Campylobacter Enteritis

• The source of infection is often undercooked meat, especially poultry. Studies have estimated 50% chicken carcasses are contaminated with campylobacter. It can also arise from unpasteurised milk and untreated water. It may arise from birds like blue tits pecking milk on doorsteps or from pets with diarrhoea.¹ The source of infection in the majority of cases remains elusive.
• The infective dose is relatively low for some people (<500) and the organism does not multiply in food. Outbreaks from food are rare. Large outbreaks are usually from raw and inadequately pasteurised milk and contaminated water supplies.² Occupational exposure when processing poultry in abattoirs may cause some cases.
• Incidence is highest in children followed by young adults.
• There may be person to person transmission (faeco-oral route) with poor personal hygiene. Outbreaks occasionally occur in nurseries and institutions (attack rate 15-20%)³
• Duration of shedding is 0-3 weeks, average 15 days. Untreated duration is 4 weeks. There is limited information on period of infectiousness, but patients probably not infectious if treated and diarrhoea has resolved.
• For work or school the exclusion period should be 24 hours from last episode of diarrhoea,⁴ although a longer period of exclusion may be appropriate for children under 5 years and for older children who are unable to maintain good personal hygiene e.g. 48 hours.⁵

According to the Health Protection Agency the number of faecal isolates of campylobacter rose from just under 25,000 in England and Wales in 1986 to a peak of over 57,000 in 2000, falling to around 46,603 in 2006.⁶ It is impossible to state if the rise in trend was a true rise in incidence or greater use of the laboratory service.

Risk factors

• Undercooked meat, especially poultry
• Birds pecking milk on doorsteps
• Pets with diarrhoea
• Raw and inadequately pasteurised milk
• Contaminated water supplies
• Occupational exposure when processing poultry in abattoirs
• Traveller's diarrhoea in south east Asia, especially Thailand

History

• The incubation period can be from 1 to 11 days but is usually 2 to 5 days
• There is a prodromal illness of fever, headache and myalgia lasting up to 24 hours. The fever may be as high as 40ºC and fever, whether high or low, may persist for a week.
• There are abdominal pains and cramps and profuse diarrhoea with up to 10 stools a day. The stool is watery and often bloody.
• There may be localised tenderness
• Around a quarter of suffers have tenesmus

Examination

• The patient often looks ill.
• Temperature may be high or low, but pyrexia is present in over 90%.
• The abdomen is diffusely tender, but tenderness may be more localised as right iliac fossa pain or left iliac fossa pain.

• A sample of faeces is sent for culture to isolate the organism. A single negative sample does not exclude the disease. Cultures are rarely positive after 2 weeks.
• Microscopy of faeces may show erythrocytes and leukocytes.
• U&E and creatinine may show evidence of dehydration.
• Proctoscopy or sigmoidoscopy often shows proctocolitis, but it is difficult to distinguish from pseudomembranous colitis or ulcerative colitis.

• Bloody diarrhoea is usually suggestive of E. coli O157.
• Right iliac fossa pain may mimic appendicitis.
• Campylobacter produces abdominal pain rather more than Salmonella spp. or Shigella spp.

Public Health should be notified of the case.
Avoid antimotility drugs as they prolong the illness and have even been associated with fatality. The basis of management is rehydration.

Rehydration

This can usually be achieved by the oral route, but in more severe cases intravenous fluids may be needed.

Antibiotics

The role of antibiotics is controversial.^7,8 Some studies show that erythromycin rapidly eliminates campylobacter from the stool, but does not affect the duration of illness. Studies in children with dysentery due to C. jejuni have shown benefit from early treatment with erythromycin. Campylobacter acquired from animals may show multiple resistance to antibiotics because of the use of antibiotics in animals.⁹ However, rising numbers of ciprofloxacin resistant cases prompted withdrawal of quinolone use from commercial poultry farming recently in the USA.¹⁰

• Acute bacterial gastroenteritis has been linked with the onset of irritable bowel syndrome (IBS) symptoms in approximately 15% of patients.¹³ These cases have been called postinfectious IBS. Campylobacter is commonly associated with postinfectious IBS as is E. coli, Salmonella spp.and Shigella spp.
• Unusual complications include haemolytic uraemic syndrome and thrombotic thrombocytopenic purpura.
• Other rare complications include Guillain Barré syndrome and reactive arthritis in the form of Reiter's syndrome.
• Toxic megacolon is a rare, but serious complication.

The disease is usually self limiting. Occasionally death may occur from dehydration in the elderly and vulnerable, especially if immunocompromised. C.jejuni can produce a serious bacteraemic condition in AIDS.

• Milk should be pasteurised and drinking water chlorinated. It has been suggested that the provision of clean chlorinated water for chicken flocks might reduce the amount of contaminated meat reaching the market.
• Meat must be adequately cooked.
• Infected healthcare workers should not work. Antibiotic may reduce spread by curtailing the duration of excretion.
• Cutting boards for cooked and uncooked meats and knives and other utensils must be kept apart. The prevention section of salmonella gastroenteritis is just as applicable to campylobacter.