Campylobacter infection
  • Presumptive diagnosis can be made by examination of fecal specimens by darkfield or phase-contrast microscopy, which demonstrates the characteristic darting motility, and a Gram stain of the stool, which shows Vibrio forms (slim, short, curved rods). RBCs and neutrophils are present in stool in approximately 75% of patients with Campylobacter enteritis.
  • Definitive diagnosis of infection is based on isolation of organisms from stool culture or from another site.
  • Culture of C jejuni from stool requires special isolation techniques and special media such as Campy-BAP or Skirrow. These media contain antibiotics that reduce the emergence of other enteric microorganisms. Inoculated media should be incubated in 5% oxygen and 10% carbon dioxide at 42°C. If C fetus or other atypical enteric species are suspected, isolation from stool requires inoculation on media lacking antibiotics and at 37°C. Filtration technique may be needed. Routine media are adequate for isolation of Campylobacter from normally sterile sites such as blood, body fluids, and tissues.
• Hematology and blood chemistries
  • Peripheral WBC count is usually within the reference range; however, a left shift may occur.
  • The alanine aminotransferase level and the erythrocyte sedimentation rate (ESR) may be slightly elevated.
  • Other laboratory evaluations are within the reference ranges.
• Serology
  • Diagnostic rise usually occurs after symptoms have resolved. Because the median duration of fecal excretion in the convalescent phase is less than 3 weeks, serology testing may be more sensitive than culture for the diagnosis of recent C jejuni infection.
  • Although serologic testing is also useful for epidemiologic investigations it is not recommended for routine diagnosis.

Other Tests

• DNA probes and polymerase chain reaction are mainly research tools at this time and are not routinely performed.

Procedures

• In patients with Campylobacter colitis with history of acute onset of diarrhea, abdominal pain and rectal bleeding, sigmoidoscopy done early (within 5 d) during the illness revealed hyperemic rectal mucosa with occasional shallow aphthous ulcers, whereas findings of granularity and hyperemia were seen in patients whose sigmoidoscopy were done later (³ 7 d) during the illness.²⁰

Histologic Findings

• The spectrum of histologic findings in the intestinal tract ranges from minimal edema with acute and chronic inflammatory cells without vascular congestion, to moderate inflammation and cryptitis, to crypt abscess formation.
• For perinatal infections secondary to C jejuni and C fetus, the placenta may have areas of necrosis, infarction, microabscesses, and inflammation.¹⁶

Treatment

Medical Care

• Evaluation of patients with Campylobacter infections can usually be performed on an outpatient basis.
• Intravenous hydration and inpatient care may be necessary for patients who are severely dehydrated and cannot tolerate oral hydration.

Surgical Care

• Occasionally, acute abdominal pain may be the only presenting symptom, often mimicking acute appendicitis and resulting in immediate laparotomy.

Consultations

• Consultation with an infectious disease specialist and a gastroenterologist may be necessary for complicated cases.

Diet

• Because rehydration and electrolyte replacement are the mainstays for treating diarrheal disease, oral rehydration with an electrolyte and glucose solution is necessary.

Activity

• Permit activity as tolerated.

Medication

Most C jejuni infections are generally mild and self-limited. The need to administer antimicrobials in uncomplicated cases is still controversial. Correction of electrolyte abnormalities and rehydration are the mainstay of treatment for enteritis due to Campylobacter species. Antimicrobial therapy should be considered in immunocompromised hosts or in individuals with fever, increasing bloody diarrhea, or symptoms that last longer than 1 week.²¹

C jejuni is usually sensitive to erythromycin, azithromycin, gentamicin, tetracycline, and chloramphenicol. Reports of ciprofloxacin-resistant strains are increasing in most countries.²² A meta-analysis was done to assess the effects of antibiotic treatment versus placebo on duration of symptoms in patients with Campylobacter infections.²¹ This study included 11 randomized controlled trials with a total of 479 patients. Ninety one of 479 were pediatric patients and accounted for 19% of the participants. Antibiotics tested included erythromycin (6 trials), ciprofloxacin,³ and norfloxacin.³ This meta-analysis showed a decrease in duration of symptoms by 1.3 days with antibiotic treatment compared with placebo. Antibiotic treatment also decreases the duration of fecal shedding. In addition, antibiotics were beneficial if initiated within the first 3 days of illness, with a mean decrease of symptoms of 0.35 days of earlier treatment.

