Transactions of the Royal Society of Tropical Medicine and Hygiene (2005) 99, 207—214

Campylobacter species and drug resistance in anorth Indian rural community

Deepika Jaina, Sushmita Sinhaa, Kashi N. Prasada,∗, Chandra M. Pandeyb

a Department of Microbiology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow226014, Indiab Department of Biostatistics, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow226014, India

Received 28 June 2004; received in revised form 16 September 2004; accepted 16 September 2004A

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vailable online 19 November 2004

KEYWORDSDiarrhoea;Campylobacter;Salmonella;Shigella;Drug resistance;India

Summary Campylobacter species are known as agents of enteritis worldwide.However, rural community-based studies on Campylobacter infections are lacking.We carried out a prospective case-control study from July to December 2002 to in-vestigate the prevalence and socio-epidemiological determinants of Campylobacterinfection in a rural community in north India and the drug resistance of Campylobac-ter strains isolated from the community. Stool specimens from 348 subjects withdiarrhoea and 351 age- and gender-matched asymptomatic controls were culturedfor Campylobacter, Salmonella and Shigella. All Campylobacter strains were iden-tified and tested for antibiotic susceptibility. Campylobacter species were isolatedfrom 47 (13.5%) subjects with diarrhoea and 2 (0.6%) asymptomatic controls respec-tively (P < 0.001). Campylobacter infection was significantly higher in children agedless than 5 years, families engaged in agriculture and persons who did not wash theirhands with soap after peri-anal washing following defaecation. Campylobacter infec-tions were more frequent than combined Salmonella and Shigella infections (47/348vs. 15/351; P < 0.001) in subjects with diarrhoea. Only two Campylobacter-infectedindividuals with diarrhoea had bloody stools. Antibiotic resistance of Campylobac-ter species was as follows: ampicillin 81.6%, ciprofloxacin 71.4%, tetracycline 26.5%,furazolidine 14.3%, gentamicin 10.2% and erythromycin 6.1%; 30.6% of strains weremultidrug resistant. Increased quinolone resistance and multidrug resistance posemajor risks for treatment failure.© 2004 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd.All rights reserved.

* Corresponding author. Tel.: +91 522 2668631;ax: +91 522 26688017/2668078.

E-mail address: knprasad@sgpgi.ac.in (K.N. Prasad).

1. Introduction

Campylobacter species have been recognized as im-portant enteropathogens worldwide. The epidemi-ology of Campylobacter infection in developing

035-9203/$ — see front matter © 2004 Royal Society of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.oi:10.1016/j.trstmh.2004.09.006

208 D. Jain et al.

countries differs markedly from that of thedeveloped world. Studies from the USA andother developed countries show that enteritisdue to Campylobacter exceeds cases caused bySalmonella species, Shigella species or Escherichiacoli O157:H7 (Blaser et al., 1983; Slutsker et al.,1997). Campylobacter jejuni is the most commonspecies isolated from diarrhoeal illnesses in humansfollowed by C. coli (Goosens and Butzler, 1992).Numerous studies from developed countries havedemonstrated C. jejuni in 4—14% of patients withdiarrhoea and in fewer than 1% of asymptomaticpersons (Blaser et al., 1984). It is estimated thattrue Campylobacter infection rates in the USA andUK are as high as 1% of the population per year(Linton et al., 1997). In developing countries, C. je-juni is isolated more frequently but also the ratesof carriage in healthy populations are often high(Oberhelman and Tayor, 2000). There are also somereports from developing countries, where C. jejuniand C. coli have been isolated mostly from popula-tions with diarrhoeal illness (De Mol and Bosnians,1978; De Mol et al., 1983; Prasad et al., 1991).Social culture, population density, climate andethnic background of individuals in developing

tion screening was done prospectively by a teamof trained research fellows. Individuals sufferingfrom diarrhoea were identified and stool samplesfrom such individuals and matching asymptomaticswere collected the following morning. Stool speci-mens were examined microscopically for parasitesand cultured for Campylobacter, Salmonella andShigella within 2 h of collection.

