|Year : 2017 | Volume
| Issue : 7 | Page : 53-58
Speciation, clinical profile & antibiotic resistance in Aeromonas species isolated from cholera-like illnesses in a tertiary care hospital in north India
Balvinder Mohan, Nandini Sethuraman, Ritu Verma, Neelam Taneja
Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
|Date of Submission||10-Mar-2015|
|Date of Web Publication||4-Dec-2017|
Department of Medical Microbiology, Research Block A, Postgraduate Institute of Medical Education & Research, Sector 12, Chandigarh 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background & objectives: Aeromonas species have been reported to cause various illnesses in humans such as wound infections, septicaemia, peritonitis and pneumonia. Their role in causation of cholera-like illness is also being increasingly recognized. This retrospective study was done to know the presence of Aeromonas as a cause of acute diarrhoea in a tertiary care hospital and to find the common species of Aeromonas causing diarrhoea and their antibiotic susceptibility patterns.
Methods: Fifty isolates of Aeromonas were obtained over a period of 15 yr from 2000 to 2014 from patients of suspected acute gastroenteritis resembling cholera. Biotyping was done for 35 of these isolates available in culture collection, based on a panel of 13 biochemical reactions. Antibiogram was put up for all of these isolates by disk diffusion methods and interpreted according to the Clinical and Laboratory Standards Institute guidelines.
Results: Of the 50 patients of Aeromonas-related acute gastroenteritis, 13 (26%) had typical features of cholera with rice water stools and severe dehydration. Eight patients (16%) had dysentery-like picture. One patient died of severe dehydration and septicaemia. The most common species were found to be Aeromonas caviae (34%) followed by Aeromonas veronii biovar veronii (29%), Aeromonas veronii biovar sobria (26%) and Aeromonas hydrophila (9%). All tested isolates were uniformly susceptible to cefepime, amikacin, azithromycin and meropenem; 14 per cent were susceptible to amoxicillin, 32 per cent to nalidixic acid, 60 per cent to co-trimoxazole, 54 per cent to ciprofloxacin, 60 per cent to ofloxacin, 74 per cent to chloramphenicol, 76 per cent to ceftriaxone, 74 per cent to cefotaxime, 88 per cent to gentamicin and 86 per cent to furoxone.
Interpretation & conclusions: Aeromonas is an important, often neglected pathogen capable of causing a variety of gastrointestinal tract symptoms such as acute diarrhoea and dysentery and may even mimic cholera. It is, therefore, pertinent to recognize this pathogen as an important agent in the causation of severe diarrhoea.
Keywords: Acute gastroenteritis - Aeromonas- cholera-like illness
|How to cite this article:|
Mohan B, Sethuraman N, Verma R, Taneja N. Speciation, clinical profile & antibiotic resistance in Aeromonas species isolated from cholera-like illnesses in a tertiary care hospital in north India. Indian J Med Res 2017;146, Suppl S1:53-8
|How to cite this URL:|
Mohan B, Sethuraman N, Verma R, Taneja N. Speciation, clinical profile & antibiotic resistance in Aeromonas species isolated from cholera-like illnesses in a tertiary care hospital in north India. Indian J Med Res [serial online] 2017 [cited 2019 Apr 20];146, Suppl S1:53-8. Available from: http://www.ijmr.org.in/text.asp?2017/146/7/53/219465
Diarrhoea is an important cause of morbidity and mortality, especially in the developing world. It is estimated that each year, 1.67 billion episodes of diarrhoea occur in children under five years of age and 430 million episodes occur in adults >16 yr of age, the burden being heaviest in Asian and African countries . The pathogens causing diarrhoea are varied and numerous. According to the Global Enteric Multicenter Study (GEMS) study, the largest contributors to childhood diarrhoea are Rotavirus, Cryptosporidium, enterotoxigenic Escherichia More Details coli and Shigella, other common agents being adenovirus 40/41, Aeromonas and Campylobacter. Aeromonas was among the top five enteropathogens causing childhood diarrhoea in Asia, especially in Pakistan and Bangladesh . Of the more dangerous forms of diarrhoea is cholera, caused by Vibrio cholerae, which leads to severe dehydration and high mortality if left untreated. Globally, it leads to about 120,000 deaths annually . It is highly endemic in Southern Asia and India where it causes seasonal outbreaks as well as sporadic cases .
