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Multistate Outbreak of Multidrug-Resistant Campylobacter Infections Linked to Contact with Pet Store Puppies

Posted October 30, 2017 4:00 PM ET

Outbreak Advisory

67
Cases

15
States

17
Hospitalizations

0
Deaths

  • Read Advice to Pet Owners and Advice to Pet Store Workers.
  • Read Advice to Clinicians and Advice to Veterinarians.
  • CDC, several states, and the U.S. Department of Agriculture’s Animal and Plant Health Inspection Service (USDA-APHIS) are investigating a multistate outbreak of multidrug-resistant Campylobacter infections.
  • Campylobacter bacteria isolated from clinical samples from people sickened in this outbreak were found to be resistant to commonly recommended, first-line antibiotics. This antibiotic resistance means it may be difficult to treat infections with the outbreak strain with the antibiotics usually prescribed for Campylobacter infections.
  • Since the last update on October 3, 2017, 12 more ill people have been reported from 8 states. The most recent illness began on October 14, 2017.
  • As of October 23, 2017, a total of 67 people with laboratory-confirmed infections or symptoms consistent with Campylobacter infection have been linked to this outbreak. Illnesses have been reported from 15 states.
    • Of 62 ill people with available information, 17 (27%) have been hospitalized. No deaths have been reported.
    • Illnesses started on dates ranging from September 15, 2016 to October 14, 2017.
  • Epidemiologic and laboratory investigations linked this outbreak to contact with pet store puppies.
    • Of the 67 ill people in this outbreak, 62 (93%) have an epidemiological link to puppies at or from a Petland store.
      • Eighteen patients were Petland employees.
      • Forty- four people either recently purchased a puppy from Petland, visited a Petland store, or live in or visited a home with a puppy sold by Petland before their illness began.
      • Of the other five ill people, four reported contact with puppies from other sources and one had a laboratory-confirmed infection and did not report any puppy exposure.
    • Whole genome sequencing (WGS) showed that the Campylobacter isolates from ill people and from puppies were closely related genetically.
    • WGS provides additional evidence that the source of human illness in this outbreak is contact with puppies from Petland.
  • Antibiotic resistance may be associated with increased risk of hospitalization, development of a bloodstream infection, or treatment failure in patients.
    • WGS has identified multiple antimicrobial resistance genes and mutations in outbreak-associated isolates from 13 ill people and 8 puppies. This finding matches results from standard antibiotic resistance testing methods used by CDC’s National Antimicrobial Resistance Monitoring System (NARMS) laboratory on 10 clinical isolates from 4 ill people and 6 puppies in this outbreak.
    • The 10 isolates tested by standard methods were resistant to azithromycin, ciprofloxacin, clindamycin, erythromycin, nalidixic acid, telithromycin, and tetracycline. In addition, 8 of these isolates were resistant to gentamicin, and 2 of these isolates were resistant to florfenicol.
  • Follow these steps to prevent illness when handling puppies or dogs:
    • Always wash your hands thoroughly with soap and water right after touching puppies or picking up their poop.
    • Work with your veterinarian to keep your animals healthy and prevent diseases.
  • This investigation is ongoing and we will provide updates as more information becomes available.