2.1. Statistical methods

The study was conducted in two stages. A ques-tionnaire was developed to collect information onthe socio-epidemiological status of each family. Foreach individual in the family, information was col-lected on age, education, occupation, food habits,health and hygiene, and morbidity during the pre-vious 15 days. The survey tools were tested in apilot study and corrections were made before finalimplementation. The prevalence of Campylobacterinfection in the presence and absence of expectedrisk factors was compared using the Z test and rela-tive risk (RR) was also computed. A P value of≤0.05was considered significant. Data cleaning was doneto remove inconsistencies. Analysis was done us-iU

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countries being different from those in the devel-oped world, it is likely that there are geograph-ical differences in Campylobacter infections. Thesocio-epidemiological determinants responsible forCampylobacter infection in India are little studied.

While most Campylobacter infections are self-limiting, occasionally a more invasive illness can oc-cur that requires effective antimicrobial therapy. Insuch cases, erythromycin and fluoroquinolones areoften recommended. Though levels of resistanceto erythromycin have remained fairly stable, re-cent data from Taiwan, Thailand and Spain showfluoroquinolone resistance in 56.7, 84 and 88% ofC. jejuni/C. coli strains respectively (Gallardo etal., 1998; Hoge et al., 1998; Li et al., 1998). Emer-gence of multidrug-resistant Campylobacter strainsappears to be another major concern.

The present study was conducted prospectivelyto determine the prevalence of Campylobacter in-fection and its socio-epidemiological determinantsin a rural community and the frequency of drug re-sistance in campylobacters isolated from that com-munity.

2. Materials and methods

The study was conducted in a rural communityof Lucknow district from July to December 2002.Lucknow is the capital of Uttar Pradesh, thelargest state of India. A community-based popula-

ng SPSS statistical software (SPSS Inc., Chicago, IL,SA).

.2. Processing of specimens

.2.1. Direct smearormal saline and iodine preparations of stool sam-les were examined under a microscope for theresence of pus cells, red blood cells and differentarasites.

.2.2. Culture and isolation of Campylobacteraecal samples were cultured on blood-free se-ective charcoal cefoperazone deoxycholate agarNachamkin, 1999). The plates were incubated at7 ◦C for 72 h under microaerophilic conditions (5%2, 5% CO2, 5% H2, 85% N2) using the Anoxomatystem (Mart® Microbiology BV, Lichtenvoorde, Theetherlands). The plates were examined after 48 hnd finally after 72 h. Characteristic Campylobac-er colonies were confirmed by Gram stain and ox-dase test followed by standard biochemical testsNachamkin, 1999; On, 1996).

.2.3. Culture and isolation of Salmonella andhigellatool samples were directly cultured on MacConkeynd deoxycholate agar (DCA) (Difco, Sparks, MD,SA) plates; specimens were also enriched in Gram-egative broth and subcultured on MacConkey and

Campylobacter species and drug resistance 209

DCA (Difco, Sparks, MD, USA) plates. The plateswere incubated at 37 ◦C for 24 h. Characteristiccolonies were identified following standard bio-chemical tests and serology (Bopp et al., 1999).

2.3. Antimicrobial susceptibility testing ofCampylobacter species

All Campylobacter strains were tested for theirsusceptibility to various antimicrobial agents byusing disc diffusion methods on Muller-Hintonagar (Difco, Sparks, MD, USA) supplementedwith 5% sheep blood. The plates were incubatedat 37 ◦C for 24 h in a microaerophilic atmo-sphere. The antibiotics tested included ampicillin(10�g/disc), tetracycline (30�g/disc), ery-thromycin (15�g/disc), ciprofloxacin (5�g/disc),furazolidine (100�g/disc) and gentamicin(10�g/disc). Susceptibility categorization wasdone according to National Committee for ClinicalLaboratory Standards (NCCLS) recommendations(NCCLS, 1997). Resistance to ciprofloxacin anderythromycin was further confirmed by an agardilution method using two-fold dilutions (256�g to0wmcpupMtmdattT

plate without antibiotic was inoculated in eachseries. Complete inhibition of macroscopic growthafter 48 h incubation was taken as the endpoint.Quality control guidelines established by the NCCLSwere followed (NCCLS, 1997).

