Volume 9, Number 5—May 2003
Aeromonas spp. and Traveler’s Diarrhea: Clinical Features and Antimicrobial Resistance
Traveler’s diarrhea is the most common health problem of international travelers. We determined the prevalence of Aeromonas spp. associated with traveler’s diarrhea and analyzed the geographic distribution, clinical features, and antimicrobial susceptibility. Aeromonas spp. were isolated as a cause of traveler’s diarrhea in 18 (2%) of 863 patients. A. veronii biotype sobria was isolated in nine patients, A. caviae in seven patients, and A. jandai and A. hydrophila in one patient each. Aeromonas spp. were isolated with a similar prevalence in Africa, Latin America, and Asia. Watery and persistent diarrhea, fever, and abdominal cramps were common complaints. All strains were resistant to ampicillin; showed variable resistance to chloramphenicol, tetracycline, and cotrimoxazole; and were susceptible to cefotaxime, ciprofloxacin, and nalidixic acid. The persistence of symptoms made antimicrobial treatment necessary.
Traveler’s diarrhea is the main infectious disease reported in persons traveling abroad. Among the microorganisms responsible, bacteria represent approximately 61% (1). Enterotoxigenic Escherichia coli, enteroaggregative E. coli, and Shigella spp. are the most common bacteria involved (1,2). Other bacteria that cause diarrhea, such as Salmonella, Campylobacter, Yersinia, Aeromonas, and Plesiomonas spp., are isolated less often (1).
The genus Aeromonas has high diversity: at least 16 DNA hybridization groups are recognized (3). Among these genospecies, A. hydrophila, A. caviae, and A. veronii biotype sobria are considered of clinical significance (4,5). The spectrum of infectious diseases caused by Aeromonas species includes gastrointestinal infections as well as extraintestinal infections such as cellulitis, wound infections, septicemia, urinary tract infections, and hepatobiliary and ear infections, among others (6). Although healthy carriers of Aeromonas spp. have been described, several case-control studies have shown that these bacteria cause diarrhea (6). With the incorporation of genotypic techniques, identification of Aeromonas to species level has improved (7). The main objective of this study was to determine the prevalence of Aeromonas spp. as a cause of traveler’s diarrhea and to analyze the species’ geographic distribution, clinical features, and susceptibility to antimicrobial agents.
A total of 863 patients with traveler’s diarrhea were recruited from the Tropical Medicine Unit of the Hospital Clinic of Barcelona, Spain, during the period January 1999–December 2001. All patients completed an epidemiologic questionnaire; their clinical history was taken, and a physical examination was performed. Traveler’s diarrhea was defined as the occurrence of three or more episodes of watery stool within a 24-hour period, with or without other symptoms, or the occurrence of unformed stools accompanied by one of the following: vomiting, nausea, abdominal cramps, fever, chills, prostration, or tenesmus. Persistent diarrhea was defined as that of >14 days’ duration.
A stool sample was collected, sent to the Laboratory of Clinical Microbiology, and processed for bacterial, viral, and parasitologic studies. To isolate Aeromonas spp., blood agar supplemented with ampicillin and a selective media, CIN (cefsulodin-irgasan-novobioci) agar, were used. After incubation at 37°C for 24–48 hours, an oxidase test was performed on the colonies compatible with bacilli. Biochemical criteria were used to identify Aeromonas. Identification of the species was performed by 16S rDNA–restriction fragment length polymorphism as previously described (7,8). The biotype of A. veronii strains was identified on the basis of a positive reaction to arginine dihydrolase and negative response to bilis-esculin hydrolysis and production of ornithine decarboxylase (9).
Antimicrobial susceptibility tests were performed by using an agar disk diffusion method advocated by the National Committee for Clinical Laboratory Standards (10). Antimicrobial disks (ampicillin 10 μg; cefotaxime 30 μg; chloramphenicol 30 μg; ciprofloxacin 5 μg; nalidixic acid 30 μg; tetracycline 30 μg; and trimethoprim-sulfamethoxazole 1.25/23.75 μg) were obtained from Becton Dickinson (Cockeysville, MD). E. coli ATCC 25922 and Pseudomonas aeruginosa ATCC 27853 were used as quality-control strains.
