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Multidrug-resistant Campylobacter coli in men who have sex with men, Quebec, Canada, 2015.

To the Editor: In 2015, an outbreak of multidrug-resistant Campylobacter coli was documented in Montreal, Quebec, Canada. We report results of an epidemiologic and molecular investigation suggesting a sexually transmitted enteric infection among men who have sex with men (MSM).

The ethics committee of Centre Hospitalier de l'Universite de Montreal approved the research. During January 14-February 7, 2015, six men 35-62 years of age were documented with an enteric, erythromycin-, tetracyclineand ciprofloxacin-resistant C. coli pulsovar 15 infection. All 6 men had diarrhea; 5 had abdominal pain; 1 had fever [greater than or equal to] 39[degrees]C; 1 had blood in feces; and 1 had vomiting. No extraintestinal focus was documented in these patients.

Five men were evaluated in the outpatient clinic or emergency department; 1 man was hospitalized for 3 days. Five patients were treated with an antimicrobial agent. Three were treated orally for 4-7 days: 1 with ciprofloxacin, 1 with azithromycin, and 1 with both drugs. One patient was treated for 3 days with intravenous ceftriaxone and vancomycin followed by 10 days of amoxicillin for simultaneous Streptococcus pneumoniae septicemia. One man was treated with 1 intramuscular ceftriaxone dose, doxycycline for 21 days, and intravenous ertapenem for 3 days for proctitis and enterocolitis. All patients recovered with treatment (in vitro susceptible or resistant agent) or without treatment.

The 6 men reported to be MSM. The week before symptom onset, 4 men reported having had unprotected sex, 2 in bathhouses. Before the C. coli incubation period and after the outbreak started, 1 of these 2 men had traveled to the Caribbean but did not have sexual relations there. These men were not explicitly linked to each other. Five men were HIV positive; 1 was HIV negative. The 5 HIV-positive men had CD4 counts ranging from 210 to 1,150 x [10.sup.6] cells/L and HIV viral load of <40 copies/mL. Since 2010, the 6 men had 15 documented sexually transmitted infections (STIs) other than HIV, 1-3 (median 3) STIs per patient: 4 Treponema pallidum infections; 3 Chlamydia trachomatis infections (1 rectal C. trachomatis serovar L2b, a lymphogranuloma venereum agent); 4 Neisseria gonorrhoeae infections; 3 Shigella spp. infections; and 1 C. jejuni infection.

The Laboratoire de Sante Publique du Quebec (LSPQ, Sainte-Anne-de-Bellevue, QC, Canada) confirmed the 6 C. coli infections using cpn60 gene sequencing (1). Drug susceptibility testing was done by using disk diffusion method for nalidixic acid and Etest (AB Biodisk, Solna, Sweden) for 12 other agents (1-3).The susceptibility and resistance breakpoints were Clinical and Laboratory Standards Institute Campylobacter, Enterobacteriaceae, and other breakpoints as reported (1-4). The 6 C. coli pulsovar 15 were resistant to erythromycin, azithromycin, clarithromycin, clindamycin, tetracycline, ciprofloxacin, nalidixic acid, ampicillin, and cefotaxime. All isolates were susceptible to amoxicillin/clavulanic acid, imipenem, ertapenem, and gentamicin. The 6 isolates were [beta]-lactamase positive in <1 min with nitrocefin disk. Pulsed-field gel electrophoresis, done at LSPQ as described by PulseNet Canada procedures (1), showed that the 6 isolates presented the same pattern with both SmaI and KpnI enzymes designed pulsovar 15 (Figure).

These phenotypic, epidemiologic, and molecular data confirmed a cluster of an erythromycin-, tetracycline-, and ciprofloxacin-resistant C. coli pulsovar 15 infections in Montreal, Quebec, Canada, during January-February 2015. Epidemiologic data suggested enteric STIs. All 6 patients reported being MSM; 4 reported having unprotected sex the week before symptom onset; 5 were HIV-positive; the 6 men had 15 other STIs; and no food was suspected to be the source of the infection.

Campylobacter is an important human enteropathogen bacterium, and C. coli is the second most frequently reported species (4-6). Few C. coli clusters have been reported, and the outbreaks caused by this Campylobacter species might be underestimated (1,7). At the LSPQ, a high heterogeneity was documented in C. coli isolates characterized routinely from suspected outbreaks during 2011-2015 (Figure) (1; this study). The erythromycin, tetracycline, and ciprofloxacin susceptibilities were epidemiologic markers in this study and in previous studies (1,8). The presence of a strong [beta]-lactamase with resistance to ampicillin was also a marker in this study; epidemic C. jejuni and C. coli isolates were [beta]-lactamase negative with susceptibility to ampicillin in previous outbreaks in MSM (1,8). Higher proportions of C. coli isolates are erythromycin- and multidrug-resistant than are C. jejuni isolates (4,6). When indicated, the proper antimicrobial treatment of enteric erythromycin- and ciprofloxacin-resistant Campylobacter spp. is not known because no clinical studies have been done for infections with such isolates, but tetracycline or amoxicillin/clavulanic acid can be used if isolates are susceptible in vitro (1,8; this study).