Aeromonas, on the other hand, is a less well-characterized pathogen. It is a Gram-negative rod, facultatively anaerobic and is oxidase positive . It normally inhabits aquatic environments, not only fresh water but also salty estuarine waters, causing soft tissue infections in aquatic animals. It is responsible mainly for three clinical syndromes i.e. septicaemia, wound infections and acute gastroenteritis. The acquisition of this infection can usually be traced back to ingestion of seafood or exposure to seawater or estuarine environment, in which the organism is seen to be present often causing disease in aquatic animals . We describe here the results of a retrospective descriptive study of a period of 15 yr i.e. 2000-2014, of the cases of acute gastroenteritis and acute watery diarrhoea resembling cholera, due to Aeromonas, at a tertiary care hospital in north India.
| Material & Methods|| |
Diarrhoeal stool samples from 1595 patients suspected to have cholera were collected over a period of 15 yr between 2000 and 2014, irrespective of age group from both inpatient and outpatient facilities at Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India. The samples were transported to the Enteric Microbiology Laboratory in Cary-Blair medium or in sterile containers and processed within two hours of receipt of samples in the laboratory. Patients' clinicodemographic details were noted wherever available. These included age, sex, ward/outpatient department, presenting clinical features and underlying illness.
Bacteriological isolation: Conventional culture technique for isolation of stool pathogens was followed. In addition, samples were also inoculated onto 5 per cent sheep blood agar plate without ampicillin. Apart from direct plating, enrichment broths such as selenite-F and alkaline peptone water were used. Colonies showing typical characters of Aeromonas with haemolysis and oxidase positivity were sub-cultured onto 5 per cent sheep blood agar for further characterization. Species identification was done based on conventional biotyping according to the Aerokey II system with slight modifications following a panel of 13 biochemical reactions ,. Isolates were stored in brain–heart infusion broth with 10 per cent glycerol at −80°C.
Antimicrobial susceptibility testing: Antimicrobial susceptibility testing of the Aeromonas isolates was carried out by the disk diffusion method of Kirby–Bauer . Mueller-Hinton agar was used for susceptibility testing. Commercially available disks (HiMedia Laboratories Pvt. Ltd., Mumbai) of amikacin (30 μg), amoxicillin (10 μg), azithromycin (15 μg), cefepime (30 μg), cefotaxime (30 μg), ceftriaxone (30 μg), chloramphenicol (30 μg), ciprofloxacin (5 μg), co-trimoxazole (25 μg), furoxone (30 μg), gentamicin (10 μg), meropenem (10 μg), nalidixic acid (30 μg), ofloxacin (5 μg) and tetracycline (30 μg) were used. Standard strain of E. coli ATCC 25922 susceptible to all the drugs was used for quality control of disks. Results of zone diameters were interpreted as sensitive, intermediate resistant or resistant according to the Clinical and Laboratory Standards Institute criteria .
| Results|| |
Aeromonas was isolated from 50 of the 1595 samples from patients suspected of cholera from 2000 to 2014. Age range of cases is depicted in [Table 1]. Maximum number of patients (n=18) were seem during the months of July and August. Males outnumbered females by a ratio of 2:1. Of the 50 patients, 13 (26%) had severe dehydration and rice water stools typical of cholera. Eight patients (16%) had features of dysentery with bloody stools. One patient, from whom Aeromonas caviae was isolated, died after developing severe dehydration following consumption of seafood and alcohol at a party. Two patients had dual bacterial infections with Shigella sonnei and Salmonella More Details Senftenberg, respectively. All others were monoinfections.
Of the 35 strains for which biochemical speciation was done, the most common species was found to be A. caviae (34%), followed by Aeromonas veronii biovar veronii (29%), Aeromonas veronii biovar sobria (26%) and Aeromonas hydrophila (9%). A single isolate of Aeromonas jandaei was obtained.
