Ciprofloxacin and azithromycin resistance of Campylobacter spp isolated from international travellers,

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1 Ciprofloxacin and azithromycin resistance of Campylobacter spp isolated from international travellers, Niki van Waterschoot a, Annelies Post b, Emmanuel Bottieau b, Erika Vlieghe b, Marjan Van Esbroeck b, Olivier Vandenberg cd, Jan Jacobs be a Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands; b Department of Clinical Sciences, Institute of Tropical Medicine, Antwerp, Belgium; c Department of Microbiology, National Reference Center for Enteric Campylobacter, Iris-Lab, Iris- Brussels Public Hospital Network, Brussels, Belgium; d Ecole de Santé Publique, Université Libre de Bruxelles, Brussels, Belgium e Department of Microbiology and Immunology, KU Leuven

2 Introduction The speaker, Niki van Waterschoot MD student at Maastricht University Research internship at Institute of Tropical Medicine The organism Campylobacter Frequent cause of diarrhoea Increasing resistance rates 2

3 Contents Background Objectives Results Discussion Conclusion 3

4 Background Campylobacter spp. Most reported zoonosis in Europe 1 Major bacterial cause of diarrhoea 2 Transmission Fecal-oral Person to person Immunocompromised patients High risk (systemic) illness More severe complaints 1. European Food Safety Authority, European Centre for Disease Prevention and Control. The European Union Summary Report on Trends and Sources of Zoonoses, Trends and Sources of Zoonoses, Zoonotic Agents and Food-borne Outbreaks in ;12(2). doi: /j.efsa Ross AGP, Olds GR, Cripps AW, Farrar JJ, McManus DP. Enteropathogens and chronic illness in returning travelers. N. Engl. J. Med. 2013;368(19): doi: /nejmra

5 Background Most infections are self-limited Antibiotic treatment is indicated when: Severely dehydrated High fever with bloody diarrhoea Gastro-intestinal complaints >1 week Systemic infection High risk patients 5

6 Objectives Evolution of resistance Differences in travel regions 6

7 Methods Period: May 2008 November 2014 Travel destinations were grouped according to UN composition MIC values determined by E-tests (biomérieux) Breakpoints ciprofloxacin S 1 / R 4 1 azithromycin S 2 / R 8 1. CLSI Guideline fastidious Bacteria, M45-A2, August

8 Methods 8

9 Methods Campylobacter N=189 (2.3%) Available isolates N=188 HIV/STI patients N=21 Domestic patients N=4 Travellers N=163 Patients screened for Campylobacter N=7979 Shigella N=113 (1.4%) Salmonella N=96 (1.2%) 9

10 Results Overall resistance Ciprofloxacin resistance % (93/163) Lowest rate (2013) 43.5% Highest rate: (2014) 72.2% Azithromycin resistance % (12/163) Lowest rate (2010) 3.1% Highest rate (2013) 13.0% Resistance ,0% 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0% % Resistance ciprofloxacin % Resistance azithromycin 10

11 Results Distribution of MIC values * MIC 50 ** MIC 90 11

12 Results World map 12

13 Results Region Resistance ciprofloxacine Resistance azithromycin Caribbean, Central- and South America Asia - Southern Asia 11/16 (68.8%) 2/16 (12.5%) 50/66 (75.8%)* - 33/38 (86.8%)* 7/66 (10.6%) - 6/38 (15.8%) Africa 28/72 (38.9%)* 3/72 (4.2%) HIV/STI 19/21 (90.5%) 4/21 (19.0%) *P<

14 Results ciprofloxacin + azithromycin resistant isolates CIP-R 85 CIP+AZI-R 8 (4.9%) AZI-R 4 Fig 1: Ciprofloxacin and/or azithromycin resistant isolates of the study population. 70/163 CIP-S. 151/163 AZI-S Travel destination India India India India India Costa Rica Cameroon Nepal 14

15 Discussion Fluoroquinolone resistance present study: International travellers % Fluoroquinolone resistance earlier study: International travellers % % 1 Fluoroquinolone resistance domestic studies: United States: % 2 The Netherlands % 3 Belgium: % 4 1. Vlieghe ER, Jacobs J a, Van Esbroeck M, Koole O, Van Gompel A. Trends of norfloxacin and erythromycin resistance of Campylobacter jejuni/campylobacter coli isolates recovered from international travelers, 1994 to J. Travel Med. 2008;15(6): CDC Antibiotic resistance threats, United States Graveland H, Roest H-J, Stenvers O, et al. Staat van de Zoönosen RIVM Centre National de Référence Campylobacter, Rapport d activités pour l année

16 Discussion Macrolide resistance present study: International travellers % Macrolide resistance earlier study: International travellers % % 1 Macrolide resistance domestic studies: United States: % 2 The Netherlands % 3 Belgium: % 4 1. Vlieghe ER, Jacobs J a, Van Esbroeck M, Koole O, Van Gompel A. Trends of norfloxacin and erythromycin resistance of Campylobacter jejuni/campylobacter coli isolates recovered from international travelers, 1994 to J. Travel Med. 2008;15(6): CDC Antibiotic resistance threats, United States Graveland H, Roest H-J, Stenvers O, et al. Staat van de Zoönosen RIVM Centre National de Référence Campylobacter, Rapport d activités pour l année

17 Relevance Antibiotic treatment Current treatment recommendations Dysentery (empirical) Returning travellers ITM Guidelines From Asia azithromycin 500mg, 1-3 days Other travellers ciprofloxacin 2dd 500mg, 3-5days Campylobacter infection Netherlands - SWAB azithromycin 500mg, 3 days Belgium Sanford guide azithromycin 500mg, 3 days Clinical correlation with in-vitro fluoroquinolone resistance is not straightforward 17

18 Discussion Limitations of the study Retrospective Numbers of isolates are limited No differentiation by reason of travel Standardised Isolates are stored 18

19 Future research Testing isolates stored Testing susceptibility other antibiotics Tetracyclin Amoxicillin clavulanic acid Meropenem (Cefixim) 19

20 Conclusion Findings: Stable resistance rates Fluoroquinolones 57.1% Macrolides 7.4% Marked geographical differences (Asia > Africa) High level resistance among azithromycin resistant isolates Confirmation: azithromycin as treatment of choice, when antibiotics are indicated 20

21 Conclusion Need for: Continue monitoring of resistance rates (azithromycin) Azithromycin treatment recommendation for diarrhoea in travellers should be extended Asia Caribbean, Central- and South America 21

22 Thank you for your attention Contact: 22

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