Septic Shock with Multi Organ Failure Due to Fluoroquinolones Resistant Campylobacter Jejuni

Background

Campylobacter spp infections are typically self-limited and severe complications are quite rare. Bacteremia caused by Campylobacter spp has been detected in less than 1% of patients with gastroenteritis due to these species. Attributable mortality of Campylobacter spp bacteremia has been estimate to be 4–16%. The impact of appropriateness of antimicrobial therapy on outcomes is controversial. Moreover, in the last 20 years, the incidence of fluoroquinolone resistance has been increasingly reported: in 2007, in the USA, it peaked at nearly 26% of human isolates.

Case Report

URINE AND STOOLS REMAINED NEGATIVE:

Because of antimicrobial susceptibility results and the patient’s improvement and ability to take oral medication, empirical therapy was shifted to azithromycin 500 mg orally daily. For the same reason, lactulose enemas were suspended and the patient was commenced on lactulose oral solution.

One week after admission, the patient’s acute decompensation of liver function, disseminated intravascular coagulation, and acute renal failure resolved. The patient was discharged one week later.

Discussion

Campylobacter jejuni is a microaerophilic, gram negative rod. Most frequently infections caused by Campylobacter jejuni manifest as a self-limited diarrheal illness with an associated abdominal pain.

In Europe, bacteremia due to Campylobacter spp was detected in less than 1% of the patients with gastroenteritis [1]. The low rate of detection could partly be explained by under diagnosis due to bactericidal properties of human serum against the species [2]. Another possible explanation is that blood cultures are not routinely performed for acute gastroenteritis, even when patients are febrile [2].

Campylobacter jejuni is the most frequently isolated species causing sepsis [1]. Septicemia occurs mostly among immunocompromised patients (mainly AIDS) or those with other comorbidities (malignancies and liver disease) [3]. In Italy, evidence is limited to some case reports [2,4].

The absence of a portal of origin is documented in less than 30% of the patients [1].

In the Pigrau et al. case series, only 1 out of 47 bacteremia cases were due Campylobacter jejuni developed septic shock [5]. Even if case fatality rate due to Campylobacter jejuni bacteremia is low, around 10% (but may be higher in HIV infected patients) [1], blood stream infections associated with high Pittsburgh Bacteremia Score can cause death [6,7]. In a recent retrospective study the mortality attributable to septic shock caused by Campylobacter jejuni was high (4 out of 4 cases died) [1]. In our patient, the severity of infection could have been enhanced by his immunosuppression induced by cirrhosis. Fluoroquinolones resistance has been documented; and it is increasingly common in some countries such as Spain [1] and Taiwan [8] where these drugs should not be considered for empirical therapy. In addition, emergence of resistance could represent an important issue for returning traveler’s diarrhea.

Nevertheless, in patients with Campylobacter spp bacteremia, the impact of an appropriate treatment on prognosis continues to be controversial and there is a lack of evidence, especially for severe infections [1]. Pacanowsky et al. reported that failure to administer appropriate antibiotics in bacteremia caused by Campylobacter spp was associated with fatal outcome [9].

However, in two recent Spanish [1] and Finnish [3] retrospective studies, inappropriate antimicrobial therapy did not alter outcomes. More studies are needed to determine the impact of appropriateness of therapy on mortality.

Conclusions

The presented case of septic shock caused by fluoroquinolone-resistant Campylobacter jejuni on one hand was treated with an inappropriate antibacterial therapy and on the other hand was treated with a timely point of care multi-organ ultrasound-guided resuscitation. We feel that the latter aspects could have contributed significantly to positive outcome.