Distribution and Geographic Origin of Species Causing Traveler’s Diarrhea
Aeromonas spp. were isolated as a cause of traveler’s diarrhea in 18 (2%) of 863 patients. A. veronii biotype sobria was isolated in nine patients, A. caviae in seven patients, and A. jandaei and A. hydrophila in one patient each (Table 1). In three of these patients, another enteropathogen was also found: in one patient who had traveled to Mexico, Shigella sonnei was isolated together with A. veronii; in another patient traveling to India, Giardia lamblia was detected together with A. veronii; in the third patient, who had traveled to Thailand, Salmonella Typhimurium was found with A. veronii. The frequency of Aeromonas spp. as a cause of traveler’s diarrhea was similar in patients returning from Africa (1.7%), Latin America (1.8%), and Asia (2.3%) (Table 1).
The signs and symptoms of Aeromonas enteritis in these 18 patients are summarized in Table 2. Sixteen of the 18 patients had watery diarrhea; these were the cases associated with A. veronii biotype sobria and A. caviae. The patients with enteritis caused by A. hydrophila and A. jandaei had loose stools. Fifty percent of the patients had fever and abdominal cramps, whereas nausea and vomiting were uncommon complaints. Gross blood was observed in the stools of one patient, but this could be attributed to the S. sonnei isolated in the same stool. In 9 of the 18 patients, diarrhea was persistent.
The antimicrobial susceptibility of Aeromonas spp. isolates causing traveler’s diarrhea is shown in Table 3. All strains were resistant to ampicillin but susceptible to cefotaxime, ciprofloxacin, and nalidixic acid. The susceptibility to chloramphenicol, tetracycline, and trimethoprim-sulfamethoxazole varied. Some 66.6% of A. veronii biotype sobria strains and 71.4% of A. caviae strains were susceptible to chloramphenicol; 55.6% of A. veronii biotype sobria strains and 71.4% of the A. caviae strains were susceptible to tetracycline; and 77.8% of A. veronii biotype sobria and 100% of A. caviae were susceptible to trimethoprim-sulfamethoxazole.
While travelling, two patients received treatment, amoxicillin in one case and amoxicillin plus clavulanic acid in the other. Patients with persistent diarrhea were treated with the following antibiotics: norfloxacin (one patient), ciprofloxacin (six patients), and trimethoprim-sulfamethoxazole (two patients); all recovered.
In this study we describe the prevalence of different types of Aeromonas species associated with traveler’s diarrhea in a cohort of travelers to a variety of tropical and subtropical countries. In contrast, other published studies have often been selective in terms of the types of travelers, geographic areas visited, or attempts to isolate specific microorganisms with the aim of testing antibiotic efficiency. In our study, Aeromonas spp. were isolated in 18 (2%) of 863 patients with traveler’s diarrhea. A. veronii biotype sobria and A. caviae were the most frequently isolated species. These findings agree with the results of Hänninen et al. (11), who reported that these were the most common Aeromonas spp. associated with traveler’s diarrhea in tourists traveling to Morocco. Likewise, Yamada et al. (12) found that A. veronii biotype sobria was the Aeromonas species most frequently implicated as a cause of traveler’s diarrhea in Japanese travelers returning from unindustrialized countries. In our study, the geographic distribution of Aeromonas species did not favor any predominant area: species were isolated with a similar prevalence in Africa, Latin America, and Asia. However, all four species (A. veronii biotype sobria, A. caviae, A. jandaei, and A. hydrophila) were isolated from patients returning from India. In India, Aeromonas spp. has been identified as an enteric pathogen in 1.8% of patients with diarrhea (13). In a recent study performed in Dhaka (Bangladesh), Aeromonas spp. were significantly associated with diarrhea, similar to occurrences in other countries (14–17).