MSM should be counseled about preventing STIs, including enteric infections. Barriers should be used during genital, oral, and anal sex, and genital and hand washing before and after sex should be done (9,10). Our study increases evidence of clusters of Campylobacter STIs in MSM (1,8).


We thank the personnel of bacteriology sections of Centre Hospitalier de l'Universite de Montreal-Hopital Saint-Luc and of LSPQ for technical assistance.


(1.) Gaudreau C, Helferty M, Sylvestre JL, Allard R, Pilon PA, Poisson M, et al. Campylobacter coli outbreak in men who have sex with men, Quebec, Canada, 2010-2011. Emerg Infect Dis. 2013; 19:764-7.

(2.) Clinical and Laboratory Standards Institute. Methods for antimicrobial dilution and disk susceptibility testing for infrequently-isolated or fastidious bacteria: approved guidelines (M45). 3rd ed. Wayne (PA): The Institute; 2015.

(3.) Clinical and Laboratory Standards Institute. Performance standards for antimicrobial susceptibility testing; 24th informational supplement (M100S). 26th ed. Wayne (PA): The Institute; 2016.

(4.) Centers for Disease Control and Prevention. National Antimicrobial Resistance Monitoring System. Enteric bacteria 2013 [cited 2016 Feb 29]. Human isolates final report. reports/

(5.) Crim SM, Griffin PM, Tauxe R, Marder EP, Gilliss D, Cronquist AB, et al.; Centers for Disease Control and Prevention. Preliminary incidence and trends of infection with pathogens transmitted commonly through food--Foodborne Diseases Active Surveillance Network, 10 U.S. sites, 2006-2014. MMWR Morb Mortal Wkly Rep. 2015; 64:495-9.

(6.) Gaudreau C, Boucher F, Gilbert H, Bekal S. Antimicrobial susceptibility of Campylobacter jejuni and Campylobacter coli in Montreal, Quebec, Canada, 2002-2013. J Clin Microbiol. 2014; 52:2644-6.

(7.) Zeigler M, Claar C, Rice D, Davis J, Frazier T, Turner A, et al. Outbreak of campylobacteriosis associated with a long distance obstacle adventure race--Nevada, October 2013. MMWR Morb Mortal Wkly Rep. 2014; 63:375-8.

(8.) Gaudreau C, Rodrigues-Coutlee S, Pilon PA, Coutlee F, Bekal S. Long-lasting outbreak of erythromycin- and ciprofloxacin-resistant Campylobacter jejuni subsp. jejuni from 2003 to 2013 in men who have sex with men, Quebec, Canada. Clin Infect Dis. 2015; 61:1549-52.

(9.) Centers for Disease Control and Prevention. Ciprofloxacin- and azithromycin-nonsusceptible shigellosis in the United States. CDC Health Alert Network. June 4, 2015 [cited 2016 Jan 20].

(10.) Gaudreau C, Barkati S, Leduc JM, Pilon PA, Favreau J, Bekal S. Shigella spp. with reduced azithromycin susceptibility, Quebec, Canada, 2012-2013. Emerg Infect Dis. 2014; 20:854-6.

Christiane Gaudreau, Pierre A. Pilon, Jean-Loup Sylvestre, France Boucher, Sadjia Bekal

Author affiliations: Universite de Montreal, Montreal, Quebec, Canada (C. Gaudreau, P.A. Pilon, S. Bekal); Centre Hospitalier de l'Universite de Montreal, Montreal (C. Gaudreau, F. Boucher); Centre Integre Universitaire de Sante et de Services Sociaux du Centre-Sud-de-l'Tle-de-Montreal, Montreal (P.A. Pilon, J.-L. Sylvestre); Laboratoire de Sante Publique du Quebec/Institut National de Sante Publique du Quebec, Sainte-Anne-de-Bellevue, Quebec, Canada (S. Bekal)


Address for correspondence: Christiane Gaudreau, Microbiologie Medicale et Infectiologie, CHUM-Hopital Saint-Luc, 1058 rue Saint-Denis, Montreal, QC H2X 3J4, Canada; email:


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Title Annotation:LETTERS
Author:Gaudreau, Christiane; Pilon, Pierre A.; Sylvestre, Jean-Loup; Boucher, France; Bekal, Sadjia
Publication:Emerging Infectious Diseases
Article Type:Letter to the editor
Geographic Code:1CQUE
Date:Sep 1, 2016
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