Campylobacteriosis is an infectious disease caused by bacteria of the genus Campylobacter and is the most common reported bacterial cause of infectious intestinal disease in England and Wales.
17 species and 6 subspecies exist, many of which are considered pathogenic to humans, causing enteric and extra-intestinal illnesses. Two species are responsible for most cases of enteric campylobacteriosis: Campylobacter jejuni and Campylobacter coli. They both produce a similar illness.
Campylobacteriosis is a zoonosis - that is, a disease transmitted to humans from animals or animal products.The usual route of transmission is foodborne, through eating undercooked meat and meat products. Other sources include raw or contaminated milk and contaminated water or ice. Some cases occur following contact with contaminated water during recreational activities. There may be person-to-person transmission (faeco-oral route) with poor personal hygiene. Outbreaks occasionally occur in nurseries and institutions.
97% of sporadic disease can be attributed to animals farmed for meat and poultry. The Food Standards Agency (FSA) estimates 70-80% of campylobacteriosis in the UK comes from contaminated poultry, and a survey in 2007- 2008 found Campylobacter spp. to be present in 65% of chicken sold. At a similar time, a European Union study found the prevalence of Campylobacter spp. in broiler batches in the UK to be 71% and in broiler carcasses 76%, resulting in a management strategy to reduce this prevalence.
The incubation period can be between 1 and 11 days but is usually 2-5 days. There is limited information on the period of infectiousness but patients are probably not infectious if treated and diarrhoea has resolved.
According to the Health Protection Agency (HPA - now part of Public Health England) the incidence of Campylobacter spp. in England and Wales increased from 1989 to 2000, declined in numbers between 2000 and 2004 and has risen again since 2004. Campylobacter spp. cases reported to the HPA for England and Wales (isolated from all body sites) decreased from over 58,000 in 2000 to 44,544 in 2004; it increased thereafter to 65,032 in 2012. It has increased particularly in the older population and incidence has reduced in infants and children. A number of factors could contribute to these increased numbers - eg, an ageing population, increased travel, more eating out, changes in health-seeking behaviour.One study suggests that the rise is in fact an artefact caused by more stool samples being taken from older people.
- Undercooked meat, especially poultry.
- Pets with diarrhoea.
- Raw and inadequately pasteurised milk.
- Contaminated water supplies.
- Occupational exposure when processing poultry in abattoirs.
- Traveller's diarrhoea, particularly in Southeast Asia.
- 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 40°C and, 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.
- There may be tenesmus.
- In some cases, symptoms are mild.
- The person often looks ill.
- Temperature may be high or low but pyrexia is present in the majority.
- The abdomen is diffusely tender; however, tenderness may be more localised as right iliac fossa pain or left iliac fossa pain.
A sample of faeces sent for culture will usually isolate the organism. A stool culture is not always necessary. It is advisable to send a stool culture for a person with diarrhoea if:
- The person is systemically unwell.
- There is blood or pus in the stool.
- The person is immunocompromised.
- There is a history of recent hospital admission and/or antibiotic treatment.
- There is a recent history of foreign travel to anywhere other than Western Europe, North America, Australia, or New Zealand.
- Diarrhoea is persistent.
- There is uncertainty about the diagnosis.
- There is a potential public health risk (eg, food handlers, health workers, or in pinpointing the source of a local outbreak).
When sending a stool sample include information about recent travel, infectious contacts, possible food sources and clinical features. Where food poisoning with Campylobacter spp. is confirmed, the local health protection team should be notified.
In more severe illness, U&E and creatinine may show evidence of dehydration.
- Other infections - for example:
- Inflammatory bowel disease.
- Pseudomembranous enterocolitis secondary to Clostridium difficile.
- Intussusception in infants.
The basis of management is rehydration. Assess for features of rehydration or shock and, where present, consider hospital admission. This is not usually required.
This can usually be achieved by the oral route but, in more severe cases, intravenous fluids may be needed. Age-specific information on advice regarding rehydration is covered in the separate Gastroenteritis in Adults and Older Children and Gastroenteritis in Children articles.
Racecadotril is an intestinal antisecretory enkephalinase inhibitor that inhibits the breakdown of endogenous enkephalins.It reduces the hypersecretion of water and electrolytes into the intestine. It is licensed for the complementary symptomatic treatment of acute diarrhoea in children (aged over 3 months) together with oral rehydration and the usual support measures (dietary advice and increased daily fluid intake), when these measures alone are insufficient to control the clinical condition. It is not recommended for use within NHS Scotland for the treatment of acute diarrhoea in children because there is insufficient evidence that it improves the recovery rate.
These should not be used routinely but may be occasionally considered for adults:
- Who need to return to work or attend a special event.
- Who have difficulty reaching the toilet quickly.
- Who need to travel.