The recommended duration for antibiotic treatment for gastroenteritis is 5-7 days. Antimicrobial therapy for all immunocompromised patients with C jejuni bacteremia should be selected based on a laboratory susceptibility test. Begin therapy with gentamicin, imipenem, third-generation cephalosporins, or chloramphenicol until susceptibility test results are available.

Because infections with C fetus are usually systemic, intravenous antibiotics are usually required. Aminoglycosides, such as gentamicin and carbapenem, are usually used for empiric treatment. Based on in vitro susceptibility test results,^23,24 alternatives for C fetus bacteremia include ampicillin, chloramphenicol, and third-generation cephalosporins. Duration of therapy is empiric. Patients with CNS infection require treatment for 2-3 weeks with a third-generation cephalosporin, ampicillin, or chloramphenicol Those with endovascular infection should be treated for at least 4 weeks with gentamicin as the drug of choice (DOC). Treatment with ampicillin or third-generation cephalosporins are other alternatives. Erythromycin is the DOC in patients with diarrheal illness secondary to C fetus infection.

Macrolide antibiotics

Ease of administration, lack of serious adverse effects, and fewer propensities to select for plasmid-mediated antibiotic resistance make erythromycin the DOC.

Erythromycin (E.E.S., E-Mycin, Eryc, Ery-Tab)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes causing RNA-dependent protein synthesis to arrest.
In children, age, weight, and severity of infection determine proper dosage. When bid dosing is desired, half-total daily dose may be taken q12h. For more severe infections, double the dose.

Dosing

Adult

800 mg (EES) PO qid; not to exceed 4 g/d
250-500 mg (base, stearate, or estolate) PO qid; not to exceed 4 g/d
15-20 mg/kg/d IV divided q6h; not to exceed 4 g/d

Pediatric

30-50 mg/kg/d PO divided q6h; not to exceed 2 g/d
20-50 mg/kg/d IV divided q6h; not to exceed 2 g/d

Interactions

Inhibits CYP450 isoenzymes 1A2 and 3A3/4; decreases clearance of terfenadine, cisapride, and astemizole, which may result in serious cardiac arrhythmias; may also decrease clearance and therefore potentiate carbamazepine, methylprednisolone, cyclosporine, digoxin, hexobarbital, theophylline, warfarin, ergotamine, triazolam, and others; avoid lovastatin; coadministration with lovastatin and simvastatin, increases risk of rhabdomyolysis; decreases metabolism of repaglinide, thus increasing serum levels and effects

Contraindications

Documented hypersensitivity; hepatic impairment; concomitant administration of terfenadine (recalled from US market), cisapride, and astemizole (recalled from US market)

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Caution in liver disease; estolate formulation may cause cholestatic jaundice; GI adverse effects are common (administer pc); discontinue use if nausea, vomiting, malaise, abdominal colic, or fever occur

Azithromycin (Zithromax)

Acts by binding to 50S ribosomal subunit of susceptible microorganisms and blocks dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Nucleic acid synthesis is not affected. Concentrates in phagocytes and fibroblasts as demonstrated by in vitro incubation techniques. In vivo studies suggest that concentration in phagocytes may contribute to drug distribution to inflamed tissues. Treats mild-to-moderate microbial infections.
Plasma concentrations are very low, but tissue concentrations are much higher, giving it value in treating intracellular organisms. Has a long tissue half-life. Single dose is recommended.
May become DOC because of safety profile, ease of use, and improved GI tract tolerability relative to erythromycin. Administer caps and PO susp on an empty stomach, at least 1 h before or 2 h after meals. Tab and PO powder (sachet) may be administered with food.

Dosing

Adult

Day 1: 500 mg PO
Days 2-5: 250 mg/d PO

Pediatric

<6 months: Not established
>6 months:
Day 1: 10 mg/kg PO once; not to exceed 500 mg/d
Days 2-5: 5 mg/kg/d PO; not to exceed 250 mg/d

Interactions

May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine

Contraindications

Documented hypersensitivity; hepatic impairment; do not administer with pimozide

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Site reactions can occur with IV route; bacterial or fungal overgrowth may result from prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients

Tetracyclines

These agents may be used in children but are not approved for children younger than 9 years because of the risk of dental staining.