2.4. Detection of �-lactamase

Production of �-lactamase by Campylobacterstrains was detected using cefinase discs (Difco,Sparks, MD, USA) according to the manufacturer’sinstructions.

3. Results

A total of 1750 individuals was surveyed and diar-rhoeal illnesses were reported in 348. Age-specificprevalence of diarrhoea in the community is pre-sented in Table 1. The overall prevalence of di-arrhoea in the community under study was 19.9%.Parasitic and bacterial aetiological agents were de-tected in 33 and 17.8% of diarrhoeal cases respec-tively (P < 0.001) (Table 1).

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.25�g/ml) of each drug. Resistance breakpointsere defined according to NCCLS criteria: mini-um inhibitory concentration (MIC) ≥4�g/ml foriprofloxacin and ≥8�g/ml for erythromycin. Thelates were read after incubation at 37 ◦C for 48 hnder microaerophilic conditions. Inocula wererepared in Muller-Hinton broth (Difco, Sparks,D, USA); the density of inocula was adjustedo 0.5 McFarland standard for the disk diffusionethod and by a 1 in 10 dilution for the agarilution method. For the agar dilution method,1�l volume of each inoculum, corresponding

o approximately 5× 105 bacteria, was deliveredhrough a microplanter (Oriental Instruments Ltd.,okyo, Japan) onto Muller-Hinton agar. A control

Table 1 Age-related prevalence of diarrhoeal, bacter

Age (years) No. of individuals No. with dia

0—5 314 76 (24.2)5—15 519 96 (18.5)15—30 399 74 (18.5)30—45 325 58 (17.8)45—76 193 44 (22.8)

Total 1750 348 (19.9)

a Campylobacter species 47, Shigella species 11 and Salmonelb Giardia lamblia 69, Entamoeba histolytica/E. dispar 32, Stroc Bacterial vs. parasitic infections: P < 0.001.

Campylobacter species were isolated from7 (13.5%) of subjects with diarrhoea and 20.6%) of asymptomatic controls (P < 0.001). Theocio-epidemiological features and their associa-ion with Campylobacter infection are shown inable 2. The prevalence of Campylobacter in-ections in the community was not influencedy gender (Z = 0.579, P = 0.562), defaecation prac-ice (Z = 0.295, P = 0.768) or food habits (Z = 0.886,= 0.376). However, it was significantly highermong children aged less than 5 years (Z = 2.101,= 0.036). Children up to 5 years of age have abouttwo-fold higher risk of infection compared with in-ividuals agedmore than 5 years (RR = 1.837). Otherisk groups for Campylobacter infection were as

nd parasitic infections

ea (%) Pathogens isolated fromindividuals with diarrhoea n (%)

Bacteriala Parasiticb

18 (23.7) 22 (28.9)21 (21.9) 36 (37.5)11 (14.9) 26 (35.1)5 (8.6) 19 (32.8)7 (15.9) 12 (27.3)

62 (17.8)c 115 (33.0)c

cies 4.oides stercoralis 5, mixed parasites 9.

210 D. Jain et al.

Table 2 Socio-epidemiological determinants of Campylobacter infection and relative risk

Campylobacter infection Statistical significance Relative risk (95% CI)

Present (%) Total subjects Z P value

Age group (years)0—5 16 (10.96) 146 2.101 0.036 1.837 (0.988—3.340)6—76 33 (5.97) 553

GenderMale 26 (7.58) 343 0.579 0.562 1.173 (0.659—2.092)Female 23 (6.46) 356

OccupationAgriculture 14 (11.02) 127 1.958 0.050 1.802 (0.943—3.341)Othera 35 (6.12) 572

DefaecationOpen field 41 (7.14) 574 0.295 0.768 1.116 (0.521—2.542)Toilet 8 (6.40) 125

