E D I T O R I A L C O M M E N TA R Y
The Health Burden of Campylobacter Infection
and the Impact of Antimicrobial Resistance: Playing Chicken
Guillermo M. Ruiz-Palacios
National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
(See the brief report by Ternhag et al. on pages 696–700)
Campylobacter species are among the most
common pathogens in humans and are
commensal in birds, swine, and cattle. It
is the most common cause of culture-
proven bacterial gastroenteritis in devel-
oped and developing countries, respon-
sible for 400 million–500 million cases of
diarrhea each year. In the United States,
11% of the population acquires the in-
fection each year. Although diarrhea is the
most frequent clinical manifestation of
Campylobacter species infection, a broad
clinical spectrum is associated with this
infection, from asymptomatic carriage to
systemic illness and bacteremia to local-
ized infection and association with Guil-
lain-Barré syndrome, a severe immuno-
reactive complication.
In the United States, an estimated 2 mil-
lion cases of campylobacteriosis occur
each year. It is the most common bacterial
cause of foodborne illness [1]. The overall
incidence of laboratory-confirmed Cam-
pylobacter infection in 2005 in the United
States was 12.7 cases per 100,000 popu-
lation, representing a 30% decrease since
Received 25 September 2006; accepted 25 September
2006; electronically published 25 January 2007.
Reprints or correspondence: Dr. Guillermo M. Ruiz-Palacios,
National Institute of Medical Science and Nutrition, Vasco
de Quiroga 15, Tlalpan, 14000 Mexico (gmrps@servidor
.unam.mx).
Clinical Infectious Diseases 2007; 44:701–3
 2007 by the Infectious Diseases Society of America. All
rights reserved.
1058-4838/2007/4405-0013$15.00
DOI: 10.1086/509936
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1996 [2]. However, the incidence of symp-
tomatic Campylobacter species infection
has been estimated at 760–1100 cases per
100,000 population [3]. Age-specific rates
of Campylobacter jejuni isolation in pa-
tients with diarrhea differ among coun-
tries. In industrialized countries, C. jejuni
is isolated from 5%–16% of children with
diarrhea, with a prevalence of infection in
healthy children of 0%–1.5% [1]. In chil-
dren !5 years of age, the incidence of lab-
oratory-confirmed Campylobacter species
infection is 43.4 cases per 100,000 person-
years (up to 54.3 cases per 100,000 person-
years in children !1 year of age), and the
associated male-female ratio is 1.34:1 [4].
It is the third most common cause of hos-
pitalization for gastroenteritis after rota-
virus and Salmonella species infection,
with a hospitalization rate of 10.8% for all
Campylobacter species infections [5–7].
Studies of the disease burden of Campy-
lobacter species infection in The Nether-
lands have estimated that intestinal infec-
tion in general accounts for 67,000
disability-adjusted life years per year and
that Campylobacter species infections rep-
resent at least one-third of the disease bur-
den of all intestinal infections [8]. The cost
per case of gastrointestinal infection in Eu-
rope has been estimated to be US$94–
US$132. In England, the total cost of gas-
trointestinal infections was estimated to be
US$1.23 billion each year. Of this amount,
US$116 million is spent on cases of Cam-
EDITORIAL COMMENTARY • CID 2007:44 (1 March) • 701
pylobacter species infection, the highest
cost associated with a particular pathogen
(including rotavirus and Salmonella) [9].
Campylobacter species infection is gen-
erally associated with mild illness and only
occasionally is fatal [10]. The mortality
rate associated with symptomatic Cam-
pylobacter species infection has been esti-
mated at 24 deaths per 10,000 culture-
confirmed cases, or 200 deaths per year in
the United States [3].
In areas of endemicity in developing
countries, the isolation rate in children
with diarrhea is 8%–45%, with a similar
rate of isolation in asymptomatic children
[11–14]. Infections occur early in life, with
the highest proportion of C. jejuni isolates
obtained from children !5 years of age
[12–14]. The annual incidence of Cam-
pylobacter species infections can be as high
as 2.1 episodes per child. Infections ac-
quired early in life are more likely to be
associated with diarrhea, whereas those
occurring beyond the age of 4 years, al-
though relatively common, are mostly
asymptomatic [12].