Tetracycline (Sumycin)

Inhibits bacterial protein synthesis by binding with 30S and possibly 50S ribosomal subunit(s).

Dosing

Adult

250-500 mg/dose PO q6h; not to exceed 2 g/d

Pediatric

<8 years: Not recommended
>8 years: 25-50 mg/kg/d PO divided q6h; not to exceed 2 g/d

Interactions

May increase serum digoxin levels; antacids, iron, zinc, calcium, magnesium, dairy products, urinary alkalinizers, and food reduce absorption; avoid concomitant methoxyflurane; monitor prothrombin time with PO anticoagulant

Contraindications

Documented hypersensitivity; severe hepatic dysfunction

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Renal impairment; monitor blood, renal, and liver function in long-term use; avoid excessive sun or UV light; not recommended for nursing mothers; use of tetracyclines during tooth development (last half of pregnancy through age 8 y) can cause permanent discoloration of the teeth; never administer outdated tetracyclines; degradation products of tetracyclines are highly nephrotoxic and can cause a Fanconilike syndrome

Lincosamide antibiotics

These drugs represent an alternative to tetracycline.

Clindamycin (Cleocin)

Inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.

Dosing

Adult

150-450 mg/dose PO q6-8h; not to exceed 1.8 g/24h
600-2700 mg/d IM/IV divided q6-12h; not to exceed 4.8 g/24h

Pediatric

20-30 mg/kg/d PO divided q6h
25-40 mg/kg/d IM/IV divided q6-8h

Interactions

May potentiate neuromuscular blocking agents; may antagonize erythromycin; antiperistaltic agent may worsen colitis

Contraindications

Documented hypersensitivity to preparations containing clindamycin or lincomycin; pseudomembranous colitis; hepatic impairment

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Not for treatment of meningitis; discontinue if colitis occurs and treat; monitor neonates and those with gastrointestinal disease; monitor blood, renal, and hepatic function in long-term use and in children; use with caution in patients with renal or hepatic disease with metabolic aberrations; nursing mothers

Aminoglycoside antibiotics

Reserve these drugs for treatment of infections caused by organisms not sensitive to less toxic agents.

Gentamicin (Garamycin, Pediatric Gentamicin Sulfate)

Aminoglycoside antibiotic for gram-negative coverage. Used in combination with both an agent against gram-positive organisms and one that covers anaerobes.

Dosing

Adult

1 mg/kg/dose IM/IV q8h or total dose once a day; not to exceed 5 mg/kg/d
Dosing intervals based on CrCl:
>60 mL/min: Administer q8h
40-60 mL/min: Administer q12h
20-40 mL/min: Administer q24h
10-20 mL/min: Administer q48h
<10 mL/min: Administer q72h

Pediatric

Neonates/Infants:
<29 weeks postconception, 0-28 days postnatal:
2.5 mg/kg/dose IM/IV qd
<29 weeks postconception, >28 days postnatal:
3 mg/kg/dose IM/IV qd
30-36 weeks postconception, 0-14 days postnatal:
3 mg/kg/dose IM/IV qd
30-36 weeks postconception, >14 days postnatal:
2.5 mg/kg/dose IM/IV q12h
>37 weeks postconception, 0-7 days postnatal:
2.5 mg/kg/dose IM/IV q12h
>37 weeks postconception, >7 days postnatal:
2.5 mg/kg/dose IM/IV q8h
Children: 2-2.5 mg/kg/dose IM/IV q8h

Interactions

Avoid concomitant furosemide, ethacrynic acid, other nephrotoxic or neurotoxic drugs including cephalosporins; may potentiate neuromuscular blockade

Contraindications

Documented hypersensitivity to gentamicin or another aminoglycoside

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor for nephrotoxicity and neurotoxicity; avoid peak serum levels >12 mcg/mL and trough levels >2 mcg/mL; for renal impairment, reduce dose, maintain adequate hydration; prolonged use or excessive doses; asthma; neuromuscular disorders

Fluoroquinolone antibiotics

Ciprofloxacin and other fluoroquinolones are alternative agents to erythromycin but are not approved for those younger than 18 years.

Ciprofloxacin (Cipro)

Inhibits bacterial DNA synthesis and, consequently, growth. Continue treatment for at least 2 d after signs and symptoms have disappeared.