Previous Outbreak Advisories

October 3, 2017

55
Cases

12
States

13
Hospitalizations

0
Death

  • Read Advice to Pet Owners and Advice to Pet Store Workers.
  • Read Advice to Clinicians and Advice to Veterinarians.
  • The Ohio Department of Health, several other states, the Centers for Disease Control and Prevention (CDC), and the U.S. Department of Agriculture Animal and Plant Health Inspection Service (USDA-APHIS) are investigating a multistate outbreak of human Campylobacter infections linked to puppies sold through Petland, a national pet store chain.
    • Clinical samples from people sickened in this outbreak appear to be resistant to commonly recommended, first-line antibiotics. This means infections with the outbreak strain may not respond well to oral antibiotics usually prescribed to treat Campylobacter infections.
  • 16 more ill people with a Campylobacter infection linked to the outbreak have been reported since September 11, 2017. The most recent illness began on September 12, 2017.
  • As of October 3, a total of 55 people with laboratory-confirmed infections or symptoms consistent with Campylobacter infection who live in 12 states (Florida, Kansas, Maryland, Missouri, New Hampshire, New York, Ohio, Pennsylvania, Tennessee, Utah, Wisconsin, and Wyoming) have been linked to this outbreak.
    • Of the 55 ill people in this outbreak, 49 (89%) have an epidemiological link to puppies at a Petland store.
    • Fourteen illnesses occurred among Petland employees. Thirty five people  in this outbreak either recently purchased a puppy at Petland, visited a Petland store, or live in or visited a home with a puppy sold through Petland before illness began.
    • The other ill people reported either contact with puppies from other sources (four people), contact with an ill person infected with the outbreak strain (one person), or were linked by laboratory testing to the outbreak but did not report puppy exposure (one person).
  • Ill people range in age from <1 year to 86 years, with a median age of 23 years; 38 (69%) are female; and 13 (24%) report being hospitalized. No deaths have been reported.
  • Epidemiologic and laboratory evidence indicates that puppies sold through Petland stores are a likely source of this outbreak.
  • Whole genome sequencing showed samples of Campylobacter isolated from the stool of puppies sold through Petland were closely related to Campylobacter samples isolated from the stool of ill people in multiple states.
  • CDC’s National Antimicrobial Resistance Monitoring System (NARMS) team analyzed whole genome sequence data from Campylobacter isolated from stools of seven ill people and six puppies to look for genes that predict antibiotic resistance.
    • Analysis suggests that all 13 isolates are resistant to azithromycin, ciprofloxacin, clindamycin, erythromycin, nalidixic acid, and telithromycin. In addition, 9 isolates appear resistant to gentamicin, and 12 isolates appear resistant to tetracycline.
    • Typically, predicted antibiotic resistance using whole genome sequence data matches the results of traditional antibiotic resistance testing for Campylobacter.*
    • NARMS performed traditional antibiotic resistance testing on one isolate from an ill person. It showed resistance to the same antibiotics that analysis of whole genome sequence data predicted: azithromycin, ciprofloxacin, clindamycin, erythromycin, gentamicin, nalidixic acid, telithromycin, and tetracycline.
  • Campylobacter can spread through contact with dog poop. It usually does not spread from one person to another, however, activities such as changing an infected person’s diapers or sexual contact with an infected person can lead to infection.
  • Regardless of where they are from, puppies might carry Campylobacter germs. Read Advice to Pet Owners and Advice to Pet Store Workers for illness prevention tips.
  • This investigation is ongoing. CDC will provide updates as more information becomes available.

 

* Zhao, S., Tyson, G.H., Chen, Y., Li, C., Mukherjee, S., Young, S., et al. (2015). Whole genome sequencing accurately predicts antimicrobial resistance phenotypes in Campylobacter species. Appl Environ Microbiol, 82(2), 459 – 466.

Initial Announcement

September 11, 2017

The Ohio Department of Health, several other states, CDC, and USDA-APHIS are investigating a multistate outbreak of human Campylobacter infections linked to puppies sold through Petland stores. Investigators are looking for the source of infections so they can recommend how to stop the outbreak and prevent more illnesses in order to protect human and animal health.

As of September 11, 2017, the outbreak includes 39 cases in 7 states (Florida, Kansas, Missouri, Ohio, Pennsylvania, Tennessee, and Wisconsin). A list of the number of cases by state can be found on the Case Count Map page.

Illnesses began on dates ranging from September 15, 2016 through August 12, 2017. The most recent illness was reported on September 1, 2017.

Ill people range in age from <1 year to 64 years, with a median age of 22 years; 28 (72%) are female; and 9 (23%) report being hospitalized. No deaths have been reported.

Epidemiologic and laboratory findings have linked the outbreak to contact with puppies sold through Petland stores. Among the 39 ill people, 12 are Petland employees from 4 states and 27 either recently purchased a puppy at Petland, visited a Petland, or visited or live in a home with a puppy sold through Petland before illness began.

Whole genome sequencing showed samples of Campylobacter isolated from the stool of puppies sold through Petland in Florida were closely related to Campylobacter isolated from the stool of an ill person in Ohio. Additional laboratory results from people and dogs are pending.

Regardless of where they are from, puppies might carry Campylobacter germs. Read Advice to Pet Owners and Advice to Pet Store Workers for illness prevention tips.

Advice

Advice to Pet Owners

Puppies and dogs can carry Campylobacter, a germ that can make people sick. Follow the steps below to prevent illness.

Always wash hands thoroughly with soap and water after touching your puppy or dog, after handling their food, and after cleaning up after them.

  • Adults should supervise handwashing for young children.
  • If soap and water are not readily available, use hand sanitizer until you are able to wash your hands with soap and water.
  • Use disposable gloves to clean up after your puppy or dog, and wash your hands afterwards. Clean up any urine (pee), feces (poop), or vomit in the house immediately. Then disinfect the area using a water and bleach solution.
  • Don’t let pets lick around your mouth and face.
  • Don’t let pets lick your open wound or areas with broken skin.
  • Take your dog to the veterinarian regularly to keep it healthy and to help prevent the spread of disease.

Within a few days after getting a new puppy or dog, take it to the veterinarian for a health check-up.