Hand wash (post-defaecation)With soap 16 (4.27) 375 3.056 0.002 2.387 (1.297—4.465)Without soap 33 (10.19) 324

Food habitNon-vegetarian 31 (7.75) 400 0.886 0.376 1.287 (0.711—2.358)Vegetarian 18 (6.02) 299

DiarrhoeaPresent 47 (13.50) 348 6.698 0.000 23.703 (5.769—140.835)Absent 2 (0.57) 351

Abdominal painPresent 11 (18.64) 59 3.349 0.001 2.865 (1.429—5.389)Absent 38 (6.51) 584

a Service, skilled worker, business.

follows: households (families) having agriculture astheir main occupation (RR = 1.802), individuals whodid not wash their hands with soap after peri-analwashing following defaecation (RR = 2.387), and in-dividuals with diarrhoea (RR = 23.703) and abdomi-nal pain (RR = 2.865) (Table 2). Only 2 (4.3%) of 47Campylobacter-infected individuals with diarrhoeahad blood in their stool and the remaining 45 hadwatery or mucoid diarrhoea.

In 36 (76.6%) of subjects with diarrhoea, Campy-lobacter was the sole enteric pathogen and in theother 11 (23.4%) cases, it was associated with pro-tozoal pathogens. Campylobacter jejuni was themost common species isolated (41/49; 83.7%), fol-lowed by C. coli (7/49; 14.3%) and C. lari (1/49;2%). Shigella species were isolated from 11 (3.0%)and Salmonella species from 4 (1.1%) subjects withdiarrhoea. The frequency of isolation of Campy-lobacter species from subjects with diarrhoea wassignificantly higher than the combined frequencyof Salmonella and Shigella (47/348 vs. 15/348;P < 0.001). The distributions of bacterial pathogens

in the diarrhoeal and healthy populations are shownin Table 3.

The frequency of resistance to various antibioticsby disc diffusion was as follows: ampicillin 81.6%(40/49), gentamicin 10.2% (15/49), ciprofloxacin71.4% (35/49), tetracycline 26.5% (13/49), furazo-lidine 14.3% (7/49) and erythromycin 6.1% (3/49).Resistance to single drugs or two-drug combina-tions was detected in 59.2% (29/49) strains; themost common combination being ampicillin andciprofloxacin (21/49; 42.9%). Multidrug (more thantwo drugs) resistance was observed in 30.6% (15/49)strains; ampicillin, tetracycline and quinolone(7/49; 14.3%) was the most common combination(Table 4). Only 5 (10.2%) strains were sensitive toall antibiotics tested. Resistance to ciprofloxacinand erythromycin was further confirmed by agardilution; the MICs of resistant strains rangedfrom 4 to 128�g/ml for ciprofloxacin and from8 to 16�g/ml for erythromycin. All ampicillin-resistant strains were found to be �-lactamasepositive.

Campylobacter species and drug resistance 211

Table 3 Distribution of bacterial pathogens in diarrhoeal and healthy (asymptomatic) populations

Study population Campylobacter species isolated Other bacterial pathogens

C. jejuni C. coll C. lari Total (%) Salmonella Shigella Total (%)

Diarrhoeal (n = 348) 39 7 1 47 (13.5)a,b 4 11 15 (4.3)b

Healthy control (n = 351) 2 0 0 2 (0.6)a 0 0 0

a Diarrhoeal vs. healthy population: 47/348 vs. 2/351; P < 0.001.b Campylobacter vs. Salmonella and Shigella combination in diarrhoea: 47/348 vs. 15/348; P < 0.001.

Table 4 Resistance of Campylobacter species (n = 49) to various antibiotics

Antibiotic Campylobacter speciesa Total (%)

C. jejuni C. coli C. lari

Single drug/two drugsAm 2 0 0 2Am+Tc 2 0 0 2Am+E 1 0 0 1Am+Cf 17 3 1 21E +Cf 0 1 0 1Tc + Fz 1 0 0 1Tc +G 1 0 0 1

Total 24 4 1 29 (59.2)

Multiple drugsAm+Cf +G 2 0 0 2Am+Cf + Fz 3 0 0 3Am+Tc +Cf 5 2 0 7Am+Tc + E + Fz 1 0 0 1Am+Cf + Fz +G 0 1 0 1Tc +Cf + Fz +G 0 1 0 1

Total 11 4 0 15 (30.6)

Am: ampicillin; Tc: tetracycline; E: erythromycin; Cf: ciprofloxacin: Fz: furazolidine; G: gentamicin.a Five strains (10.2%) were sensitive to all antibiotics tested.