Dosing

Adult

250-750 mg/dose PO q12h; not to exceed 2 g/d
200-400 mg/dose IV q12h; not to exceed 800 mg/d

Pediatric

Data limited; suggested doses
20-30 mg/kg/d PO divided bid; not to exceed 1.5 g/d
10-20 mg/kg/d IV divided q12h; not to exceed 800 mg/d

Interactions

May increase theophylline levels; avoid PO forms with antacids, calcium, iron, zinc, and sucralfate; avoid urinary alkalinizers; potentiated by probenecid; interferes with caffeine metabolism; severe hypoglycemia with glyburide (rare); increased serum creatinine level with cyclosporine; monitor PO anticoagulants (potentiation) and phenytoin (variable effects)

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Renal (creatinine clearance <29 mL/min) or hepatic dysfunction, reduce dose; discontinue if tendon pain, inflammation, or rupture occur; discontinue if rash, phototoxicity, or other sign of hypersensitivity occurs; may cause CNS or convulsive disorders; maintain hydration, avoid alkaline urine to avoid crystalluria; avoid excessive sun and UV light; not recommended for breastfeeding mothers

Antibiotics, other

Alternatives for C fetus bacteremia include ampicillin, imipenem, chloramphenicol, and third-generation cephalosporins. Reported synergistic combinations include ampicillin with gentamicin and imipenem with gentamicin. Duration of therapy is empiric.

Imipenem and cilastatin sodium (Primaxin)

Carbapenem antibiotic. For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.

Dosing

Adult

Based on imipenem component, 250-1000 mg/dose IV q6-8h; not to exceed 4 g/d or 50 mg/kg/d

Pediatric

50-100 mg/kg/d IV divided q6-8h; not to exceed 4 g/d

Interactions

Coadministration with cyclosporine may increase CNS adverse effects of both agents; coadministration with ganciclovir may result in generalized seizures

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Penicillin, cephalosporin, or other allergy; CNS disorders, especially brain lesions or seizures; reduce dose for renal impairment

Chloramphenicol (Chloromycetin)

Binds to 50 S bacterial-ribosomal subunits and inhibits bacterial growth by inhibiting protein synthesis. Effective against gram-negative and gram-positive bacteria.

Dosing

Adult

50-100 mg/kg/d IV divided q6h; not to exceed 4 g/d

Pediatric

Neonates:
Loading dose: 20 mg/kg IV
Maintenance dose: Administer first maintenance dose 12h after loading dose
<7 days: 25 mg/kg/d IV qd
>7 days:
<2 kg: 25 mg/kg/d IV qd
>2 kg: 50 mg/kg/d IV divided q12h
Infants/children: 50-100 mg/kg/d IV divided q6h; not to exceed 4 g/d

Interactions

Avoid other agents that cause bone marrow depression; may increase effects of hydantoins or sulfonylureas; may increase serum iron levels, decrease response to iron, vitamin B-12
When administered concurrently with barbiturates, chloramphenicol serum levels may decrease and barbiturate levels may increase, causing toxicity; rifampin may reduce serum chloramphenicol levels, presumably through hepatic enzyme induction; may increase effects of anticoagulants

Contraindications

Trivial infections or prophylaxis; previous toxic reactions to chloramphenicol; G-6-PD deficiency

Precautions

Pregnancy

D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus

Precautions

Caution in pregnancy at term or during labor because of potential toxic effects on fetus (gray baby syndrome)
Perform blood tests at baseline and q2d during therapy; discontinue if blood dyscrasias, optic neuritis, or peripheral neuritis develops; avoid repeat therapy; monitor serum levels; breastfeeding women

Ceftriaxone (Rocephin)

Third-generation cephalosporin. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Dosing

Adult

1-4 g/d IV divided q12-24h; not to exceed 4 g/d

Pediatric

Infants and children: 50-75 mg/kg/d IM/IV divided q12-24h
Meningitis: 100 mg/kg/d IV/IM divided q12-24h; not to exceed 4 g/d

Interactions

May cause false-positive Clinitest results; potentiated by probenecid

Contraindications

Documented hypersensitivity

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Penicillin or other allergy; concomitant renal and hepatic impairment, (not to exceed 2 g/d); chronic hepatic disease or malnutrition, monitor prothrombin time; GI disease

Ampicillin (Marcillin, Omnipen)

Broad-spectrum penicillin. Bactericidal activity against susceptible organisms.