  • When choosing a pet, pick a puppy or dog that is bright, alert, and playful.
  • Signs of illness include appearing lethargic (sluggish or tired), not eating, having diarrhea, and breathing abnormally. However, even a dog that appears healthy can spread germs to people and other animals.
  • If your dog becomes sick or dies soon after purchase or adoption, take your dog to the veterinarian promptly and inform the pet store, breeder, or rescue organization about the pet’s illness or death. Thoroughly clean the area occupied by your pet by using a water and bleach solution.
  • If your dog dies, consider waiting at least a few weeks before purchasing or adopting another pet.

Advice to Pet Store Workers

Puppies and dogs can carry Campylobacter, a germ that can make people sick. Follow the steps below to prevent illness.

Wash your hands with soap and water after handling puppies or dogs.

  • Wash your hands thoroughly with running water and soap every time you handle dogs or anything in the area where they live and roam, including their food, treats, or food and water containers. Even a dog that appears healthy can spread germs to people and other animals.
  • Wash your hands immediately after cleaning up dog pee, poop, or vomit.
  • Dry hands using a clean paper towel or air-dry them. Do not dry hands on clothing.

Eat and store your food safely.

  • Always eat and drink in designated break areas away from places where animals roam or are caged and exercised.
  • Keep your food away from areas where pet food and treats are stored, and where animals roam or are caged or exercised.

Clean up messes safely.

  • Clean up any pee, poop, or vomit in the store immediately, and disinfect the area according to store protocols.
  • Use disposable gloves for clean-ups, and wash your hands thoroughly afterwards.
  • Wash work shoes or boots, clothes, and equipment regularly, and do so in an area that is not used to store or prepare food for people.

Follow store protocols for identifying and reporting sick or injured animals.

Information for Healthcare Providers

Campylobacter bacteria isolated from clinical samples from ill people and from puppies in this outbreak are resistant to recommended, first-line antibiotics used to treat severe Campylobacter infections.
  • CDC’s antimicrobial susceptibility testing of Campylobacter isolates from stools of 4 ill people and 6 puppies found that all 10 isolates were resistant to azithromycin, ciprofloxacin, clindamycin, erythromycin, nalidixic acid, telithromycin, and tetracycline.
  • Also, isolates from 2 of 4 people and 6 of 6 puppies were resistant to gentamicin, and isolates from 2 of 4 people were resistant to florfenicol.

Clinicians should consider the following when managing patients who have suspected or confirmed Campylobacter infection related to this outbreak:

  • Supportive care (for example, rehydration, and electrolyte repletion) should be sufficient for most patients.
  • For patients who may require antibiotics (for example, those who are at high risk for serious illness, such as infants and young children, adults aged 65 years and older, pregnant women, and people with compromised immunity):
    • Order stool culture and antimicrobial susceptibility testing
    • Choose an antibiotic based on the results of the patient’s stool cultures and antimicrobial susceptibility testing.
    • Consider consulting an infectious disease specialist for patient management.
  • When empiric treatment is required, avoid agents to which the outbreak strain is resistant. This includes the antibiotics listed above as well as penicillins, amoxicillin-clavulanic acid, cephalosporins, metronidazole, and trimethoprim-sulfamethoxazole, to which Campylobacter jejuni are inherently resistant.

Information for Veterinarians

Dog Testing
  • Puppies under 12 months of age or dogs adopted from crowded environments or from pet stores who show signs of Campylobacter infection, including bloody mucoid diarrhea, should be examined by a licensed veterinarian who may perform receive a gram-stained fecal smear to identify Campylobacter-like organisms, and perform other diagnostic tests as appropriate.
  • Laboratory confirmation of Campylobacter infection can be made from a fecal sample transported in Cary-Blair medium, or a quantitative-polymerase chain reaction (PCR) from a fresh stool sample, in consultation with a veterinary diagnostic lab.
  • Isolate puppies and dogs with Campylobacter to prevent the spread of the bacteria. Campylobacter infections are often self-limited and supportive care is often the only treatment needed.
  • If laboratory testing confirms Campylobacter infection, the puppy or dog has hemorrhagic diarrhea or a fever, and antibiotic treatment is warranted, the choice of antibiotic should be guided by culture and sensitivity results. The antibiotic resistance profile for this outbreak includes commonly used antibiotics such as fluoroquinolones and macrolides. Campylobacter jejuni has inherent antibiotic resistance to other commonly prescribed antibiotics such as penicillins, cephalosporins, trimethoprim-sulfamethoxazole, amoxicillin-clavulanic acid, and metronidazole. Therefore, infections with the outbreak strain may be difficult to treat.

Thoroughly clean surfaces and equipment that have been in contact with stool from any dog suspected to have a Campylobacter infection.

Talk to pet owners about taking simple steps to prevent getting sick from their puppies or dogs.

  • Tell clients that dogs and puppies can carry the Campylobacter germ and can make people sick. If the client or any of their family members are ill, encourage them to contact a healthcare provider immediately.
  • Direct clients to the Advice for Pet Owners above.

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