4. Discussion

The epidemiology of Campylobacter infection dif-fers markedly between developed and develop-ing countries. High carriage rates of Campylobac-ter species have been reported from many de-veloping countries (Oberhelman and Tayor, 2000)and also infections with multiple pathogens arecommon in patients with diarrhoea from the de-veloping world. In the present prospective cross-sectional study, 20% of individuals from a rural com-munity in north India presented with diarrhoea;parasites causing diarrhoea were more frequentlydetected than bacterial pathogens. Among the bac-terial pathogens, infections due to Campylobac-ter species were significantly higher than that ofcombined Salmonella and Shigella species. A CDCconducted study at eight USA hospitals showedthat Campylobacter species were isolated twice

as often as Salmonella and 4.5 times as often asShigella (Blaser et al., 1983). Later studies alsoconfirmed that Campylobacter infections were de-tected 2—7 times as frequently as infections withSalmonella species, Shigella species or Escherichiacoli O157:H7 (Slutsker et al., 1997). Our study sug-gests that Campylobacter infection is several-foldhigher than the combined Salmonella and Shigellainfection at the community level. It appears thatCampylobacter infection is grossly under-reportedcompared with Salmonella and Shigella from ru-ral India, possibly because of lack of laboratory fa-cilities to culture Campylobacter species. Currentestimates even from the developed world suggestthat only 1 in 38 cases of Campylobacter infec-tion is reported (Mead et al., 1999). Some earlierstudies have reported that Campylobacter speciesare isolated almost in equal proportions from per-sons with diarrhoea and healthy individuals in the

212 D. Jain et al.

developing world. The present study in a rural com-munity demonstrated that isolation of Campylobac-ter species was significantly higher in cases withdiarrhoea (13.5%) compared with age- and gender-matched healthy individuals (0.6%). We reportedsimilar observations in our earlier hospital-basedstudies (Prasad et al., 1991, 2001). The presentreport, like our earlier studies, suggests that theasymptomatic carriage rate of Campylobacter islow, at least in this part of north India. Someother developing countries have also reported thatCampylobacter was mostly isolated from diarrhoealpopulations (De Mol and Bosnians, 1978; De Mol etal., 1983).

Although Campylobacter infection was detectedin all age groups of our study populations, chil-dren aged less than 5 years were most commonlyaffected and the RR of infection was higher thanfor persons above that age. Demographic data fromother developing countries also suggest that chil-dren aged less than 5 years are commonly affected(Oberhelman and Tayor, 2000). Campylobacter af-fects all age groups in the developed world but hasa bimodal age distribution with one peak in chil-dren aged less than 4 years and another peak in

acquiring this infection. Person to person spreadthrough food etc. contaminated by unwashed handsmight be responsible for high infection rates insuch families. Although Campylobacter infectionsin the developed world are attributed to eatingchicken and other animal products (Friedman et al.,2000), we could not find any difference in infec-tion rates between families who ate non-vegetariandiets (poultry and other meat products) and veg-etarian diets, probably because consumption ofraw/undercooked poultry and meat products is notthe usual practice in the rural community of northIndia.

Campylobacter-associated clinical illnesses dif-fer markedly between developed and developingcountries. In developed countries, grossly bloodystool and abdominal pain, often with fever, arethe characteristic presentations of campylobacte-riosis, while in developing countries Campylobac-ter infections are usually milder and present withwatery/mucoid diarrhoea (Friedman et al., 2000;Taylor et al., 1988). In the present study, diarrhoeaand abdominal pain had significant association withCampylobacter infection but only 4.3% of the in-fected populations had blood in their stools.