Dosing

Adult

500-3000 mg IV q4-6h; not to exceed 12 g/d IV

Pediatric

Neonates <7 days:
<2 kg: 50-100 mg/kg/d IV divided q12h
>2 kg: 75-150 mg/kg/d IV divided q8h
Neonates >7 days:
<1.2 kg: 50-100 mg/kg/d IV divided q12h
1.2-2 kg: 75-150 mg/kg/d IV divided q8h
>2 kg: 100-200 mg/kg/d IV divided q6h
Children:
Mild-to-moderate infections: 100-200 mg/kg/d IV divided q6h
Severe infections: 200-400 mg/kg/d IV divided q4-6h

Interactions

May cause false-positive Clinitest result; potentiated by probenecid

Contraindications

Documented hypersensitivity; contraindicated in infections caused by penicillinase-producing organism

Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

May have cross-sensitivity with cephalosporins or imipenem; high incidence of rash with mononucleosis; monitor blood, renal, and liver function with long-term use

Follow-up

Further Inpatient Care

• Evaluate protracted cases of Campylobacter infection further to rule out other causes of fever, diarrhea, and sepsis.
• Provide close monitoring and support in the intensive care unit for immunoreactive complications such as Guillain-Barré syndrome (GBS).

Further Outpatient Care

• Assess the resolution of illness and patient compliance with medication.

Inpatient & Outpatient Medications

• Rehydrate intravenously or orally.
• Administer antibiotics as indicated.

Transfer

• Patients with immunoreactive complications such as GBS may require transfer to a chronic care facility for rehabilitation after their condition stabilizes.

Complications

• Guillain-Barré syndrome
  • GBS is a disorder of peripheral nerves and is characterized by ascending paralysis.
  • Strong evidence suggests an association between preceding C jejuni infection and GBS. The antigenic similarity between specific regions (terminal tetrasaccharide) of lipopolysaccharide of C jejuni and human gangliosides (GM1) led to the concept of molecular mimicry.²⁵ This concept implies the sharing of homologous epitopes between the bacterial lipopolysaccharide and ganglioside surface components of the peripheral nerve. Immune response from simple C jejuni infection could induce antibodies that cross-react to the gangliosides and trigger GBS.
  • Other variants of GBS associated with c jejuni infection include the following:
    • Acute motor axonal neuropathy (AMAN), or Chinese paralytic syndrome, is characterized by a rapid onset of paralysis with progression to tetraplegia and respiratory failure and occurs in children in northern China during summer and fall.²⁶
    • Fisher syndrome is characterized by ophthalmoplegia, areflexia, and cerebellar ataxia.
• Reactive arthritis
  • Incidence and prevalence of Campylobacter- associated reactive arthritis varies among different reports, ranging from 0.6-24%.²⁷
  • Development of reactive arthritis has been associated with human leukocyte antigen (HLA)-B27 allele; in these individuals, the disease is more severe than in individuals without HLA-B27.²⁸ However, a more recent population-based study did not show the association.²⁹
  • Arthritis starts a few days to several weeks after the episode of diarrhea. The course is usually self-limited, ranging from 1 week to several months (<6 mo).²⁷
• Other infrequently reported complications are as follows:
  • Reiter syndrome
  • Erythema nodosum
  • Hepatitis
  • Intestinal nephritis
  • Hemolytic-uremic syndrome
  • Immunoglobulin A (IgA) nephropathy

Prognosis

• Most patients fully recover after C jejuni infection, with or without antibiotics.
• Campylobacter septicemia in patients with immune deficiencies (including congenital hypogammaglobulinemia, acquired hypogammaglobulinemia, malnutrition, HIV) and in neonates is associated with a high mortality rate.
• Even with plasmapheresis and intravenous immunoglobulin, as many as 20% of patients with GBS may require mechanical ventilation. Between 15% and 20% of all patients may develop severe neurologic deficit. GBS disease may result in mortality in 5-10% of all patients. Because GBS secondary to C jejuni may be more severe, the number of patients who require mechanical ventilation, experience severe neurologic sequelae, and die may also be higher.
• Previously healthy persons infected with C fetus usually recover without sequelae. This infection may be lethal to patients with altered immune status and neonates. Prognosis for these patients depends on the early administration of fluids and appropriate antimicrobial therapy.