Antibiotic susceptibility testing was done for all 50 isolates [Table 2]. All tested isolates were uniformly susceptible to cefepime, amikacin, azithromycin and meropenem. Multidrug resistance was defined as non-susceptibility to ≥1 drug belonging to ≥3 classes of antimicrobial agents as proposed by the Centers for Disease Prevention and Control (CDC) and European CDC . It was found that 24 (48%) isolates were multidrug resistant.
| Discussion|| |
In a country like India where there is high morbidity due to diarrhoeal diseases, it is pertinent to identify the true cause of diarrhoea and target the particular organism for treatment. Aeromonas is present ubiquitously in the environment and presents itself to multiple opportunities for human contact. Before it was established as an aetiologic agent in human infections, it was well known as a cause of soft tissue infections and septicaemia in aquatic animals. Aeromonas as an enteropathogen has received a lot of controversies. According to Janda and Abbott , for an organism to be labelled as enteropathogenic, it should have led to clonal outbreaks and a source of outbreak should be established. Aeromonas is a normal habitant of aquatic environments, fresh as well as salty estuarine waters . Multiple species may also exist in a single environment, making it difficult to establish the common source. Infections are believed to be acquired through contaminated water or food items indirectly on contact with contaminated irrigation water or seafood due to their filter feeding mechanism . Only a few outbreaks of Aeromonas-related gastroenteritis are reported . From our centre, a unique outbreak of hospital-acquired diarrhoea due to Aeromonas sobria was reported in 2004 affecting six children in a haemato-oncology unit . These isolates had similar biotypes and antibiograms; however, molecular typing could not be performed. In a review of Aeromonas-associated diarrhoea by von Graevenitz , a causal role of Aeromonas in gastroenteritis could not be established due to high degree of co-infections reported and lack of clonality in outbreak clinical and environmental isolates. It is, therefore, important that more evidence is available to establish causation. In the present study, over 15 yr, 1595 cases were clinically suspected of cholera, of whom 50 (3.14%) were found to be due to Aeromonas species. This may be an underestimation of the overall incidence of Aeromonas- related gastroenteritis as we studied its role in causation of cholera-like illness only, in the setting of ongoing cholera outbreaks. In a prospective study over two years conducted in two tertiary care centres in Kolkata, India, 3.1 and 6.5 per cent of their total diarrhoea cases had Aeromonas isolated from them, amounting to a total of 164 cases . About 42 per cent of these cases had co-infections with other pathogens. In our study, only in two cases, there were other pathogens identified i.e. S. sonnei and Salmonella enterica serotype Senftenberg. The estimates of asymptomatic carriage range between 1 and 4 per cent overall and <1 per cent in industrialized countries ,,,. Aeromonas is known to infect immunocompetent and immunocompromised individuals of all age groups . However, some studies specify adults as a vulnerable population more than children ,. In our study, maximum infection was found in children aged under-five (36% of total) followed by 16-25 age group (24%). This pattern did not change even after excluding the six cases of hospital-acquired diarrhoea previously reported . According to the GEMS study also, Aeromonas ranks among the top five most common enteropathogens causing childhood diarrhoea in developing countries . We also observed that the isolation rates were maximal in the warmer months of the year that is July-August, similar to other studies ,.
Ability of Aeromonas to cause cholera-like disease with typical rice water stools has been rarely reported and is limited to a handful of case reports ,,. These cases range in age from two year old to 67 yr old patients. However, in our study, there were 13 patients with typical rice water stools and severe dehydration. In the Kolkata study, 44.9 per cent of 78 patients were reported to have severe dehydration although the typical stool character was not described. In our study, one of the patients died shortly following consumption of seafood at a party, which was likely the source of Aeromonas isolated from his stool. He had severe dehydration followed by hypotension, shock and death. More prospective studies focussed on this grave presentation may further support this important finding.