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young adults aged 15—44 years (Friedman et al.,2000). Compared with the developed world, multi-ple enteric pathogens are commonly isolated frompatients with diarrhoea in developing countries.Campylobacter species were isolated from 18% ofThai children with diarrhoea and half of them har-boured another enteric pathogen (Taylor et al.,1988). In the present study, only 23.4% of Campy-lobacter - infected persons with diarrhoea also har-boured a protozoal enteric pathogen.

The socio-epidemiological determinants associ-ated with Campylobacter infection are little under-stood. In the present case-control study, householdsengaged in agriculture had a high RR of Campy-lobacter infection. In rural India, farmers use cattleto cultivate land for agriculture and almost all agri-culturists have cattle that share the same dwellingarea with other family members. Campylobactershave long been recognized as a cause of diarrhoea incattle (Friedman et al., 2000); direct contact withcattle and transmission from cattle is likely to beassociated with the high prevalence of Campylobac-ter infection in these households.

Most rural Indians have the habit of open fielddefaecation and peri-anal washing after defaeca-tion. Although open field defaecation was not as-sociated with increased rate of Campylobacter in-fection, people who did not wash their hands withsoap or other detergent after peri-anal washing fol-lowing defaecation had significantly higher ratesof Campylobacter infection with increased RR of

Susceptibility testing of Campylobacter speciess important to facilitate appropriate treatmenthere indicated and also for surveillance of emer-ence of drug resistance. We observed a sharpncrease in resistance to ampicillin, ciprofloxacinnd tetracycline compared with our earlier re-ort (Prasad et al., 1994) on human strains iso-ated from 1989 to 1993 (81.6% vs. 26.6%, 71.4%s. 4.4% and 26.5% vs. 11.1% respectively); how-ver, resistance to erythromycin remained almosttable (6.1% vs. 4.4%). All our ampicillin-resistanttrains were found to produce �-lactamase. Al-hough ampicillin is not recommended for the treat-ent of Campylobacter infection (Gaudreau andilbert, 1998), high �-lactamase-mediated resis-ance in a rural community is a major concern be-ause of possible transfer of resistance to otheracteria responsible for community-acquired infec-ions. In Canada, 0, 12.7 and 55.7% of C. jejunitrains isolated in 1995—1997 were resistant to ery-hromycin, ciprofloxacin and tetracycline respec-ively; increase in resistance to both ciprofloxacinnd tetracycline was significantly higher whenompared to strains isolated in 1992—1993 and985—1986 (Gaudreau and Gilbert, 1998). In north-est England and Wales, resistance to quinolonesccurred in 12% of strains (Thwaites and Frost,999). In the USA, 0, 2 and 55% of campylobac-ers isolated from 1982 to 1992 were resistanto ciprofloxacin, erythromycin and tetracycline re-pectively (Nachamkin, 1994). In Minnesota (USA),

Campylobacter species and drug resistance 213

fluoroquinolone resistance among campylobactersisolated from humans increased from 1.3% in 1992to 10.2% in 1998 (Smith et al., 1999). Recent datafrom Taiwan, Spain and Thailand show that 56.7, 84and 88% of C. jejuni/C. coli strains respectively areresistant to fluoroquinolones (Gallardo et al., 1998;Hoge et al., 1998; Li et al., 1998). In most cases,rapid emergence of quinolone resistance in Campy-lobacter species is related to inadequate clinicaluse or overuse to treat human infections or use ofquinolones in veterinary practice. It has been re-ported that fluoroquinolone resistance in Campy-lobacter can occur in vivo, sometimes even afterone or two administrations of the drug (Adler etal., 1991).

Multidrug resistance was detected in 30.6% ofour C. jejuni/C. coli strains and the most fre-quent combination was ampicillin, tetracycline andciprofloxacin (14.9%). This differs markedly fromwhat we had reported earlier in Campylobacterspecies isolated from north India during 1989—1993when multidrug resistance was detected only in2.2% strains (Prasad et al., 1994). Hoge et al.(1998) reported 100% co-resistance to azithromycinand ciprofloxacin in Thailand. Li et al. (1998) re-

References

Adler, M., Luthy, H., Martinetti, L., Burnens, A., Altwegg,M., 1991. Development of resistance to quinolones in fivepatients with campylobacteriosis treated with norfloxacinor ciprofloxacin. Eur. J. Clin. Microbiol. Infect. Dis. 10,953—957.

