Banerji, S.; Holland, G.; Laue, M.; Flieger, A.

Background: Campylobacter is a major food-borne pathogen causing diarrhea. In severe cases, treatment typically involves fluoroquinolones (FQ) and macrolides. However, high proportions of FQ resistance (FQR) have made macrolides the remaining first-line treatment option. As part of the Campylobacter surveillance program in Germany, we investigated multidrug resistance (MDR) in clinical Campylobacter samples collected 2010 to 2022. Methods: A total of 6,980 samples was single-colony purified and analyzed for antimicrobial resistance phenotypes. Genome sequencing was performed for 2,912 samples, and antimicrobial resistance genes were mapped. Cultures showing MDR were further analyzed for contaminating DNA and studied using scanning electron microscopy (SEM). Findings: We found that 453 (6%) Campylobacter samples were resistant to both FQ and macrolides. Two of the C. jejuni samples were resistant to antibiotics from ten different classes. Genome analysis revealed that these samples, despite being derived from single colonies, contained >10% Enterococcus DNA reads. SEM confirmed the presence of coccoid bacteria interspersed with spiral-shaped Campylobacter. Additional culture-based purification resulted in pure C. jejuni isolates that retained FQR but lost macrolide resistance. We further showed that presence of MDR Enterococcus spp. in the mixed samples protected C. jejuni from above-MIC (minimum inhibitory concentration) of several ribosome-targeting antimicrobials whereas pure Campylobacter were susceptible. These findings revealed that Campylobacter may gain antimicrobial resistance advantages through close interactions with Enterococcus spp. Interpretation: MDR phenotypes in Campylobacter cultures may arise through close, dual-species interactions with other highly resistant intestinal bacteria, such as MDR Enterococcus spp. and may have practical implications for antibiotic treatment. Funding: This study was funded by the German Ministry of Health dedicated to the National Reference Centre for Salmonella and other Bacterial Enteric Pathogens.