When used, loperamide is the antimotility agent of choice. It should not be used if features suggest a possible differential diagnosis of:
- E. coli 0157
- Inflammatory bowel disease
- Pseudomembranous colitis
Antibiotic treatment is not usually required, as most cases are self-limiting. Consider antibiotic treatment if:
- Symptoms are severe - high fever, blood in stools or more than eight stools per day.
- There is immune compromise.
- Symptoms are worsening.
- Diarrhoea has lasted for more than a week.
If an antibiotic is indicated, the first-line choice is erythromycin 250-500 mg qds for 5-7 days. Azithromycin or clarithromycin are alternatives if erythromycin is not tolerated. Ciprofloxacin 500 mg bd for 5-7 days is an alternative to treatment with macrolides.
Antibiotic resistance is known to be increasing.
Lactobacilli and probiotics may have a place in the prevention and treatment of campylobacteriosis and other forms of gastroenteritis. Further studies are needed before recommendations may be made. See separate Probiotics and Prebiotics article.
Preventing spread of infection
For work or school the exclusion period should be 48 hours from the last episode of diarrhoea.
Advise about other hygiene methods to help prevent spread such as:
- Meticulous attention to hand-washing (after going to the toilet, before preparing meals or eating, after assisting a child or elderly person clean themself following diarrhoea, etc).
- Not sharing towels and flannels.
- Washing soiled bed linen and clothes at 60°C or higher.
- Cleaning and disinfecting toilet seats, flush handles, taps and bathroom door handles regularly
- Dehydration and electrolyte disturbance may occur. Occasionally where not rectified, this can have fatal consequences. Infants, the elderly and those with immunological compromise are more likely to have more severe disease and to require admission to hospital for rehydration. Pregnant women are also more at risk of dehydration.
- 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.
- Acute bacterial gastroenteritis has been linked with the onset of irritable bowel syndrome (IBS) symptoms in approximately 15% of patients. These cases have been called postinfectious IBS. Campylobacter spp. is commonly associated with postinfectious IBS, as are E. coli O157, Salmonella spp. and Shigella spp.
- Severe diarrhoea may interfere with absorption of regular medication required for control of chronic disease.
The disease is usually self-limiting. Occasionally, death may occur from dehydration in the elderly and vulnerable, especially if immunocompromised. C. jejuni can produce bacteraemic illness in people with AIDS.
Prevention requires measures at all stages of the food chain, from agricultural production to domestic preparation of food. National strategies include ongoing research, reduction of Campylobacter spp. prevalence at the food source, reduction of cross-contamination with other food products, control of imported sources, water treatment, etc.
Heating by cooking destroys the bacteria, so at a domestic level adequate cooking of meat (particularly poultry) prevents infection. Uncooked meats should be kept separately from cooked and ready-to-eat foods in order to avoid cross-contamination. Hands should be washed after handling raw meat.
Other precautions the general public can take include:
- Milk should be pasteurised and drinking water chlorinated. When travelling to areas where tap water has not been treated to make it safe to drink, water should be boiled and/or sterilised. Ice cubes made from tap water should be avoided, as should salad washed in tap water.
- Those who are ill should not prepare or handle food.
- Cutting boards for cooked and uncooked meats and knives and other utensils must be kept apart.
- Hands should be washed before handling different food items, before eating or drinking, after going to the toilet and also after contact with animals, particularly pets and their bedding.
- Infected healthcare workers should not work. Antibiotics may reduce spread by curtailing the duration of excretion.
Further reading and references
Foodborne Disease Strategy; Food Standards Agency (FSA) May 2011
Gastroenteritis; NICE CKS, July 2015 (UK access only)
Campylobacter; World Health Organization (WHO) Fact sheet. October 2011
Campylobacter: guidance, data and analysis; Public Health England
Wilson DJ, Gabriel E, Leatherbarrow AJ, et al; Tracing the source of campylobacteriosis. PLoS Genet. 2008 Sep 264(9):e1000203.
UK Research and Innovation Strategy for Campylobacter in the food chain; Food Standards Agency, 2010-2015
Nichols GL, Richardson JF, Sheppard SK, et al; Campylobacter epidemiology: a descriptive study reviewing 1 million cases in England and Wales between 1989 and 2011. BMJ Open. 2012 Jul 122(4). pii: e001179. doi: 10.1136/bmjopen-2012-001179. Print 2012.
Janiec J, Evans MR, Thomas DR, et al; Laboratory-based surveillance of Campylobacter and Salmonella infection and the importance of denominator data. Epidemiol Infect. 2012 Nov140(11):2045-52. Epub 2012 Jan 5.
UK Standards for Microbiology Investigations: Gastroenteritis and Diarrhoea; Public Health England, 2013
List of notifiable diseases (England); Public Health England
Acute diarrhoea in children: racecadotril as an adjunct to oral rehydration; NICE Evidence Summary, March 2013
British National Formulary (BNF); NICE Evidence Services (UK access only)
Smith JL, Bayles D; Postinfectious irritable bowel syndrome: a long-term consequence of bacterial gastroenteritis. J Food Prot. 2007 Jul70(7):1762-9.
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