Blaser, M.J., Taylor, D.N., Feldman, R.A., 1984. Epidemiologyof Campylobacter infections. In: Butzler, J.P. (Ed.), Campy-lobacter infections in man and animals. CRC Press Inc., BocaRaton, FL, pp. 143—161.

Blaser, M.J., Wells, J.G., Feldman, R.A., Pollard, R.A., Allen,J.R., 1983. Campylobacter enteritis in the United States: amulticentre study. Ann. Intern. Med. 98, 360—365.

Bopp, C.A., Brenner, F.W., Wells, J.G., Strockbine, N.A., 1999.Escherichia, Salmonella and Shigella. In: Murray, P.R., Baron,E.J., Pfaller, M.J., Tenover, F.C., Yolken, R.H. (Eds.), Manualof Clinical Microbiology, seventh ed. ASM Press, Washington,DC, pp. 459—474.

De Mol, P., Bosnians, E., 1978. Campylobacter enteritis in CentralAfrica. Lancet i, 604.

De Mol, P., Brasseur, D., Hemelhof, W., Kalala, T., Butzler, J.P.,Vis, H.L., 1983. Enteropathogenic agents in children withacute diarrhoea in rural Zaire. Lancet i, 516—518.

Friedman, C.R., Neimann, J., Wegener, H.C., Tauxe, R.V.,2000. Epidemiology of Campylobacter jejuni infections inthe United States and other industrialized nations. In:Nachamkin, I., Blaser, M.J. (Eds.), Campylobacter, seconded. ASM Press, Washington, DC, pp. 121—138.

Gallardo, F., Gascon, J., Ruiz, J., Corachan, M., de Anta, M.T.,

G

G

H

L

L

M

N

N

N

Vila, J., 1998. Campylobacter jejuni as a cause of traveler’sdiarrhea: clinical features and antimicrobial susceptibility. J.Travel Med. 5, 23—26.

audreau, C., Gilbert, H., 1998. Antimicrobial resistance of clin-ical strains of Campylobacter jejuni subsp. jejuni isolatedfrom 1985 to 1997 in Quebec, Canada. Antimicrob. AgentsChemother. 42, 2106—2108.

oosens, H., Butzler, J.P., 1992. Isolation and identification ofCampylobacter spp. In: Nachamkin, I., Blaser, M.J., Tomp-kins, L.S. (Eds.), Campylobacter jejuni: current status andfuture trends. American Society for Microbiology, Washing-ton, DC, pp. 93—109.

oge, C.W., Gambel, J.M., Srijan, A., Pitarangsi, C., Echever-ria, P., 1998. Trends in antibiotic resistance among diarrhealpathogens isolated in Thailand over 15 years. Clin. Infect.Dis. 26, 341—345.

i, C.C., Chiu, C.H., Wu, J.L., Huang, Y.C., Lin, T.Y., 1998. An-timicrobial susceptibilities of Campylobacter jejuni and coliby using E-test in Taiwan. Scand. J. Infect. Dis. 30, 39—42.

inton, D., Lawson, A.J., Owen, R.J., Stanley, J., 1997. PCR de-tection, identification to species level, and fingerprinting ofCampylobacter jejuni and Campylobacter coli direct fromdiarrheic samples. J. Clin. Microbiol. 35, 2568—2572.

ead, P.S., Slutsker, L., Dietz, V., Griffin, P.M., Tauxe, R.V., 1999.Food-related illness and death in the United States. Emerg.Infect. Dis. 5, 607—625.

achamkin, I., 1994. Antimicrobial susceptibility of Campy-lobacter jejuni and Campylobacter coli to ciprofloxacin, ery-thromycin and tetracycline from 1982 to 1992. Med. Micro-biol. Lett. 3, 300—305.

achamkin, I., 1999. Campylobacter and Arcobacter. In: Mur-ray, P.R., Baron, E.J., Pfaller, M.J., Tenover, F.C., Yolken,R.H. (Eds.), Manual of Clinical Microbiology, seventh ed. ASMPress, Washington, DC, pp. 716—726.