In our study, 3 (16.7%) of the Aeromonas isolates were detected together with other enteropathogens. This situation allowed us to consider that the symptoms we observed in the patients with traveler’s diarrhea associated with Aeromonas spp. were due to the presence of this Aeromonas organisms. In our study, watery stools, fever, and abdominal cramps were the most common symptoms, which is consistent with other reports (11,18). Albert et al. (18) suggested that isolates of Aeromonas spp. positive for both the alt and ast genes, which encode enterotoxins, were associated with watery diarrhea but that isolates positive only for the alt gene were associated with loose stools.
Fifty percent of the patients with Aeromonas spp. enteritis had persistent diarrhea. Chronic diarrhea lasting more than 1 year caused by A. caviae has been reported (2). A direct link between drinking water and food contaminated with Aeromonas spp. and gastrointestinal disease has been demonstrated (19).
Patients with prolonged enteritis required treatment. A quinolone was the drug of choice, although increased occurrence of quinolone-resistant Aeromonas spp. strains has been reported in industrialized countries (20,21). Regarding the β-lactam antibiotics, Aeromonas spp. strains analyzed in this study were, as expected, uniformly resistant to ampicillin, whereas third-generation cephalosporins, such as cefotaxime, showed good activity. These results are in accordance with those reported by other authors, showing that third-generation cephalosporins are active against Aeromonas spp (2,22). The percentage of strains with resistance to chloramphenicol, tetracycline, or trimethoprim-sulfamethoxazole ranged from 22.9% to 45%. These levels of resistance are likely related to the extensive use of these antimicrobial agents in unindustrialized countries.
In summary, A. veronii biotype sobria and A. caviae are the Aeromonas species most frequently associated with traveler’s diarrhea; watery diarrhea, fever, and abdominal cramps are the predominant clinical features. The persistence of symptoms makes the use of antimicrobial treatment necessary.
Dr. Vila is a professor of microbiology, School of Medicine, University of Barcelona, and consultant to the Clinical Microbiology Laboratory of the Hospital Clinic, Barcelona. His research interests lay in the molecular bases of antimicrobial resístance.
This work was partially supported by grant FIS00/0997 of Fondo de Investigaciones Sanitarias.
- Gascón J, Vila J, Valls ME, Ruiz L, Vidal J, Corachan M, Etiology of traveller’s diarrhea in Spanish travellers to developing countries. Eur J Epidemiol. 1993;9:217–23.
- Rautelin H, Hänninen ML, Sivonen A, Turunen U, Valtonen V. Chronic diarrhea due to single strain of Aeromonas caviae. Eur J Clin Microbiol Infect Dis. 1995;14:51–4.
- Figueras MJ, Guarro J, Martínez-Murcia AJ. Clinical relevant Aeromonas species. Clin Infect Dis. 2000;30:988–9.
- Janda JM. Recent advances in the study of the taxonomy, pathogenicity, and infectious syndromes associated with the genus Aeromonas. Clin Microbiol Rev. 1991;4:397–410.
- Janda JM, Abbott SL. Evolving concepts regarding the genus Aeromonas: an expanding panorama of species, disease presentations, and unanswered questions. Clin Infect Dis. 1998;27:332–44.
- Janda JM, Abbott SL, Morris JG Jr. Aeromonas, Plesiomonas, and Edwarsiella. In: Blaser MJ, Smith PD, Ravdin JI, Greenberg HB, Guerrant RL, editors. Infections of gastrointestinal tract. New York: Raven Press; 1995.
- Borrell N, Acinas SG, Figueras MJ, Martínez-Murcia AJ. Identification of Aeromonas clinical isolates by restriction fragment length polymorphism of PCR-amplified 16S rDNA genes. J Clin Microbiol. 1997;35:1671–4.
- Figueras MJ, Soler L, Chacón MR, Guarro J, Martínez-Murcia AJ. Extended method for discrimination of Aeromonas spp. by 16S rDNA-RFLP analysis. Int J Syst Evol Microbiol. 2000;50:2069–73.
- Borrell N, Figueras MJ, Guarro J. Phenotypic identification of Aeromonas genomospecies from clinical and environmental sources. Can J Microbiol. 1998;44:7–12.