Rehydration and correction of electro-
lyte abnormalities are the mainstay of
treatment of patients with Campylobacter
species enteritis. Debate exists over the
need to administer antimicrobial agents
in uncomplicated infections. Antibiotic
treatment should be considered for C. je-
juni–infected patients who have bloody di-
arrhea, fever, worsening of symptoms, or
 a large number of stools, or in those who
are immunosuppressed. Campylobacter
species are often resistant to penicillin,
ampicillin, and cephalosporins, as a result
of an alarming increase in fluoroquino-
lone resistance in the past decade in most
countries [15]. This increase in fluoro-
quinolone resistance coincides with the re-
cent licensure of fluoroquinolones (saraf-
loxacin and enrofloxacin) for use in
poultry and in veterinary medicine in gen-
eral, which has increased the reservoir of
resistant Campylobacter species [16]. Most
strains of C. jejuni and Campylobacter coli
are susceptible to erythromycin, azithro-
mycin, gentamicin, tetracycline, and chlo-
ramphenicol [17]. When antibiotic ther-
apy is indicated, erythromycin is the drug
of choice and is administered for 5–7 days
[18]. Campylobacter species have little pro-
pensity to select for plasmid-mediated re-
sistance to erythromycin, although resis-
tance to this antibiotic has been reported
in many countries where it is used indis-
criminately [19]. Studies have shown no
clinical benefit of erythromycin therapy
versus placebo if administered late in the
course of illness. Shedding of the organism
can persist for 2 weeks to 3 months in
immunocompetent hosts who are not
treated with antibiotics. Furazolidone or
azithromycin may be useful in the treat-
ment of C. jejuni infections of the gastro-
intestinal tract. In severe sepsis, parenteral
antibiotics are necessary. Although it is
rarely associated with mortality, Campy-
lobacter infection is an important public
health concern as a consequence of its
high incidence, its frequent association
with severe diarrhea, and the occurrence
of extraintestinal complications, such as
Guillain-Barré syndrome. Thus, treatment
of this infection is justified on this basis.
However, several observations lead to
questioning of the beneficial effects of an-
tibiotics. First, a significant clinical effect
is only observed when treatment is estab-
lished early during the course of illness, as
suggested by the meta-analysis study by
Ternhag et al. [21], published in this issue
of Clinical Infectious Diseases. Second, no
702 • CID 2007:44 (1 March) • EDITORIAL COMMENTARY
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information is available on the outcome
of the use of effective treatment to prevent
extraintestinal immunoreactive compli-
cations. Third, there has recently been an
alarming emergence of drug resistant
strains, especially fluoroquinolone-resis-
tant strains, as a consequence of antibiotic
misuse in veterinary medicine. Several
studies have shown that patients infected
with a quinolone- or erythromycin-resis-
tant strain of Campylobacter species have
an increased risk of an adverse event, com-
pared with patients infected with quino-
lone- and erythromycin-susceptible Cam-
pylobacter species strains, and that
infection with quinolone- or erythromy-
cin-resistant Campylobacter species strains
causes a longer duration of illness [19, 20].
There are very few randomized studies
that compare antibiotics with placebo for
the treatment of Campylobacter species–
related diarrhea. Some of these studies
show that antibiotics have no effect; there-
fore, the meta-analysis study by Ternhag
et al. [21], which includes all relative pub-
lished trials, is justified. This analysis
clearly shows a significant decrease in
symptoms and bacterial shedding time;
further, although not significant, a trend
was observed for a beneficial effect of an-
tibiotics only when early treatment was
started. When analyzing individual stud-
ies, this effect is more evident for severe
diarrhea, dysentery-related diarrhea, and
diarrhea in more-susceptible individuals
and in travelers. Therefore, to be effective,
antimicrobial treatment should be initi-
ated early in the course of illness and
should include active antibiotics. Unfor-
tunately, the high resistance of this organ-
ism to quinolones and the rapid emer-
gence of erythromycin-resistant strains
limit the available options, leaving the
problem of treatment of Campylobacter
species infections unresolved. Thus, pre-
vention and control programs become rel-
evant and should focus on (1) banning
the use of antibiotics as growth promoters
in poultry farms at the international level,
especially in countries with emerging
economies where antibiotic use is unre-
stricted; (2) universal implementation of
control systems to prevent transmission of
Campylobacter species in intensive poultry
industries; and (3) the promotion of
health education in populations at risk.
The research on new anti-infective agents
that appear to avoid the drug resistance,
such as agents that use synthetic receptor
analogue oligosaccharides and glycocon-
jugates, as well as pre- and probiotics, is
warranted [22].
Acknowledgments
Potential conflicts of interest. G.M.R-P.: no
conflicts.
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