CCLS (National Committee for Clinical Laboratory Standards),1997. Methods for dilution antimicrobial tests for bacteria

ported concomitant resistant to quinolones and ery-thromycin, clindamycin, gentamicin and tetracy-cline in various proportions. Emergence of mul-tidrug resistance calls for regular monitoring of an-timicrobial resistance in Campylobacter species toinitiate appropriate therapy when needed.

The present study shows that Campylobacterinfection is more frequent than Salmonella andShigella in a rural community of this part ofnorth India. High-risk groups for infection in-clude children aged less than 5 years, familieswith agriculture as an occupation and individ-uals who do not wash their hands with soap ordetergent after defaecation. High frequency ofciprofloxacin resistance and multidrug resistancein Campylobacter species appear to be a majorchallenge.

Conflicts of interest statementThe authors have no conflicts of interest to reportconcerning the work reported in this paper.

Acknowledgements

This study was supported by Indian Council of Med-ical Research (grant reference no. 5/3/3/2/2000-ECD-I) and an intramural research grant from SanjayGandhi Postgraduate Institute of Medical Sciences,Lucknow 226014, India.

214 D. Jain et al.

that grow aerobically. In: Approved standard., fourth ed. Na-tional Committee for Clinical Laboratory Standards, Wayne,PA, NCCLS publication no. M7-A4.

Oberhelman, R.A., Tayor, D.N., 2000. Campylobacter infec-tions in developing countries. In: Nachamkin, I., Blaser, M.J.(Eds.), Campylobacter, second ed. ASM Press, Washington,DC, pp. 139—154.

On, S.L.W., 1996. Identification methods for Campylobacters,Helicobacter and related organisms. Clin. Microbiol. Rev. 9,947—953.

Prasad, K.N., Anupurba, S., Dhole, T.N., 1991. EnterotoxigenicCampylobacter jejuni & C. coli in the etiology of diarrhea innorthern India. Indian J. Med. Res. 93, 81—86.

Prasad, K.N., Dixit, A.K., Ayyagari, A., 2001. Campylobacterspecies associated with diarrhoea in patients from a ter-tiary care centre of north India. Indian J. Med. Res. 114, 12—17.

Prasad, K.N., Mathur, S.K., Dhole, T.N., Ayyagari, A., 1994.Antimicrobial susceptibility and plasmid analysis of Campy-

lobacter jejuni isolated from diarrhoeal patients and healthychickens in northern India. J. Diarrhoeal Dis. Res. 12,270—273.

Slutsker, L.A., Ries, A.A., Greene, K.D., Wells, J.G., Hutwagner,L., Griffin, P.M., 1997. Escherichia coli O157:H7 diarrhoeain the United States: clinical and epidemiological features.Ann. Intern. Med. 126, 505—513.

Smith, K.E., Besser, J.M., Hedberg, C.W., Leano, F.T., Ben-der, J.B., Wicklund, J.H., Johnson, B.P., Moore, K.A., Oster-holm, M.T., 1999. Quinolone-resistant Campylobacter jejuniinfections in Minnesota, 1992—1998. N. Engl. J. Med. 340,1525—1532.

Taylor, D.N., Echeverria, P., Pitarangsi, C., Seriwatana, J., Bod-hidatta, L., Blaser, M., 1988. Influence of strain character-istics and immunity on the epidemiology of Campylobacterinfections in Thailand. J. Clin. Microbiol. 26, 863—868.

Thwaites, R.T., Frost, J.A., 1999. Drug resistance in Campylobac-ter jejuni, C. coli, and C. lari isolated from humans in NorthWest England and Wales. J. Clin. Pathol. 52, 812—814.