Patient Education

• Tips for preventing campylobacteriosis
  • Thoroughly cook all poultry products. If served undercooked poultry in a restaurant, return it for further cooking.
  • Wash hands with soap before and after handling raw foods of animal origin.
  • Prevent cross-contamination in the kitchen
    • Use separate cutting boards for foods of animal origin and other foods.
    • Carefully clean all cutting boards, countertops, and utensils with soap and hot water after preparing raw food of animal origin.
  • Avoid consuming unpasteurized milk and untreated surface water.
  • Make sure that persons with diarrhea, especially children, carefully and frequently wash their hands with soap to reduce the risk of spreading infection.
  • Wash hands with soap after contact with pet feces.

Miscellaneous

Medicolegal Pitfalls

• Failure by physicians and clinical laboratories to report diagnosis of campylobacteriosis to local health departments to further prevent possible outbreaks.

Special Concerns

• Because of the widespread use of antibiotics, especially quinolones, in humans and animal food, increasing resistance to these agents is reported.

Multimedia

Media file 1: Scanning electron microscope image of Campylobacter jejuni, illustrating its corkscrew appearance and bipolar flagella. Source: Virginia-Maryland Regional College of Veterinary Medicine, Blacksburg, Virginia.

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Keywords

Campylobacter infections, campylobacteriosis, Campylobacteraceae, Campylobacter, Campylobacter jejuni, C jejuni, Campylobacter fetus, C fetus, Arcobacter, C jejuni subspecies doylei, Campylobacter coli, Campylobacter upsaliensis, Campylobacter Lari, C fetus subspecies fetus, Campylobacter hyointestinalis, Campylobacter concisus, Campylobacter sputorum, Campylobacter curvus, Campylobacter rectus, Campylobacter pylori, Helicobacter pylori, meningitis, cholecystitis , urinary tract infection, mesenteric adenitis, bacteremia, gravid uterus, enteritis, arthritis, pancreatitis, osteomyelitis

Contributor Information and Disclosures

Author

Jocelyn Y Ang, MD, Assistant Professor, Department of Pediatrics, Division of Infectious Diseases, Children's Hospital of Michigan and Wayne State University
Jocelyn Y Ang, MD is a member of the following medical societies: American Academy of Pediatrics, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Coauthor(s)

Sharon Nachman, MD, Chief of Pediatric Infectious Diseases, Associate Professor, Department of Pediatrics, Division of Infectious Diseases, State University of New York at Stony Brook
Sharon Nachman, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, and Pediatric Infectious Diseases Society
Disclosure: Nothing to disclose.

Medical Editor

Itzhak Brook, MD, MSc, Professor, Department of Pediatrics, Georgetown University School of Medicine
Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Federation for Clinical Research, American Medical Association, American Society for Microbiology, Armed Forces Infectious Diseases Society, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Ear, Nose and Throat Advances in Children, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, and Surgical Infection Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
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Managing Editor

Mark R Schleiss, MD, American Legion Chair of Pediatrics, Professor of Pediatrics, Division Director, Division of Infectious Diseases and Immunology, Department of Pediatrics, University of Minnesota Medical School
Mark R Schleiss, MD is a member of the following medical societies: American Pediatric Society, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Society for Pediatric Research
Disclosure: Nothing to disclose.

CME Editor

Robert W Tolan Jr, MD, Chief, Division of Allergy, Immunology and Infectious Diseases, The Children's Hospital at Saint Peter's University Hospital; Clinical Associate Professor of Pediatrics, Drexel University College of Medicine
Robert W Tolan Jr, MD is a member of the following medical societies: American Academy of Pediatrics, American Medical Association, American Society for Microbiology, American Society of Tropical Medicine and Hygiene, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa, and Physicians for Social Responsibility
Disclosure: GlaxoSmithKline Honoraria Speaking and teaching; MedImmune Honoraria Speaking and teaching; Merck Honoraria Speaking and teaching; sanofi pasteur Honoraria Speaking and teaching; Baxter Healthcare Honoraria Speaking and teaching

Chief Editor

Russell W Steele, MD, Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine
Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association
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