The identification of the organism often requires a high index of suspicion with the inclusion of selective medium in the routine identification scheme for stool pathogens. We introduced 5 per cent sheep blood agar into the conventional bacterial identification scheme for stool samples to isolate Aeromonas to increase the sensitivity of isolation of even ampicillin susceptible strains. It was found that 14 per cent of our isolates, none of which were Aeromonas trota, were susceptible to amoxicillin. This has been reported in other studies also confirming that some isolates are missed using ampicillin blood agar as a medium for selective isolation of Aeromonas,. Moreover, 35 per cent of A. caviae has been reported to be susceptible to ampicillin . The species frequency isolated from diarrhoea cases is similar to other studies wherein A. caviae and A. veronii remain the most common species isolated ,. A. hydrophila, which is the most common species reported in clinical cases overall, more often causes septicaemia and wound infections ,. There is a certain difference in the species distribution according to the geographical area also. In Australia and Thailand, A. hydrophila was the most common species whereas, in Europe and Americas, A. caviae is most common . In the Kolkata study also, A. caviae was found to be the most common species of Aeromonas causing gastroenteritis .
It is important to recognize the presence of multidrug resistance in this organism. In our study 48 per cent of isolates were multidrug resistant, similar to the Kolkata study and in contrast to a study from Western Australia ,. In the current study, a high-level resistance to quinolones and co-trimoxazole was observed. In a previous report from our centre also, 36 per cent ciprofloxacin resistance was reported in 14 Aeromonas isolates . In Western countries such as Spain and Australia, fluoroquinolone resistance was much less seen although nalidixic acid resistance of 41 per cent was reported in a Spanish study in clinical isolates of Aeromonas. In the Kolkata study, 12-22 per cent resistance to ciprofloxacin was reported and the mechanism involved was shown to be mutations in the quinolone resistance-determining region of gyrA and parC,. Resistance to third-generation cephalosporins was 24 per cent which was similar to the previous report in 2004 from our centre, but in contrast to Western countries, where no or low-level resistance was seen to third- and fourth-generation cephalosporins ,,. Macrolides such as azithromycin are viable treatment options to which the organism was seen to be uniformly susceptible. Cholera being one of the most common causes of bacterial diarrhoea, cases with classical symptoms of acute watery stools are often assumed to be cholera and treated with ciprofloxacin to which they are more or less uniformly susceptible although, in the last decade, fluoroquinolone resistance is emerging in cholera ,.
The importance of Aeromonas as a gastrointestinal pathogen must be recognized, and therefore, it must be actively sought in a diarrhoea case.
Conflicts of Interest: None.
| References|| |
Lamberti LM, Fischer Walker CL, Black RE. Systematic review of diarrhea duration and severity in children and adults in low- and middle-income countries. BMC Public Health
Kotloff KL, Nataro JP, Blackwelder WC, Nasrin D, Farag TH, Panchalingam S, et al.
Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): A prospective, case-control study. Lancet
Sack DA, Sack RB, Chaignat CL. Getting serious about cholera. N Engl J Med
Taneja N, Sangar G, Chowdhury G, Ramamurthy T, Mishra A, Singh M, et al.
Molecular epidemiology of Vibrio cholerae
causing outbreaks and sporadic cholera in Northern India. Indian J Med Res
Janda JM, Abbott SL. The genus Aeromonas
: Taxonomy, pathogenicity, and infection. Clin Microbiol Rev
Janda JM, Guthertz LS, Kokka RP, Shimada T. Aeromonas
species in septicemia: Laboratory characteristics and clinical observations. Clin Infect Dis
Carnahan AM, Behram S, Joseph SW. Aerokey II: A flexible key for identifying clinical Aeromonas
species. J Clin Microbiol
Veraslovic J, Carroll KC, Funke G, Jorgensen JH, Landry ML, Warnock DW, editors. Manual of clinical microbiology
ed. Washington, DC: ASM Press; 2011.
Bauer AW, Kirby WM, Sherris JC, Turck M. Antibiotic susceptibility testing by a standardized single disk method. Am J Clin Pathol
Clinical and Laboratory Standards Institute. Performance Standards for Antimicrobial Susceptibility Testing; Twenty-First Informational Supplement
. Wayne, PA: CLSI; 2011.
Magiorakos AP, Srinivasan A, Carey RB, Carmeli Y, Falagas ME, Giske CG, et al.