- National Committee for Clinical Laboratory Standards. Performance standards for antimicrobial susceptibility testing: approved standard M100-S11.Wayne (PA): The Committee; 2001.
- Hänninen ML, Salmi S, Mattila L, Taipalinen R, Siitonen A. Association of Aeromonas spp. with travellers’ diarrhoea in Finland. J Med Microbiol. 1995;42:26–31.
- Yamada S, Matsushita S, Dejsirilert S, Kudoh Y. Incidence and clinical symptoms of Aeromonas-associated traveller’s diarrhoea in Tokyo. Epidemiol Infect. 1997;119:121–6.
- Deodhar LP, Saraswathi K, Varudkar A. Aeromonas spp. and their association with human diarrheal disease. J Clin Microbiol. 1991;29:853–6.
- Albert JM, Faruque ASG, Faruque SM, Sack RB, Mahalanabis D. Case-control study of enteropathogens associated with childhood diarrhea in Dhaka, Bangladesh. J Clin Microbiol. 1999;37:3458–64.
- Begue RE, Castellares G, Hayashi KE, Ruiz R, Meza R, English CK, Diarrheal disease in Peru after the introduction of cholera. Am J Trop Med Hyg. 1994;51:585–9.
- Kühn I, Albert MJ, Ansaruzzaman M, Bhuiyan NA, Alabi SA, Islam MS, Characterization of Aeromonas spp. isolated from humans with diarrhea, from healthy controls, and from surface water in Bangladesh. J Clin Microbiol. 1997;35:369–73.
- Ogunsanya TI, Rotimi VO, Adenuga A. A study of the aetiological agents of childhood diarrhea in Lagos, Nigeria. J Med Microbiol. 1994;40:10–4.
- Albert MJ, Ansaruzzaman M, Talukder KA, Chopra AK, Kuhn I, Rahman M, Prevalence of enterotoxin genes in Aeromonas spp. isolated from children with diarrhea, healthy controls, and the environment. J Clin Microbiol. 2000;38:3785–90.
- Joseph SW. Aeromonas gastrointestinal disease: a case study in causation? In: Austin B, Altwegg M, Gosling PJ, Joseph S, editors. The genus Aeromonas. New York: John Wiley & Sons; 1996.
- Goñi-Urriza M, Pineau L, Capdepuy M, Roques C, Caumette P, Quentin C. Antimicrobial resistance of mesophilic Aeromonas spp. isolated from two European rivers. J Antimicrob Chemother. 2000;46:297–301.
- 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 biotype sobria. J Antimicrob Chemother. 2002;49:701–2.
- Motyl MRG, MacKinley G, Janda JM. In vitro susceptibilities of Aeromonas hydrophila, Aeromonas sobria, and Aeromonas caviae to 22 antimicrobial agents. Antimicrob Agents Chemother. 1985;28:151–3.
- Table 1. Species and geographic distribution of clinical isolates of Aeromonas spp. causing traveler’s diarrhea
- Table 2. Clinical features of patients with traveler’s diarrhea associated with Aeromonas spp.
- Table 3. Antimicrobial susceptibility of Aeromonas spp. causing traveler’s diarrhea
Suggested citation for this article: 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 [serial online] 2003 May [date cited]. Available from: URL: http://wwwnc.cdc.gov/eid/article/9/5/02-0451
Please use the form below to submit correspondence to the authors or contact them at the following address:
Jordi Vila, Laboratori de Microbiologia, Institut d’Infeccions i Immunologia, Institut d’Investigacions Biomèdiques August Pi i Sunyer, Fascultat de Medicina, Universitat de Barcelona, Villarroel, 170; 08036 Barcelona, Spain; fax: 34.93.2279372
Comment submitted successfully, thank you for your feedback.
The conclusions, findings, and opinions expressed by authors contributing to this journal do not necessarily reflect the official position of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
- Page created: December 09, 2010
- Page last updated: December 09, 2010
- Page last reviewed: December 09, 2010
- Centers for Disease Control and Prevention,
National Center for Emerging and Zoonotic Infectious Diseases (NCEZID)
Office of the Director (OD)