Multidrug-resistant, extensively drug-resistant and pandrug-resistant bacteria: An international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect
Von Graevenitz A. The role of Aeromonas
in diarrhea: A review. Infection
Taneja N, Khurana S, Trehan A, Marwaha RK, Sharma M. An outbreak of hospital acquired diarrhea due to Aeromonas sobria
. Indian Pediatr
Sinha S, Shimada T, Ramamurthy T, Bhattacharya SK, Yamasaki S, Takeda Y, et al.
Prevalence, serotype distribution, antibiotic susceptibility and genetic profiles of mesophilic Aeromonas
species isolated from hospitalized diarrhoeal cases in Kolkata, India. J Med Microbiol
(Pt 6) : 527-34.
Golik A, Modai D, Gluskin I, Schechter I, Cohen N, Eshchar J. Aeromonas
in adult diarrhea: An enteropathogen or an innocent bystander? J Clin Gastroenterol
Holmberg SD, Farmer JJ 3rd
. Aeromonas hydrophila
and Plesiomonas shigelloides
as causes of intestinal infections. Rev Infect Dis
Utsalo SJ, Eko FO, Antia-Obong OE, Nwaigwe CU. Aeromonads in acute diarrhoea and asymptomatic infections in Nigerian children. Eur J Epidemiol
Verenkar M, Naik V, Rodrigues S, Singh I. Aeromonas
species and Plesiomonas shigelloides
in diarrhoea in Goa. Indian J Pathol Microbiol
Gurwith M, Bourque C, Cameron E, Forrest G, Green M. Cholera-like diarrhea in Canada. Report of a case associated with enterotoxigenic Escherichia coli
and a toxin-producing Aeromonas hydrophila
. Arch Intern Med
Kumar KJ, Kumar GS. Cholera-like illness due to Aeromonas caviae
. Indian Pediatr
Aravena-Román M, Inglis TJ, Henderson B, Riley TV, Chang BJ. Antimicrobial susceptibilities of Aeromonas
strains isolated from clinical and environmental sources to 26 antimicrobial agents. Antimicrob Agents Chemother
Huddleston JR, Zak JC, Jeter RM. Sampling bias created by ampicillin in isolation media for Aeromonas
. Can J Microbiol
Vila J, Ruiz J, Gallardo F, Vargas M, Soler L, Figueras MJ, et al. Aeromonas
spp. and traveler's diarrhea: Clinical features and antimicrobial resistance. Emerg Infect Dis
Li F, Wang W, Zhu Z, Chen A, Du P, Wang R, et al.
Distribution, virulence-associated genes and antimicrobial resistance of Aeromonas
isolates from diarrheal patients and water, China. J Infect
Tang HJ, Lai CC, Lin HL, Chao CM. Clinical manifestations of bacteremia caused by Aeromonas
species in Southern Taiwan. PLoS One
Chao CM, Lai CC, Tang HJ, Ko WC, Hsueh PR. Skin and soft-tissue infections caused by Aeromonas
species. Eur J Clin Microbiol Infect Dis
Altwegg M, Geiss HK. Aeromonas
as a human pathogen. Crit Rev Microbiol
Taneja N, Mohan B, Khurana S, Sharma M. Antimicrobial resistance in selected bacterial enteropathogens in North India. Indian J Med Res
Vila J, Marco F, Soler L, Chacon M, Figueras MJ. In vitro
antimicrobial susceptibility of clinical isolates of Aeromonas caviae
, Aeromonas hydrophila
and Aeromonas veronii
. J Antimicrob Chemother
Sinha S, Chattopadhyay S, Bhattacharya SK, Nair GB, Ramamurthy T. An unusually high level of quinolone resistance associated with type II topoisomerase mutations in quinolone resistance-determining regions of Aeromonas caviae
isolated from diarrhoeal patients. Res Microbiol
Rashed SM, Mannan SB, Johura FT, Islam MT, Sadique A, Watanabe H, et al.
Genetic characteristics of drug-resistant Vibrio cholerae
O1 causing endemic cholera in Dhaka, 2006-2011. J Med Microbiol
(Pt 12) : 1736-45.
Ghosh A, Ramamurthy T. Antimicrobials and cholera: Are we stranded? Indian J Med
Res 2011; 133
[Table 1], [Table 2]